Monday, January 8th, 2018
Re: Report on the Development of Practice Recommendations for the Use of Sedation for Hospital-Based Routine Colonoscopies, published on Dec 14, 2017 by Dr. N. Baxter et al
Ontario’s Anesthesiologists - a Section of the Ontario Medical Association, self-identifies as a major stakeholder in the practice of sedation for routine in (and out)-of-hospital colonoscopy. Unfortunately, we were not invited to participate in this consensus based document. However, we became aware of the existence of this work, having been asked by the Canadian Anesthesiologists’ Society to recommend an anesthesiologist to participate in the Expert Panel. The anesthesiologists who participated in this work did so as individuals and not as representatives of either the CAS or Ontario’s Anesthesiologists. As the physicians who administer the majority of deep sedation for colonoscopy and as the recognized content experts in the practice of sedation, we believe our opinion is crucial at any policy discussion.
We commend Dr. Baxter and her team for undertaking the task of creating these recommendations. We recognize the need for a high-quality evidence base to develop guidelines in this domain, and are aware of the paucity of high quality evidence to support any one particular sedation practice for routine colonoscopy. The controversy surrounding who does what and how for sedation for colonoscopy is not new and inevitably different parties will have different opinions and interests based on their own experience and arguably their inherent bias. We assume that all panelists were screened for potential conflicts of interest as we acknowledge the importance of confirmation bias in decision making and interpretation of evidence. For greater transparency, we recommend sharing the screening used as well as publishing the pre-existing beliefs of all panelists on this subject. It would also be of value to describe the process by which panelists, consultants and speakers at the daylong event were chosen.
While we believe the recommendations have been made in good faith, we have reservations regarding the validity of using them as justification for any major policy change. We suggest that the ranking of the various factors and outcomes associated with sedation techniques are misleading and perhaps represent a bias in the process. Specifically, we believe that ‘death’ as an outcome is spurious. Death following routine endoscopy should be so vanishingly uncommon that it is a misleading outcome in terms of choice of sedative practice. That patients do not die on a frequent basis in endoscopy suites could be testament to the resilience of the human body and the ready availability of flumazenil and naloxone as well as judicious use of sedative techniques and skills of sedationists. More importantly, we believe that in a patient centered health care system, patient satisfaction, including recovery time are in fact extremely important outcome measures. Relegating these to second and third tier outcomes is neither representative of patient centered care nor the mandate to find efficiencies in the system.
The Cochrane review referenced in the document suggests an odds ratio of 0.35 for patient satisfaction in favour of propofol sedation. The implication of this is that patients are three times more likely to be dissatisfied with their sedation when they are not offered deep sedation/propofol for endoscopy. In our aim to provide patient centered care, we suggest that patient satisfaction must be an ‘extremely important’ outcome. Providing an excellent patient experience is our shared responsibility, and it is apparent that deep sedation with propofol provides the highest patient satisfaction outcomes. Moreover, that strategies are required to increase the acceptability of moderate sedation suggests that this technique is inherently inferior.
We believe that recovery time is also an ‘extremely important’ outcome inasmuch as efficiencies are being sought. Reduced recovery time will have effects on access and other human resource issues in endoscopy suites. Throughput in endoscopy units is inexorably linked to recovery time, and is an important quality measure. Moreover, an accounting of lost patient productivity due to the prolonged effects of sedative drugs should be undertaken. Missing from the guidelines is an actual recommendation on the dosing of drugs for moderate sedation and recommended maximum doses. The use of large doses of midazolam leads to prolonged lingering effects and negative patient experience.
