Douglas K. Rex, MD
Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-2863.
Requests for Single Reprints: Douglas K. Rex, MD, Indiana University Hospital, #4100, 550 North University Boulevard, Indianapolis, IN 46202; e-mail, email@example.com.
Author Contributions: Drafting of the article: D.K. Rex.
Final approval of the article: D.K. Rex.
Rex D.; Effect of the Centers for Medicare & Medicaid Services Policy About Deep Sedation on Use of Propofol. Ann Intern Med. 2011;154:622-626. doi: 10.7326/0003-4819-154-9-201105030-00007
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Published: Ann Intern Med. 2011;154(9):622-626.
On 11 December 2009, the Centers for Medicare & Medicaid Services issued a policy stating that deep sedation can only be administered by an anesthesiologist, a certified registered nurse anesthetist, or a trained medical doctor or a doctor of osteopathy not involved in the performance of a medical procedure. Propofol is a popular sedation agent that is usually administered by anesthesia specialists in a service termed monitored anesthesia care (MAC). Monitored anesthesia care adds substantial new fees to procedural sedation. However, available evidence shows that propofol can be used safely by nonanesthesiologists for procedural sedation. The American Society of Anesthesiologists considers that propofol implies deep sedation and should only be administered by anesthesia specialists. The Centers for Medicare & Medicaid Services policy on deep sedation can be viewed as supporting an ongoing conversion to MAC to deliver propofol for procedural sedation. However, the absence of an evidence base supporting a need for MAC to deliver propofol, combined with its high cost, suggests that alternatives to MAC to deliver propofol deserve fair and balanced evaluation.
Alexander A. Hannenberg
American Society of Anesthesiologists
May 24, 2011
Barriers to Propofol Use
Dr. Rex's commentary on Medicare policy as it affects use of propofol for procedural sedation confuses the standards set by CMS for deep sedation. The author, like any physician - anesthesiologist or not - is permitted under Medicare policy to administer deep sedation or general anesthesia if their facility has granted privileges for doing so. CMS doesn't forbid gastroenterologists from administering sedation and anesthesia but it does forbid them from delegating this responsibility to an endoscopy nurse while occupied with the endoscopy procedure, a policy shared by dozens of state nursing boards. FDA's "black box" warning for propofol forbids its use while simultaneously performing a procedure such as endoscopy. This reflects the judgment that the administration of such potent drugs requires the undivided attention of the responsible physician. The Institute for Safe Medication Practices, the American Society of Anesthesiologists and other groups take the same view on the hazard of multi-tasking with deep sedation or anesthesia. These groups all go further than CMS in stating that the use of propofol, because of the unique characteristics of the drug, also requires that the user be trained in the administration of anesthesia. CMS relies on individual institutions, under a single anesthesia service, to define the qualifications of those given privileges to administer sedation and anesthesia. Dr. Rex need look no further than oral surgery for an example of a group that has established explicit and uniform training requirements for non-anesthesiologist anesthesia practice. Gastroenterology's failure to do likewise is the real barrier to acceptance of the practice he proposes.
Steven P. Goldenberg
Albert Einstein College of Medicine
June 2, 2011
Patient Care Most Important
TO THE EDITOR:
Rex (1) bemoans the use of monitored anesthesia care for routine endoscopic procedures, because of the addition of substantial fees for procedural sedation and the safety record of non-anesthesiologist- administered propofol. We believe that his perspective is contrary to the best interests of patient care and safety, and is not the primary driver of increased procedural costs.
Rex noted a "20% decrease in patient-satisfaction scores" at his own institution when returning patients who had previously been sedated with propofol rendered their objections to lesser sedation, necessitating the anesthesiologists' return (I). Indeed, there has been an explosion in propofol utilization for endoscopy because of enhanced patient comfort and safety, as well as increased efficiency (2). In many communities, it has become the standard of care.
A recent retrospective study found a 25% increase in polyp detection rates when the medical team includes an anesthesiology professional (3). When the endoscopist shifts his focus away from the video screen to the cardiac monitor, polyp detection rate declines and the procedure time increases.
We are also concerned about the medicolegal risks of having a complication in the office setting, especially one that might have been more quickly recognized and successfully handled by an anesthesia professional (4). It is naive to assume that BLS and ACLS certification and/or taking a weekend CME course for administering anesthesia and handling airway complications is comparable to the training received by anesthesia professionals. By assuming this responsibility, we jeopardize the safety and comfort of our patients, are less likely to detect colonic pathology, and increase our liability in the event of a misadventure.
Rex alludes to the increased fees attributable to the utilization of anesthesiologists for endoscopy (I). Although many insurance plans reimburse anesthesiologists at higher rates than Medicare, these amounts are dwarfed by the facility fees charged by hospitals for procedures. In the office setting, the total cost per procedure is a fraction of what endoscopy costs at most University and Hospital settings even when costs related to anesthesia professionals are factored into the equation.
Patient care is not "one size fits all." Hospital-based physicians and those of us who do much of our work in office-based facilities have disparate needs, experiences, back-up systems and comfort levels. Rather than pondering whether anesthesiology professional-administered propofol is worth the extra cost to the system, we should be asking whether the total expense of endoscopy is affordable and offers value. Ultimately, we must all persevere in our quest to do what we feel is in the best interest of our patients.
1. Rex DK. Effect of the Centers for Medicare & Medicaid Services policy about deep sedation on use of propofol. Ann Intern Med. 2011; 154: 622-6.
2. Inadomi JM, Gunnarsson CL, Rizzo JA, Fang H. Projected increased growth rate of anesthesia professional-delivered sedation for colonoscopy and EGD in the United States: 2009 to 2015. Gastrointest Endosc. 2010;72:580-6. [PMID: 20630511]
3. Wang A, Hoda KM, Holub JL, Eisen GM. Does level of sedation impact detection of advanced neoplasia? Dig Dis Sci. 2010; 55: 2337-43.
4. Aisenberg J, Cohen L, Piorkowski J. Propofol use under the direction of trained gastroenterologists: an analysis of the medicolegal implications. Am J Gastroenterol. 2007; 101: 707-13.
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