Anesthesia Service Use During Outpatient Gastroenterology Procedures Continued to Increase From 2010 to 2013 and Potentially Discretionary Spending Remained High

Propofol sedation does not improve measures of colonoscopy quality but increase cost - findings from a large population-based cohort study

Background

Propofol is often used for sedation during colonoscopy. We assessed the impact of propofol sedation on colonoscopy related quality metrics and cost in a population-based cohort study.

Methods

All colonoscopies performed at 21 hospitals in the province of Ontario, Canada, during an 18-month period, from April 1, 2017 to October 31, 2018, using either propofol or conscious sedation were evaluated. The primary outcome was adenoma detection rate (ADR) and secondary outcomes were sessile serrated polyp detection rate (ssPDR), polyp detection rate (PDR), cecal intubation rate (CIR), and perforation rate. Binary outcomes were assessed using a modified Poisson regression model adjusted for clustering and potential confounders based on patient, procedure, and physician characteristics.

Findings

A total of 46,634 colonoscopies were performed, of which 16,408 (35.2%) received propofol and 30,226 (64.8%) received conscious sedation. Compared to conscious sedation, the use of propofol was associated with a lower ADR (24.6% vs. 27.0%, p < 0.0001) but not ssPDR (5.0% vs. 4.7%, p = 0.26), PDR (40.5% vs 40.4%, p = 0.79), CIR (97.1% vs. 96.8%, p = 0.15) or perforation rate (0.04% vs. 0.06%, p = 0.45). On multi-variable analysis, propofol sedation was not associated with any differences in ADR (RR = 0.90, 95% CI 0.74-1.10, p = 0.30), ssPDR (RR = 1.20, 95% CI 0.90-1.60, p = 0.22), PDR (RR = 1.00, 95% CI 0.90-1.11, p = 0.99), or CIR (RR = 1.00, 95% CI 0.80-1.26, p = 0.99). The additional cost associated with propofol sedation was $12,730,496 for every 100,000 cases.

Interpretation

The use of propofol sedation was not associated with improved colonoscopy related quality metrics but increased costs. The routine use of propofol for colonoscopy should be reevaluated.

Funding

None.

Safety considerations with the current ambulatory trends: more complicated procedures and more complicated patients

In the last quarter of a century, the backdrop of appropriate ambulatory and office-based surgeries has changed dramatically. Procedures that were traditionally done in hospitals or patients being admitted after surgery are migrating to the outpatient setting and being discharged on the same day, respectively, at a remarkable rate. In the face of this exponential growth, anesthesiologists are constantly being challenged to maintain patient safety by understanding the appropriate patient selection, procedure, and surgical location. Recently published literature supports the trend of higher, more medically complex patients, and more complicated procedures shifting towards the outpatient arena. Several reasons that may account for this include cost incentives, advancement in anesthesia techniques, enhanced recovery after surgery (ERAS) protocols, and increased patient satisfaction. Anesthesiologists must understand that there is a lack of standardized state regulations regarding ambulatory surgery centers (ASCs) and office-based surgery (OBS) centers. Current and recently graduated anesthesiologists should be aware of the safety concerns related to the various non-hospital-based locations, the sustained growth and demand for anesthesia in the office, and the expansion of mobile anesthesia practices in the US in order to keep up and practice safely with the professional trends. Continuing procedural ambulatory shifts will require ongoing outcomes research, likely prospective in nature, on these novel outpatient procedures, in order to develop risk stratification and prediction models for the selection of the proper patient, procedure, and surgery location.

Organizational Factors Driving Selection of Gastrointestinal Endoscopic Sedation in Veterans Health Administration and Community Settings

INTRODUCTION

Previous studies suggest that unmeasured organizational factors drive variability in anesthesia-assisted sedation (AA) use.

METHODS

A mixed-methods study of 11 Veterans Health Administration and community gastrointestinal endoscopy sites; qualitative interviews of key sedation decision-makers.

RESULTS

Three key interview themes were identified: (i) Increased AA demand and changes in endoscopist sedation training in fellowship drove site-level AA capacity expansion; (ii) this expansion further influenced sedation decisions in favor of AA use; and (iii) additional organizational factors influencing AA use included site-level decision-making processes and differences between Veterans Health Administration and community practice economics/mission.

DISCUSSION

Key organizational factors drive variability in AA use across settings.

The Quality and Safety of Sedation and Monitoring in Adults Undergoing Nonoperative Transesophageal Echocardiography

Sedation is an essential component of the transesophageal echocardiography (TEE) procedure for patient comfort. The use and the clinical implications of cardiologist-supervised (CARD-Sed) versus anesthesiologist-supervised sedation (ANES-Sed) are unknown. We reviewed nonoperative TEE records from a single academic center over a 5-year period and identified CARD-Sed and ANES-Sed cases. We evaluated the impact of patient co-morbidities, cardiac abnormalities on transthoracic echocardiogram, and the indication for TEE on sedation practice. We analyzed the use of CARD-Sed versus ANES-Sed in light of institutional guidelines; the consistency in the documentation of preprocedural risk stratification; and the incidence of cardiopulmonary events, including hypotension, hypoxia, and hypercarbia. A total of 914 patients underwent TEE, with 475 patients (52%) receiving CARD-Sed and 439 patients (48%) receiving ANES-Sed. The presence of obstructive sleep apnea (p = 0.008), a body mass index of >45 kg/m2 (p <0.001), an ejection fraction of <30% (p <0.001), and pulmonary artery systolic pressure of more than 40 mm Hg (p = 0.015) were all associated with the use of ANES-Sed. Of the 178 patients (19.5%) with at least 1 caution to nonanesthesiologist-supervised sedation by the institutional screening guideline, 65 patients (36.5%) underwent CARD-Sed. In the ANES-Sed group, where intraprocedural vital signs and medications were documented in all cases, hypotension (n = 91, 20.7%), vasoactive medication use (n = 121, 27.6%), hypoxia (n = 35, 8.0%), and hypercarbia (n = 50, 11.4%) were noted. This single-center study revealed that 48% of the nonoperative TEE used ANES-Sed over 5 years. Sedation-related hemodynamic changes and respiratory events were not infrequently encountered during ANES-Sed.

