Nearly a quarter of screening colonoscopies performed in the Medicare population involve an anesthesiologist—a percentage that has more than doubled in the past 5 years, according to findings reported in the January issue of Clinical Gastroenterology and Hepatology.
Many patients do not receive screening colonoscopies because they are concerned about discomfort during the procedure. So there is much interest in sedation practices and the involvement of anesthesiologists in the procedure.
Sedation for screening colonoscopies was initially provided with midazolam and an opioid, but in the past decade, new options have become available—approximately 25% of patients now receive sedation with propofol instead. Anesthesiologists usually administer propofol, but little was known about the degree to which this specialty has become involved in colonoscopy screening exams.
Vijay Khiani et al. determined how many screening colonoscopies performed over a 5-year period involved an anesthesiologist using the using the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. The SEER database is an important source for cancer statistics—it provides data from geographic areas that represent approximately 28% of the US population. Khiani et al. analyzed data from 16,268 individuals, 68 years or older, who received screening colonoscopies from 2001 through 2006.
They found that found that anesthesiologist involvement in screening colonoscopies among Medicare beneficiaries increased substantially over this time period—from 11% to 23.4%. Because the numbers of screening colonoscopies doubled over the interval examined, there was actually a multiplicative effect on the absolute numbers of anesthesia-assisted colonoscopies (see figure).
Khiani et al. found that surgeons involved an anesthesiologist in 24.2% of colonoscopies, compared with 18.0% of gastroenterologists and 11.3% of primary care providers. The percentage of colonoscopies that involved an anesthesiologist varied among regions, ranging from 1.6% in San Francisco to 57.8% in New Jersey. Anesthesiologist involvement increased the cost by approximately 20% per screening colonoscopy.
Anesthesiologist involvement could provide many important benefits, including increased comfort and safety, yet there is concern about the cost. Khiani et al. say that, in the absence of an anesthesiologist, there has not been a fee for the sedation of average-risk patients undergoing a screening colonoscopy. Incorporating an anesthesiologist into the colonoscopy increased the costs by $103 per case in this study—an additional $20 million during the study period. In an editorial that accompanies the article, John Vargo estimates that if we assume 100% market penetration of monitored anesthesia care, the costs for such a transition would be $5 billion annually.
But does anesthesia-assisted sedation improve outcomes of endoscopic procedures? Vargo states that that there are no data to support the safety and efficacy this practice. A position statement from a multi-society gastroenterology task force says that administration of propofol by an endoscopist has better efficacy and safety than standard sedation, provided that proper training and patient selection is used. The position statement considered the use of anesthesiologist-administered propofol for healthy individuals undergoing elective endoscopy to be cost prohibitive and provides no improvements to safety or outcomes. However, there has been much controversy over whether the endoscopist or the anesthesiologist is the best person to administer the sedative.
Khiani et al. add that the study did not take into account competition among gastroenterology practices in specific regions or specific volume of cases per session per practitioner, or perform a side-by-side comparison with patients of other third-party payors or non-screening colonoscopy cases. Furthermore, the claims data did not specify whether a nurse anesthetist or anesthesiologist provided services.
They conclude that further research is needed to determine the effects of anesthesiologist involvement on patients and outcomes—especially to determine patients’ perspectives about comfort and their willingness to undergo the procedure with or without an anesthesiologist. An investigation of the potential benefits (such as polyp detection rate) and risks (such as the complication rate) is needed to determine the most safe, comfortable, and cost-effective approach to screening colonoscopies.
Read the article online. This article has accompanying CME activities.
Khiani SV, Soulos P, Gancayco J, et al. Anesthesiologist involvement in screening colonoscopy: temporal trends and cost implications in the medicare population. Clin Gastroenterol and Hepatol 2012;10:58-64.e1
Read the accompanying editorial.
Vargo JJ. A SEER snapshot of anesthesiologist-assisted procedural sedation: in or out of focus? Clin Gastroenterol and Hepatol 2012;10:7–8.e1