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Responding to an article last week by business columnist David Lazarus that insurer Anthem Blue Cross declared propofol-induced total sedation during colonoscopies “not medically necessary,” several readers argued that Anthem’s bean counters should undergo this review procedure. only under moderate sedation before denying other patients access to propofol (one such letter was published today).
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Lazar cited several doctors to back up his claim that Anthem’s decision not to pay for propofol during colonoscopies risks turning many patients away from a potentially life-saving procedure.
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Among the twenty or so letters written in response to Lazarus were several doctors who agreed with Hymn. One such doctor’s letter was published on Tuesday; Several others, not published in the article, reported their experiences with colonoscopy under moderate sedation. Of the few doctors who wrote to us, only one agreed with Lazar.
Jerome P. of Venice. Helman, a physician and frequent correspondent in all areas of medicine, says that propofol for colonoscopy is a relatively new expectation:
“Lazarus ignores past community standards. As a senior gastroenterologist, we once performed endoscopy without an anesthetist present. We called it moderate sedation because deeper sedation levels of anesthesia are not necessary for such procedures and we administered the drug ourselves.
“Then came propofol and the need for anesthesia.” Reimbursement for endoscopy has decreased significantly, so investments in endoscopy centers have resulted in significantly greater returns to the gastroenterologist.”
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“Moderate sedation with drugs such as fentanyl and Versar is universally used for colonoscopies. At my endoscopy center in Fullerton, we perform approximately 12,000 procedures a year, and 95% of them are performed under moderate sedation. Patient satisfaction is high, there were no pain complaints during these procedures. I don’t know of a single patient who refused a colonoscopy because propofol was not used.
“Propofol recovery time may be slightly shorter, which does not make a significant difference for patients who are told not to work or drive on the day of the procedure with any type of anesthesia. All high-risk patients are treated with propofol administered by an anesthesiologist.
“Complications, including aspiration, perforation, or splenic injury, have been reported to be more common in patients receiving general anesthesia.
“For my center alone, the cost of not using propofol was about $60 million. Approximately 10 million people in the United States receive colonoscopies each year, with annual costs exceeding $10 billion. Creating a procedure to administer propofol for colonoscopies increases this amount significantly without any benefit.”
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Thousand Oaks doctor Edward Evans thinks it’s okay to bash insurance companies, but not for the reasons Lazarus says:
“I generally agree wholeheartedly with Lazarus’s views on consumer protection, but I found him to be really unreasonable. As a doctor, I like to vilify insurance companies as much as the next person, [but] in this case I think they’re right.
“The administration of propofol during colonoscopy is an example of rising medical costs. We have an insatiable desire to improve our health. Colonoscopy costs have skyrocketed.
“Colonoscopies were originally office procedures with sedation and analgesics safely administered by the physician. This type of conscious sedation is successfully used for many procedures, including chest tube insertion and central line placement.
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“But recently, and in part due to advocacy by anesthesiologists, colonoscopies have been elevated to ambulatory surgery, with an anesthesiologist present and often performed in a full surgical suite. Both increase costs significantly but do not provide much benefit to the patient.”
“What can be said is that propofol is widely accepted in practice not only because it is more liked by patients, but also because it contributes to increasing its efficiency, because very short induction, procedure and recovery times allow endoscopic “passability”. will be significantly increased. Since only one nurse anesthetist is required for the endoscopic unit, the additional cost and procedure is offset by the increased number of procedures performed.
“Furthermore, by using propofol, the endoscopist can perform the exam faster, more thoroughly, and more thoroughly. Thus, many practitioners have chosen propofol because it makes economic and medical sense.
“I hope that insurers will not penalize patients for requiring anesthesia that provides a complete, comfortable and safe procedure while increasing reasonableness and efficiency, which in turn will increase the percentage of the population undergoing this beneficial test.” Personal Health Navigator is available to all Canadian patients. Questions about your doctor, hospital or navigating the health care system can be sent to [email protected].
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Question: I am having a colonoscopy soon. I had it 10 years ago. My doctor recommended a test to check for colon cancer. Now, he says, it’s time to do it again. I didn’t mind the procedure. But I hated having to drink this horrible liquid beforehand to cleanse my bowels. Why is this thing so scary and is there an alternative?
Colonoscopy itself – the viewing area is inserted into the rectum – is not all bad. At this point, most patients are sedated.
But there is no escape from terrible preparation. Before the doctor inserts a 5- to 6-foot-long flexible nozzle into the colon, the colon must be clean as a whistle.
Therefore, you need to cleanse the intestines. The standard preparation is sold under several different brand names, including Peglyte, GoLytely, Colyte, and Klean-Prep.
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Kits usually consist of a container containing a powder mixture to which you add four liters of water to form a solution. Then you drink the mixture for a few hours the day before your colonoscopy.
“The idea behind the preparation is that the large volume of fluid flushes and cleanses the colon,” explains Dr. Michael Bernstein, a gastroenterologist at Sunnybrook Health Sciences Center.
“It’s not a pleasant experience,” admits Annie Hui, a Sunnybrook pharmacist. “You should be at home ready to go to the bathroom. You will have watery stools for several hours – at the end of the preparation, the rectal discharge will be a clear liquid. Everything is cleared.”
Drinking four liters of liquid would be difficult in itself. However, it’s the powder mixture that provides the added burden of the horrible taste.
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One of the ingredients in the mixture is polyethylene glycol, which is sometimes used in small amounts to treat constipation. It works by drawing water into the colon, which softens the stool and stimulates the muscles in the colon that cause bowel movements.
The bad taste comes from the second main ingredient in the mix—electrolytes like sodium and potassium, which are minerals that normally circulate in the blood and help regulate everything from nerve conduction to heart function.
“The body loses a lot of fluid and electrolytes during the bowel preparation process,” says Dr. Hui. For this reason, there are lots and lots of electrolytes in the mix to make sure the body’s supply of these minerals is in balance. They are mainly salts. Thus, the mixture mainly contains heavy sweet flavorings to mask the salty taste.
For those who can’t get everything down the hatch, there are a few “low-volume” alternatives. Pico-Salax and a similar product called Purg-Odan are among the most commonly used brands.
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Pico-Salax contains three ingredients—sodium picosulfate, magnesium oxide, and citric acid—that act as laxatives, stimulate muscle contractions in the colon, and draw water into the colon.
With this product, you add one packet of the mixture to a 150 milliliter glass of water and drink it. It doesn’t taste very good. Then about six or more hours later—depending on the time of your colonoscopy—you add another packet to a glass of water and gulp down the fizzy drink. (Many doctors also prescribe a stimulant laxative the day before training to “jumpstart” the process.)
You still have to drink a lot of fluids to cleanse your colon, but you can use almost any clear liquid you like, such as water, juice, or Gatorade (but no red, purple, or blue colored drinks that stain your colon and cause false test results. .)
“The upside is that this method is much more attractive to patients in terms of how much [bad-tasting liquid] has to pass,” says Dr. Bernstein.
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Laxatives can also cause cramps. Also, the patient’s electrolytes may be out of balance. Therefore, only healthy people should use this method. “People with severe kidney disease or heart disease should not use the low-volume drug,” says Dr. Bernstein.
He usually recommends his patients stick to a high-volume colon
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