S1011 The Burden of Digestive Diseases in Korea

most prevalent diseases at ambulatory visit were in order of gastritis (9.0 million cases/ year), GERD (3.7 million), gastroenteritis, peptic ulcer disease, irritable bowel syndrome, constipation. At least four of these (gastritis, GERD, IBS, constipation) might be largely caused by functional gastrointestinal disorders (FGIDs). The most common digestive diseases diagnoses on hospital discharge records were stomach cancer (1.0 million visit days/year). Except the malignancy, hemorrhoid, appendix, gall stone, peptic ulcer disease are the leading causes of hospitalization orderly. The major difference between ambulatory visit and hospital discharge was the high number of FGIDs, considering substantial patients with gastritis who could be classified as functional dyspepsia, at ambulatory visit and malignancy in hospitalization. Stomach cancer continues to be leading cause of GI-related death during from 2005 to 2007 in Korea. Conclusions: GI and liver diseases exact heavy economic and social costs and also contributes to the morbidity and mortality in Korea. The healthcare utilization burden by FGIDSs appears to be high because of the high morbidity although no mortality.

AGA Abstracts

would appear to benefit most from implementing Care Pathways to achieve greater uniformity in care provided.

S1012 Understanding Lack of Colonoscopy Follow-up in Fecal Occult Blood Test (FOBT) Patients Ryan J. De Lee, Douglas Robertson Background: We previously have reported on the use of FOBT in those with a recent (last 10 years) normal colonoscopy at our center. During that analysis, we found that many FOBT positive patients were not followed up with timely colonoscopy. Aim: To determine why those in this cohort found to be FOBT positive were not followed up with colonoscopy. Methods: We used local VA administrative data and identified all Veterans with a normal colonoscopy (CPT 45378) over a 6 year period: 1997 - 2002 (n=1,768, mean age 64 years, 95% male). Using clinical data files, we then identified all FOBT testing and results done after initial normal colonoscopy through August 2008. We developed a standardized abstraction form to determine whether the FOBT result was recognized by the provider and whether subsequent colonoscopy was ordered (and if not, we noted the reasons why). That abstraction form was applied to all cases where the positive FOBT did not result in a colonoscopy within a 1 year time frame. Results: Thirty-six percent (n=629) of the cohort underwent FOBT testing during the follow up period and 20% of those (n=122) had a positive result. Of the 122 patients with a positive result, 35% (n=43) underwent colonoscopy at our institution in the following year and 65% (n=79) did not. On chart review three of the 79 underwent timely endoscopic evaluation outside the VA system and will not be considered further, leaving 76 patients with a positive FOBT and no apparent subsequent colonoscopy. In 56 of the 76 patients, colonoscopy was never ordered. A provider decided not to pursue a colonoscopy in 31 patients, many of whom were too sick or frail to consider endoscopy (n=16). Nineteen patients underwent another test or evaluation of the heme positive stool, such as EGD or ERCP. The positive FOBT was not recognized nor pursued at all in six patients. In 5 of these 6, the PCP was directly involved in ordering the test, but never acted on the positive result. In 20 of the 76 patients a colonoscopy was in fact ordered. However, more than half were cancelled by the GI physician (7), or patient (8). In one case the consult was accepted but not acted upon by the GI service. Conclusion: While many positive FOBT were not followed up with colonoscopy, few were due to administrative oversight. Decisions were made not to pursue colonoscopy for a number of reasons including patient frailty or a desire not to repeat colonoscopy since one had already been done. More judicious distribution of stool cards is likely warranted.

