Upper and lower endoscopies are among the most prevalent procedures performed in the US today.  While historically sedation has been provided by endoscopists with the assistance of nursing staff, over the past decade there has been an increase in the involvement of anesthesia services, particularly for patients with complex comorbidities or need for deeper sedation. As sedation and anesthesia for GI endoscopy evolves, there is ongoing debate and emerging research on the safety and outcomes of various drug regimens and their administrators.

Not all endoscopy procedures are equivalent. The sedation required for routine colonoscopy or sigmoidoscopy is generally less than that required for an upper endoscopy, and more advanced procedures such as endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasonography (EUS) and balloon endoscopy require an even deeper plane of anesthesia. Factors in choosing the level of anesthesia include procedural needs (e.g. immobility for EUS with fine needle biopsy), patient comorbidities and patient’s degree of cooperativeness/pain tolerance.

Below is a description of the sedation continuum as defined by the American Society of Anesthesiologists. A provider targeting one level of sedation should be prepared to manage the next level deeper. Therefore while most routine GI endoscopies can be performed under moderate or “conscious” sedation, it is important for the responsible provider to be able to react to airway compromise, interruptions in spontaneous ventilation, and cardiovascular instability.

 Controversy exists regarding whether non-anesthesia providers are capable of ensuring patient safety in the face of the above concerns. While some retrospective studies have demonstrated a low incidence of cardiopulmonary complications with gastroenterologist-directed administration of drugs with narrow safety margins such as propofol, confounding factors and a lack of prospective randomized trials make current evidence insufficient. What can be said is that patients are often more obese with more complex comorbidities than those endoscopists encountered decades ago, and a dedicated anesthesia provider is uniquely qualified for recognizing and intervening upon common complications of sedation for endoscopy: airway obstruction, apnea, aspiration and hypotension.

Drug regimens used for sedation during GI endoscopy generally fall under two categories: a combination of benzodiazepine and narcotic (e.g. midazolam and fentanyl) and propofol as a bolus and/or infusion. In the United States, the former has been traditionally administered by gastroenterologists, the latter by anesthesiologists. Propofol has the advantage of achieving deep sedation with reliable and rapid onset, and has been borne out in research studies to have superior recovery times and overall patient and physician satisfaction. However, it is less forgiving than benzodiazepine/narcotic regimens given its narrow therapeutic window before encountering hypotension and apnea. Furthermore it lacks a reversal agent such as flumazenil or naloxone which can rapidly rescue overdose of these other agents.

The American Society for Gastrointestinal Endoscopy recommends providers administering propofol sedation possess specific training on the properties and use of this drug, as well as expertise in emergency airway management. Personnel should be dedicated to monitoring the patient’s airway and ventilation, with capnography strongly encouraged.

While ASGE guidelines do not require an anesthesiologist perform these functions during propofol sedation, it is a point of contention whether adequate monitoring and airway management can be provided by the gastroenterologist performing the procedure or nursing staff who may be juggling multiple tasks. The attention and experience required to detect airway and hemodynamic instabilities, which can present with an insidious onset prior to decompensation, and the skill set necessary to quickly perform high quality mask ventilation, insert advanced airway devices, manage blood pressure abnormalities and tailor sedation regimens to complex patient comorbidities is uniquely suited to the skill set of a dedicated anesthesiologist. Reliance on alarms is far from foolproof, for capnography is less reliable in upper endoscopies given carbon dioxide escape from a necessarily open system as the mouth is accessed, and pulse oximetry has a dangerous lag time between apnea and registered desaturation.

Despite these concerns, the existing evidence – albeit imperfect – has not lent much weight to fears for patient safety during non-anesthesia administration of propofol sedation. Biases in study conduction, publication, patient population and sampling are among the variables that must be examined when these data are scrutinized. What can be said for certain is that the role of anesthesia services in GI endoscopy will continue to be a topic of debate and evolution, and it behooves all parties to be well apprised of current practice and incoming research.

