Cancer Care in the ASC— Taking Back Control

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Patient preference for comfortable, easy-access cancer care driving trend to outpatient settings

A full range of emotions can come with a cancer diagnosis. One of the most common? Loss of control.

In the wake of this difficult medical news, it’s hard for many not to feel defined by their illness. Appointments and tests start to fill the calendar every week, and with so many unknowns regarding response to treatment, it’s easy to feel as if everything is unmanageable.

Tack on the anxiety over prognosis and the potentially tricky treatment road ahead, and individuals can suddenly feel overwhelmed.

First Things First

To regain some control, one of the best first steps is to set a concrete plan forward for treatment and care. The lists of required scans, blood work, therapies, and treatments start to pile up quickly, and having a clear path toward remission is helpful.

As the appointments mount, the advantage of seeking treatment at an outpatient setting or an ambulatory surgery center (ASC) is clear. With ASCs, patients benefit from easier geographic access to treatment without traveling to and navigating large hospitals. Additionally, they can typically find more flexible scheduling options and even be seen for treatments sooner or more regularly than in a hospital.

With the flexibility of scheduling, patients feel that their care is prioritized as they do not often have to wait as long for appointments. Typically, physicians at ASCs are more able to accommodate a patient’s scheduling needs.

Living Beyond a Diagnosis

Outpatient centers are also more desirable for many patients because the additional services offered provide a glimpse into what life will be like when the battle ends and the cancer is defeated. Ancillary services, including physical therapy, nutrition and dietetics, and psychological services right on-site in an ASC or outpatient clinic, promote hope and help patients regain control.

But, perhaps most importantly, the most significant driver behind the trend out of hospitals for cancer care is the patient preference for the familiar. Aside from the convenience and ease of access, including more accessible parking and less time spent at the ASC, outpatient care is more comfortable compared to going into a hospital regularly. And when facing something as difficult as a cancer battle, every bit of comfort can make an impact.

How to Establish an Effective EUS Practice

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A patient with unexplained, chronic abdominal pain has struggled for months to find the cause of his discomfort. His physicians suspect something serious, and order an endoscopic ultrasound for further examination.

Without a local option for care, the man is stuck waiting months for an appointment and must travel hours for the advanced endoscopic procedure. While most patients prefer to be seen in ambulatory surgical centers (ASCs) due to convenience and, often, lower costs, EUS is not always readily available in ASCs.

Unfortunately, barriers to bringing EUS to ASCs or outpatient clinics include limited training opportunities for physicians – especially post-fellowship – and equipment costs for ASCs and outpatient centers. But, bringing the procedure to your practice can drive revenue and significantly help patients in the community.

There are always questions about if a group should start an EUS program, but once that decision is “Yes”, the new set of questions becomes “How”.  So, if a physician who is already trained in EUS is thinking about starting in another setting, then here is an outline of how to get it done:

Explore:

Take stock and determine if EUS is the right fit for your practice and community.

A team of representatives from gastroenterology, nursing, materials management, pathology, radiology, procurement and medical device reprocessing should collaborate to determine goals of an EUS program, the target patient population and the overall implementation plan. The team will also need to analyze the current availability of adequate resources (budget, equipment, trained personnel, reprocessing facilities, etc.) to implement an advanced procedure like EUS in your practice, and/or what will need further investment.

Plan:

Develop an implementation timeline complete with short-, medium- and long-term goals and measures for success.

The implementation plan should include how your team will meet training requirements, acquire equipment and market the new offering to the community. Post-fellowship training fellowships are available for endoscopists seeking to gain competency in EUS. Reprocessing personnel also require training on proper handling and cleaning of specialized endoscopes. All credentialling requirements must be met as well.

Implement: 

Install equipment and train appropriate staff to cover all aspects of procedure, from preparation, to anesthesia, to performance, to reprocessing of endoscopes to follow-up care.

An advanced endoscopic procedure such as EUS requires a large amount of institutional support to be performed successfully. Facilities may choose to engage with medical device manufacturer clinical support teams, especially with using new equipment and setting up brand-new services. The needs of additional stakeholders, like anesthesia and radiology, should also be factored into implementation timelines and plans.

Review:

After successfully launching EUS as part of your practice, take time to review what went well and what could be improved for both team members and patients.

No new program implementation will ever be perfect, and this is a good time to review all procedures and protocols to ensure all patient and department needs are met. Additionally, the implementation team described above can determine future clinical needs for continued operation and expansion of a successful EUS program.

