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CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2012;10:371–376

ENDOSCOPY CORNER

Fiscal Analysis of Establishment of a Double-Balloon EnteroscopyProgram and Reimbursement

MARK E. BENSON,* WENDY HORTON,‡ JILL GLUTH,‡ PATRICK R. PFAU,* SIGURDUR EINARSSON,*ICHAEL R. LUCEY,* ANURAG SONI,* MARK REICHELDERFER,* and DEEPAK V. GOPAL*

*Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health; and ‡University of Wisconsin

ospitals and Clinics, Madison, Wisconsin

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BACKGROUND & AIMS: As double-balloon enteroscopy(DBE) programs continue to be established, further research isneeded to assess their financial impact. We evaluated actualfinancial outcomes and compared them with estimated returnon investment (ROI) projections for DBE. METHODS: Weretrospectively compared the predicted and actual financialresults for outpatients referred for DBE at an academic tertiaryreferral center. RESULTS: The ROI analysis was based on a

-year time frame. The analysis projected a net present value of64,623 and an internal rate of return of 24.6%. The projectedrst-year volume was 52 outpatient cases; however, the actualxperience was 20 outpatient cases. The predicted percent mar-in for these outpatient cases was 16.6%; the actual margin was4.4%. After 37 months, 52 outpatient cases were completed,nd the actual percent margin was 4.6%. Payer type had aignificant influence on the financial outcomes when projectedctivity and actual activity were compared. CONCLUSIONS:

Institutions interested in establishing a DBE programshould be aware of the financial implications of programestablishment, which can be evaluated in a return on in-vestment analysis. Payer mix significantly influences DBEreimbursement and collection rates.

Keywords: Diagnostic; Net Present Value (NPV); Health CareResources; Cost Effective.

Since its introduction approximately a decade ago, double-balloon enteroscopy (DBE) has been a growing endoscopic

echnique that enables diagnostic and therapeutic interventionso be performed within the entire small bowel.1,2 Relative tother endoscopic procedures such as esophagogastroduodenos-opy or colonoscopy, DBE is a time-consuming and labor-ntensive procedure that requires utilization of specializedealth care resources including fluoroscopy, general anesthesia,nd additional health care personnel. Although DBE is consid-red a safe procedure, published literature has reported higheromplication rates as compared with standard endoscopic pro-edures.3–5 Endoscopists performing DBE require specialized

training to become competent and familiar with the novelprocedure. Few studies have focused on the actual long-termfinancial aspects of this innovative endoscopic technique. Byusing financial modeling, DBE has been reported to be cost-effective in the work-up and treatment of patients with obscure

gastrointestinal blood loss.6,7 In addition, it has been projected

hat DBE would generate a significant amount of downstreamevenue in large academic medical centers; however, there haveeen no large studies published evaluating the long-term finan-ial outcomes of DBE.8 However, other financial models haveeported the cost of DBE to be higher with longer-durationrocedures and in centers where relatively few DBEs are per-ormed per year.9 The aim of our study was to evaluate the

actual financial experience of initiating a DBE program com-pared with the predicted return on investment (ROI) projec-tions at a large open-access tertiary care academic center.

The University of Wisconsin Hospitals and Clinics (UWHC)Technology Assessment Program is charged with ensuring ra-tional use and adoption of technologies at our institution. Thiscommittee is composed of 25 members and includes represen-tatives from the medical staff, nursing, hospital administration,financial analysts, and service line leaders. Novel technologiesrequested for adoption are required to undergo a systematicreview process that includes an evidence-based literature reviewto evaluate the safety, efficacy, and effectiveness of the technol-ogy. This scientific review is then partnered with an institution-specific financial analysis. Together this information is used tomake a data-driven decision on whether the technology shouldbe adopted. After reviewing the clinical and financial informa-tion on DBE, the committee voted to recommend acquiring thetechnology. At the time the DBE program was developed, therewere other options for resource allocation including expandingthe endoscopic ultrasound and screening colonoscopy pro-grams. However, there were no large centers locally that pro-vided balloon-assisted therapeutic deep enteroscopy, and it wasbelieved that this was a valuable procedure to bring to the area.The primary drivers that led to the adoption of DBE at ourinstitution included the ability to diagnose and treat diseases ofthe entire small bowel, the complementary role DBE adds tocapsule endoscopy, the relatively minimally invasive nature ofthe procedure compared with intraoperative enteroscopy, andits unique ability to allow therapeutic endoscopic interventions

Abbreviations used in this paper: DBE, double-balloon enteroscopy;ERCP, endoscopic retrograde cholangiopancreatography; IRR, internalrate of return; NPV, net present value; ROI, return on investment;UWHC, University of Wisconsin Hospitals and Clinics.

