Our expert answers 3 Questions
As we move toward greater transparency and accountability in healthcare, there has been increased focus in recent years on identifying the drivers of inappropriate use of medical resources. As a gastroenterologist, I am particularly concerned with inappropriate use of GI endoscopy and peri-endoscopic resources, as this potentially exposes patients to unnecessary harms, drives up healthcare costs, and reduces access for patients who are most likely to benefit from these interventions. I also have an interest in the way in which the perception of medical professional liability may influence medical decision-making and lead to procedural overuse. My current research focuses on examining trends and variation in utilization of anesthesia assistance for gastrointestinal endoscopic sedation in the Veterans Health Administration.
Variation in utilization of medical services has come under increased scrutiny in recent years, due to ballooning healthcare costs, greater recognition of overuse and misuse and related patient harms, and increased calls for value-based utilization. The greatest variation in utilization is often seen with procedures or interventions where the risks versus benefits are less clear, leading to greater discretionary decision-making by the ordering physician. In the case of anesthesia assistance for gastrointestinal endoscopy, a multitude of factors may drive decision-making regarding sedation triage, including patient-related factors, provider and facility-level factors, and regional payer factors influencing reimbursement. The interplay between these factors and their relative influence on provider decision-making fascinates me.
Studies of Medicare patients suggest widespread use of anesthesiology assistance for GI endoscopy in low risk patients, despite GI society guidelines suggesting that use of anesthesia assistance in healthy, low-risk patients is not cost-effective. While the significant increase in utilization of anesthesia assistance for GI endoscopic sedation in Medicare patients has been largely attributed to economic factors/reimbursement issues, there have been no studies examining trends in utilization of anesthesia assistance in integrated healthcare delivery systems such as the Veterans Health Administration where economic factors should theoretically not be a significant influence on medical decision-making. If similar increases are seen in this system, it suggests that there are other significant drivers of utilization of anesthesia assistance aside from economic factors. Understanding these factors is essential to devising strategies to encourage more appropriate use of endoscopic and peri-endoscopic resources such as monitored anesthesia care.