“EUS program leaders and healthcare administrators must work collaboratively to measure preestablished metrics of success, operationalize identified opportunities for improvement, and regularly evaluate the overall clinical care system,” according to an article in the January 2022 edition of Endoscopic Ultrasound about establishing EUS in practice. “[EUS] programs require a comprehensive and interprofessional approach to strategic planning, goal setting, implementation, training, and program maintenance.”

Adding EUS to your practice.  What are the benefits?

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The first experimental endoscopies were performed on sword swallowers – those who had the skills to allow long tubes down their throats without causing harm to their bodies. Today, no such patient skills are required to undergo an endoscopy, thankfully. And with advancements in imaging technology, patients can wake up to view images directly from their digestive tract, lungs, urinary tract or uterus even immediately after their procedure.

Millions of patients undergo endoscopic procedures every year in the U.S. This minimally invasive option for treatment that sends long, thin tubes into hollow cavities of the body for diagnostic and therapeutic procedures. Several hundred years since those early sword swallowing days, those tubes can even facilitate ultrasound imaging.

Endoscopic ultrasound (EUS) has become increasingly attractive to patients and physicians. For gastroenterologists, these procedures allow physicians to diagnose severe digestive illnesses more efficiently. GI EUS is used to diagnose and evaluate a variety of conditions, including:

  • Mediastinal diseases
  • Pancreatic cysts and masses
  • Anorectal pathology
  • Subepithelial gastrointestinal lesions

Dr. Stephen Steinberg, co-founder and president of EndoSound, describes EUS as an incremental skill, meaning endoscopists don’t need to have mastered every advanced technique of the procedure in order to offer the benefits of EUS to their patients. There is still much to be gained from a “basic” EUS procedure, that could save patients time and money from having to travel to other medical centers for the kind of attention they need.

For example, EUS can provide endoscopists with more information than other imaging tests and evaluate lumps or lesions previously detected in other endoscopies. The ultrasound images can inform the origin of abnormalities and help inform treatment decisions. The procedure has proven successful in helping physicians diagnose diseases that couldn’t be confirmed with other testing options.

“While exciting diagnostic and therapeutic advances hold our attention, it may be important to highlight the one trend that could be the most important for patients – the increasing integration of EUS into general gastrointestinal (GI) training and practice,” wrote Anand V Sahai, in his 2018 Endoscopic Ultrasound journal article, “EUS is Trending!”

But, since EUS competency requires additional training, “it remains limited to a selected group of physicians willing to make this extra sacrifice, to allow them to include EUS in their GI practice,” according to Sahai’s article.

Challenges remain all over the world in establishing EUS in routine practice. These include the required physician competency and upfront equipment costs, specialized endoscopes, and accessories for EUS-guided fine-needle aspiration or EUS-guided fine-needle biopsy.

GI endoscopists need to complete close to 400 EUS procedures addressing multiple areas (mucosal tumors, pancreaticobiliary, etc.) over the course of 24 months to have full competency in EUS, according to guidance from the American Society for Gastrointestinal Endoscopy (ASGE). Training programs, even post-fellowship opportunities through the ASGE, are available and often at capacity. U.S. physicians may also find training opportunities abroad, where there are fewer restrictions for visiting endoscopists to perform procedures.

The benefits to seeking that additional training go beyond those for the patient and can outweigh time and revenue lost during training and acquiring necessary tools. If patients can undergo EUS at their local hospital or ambulatory surgery center (ASC), they can benefit from an advanced procedure that can assess damage to the digestive system, assist in diagnosing cancers, or potentially receive therapeutic procedures like cyst drainage, all without the added stress of travel to large medical centers were EUS is typically performed. For those that can receive EUS in an ASC, they avoid a potentially unnecessary hospital stay and may find more affordable care.

So, even for well-established GI endoscopists several years removed from fellowship training, pursuing mid-career training in EUS could open more possibilities for treatment and care in facilities and practice. There are initial steps, including time needed for training and upfront equipment costs, but the rewards for quality of care provided to patients just may be worth it in expanding a growing practice.

Routine GI Endoscopy Already Popular in ASCs, Will EUS Be Next?

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The first Ambulatory Surgery Center (ASC) in the U.S. opened in 1970, offering an opportunity for patients to have access to the quality care they needed, without the wait time and cost often associated with hospitals.

Fast forward 50 years and the global COVID-19 pandemic fueled an already growing trend of patient preference for the convenience of ASCs. Today, more than 30 million surgeries and procedures are performed at more than 5,800 ASCs nationwide every year.

Large investments from MedTech industry giants may help fuel the still growing trend for out of hospital care. A recent partnership of GE Healthcare and Medtronic announced in April promises “cost-effective advanced technology” support for the growing suite of ASCs across the country.

