Direct access colonoscopy delivers wins for patients and health system

Direct access colonoscopy (DAC) services cut waiting times and save patients money – at the expense of gastroenterologists’ incomes, a NSW study shows.

Operating since 2014, the DAC service in Newcastle allows National Bowel Cancer Screening Program participants with a positive faecal immunochemical test (FIT) and no contraindications to book a colonoscopy over the phone without attending a specialist outpatient appointment.

A retrospective analysis covering 601 patients who used the direct access pathway found they had a median waiting time of 49 days for colonoscopy, significantly shorter than the 79 day waiting time experienced by 289 patients using the previous specialist colonoscopy service.

The evaluation also showed that 15.1% of patients in the direct access group had their colonoscopy within the recommended timeframe of 30 days from GP referral, significantly better than in the ‘normal service’ group (4.5%) in which patients saw a gastroenterologist or colorectal surgeon before their colonoscopy.

Financial modelling based on real-world referral figures for the direct access service from January 2014 to June 2016 estimated that patients using the service saved $103 in travel costs and out-of-pocket specialist fees.

And by avoiding a specialist appointment, working patients gained $208 in productivity savings.

However the direct access model resulted in a modest loss in income for the gastroenterologists and colorectal surgeons who would have performed those consultations.

“This is unlikely to be significant to many specialists, as most work with significant waiting lists for appointments and therefore their income is maintained using the appointment that is not used for a FIT patient for another patient,” wrote co-authors led by Dr Louise Clarke, a colorectal surgical fellow from John Hunter Hospital in Newcastle.

There was a net neutral cost-benefit to the local health district, which gained income from state government to run the service, but lost the cost of employing a specialist nurse to triage phone bookings.

However, they found the service’s $129 per patient cost to Medicare represents “a low cost for a high value health intervention” and the value is in the freeing up of appointments can then be used for other indications.

“The DAC increases the availability of outpatient consultations to other patients, which is not a quantifiable economic benefit, it is likely to be an overall health benefit.”

“These dollars ($129 per patient) are buying more efficient delivery (shorter waiting times) of a high value health intervention (Bowel Cancer Screening) that has a significant financial benefit to the patients affected by the intervention.”

Speaking to the limbic, study co-author Dr Peter Pockney said the success of the direct access model has resulted in it being given the nod for the model to be rolled out statewide.

However he stressed the need for a tailored approach at local levels, such as with hard-to-reach populations in rural areas.

“Those are particularly scattered remote populations of Indigenous people where they don’t necessarily have phone connections and the non-English speaking migrant populations in our cities.

“To reach those people and provide the service that is required we are going to have to use different methods,” said Dr Pockney, a colorectal surgeon at John Hunter Hospital in Newcastle.

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