Cost-Based Comparison of Anesthetist-Administered Propofol Versus Endoscopist-Directed Propofol as Sedation During Screening Colonoscopies in an Academic University Center

Abstract

Introduction: Propofol use for sedation during colonoscopy is gaining wider acceptance, due, in part, to a better-reported safety profile, shorter recovery times, and better intra-procedure tolerability. However, requirements for administration of the agent differ markedly. In most academic settings, there is a requirement for the presence of an anesthetist during the procedure, which is not usually the case in non-academic settings, where endoscopist-directed administration prevails. Our aim was to perform a cost-based analysis of the presence of an anesthetist during colonoscopies performed under propofol sedation as compared to endoscopist-directed propofol administration. Methods: We retrospectively evaluated 20 colonoscopies performed for colorectal cancer (CRC) screening by a single certified endoscopist using propofol in the absence of an anesthetist or certified registered nurse anesthetist (CRNA), and determined the average duration per procedure. Timebased billing charges for the presence of an anesthetist during a colonoscopy were obtained from the billing department (5 units+duration of procedure; each unit=15 minutes or $80). The mean hourly wage of a CRNA was obtained from the Bureau of Labor Statistics, U.S. Department of Labor ($74.22, May 2012). Results: The average duration of a colonoscopy with indications as above, performed under endoscopistdirected Propofol, was 19.5 minutes. The average per procedure charge for the presence of an Anesthetist was calculated as $504. Conclusion: In a large university setting, the per procedure cost of anesthetist-administered propofol during routine colonoscopies for CRC screening is markedly higher than that with endoscopist-directed propofol administration, with a per-procedure cost difference of at least $504. The anesthetist’s time for intubation, induction of anesthesia, and recovery was not taken into account and could add considerably to this cost. The cost of training a gastroenterologist was also not considered; however, this is likely to have a minimal impact on the difference. In a private practice setting, routine use of a CRNA is common; however, the per procedure additional cost would remain low (per our observations, an addition of $24.12 per procedure). Growing evidence suggests that with appropriate patient selection and training, gastroenterologists can safely and effectively administer propofol during colonoscopies. There is also some evidence that anesthetists target deeper sedation with larger doses of propofol, potentially placing the patient at a higher risk for complications; hence, with appropriate training, endoscopist-guided propofol administration during colonoscopies can be a cost-effective and safe alternative to the presence of an anesthetist in any healthcare setting.