AGA White Paper: Challenges and Gaps in Innovation for the Performance of Colonoscopy for Screening and Surveillance of Colorectal Cancer

In 2018, the American Gastroenterological Association's Center for GI Innovation and Technology convened a consensus conference, entitled "Colorectal Cancer Screening and Surveillance: Role of Emerging Technology and Innovation to Improve Outcomes." The conference participants, which included more than 60 experts in colorectal cancer, considered recent improvements in colorectal cancer screening rates and polyp detection, persistent barriers to colonoscopy uptake, and opportunities for performance improvement and innovation. This white paper originates from that conference. It aims to summarize current patient- and physician-centered gaps and challenges in colonoscopy, diagnostic and therapeutic challenges affecting colonoscopy uptake, and the potential use of emerging technologies and quality metrics to improve patient outcomes.

Anesthesia for digestive tract endoscopy

PURPOSE OF REVIEW

Nonoperating room anesthesia for digestive tract endoscopy has its own specificities and requires practical training. Monitoring devices, anesthetic drugs, understanding of procedures and management of complications are critical aspects.

RECENT FINDINGS

New data are available regarding risk factors for intra- and postoperative complications (based on anesthesia registries), airway management, new anesthetic drugs, techniques of administration and management of advances in interventional endoscopy procedures.

SUMMARY

Digestive tract endoscopy is a common procedure that takes place outside the operating room most of the time and has become more and more complex due to advanced invasive procedures. Prior evaluation of the patient's comorbidities and a good understanding of the objectives and constraints of the endoscopic procedures are required. Assessing the risk of gastric content aspiration is critical for determining appropriate anesthetic protocols. The availability of adequate monitoring (capnographs adapted to spontaneous ventilation, bispectral index), devices for administration of anesthetic/sedative agents (target-controlled infusion) and oxygenation (high flow nasal oxygenation) guarantees the quality of sedation and patient' safety during endoscopic procedures. Knowledge of the specificities of each interventional endoscopic procedure (endoscopic retrograde cholangiopancreatography, submucosal dissection) allows preventing complications during anesthesia.

Factors associated with non-attendance at appointments in the gastroenterology endoscopy unit: a retrospective cohort study

Background and Aims

Gastrointestinal (GI) endoscopy is a limited health resource because of a scarcity of qualified personnel and limited availability of equipment. Non-adherence to endoscopy appointments therefore wastes healthcare resources and may compromise the early detection and treatment of GI diseases. We aimed to identify factors affecting non-attendance at scheduled appointments for GI endoscopy and thus improve GI healthcare outcomes.

Methods

This was a single-center retrospective cohort study performed at a tertiary hospital gastroenterology endoscopy unit, 12 months before and 12 months after the start of the COVID-19 pandemic. We used multiple logistic regression analysis to identify variables associated with non-attendance at scheduled appointments.

Results

Overall, 5,938 appointments were analyzed, and the non-attendance rate was 18.3% (1,088). The non-attendance rate fell significantly during the pandemic (22.6% vs. 11.6%, p < 0.001). Multivariable regression analysis identified the absence of deep sedation (OR: 3.253, 95% CI [2.386-4.435]; p < 0.001), a referral from a physician other than a gastroenterologist (OR: 1.891, 95% CI [1.630-2.193]; p < 0.001), a longer lead time (OR: 1.006, 95% CI [1.004-1.008]; p < 0.001), and female gender (OR: 1.187, 95% CI [1.033-1.363]; p = 0.015) as associated with appointment non-attendance.

Conclusions

Female patients, those undergoing endoscopic procedures without deep sedation, those referred by physicians other than gastroenterologists, and with longer lead time were less likely to adhere to appointments. Precautions should be directed at patients with one or more of these risk factors, and for those scheduled for screening procedures during the COVID-19 pandemic.

Endoscopic Screening Program for Control of Esophageal Adenocarcinoma in Varied Populations: A Comparative Cost-Effectiveness Analysis

BACKGROUND & AIMS

Guidelines suggest endoscopic screening for esophageal adenocarcinoma (EAC) among individuals with symptoms of gastroesophageal reflux disease (GERD) and additional risk factors. We aimed to determine at what age to perform screening and whether sex and race should influence the decision.

METHODS

We conducted comparative cost-effectiveness analyses using 3 independent simulation models. For each combination of sex and race (White/Black, 100,000 individuals each), we considered 41 screening strategies, including one-time or repeated screening. The optimal strategy was that with the highest effectiveness and an incremental cost-effectiveness ratio <$100,000 per quality-adjusted life-year gained.

RESULTS

Among White men, 536 EAC deaths were projected without screening, and screening individuals with GERD twice at ages 45 and 60 years was optimal. Screening the entire White male population once at age 55 years was optimal in 26% of probabilistic sensitivity analysis runs. Black men had fewer EAC deaths without screening (n = 84), and screening those with GERD once at age 55 years was optimal. Although White women had slightly more EAC deaths (n = 103) than Black men, the optimal strategy was no screening, although screening those with GERD once at age 55 years was optimal in 29% of probabilistic sensitivity analysis runs. Black women had a very low burden of EAC deaths (n = 29), and no screening was optimal, as benefits were very small and some strategies caused net harm.

CONCLUSIONS

The optimal strategy for screening differs by race and sex. White men with GERD symptoms can potentially be screened more intensely than is recommended currently. Screening women is not cost-effective and may cause net harm for Black women.

Association between sedation and small neoplasm detection during diagnostic esophagogastroduodenoscopy: a propensity score-matched retrospective study

BACKGROUND

Esophagogastroduodenoscopy (EGD) is fundamental for detecting upper gastrointestinal (GI) neoplasms. However, the impact of sedation on small neoplasm detection during EGD has not been evaluated. The aim of this study was to investigate whether EGD with sedation could improve small upper GI neoplasm detection.

METHODS

This propensity score-matched retrospective study analyzed the medical records of outpatients undergoing diagnostic EGD at a large tertiary center between January 2013 and December 2018. The primary outcome was the detection rate of small upper GI neoplasms (≤10 mm). The secondary outcomes were biopsy rate and small neoplasms in different anatomic subsites.

RESULTS

After propensity score matching, 20,052 patients undergoing diagnostic EGD with or without propofol sedation were identified. A higher detection rate of small upper GI neoplasms was observed in the sedation group (2.80% vs. 2.02%; p < .001). In particular, the detection rate of small cancers in the sedation group was 3-fold higher than that in the no-sedation group (0.16% vs. 0.05%; p = .023). Small neoplasms were more likely identified at the gastric antrum (1.60% vs. 1.09%; p = .002) and angulus (0.66% vs. 0.45%; p = .044) in the sedation group. In addition, endoscopists were more likely to take biopsies when performing sedated EGD (41.4% vs. 36.4%, p < .001), and a higher biopsy rate was associated with an increased detection rate of small neoplasms.