© 2012 by the AGA Institute1542-3565/$36.00

doi:10.1016/j.cgh.2011.12.033

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372 BENSON ET AL CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 10, No. 4

in special circumstances such as endoscopic retrograde cholan-giopancreatography (ERCP)–assisted DBE.

MethodsThe financial modeling was based on 3 underlying as-

sumptions: (1) DBE is a minimally invasive procedure per-formed primarily on an outpatient basis; (2) it was estimatedthat two-thirds of the center’s capsule endoscopy cases wouldbe referred for DBE, on the basis of the previously publishedliterature as well as prior institution experience showing thatapproximately 65% of the capsule endoscopy cases had findingswarranting further diagnostic or therapeutic evaluation10,11;

nd (3) DBE would replace a proportion of both the inpatientnd outpatient push enteroscopy cases. It was predicted thatost of the DBE procedure indications would be for occult or

bscure gastrointestinal bleeding, however, noting that non–mall bowel sources are sometimes found in such patients.12

The ROI analysis evaluated the financial implications to thehospital during a 5-year period. The analysis calculated the netpresent value (NPV), defined as the difference between theprogram’s future net financial value and the hospital’s initialinvestment for the program, as well as the internal rate ofreturn (IRR), the return rate at which the NPV equals zero, forthe DBE program. The findings from both the clinical reviewand the financial analysis led to the hospital-supported adop-tion of the DBE technology. For this study, we retrospectivelycompared our predicted and actual financial experience be-tween May 1, 2007, and June 30, 2010.

At the University of Wisconsin, the financial payment struc-ture for endoscopic procedures includes both professional feesand technical (or facility) fees. The costs for the proceduresinclude all direct and indirect costs for providing the patientcare. Indirect or “institutional” costs are determined and allo-cated on the basis of system-generated statistics of the institu-tion’s cost-accounting system. Direct costs are costs borne bythe patient care departments and include variable direct costs(supplies, patient care labor, etc) as well as fixed direct costs(patient care capital equipment depreciation and maintenance,patient care department supervisory labor, etc). This analysisincludes the fees and costs for DBEs performed in the outpa-tient setting.

ResultsThe ROI analysis, which was based on a 5-year time

frame, predicted an NPV of $64,623 for the DBE technology.Furthermore, the predicted IRR was projected at 24.6%. On thebasis of the institution’s push enteroscopy and capsule endos-

Table 1. Projected and Actual Financial Experience 1 YearAfter Adopting a DBE Program at UWHC

Projectedactivity

Actual experiencein 1st year

Volume (n) 52 20evenue ($) 89,433 43,252ost ($) 74,605 41,025argin ($) 14,828 13,277argin (%) 16.6% 24.4%

copy program, the DBE case volume projected 52 outpatient

cases would be performed during the first year of acquiring thetechnology. However, the actual outpatient case volume per-formed during the first year was 20 patients. The predictedpercent margin, expressed as percent of net revenue, for outpa-tient cases was 16.6%, whereas the actual percent margin was24.4% for outpatient cases during the first year after adoption.The first-year projected and actual volumes, revenue, costs, andmargin are detailed in Table 1. The revenue collected was frompayers for the hospital fees (including supplies, facilities, nurs-ing, technicians etc). The IRR and NPV do not consider profes-sional billing revenues or costs.

