Why more colonoscopies need anesthesiologists

Using data from Medicare and private insurers, analysts at the RAND Corporation found that the rate of involvement of anesthesiologists for upper GI endoscopy and colonoscopy in low-risk patients had risen steadily over the last few years and is estimated to add $1.1 billion in what may be unnecessary health care costs. There was wide regional variation in the use of anesthesiologists which suggests that some or most of the practice is discretionary and could be eliminated without harm to patients.

From the abstract:

In both populations, the proportion of procedures using anesthesia services increased from approximately 14% in 2003 to more than 30% in 2009, and more than two-thirds of anesthesia services were delivered to low-risk patients. There was substantial regional variation in the proportion of procedures using anesthesia services in both populations (ranging from 13% in the West to 59% in the Northeast).

From the paper itself:

However, prior literature has demonstrated that in low risk patients, sedation administered by nonanesthesiologists is safe or offers patient satisfaction comparable with sedation administered by an anesthesiologist or nurse anesthetist. In fact, the only published randomized clinical trial on the topic shows that endoscopist administered sedation during colonoscopies results in higher patient satisfaction and fewer adverse effects than anesthetist-administered sedation.

The paper and its accompanying editorial can be found in JAMA or you can read a summary of it in this Reuters Health article.

I am surprised that the percentage is only 59% in the Northeast as in just about every hospital I am familiar with, nearly every patient undergoing these procedures has general anesthesia administered by an anesthesiologist or nurse anesthetist.

The authors and the editorialist speculated on the causes of this citing medicolegal issues, the fact that anesthesiologist can offer deeper sedation than what a gastroenterologist or procedure nurse can give, the study can be completed more quickly and more thoroughly, patient preference and even financial gain for physicians.

I can think of other reasons.

In the name of patient safety, certain state health departments and national regulatory groups have mandated strict rules for the administering of moderate sedation to patients undergoing procedures. Passing an examination to be credentialed to give moderate sedation and the amount of documentation needed are seen by some as excessive. Ironically, this sometimes results in patients simply not receiving sedation for some types of other operations done under local anesthesia.

The other reason is related to the term “medicolegal,” but put more bluntly is known as “Cover Your Ass,” otherwise known as defensive medicine. I don’t perform endoscopy or colonoscopy, but I can tell you that if you are a patient and you have airway problems or vomit during a colonoscopy, you will be glad that your gastroenterologist is not the only doctor in the room.

If there is no anesthesiologist and the outcome is bad, you can bet that the plaintiff’s lawyer will conveniently ignore all the evidence that outcomes are just as good whether an anesthesiologist is present or not.

“Skeptical Scalpel” is a surgeon who blogs at his self-titled site, Skeptical Scalpel.

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  • drdisaia

    We are the fools. Medicare potentially cuts the service and physicians accept more liability. All this for less than 15% of the healthcare dollar.

  • westeasterly

    A surgeon blogging about the importance of good anesthesia care; I never thought I’d see the day! ;)

  • http://twitter.com/Skepticscalpel Skeptical Scalpel

    Thanks for the comments.

    Westeasterly, Miracles do happen.
    Drdisaia, I agree with you.

  • http://twitter.com/RyanMadanickMD Ryan Madanick, MD

    Thanks. There are other issues as well. More and more, patients expect to remember nothing from the procedure, when this is not the actual purpose of sedation. The purpose is to keep the patient relaxed enough so that the procedure can be completed. But as there is more general diffusion and acceptance of this type of anesthesia, less and less will true moderate sedation will be the norm. This is not necessarily a bad thing. Procedures are more complex. Even screening procedures could be done with higher quality, as the focus of the endoscopist can be on finding adenomas behind folds, which is easier with a patient who is not experiencing cramps. Not that I believe every patient should receive this type of care, but we are much less accepting of the variability that moderate sedation provides than we used to be.

  • davemills555

    That’s no big mystery! It’s to keep the cash register ringing!

  • scott mackinnon

    Hey, Kevin.  As an anesthesiologist practicing in the NE for twenty years, I’ve noticed this trend.  Five of those years I served as the chief of anesthesia at a small 120 bed hospital equipped with 5 OR’s and two endo suites, all in the same area.  It was easy(term used loosely) to simply jump into the endo suite between OR cases to “heavily sedate” a developmentally delayed patient undergoing a scope.  Also the elderly, demented, unccoperative patient.   Then came the “nervous”, then the “overly-neurotic”; as time passed, the endoscopists called on us more and more.  Their biggest reason?  Quick turnover.  With us involved, they could start and end their cases quicker.  We didn’t use potent inhalational agents but rather a propofol infusion in a spontaneously ventilated patient.  Quick on, quick off, minimal side effects.  In fact, I did not use any opiates at all(many “sedators” use a small amount of fentanyl), thus minimizing the occurrence of nausea.  In short, if anesthesia services are available and committed, it makes the process move a lot quicker(and, i might add, safer in ill patients)  The problem from my end, is our services are hugely requested throughout the hospital-we are asked to provide anesthesia in places previously unheard of.  In addition, trying to get reimbursement for many of these anesthetics is futile, and even in doing so the level of administrative work(proof of need, documentation of need etc) is burdensome and expensive.  So the approach we take is to do the best you can and keep in good relations with the hospital.  In some cases, I’ve provided seminars to the sedation nurses(not nurse anesthetists, mind you), educating them in moderate sedation and so forth.  But to commit to providing anesthesia in all of these locations is impossible without increasing staff numbers and the level of compensation obtained from these procedures cannot support that.  We end up having to ask the hospital for support.  So, in the end, it comes down to consumerism.  Do we continue to scope the 88 year old, demented nursing home patient for routine surveillance?  Does everyone with indigestion need to be scoped?  Why is it that some of these patients seem to be here every few months?  These are the real questions that we as physicians are going to have to take a more active role in addressing.  As volume driven revenue becomes more the norm, we may soon be routinely scoping first graders, just in case.

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