Gastroenterology Department, Nuovo Regina Margherita Hospital, Rome, Italy.
Endoscopy. 2012 May;44(5):456-64. doi: 10.1055/s-0032-1308936. Epub 2012 Apr 24.
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.
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.
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.
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.
在美国（US）和欧洲，大部分结肠镜检查都由麻醉师或麻醉科护士使用丙泊酚进行。最近提出了由非麻醉师进行的内镜医师指导的丙泊酚给药（EDP），这可能会节省麻醉师的报销费用。我们旨在评估在筛查环境中 EDP 相关的潜在益处。
在一个马尔可夫模型中，估计了 100000 名美国受试者队列中的筛查和随访结肠镜检查总数。比较了麻醉师辅助结肠镜检查和 EDP 策略。模型输出被投影到 50-80 岁的美国人群上，假设当前结肠镜筛查的采用率为 27%。使用相应的 Medicare 代码（≥65 岁）和商业保险信息（50-64 岁）来估计麻醉师的费用。从 Medicare 数据库中估计了需要麻醉师协助的结肠镜检查比例。使用护士平均工资来估计两周 EDP 培训的成本。通过将经过认证的胃肠病学家人数增加 33%来估计美国内镜医生的绝对数量。在参考方案中，假设 EDP 没有死亡率，在敏感性分析中为 0.0008%。采用了美国人口普查数据。使用类似的输入来评估法国的 EDP 相关益处。
为 17166 名护士（每位美国内镜医生一名）进行 EDP 培训的成本为 4700 万美元。结肠镜检查中麻醉师协助的成本估计为 95 美元（医疗保险）和 450 美元（非医疗保险商业保险），需要麻醉师协助的结肠镜检查占 34.8%。在美国实施 EDP 政策显示，在 10 年内节省了 32 亿美元（蒙特卡罗分析 5-95%百分位 27-119 亿美元）。在敏感性分析中，假设 50%的结肠镜检查需要麻醉师协助，则 EDP 的获益为 46 亿美元。假设死亡率为 0.0008%，麻醉师辅助结肠镜检查与 EDP 政策相比，每获得一个生命年的增量成本效益为 150 万美元，支持 EDP 作为最佳选择。在这种情况下，EDP 相关死亡率增加 31 倍或麻醉师辅助结肠镜检查的成本降低 17 倍，EDP 才会变得不具有成本效益。在法国，在愈创木脂粪便潜血试验（gFOBT）筛查项目中实施 EDP 政策，估计在 10 年内可节省 8 亿欧元。
在筛查环境中实施 EDP 的绝对经济益处可能是巨大的，在美国节省 32 亿美元，在法国节省 8 亿欧元。EDP 相关死亡率对 EDP 的成本效益的影响似乎微不足道。麻醉师辅助结肠镜检查所需的巨额经济和医疗资源可以更有效地投资于其他临床领域。
