Endoscopy Without Sedation?

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New technology makes it feasible, but patients' acceptance is lacking.


When Wanda Batch, CGRN, tells you that the physicians at Gastroenterology Consultants of San Antonio perform quick, comfortable sedationless upper endoscopy, she knows what she's talking about. Ms. Batch, the administrator of the Texas facility, once arrived at her center an hour early, had her upper GI tract examined without sedation and then began preparing for the day's surgical schedule. "I was in my clothes and back behind my desk before the rest of the staff arrived," she says.

Despite a less-than-enthusiastic response from patients, endoscopy performed without sedation is gaining a bit of traction. Proponents say the practice is convenient for patients, who can drive themselves to the center, spend mere minutes in recovery and return to their day's activities without the grogginess of a narcotic hangover. Instrument manufacturers are developing thinner instruments. And some insurers are forcing your hand (no pun intended) by refusing to pay for anesthesia providers for routine endoscopy cases. Here's a closer look at this issue.

Insurance against anesthesia
Claiming a lack of medical necessity for routine endoscopy cases, many insurers refuse to reimburse for anesthesia services used during the procedure. In May 2006, Aetna released a letter concerning its reimbursement policy for monitored anesthesia care used in GI procedures. Key provisions:

  • For patients aged 18 to 65, MAC codes 00740 or 00810 won't be eligible for separate payment for upper and lower endoscopy procedures performed in the physician's office and billed with modifiers P1, P2 or with no modifier.
  • MAC codes 00740 or 00810 will be eligible for payment at the moderate sedation rate (CPT4 codes 99149 and 99150) for upper and lower endoscopy procedures performed in an ASC or hospital billed with modifier P1, P2 or with no modifier when submitted by an anesthesiologist or certified nurse anesthetist.

Aetna based its policy changes on the 2004 joint recommendations from the American College of Gastroenterology, American Gastroenterological Association and American Society for Gastrointestinal Endoscopy. The groups stated that "the routine assistance of an anesthesiologist/anesthetist for average-risk patients undergoing standard upper and lower endoscopic procedures is not warranted."

The recommendations also state that you can successfully perform diagnostic and uncomplicated therapeutic endoscopy and colonoscopy with moderate sedation or propofol administered by adequately trained non-anesthesiologists. They further state that reimbursement for conscious sedation is included within the codes covering endoscopic procedures.

In a letter dated June 2, Orin F. Guidry, MD, president of the American Society of Anesthesiologists, responded to Aetna's policy change. Dr. Guidry notes that the gastroenterology societies' recommendations admit complex procedures and procedures in high-risk patients justify the use of anesthesia providers to provide conscious or deep sedation. The societies' and Aetna's belief that non-anesthesia providers can administer anesthesia drugs also raises concern, says Dr. Guidry, who points to the controversy surrounding nurses pushing propofol as an example of how the reimbursement policies of insurance carriers force administrators into dangerous anesthesia policies.

Medicare generally doesn't reimburse for sedation, whether administered by anesthesiologists or gastroenterologists, according to a study published in the May 2006 American Journal of Gastroenterology. But reimbursement policies are usually driven by local Medicare carriers. Rates of anesthesia utilization during endoscopy therefore vary in relation to regional payor policies, say the researchers. The study notes that 35 percent of all code 00810 procedures in 2002 were billed in either Florida or the New York metropolitan area, two regions where Medicare policies allow for reimbursement during endoscopy.

The use of propofol also varies by region and serves as an indicator of anesthesia service utilization during endoscopy. A 2004 survey of 5,000 gastroenterologists showed 7 percent of their colleagues in the Northeastern states used propofol, an area where carrier policies are unfavorable toward anesthesiologists. Conversely, 43 percent of gastroenterologists in the Mid-Atlantic states employ propofol, a region with more favorable policies.1

Administrators must walk the risk-reward tightrope when working with insurance that doesn't reimburse for anesthesia services in endoscopy procedures. In states where nursing boards allow non-anesthesia providers to push propofol, the drug is a viable, albeit potentially dangerous option. It's short acting, enabling patients to recover quickly, but patients sedated with propofol can also crash quickly, say many anesthesia experts.

An alternative sedative regimen is the fentanyl and midazolam combination. Non-anesthesia providers can push this cocktail, making it an ideal alternative to propofol. The drugs, however, linger in patients, resulting in longer recovery times and decreased case efficiency.

Slimmer scopes
Or, perhaps, you and your staff can turn to performing endoscopy without sedation. Developing technology now makes upper endoscopy a viable option, says Richard Rothstein, MD, professor of medicine at Dartmouth Hitchcock Medical Center in Lebanon, N.H.

Dr. Rothstein notes that new scopes by Olympus, Fujinon and Pentax are of sufficient length to reach the duodenum and have outer diameters less than 6mm - Olympus's scope is sub-5mm - allowing for complete endo exams with greater patient tolerance. He adds that the diagnostic results of the slimmer scopes match the accuracy of standard endo instruments.

