Utilization of anesthesia services during outpatient endoscopies and colonoscopies and associated spending in 2003-2009

Evidence to suggest adoption of water exchange deserves broader consideration: Its pain alleviating impact occurs in 90% of investigators

AIM: To determine whether observations were reproducible among investigators.

METHODS: From March 2013 through June 2014, 18-85-year-old diagnostic and 50-70-year-old screening patients were enrolled at each center to on-demand sedation colonoscopy with water exchange (WE), water immersion (WI) and insufflation with air or CO₂ for insertion and withdrawal [air or carbon dioxide (AICD)]. Data were aggregated for analysis. Primary outcome: Variations in real-time maximum insertion pain (0 = none, 1-2 = discomfort, 10 = worst).

RESULTS: One thousand and ninety-one cases analyzed: WE (n = 371); WI (n = 338); AICD (n = 382). Demographics and indications were comparable. The WE group had the lowest real-time maximum insertion pain score, mean (95%CI): WE 2.8 (2.6-3.0), WI 3.8 (3.5-4.1) and AICD 4.4 (4.1-4.7), P < 0.0005. Ninety percent of the colonoscopists were able to use water exchange to significantly decrease maximum insertion pain scores. One investigator had high insertion pain in all groups, nonetheless WE achieved the lowest real-time maximum insertion pain score. WE had the highest proportions of patients with painless unsedated colonoscopy (vs WI, P = 0.013; vs AICD, P < 0.0005); unsedated colonoscopy with only minor discomfort (vs AICD, P < 0.0005), and completion without sedation (vs AICD, P < 0.0005).

CONCLUSION: Aggregate data confirm superiority of WE in lowering colonoscopy real-time maximum insertion pain and need for sedation. Ninety percent of investigators were able to use water exchange to significantly decrease maximum insertion pain scores. Our results suggest that the technique deserves consideration in a broader scale.

Quality measures for colonoscopy: where should we be in 2015?

Colonoscopy is an effective colorectal cancer (CRC) screening and prevention modality as evidenced by a 30-year decline in both incident colon cancers and CRC mortality in the USA. The USA is unique among the developed countries in its use of colonoscopy as the most common method to screen for CRC. Individual patients gain maximum value from their colonoscopy experience when they undergo a comfortable exam that is of highest quality, during which all polyps are found and removed safely and completely, where their physicians adhere to all appropriate guidelines and when they (or their insurance) pay a reasonable amount for their care. Colonoscopy "quality" publications to date have been focused on how to improve the individual physician's procedural results and this narrow focus has birthed an entire industry (usually based on entering data into a national registry) that is focused on demonstrating a physician's success in achieving a certain threshold performance metric that is usually (a) marginally related to true health outcomes, (b) can be captured from the myriad electronic medical records (EMR) in existence today, and (c) is attainable by most practicing gastroenterologists. Medical societies have worked diligently to link these registries and recognition programs to commercial or federal payer-based incentive funds. As health care reform drives massive consolidation of delivery systems and reimbursement moves toward population-level two-sided financial risk models, our current measurement infrastructure will become irrelevant. The focus on "value" and the Triple Aim will drive development of a radically different approach. The process by which individual gastroenterologists (or practices) demonstrate the value of colonoscopy as a colorectal cancer (CRC) prevention tool will change dramatically. Essentially, six measures will be reported by a health system: (1) percent of eligible population screened, (2) access to colonoscopy services, (3) complication rates, (4) patient experience scores, (5) episode (bundle) cost, and (6) frequency with which interval cancers occur after a colonoscopy exam (likely using a 3-year interval). Each gastroenterologist within a health system will be evaluated using familiar metrics (cecal intubation, withdrawal time, adenoma detection rate) but these results will likely be used internally to determine whether they are included in a provider network. If they continue to be used in commercial or government incentive programs, then the enterprise electronic medical record will be constructed to populate external programs directly. Population-level metrics (listed above) will determine whether higher cost provider networks (including academic health centers) who might deliver better health outcomes can compete successfully for regional market share with lower cost providers. This article will outline a plan for a health system initiative focused on provision of colonoscopy for CRC prevention; a plan that will help a group of gastroenterologists (whether employed within a health system or independent) demonstrate why they should be a preferred provider and whether they will survive and thrive in the coming world of accountable care.

Prevalence and predictors of patient no-shows to outpatient endoscopic procedures scheduled with anesthesia

BACKGROUND

Demand for endoscopic procedures scheduled with anesthesia is increasing and no-show to appointments carries significant patient health and financial impact, yet little is known about predictors of no-show.

METHODS

We performed a 16-month retrospective observational cohort study of patients scheduled for outpatient endoscopy with anesthesia at a county hospital serving the safety-net healthcare system of San Francisco. Multivariate logistic regression analysis was performed to evaluate associations between attendance and predictors of no-show.

