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Sa1168 Why Are We Not Treating Enough Hepatitis C?
AGA Abstracts
cancer surgery is unclear. The aim of this study was to assess the feasibility and safety of surgery in obese patients with colorectal cancer. METHODS: A computerized medical literature search was performed using Medline, Embase, Scopus, the Cochrane library, and the ISI web of knowledge from 1980 to June 2012. Pooled odds ratios (OR) for dichotomous outcomes and weighted mean differences (WMD) for continuous variables, with 95% confidence intervals (95% CI), were calculated using fixed or random effects models. We systematically reviewed 20 observational studies, comparing obese and non-obese patients undergoing surgery for colon, rectal or colorectal cancer. Heterogeneity and publication bias were assessed. RESULTS: Twenty observational studies (totaling 9210 patients) were included. Mortality, overall complication rate, blood loss, anastomotic leakage, sepsis, length of hospital stay, lymph node harvesting, and post-operative staging did not appear to differ significantly between both groups. Conversion rate to open surgery OR=2.19 (95%CI, 1.61-2.98) and wound infection rate OR = 1.84 (95% CI, 1.27-2.68) were found to be significantly increased in obese subjects. Sensitivity and subgroups analyses showed that when both operative and post-operative outcomes were considered, or when studies assessing rectal or colo-rectal cancer as a whole were excluded, overall complication rates were increased in the obese group (OR=1.38 (95% CI1.13-1.67); and 1.27 (95% CI1.08-1.51, respectively). Studies including only Asian patients suggest a higher risk for wound infection and overall complication. CONCLUSIONS: Obesity does not appear to influence negatively lymph node retrieval and cancer staging. Nevertheless wound infection and overall complication rate are increased, maybe more markedly in non-Asian studies. Sa1166 Systematic Review and Meta-Analysis of Enhanced Recovery Programmes in Esophageal Cancer Surgery Andrew J. Beamish, David S. Chan, Alex Karran, Paul A. Blake, Charlotte Thomas, Wyn G. Lewis
Sa1168 Why Are We Not Treating Enough Hepatitis C? Jennifer Hsieh, Suvin Banker, Asim Khokhar
Aims. This systematic review and meta-analysis was performed to determine the influence of enhanced recovery programmes (ERPs) on outcomes after esophageal cancer surgery. Methods. PubMed, Embase, the Cochrane library, and ClinicalTrials.gov were searched for studies on outcomes of esphagectomy in enhanced recovery programme or fast-track programmes. The primary outcome measure was post-operative duration of hospital stay (LOHS), and secondary outcome measures were selected based on inclusion in two or more studies. Statistical analysis was performed using odds ratio (OR) as the summary statistic. Results. Five studies totalling 854 patients with esophageal cancer were analysed. LOHS was significantly shorter after ERP, when compared with controls (CON, standardised mean difference SMD -0.51, 95% confidence interval -0.66 to -0.35, p ,0.00001), but with significant heterogeneity between studies (I2=96%, p ,0.00001). ERP was associated with less operative morbidity (p,0.0001), operative mortality (30-day mortality, p=0.020), and fewer anastomotic leaks (p=0.010). ERP was not associated with a higher incidence of pulmonary complications (p=0.560) or more frequent readmission to hospital (p=0.800). Conclusion. Multimodal, standardised approaches to perioperative esophagectomy care was feasible, and cost effective.
Background: Hepatitis C virus (HCV) has now become a major healthcare burden in the United States and is a leading cause of end-stage liver disease and transplantation. Though HCV therapy is widely available, numerous barriers to treatment including patient, provider and payer factors may influence the delivery of care. In the USA only 21% of infected individuals had received antiviral therapy by the end of 2007. Aims: To examine the barriers encountered by medical providers during treatment of HCV genotype 1 patients. Methods: We surveyed 66 gastroenterology providers at the 2012 annual American College of Gastroenterology meeting in Las Vegas, Nevada. The questions included provider and patient demographics, frequency of patient visits and patient characteristics that would bar treatment. Results: Most practices were in urban/suburban areas with minority being rural. 38% of practitioners had more than 15 yrs of experience vs. 42% with less than 5 years. 24% of respondents had hepatology training. 53% of providers had nurse practitioners that assisted them. All practitioners had patient populations with mixed insurance payers. The majority experienced barriers in 25% of patients (past and present substance abuse, patient preference against treatment, psychiatric and medical co-morbidities, delays in obtaining clearance from specialists, and loss to follow-up). Most preferred to use triple therapy and more providers preferred Teleprivir to Boceprivir, citing a simpler protocol and ease of use. 57% practitioners saw patients once a month while on treatment, while 24% twice a month, 8% once a week and 11% as needed. 86% of the providers felt financial compensation was inadequate for the amount of work required. Discussion: Numerous barriers exist that prevent HCV patients from being treated. In this study, we examined barriers faced by the medical providers. Most gastroenterologists were currently treating less than ten patients with hepatitis C genotype 1, about half had help in the form of nurse practitioners, and most felt the financial compensation was inadequate for the time spent in taking care of patients. Much has been studied and published about the high costs of HCV treatment. Medications, blood work and hospitalization costs if needed, are significant. On the other hand, physician compensation is only a small proportion. Providers spend a significant amount of time and energy during the treatment course along with responsibility and liability. Physicians are only compensated up to two office visits a month under most insurances. Financially, this may be manageable in a large academic center setting but not in private practice. Providers will face difficulty in light of emerging therapies and complex treatment plans. Physician factors should be considered and solutions sought, otherwise much of Hepatitis C will remain untreated.