CONCLUSIONS

Sedation was significantly associated with a higher detection rate of small upper GI neoplasms and might be recommended for improving the quality of EGD.

Academy of Medicine, Singapore clinical guideline on the use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting

INTRODUCTION

In Singapore, non-anaesthesiologists generally administer sedation during gastrointestinal endoscopy. The drugs used for sedation in hospital endoscopy centres now include propofol in addition to benzodiazepines and opiates. The requirements for peri-procedural monitoring and discharge protocols have also evolved. There is a need to develop an evidence-based clinical guideline on the safe and effective use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting.

METHODS

The Academy of Medicine, Singapore appointed an expert workgroup comprising 18 gastroenterologists, general surgeons and anaesthesiologists to develop guidelines on the use of sedation during gastrointestinal endoscopy. The workgroup formulated clinical questions related to different aspects of endoscopic sedation, conducted a relevant literature search, adopted Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology and developed recommendations by consensus using a modified Delphi process.

RESULTS

The workgroup made 16 recommendations encompassing 7 areas: (1) purpose of sedation, benefits and disadvantages of sedation during gastrointestinal endoscopy; (2) pre-procedural assessment, preparation and consent taking for sedation; (3) Efficacy and safety of drugs used in sedation; (4) the role of anaesthesiologist administered sedation during gastrointestinal endoscopy; (5) performance of sedation; (6) post-sedation care and discharge after sedation; and (7) training in sedation for gastrointestinal endoscopy for non-anaesthesiologists.

CONCLUSION

These recommendations serve to guide clinical practice during sedation for gastrointestinal endoscopy by non-anaesthesiologists in the hospital setting.

Role of Anesthesia in Endoscopic Operations

Utilization of anesthesia service in endoscopic operations can facilitate the procedural conditions and improve patient satisfaction. Comprehensive preprocedural/preanesthetic assessment should be preceded with focus on medical history, disorders that increase risk of aspiration, NPO status, ASA status, and airway evaluations, as these play an important role in perioperative complications. Preanesthetic assessment should serve as a guide to determining the appropriate depth of sedation for the patient, and indications for general anesthesia with endotracheal intubation should be reviewed. Finally, anesthesia care can be successfully implemented in ambulatory settings, including ambulatory surgery center and ambulatory endoscopy center with appropriate equipment and scheduling.

Efficacy of a small-caliber colonoscope for pain in female patients during unsedated colonoscopy: a randomized controlled study

Background and study aims  Female sex has been identified as a factor increasing patients' pain during colonoscopy. The aim of this randomized controlled study was to investigate the efficacy of a small-caliber colonoscope, PCF-PQ260 L, for limiting pain in women during unsedated colonoscopy. Patients and methods  Women who underwent unsedated colonoscopy were randomly allocated to either the small-caliber or standard colonoscope group. The primary outcome was overall pain and secondary outcomes were maximum pain and procedural measures. In addition, the effects of colonoscope type were analysed using analysis of covariance and logistic regression with adjustment for stratification factors, age and prior abdomino-pelvic surgery. Results  A total of 220 women were randomly assigned to the small-caliber (n = 110) or standard (n = 110) colonoscope groups. Overall and maximum pain scores were significantly lower in the small-caliber colonoscope group than the standard colonoscope group (overall pain, 20.0 vs. 32.4, P < 0.0001; maximum pain, 28.9 vs. 47.2, P < 0.0001). The small-caliber colonoscope group achieved a superior cecal intubation rate (99 % vs. 93 %, P = 0.035). The rate of patient acceptance of unsedated colonoscopy in the future was higher in the small-caliber colonoscope group than in the standard colonoscope group (98 % vs. 87 %, P = 0.003). In addition, the small-caliber colonoscope was superior with respect to reducing pain and improving the rate of patient acceptance of unsedated colonoscopy with adjustment. Conclusions  This study demonstrates the efficacy of the small-caliber colonoscope for reducing pain in women and improving their rate of acceptance of unsedated colonoscopy.

Safety of endoscopist-directed nurse-administered balanced propofol sedation in patients with severe systemic disease (ASA class III)

BACKGROUND AND AIMS

The safety of endoscopist-directed nurse-administered propofol sedation (EDNAPS) has been demonstrated in low-risk patients (American Society of Anesthesiologists [ASA] class I and II). There are limited data regarding the safety of EDNAPS for endoscopic procedures in ASA class III patients. The purpose of this study was to determine the safety of EDNAPS for routine outpatient endoscopy in this population.

METHODS

We retrospectively reviewed all outpatient EGDs and colonoscopies performed with EDNAPS at the University of Utah from January 2015 to November 2018. Exclusion criteria were inpatient procedures, combined procedures, ASA IV or higher, use of continuous or bilevel positive airway pressure at the start of the procedure, or procedures performed by a nongastroenterologist. Major adverse events were defined as intubation or death. Minor adverse events were defined as hypoxia, hypotension, bradycardia, or need for airway interventions. Patients were stratified by procedure type and ASA I/II status and were compared with patients with ASA III status and matched according to age, gender, and the involvement of a fellow in a 3 to 1 fashion.

RESULTS

The final sample size was 18,910 colonoscopy procedures (17,205 patients) and 9178 EGD procedures (6827 patients). In both colonoscopy and EGD procedures, there were no major adverse events such as intubation, need for resuscitation, or death. The rates of any airway intervention, jaw thrust, oral nasal airway, or use of positive pressure ventilation were low in both procedure types and not different between ASA I/II and ASA III patients.

CONCLUSION

EDNAPS is safe in both ASA I/II and ASA class III patients undergoing routine outpatient endoscopy.

Prospective Comparison of Moderate Conscious Sedation and Anesthesia Assistance for the Performance of Endoscopic Retrograde Cholangiopancreatography (ERCP)

OBJECTIVES

Recent trends have favored the use of anesthesia personnel more frequently for advanced endoscopic procedures. We hypothesize a selective sedation approach based on patient and procedural factors using either moderate conscious sedation (MCS) or general anesthesia (GA) will result in similar outcomes and safety with significant cost savings.

METHODS

A 12-month prospective study of all adult endoscopic retrograde cholangiopancreatography (ERCPs) performed at a tertiary medical center was enrolled. Technical success, cannulation rates, procedural related complications, procedure time, and cost were compared between MCS and GA.

