Use of monitored anesthesia care for gastrointestinal endoscopy has increased in the Veterans Health Administration (VHA) as in fee-for-service environments, despite the absence of financial incentives.
Dr Megan Adams and colleagues investigated factors associated with use of monitored anesthesia care in an integrated health care delivery system with a capitated payment model.
The research team performed a retrospective cohort study using multilevel logistic regression, with monitored anesthesia care use modeled as a function of procedure year, patient- and provider-level factors, and facility effects.
The team collected data from 2,091,590 veterans who underwent outpatient esophagogastroduodenoscopy and/or colonoscopy during fiscal years 2000-2013 at 133 facilities.
|Unmeasured facility-level effects had the greatest effect on the trend of monitored anesthesia care use|
The adjusted rate of monitored anesthesia care use in the VHA increased 17% per year from fiscal year 2000 through 2013.
The researchers observed that the most rapid increase occurred starting in 2011.
VHA use of monitored anesthesia care was associated with patient-level factors that included obesity, obstructive sleep apnea, higher comorbidity, and use of prescription opioids and/or benzodiazepines, although the magnitude of these effects was small.
The research team found that provider-level and facility factors were also associated with use of monitored anesthesia care, although again the magnitude of these associations was small.
Unmeasured facility-level effects had the greatest effect on the trend of monitored anesthesia care use.
Dr Adams' team concludes, "In a retrospective study of veterans who underwent outpatient esophagogastroduodenoscopy and/or colonoscopy from fiscal year 2000 through 2013, we found that even in a capitated system, patient factors are only weakly associated with use of monitored anesthesia care."
"Facility-level effects are the most prominent factor influencing increasing use of monitored anesthesia care."
"Future studies should focus on better defining the role of monitored anesthesia care, and facility and organizational factors that affect choice of endoscopic sedation."
"It will also be important to align resources and incentives to promote appropriate allocation of monitored anesthesia care based on clinically meaningful patient factors."