Utilization of sigmoidoscopy by family physicians in Canada Stuart R. Glaser, MD, CCFP Objective: To determine the extent to which sigmoidoscopy is used as an investigative tool by family physicians in Canada. Design: Retrospective study of data from provincial and territorial health agencies for the fis- cal year 1989. Setting: Canada. Participants: All family physicians. Main outcome measures: Number of physicians in each province and territory who per- formed sigmoidoscopy (flexible and rigid), type of physician (generalist or specialist), num- ber of procedures performed, fee schedule and number of physicians billing medicare in each province and territory. Results: During the study period 3849 (15.1%) of all family physicians performed rigid sig- moidoscopy; the proportion varied from 3.4% (in Quebec) to 40.0% (in the Northwest Terri- tories). A total of 43 914 rigid sigmoidoscopies were performed by family physicians, representing 23% of all such procedures. Flexible sigmoidoscopy was performed by 381 (1.5%) of all family physicians; the proportion varied from 0.4% (in Quebec) to 6.8% (in Prince Edward Island). A total of 5361 flexible sigmoidoscopies were performed, represent- ing 6.0% of all such procedures. Conclusion: The proportion of Canadian family physicians who are using sigmoidoscopy, rigid or flexible, as a diagnostic tool is low. Objectif: Determiner dans quelle mesure les medecins de famille du Canada utilisent la sig- moidoscopie comme technique d'examen. Conception: Etude retrospective de donnees provenant d'organismes provinciaux et territo- riaux de sante pour l'exercice 1989. Contexte : Canada. Participants : Tous les medecins de famille. Principales mesures des resultats: Nombre de medecins de chaque province et terri- toire qui ont procede a une sigmo-idoscopie (flexible et rigide), type de medecin (genera- liste ou specialiste), nombre d'examens effectues, grille des honoraires et nombre de medecins qui soumettent des factures au regime d'assurance-maladie de chaque province et territoire. Resultats: Au cours de la periode d'etude, 3 849 m6decins de famille (15,1 %) ont procede a une sigmofdoscopie rigide et leur pourcentage a varie de 3,4 % (au Quebec) a 40,0 % (dans les Territoires du Nord-Ouest). Au total, les medecins de famille ont procede a 43 914 sig- moidoscopies rigides, chiffre qui represente 23 % de tous les examens de cette nature. Trois cent quatre-vingt-un medecins de famille (1,5 %) ont procede a une sigmoidoscopie flexible, et leur pourcentage a varie de 0,4 % (au Quebec) a 6,8 % (dans l'Ile-du-Prince-Edouard). Au total, on a procede a 5 361 sigmofdoscopies flexibles, chiffre qui represente 6,0 % du total de ces examens. Conclusion: Le pourcentage des medecins de famille du Canada qui utilisent la sigmofdos- copie rigide ou flexible comme technique de diagnostic est faible. Dr. Glaser is an assistant professor offamily medicine, McGill University, and is in the Department of Family Medicine, St. Mary's Hospital, Montreal, Que. Reprint requests to: Dr. Stuart R. Glaser, 385-1255 Laird Blvd., Mount Royal, PQ H3P 2T1 CAN MED ASSOC J 1994; 150 (3) 367 x- For prescribing information see page 407
Transcript
Utilization of sigmoidoscopy by family physiciansin Canada
Stuart R. Glaser, MD, CCFP
Objective: To determine the extent to which sigmoidoscopy is used as an investigative toolby family physicians in Canada.Design: Retrospective study of data from provincial and territorial health agencies for the fis-cal year 1989.Setting: Canada.Participants: All family physicians.Main outcome measures: Number of physicians in each province and territory who per-formed sigmoidoscopy (flexible and rigid), type of physician (generalist or specialist), num-ber of procedures performed, fee schedule and number of physicians billing medicare in eachprovince and territory.Results: During the study period 3849 (15.1%) of all family physicians performed rigid sig-moidoscopy; the proportion varied from 3.4% (in Quebec) to 40.0% (in the Northwest Terri-tories). A total of 43 914 rigid sigmoidoscopies were performed by family physicians,representing 23% of all such procedures. Flexible sigmoidoscopy was performed by 381(1.5%) of all family physicians; the proportion varied from 0.4% (in Quebec) to 6.8% (inPrince Edward Island). A total of 5361 flexible sigmoidoscopies were performed, represent-ing 6.0% of all such procedures.Conclusion: The proportion of Canadian family physicians who are using sigmoidoscopy,rigid or flexible, as a diagnostic tool is low.