RESULTS

A total of 876 ERCPs were included in the study with 74% performed with MCS versus 26% with GA. The intended intervention was completed successfully in 95% of cases with MCS versus 96% cases with GA (p = 0.59). Cannulation success rates with MCS were 97.5 versus 97.8% with GA (p = 0.81). Overall, adverse event rates were similar in both groups (MCS: 6.6% vs. GA: 9.2%, p = 0.21). Mean procedure time was less for MCS versus GA, 18.3 and 26 minutes, respectively (p < 0.0001). Selective use of MCS vs. universal sedation with GA resulted in estimated savings of $8,190 per case and $4,735,202 per annum.

CONCLUSIONS

Preselection of ERCP sedation of moderate conscious sedation versus general anesthesia based upon patient risk factors and planned therapeutic intervention allows for the majority of ERCPs to be completed with MCS with similar rates of technical success and improvement in resource utilization and cost savings compared to performing ERCPs universally with anesthesia assistance.

Nurse-Administered Propofol Continuous Infusion Sedation: A New Paradigm for Gastrointestinal Procedural Sedation

INTRODUCTION

Nurse-Administered Propofol Continuous Infusion Sedation (NAPCIS) is a new nonanesthesia propofol delivery method for gastrointestinal endoscopy. NAPCIS is adopted from the computer-assisted propofol sedation (CAPS) protocol. We evaluated the effectiveness, efficiency, and safety of NAPCIS in low-risk subjects.

METHODS

Between December 2016 and July 2017, patients who underwent esophagogastroduodenoscopy or colonoscopy with NAPCIS at our center were compared against 2 historical control groups of similar patients who had undergone procedures with CAPS or midazolam and fentanyl (MF) sedation.

RESULTS

The mean age of the NAPCIS cohort (N = 3,331) was 55.2 years (45.8% male) for 945 esophagogastroduodenoscopies and 57.8 years (48.7% male) for 2,386 colonoscopies. The procedural success rates with NAPCIS were high (99.1%-99.2%) and similar to those seen in 3,603 CAPS (98.8%-99.0%) and 3,809 MF (99.0%-99.3%) controls. NAPCIS recovery times were shorter than both CAPS and MF (24.8 vs 31.7 and 52.4 minutes, respectively; P < 0.001). On arrival at the recovery unit, 86.6% of NAPCIS subjects were recorded as "Awake" compared with 82.8% of CAPS and 40.8% of MF controls (P < 0.001). Validated clinician and patient satisfaction scores were generally higher for NAPCIS compared with CAPS and MF subjects. For NAPCIS, there were only 4 cases of oxygen desaturation requiring transient mask ventilation and no serious sedation-related complications. These low complication rates were similar to those seen with CAPS (8 cases of mask ventilation) and MF (3 cases).

DISCUSSION

NAPCIS seems to be a safe, effective, and efficient means of providing moderate sedation for upper endoscopy and colonoscopy in low-risk patients.

[The Guideline "Sedation for Gastrointestinal Endoscopy"]

The guideline "Sedation for gastrointestinal endoscopy" (AWMF-register-no. 021/014) was published initially in 2008. Because of new and developing evidence, the guideline was updated in 2015. The aim of the guideline is to define the necessary structural, equipment and personnel requirements that contribute to minimizing the risk of sedation for endoscopy. In view of the high and increasing significance of gastrointestinal endoscopy, the guideline will remain highly relevant in the future. Essential aspects are the selection of sedatives/hypnotics, structural requirements, personnel requirements with regard to number, availability and training, management of complications and quality assurance. In this article, the development and evaluation of the evidence and its influence on the practical implementation, in particular for anaesthesia, are highlighted.

Sedation practices for routine gastrointestinal endoscopy: a systematic review of recommendations

BACKGROUND

Sedation is commonly used in gastrointestinal endoscopy; however, considerable variability in sedation practices has been reported. The objective of this review was to identify and synthesize existing recommendations on sedation practices for routine gastrointestinal endoscopy procedures.

METHODS

We systematically reviewed guidelines and position statements identified through a search of PubMed, guidelines databases, and websites of relevant professional associations from January 1, 2005 to May 10, 2019. We included English-language guidelines/position statements with recommendations relating to sedation for adults undergoing routine gastrointestinal endoscopy. Documents with guidance only for complex endoscopic procedures were excluded. We extracted and synthesized recommendations relating to: 1) choice of sedatives, 2) sedation administration, 3) personnel responsible for monitoring sedated patients, 4) skills and training of individuals involved in sedation, and 5) equipment required for monitoring sedated patients. We assessed the quality of included documents using the Appraisal of Guidelines for Research & Evaluation (AGREE) II tool.

RESULTS

We identified 19 guidelines and 7 position statements meeting inclusion criteria. Documents generally agreed that a single, trained registered nurse can administer moderate sedation, monitor the patient, and assist with brief, interruptible tasks. Documents also agreed on the routine use of pulse oximetry and blood pressure monitoring during endoscopy. However, recommendations relating to the drugs to be used for sedation, the healthcare personnel capable of administering propofol and monitoring patients sedated with propofol, and the need for capnography when monitoring sedated patients varied. Only 9 documents provided a grade or level of evidence in support of their recommendations.

CONCLUSIONS

Recommendations for sedation practices in routine gastrointestinal endoscopy differ across guidelines/position statements and often lack supporting evidence with potential implications for patient safety and procedural efficiency.

Propofol versus midazolam with or without short-acting opioids for sedation in colonoscopy: a systematic review and meta-analysis of safety, satisfaction, and efficiency outcomes

BACKGROUND AND AIMS

Propofol is increasingly being used for sedation in colonoscopy; however, its benefits over midazolam (± short-acting opioids) are not well quantified. The objective of this study was to compare safety, satisfaction, and efficiency outcomes of propofol versus midazolam (± short-acting opioids) in patients undergoing colonoscopy.

METHODS

We systematically searched Medline, Embase, and the Cochrane library (to July 30, 2018) for randomized controlled trials of colonoscopies performed with propofol versus midazolam (± short-acting opioids). We pooled odds ratios for cardiorespiratory outcomes using mixed-effects conditional logistic models. We pooled standardized mean differences (SMDs) for patient and endoscopist satisfaction and efficiency outcomes using random-effects models.

RESULTS

Nine studies of 1427 patients met the inclusion criteria. There were no significant differences in cardiorespiratory outcomes (hypotension, hypoxia, bradycardia) between sedative groups. Patient satisfaction was high in both groups, with most patients reporting willingness to undergo a future colonoscopy with the same sedative regimen. In the meta-analysis, patients sedated with propofol had greater satisfaction than those sedated with midazolam (± short-acting opioids) (SMD, .54; 95% confidence interval [CI], .30-.79); however, there was considerable heterogeneity. Procedure time was similar between groups (SMD, .15; 95% CI, .04-.27), but recovery time was shorter in the propofol group (SMD, .41; 95% CI, .08-.74). The median difference in recovery time was 3 minutes, 6 seconds shorter in patients sedated with propofol.

