- Email: [email protected]
Sa1047 Utilization and Appropriateness of Repeat Upper Endoscopy Within the U.S. Veterans Health Administration
AGA Abstracts
alarm features. We developed a computer algorithm called Automated Evaluation of Gastrointestinal Symptoms (AEGIS) that systematically collects patient symptoms and GI alarm features online, and then "translates" the information into a full narrative history of present illness (HPI). We compared the number of alarms documented by physicians during usual care vs. that collected by AEGIS. Methods: We performed a cross-sectional study with a paired sample design among patients visiting outpatient university and VA-based GI teaching clinics. Participants first received usual care by their physicians and then completed AEGIS either on a clinic computer or at home. While on AEGIS, patients were guided through tailored questions drawn from a library of over 300 clinical factors measuring the timing, severity, frequency, location, quality, and character of their GI symptoms. AEGIS also asked about recent alarm features including hematochezia, melena, hematemesis, unintentional weight loss, decreased appetite, and fevers. AEGIS then simulated a GI physician history and converted the results into a full HPI. Each individual thereby had both a physiciandocumented HPI and AEGIS HPI. A blinded physician reviewer enumerated the positive and negative alarms explicitly mentioned in each HPI without knowing half were written by a computer. We compared the number of documented alarms using the Wilcoxon signedrank test. Results: Seventy-five patients had both physician and AEGIS HPIs. Overall, AEGIS identified more patients with alarm features vs. physicians (53% vs. 27%; p<.001). AEGIS documented more positive alarms (median 1, interquartile range [IQR] 0-2) vs. physicians (median 0, IQR 0-1; p<.001) and more negative alarms (median 5, IQR 4-6) vs. physicians (median 2, IQR 0-3; p<.001). Findings were unchanged in the sub-groups who completed AEGIS anytime within one week of their clinic visit (n=55; p<.001) and those being seen for an initial visit (n=39, p<.001). We evaluated whether positive alarms in the physician HPI matched the alarms in AEGIS: hematochezia (3/9; 33%), melena (1/10; 10%), hematemesis (2/4; 50%), unintentional weight loss (9/22; 41%), decreased appetite (5/24; 21%), and fevers (0/2; 0%). Conclusion: A computerized GI HPI identified more alarm features vs. physicians during usual care in GI clinics at academic medical centers. Physicians documented less than one-third of red flags reported by patients to AEGIS. These data indicate that physicians may underreport alarm features and that computerized "checklists" could serve as a vital complement to standard HPIs.
and found the following: Type of disease were 98.8% (95.8-99.8), diagnosis date 59.8% (52.1-67.2), extent of disease 76.7% (69.7-82.8), extraintestinal manifestations 42.4% (34.950.1), previous medications 63.3% (55.6-70.5), current medications 95.3% (91.0-97.9), date of last symptom exacerbation 26.1% (19.7-33.3), last steroid use 30.2% (23.5-37.7), previous surgeries 39.5% (32.1-47.2), family history of IBD 15.1% (10.1-21.3), smoking status 19.7% (14.1-26.5), and endoscopic and histologic findings 43.6% (36.1-51.3). Conclusion:We demonstrated several deficiencies in documenting important clinical information that is crucial for the care of IBD patients. We anticipate that using a template to document those clinical encounters will improve such documentation and improve the care of the IBD patients. Our next step is to develop an intervention tool to improve medical record documentation in patients with IBD.
Sa1047 Utilization and Appropriateness of Repeat Upper Endoscopy Within the U.S. Veterans Health Administration Joel H. Rubenstein, Heiko Pohl, Eve Kerr, Robert Holleman, Sandeep Vijan, Jason A. Dominitz, John M. Inadomi, Dawn Provenzale, Joseph Francis, Sameer D. Saini Background: Veterans Affairs (VA) medical centers struggle to meet the demand for endoscopy. Reducing utilization of low-value procedures could help meet that demand. In many scenarios, repeated upper endoscopy (EGD) is a low-value procedure that may be overused. Aims: To describe utilization and appropriateness of repeat EGDs within VA, and identify associated factors. Methods: We queried national VA Corporate Data Warehouse from fiscal year 2003 through the middle of 2007, identifying individuals who had both: (1) at least 1 EGD ("index" EGD), and (2) at least 1 outpatient visit every 24 months in the 5 years following the index EGD (indicating regular use of VA health care). We then identified repeat EGDs during 5 years of follow-up. Using diagnostic and procedure codes at the time of index EGD and during the follow-up period, we classified appropriateness of repeat EGDs into 3 categories, modified from an algorithm previously used in Medicare data (Annals Internal Medicine; 2014;160:154): "likely appropriate" (e.g., varices, Barrett's