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RISING RATES OF COLONOSCOPIES PERFORMED IN NON-HOSPITAL SETTINGS AND WITH THE ASSISTANCE OF AN ANESTHETIST IN ONTARIO
O Alharbi1, L Rabeneck1,2, R Sutradhar2, D Wijeysundera2, L Yun2, L Paszat2, C Vinden3, J Tinmouth1,2
1Division of Gastroenterology, University of Toronto, 2Institute for Clinical Evaluative Sciences, Toronto, Ontario; 3University of Western Ontario, London, Ontario
BACKGROUND: In the setting of rising colonoscopy (CS) rates and of fixed global hospital budgets in Ontario, CS may be increasingly performed in non-hospital (NH) based clinics. Anecdotally, the rate of anesthetist-assisted CS may also be rising.
OBJECTIVE: To describe temporal trends in NH-based CS and anesthetist-assisted CS in Ontario between 1993-2005 and to identify patient, endoscopist and institutional factors associated with these practices.
METHODS: Using the databases housed at the Institute for Clinical Evaluative Sciences (ICES), including Ontario Health Insurance Plan (OHIP), we identified all outpatients CS performed on adults in Ontario between 1993-2005. Use of anesthesia and CS setting (hospital-based vs. NH-based) were determined. Patient age, sex, comorbidity, income quintile and LHIN as well as endoscopist specialty and annual volume of CS were collected. Hospitals were categorized by type and proportion of CS that were anesthetist-assisted (low, <= 20 % of CS; medium, 21-80% of CS; or high, >80% of CS). Hospital type included academic or community with the latter further categorized by volume of acute weighted cases (AWC) into low, medium and high volume.
RESULTS: During the study period, 1,838,879 CS were performed in hospital and NH settings. We found a temporal increase in NH-based colonoscopy, from 10.7% in 1993 to 15.5% in 2005 (P<0.0001). Rates of anesthetist-assisted CS also rose over time, increasing from 8.4% in 1993 to 19.2% in 2005 (P<0.0001). Anesthesia was used in 15.2% of hospital-based and 4.9% of NH-based CS (P<0.0001). Younger, healthier men living in higher income areas were more likely to have NH-based CS. Surgeon and high volume endoscopists were more likely to practice in NH settings. In 2005, anesthesia use was highly institution dependent with 85% of hospitals falling into either high or low categories. All 14 academic centers fell into the lowest tertile of anesthesia use, using it for <1% of CS, while 36% of low volume community hospital used anesthesia for >80% of CS.
CONCLUSIONS: Rates of NH CS and of anesthetist-assisted CS are rising. NH-based endoscopy facilities are currently unregulated however; the increasing proportion of CS being done in these settings may support a change in government policy in this regard. Institutional factors accounting for the variation in anesthesia use need to be further explored.