CONCLUSIONS

Both propofol and midazolam (± short-acting opioids) result in high patient satisfaction and appear to be safe for use in colonoscopy. The marginal benefits to propofol are small improvements in satisfaction and recovery time.

Effect of sevoflurane anaesthesia on nasal mask in endoscopic retrograde cholangiopancreatography: is it a preferred alternative?

Background/aim

Endoscopic retrograde cholangiopancreatography (ERCP) often requires deep sedation. Propofol provides adequate sedation and amnesia at subhypnotic doses, but safe guarding the patient’s airway is important for preventing respiratory depression or u28ba events. This study compared sedation levels, operator satisfaction, intraoperative and recovery characteristics using sevoflurane with nasal mask and propofol in ERCP.

Material and methods

Sixty-one patients underwent ERCP (Group I: propofol, n = 31; Group II, sevoflurane, n = 30), with sedation controlled by the Ramsay sedation scale (RSS). The patients’ demographic data, procedure length, overall drug dose, hemodynamic changes, duration of recovery and Aldrete scores during recovery were evaluated. In addition, satisfaction of the gastroenterologist was evaluated.

Results

The mean sphincterotomy satisfaction scores were statistically significant (P= 0.043). The Aldrete scores and RSS of the groups were similar; there was a significant difference between groups at the beginning of the procedure regarding peripheric oxygen saturations and Group II’s saturation levels increased during sedation.

Conclusion

In ERCP, propofol infusion provides shorter recovery duration and adequate sedation levels. Sevoflurane and oxygen with a nasal mask can be chosen to generate specific anaesthesia in patients, especially for strong airway support and safety treating hypoxemic patients.

Sedation During Endoscopy in Patients with Cirrhosis: Safety and Predictors of Adverse Events

BACKGROUND

Sedation during endoscopy in cirrhotic patients is typically via moderate sedation, most commonly using a combination of a benzodiazepine (i.e., midazolam) and narcotic (i.e., fentanyl) or with propofol using monitored anesthesia care (MAC). Here, we examined the safety of moderate sedation and MAC in patients with cirrhosis.

METHODS

This retrospective cohort study of cirrhotic patients undergoing endoscopy from a large academic medical center between 2010 and 2014 examined extensive clinical data including the following: past history, physical findings, laboratory results, and procedural adverse events. Adverse events were defined a priori and included hypoxia, hypotension, bleeding, and death.

RESULTS

We identified 2618 patients with cirrhosis who underwent endoscopic procedures; the mean age was 56 years, 36% were female, the mean Child-Pugh score was 9.3 (IQR: 8, 11), and Charlson Comorbidity Index score was 3.2 (IQR: 1, 4); 1157 had MAC; and 1461 had moderate sedation. There was no difference in the frequency of adverse events in MAC and moderate sedation groups, with a total of 15 adverse events (7/1157 MAC and 8/1461 moderate sedation). The most common procedure performed was esophagogastroduodenoscopy (EGD, n = 1667) and was associated with 10 adverse events. Overall, adverse events included bradycardia (1), hypoxia (7), bleeding (5), laryngospasm (1), and perforation (1). The frequency was similar for EGD, ERCP, and colonoscopy-each at a rate of 0.6%.

CONCLUSIONS

Adverse events in cirrhotic patients undergoing endoscopy appeared to be similar with moderate sedation or MAC, and the frequency was the same for different types of procedures.

Creation of a score to predict risk of high conscious sedation requirements in patients undergoing endoscopy

BACKGROUND AND AIMS

The administration of intravenous conscious sedation to patients undergoing GI endoscopy carries a risk of cardiopulmonary adverse events. Our study aim was to create a score that stratifies the risk of occurrence of either high-dose conscious sedation requirements or a failed procedure.

METHODS

Patients receiving endoscopy via endoscopist-directed conscious sedation were included. The primary outcome was occurrence of sedation failure, which was defined as one of the following: (1) high-dose sedation, (2) the need for benzodiazepine/narcotic reversal agents, (3) nurse-documented poor patient tolerance to the procedure, or (4) aborted procedure. High-dose sedation was defined as >10 mg of midazolam and/or >200 μg of fentanyl or the meperidine equivalent. Patients with sedation failure (n = 488) were matched to controls (n = 976) without a sedation failure by endoscopist and endoscopy date.

RESULTS

Significant associations with sedation failure were identified for age, sex, nonclonazepam benzodiazepine use, opioid use, and procedure type (EGD, colonoscopy, or both). Based on these 5 variables, we created the high conscious sedation requirements (HCSR) score, which predicted the risk of sedation failure with an area under the curve of 0.70. Compared with the patients with a risk score of 0, risk of a sedation failure was highest for patients with a score ≥3.5 (odds ratio, 17.31; P = 2 × 10^-14). Estimated area under the curve of the HCSR score was 0.68 (95% confidence interval, 0.63-0.72) in a validation series of 250 cases and 250 controls.

CONCLUSIONS

The HCSR risk score, based on 5 key patient and procedure characteristics, can function as a useful tool for physicians when discussing sedation options with patients before endoscopy.

Practice recommendations for the use of sedation in routine hospital-based colonoscopy

Objective

Although sedation improves patient experience during colonoscopy, there is great jurisdictional variability in sedative practices. The objective of this study was to develop practice recommendations for the use of moderate and deep sedation in routine hospital-based colonoscopy to facilitate standardisation of practice.

Design

We recruited 32 multidisciplinary panellists to participate in a modified Delphi process to establish consensus-based recommendations for the use of sedation in colonoscopy. Panel members participated in a values assessment survey followed by two rounds of anonymous online voting on preliminary practice recommendations. An inperson meeting was held between voting rounds to facilitate consensus-building. Consensus was defined as >60% agreement/disagreement with recommendation statements; >80% agreement/disagreement was considered indicative of strong consensus.

Results

Twenty-nine panellists participated in the values assessment survey. Panellists ranked all factors presented as important to the development of practice recommendations. The factor considered most important was patient safety. Patient satisfaction, procedural efficiency, and cost were considered less important. Strong consensus was achieved for all nine practice recommendations presented to the panel. These recommendations included that all endoscopists be able to perform colonoscopy with moderate sedation, that an endoscopist and a single trained nurse are sufficient for performing colonoscopy with moderate sedation, and that anaesthesia-provided deep sedation be used for select patients.