esophagus, stricture, etc.), "likely inappropriate" (e.g., heartburn, nausea, non-bleeding gastritis, etc.), and "uncertain" (bleeding lesions, ulcer, esophagitis). Multi-level logistic regression was performed to estimate the impact of patient-level and site-level factors on the odds of repeat EGD. Results: 262,939 veterans underwent an index EGD, including 83,205 (31.6%) for whom a repeat would be likely appropriate, 62,383 (23.7%) for whom a repeat would be likely inappropriate, and 117,351 (44.6%) with uncertain appropriateness. Within 5 years, 100,693 had undergone at least 1 repeat EGD (38.3%) with rates at the 159 individual sites providing EGD ranging from 14.1% to 55.2% (Figure). Repeat EGD was performed in 57.1% of those where repeat would likely be appropriate, 33.6% of those with uncertain appropriateness, and 22.0% of those where repeat was likely inappropriate. Access to high volume endoscopy sites and more frequent interaction with VA, particularly visits to a gastroenterologist, were associated with receipt of a repeat EGD, both in scenarios where repeat EGD was likely appropriate and in those where it was likely inappropriate (Table). Conclusions: Once a veteran undergoes EGD, a repeat EGD is common. There is substantial variation in the rate of repeat EGD between sites, suggesting practice patterns are influential. Most repeat EGDs are likely appropriate, but thousands of repeat EGDs in VA each year are unlikely appropriate. Frequent visits with a gastroenterologist are associated with receipt of EGD both in scenarios where it is likely appropriate and where it is likely inappropriate. Further research is needed to validate this classification scheme for appropriateness of repeat EGD, and to develop strategies for addressing potential over- and under-utilization of repeat EGD. Multivariable Multi-level Logistic Regression for Receipt of Repeat EGD, Stratified by Appropriateness of Repeat
Sa1045 Retrospective Analysis of Vaccination Against Hepatitis A and Hepatitis B in Hepatitis C Patients Karl DeMarco, Kathy Geissler, Joseph J. Vicari Background and Aims: The American Gastroenterological Association (AGA) recommends all patients infected with Hepatitis C (HCV) be vaccinated against Hepatitis A (HAV) and Hepatitis B (HBV) if no prior exposure. With the trend toward documentation of quality metrics, we examined providers' compliance with this metric in a large community-based GI practice. Methods: A retrospective review of office electronic medical records (EMR) of patients with newly diagnosed HCV from June 2012 through December 2013 was conducted. Data collected included documentation of orders for HAV and HBV serologic testing. Orders were placed either by the gastroenterologist or the primary physician. Subsequent vaccination (or patient refusal) in appropriate individuals was also documented. A total of 196 charts were eligible for review. Results: HAV serologic testing was ordered for 63.3% of HCV patients. HBV serologic testing was ordered for 67.3% of HCV patients. Of the 88 HAV cases (44.9%) and 90 HBV cases (45.9%), the testing was ordered by the gastroenterologist. Thirteen patients (8.5%) did not follow through with ordered serologic testing and were subsequently lost to follow up. Forty four patients (28.9%) did not require vaccination due to immunity. Vaccines were ordered for 87 (57.2%) patients who were not immune. Documentation of vaccination was found in 27.6% of cases. Conclusion: Our study demonstrates poor compliance with ordering serologic testing of HAV and HBV as well as poor documentation of successful vaccination in our HCV population. The compliance gap may be related to decreased physician point of service compliance with the quality metric and poor documentation of completion of the vaccination series. Further testing including more robust documentation tools within EMR is needed to determine the causes of compliance failure within our practice.
Sa1046 Improving Medical Record Documentation of Clinical Encounters in Inflammatory Bowel Disease (IBD) Patients: A Review of Current Practice Ashraf A. Almashhrawi, Fazia A. Mir, Amin Mahdi, Anjana Sathyamurthy, Richard Madsen, Matthew L. Bechtold, Ravinder Mankoo, Jack Bragg, Akwi W. Asombang Background:IBD is a chronic condition with significant socioeconomic burden attributed to hospitalizations, outpatient care and pharmaceutical costs. The estimated mean annual cost is $8265 and $5066 per patient for Crohn's disease (CD) and ulcerative colitis (UC), respectively. Deficiencies in quality of medical care and expert recommendations are contributing factors to poor patient care and poor documentation of IBD-related issues. Given these deficiencies, we examined the quality of clinical encounter notes in the IBD clinics at a tertiary academic medical center. Methods:This was a retrospective analysis of electronic medical records for IBD patients' presenting to gastroenterology clinic over a 3-month time. We specifically extracted