Endoscopy in the Ambulatory Setting

Endoscopy in the Ambulatory Setting

BY KATHY DIX

Among specialties in ambulatory surgery centers (ASCs), the most popular — ophthalmology, orthopedics, ENT — are accompanied by the all-encompassing endoscopy. Endoscopes — used to examine the interior of a bodily canal or a hollow organ such as the colon, bladder, or stomach — can be utilized in many specialties, but are most commonly applied in gastroenterology.

Advances in this particular branch of medicine have been stunning over the last ten to twenty years. Endoscopes are now used for much simpler diagnostic procedures to assess the health of the esophagus, stomach, and colon.

Innovations

Hillel Chiel, PhD, professor of biology, neurosciences, and biomedical engineering at Case Western Reserve University, has developed a robotic device to help endoscopes move through the body. Understanding the way slugs, leeches, and earthworms crawl and eat has led to two new inventions at the university that have the potential to make procedures such as colonoscopies and other invasive testing safer for patients and easier for doctors to administer. Inspired by the animals’ movements, researchers also envision creating flexible, self-propelling robots that are equipped with sensors and can maneuver through earthquake rubble, twisting pipes or clogged arteries and even pick up delicate soft objects (like chocolate and fresh fruit) using a novel gripping device.

Investigators from the departments of biology, mechanical and aerospace engineering and electrical engineering and computer science recently received a patent for “Peristaltically Self-Propelled Endoscopic Device” and a provisional patent on “the Gripper.” The prototype peristaltic endoscope has the appearance of a nine-inch-long hollow worm, which is composed of three muscle-like actuators made of bladders of latex surrounded by nylon mesh. “When the bladder of each actuator inflates with air or water, it contracts to become short and fat. The device propels itself forward as it proceeds through the sequence of inflating and contracting each actuator segment. This movement mimics the undulating way slugs and worms traverse their environments,” according to a university press release.

According to Chiel, the device can be used as an aid in current endoscopes, or can eventually be miniaturized and work autonomously with attached sensors. “This could be extremely useful in terms of making it easier for patients to tolerate having catheters inserted or other medical procedures, and thus, increasing compliance for having these health tests done,” says Chiel. A more flexible device could possibly reduce the risks of injury to the patient.

“This device can literally worm its way into complicated places or in curving tubing such as the colon,” explained Chiel. The researchers also plan to make it more flexible, incorporating the known reflexes that slugs and worms use to respond to changes in the surrounding environment.

The other invention is the Gripper, which mimics the way California sea slugs in Chiel’s lab grasp seaweed in its many slippery forms. The Gripper is a nickname for “The Biologically Inspired Gripping Device.” The prototype is a four-inch, ball-like device with a mouth that opens and closes and is located inside an outer tube. The ball pushes forward, opens its mouth and grasps at an object. The rings surrounding the ball push it forward and backward and are also made of muscle-like actuators. This novel grasping device responds to an industrial need for grippers that can harvest and pick up soft materials that rigid grippers cannot grasp without destroying the soft object.

“Building grippers to pick up soft materials has been very hard. Most gripper devices are fairly rigid and designed to work effectively with things that have a fixed orientation or a certain texture or toughness,” says Chiel. This device has the potential to eat its way through tubing or occluded vessels in the body and pick up soft objects.

The “Real World” of Endoscopy

Barry Tanner, CPA, is president and chief executive officer (CEO) of Physicians Endoscopy, based in Philadelphia. Physicians Endoscopy specializes in the development and management of freestanding endoscopic ASCs in partnership with practicing gastrointestinal (GI) physicians. The company operates eight endoscopy centers around the country and anticipates opening six more in 2006.

“Most of the large GI groups probably at this point have an endoscopy center of some sort, so the two primary markets we focus on are coalitions of physicians and physician-hospital joint ventures. Hospitals are finding ways to partner with physicians,” Tanner says.

Entirely new technologies are not being seen; however, upgrades in the current technologies recently have been released by nearly all major endoscope manufacturers. But even if the technology advances dramatically, that may not be reflected in the equipment owned by ASCs for some time. “Part of that is simply that the centers are only licensed for certain types of procedures, and Medicare still has a limited list of procedures that can be done in an ambulatory surgery center setting,” Tanner explains. “So in spite of what new technologies may come down, ASCs are still limited to pre-approved ASC procedures. Those tend to be colonoscopies and esophagogastroduodenoscopies (EGDs), and variations on that; it’s a fairly narrow range. Other things that you tend to hear about some ASCs doing are, for example, Remicade infusions; those are not approved procedures for an endo center. In order to do them inside an ASC, it’s fairly difficult, so the bottom line is, from an endoscopy center point of view, the procedures are relatively the same, but slightly improved recently with the improved technologies.”

