Original Article

Increased Anesthesia Usage in a Large-Volume Endoscopy Unit: Patient Acuity Is Not the Main Predictor

Authors: Amit Aravapalli, MD, H. James Norton, PhD, Nigel Rozario, MS, Jovona Simpson, RHIT, BS, Brian DelGrosso, MS, CRNA, Martin W. Scobey, MD

Abstract

Objectives: The use of monitored anesthesia care (MAC) for colonoscopy sedation continues to increase. This study examined trends during a 9-year period in the use of MAC and explored which patient variables may have influenced these trends.

Methods: This was a retrospective review of all colonoscopies performed in our hospital-based endoscopy unit from 2003 through 2012. We determined whether MAC was used and if not, which quantitative doses of sedative agents were used. Several patient-related variables were evaluated for correlation. Data were analyzed ( t test, χ2 , logistic regression) using SAS statistical software.

Results: Between January 2003 and October 2012, we identified 37,803 performed colonoscopies. The use of MAC increased significantly, from 0.38% in 2003 to 10.0% in 2012 ( P < 0.0001). For cases in which conscious sedation was used, the mean doses of sedatives did not change significantly over time. Although there was an association between certain patient variables (female sex; higher American Society of Anesthesiologists class; diagnostic procedures; and pulmonary, psychiatric, renal or cerebrovascular diseases) and the use of MAC, the greatest predictor of MAC use was the year of the procedure. After adjusting for the patient variables that were examined, the odds of using MAC increased by approximately 1.5 times per year from 2003 through 2012. The adjusted odds of using MAC in 2012 were 35.8 times higher than in 2003.

Conclusions: The use of MAC for colonoscopies performed in our endoscopy unit increased significantly from 2003 to 2012. Although increased MAC use was associated with some patient variables, it was most significantly associated with the year of the procedure. This suggests that there were other nonpatient-related factors influencing its use.

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References

1. Blesalier R. Colorectal cancer, in Freedman M, Freedman L, Brand L (eds): Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, 9th ed. Philadelphia, Saunders, 2010, pp 2191-2238.
 
2. Levin B, Lieberman DA, McFarland B, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA Cancer J Clin 2008;58:130-160.
 
3. US Preventive Services Task Force. Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2008;149:627-637.
 
4. Centers for Disease Control and Prevention. Vital signs: colorectal cancer screening test use--United States, 2012. MMWR Morb Mortal Wkly Rep 2013;62:881-888.
 
5. Centers for Medicare & Medicaid Services. Welcome to the Medicare coverage database. https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed November 3, 2014.
 
6. Seeff LC, Richards TB, Shapiro JA, et al. How many endoscopies are performed for colorectal cancer screening? Results from CDC’s survey of endoscopic capacity. Gastroenterology 2004;127:1670-1677.
 
7. Mitka M. Colorectal cancer screening rates still fall far short of recommended levels. JAMA 2008;299:622.
 
8. Henry J. Kaiser Family Foundation. Summary of the Affordable Care Act. April 25, 2013. http://kff.org/health-reform/fact-sheet/summary-of-the-affordable-care-act. Accessed November 3, 2014.
 
9. Liu H, Waxman DA, Main R, et al. Utilization of anesthesia services during outpatient endoscopies and colonoscopies and associated spending in 2003-2009. JAMA 2012;307:1178-1184.
 
10. Vargo JJ, Cohen LB, Rex DK, et al. Position statement: nonanesthesiologist administration of propofol for GI endoscopy. Gastroenterology 2009; 137:2161-2167.
 
11. Inadomi JM, Gunnarsson CL, Rizzo JA, et al. Projected increased growth rate of anesthesia professional-delivered sedation for colonoscopy and EGD in the United States: 2009 to 2015. Gastrointest Endosc 2010;72:580-586.
 
12. Hazeldine S, Fritschi L, Forbes G. Predicting patient tolerance of endoscopy with conscious sedation. Scand J Gastroenterol 2010;45:1248-1254.
 
13. Alharbi O, Rabeneck L, Paszat LF, et al. A population-based analysis of outpatient colonoscopy in adults assisted by an anesthesiologist. Anesthesiology 2009;111:734-740.
 
14. Khiani VS, Soulos P, Gancayco J, et al. Anesthesiologist involvement in screening colonoscopy: temporal trends and cost implications in the Medicare population. Clin Gastroenterol Hepatol 2012;10:58-64.
 
15. Sebel PS, Lowden JD. Propofol: a new intravenous anesthetic.Anesthesiology 1989;71:260-277.
 
16. Hillier H, Mazurek M, Hauidich J. Monitored anesthesia care, in Barash P, Cullen B, Stoelting R (eds): Clinical Anesthesia, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2005, pp 1246-1261.
 
17. Rex DK. Anesthesia care for low-risk patients undergoing gastrointestinal endoscopies. JAMA 2012;307:2585-2586.
 
18. Rex DK. Effect of the Centers for Medicare & Medicaid Services policy about deep sedation on use of propofol. Ann Intern Med 2011;154:622-626.
 
19. Fleisher LA. Assessing the value of ‘‘discretionary’’ clinical care: the case of anesthesia services for endoscopy. JAMA 2012;307:1200-1201.
 
20. Vargo JJ. A SEER snapshot of anesthesiologist-assisted procedural sedation: in or out of focus? Clin Gastroenterol Hepatol 2012;10:7Y8.
 
21. Singh H, Poluha W, Cheung M, et al. Propofol for sedation during colonoscopy. Cochrane Database Syst Rev 2008;4:CD006268.
 
22. Centers for Disease Control and Prevention (CDC). Overweight and obesity. http://www.cdc.gov/obesity/data/adult.html. Accessed November 3, 2014.
 
23. North Carolina Session Law 2005-346, House Bill 1060. September 2, 2005. http://www.ncleg.net/gascripts/BillLookUp/BillLookUp.pl?Session=2005&BillID=h1060. Accessed November 3, 2014.