data from the most recent clinical note of the patient using a uniform data extraction sheet. The clinical notes were analyzed for presence or lack of documentation of specific variables. Data extracted included demographics (age, gender, race) and twelve items we deemed as relevant to management of IBD patients. The twelve items were: Type of disease (UC/CD), date of diagnosis, extent of disease involvement, extraintestinal manifestation, previous medications, current medications, last use of steroids, date of last flare, previous surgeries related to the diagnosis, family history of IBD, smoking status, and endoscopic and histopathologic findings. Data was entered as "yes" if the information was documented and criterion considered to have been met. Each individual item was reported as a proportion of cases where the criterion was met as well as a 95% confidence interval estimate of the proportion. Results:One-hundred and seventy-two patients' electronic medical records were reviewed. For the summary score, analyzing all twelve items, we found complete documentation in 1 of the 172 records (0.58%). We analyzed the proportions of notes that included each of the individual items relevant to IBD management
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Sa1049 Evaluation of Mucosal Healing in Ulcerative Colitis by Fecal Calprotectin Versus Fecal Immunochemical Test Shiho Takashima, Jun Kato, Sakiko Hiraoka, Asuka Nakarai, Daisuke Takei, Toshihiro Inokuchi, Yuusaku Sugihara, Masahiro Takahara, Keita Harada, Hiroyuki Okada, Kazuhide Yamamoto OBJECTIVES: Recently, not only clinical remission but also endoscopic mucosal healing is being pursued as the treatment goal for UC. We have reported that fecal immunochemical test (FIT) is useful as an indicator of mucosal healing evaluation in UC. However, few have been reported on the correlation between FIT and fecal calprotectin (Fcal) which is frequently used in Western countries. The aim of this study was to compare the usefulness of FIT and Fcal in mucosal healing evaluation in UC. METHODS: Consecutive UC patients who underwent scheduled colonoscopy were requested to bring fecal samples for the examination of FIT and Fcal. The mucosal status of UC patients was assessed via the Mayo endoscopic subscore (MES) classification. Evaluation was performed at each portion of the colorectum (cecum and ascending colon combined, transverse colon, descending colon, sigmoid colon, and rectum), and mucosal healing was defined in two different manners: MES 0 alone and MES 0 or 1 throughout the colorectum. RESULTS: In total, 105 colonoscopies in 92 UC patients were evaluated in conjunction with the FIT and Fcal results. The correlations between FIT, Fcal, and colonoscopic findings (maximum MES in the colorectum) were analyzed. Both the FIT results and Fcal levels were significantly correlated with the maximum MES (Spearman rank correlation coefficient: 0.61, p < 0.0001 and 0.58, p < 0.0001, respectively) in the colorectum. When mucosal healing was defined as MES 0 alone, the sensitivity of FIT was more than 10 points higher than that of Fcal based on either the standard (< 100 ng/mL for FIT and < 250 mg/g for Fcal) or the optimal (determined by ROC analysis: < 75 ng/mL for FIT and < 200 mg/g for Fcal) cutoffs (standard cutoffs, 0.95 vs. 0.82; optimal cutoffs, 0.93 vs. 0.77). The specificity did not differ largely when either cutoff was used (standard cutoffs, 0.62 vs. 0.62; optimal cutoffs, 0.67 vs. 0.72). Similar AUCs were obtained by ROC analysis for the FIT and Fcal results (0.83 vs. 0.82). When mucosal healing was defined as MES 0 or 1, the sensitivity of the FIT was more than 10 points higher than that of the Fcal based on the standard cutoffs (0.81 vs. 0.70); however, similar sensitivity was observed based on the optimal (< 280 ng/mL for FIT and < 369 mg/g for Fcal) cutoffs (0.86 vs. 0.86). The specificity was also similar regardless of which cutoff was used (standard cutoffs, 0.68 vs. 0.66; optimal cutoffs, 0.66 vs. 0.63). Also in this case, similar AUCs were obtained by ROC analysis between the FIT and Fcal (0.79 vs. 0.80). CONCLUSION: Both FIT and Fcal effectively predicted mucosal healing in UC patients. The results also indicated that FIT is more sensitive toward MES 0 than Fcal. The difference in clinical utility, including predictability for risk of relapse or colectomy, between the two fecal tests should be further investigated.
Sa1050 Prevalence of DNA Biomarkers in Fecal Immunochemical Test Positive and Negative Colorectal Cancers Theodore R. Levin, Chyke A. Doubeni, Christopher D. Jensen, Wei K. Zhao, Alexis Zebrowski, Rebecca Oldham-Haltom, William R. Taylor, David A. Ahlquist, Hatim T. Allawi, Graham P. Lidgard, Douglas A. Corley, Barry M. Berger
Probability of Repeat EGD at each of 159 VA Sites. {BR}Rate of repeat EGD at each site and 95% confidence interval was estimated in an empty multi-level regression model without any predictors, and sorted by the rate of repeat EGD.
