- Email: [email protected]
Sa1038 Annual Endoscopic Workshop Highlighting Prophylactic Mechanical Hemostasis Techniques Is Associated With a Significant Decrease in Adverse Events
methods/tools for each rotation or learning experience and program evaluation and improvement tools. The new curriculum will be piloted from April through June 2014, with rollout of the full revision planned for July 2014. Sample objectives and evaluation designs
AGA Abstracts
fellows' self-reported perception of their teaching skills, ability to give feedback, and speaking and presentation skills. Seventy-five percent of these fellows subsequently taught gastrointestinal pathophysiology. The majority of fellows organized teaching sessions locally, regionally and nationally in their current positions. One third perceived that the fellowship helped their academic promotions. On the basis of these data, we recommend that an optional, unfunded Gastrointestinal Pathophysiology Teaching Fellowship be incorporated into GI Fellowship Programs as a means of increasing academic teaching and leadership skill sets in interested fellows.
Sa1037 Sa1035 Accuracy of Melena Identification on Physical Exam in Post Graduate Training - Implications of Level of Training, Medical Specialty, Rectal Exam Concordance and Appropriateness of Therapy Richard Wu, Eugene Han, Andrew Dargan, Cecilia Kelly, Mitchell Conn
A High Stakes Learning Environment: Fellow-Performed Colonoscopies Are Associated With Lower ADRs Brandon Rieders, Jessica Davis, Lakshmi Lattimer, Vikesh Khanijow, Sonia Taneja, Aung Myint, Abdullah A. Al-Shahrani, Samah Nassereddine, Marie L. Borum
Background: Accurate melena identification can be difficult for inpatient medical resident physicians early in their careers; however, the magnitude of this physical exam misidentification has not been quantified. Precise identification of melena may have important diagnostic and therapeutic implications. Methods: This is a 10 month retrospective analysis of a cohort of Internal (IM) and Emergency (EM) Medicine residents at a tertiary academic center caring for inpatient adults with overt or occult GI bleeding requiring gastroenterology consultation. Clinical data, focused on the documented rectal exams from both residents and GI consultants (GI), and electronic medical record were analyzed based on post grad years (PGY) in training and residency specialty. The concordance rate (CR) of melena on exam was subsequently correlated with endoscopic findings, route of proton pump inhibitor use, and ICU requirement. Odds ratios and statistical significance were analyzed with Fisher Exact Probability testing. Results: Of 321 patients with GI bleeding or anemia, 183 (57%) had a documented rectal exam and was included for analysis. 63 (20%) had rectal exams by both a resident and GI. EM, IM, and GI performed 117 (95%), 26 (72%), and 100 (54%) of the indicated rectal exams, respectively (p = .0003). Rectal exam CR between residents and GI is 52%. Melena was documented in 52 patients. For IM and EM, melena CR is 64% and 47%, respectively (p=0.5). CR is inversely proportional to level of training, with PGY 1, 2, and 3 being 56%, 33% and 14%, respectively (p=0.25). Among patients with melena, 100% of patients with concordant vs. 50% with discordant rectal exams denied oral iron use (p= 0.11). The CR for stool color Maroon, Green, Dark Brown, and Melena are 33%, 17%, 15%, and 46%, respectively (p=0.003). Dark Brown stool is the most common discordant exam (OR= 5.5, p= 0.065). The percentage of appropriateness of PPI (APPI) use among all patients is 64% with any rectal exam and 58% without a rectal exam (p=0.26), and not associated with a concordant rectal exam (p=0.56). With melena, APPI is 90% with rectal concordance and 83% with discordance (p=0.57). APPI use among PGY 1,2,3 are 57%, 67%, and 73%, respectively (p=0.65). Conclusions: The overall rate of complete rectal exams for GI bleeding is low among residents and GI consultants. EM residents performed the majority of the initial rectal exams. More than half the time melena is misidentified; factors such as iron utilization and inability to distinguish colors commonly mistaken for melena, specifically dark brown, may play a role in discordant exams. Further education of objective identification of melena is necessary. Concordance rate and APPI was not associated with PGY level, residency specialty, or accurate melena identification. Although a trend towards higher APPI with a performed rectal exam is possible.
