Background & Aims

Use of monitored anesthesia care (MAC) for gastrointestinal endoscopy has increased in the Veterans Health Administration (VHA) as in fee-for-service environments, despite the absence of financial incentives. We investigated factors associated with use of MAC in an integrated health care delivery system with a capitated payment model.

Methods

We performed a retrospective cohort study using multilevel logistic regression, with MAC use modeled as a function of procedure year, patient- and provider-level factors, and facility effects. We collected data from 2,091,590 veterans who underwent outpatient esophagogastroduodenoscopy and/or colonoscopy during fiscal years 2000−2013 at 133 facilities.

Results

The adjusted rate of MAC use in the VHA increased 17% per year (odds ratio for increase, 1.17; 95% confidence interval, 1.09−1.27) from fiscal year 2000 through 2013. The most rapid increase occurred starting in 2011. VHA use of MAC 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. Provider-level and facility factors were also associated with use of MAC, although again the magnitude of these associations was small. Unmeasured facility-level effects had the greatest effect on the trend of MAC use.

Conclusions

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 MAC. Facility-level effects are the most prominent factor influencing increasing use of MAC. Future studies should focus on better defining the role of MAC 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 MAC based on clinically meaningful patient factors.

中文翻译：

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在按人头付费系统中对门诊胃肠内窥镜检查使用监测麻醉护理的预测因素

 背景与目标

尽管缺乏经济激励，但退伍军人健康管理局 (VHA) 与按服务收费环境一样，越来越多地使用监测麻醉护理 (MAC) 进行胃肠道内窥镜检查。我们调查了在采用按人头付费模式的综合医疗保健服务系统中使用 MAC 的相关因素。

 方法

我们使用多级逻辑回归进行了一项回顾性队列研究，将 MAC 使用建模为手术年份、患者和提供者层面的因素以及设施影响的函数。我们收集了 2,091,590 名退伍军人的数据，这些退伍军人在 2000-2013 财年期间在 133 个机构接受了门诊食管胃十二指肠镜检查和/或结肠镜检查。

 结果

从 2000 财年到 2013 年，VHA 中 MAC 使用率的调整后每年增加 17%（增加优势比为 1.17；95% 置信区间为 1.09−1.27）。从 2011 年开始增长最快。 MAC 与患者层面的因素相关，包括肥胖、阻塞性睡眠呼吸暂停、较高的合并症以及处方阿片类药物和/或苯二氮卓类药物的使用，尽管这些影响的程度很小。提供者水平和设施因素也与 MAC 的使用相关，尽管这些关联的幅度很小。未测量的设施层面的影响对 MAC 使用趋势的影响最大。

 结论

在一项对 2000 财年至 2013 财年接受门诊食管胃十二指肠镜检查和/或结肠镜检查的退伍军人进行的回顾性研究中，我们发现即使在按人头付费的系统中，患者因素与 MAC 的使用也只有微弱的相关性。设施层面的影响是影响 MAC 使用增加的最突出因素。未来的研究应侧重于更好地定义 MAC 的作用以及影响内镜镇静选择的设施和组织因素。调整资源和激励措施以促进基于临床意义的患者因素适当分配 MAC 也很重要。