BACKGROUND: While fecal immunochemical test (FIT) screening identifies the majority of patients with asymptomatic colorectal cancer (CRC), the addition of stool DNA biomarkers to FIT has been shown to significantly improve detection. We sought to determine if DNA biomarkers in CRC tumor tissue differ between FIT-positive and FIT-negative CRCs. METHODS: Patients were Kaiser Permanente Northern California health plan members 5077 years of age at the date of CRC diagnosis in 2009-2010 and were FIT (OC FIT CHEK, Polymedco) screened in the 24-months before diagnosis. FIT-positive CRC patients were frequency matched to FIT-negative patients on age (in 5-year intervals), sex, and tumor stage. CRC-associated biomarkers were assessed on DNA isolated from formalin-fixed, paraffinembedded (FFPE) tissue, blinded to FIT positivity status, using quantitative allele specific real-time target and signal amplification (QuARTS) assays, first for KRAS mutations (7; Exon 2, codons 12 and 13) and aberrant methylation markers (BMP3 and NDRG4), and subsequently for eight novel methylation markers [SFMBT2 (Regions 895, 896, and 897), CHST2 (Regions 7889 and 7890), PDGFD, VAV3, and DTX1]. There was sufficient DNA available to complete all markers for 421 of 490 patients. The results from 40 FFPE normal colorectal tissue samples were used to set positivity cut-off values for each marker at 100% specificity. Differences in DNA biomarker positivity rates between the groups were compared using the chi-square test. RESULTS: Patients averaged 66.0 years of age, 51.3% were female, 67.5% were white, 56.1% of CRCs were diagnosed at a localized stage, and 73.6% were moderately differentiated. These characteristics were similar between the groups ( Table 1). The groups differed in CRC location: 60.7% of FIT-positive and 47.1% of FIT-negative CRCs were in the distal colon (p=0.01). For the initial set of three biomarkers, overall positivity ranged from 78.1% for NDRG4 to 38.0% for a KRAS mutation, but there were no significant differences between the groups. Overall, 86.7% of CRCs tested positive for at least one of these three markers. The overall positivity rates of the eight novel methylation markers ranged from 89.8% for SFMBT2 (Region 895) to 70.6% for CHST2 (Region 7889). Significant differences between FIT-positive versus FIT-negative cancers were found only
Sa1048 Comparison of Gastric Acid Inhibition With 4-Times-Daily Dosing of Esomeprazole and Rabeprazole in Healthy Japanese Individuals Shu Sahara, Mitsushige Sugimoto, Hitomi Ichikawa, Takuma Kagami, Mihoko Yamade, Takahiro Uotani, Yasushi Hamaya, Moriya Iwaizumi, Satoshi Osawa, Ken Sugimoto, Takahisa Furuta Background: Potent neutralization of intragastric pH is important in the treatment of acidrelated diseases such as peptic ulcers and gastroesophageal reflux disease (GERD). However, once (o.i.d.)- or twice (b.i.d.)-daily dosing of a standard dose of proton pump inhibitors (PPIs) does not always provide sufficient acid inhibition over a 24-h period, particularly for rapid metabolizers (RMs) of CYP2C19. We previously reported that esomeprazole (b.i.d.) exerts [check] potent acid inhibition in CYP2C19 RMs compared to omeprazole, lansoprazole, and rabeprazole, and that complete inhibition of gastric acid secretion in all patients is difficult. Although rabeprazole (10 mg, q.i.d.) and lansoprazole (30 mg, q.i.d.) reportedly induce sufficient acid inhibition in CYP2C19 RMs, whether or not esomeprazole (20 mg, q.i.d.) can induce sufficient inhibition over a 24-h period in RMs remains unclear. We therefore examined the efficacy of esomeprazole q.i.d. in achieving sufficient acid inhibition. Methods: In a randomized cross-over study, 30 healthy, Helicobacter pylori-negative, young Japanese volunteers (10 RMs, 10 intermediate metabolizers [IMs], and 10 poor metabolizers [PMs] of CYP2C19) received esomeprazole 20 mg b.i.d. or q.i.d. for 1 week. Intragastric pH monitoring was performed on Day 7. Intragastric pHs were also compared to esomeprazole 20 mg q.i.d. and rabeprazole 10 mg q.i.d. (13 RMs, 15 IMs and 7 PMs). Data from 24-h pH monitoring from our previous study of the efficacy of rabeprazole 10 mg q.i.d was used for comparison. Results: Median pH attained with esomeprazole 20 mg b.i.d. differed
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significantly by CYP2C19 genotype (p=0.004), with 5.3 (range: 3.5-6.8) in RMs, 5.5 (4.36.2) in IMs, and 6.2 (5.2-7.2) in PMs. In contrast, median pH values with esomeprazole 20 mg q.i.d. in CYP2C19 RMs (6.6 [range: 4.5-7.5]), IMs (6.8 [5.9-7.7]), and PMs (7.0 [5.0-7.8]) were similar (p=0.384) and significantly higher than those for 20 mg b.i.d. in RMs (p=0.022) and IMs (p=0.005). On comparing median pH values with rabeprazole 10 mg q.i.d. of 6.7 (4.9-8.0) in RMs, 6.4 (5.0-7.5) in IMs, and 7.4 (6.5-8.4) in PMs, no significant differences were noted. Conclusion: Esomeprazole 20 mg q.i.d. achieved potent acid inhibition throughout a 24-h period in all H. pylori-negative subjects, as well as rabeprazole 10 mg q.i.d., irrespective of CYP2C19 genotype. This observation suggests that PPI q.i.d. treatment might be the optimum regimen for patients with acid-related diseases refractory to PPI treatment.
