Anesthesia Services Used Unnecessarily for GI Endoscopies

Troy Brown

March 20, 2012

March 20, 2012 — The proportion of endoscopy procedures using anesthesia services for deep sedation or general anesthesia more than doubled between 2003 and 2009. More than two thirds of those procedures were in low-risk patients who might have been candidates for less costly intravenous (IV) sedation provided by the endoscopist with nursing support, according to a study published in the March 21 issue of JAMA.

Hangsheng Liu, PhD, associate policy researcher at RAND Corporation in Boston, Massachusetts, and colleagues conducted a retrospective analysis of insurance claims data for 1.1 million Medicare patients and 5.5 million commercially insured patients who underwent outpatient gastrointestinal (GI) endoscopy between 2003 and 2009 to assess the use of anesthesia services in low-risk patients.

Low-risk patients undergoing GI endoscopy may receive IV sedation by the endoscopist with nursing support during the procedure. Patients who are high risk or who desire deep sedation or general anesthesia require more costly care by an anesthesiologist or nurse anesthetist.

Dr. Liu and colleagues used 2 data sets: the Medicare Limited Data set, consisting of a nationally representative 5% sample of Medicare beneficiaries, and the Thomson Reuters MarketScan data set, with approximately 40 million individuals commercially insured through 150 plans at larger companies.

The researchers excluded patients younger than 18 years because different decision criteria are used for anesthesia, as well as patients with incomplete claims data for the 6 months preceding the procedure.

They used the American Society of Anesthesiologists (ASA) physical status classification to determine the need for anesthesia services: patients with a level 3, which indicated severe systemic disease, or higher required anesthesia services. Patients who were classified as level 1 or 2 were considered low risk, and the use of anesthesia services was deemed potentially discretionary.

More Than Two Thirds of Patients Are Low Risk

A total of 2.2 million GI procedures were performed on Medicare patients, and 7.0 million procedures were performed on commercially insured patients during the study period. The number of procedures per million enrollees per year remained stable in Medicare beneficiaries (mean, 136,718) but increased more than 50% in the commercially insured group, from 33,599 in 2003 to 50,816 in 2009. The proportion of procedures using anesthesia services increased at a similar rate in Medicare patients (from 13.5% to 30.2%) and commercially insured patients (from 13.6% to 35.5%).

In all years, anesthesia services varied substantially between geographic areas. Patients in both groups received anesthesia services most often in the northeastern part of the United States (47.5% in the Medicare sample and 59.0% in the commercially insured sample in 2009) and least often in the western part of the country (14.0% and 12.6% in 2009, respectively).

Overall, the proportion of anesthesia services used in low-risk patients was more than two thirds in the Medicare group and more than three quarters in the commercially insured group. This proportion decreased over the study period, from 78.6% (95% CI, 77.9% - 79.2%) in 2003 to 64.1% (95% CI, 63.2% - 64.6%) in 2009 in the Medicare group, but it remained steady in the commercially insured group (86.5% [95% CI, 85.8% - 86.9%] in 2003 and 83.9% [95% CI, 83.7% - 84.0%] in 2009).

In Medicare patients, the number of procedures that used anesthesia services almost doubled, from 13,989 (95% CI, 13,867 - 14,098) procedures per 1 million enrollees in 2003 to 25,069 (95% CI, 24,721 - 25,265) in 2009. Annual payments per 1 million patients increased by about 8% per year, from $1.69 (95% CI, $1.67 - $1.71) million in 2003 to $2.65 (95% CI, $2.63 - $2.68) million in 2009.

In commercially insured patients, the use of anesthesia services increased almost 4-fold (from 3938 [95% CI, 3908 - 3957] to 15,108 [95% CI, 15,077 - 15,143] per 1 million enrollees). Annual payments per 1 million patients also increased more than 4-fold (from $1.69 [95% CI, $1.68 - $1.70] million to $7.05 [95% CI, $7.04 - $7.06] million).

Spending on Anesthesia Services for Endoscopy Has Tripled

The researchers estimate that annual spending on anesthesia services for endoscopy more than tripled during the study period, with an increase from $0.4 billion in 2003 to $1.3 billion in 2009. They estimated that anesthesia services were provided to low-risk patients in 3.1 million procedures in 2009 (1.2 million procedures in Medicaid patients and 1.9 million procedures in commercially insured patients), with estimated spending of $1.1 billion in 2009.

"Our study is the first to our knowledge to stratify anesthesia use during gastrointestinal endoscopies by predicted ASA physical status classification, and to quantify the payments associated with use among low-risk patients," the authors write. "Our results suggest that the majority of gastroenterology-related anesthesia services are provided to low-risk patients and can be considered potentially discretionary based on current payment policies," they add.

In an accompanying editorial, Lee A. Fleisher, MD, from the Department of Anesthesiology and Critical Care at Perelman School of Medicine and the Leonard Davis Institute of Health Economics at the University of Pennsylvania in Philadelphia, notes that there are many reasons endoscopists might choose to use anesthesia services.

Deep sedation or general anesthesia might enable endoscopists to complete the examination in less time and possibly do a more thorough examination. Patients may be more willing to have the procedure if they can have deep sedation or general anesthesia.

The use of anesthesia services may be attractive to endoscopists for practical, as well as medicolegal, reasons, because the responsibility for maintaining the patient's airway and respiratory status lies with the anesthesiologist/anesthetist, allowing the endoscopist to focus on the procedure.

Finally, Dr. Fleisher writes, financial considerations may be a factor. Anesthesiologist-administered propofol has a faster onset/offset profile, and may allow the endoscopist to perform more procedures in a given day.

"The results of the study by Liu et al demonstrate wide variability in utilization of anesthesia services in low-risk patients and suggest that there is discretionary use in a large population of patients who do not have medical necessity for anesthesia services," Dr. Fleisher writes.

"Careful implementation of new policies regarding 'potentially' discretionary services need to incorporate the patient and clinician perspective while continuing to implement change that bends the cost curve. This may require all parties, including patients, clinicians, and facilities, to have a greater stake in the financial consequences of their action," he concludes.

Ethicon Endo-Surgery Inc financially supported the study. The authors and editorialist have disclosed no relevant financial relationships.

JAMA. 2012;307:1178-1184, 1200-1201. Article abstract, Editorial extract

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