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Endoscopy 2012; 44(05): 456-464
DOI: 10.1055/s-0032-1308936
Original article
© Georg Thieme Verlag KG Stuttgart · New York

Endoscopist-directed propofol administration versus anesthesiologist assistance for colorectal cancer screening: a cost–effectiveness analysis

C. Hassan
1   Gastroenterology Department; Nuovo Regina Margherita Hospital, Rome, Italy
,
D. K. Rex
2   Division of Gastroenterology/Hepatology; Indiana University Medical Center, Indianapolis, Indiana, USA
,
G. S. Cooper
3   Division of Gastroenterology, University Hospitals Case Medical Center, Cleveland, Ohio; USA
,
R. Benamouzig
4   Service de Gastroentérologie Hôpital Avicenne, Paris, France
› Author Affiliations
Further Information

Publication History

submitted 06 March 2011

accepted after revision 15 January 2012

Publication Date:
24 April 2012 (online)

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Background: Propofol for colonoscopy is largely administered by anesthesiologists or anesthesiology nurses in the United States (US) and Europe. Endoscopist-directed administration of propofol (EDP) by nonanesthesiologists has recently been proposed, with potential savings of anesthetist reimbursement costs. We aimed to assess potential EDP-related benefit in a screening setting.

Methods: In a Markov model the total number of screening and follow-up colonoscopies in a cohort of 100 000 US subjects were estimated. Anesthetist-assisted colonoscopy was compared with an EDP strategy. Model outputs were projected onto the 50 – 80-year-old US population, assuming 27 % as the current uptake for colonoscopy screening. Anesthetist costs were estimated using the mean reimbursement for the corresponding Medicare code (≥ 65-year-olds) and from commercial insurance information (50 – 64-year-olds). The proportion of colonoscopies with anesthesiologist assistance was estimated from the Medicare database. Mean nurse salary was used to estimate the cost of a 2-week EDP training. The absolute number of US endoscopists was estimated by inflating by 33 % the number of board-certified gastroenterologists. No EDP mortality was assumed in the reference scenario, and 0.0008 % mortality in the sensitivity analysis. US census data were adopted. Analogous inputs were used for France to assess EDP-related benefit in a European country.

Results: EDP training for 17 166 nurses (one for each US endoscopist) showed a cost of $  47 million. Cost estimates for anesthesiologist assistance for colonoscopy were $ 95 (Medicare) and $ 450 (non-Medicare commercial insurance), with 34.8 % of colonoscopies requiring anesthesiologist assistance. US implementation of an EDP policy showed a 10-year saving of $ 3.2 billion (Monte Carlo analysis 5 – 95 % percentiles $ 2.7 – $ 11.9 billion). In the sensitivity analysis, assuming 50 % of colonoscopies were anesthetist-assisted showed an EDP benefit of $ 4.6 billion. Assuming a 0.0008 % mortality rate, the incremental cost – effectiveness of anesthetist-assisted colonoscopy versus an EDP policy was $ 1.5 million per life-year gained, supporting EDP as the optimal choice. A 31-fold increase of EDP-related mortality or a 17-fold cost reduction for anesthetist-assisted colonoscopy was required for EDP to become not cost-effective in this scenario. Implementation of an EDP policy in France, within a guaiac-fecal occult blood test (g-FOBT) screening program, was estimated to save € 0.8 billion in 10 years.

Conclusions: The absolute economic benefit of EDP implementation in a screening setting is probably substantial with 10-year savings of $3.2 billion in the US and €0.8 billion in France. The impact of an eventual EDP-related mortality on EDP cost – effectiveness seems marginal. The huge economic and medical resources entailed by anesthetist-assisted colonoscopy could be more efficiently invested in other clinical fields.

Appendix e1, Table e2, Fig. e1, Fig. e2 and References 30–52 are available online:

 

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