Despite the small diameters, the new generation scopes also have excellent optical systems, providing detailed images and depth of vision, adds Dr. Rothstein. He says advances in scope technology allow for sedationless upper endoscopy through the nose. "In my experience, transnasal endoscopy produces less gagging and less intolerance," he says.

Identifying patients who can tolerate the procedure is key, says Dr. Rothstein. He advises against selecting patients younger than 30, and steers clear of already anxious individuals. Patient apprehension can, however, be quelled by a self-assured doc. "A physician's confidence is just as important as his skill," says Dr. Rothstein. "Endoscopists need to feel comfortable and have an attitude that the procedure can be done before canvassing patients to determine interest levels."

A physician's confidence is often in direct proportion his self-perceived skills. And while few docs question their ability in the OR, performing endoscopy without sedation can give pause to even the most self-assured practitioner. "Not every physician is a good choice for performing procedures without sedation," says Michael L. Weinstein, MD, of the Endoscopy Center of Washington, D.C. "Physicians have to be exquisitely gentle in order to maneuver the scope in such a way that the colon does not stretch."

What about case costs?
The price of sedative drugs isn't cost-prohibitive to endoscopy with sedation, says Ms. Batch, whose facility uses fentanyl and midazolam. "We can give drugs by the gallon and it isn't going to increase our cost," she says.

If Dr. Weinstein is going to sedate patients, he'll go with 1mg to 2mg of midazolam (Versed) and 20mg to 50mg of meperidine (Demerol), a cocktail he says costs less than $2 per case.

Case cost becomes a factor when you add propofol to the equation. Dr. Weinstein says the drug costs $7 to $10 per procedure. Facilities in states that require the administration of propofol by anesthesia providers face additional expenses, ranging from $100 to $400 per case - money that comes out of the GI doc's pocket if the anesthesia provider can't bill separately. Trained RNs would probably have a salary less than half of a nurse anesthetist and one-fourth of an anesthesiologist, says Dr. Weinstein.

Aside from cost savings and reduced potential for sedation-related complications, you'd think that the biggest potential plus of endoscopy without sedation lay in the opportunity for increased case efficiency. While patients' spending less time in recovery is certainly a time saver, Ms. Batch says its overall benefits are minimal. "Performing endoscopy without sedation will relieve pressure in the recovery area, but if your facility is built properly, that's not going to result in a dramatic increase in the amount of patients you can see," she says.

Dr. Weinstein says the extra care needed to perform procedures without sedation actually slows down his total output by as much as 10 minutes per case. "Some physicians prefer working with sedation because they can push harder and work faster," he says, adding that great care is needed to maneuver the scope in ways that minimize pushing on organ walls when you don't use sedation.

Patient fears
Most patients expressing interest in sedationless endoscopy enter facilities with ingrained fears of anesthetics. Others who refuse drugs have had positive experiences with sedation-free endoscopy. Regardless of preconceived notions, experts advise that you notify all patients of the option.

"Endoscopy without sedation is an attractive alternative for patients," says Dr. Rothstein. "They don't have to find an escort, miss work or arrange for child care. It's a time- and money-saver."

Despite obvious advantages, patients are slow to accept the notion of undergoing the procedure without sedation. "Most people in the United States are averse to pain and want to be knocked out for everything," says Dr. Weinstein, adding that he performs one of his 40 upper endoscopy procedures each month without sedation. Out of 100 monthly colonoscopies, Dr. Weinstein performs six procedures without sedation.

A 2004 study published in the Southern Medical Journal concluded that, "In contrast to reports from some major medical centers, most patients as well as medical professionals were unwilling to undergo endoscopy without sedation."2

A simple attitude change could mark a shift in standard endoscopy practices. "Patients with the mindset that they want to get it done without sedation can easily endure one of the small scopes," says Bergein F. "Gene" Overholt, MD, FACP, MACG, founder of Gastrointestinal Associates in Knoxville, Tenn. His group owns three GI centers that perform close to 20,000 procedures a year. Less than 1 percent of his patients request upper endoscopy without sedation.

Pointing to the production of endoscoes with thin outer diameters and improved optic quality, Dr. Rothstein believes lagging patient acceptance will soon rise: "I think we'll see a growth in unsedated endoscopy over the next few years."

References
1. Aisenberg J, Brill JV, Ladabaum U, Cohen LB. Sedation for Gastrointestinal Endoscopy: New Practices, New Economics. Am J Gastroenterol. 2005;100(5):996-1000.
2. Madan A, Minocha A. Who Is Willing to Undergo Endoscopy Without Sedation: Patients, Nurses, or the Physicians? Southern Medical Journal. 2004;97(9):800-805.

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