Sa1167 Determinants of Health-Related Quality of Life in Crohn's Disease: A Systematic Review and Meta-Analysis Mike V. Have, Karen S. van der Aalst, Adrian A. Kaptein, Max Leenders, Peter D. Siersema, Bas Oldenburg, Herma Fidder Background and aims: Health-related quality of life (HRQOL) is increasingly recognized as an important patient-reported outcome, although rarely implemented into clinical practice. A comprehensive understanding of the determinants of Crohn's Disease patients' HRQOL may facilitate clinicians in clinical decision making, defining risk groups and allowing more accurate prediction of HRQOL. Therefore, we systematically assessed the determinants of HRQOL in adult CD patients. Methods: The databases PubMed, EMBASE, the Cochrane Library, PsycINFO and CINAHL were searched for English abstracts related to socio-demographic, psychological, clinical and treatment-related determinants of HRQOL in CD. Two independent reviewers extracted study characteristics and assessed the methodological quality according the criteria of Hayden et al. Main outcome was the number of studies showing a statistically significant association between the above-mentioned determinants and HRQOL. A meta-analysis was performed to quantify the relationship between disease activity and HRQOL. Results: Of the 2,060 articles identified, 24 original studies were included. The majority of studies originated from Europe (15/24; 63%) and had a cross-sectional design (15/24; 63%). Sample sizes varied between 52 and 628 patients, with a majority of females (3576/ 5735; 62%) and with mean/median ages ranging from 29 to 45 years. Most studies had a moderate to high quality. Data on psychological determinants were limited. Work disability, increased disease activity, number of relapses, corticosteroid use and hospitalization rate were significantly associated with a lower HRQOL in the majority of included studies. Use of biologicalspositively influenced HRQOL. The pooled data on the association between disease activity and HRQOL resulted in a weighed mean correlation coefficient of -0.61 (CI -0.65 to -0.57). Conclusions: HRQOL of adult CD patients is consistently determined by markers of active disease, including work disability, increased disease activity, number of relapses, corticosteroid use and hospitalization rate. However, these determinants are not very helpful for clinicians when dealing with asymptomatic CD patients or when choosing between treatments with a comparable clinical efficacy. In addition, as disease activity contributed to only 37% of CD patients' HRQOL, there remains a need for additional, possibly modifiable, determinants.
Sa1169 Incidence of Venous Thromboembolism in Gastrointestinal Bleeding Neel Malhotra, Nilesh Chande Background: Patients with acute gastrointestinal (GI) bleeding represent a challenging population to manage with respect to the safety of anticoagulant therapy for prophylaxis against venous thromboembolism during hospital admission. Methods: Over a two-year period, 1014 patients with acute upper or lower GI bleeding were hospitalized at our centre. Inclusion criteria included those admitted with a primary diagnosis of a GI bleed along with any endoscopic confirmed source. Patients who developed GI bleeding while already admitted for another reason were excluded. Only the initial event was considered in those with recurrent hospitalizations. The primary end point was the development of venous thromboembolism (deep venous thrombosis or pulmonary embolism) within one year after presentation. Results: Among those excluded, 359 patients developed GI bleeding after admission and 121 had no definitive source of bleed identified. Data for 504 patients admitted with GI bleeding was eligible for review. Prior to admission, 324 patients were on some form of anticoagulation (mostly aspirin, n=256). Upper gastrointestinal bleeding was more common than lower (n=350 vs. n=154). 397 patients (78.8%) were not given VTE prophylaxis during their hospitalization. Of those that were, 36 patients (7.2%) were given prophylactic dalteparin or heparin for the duration of their stay. A further 38 patients (7.6%) were given VTE prophylaxis for a portion of their hospitalization. 113 patients had at least one other risk factor for VTE including recent or subsequent surgery, past thrombotic events or malignancy, however only 24 of these patients received VTE prophylaxis. The total number of VTE events was 20 (3.97%). However, the incidence of thrombosis in those with other
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AGA Abstracts