RESULTS

In total, 511 patients underwent endoscopy with anesthesia during the study period. Twenty-seven percent of patients failed to attend an appointment and were considered "no-show". In multivariate analysis, higher no-show rates were associated with patients with a prior history of no-show (odds ratio [OR] 6.4; 95% confidence interval [CI], 2.4- 17.5), those with active substance abuse within the past year (OR 2.2; 95% CI 1.4-3.6), those with heavy prescription opioids/benzodiazepines use (OR 1.6; 95% CI 1.0-2.6) and longer wait-times (OR 1.05; 95% CI 1.00-1.09). Inversely associated with patient no-show were active employment (OR 0.38; 95% CI 0.18-0.81), patients who attended a pre-operative appointment with an anesthesiologist (OR 0.52; CI 0.32-0.85), and those undergoing an advanced endoscopic procedure (OR 0.43; 95% CI 0.19-0.94).

CONCLUSION

In a safety-net healthcare population, behavioral and social determinants of health, including missed appointments, active substance abuse, homelessness, and unemployment are associated with no-shows to endoscopy with anesthesia.

Practice patterns of sedation for colonoscopy

BACKGROUND

Sedative and analgesic medications have been used routinely for decades to provide patient comfort, reduce procedure time, and improve examination quality during colonoscopy.

OBJECTIVE

To evaluate trends of sedation during colonoscopy in the United States.

SETTING

Endoscopic data repository of U.S. gastroenterology practices (Clinical Outcomes Research Initiative, CORI database from 2000 until 2013).

PATIENTS

The study population was made up of patients undergoing a total of 1,385,436 colonoscopies.

INTERVENTIONS

Colonoscopy without any intervention or with mucosal biopsy, polypectomy, various means of hemostasis, luminal dilation, stent placement, or ablation.

MAIN OUTCOME MEASUREMENTS

Dose of midazolam, diazepam, fentanyl, meperidine, diphenhydramine, promethazine, and propofol used for sedation during colonoscopy.

RESULTS

During the past 14 years, midazolam, fentanyl, and propofol have become the most commonly used sedatives for colonoscopy. Except for benzodiazepines, which were dosed higher in women than men, equal doses of sedation were given to female and male patients. White patients were given higher doses than other ethnic groups undergoing sedation for colonoscopy. Except for histamine-1 receptor antagonists, all sedative medications were given at lower doses to patients with increasing age. The dose of sedatives was higher in colonoscopies associated with procedural interventions or of long duration.

LIMITATIONS

Potential for incomplete or incorrect documentation in the database.

CONCLUSION

The findings reflect on colonoscopy practice in the United States during the last 14 years and provide an incentive for future research on how sex and ethnicity influence sedation practices.

Review on sedation for gastrointestinal tract endoscopy in children by non-anesthesiologists

AIM

To present evidence and formulate recommendations for sedation in pediatric gastrointestinal (GI) endoscopy by non-anesthesiologists.

METHODS

The databases MEDLINE, Cochrane and EMBASE were searched for the following keywords "endoscopy, GI", "endoscopy, digestive system" AND "sedation", "conscious sedation", "moderate sedation", "deep sedation" and "hypnotics and sedatives" for publications in English restricted to the pediatric age. We searched additional information published between January 2011 and January 2014. Searches for (upper) GI endoscopy sedation in pediatrics and sedation guidelines by non-anesthesiologists for the adult population were performed.

RESULTS

From the available studies three sedation protocols are highlighted. Propofol, which seems to offer the best balance between efficacy and safety is rarely used by non-anesthesiologists mainly because of legal restrictions. Ketamine and a combination of a benzodiazepine and an opioid are more frequently used. Data regarding other sedatives, anesthetics and adjuvant medications used for pediatric GI endoscopy are also presented.

CONCLUSION

General anesthesia by a multidisciplinary team led by an anesthesiologist is preferred. The creation of sedation teams led by non-anesthesiologists and a careful selection of anesthetic drugs may offer an alternative, but should be in line with national legislation and institutional regulations.

Revenue from single-balloon enteroscopy is driven by anesthesia: experience from a tertiary care facility

BACKGROUND/AIMS

Resource-intensive endoscopic procedures have shown to generate more costs than revenue under the current reimbursement system in the USA. Single-balloon enteroscopy (SBE), a resource-intensive procedure, has never been evaluated for its financial impact at tertiary care hospitals, and thus, our aim was to determine the sources of revenue that SBE procedures generate.

METHODS

Retrospective review of all procedures performed using the SBE system during the first year of implementation at a single tertiary referral center. Financial data from two subspecialties in the form of revenues for physician and facility fees were collected and analyzed. Revenues were analyzed in total and as a function of payer (insurance) and physician type.

