A road map to safer pain control, cost savings during colonoscopies

At a time when several U.S. health insurers have discontinued payment for use of the sedative propofol during most screening colonoscopies, physicians at the University of Pennsylvania School of Medicine have discovered that an alternative way to administer the drug could both save millions of health care dollars and provide a safer way to deliver optimal pain relief.

The researchers studied two groups of patients who received patient-controlled sedation – administered themselves with the push of a button – during their colonoscopy. One group received a combination of the sedatives propofol and remifentanil, while the other received the drugs midazolam and fentanyl. Those in the propofol arm took only about half as long to be sedated, were able to walk quicker after the procedure, and spent much less time in the recovery room.

The findings, published in the February issue of the journal Anesthesia and Analgesia, shed additional light on Aetna, Humana and other large health insurers' recent decisions to discontinue payment for the use of the sedative propofol during most routine colonoscopies, because it generally requires an anesthesiologist to be present to monitor for adverse reactions during the procedure. Their involvement adds several hundred dollars to the cost of the procedure, but without insurance coverage for this popular pain relief choice, physicians worry that more patients will avoid the lifesaving test, which detects and removes pre-cancerous polyps. Last year, 55,000 Americans died of colorectal cancer, making it the nation's second-leading cancer killer.

“Compliance with screening regimens will save lives at a rate several orders of magnitude greater than the number of lives lost to sedation,” says Jeff E. Mandel, MD, MS, clinical associate professor Anesthesiology and Critical Care at Penn. “As physicians, we should look for ways to find the optimal balance between access to care and risks. No one's interest is served by fewer patients having access to safe, painless colonoscopy.”

Previous studies showed propofol helps patients relax quicker, and that can be associated with a more thorough exam. The Penn researchers say that blending patient-controlled IV propofol and remifentanil with continuous monitoring by an anesthesiologist – similar to the way in which the doctors keep tabs on patients receiving epidural pain relief during labor and following many surgeries -- would provide patients with an ideal mix of pain relief and care from a trained anesthesiologist.

Since the researchers found that patients in the study's propofol/remifentanil arm were able to walk unassisted sooner after their procedure than those who received midazolam and fentanyl for sedation, the research also points to ways to reduce staffing in hospitals' postanesthesia care units – a major cost savings to third-party payers.

“Any solution that ignores economic realities is doomed to failure,” says Dr. Mandel. “But no solution that ignores the best interest of patients is likely to succeed.”