ASCs Offer Extensive Gastroenterology-Related Treatment

ASCs Offer Extensive Gastroenterology-Related Treatment

By Kathy Dix

Gastroenterology comprises the treatment of diseases and disorders related to the organ system that includes the esophagus, stomach, liver, pancreas and biliary system, small intestine and colon. Gastroenterology offerings in the outpatient arena are no longer limited to upper endoscopies and colonoscopies or sigmoidoscopies. Ambulatory surgery centers (ASCs) and affiliated physician offices can also provide treatment for long-term conditions such as Crohn’s disease and ulcerative colitis, collectively known as inflammatory bowel disease (IBD), or treat patients for peptic or duodenal ulcers. They may even provide simpler bariatric procedures, such as laparoscopic banding, although more traditional gastric bypasses — the Roux-en-Y procedures — remain mainly inpatient procedures.

At Children’s Memorial Hospital in Chicago, a pediatric gastroenterology (GI) outpatient clinic sees pediatric patients with IBD, gastroesophageal reflux, failure to thrive, recurrent abdominal pain and stooling disorders.

Carol Fairchild, RN, director of ambulatory surgery services at the Holzer Clinic of Jackson, Ohio, says that the center has extensive offerings for GI — upper and lower endoscopy, banding of esophageal varices, esophageal dilatations, polyp removals and biopsies. “We have our own pathology department,” she adds. “We are 130- physician group organization with nine locations, and our pathologists also provide pathology services to two local hospitals. We have stat labs in every facility, but some things go to one central lab, including pathology.”

The organization recently began offering capsule endoscopy as well. Barium swallows are provided in the diagnostic testing center, which is attached to the surgery center. “The building includes the ambulatory surgery center, an emergent care center, diagnostic testing that includes laboratory services, two MRIs, and a CAT scan, as well as services in other medical specialties. That’s all within the confines of this one building. The gastroenterologists do cases in the surgery center, and then they see patients upstairs in the office,” Fairchild says. “We have five gastroenterologists, some of whom offer additional services such as interventional endoscopic retrograde cholangiopancreatography (ERCP). They all do endoscopy, and we have three doing the capsule endoscopy.”

Of course, upper endoscopies and colonoscopies/sigmoidoscopies remain one of the main services that gastroenterology-specific ASCs provide. Physicians Endoscopy specializes in the development and management of freestanding endoscopic ASCs in partnership with practicing gastrointestinal (GI) physicians. Each center is located adjacent to, or in the immediate vicinity of, the office of the physician group partner’s GI practice. This particular sub-group of GI services — upper and lower endoscopy — is in such demand that the company operates eight endoscopy centers around the country and anticipates opening six more centers in 2006.

Patients presenting for these types of procedures generally meet the following characteristics: those undergoing the recommended screening colonoscopy after age 50 and every 10 years thereafter; those with a family history of colon cancer or polyps, or a personal history of polyp removal or cancer; those with chronic diarrhea for longer than six months or changes in bowel habits; those with blood in the stool, anemia, IBD, or a history of ovarian, uterine or cervical cancer; and those with upper or lower GI abnormalities, chronic heartburn, gastroesophageal reflux disease (GERD) or difficulty swallowing.

Although Medicare has a limited list of procedures that can be done in an ASC setting, and many facilitiess are limited to preapproved ASC procedures, gastroenterology remains one of the most popular specialties seen in the ambulatory arena. Recent recommendations for screening colonoscopy have overwhelmed gastroenterologists with new patients, and although ERCP is still performed more frequently as an inpatient procedure, certain outpatient centers do offer it.

Bariatric Surgeries

The number of outpatient centers offering bariatric gastroenterology services — still very small — may increase, now that Medicare has decided to pay for gastric bypass surgeries. On Feb. 21, the Centers for Medicare & Medicaid Services (CMS) announced that it would expand Medicare’s national coverage of bariatric surgery for all Medicare beneficiaries. However, for seniors — who have experienced high complication rates in some settings — Medicare will cover the procedure only in high-volume centers that achieve low mortality rates. The list of nationally-covered procedures includes open and laparoscopic Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, and open and laparoscopic bilio-pancreatic diversion with duodenal switch. Patients will only be covered if they have been diagnosed with obesity and a comorbidity such as hypertension, type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea, respiratory problems, and certain types of cancers.

