Increase seen in use of anesthesiologists to provide sedation during endoscopies, colonoscopies

March 20, 2012, JAMA and Archives Journals

Between 2003 and 2009, the use of anesthesia services to provide sedation during endoscopies and colonoscopies increased substantially, according to a study in the March 21 issue of JAMA. The authors also found that most of the gastroenterology anesthesia use was for low-risk patients, and that there was considerable regional variation in use.

"The continuous increase in spending on medical care has triggered a debate concerning which services and procedures provide adequate value and which do not, and therefore represent potential areas to reduce cost. The use of anesthesiologists, nurse anesthetists, or both during gastrointestinal endoscopies has been identified as one such potential area. Under current payment guidelines for gastrointestinal endoscopies, if intravenous sedation is needed, the endoscopist has to administer it with support of a nurse, and the sedation component is included in the professional fee. Involvement of an anesthesiologist or nurse anesthetist, which implies an additional payment, is only justified for procedures performed on high-risk ," according to background information in the article. "The frequency with which anesthesiologists or nurse anesthetists provide sedation for gastrointestinal endoscopies, especially for low-risk patients, is poorly understood and controversial."

Hangsheng Liu, Ph.D., of the RAND Corporation, Boston, and colleagues analyzed data to examine the proportion of gastroenterology procedures assisted by a separate anesthesiologist or nurse anesthetist and the associated payments for these services. The authors also evaluated regional variation in anesthesia use and estimated what proportion of these services were potentially discretionary. The study analysis included claims data for a 5 percent of Medicare fee-for-service patients (1.1 million adults) and a sample of 5.5 million commercially insured patients between 2003 and 2009, who had either an upper gastrointestinal endoscopy or colonoscopy as outpatients. Overall, 26.6 percent of Medicare patients and 28.6 percent of commercially insured patients received anesthesia services.

Although the number of gastroenterology procedures per million enrollees per year remained largely unchanged among Medicare patients, with an average of 136,718, the number of gastroenterology procedures per million enrollees per year increased more than 50 percent in commercially insured patients, from 33,599 in 2003 to 50,816 in 2009. The proportion of procedures using anesthesia services increased at a similar rate for commercially insured patients (13.6 percent to 35.5 percent) and Medicare patients (13.5 percent to 30.2 percent). Payments for gastroenterology anesthesia services doubled among Medicare patients and quadrupled among commercially insured patients over the study period.

The authors found that the proportion of procedures with anesthesia services varied substantially by geographic region. Patterns were similar for Medicare and commercially insured patients, with the lowest use in the West region (Medicare sample, 14.0 percent; and commercially insured sample, 12.6 percent in 2009) and the highest use in the Northeast region (47.5 percent and 59.0 percent in 2009, respectively).

Overall, the proportion of anesthesia services delivered to low-risk patients (as defined by a measure of the American Society of Anesthesiologists) was more than two-thirds in the Medicare population, and more than three-quarters among the commercially insured population. Also, the number of procedures with anesthesia services for low-risk patients increased substantially in both populations during the study period.

"Our results suggest that the majority of gastroenterology-related anesthesia services are provided to low-risk patients and can be considered potentially discretionary based on current payment policies," the authors write. "Because anesthesia use is projected to increase further, addressing such potentially discretionary use represents a sizeable target for cost savings. This is particularly true because the number of colonoscopies is likely to increase in the coming years."

Lee A. Fleisher, M.D., of the University of Pennsylvania, Philadelphia, writes in an accompanying editorial addressing the increase in the use of anesthesia services that there are several reasons endoscopists might prefer to use these services.

"One reason is that anesthesiologists and anesthetists provide deep sedation or general anesthesia as opposed to moderate sedation, which would potentially allow for the examination to be completed in a shorter time. … A second reason may be related to patient acceptance. Although it is difficult to conclusively demonstrate a link between procedure volume and anesthesia services, patient acceptance of endoscopy and colonoscopy may be directly related to the assurance of deep sedation or general anesthesia for the procedure, as the authors indicated."

"A third reason endoscopists might prefer to use anesthesia services may be that the presence of anesthesia services transfers the responsibility for managing sedation from the endoscopist to the or nurse anesthetist; doing so has little financial consequence but may reduce medicolegal consequences for the endoscopist. … A fourth reason might relate to financial considerations. The current reimbursement for gastroenterologists performing endoscopy includes provision of sedation, and the transfer of care to anesthesia services results in no decrease in their fees. With the addition of anesthesia fees, there is a net increase in total costs of provision of and ."

Explore further: Uninsured receive same quantity, value of imaging services as insured in hospital, in-patient setting

More information: JAMA. 2012;307[11]:1178-1184.
JAMA. 2012;307[11]:1200-1201.

Related Stories

Uninsured receive same quantity, value of imaging services as insured in hospital, in-patient setting

January 6, 2012
Insurance status doesn't affect the quantity (or value) of imaging services received by patients in a hospital, in-patient setting, according to a study in the January issue of the Journal of the American College of Radiology.

Is anesthesia dangerous?

July 21, 2011
In pure numerical terms, anesthesia-associated mortality has risen again. The reasons for this are the disproportionate increase in the numbers of older and multimorbid patients and surgical procedures that would have been ...

Recommended for you

Best of Last Year—The top Medical Xpress articles of 2017

December 20, 2017
It was a good year for medical research as a team at the German center for Neurodegenerative Diseases, Magdeburg, found that dancing can reverse the signs of aging in the brain. Any exercise helps, the team found, but dancing ...

Pickled in 'cognac', Chopin's heart gives up its secrets

November 26, 2017
The heart of Frederic Chopin, among the world's most cherished musical virtuosos, may finally have given up the cause of his untimely death.

Sugar industry withheld evidence of sucrose's health effects nearly 50 years ago

November 21, 2017
A U.S. sugar industry trade group appears to have pulled the plug on a study that was producing animal evidence linking sucrose to disease nearly 50 years ago, researchers argue in a paper publishing on November 21 in the ...

Female researchers pay more attention to sex and gender in medicine

November 7, 2017
When women participate in a medical research paper, that research is more likely to take into account the differences between the way men and women react to diseases and treatments, according to a new study by Stanford researchers.

Drug therapy from lethal bacteria could reduce kidney transplant rejection

August 3, 2017
An experimental treatment derived from a potentially deadly microorganism may provide lifesaving help for kidney transplant patients, according to an international study led by investigators at Cedars-Sinai.

Exploring the potential of human echolocation

June 25, 2017
People who are visually impaired will often use a cane to feel out their surroundings. With training and practice, people can learn to use the pitch, loudness and timbre of echoes from the cane or other sounds to navigate ...


Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.