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Sa1093 Do We Need to Repeat Upper Endoscopy After First Endoscopy Presents Reflux Esophagitis?
AGA Abstracts
Methods: In this multicenter observational study, consecutive IBD patients visiting the outpatient clinic were included. Patients completed the validated Modified Morisky Adherence Scale-8 with a score on this scale of ,6 indicating low adherence. Clinical disease activity was assessed by the modified Harvey Bradshaw Index (Crohn's disease) or the Simple Clinical Colitis Activity Index (ulcerative colitis). We also assessed demographic and behavioural characteristics, including medication beliefs (Beliefs about Medicines Questionnaire) and illness beliefs (Brief-Illness Perception Questionnaire). A hierarchical logistical regression analysis was performed to determine factors associated with low adherence. Results: Seventy-three patients were included (27 IFX, 46 ADA), median age 35 years (IQR 24-51), 27 males (37%). Median disease duration was 11 years (IQR 3-18). Clinical disease activity was present in 19 patients (26%). Fifteen of 46 patients on ADA (33%) and 6 of 27 patients on IFX (22%) reported a low adherence (p = 0.32). Attitudinal analysis showed that while 38% of the patients was "accepting" maintenance therapy, including anti-TNF therapy (high necessity, low concerns), more than half of patients (58%) was "ambivalent" about maintenance therapy (high necessity, high concerns). Factors independently associated with low adherence were high perceived personal control over the illness (OR 1.38, 95% CI 1.01-1.89), symptoms attributed to the illness (OR 0.60, 95% CI 0.39-0.93), and strong beliefs about how the illness affects one's emotional well-being (OR 1.61, 95% CI 1.122.32). Non-adherence was not significantly affected by young age, male gender, disease activity or concerns about potential adverse effects of anti-TNF therapy. Conclusions: The overall non-adherence rate of anti-TNF therapy is comparable to rates found in oral medication. A substantial proportion of patients were ambivalent about maintenance therapy, including anti-TNF therapy and several illness beliefs were significantly associated with nonadherence. As illness beliefs are potentially modifiable factors, they may provide a relevant target for interventions aimed at improving adherence and health outcomes.
in polypharmacy and the data suggests it could ultimately lead to a decrease in associated risks such as hospital acquired CDI.
Root cause analysis to identify areas in clinical practice that lead to inappropriate PPI use. The starred boxes represent areas for intervention.
Sa1093 Do We Need to Repeat Upper Endoscopy After First Endoscopy Presents Reflux Esophagitis? Michael Abeles, Boris Sapoznikov, Sara Welinsky, Rachel Gingold Belfer, Yaron Niv, Lital Boker Keinan, Irena Liphshitz, Zohar Levi Background: Patients with a primary endoscopic diagnosis of Reflux Esophagitis (RE) are often advised to repeat upper endoscopy. We aimed to assess the adherence for repeat endoscopy and evaluate the outcomes at our center. Methods: Included all patients with a first endoscopy revealing RE from 2003 to 2011. The endoscopic diagnosis of reflux esophagitis was extracted from the electronic medical records database, and all cases were tracked for further endoscopy, pathology results and for any record of gastro-esophageal cancer through the National cancer Registry (NCR). Results: Included 958 cases: 62.5% had Los Angeles (LA)-A, 17.7% had LA-B and 19.7 % had LA-C/D. Of all cases, 616 (64.3%) had repeat endoscopy. The proportion of repeat endoscopy was not correlated with severity of RE (p=0.4). Pathology confirmed that Barrett's Esophagus (BE) was found in 49/368 (13.3%) of LA-A, 23/126 (18.3%) of LA-B and 20/122 (16.4%) of LA-C/D (p=0.35). BE with dysplasia was found in 11/368 (3.0%) of LA-A, 4/126 (3.2%) of LA-B and 4/122 (3.3%) of LA-C/D (p=0.98). BE with cancer was found in 2/368 (0.5%) of LA-A and none in LA-B and LAC/D (p=0.64). No further gastro-esophageal cancer was detected by the NCR. Conclusions: Repeat endoscopy was performed in about two thirds of patients who were formerly found to have RE. Interestingly, most of the cases of Barrett's Esophagus with and without dysplasia occurred in the group of mild RE. Repeat endoscopy is strongly advised to all patients with all degrees of RE.