Introduction: Colonoscopies are the most common procedure performed by gastroenterologists. Fellowship training ensures competency in colonoscopic examinations and polyp removal. All colonoscopies performed by gastroenterology fellows are completed under the direct supervision of faculty physicians. Adenoma detection rate (ADR) is an indicator for quality procedures. This study evaluated adenoma detection rates for colonoscopies performed by faculty gastroenterologists with and without fellows. Methods: A retrospective medical record review of all colonoscopies performed at an urban university medical center in a 12-month period was conducted using an electronic health record. There were no exclusion criteria. Patient age, gender and race were documented. Colonoscopies were categorized based upon whether it was performed by a faculty gastroenterologist with or without a fellow. The year of fellowship training was noted. Endoscopic findings were recorded. Microsoft Excel was used to generate a database that maintained patient confidentiality. Statistical analysis was performed using Fisher Exact test, with significance set at p<0.05. The study was approved by the university institutional review board. Results: 3,189 colonoscopy records (1807 women, 1382 men) were reviewed. There were 1034 Caucasian patients, 1543 African-American patients, 218 Hispanic patients, and 394 patients of other or undocumented ethnicity. The mean patient age was 58.2 years. 8 faculty gastroenterologists performed all colonoscopies. There were 2547 procedures performed without fellows and 644 procedures performed with fellows. 240 adenomas (ADR 37.9%) were detected in procedures performed with fellows and 1083 adenomas were detected in procedures performed without fellows (ADR 42.5%). There was a significant difference in the rate at which adenomas were found by faculty gastroenterologists with and without fellows (p=0.038). Colonoscopy ADR was 41.6% with a 1st year fellow, 36% with a 2nd year fellow and 35.4% with a 3rd year fellow. There was no statistical significant in ADR based on year of fellowship (1st vs 2nd p = .26, 2nd vs 3rd p = .92, 1st vs 3rd p= .26) Discussion: Adenoma detection rate (ADR) is a quality indicator for colonoscopies. Multiple factors can impact upon ADR. This study revealed that there was a significant difference in the ADR of colonoscopies performed by faculty gastroenterologists with and without fellows. There was no difference in ADR based upon the fellowship year of training. Since all colonoscopies during which a gastroenterology fellow is present are performed or directly supervised by a faculty gastroenterologist, it is critical to identify factors that impact upon decreased ADR. Focused instruction on both technical skills and adenoma detection are essential for optimal endoscopic education.
Sa1036 Sa1038 Toward Revision of a GI Fellowship Curriculum to Incorporate Entrustable Professional Activities Christen K. Dilly
Annual Endoscopic Workshop Highlighting Prophylactic Mechanical Hemostasis Techniques Is Associated With a Significant Decrease in Adverse Events Mark V. Larson, Ferga C. Gleeson, Louis M. Wong Kee Song, Navtej Buttar, Felicity Enders, Kimberly Hallum, Sunanda V. Kane
Background: A list of EPAs were recently published by the OWN, a consortium of GI professional societies. A fellowship curriculum based on these EPAs would be ideal. However, no description has yet been published on transformation of the EPAs into a workable curriculum. Aims: To revise a GI fellowship curriculum to incorporate the EPAs. Methods: Nutrition was considered to be the area requiring most revision, so this EPA was addressed first. The detailed list of sub-EPAs were revised into learning objectives using SMART criteria. The learning objectives wre then mapped onto existing clinical experiences, and new experiences were created where there were gaps in the existing rotations. An evaluation plan was created for each learning objective, using milestones-based assessment when possible. Program outcome objectives and process objectives were also written and a plan for evaluation was created. Results: See table for examples of modified learning objectives mapped to educational experiences, along with evaluation plans. Conclusions: This curriculum revision describes a process by which the nutrition EPA has been incorporated into an existing GI fellowship curriculum. The process will be repeated for the remaining 12 EPAs. The final product will consist of a list of learning objectives organized by rotation, evaluation
