Frequency of Bundling for Bidirectional Endoscopy in the U.S.

Summary and Comment |
January 24, 2014

Frequency of Bundling for Bidirectional Endoscopy in the U.S.

  1. Douglas K. Rex, MD

In a sample of U.S. Medicare patients, over one third did not undergo upper and lower endoscopies on the same day, representing a missed opportunity to lower healthcare costs.

  1. Douglas K. Rex, MD

Some patients have indications for both upper endoscopy and colonoscopy. Performing both procedures on the same day (bundling) is convenient for patients and reduces healthcare costs because one procedure is billed at a lower rate.

Using claims data from 12,982 U.S. Medicare patients who had colonoscopy and esophagogastroduodenoscopy (EGD) within 180 days of each other, investigators examined the prevalence of bundling and whether demographic or clinical characteristics of patients varied by bundling status. Results were as follows:

  • Colonoscopy and EGD were bundled in 65% of patients, performed within 30 days of each other in 18%, and performed between 30 and 180 days of each other in 17%.

  • Unbundling was more common in the Northeast and less common in the West compared with the Midwest.

  • Unbundling was more common in patients aged ≥85 (vs. <70) years, in black or Hispanic (vs. white) patients, and in patients with multiple comorbidities (vs. none).

  • Unbundling was less common in urban (vs. metropolitan) settings and for indications of gastrointestinal symptoms and bleeding compared with surveillance or screening.

  • Unbundling was slightly less common when procedures were performed by family physicians or general surgeons versus gastroenterologists.

  • Almost 30% of unbundled procedures were performed within 4 days of each other.


The cost of unbundling includes increased procedure costs, increased costs for sedation, and increased indirect costs (e.g., time lost from work). As is often the case, healthcare costs are highest in the Northeast. The authors suggest that consideration should be given to removing the financial disincentives to bundling.

Editor Disclosures at Time of Publication

  • Disclosures for Douglas K. Rex, MD at time of publication Consultant / Advisory board Exact Sciences; Ferring Pharmaceuticals; Given Imaging; Olympus Speaker’s bureau Boston Scientific; Braintree; Ferring Pharmaceuticals Grant / research support Battelle; Braintree; Northwestern University; Olympus America Editorial boards Annals of Gastroenterology and Hepatology; Comparative Effectiveness Research; Expert Review of Gastroenterology and Hepatology; Gastroenterology; Gastroenterology and Hepatology News; Gastroenterology Report; Gastroenterology Research and Practice; Journal of Clinical Gastroenterology; Techniques in Gastrointestinal Endoscopy; World Journal of Gastroenterology; World Journal of Gastrointestinal Oncology; World Journal of Gastrointestinal Pathophysiology; World Journal of Gastrointestinal Pharmacology and Therapeutics


Reader Comments (1)

Lloyd, Stephen MD, PhD Physician, Internal Medicine, Carolina Colonoscopy Center

Isn't the most dangerous component of either upper or lower endoscopy the sedation/anesthesia? I cannot think of a reason to separate the tests in the outpatient setting. Appears to increase risks of anesthesia complications.

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