Who should sedate GI patients? The issue is once again front and center, this time the debate having more to do with money than medicine. The talk has shifted from the safety of propofol in untrained hands to insurers unwilling to pay for anesthesia for routine colonoscopy procedures and shrinking reimbursements that might force endo centers to employ conscious sedation nurses rather than using trained anesthesia providers.

"The days of anesthesiologists being reimbursed as much, or in some cases, more than the professional fee for colonoscopy appear to be in full wane," says one GI doc who spoke on the condition of anonymity. "A lot of GI docs have gotten comfortable having an anesthesiologist in the room sedating and monitoring the patient because that's one less nurse they need. It's simpler, but it's not any safer."

Many endoscopies are performed safely and satisfactorily without anesthesiologists' involvement. Besides some preliminary unpublished data that the frequency of polyp detection may improve with an anesthesiologist's involvement, it's hard to make a case that an anesthesiologist's involvement makes the procedure safer.

"Intuitively, we all believe that is true for some patients, but can we prove it?" asks ASA immediate past president Orin F. Guidry, MD. "Some believe that an anesthesiologist's involvement improves the efficacy of the procedure."

C. Allen Woods, MD, one of two physician-owners at Valdosta Endoscopy Center in Valdosta, Ga., says, "For the vast majority of outpatient procedures, both in ASCs and in hospitals, the use of anesthesiologists is an unnecessary expense without any significant benefit."

The revised ASC payment system is spurring the renewed debate. Under the new system, payment for most GI procedures would drop by 17 percent at the end of a four-year phase-in period.

"It's all about patient comfort at the lowest cost - and that means risks," says Beverly K. Philip, MD, professor of anesthesia at Harvard Medical School and director of the day surgery unit at Brigham and Women's Hospital in Boston. "Some places feel that anesthesia providers are too expensive to have around, but many in the GI community understand that they're taking on additional risk by [sedating patients] themselves."

Hybrid model of endo sedation
Three Rivers Endoscopy Center in Coraopolis, Pa., could serve as a model for the future of endoscopy anesthesia. Three days out of the week, patients receive physician-directed and nurse-administered anesthesia, typically Versed and Demerol or Fentanyl. On the other two days, contracted anesthesia providers sedate higher-risk patients - those suffering, for example, from diabetes, obesity and coronary artery disease - with propofol.

"I think you'll end up seeing more hybrid situations similar to what we have, where certain cases have to be done with anesthesiologists and the majority of cases do not," says gastroenterologist Lester Stine, MD, of Three Rivers.

One downside to Three Rivers's hybrid approach is that most patients don't receive propofol. Many regard the ultrashort-acting sedative as the perfect agent for GI procedures because it reduces the need for opioids, speeds recovery times and is easy to titrate. But in the hands of an RN without the proper anesthesia training or support, propofol can be dangerous - even deadly. "It requires someone who can mange an airway," says Dr. Stine.

Dr. Stine says it takes patients longer to emerge from Versed and Demerol or Fentanyl than from propofol. "We're talking minutes per case," he says. "But when you multiply that out by how many cases we do in a day, it can be significant."

Patient throughput is precisely the reason why Main Line Endoscopy Center in suburban Philadelphia won't alter its contract with its anesthesia services group. "We're going to have to cut costs," says the center's clinical director Andrea Cannon, RN, "but not on the anesthesia side."

Even though nurse-administered sedation would save on drug costs - Demerol is $1 a syringe and propofol is about $5 a syringe - Ms. Cannon says that anesthesia providers let her do four or five more procedures per day thanks to significantly quicker discharge times. "Our anesthesia group pays for itself in the number of cases we can get done," she says.

Besides, nurse-administered sedation would necessitate an additional nurse in both the pre-procedure area and in each procedure room. Staffing costs and fewer cases would offset the drug savings.

"Anesthesiologists improve turnover and productivity," says Dr. Philip. "We can provide a rapid induction and a rapid awakening and they can go right on to the next case. We absolutely improve efficiency."

At what price safety?
Some say the debate shouldn't be about money, but rather about patient outcomes and safety.

"Every patient deserves an anesthesiologist. Every patient should have the safest, optimum care," says Dr. Philip. "The GI folks must decide how much risk they're going to assume."

Texas GI nurse Misty Montellano, RN, BSN, is a proponent of nurse-administered sedation. In 2005, she wrote a letter to the FDA in favor of removing the warning that only trained persons should administer propofol from propofol's label.

"The RNs at our facility have ACLS, advanced airway training ..., take a written test on propofol sedation, and undergo a rigorous hands-on training program with the gastroenterologist and RN," she writes. "We've had no adverse outcomes in the four months we have been administering this medication. ' I have watched anesthesiologists give this medication, and our doses are much smaller in comparison. We have a very strict protocol to follow, which includes closely monitoring the patient's physiological status and response to stimuli. We do not multi-task during the administration of this medication. Our only concern is the patients' condition and sedation level."

Others contend the labeling change would make the use of propofol available to gastroenterologists who want to use the drug without incurring the expense of hiring and using an anesthesiologist.

Anesthesiologist Marc E. Koch, MD, MBA, president and CEO of Somnia in New Rochelle, N.Y., testified about the administration of propofol before the FDA. "Because there are no antagonistic agents for this anesthetic [propofol], it is crucial that a formally educated and trained anesthesia provider, with primary and sole responsibility for advanced airway and resuscitative support, be responsible for its administration," says Dr. Koch.

Unfortunately for some, such talk has not slowed the ascension of the conscious sedation nurse. The reality of sedation practice is that there are far more sedations required than could ever be staffed by anesthesia-trained individuals, says Peter L. Bailey, MD, of Rochester, N.Y. At a recent presentation, Mark J. Lema, MD, PhD, the president of the ASA and professor and chair of anesthesiology at the State University of New York, Buffalo, discussed the expansion of conscious sedation nurses. He says CSNs are popular for simple procedures, less expensive than either CRNAs or MDs, and more easily controlled by the proceduralist. In some cases, CSN services are billable.

In "The Science and Politics of Propofol" (Am J Gastroenterol 2004;99:2080-2083), Douglas K. Rex, MD, professor of medicine at Indiana University School of Medicine, writes, "Propofol's administration by registered nurses under the supervision of endoscopists has thus far proven safe, but is not realistically feasible in most U.S. endoscopy units."

"Society will solve the anesthesia provider shortage and the high cost of care by letting others partake in anesthesia care to drive down prices and improve access," says Dr. Lema.