Monitored anesthesia care (MAC) has largely replaced endoscopist-directed conscious sedation for routine outpatient GI endoscopy in the United States. However, Megan Adams, MD, JD, MSc, of the University of Michigan, argues that the shift warrants renewed scrutiny because its clinical benefits for low-risk patients remain uncertain, while costs and some complication risks are higher.
A 2017 study estimated that MAC use in low-risk patients was associated with approximately $1.5 billion in excess annual spending among Medicare and commercially insured patients. Research has also reported associations between MAC and increased risks of complications, including aspiration and hospitalization, although the absolute difference in sedation risk is small. Evidence has not established improvements in adenoma detection or cecal intubation rates with MAC.
In an analysis of more than 300,000 routine colonoscopies and upper endoscopies performed in Veterans Affairs settings, conscious sedation failed in just 0.1% of cases, increasing to 0.3% among patients in the highest-risk decile. The findings suggest that predicting sedation failure may be difficult and that routine MAC use may not be necessary for every patient.