The question remains how ASCs will be able to adapt to the increased demand for outpatient care when it comes to more advanced procedures – especially those performed by physicians with specialized training and requiring costly equipment, typically only found in hospitals.

GI Care in the ASC

In gastroenterology, there has been a huge uptick to procedures in ASCs, especially for routine endoscopy. Since ASCs typically offer a more convenient location, time-saving, and cost-saving alternative, they can be especially attractive to patients needing a routine colonoscopy.

The ASC Association lists endoscopy as one the primary specialties certain ASCs may offer (about 32 percent). Definitive Healthcare reported colonoscopies topped the list of reported procedures charged at ASCs in 2018 – approximately $3.2 billion in submitted claims.

Since average costs for colonoscopies can range from around $3,000 to as high as $19,000, it’s not surprising patients are choosing ASCs over the hospital for routine care.

As another example, a review of South Carolina colonoscopy rates and locations found that while the number of procedures stayed constant between 2001 and 2017, there was an 125 percent increase in colonoscopies performed in urban ASCs in that timespan.

EUS Outside of the Hospital

As the number of ASC sites grows and advanced medical technology becomes more readily available, there have been signs that more specialized gastroenterological endoscopy procedures may become more popular at the ASC as well.

Endoscopic ultrasound (EUS) is a minimally invasive procedure used to diagnose disease in the digestive and respiratory tracts. An alternative to surgery, EUS tools allow physicians to take images and samples for biopsies with specialized endoscopes. EUS is typically performed in the hospital endoscopy unit with patients under general anesthesia.

Given the expense of EUS technology and specialization required from physicians, transitioning procedures to an ASC could prove burdensome, with few doctors able to perform the procedures at these locations. A 2016 study from Dr. Shaffer R. S. Mok, et al, out of the MD Anderson Cancer Center in Jersey shows the feasibility and safety of EUS in the ASC, and the idea has gained more traction in recent years.

Continued innovation of EUS technology could be one of the ways to help move procedures to the ASC from the hospital, at great benefit to patients.

Six AI updates in GI for 2021

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Artificial intelligence has a growing presence in gastroenterology. From colonoscopy procedures to imaging techniques, here is a link to six AI updates in GI so far in 2021:

Original article From Becker’s ASC

AI in GI: 6 updates in 2021

Patsy Newitt –   

Artificial intelligence has a growing presence in gastroenterology. From colonoscopy procedures to imaging techniques, here are six AI updates in GI so far in 2021:

1. The FDA granted de novo clearance for Medtronic’s first AI system for colonoscopies. The endoscopy module, GI Genius, uses AI to identify colorectal polyps, according to an April 12 news release.

2. Pristine Surgical and NexOptic have agreed to combine their technologies for a single-use endoscopic visualization platform. Pristine Surgical’s single-use endoscopes will use NexOptic’s AI imaging technology, All Light Intelligent Imaging Solutions, according to an April 7 news release.

3. A team at Washington University in St. Louis developed an imaging technique for rectal tissues to assess risk management of CRC. Biomedical professor Quing Zhu, PhD, and her team created the imaging technique, acoustic resolution photoacoustic microscopy coregistered with ultrasound, and paired it with AI.

4. GI-focused software companies Iterative Scopes and Provation partnered to link Provation’s GI documentation software with Iterative Scopes’ inflammatory bowel disease data and AI insights, according to a March 17 news release.

5, A partnership reached between Iterative Scopes and Eli Lilly Feb. 18 will explore how AI can improve understanding of IBD pathophysiology and target identification. Iterative Scopes closed a $5.2 million seed round in January 2020.

6. Chattanooga, Tenn.-based Erlanger Health System began a clinical trial to test an AI device used to increase polyp detection during colonoscopy, thechattanoogan.com reported Feb. 8.

CMS Will Eliminate Inpatient-Only Procedure List by 2024

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This year, ASCs can perform and be paid for hundreds of additional procedures.

JOINT SUPPLEMENT CMS will now pay for total hip replacements performed at ASCs.

CMS’s Outpatient Prospective Payment System and Ambulatory Surgical Center final rule, which took effect on January 1, further blurs the lines between inpatient and outpatient surgical care, as well as between ASCs and HOPDs within the outpatient sphere.

The big news is the gradual elimination of the inpatient-only procedure list. This year, CMS has removed a total of 298 mostly musculoskeletal procedures from that list, and now will pay for them in HOPD settings when clinically appropriate. By 2024, the remaining 1,400 or so procedures on the inpatient-only list will be removed. Read more