It was not until June 2010, 37 months after the initiation ofthe DBE program, that our institution completed 52 outpatientcases, which was the projected volume to be completed in thefirst year of the program. Approximately 90% of the DBE pro-cedure indications were for occult or obscure gastrointestinalbleeding. Because of the length and invasiveness of the proce-dure as well as local expertise, general anesthesia was used foroutpatient DBE procedures, similar to other institutions.13,14

Although nurse- or physician-assisted propofol sedation has beenused safely for DBE, propofol use in Wisconsin can only beadministered by an anesthesiologist.13 Eighty-three percent of theDBE procedures were antegrade, and 17% were retrograde. Theactual percent margin was 4.6% for the 52 outpatient cases. Thepredicted and actual volumes, revenues, costs, and margin forthe 52 outpatient cases are detailed in Table 2. Both the revenuegenerated and the costs for the outpatient DBE procedures werehigher than projected. Impacting the margin is the total cost forpatient care that includes direct costs, fixed and variable opera-tional costs, and indirect costs, which represent the allocation ofoverhead costs. A percentage breakdown of the costs of outpatientDBE is provided in Supplementary Table 1 along with a compar-ison of percentage cost breakdown for inpatient cases.

Push Enteroscopies and Capsule EndoscopyIt was estimated in the financial model that DBE would

replace a portion of the inpatient and outpatient push enteros-copies. Contrary to the predicted model, the annual number ofpush enteroscopies completed actually increased. Furthermore,the financial model assumed that approximately two-thirds ofthe institution’s capsule endoscopy cases would be referred forDBE; however, only a small minority of the center’s capsuleendoscopy cases (4.2%) proceeded on to DBE. Table 3 detailsthe annual number of push enteroscopies, capsule endoscopies,and capsule endoscopies leading to DBE procedures before andafter the initiation of the DBE program.

Table 2. Projected and Actual Financial DBE ExperienceBetween May 1, 2007, and June 30, 2010, atUWHC

Projectedactivitya Actual experience

Volume (n) 52 52Revenue ($) 89,433 131,376Total cost ($) 74,605 125,312Margin ($) 14,828 6064Margin (%) 16.6 4.6

NOTE. Technology investment was $148,277.aEquipment depreciation was $14,569 annual depreciation in the

direct cost and depreciated over 5 years.

POT

April 2012 FISCAL ANALYSIS OF DOUBLE-BALLOON ENTEROSCOPY 373

Payer Mix ResultsPayer mix modeling was based on historical institution-

specific experience for push enteroscopy, intraoperative enteros-copy, and capsule endoscopy. The ROI projected that the DBEpayer mix would include 39% Medicare patients. However, fromthe time the original projections were made, there was a payermix shift that resulted in a higher proportion of outpatientDBE procedures being reimbursed by Medicare in the first year.The model predicted 50% of the procedures would be reim-bursed from private payers, whereas the actual rate was 46% forthe first year and 52% for the first 3 years. The projected andactual payer mix proportions for the first year and for the first3 years are shown in Table 4. The level of reimbursement for theenteroscopy varied significantly depending on the type of payer,with Medicare having the lowest collection rate of 29% andprivate having the highest reimbursement rate at 70%. The DBEpayer collection rates are shown in Table 5.

Cost ResultsThe initial endoscopic equipment expense was depreci-

ated over 5 years. The assumed cost of capital for the initialinvestment was $148,277. As a part of the initial DBE programestablishment, 2 endoscopists and technicians were trained tosafely perform the procedure by attending a hands-on univer-sity-based weekend course that included didactic lectures,hands-on experience, and knowledge about DBE learningcurve.15 Two subsequent endoscopists were trained in a similarfashion. All of the DBE endoscopists had experience and inter-est in advanced therapeutic endoscopy. The total cost for pa-tient care for patients undergoing DBE included direct costsincluding both fixed and variable institution costs associatedwith providing patient care as well as indirect costs that in-cluded the allocation of overhead costs. For outpatient proce-dures, the largest proportion of costs was generated from theinstitution’s ambulatory procedure center facility as well as thefacility’s patient preparation and recovery areas. As the DBEprogram began, a proportion of the outpatients were admittedfor postprocedure observation because of their age and medicalcomorbidities, thus influencing the costs. As the program ma-

Table 3. Annual Number of Push Enteroscopies andCapsule Endoscopies Completed at UWHC

Year 2006 2007a 2008

No. of push enteroscopies completed 18 33 40No. of capsule endoscopies

completed121 132 120

No. (%) of capsule endoscopiesleading to DBE

0 5 (3.8) 5 (4.2)

aYear DBE program was initiated.

