Many would suggest that the cost of healthcare has gotten out of control, but it’s not likely those same people would likely trade comfort for cost, particularly when it comes to colonoscopy. Greg Miller, MD, from Vibrant Health Family Clinics in River Falls has been proactive in identifying ways to provide comfort and quality, while also controlling costs. In the world of healthcare, this approach is called meeting the Triple Aim.
According to the CDC, colon cancer is the 2nd leading cancer killer in the United States. Early detection equals higher patient survival rate, which leads the U.S. Preventive Services Task Force (USPSTF) to recommend that adults age 50 to 75 be screened for colorectal cancer as part of their preventive care. It’s important to talk to your doctor about which test is right for you, but many patients choose colonoscopy.
“Unfortunately there is no perfect standard asserting what is necessary or unnecessary for sedation for a colonoscopy,” said Miller. “Different facilities have different protocols.”
For several decades, the colonoscopy has been performed using air to distend the colon and proceed to the cecum (the end of the large intestine) and most were done with conscious sedation. This method could cause the patient to complain about significant pain. If a Certified Registered Nurse Anesthetist (CRNA) was available to assist, the patient could receive Propofol to help with sedation and relaxation to allow the completion of the colonoscopy. Without a CRNA, a repeat colonoscopy on a future day would be required, potentially creating an inconvenience and negative experience for the patient.
To help patients avoid discomfort, many facilities incorporated policies that started all of their procedures with Propofol, which requires a CRNA and adds expense and potential respiratory complications to the procedure.
“Because of higher premiums and high-deductible plans, patients are bearing more of the cost of healthcare services. I was hearing their frustration, but I didn’t want them to be uncomfortable, Miller said.
That’s when Dr. Miller went on a mission. While attending an endoscopy conference, Dr. Miller discovered a lecture on water exchange colonoscopy as a possible solution to both high cost and abdominal discomfort. He changed from air-based colonoscopy to water exchange colonoscopy.
Air and water distend the colon differently during a colonoscopy. With the patient in the left lateral position, air causes the mobile sigmoid colon to rise in the abdomen, creating sharp angulations and even bowel loops in the abdominal cavity (which is basically a box of finite dimensions), making it more difficult to navigate through the colon with the colonoscope.
Water weighs the mobile sigmoid colon down and keeps it in a more favorable anatomical position allowing for easier maneuvering of the colonoscope with less discomfort to the patient.
Dr. Miller shadowed a gastroenterologist and learned to incorporate the finer points of the water exchange technique. Water exchange colonoscopy can be associated with so little discomfort, that no sedation has been necessary for an increasing number of patients.
(a CRNA is always present in the facility and can be called to the procedure room to assist if needed).
“The biggest barrier we encounter is trying to convince patients and co-workers that colonoscopy can be relatively pain-free in the absence of the use of benzodiazepines and opioids (pain medication),” Miller said. “My new mission is to educate as many as possible on their choices and the benefits of water exchange colonoscopy.”
Before implementing the water exchange colonoscopy method, out of 100 patients, 52% required the use of Propofol. After implementation of the water exchange method, out of 100 patients, only 4% required Propofol. In addition, conscious sedation required significantly less medication.
Dr. Miller submitted his findings and recently attended the Partners in Excellence celebration dinner hosted by HealthPartners.