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.”

The Role Payors Play in Where Patients Seek Care

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There are many factors to consider when deciding where to seek care for patients needing a routine or advanced endoscopic procedure. Perhaps it’s urgency for diagnostic or therapeutic care, the ability to travel, a desired physician to see, the convenience of available appointment times, or simply going to the first place found on Google.

But one influence is increasingly difficult to ignore: the bill.

Depending on type of coverage and whether benefits are from private or public sources, patients may unknowingly be directed to select certain locations for care. Increasingly, payors are favoring ambulatory service centers (ASCs) as a cost-effective alternative to hospitals.

“The ASC is usually more efficient, and the patient will benefit by having specialized care in a more efficient manner,” according to Dr. Adam Goodman, a gastroenterologist and professor at NYU Langone Hospital-Brooklyn. “The system benefits by less administrative costs, greater efficiency, and more procedures getting done in a similar amount of time.”

Ultimately, patients receive the same quality of care, but at a much-reduced cost, Goodman said.

It is estimated today that 90 percent of colonoscopies are performed in ASCs, hospital outpatient clinics, or in physician’s offices. Up to 32 percent of the ASC’s in the U.S. specialize in endoscopy alone, while 37 percent of the multi-specialty centers offer endoscopy services, including upper GI endoscopy, sigmoidoscopy, endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS).

Since ASCs typically offer specialized care, procedures can usually be performed more efficiently and quickly than at hospitals, resulting in lower costs. Patients seeking care at ASCs are likely also to have fewer complex conditions, requiring fewer resources for care. A recent study in California found colonoscopies cost an average $2,300 less when performed at an ASC rather than a hospital.

In fact, large payors have increasingly created policies that favor ASC care and may put continued pressure on physicians to perform non-urgent procedures in these settings. In some instances, insurance companies won’t pay for a routine colonoscopy in the hospital anymore. For example, United Healthcare now restricts sites available for non-emergent surgeries and Empire Blue Cross Blue Shield in New York began requiring proof of medical necessity for certain procedures to be performed outside of an ASC in 2021. The New York-based company argued procedures they were pushing to ASCs have been safely provided in such settings for many years. This is particularly true for GI endoscopy.

Studies have shown how care provided at ASCs is significantly cheaper than hospitals – with one report from Regent Surgical Health estimating healthcare cost savings up to $38 billion annually. Additionally, combined out-of-pocket expenses for patients could be reduced by roughly $5 million annually, according to the report. Even for advanced GI endoscopy procedures like ERCP or EUS, ASCs can offer a cost-effective alternative to a hospital.

ASCs are becoming increasingly popular throughout the country, and there are more than 5,000 operating nationwide today. If payors continue to drive future care to the centers, that number will only grow.

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.

Exploring EUS Competency and Training Opportunities

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It is estimated between 60 and 70 million people in the U.S. are affected by digestive diseases and gastrointestinal endoscopy has played an increasingly major role in management of those disorders.

While safer than, and often preferable to, invasive surgery, endoscopic procedures ranging from routine colonoscopy to more advanced procedures like endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) are not without risk. Physician competency is paramount to patient safety and can prevent misdiagnosis or poor treatment.

Competency in GI endoscopy is often measured by number of procedures completed in formal training programs, like post-residency fellowships. However, there is no formal specialized endoscopy board for the discipline, meaning training varies greatly across the nation and globe.

As the popularity of the discipline grows and endoscopic technology and techniques continue to evolve over time, it’s worth looking at what training opportunities are available, particularly for endoscopists who may choose later in their career to pursue more advanced endoscopic therapies in their practice.

Measuring Competency in EUS

EUS is an advanced endoscopic procedure used to assess and treat digestive and lung diseases (EBUS). Endoscopists use a specialized endoscope to take ultrasound images of the lining of walls of digestive system or lungs, or obtain images of organs like the pancreas and liver. These images can prove essential in the diagnosis of digestive or respiratory diseases. Additionally, endoscopists can perform therapies during more complex EUS procedures.

