- Email: [email protected]
A Structured Program of Pharmaceutical Care Benefits Outpatients With Inflammatory Bowel Diseases Undergoing Continuous Drug Therapy
a structured pharmaceutical care program to the clinical treatment of outpatients with IBD assisted at a reference hospital. Methods - After giving written informed consent, 35 outpatients with Crohn's disease or ulcerative colitis undergoing continuous drug therapy were randomly assigned to either a PC program (N=18; median age: 44 years, 9 women) or a control group (N=17; median age: 49 years, 9 women). The PC program procedures was carried out by trained pharmacists and included detection of drug-related problems and educational interventions. Patients in both groups were evaluated at entrance and after one year. Patient knowledge on drugs used was evaluated using a modified version of the MedTake test and compliance to drug treatment was evaluated using the Morisky test. Disease clinical activity was assessed by specific indexes and quality of life was assessed by the “short form” (SF-36)survey. Results - There were no differences between groups regarding demographical and clinical aspects at study entrance. After one year of PC, there was a significant increase in patient's knowledge about drugs used in the PC group (median; range: 80%;40-100 vs. 100%;100-100; p<0.0001), which was not found in the control group (80%;0-100 vs. 80%;60-100%). Also, there was a significant increase in the percentage of patients who were more compliant to drug treatment in the PC group (27.8% vs. 72.2%; p=0.04), but not in the control group (41.2% vs. 41.2%). There was a significant decrease in the values of indexes for disease clinical activity in the PC group (logarithmic values: 2.20;0.99-3.77 vs. 1.90;0.99-3.77; p=0.02), but not in the control group (1.69;0.99-3.77 vs. 1.69;0.99-3.48; p>0.20). Regarding quality of life, there was a statistically significant increase (p<0.05) only in the scores for the mental health domain, which however occurred in both the PC group (57.5 vs. 65.3) and the control group (56.9 vs. 67.0). The PC program enabled the identification of a number of drug-related problems per patient (3.0;1.0-9.0), which were solved by interventions predominantly focused on patient education, and were missed in the control group. Conclusions - The implementation of a structured pharmaceutical care program to outpatients with IBD followed at a reference hospital gave a positive contribution to patient treatment, providing measurable benefits to patients in aspects related to knowledge on drugs used, compliance to treatment, disease clinical activity and solution of drug-related problems.
Emergency Hospital Admission as a Route for Oesophagogastric Cancer Diagnosis: A Marker of Poor Outcome and a Candidate Quality Indicator for Local Services Mustafa Shawihdi, Nick Stern, Elizabeth B. Thompson, Richard Sturgess, Neil Kapoor, Michael Pearson, Keith Bodger Introduction: The UK National Cancer Plan (2000) introduced a ‘two week’ waiting time standard for investigating suspected malignancy and guidance to encourage early diagnosis. Improved access to elective (ELECT) investigation should reduce the need for emergency (EMERG) admission. This study examined route of diagnosis and outcomes for oesophagogastric cancer (OGC), both locally and nationally. Methods: Local OGC cases were audited for 2-year periods before (“Pre”: July 97-June 99) and after (“Post”: Jan 01-Dec 02) service re-design, collecting details of demographics, tumour type, stage, dates of referral, diagnosis, treatment and survival. Within a project funded by the NHS Information Centre, we developed novel linkage algorithms to analyse Hospital Episode Statistics for England (20068) and methods to track OGC care chronologically, selecting only incident cases with a valid pathway of coded diagnostic and therapeutic interventions. External linkage to death registry established date of death and 2-year survival. Results: LOCAL DATA: n=333 cases (Pre, n=152; Post, n=181). No change in % of patients diagnosed via EMERG route after service re-design (Pre: 30.9% v Post: 31.5%; p=0.981), nor any change in age, symptom or tumour profile of EMERG cases. Local EMERG cases were older than ELEC (75 v 68 yrs; p<0.0001), less likely to have potentially curative treatment (13.5% v 40%; p<0.0001) and had poorer 3 yr survival (10.6% v 22.2%, p=0.013). EMERG cases with dysphagia and/or weight loss had lower 3 year survival than those with other presenting features (p=0.035). NATIONAL DATA We identified 33,115 patients with OGC, of whom 26,097 (79%) met study criteria. Of these, 7,082 (27%) were EMERG and 19,015 ELEC (73%). EMERG cases were older (74 yrs v 70 yrs; p<0.001), less likely to undergo surgery (516 [2%] v 3,780 [14.5%], p<0.001) and had poorer 2 yr survival (19.6% v 32.9%, p<0.001). The % of EMERG cases varied widely between cancer networks (22% to 40%). Conclusion: Findings are consistent with a recent report by the UK National Cancer Intelligence Network suggesting that a quarter of major cancers are diagnosed via the EMERG route. Our national linkage study suggests 27% of new OGC cases in England are diagnosed as EMERG and this mode of presentation predicts a poor outcome, confirmed by detailed local audit. Although EMERG admission is unavoidable for some cases, the observed variation across the country suggests possible unresolved inequalities in patient access. Monitoring of this candidate indicator could assess the impact of new initiatives to promote earlier elective diagnosis.