Conclusion

The recommendations presented in this study were agreed on by a multidisciplinary group and provide guidance for the use of sedation in routine hospital-based colonoscopy. Standardised sedation practices will promote safe, effective, and efficient colonoscopy for all patients.

Comparing blind spots of unsedated ultrafine, sedated, and unsedated conventional gastroscopy with and without artificial intelligence: a prospective, single-blind, 3-parallel-group, randomized, single-center trial

BACKGROUND AND AIMS

EGD is the most vital procedure for the diagnosis of upper GI lesions. We aimed to compare the performance of unsedated ultrathin transoral endoscopy (U-TOE), unsedated conventional EGD (C-EGD), and sedated C-EGD with or without the use of an artificial intelligence (AI) system.

METHODS

In this prospective, single-blind, 3-parallel-group, randomized, single-center trial, 437 patients scheduled to undergo outpatient EGD were randomized to unsedated U-TOE, unsedated C-EGD, or sedated C-EGD, and each group was then divided into 2 subgroups: with or without the assistance of an AI system to monitor blind spots during EGD. The primary outcome was the blind spot rate of these 3 groups with the assistance of AI. The secondary outcomes were to compare blind spot rates of unsedated U-TOE, unsedated, and sedated C-EGD with or without the assistance of AI, respectively, and the concordance between AI and the endoscopists' review.

RESULTS

The blind spot rate with AI-assisted sedated C-EGD was significantly lower than that of unsedated U-TOE and unsedated C-EGD (3.42% vs 21.77% vs 31.23%, respectively; P < .05). The blind spot rate of the AI subgroup was lower than that of the control subgroup in all 3 groups (sedated C-EGD: 3.42% vs 22.46%, P < .001; unsedated U-TOE: 21.77% vs 29.92%, P < .001; unsedated C-EGD: 31.23% vs 42.46%, P < .001).

CONCLUSIONS

The blind spot rate of sedated C-EGD was the lowest among the 3 types of EGD, and the addition of AI had a maximal effect on sedated C-EGD. (Clinical trial registration number: ChiCTR1900020920.).

Impact of the supine position versus left horizontal position on colonoscopy insertion: a 2-center, randomized controlled trial

BACKGROUND AND AIMS

Colonoscopy insertion is painful for some patients and is one of the main barriers to screening colonoscopy. Few studies have assessed the impact of the supine position (SP) on colonoscopy insertion, especially for unsedated patients. The aim of this randomized controlled trial was to clarify this issue.

METHODS

Unsedated patients were randomized to SP or left horizontal position (LHP) as the starting position of colonoscopy insertion. The primary outcome measure was cecal intubation time (CIT), and the secondary outcome measures were descending colon intubation time (DIT), pain score of patients, difficulty score according to the endoscopist, and patients' acceptance of unsedated colonoscopy.

RESULTS

A total of 347 patients were randomized to the SP group (175) or the LHP group (172). The CIT in the SP group was significantly shorter than that in the LHP group (275.0 seconds [interquartile range (IQR), 234.0-328.5 seconds] versus 316.0 seconds [IQR, 261.0-370.0 seconds], P < .001). The DIT was also shorter in the SP group (64.5 seconds [IQR, 52.0-86.3 seconds] versus 74.0 seconds [IQR, 62.0-92.0 seconds], P = .001). Compared with the LHP, the SP had a lower pain score (3.3 versus 3.9, P = .002), a lower difficulty score (3.1 versus 3.7, P < .001), a lower frequency of position change (7.1% versus 38.0%, P < .001), and less need for abdominal compression (39.1% versus 45.5%, P = .02). SP was the only modifiable and independent factor identified to reduce CIT and pain score and improve patients' acceptance of unsedated colonoscopy.

CONCLUSIONS

As an economical and convenient method, SP can reduce CIT, ease pain, and improve patients' acceptance of unsedated colonoscopy. (Clinical trial registration number: NCT03289442.).

Recent advances in respiratory monitory in nonoperating room anesthesia

PURPOSE OF REVIEW

Sedation for nonoperating room procedures is experiencing a considerable increase in demand. Respiratory compromise is one of the most common adverse events seen in sedation. Capnography is a modality that has been widely adopted in this area, but may not be well suited to the special demands of nonoperating room sedation. This review is an assessment of new technologies that may improve outcomes beyond those achievable with capnography.

RECENT FINDINGS

New devices for detecting the onset of apnea and for assessing respiratory depression have emerged which have advantages over conventional capnography for detecting apnea without excessive false positive and false negative rates. In addition, monitors that assess respiratory drive have become available, and these may prove useful in regulating depth of sedation.

SUMMARY

No single monitor is ideal for all settings. During brief endoscopic sedation, detection of apnea is paramount, while during longer procedures, avoiding excessive respiratory depression is more critical. The clinician must choose the appropriate monitor based on an understanding of the challenges of the particular environment.

Use and Associated Spending for Anesthesiologist-Administered Services in Minor Hand Surgery

BACKGROUND

Evidence is lacking to support the use of specialized anesthesia providers in minor surgical operations for patients without medical necessity. The authors sought to estimate the extent of potentially discretionary service use (anesthesiologist-administered anesthesia services among low-risk patients).

METHODS

The authors performed a retrospective claims analysis using the Truven MarketScan Database to estimate the prevalence and cost of anesthesiologist-administered anesthesia services provided to patients undergoing minor hand surgery (i.e., carpal tunnel release, trigger finger release, or de Quervain release) from 2010 to 2015. A predictive probability model was created to estimate patient risk status. The authors examined the relationship between patient risk status and anesthesia use using multivariable regression models.

RESULTS

Of 441,579 eligible procedures, 352,779 (80 percent) involved anesthesiologist-administered anesthesia services. The total proportion of estimated anesthesiologist-administered anesthesia use in low-risk patients who did not need anesthesiologist support declined over the study period (from 69.7 percent in 2010 to 65.8 percent in 2015). Although total payments for these services remained steady between 2010 and 2014, the average payment per procedure increased regardless of procedure type (from $376.8 in 2010 to $427.9 in 2015 for a carpal tunnel release operation). Approximately 83.7 percent of payments ($133 million) to anesthesia providers is credited to services in low-risk patients.

CONCLUSIONS

Anesthesiologist-administered anesthesia services are commonly rendered to low-risk surgical patients. Existing health care reform efforts do not adequately address discretionary services that can be a targeted area for cost saving. It is important to consider the implications of potentially discretionary use of specialized anesthesia providers, particularly with the advancement of bundled payment models.