References:

1. Goudra B, Singh PM. Anesthesia for gastrointestinal endoscopy: A subspecialty in evolution? Saudi Journal of Anaesthesia. 2015;9(3):237-238. doi:10.4103/1658-354X.154691.
2. http://www.asge.org/uploadedFiles/Publications_and_Products/Practice_Guidelines/Sedation%20and%20Anesthesia%20in%20GI%20Endoscopy%202008.pdf
3. Vaibhav Wadhwa, Danny Issa, Sushil Garg, Rocio Lopez, Madhusudhan R. Sanaka, John J. Vargo. Similar Risk of Cardiopulmonary Adverse Events Between Propofol and Traditional Anesthesia for Gastrointestinal Endoscopy: A Systematic Review and Meta-analysis. Clinical Gastroenterology and Hepatology. Available online 21 July 2016, ISSN 1542-3565, http://dx.doi.org/10.1016/j.cgh.2016.07.013.

As the healthcare system becomes increasingly electronic, it is necessary to examine the security measures that are in place to safeguard patients and their data. Not only are medical facilities and hospitals now using cyber information networks to communicate, medical equipment and devices are also linked to the web, and patient information files filled with confidential information are stored on computers and transmitted electronically. So what exactly is cybersecurity as it relates to safeguarding patients and their data in the healthcare system? First, it is important to distinguish between privacy and confidentiality. Privacy is defined as the right to both keep personal information from others as well as the right to determine how, why, and with whom personal information is shared. In contrast, confidentiality is the obligation to respect the privacy of patients. Violation of confidentiality can occur when private information is shared with others without patient consent. Unfortunately, hospitals, patients, medical device manufacturers, and more specialized service providers such as anesthesia management companies are all at risk of cyberattacks and thus focus must be put on safeguarding measures to protect patients and data.

In August 2016, an Arizona anesthesia services group notified over 880,000 patients of a potential data breach of protected health information. As is the case with many “potential” breaches, there was no evidence that the data on the computers had been accessed, though such access could not be ruled out as there was evidence that an individual had accessed a system that contained protected health information. The computer system that was accessed included patient names, limited clinical information, health insurance information, and some social security numbers. This cybersecurity breach of an anesthesia services group’s system is not unique among healthcare data systems. The Sixth Annual Benchmark Study on Privacy & Security of Healthcare Data conducted by the Ponemon Institute revealed that of the 91 healthcare organizations studied, over 90% had a data breach in the past two years and 45% had more than five data breaches. Additionally, the average cost of a healthcare organization data breach is over $2.2 million dollars.

Protected health information is not the only aspect of the health system that is vulnerable to cyberattacks. A two year study found that many types of medical devices, including drug infusion pumps, Bluetooth-enabled defibrillators, certain x-ray systems, and refrigerators storing key medical supplies, among others, can be hacked and manipulated by those with malicious intent. The study concluded that many hospitals are “unaware of the high risk associated with these devices […and] aren’t doing the testing they need to do”. The FDA and DHS have taken notice of this problem, issuing a warning to the health care industry about issues with devices including ventilators, pumps, defibrillators, and surgical and anesthesia devices, noting issues with hard-coded passwords in the devices. However, the one positive finding of this study involved ventilators and anesthesia equipment: while they might have security problems regarding passwords, they are generally not part of a cybernetwork and do not allow web access, making them more secure than other devices. However, the question of protection still remains: what can be done to help safeguard patients and data?

It is clear that the gaps in cybersecurity need to be closed in order to best protect patients and data in the healthcare system. Schumer Clinical Partners recommend ten different ways that hospitals can help safeguard their data, including establishing a security culture, protecting mobile devices, using a firewall, installing and maintaining anti-virus software, using strong passwords and changing them regularly, limiting network access, and controlling physical access. Another key aspect of keeping patients and data secure is having a plan for when the system is hacked. This way, healthcare organizations will know how to proceed in the event of a data breach and hopefully thwart the malicious attack quickly. Hospitals and health care providers need to work with manufacturers and medical providers such as specialized anesthesia management companies and ambulatory surgical centers to be sure that all parts of the system are secure with upgraded security systems and that everyone is using the tightest security protocols. These are just a few of the steps that must be taken to ensure that patient information and medical data are secure. Cybersecurity is of the utmost importance in this increasingly electronic and online healthcare system and thus must be thoroughly examined and implemented to ensure the highest levels of security possible.

