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Market forces and maturing technology have prompted increasing numbers of generalist physicians to perform complex gastrointestinal (GI) procedures that once were done only by gastroenterologists, a trend that is expected to continue. In fact, a new study shows that 41 percent of sigmoidoscopies (insertion of a lighted optical instrument to examine the mucous membrane lining of the colon) were performed by generalists in 1993. However, gastroenterologists were more apt than generalists to perform more complex GI procedures and procedures on sicker patients who had more serious indications for the procedures (for example, cancer as opposed to screening).
Forty percent of U.S. health care service areas are without a gastroenterologist. Thus, one benefit of more generalist physicians performing GI procedures is improved access, especially by patients in rural areas, to such procedures, notes Gregg S. Meyer, M.D., M.Sc., of the Agency for Healthcare Research and Quality. Dr. Meyer is Director of AHRQ's Center for Quality Measurement and Improvement.
With support from the Robert Wood Johnson Foundation (Generalist Physician Faculty Scholar Award to Dr. Meyer), the researchers analyzed a random 5 percent sample of Medicare beneficiaries (1,369,179) listed in the 1993 Medicare National Claims History File. They identified claims for various types of gastrointestinal endoscopies (insertion of a lighted rigid or flexible tube to visualize the esophagus, stomach, or colon), as well as the specialty of the physician who performed the procedure.
Overall, 35 percent of rigid sigmoidoscopies, 43 percent of flexible sigmoidoscopies, 8 percent of colonoscopies, and 9 percent of esophagogastroduodenoscopies (EGDs) were performed by generalists. But for all four procedures, specialists were four times more likely (odds ratio, OR 4 to 4.4) than generalists to have performed a procedure for biopsy, excision of polyps (polypectomy), or treatment as for diagnostic purposes alone. Patients who received EGDs or sigmoidoscopies from specialists were sicker (more apt to be hospitalized or die within the year) than patients who received these procedures from generalists. Generalists were more likely than specialists to provide all four procedures to patients residing in rural areas and in areas other than the Northeast. The study did not examine differences in outcomes of patients treated by generalists and specialists.
See "Differences between generalists and specialists in characteristics of patients receiving gastrointestinal procedures," by Dr. Meyer, Eme Y. Cheng, M.B.A., M.P.H., M.S., and Jeffrey Elting, M.D., M.P.H., in the March 2000 Journal of General Internal Medicine 15, pp. 188-194.
Reprints (AHRQ Publication No. 00-R026) are available from the AHRQ Publications Clearinghouse.
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