Sa1029 Resource Utilization and Cost of Hospitalization for Acute Nonvariceal Upper Gastrointestinal Hemorrhage at a Tertiary Care Hospital in Ontario, Canada Gurbir Sekhon, Vishal Patel, James C. Gregor AIMS: To investigate resource utilization and cost of hospitalization of patients with nonvariceal upper gastrointestinal (GI) hemorrhage at two tertiary care hospitals in London, Ontario, Canada. METHODS: A retrospective analysis of hospital discharge data for patients admitted with non-variceal upper GI hemorrhage between 2007 and 2009 was performed. Patients were identified using specific ICD-10 CA codes. Only data from the first admission during this time was used. Data collection included age, sex, comorbid diagnoses, number of blood transfusions required, number of endoscopies during hospitalization, length of stay, total cost of hospitalization (excluding physician billings), and number of readmissions within 28 days post-discharge. The American Society of Anaesthesiologists (ASA) category was determined for each patient using the discharge diagnoses. Comparisons were made between patients admitted under an inpatient GI service and those admitted under General Internal Medicine with consultation from GI. A small minority of patients required admission to Intensive Care and were excluded. RESULTS: There were a total of 176 patients identified of which 164 patients were included in the analysis. 3 of the 12 patients excluded were admitted to the ICU. There were 91 patients that were admitted to the inpatient GI ward and 73 that were admitted to General Internal Medicine with GI consultation. Overall, there were no significant differences between the two groups. The average age for the entire group was 67.2 y ± 17.9 y. The health status was also similar with a mean ASA classification of 1.95 ± 0.95 (range 1 - 4). 60% of the GI ward patients received at least 1 blood transfusion whereas only 51% of the General Internal Medicine patients received a transfusion. All patients underwent a mean of 1.2 ± 0.5 endoscopies during their admission. The average length of stay was 3.2 ± 2.2 days. There was no difference in the cost of hospitalization between the two groups. The average cost of hospitalization (excluding physician billings) for all the patients was $3236 ± $2168 in 2010 Canadian Dollars. The average daily cost of hospitalization for all patients was $1138 ± $578 per day. The readmission rate was 8.5% for all patients. CONCLUSION: The patient care experience for patients with non-variceal upper GI hemorrhage is comparable between an inpatient GI team and General Medicine team in terms of hospital length of stay, utilization of endoscopies, and readmission rate. This study shows a lower inflation-adjusted cost of hospitalization and a shorter length of hospital stay when compared to the findings from the Ontario GI Bleed study (1999).
Sa1027 Narcotic Bowel Syndrome: Under Recognized Diagnosis Resulting in OverUtilization of Healthcare Resources Oksana Anand, Katherine Roeser, Rexy A. Thomas, Mojtaba S. Olyaee, Savio Reddymasu, Elena Sidorenko, Tuba Esfandyari Background: Narcotic bowel syndrome (NBS) is defined as chronic (more than 3 months in duration) non-cancer abdominal pain, requiring at least 100 mg of morphine equivalent per day in the setting of continued or escalating dosage of narcotic pain medications with very little or no relief in abdominal pain. The prevalence of narcotic bowel syndrome varies based on the population studied and presenting symptoms, ranging from 0.19% in general population to 58% in patients with chronic non-cancer abdominal pain and 9% in patients on chronic narcotics with vomiting as major presenting complaint. Aims: The aim of our study was to evaluate the healthcare resource utilization in patients with narcotic bowel syndrome. Methods: This is a retrospective chart review study of health care utilization in patients with narcotic bowel syndrome in a subspecialty clinic at tertiary care center. Inclusion criteria were 1) adult patients 18 years of age or older with chronic non-cancer abdominal pain of otherwise undetermined etiology 2) on 100 mg or more of morphine equivalent per day 3) no history of bowel resection or Inflammatory Bowel Disease 4) non-pregnant. Results: Medical records of 4723 patients seen in Gastrointestinal Clinic at the University of Kansas Medical Center from 2005 to 2010 were reviewed. Seventy-eight patients met inclusion criteria for NBS. Male to female ratio was 1:3 with mean age of 44 years, consuming on average 410 mg of morphine equivalent daily. Duration of abdominal pain ranged from 6 months to 20 years. The disability rate was 74% with hospitalization/ER visit rate of 96% within last year (53% had multiple visits). The most common accompanying symptoms were nausea and vomiting 80%, constipation 72%, anorexia 68% and abdominal bloating 45%. All aforementioned symptoms were present in 26% of patients with NBS. 96.2% of patients with NBS had at least one abdominal imaging study within the past one year for a total of 544 abdominal imaging studies being done, resulting in average of 7 imaging tests per person. 94.5% of patients had at least one endoscopic evaluation within the past one year: 20.5% had only EGD, 3.9% had only colonoscopy, 57.7% had both and 12.8% had ERCP, upper/lower EUS or both. Health care provider time devoted to these patients during multiple ER/office visits (primary care physicians and gastroenterologists alike) and hospitalization needs to be taken into consideration as well. Conclusion: NBS is common in patients taking opiates for chronic non-cancer pain and is associated with a large burden on health care utilization. Cost analysis will be done to analyze the financial burden. Better physician education directed at recognition of NBS as an etiology of abdominal pain and judicious use of opiates are required to minimize exhaustive, repetitive evaluations.
