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⁎3413 The inappropriate use of colonoscopy in an openaccess setting: a prospective multicenter study.
*3413 THE INAPPROPRIATE USE OF COLONOSCOPY IN AN OPENACCESS SETTING: A PROSPECTIVE MULTICENTER STUDY. Sergio Morini, Giorgio Minoli, Cesare Hassan, Anna Toldi, Gianmichele Meucci, Dino Porto, GI Unit N Regina Margherita Hosp, Rome, Italy; II DEPT MED VALDUCE Hosp, Como, Italy; GI UNIT S GIACOMO Hosp, Rome, Italy. Background: Based on ASGE guidelines or complex derived criteria, mainly related to specific clinically scenarios, up to 30% of lower GI tract endoscopy (LE) are inappropriate in an open-access system. Aims: To assess a)the inappropriate rate of LE required by general practitioners (GPs) or specialists, and b)the clinical indications and diagnostic yield of inappropriate vs appropriate LE. Methods: From June to December 1998, consecutive patients referred for LE were prospectively studied. Before endoscopy, a questionnaire was filled to assess the appropriateness of the request in the 8 scheduled clinical situations in which ASGE-guidelines were reduced: screening, follow-up, long-lasting (> 3 months) or recentonset symptoms or signs in patients never or already studied, operative endoscopy and to complete a previous colonic study (endoscopy or barium enema). Results: Out of 1045 LE, 154/393(40%) sent by GPs and 150/652 (23%)sent by specialists were judged inappropriate (p<0.0001). GPs’ vs specialists’ inappropriate rates were as follow:55% vs 32% for follow-up (p<0.002);51% vs 54% (NS) and 68% vs 20% (p<0.0002)for long-standing symptoms in patients either never or already studied,respectively;15% vs 36% (NS) and 28% vs 7% (NS)for recent-onset symptoms in patients either never or already studied, respectively; 10% vs 8% (NS) for screening. Positive findings (adenoma, cancer, IBD or angiodysplasia) were detected in 33/304(11%)inappropriate procedures vs 341/741 (46%) appropriate endoscopies(p<0.001). Conclusions:1)In our study inappropriate use of LE is high, accounting for 29% of all the referrals. 2)GP’s inappropriate rate is significantly higher than that of specialists, namely for patients referred for follow-up and long-standing symptoms.3)Specialists’ referrals for follow-up are unexpectedly inappropriate in more than 30% of cases. 4)The diagnostic yield of inappropriate endoscopies is significantly lower than that of appropriate ones.5)Overuse of open-access colonoscopy could be reduced by referring patients with long-standing symptoms or in follow-up to outpatient GI clinic.6)Reducing ASGE-guidelines to a few systematic clinical situations may be helpful in identifying areas of overuse of endoscopy.
*3415 IN-VIVO EVALUATION OF REUSABLE BIOPSY FORCEPS: CHAPTER 2. Richard A. Kozarek, Fouad M. Attia, Stanford E. Sumida, Shirley L. Raltz, Shannon K. Roach, Drew B. Schembre, John J. Brandabur, Michael Gluck, Geoffrey C. Jiranek, David J. Patterson, James E. Bredfeldt, Martin Gelfand, Virginia Mason Med Ctr, Seattle, WA. Disposable biopsy (bx) forceps are marketed as more efficacious and safer than reusable ones, but there are few data to support these claims. We report the continuation of a prospective study begun in1998 to evaluate invivo efficacy of a reusable bx forceps (Olympus America, Inc., Melville, NY). Methods: Prospectively, over a 14-month period (9/98-11/99), 15 new bx forceps were assessed. Data collected included pt demographics, procedure and date, bx site, adequacy of bx specimen, and problems at sample collection. Results: 1273 biopsy sessions were undertaken in 1124 procedures (623 EGD, 452 colonoscopies, 24 flexible sigmoidoscopies, 21 EUS, and 4 ileoscopies). Bx sites were esophagus 235, stomach 408 (CLO 178), small bowel 156, large bowel 444, and surgical anastmoses 30 (ileo-colonic 18, eso-gastric 2, gastro-enteric 3, pyloroplasty 1, rectal stump 1, soft palate 1, ileal pouch 2, ileo-rectal 1, and pharynx 1). Forceps were reported as new or like new 1066/1124 (94.8%), some loss of function, but usable 52/1124 (4.7%); and 6/1124 inadequate function to use clinically (0.5%). Histologically, 1269 were adequate (99.7%) and mean specimen size was 2.71 ± 0.07 mm (0.9mm-10mm), with four specimens greater than 1 cm. No forceps problems were encountered in 1210/1273 (95%) of sessions. Mechanical problems were noted in (30/1273, 2.4%) and included: inadequate cusp closure 7, sticky forceps 7, failure to open or open slowly 8, caught in scope channel 1, kink 5, bent needle 1, and difficulty removing the specimen 1. Endoscopists expressed a concern of specimen adequacy in 28 cases (2%), only 2 of the 28 (7%) were determined to be pathologically inadequate. Mean number of uses of forceps to date is 81 ± 8 (19-103). 12 bx forceps are still in use, whereas 3 of the 15 broke after 19, 63, and 64 procedures respectively. Conclusions: 1) To date, this reusable forceps maintained its function for a mean of 81 uses, and 12 of 15 remain in service. 2) Operational problems with the forceps were reported in 30/1273 (2.4%). 3) Endoscopists were satisfied with bx specimen size in 1245/1273 (98%) sessions whereas pathologists reported specimen adequacy in 1269/1273 (99.7%). 4) Prospective in-vivo evaluation to include cost data continues.
