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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