Timing and scheduling of endoscopic procedures.

BACKGROUND: The aim of the present analysis is to compare the costs associated with different schemes of scheduling tests and to develop recommendations concerning the most cost-effective means for timing individual endoscopic procedures.
METHODS: The diagnostic costs of three competing strategies to schedule various radiologic and endoscopic procedures in patients with jaundice or gastrointestinal hemorrhage are compared by computer models using a Monte Carlo simulation. In strategy 1, the evaluation is started with the most promising procedure and proceeds with the next most promising procedure in case of a normal finding. In strategy 2, physicians adhere to a rigid sequence of diagnostic tests that starts with the least expensive procedure and advances through progressively more expensive procedures. In strategy 3, all promising tests are scheduled at the onset without waiting for test results to decide in favor or against individual procedures. In the Monte Carlo simulation, two hypothetical populations of 5000 inpatients or outpatients are subjected to each strategy.
RESULTS: Unless one particular diagnosis is suspected with a high a priori probability, a rigid sequence of advancing from less to more expensive and invasive procedures provides the cheapest diagnostic strategy. In case of limited access to endoscopy and long waiting times, the cheapest work-up may include simultaneous scheduling of complementary procedures without waiting for intermediate test results. Strategy 1 of starting with the most promising test procedure becomes the least expensive option, if the prior probability assigned to the most likely diagnosis exceeds a threshold between 40% and 70%, depending on the type of test needed to make the diagnosis.
CONCLUSIONS: An expeditious diagnostic evaluation or an evaluation that is guided primarily by medical considerations is more likely to result in low healthcare costs.