The document identifies a cost of $152.27 per patient for anesthesiologist directed sedation. We believe this needs context in terms of the overall costs associated with colonoscopy. While $18 million is a large sum of money and while there has been a significant increase in the prevalence of anesthesia directed deep sedation in Ontario (although not dissimilar from other jurisdictions), there is a need to present this as a proportional cost of all endoscopy services. Another issue which we believe deserves commentary is the value provided by this $152.27. Our position is that $152.27 is extraordinary value for the service, expertise and quality delivered by an anesthesiologist in the endoscopy suite. Furthermore, some of the efficiencies realized by reduced recovery time inevitably translate into savings not accounted for in this document. A far more extensive cost analysis is warranted before an isolated line item is used to guide policy. With respect to procedure time, although 1-2 minutes may not seem clinically significant, on a day of 15 procedures, when added up, the time gained allows for an additional patient to receive testing, thus improving access. We also challenge the assertion that eliminating deep sedation will “save money” to allow for spending on FIT rollout. We suspect, and experience tells us that any savings in anesthesia fees for colonoscopy sedation will be offset by compensation for services provided in other areas of need. We are also very concerned by the comments of participants that suggested a hidden financial agenda was the main driver for this work as opposed to one looking to increased quality of care.
CCO is an important body, and no doubt recommendations from CCO will carry significant weight at the Provincial and National level. We believe that careful thought needs to be given to the potential for unintended consequences from such recommendations.
Should these recommendations translate into significant policy changes with respect to whether and how anesthesia services for endoscopy are insured, the availability of anesthesia services for the patients who absolutely require them will be jeopardized. Pediatric patients, patients having prolonged and more complicated procedures, patients who refuse endoscopy without deep sedation, patients with significant medical co-morbidities and patients who are difficult to sedate due to chronic use of opioids and sedatives are examples of groups that require the involvement of anesthesiologists. One must also consider patients who have had endoscopy under deep sedation in the past – will they be eligible to receive deep sedation again? What about patients who have had a negative
experience with moderate sedation? Arguably, patients denied deep sedation may defer or default on necessary colonoscopy with potentially disastrous consequences.
We are aware that there have been incidents where patients have suffered adverse events associated with sedation in endoscopy suites, and we believe having anesthesiologists present in these environments can reduce the incidence and mitigate the severity of these adverse events.
Further, the viability of many out of hospital clinics might be jeopardized with consequent increased demands on hospital-based services and increased wait-lists. Additionally, we are concerned that one of
the recommendations contradict current CPSO policy for OHPs that requires the health care professional monitoring the patient to not engage in other activities. Finally, consideration should be given to the human resource implications to hospital-based operative anesthesia services, particularly in smaller hospitals in under serviced areas where provision of anesthesia for endoscopy is required to maintain a viable department of anesthesia.
Anecdote and patient experience remain important factors. It might have been informative for the panel to have included patients who have had sedation with and without propofol when considering their recommendations. It is apparent to many that there is a significant cohort of patients who do better when they are offered propofol, and arguably they need deep sedation. Pre-emptively identifying these patients will be logistically very difficult, and structuring services around these needs will be challenging. Consideration of these and other barriers to a thoughtful implementation of a policy change are missing from the document.
Presenting the preliminary recommendations by percentage is somewhat problematic in a survey-based document, as inevitably levels of expertise will differ depending on the context of the question being asked and the respondent’s knowledge base and experience. For instance, it would be illuminating to know which three respondents strongly disagree that ‘deep sedation for colonoscopy should only be administered by an anesthesia provider’, and what their jurisdictional experience in this domain is.
Ontario’s Anesthesiologists – a section of the Ontario Medical Association generally welcome the development of practice guidelines, however we do not see this first attempt as the ‘final word’ in this area but as more of a conversation starter. We believe there is much more work needed prior to contemplating any major policy decisions. We stand ready and willing to participate in this work.
The Executive Committee for Ontario’s Anesthesiologists
Click here to access: Report on the Development of Practice Recommendations for the Use of Sedation for Hospital-Based Routine Colonoscopies, published on Dec 14, 2017 by Dr. N. Baxter et al
2017/2018 Executive Committee
Member at Large- Dr. Greg Bosey
Member at Large- Dr. Nam Le
Member at Large- Dr. Paul Gill
Member at Large- Dr. Rohit Kumar
Resident Rep- Dr. Fady Ebrahim and Dr. Ameya Bopardikar
Administrative Coordinator- Emily Hill
Chair- Dr. Christopher Harle
Vice- Chair- Dr. Monica Olsen
Past-Chair- Dr. Paul Tenenbein
Treasurer- Dr. Kashif Yousuf
Tariff Chair- Dr. Eric Goldszmidt
Secretary- Dr. Tarit Saha