alarm features. We developed a computer algorithm called Automated Evaluation of Gastrointestinal Symptoms (AEGIS) that systematically collects patient symptoms and GI alarm features online, and then "translates" the information into a full narrative history of present illness (HPI). We compared the number of alarms documented by physicians during usual care vs. that collected by AEGIS. Methods: We performed a cross-sectional study with a paired sample design among patients visiting outpatient university and VA-based GI teaching clinics. Participants first received usual care by their physicians and then completed AEGIS either on a clinic computer or at home. While on AEGIS, patients were guided through tailored questions drawn from a library of over 300 clinical factors measuring the timing, severity, frequency, location, quality, and character of their GI symptoms. AEGIS also asked about recent alarm features including hematochezia, melena, hematemesis, unintentional weight loss, decreased appetite, and fevers. AEGIS then simulated a GI physician history and converted the results into a full HPI. Each individual thereby had both a physiciandocumented HPI and AEGIS HPI. A blinded physician reviewer enumerated the positive and negative alarms explicitly mentioned in each HPI without knowing half were written by a computer. We compared the number of documented alarms using the Wilcoxon signedrank test. Results: Seventy-five patients had both physician and AEGIS HPIs. Overall, AEGIS identified more patients with alarm features vs. physicians (53% vs. 27%; p<.001). AEGIS documented more positive alarms (median 1, interquartile range [IQR] 0-2) vs. physicians (median 0, IQR 0-1; p<.001) and more negative alarms (median 5, IQR 4-6) vs. physicians (median 2, IQR 0-3; p<.001). Findings were unchanged in the sub-groups who completed AEGIS anytime within one week of their clinic visit (n=55; p<.001) and those being seen for an initial visit (n=39, p<.001). We evaluated whether positive alarms in the physician HPI matched the alarms in AEGIS: hematochezia (3/9; 33%), melena (1/10; 10%), hematemesis (2/4; 50%), unintentional weight loss (9/22; 41%), decreased appetite (5/24; 21%), and fevers (0/2; 0%). Conclusion: A computerized GI HPI identified more alarm features vs. physicians during usual care in GI clinics at academic medical centers. Physicians documented less than one-third of red flags reported by patients to AEGIS. These data indicate that physicians may underreport alarm features and that computerized "checklists" could serve as a vital complement to standard HPIs.
and found the following: Type of disease were 98.8% (95.8-99.8), diagnosis date 59.8% (52.1-67.2), extent of disease 76.7% (69.7-82.8), extraintestinal manifestations 42.4% (34.950.1), previous medications 63.3% (55.6-70.5), current medications 95.3% (91.0-97.9), date of last symptom exacerbation 26.1% (19.7-33.3), last steroid use 30.2% (23.5-37.7), previous surgeries 39.5% (32.1-47.2), family history of IBD 15.1% (10.1-21.3), smoking status 19.7% (14.1-26.5), and endoscopic and histologic findings 43.6% (36.1-51.3). Conclusion:We demonstrated several deficiencies in documenting important clinical information that is crucial for the care of IBD patients. We anticipate that using a template to document those clinical encounters will improve such documentation and improve the care of the IBD patients. Our next step is to develop an intervention tool to improve medical record documentation in patients with IBD.
Sa1047 Utilization and Appropriateness of Repeat Upper Endoscopy Within the U.S. Veterans Health Administration Joel H. Rubenstein, Heiko Pohl, Eve Kerr, Robert Holleman, Sandeep Vijan, Jason A. Dominitz, John M. Inadomi, Dawn Provenzale, Joseph Francis, Sameer D. Saini Background: Veterans Affairs (VA) medical centers struggle to meet the demand for endoscopy. Reducing utilization of low-value procedures could help meet that demand. In many scenarios, repeated upper endoscopy (EGD) is a low-value procedure that may be overused. Aims: To describe utilization and appropriateness of repeat EGDs within VA, and identify associated factors. Methods: We queried national VA Corporate Data Warehouse from fiscal year 2003 through the middle of 2007, identifying individuals who had both: (1) at least 1 EGD ("index" EGD), and (2) at least 1 outpatient visit every 24 months in the 5 years following the index EGD (indicating regular use of VA health care). We then identified repeat EGDs during 5 years of follow-up. Using diagnostic and procedure codes at the time of index EGD and during the follow-up period, we classified appropriateness of repeat EGDs into 3 categories, modified from an algorithm previously used in Medicare data (Annals Internal Medicine; 2014;160:154): "likely appropriate" (e.g., varices, Barrett's esophagus, stricture, etc.), "likely inappropriate" (e.g., heartburn, nausea, non-bleeding