Background and Aims: Bleeding is the most common postpolypectomy adverse event. Bleeding risk is attributed to polyp size and location, polypectomy technique, and use of antithrombotic agents. Prophylactic placement of hemoclips to prevent delayed postpolypectomy or post biopsy bleeding is controversial. We aimed to assess the clinical and financial impact of a 1-day endoscopic workshop, held in April each year, which reviews tools and techniques for polypectomy and closure of resection defects for our outpatient diagnostic and preventive endoscopy units. Methods: Procedural volumes, colonoscopy and polypectomy burden, hemoclip placement with attendant expense, and bleeding specific adverse events requiring an unplanned hospitalization were evaluated pre and post each workshop over a 3-year time period. Results: Following the annual workshops, there was an increase in patients in receipt of ‡ 1 hemoclip (p=0.0001), with a 2-fold increase in associated expense (Table 1). Overall bleeding specific adverse events requiring an unplanned
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AGA Abstracts
AGA Abstracts
hospitalization rate was reduced from 0.13% to 0.07% during the study period (p=0.034). This reduction in an overall bleeding adverse event rate was associated with the increase in patients in receipt of ‡ 1 hemoclip (p=0.047) and approached statistical significance when compared to the increase in total cost (p=0.075). Table 2 shows the change in the bleeding requiring an unplanned hospitalization adverse event rate (EGD, Colonoscopy, and Overall) and associated change in the number of patients with ‡ 1 hemoclip placement over the 3 year intervention period. Conclusion: Although the expense in hemoclip utilization doubled following serial annual endoscopic workshops, the associated decrease in bleeding specific adverse events requiring an unplanned hospitalization rate over time supports the continued role of a 1-day workshop and the prophylactic use of hemoclip placement in our outpatient diagnostic and preventive endoscopy practice. Table 1
2014 (FIT). To examine resource intensity, we included 1,339 colonoscopies performed for FIT+ (65% male, mean age 60 years) and 5,113 for AR screening (51% male, mean age 58 years) from Jan-June 2014. Data was abstracted from the Centre's endoscopy reporting system (Endopro) and pathology and scheduling databases. One procedure per patient was included based on hierarchy of first complete and first adequate bowel preparation. Resource intensity was assessed by the proportion with any screen-relevant lesion (adenoma, significant serrated polyp, cancer) or an advanced adenoma, use of endoclips, withdrawal time and timing of surveillance colonoscopy. Use of endoclips and withdrawal time was used as a surrogate measure of the complexity of the case due to removal of identified polyps. Multivariate logistic regression was conducted to compare the risk of a screen-relevant lesion, an advanced adenoma and a withdrawal time greater than 10 minutes in FIT+ versus AR patients while adjusting for age and gender. Results: With FIT, the number of AR referrals decreased from 8,284 to 4,604 (44% decrease), and the number of referrals for positive occult blood increased from 321 to 2,177 (578% increase). Colonoscopy outcomes are shown in the table. FIT+ (OC-Sensor >75 ng/ml) patients had a 2.0 (95% CI 1.7 - 2.2) greater risk of any screen-relevant lesion and a 5.1 (95% CI 4.2-6.2) greater risk of an advanced adenoma. The odds ratio for a withdrawal time longer than 10 minutes was 3.4 (95% CI 2.9 - 3.8) for the comparison of FIT+ to AR. Men (OR 1.7, 95% CI 1.5-1.9) and those age 65 - 75 years (OR 2.0, 95% CI 1.1 - 3.6) were also more likely to have a longer withdrawal time. For FIT+ patients, the proportion recommended to undergo repeat colonoscopy within 6 months, at 1 year and at 3 years from initial colonoscopy was 15%, 5% and 42%, respectively. This compares with 7%, 1% and 27% for the same surveillance intervals in the AR patients. Conclusions: FIT+ patients were much more likely to have any screen-relevant lesion or an advanced adenoma compared with AR patients. This translated into much more resource intensive colonoscopies as measured by withdrawal time and the use of endoclips. FIT+ patients are more likely to require early surveillance. Screening programs and endoscopy units should consider the complexity and resource intensity of FIT+ colonoscopies when planning for and implementing a FIT-based screening program.
Table 2
†For each procedure type (EGD, Colon, and Overall), we compared the adverse event rate between the first year and the two later years to account for the impact of training using a log-linear regression with a natural log offset for the total number of procedures during each period. ‡Because the data for hemoclips and cost were only available at the aggregate level, the analysis of these predictor variables was done using the outcome of overall adverse event rate predicted by either hemoclips or cost within the time period, again using loglinear regression with a natural log offset for the number of procedures.
