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Nurse-Administered Propofol Continuous Infusion Sedation: A New Paradigm for Gastrointestinal Procedural Sedation. Am J Gastroenterol 2021; 116:710-716. [PMID: 33982940 DOI: 10.14309/ajg.0000000000000969] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Nurse-Administered Propofol Continuous Infusion Sedation (NAPCIS) is a new nonanesthesia propofol delivery method for gastrointestinal endoscopy. NAPCIS is adopted from the computer-assisted propofol sedation (CAPS) protocol. We evaluated the effectiveness, efficiency, and safety of NAPCIS in low-risk subjects. METHODS Between December 2016 and July 2017, patients who underwent esophagogastroduodenoscopy or colonoscopy with NAPCIS at our center were compared against 2 historical control groups of similar patients who had undergone procedures with CAPS or midazolam and fentanyl (MF) sedation. RESULTS The mean age of the NAPCIS cohort (N = 3,331) was 55.2 years (45.8% male) for 945 esophagogastroduodenoscopies and 57.8 years (48.7% male) for 2,386 colonoscopies. The procedural success rates with NAPCIS were high (99.1%-99.2%) and similar to those seen in 3,603 CAPS (98.8%-99.0%) and 3,809 MF (99.0%-99.3%) controls. NAPCIS recovery times were shorter than both CAPS and MF (24.8 vs 31.7 and 52.4 minutes, respectively; P < 0.001). On arrival at the recovery unit, 86.6% of NAPCIS subjects were recorded as "Awake" compared with 82.8% of CAPS and 40.8% of MF controls (P < 0.001). Validated clinician and patient satisfaction scores were generally higher for NAPCIS compared with CAPS and MF subjects. For NAPCIS, there were only 4 cases of oxygen desaturation requiring transient mask ventilation and no serious sedation-related complications. These low complication rates were similar to those seen with CAPS (8 cases of mask ventilation) and MF (3 cases). DISCUSSION NAPCIS seems to be a safe, effective, and efficient means of providing moderate sedation for upper endoscopy and colonoscopy in low-risk patients.
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Valuing innovative endoscopic techniques: prophylactic clip closure after endoscopic resection of large colon polyps. Gastrointest Endosc 2020; 91:1353-1360. [PMID: 31962121 DOI: 10.1016/j.gie.2020.01.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 01/09/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Clip closure of the mucosal defect after resecting large (≥20 mm) nonpedunculated colorectal polyps reduces postprocedure bleeding and is cost saving for payers. Clip costs are not reimbursed by payers, posing a major barrier to adoption of this technique in the community. We aimed to determine appropriate clip costs to support broader use of this procedure in practice. METHODS We performed budget impact analysis using our recent decision analytic model, comparing prophylactic clip closure with no clip closure on national cost and outcomes data, to determine the maximum feasible clip price while maintaining cost savings in practice. Sensitivity analyses were performed on important clinical factors. RESULTS In the original model, the baseline postprocedure bleeding risk was 6.8%, increasing cost of care by $614.11 averaged among all patients undergoing large polyp resection without clip closure. Prophylactic clip closure of only large right-sided polyps reduced postprocedure bleeding risk by 70.7% but resulted in cost saving only if the price of clips was $100 or less. Comparatively, prophylactic clip closure of large left-sided polyps had no clinical benefit and was not cost saving. Clip closure strategies focused only on extra-large polyps (≥40 mm), or patients taking antithrombotics regardless of polyp characteristics, were only minimally cost saving. Cost savings and maximum tolerated clip prices depended on medical comorbidity, which directly influences the costs of care to manage postprocedure bleeding. CONCLUSIONS Prophylactic clip closure after endoscopic resection of large colon polyps, particularly those in the right colon segment, is cost saving but requires clip costs less than $100. Translating these findings into practice requires gastroenterology practices to obtain reimbursement from payers for improved clinical outcomes and to align commercial clip prices with this clinical indication.