Objectif: Determiner dans quelle mesure les medecins de famille du Canada utilisent la sig-moidoscopie comme technique d'examen.Conception: Etude retrospective de donnees provenant d'organismes provinciaux et territo-riaux de sante pour l'exercice 1989.Contexte : Canada.Participants : Tous les medecins de famille.Principales mesures des resultats: Nombre de medecins de chaque province et terri-toire qui ont procede a une sigmo-idoscopie (flexible et rigide), type de medecin (genera-liste ou specialiste), nombre d'examens effectues, grille des honoraires et nombre demedecins qui soumettent des factures au regime d'assurance-maladie de chaque provinceet territoire.Resultats: Au cours de la periode d'etude, 3 849 m6decins de famille (15,1 %) ont procedea une sigmofdoscopie rigide et leur pourcentage a varie de 3,4 % (au Quebec) a 40,0 % (dansles Territoires du Nord-Ouest). Au total, les medecins de famille ont procede a 43 914 sig-moidoscopies rigides, chiffre qui represente 23 % de tous les examens de cette nature. Troiscent quatre-vingt-un medecins de famille (1,5 %) ont procede a une sigmoidoscopie flexible,et leur pourcentage a varie de 0,4 % (au Quebec) a 6,8 % (dans l'Ile-du-Prince-Edouard). Autotal, on a procede a 5 361 sigmofdoscopies flexibles, chiffre qui represente 6,0 % du total deces examens.Conclusion: Le pourcentage des medecins de famille du Canada qui utilisent la sigmofdos-copie rigide ou flexible comme technique de diagnostic est faible.
Dr. Glaser is an assistant professor offamily medicine, McGill University, and is in the Department of Family Medicine, St. Mary's Hospital,Montreal, Que.
Reprint requests to: Dr. Stuart R. Glaser, 385-1255 Laird Blvd., Mount Royal, PQ H3P 2T1
CAN MED ASSOC J 1994; 150 (3) 367x- For prescribing information see page 407
C olon cancer accounts for roughly 15% of allcases of cancer in Canada. It is the second lead-ing cause of death from cancer. The survival rate
is lowest among patients who present with advanced dis-ease. The estimated 10-year survival rate is 74% for lo-calized disease (Dukes' class A and B), 36% for cancerwith regional spread (Dukes' class C) and only 5% fordisseminated disease (Dukes' class D).' Various exami-nations are used to screen for colorectal cancer, includ-ing digital rectal examination, testing for occult bloodin stool samples, rigid and flexible sigmoidoscopy,colonoscopy and barium enema. It appears that none isideal, and we are still waiting for results from random-ized clinical trials.
Sigmoidoscopy allows for the direct examinationof the anus, rectum and distal colon. It is useful for di-agnosing a variety of disorders such as inflammatorybowel disease and for detecting polyps and cancer.Whether sigmoidoscopy is useful as a screening toolfor colorectal cancer is still under considerable debate.2Nevertheless, most experts would agree that in sympto-matic patients it is an important tool, since the rectumand sigmoid colon are not clearly seen through bariumenema examination.34 Colonoscopy, sometimes re-quired later in the investigation, is not easily performedby the family physician. Flexible sigmoidoscopy hasbeen shown to be superior to rigid sigmoidoscopy be-cause of not only better patient acceptance but alsogreater diagnostic yield owing to deeper penetration ofthe bowel.5
Only two reported studies have described the ex-perience of Canadian family physicians in using sigmoi-doscopy. In 1989 Grand'Maison and associates6 reportedthe results of 1046 endoscopic examinations done in afamily practice unit in Quebec from July 1982 to June
1986. Of the examinations 27.4% were done for screen-ing purposes. A flexible sigmoidoscope was used in 77%of the procedures, and more than 12% of the patients hadat least one polypoid lesion detected. Also in 1989 I re-ported my 10-year experience, from 1977 to 1986, withrigid sigmoidoscopy in private practice. Of 961 exami-nations performed 56.3% were for screening purposes.At least one polypoid lesion was detected in 12.9% ofthe cases; two were carcinoma in situ.
There have been no surveys of the rate of utilizationof sigmoidoscopy among Canadian family physicians;however, there have been several surveys in the UnitedStates. In 1984 the American Cancer Society,8 in a tele-phone survey of 1035 family physicians, found the fol-lowing: 71% of family physicians performed sig-moidoscopy, 39% had been trained or able to performflexible sigmoidoscopy, 24% had a flexible sigmoido-scope in their offices, and 35% were screening asympto-matic patients. In 1986 Buckley, Smith and Katner9surveyed 1057 randomly selected members of the Amer-ican Academy of Family Physicians. They found thatalmost half performed either rigid or flexible sigmoi-doscopy and that about one third did flexible sigmoi-doscopy. Those doing rigid sigmoidoscopy reportedperforming 4.8 procedures per month on average, ascompared with 7.9 procedures per month on average re-ported by those doing flexible sigmoidoscopy. In 1989the American Cancer Society'0 repeated its survey andfound that use of flexible sigmoidoscopy had doubled:71% of the family physicians performing sigmoidoscopywere using a flexible sigmoidoscope, 41% owned a flex-ible sigmoidoscope in their offices, and 49% werescreening asymptomatic patients.