gastritis, etc.), and "uncertain" (bleeding lesions, ulcer, esophagitis). Multi-level logistic regression was performed to estimate the impact of patient-level and site-level factors on the odds of repeat EGD. Results: 262,939 veterans underwent an index EGD, including 83,205 (31.6%) for whom a repeat would be likely appropriate, 62,383 (23.7%) for whom a repeat would be likely inappropriate, and 117,351 (44.6%) with uncertain appropriateness. Within 5 years, 100,693 had undergone at least 1 repeat EGD (38.3%) with rates at the 159 individual sites providing EGD ranging from 14.1% to 55.2% (Figure). Repeat EGD was performed in 57.1% of those where repeat would likely be appropriate, 33.6% of those with uncertain appropriateness, and 22.0% of those where repeat was likely inappropriate. Access to high volume endoscopy sites and more frequent interaction with VA, particularly visits to a gastroenterologist, were associated with receipt of a repeat EGD, both in scenarios where repeat EGD was likely appropriate and in those where it was likely inappropriate (Table). Conclusions: Once a veteran undergoes EGD, a repeat EGD is common. There is substantial variation in the rate of repeat EGD between sites, suggesting practice patterns are influential. Most repeat EGDs are likely appropriate, but thousands of repeat EGDs in VA each year are unlikely appropriate. Frequent visits with a gastroenterologist are associated with receipt of EGD both in scenarios where it is likely appropriate and where it is likely inappropriate. Further research is needed to validate this classification scheme for appropriateness of repeat EGD, and to develop strategies for addressing potential over- and under-utilization of repeat EGD. Multivariable Multi-level Logistic Regression for Receipt of Repeat EGD, Stratified by Appropriateness of Repeat
Sa1045 Retrospective Analysis of Vaccination Against Hepatitis A and Hepatitis B in Hepatitis C Patients Karl DeMarco, Kathy Geissler, Joseph J. Vicari Background and Aims: The American Gastroenterological Association (AGA) recommends all patients infected with Hepatitis C (HCV) be vaccinated against Hepatitis A (HAV) and Hepatitis B (HBV) if no prior exposure. With the trend toward documentation of quality metrics, we examined providers' compliance with this metric in a large community-based GI practice. Methods: A retrospective review of office electronic medical records (EMR) of patients with newly diagnosed HCV from June 2012 through December 2013 was conducted. Data collected included documentation of orders for HAV and HBV serologic testing. Orders were placed either by the gastroenterologist or the primary physician. Subsequent vaccination (or patient refusal) in appropriate individuals was also documented. A total of 196 charts were eligible for review. Results: HAV serologic testing was ordered for 63.3% of HCV patients. HBV serologic testing was ordered for 67.3% of HCV patients. Of the 88 HAV cases (44.9%) and 90 HBV cases (45.9%), the testing was ordered by the gastroenterologist. Thirteen patients (8.5%) did not follow through with ordered serologic testing and were subsequently lost to follow up. Forty four patients (28.9%) did not require vaccination due to immunity. Vaccines were ordered for 87 (57.2%) patients who were not immune. Documentation of vaccination was found in 27.6% of cases. Conclusion: Our study demonstrates poor compliance with ordering serologic testing of HAV and HBV as well as poor documentation of successful vaccination in our HCV population. The compliance gap may be related to decreased physician point of service compliance with the quality metric and poor documentation of completion of the vaccination series. Further testing including more robust documentation tools within EMR is needed to determine the causes of compliance failure within our practice.
Sa1046 Improving Medical Record Documentation of Clinical Encounters in Inflammatory Bowel Disease (IBD) Patients: A Review of Current Practice Ashraf A. Almashhrawi, Fazia A. Mir, Amin Mahdi, Anjana Sathyamurthy, Richard Madsen, Matthew L. Bechtold, Ravinder Mankoo, Jack Bragg, Akwi W. Asombang Background:IBD is a chronic condition with significant socioeconomic burden attributed to hospitalizations, outpatient care and pharmaceutical costs. The estimated mean annual cost is $8265 and $5066 per patient for Crohn's disease (CD) and ulcerative colitis (UC), respectively. Deficiencies in quality of medical care and expert recommendations are contributing factors to poor patient care and poor documentation of IBD-related issues. Given these deficiencies, we examined the quality of clinical encounter notes in the IBD clinics at a tertiary academic medical center. Methods:This was a retrospective analysis of electronic medical records for IBD patients' presenting to gastroenterology clinic over a 3-month time. We specifically extracted data from the most recent clinical note of the patient