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Is expensive anesthesia for colonoscopy worth it?

By Megan Brooks

NEW YORK (Reuters Health) - Given a choice, most doctors and nurses who perform colonoscopy would choose to be fully anesthetized when undergoing the procedure themselves - unless they had to pay full price for the anesthesia, a new study finds.

Screening colonoscopies can be performed when a patient is sedated but partly conscious, though increasingly in the U.S. they're done with the expensive general anesthetic propofol - made infamous by its link to the death of singer Michael Jackson.

In medical circles, propofol is known for a quicker recovery time and other desirable characteristics, but it can add from $600 to $2,000 dollars to the price of a procedure that is recommended for most people age 50 and over.

Is it worth it? Since patients who have never undergone the procedure can't know the answer beforehand, researchers asked the experts what they would choose for themselves.

Dr. James Scheiman of the University of Michigan in Ann Arbor, who wasn't involved in the research, told Reuters Health, "This is an incredibly controversial issue and (the authors) have tackled it in an interesting and bold way and I applaud them for it."

Dr. Don Rockey, chairman of the department of medicine at the Medical University of South Carolina in Charleston, and Dr. Deepak Agrawal, from the division of digestive and liver diseases at University of Texas Southwestern Medical Center in Dallas, approached this question by asking those most familiar with colonoscopy and sedation medications - gastroenterologists and endoscopy nurses - three questions.

First, if you were having screening colonoscopy, what sedation would you prefer? Choices were no sedation, midazolam-fentanyl (moderate sedation) or propofol (deep sedation).

Second, if you prefer propofol, how much extra would you be willing to pay out of pocket for it? Possible answers ranged from nothing to more than $500 or "doesn't matter."

Finally, they asked, if you prefer propofol, why? Choices were: I don't want to feel anything; my recovery time will be faster; or, I want to be taken care of by the anesthesiologist/certified RN anesthesiologist. Respondents could check all that apply.

Rockey and Agrawal received responses from 451 gastroenterologists and 460 nurses. Most responders in both groups said they preferred deep sedation with propofol, mainly because they didn't want to feel anything and the recovery time would be faster.

Yet, among those that did prefer propofol, most were unwilling to pay more than $200 for it, far less than is currently charged to patients, the authors point out in the journal JAMA Internal Medicine.

So why are gastroenterologists performing so many colonoscopies with propofol when they value it at less than current cost? The answer is "undoubtedly complex," Rockey and Agrawal write.

"First, since recovery is faster after propofol (by approximately 21 minutes), it may increase endoscopy unit efficiency," they point out. "(Though) for the patient, earlier discharge offers only a limited advantage since discharge instructions are the same for propofol and standard moderate sedation…. a recent meta-analysis demonstrated that pain scores were no different than with moderate sedation. Finally, depending on the business model and anesthesiologist contracting, professional and facility fees associated with propofol can be quite financially lucrative."

They say it's also important to keep in mind that insurers often do not cover the entire cost of propofol administration, and patients then end up paying considerable amounts for this service.

"Thus, it behooves us to ask: is it fair for a gastroenterologist to ask a patient to pay more for a service than what she or he is willing to pay?" they write. "Would patients react differently if they were told that many gastroenterologists prefer moderate sedation or that 70 percent would not pay more than $100 for propofol?"

"My own bias is that we should discuss this with our patients all of the time, but we don't always do that," Rockey told Reuters Health. "I'm not sure how we can change this part of clinical practice, but a fair amount of money could be saved."

Even when patients may not have to pay extra for propofol, Rockey and Agrawal wonder whether the additional expense to the health care system is justifiable. One respondent to their survey told them: "I will fly first class if I don't have to pay for it."

It seems that many are flying first class when we cannot really afford it, the authors add.

Scheiman, director of endoscopic research and the advanced endoscopy training program at University of Michigan, pointed out that there is "a wealth of literature on the safety of gastroenterologist-directed, nurse-administered propofol, but this has not made it through regulatory agencies and has been lobbied against aggressively by anesthesiologists."

"Colonoscopy," Scheiman added, "is the most cost-effective and the most effective cancer screening test we have. By doubling its cost with propofol that equation will change. The anesthesia costs related to (the) anesthesiologist's fee is substantially more than the colonoscopist's fee, yet the value of the procedure is the colonoscopy and polypectomy not the sedation, so this has become a contentious matter."

Scheiman said it's "pretty obvious that patients prefer propofol. I personally feel very strongly that propofol is overused and is way too expensive. I believe that use of propofol for average-risk patients should be cost-shared by the people who benefit from it, although that's a complex issue."

SOURCE: http://bit.ly/15I65lK JAMA Internal Medicine, online July 15, 2013.

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