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

Abstract

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.

Substantial Increase in Anesthesia Assistance for Outpatient Colonoscopy and Associated Cost Nationwide

“…Previous studies have consistently found that anesthesia use during outpatient colonoscopy varies significantly by region of the country, and the Northeast has been the region with the highest use of AA in many of these studies. [2][3][4][5]8,12 We also found this significant variation in anesthesia use by region, though the South was found to have a higher proportion of AA during outpatient colonoscopy as compared with the Northeast. This conflicting finding may be secondary to a potentially higher representation of the state of Florida in the sample of southern hospitals in the Perspective database, as multiple prior studies have found rates of AA use in Florida to be similar to those in the Northeast.…”

“…In addition to being associated with increased cost, [2][3][4] this widespread practice has been associated with a possible increase in overall complication rates, 5,6 including aspiration pneumonia risk, 6,7 without being shown to increase overall colonoscopy quality indicators such as adenoma detection [8][9][10] and cecal intubation rates. 10,11 Previous studies have assessed various geographic, patient-related, and facility-related predictors of the use of AA using claims data from commercial insurers and Medicare, [2][3][4][5][6]8,12 but data on hospital-based endoscopy, which have represented between 19% and 57% of screening colonoscopies in the Medicare population in prior analyses, 2,6 have been limited. In these prior studies, use of AA has generally been found to be highest in the Northeast compared with other regions in the United States, but results on patient-related factors such as age and race have been mixed.…”

Feasibility of sedation on demand in Taiwan using water exchange and air insufflation: A randomized controlled trial

“…Traditionally, benzodiazepines have been used as the ondemand sedative. 37 In our endoscopic unit, we usually have two nurse anesthetists supervised by one anesthesiologist, who readily administered propofol when needed. Propofol has a rapid onset (< 1 min), which comes in handy for patients suffering from pain during colonoscopy.…”

“…However, because of its narrow therapeutic window, an anesthesia specialist is usually required to administer it. 37 In our endoscopic unit, we usually have two nurse anesthetists supervised by one anesthesiologist, who readily administered propofol when needed. In settings without the presence of an anesthesia specialist, endoscopist-directed propofol sedation might be a feasible alternative, 38 given the low dose of propofol required by on-demand sedation.…”

Putting the Horse Back in the Barn: Right-Sizing Use of Anesthesia Assistance for Routine Gastrointestinal Endoscopy

“…Indeed, studies of AA use in integrated health care delivery systems showing increased utilization even in the absence of economic incentives suggest that focusing solely on economic drivers may be misguided, and a more nuanced approach may be needed. 19 By focusing on developing more refined, evidence-based clinical criteria regarding which patients are most likely to benefit from AA, whether because they would not be sedated adequately with standard sedatives or because they would be at higher risk of procedural or sedation-related complications with standard sedation, we can advance the dialogue and help gastroenterologists to better demonstrate the value of the services they provide.…”