RESULTS

Fifty-two procedures using the SBE system were identified during the first year of implementation at a single tertiary care center. Total revenue generated for all SBE procedures was $123,714 including $64,475 dollars from physician fees and $59,239 dollars from the facility fees. Revenue generated by anesthesia physician fees was higher from Medicare cases compared to private insurance cases (p < 0.01); however, revenues from facility fees were higher for private insurance cases compared to Medicare (p < 0.01). Revenues from anesthesiology physician fees were significantly more than revenues from GI physician fees (p < 0.01). Of the three referred cases, one generated additional downstream revenues from other non-SBE-related services totaling $4727.

CONCLUSION

A large proportion of revenues generated from SBE cases come in the form of ancillary services provided by anesthesia. Projected revenue generation (and it sources) should be considered when establishing a device-assisted enteroscopy program.

Contrasting Perspectives of Anesthesiologists and Gastroenterologists on the Optimal Time Interval between Bowel Preparation and Endoscopic Sedation

Background. The optimal time interval between the last ingestion of bowel prep and sedation for colonoscopy remains controversial, despite guidelines that sedation can be administered 2 hours after consumption of clear liquids. Objective. To determine current practice patterns among anesthesiologists and gastroenterologists regarding the optimal time interval for sedation after last ingestion of bowel prep and to understand the rationale underlying their beliefs. Design. Questionnaire survey of anesthesiologists and gastroenterologists in the USA. The questions were focused on the preferred time interval of endoscopy after a polyethylene glycol based preparation in routine cases and select conditions. Results. Responses were received from 109 anesthesiologists and 112 gastroenterologists. 96% of anesthesiologists recommended waiting longer than 2 hours until sedation, in contrast to only 26% of gastroenterologists. The main reason for waiting >2 hours was that PEG was not considered a clear liquid. Most anesthesiologists, but not gastroenterologists, waited longer in patients with history of diabetes or reflux. Conclusions. Anesthesiologists and gastroenterologists do not agree on the optimal interval for sedation after last drink of bowel prep. Most anesthesiologists prefer to wait longer than the recommended 2 hours for clear liquids. The data suggest a need for clearer guidelines on this issue.

No association between Centers for Medicare and Medicaid services payments and volume of Medicare beneficiaries or per-capita health care costs for each state

The Centers for Medicare and Medicaid Services recently published data on Medicare payments to physicians for 2012. We investigated regional variations in payments to gastroenterologists and evaluated whether payments correlated with the number of Medicare patients in each state. We found that the mean payment per gastroenterologist in each state ranged from $35,293 in Minnesota to $175,028 in Mississippi. Adjusted per-physician payments ranged from $11 per patient in Hawaii to $62 per patient in Washington, DC. There was no correlation between the mean per-physician payment and the mean number of Medicare patients per physician (r = 0.09), there also was no correlation between the mean per-physician payment and the overall mean per-capita health care costs for each state (r = -0.22). There was a 5.6-fold difference between the states with the lowest and highest adjusted Medicare payments to gastroenterologists. Therefore, the Centers for Medicare and Medicaid Services payments do not appear to be associated with the volume of Medicare beneficiaries or overall per-capita health care costs for each state.

Endoscopic sedation and monitoring practices in Portugal: a nationwide web-based survey

BACKGROUND

National surveys have been used to obtain information on sedation and monitoring practices in endoscopy in several countries.

AIMS

To provide data from Portugal and query the Portuguese endoscopists on nonanesthesiologist administration of propofol.

MATERIALS AND METHODS

A 31-item web survey was sent to all 490 members of the Portuguese Society of Gastroenterology.

RESULTS

A total of 129 members (26%) completed the questionnaire; 57% worked in both public and private practice. Most performed esophagogastroduodenoscopy without sedation (public - 70%; private - 57%) and colonoscopies with sedation (public - 64%; private - 69%). Propofol was the most commonly used agent for colonoscopy, especially in private practice (52 vs. 33%), and it provided the best satisfaction (mean 9.6/10). A total of 94% chose propofol as the preferred sedation for routine colonoscopy. Nonanesthesiologist administration of propofol was performed only by four respondents; however, 71% reported that they would consider its use, given adequate training. Pulse oximetry is monitored routinely (99%); oxygen supplementation is administered by 81% with propofol and 42% with traditional sedation. Most (82%) believed that propofol sedation may increase the uptake of endoscopic screening for colorectal cancer.

CONCLUSION

The use of sedation is routine practice in colonoscopy, but not esophagogastroduodenoscopy. The preferred agent is propofol and it is used almost exclusively by anesthesiologists.

