Colonoscopies—Reducing the Cancer Toll, With or Without Anesthesia

The New York Times has continued its assault on colonoscopies in its June 1st article entitled “The $2.7 Trillion Medical Bill:  Colonoscopies Explain why U.S. Leads the Work in Health Expenditures.”

The Times’ charge that health care costs more in the U.S. is directed against medical services in general, with colonoscopy singled out as a “compelling case study.”  The article claims that they are the most expensive screening test that healthy Americans routinely undergo, with more than 10 million patients purportedly undergoing the procedures every year (a number ten times greater than a decade ago).  Moreover, as is true of many other health care services, screening colonoscopies vary considerably across the country in both the frequency with which they are performed and in pricing.  The Times included data from the Healthcare Blue Book showing that the cost of colonoscopy varied, in metropolitan areas across the U.S., from a low of $1,908 in Baltimore to a high of $8,577 in New York.

Like the American College of Gastroenterology in its response to the Times article, Anesthesia Business Consultants and its clients have “deep reservations about the cost methodology employed in the article, and its failure to acknowledge the cost-effectiveness of screening colonoscopy and the dramatic reduction in colorectal cancer incidence that has emerged in recent years.”

According to the most recent CDC data available, in 2009, 136,717 people in the United States were diagnosed with colorectal cancer, and 51,848 people died from colorectal cancer.  Proper screening would save more than 60 percent of those lives.  The United States Preventive Services Task Force recommends that persons 50 to 75 years old should be screened for colorectal cancer in one of the following three ways—

• A high-sensitivity fecal occult blood test (FOBT) every year;
• Sigmoidoscopy every five years and a high-sensitivity FOBT every three years; and
• A colonoscopy every 10 years;

but data from the National Health Interview Survey reveal that in 2010, the colorectal cancer screening was only 58.6 percent.  We can and should do better.

Anesthesiologists, who came under special fire in the Times article for adding to the cost of colonoscopies, have just one role to play in regard to the performance of colonoscopies:  to provide high quality sedation for the patients who undergo colonoscopies with anesthesia as ordered by their gastroenterologists.  It would not be appropriate for anesthesiologists, or for nurse anesthetists, to override the professional judgment of gastroenterologists or the preference of patients who opt for deep sedation rather than conscious sedation.  Indeed, our anesthesiologist and nurse anesthetist clients are concerned that no one avoid recommended screening tests because of fear of pain and discomfort.

Anesthesia and deep sedation offer clear advantages over conscious sedation.  Steven Konstadt, MD, FACC, Professor and Chairman of the Department of Anesthesiology, Maimonides Medical Center, Brooklyn, NY summarizes the differences thus:  “Anesthesia is preferable to conscious sedation for colonoscopy because it is dramatically safer, it provides better patient comfort, and it allows the patient to return to normal activities much more rapidly than conscious sedation.”  Trevor Myers, MD, President of Dominion Anesthesia in Arlington, VA elaborates:

At the request of the GI physicians in our facility, almost all procedural analgesia is provided by the anesthesia care team, rather than mediated by conscious sedation.  Traditionally, conscious sedation requires the gastroenterologists to not only perform the procedure, but also supervise medication delivery, monitor vital signs, assess patient comfort, and ultimately be responsible for patient safety.  This division of labor and attention by the GI provider can potentially be deleterious or dangerous in finding ulcers, polyps, cancers or other potentially life threatening lesions during the procedure(s).  By allowing the anesthesia care team to focus entirely on patient comfort and safety, the gastroenterologists can maximize procedural vigilance and optimize patient outcomes.  This clinical focus, combined with very high patient satisfaction scores, has led to anesthesia being the model of choice in our facility.

The drug of choice for deep sedation is propofol, a powerful anesthetic agent that the FDA has determined should only be administered by clinicians with training in the administration of anesthesia and who have no other responsibilities than to monitor the cardiopulmonary status of the anesthetized patient.  In practice, that means dedicated anesthesiologists and nurse anesthetists—not the gastroenterologist who is occupied with viewing the intestine through an endoscope.  The Times article misses this important point in its assumption that the gastroenterologist can provide adequate “moderate” sedation using a “low dose” of propofol while performing the colonoscopy.  A low dose may be intended, but titrating propofol so that the individual patient receives as much but not more than is necessary should never be a sideline. As explained by Dr. Nicholas C. Gagliano, Vice Chairman, Department of Anesthesia and Medical Director, Christiana Health System  ORs, Newark, DE:

As physicians uniquely trained to provide any level of sedation or anesthesia for diagnostic or therapeutic procedures and operations, anesthesiologists are the physicians best equipped to monitor and immediately respond to the cardiovascular, respiratory and neurologic changes that occur during the use of intravenous propofol.  One of the primary concerns of our specialty is patient safety.  We believe that the best outcomes for patients who receive sedation for colonoscopy are achieved through the oversight of physician anesthesiologists, especially for high-risk patients.

The cost of the anesthetic service varies between anesthesia providers and from location to location—as it is with all medical care not just in the U.S., but also between the U.S. and other countries.  The Times article pointed to a single example taken from the highest-cost city in the U.S.  The anesthesiologist in question billed a fee of $2,400 and the insurance company paid $1,568.  With a total cost of $8,577 for a colonoscopy in New York City, it is impossible to state that the anesthesiologist’s share was disproportionate to the amounts paid to the gastroenterologist and/or to the outpatient facility. 

Note that Medicare would pay the anesthesiologist $216.27 for a one-hour procedure in New York City.  The national average payment would be $197.28, less than half of the payment to the gastroenterologist.  Is that any more reasonable than $1,568?  It is well known that Medicare’s level of payments to anesthesiologists depends heavily on effective subsidization by commercial insurance.

One of the many other questionable assertions made in the Times article was that “Until the last decade or so, colonoscopies were mostly performed in doctors’ office suites,” the implication being that the movement to ambulatory surgical or endoscopy centers has been unwarranted.  Procedures requiring general anesthesia or deep sedation should only be done in locations offering the necessary personnel and equipment, and most doctors’ offices do not qualify.  The choice of location depends on many factors and is made by the gastroenterologist.  Anesthesiologists and nurse anesthetists can and do willingly provide services in accredited offices.  As stated by Fred E. Shapiro, DO, Assistant Professor of Anaesthesia at Harvard Medical School and President and Founder of the Institute for Safety in Office-Based Surgery, "In the debate between office versus ambulatory surgery center, the most important factor is not so much theoretical effect on cost, but accreditation and policies regarding patient safety.  For example, either an ASC or an office may be the safer option depending on whether or not they use checklists (teamwork) and other mechanisms to standardize patient selection, flow and on how procedures are performed."

Is the cost of health care high in the U.S.?  Higher than elsewhere?  Yes, of course.  While we commend the Times on launching a series that will explore the causes, we urge that all the variables be considered:  not just the cost, but also the efficacy and effectiveness of care—and patients’ preferences.  Let us never forget that in the end, the patient is the most important agent in the system.