Advertisement

A SEER Snapshot of Anesthesiologist-Assisted Procedural Sedation: In or Out of Focus?

Published:September 26, 2011DOI:https://doi.org/10.1016/j.cgh.2011.09.009
      In this issue of Clinical Gastroenterology Hepatology, Khiani et al
      • Khiani V.S.
      • Soulos P.
      • Gancayo J.
      • et al.
      Anesthesiologist involvement in screening colonoscopy: temporal trends and cost implications in the Medicare population.
      provide an important glimpse into the evolution of the practice of procedural sedation for gastrointestinal endoscopy in the United States. By using the Surveillance Epidemiology and End Results Medicare database, the authors found that anesthesiologist involvement in screening colonoscopies among Medicare beneficiaries increased substantially over a 5-year period from 11% to 23.4%. Given the fact that the screening colonoscopy rate more than doubled over the interval examined, there is actually a potent multiplicative effect in the absolute numbers of patients undergoing anesthesia-assisted colonoscopy. Is this a welcome development in the effort to provide safe and effective endoscopic procedures for this, or is this a pernicious portent that could disrupt the economic landscape of medical health care?
      This shift in demographics of procedural sedation is hardly surprising, yet the rate of change is staggering. A national survey of American College of Gastroenterology membership found that endoscopist satisfaction with sedation is greater among those using the conventional combination of an opioid and benzodiazepine. At the time of this survey in 2006, propofol sedation was preferred by 25.7% of the respondents.
      • Cohen L.B.
      • Wecsler J.S.
      • Gaetano J.N.
      • et al.
      Endoscopic sedation in the United States: results from a nationwide survey.
      Another study analyzing national survey data from 2003 to 2007 found that the rate of anesthesia-delivered sedation is expected to double from 2009 to 2015.
      • Inadomi J.M.
      • Gunnarsson C.L.
      • Rizzo J.A.
      • et al.
      Projected increased growth rate of anesthesia professional-delivered sedation for colonoscopy and EGD in the United States: 2009 to 2015.
      This means that more than 50% of upper endoscopies and colonoscopies will be under the auspices of anesthesia care. Interestingly, anesthesia-assisted sedation was greater in areas with higher incomes and lower unemployment rates. Both this study
      • Inadomi J.M.
      • Gunnarsson C.L.
      • Rizzo J.A.
      • et al.
      Projected increased growth rate of anesthesia professional-delivered sedation for colonoscopy and EGD in the United States: 2009 to 2015.
      as well as that of Khiani et al
      • Khiani V.S.
      • Soulos P.
      • Gancayo J.
      • et al.
      Anesthesiologist involvement in screening colonoscopy: temporal trends and cost implications in the Medicare population.
      found a lower participation rate among African Americans for anesthesia-assisted sedation.
      In this era of economic uncertainty, cost and quality issues are paramount. In the current study, the mean charge estimate was $103 per case for anesthesia involvement. This equates to an additional $20 million of additional cost during this study period. If this is extrapolated to 100% anesthesia support, this would equate to approximately $120 million in additional costs. Brill
      • Brill J.V.
      Endoscopic sedation: legislative update and implications for reimbursement.
      estimated that the Centers for Medicare and Medicaid Services pays an average of $155 to the anesthesia provider for monitored anesthesia care, using Current Procedural Terminology code 00810. This figure nearly triples to $437 for the average payment by private insurers. If we assume 100% market penetration of monitored anesthesia care then costs for such a transition would be $5 billion annually.
      The business model of procedural sedation also has undergone an evolution. The days of the anesthesiologist as an independent contractor has waned and is being replaced by an employee or company model whereby endoscopists hire anesthesia specialists and pay them either a set fee for each procedure or a salary and bill the insurers for anesthesia services.
      • Kaye J.M.
      Five ways your ASC can profit from anesthesia services.
      An income stream is generated from the difference between the billing for anesthesia services and what is paid to the anesthesiologist.
      Perhaps the most overarching concern is that of safety quality: does anesthesia-assisted sedation result in better outcomes from various endoscopic procedures? The safety data on anesthesia-assisted endoscopy are extremely limited. A study of 799 patients undergoing advanced upper endoscopic procedures such as endoscopic retrograde cholangiopancreatography and endoscopic ultrasound found that active airway management by anesthesia personnel was not uncommon.
      • Cote G.A.
      • Hovis R.M.
      • Ansstas M.A.
      • et al.
      Incidence of sedation-related complications with propofol use during advanced endoscopic procedures.
      The sample study size was too small to determine any risk of significant adverse events. In contradistinction, the data on the safety of endoscopist-directed propofol sedation are quite robust. In a total of 646,080 procedures, 11 instances of endotracheal intubation and 489 cases of mask ventilation were noted.
      • Rex D.K.
      • Deenadayalu V.P.
      • Eid E.
      • et al.
      Endoscopist-directed administration of propofol: a worldwide safety experience.
      These data coupled with multiple randomized controlled trials showing the efficacy of endoscopist-directed propofol sedation resulted in a multisociety gastroenterology task force to craft a position statement that endoscopist-directed propofol was superior to standard sedation with respect to efficacy and safety profiles, provided that proper training and patient selection is used.
      • Vargo J.J.
      • Cohen L.B.
      • Rex D.K.
      • et al.
      Position statement: nonanesthesiologist administration of propofol for GI endoscopy.
      Furthermore, the position statement considered the use of anesthesiologist-administered propofol for healthy individuals undergoing elective endoscopy to be cost prohibitive with no demonstrated improvement patient safety or procedural outcomes.
      However, in December 2009 the Centers for Medicare and Medicaid Services issued a clarification statement of an interpretive guideline that essentially shut down the practice of endoscopist-directed propofol sedation in the United States.
      Centers for Medicare and Medicaid Services (CMS)
      Clarification of the interpretative guidelines for the anesthesia services condition of participation and revised hospital anesthesia services guidelines-state operations manual (SOM) Appendix A, S&C-10–09-Hospital. CMS publication no. 100–07.
      Key components to this interpretive guideline included: the hospital anesthesiology department were made the captain of the ship for the administration of procedural sedation policies, that only a trained physician not involved in the performance of the procedure could administer deep sedation or general anesthesia, and that an example of deep sedation was propofol-mediated colonoscopy. Because this was a clarification of a previously published guideline, the reinterpretation was not subject to the scrutiny of a peer-review process or public input. In a revised appendix, published in January 2011, the Centers for Medicare and Medicaid Services removed the mention of propofol altogether and that hospitals should establish policies and procedures based on nationally recognized guidelines.
      Centers for Medicare and Medicaid Services (CMS)
      State operations provider certification Revised appendix A, Interpretative Guidelines for Hospitals. CMS publication no. 100–07.
      Despite the fact that the multisociety gastroenterology guidelines for endoscopist-directed propofol sedation were cited, the steep hurdle of deep sedation still exists because the American Society of Anesthesiologists still considers propofol-mediated sedation for endoscopy to be targeted for deep sedation and hence, a no-man's land for the gastroenterologist.
      In summary, the study by Khiani et al
      • Khiani V.S.
      • Soulos P.
      • Gancayo J.
      • et al.
      Anesthesiologist involvement in screening colonoscopy: temporal trends and cost implications in the Medicare population.
      shows the continued expansion of anesthesiologist-directed procedural sedation across the United States. This is despite the fact that there are no data to support this practice from the standpoints of safety and efficacy. The multibillion-dollar questions that have yet to be answered are who is going to pay for these services in the future and will endoscopist-directed sedation be regulated into extinction? Currently, only endoscopist-directed propofol sedation and not its anesthesiologist-directed counterpart has passed the litmus tests of safety, efficacy, and cost effectiveness, yet regulatory groups continue to ignore the data as they set policy standards. Perhaps we as a profession should ask ourselves how to solve this policy gridlock before the obituary on our privilege to provide procedural sedation is written.