A) Overall inappropriate use decreased from 35% during the baseline phase to 1.6% during the Pilot Phase. This was a highly statistically significant change (P-value , 0.001). B) Overall inappropriate use decreased from 35% during the Baseline Phase to 15% during the Expansion Phase. This was a statistically significant change (P-value = 0.0018). Sa1095 Assessment of Quality Indicators for Colonoscopy At Two Large Academic Institutions After Intervention Lauren M. Shea, Melissa Osborn, Jay M. Anderson, Robin Rutherford, Mohammad Wehbi, Julia Massaad
Sa1094 A Sustained Reduction of Inappropriate Proton Pump Inhibitor Use Through a Process Improvement Initiative At an Academic Teaching Hospital Rena Shah, Andrew Lichtmann, Dana Russell, Tristan Grogan, Nasim Afsarmanesh, Daniel Uslan
Background: Colorectal cancer (CRC) is the second leading cause of cancer death in the United States. Colonoscopy is the gold standard of screening for CRC. Despite strong evidence that this test has decreased mortality from CRC, there is marked variation in the performance and reporting of this testing modality, and a great emphasis in the literature on QUALITY colonoscopy. In 2009, we conducted a retrospective review to assess the performance and reporting techniques of 11 of our endoscopists. After analysis of the data, each endoscopist was given face to face feedback on their performance and reporting techniques. Following that, we conducted a prospective study to see what changes/improvements were displayed in the endoscopists' performance and reporting techniques. Aim: to determine if there was a change/ improvement in the performance as well as the reporting of endoscopists after they were provided with feedback on their prior performance status. Methods: For each of 12 gastroenterologists, we reviewed 200 colonoscopy reports performed between May, 2010 and February, 2012. 6 gastroenterologists participated in the retrospective study. The other 6 were aware that their performance was being monitored. The reports reviewed included exams performed for average risk screening, guaiac positive stool, history of polyps, or family history of CRC. Each report was analyzed for documentation of patient demographics, indication for the procedure, quality of the preparation, extent of the exam, polyp descriptors and withdrawal time. The data were collected using Access (Microsoft) and analyzed with SAS 9.1. Results: Among the 2270 reports reviewed, more than 99% included patient age and gender, procedural indication, quality of the preparation, and extent of the exam. 47.7% recorded race. The overall cecal intubation rate was 97.3%. Polyps were found in 49.7% of patients. The adenoma detection rate was 33.7% among all patients. 99% of the reports included the polyp morphology. 1872 reports used standard descriptive terms to describe the quality of the preparation (68.6% good, 20% fair/adequate, 4.8% fair/inadequate, poor 6.3%). Withdrawal time was documented 85.8% of the time. Conclusions: This study provides evidence of improvement in endoscopy performance and quality of reporting after providing feedback to endoscopists, and standardizing the data collecting system. As compared to the retrospective study, there was improvement in recording cecal landmarks (.95%) and withdrawal time 85.8%. The patient's race was reported in 47.7% of reports as compared to 0.05% in the retrospective study. The overall adenoma detection rate increased from 25.4% to 33.7%. Conclusion: Standardization of colonoscopy reporting, and feedback on performance are necessary for the improvement in the performance and reporting of colonoscopies.
Background: Proton pump inhibitors (PPIs) are one of the most widely used medications. Studies have shown 60% of inpatient PPI use is inappropriate. Inpatient PPI use is associated with risks such as Clostridium difficile infection (CDI) and nosocomial pneumonia. We implemented a process improvement initiative to decrease inappropriate PPI use on an internal medicine teaching service. Methods: We utilized quality improvement tools and lean methodology to implement our initiative. First, we retrospectively reviewed 100 internal medicine patients to determine the baseline rate of inappropriate PPI use. Appropriateness was determined according to the American Society of Health System Pharmacists' guidelines for PPI utilization. We administered a survey to housestaff regarding PPI indications and side effects. Next we developed an A3 report and performed a root cause analysis to identify areas contributing to inappropriate PPI use. We implemented an initiative focused on housestaff education. We led didactic sessions, distributed informational pocketcards and encouraged housestaff to qualify PPI use on their progress notes. We also incorporated formal indications for PPI use onto electronic ordersets and worked with pharmacy to develop a formal PPI review process in the hospital. Initially, a pilot phase was conducted with medicine team C. The rate of inappropriate PPI use and qualification of PPI use on progress notes was monitored on a daily basis for 14 days. Next we expanded the initiative to the entire internal medicine service and followed patients for 6 weeks. Results: According to the baseline data, 63% of internal medicine inpatients were placed on a PPI and 35% of PPI utilization was inappropriate. Housestaff scored an average of 34% on the survey. The root cause analysis identified multiple areas for intervention including lack of physician awareness of PPI indications and risks, preset PPI checkboxes on ordersets and absence of a formal hospital PPI review process (Figure 1). In the pilot phase, inappropriate PPI use decreased from 35% to 1.6% (p ,0.001) and qualification of PPI use increased from 0% to 74%. During the expansion phase, inappropriate PPI use decreased from 35% to 15% (p= 0.0018) (Figure 2). Conclusion: Through a formal quality improvement process, we achieved a significant and sustainable decrease in inappropriate PPI use on an inpatient internal medicine service. An integral component was housestaff education and incorporation of PPI qualification into daily progress notes. Decrease in inappropriate PPI use led to a decrease
AGA Abstracts
S-200
Methods: In this multicenter observational study, consecutive IBD patients visiting the outpatient clinic were included. Patients completed the validated Modified Morisky Adherence Scale-8 with a score on this scale of ,6 indicating low adherence. Clinical disease activity was assessed by the modified Harvey Bradshaw Index (Crohn's disease) or the Simple Clinical Colitis Activity Index (ulcerative colitis). We also assessed demographic and behavioural characteristics, including medication beliefs (Beliefs about Medicines Questionnaire) and illness beliefs (Brief-Illness Perception Questionnaire). A hierarchical logistical regression analysis was performed to determine factors associated with low adherence. Results: Seventy-three patients were included (27 IFX, 46 ADA), median age 35 years (IQR 24-51), 27 males (37%). Median disease duration was 11 years (IQR 3-18). Clinical disease activity was present in 19 patients (26%). Fifteen of 46 patients on ADA (33%) and 6 of 27 patients on IFX (22%) reported a low adherence (p = 0.32). Attitudinal analysis showed that while 38% of the patients was "accepting" maintenance therapy, including anti-TNF therapy (high necessity, low concerns), more than half of patients (58%) was "ambivalent" about maintenance therapy (high necessity, high concerns). Factors independently associated with low adherence were high perceived personal control over the illness (OR 1.38, 95% CI 1.01-1.89), symptoms attributed to the illness (OR 0.60, 95% CI 0.39-0.93), and strong beliefs about how the illness affects one's emotional well-being (OR 1.61, 95% CI 1.122.32). Non-adherence was not significantly affected by young age, male gender, disease activity or concerns about potential adverse effects of anti-TNF therapy. Conclusions: The overall non-adherence rate of anti-TNF therapy is comparable to rates found in oral medication. A substantial proportion of patients were ambivalent about maintenance therapy, including anti-TNF therapy and several illness beliefs were significantly associated with nonadherence. As illness beliefs are potentially modifiable factors, they may provide a relevant target for interventions aimed at improving adherence and health outcomes.
in polypharmacy and the data suggests it could ultimately lead to a decrease in associated risks such as hospital acquired CDI.
Root cause analysis to identify areas in clinical practice that lead to inappropriate PPI use. The starred boxes represent areas for intervention.
Sa1093 Do We Need to Repeat Upper Endoscopy After First Endoscopy Presents Reflux Esophagitis? Michael Abeles, Boris Sapoznikov, Sara Welinsky, Rachel Gingold Belfer, Yaron Niv, Lital Boker Keinan, Irena Liphshitz, Zohar Levi Background: Patients with a primary endoscopic diagnosis of Reflux Esophagitis (RE) are often advised to repeat upper endoscopy. We aimed to assess the adherence for repeat endoscopy and evaluate the outcomes at our center. Methods: Included all patients with a first endoscopy revealing RE from 2003 to 2011. The endoscopic diagnosis of reflux esophagitis was extracted from the electronic medical records database, and all cases were tracked for further endoscopy, pathology results and for any record of gastro-esophageal cancer through the National cancer Registry (NCR). Results: Included 958 cases: 62.5% had Los Angeles (LA)-A, 17.7% had LA-B and 19.7 % had LA-C/D. Of all cases, 616 (64.3%) had repeat endoscopy. The proportion of repeat endoscopy was not correlated with severity of RE (p=0.4). Pathology confirmed that Barrett's Esophagus (BE) was found in 49/368 (13.3%) of LA-A, 23/126 (18.3%) of LA-B and 20/122 (16.4%) of LA-C/D (p=0.35). BE with dysplasia was found in 11/368 (3.0%) of LA-A, 4/126 (3.2%) of LA-B and 4/122 (3.3%) of LA-C/D (p=0.98). BE with cancer was found in 2/368 (0.5%) of LA-A and none in LA-B and LAC/D (p=0.64). No further gastro-esophageal cancer was detected by the NCR. Conclusions: Repeat endoscopy was performed in about two thirds of patients who were formerly found to have RE. Interestingly, most of the cases of Barrett's Esophagus with and without dysplasia occurred in the group of mild RE. Repeat endoscopy is strongly advised to all patients with all degrees of RE.