Sa1041 Premature Surveillance Colonoscopy Occurs Most Frequently Without Any Clinical Justification Vishal Desai, Daniel A. Sussman, Sandeep Dayanand, Kevin Ollington, Sheena Patel, Joshua E. Melson
Sa1039 The Withdrawal Time for Adequate Adenoma Detection Rate for Colonoscopy Trainee Hong Jun Park, Hyun-Soo Kim
Background: Surveillance colonoscopy is widely performed prematurely. It is unclear to what extent early surveillance is driven by suboptimal visualization at index colonoscopy, new clinical concerns, or guideline deviation without rationale. The aim of the study is to define the extent to which surveillance colonoscopy is performed prematurely without any documented rationale versus due to clinical or bowel prep concerns at two academic medical centers. Methods: Patients who underwent colonoscopy with indication of "surveillance of polyps" (ICD-9-CM V12.72) from 2008-14 were identified by review of endoscopy records at Rush University Medical Center (RUMC) and University of Miami Miller School of Medicine (UM). Patients aged < 50 or > 75, with personal history of IBD or colorectal cancer (CRC), family history of CRC, or > one prior colonoscopy were excluded. Patients were divided into categories "Adherent" or "Non-Adherent" depending on whether the minimum interval since last colonoscopy was consistent with USMSTF 2012 guidelines. The primary endpoint was the rate of premature surveillance in the absence of prep or clinical justification. If the index colonoscopy had suboptimal prep (fair or poor), non-adherence was deemed preprelated. For those with adequate or better prep on index, clinic notes, colonoscopy order and procedure note were reviewed to assess if clinical rationale led to early surveillance. If no prep or clinical justification was listed then the premature case was "without rationale". Results: 700 subjects met inclusion criteria. Index colonoscopy revealed low risk adenoma (LRA) in 45.5%; advanced adenoma (AA) 27.4%, and hyperplasic polyps (HP) 27.1%. The total rate of non-adherence with a shorter than USMSTF recommended interval was 48.4% (n=339). The overall premature surveillance rate at RUMC was 41.8% (193/462) and 61.3% (146/238) at UM. Overall, the fraction of non-adherent cases attributed to suboptimal bowel prep was 17.4% (59/339), and by a new clinical indication was 18.3% (62/339). Most frequently and at both centers premature colonoscopy was performed without rationale in 64.3% (218/339; RUMC 70% and UM 56.9%). In all groups stratified by the findings on index colonoscopy, premature surveillance was done in the absence of a clinical or preparation related rationale reason (57.4% AA, 63.0% LRA, and 67.9% HP). Conclusion: Most early surveillance (64.3%) is performed without clinical or bowel prep justification documented as rationale for prematurity at each of two centers. Premature surveillance is performed most commonly without clinical or bowel prep justifications regardless of prior histology on the index colonoscopy. Clinical decision support tools should be considered to reduce inappropriate early surveillance colonoscopy, as early surveillance does not usually have a clinical decision-making rationale.
Background/Aim: The adenoma detection rate (ADR) is a critical quality indicator in successful colonoscopy, therefore it is important to improve ADR in learning colonoscopy for trainees. The aim of this study was to evaluate the proper withdrawal time (WT) for trainees to detect adenomas more than 20% or 35% before and after technical competency. Method: In this retrospective study, from March 2011 to February 2013, six first-year GI fellows performed 500 colonoscopies respectively were enrolled. Each fellow fulfilled the "colonoscopy learning protocol" which includes all of colonoscopy related parameters until 500th colonoscopy. We defined a competency of colonoscopy as the successful rate of cecal intubation over 90 percent that is achieved after about 150 cases of colonoscopy. We analyzed optimal withdrawal time for ADR more than 20% (recommended withdrawal time) and 35% (ADR previous reported in Korea) before and after colonoscopy competency. Results: Among a total of 3,000 colonoscopy procedures, 1272 cases of first-time screening colonoscopies performed by six trainees were analyzed. With 50th cases interval, WTs were significant decreased (p<0.001), however, the ADRs and numbers of adenomas were not changed so much (p=0.347 and p=0.395, respectively). So, the numbers of adenomas per minute were significant increased due to decreased withdrawal time (p=0.011). Before competency (n= 406) and after competency (n=866), there was positive correlation between ADR and WT respectively (P<0.001). In ROC curve analysis, trainees should inspect more than 8 minutes for over 20% of ADR and more than 10 minutes for over 35% of ADR before competency (AUROC=0.696). After competency, 6.5 minutes of WT was required for over 20% of ADR and 7.5 minutes of WT for over 35% of ADR (AUROC=0.720). Conclusion: To maintain optimal ADR, more withdrawal times was needed during training period especially before competency. Therefore, a different WT should be recommended according to training period to improve quality of colonoscopy.
