COVID's Impact on Colonoscopies

When the American Cancer Society recommended colonoscopy screenings should start at age 45 instead of age 50 last May, you might have wondered how you were going to accommodate the influx of new patients. Fast forward one year and a global pandemic later, and you're probably wondering how you'll convince reluctant patients to get their screenings done so your case volumes return to the level they were before COVID-19.

Physicians at the Center for Digestive Health & Nutrition in Moon Township, Pa., typically perform approximately 5,000 colonoscopies each year. During the height of the pandemic, when elective procedures were put on hold and only colonoscopies that met the strict definition of emergent were being done, the facility saw an 80% to 90% reduction in their normal screening volume.

"We would run three rooms, three days a week and then two rooms, two days a week," says Frank Kim, MD, a gastroenterology specialist at the center. "During the worst of it, we were scheduling cases on only one morning."

Thankfully, the center's case volumes are nearly back to where they were before the coronavirus outbreak. But the entire patient scheduling and procedural process is far different than it was pre-pandemic. Let's look at everything you're likely to encounter as you get your colonoscopy service line back to a stable, consistent level.

• Convince reluctant patients. Colonoscopy screenings are potentially life-saving procedures, but they're still considered preventative care and ultimately elective. Many patients, especially older individuals with pre-existing conditions, are willing to wait until there's less uncertainty surrounding COVID-19.

Indeed, that's the situation Mohammad A. Al-Haddad, MD, is facing. "We're still seeing a significant number of last-minute cancellations which occur within three days of the procedure," says Dr. Al-Haddad, a gastroenterologist with Indiana University Health in Indianapolis.

He points out patients might become anxious about entering a healthcare facility, change their minds or view the screening as a test that can wait another year.

There's another major reason for the cancellations. "One of our biggest issues has been the pre-screening COVID test," says Dr. Al-Haddad.

"We now ask every patient to get tested. Unfortunately, some patients cannot get tested or refuse to get tested, and they fall off the schedule."

Like many facilities, IU Health's outpatient endoscopy centers saw a 75% reduction in volume between the end of March and the beginning of May, when physicians were performing only emergent and urgent-access colonoscopies. In late June, its colonoscopy volume was back up to three-fourths of its pre-COVID-19 levels, at least in part because of the facility's patient outreach efforts. When staff repeatedly heard from patients who didn't want to undergo screenings, they took a more aggressive approach.

"We developed a brief training program to teach schedulers how to better communicate with reluctant patients," says Dr. Al-Haddad. "The program helps them reassure patients, talk them through anxieties and share the facilities' safety data."

If a scheduler is having trouble convincing a patient, they can request back-up. "The advice of a nurse is sometimes more impactful in changing a patient's mind," says Dr. Al-Haddad.

• Focus your efforts. You want as many patients as possible to keep their regularly scheduled (or rescheduled) screenings, but it's important to recognize procedures are more important for some patents. "The key is to identify patients who are at a higher risk of colorectal cancer," says Rajesh N. Keswani, MD, medical director of quality at Northwestern Medicine Digestive Health Center in Chicago. "Instead of calling every patient on the cancelation list to see who shows up, try to identify high-risk individuals, because they're more likely to come."

Dr. Keswani, who recently co-authored a detailed report on reactivating outpatient GI practices (osmag.net/ppQAR5), says your physicians need to play a more active role in engaging patients. "Whenever possible, they should reach out to patients to remind them about the importance of screenings, especially if they have a family history of colon cancer," he says.

"That dialogue between physician and patient is much more likely to result in the patient agreeing to get screened."

• Virtual appointments. As a result of the pandemic, Dr. Kim's facility is offering telehealth for the first time (physicians still schedule in-person consults for new patients). "I think it's worked out really well so far," he says. "Our patients love it because it saves them time, they don't have to drive and the appointments are reimbursed as long as they're not within 72 hours of scheduled procedures."

Cancer doesn't wait

There's no one-size-fits-all approach to ramping up your colonoscopy service line in the era of COVID-19. "A small endoscopy center in a rural county is not the same as an urban center in the middle of a bustling metropolis," says Dr. Al-Haddad.

While there's no doubt a very compelling business reason to get your colonoscopy service line back to pre-pandemic levels, there's an even more powerful patient-driven reason to make sure people don't forego critical care that can still be done safely. "We don't call colonoscopies elective procedures, we call them life-saving procedures," says Dr. Kim. "If patients have colon polyps and we get them out, we've saved their life." OSM