      References

        • Khiani V.S.
        • Soulos P.
        • Gancayo J.
        • et al.
        Anesthesiologist involvement in screening colonoscopy: temporal trends and cost implications in the Medicare population.
        Clin Gastroneterol Hepatol. 2012; 10: 58-64
        • Cohen L.B.
        • Wecsler J.S.
        • Gaetano J.N.
        • et al.
        Endoscopic sedation in the United States: results from a nationwide survey.
        Am J Gastroenterol. 2006; 101: 967-974
        • Inadomi J.M.
        • Gunnarsson C.L.
        • Rizzo J.A.
        • et al.
        Projected increased growth rate of anesthesia professional-delivered sedation for colonoscopy and EGD in the United States: 2009 to 2015.
        Gastrointest Endosc. 2010; 72: 580-586
        • Brill J.V.
        Endoscopic sedation: legislative update and implications for reimbursement.
        Gastrointest Endosc Clin N Am. 2008; 18: 665-678
        • Kaye J.M.
        Five ways your ASC can profit from anesthesia services.
        SurgiStrategies. 2005; (Accessed September 7, 2011)
        • Cote G.A.
        • Hovis R.M.
        • Ansstas M.A.
        • et al.
        Incidence of sedation-related complications with propofol use during advanced endoscopic procedures.
        Clin Gastroneterol Hepatol. 2010; 8: 137-142
        • Rex D.K.
        • Deenadayalu V.P.
        • Eid E.
        • et al.
        Endoscopist-directed administration of propofol: a worldwide safety experience.
        Gastroenterology. 2009; 137: 1229-1237
        • Vargo J.J.
        • Cohen L.B.
        • Rex D.K.
        • et al.
        Position statement: nonanesthesiologist administration of propofol for GI endoscopy.
        Gastroenterology. 2009; 137: 2161-2167
        • Centers for Medicare and Medicaid Services (CMS)
        Clarification of the interpretative guidelines for the anesthesia services condition of participation and revised hospital anesthesia services guidelines-state operations manual (SOM).
        (Accessed October 23, 2011)
        • Centers for Medicare and Medicaid Services (CMS)
        State operations provider certification.
        (Accessed October 23, 2011)

      Linked Article