Prescribing patterns of the four most commonly used sedatives in endoscopic examination in Korea: propofol, midazolam, diazepam, and lorazepam

As the sedative use increases due to the effectiveness and relatively safe profile, the abuse potential is also increasing. This study was conducted to examine the usage of four sedative agents in endoscopic examination and to compare the propofol use with the other three sedatives. Using National Health Insurance claims data from 2008 to 2012, we identified the number of cases of conscious sedation during endoscopy using one or more of the following agents: propofol, midazolam, diazepam, and lorazepam. The general characteristics of patients and medical service providers were analyzed, and the regional and annual distributions of frequency of use were compared. We also identified patient cases with excessive number of endoscopic examinations. Among the total of 3,156,231 sedatives users, midazolam was the most commonly used agent (n=2,845,250, 90.1%). However, the largest increase in patient number, which increased from 11,410 in 2008 to 28,170 in 2012, was observed with propofol. While the majority of patients received an annual endoscopy, we identified several suspected abuse cases of patients receiving endoscopies repetitively as many as 114 times in five years. The rise of sedative use in endoscopic examinations and several patient cases of repeated sedative administration suggest a potential risk for abuse. Medical service providers should be cautious when using sedatives and carefully review each patient's medical history prior to the procedure.

Pricing practices of gastroenterologists in New York

There is growing awareness of the price disparities for equivalent services in healthcare. We aimed to characterize regional variations in fees charged by gastroenterologists in Manhattan, NY. All private practice gastroenterologists in Manhattan were contacted and asked what they charge fee-paying patients for initial consultations for nonspecific gastrointestinal symptoms. Cost information was obtained from 89 offices, and practices were classified on the basis of location in Manhattan. We observed significant regional variation; gastroenterologists on the Upper East Side (1.20-fold the overall mean) charged more than twice as those on the Upper West Side (0.58-fold the mean) and 50% more than gastroenterologists in South Manhattan (0.76-fold the mean). The coefficient of variation was 46%; the most expensive gastroenterologist charged 14-fold more than the least expensive. We provide evidence for significant regional variation in prices for medical services. Future studies are needed to characterize regional price variations in other aspects of healthcare.

Colorectal testing utilization and payments in a large cohort of commercially insured US adults

OBJECTIVES

Screening decreases colorectal cancer (CRC) mortality. The national press has scrutinized colonoscopy charges. Little systematic evidence exists on colorectal testing and payments among commercially insured persons. Our aim was to characterize outpatient colorectal testing utilization and payments among commercially insured US adults.

METHODS

We conducted an observational cohort study of outpatient colorectal test utilization rates, indications, and payments among 21 million 18-64-year-old employees and dependants with noncapitated group health insurance provided by 160 self-insured employers in the 2009 Truven MarketScan Databases.

RESULTS

Colonoscopy was the predominant colorectal test. Among 50-64-year olds, 12% underwent colonoscopy in 1 year. Most fecal tests and colonoscopies were associated with screening/surveillance indications. Testing rates were higher in women, and increased with age. Mean payments for fecal occult blood and immunochemical tests were $5 and $21, respectively. Colonoscopy payments varied between and within sites of service. Mean payments for diagnostic colonoscopy in an office, outpatient hospital facility, and ambulatory surgical center were $586 (s.d. $259), $1,400 (s.d. $681), and $1,074 (s.d. $549), respectively. Anesthesia and pathology services accompanied 35 and 52% of colonoscopies, with mean payments of $494 (s.d. $354) and $272 (s.d. $284), respectively. Mean payments for the most prevalent colonoscopy codes were 1.4- to 1.9-fold the average Medicare payments.

CONCLUSIONS

Most outpatient colorectal testing among commercially insured adults was associated with screening or surveillance. Payments varied widely across sites of service, and payments for anesthesia and pathology services contributed substantially to total payments. Cost-effectiveness analyses of CRC screening have relied on Medicare payments as proxies for costs, but cost-effectiveness may differ when analyzed from the perspectives of Medicare or commercial insurers.

The safety of nurse-administered procedural sedation compared to anesthesia care in a historical cohort of advanced endoscopy patients

BACKGROUND

In April 2010, in response to a change in Centers for Medicare and Medicaid Services regulation placing deep sedation under hospital anesthesia services, our institution began providing anesthesia care for all advanced endoscopic procedures. Because it remains unknown whether anesthesia care reduces sedation-related complications or improves quality of care versus nurse-administered sedation for endoscopic retrograde cholangiopancreatography and endoscopic ultrasound patients, we retrospectively compared complications in a 5-year historical cohort before and after the policy change.

METHODS

We reviewed a historical cohort of 9598 consecutive endoscopic retrograde cholangiopancreatography and endoscopic ultrasound examinations for adult patients at a single institution during a 5-year period (October 2007-October 2012). We compared procedures performed before and after the policy change for the incidence of sedation, endoscopic, and total complications, and for major morbidity and mortality.

RESULTS

The incidence of reported sedation-related complications was 0.38% (17 of 4514) before the policy change and 0.08% (4 of 5084) after the policy change, which was statistically significant (P = 0.002, diff = 0.3, 95% confidence interval, 0.11%-0.53%). Endoscopic complications were not significantly different before versus after: 0.66% vs 0.87% (P = 0.293, diff = 0.2, 95% confidence interval, -0.16% to 0.56%). Total complications (1.11% vs 1.00%, P = 0.618) and major morbidity and mortality (0.27% vs 0.33%, P = 0.581) did not differ between the 2 time periods.