*3414 COST EFFECTIVE APPROACH TO PATIENTS ON LONG TERM ANTICOAGULATION WHO NEED ENDOSCOPY. Abraham Mathew, Ann Ouyang, Thomas R. Riley, Mark Young, The Pennsylvania State Univ Coll of Medicine, Hershey, PA. Patients (pts) requiring long term anticoagulation may need endoscopic procedures. These are often done in the inpatient setting using a ‘heparin window’. Aim: To determine whether an initial diagnostic endoscopic examination is a cost-effective strategy in these patients. Methods: A decision tree was made outling two strategies: 1) a diagnostic endoscopy (on full anticoagulation) followed by therapeutic endoscopy if needed using standard practice, and 2) standard coumadin reversal (reverse coumadin, start intravenous heparin, perform endoscopy, restart coumadin). Costs were compared using decision analysis. Clinical data [indication for anticoagulation and endoscopy, findings at endoscopy, therapeutic impact and time spent waiting a targeted INR] was obtained by retrospective analysis of inpatients from 1997 to 1999. Results: Sixty-four charts, where standard coumadin reversal approach was used, were analyzed. Eighty-six endoscopies were done in the 64 pts (38 EGD, 30 colonoscopies, 9 enteroscopies, 7 ERCPs, 1 flexible sigmoidoscopy and 1 PEG]. In the overall cohort, 211 additional days were spent waiting for a targeted INR [3.3 days/patient]. When the indication suggested significant bleeding, therapeutic intervention was done in 57% of the cases. ERCP was always therapeutic (100%). Overall, 31% of the cases required therapeutic intervention. The diagnostic endoscopy approach will reduce hospital stay by 330 days per 100 pts. Considering only room costs and assuming equal costs for initial endoscopy, the savings = Cost of standard approach - Cost of proposed approach = [No. of Pts X No. of days X cost of a day] - [(Pts needing repeat procedure X No. of days X cost of a day) + (No. of additional procedures X cost of a procedure)]. Using our clinical data and conservative cost estimates [$500/day and $300/procedure], savings for 100 pts = (100 X 3.3 X 500) - [(31 X 3.3 X 500) + (31 X 300)] = $104,550. Threshold analysis showed diagnostic endoscopy on anticoagulation was preferred as long as expected chances of therapeutic intervention were less than 83% [1500/(300 + 1500) or H/H+P, where ‘H’ = cost of hospital stay and ‘P’ = cost of procedure.] Conclusion: In anticoagulated patients, the most cost-effective strategy is diagnostic endoscopy approach on anticoagulation except when ERCP is indicated. This approach will lead to significant cost savings ($104,550 per 100 patients) by reducing duration of hospital stay.