Endoscopic retrograde cholangiopancreatographies (ERCPs) are another procedure that is being performed more — but not yet in outpatient centers. “All of our physicians who do ERCPs do them in the hospital, probably because they require fluoro, and probably because they are deemed to be higher risk,” says Tanner.

One of the most impressive developments in endoscopy has been the sizing of endoscopes and their associated tools. “We have seen scopes get smaller,” Tanner explains. “If you think of the concept of an endoscope, the technology has changed dramatically through the years, and gotten to the point of being almost microscopic in nature. There are scopes now that are honestly not much bigger than a hair and have all sorts of other applications, not as it relates to what GI physicians do, which is what I’m focused on — certainly endoscopes themselves are developing a broader application.”

Endoscopic procedures bring with them several challenges. “There is a shortage of GI physicians; the demographics of population means that there are more patients who are eligible for screening in terms of colonoscopy,” says Tanner. “There’s still a fear of the procedure in a large portion of the eligible patients because of its invasiveness and the prep that goes along with it. Some of the things we’ll see over the next few years are that new DNA types of technologies or virtual colonoscopy will begin to reach a larger portion of the eligible population who are not going for colonoscopy right now, particularly if something like virtual colonoscopy begins to be reimbursed by Medicare and other third party payors. I think we’ll see that technology grow dramatically in terms of a screening/diagnostic tool, which will in turn drive more business to the endo centers; however, it will be more therapeutic in nature as opposed to diagnostic. Our endo centers over time may become less efficient because they will then be treating patients while looking for something that the radiologist thinks they saw. Then the GI physician may be doing a colonoscopy looking for a polyp that may or may not be there; it could have been a false positive, so he or she is spending extra time trying to find something that isn’t there, or instead of a straight screening, they’re spending more time removing polyps, which means more therapeutic procedures, more time consuming procedures, and therefore less efficiency within the endo center itself.”

Physicians Endoscopy is not yet performing virtual colonography (also known as virtual colonoscopy) in its centers. “We are following the technology very closely, but because of the lack of reimbursement, it’s really kind of like several years ago when there was a big push and publicity for people to go in and have full body scans. It’s similar to that right now — it’s entirely private pay, and given the equipment and software needed, it’s a fairly big outlay with a fairly limited population of patients who are going to walk up and plunk down $750 to $1,000 for virtual colonoscopy. Right now I would say that it’s still coming into its own, and it’s more of an add-on procedure; if someone has an imaging center, and a 64 slice CT, where they can just add on the software, then that’s where you’re seeing it now. But I think once it becomes reimbursable, and therefore it generates a greater patient flow, it’s a technology that will definitely come into its own.”

Integrating endoscopy into an existing ASC is not always cost effective. “In order to be worthwhile in an ASC, endoscopy has to be done in an efficient fashion,” Tanner states. “The reimbursement on average for most of what we do in endoscopy centers, from a Medicare standpoint, is a Group 2 procedure. Most endoscopies are Group 2, so let’s say the average reimbursement is $430 to $440 nationally. Given the staff time and the cost of setting up a center, you really have to do endoscopy efficiently to break even, frankly, or to be profitable. That is in contrast to other types of specialties such as orthopedics or ENT; the dollars per procedure are substantially higher. In terms of room turnover, patient turnover, in order to have endoscopy done well, it needs to be done efficiently in terms of block scheduling and staff time.”

Their centers follow a standard 30-minute schedule; each procedure is given that half-hour. Some procedures may take a shorter or longer time, but 30 minutes is the average. “Generally speaking, an upper endoscopy is probably faster than a colonoscopy, so some procedures may be done in as little as 15 minutes. Other more complicated procedures may take 40 or 45 minutes. Room turnover time is probably less than five minutes. The old equipment goes out and the new equipment comes in; while in the admit area, the patient is prepped for the procedure. They stay on that particular stretcher that is taken into the procedure room, and that same patient stays on that stretcher through recovery, so there is a constant flow. As soon as the procedure is done, the old scopes are taken to decontamination, new scopes are brought in and the new patient comes into the room, while the physician is doing dictation, and by the time he or she is done with dictation, the next patient is ready to go.”

Another element of that timing is the disinfection and cleaning of endoscopes. “Typically, we are reprocessing several endoscopes, and depending on the number of rooms we have, we’ll have multiple reprocessors. Typically, they will take one or two scopes at a time; it’s important to have enough scopes so you don’t slow down in terms of turnover, because reprocessing tends to be 40 minutes to an hour. Given the turnover time, you don’t want to run short of scopes,” Tanner concludes.