What’s a “good” colonoscopy?

November 23, 2012 in health care costs, Medical Care, Quality of care

No bad jokes.  I’m serious.

I’ve reached the wonderful age at which I’m supposed to have this test as part of my general health care.  I had one 10 or so years ago, so I know what I’m in for.  The best thing to be said is that the drugs gave me a deeply restful nap.

The first time, I went wherever my doctor told me to go.  This time, I have a couple of references from my doctor, but I’m going to ask some more questions before I decide whom will perform the delicate procedure.

I’ve talked to a few docs and looked at some websites.  Here’s my list of questions.  Is there anything I should add?

1)     About the prep – what will give me the best cleaning out with the least discomfort?  There’s no point in going through all this if the doc can’t see what s/he is doing.

2)     What’s the doctor’s detection rate?  One medical society (the American Society for Gastrointestinal

Borrowed from Asian Scientist where study found that 30% of colonoscopy patients had polyps.

Endoscopy) says a doctor should find a polyp in 25% of men and 15% of women (why the difference?), but I know that some physician groups around Boston say the average is 40-50% among docs who really look for polyps.

3)     How much time does the doctor spend, on average, on the test?  I think more is better, is that right?

4)     Does the doctor always get to the end of the colon? OK, I may not be able to ask this.  One website says I should ask the doctor to take a picture so that I know they got to the end – but this is too gross and how would I know what to look for anyway?

5)    How many colonoscopies does the doc do each year?  The avg., according to the ASGE, is 750.  Again, more is better.

6)    What’s the doc’s error or complication rate per 1,000 patients.  I do not want to see blood afterward, although if the doc finds and snips a polyp, I suppose I will.

7)    One site says I should ask about the procedures for disinfecting equipment.  Really? Isn’t flawless disinfection standard procedure?

8)  And finally, I’ll ask how much each doc charges.  I’m supposed to be looking for the best test at the best price.

Shopping for a colonoscopy could take weeks, not including the procrastination factor.

 

8 responses to What’s a “good” colonoscopy?

  1. Martha,

    Your questions are great. I would add one more based on my experiences. Be sure the Dr. in charge of sedation gives you enough! The first procedure I had was less than comfortable! It was done in a relatively emergent situation and I didn’t know enough to ask about it. The second was a piece of cake from that perspective. My sister works in the GI unit at MA General. This is rated the best place to go and the Drs/nurses (including my sister, but I am not bias!) are fantastic! I debated sites for my second procedure, but ended up choosing to stay locally at NWH. The procedure room at the time was newer than MGH and the Drs from the “big house” funnel through both sites. I chose to stay with my NW Dr. who is great….I got the prep that was less intensive, excellent sedation and had a great experience. Only one other comment…if you have scarred veins, ask for the IV nurse! I had, but the nurse thought she could handle it…two sticks later and a need to change arms, they brought in the IV nurse! Still, they were all so wonderful, I cannot complain!

    Good luck with your procedure! I will go back soon and I am prodding my husband to go!

  2. Joan – great suggestion on the sedative, I will add this to my list of questions. When you say Mass General is rated as the best place to go for a colonoscopy, what do you mean? What rating? Thanks!

    • i was going to make a similar suggestion based on my work working with folks having colonoscopies in ny some years ago. but it might be covered in your question about the completion rate; with many of the patients, there was a correlation between a certain Doc not waiting long enough for sedation to kick in and incomplete colonoscopies because the patient was in pain, moving, etc. the Doc tended to blame the patient for not having cleansed thoroughly or correctly, but given the fact that we had records on several Docs, we saw and began to understand the pattern re: sedation. not sure how this can be measured though.

  3. I did not ask questions that I should have asked but NE Baptist was the best. BI was good when I had major health insurance but after I retired with Medicare and a supplement, the same doctor and staff were horrendous. I was struck 3-5 times w/in 45 min. period for set up and it was painful because I had too little sedative without apology they seemed very aggravated that I was having another colonoscopy and did not want me to go back to them.

  4. I second Joan’s suggestion about sedation. My first colonoscopy was without problems. I returned to the same team for the second one, but this time it was excruciating. I “awoke” sufficiently to be aware that I was yelling in pain and being held down by personnel who kept telling me everything was “okay,” which it definitely was not. I mentioned the ordeal to the doc after the Versed had been reversed and he said most people complain during the procedure but don’t remember it when they awaken, as if my remembering it was the abnormality. It can mess with your mind, hearing the people to whom you’ve entrusted your safety tell you everything is okay while they hold you down and the procedure continues. The one bit of good news is that the doc said when I’m due for the next exam, in all likelihood the colonoscopy will have been replaced by a blood test which apparently is being developed as we speak.

