10.1055/a-1548-1631In an ideal world, a decision about what is in a patient’s best interests should not
be constrained by available expertise to manage the problem. This is particularly
the case for removing polyps from the colon, when there is always time to assess lesions
properly, consider the options and, if these are finally balanced, share the decision
with the patient.
We are very far from this ideal. There is unacceptable variation in polypectomy outcomes
[1] and rates of surgery for benign colorectal disease are increasing when they should
be in decline [2]. There is plenty of evidence showing that endoscopic removal of larger polyps is
effective, safer, and cheaper than surgery [3]
[4]
[5], so why is there so much variation in outcomes and why are so many patients having
operations for benign disease?
At the heart of the problem is lack of knowledge about what is possible and inadequate
expertise to remove large polyps, coupled with lack of clear pathways to access such
expertise. If it is impossible, or just difficult, to refer a patient elsewhere, the
easy option is to “give it a go,” or ask a local surgeon. Surgical expertise to remove
part of the colon is widespread. In contrast, the required endoscopic expertise often
is not available locally, and in some instances, it may be many hours away. Even when
it is not far away, there are no well-defined pathways making it at least as easy
to refer to endoscopy as to surgery.
Of course, there are other issues, such as complex and varied scoring systems for
polyps and differences of opinion about the optimal way to remove polyps. These factors
are compounded by a general lack of awareness about what is possible and lack of appreciation
of the impact on a patient when procedures are not done properly. There are cultural
influences and, in some jurisdictions, perverse financial incentives affecting clinical
decisions.
In some units it will be possible to ask a colleague to “pop in” to provide advice
about a polyp: What type of polyp is it? What is the risk of malignancy? Should I
leave it to someone else and if not, what technical approach should I take? If removing
the lesion is beyond the expertise of the endoscopist, the expert colleague may be
able deal with the lesion then, or at later date. Unfortunately, such expertise is
usually not at hand.
The endoscopy team from Southern Denmark have a potential solution for providing immediate
advice about polyp assessment and removal [6]. They report a feasibility study of real-time conference between an endoscopist
who needs advice and an expert able to provide that advice, but working in a remote
location. There remains a lot to do to get this right, but with rapidly improving
conferencing capability, there is no reason why remote support for endoscopic procedures
(the Zoom equivalent of a colleague “popping in”) should not be commonplace.
We can assume that the technical challenges the Danes encountered will be overcome.
This is an application of established, not new technology; it just needs tweaking.
The main obstacles to widespread adoption are lack of perceived need, availability
of expert advice, and robust funding mechanisms. There also will be medico-legal,
political, and cultural barriers to overcome. But it is possible, it is likely to
make a difference to decision-making, and it will have other beneficial effects, such
as training those who seek advice and potentially creating a library of cases for
more widespread learning. So how can endoscopy conferencing become mainstream?
First, we need more examples of endoscopy conferencing to tease out the technical
problems: to make the process so slick there is no technical barrier to seeking advice.
These studies need to determine not just the feasibility, but also the practicalities
of the service: who will be on call and for how long; how many endoscopy units it
is possible to cover; whether it is better to have several experts available, in case
one or more are busy; and whether there are clear pathways for patients who need to
go elsewhere for their polypectomy. We need further evidence of impact: what proportion
of calls were answered; what the outcome was of the advice; how many operations were
saved; how many patients were referred on; whether the polyps were removed safely
and completely. Critically, we need to know the costs, not just of providing the technology,
but most importantly the absolute and opportunity cost of expert advice.
The expert needs to be able to stop doing whatever they were doing to provide immediate
advice. This effectively precludes being “on call” during an endoscopy list, and possibly
other activities such as clinics and ward rounds. But we all need periods “in the
office” and these might be the best times to be available and, as such, they may not
be that expensive.
Without cost-effectiveness analyses it will be difficult to attract the resources
needed to develop endoscopy conferencing. Eventually, endoscopy units will have to
pay for advice. Payments are probably best insurance-based (licensed), rather than
payment per case, as the latter will be a barrier to seeking help. Use of the service
could be incentivized, for example, with CPD points for each call. On the other hand,
careful monitoring of polypectomy outcomes (particularly incomplete resection) and
surgical referrals will enable services to challenge those who don’t use the service.
The pandemic has accelerated the use of technology to improve communication. In health
care, both health professionals and patients have accepted and become more familiar
with remote interactions. There is an obvious role for it in supporting decision-making
in endoscopy that could expand well beyond decisions about polypectomy. We now need
cost-effectiveness studies to determine how to use it, and to justify implementing
it.
