More patients underwent general anesthesia during gastroenterological procedures such as colonoscopy between 2003 and 2009, researchers said.

During that time period, as the number of procedures rose, so too did the use of anesthesiology services - from about 14% to more than 30% in both Medicare and commercially insured patients, Soeren Mattke, MD, of the RAND Corporation in Boston, and colleagues reported in the March 21 issue of the Journal of the American Medical Association.

Most of that use occurred in low-risk patients, which suggests that a “substantial share of the spending for gastroenterology anesthesia may be considered potentially discretionary,” they wrote.

An increased focus on healthcare spending has brought more scrutiny of potentially unnecessary medical procedures, and the use of anesthesiologists and nurse anesthetists during some gastroenterological procedures has become one example.

In some instances, insurers have proposed restricting coverage of anesthesiology for these procedures, though most have not implemented the policy, researchers said.

So to assess the use of anesthesiologists in gastroenterological procedures, Mattke and colleagues conducted a retrospective analysis of claims data for 1.1 million Medicare patients and data from a sample of 5.5 million commercially insured patients between 2003 and 2009.

Overall, the number of gastroenterology procedures remained largely unchanged for Medicare patients at a mean of 136,718 procedures per million enrollees per year, but rose by more than 50% for commercially insured patients during that time, from 33,599 to 50,816 per million per year.

They found that the proportion of procedures using anesthesia services rose similarly in both groups during that time:

  Commercially insured: 13.6% to 35.5%
  Medicare: 13.5% to 30.2%

The majority of anesthesia use occurred among low-risk patients, with more than two-thirds of anesthesia services delivered to low-risk Medicare patients and three-quarters to commercially insured patients, they reported.

Similarly, payments for anesthesia doubled in Medicare patients, from $2.2 million in 2003 to $4.2 million in 2009. Payment quadrupled in commercially insured patients, from $1.9 million in 2003 to $8.4 million in 2009.

Mattke and colleagues also saw a substantial regional variation in anesthesia use in both groups, ranging from 14% for Medicare insurers and 12.6% for commercial insurers in the western U.S. to 47.5% (Medicare) and 59% (commercial) in the Northeast.

Taken together, the findings suggest that the “majority of gastroenterology-related anesthesia services are provided to low-risk patients and can be considered potentially discretionary based on current payment policies,” they wrote, adding that addressing such discretionary use “represents a sizable target for cost savings.”

“As both colonoscopy rates and use of anesthesia during gastrointestinal endoscopies are projected to increase in the coming years, the overall cost of colonoscopy screening programs will be closely scrutinized by payers and policymakers,” they concluded.

The study was limited because patient risk levels were estimated, and because the researchers couldn’t assess the actual clinical need for anesthesia in individual patients.

In an accompanying editorial, Lee Fleisher, MD, of the University of Pennsylvania in Philadelphia, cautioned that this latter limitation may be of importance.

Patient acceptance of endoscopy and colonoscopy, Fleisher explained, may be related to the assurance of deep sedation or general anesthesia for the procedures. Thus, strategies that increase adherence with screening guidelines may be cost-effective, he wrote.

Clinicians may also rely on anesthesia to reduce medicolegal consequences and take overall costs into account, he added.

Fleisher concluded that “careful implementation of new policies regarding ‘potentially’ discretionary services need to incorporate the patient and clinician perspective while continuing to implement change that bends the cost curve.”

Primary source: Journal of the American Medical Association
Source reference: Liu H, et al “Utilization of anesthesia services during outpatient endoscopies and colonoscopies and associated spending in 2003-2009” JAMA 2012; 307(11): 1178-1184.

Additional source: Journal of the American Medical Association
Source reference: Fleisher LA “Assessing the value of ‘discretionary’ clinical care” JAMA 2012; 307(11): 1200-1201.