Letter to the Editor: Colonoscopy Anesthesia

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This is a response to the recent article "GI Centers of the Future: Forecasting Colonoscopy Demand, Value-Added Services."

My response is to Dr. Cohen's comments, in which he states that possible cost savings measures include "replacement of MD anesthetists with [CRNAs] for the provision of sedation, or reverting to conventional sedation using an opioid and midazolam to eliminate the cost of an anesthesia specialist altogether."

To me, this represents backward-thinking, in that propofol-based sedation for endoscopy has been demonstrated to be superior to the classic benzodiazepene/narcotic technique, in terms of multiple factors, including patient satisfaction, proceduralist satisfaction, speed of procedure, PACU discharge time, and rates of nausea/vomiting. Using anxiolytic and narcotic agents with unfavorable pharmacokinetics for short encounters that entail zero-post procedure discomfort is counter-intuitive when there is a deeply sedating, amnestic, anxiolytic, readily titratable drug with a very short half-life available. The (nominal) cost of propofol itself, and/or the fees collected by the anesthesia provider(s), will in the long run be easily justified by greatly enhanced patient throughput, lower rates of nausea, high patient satisfaction scores, and, finally, increased colonoscopy completion rates (e.g. difficult colonoscopy requiring extra procedural time, patient re-positioning, external abdominal pressure, etc., is much more readily achieved via propofol).

My extensive experience working in hospitals and free-standing surgery centers, providing propofol-based endoscopy, has borne out the above contentions. As a notable example, one facility that I regularly worked at, a successful GI-only ambulatory center, saw recovery times for colonoscopy go from an average of 45 minutes down to 25 minutes, once propofol-based sedation was adopted. In addition, recovery times for EGD were around 20 minutes, and nausea and vomiting became unheard of. The return on investment was immediate, though in truth there was no facility "investment"--the anesthesiologist(s) working there were self-funded by anesthesia fees, as the endoscopy case volume was robust and consistent.

As far as who provides the anesthesia for endoscopies, this is a politically charged topic and is currently hotly debated. Dr. Cohen mentions using CRNAs in lieu of anesthesiologists to realize cost savings. I would counter that CRNAs working independently, or medically directed by a proceduralist (as opposed to an anesthesiologist), are NOT a functional equivalent to physician anesthesiologists personally providing or medically directing care, in terms of quality or safety. There may not (yet) exist a randomized, double-blinded analysis, nor other similar type of literature, to substantiate this at present (nor is there legitimate evidence in the other direction), but I believe this point to be intuitive. I have medically directed CRNAs for a decade, and continue to do so, and I greatly value their collective expertise, work ethic, and devotion to patient safety. That being said, physician anesthesiologists are the most rigorously trained members of the anesthesia care team, and, by virtue of that fact, deliver the highest level of care.

In conclusion, I respectfully submit to Dr. Cohen that "cutting corners" in terms of proper medications, and/or the training level of the personnel administering them, only serves to deny our endoscopy patients the smoothest, safest experience possible. Changes in anesthetic practice such as he describes cannot realistically lead to cost savings in today's healthcare world of "pay for performance," pervasive quality metrics, and decreasing margins.

Thank you for your consideration.

Zachary Deutch, MD
University of Florida Health
Jacksonville, FL

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