The American Society for Gastrointestinal Endoscopy (ASGE) recommends at least 24 months of GI or formal surgical training for GI endoscopists seeking competency in EUS. Further procedural requirements for competency, as outlined by the society, include:

  • Mucosal tumors: 75
  • Submucosal lesions only: 40
  • Mucosal and submucosal lesions: 100
  • Pancreaticobiliary: 75
  • EUS-guided FNA
    • Non-pancreatic: 25
    • Pancreatic: 25
  • Comprehensive competence: 50

The society also notes that competency in one type of advanced endoscopic procedure, such as EUS, does not guarantee competency in another like ERCP. Unique procedural requirements are set forth for each, as the skillsets required are quite different.

While EUS is typically performed at high-volume medical centers, especially given the procedural requirements for competency, there has been increased interest in smaller centers for physicians to take on the diagnostic and therapeutic practice.

Dr. Stephen Steinberg, co-founder and president of EndoSound, describes EUS as an “incremental skill.” There are less complex EUS procedures that can be performed competently with fewer training hours than the more advanced practices, he said. Still, beginning with these less complex procedures can be a pathway to improving skills and offer a way for  endoscopists to gather the imagery that will still be helpful in diagnoses and recommendations for care.

EUS Training Post-Medical School

There are currently 86 fellowship programs for advanced endoscopy, according to the American College of Gastroenterology (ACG). But, after fellowship, options become more limited.

“In the U.S., it’s really hard to get hands on experience,” Steinberg said, especially if the endoscopist is not part of a formal training program or fellowship. “Getting temporary privileges to work in another state for training isn’t typically available in the U.S.”

This leads many physicians to pursue advanced endoscopy training abroad.

In a 2014 op-ed penned by Dr. Todd Baron of the University of North Carolina, Dr. Baron explores the roadblocks he faced in pursuing EUS competency mid-career. Given how nationwide post-residency fellowship programs are geared to newly trained physicians, Dr. Baron said he did much of his training outside of the U.S. He said many physicians may find the same path challenging given the year needed to complete a fellowship and a medical center’s reluctance to losing a practicing physician for that length of time.

The COVID-19 pandemic has put even more pressure on developing new opportunities for EUS training that fall outside the realm of a traditional post-residency fellowship. During pandemic-era lockdowns, most non-emergency endoscopy procedures were delayed or postponed, greatly impacting the ability to train new endoscopists in the field. Thus, hands-on models and simulators, virtual conferences, and endoscopic video rounds were used more commonly.

Additionally, Steinberg said the availability of online videos or virtual training sessions and web streaming of live events can help those seeking new EUS skills learn techniques or see the latest available technologies.

Looking Forward

A recent article for the ACG Case Reports Journal outlined some avenues in which advanced endoscopy training could change to provide greater access to more physicians, including:

  • Incorporating EUS and ERCP training into the final year of residency
  • Standardizing advanced endoscopy training across fellowship programs
  • More exploration of non-traditional methods of training

GI endoscopy offers a safe and viable way for patients to receive preventative and therapeutic care without invasive surgery. More advanced procedures like EUS allow physicians to get a detailed look at the advancement of digestive and respiratory illnesses with minimal risk and discomfort to often quite ill patients.

Like most fields of medicine, endoscopy is ever evolving, making further opportunities for training increasingly important. There’s a real appetite for more training in EUS, especially as the procedure becomes more critical to endoscopic treatment, Steinberg said. This is especially noticeable as the ASGE training program for EUS is oversubscribed, he added.

New techniques and technologies are being developed all the time; to keep pace post fellowship training must accompany these advancements to continue to progress endoscopy.  Endoscopists and patients alike would benefit from more exposure to new techniques and advanced technologies.

 

 

 

 

 

 

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.