New single-use duodenoscopes could have higher financial and environmental costs than the reusable standbys at high-volume endoscopy centers, according to two studies presented at the 2021 virtual Digestive Disease Week. A third study found that improving provider awareness of the costs of the equipment they use is not easy.
In 2020, the FDA recommended that gastroenterology practices switch from entirely reusable to partly or wholly disposable scopes for endoscopic retrograde cholangiopancreatography (ERCP) to guard against infections. Now, manufacturers offer scopes with disposable end caps, fully disposable models, and even one that has a disposable elevator mechanism.
The studies presented at DDW start to answer some of the myriad questions facing providers and health care systems about the newer scopes. “Disruptive technologies always make physicians and providers stop and think about the best way forward,” said Vivek Kaul, MD, the Segal-Watson Professor of Medicine in the Division of Gastroenterology and Hepatology at the University of Rochester Medical Center, in New York, who was not involved in the studies.
Many unknowns remain—the pros and cons of disposable scopes for low-volume ERCP centers, the effectiveness of scopes with disposable end caps in reducing infections, the logistics involved in storing all these disposable scopes, and more, said Jennifer Higa, MD, who also was not involved in the studies. “Overall, what we’re needing very desperately is more information on financial and logistical viability for implementing these technologies and the environmental impacts,” said Dr. Higa, an assistant professor of medicine in gastroenterology at Fox Chase Cancer Center at Temple Health, in Philadelphia.
A Financial Comparison
Switching to entirely disposable duodenoscopes could be economically costly. At the University of California, Irvine (UCI), researchers compared the costs of ERCP performed with reusable versus single-use duodenoscopes at their high-volume academic center (presentation 135).
In the analysis, UCI clinical research fellow Anastasia Chahine, MD, calculated the cost per procedure with a reusable duodenoscope by looking at scope price and outlays for repairs and reprocessing over a two-year period. The researchers then compared that cost with the price of single-use duodenoscopes.
In total, the cost of one ERCP procedure using a reusable duodenoscope was $228.83. The quoted price of a single-use duodenoscope, $1,950, was eight times more expensive.
One of the biggest limitations of the study is that it does not include the cost of duodenoscope-related infections. “That’s where the money adds up quickly,” Dr. Higa said. A 2017 modeling study found the cost of one carbapenem-resistant Enterobacterales infection ranged from $22,484 to $66,031 for hospitals, $10,440 to $31,621 for third-party payors, and $37,778 to $83,512 for society (Clin Microbiol Infect 2017;23[1]:48.e9-48.e16).
How much of the cost of the disposable scopes will be covered by insurance is an open question that could make the switch to the newer devices more or less feasible for centers, said Jason Samarasena, MD, a gastroenterologist and associate professor of medicine at UCI and a co-investigator on the study.
In addition, Dr. Kaul said the results of this study are specific to a high-volume center, and the economic realities could be different for a center that only does a few ERCPs per year.
Environmental Impact
Disposable duodenoscopes, by definition, can only be used once and don’t require the harmful chemicals involved in reprocessing, but they still carry real environmental trade-offs.
In a preliminary life cycle analysis (LCA), Lyndon Hernandez, MD, a gastroenterologist with GI Associates in Kenosha, Wis., worked with LCA expert Oliver Jolliet, PhD, a professor of environmental health sciences at the University of Michigan School of Public Health, in Ann Arbor, and a group of Dr. Jolliet’s students to evaluate the environmental impact of each major type of duodenoscope.
In the study (presentation 479), the researchers estimated the carbon dioxide (CO2) emissions from the manufacturing, running, cleaning and disinfecting, transporting and disposing of a reusable scope and a duodenoscope with a disposable end cap. They compared the results with the estimated emissions associated with the manufacturing, use and disposal of a single-use duodenoscope. They also included the carbon emissions of the number of ICU stays associated with a baseline infection rate of 0.09% for the reusable duodenoscope, and theoretical infection rates of 0% for the single-use option and 0.0045% and 0.0022% for duodenoscopes with disposable end caps.
The model showed that using one completely disposable duodenoscope for one ERCP released 29.3 kg of CO2 (Figure). This amount is 20 times more than that released if a reusable duodenoscope (1.55 kg) or a duodenoscope with a disposable end cap (1.37 kg) is used. Nearly all of the emissions associated with a disposable scope (96%) are generated in the production of the device, including its largely nonrecyclable electronic parts, Dr. Jolliet said.
These data are intended as a starting place to be followed up with a full life cycle analysis. Still, Dr. Jolliet said he thinks the general findings are applicable because the emissions from manufacturing one scope are so substantial. “This is a good starting point to raise the conversation about what impact single-use duodenoscopes and other disposable devices will have on the environment and the planet long term,” Dr. Kaul said.
Knowledge of Pricing
To address a lack of awareness of many practicing gastroenterology providers at academic medical centers about about the cost of the equipment they use every day, researchers at the University of North Carolina at Chapel Hill School of Medicine tried a series of quality improvement interventions to boost price knowledge.
Reasoning that the increased knowledge would lead to better choices of devices that providers use during endoscopic cases, Lisa Gangarosa, MD, a professor of medicine in the Division of Gastroenterology and Hepatology, and gastroenterology fellow Cary Cotton, MD, MPH, selected 20 devices and asked 38 GI fellows, attending physicians and endoscopy staff members to guess the cost the university system paid for each (abstract Sa104).
At two locations, the researchers posted pictures of the devices with their prices for 60 days. At the third site, they had hospital staff tell providers the cost of a device every time they asked for it over a 60-day period. Dr. Gangarosa then resurveyed the study participants.
“Unfortunately, it was not a huge improvement,” she said. Nineteen people completed the follow-up questionnaire, due largely to pandemic-related delays and staff relocations. Participants guessed within 15% of the actual cost for 2.4 of the 20 devices at baseline and 4.6 devices at follow-up (P=0.01). They found that participants were within 30% of the actual cost for a mean of 3.8 devices at baseline and 6.1 devices at follow-up (P=0.04). The group that improved the most was endoscopy staff, Dr. Gangarosa said.
Thinking about ways to improve the knowledge and awareness of the cost of medical care is a step in the right direction, Dr. Kaul said. “I think the era of cost-conscious, fiscally responsible medicine is upon us.”
—Jillian Mock
Drs. Gangarosa, Hernandez, Chahine, Higa and Jolliet reported no relevant financial disclosures. Dr. Kaul reported a financial relationship with Ambu and is a member of the editorial board of Gastroenterology & Endoscopy News. Dr. Samarasena reported financial relationships with ConMed, Cook Medical, Docbot, GI Supply, Mauna Kea, Medtronic, MicroTech, Motus, Neptune Medical, Olympus, Pentax and Steris.
This article is from the September 2021 print issue.