using a uniform data extraction sheet. The clinical notes were analyzed for presence or lack of documentation of specific variables. Data extracted included demographics (age, gender, race) and twelve items we deemed as relevant to management of IBD patients. The twelve items were: Type of disease (UC/CD), date of diagnosis, extent of disease involvement, extraintestinal manifestation, previous medications, current medications, last use of steroids, date of last flare, previous surgeries related to the diagnosis, family history of IBD, smoking status, and endoscopic and histopathologic findings. Data was entered as "yes" if the information was documented and criterion considered to have been met. Each individual item was reported as a proportion of cases where the criterion was met as well as a 95% confidence interval estimate of the proportion. Results:One-hundred and seventy-two patients' electronic medical records were reviewed. For the summary score, analyzing all twelve items, we found complete documentation in 1 of the 172 records (0.58%). We analyzed the proportions of notes that included each of the individual items relevant to IBD management
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Sa1049 Evaluation of Mucosal Healing in Ulcerative Colitis by Fecal Calprotectin Versus Fecal Immunochemical Test Shiho Takashima, Jun Kato, Sakiko Hiraoka, Asuka Nakarai, Daisuke Takei, Toshihiro Inokuchi, Yuusaku Sugihara, Masahiro Takahara, Keita Harada, Hiroyuki Okada, Kazuhide Yamamoto OBJECTIVES: Recently, not only clinical remission but also endoscopic mucosal healing is being pursued as the treatment goal for UC. We have reported that fecal immunochemical test (FIT) is useful as an indicator of mucosal healing evaluation in UC. However, few have been reported on the correlation between FIT and fecal calprotectin (Fcal) which is frequently used in Western countries. The aim of this study was to compare the usefulness of FIT and Fcal in mucosal healing evaluation in UC. METHODS: Consecutive UC patients who underwent scheduled colonoscopy were requested to bring fecal samples for the examination of FIT and Fcal. The mucosal status of UC patients was assessed via the Mayo endoscopic subscore (MES) classification. Evaluation was performed at each portion of the colorectum (cecum and ascending colon combined, transverse colon, descending colon, sigmoid colon, and rectum), and mucosal healing was defined in two different manners: MES 0 alone and MES 0 or 1 throughout the colorectum. RESULTS: In total, 105 colonoscopies in 92 UC patients were evaluated in conjunction with the FIT and Fcal results. The correlations between FIT, Fcal, and colonoscopic findings (maximum MES in the colorectum) were analyzed. Both the FIT results and Fcal levels were significantly correlated with the maximum MES (Spearman rank correlation coefficient: 0.61, p < 0.0001 and 0.58, p < 0.0001, respectively) in the colorectum. When mucosal healing was defined as MES 0 alone, the sensitivity of FIT was more than 10 points higher than that of Fcal based on either the standard (< 100 ng/mL for FIT and < 250 mg/g for Fcal) or the optimal (determined by ROC analysis: < 75 ng/mL for FIT and < 200 mg/g for Fcal) cutoffs (standard cutoffs, 0.95 vs. 0.82; optimal cutoffs, 0.93 vs. 0.77). The specificity did not differ largely when either cutoff was used (standard cutoffs, 0.62 vs. 0.62; optimal cutoffs, 0.67 vs. 0.72). Similar AUCs were obtained by ROC analysis for the FIT and Fcal results (0.83 vs. 0.82). When mucosal healing was defined as MES 0 or 1, the sensitivity of the FIT was more than 10 points higher than that of the Fcal based on the standard cutoffs (0.81 vs. 0.70); however, similar sensitivity was observed based on the optimal (< 280 ng/mL for FIT and < 369 mg/g for Fcal) cutoffs (0.86 vs. 0.86). The specificity was also similar regardless of which cutoff was used (standard cutoffs, 0.68 vs. 0.66; optimal cutoffs, 0.66 vs. 0.63). Also in this case, similar AUCs were obtained by ROC analysis between the FIT and Fcal (0.79 vs. 0.80). CONCLUSION: Both FIT and Fcal effectively predicted mucosal healing in UC patients. The results also indicated that FIT is more sensitive toward MES 0 than Fcal. The difference in clinical utility, including predictability for risk of relapse or colectomy, between the two fecal tests should be further investigated.
Sa1050 Prevalence of DNA Biomarkers in Fecal Immunochemical Test Positive and Negative Colorectal Cancers Theodore R. Levin, Chyke A. Doubeni, Christopher D. Jensen, Wei K. Zhao, Alexis Zebrowski, Rebecca Oldham-Haltom, William R. Taylor, David A. Ahlquist, Hatim T. Allawi, Graham P. Lidgard, Douglas A. Corley, Barry M. Berger
Probability of Repeat EGD at each of 159 VA Sites. {BR}Rate of repeat EGD at each site and 95% confidence interval was estimated in an empty multi-level regression model without any predictors, and sorted by the rate of repeat EGD.
