Few people want to be wide awake during their colonoscopy exams, but new research suggests too many are getting extra sedation treatment, costing as much as $1 billion yearly in potentially needless services.
Use of anesthesiologists to monitor sedation during colonoscopies and other digestive imaging tests has more than doubled in recent years, and they're used most often for low-risk patients who typically don't need the extra help, the study authors said.
"These services are not harming patients. They're basically giving them a luxury that is not strictly necessary," said the study's lead author, Dr. Soeren Mattke, a senior Rand Corp. scientist. That matters at a time when policymakers are trying to rein in rising medical costs, the authors said.
Patients usually are briefly sedated for a colonoscopy, and some kinds of sedation require monitoring by specialists. That includes use of propofol, a powerful intravenous drug that can cause deep sedation and was implicated in pop star Michael Jackson's death. Anesthesiologist-monitored sedation, with or without propofol, is recommended for high-risk patients, including those who are old or sick or previously had complications with anesthesia.
While propofol sedation is also sometimes given to low-risk colonoscopy patients, the study authors suggest that's often unnecessary. Drugs usually recommended for these patients typically cause lighter sedation, though most patients don't remember anything about the exams afterward. These drugs can be given by the doctor doing the exam, but the study suggests they're often also being given and monitored by anesthesiologists.
The researchers analyzed insurance claims data on more than 6 million U.S. adults who had the colon exams or imaging scopes of the upper digestive tract between 2003 and 2009. The tests are done to screen for colon cancer, acid reflux and other illnesses.
When the study began, 14 percent of these tests included an anesthesiologist. That climbed to more than 30 percent by 2009. The portion of this extra sedation treatment given to low-risk commercially insured patients remained constant during the study and fell slightly in Medicare fee-for-service patients. But the study authors said far too many low-risk patients are still getting this treatment - more than three-fourths of the commercially insured patients and two-thirds of the Medicare group.
The extra treatment added an average of about $500 to an insured patient's bill in 2009, and $150 to a Medicare bill. In 2009, about 3 million colonoscopies and other digestive scoping tests were done in low-risk patients but included anesthesia services, amounting to $1 billion in potentially unnecessary costs, the study authors estimated.
The study appears in Wednesday's Journal of the American Medical Association.
While some insurance policies exclude coverage for anesthesiologist monitoring for low-risk patients undergoing these exams, insurers sometimes pay for it, Mattke said.
Because of doctor backlash, Aetna, one of the nation's largest health insurers, has indefinitely delayed a policy it tried to implement in 2008 that would have excluded this coverage for low-risk patients, said Dr. James Cross, Aetna's chief of national medical policy and operations.
Reasons for the frequent use of anesthesiologists during these exams vary. Sometimes low-risk patients undergoing colonoscopies and other digestive scoping exams request propofol because they want to be totally unconscious and have heard that it wears off quickly and doesn't cause grogginess, unlike other sedatives, said Dr. John Vargo, a spokesman for the American Society for Gastrointestinal Endoscopy and a digestive specialist at the Cleveland Clinic.
Propofol requires careful monitoring because it has "a narrow window between providing deep sedation and making people stop breathing," and unlike other sedatives, there's no rescue drug to reverse its effects, said Dr. Norm Cohen, vice president for professional affairs at the American Society of Anesthesiologists.
The rising use of anesthesiologists may partly reflect more obese patients and users of Vicodin and other opiate-based prescription drugs, Cohen said. Both may be missed under coding used in the study, but they should be considered at risk because sleep apnea that often accompanies obesity makes sedation trickier, and users of opiate painkillers often require higher than usual doses of sedation, he said.
Vargo said doctors who do the exams can be trained to use propofol in healthy patients, but a journal editorial said some prefer anesthesiologist assistance because it allows them to focus on the colon exam, and if something goes wrong with the sedation, they may not be held legally accountable.
Dawn Meehan, 42, an Orlando, Fla.-area teacher's assistant and writer, had a colonoscopy last month under deep sedation monitored by an anesthesia specialist; her insurance covered everything. Colonoscopies to screen for colon cancer usually aren't recommended until age 50 but Meehan had the exam because of symptoms for a common digestive disease.
She was a low-risk patient and said if her colonoscopy doctor had offered it, she might have chosen light sedation. But even though the extra sedation is more costly, Meehan said patients who want it should get it, because otherwise some might "shy away from getting screened."