Sa1040 The Impact of the Fecal Immunochemical Test on Colonoscopy Utilization and Resources at a Canadian Regional Screening Centre Robert J. Hilsden, S. Elizabeth McGregor, Ronald Bridges, Alaa Rostom, Catherine Dube, Steven J. Heitman Background: The fecal immunochemical test (FIT) replaced the guaiac occult blood test in Alberta, Canada in November 2013. We examined the impact of FIT on referrals for screening colonoscopy and the resource intensity of the colonoscopies. Methods: We included all referrals to the Forzani & MacPhail Colon Cancer Screening Centre for average risk (AR) screening or for a positive occult blood test for the first six months of 2013 (guaiac) and
AGA Abstracts
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AGA Abstracts
fellows' self-reported perception of their teaching skills, ability to give feedback, and speaking and presentation skills. Seventy-five percent of these fellows subsequently taught gastrointestinal pathophysiology. The majority of fellows organized teaching sessions locally, regionally and nationally in their current positions. One third perceived that the fellowship helped their academic promotions. On the basis of these data, we recommend that an optional, unfunded Gastrointestinal Pathophysiology Teaching Fellowship be incorporated into GI Fellowship Programs as a means of increasing academic teaching and leadership skill sets in interested fellows.
Sa1037 Sa1035 Accuracy of Melena Identification on Physical Exam in Post Graduate Training - Implications of Level of Training, Medical Specialty, Rectal Exam Concordance and Appropriateness of Therapy Richard Wu, Eugene Han, Andrew Dargan, Cecilia Kelly, Mitchell Conn
A High Stakes Learning Environment: Fellow-Performed Colonoscopies Are Associated With Lower ADRs Brandon Rieders, Jessica Davis, Lakshmi Lattimer, Vikesh Khanijow, Sonia Taneja, Aung Myint, Abdullah A. Al-Shahrani, Samah Nassereddine, Marie L. Borum
Background: Accurate melena identification can be difficult for inpatient medical resident physicians early in their careers; however, the magnitude of this physical exam misidentification has not been quantified. Precise identification of melena may have important diagnostic and therapeutic implications. Methods: This is a 10 month retrospective analysis of a cohort of Internal (IM) and Emergency (EM) Medicine residents at a tertiary academic center caring for inpatient adults with overt or occult GI bleeding requiring gastroenterology consultation. Clinical data, focused on the documented rectal exams from both residents and GI consultants (GI), and electronic medical record were analyzed based on post grad years (PGY) in training and residency specialty. The concordance rate (CR) of melena on exam was subsequently correlated with endoscopic findings, route of proton pump inhibitor use, and ICU requirement. Odds ratios and statistical significance were analyzed with Fisher Exact Probability testing. Results: Of 321 patients with GI bleeding or anemia, 183 (57%) had a documented rectal exam and was included for analysis. 63 (20%) had rectal exams by both a resident and GI. EM, IM, and GI performed 117 (95%), 26 (72%), and 100 (54%) of the indicated rectal exams, respectively (p = .0003). Rectal exam CR between residents and GI is 52%. Melena was documented in 52 patients. For IM and EM, melena CR is 64% and 47%, respectively (p=0.5). CR is inversely proportional to level of training, with PGY 1, 2, and 3 being 56%, 33% and 14%, respectively (p=0.25). Among patients with melena, 100% of patients with concordant vs. 50% with discordant rectal exams denied oral iron use (p= 0.11). The CR for stool color Maroon, Green, Dark Brown, and Melena are 33%, 17%, 15%, and 46%, respectively (p=0.003). Dark Brown stool is the most common discordant exam (OR= 5.5, p= 0.065). The percentage of appropriateness of PPI (APPI) use among all patients is 64% with any rectal exam and 58% without a rectal exam (p=0.26), and not associated with a concordant rectal exam (p=0.56). With melena, APPI is 90% with rectal concordance and 83% with discordance (p=0.57). APPI use among PGY 1,2,3 are 57%, 67%, and 73%, respectively (p=0.65). Conclusions: The overall rate of complete rectal exams for GI bleeding is low among residents and GI consultants. EM residents performed the majority of the initial rectal exams. More than half the time melena is misidentified; factors such as iron utilization and inability to distinguish colors commonly mistaken for melena, specifically dark brown, may play a role in discordant exams. Further education of objective identification of melena is necessary. Concordance rate and APPI was not associated with PGY level, residency specialty, or accurate melena identification. Although a trend towards higher APPI with a performed rectal exam is possible.