Anesthesia for Colonoscopy and Lower Endoscopic Procedures

Demand for anesthesiologist-assisted sedation is expanding for gastrointestinal lower endoscopic procedures and may add to the cost of these procedures. Most lower endoscopy can be accomplished with either no, moderate, or deep sedation; general anesthesia and active airway management are rarely needed. Propofol-based sedation has advantages in terms of satisfaction and recovery over other modalities, but moderate sedation using benzodiazepines and opiates work well for low-risk patients and procedures. No sedation for routine colonoscopy works well for selected patients and eliminates sedation-related risks. There is no difference in outcome measures based on sedation received.

Do we really need an anesthesiologist for routine colonoscopy in American Society of Anesthesiologist 1 and 2 patients?

PURPOSE OF REVIEW

In an era where healthcare costs are being heavily scrutinized, every expenditure is reviewed for medical necessity. Multiple national gastroenterology societies have issued statements regarding whether an anesthesiologist is necessary for routine colonoscopies in American Society of Anesthesiologist (ASA) 1 and 2 patients.

RECENT FINDINGS

A large percentage of patients are undergoing screening colonoscopy without any sedation at all, which would not require an independent practitioner to administer medications. Advances in technique and technology are making colonoscopies less stimulating. Advantages to administering sedation, including propofol, have been seen even when not administered under the direction of an anesthesiologist and complications seem to be rare. The additional cost of having monitored anesthesia care appears to be a driving factor in whether a patient receives it or not.

SUMMARY

A large multiinstitutional randomized control trial would be necessary to rule out potential confounders and to determine whether there is a safety benefit or detriment to having anesthesiologist-directed care in the setting of routine colonoscopies in ASA 1 and 2 patients. Further discussion would be necessary regarding what the monetary value of that effect is if a small difference were to be detected.

Assessing coding practices for gastrointestinal surgery over time in the United States

BACKGROUND

Variations in hospital billing practices may reflect differences in patient risk or may represent the "upcoding" of patients in response to payer incentives/policies. The current study sought to assess whether coding practices for gastrointestinal surgery have changed over time and to evaluate the association between upcoding and in-hospital costs.

METHODS

A total of 1,344,152 patients aged >18 years undergoing a gastrointestinal operation between 2001 and 2011 were identified using the National Inpatient Sample. Coding practices were compared by hospital and patient characteristics. Multivariable analysis was performed to evaluate the association between coding practices and in-hospital costs.

RESULTS

The mean and median number of codes per admission were 8.8 (standard deviation = 4.58) and 9 (interquartile range: 5-11), respectively. Over time, the proportion of admissions being upcoded (>9 codes/admission) increased from 14.1% to 32.9% (∆ = +133.3%, P < .001). This trend was observed for each gastrointestinal operation and was greatest for hepatectomy (∆ = +73.3%). Although admissions that were upcoded were more likely to be for patients with greater comorbidity and Medicare enrollees, an increase in the proportion of patients upcoded was also observed regardless of the primary payer, among patients presenting without comorbidity, and among patients undergoing an elective operation (all P < .001). On adjusted analysis, admissions that were upcoded were independently associated with a $13,754 (95% confidence interval: $13,638-$13,870) greater in-hospital cost.

CONCLUSION

The number of "upcoded" patients was observed to increase with time. Greater education, regulation, and scrutiny are required of coding practices.

Nonoperating room anesthesia for gastrointestinal endoscopic procedures

PURPOSE OF REVIEW

To assess the trends in nonoperating room anesthesia (NORA) for gastrointestinal endoscopy over the past few years, and to describe alternative methods of delivering propofol sedation in selected low-risk patients.

RECENT FINDINGS

The use of NORA for routine gastrointestinal endoscopic procedures has been rising steadily over the past decade in the United States, considerably increasing healthcare costs. Because of this, there have been attempts to develop nonanesthesiologist-administered propofol sedation methods in low-risk patients. There is controversy as to whether properly trained nonanesthesia personnel can use propofol safely via the modalities of nurse-administered propofol sedation, computer-assisted propofol sedation or nurse-administered continuous propofol sedation SUMMARY: The deployment of nonanesthesia-administered propofol sedation for low-risk procedures allows for optimal allocation of scarce anesthesia resources, which can be more appropriately used for more complex cases. This can address some of the current shortages in anesthesia provider supply, and can potentially reduce overall healthcare costs without sacrificing sedation quality. We also address the realm of anesthesia provider care for advanced endoscopic procedures including setup for administration of anesthesia, decision-making regarding placement of an endotracheal tube, and the potential need to move a challenging case to the operating room.

Physician Reimbursement for Prostate Biopsies Falls as Procedures Shift From Offices to Facilities

OBJECTIVE

To examine how Medicare reimbursement for prostate biopsies was allocated to physicians, ambulatory surgery centers (ASCs), and hospitals from 2012 to 2015.

MATERIALS AND METHODS

Using Medicare Provider Utilization and Payment Data (2012-2015), we assessed provider payments to physicians and ASCs for transrectal ultrasound-guided prostate biopsies (Current Procedural Terminology 55700, 76842, 76972) for fee-for-service Medicare beneficiaries. Data were aggregated at provider-level for those reporting >10 biopsies per year. Hospital payments were estimated based on Outpatient Prospective Payment System. We report average and total payments for physicians, hospitals, and ASCs.

RESULTS

We identified 534,807 prostate biopsies, of which 13.3% and 14.8% were associated with an ASC and hospital, respectively. Payments for all biopsies totaled $276.7 million ($152.7 million to physicians; $35.1 million to ASCs, $88.9 million to hospitals). From 2012 through 2015, physician payments for biopsies declined by $19 million (Δ=-43.2%, P = .06 for trend). Payments to ASCs (+$3.2 million, Δ = 38.8%, P = .29) and hospitals (+$11.1 million, Δ = 58.6%, P = .16) both increased. The decline in physician payments was due to a 13.7% decline in volume and lower median reimbursement for office-based procedures ($415 to $277, P = .04). The share of biopsies performed at facilities increased from 26.5% to 30.0%, and the proportion of payments associated with those settings also increased from 42.7% to 65.3%.

CONCLUSION

Over time, a greater share of Medicare payments for biopsies has been directed toward facilities instead of physicians. Understanding the relationship between these trends and cancer screening and Medicare payment policies will be crucial in the future.