CONCLUSIONS

Anesthesia care for advanced endoscopy in a high-risk population significantly reduced sedation complications compared with nurse-administered sedation. Endoscopic complications were unchanged. The sedation risk reduction did not reduce major morbidity, mortality, or total complications.

Development and validation of a clinical prediction score (the SCOPE score) to predict sedation outcomes in patients undergoing endoscopic procedures

BACKGROUND

Use of anaesthesia services during endoscopy has increased, increasing cost of endoscopy.

AIM

To identify risk factors for and develop a clinical prediction score to predict difficult conscious sedation.

METHODS

We performed a retrospective cross-sectional study of all patients who underwent oesophagogastroduodenoscopy (OGD) and colonoscopy with endoscopist-administered conscious sedation. The endpoint of difficult sedation was a composite of receipt of high doses (top quintile) of benzodiazepines and opioids, or the documentation of agitation or discomfort. Univariate and multivariate analyses were performed to measure association of the outcome with: age, sex, body mass index (BMI), procedure indication, tobacco use, self-reported psychiatric history, chronic use of benzodiazepines, opioids or other psychoactive medications, admission status and participation of a trainee. A clinical prediction score was constructed using statistically significant variables.

RESULTS

We identified 13,711 OGDs and 21,763 colonoscopies, 1704 (12.4%) and 2299 (10.6%) of which met the primary endpoint, respectively. On multivariate analysis, factors associated with difficulty during OGD were younger age, procedure indication, male sex, presence of a trainee, psychiatric history and benzodiazepine and opioid use. Factors associated with difficulty during colonoscopy were younger age, female sex, BMI <25, procedure indication, tobacco, benzodiazepine, opioid and other psychoactive medication use. A clinical prediction score was developed and validated that may be used to risk-stratify patients undergoing OGD and colonoscopy across five risk classes.

CONCLUSIONS

Using the Stratifying Clinical Outcomes Prior to Endoscopy (SCOPE) score, patients may be risk stratified for difficult sedation/high sedation requirement during OGD and colonoscopy.

Navigating the murky waters of colorectal cancer screening and health reform

The Affordable Care Act (ACA) mandates that both Medicaid and insurance plans cover life-saving preventive services recommended by the US Preventive Services Task Force, including colorectal cancer (CRC) screening and choice between colonoscopy, flexible sigmoidoscopy, and fecal occult blood testing (FOBT). People who choose FOBT or sigmoidoscopy as their initial test could face high, unexpected, out-of-pocket costs because the mandate does not cover needed follow-up colonoscopies after positive tests. Some people will have no coverage for any CRC screening because of lack of state participation in the ACA or because they do not qualify (e.g., immigrant workers). Existing disparities in CRC screening and mortality will worsen if policies are not corrected to fully cover both initial and follow-up testing.

The diagnostic yield of upper endoscopy procedures in children- is it cost effective?

Upper endoscopy is an invaluable tool for the diagnosis and treatment of various gastrointestinal symptoms in children. Over the years, the number of endoscopic procedures performed in different medical centers has increased considerably and the cost associated with the procedure has become unsustainable. Recently, the US government has investigated this topic and has suggested steps to reduce the cost and use of endoscopic procedures in the adult population, changes that have not been accepted favorably by the American Gastroenterology Associations (AGA). In the present report, we evaluate the diagnostic yield of the procedure in children and suggest steps to reduce the annual number of upper endoscopic procedures in children. The diagnostic yield and the cost-effectiveness of the procedure are also discussed.

Preoperative consultations for medicare patients undergoing cataract surgery

IMPORTANCE

Low-risk elective surgical procedures are common, but there are no clear guidelines for when preoperative consultations are required. Such consultations may therefore represent a substantial discretionary service.

OBJECTIVE

To assess temporal trends, explanatory factors, and geographic variation for preoperative consultation in Medicare beneficiaries undergoing cataract surgery, a common low-risk elective procedure.

DESIGN, SETTING, AND PARTICIPANTS

Cohort study using a 5% national random sample of Medicare part B claims data including a cohort of 556,637 patients 66 years or older who underwent cataract surgery from 1995 to 2006. Temporal trends in consultations were evaluated within this entire cohort, whereas explanatory factors and geographic variation were evaluated within the 89,817 individuals who underwent surgery from 2005 to 2006.

MAIN OUTCOMES AND MEASURES

Separately billed preoperative consultations (performed by family practitioners, general internists, pulmonologists, endocrinologists, cardiologists, nurse practitioners, or anesthesiologists) within 42 days before index surgery.