Sa1030 Longterm Survival in Gastroesophageal Cancer Shuet Fong Neong, Julie Deacon, Ian R. Sargeant, Danielle L. Morris Introduction: One of the changes implemented following the publication of the Improving Outcome Guidances (IOG) is the centralisation of cancer services to ensure delivery of an effective management plan to patients with gastroesophageal cancer. With the high mortality rate, monitoring and auditing treatment outcomes is vital in ensuring that patients receive the best available treatment. The recent publication of the National Oesophago-Gastric Cancer Audit data re-iterates this and forms the crux of evidence-based management of these patients. Methods: The aim is to measure the survival outcome of patients diagnosed with gastroesophageal cancer in our 2 district general hospitals with a catchment population of 500,000. We retrospectively reviewed the medical notes, computerised notes of the multidisciplinary team (MDT) meetings and endoscopy reports of all patients diagnosed with gastroesophageal cancer in the 5-year period from 1 January 2004 to 31 December 2008. The date of death was noted and the number of survivors as of 15 July 2010 were taken into account. Results: 234 and 139 patients were diagnosed with oesophageal and gastric cancer respectively, of which data from 6 patients were unavailable. As of 15 July 2010, 46 (12%) of all patients traced are still alive, 31 (13%) with oesophageal cancer and 15 (11%) with gastric cancer. For those that have died, the median survival was 156 days (2-1594) and 251 days (4-1413) for patients with gastric and oesophageal cancer respectively.
Sa1028 A Structured Program of Pharmaceutical Care Benefits Outpatients With Inflammatory Bowel Diseases Undergoing Continuous Drug Therapy Nathalie L. Dewulf, Vania D. Santos, Leonardo R. Pereira, Luiz E. Troncon Background - Patients with inflammatory bowel diseases (IBD) are usually treated with drugs for inducing or maintaining disease remission. Pharmaceutical care (PC) is a novel outpatient care modality aiming at providing responsible drug therapy, which has not been extensively evaluated in patients with IBD. Aims - This study aimed at evaluating the contribution of
S-207
AGA Abstracts
AGA Abstracts
Sa1026
Emergency Hospital Admission as a Route for Oesophagogastric Cancer Diagnosis: A Marker of Poor Outcome and a Candidate Quality Indicator for Local Services Mustafa Shawihdi, Nick Stern, Elizabeth B. Thompson, Richard Sturgess, Neil Kapoor, Michael Pearson, Keith Bodger Introduction: The UK National Cancer Plan (2000) introduced a ‘two week’ waiting time standard for investigating suspected malignancy and guidance to encourage early diagnosis. Improved access to elective (ELECT) investigation should reduce the need for emergency (EMERG) admission. This study examined route of diagnosis and outcomes for oesophagogastric cancer (OGC), both locally and nationally. Methods: Local OGC cases were audited for 2-year periods before (“Pre”: July 97-June 99) and after (“Post”: Jan 01-Dec 02) service re-design, collecting details of demographics, tumour type, stage, dates of referral, diagnosis, treatment and survival. Within a project funded by the NHS Information Centre, we developed novel linkage algorithms to analyse Hospital Episode Statistics for England (20068) and methods to track OGC care chronologically, selecting only incident cases with a valid pathway of coded diagnostic and therapeutic interventions. External linkage to death registry established date of death and 2-year survival. Results: LOCAL DATA: n=333 cases (Pre, n=152; Post, n=181). No change in % of patients diagnosed via EMERG route after service re-design (Pre: 30.9% v Post: 31.5%; p=0.981), nor any change in age, symptom or tumour profile of EMERG cases. Local EMERG cases were older than ELEC (75 v 68 yrs; p<0.0001), less likely to have potentially curative treatment (13.5% v 40%; p<0.0001) and had poorer 3 yr survival (10.6% v 22.2%, p=0.013). EMERG cases with dysphagia and/or