Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

What is the comparative effectiveness of using conscious sedation (e.g. a benzodiazepine plus and opioid) vs. anesthesia (e.g., propfol) for performing colonoscopies? What are the advantages and disadvantages of each? What evidence supports sedation vs. anesthesia, given the side effects of each for the patients? How does the setting (physician procedure room vs. outpatient hospital) and the staffing differences (endoscopist to provide sedation vs. need for an anesthesiologist or other person to provide monitored anesthesia care) impact the colonoscopy screening rates and potential harms? How might the evidence be translated to patients, ultimately to increase the rates of early identification of polyps or colorectal cancer?

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

• A benzodiazepine or opioid vs. IV anesthetic like propofol
• Office-based vs. hospital based
• Endoscopist administered vs. anesthesiologist administered

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

Men and women of all racial and ethnic groups 50 years and older. These are persons at standard risk of colorectal cancer.

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

Persons at defined high risk, e.g., persons with familial adenomatosis require screening more frequently and beginning at younger ages.

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

Increasing early identification of polyps and localized colorectal cancer in men and women over 50. The national screening rates are low because of the perception that optical colonoscopy is an uncomfortable, invasive procedure. Only a small proportion of eligible persons 50 years of age and older have optical colonoscopy performed. Therefore, many persons with colorectal cancer are not identified until their cancer is no longer localized, with a commensurately poorer prognosis.

Describe any health-related risks, side effects, or harms that you are concerned about.

Avoidance of optical colonoscopy due to fear of pain; incomplete colonoscopy due to inadequate sedation/anesthesia; temporary cognitive impairment following sedation; need for possible airway support with anesthesia; need for a second health care professional for monitored anesthesia care; longer time needed for sedation than for monitored anesthesia care.

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Cancer

AHRQ Priority Populations

• Low income groups
• Minority groups
• Women

Federal Health Care Program

• Medicaid

Importance

Describe why this topic is important.

The perception by consumers who have not had their first screening is that the procedure is very invasive and therefore many avoid the test. We are interested in exploring additional evidence on the various approaches that a) can be provided and b) be translated effectively to patients improve early identification of localized colorectal cancer and improved survival rates.

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

Interest in improved colon screening rates on a population basis.

Interest in increasing screening rates for population health and member health benefit management.

Interest in developing a clinical guideline for physicians to assure that persons undergoing optical colonoscopy have a level of sedation/anesthesia appropriate to their need. Our internal data analysis causes us to conclude that the rate of anesthesia use is based upon the availability of the anesthesiologist, rather than the clinical needs of the patient.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

Clinicians may be performing procedures based on their training/background rather than evidence of which procedure/setting shows most benefit/least harm. In addition, patients are reluctant to engage in discussion about options with their physician and need information with which to do so.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

• Increasing the screening rates for colon cancer will increase the early detection and earlier management of the disease.
• Information to members to encourage screening.
• Physician reimbursement/management
• Benefit and coverage design.

Describe the timeframe in which an answer to your question is needed.

As soon as practical.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

Asian/Pacific Islander; Hispanic, African American, American Indian/Alaska Native

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

• Increasing the screening rates for colon cancer will increase the early detection and earlier management of the disease.
• Information to members to encourage screening.
• Physician reimbursement/management
• Benefit and coverage design.

Are you making a suggestion as an individual or on behalf of an organization?

Organization

Please tell us how you heard about the Effective Health Care Program