RESULTS

The frequency of preoperative consultations increased from 11.3% in 1998 to 18.4% in 2006. Among individuals who underwent surgery in 2005 to 2006, hierarchical logistic regression modeling found several factors to be associated with preoperative consultation, including increased age (75-84 years vs 66-74 years: adjusted odds ratio [AOR], 1.09 [95% CI, 1.04-1.13]), race (African American race vs other: AOR, 0.71 [95% CI, 0.65-0.78]), urban residence (urban residence vs isolated rural town: AOR, 1.64 [95% CI, 1.49-1.81]), facility type (outpatient hospital vs ambulatory surgical facility: AOR, 1.10 [95% CI, 1.05-1.15]), anesthesia provider (anesthesiologist vs non-medically directed nurse anesthetist: AOR, 1.16 [95% CI, 1.10-1.24), and geographic region (Northeast vs South: AOR, 3.09 [95% CI, 2.33-4.10]). The burden of comorbidity was associated with consultation, but the effect size was small (<10%). Variation in frequency of consultation across hospital referral regions was substantial (median [range], 12% [0-69%]), even after accounting for differences in patient-level, anesthesia provider-level, and facility-level characteristics.

CONCLUSIONS AND RELEVANCE

Between 1995 and 2006, the frequency of preoperative consultation for cataract surgery increased substantially. Referrals for consultation seem to be primarily driven by nonmedical factors, with substantial geographic variation.

Can a validated sleep apnea scoring system predict cardiopulmonary events using propofol sedation for routine EGD or colonoscopy? A prospective cohort study

BACKGROUND

Obstructive sleep apnea (OSA), which is linked to the prevalence of obesity, continues to rise in the United States. There are limited data on the risk for sedation-related adverse events (SRAE) in patients with undiagnosed OSA receiving propofol for routine EGD and colonoscopy.

OBJECTIVE

To identify the prevalence of OSA by using the STOP-BANG questionnaire (SB) and subsequent risk factors for airway interventions (AI) and SRAE in patients undergoing elective EGD and colonoscopy.

DESIGN

Prospective cohort study.

SETTING

Tertiary-care teaching hospital.

PATIENTS

A total of 243 patients undergoing routine EGD or colonoscopy at Cleveland Clinic.

INTERVENTION

Chin lift, mask ventilation, placement of nasopharyngeal airway, bag mask ventilation, unplanned endotracheal intubation, hypoxia, hypotension, or early procedure termination.

MAIN OUTCOME MEASUREMENTS

Rates of AI and SRAE.

RESULTS

Mean age of the cohort was 50 ± 16.2 years, and 41% were male. The prevalence of SB+ was 48.1%. The rates of hypoxia (11.2% vs 16.9%; P = .20) and hypotension (10.4% vs 5.9%; P = .21) were similar between SB- and SB+ patients. An SB score ≥3 was found not to be associated with occurrence of AI (relative risk [RR] 1.07, 95% confidence interval [CI] 0.79-1.5) or SRAE (RR 0.81, 95% CI, 0.53-1.2) after we adjusted for total and loading dose of propofol, body mass index (BMI), smoking, and age. Higher BMI was associated with an increased risk for AI (RR 1.02; 95% CI, 1.01-1.04) and SRAE (RR 1.03; 95% CI, 1.01-1.05). Increased patient age (RR 1.09; 95% CI, 1.02-1.2), higher loading propofol doses (RR 1.4; 95% CI, 1.1-1.8), and smoking (RR 1.9; 95% CI, 1.3-2.9) were associated with higher rates of SRAE.

LIMITATIONS

Non-randomized study.

CONCLUSION

A significant number of patients undergoing routine EGD and colonoscopy are at risk for OSA. SB+ patients are not at higher risk for AI or SRAE. However, other risk factors for AI and SRAE have been identified and must be taken into account to optimize patient safety.

Colorectal cancer and the elderly

Colorectal cancer and precancerous adenomas disproportionately affect the elderly, necessitating the need for screening and surveillance in this group. However, screening and surveillance decisions in the elderly can be challenging. Special considerations such as comorbid medical conditions, functional status, and cognitive ability play a role in one's decisions regarding the utility of screening and surveillance as well as the success and safety of various screening modalities. This article explores the evidence for screening and surveillance in the elderly, and addresses key challenges unique to this population.

Preprocedural considerations in gastrointestinal endoscopy

The current practice of open-access endoscopy allows primary care and other non-gastroenterology physicians to directly refer patients for routine gastrointestinal endoscopic procedures. Open-access endoscopy is considered to be more cost-effective and time efficient than the traditional practice of referring patients for preprocedural consultation with a gastrointestinal endoscopist. Several studies have evaluated the performance of endoscopic procedures in an open-access environment and the utility of structured referral mechanisms to ensure safe and appropriately indicated procedures. This review focuses on 4 common preprocedural issues in gastrointestinal endoscopy encountered by primary care physicians: management of anticoagulation and antiplatelet therapy, indication for prophylactic antibiotic drug therapy, need for anesthesia-assisted sedation, and management of poor bowel preparation. We summarize the current guidelines that address these 4 common preprocedural issues to facilitate safe and clinically appropriate procedures in open-access endoscopy.

