Endoscopist-directed propofol versus monitored anesthesia care in outpatient endoscopy: Quality and safety metrics

BACKGROUND: Endoscopist-directed propofol (EDP) is endorsed by multisociety guidelines for elective outpatient endoscopy in low-risk patients, yet formal credentialing pathways for EDP remain absent from some health systems. We report procedural quality and sedation safety metrics from comparing an initial EDP period with a subsequent monitored anesthesia care (MAC) period with the aim of generating the regional evidence base required to inform a national EDP credentialing framework. METHODS: This is a retrospective before-after cohort study of 3,049 consecutive endoscopic procedures performed at a single consultant-led endoscopy unit. Two sequential periods were defined by the date on which an attending anesthesiologist joined the unit: EDP period (n = 1,037; propofol directed by the performing gastroenterologist) and MAC period (n = 2,012; propofol directed by the anesthesiologist). Neither period received concurrent benzodiazepine or opioid coadministration. RESULTS: Procedure-type mix, sex (46.3% female in both), and age (median 41.5 vs 43.3 years; P = 0.08) were well balanced between periods. The MAC period was associated with higher median propofol doses (150 vs 140 mg; P < 0.001), but there was no difference in cecal intubation rate (99.7% EDP vs 99.1% MAC; P = 0.57), PDR (26.4% vs 23.7%; P = 0.35), or polypectomy rate (20.7% vs 17.9%; P = 0.28). Zero documented adverse events were recorded in the EDP period versus one documented adverse event in the MAC period ( P = 1.00). All metrics in both periods exceeded ASGE, ESGE, and SGA benchmarks. CONCLUSIONS: In this retrospective single-center cohort, measured procedural-quality outcomes were similar during sequential EDP and MAC periods. Prospective multicenter studies with structured adverse-event capture should be performed.