Effect of left lateral tilt-down position on cecal intubation time: a 2-center, pragmatic, randomized controlled trial

BACKGROUND AND AIMS

Colonoscopy insertion is technically challenging, time-consuming, and painful, especially for the sigmoid. Several pilot studies indicated that the (left) tilt-down position could facilitate the insertion procedure, but no formal trials have been published to demonstrate its efficacy. We performed this study to verify the benefits of the left lateral tilt-down position (LTDP) on the insertion process.

METHODS

This 2-center prospective trial randomized unsedated patients to the LTDP or left lateral horizontal position (LHP) to aid insertion. The primary outcome measure was cecal intubation time (CIT). Secondary outcome measures included decending colon intubation time (DIT), pain score of insertion, acceptance of unsedated colonoscopy for future examinations, difficulty score for insertion, and the adverse event rate of colonoscopy.

RESULTS

Two hundred fifty-eight patients were randomized to the LTDP (128) or LHP (130) in 2 centers. The median CIT and DIT were shorter with patients positioned in LTDP than in LHP (CIT, 280.0 vs 339.5 s, P < .001; DIT, 53.0 vs 69.0 s, P < .001, respectively) and patients with high and low body mass index (BMI) benefited more from LTDP than from LHP, as opposed to patients with normal BMI. In addition, colonoscopy insertion in LTDP was less painful (3.4 ± 1.6 vs 4.0 ± 1.7, P = .02) and less difficult (3.1 ± 1.9 vs 3.7 ± 1.4, P < .001), showing a higher tendency to acceptance of unsedated colonoscopy (82.9% vs 73.8%, P = .08). The rates of adverse events were extremely low and did not differ significantly in the 2 groups.

CONCLUSIONS

LTDP for colonoscopy insertion can reduce insertion time and pain, and potentially improves patients' acceptance of unsedated colonoscopy. (Clinical trial registration number: NCT02842489.).

Using Time-Driven Activity-Based Costing as a Key Component of the Value Platform: A Pilot Analysis of Colonoscopy, Aortic Valve Replacement and Carpal Tunnel Release Procedures

Background

Time-driven activity-based costing (TDABC) is a methodology that calculates the costs of healthcare resources consumed as a patient moves along a care process. Limited data exist on the application of TDABC from the perspective of an anesthesia provider. We describe the use of TDABC, a bottom-up costing strategy and financial outcomes for three different medical-surgical procedures.

Methods

In each case, a multi-disciplinary team created process maps describing the care delivery cycle for a patient encounter using the TDABC methodology. Each step in a process map delineated an activity required for delivery of patient care. The resources (personnel, equipment and supplies) associated with each step were identified. A per minute cost for each resource expended was generated, known as the capacity cost rate, and multiplied by its time requirement. The total cost for an episode of care was obtained by adding the cost of each individual resource consumed as the patient moved along a clinical pathway.

Results

We built process maps for colonoscopy in the gastroenterology suite, calculated costs of an aortic valve replacement by comparing surgical aortic valve replacement (SAVR) versus transcatheter aortic valve replacement (TAVR) techniques, and determined the cost of carpal tunnel release in an operating room versus an ambulatory procedure room.

Conclusions

TDABC is central to the value-based healthcare platform. Application of TDABC provides a framework to identify process improvements for health care delivery. The first case demonstrates cost-savings and improved wait times by shifting some of the colonoscopies scheduled with an anesthesiologist from the main hospital to the ambulatory facility. In the second case, we show that the deployment of an aortic valve via the transcatheter route front loads the costs compared to traditional, surgical replacement. The last case demonstrates significant cost savings to the healthcare system associated with re-organization of staff required to execute a carpal tunnel release.

Predictors of Use of Monitored Anesthesia Care for Outpatient Gastrointestinal Endoscopy in a Capitated Payment System

BACKGROUND & AIMS

Use of monitored anesthesia care (MAC) for gastrointestinal endoscopy has increased in the Veterans Health Administration (VHA) as in fee-for-service environments, despite the absence of financial incentives. We investigated factors associated with use of MAC in an integrated health care delivery system with a capitated payment model.

METHODS

We performed a retrospective cohort study using multilevel logistic regression, with MAC use modeled as a function of procedure year, patient- and provider-level factors, and facility effects. We collected data from 2,091,590 veterans who underwent outpatient esophagogastroduodenoscopy and/or colonoscopy during fiscal years 2000-2013 at 133 facilities.

RESULTS

The adjusted rate of MAC use in the VHA increased 17% per year (odds ratio for increase, 1.17; 95% confidence interval, 1.09-1.27) from fiscal year 2000 through 2013. The most rapid increase occurred starting in 2011. VHA use of MAC was associated with patient-level factors that included obesity, obstructive sleep apnea, higher comorbidity, and use of prescription opioids and/or benzodiazepines, although the magnitude of these effects was small. Provider-level and facility factors were also associated with use of MAC, although again the magnitude of these associations was small. Unmeasured facility-level effects had the greatest effect on the trend of MAC use.

CONCLUSIONS

In a retrospective study of veterans who underwent outpatient esophagogastroduodenoscopy and/or colonoscopy from fiscal year 2000 through 2013, we found that even in a capitated system, patient factors are only weakly associated with use of MAC. Facility-level effects are the most prominent factor influencing increasing use of MAC. Future studies should focus on better defining the role of MAC and facility and organizational factors that affect choice of endoscopic sedation. It will also be important to align resources and incentives to promote appropriate allocation of MAC based on clinically meaningful patient factors.

Sedation for routine gastrointestinal endoscopic procedures: a review on efficacy, safety, efficiency, cost and satisfaction

Most gastrointestinal endoscopic procedures are now performed with sedation. Moderate sedation using benzodiazepines and opioids continue to be widely used, but propofol sedation is becoming more popular because its unique pharmacokinetic properties make endoscopy almost painless, with a very predictable and rapid recovery process. There is controversy as to whether propofol should be administered only by anesthesia professionals (monitored anesthesia care) or whether properly trained non-anesthesia personnel can use propofol safely via the modalities of nurse-administered propofol sedation, computer-assisted propofol sedation or nurse-administered continuous propofol sedation. The deployment of non-anesthesia administered propofol sedation for low-risk procedures allows for optimal allocation of scarce anesthesia resources, which can be more appropriately used for more complex cases. This can address some of the current shortages in anesthesia provider supply, and can potentially reduce overall health care costs without sacrificing sedation quality. This review will discuss efficacy, safety, efficiency, cost and satisfaction issues with various modes of sedation for non-advanced, non-emergent endoscopic procedures, mainly esophagogastroduodenoscopy and colonoscopy.