President-elect Donald Trump has repeatedly promised to repeal and replace the Affordable Care Act (ACA), also known as Obamacare, during his campaign. According to his campaign website, “[o]n day one of the Trump Administration, [the Trump administration] will ask Congress to immediately deliver a full repeal of Obamacare”. From there, the Trump administration plans to work to reform healthcare in the United States by issuing a series of reforms that “follow free market principles”. Trump is an advocate of an open market system, which he says will increase competitions and lower prices. During his campaign, he has stated that he would allow insurance companies to sell insurance plans across state lines to increase competition along with making premiums for individuals tax-free.

One main component of Trump’s healthcare plan is the use of health savings accounts, or HSAs. People would pay medical expenses with their own personal savings, which Trump hopes would allow young people who may not have many health expenses to be able to have high-deductible healthcare plans. People would be able to spend HSA money on family members who need it. During his campaign, Trump has said that he plans to require price transparency from all healthcare providers in hopes of lowering prices of medical procedures and exams. He also plans to remove barriers to entry into free markets for drug providers, stating the government’s special interests in the pharmaceutical industry as a barrier for free trade and lower prices.

While these plans to repeal Affordable Care Act were emphasized in his campaign for President of the United States, Trump has hinted at keeping some of Affordable Care Act’s policies since his win on election night.  After meeting with President Obama, he said he is reconsidering his stance on repealing the Affordable Care Act, hinting that he would like to keep the policy that mandates insurers to cover people with pre-existing health conditions and the policy that allows children to be covered by parents into their mid-20s.

With regard to anesthesiologists and other health professionals, Trump’s new healthcare plans likely means many changes in reimbursement policies and other regulations in the near future. It is currently unclear how Trump specifically plans to change healthcare in the United States and the exact effect it will have on healthcare professionals. For the many anesthesiologists that rely on Medicare & Medicaid reimbursements, it will become increasingly more important to stay up to date on changes in Trump’s plan for healthcare reform.

If Trump does repeal the Affordable Care Act, many bi-partisan research companies project that millions of Americans will be without healthcare coverage for some time, leading to more emergency room visits and fewer routine checkups. As Trump finalizes his plan for healthcare in the United States, healthcare professionals are also advised to re-evaluate their own business models to ensure longevity amidst changes in the healthcare world.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was signed into law in April 2015 and repeals the Medicare sustainable growth rate (SGR), which was the previous method of controlling spending on physician services.  According to the Office of the Federal Register, MACRA is effective on January 1, 2017 and implementation is slated for January 1, 2019. MACRA replaces SGR with an approach to payment called Quality Payment Program, which rewards high-quality patient care through Advanced Alternative Payment Models (Advanced APMs) and the Merit-based Incentive Payment System (MIPS) for eligible clinicians.

Alternative Payment Models provide added incentives to deliver high-quality and cost-effective care (1). MIPS, a program for certain Medicare-enrolled practitioners, consolidates the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program for Eligible Professionals. Like APMs, MIPS also hopes to focus on quality and cost. One key difference between MIPS and APMs is that MIPS will start to see a range of payment adjustments, with potential penalties of -4% and bonuses as high as 12% in 2019 (3). These penalties and bonuses are expected to increase after the first few years, with reductions as much as -9% and bonuses as high as 27%. Clinicians that participate in APMs are exempt from MIPS requirements and can earn favorable financial rewards, although only those who are a part of risk-based payment models are qualified.

