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Commentary |
1 Department of Radiology, Wake Forest University School of Medicine, Medical Center Blvd., Winston-Salem, NC 27157.
Received May 13, 2008; accepted after revision July 11, 2008.
Address correspondence to D. J. DiSantis
(ddisanti{at}wfubmc.edu).
OBJECTIVE. We used Medicare data to quantify trends in gastrointestinal fluoroscopy volume.
CONCLUSION. Although overall gastrointestinal fluoroscopy procedures continue to decline, the fall is not uniform. Nationwide Medicare data from 2001 to 2006 reveal that the volumes of barium enema and upper gastrointestinal studies suffered a steep drop, but the numbers of esophagograms and swallowing studies actually increased. These numbers highlight the challenge facing gastrointestinal fluoroscopy training and offer guidance for modifying curricula.
Keywords: fluoroscopy • gastrointestinal tract • practice of radiology
...the results of the survey indicate that the present downward trend in the numbers of gastrointestinal procedures will almost certainly persist...as indicated by their virtually straight-line decline... [1]....one can imagine a [worst case] scenario in which the steady decline in the volume of upper gastrointestinal series continues unabated until the examination is no longer performed [2].
Not only will there be reduced clinical experience to perform [double-contrast barium enemas] in the future, but resident trainees will have neither the volume nor the teachers available to help them master the needed skills.... If our poor experience with the double-contrast barium enema applies to other practices, its era is over [3].
...we are rather pessimistic about the future of barium radiology.... Radiology residents must perform many barium examinations to acquire the skills to become effective in this area. Practicing radiologists...will lose their skills and interpretive expertise as they perform fewer of these studies [4].
These excerpts come from the "grand old men" of gastrointestinal radiology, all luminaries in the field. When you hear those quotations, it's difficult to be optimistic about the prospects of gastrointestinal radiology, or at least the future of fluoroscopic contrast studies.
Yes, I've seen the terrific images from CT and MR enterography and rejoiced at the success of the recent ACRIN (American College of Radiology Imaging Network) CT colonography trial. I realize that cross-sectional imaging can see beyond the lumen. I understand that endoscopy finds more polyps than we can, and that endoscopic ultrasound can assess the bowel wall and more. But is it already time to toss out the cups and bags of barium and to let the bottles of Gastrografin (meglumine diatrizoate, Bracco) expire unused? Will barium go the way of oral cholecystograms and lung scans? Should we cut the training time in gastrointestinal radiology if residents really won't need to know much when they go into the real world? Should we change the whole way we teach gastrointestinal radiology to fit this new reality?
I work in an academic practice at a teaching hospital. After being here about 6 months, I wanted to get an idea of the trends in gastrointestinal studies. In 8 short years—from 1998 to 2006—the number of upper gastrointestinal (UGI) studies plummeted by 47%, and barium enemas plunged a similar 46%. Nearly half of our teaching volume vanished in less than a decade.
Twenty years ago, three Wake Forest radiologists, David Gelfand, David Ott, and Michael Chen, surveyed mostly academic practices and a few private practices about their gastrointestinal radiology volumes. They docu mented a steady decline since 1975, and found no real difference between academic and private practice responses [1].
My purely anecdotal observation from recent work in a busy private practice is that radiologists in a general hospital still do a fair number of barium studies, even though the days of 20 UGI studies and 20 barium enemas are long gone. I took a snapshot of the gastrointestinal fluoroscopy load at a bustling 343-bed general hospital (Hamot Medical Center, Erie, PA) by choosing a random month (October 2007) and tallying the procedures.
Here is the breakdown (Table 1): A respectable number of swallowing studies and esophagograms, a middling amount of upper gastrointestinal studies and small bowel work, and a few barium enema examinations. The total was 222 studies for the month. Assuming that very few of these were done on the weekend, this comes out to about 10 studies per weekday.
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That prompted me to seek a bigger picture of the kind and number of gastrointestinal fluoroscopy studies we actually are doing. Mythreyi Bhargavan, director of research at the American College of Radiology, was kind enough to share the latest nationwide numbers with me.
The Medicare procedure volume for non–managed care enrollees provides the baseline value, then add another 0.2 for the Medicare patients in managed care plans. Because Medicare costs consistently are one third of health care expenditures, we assume that imaging of Medicare patients is likewise one third of total imaging. So nationwide, total imaging utilization is about 1.2 x 3, or 3.6 times the Medicare utilization. (You actually multiply by 3.5 to account for less imaging in managed care plans.) Data from independent sources (e.g., IMV Market Benchmark Reports) have confirmed that the 3.5 multi-plier comes quite close to survey-based estimates for procedure volume—an accurate snapshot of gastrointestinal fluoroscopy in current clinical practice (Mythreyi Bhargavan, personal communication).
It should come as no surprise that over the survey period, from 2001 to 2006, the nationwide total number of gastrointestinal fluoroscopic examinations decreased. In 2001, we performed 5.4 million studies. That total fell by 22%, to 4.2 million, in 2006. Now take a closer look at the actual Medicare numbers. (Note that the data include both barium and water-soluble contrast studies.)
First the bad news: Optical and virtual colonoscopy predictably have taken their toll, with barium enemas plummeting 56% (from 354,458 to 156,330 examinations) over just these few years. The number of single-contrast enemas decreased 52%, and double-contrast examinations fell 60%.