The purpose of this study was to determine the ex-tent to which sigmoidoscopy is used as an investigative
No. (ana %s) ot FPsMean no. of
Provnnfl Performing No. of proceduresterritory Total proceduce procedures per FP Basi fee, $
Y"NA ant vallaNle.tine promnce or territor pays an additonal fee if a biopsy Wpedmen is obned ora polyp is reroved, or both.
368 CAN MED ASSOC J 1994; 150 (3) LE ]er FEVRIER 1994
tool in family practices across Canada. Because of ournational health care policy it is possible to retrieve theprecise number of examinations performed over a givenperiod, to know who performed these services and to ob-tain the fee schedule.
Methods
Health care costs in Canada are covered by provin-cially or territorially managed and funded agencies.Physicians are paid for services they provide by billingthese agencies, using a schedule of codes for exami-nations and procedures. These agencies keep statisticson their costs and the billing practices of each physician.The following information was requested in writingfrom each provincial and territorial agency: the numberof physicians who perform sigmoidoscopy (flexible andrigid), the number of procedures (flexible and rigid)billed over 1 year, the type of physician performing theprocedure (generalist or specialist), the fee schedule andthe number of physicians billing medicare in eachprovince and territory. No data were available on rigidsigmoidoscopy from the Yukon Health and Human Re-sources. All data collected were for the fiscal year 1989.
Billing codes are unrelated to diagnosis or indica-tions. Therefore, it was not possible to distinguish be-tween procedures for cancer screening in asymptomaticpatients and those for diagnostic purposes in sympto-matic patients. As well, it was not possible to determinefrom the data the length of the flexible sigmoidoscopeused.
Results
Rigid sigmoidoscopy
A total of 189 655 rigid sigmoidoscopies were per-
formed by all physicians in Canada in 1989: 43 914(23.2%) by family physicians and 145 741 (76.8%) byspecialists. Of the 25 556 family physicians in Canada3849 (15.1%) performed rigid sigmoidoscopy; the pro-portion varied from 3.4% (in Quebec) to 40.0% (in theNorthwest Territories) (Table 1). The mean number ofprocedures per family physician who performed thistype of examination was 11.4 per year.
The fee schedule for rigid sigmoidoscopy variedfrom $15 (in Quebec) to $52 (in the Northwest Territo-ries); the mean fee was $28.85.
Flexible sigmoidoscopy
A total of 93 962 flexible sigmoidoscopies wereperformed by all physicians in Canada in 1989: 5361(5.7%) by family physicians and 88 601 (94.3%) by spe-cialists. Of all the family physicians 381 (1.5%) per-formed flexible sigmoidoscopy; the proportion variedfrom 0.4% (in Quebec) to 6.8% (in Prince Edward Is-land) (Table 2). The mean number of procedures perfamily physician who performed this type of exami-nation was 14.1 per year.
The fee schedule for flexible sigmoidoscopy variedfrom $35 (in Quebec) to $85.10 (in the Yukon Territory);the mean fee was $58.13.
Discussion
Approximately 15% of family physicians in Canadaperform rigid sigmoidoscopy, but only 1.5% performflexible sigmoidoscopy. These physicians perform 23%and 6% of all rigid and flexible sigmoidoscopies respec-tively in Canada. The data confirm the hypothesis thatonly a small proportion of family physicians in Canadause sigmoidoscopy as a diagnostic tool. Clearly, special-ists carry the main burden of performing this procedure.
No. (and %) of FPsMean no. of
Provincel Performing No. of proceduresterritory Total procedure procedures per FP Basic fee,
Canada 25556 381 (1.5) -5361 14.1 58.13lTb province pays an addiional fee if a biopsy specimen i obtained qr a polyp Is removed, pr both.
