Thursday, March 22, 2012

Anesthesia fees for routine endoscopy/colonoscopy are expensive and may be unnecessary. Why are anesthesiologists used?

Using data from Medicare and private insurers, analysts at the RAND Corporation found that 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 the March 21, 2012 issue of 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.

[Digression: Once upon a time, an outpatient surgical procedure not requiring the presence of an anesthesiologist could be documented on a single page of the medical record. Now such a procedure generates 20-25 pages of BS. And that is in hospitals with mature electronic medical records, so-called “paperless” hospitals!]

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.


Diane said...

My husband had a scope done via the Veteran's hospital a few years back- no valium, no nothing...My husband has continued issues that need another scope- but he won't go back, even with the promise by a less "barbaric" Dr. that they will knock him out- it was that awful- and this a guy who weathered prostate exams for no reason, yearly vaccines, losing a enough meat off his leg to show the bone and the Dr. telling him to buy a bandaid.. and he won't go back...
My daughter just had a scope. Full sedation. She woke up immediately with a grin- said that is how they should do all procedures. She has had an open muscle biopsy with just a local, twilight sedation for a kidney biopsy- she would go back without hesitation if her Dr. said she needed another scope.

So, perhaps, the less barbaric the procedure with minimal risk via sedation these days, the more likely Drs. won't encounter- what we as patients so often hear complaints about - The Non-Compliant Patient.

Josh said...

I haven't read the article, but have noticed a similar trend where I am. It relates to the use of propofol for scopes. The endoscopists prefer propofol because the patients go to sleep faster, stay sedated better, and wake up and go home faster. I suppose they don't feel as comfortable with propofol dosing and administration, though they could easily learn. That's just what I've seen.

Solitary Diner (Also Known as The Frugalish Physician) said...

This must be a difference between Canadian and American practice (likely resulting from the vast difference in litigation between the two countries), as virtually every endoscopy/colonoscopy at our local hospitals is done under endoscopist-administered sedation. With properly administered fentanyl and midazolam, most of the patients have little to no memory of the procedure and are relatively calm throughout.

Skeptical Scalpel said...

Thanks to all for the interesting comments. It is a good topic for discussion.

Doctors said...

I think its necessary for the patients to examined routine wise.

Anonymous said...

As a nurse who has worked in a small rural hospital for years and assisted with 100s of scopes...Let me tell you...You won't be doing my scope unless you have a CRNA pushing the drugs. I value my safety as well as my comfort. Our CRNA is fabulous and our patient satifaction rate is above tops.

RobertL39 said...

Do general surgeons and gastroenterologists learn sedation in residency? Yes, I know, it's not hard to learn if they want to. If they don't learn it in residency, it's about time they did. It's SO straightforward. And who do you suppose writes the often onerous qualifications for being to be able to give 'conscious sedation'? Did you say anesthesiologists? YUP. Instead of CYA it's "cover your turf".
As an added comment on Josh's remark, anesthesiologists apparently have come to believe that propofol is an anxiolytic. IT'S NOT!!!! Yeah, they go to sleep and stop breathing [so they're 'sedated'] but they wake up quickly and sometimes anxious, just like they were before the procedure. Anesthesia needs to remember the difference between sedation and anxiolysis. Anxiolysis makes happier patients! I have noticed that this problem is getting worse and worse. Some even refer to midazolam as 'antique'! Get with it, guys!

Skeptical Scalpel said...

Anonymous and RobertL39

Good points. Thanks.

Anonymous said...

Yes!!!! Robert.39!


Waking Up Costs said...

None of the outpatient endoscopy centers in my area use anesthesiologists. They all use CRNA's. The simple fact is that a center's 'throughput' is much greater with propofol anesthetics than it would be with versed/fentanyl. i.e. it's more profitable for the center to have anesthetists there.

In our hospitals, it's not the anesthesiologists who are pushing to go to endoscopy. It's the endoscopists who are demanding our services.

Finally, the idea that giving sedation is " SO straightforward" misses the fact that someone who is administering any manner of sedation must be able to rescue form the next deepest level should there be an overshoot. If someone is getting 'unconscious sedation', that person administering it should be able to rescue from general anesthesia.

So, in my mind, it's not about money or cya or cy turf for anesthesiologists--but it may be for others.

Skeptical Scalpel said...

Waking Up Costs,

Thanks for the comments. Good points.

Anonymous said...

I was always taught to (1) be safe and (2) be competent, and (3) ask for help if you need it.

I can't tell you how helpful an anesthesiologist can be in an endoscopy procedure!

I'd suggest EVERY single HMO/PPO/Medicare administrator have a colonoscopy, without ANY anesthesia (that's the chepest and safest. . .pain doesn't really HARM you...does it?) and then let them print this crap.

I hate what medicine has become.

Are you going to vote Democrat or Republican? I realized, today, after some introspection, that NEITHER god-damn party has helped medicine. NEITHER ONE.

Come to think of it, let's scope the entire legislative branch of anesthesiologist. . just a nice, easy, colonoscopy--you know...what they do to us every day--regardless of your party affiliation!

Skeptical Scalpel said...

I agree there's not much choice in this election as far as medicine in concerned. I've made the decision to get out of the business and write about it from the sidelines.

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