A) Overall inappropriate use decreased from 35% during the baseline phase to 1.6% during the Pilot Phase. This was a highly statistically significant change (P-value , 0.001). B) Overall inappropriate use decreased from 35% during the Baseline Phase to 15% during the Expansion Phase. This was a statistically significant change (P-value = 0.0018). Sa1095 Assessment of Quality Indicators for Colonoscopy At Two Large Academic Institutions After Intervention Lauren M. Shea, Melissa Osborn, Jay M. Anderson, Robin Rutherford, Mohammad Wehbi, Julia Massaad
Sa1094 A Sustained Reduction of Inappropriate Proton Pump Inhibitor Use Through a Process Improvement Initiative At an Academic Teaching Hospital Rena Shah, Andrew Lichtmann, Dana Russell, Tristan Grogan, Nasim Afsarmanesh, Daniel Uslan
Background: Colorectal cancer (CRC) is the second leading cause of cancer death in the United States. Colonoscopy is the gold standard of screening for CRC. Despite strong evidence that this test has decreased mortality from CRC, there is marked variation in the performance and reporting of this testing modality, and a great emphasis in the literature on QUALITY colonoscopy. In 2009, we conducted a retrospective review to assess the performance and reporting techniques of 11 of our endoscopists. After analysis of the data, each endoscopist was given face to face feedback on their performance and reporting techniques. Following that, we conducted a prospective study to see what changes/improvements were displayed in the endoscopists' performance and reporting techniques. Aim: to determine if there was a change/ improvement in the performance as well as the reporting of endoscopists after they were provided with feedback on their prior performance status. Methods: For each of 12 gastroenterologists, we reviewed 200 colonoscopy reports performed between May, 2010 and February, 2012. 6 gastroenterologists participated in the retrospective study. The other 6 were aware that their performance was being monitored. The reports reviewed included exams performed for average risk screening, guaiac positive stool, history of polyps, or family history of CRC. Each report was analyzed for documentation of patient demographics, indication for the procedure, quality of the preparation, extent of the exam, polyp descriptors and withdrawal time. The data were collected using Access (Microsoft) and analyzed with SAS 9.1. Results: Among the 2270 reports reviewed, more than 99% included patient age and gender, procedural indication, quality of the preparation, and extent of the exam. 47.7% recorded race. The overall cecal intubation rate was 97.3%. Polyps were found in 49.7% of patients. The adenoma detection rate was 33.7% among all patients. 99% of the reports included the polyp morphology. 1872 reports used standard descriptive terms to describe the quality of the preparation (68.6% good, 20% fair/adequate, 4.8% fair/inadequate, poor 6.3%). Withdrawal time was documented 85.8% of the time. Conclusions: This study provides evidence of improvement in endoscopy performance and quality of reporting after providing feedback to endoscopists, and standardizing the data collecting system. As compared to the retrospective study, there was improvement in recording cecal landmarks (.95%) and withdrawal time 85.8%. The patient's race was reported in 47.7% of reports as compared to 0.05% in the retrospective study. The overall adenoma detection rate increased from 25.4% to 33.7%. Conclusion: Standardization of colonoscopy reporting, and feedback on performance are necessary for the improvement in the performance and reporting of colonoscopies.
Background: Proton pump inhibitors (PPIs) are one of the most widely used medications. Studies have shown 60% of inpatient PPI use is inappropriate. Inpatient PPI use is associated with risks such as Clostridium difficile infection (CDI) and nosocomial pneumonia. We implemented a process improvement initiative to decrease inappropriate PPI use on an internal medicine teaching service. Methods: We utilized quality improvement tools and lean methodology to implement our initiative. First, we retrospectively reviewed 100 internal medicine patients to determine the baseline rate of inappropriate PPI use. Appropriateness was determined according to the American Society of Health System Pharmacists' guidelines for PPI utilization. We administered a survey to housestaff regarding PPI indications and side effects. Next we developed an A3 report and performed a root cause analysis to identify areas contributing to inappropriate PPI use. We implemented an initiative focused on housestaff education. We led didactic sessions, distributed informational pocketcards and encouraged housestaff to qualify PPI use on their progress notes. We also incorporated formal indications for PPI use onto electronic ordersets and worked with pharmacy to develop a formal PPI review process in the hospital. Initially, a pilot phase was conducted with medicine team C. The rate of inappropriate PPI use and qualification of PPI use on progress notes was monitored on a daily basis for 14 days. Next we expanded the initiative to the entire internal medicine service and followed patients for 6 weeks. Results: According to the baseline data, 63% of internal medicine inpatients were placed on a PPI and 35% of PPI utilization was inappropriate. Housestaff scored an average of 34% on the survey. The root cause analysis identified multiple areas for intervention including lack of physician awareness of PPI indications and risks, preset PPI checkboxes on ordersets and absence of a formal hospital PPI review process (Figure 1). In the pilot phase, inappropriate PPI use decreased from 35% to 1.6% (p ,0.001) and qualification of PPI use increased from 0% to 74%. During the expansion phase, inappropriate PPI use decreased from 35% to 15% (p= 0.0018) (Figure 2). Conclusion: Through a formal quality improvement process, we achieved a significant and sustainable decrease in inappropriate PPI use on an inpatient internal medicine service. An integral component was housestaff education and incorporation of PPI qualification into daily progress notes. Decrease in inappropriate PPI use led to a decrease
AGA Abstracts
S-200