*3416 PHOTODYNAMIC THERAPY PROBES: CAN THEY BE REUSED? Timothy P. Kinney, Drew B. Schembre, Stanford E. Sumida, Richard A. Kozarek, Virginia Mason Med Ctr, Seattle, WA. Background: Fiber optic diffuser probes used in photodynamic therapy (PDT) are marketed as single-use disposable items. The relatively simple design of these probes (i.e. no moving parts, no open lumens) suggests that they might be safely sterilized and reused, without significant degradation in function. We prospectively evaluated PDT probes for sterility and loss of function in vivo and in vitro. Methods: Three patients underwent a total of five PDT treatments for esophageal cancer, with treatment time averaging 19 minutes per session. PDT probes were reused on two patients, but never shared between patients. Light transmission was evaluated prior to each treatment. After use, the PDT probe was cultured and sent for manual cleaning and sterilization using the STERIS system (Steris Corp., Mentor, Ohio). The probes were then recultured to assess sterility, and light transmission was measured to test for degradation in function. All cultures were incubated aerobically and anaerobically for more than 48 hours. To further evaluate the potential for sterilization and reuse, a separate probe was exposed in vitro to a suspension of 2.1 x 107 B. Stearothermophilus spores. The probe was cultured to ensure contamination by the spores. After manual cleaning and sterilization, the probe was recultured and tested for light transmission. This procedure was repeated five times. Results: Cultures of PDT probes following treatment in vivo grew numerous colonies of oropharyngeal flora. Culture of the probe exposed to B. Stearothermophilus spores grew numerous colonies of this organism. After sterilization, all probe cultures showed no growth, including eradication of B. Stearothermophilus spores. Light transmission did not change significantly in any probes following two treatments in vivo and up to five sterilizations in vitro. Conclusions: 1) Sterilization of PDT probes was achieved by manual cleaning followed by STERIS system reprocessing. 2) Reuse and reprocessing of PDT probes did not affect light transmission or probe function after up to five sterilizations. 3) The number of procedures which may be performed before significant deterioration in probe function has yet to be determined.
AB86
GASTROINTESTINAL ENDOSCOPY
VOLUME 51, NO. 4, PART 2, 2000
*3415 IN-VIVO EVALUATION OF REUSABLE BIOPSY FORCEPS: CHAPTER 2. Richard A. Kozarek, Fouad M. Attia, Stanford E. Sumida, Shirley L. Raltz, Shannon K. Roach, Drew B. Schembre, John J. Brandabur, Michael Gluck, Geoffrey C. Jiranek, David J. Patterson, James E. Bredfeldt, Martin Gelfand, Virginia Mason Med Ctr, Seattle, WA. Disposable biopsy (bx) forceps are marketed as more efficacious and safer than reusable ones, but there are few data to support these claims. We report the continuation of a prospective study begun in1998 to evaluate invivo efficacy of a reusable bx forceps (Olympus America, Inc., Melville, NY). Methods: Prospectively, over a 14-month period (9/98-11/99), 15 new bx forceps were assessed. Data collected included pt demographics, procedure and date, bx site, adequacy of bx specimen, and problems at sample collection. Results: 1273 biopsy sessions were undertaken in 1124 procedures (623 EGD, 452 colonoscopies, 24 flexible sigmoidoscopies, 21 EUS, and 4 ileoscopies). Bx sites were esophagus 235, stomach 408 (CLO 178), small bowel 156, large bowel 444, and surgical anastmoses 30 (ileo-colonic 18, eso-gastric 2, gastro-enteric 3, pyloroplasty 1, rectal stump 1, soft palate 1, ileal pouch 2, ileo-rectal 1, and pharynx 1). Forceps were reported as new or like new 1066/1124 (94.8%), some loss of function, but usable 52/1124 (4.7%); and 6/1124 inadequate function to use clinically (0.5%). Histologically, 1269 were adequate (99.7%) and mean specimen size was 2.71 ± 0.07 mm (0.9mm-10mm), with four specimens greater than 1 cm. No forceps problems were encountered in 1210/1273 (95%) of sessions. Mechanical problems were noted in (30/1273, 2.4%) and included: inadequate cusp closure 7, sticky forceps 7, failure to open or open slowly 8, caught in scope channel 1, kink 5, bent needle 1, and difficulty removing the specimen 1. Endoscopists expressed a concern of specimen adequacy in 28 cases (2%), only 2 of the 28 (7%) were determined to be pathologically inadequate. Mean number of uses of forceps to date is 81 ± 8 (19-103). 12 bx forceps are still in use, whereas 3 of the 15 broke after 19, 63, and 64 procedures respectively. Conclusions: 1) To date, this reusable forceps maintained its function for a mean of 81 uses, and 12 of 15 remain in service. 2) Operational problems with the forceps were reported in 30/1273 (2.4%). 3) Endoscopists were satisfied with bx specimen size in 1245/1273 (98%) sessions whereas pathologists reported specimen adequacy in 1269/1273 (99.7%). 4) Prospective in-vivo evaluation to include cost data continues.