weight loss had lower 3 year survival than those with other presenting features (p=0.035). NATIONAL DATA We identified 33,115 patients with OGC, of whom 26,097 (79%) met study criteria. Of these, 7,082 (27%) were EMERG and 19,015 ELEC (73%). EMERG cases were older (74 yrs v 70 yrs; p<0.001), less likely to undergo surgery (516 [2%] v 3,780 [14.5%], p<0.001) and had poorer 2 yr survival (19.6% v 32.9%, p<0.001). The % of EMERG cases varied widely between cancer networks (22% to 40%). Conclusion: Findings are consistent with a recent report by the UK National Cancer Intelligence Network suggesting that a quarter of major cancers are diagnosed via the EMERG route. Our national linkage study suggests 27% of new OGC cases in England are diagnosed as EMERG and this mode of presentation predicts a poor outcome, confirmed by detailed local audit. Although EMERG admission is unavoidable for some cases, the observed variation across the country suggests possible unresolved inequalities in patient access. Monitoring of this candidate indicator could assess the impact of new initiatives to promote earlier elective diagnosis.
Sa1029 Resource Utilization and Cost of Hospitalization for Acute Nonvariceal Upper Gastrointestinal Hemorrhage at a Tertiary Care Hospital in Ontario, Canada Gurbir Sekhon, Vishal Patel, James C. Gregor AIMS: To investigate resource utilization and cost of hospitalization of patients with nonvariceal upper gastrointestinal (GI) hemorrhage at two tertiary care hospitals in London, Ontario, Canada. METHODS: A retrospective analysis of hospital discharge data for patients admitted with non-variceal upper GI hemorrhage between 2007 and 2009 was performed. Patients were identified using specific ICD-10 CA codes. Only data from the first admission during this time was used. Data collection included age, sex, comorbid diagnoses, number of blood transfusions required, number of endoscopies during hospitalization, length of stay, total cost of hospitalization (excluding physician billings), and number of readmissions within 28 days post-discharge. The American Society of Anaesthesiologists (ASA) category was determined for each patient using the discharge diagnoses. Comparisons were made between patients admitted under an inpatient GI service and those admitted under General Internal Medicine with consultation from GI. A small minority of patients required admission to Intensive Care and were excluded. RESULTS: There were a total of 176 patients identified of which 164 patients were included in the analysis. 3 of the 12 patients excluded were admitted to the ICU. There were 91 patients that were admitted to the inpatient GI ward and 73 that were admitted to General Internal Medicine with GI consultation. Overall, there were no significant differences between the two groups. The average age for the entire group was 67.2 y ± 17.9 y. The health status was also similar with a mean ASA classification of 1.95 ± 0.95 (range 1 - 4). 60% of the GI ward patients received at least 1 blood transfusion whereas only 51% of the General Internal Medicine patients received a transfusion. All patients underwent a mean of 1.2 ± 0.5 endoscopies during their admission. The average length of stay was 3.2 ± 2.2 days. There was no difference in the cost of hospitalization between the two groups. The average cost of hospitalization (excluding physician billings) for all the patients was $3236 ± $2168 in 2010 Canadian Dollars. The average daily cost of hospitalization for all patients was $1138 ± $578 per day. The readmission rate was 8.5% for all patients. CONCLUSION: The patient care experience for patients with non-variceal upper GI hemorrhage is comparable between an inpatient GI team and General Medicine team in terms of hospital length of stay, utilization of endoscopies, and readmission rate. This study shows a lower inflation-adjusted cost of hospitalization and a shorter length of hospital stay when compared to the findings from the Ontario GI Bleed study (1999).