BACKGROUND: While fecal immunochemical test (FIT) screening identifies the majority of patients with asymptomatic colorectal cancer (CRC), the addition of stool DNA biomarkers to FIT has been shown to significantly improve detection. We sought to determine if DNA biomarkers in CRC tumor tissue differ between FIT-positive and FIT-negative CRCs. METHODS: Patients were Kaiser Permanente Northern California health plan members 5077 years of age at the date of CRC diagnosis in 2009-2010 and were FIT (OC FIT CHEK, Polymedco) screened in the 24-months before diagnosis. FIT-positive CRC patients were frequency matched to FIT-negative patients on age (in 5-year intervals), sex, and tumor stage. CRC-associated biomarkers were assessed on DNA isolated from formalin-fixed, paraffinembedded (FFPE) tissue, blinded to FIT positivity status, using quantitative allele specific real-time target and signal amplification (QuARTS) assays, first for KRAS mutations (7; Exon 2, codons 12 and 13) and aberrant methylation markers (BMP3 and NDRG4), and subsequently for eight novel methylation markers [SFMBT2 (Regions 895, 896, and 897), CHST2 (Regions 7889 and 7890), PDGFD, VAV3, and DTX1]. There was sufficient DNA available to complete all markers for 421 of 490 patients. The results from 40 FFPE normal colorectal tissue samples were used to set positivity cut-off values for each marker at 100% specificity. Differences in DNA biomarker positivity rates between the groups were compared using the chi-square test. RESULTS: Patients averaged 66.0 years of age, 51.3% were female, 67.5% were white, 56.1% of CRCs were diagnosed at a localized stage, and 73.6% were moderately differentiated. These characteristics were similar between the groups ( Table 1). The groups differed in CRC location: 60.7% of FIT-positive and 47.1% of FIT-negative CRCs were in the distal colon (p=0.01). For the initial set of three biomarkers, overall positivity ranged from 78.1% for NDRG4 to 38.0% for a KRAS mutation, but there were no significant differences between the groups. Overall, 86.7% of CRCs tested positive for at least one of these three markers. The overall positivity rates of the eight novel methylation markers ranged from 89.8% for SFMBT2 (Region 895) to 70.6% for CHST2 (Region 7889). Significant differences between FIT-positive versus FIT-negative cancers were found only
Sa1048 Comparison of Gastric Acid Inhibition With 4-Times-Daily Dosing of Esomeprazole and Rabeprazole in Healthy Japanese Individuals Shu Sahara, Mitsushige Sugimoto, Hitomi Ichikawa, Takuma Kagami, Mihoko Yamade, Takahiro Uotani, Yasushi Hamaya, Moriya Iwaizumi, Satoshi Osawa, Ken Sugimoto, Takahisa Furuta Background: Potent neutralization of intragastric pH is important in the treatment of acidrelated diseases such as peptic ulcers and gastroesophageal reflux disease (GERD). However, once (o.i.d.)- or twice (b.i.d.)-daily dosing of a standard dose of proton pump inhibitors (PPIs) does not always provide sufficient acid inhibition over a 24-h period, particularly for rapid metabolizers (RMs) of CYP2C19. We previously reported that esomeprazole (b.i.d.) exerts [check] potent acid inhibition in CYP2C19 RMs compared to omeprazole, lansoprazole, and rabeprazole, and that complete inhibition of gastric acid secretion in all patients is difficult. Although rabeprazole (10 mg, q.i.d.) and lansoprazole (30 mg, q.i.d.) reportedly induce sufficient acid inhibition in CYP2C19 RMs, whether or not esomeprazole (20 mg, q.i.d.) can induce sufficient inhibition over a 24-h period in RMs remains unclear. We therefore examined the efficacy of esomeprazole q.i.d. in achieving sufficient acid inhibition. Methods: In a randomized cross-over study, 30 healthy, Helicobacter pylori-negative, young Japanese volunteers (10 RMs, 10 intermediate metabolizers [IMs], and 10 poor metabolizers [PMs] of CYP2C19) received esomeprazole 20 mg b.i.d. or q.i.d. for 1 week. Intragastric pH monitoring was performed on Day 7. Intragastric pHs were also compared to esomeprazole 20 mg q.i.d. and rabeprazole 10 mg q.i.d. (13 RMs, 15 IMs and 7 PMs). Data from 24-h pH monitoring from our previous study of the efficacy of rabeprazole 10 mg q.i.d was used for comparison. Results: Median pH attained with esomeprazole 20 mg b.i.d. differed
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AGA Abstracts
AGA Abstracts
significantly by CYP2C19 genotype (p=0.004), with 5.3 (range: 3.5-6.8) in RMs, 5.5 (4.36.2) in IMs, and 6.2 (5.2-7.2) in PMs. In contrast, median pH values with esomeprazole 20 mg q.i.d. in CYP2C19 RMs (6.6 [range: 4.5-7.5]), IMs (6.8 [5.9-7.7]), and PMs (7.0 [5.0-7.8]) were similar (p=0.384) and significantly higher than those for 20 mg b.i.d. in RMs (p=0.022) and IMs (p=0.005). On comparing median pH values with rabeprazole 10 mg q.i.d. of 6.7 (4.9-8.0) in RMs, 6.4 (5.0-7.5) in IMs, and 7.4 (6.5-8.4) in PMs, no significant differences were noted. Conclusion: Esomeprazole 20 mg q.i.d. achieved potent acid inhibition throughout a 24-h period in all H. pylori-negative subjects, as well as rabeprazole 10 mg q.i.d., irrespective of CYP2C19 genotype. This observation suggests that PPI q.i.d. treatment might be the optimum regimen for patients with acid-related diseases refractory to PPI treatment.