Introduction: Colonoscopies are the most common procedure performed by gastroenterologists. Fellowship training ensures competency in colonoscopic examinations and polyp removal. All colonoscopies performed by gastroenterology fellows are completed under the direct supervision of faculty physicians. Adenoma detection rate (ADR) is an indicator for quality procedures. This study evaluated adenoma detection rates for colonoscopies performed by faculty gastroenterologists with and without fellows. Methods: A retrospective medical record review of all colonoscopies performed at an urban university medical center in a 12-month period was conducted using an electronic health record. There were no exclusion criteria. Patient age, gender and race were documented. Colonoscopies were categorized based upon whether it was performed by a faculty gastroenterologist with or without a fellow. The year of fellowship training was noted. Endoscopic findings were recorded. Microsoft Excel was used to generate a database that maintained patient confidentiality. Statistical analysis was performed using Fisher Exact test, with significance set at p<0.05. The study was approved by the university institutional review board. Results: 3,189 colonoscopy records (1807 women, 1382 men) were reviewed. There were 1034 Caucasian patients, 1543 African-American patients, 218 Hispanic patients, and 394 patients of other or undocumented ethnicity. The mean patient age was 58.2 years. 8 faculty gastroenterologists performed all colonoscopies. There were 2547 procedures performed without fellows and 644 procedures performed with fellows. 240 adenomas (ADR 37.9%) were detected in procedures performed with fellows and 1083 adenomas were detected in procedures performed without fellows (ADR 42.5%). There was a significant difference in the rate at which adenomas were found by faculty gastroenterologists with and without fellows (p=0.038). Colonoscopy ADR was 41.6% with a 1st year fellow, 36% with a 2nd year fellow and 35.4% with a 3rd year fellow. There was no statistical significant in ADR based on year of fellowship (1st vs 2nd p = .26, 2nd vs 3rd p = .92, 1st vs 3rd p= .26) Discussion: Adenoma detection rate (ADR) is a quality indicator for colonoscopies. Multiple factors can impact upon ADR. This study revealed that there was a significant difference in the ADR of colonoscopies performed by faculty gastroenterologists with and without fellows. There was no difference in ADR based upon the fellowship year of training. Since all colonoscopies during which a gastroenterology fellow is present are performed or directly supervised by a faculty gastroenterologist, it is critical to identify factors that impact upon decreased ADR. Focused instruction on both technical skills and adenoma detection are essential for optimal endoscopic education.
Sa1036 Sa1038 Toward Revision of a GI Fellowship Curriculum to Incorporate Entrustable Professional Activities Christen K. Dilly
Annual Endoscopic Workshop Highlighting Prophylactic Mechanical Hemostasis Techniques Is Associated With a Significant Decrease in Adverse Events Mark V. Larson, Ferga C. Gleeson, Louis M. Wong Kee Song, Navtej Buttar, Felicity Enders, Kimberly Hallum, Sunanda V. Kane
Background: A list of EPAs were recently published by the OWN, a consortium of GI professional societies. A fellowship curriculum based on these EPAs would be ideal. However, no description has yet been published on transformation of the EPAs into a workable curriculum. Aims: To revise a GI fellowship curriculum to incorporate the EPAs. Methods: Nutrition was considered to be the area requiring most revision, so this EPA was addressed first. The detailed list of sub-EPAs were revised into learning objectives using SMART criteria. The learning objectives wre then mapped onto existing clinical experiences, and new experiences were created where there were gaps in the existing rotations. An evaluation plan was created for each learning objective, using milestones-based assessment when possible. Program outcome objectives and process objectives were also written and a plan for evaluation was created. Results: See table for examples of modified learning objectives mapped to educational experiences, along with evaluation plans. Conclusions: This curriculum revision describes a process by which the nutrition EPA has been incorporated into an existing GI fellowship curriculum. The process will be repeated for the remaining 12 EPAs. The final product will consist of a list of learning objectives organized by rotation, evaluation
