It is clear that addition of anesthesia services to provide sedation increases the cost of colonoscopy. The economics of sedation , therefore, revolve around the requirement for propofol to be administered by an anesthesia professional. Several studies have demonstrated the safety of nonanesthesia professional administered propofol (NAAP) for gastrointestinal endoscopic procedures. A systematic review of randomized controlled trials comparing NAAP with traditional sedation in patients undergoing routine upper endoscopy and colonoscopy found no significant difference in hypoxemia, bradycardia, or hypotension [27]. The American Gastroenterological Association Position Statement on NAAP for GI endoscopy concludes that the safety profile of NAAP is equivalent to that of standard sedation with respect to the risks of hypoxemia, hypotension, and bradycardia for upper endoscopy and colonoscopy. Further, NAAP sedation improves practice efficiency compared to standard sedation and the use of anesthesia-administered sedation for healthy, low-risk patients undergoing routine GI endoscopy results in higher costs with no proven benefit with respect to patient safety or procedural efficacy [28].

There are now alternatives in the manner in which propofol may be administered during routine colonoscopy. A computer-assisted sedation system integrating propofol delivery with patient monitoring has been approved by the FDA to enable endoscopists and nurses to administer propofol without an anesthesia professional. In a multicenter randomized study, 496 patients undergoing routine colonoscopy or upper endoscopy were randomized to receive sedation using the computer-assisted sedation system versus traditional sedation with narcotic and benzodiazepine [29]. Oxygen desaturation was significantly lower in the computer-assisted sedation system arm and the overall incidence of adverse events was not significantly different (5.8 % computer-assisted sedation versus 8.7 % traditional sedation).

Who gains when propofol is administered during colonoscopy? The efficiency of an endoscopy unit may improve with propofol sedation due to increased throughput. Patients may have greater satisfaction with colonoscopy and perhaps may be motivated to repeated screening and surveillance due to reduced anxiety and fears of colonoscopy. While some studies highlight a concern that adverse events such as perforation could be increased due to limited patient feedback with deep sedation, this is not a consistent finding. There is no evidence, however, that anesthesia administration of sedation improves colonoscopy quality metrics such as adenoma detection rates .

In the absence of clear evidence demonstrating harm or benefit, the gastroenterology and anesthesia communities should determine whether the benefit from anesthesia services is worth the financial costs, particularly in population screening for colorectal cancer where the emphasis is on less-expensive tests to increase access and cost-effectiveness. The economic debate should also focus on the scientific basis for the requirement that propofol and similar sedation agents be administered by anesthesia professionals. In addition to clinical studies demonstrating safety of propofol administration by nonanesthesiologists, there are technological advances that may allow these drugs to be safely delivered in a setting sufficiently monitored so as to mitigate the potential risks of deep sedation with these agents.