* calculated based on 2007 inpatients (n=341) S1010 Validation of Utilizing an Administrative Database for Determination of Colorectal Cancer Screening Test use in a Safety-Net Health System Samir Gupta, Liyue Tong, Paula R. Anderson, Bonnie Rose, Elizabeth Carter, Mark Koch, Keith Argenbright, Chul Ahn, Don C. Rockey, Celette S. Skinner Introduction: We previously utilized an administrative dataset, created for the purpose of recording diagnoses and visit/test charges at patient encounters, to identify that just 22% of over 20,000 screen eligible patients in the safety-net health system serving Fort Worth, Texas were up to date with colorectal cancer(CRC) screening(Gupta ‘09). While this study suggested that administrative data may be used to efficiently assess screening, the validity this approach has not been extensively studied. Further, test indication(screening vs. nonscreening), and the quality of test performance are not discernible from administrative data, which do not serve as a complete medical record. Understanding the validity of test use measurements, and quality of test use are critical for optimizing screening. We hypothesized that while administrative coding would be accurate for test use capture, many tests would be for non-screening indications, and further, that direct chart review would provide insight into test performance quality. Primary aims: 1) Determine validity of using administrative data coding for CRC test completion to measure screening test use, and 2) Evaluate test performance quality. Methods: Test use was determined by administrative coding for: 1) Fecal occult blood test(FOBT), 2) Barium enema, 3) Sigmoidoscopy, 3) Colonoscopy(COLO), or 5) No screening over a 5-year period(Gupta CEBP, DDW ‘09). 100 subjects from each category were randomly selected for medical chart abstraction, which served as the validation gold standard. A tool validated for determining accuracy of Medicare screening test claims data(Schenck ‘07) was adapted to abstract test indication(screening vs. sign/symptom evaluation), presence of test completion, and quality parameters. Agreement was estimated by the Kappa(κ) statistic. Descriptive statistics were used to characterize test indication and quality. Results: Agreement between the administrative database and chart abstraction was almost perfect for FOBT(κ=0.83, 95%CI:0.75-0.90) and COLO(κ=0.91, 95%CI:0.85-0.96), and fair for sigmoidoscopy(κ=0.39, 95%CI:0.28-0.49) and barium enema(κ=0.21, 95%CI:0.12-0.29). 40% of tests were for the indication of screening. Test quality, and record of quality parameters were variable. For example, among subjects with positive FOBT, follow-up COLO was noted as recommended for 46%, and bowel preparation quality and cecal intubation were undocumented for 42% and 17% of COLO, respectively. Conclusions: Administrative data have validity for CRC test completion measurement. For assessment of test indication and quality, medical chart review, or implementation of alternate data systems are required.

S1013 Diagnostic Yield in Equivocal Barium Enemas: Experience From a UK District General Hospital Said Isse, Babu Krishnan, Asma Sarwar, Javaid Subhani Introduction. Barium enema (BE) study is known to have a lower sensitivity and specificity than colonoscopy but is often used in less fit patients or those with a lower risk of significant disease. A follow on colonoscopy is required either for therapy (i.e. removal of a polyp) or clarification of “equivocal” radiological findings. The very anatomy (e.g. marked diverticular disease) that leads to an equivocal BE may make the colonoscopy difficult or even dangerous. Further in anecdotal clinical practice few of these “equivocal” BE resulted in a proven pathology. The study assessed the yield of lower gastrointestinal endoscopy (LGE) used to clarify equivocal BE over a 12-month period at our institution. Methods: The list of all patients who had a BE during a 12-month period was obtained from the radiology database. This was matched to patients who had a LGE in a 14-month period from the same start point. The extended period allowed for delays in arranging the LGE. Patients who had a LGE after the BE and whose indications included “equivocal” BE were identified. Their radiology and endoscopic reports were assessed for indications and findings. Results: 1381 barium enemas were performed, and 2559 lower GI endoscopies. 139 patients in total were identified who had LGE following a BE. 44 of these patients had LGE due to an equivocal BE. Of these 44 patients 2 had no clinical indication on retrospective case review. A third (14/44) of the patients were over 70 years old. Of the 42 patients, 41 had normal findings at the area of suspicion (98%). One patient (2%) had a benign stricture confirmed on LGE but did not require any intervention. Furthermore no cancers were detected, however, 4/ 44 (9.1%) had polyps not identified on the BE. In the remaining 95 patients who had LGE following a BE for other indications, primarily therapy or biopsies; polyps were identified in 34% and cancers in 13%. Conclusions: Very few BE required clarification of equivocal findings (42/1381) 3.0%, furthermore, definite abnormalities at BE had a high yield at subsequent LGE. Although this study was not designed to primarily assess the efficacy of BE it appears a useful investigation. Equivocal results on BE do not seem to be related to the suspicion of a lesion as much as a comment on the technical limitations of the study. Clinicians however seem to feel an equivocal result must require clarification. We would urge a different paradigm with review of the case and radiology prior to LGE. This may result in a reduction in these unnecessary procedures often in patients known to be at the greatest risk of complications (i.e. over 70 year olds).

S1011 The Burden of Digestive Diseases in Korea Hye-kyung Jung, Youn Hee Kim, Joo Yeon Park, BoHyoung Jang, Sun Young Park, MiHee Nam, Myung-Gyu Choi Background and aims: Gastrointestinal (GI) and liver diseases impose a heavy economic burden. Although the burden is considerable, current and accessible information on the medical cost is lack in Korea. We aimed to provide a first-time report on the health care utilization and costs of digestive disease in Korea. Methods: We collected the data from the National Health Insurance Corporation, which included all insurance claims database in Korea and the Korea National Statistical Office's cause of death database. We compiled information about all digestive disease as a primary diagnosis on clinic visits, hospitalization, cancer incidence, mortality and cause of death from these databases. Results: The estimated direct cost for all these GI and liver disease was 3,904 billion won (0.4% of GDP). The

AGA Abstracts

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