Endoscopic retrograde cholangiopancreatography under moderate sedation and factors predicting need for anesthesiologist directed sedation: A county hospital experience

AIM

To evaluate variables associated with failure of gastroenterologist directed moderate sedation (GDS) during endoscopic retrograde cholangiopancreatography (ERCP) and derive a predictive model for use of anesthesiologist directed sedation (ADS) in selected patients.

METHODS

With institutional review board approval, we retrospectively analyzed consecutive records of all patients who underwent ERCPs between July 1, 2009 to October 1, 2011 to identify patient related and procedure related factors which could predict failure of GDS. For patient related factors, we abstracted and analyzed data regarding the age, gender, ethnicity, alcohol and illicit drug use habits. For procedure related factors, we abstracted data regarding initial or repeat procedures, indication for performing ERCP, the interventions performed during ERCP, and the grade d difficulty of cannulation as defined in the American Society for Gastrointestinal Endoscopy guidelines. Our outcome of interest was procedural success. If the procedure was not successful, the reasons for failure of procedures were recorded along with immediate post procedure complications. Multivariate analysis was then performed to define factors associated with failure of GDS and a model constructed to predict requirement of ADS.

RESULTS

Fourteen percent of patients undergoing GDS could not complete the procedure due to intolerance and 2% due to cardiovascular complications. Substance abuse, male gender, black race and alcohol use were significant predictors of failure of GDS on univariate analysis and substance abuse and higher grade of procedure remained significant on multivariate analysis. Using our predictive model where the presence of substance abuse was given 1 point and planned grade of intervention was scored from 1-3, only 12% patients with a score of 1 would require ADS due to failure of GDS, compared to 50% with a score of 3 or higher.

CONCLUSION

We conclude that ERCP under GDS is safe and effective for low grade procedures, and ADS should be judiciously reserved for procedures which have a higher risk of failure with moderate sedation.

Complications following colonoscopy with anesthesia assistance: a population-based analysis

IMPORTANCE

Deep sedation for endoscopic procedures has become an increasingly used option but, because of impairment in patient response, this technique also has the potential for a greater likelihood of adverse events. The incidence of these complications has not been well studied at a population level.

DESIGN

Population-based study.

SETTING AND PARTICIPANTS

Using a 5% random sample of cancer-free Medicare beneficiaries who resided in one of the regions served by a SEER (Surveillance, Epidemiology, and End Results) registry, we identified all procedural claims for outpatient colonoscopy without polypectomy from January 1, 2000, through November 30, 2009.

INTERVENTION

Colonoscopy without polypectomy, with or without the use of deep sedation (identified by a concurrent claim for anesthesia services).

MAIN OUTCOME MEASURES

The occurrence of hospitalizations for splenic rupture or trauma, colonic perforation, and aspiration pneumonia within 30 days of the colonoscopy.

RESULTS

We identified a total of 165 527 procedures in 100 359 patients, including 35 128 procedures with anesthesia services (21.2%). Selected postprocedure complications were documented after 284 procedures (0.17%) and included aspiration (n = 173), perforation (n = 101), and splenic injury (n = 12). (Some patients had >1 complication.) Overall complications were more common in cases with anesthesia assistance (0.22% [95% CI, 0.18%-0.27%]) than in others (0.16% [0.14%-0.18%]) (P < .001), as was aspiration (0.14% [0.11%-0.18%] vs 0.10% [0.08%-0.12%], respectively; P = .02). Frequencies of perforation and splenic injury were statistically similar. Other predictors of complications included age greater than 70 years, increasing comorbidity, and performance of the procedure in a hospital setting. In multivariate analysis, use of anesthesia services was associated with an increased complication risk (odds ratio, 1.46 [95% CI, 1.09-1.94]).

CONCLUSIONS AND RELEVANCE

Although the absolute risk of complications is low, the use of anesthesia services for colonoscopy is associated with a somewhat higher frequency of complications, specifically, aspiration pneumonia. The differences may result in part from uncontrolled confounding, but they may also reflect the impairment of normal patient responses with the use of deep sedation.

Regional variation in anesthesia assistance during outpatient colonoscopy is not associated with differences in polyp detection or complication rates

BACKGROUND & AIMS

We investigated the rate and predictors of anesthesia assistance during outpatient colonoscopy and whether anesthesia assistance is associated with colonoscopy interventions and outcomes.

METHODS

We performed a retrospective cohort study using a 20% sample of Medicare administrative claims submitted during the 2003 calendar year. We analyzed data from 328,177 adults, 66 years old or older, who underwent outpatient colonoscopy examinations.