Background and Aims: Bleeding is the most common postpolypectomy adverse event. Bleeding risk is attributed to polyp size and location, polypectomy technique, and use of antithrombotic agents. Prophylactic placement of hemoclips to prevent delayed postpolypectomy or post biopsy bleeding is controversial. We aimed to assess the clinical and financial impact of a 1-day endoscopic workshop, held in April each year, which reviews tools and techniques for polypectomy and closure of resection defects for our outpatient diagnostic and preventive endoscopy units. Methods: Procedural volumes, colonoscopy and polypectomy burden, hemoclip placement with attendant expense, and bleeding specific adverse events requiring an unplanned hospitalization were evaluated pre and post each workshop over a 3-year time period. Results: Following the annual workshops, there was an increase in patients in receipt of ‡ 1 hemoclip (p=0.0001), with a 2-fold increase in associated expense (Table 1). Overall bleeding specific adverse events requiring an unplanned
S-203
AGA Abstracts
AGA Abstracts
hospitalization rate was reduced from 0.13% to 0.07% during the study period (p=0.034). This reduction in an overall bleeding adverse event rate was associated with the increase in patients in receipt of ‡ 1 hemoclip (p=0.047) and approached statistical significance when compared to the increase in total cost (p=0.075). Table 2 shows the change in the bleeding requiring an unplanned hospitalization adverse event rate (EGD, Colonoscopy, and Overall) and associated change in the number of patients with ‡ 1 hemoclip placement over the 3 year intervention period. Conclusion: Although the expense in hemoclip utilization doubled following serial annual endoscopic workshops, the associated decrease in bleeding specific adverse events requiring an unplanned hospitalization rate over time supports the continued role of a 1-day workshop and the prophylactic use of hemoclip placement in our outpatient diagnostic and preventive endoscopy practice. Table 1
2014 (FIT). To examine resource intensity, we included 1,339 colonoscopies performed for FIT+ (65% male, mean age 60 years) and 5,113 for AR screening (51% male, mean age 58 years) from Jan-June 2014. Data was abstracted from the Centre's endoscopy reporting system (Endopro) and pathology and scheduling databases. One procedure per patient was included based on hierarchy of first complete and first adequate bowel preparation. Resource intensity was assessed by the proportion with any screen-relevant lesion (adenoma, significant serrated polyp, cancer) or an advanced adenoma, use of endoclips, withdrawal time and timing of surveillance colonoscopy. Use of endoclips and withdrawal time was used as a surrogate measure of the complexity of the case due to removal of identified polyps. Multivariate logistic regression was conducted to compare the risk of a screen-relevant lesion, an advanced adenoma and a withdrawal time greater than 10 minutes in FIT+ versus AR patients while adjusting for age and gender. Results: With FIT, the number of AR referrals decreased from 8,284 to 4,604 (44% decrease), and the number of referrals for positive occult blood increased from 321 to 2,177 (578% increase). Colonoscopy outcomes are shown in the table. FIT+ (OC-Sensor >75 ng/ml) patients had a 2.0 (95% CI 1.7 - 2.2) greater risk of any screen-relevant lesion and a 5.1 (95% CI 4.2-6.2) greater risk of an advanced adenoma. The odds ratio for a withdrawal time longer than 10 minutes was 3.4 (95% CI 2.9 - 3.8) for the comparison of FIT+ to AR. Men (OR 1.7, 95% CI 1.5-1.9) and those age 65 - 75 years (OR 2.0, 95% CI 1.1 - 3.6) were also more likely to have a longer withdrawal time. For FIT+ patients, the proportion recommended to undergo repeat colonoscopy within 6 months, at 1 year and at 3 years from initial colonoscopy was 15%, 5% and 42%, respectively. This compares with 7%, 1% and 27% for the same surveillance intervals in the AR patients. Conclusions: FIT+ patients were much more likely to have any screen-relevant lesion or an advanced adenoma compared with AR patients. This translated into much more resource intensive colonoscopies as measured by withdrawal time and the use of endoclips. FIT+ patients are more likely to require early surveillance. Screening programs and endoscopy units should consider the complexity and resource intensity of FIT+ colonoscopies when planning for and implementing a FIT-based screening program.
Table 2
†For each procedure type (EGD, Colon, and Overall), we compared the adverse event rate between the first year and the two later years to account for the impact of training using a log-linear regression with a natural log offset for the total number of procedures during each period. ‡Because the data for hemoclips and cost were only available at the aggregate level, the analysis of these predictor variables was done using the outcome of overall adverse event rate predicted by either hemoclips or cost within the time period, again using loglinear regression with a natural log offset for the number of procedures.