MACRA hopes to ease into the new reporting systems by including more flexibility for rural and smaller practices (2). Nearly a third of Medicare physicians could be exempt from Medicare’s MIPS, and representatives from the Centers of Medicare and Medicaid (CMS) expect only 25% of physicians to participate in APMs in 2018. This final rule also includes a Pick Your Pace option for physicians to allow for an easier transition and is also geared toward smaller practices. Additionally, CMS raised the low-volume threshold from $10,000 to $30,000. This allows physicians with less than $30,000 in Medicare payments or fewer than 100 Medicare patients to be exempt from the MIPS reporting requirements.

For anesthesiologists and other healthcare providers, there is some flexibility and choice with which track of payment to pursue (3). Some may choose to enter into Advanced APMs by strategically increasing traditional Medicare payments or patient counts tied to Advanced APM models. Those that already meet the criteria for APM cannot, however, opt out. There is also a third option called Partial Qualifying APM Participants in between MIPS and APM tracks that may be a better option for physicians that are on the border of both tracks.

While the final MACRA rule of nearly 2,400 pages will go into effect in 2017, it is expected that this rule will see many changes in the future (2). Andy Slavitt, CMS’s Acting Administrator, reported that “[w]e know that this law and regulation need to evolve.”

Sources:

1.  https://www.federalregister.gov/documents/2016/11/04/2016-25240/medicare-program-merit-based-incentive-payment-system-mips-and-alternative-payment-model-apm
2. http://www.physiciansnewsnetwork.com/la_county/article_e9ccb134-948c-11e6-bb18-6780ed48f846.html#utm_source=physiciansnewsnetwork.com&utm_campaign=%2Fnewsletters%2Fla-county%2F%3Fsdlfk&utm_medium=email&utm_content=read%20more
3. https://www.advisory.com/research/physician-practice-roundtable/members/expert-insights/2016/nine-faqs-on-provider-payment-under-macra

Once a student registered nurse anesthetist (SRNA) graduates from an accredited training program and passes the National Certification Exam offered by the National Board of Certification and Recertification for Nurse Anesthetists, they can be employed as an entry-level Certified Registered Nurse Anesthetist (CRNA) by any hospital or anesthesia management company and embark on an exciting and fulfilling career in healthcare. There indeed could not be a better time to join the field, as CRNAs are in high demand in many markets as healthcare organizations attempt to lower costs, causing a rise in mean annual compensation to approximately $160,000.  The US Bureau of Labor Services estimates that CRNAs will experience a job growth rate of 31% over the next decade.

Due to this expanding need for CRNAs and the respect that is given to CRNAs in the healthcare industry, one should expect a great level of autonomy and opportunities even during their first days as a CRNA. Although a CRNA will many times be working in a team with other doctors, surgeons, and anesthesiologists, they will have considerable independence in preparing and administering anesthesia and also in overseeing the patient’s recovery and post-operative care . Because of the extensive training and education that SRNAs endure, CRNAs are able to participate in complex surgeries and practice in diverse settings outside of the formal hospital. For example, CRNAs provide anesthesia for the majority of outpatient surgical procedures throughout the country and have a crucial role in ensuring that the patient is safe and monitored appropriately.  Furthermore, many CRNAs use their experience to eventually become researchers or administrators who manage the delivery of anesthesia services . Such examples show the endless diversity in opportunities and positions for incoming CRNAs and the ability to shape this career to your interests and professional preferences.

While it can be difficult to become acclimated to the fast-paced environment of healthcare, experienced CRNAs are always more than ready to help with professional development and offer mentorship opportunities. The average age of a CRNA is presently 47.3 years old, therefore most CRNAs have extensive experience to draw on to aid you in your transition to this new career. CRNAs are truly excited and pleased by their career choice, with studies finding that 93.3% of CRNAs were extremely satisfied with their career, and that the stress level of CRNAs was about half that of the stress level of SRNAs.  So while it may take time to establish professional confidence and comfort, there are a multitude of opportunities and individuals at your disposal to ensure that you are nothing but satisfied with your career as a CRNA.

If you are a CRNA and interested in a job, please contact us at Xenon Health (https://xenonhealth.com/contact-us/) at 888-894-5143 or info@xenonhealth.com.