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Computer-Assisted Propofol Sedation for Esophagogastroduodenoscopy Is Effective, Efficient, and Safe. Dig Dis Sci 2019; 64:3549-3556. [PMID: 31165379 DOI: 10.1007/s10620-019-05685-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 05/25/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS Computer-assisted propofol sedation (CAPS) allows non-anesthesiologists to administer propofol for gastrointestinal procedures in relatively healthy patients. As the first US medical center to adopt CAPS technology for routine clinical use, we report our 1-year experience with CAPS for esophagogastroduodenoscopy (EGD). METHODS Between September 2014 and August 2015, 926 outpatients underwent elective EGDs with CAPS at our center. All EGDs were performed by 1 of 17 gastroenterologists certified in the use of CAPS. Procedural success rates, procedure times, and recovery times were compared against corresponding historical controls done with midazolam and fentanyl sedation from September 2013 to August 2014. Adverse events in CAPS patients were recorded. RESULTS The mean age of the CAPS cohort was 56.7 years (45% male); 16.2% of the EGDs were for variceal screening or Barrett's surveillance and 83.8% for symptoms. The procedural success rates were similar to that of historical controls (99.0% vs. 99.3%; p = 0.532); procedure times were also similar (6.6 vs. 7.4 min; p = 0.280), but recovery time was markedly shorter (31.7 vs. 52.4 min; p < 0.001). There were 11 (1.2%) cases of mild transient oxygen desaturation (< 90%), 15 (1.6%) cases of marked agitation due to undersedation, and 1 case of asymptomatic hypotension. In addition, there were six (0.6%) patients with more pronounced desaturation episodes that required brief (< 1 min) mask ventilation. There were no other serious adverse events. CONCLUSIONS CAPS appears to be a safe, effective, and efficient means of providing sedation for EGD in healthy patients. Recovery times were much shorter than historical controls.
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Affiliation(s)
- Spencer D Dorn
- University of North Carolina School of Medicine, Chapel Hill North Carolina
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Samei E, Pawlicki T, Bourland D, Chin E, Das S, Fox M, Freedman DJ, Hangiandreou N, Jordan D, Martin M, Miller R, Pavlicek W, Pavord D, Schober L, Thomadsen B, Whelan B. Redefining and reinvigorating the role of physics in clinical medicine: A Report from the AAPM Medical Physics 3.0 Ad Hoc Committee. Med Phys 2018; 45. [PMID: 29992598 DOI: 10.1002/mp.13087] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 07/05/2018] [Accepted: 07/08/2018] [Indexed: 11/11/2022] Open
Abstract
Derived from 2 yr of deliberations and community engagement, Medical Physics 3.0 (MP3.0) is an effort commissioned by the American Association of Physicists in Medicine (AAPM) to devise a framework of strategies by which medical physicists can maintain and improve their integral roles in, and contributions to, health care and its innovation under conditions of rapid change and uncertainty. Toward that goal, MP3.0 advocates a broadened and refreshed model of sustainable excellence by which medical physicists can and should contribute to health care. The overarching conviction of MP3.0 is that every healthcare facility can benefit from medical physics and every patient's care can be improved by a medical physicist. This large and expansive challenge necessitates a range of strategies specific to each area of medical physics: clinical practice, research, product development, and education. The present paper offers a summary of the Phase 1 deliberations of the MP3.0 initiative pertaining to strategic directions of the discipline primarily but not exclusively oriented toward the clinical practice of medical physics in the United States.
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Affiliation(s)
| | | | | | - Erika Chin
- British Columbia Cancer Agency - Vancouver Island Centre, Victoria, BC, Canada
| | - Shiva Das
- University of North Carolina, Chapel Hill, NC, USA
| | - Mary Fox
- Minneapolis Radiation Oncology, Minneapolis, MN, USA
| | | | | | - David Jordan
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | | | - Robin Miller
- Northwest Medical Physics Center, Lynnwood, WA, USA
| | | | | | - Lisa Schober
- American Association of Physicists in Medicine, Alexandria, VA, USA
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Singh S. PROMises Made, PROMises To Be Kept: Patient-Reported Outcome Measures in Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol 2018; 16:624-626. [PMID: 29409805 DOI: 10.1016/j.cgh.2018.01.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 01/16/2018] [Accepted: 01/21/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California; Division of Biomedical Informatics, University of California San Diego, La Jolla, California
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Dorn SD. Repeal and Replace? Repair or Despair? 2017 Health Care Reform and Clinical Gastroenterology. Gastroenterology 2017; 153:1465-1468. [PMID: 29100846 DOI: 10.1053/j.gastro.2017.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Spencer D Dorn
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Lin OS. Sedation for routine gastrointestinal endoscopic procedures: a review on efficacy, safety, efficiency, cost and satisfaction. Intest Res 2017; 15:456-466. [PMID: 29142513 PMCID: PMC5683976 DOI: 10.5217/ir.2017.15.4.456] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 08/03/2017] [Accepted: 08/03/2017] [Indexed: 02/07/2023] Open
Abstract
Most gastrointestinal endoscopic procedures are now performed with sedation. Moderate sedation using benzodiazepines and opioids continue to be widely used, but propofol sedation is becoming more popular because its unique pharmacokinetic properties make endoscopy almost painless, with a very predictable and rapid recovery process. There is controversy as to whether propofol should be administered only by anesthesia professionals (monitored anesthesia care) or whether properly trained non-anesthesia personnel can use propofol safely via the modalities of nurse-administered propofol sedation, computer-assisted propofol sedation or nurse-administered continuous propofol sedation. The deployment of non-anesthesia administered propofol sedation for low-risk procedures allows for optimal allocation of scarce anesthesia resources, which can be more appropriately used for more complex cases. This can address some of the current shortages in anesthesia provider supply, and can potentially reduce overall health care costs without sacrificing sedation quality. This review will discuss efficacy, safety, efficiency, cost and satisfaction issues with various modes of sedation for non-advanced, non-emergent endoscopic procedures, mainly esophagogastroduodenoscopy and colonoscopy.