Table 4. ROI Projected and Actual DBE Payer Mix at UWHC

Payer

ROIassumption

(%)Year 1, 20 outpatient

actual cases (%)Year 3, 52 outpatient

actual cases (%)

Medicare 39 46 35Private 50 46 52

Other 11 7 13

tured and the experience of the endoscopists grew, fewer out-patients were admitted after procedure for observation. Table 6details the institution’s costs for the DBE procedures comparedwith the ROI model, with actual experience having used highercosts within the recovery rooms and anesthesia. Applying a costinflation rate to the ROI model to make a year-to-date compar-ison shows the cost per procedure to be 34% lower in the modelcompared with actual experience.

Patient Origin ResultsApproximately 22% of the patients were from our local

market (Dane County), 28% of the patients were referred fromring markets that include the counties surrounding DaneCounty, Wisconsin, and 7% were from tertiary markets. Thetertiary markets were identified by UWHC as priority marketson the basis of payer mix, population size, and the level of acutecare cases being referred from these markets. Approximately20% of the patients were from markets from the northernmostcounties of Wisconsin, and 24% of the patients were from outof state. The UWHC has a strong referral pattern that is dem-onstrated by the patients seeking this procedure, with approx-imately 75% originating from Wisconsin and 25% from out ofstate (Supplementary Figure 1). Patient origin influences ourinstitutional payer mix because UWHC’s local market containsa high percentage of managed care, which dictates where pa-tients seek care.

Age ResultsThe majority of the patients who had DBE procedures

completed were older than 50 years of age. The largest propor-tion of procedures performed, 51%, was on patients older than60 years of age. There was 1 pediatric patient and 9 octogenar-ian patients. Population growth trends are an important factorto consider when planning a program. For example, during thenext 5 years it is anticipated that the population in Wisconsinwill grow by nearly 6%, with the fastest growing populationgroup (18%) in the age range of 55– 69. This information will beneeded to project future volumes and predict the proportion ofreimbursement coming from government payers.

DiscussionDouble-balloon enteroscopy is a growing endoscopic

technique that allows for both diagnostic and therapeutic in-terventions within the small bowel. As DBE continues to beadopted nationally, research regarding the financial implica-tions of DBE program establishment will need to be considered.

Table 5. Collection Rate by Payer for DBE ProceduresBetween May 1, 2007, and June 30, 2010, atUWHC

Payer No. of casesCollection rate

(%)

Medicare 18 29rivate 27 70ther 7 36otal 52 50

In this article, we present a DBE program financial analysis

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374 BENSON ET AL CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 10, No. 4

evaluating the predicted and actual financial outcomes at alarge open-access tertiary care academic center.

In 2007, the UWHC Technology Assessment Committeeapproved the adoption of a DBE program after the completionof a thorough clinical and financial review. An ROI analysis isan accepted approach to evaluating the financial outcomes of ahealth care investment.16 –19 The ROI analysis was based on a

-year time frame and estimated the NPV of the DBE programo be $64,623. The NPV is defined as the difference between therogram’s future net financial value and UWHC’s initial invest-ent for the program. The estimated DBE IRR was 24.6%. The

RR was the return rate at which the NPV equals zero or the ratet which the discounted future financial value is equal to the initialnvestment. An IRR was used in conjunction with the NPV tovaluate the DBE capital investment.

On the basis of UWHC’s previous push enteroscopy andapsule endoscopy volumes, the DBE case volume was predictedo be 52 outpatient cases for the first year after adoption.owever, the actual outpatient case volume was only 20 pro-

edures. Initially, 2 gastroenterologists were trained to performBE. Because of unforeseen circumstances, one of the DBE-

rained gastroenterologists left the institution for personal rea-ons. As a result, the number of DBE procedures completedithin the first year was limited because of the time constraintsf scheduling all of the procedures for one gastroenterologist. Ifhe second DBE-trained gastroenterologist had remained atWHC, it is likely that the actual DBE case volume would haveeen similar to the originally estimated number. Currently,here are 3 academic gastroenterologists who regularly performBE at UWHC in both the inpatient and outpatient settings.There were a number of differences in the key assumptions

f the DBE financial projection versus actual experience, whichead to a material variance between the estimated and actualnancial results. DBE was a relatively new procedure at the timef the ROI development; therefore, payer reimbursement wasodeled after the institution’s reimbursement on historical

utpatient push enteroscopy procedures. Similarly, costs werestimated on the basis of historical direct and indirect costs.