RESULTS

Overall, 8.7% of outpatient colonoscopies were performed with anesthesia assistance. In multivariate analysis, independent predictors of anesthesia assistance included black race, female sex, and a nonscreening indication; anesthesia assistance increased with median income and comorbidities. General and colorectal surgeons, fewer years in their practice, and nonhospital site of service were also significantly associated with anesthesia assistance. The strongest predictor of anesthesia assistance was the Medicare carrier, with odds ratios ranging from 0.22 (95% confidence interval: 0.12-0.43) for the Arkansas carrier (crude rate 0.9%) to 9.90 (95% confidence interval: 7.92-12.39) for the Empire carrier in New York area (crude rate 35.3%) compared with the Wisconsin carrier (crude rate 4.3%). There was also considerable variation among endoscopists; 75% of providers had no colonoscopies with anesthesia assistance recorded in their dataset, and 4.5% of providers had anesthesia assistance in at least three quarters of their examinations. Anesthesia assistance was not associated with the diagnosis of polyps, the performance of biopsy or polypectomy, or complications in multivariate analyses.

CONCLUSIONS

There are significant variations among regions and sites of service in anesthesia assistance during outpatient colonoscopies of Medicare beneficiaries. Although this variation has considerable economic implications, it was not associated with measures of patient risk or outcomes, such as polyp detection or procedure-related complications.

Use of anesthesia on the rise in gastrointestinal endoscopy

Conscious sedation has been the standard of care for many years for gastrointestinal endoscopic procedures. As procedures have become more complex and lengthy, additional medications became essential for adequate sedation. Often time's deep sedation is required for procedures such as endoscopic retrograde cholangiography which necessitates higher doses of narcotics and benzodiazepines or even use of other medications such as ketamine. Given its pharmacologic properties, propofol was rapidly adopted worldwide to gastrointestinal endoscopy for complex procedures and more recently to routine upper and lower endoscopy. Many studies have shown superiority for both the physician and patient compared to standard sedation. Nevertheless, its use remains highly controversial. A number of studies worldwide show that propofol can be given safely by endoscopists or nurses when well trained. Despite this wealth of data, at many centers its use has been prohibited unless administered by anesthesiology. In this commentary, we review the use of anesthesia support for endoscopy in the United States based on recent data and its implications for gastroenterologists worldwide.

Automated before-procedure electronic health record screening to assess appropriateness for GI endoscopy and sedation

BACKGROUND

Endoscopists are performing greater numbers of procedures, often on patients with complex conditions, in ambulatory settings because of changing patient demographics and referral patterns. To assist with the pre-procedure assessment of such patients, we deployed an advanced electronic health record tool, the Queriable Patient Inference Dossier (QPID), to review clinical histories and generate e-mail alerts to providers, based on clinical guidelines.

OBJECTIVE

Study the feasibility of an automated pre-procedure alert system for outpatient endoscopy.

DESIGN

We retrospectively reviewed 5 physicians' use of the application and their responses to the alerts.

SETTING

A hospital-based endoscopy unit and its two satellite outpatient clinics, Boston area, Massachusetts.

PATIENTS

Adult outpatients referred for endoscopy with moderate sedation.

INTERVENTION

Pre-procedure alerts automatically sent 7 days before the procedure, highlighting any conditions/clinical history that may affect management of the patient.

MAIN OUTCOME MEASUREMENTS

Physician use of the pre-procedure alert system and its effect on patient management.

RESULTS

We studied 1682 procedures that met inclusion criteria for review by QPID and 364 alerts (1.6% of the eligible procedures). Nearly 80% of the alerts were reviewed and responded to by the physicians, and 70 total alerts resulted in a change in patient management (4.2% of eligible procedures).

LIMITATIONS

The small size of the study group and the low rate of adverse events during the study period limit our findings. We thus plan to conduct a larger follow-up study to demonstrate changes in safety and efficiency.

CONCLUSION

Use of advanced electronic health record technologies, such as QPID, may improve provider efficiency and patient outcomes in endoscopy units.

Quality assurance for gastrointestinal endoscopy

PURPOSE OF REVIEW

This review concerns quality assurance for gastrointestinal endoscopic procedures, especially colonoscopy and will emphasize research and guidelines published since January 2011. Important articles from previous years have been included for background.

RECENT FINDINGS

Critical lapses in endoscope processing and administration of intravenous sedation alerted us to the infection risk of endoscopy. Increases in cost of colonoscopy, evidence for overuse and studies demonstrating missed cancers have led some to question the value of endoscopy. Despite these setbacks, the National Polyp Study (NPS) consortium published their long-term follow-up of the original NPS patients and confirmed that colonoscopy with polyp removal can reduce the risk of colorectal cancer for an extended period. In this article, we will focus on ways to improve the value of outpatient colonoscopy.

SUMMARY

The United States national quality improvement agenda recently became organized into a more coordinated effort spearheaded by several public and private entities. They comprise the infrastructure by which performance measures are developed and implemented as accountability standards. Understanding wherein a gastroenterology (GI) practice fits into this infrastructure and learning ways we can improve our endoscopic practice is important for physicians who provide this vital service to patients. This article will provide a roadmap for developing a quality assurance program for endoscopic practice.