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

Predmore, Zachary; Nie, Xiaoyu; Main, Regan; Mattke, Soeren; Liu, Henry

doi:10.1038/ajg.2016.266

Cited by 53 publications

(47 citation statements)

References 12 publications

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“…Prior studies have primarily focused on potential overuse of MAC, inferring that the marked increases in MAC utilization outside the VHA are largely financially motivated. 3,5,8–10 However, the results of our study suggest that, in the absence of financial incentives favoring MAC use, there still may be inappropriate use including potential underuse of MAC in the patients who may benefit the most.…”

Section: Discussionmentioning

confidence: 66%

“…MAC use for GI endoscopy has markedly increased in fee-for-service delivery systems, as reflected by rates of >30% in multiple studies of Medicare and commercially-insured patients. 3,5,8–10 Evidence suggests that over two-thirds of MAC is used for routine endoscopy in healthy, low-risk patients, which suggests widespread guideline-discordant utilization. 9 Revaluation of endoscopic sedation codes by the Centers for Medicare and Medicaid Services (CMS) may help to promote appropriate use of MAC by changing financial incentives.…”

Section: Introductionmentioning

confidence: 99%

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

Adams

Prenovost²,

Dominitz

et al. 2017

Gastroenterology

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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 healthcare delivery system with a capitated payment model. Methods We performed a retrospective cohort study using multi-level 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% CI, 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, though the magnitude of these effects was small. Provider-level and facility factors were also associated with use of MAC, though again the magnitude of these associations was small. Unmeasured facility-level effects had the greatest effect on the trend of MAC use. Conclusions In 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.

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Section: Discussionmentioning

confidence: 66%

Section: Introductionmentioning

confidence: 99%

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

Adams

Prenovost²,

Dominitz

et al. 2017

Gastroenterology

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“…There is a growing demand for anesthesia service use to help facilitate gastroenterology procedures [8, 9]. At the Brigham and Women’s Hospital, Morris et al [10] used TDABC to elucidate the causes of long patient waiting times for a colonoscopy procedure, to understand scheduling and triage processes, and to reallocate clinical resources.…”

Section: Resultsmentioning

confidence: 99%

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

et al. 2018

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BackgroundTime-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.MethodsIn 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.ResultsWe 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.ConclusionsTDABC 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.

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“…In recent years, use of monitored anesthesia care (MAC) for GI endoscopy has been increasing, with rates increasing to 47.6%and 53.0%, respectively, in Medicare and commercially insured patients in 2013. 1 Monitored anesthesia care requires the presence of an anesthesiology professional and typically involves administration of propofol, leading to a deeper level of sedation. It is estimated that use of MAC for esophagogastroduodenoscopy (EGD) and colonoscopy resulted in additional national expenditures of more than $1 billion for Medicare and commercially insured patients in2009 2 and is associated with higher rates of 30-day endoscopy-related complications compared with standard sedation.…”

mentioning

confidence: 99%

“…4 Yet, more than half of MAC appears to be used for routine endoscopy in low-risk patients, suggesting widespread guideline-discordant use that may in part be driven by financial incentives. 1 …”

mentioning

confidence: 99%

National Trends in Use of Monitored Anesthesia Care for Outpatient Gastrointestinal Endoscopy in the Veterans Health Administration

et al. 2017

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

Abstract: During 2010 to 2013, anesthesia service use in GI procedures continued to increase and the proportion of these services rendered for low-risk patients remained high.

Cited by 53 publications

References 12 publications

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

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

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

National Trends in Use of Monitored Anesthesia Care for Outpatient Gastrointestinal Endoscopy in the Veterans Health Administration

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