The tally is slightly less grim for UGI studies. From 2001 to 2006, the nationwide volume fell by 37% (from 533,650 to 337,882 examinations). These numbers include both UGI procedures alone and those done with small bowel studies. The barium small bowel examination almost held its own, with a dip of just 7% (from 117,790 to 109,039 examinations).
Above the diaphragm, things are less glum. The number of barium esophagograms actually rose by 8% between 2001 and 2006 (from 202,394 to 219,547 examinations). And our colleagues in speech pathology not only still welcome our services, they use them more than ever. Barium swallowing studies have climbed 12% (from 326,726 to 366,446 examinations) over the 6-year time span.
So what do these numbers mean to the radiologist working in the trenches? For a while at least, radiologists still need to know enough about barium studies to do them on a daily basis. Take the anecdotal example of my 10 cases a day at a busy general hospital. It's reasonable to assume that the situation is similar in many other practices. Though certainly not a full day or maybe even a full morning's worth of relative value units (RVUs), it nevertheless remains a slot that must be filled on the work schedule.
We'll not likely be doing what we learned in residencies of the 1970s and 1980s, and maybe even the 1990s. Polyp hunts on double-contrast barium enema examinations already are infrequent and will become rarer. With the success of CT colonography and optical colonoscopy, it's tough to grouse too loudly about that. And I suspect that few radiologists will mourn the loss of such a physician-time-intensive procedure that Medicare believes is worth $45.52. With that economic disincentive, it just makes more sense to stay parked at your workstation.
Improved medications for ulcer disease plus the perceived primacy of endoscopy have combined to slash the number of UGI studies. Unless cost containment becomes more than just lip service, a slow downward spiral seems likely. Because small bowel studies are every resident's nightmare at Board examination time, they'll probably rejoice to see them fade away in favor of CT and MR enterography. And with capsule endoscopy and push enteroscopy in their ascendancy, it is tough to predict whether any room will be left for barium in the small bowel. But for right now, radiologists are still doing barium small bowel examinations, so we still need to know how to do them.
Some will be surprised that any barium business is flourishing, but esophagography and swallowing studies remain strong. Both take advantage of the ability of barium to depict both structure and function, an attribute not shared by any single clinical test. None of these examinations should be relegated to "what-a-bother" orphan status because among barium studies they are the new champs. As the "Baby Boomers" age into the dysphagia years, the newly trained radiologists will be doing plenty of these exams in practice. We who are training them should recognize that reality and reflect it in our curricula.
From the current Medicare data, it should be obvious that our trainees need skills in gastrointestinal fluoroscopy because these examinations are performed in radiology departments every day. Equally important are the principles of lesion analysis that bridge classical fluoroscopy and cross-sectional imaging. Thick folds are thick folds. A circumferential colon mass has the same differential whether found on CT or barium enema. Cine imaging in MR enterography uses peristalsis to localize small bowel obstruction. And all the same pelvic lines and angles could shift from the "flouro potty" to the MR scanner for defecography.
Simply analyzing the numbers can't provide a solution for the very real problems raised by the changing face of gastrointestinal fluoroscopy. Straightforward cases—like duodenal ulcers and colon tumors—in otherwise healthy patients are a rarity. Deciphering complex postsurgical anatomy in the very sick has become the new bread-and-butter study. The number of capable and interested teachers dwindles. Residents increasingly view barium as strictly old school. And fluoroscopy is still a loser in the RVU chase.
Acknowledging these challenges while taking into account the current case mix and year-to-year trends is a starting point to look for answers. Technology can help. For example, the oral Board examination already incorporates "real-time" fluoroscopy cases in its computer-based gastrointestinal radiology testing. A how-to "manual" for fluoroscopic exams using AVI- or MPG-type formats could be available online, not only preserving the techniques of master fluoroscopists, but also depicting lesions as they appear "live" on the fluoro screen. It would be particularly apt for teaching motion-focused exams such as swallowing studies. A casual search turns up multiple fluoroscopic studies already on YouTube. One barium swallow has nearly 15,000 hits (though the sword swallower fluoro has over 22,000). "Fundamentals of Fluoroscopy" won't be a YouTube Most Viewed, but I'd predict a big spike in hits just before Louisville.
Because incoming radiology residents arrive already steeped in cross-sectional imaging and instantly are inundated with more, perhaps GI fluoroscopy training no longer should be one of the early rotations. With the looming prospect of the Board examinations and a job, later-stage residents would be motivated to take the training seriously, and fluoroscopy could shed the stigma of unglamorous low-level rotation for newbies. Lumen-oriented imaging like CT colonography and MR enterography might fit nicely here.
Like the gastrointestinal radiology sages whose quotations we started with, we must acknowledge that barium won't ever regain the pinnacle position it once held in evaluation of the gastrointestinal tract. But the nationwide numbers, a "spot view" of gastrointestinal fluoroscopy in modern radiology practice, confirm that for now at least, barium still has a role. Admittedly, that role has changed and narrowed, but it isn't yet time to say, "Will the last one out of the fluoro suite please turn on the lights?"
Acknowledgments
I extend my sincere thanks to Mythreyi Bhargavan and Joseph Nedresky for their help in gathering the data presented here.
References
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