Aetna, the third-largest U.S. health insurer, will no longer pay for monitored anesthesia care for routine colonoscopies as of April 1. In a letter sent to physicians last month, Aetna says that "conscious sedation is a safe and well-tolerated choice for most patients undergoing GI endoscopy. There is no generally accepted evidence demonstrating that average-risk patients require MAC for routine GI endoscopy. Therefore, we will cover MAC only for patients undergoing GI endoscopy with sedation-related risk factors."

Those exceptions include if the patient is assessed at an American Society for Anesthesia score indicating an increased risk of complications (P3 to P5), pregnant, 18 years of age or younger, 65 years of age or older or in danger of airway compromise, such as by being morbidly obese or having sleep apnea. MAC typically adds $300 to $1,500 to the cost of a screening, says Aetna spokeswoman Susan Millerick.

Aetna notes in the letter that its clinical policy is consistent with the following 2004 statement on sedation for performing GI endoscopic procedures jointly issued by the American College of Gastroenterology, the American Gastroenterological Association and the American Society for Gastrointestinal Endoscopy: "The routine assistance of an anesthesiologist/anesthetist for average risk patients undergoing standard upper and lower endoscopic procedures is not warranted."

Aetna's revised guidelines follow similar actions by other insures. Humana announced last July that it was no longer going to cover anesthesiologist or anesthetist assistance for standard endoscopic upper or lower GI procedures performed on average-risk patients. In 2006, WellPoint updated its guidelines to say that it was unnecessary to use general anesthesia during endoscopic procedures, so there was no need to pay for the routine use of these ancillary anesthesia services.

"I am concerned anytime that there is a policy made by insurance companies that takes patient care decisions out of the hands of physicians," says David Johnson, MD, professor of medicine and chief of gastroenterology at Eastern Virginia School of Medicine in Norfolk, Va., and immediate past president of the American College of Gastroenterology. "This issue should be between the physicians and appropriately informed patients. They collectively should determine the best care plan."

Nathan Hall

Joint replacement, hysterectomies and other non-emergency inpatient procedures may put patients over the age of 60 at increased risk for long-term cognitive problems, according to a study in the in the January issue of the journal Anesthesia. What's more, many older patients who develop post-operative cognitive dysfunction (POCD) appear to be more likely to die within a year of surgery.

Researchers at Duke University Medical Center studied 1,064 patients who were categorized into three age groups (18-39, 40-59, and 60 and over). These patients completed neuropsychological tests before their procedures, at hospital discharge and again at three months. Researchers followed up a year after the procedure to determine if they survived. As a control, 210 additional participants took the same cognitive tests without undergoing surgery or anesthesia.

The data show that patients of all ages experienced POCD at discharge, but those 60 or older were more than twice as likely to still exhibit signs of POCD three months later. Additionally, these patients seemed to be more likely to die before the year follow-up.

"The large difference in the prevalence of POCD between what we termed the elderly - those aged 60 and over - and the younger groups we were studying validates the general perception that the elderly are predisposed to cognitive impairment after major surgery," says lead investigator Terri Monk, MD, an anesthesiologist at Duke and the Durham Veterans Affairs Medical Center.

Why cognitive decline is associated with early death is not completely understood, says Dr. Monk, but it's possible that patients with prolonged cognitive dysfunction may be less able to take medicine correctly or may not recognize the need to seek medical care for symptoms or complications.

Nathan Hall

Medical errors are at their root human errors, according to a recent survey of practicing physicians, attributable to miscommunications, misconnections and occasionally bad handwriting.

In the survey, conducted online by the information technology firm Thomson Healthcare in October 2007, 1,656 physicians nationwide answered questions designed to assess the American healthcare system and what they perceive are the major political roadblocks (such as healthcare costs) and clinical obstacles (such as medical errors) affecting its administration.

According to Thomson Healthcare's research brief on the survey, 31.4 percent of physicians identified doctor-patient communication as the leading cause of medical mistakes. "That suggests that, despite the availability of sophisticated, promising medical treatments, basic human interaction is a linchpin in the delivery of effective healthcare," says the research brief.

Human errors committed by caregivers, such as wrong-site surgery, retained objects or errors made while connecting IVs, were the second-most cited cause at 25.7 percent. Another 17.6 percent blamed patients who fail to comply with prescribed treatment and 11.5 percent targeted the physician's own misdiagnosis.

Comparatively few physicians - only 1.9 percent - reported miscommunication between clinical professionals as the main cause of medical mistakes. When communication does break down between a patient's primary care provider, surgeon or pharmacist, though, 40.9 percent of physicians attribute it to one party's failure to adequately document the patient's history.

Another 30.9 percent of respondents, on the other hand, argued that illegible handwriting is the leading cause of professional miscommunication, "a prime example of low-tech problems adversely affecting the high-tech world of medicine," the research brief notes.

David Bernard