*3414 COST EFFECTIVE APPROACH TO PATIENTS ON LONG TERM ANTICOAGULATION WHO NEED ENDOSCOPY. Abraham Mathew, Ann Ouyang, Thomas R. Riley, Mark Young, The Pennsylvania State Univ Coll of Medicine, Hershey, PA. Patients (pts) requiring long term anticoagulation may need endoscopic procedures. These are often done in the inpatient setting using a ‘heparin window’. Aim: To determine whether an initial diagnostic endoscopic examination is a cost-effective strategy in these patients. Methods: A decision tree was made outling two strategies: 1) a diagnostic endoscopy (on full anticoagulation) followed by therapeutic endoscopy if needed using standard practice, and 2) standard coumadin reversal (reverse coumadin, start intravenous heparin, perform endoscopy, restart coumadin). Costs were compared using decision analysis. Clinical data [indication for anticoagulation and endoscopy, findings at endoscopy, therapeutic impact and time spent waiting a targeted INR] was obtained by retrospective analysis of inpatients from 1997 to 1999. Results: Sixty-four charts, where standard coumadin reversal approach was used, were analyzed. Eighty-six endoscopies were done in the 64 pts (38 EGD, 30 colonoscopies, 9 enteroscopies, 7 ERCPs, 1 flexible sigmoidoscopy and 1 PEG]. In the overall cohort, 211 additional days were spent waiting for a targeted INR [3.3 days/patient]. When the indication suggested significant bleeding, therapeutic intervention was done in 57% of the cases. ERCP was always therapeutic (100%). Overall, 31% of the cases required therapeutic intervention. The diagnostic endoscopy approach will reduce hospital stay by 330 days per 100 pts. Considering only room costs and assuming equal costs for initial endoscopy, the savings = Cost of standard approach - Cost of proposed approach = [No. of Pts X No. of days X cost of a day] - [(Pts needing repeat procedure X No. of days X cost of a day) + (No. of additional procedures X cost of a procedure)]. Using our clinical data and conservative cost estimates [$500/day and $300/procedure], savings for 100 pts = (100 X 3.3 X 500) - [(31 X 3.3 X 500) + (31 X 300)] = $104,550. Threshold analysis showed diagnostic endoscopy on anticoagulation was preferred as long as expected chances of therapeutic intervention were less than 83% [1500/(300 + 1500) or H/H+P, where ‘H’ = cost of hospital stay and ‘P’ = cost of procedure.] Conclusion: In anticoagulated patients, the most cost-effective strategy is diagnostic endoscopy approach on anticoagulation except when ERCP is indicated. This approach will lead to significant cost savings ($104,550 per 100 patients) by reducing duration of hospital stay.
*3416 PHOTODYNAMIC THERAPY PROBES: CAN THEY BE REUSED? Timothy P. Kinney, Drew B. Schembre, Stanford E. Sumida, Richard A. Kozarek, Virginia Mason Med Ctr, Seattle, WA. Background: Fiber optic diffuser probes used in photodynamic therapy (PDT) are marketed as single-use disposable items. The relatively simple design of these probes (i.e. no moving parts, no open lumens) suggests that they might be safely sterilized and reused, without significant degradation in function. We prospectively evaluated PDT probes for sterility and loss of function in vivo and in vitro. Methods: Three patients underwent a total of five PDT treatments for esophageal cancer, with treatment time averaging 19 minutes per session. PDT probes were reused on two patients, but never shared between patients. Light transmission was evaluated prior to each treatment. After use, the PDT probe was cultured and sent for manual cleaning and sterilization using the STERIS system (Steris Corp., Mentor, Ohio). The probes were then recultured to assess sterility, and light transmission was measured to test for degradation in function. All cultures were incubated aerobically and anaerobically for more than 48 hours. To further evaluate the potential for sterilization and reuse, a separate probe was exposed in vitro to a suspension of 2.1 x 107 B. Stearothermophilus spores. The probe was cultured to ensure contamination by the spores. After manual cleaning and sterilization, the probe was recultured and tested for light transmission. This procedure was repeated five times. Results: Cultures of PDT probes following treatment in vivo grew numerous colonies of oropharyngeal flora. Culture of the probe exposed to B. Stearothermophilus spores grew numerous colonies of this organism. After sterilization, all probe cultures showed no growth, including eradication of B. Stearothermophilus spores. Light transmission did not change significantly in any probes following two treatments in vivo and up to five sterilizations in vitro. Conclusions: 1) Sterilization of PDT probes was achieved by manual cleaning followed by STERIS system reprocessing. 2) Reuse and reprocessing of PDT probes did not affect light transmission or probe function after up to five sterilizations. 3) The number of procedures which may be performed before significant deterioration in probe function has yet to be determined.
AB86
GASTROINTESTINAL ENDOSCOPY
VOLUME 51, NO. 4, PART 2, 2000