Table 6. Total Cost for DBE Activity: Actual Compared With R

Department group Pe

Actual experience, May 1, 2007, and June 30, 2010Ambulatory procedure centerPreparation/recovery roomAnesthesiaTotal

Modeled cost

Department groupPer casecost ($)

Total($

OI modeled costAmbulatory procedure center 801 41,6Preparation/recovery room 234 12,1Anesthesia 304 15,8Fluoroscopy �1h 96 49Total 1435 74,6

aCost inflation factor applied to bring cost to calendar year 2010 equ

ssumptions applied to the ROI analysis overstated the vol-

umes for the first year of implementation and underestimatedthe length of recovery time and use of sedation and anesthesia.The ROI also did not take into account the costs of patientshort-stay/observation days on nursing units. The model esti-mated that approximately 65% of the institution’s capsule en-doscopy cases would proceed to DBE; however, only a smallminority of the center’s capsule endoscopy cases (4.2%) wasactually followed by a DBE. The model’s estimate was based onthe institution’s initial 3-year case volume of 240 capsule en-doscopy cases from 2002–2005.10 Of these, 41% had positive

ndings, and 8% had equivocal findings that typically pro-eeded to more diagnostic testing. Of the normal capsule cases,6% were for obscure gastrointestinal bleeding, which was as-umed to need DBE to evaluate further. In addition, most ofhe initial UWHC capsule endoscopy cases were for evaluatingbscure gastrointestinal blood loss. Currently, the indicationsor capsule endoscopy have grown to include other small bowelathology not needing subsequent deep enteroscopy; thus, thewo-thirds estimate used for the financial model was too highn retrospect. The financial model also assumed that a propor-ion of the push enteroscopies would be replaced with DBEecause it has been shown to more deeply evaluate the smallowel and to have a higher diagnostic yield as compared withush enteroscopy.20 However, the actual number of push en-eroscopies completed after the initiation of the DBE programncreased. The institution’s push enteroscopy numbers were notignificantly influenced by the DBE program possibly becausef the unique endoscopic aspects push enteroscopy offers.ompared with DBE, push enteroscopy is less invasive, does not

equire general anesthesia, and does not require the type ofpecialized equipment needed for DBE procedures. Further-

ore, push enteroscopy can thoroughly evaluate for and detectany proximal small bowel lesions, obviating the need for aBE.12 As a result, DBE did not replace a significant proportion

of the institution’s push enteroscopy procedures. Finally, sincethe inception of the DBE program, the institution has imple-mented an electronic patient medical record system. This sys-tem impacted all hospital departments with an increased allo-

odel

e cost ($) Total cost ($) Percent of total (%)

380 71,735 57658 34,220 27372 19,357 15410 125,312 100

Modeled cost inflated by3 yearsa

Percent oftotal cost (%)

Per casecost ($)

Total cost($)

888 46,160 56259 13,475 16337 17,540 21107 5542 7

1591 82,716 100

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April 2012 FISCAL ANALYSIS OF DOUBLE-BALLOON ENTEROSCOPY 375

Despite the lower than expected first-year volume of outpa-tient DBE procedures, the ROI model predicted percent marginand actual margin were similar, 16.6% and 24%, respectively.Interestingly, the actual first-year payer mix proportions werehigher for Medicare (a less favorable payer) and slightly lowerfor private (a more favorable payer) (Table 4). A majority of thepayer mix was through private payers, thus reflecting the insti-tution’s referral pattern. Despite the discrepancy in the payermix proportion, the first-year outpatient DBE proceduresyielded an overall positive and similar financial outcome for theinstitution compared with the financial model.

