Medical, Political, and Economic Considerations for the Use of MAC for Endoscopic Sedation: Big Price, Little Justification?

Abstract

The last few decades of gastrointestinal (GI) endoscopy have seen phenomenal growth. In many aspects, GI endoscopy has led the field of nonsurgical interventional medicine. In many aspects, this growth is facilitated by advancements in sedation—both drugs and techniques. Unfortunately, the topic of GI endoscopy sedation is also mired in many controversies, mainly emanating from the cost of anesthesia providers. While no one debates their role in the majority of advanced endoscopic procedures, the practice of universal propofol sedation in the USA, delivered by anesthesia providers, needs a closer look. In this review, medical, political, and economic considerations of this important topic are discussed in a very frank and honest way. While such ubiquitous propofol use has increased satisfaction of both patients and gastroenterologists, there is little justification. More importantly, going by the evidence, there is even less justification for the mandated anesthesia providers use for such delivery. Unfortunately, the FDA could not be convinced otherwise. The new drug fospropofol met the same fate. Approval of SEDASYS ® , the first computer-assisted personalized sedation system, was a step in the right direction, nevertheless an insufficient step that failed to takeoff. As a result, in spite of years of research and efforts of many august societies, the logjam of balancing cost and justification of propofol sedation has continued. We hope that recent approval of remimazolam, a novel benzodiazepine, and potential approval of oliceridine, a novel short-acting opioid, might be able to contain the cost without compromising the quality of sedation.

Current status of perioperative hypnotics, role of benzodiazepines, and the case for remimazolam: a narrative review

“…Anaesthesiologist-provided sedation of fit patients for endoscopy is expensive. 47,48 Protocols for nonanaesthesiologist administration of propofol are evidencebased 49 and safe, 50,51 but unacceptable to many national societies. 52 Indeed, anaesthesiologist-administered deep sedation with propofol may impose avoidable risks.…”

“…If proceduralist and patient satisfaction with nonanaesthesiologist remimazolam sedation is close to that achieved by anaesthesiologist-provided propofol sedation, then a significant change in practice might ensue. 48 Crucially, respect for patient safety demands a cautious introduction of this new hypnotic.…”

Efficacy and Safety of Remimazolam in Endoscopic Sedation—A Systematic Review and Meta-Analysis

“…Remimazolam, an analog of midazolam, is a benzodiazepine and a new ultra-short-acting sedative (10,11). Compared with midazolam, remimazolam has the advantages of rapid onset, rapid recovery, and a higher safety profile (12,13).…”

A comprehensive review of remimazolam for sedation

“…This paradigm requires that an anesthesia provider be present, which is an unnecessary added cost to the patient and is unsustainable. 29 Alternatives to Propofol are especially sought out by gastroenterologists, as the use of propofol during procedures is legally binding due to the directive set out by the American Society of Anesthesiologists (ASA) "PropofolHealthcare providers must only use propofol with specialized training in airway management." 30 Since most physicians beyond anesthesiologists and emergency physicians lack additional training in airway management, there is a need for an anesthesiologist to be present during procedures in which propofol is administered.…”