CAN MED ASSOC J 1994; 150 (3) 369FEBRUARY 1, 1994
One can speculate on the many reasons for the lowutilization rate among family physicians. Studies haveshown that physicians cite a variety of reasons for notperforming sigmoidoscopy, including the low probabil-ity of positive results, patient discomfort, lack of timeand training, and high cost of the equipment.8"' Many ofthese excuses reflect a lack of motivation on the part ofthe physician. In some instances screening may be a lowpriority in a busy general practice. Some physicians mayquestion the value of screening asymptomatic patientsfor colorectal cancer with sigmoidoscopy. Whereas theAmerican Cancer Society clearly endorses the conceptof screening," the Canadian Task Force on the PeriodicHealth Examination does not.'2'l3
Moreover, various patient-related factors can in-fluence the utilization of sigmoidoscopy. It is not aprocedure that patients prefer, because it is uncom-fortable and embarrassing.'4 In addition, many pa-tients are simply ignorant of the proposed benefits ofoncologic prophylaxis and give a variety of excuses toavoid the test: "I'm healthy and see no use in thetest,"1 "I'm too old for it to be of any use" or "I see adoctor once a year, that's enough."'5 Studies haveshown that patients accept flexible sigmoidoscopymore readily than rigid sigmoidoscopy.'6" Patients re-port of less discomfort and, therefore, are more apt tocomply with re-examination.'8
Other factors, such as accessibility to medical spe-cialists, no doubt also affect the proportion of phys-icians using sigmoidoscopy. For example, almost half ofthe family physicians in the Northwest Territoriesperform this procedure because specialists are scarce.One can also speculate whether there are inconsisten-cies in the level of training that residents receive in sig-moidoscopy.
Finally, economic factors may be responsible forthe low utilization rate. The cost of a rigid sigmoido-scope, fibreoptic light source, suction apparatus and asupply of disposable scopes is less than $1000. A flexi-ble sigmoidoscope can cost from $5000 to $10 000. In1989 the mean fee in Canada was $28.85 for a rigid sig-moidoscopy and $58.13 for a flexible sigmoidoscopy. Inpractical terms, this fee schedule would allow a phys-ician to recoup his investment in equipment after 20 to30 examinations with a rigid sigmoidoscope and afterapproximately 100 with a flexible sigmoidoscope. At themean utilization rate of almost 12 examinations per yearfor rigid sigmoidoscopy it would take about 3 years torecoup the cost of equipment. At the mean utilizationrate of 14 examinations per year for flexible sigmoi-doscopy it would take at least 6 years.
It was not within the scope or purpose of this studyto compare the Canadian and US experiences. However,recent surveys in the United States have shown that71% of family physicians perform sigmoidoscopy andthat 41% have their own flexible sigmoidoscope. Incontrast, I believe that these statistics underscore the
low proportion of family physicians using this proce-dure in Canada.
Conclusion
Most Canadian family physicians do not performsigmoidoscopy, rigid or flexible. The findings of thisstudy clearly raise several issues. Have there been conse-quences on the health of Canadians as a result of the lowutilization rates? How are patients being managed whenthey present with symptoms in the lower gastrointestinaltract? Do the 85% of family physicians not performingsigmoidoscopy refer their patients to specialists for en-doscopy or do they order only a barium enema? Arethere enough specialists in Canada to carry the burden ofdoing sigmoidoscopy? Is this yet another skill that is be-ing lost by family physicians to their specialist col-leagues?
What can be done to motivate family physicians inCanada to do sigmoidoscopy? Education in the medicalschools and postgraduate training may help. In addition,provincial and territorial medical associations may haveto take a closer look at this problem and adjust feeschedules to be more in line with the realities of thecommitment expected of practitioners in treating pa-tients properly.
I thank Dr. Renaldo N. Battista, Montreal General Hospital,for his helpful suggestions in preparing the manuscript.
The study was funded by St. Mary's Hospital ResearchFoundation.
References
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4. Sherlock P, Winawer SJ: The role of early diagnosis in control-ling large bowel cancer. Cancer 1977; 40: 2609-2615
5. Winnan G, Berci G, Panish J et al: Superiority of the flexible tothe rigid sigmoidoscope in routine proctosigmoidoscopy. N Enzgl JMed 1980; 302: 1011-1012
6. Grand'Maison P, Belle-Isle J, Guilmette P et al: Colon and rec-tum rigid and flexible sigmoidoscopy. Can Fam Physician 1989;35: 2249-2253
7. Glaser SR: Sigmoidoscopy in general practice. Ibid: 2243-22468. Holleb AI: Survey of physicians' attitudes and practice in early
cancer detection. CA CancerJ Clin 1985; 35: 197-2139. Buckley RL, Smith MV, Katner HP: Use of rigid and flexible sig-
moidoscopy by family physicians in the United States. J FamPract 1988; 27: 197-200
10. Holleb AI: 1989 Survey of physicians' attitudes and practice inearly cancer detection. CA Cancer J Clin 1990; 40: 77-101
11. Eddy D: ACS report on the cancer-related health check-up. CACancer J Clin 1980; 30: 193-240
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