  5. I’ve had a few colonoscopies…but because I have a “redundant and tortuous”
    colon, they cannot completely check out the right (ascending)portion. Any thoughts on this?? Or where do I look for info?

    Thanks

  6. You’re asking great questions. One I would suggest involves my own experience. I had the procedure in 2010 and wanted to make sure there were no out of pocket expenses. I was assured that my health insurance would pay for everything and there would be no extra costs. On the day of the procedure, however, my gastroenterologist asked if I wanted him to remove any polyps that he found. If he did find any, removing them would mean I would not require a second procedure. Having done the prep, I agreed that having him remove any polyps was prudent. During the procedure, he found one and sent the specimen to the lab. By finding one polyp, the procedure was changed from screening to diagnostic and my bill went from zero to almost $1,000 (for anesthesia, the gastro’s fee, and the lab testing). I have since read that some gastros routinely change screening procedures to diagnostic procedures. One group does so at the rate of 90%, much higher than the 15% for women and 25% for men that you cited. There’s a benefit to not having to go through the prep and return for a second procedure, but I’m not sure how I would have reacted if I knew the increased cost would be $1,000.

  7. I am a physician and recently had my first and last colonoscopy. Last, as this procedure will surely be replaced (in the opinions of all experts) by non-invasive imaging or refined DNA-based stool or blood tests before I’m due for a re-check in 10 years. I had my colonoscopy at age 50 because of suspected colitis (diarrhea for 3 weeks), not primarily for cancer screening. A few months prior to my illness, I had performed a FIT (new, more accurate stool test) test at home and had a Septin 9 blood test. The former, done annually, is a acceptable substitute for colonoscopy every 10 years according to the CDC ( http://www.cdc.gov/cancer/colorectal/basic_info/screening/guidelines.htm ). I performed the Septin 9 test ( a simple blood test ) to improve the detection rate, as the FIT test detects blood in the stool and the Septin 9 test detects colon cancer DNA circulating in the blood (http://www.biomedcentral.com/content/pdf/1741-7015-9-133.pdf ). It would be rare, indeed, for both tests to miss an early cancer. Fortunately, both tests were negative and I had planned to repeat them in a year. The colonoscopy confirmed the findings of the prior tests. No cancers or polyps were found. My colon was perfectly normal.

    Now, once I learned a colonoscopy was necessary to evaluate for illness, I began to consider my options. I had an upper endoscopy in Italy years back without any sedation (the standard of care in most countries) without a hitch. I actually enjoyed viewing the images. The only feeling was that of bloating/belching, as they constantly introduce air to keep the stomach expanded. Was sedation-free colonoscopy possible? Actually, I was surprised to learn that sedation-free colonoscopy is the norm in most countries as well. I found an article from Japan in which 675 patients underwent sedation-free colonoscopy and only 6 felt the discomfort would preclude them from future colonoscopies without sedation ( http://link.springer.com/article/10.1007%2Fs10350-004-0860-0?LI=true ). Note that sedation carries about a 1.1% risk of a serious complications by itself. Furthermore, 1 in 400 patients undergoing colonoscopy will have a severe complication requiring hospitalization, such as perforation of the colon. To have a severe complication from unnecessary screening is unconscionable, yet the risk of a serious colonoscopy- or sedation-related complication in an otherwise a healthy patient is 1.35% (as the vast majority of screening colonoscopies are negative).

    Thus, Martha, in answer to your question, for the vast majority of people getting routine screening for colon cancer, a “good” colonoscopy is no colonoscopy at all! Consider the annual FIT test and perhaps adding the Septin 9 test for added protection. There are no risks associated with these tests and the former is recommended by the CDC as an alternative to colonoscopy.

    By the way, I had my colonoscopy without sedation without a hitch. Had a few mild to moderate gas/cramping pains that passed quickly. I STILL got a $2,000.00 bill from the anesthesiologist even though I had no anesthesia. Perhaps your readers will now recognize why sedation for colonoscopies is recommended by anesthesiologists in the US!

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