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Utilization of the Double-Contrast Barium Enema in the Early Era of Screening CT Colonography

University of Wisconsin Medical School Madison, WI 53792-3252

 
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I read with interest the article by Dr. Ferrucci in the July 2006 issue of the AJR [1], in which he details the recent use of the double-contrast barium enema (DCBE) at his institution over a 4-year period. As might be expected, he found that DCBE was a low-yield procedure for detecting polyps, with a high false-positive rate and dwindling overall volume. Dr. Ferrucci, whom I generally regard as the "virtual godfather" of CT colonography (CTC) for his pivotal role in its development, makes a cogent argument that CTC should replace the DCBE on approved national colon screening guidelines. At this point in time, it seems almost unconscionable that validated CTC screening methods remain largely uncovered by national third-party payers, whereas the DCBE remains widely reimbursed yet largely ineffective [2, 3]. Indeed, the persistence of the anachronistic DCBE and absence of CTC on current screening guidelines seem to reflect the political nature of such decisions and the strange times in which we live.

At the University of Wisconsin Hospital and Clinics (UWHC), we have enjoyed third-party reimbursement for CTC screening since April 2004, as a result of previous validation of our methodology [4, 5]. Dr. Ferrucci's interesting work has motivated me to look at our utilization of the DCBE at UWHC. In many ways, this represents a glimpse into the potential future of national practice patterns—that is, once CTC screening ultimately gains universal coverage.

Over a 26-month interval beginning in April 2004 (when coverage for CTC screening was initiated at UWHC), we performed a total of 424 contrast enema examinations. Of these, only 33 studies (7.8%) were performed using the double-contrast technique. Of particular interest, only one of these studies (0.2%) was performed for the purpose of screening, in conjunction with flexible sigmoidoscopy in a 49-year-old man. The remaining DCBE studies were performed either in symptomatic patients (n = 18), of whom 10 were 30 years old or younger, or patients after having undergone incomplete optical colonoscopy (n = 14). In comparison, over the same period of time we performed well over 3,000 CTC examinations at UWHC. CTC was performed for incomplete optical colonoscopy in 173 patients, but most of the remaining examinations were performed for screening asymptomatic patients.

Overall, the performance results of CTC screening in this real-world setting have surpassed what we had expected on the basis of the results with this method from an earlier multicenter screening trial [5, 6]. The reason for DCBE instead of CTC evaluation for a minority (7.5%; 14/187) of patients with incomplete colonoscopy was primarily due to the fact that our local coverage determination (LCD) for Medicare lagged behind local managed care coverage and initially was too restrictive.

The immediate impact of third-party payer coverage for screening CTC on practice patterns at our institution is clear. In short, since April 2004, there has no longer been a viable indication to perform DCBE for examination of our patient population. I suspect the same fate ultimately awaits the DCBE at the national level once widespread coverage for CTC screening is in place. However, given the fact that most of the sites (12 of 15) involved in the ongoing ACRIN (American College of Radiology Imaging Network) Trial are utilizing a CTC system largely based on primary 2D polyp detection, which has not fared well in previous studies compared with a primary 3D approach, we may be in for a bumpy ride in the near term.

References

Top References

 

1. Ferrucci JT. Double-contrast barium enema: use in practice and implications for CT colonography. AJR2006; 187:170 -173[Abstract/Free Full Text]
2. Winawer SJ, Stewart ET, Zauber AG, et al. A comparison of colonoscopy and double-contrast barium enema for surveillance after polypectomy. N Engl J Med 2000;342 : 1766-1772[Abstract/Free Full Text]
3. Rockey DC, Paulsen EK, Niedzwiecki D, et al. Analysis of air contrast barium enema, computed tomographic colonography, and colonoscopy: prospective comparison. Lancet 2005;365 : 305-311[Medline]
4. Barnes E. HMO pays for screening virtual colonoscopy. Available at: www.auntminnie.com. Accessed June 4, 2004
5. Pickhardt PJ, Choi JR, Hwang I, et al. Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. N Engl J Med 2003;349 : 2191-2200[Abstract/Free Full Text]
6. Pickhardt PJ, Taylor AJ, Kim DH, Reichelderfer M, Gopal DV, Pfau PR. Screening for colorectal neoplasia with CT colonography: initial experience from the first year of coverage by third-party payers. Radiology 2006 Sep 18; [Epub ahead of print]

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Pickhardt, P. J. Search for Related Content PubMed PubMed Citation Articles by Pickhardt, P. J. Social Bookmarking                      What's this?