A population-based analysis of outpatient colonoscopy in adults assisted by an anesthesiologist.
ABSTRACT The use of propofol to sedate patients for colonoscopy, generally administered by an anesthesiologist in North America, is increasingly popular. In the United States, regional use of anesthesiologist-assisted endoscopy appears to correlate with local payor policy. This study's objective was to identify nonpayor factors (patient, physician, institution) associated with anesthesiologist assistance at colonoscopy.
The authors performed a population-based cross-sectional analysis using Ontario health administrative data, 1993-2005. All outpatient colonoscopies performed on adults were identified. Hierarchical multivariable modeling was used to identify patient (age, sex, income quintile, comorbidity), physician (specialty, colonoscopy volume), and institution (type, volume) factors associated with receipt of anesthesiologist-assisted colonoscopy.
During the study period, 1,838,879 colonoscopies were performed on 1,202,548 patients. The proportion of anesthesiologist-assisted colonoscopies rose from 8.4% in 1993 to 19.1% in 2005 (P < 0.0001). In the hierarchical model, patients in low-volume community hospitals were five times more likely to receive anesthesiologist-assisted colonoscopy than patients in high-volume community hospitals (odds ration 4.9; 95% confidence interval 4.4-5.5). Less than 1% of colonoscopies in academic hospitals were anesthesiologist-assisted. Compared to gastroenterologists, surgeons were more likely to perform anesthesiologist-associated colonoscopy (odds ratio 1.7; 95% confidence interval 1.1-2.6).
In Ontario, rates of anesthesiologist-assisted colonoscopy have risen dramatically. Institution type was most strongly associated with this practice. Further investigation is needed to determine the most appropriate criteria for the use of anesthesiology services during colonoscopy.
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ABSTRACT: Anesthesia services are increasingly being requested for gastrointestinal (GI) endoscopy procedures. The preparation of the patients is different from the traditional operating room practice. The responsibility to optimize comorbid conditions is also unclear. The anesthetic techniques are unique to the procedures, as are the likely events that require intervention by the anesthesia team. The postprocedure care is also unique. The future needs for anesthesia services in GI endoscopy suite are likely to expand with further developments of the technology.Anesthesiology Clinics 06/2014; DOI:10.1016/j.anclin.2014.02.006
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ABSTRACT: The use of hierarchical logistic regression for provider profiling has been recommended due to the clustering of patients within hospitals, but has some associated difficulties. We assess changes in hospital outlier status based on standard logistic versus hierarchical logistic modelling of mortality. The study population consisted of all patients admitted to acute, non-specialist hospitals in England between 2007 and 2011 with a primary diagnosis of acute myocardial infarction, acute cerebrovascular disease or fracture of neck of femur or a primary procedure of coronary artery bypass graft or repair of abdominal aortic aneurysm. We compared standardised mortality ratios (SMRs) from non-hierarchical models with SMRs from hierarchical models, without and with shrinkage estimates of the predicted probabilities (Model 1 and Model 2). The SMRs from standard logistic and hierarchical models were highly statistically significantly correlated (r > 0.91, p = 0.01). More outliers were recorded in the standard logistic regression than hierarchical modelling only when using shrinkage estimates (Model 2): 21 hospitals (out of a cumulative number of 565 pairs of hospitals under study) changed from a low outlier and 8 hospitals changed from a high outlier based on the logistic regression to a not-an-outlier based on shrinkage estimates. Both standard logistic and hierarchical modelling have identified nearly the same hospitals as mortality outliers. The choice of methodological approach should, however, also consider whether the modelling aim is judgment or improvement, as shrinkage may be more appropriate for the former than the latter.Journal of Medical Systems 05/2014; 38(5):29. DOI:10.1007/s10916-014-0029-x · 1.37 Impact Factor
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ABSTRACT: A central tenet of organised cancer screening is that all persons in a target population are invited. The aims of this study were to identify participant and physician factors associated with response to mailed physician-linked invitations (study 1) and to evaluate their effectiveness in an organised colorectal cancer (CRC) screening programme (study 2). 2 studies (study 1-cohort design and study 2-matched cohort design, comprising study 1 participants and a matched control group) were conducted in the context of Ontario's organised province-wide CRC screening programme. 102 family physicians and 11 302 associated eligible patients from a technical evaluation ('the Pilot') of large-scale mailed invitations for CRC screening were included. Matched controls were randomly selected using propensity scores from among eligible patients associated with family physicians in similar practice types as the Pilot physicians. Physician-linked mailed invitation to have CRC screening. Uptake of faecal occult blood test (FOBT) within 6 months of mailed invitation (primary) and uptake of FOBT or colonoscopy within 6 months of mailed invitation (secondary). Factors significantly associated with uptake of FOBT included prior FOBT use, older participant age, greater participant comorbidity and having a female physician. In the matched analysis, Pilot participants were more likely to complete an FOBT (22% vs 8%, p<0.0001) or an FOBT or colonoscopy (25% vs 11%, p<0.0001) within 6 months of mailed invitation than matched controls. The number needed to invite to screen one additional person was 7. Centralised large-scale mailing of physician-linked invitations is feasible and effective in the context of organised CRC screening.BMJ Open 03/2014; 4(3):e004494. DOI:10.1136/bmjopen-2013-004494 · 2.06 Impact Factor