To compare the actual and predicted financial results withsimilar case volumes, we compared the financial outcomes ofthe first 52 DBE outpatient cases that were completed at ourinstitution with the ROI model. It took approximately 3 yearsafter the initiation of the DBE program to complete 52 outpa-tient cases. As noted above, the institution’s DBE volumes wereless than predicted because of the unforeseen circumstance ofone DBE-trained gastroenterologist leaving the institution. TheROI predicted margin was 16.6% for the 52 cases, and the actualmargin was 4.6% for the outpatient cases (Table 2). There areseveral possible reasons for the discrepancy between the pre-dicted and actual financial margins. Both the revenue generatedand the costs were underestimated within the financial model.Specifically, the ambulatory procedure center preparation andrecovery costs were significantly underestimated in the model aswell as the use of sedation and anesthesia. Also, there was asmall discrepancy in the estimated payer mix. During the sametime period, the percentage margin for endoscopic ultrasoundwas 2.2% and for ERCP was 12%. Although ERCP had thehighest margin, the outcomes for these procedures were greatlyinfluenced by the payer mix. Similarly, the level of reimburse-ment for the DBE procedures varied significantly depending onthe type of payer (Table 4). Last, DBE did not significantlyinfluence the number of push enteroscopies completed, andthere was a less-than-anticipated referral for DBE from thecenter’s capsule endoscopy procedures.

DBE is a relatively novel and growing endoscopic procedure.DBE has unique health care resource demands because of thespecialized nature and complexity of the procedure relative toother endoscopic procedures such as esophagogastroduodenos-copy or colonoscopy. Establishing a DBE program has signifi-cant financial implications that are dependent on institutionvolume, payer mix, and procedure location. UWHC is currently1 of 3 tertiary care referral centers that perform DBE in theentire state of Wisconsin and continues to be the only localregional referral center for DBE in Madison and surroundingDane county, south-central, north-central, and western Wiscon-sin. However, it is likely that other local medical institutionswill adopt a small bowel, balloon-assisted, or deep enteroscopyprogram in the near future, and as the technology becomesmore available and mainstream, this might significantly impactour DBE program. The downstream effects of establishing aDBE program are clearly not limited to the financial aspectsoutlined within this article. For example, many patients withtherapeutic DBE procedures for small bowel polypectomiesavoid the need for intraoperative procedures. An intraoperativeenteroscopy at our institution costs approximately 4 times theamount of an outpatient DBE procedure. Furthermore, thera-peutic DBE procedures (ie, control of hemorrhage with argon

plasma coagulation, snare polypectomy, stricture dilation) were

performed on approximately 50% of patients referred for occultor obscure gastrointestinal bleeding, and we have shown thatablating small bowel angiectasis through DBE leads to a de-crease in subsequent patient transfusion requirements.21 De-pite accurate and thorough modeling, predicting the financialutcomes of DBE program establishment can be challenging.e did not compare the facility fees or professional fees for ourBE program, which is a limitation because this information is

pecific to our institution. Moreover, the percentage costsreakdown, as provided in Supplementary Table 1, might varyn the basis of inpatient versus outpatient DBE cases, and thisight also influence the fee structure. However, this was not a

art of our original ROI model, although we acknowledge thatt might be an important factor in program planning andstablishment. Our results are institution-specific, and similaresults for DBE program establishment will likely vary for othernstitutions with different referral patterns. Endoscopists whoish to perform DBE should be aware of and clearly under-

tand the unique financial aspects of this procedure beforerogram adoption.

Supplementary MaterialNote: To access the supplementary material accompa-

nying this article, visit the online version of Clinical Gastroenter-ology and Hepatology at www.cghjournal.org, and at doi:10.1016/j.cgh.2011.12.033.

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Reprint requestsAddress requests for reprints to: Deepak V. Gopal, MD, Division of

Gastroenterology and Hepatology, University of Wisconsin School ofMedicine and Public Health, 4th Floor MFCB, 1685 Highland Avenue,Madison, Wisconsin 53705. e-mail: dvg@medicine.wisc.edu; fax: (608)

65-5677.

onflicts of interest

The authors disclose no conflicts.

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376.e1 BENSON ET AL CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 10, No. 4

Supplementary Figure 1. Map of DBE proce

l volume activity referred to UWHC by county.

April 2012 FISCAL ANALYSIS OF DOUBLE-BALLOON ENTEROSCOPY 376.e2

Supplementary Table 1. Cost as Percentage of Total Costfor Inpatient and Outpatient DBEActivity

Department groupPercent of total

(%)

OutpatientAmbulatory procedure center 44Ambulatory procedure center preparation

and recovery27

Anesthesiology 15Pharmacy 8Laboratory 3Ancillary services 2Total 100

InpatientInpatient nursing 53Laboratory 11Ambulatory procedure center 10Ancillary services 10Pharmacy 7Anesthesiology 4Other 4

Total 100