JAMA Internal Medicine: Endoscopy Topic Collection

Complications Following Colonoscopy With Anesthesia Assistance A Population-Based Analysis Complications After Colonoscopy With Anesthesia

Cooper GS, Kou TD, Rex DK. — Mon, 08 Apr 2013 00:00:00 GMT

Importance

Deep sedation for endoscopic procedures has become an increasingly used option but, because of impairment in patient response, this technique also has the potential for a greater likelihood of adverse events. The incidence of these complications has not been well studied at a population level.

Design

Population-based study.

Setting and Participants

Using a 5% random sample of cancer-free Medicare beneficiaries who resided in one of the regions served by a SEER (Surveillance, Epidemiology, and End Results) registry, we identified all procedural claims for outpatient colonoscopy without polypectomy from January 1, 2000, through November 30, 2009.

Intervention

Colonoscopy without polypectomy, with or without the use of deep sedation (identified by a concurrent claim for anesthesia services).

Main Outcome Measures

The occurrence of hospitalizations for splenic rupture or trauma, colonic perforation, and aspiration pneumonia within 30 days of the colonoscopy.

Results

We identified a total of 165 527 procedures in 100 359 patients, including 35 128 procedures with anesthesia services (21.2%). Selected postprocedure complications were documented after 284 procedures (0.17%) and included aspiration (n = 173), perforation (n = 101), and splenic injury (n = 12). (Some patients had >1 complication.) Overall complications were more common in cases with anesthesia assistance (0.22% [95% CI, 0.18%-0.27%]) than in others (0.16% [0.14%-0.18%]) (P < .001), as was aspiration (0.14% [0.11%-0.18%] vs 0.10% [0.08%-0.12%], respectively; P = .02). Frequencies of perforation and splenic injury were statistically similar. Other predictors of complications included age greater than 70 years, increasing comorbidity, and performance of the procedure in a hospital setting. In multivariate analysis, use of anesthesia services was associated with an increased complication risk (odds ratio, 1.46 [95% CI, 1.09-1.94]).

Conclusions and Relevance

Although the absolute risk of complications is low, the use of anesthesia services for colonoscopy is associated with a somewhat higher frequency of complications, specifically, aspiration pneumonia. The differences may result in part from uncontrolled confounding, but they may also reflect the impairment of normal patient responses with the use of deep sedation.

Potentially Inappropriate Screening Colonoscopy in Medicare Patients Variation by Physician and Geographic Region Potentially Inappropriate Colonoscopy in Old Age

Sheffield KM, Han Y, Kuo Y, et al. — Mon, 08 Apr 2013 00:00:00 GMT

Importance

Inappropriate use of colonoscopy involves unnecessary risk for older patients and consumes resources that could be used more effectively.

Objectives

To determine the frequency of potentially inappropriate colonoscopy in Medicare beneficiaries in Texas and to examine variation among physicians and across geographic regions.

Design, Setting, and Participants

This retrospective cohort study used 100% Medicare claims data for Texas and a 5% sample from the United States from 2000 through 2009. We identified Medicare beneficiaries aged 70 years or older who underwent a colonoscopy from October 1, 2008, through September 30, 2009.

Main Outcome Measures

Colonoscopies were classified as screening in the absence of a diagnosis suggesting an indication for the procedure. Screening colonoscopy was considered potentially inappropriate on the basis of patient age or occurrence too soon after colonoscopy with negative findings. The percentage of patients undergoing potentially inappropriate screening colonoscopy was estimated for each colonoscopist and hospital service area.

Results

A large percentage of colonoscopies performed in older adults were potentially inappropriate: 23.4% for the overall Texas cohort and 9.9%, 38.8%, and 24.9%, respectively, in patients aged 70 to 75, 76 to 85, or 86 years or older. There was considerable variation across the 797 colonoscopists in the percentages of colonoscopies performed that were potentially inappropriate. In a multilevel model including patient sex, race or ethnicity, number of comorbid conditions, educational level, and urban or rural residence, 73 colonoscopists had percentages significantly above the mean (23.9%), ranging from 28.7% to 45.5%, and 119 had percentages significantly below the mean (23.9%), ranging from 6.7% to 18.6%. The colonoscopists with percentages significantly above the mean were more likely to be surgeons, graduates of US medical schools, medical school graduates before 1990, and higher-volume colonoscopists than those with percentages significantly below the mean. Colonoscopist rankings were fairly stable over time (2006-2007 vs 2008-2009). There was also geographic variation across Texas and the United States, with percentages ranging from 13.3% to 34.9% in Texas and from 19.5% to 30.5% across the United States.

Conclusions and Relevance

Many colonoscopies performed in older adults may be inappropriate. The likelihood of undergoing potentially inappropriate colonoscopy depends in part on where patients live and what physician they see.

Anesthesia for Colonoscopy Too Much of a Good Thing? Comment on “Complications Following Colonoscopy With Anesthesia Assistance” Anesthesia for Colonoscopy

Wernli KJ, Inadomi JM. — Mon, 08 Apr 2013 00:00:00 GMT

Anesthesia services to provide sedation for endoscopic procedures are increasing in prevalence. The drivers of use are many, including the desire for improved procedural tolerance and patient satisfaction; however, economic factors may influence physicians' practice to use anesthesia. The tremendous geographic variation in anesthesia use supports the latter, especially since the geographic differences fall largely along reimbursement lines. By far the most common reason to use anesthesia services is to administer propofol, a sedative without analgesic properties. Endoscopic procedures that use propofol have reduced procedural and recovery times, which improve procedure throughput and increase the efficiency of endoscopy units.