The procedures will only be covered by Medicare in facilities that do large numbers of these procedures performed by highly qualified surgeons; CMS has agreed to cover facilities recognized as “Centers of Excellence” by the American College of Surgeons and the American Society for Bariatric Surgery. Certified facilities can be viewed at www.cms.hhs.gov/MedicareApprovedFacilitie. 

The shift in Medicare coverage may encourage additional facilities to attempt “center of excellence” approval, and facilities that already offer outpatient gastric bypass may also attempt the approval. In April 2005, Baylor Medical Center at Southwest Fort Worth initiated an outpatient gastric bypass program. This is a sister program to the outpatient bariatric surgery program at Baylor University Medical Center at Dallas, where more than 1,500 outpatient gastric bypass surgeries have been performed — nearly 75 percent of patients are discharged 23 hours after their surgery.¹

In March 2005, Cedars-Sinai Medical Center in Los Angeles became one of the first facilities in Southern California to offer the procedure on an outpatient basis for selected patients — again, with a discharge 23 hours after the surgery.

The American Society for Bariatric Surgery (ASBS) also discusses procedures that are in development. One, the implantable gastric stimulation device, utilizes small electrodes attached to the stomach which, when stimulated electrically, are supposed to create the feeling of fullness. “The intragastric balloon is being reintroduced as a simple procedure that can be placed through an endoscope. The balloon is designed to ‘take up space’ and thereby decrease the amount of food patients can eat. Both of these procedures, while interesting in their simplicity, have not had documented adequate long-term weight loss. However, as these procedures are potentially much safer than other operations, they may have a significant role in the future,” the society says on its Web site.²

Not only that, but, they add, “Surgeons are also devising different procedures to decrease the complication rate in high-risk patients — patients who have extreme obesity or severe medical comorbidities. Some surgeons are using a staged approach to bariatric surgery. This approach involves performing a less invasive procedure that reduces weight to a safer level (which in itself is not effective enough on its own) and improves overall medical condition first; then a more complex, definitive procedure is performed once the operative risks of the patient decrease significantly due to the initial weight loss. These less invasive steps have included the ‘sleeve gastrectomy,’ the gastric balloon, and the adjustable band as an interim step before a Roux-en-Y gastric bypass or duodenal switch is performed.”

Unique Innovations

Bill Hazen, RN, is the administrator of the Surgery Center at Pelham, located in Pelham, S.C. Typical of many multi-specialty ASCs, the facility provides the typical endoscopies and colonoscopies. They also offer placement of percutaneous endoscopic gastrostomy (PEG) tubes. “We have four colorectal surgeons, and our general surgeons also do that type of surgery, and we have GI physicians who are strictly endoscopists. The general surgeons do place PEGs for feeding and things of that nature,” he says.

The facility does not provide bariatric procedures; the state of South Carolina does not allow 23-hour stays or overnight stays in ASCs. “The law is unique here. The patients have to be out by midnight,” Hazen explains.

However, the co-owner of the surgery center is considering an innovative idea. (The surgery center is half-owned by Spartanburg Regional Health System and is half physician-owned.) The health system is in the preliminary stages of contemplating the creation of a cough clinic. “A lot of people have chronic cough,” Hazen points out. “In the clinic, you would provide a CT for sinuses, a GI probe for pH monitoring, and EGDs. The patients would see a pulmonologist, gastroenterologist, and an ear-nose-and-throat (ENT) doctor. All of these physicians would be involved to see where the chronic cough is coming from. It’s still preliminary, but they are thinking about offering a full service. I don’t know that we would offer that in the ASC setting; we would just do certain procedures here. Here at the ASC, we can’t see patients on an outpatient basis to diagnose them, so they’d be diagnosed in the clinic setting and then we would do these different tests to diagnose the source of the problem.”

The combination of physicians could shorten the time required to determine if a cough were caused by asthma, GERD, sinus problems, or some other issue.

“As I said, it’s very preliminary. I don’t want to misrepresent [the concept] and make it appear that the ASC is looking into it; the facility is part of a big system, and our system is looking at that. We would just do the endoscopy procedures,” adds Hazen. “Chronic cough seems to be a pretty common problem; we would try to get the specialties together to look at what’s the best for the patients. Instead of their having to go to three different doctors, it would be more cost-efficient if they saw a group of doctors working together to try to figure out the diagnosis. It’s a chronic problem, so why not give the patients what’s right for them?”

References

1. www.baylorhealth.com/aboutus/press/2005/050905.htm 

2. www.asbs.org/html/patients/horizon.html