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Affiliation(s)
- Otto S Lin
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
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Affiliation(s)
- Ziad F Gellad
- Durham VA Medical Center, Durham, North Carolina; and Duke Clinical Research Institute, Durham, North Carolina.
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Baffy G, Fisichella PM. Gastrointestinal Surgery and Endoscopy: Recent Trends in Competition and Collaboration. Clin Gastroenterol Hepatol 2017; 15:799-803. [PMID: 28235574 DOI: 10.1016/j.cgh.2017.02.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 02/09/2017] [Accepted: 02/12/2017] [Indexed: 02/07/2023]
Affiliation(s)
- György Baffy
- Department of Medicine, VA Boston Healthcare System and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - P Marco Fisichella
- Department of Surgery, VA Boston Healthcare System and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Dorn SD. Academic Gastroenterology Practice in a Value-Based World: One Size No Longer Fits All. Gastroenterology 2017; 152:1258-1261. [PMID: 28322740 DOI: 10.1053/j.gastro.2017.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Spencer D Dorn
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Lin OS, La Selva D, Kozarek RA, Tombs D, Weigel W, Beecher R, Koch J, McCormick S, Chiorean M, Drennan F, Gluck M, Venu N, Larsen M, Ross A. One year experience with computer-assisted propofol sedation for colonoscopy. World J Gastroenterol 2017; 23:2964-2971. [PMID: 28522914 PMCID: PMC5413791 DOI: 10.3748/wjg.v23.i16.2964] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Revised: 02/10/2017] [Accepted: 03/31/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To report our one-year experience with computer assisted propofol sedation (CAPS) for colonoscopy as the first United States Medical Center to adopt CAPS technology for routine clinical use.
METHODS Between September 2014 and August 2015, 2677 patients underwent elective outpatient colonoscopy with CAPS at our center. All colonoscopies were performed by 1 of 17 gastroenterologists certified in the use of the CAPS system, with the assistance of a specially trained nurse. Procedural success rates, polyp detection rates, procedure times and recovery times were recorded and compared against corresponding historical measures from 2286 colonoscopies done with midazolam and fentanyl from September 2013 to August 2014. Adverse events in the CAPS group were recorded.
RESULTS The mean age of the CAPS cohort was 59.9 years (48.7% male); 31.3% were ASA I, 67.3% ASA II and 1.4% ASA III. 45.1% of the colonoscopies were for screening, 31.5% for surveillance, and 23.4% for symptoms. The mean propofol dose administered was 250.7 mg (range 16-1470 mg), with a mean fentanyl dose of 34.1 mcg (0-100 mcg). The colonoscopy completion and polyp detection rates were similar to that of historical measures. Recovery times were markedly shorter (31 min vs 45.6 min, P < 0.001). In CAPS patients, there were 20 (0.7%) cases of mild desaturation (< 90%) treated with a chin lift and reduction or temporary discontinuation of the propofol infusion, 21 (0.8%) cases of asymptomatic hypotension (< 90 systolic blood pressure) treated with a reduction in the propofol rate, 4 (0.1%) cases of marked agitation or discomfort due to undersedation, and 2 cases of pronounced transient desaturation requiring brief (< 1 min) mask ventilation. There were no sedation-related serious adverse events such as emergent intubation, unanticipated hospitalization or permanent injury.
CONCLUSION CAPS appears to be a safe, effective and efficient means of providing moderate sedation for colonoscopy in relatively healthy patients. Recovery times were much shorter than historical measures. There were few adverse events, and no serious adverse events, related to CAPS.
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