A/Prof Dan Worthley

Removal of the MBS colonoscopy  ‘exception’ item (32228) for clinically indicated colonoscopy not covered by other item numbers would reduce detection of some cancers and pre-cancerous lesions, according to Queensland gastroenterologists.

In a research letter to the MJA they say that findings from their private practice in Brisbane suggest that about one in five ‘exception’ colonoscopies (item 32228) detect and excise advanced pre-cancerous polyps.

The article by Associate Professor Dan Worthley and colleagues at GastroIntestinal Endoscopy, Brisbane, notes that MBS item 32228 is available for a given patient for colonoscopy not covered by the six indication-specific items introduced in November 2019.

“It has been suggested that item 32228, which allows clinician discretion once in a patient’s lifetime, could be removed from the schedule,” they write.

To evaluate how well the MBS items for colonoscopy are correlated with colorectal pathology, they reviewed the data for 4422 procedures conducted by ten experienced colonoscopists at their practice in 2020.

Overall the pathological yields for all ages were 2262 (51.2%) for adenoma; 401 (9.1%) for advanced adenoma; 1391 (31.5%) for sessile serrated lesions; 531 (12%) for advanced sessile serrated lesion 2913 (65.9%) for ‘adenoma or sessile serrated lesion’ and 858 (19.4%) for ‘advanced adenoma or advanced sessile serrated lesion.

They found that as expected, adenoma detection rates were generally greater for higher risk surveillance items (32223–32226).

The proportions of colonoscopies in patients aged 50 years or more in which adenomas were removed, however, were similar for items 32228 and 32222 (diagnostic colonoscopies; 50.8% v 56.9%).

Furthermore, the sessile serrated lesion detection rate for patients aged 50 years or more was higher for item 32228 than for item 32222 colonoscopies (38% v 27.3%; P = 0.001).

In colonoscopies for patients aged 50 years or more, the rates of detection of any advanced polyp were also similar for the two items (21.5% for item 32222 vs 20% for item 32228).

In the 258 procedures using the exception item 32228 in patients over 50, the pathological yield for adenoma or sessile serrated lesion was 175 (67.8%), compared to 2321of 3292 (70.5%) for item 32222 in the same age group.

They also noted that 15 colorectal cancers were identified, 14 by item 32222 colonoscopies and one by an item 32223 colonoscopy. The authors acknowledged that colonoscopy quality was a major focus of their practice and it was possible that the pathological yield for 32228 colonoscopies might be lower in practices with overall lower polyp detection rates.

Nevertheless they concluded that deleting item 32228 from the MBS “would reduce quality of care for people.”