Sa1027 Narcotic Bowel Syndrome: Under Recognized Diagnosis Resulting in OverUtilization of Healthcare Resources Oksana Anand, Katherine Roeser, Rexy A. Thomas, Mojtaba S. Olyaee, Savio Reddymasu, Elena Sidorenko, Tuba Esfandyari Background: Narcotic bowel syndrome (NBS) is defined as chronic (more than 3 months in duration) non-cancer abdominal pain, requiring at least 100 mg of morphine equivalent per day in the setting of continued or escalating dosage of narcotic pain medications with very little or no relief in abdominal pain. The prevalence of narcotic bowel syndrome varies based on the population studied and presenting symptoms, ranging from 0.19% in general population to 58% in patients with chronic non-cancer abdominal pain and 9% in patients on chronic narcotics with vomiting as major presenting complaint. Aims: The aim of our study was to evaluate the healthcare resource utilization in patients with narcotic bowel syndrome. Methods: This is a retrospective chart review study of health care utilization in patients with narcotic bowel syndrome in a subspecialty clinic at tertiary care center. Inclusion criteria were 1) adult patients 18 years of age or older with chronic non-cancer abdominal pain of otherwise undetermined etiology 2) on 100 mg or more of morphine equivalent per day 3) no history of bowel resection or Inflammatory Bowel Disease 4) non-pregnant. Results: Medical records of 4723 patients seen in Gastrointestinal Clinic at the University of Kansas Medical Center from 2005 to 2010 were reviewed. Seventy-eight patients met inclusion criteria for NBS. Male to female ratio was 1:3 with mean age of 44 years, consuming on average 410 mg of morphine equivalent daily. Duration of abdominal pain ranged from 6 months to 20 years. The disability rate was 74% with hospitalization/ER visit rate of 96% within last year (53% had multiple visits). The most common accompanying symptoms were nausea and vomiting 80%, constipation 72%, anorexia 68% and abdominal bloating 45%. All aforementioned symptoms were present in 26% of patients with NBS. 96.2% of patients with NBS had at least one abdominal imaging study within the past one year for a total of 544 abdominal imaging studies being done, resulting in average of 7 imaging tests per person. 94.5% of patients had at least one endoscopic evaluation within the past one year: 20.5% had only EGD, 3.9% had only colonoscopy, 57.7% had both and 12.8% had ERCP, upper/lower EUS or both. Health care provider time devoted to these patients during multiple ER/office visits (primary care physicians and gastroenterologists alike) and hospitalization needs to be taken into consideration as well. Conclusion: NBS is common in patients taking opiates for chronic non-cancer pain and is associated with a large burden on health care utilization. Cost analysis will be done to analyze the financial burden. Better physician education directed at recognition of NBS as an etiology of abdominal pain and judicious use of opiates are required to minimize exhaustive, repetitive evaluations.
Sa1030 Longterm Survival in Gastroesophageal Cancer Shuet Fong Neong, Julie Deacon, Ian R. Sargeant, Danielle L. Morris Introduction: One of the changes implemented following the publication of the Improving Outcome Guidances (IOG) is the centralisation of cancer services to ensure delivery of an effective management plan to patients with gastroesophageal cancer. With the high mortality rate, monitoring and auditing treatment outcomes is vital in ensuring that patients receive the best available treatment. The recent publication of the National Oesophago-Gastric Cancer Audit data re-iterates this and forms the crux of evidence-based management of these patients. Methods: The aim is to measure the survival outcome of patients diagnosed with gastroesophageal cancer in our 2 district general hospitals with a catchment population of 500,000. We retrospectively reviewed the medical notes, computerised notes of the multidisciplinary team (MDT) meetings and endoscopy reports of all patients diagnosed with gastroesophageal cancer in the 5-year period from 1 January 2004 to 31 December 2008. The date of death was noted and the number of survivors as of 15 July 2010 were taken into account. Results: 234 and 139 patients were diagnosed with oesophageal and gastric cancer respectively, of which data from 6 patients were unavailable. As of 15 July 2010, 46 (12%) of all patients traced are still alive, 31 (13%) with oesophageal cancer and 15 (11%) with gastric cancer. For those that have died, the median survival was 156 days (2-1594) and 251 days (4-1413) for patients with gastric and oesophageal cancer respectively.
Sa1028 A Structured Program of Pharmaceutical Care Benefits Outpatients With Inflammatory Bowel Diseases Undergoing Continuous Drug Therapy Nathalie L. Dewulf, Vania D. Santos, Leonardo R. Pereira, Luiz E. Troncon Background - Patients with inflammatory bowel diseases (IBD) are usually treated with drugs for inducing or maintaining disease remission. Pharmaceutical care (PC) is a novel outpatient care modality aiming at providing responsible drug therapy, which has not been extensively evaluated in patients with IBD. Aims - This study aimed at evaluating the contribution of
S-207
AGA Abstracts
AGA Abstracts
Sa1026