Sa1041 Premature Surveillance Colonoscopy Occurs Most Frequently Without Any Clinical Justification Vishal Desai, Daniel A. Sussman, Sandeep Dayanand, Kevin Ollington, Sheena Patel, Joshua E. Melson
Sa1039 The Withdrawal Time for Adequate Adenoma Detection Rate for Colonoscopy Trainee Hong Jun Park, Hyun-Soo Kim
Background: Surveillance colonoscopy is widely performed prematurely. It is unclear to what extent early surveillance is driven by suboptimal visualization at index colonoscopy, new clinical concerns, or guideline deviation without rationale. The aim of the study is to define the extent to which surveillance colonoscopy is performed prematurely without any documented rationale versus due to clinical or bowel prep concerns at two academic medical centers. Methods: Patients who underwent colonoscopy with indication of "surveillance of polyps" (ICD-9-CM V12.72) from 2008-14 were identified by review of endoscopy records at Rush University Medical Center (RUMC) and University of Miami Miller School of Medicine (UM). Patients aged < 50 or > 75, with personal history of IBD or colorectal cancer (CRC), family history of CRC, or > one prior colonoscopy were excluded. Patients were divided into categories "Adherent" or "Non-Adherent" depending on whether the minimum interval since last colonoscopy was consistent with USMSTF 2012 guidelines. The primary endpoint was the rate of premature surveillance in the absence of prep or clinical justification. If the index colonoscopy had suboptimal prep (fair or poor), non-adherence was deemed preprelated. For those with adequate or better prep on index, clinic notes, colonoscopy order and procedure note were reviewed to assess if clinical rationale led to early surveillance. If no prep or clinical justification was listed then the premature case was "without rationale". Results: 700 subjects met inclusion criteria. Index colonoscopy revealed low risk adenoma (LRA) in 45.5%; advanced adenoma (AA) 27.4%, and hyperplasic polyps (HP) 27.1%. The total rate of non-adherence with a shorter than USMSTF recommended interval was 48.4% (n=339). The overall premature surveillance rate at RUMC was 41.8% (193/462) and 61.3% (146/238) at UM. Overall, the fraction of non-adherent cases attributed to suboptimal bowel prep was 17.4% (59/339), and by a new clinical indication was 18.3% (62/339). Most frequently and at both centers premature colonoscopy was performed without rationale in 64.3% (218/339; RUMC 70% and UM 56.9%). In all groups stratified by the findings on index colonoscopy, premature surveillance was done in the absence of a clinical or preparation related rationale reason (57.4% AA, 63.0% LRA, and 67.9% HP). Conclusion: Most early surveillance (64.3%) is performed without clinical or bowel prep justification documented as rationale for prematurity at each of two centers. Premature surveillance is performed most commonly without clinical or bowel prep justifications regardless of prior histology on the index colonoscopy. Clinical decision support tools should be considered to reduce inappropriate early surveillance colonoscopy, as early surveillance does not usually have a clinical decision-making rationale.
Background/Aim: The adenoma detection rate (ADR) is a critical quality indicator in successful colonoscopy, therefore it is important to improve ADR in learning colonoscopy for trainees. The aim of this study was to evaluate the proper withdrawal time (WT) for trainees to detect adenomas more than 20% or 35% before and after technical competency. Method: In this retrospective study, from March 2011 to February 2013, six first-year GI fellows performed 500 colonoscopies respectively were enrolled. Each fellow fulfilled the "colonoscopy learning protocol" which includes all of colonoscopy related parameters until 500th colonoscopy. We defined a competency of colonoscopy as the successful rate of cecal intubation over 90 percent that is achieved after about 150 cases of colonoscopy. We analyzed optimal withdrawal time for ADR more than 20% (recommended withdrawal time) and 35% (ADR previous reported in Korea) before and after colonoscopy competency. Results: Among a total of 3,000 colonoscopy procedures, 1272 cases of first-time screening colonoscopies performed by six trainees were analyzed. With 50th cases interval, WTs were significant decreased (p<0.001), however, the ADRs and numbers of adenomas were not changed so much (p=0.347 and p=0.395, respectively). So, the numbers of adenomas per minute were significant increased due to decreased withdrawal time (p=0.011). Before competency (n= 406) and after competency (n=866), there was positive correlation between ADR and WT respectively (P<0.001). In ROC curve analysis, trainees should inspect more than 8 minutes for over 20% of ADR and more than 10 minutes for over 35% of ADR before competency (AUROC=0.696). After competency, 6.5 minutes of WT was required for over 20% of ADR and 7.5 minutes of WT for over 35% of ADR (AUROC=0.720). Conclusion: To maintain optimal ADR, more withdrawal times was needed during training period especially before competency. Therefore, a different WT should be recommended according to training period to improve quality of colonoscopy.
Sa1040 The Impact of the Fecal Immunochemical Test on Colonoscopy Utilization and Resources at a Canadian Regional Screening Centre Robert J. Hilsden, S. Elizabeth McGregor, Ronald Bridges, Alaa Rostom, Catherine Dube, Steven J. Heitman Background: The fecal immunochemical test (FIT) replaced the guaiac occult blood test in Alberta, Canada in November 2013. We examined the impact of FIT on referrals for screening colonoscopy and the resource intensity of the colonoscopies. Methods: We included all referrals to the Forzani & MacPhail Colon Cancer Screening Centre for average risk (AR) screening or for a positive occult blood test for the first six months of 2013 (guaiac) and
AGA Abstracts
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