cancer surgery is unclear. The aim of this study was to assess the feasibility and safety of surgery in obese patients with colorectal cancer. METHODS: A computerized medical literature search was performed using Medline, Embase, Scopus, the Cochrane library, and the ISI web of knowledge from 1980 to June 2012. Pooled odds ratios (OR) for dichotomous outcomes and weighted mean differences (WMD) for continuous variables, with 95% confidence intervals (95% CI), were calculated using fixed or random effects models. We systematically reviewed 20 observational studies, comparing obese and non-obese patients undergoing surgery for colon, rectal or colorectal cancer. Heterogeneity and publication bias were assessed. RESULTS: Twenty observational studies (totaling 9210 patients) were included. Mortality, overall complication rate, blood loss, anastomotic leakage, sepsis, length of hospital stay, lymph node harvesting, and post-operative staging did not appear to differ significantly between both groups. Conversion rate to open surgery OR=2.19 (95%CI, 1.61-2.98) and wound infection rate OR = 1.84 (95% CI, 1.27-2.68) were found to be significantly increased in obese subjects. Sensitivity and subgroups analyses showed that when both operative and post-operative outcomes were considered, or when studies assessing rectal or colo-rectal cancer as a whole were excluded, overall complication rates were increased in the obese group (OR=1.38 (95% CI1.13-1.67); and 1.27 (95% CI1.08-1.51, respectively). Studies including only Asian patients suggest a higher risk for wound infection and overall complication. CONCLUSIONS: Obesity does not appear to influence negatively lymph node retrieval and cancer staging. Nevertheless wound infection and overall complication rate are increased, maybe more markedly in non-Asian studies. Sa1166 Systematic Review and Meta-Analysis of Enhanced Recovery Programmes in Esophageal Cancer Surgery Andrew J. Beamish, David S. Chan, Alex Karran, Paul A. Blake, Charlotte Thomas, Wyn G. Lewis
Sa1168 Why Are We Not Treating Enough Hepatitis C? Jennifer Hsieh, Suvin Banker, Asim Khokhar
Aims. This systematic review and meta-analysis was performed to determine the influence of enhanced recovery programmes (ERPs) on outcomes after esophageal cancer surgery. Methods. PubMed, Embase, the Cochrane library, and ClinicalTrials.gov were searched for studies on outcomes of esphagectomy in enhanced recovery programme or fast-track programmes. The primary outcome measure was post-operative duration of hospital stay (LOHS), and secondary outcome measures were selected based on inclusion in two or more studies. Statistical analysis was performed using odds ratio (OR) as the summary statistic. Results. Five studies totalling 854 patients with esophageal cancer were analysed. LOHS was significantly shorter after ERP, when compared with controls (CON, standardised mean difference SMD -0.51, 95% confidence interval -0.66 to -0.35, p ,0.00001), but with significant heterogeneity between studies (I2=96%, p ,0.00001). ERP was associated with less operative morbidity (p,0.0001), operative mortality (30-day mortality, p=0.020), and fewer anastomotic leaks (p=0.010). ERP was not associated with a higher incidence of pulmonary complications (p=0.560) or more frequent readmission to hospital (p=0.800). Conclusion. Multimodal, standardised approaches to perioperative esophagectomy care was feasible, and cost effective.
Background: Hepatitis C virus (HCV) has now become a major healthcare burden in the United States and is a leading cause of end-stage liver disease and transplantation. Though HCV therapy is widely available, numerous barriers to treatment including patient, provider and payer factors may influence the delivery of care. In the USA only 21% of infected individuals had received antiviral therapy by the end of 2007. Aims: To examine the barriers encountered by medical providers during treatment of HCV genotype 1 patients. Methods: We surveyed 66 gastroenterology providers at the 2012 annual American College of Gastroenterology meeting in Las Vegas, Nevada. The questions included provider and patient demographics, frequency of patient visits and patient characteristics that would bar treatment. Results: Most practices were in urban/suburban areas with minority being rural. 38% of practitioners had more than 15 yrs of experience vs. 42% with less than 5 years. 24% of respondents had hepatology training. 53% of providers had nurse practitioners that assisted them. All practitioners had patient populations with mixed insurance payers. The majority experienced barriers in 25% of patients (past and present substance abuse, patient preference against treatment, psychiatric and medical co-morbidities, delays in obtaining clearance from specialists, and loss to follow-up). Most preferred to use triple therapy and more providers preferred Teleprivir to Boceprivir, citing a simpler protocol and ease of use. 57% practitioners saw patients once a month while on treatment, while 24% twice a month, 8% once a week and 11% as needed. 86% of the providers felt financial compensation was inadequate for the amount of work required. Discussion: Numerous barriers exist that prevent HCV patients from being treated. In this study, we examined barriers faced by the medical providers. Most gastroenterologists were currently treating less than ten patients with hepatitis C genotype 1, about half had help in the form of nurse practitioners, and most felt the financial compensation was inadequate for the time spent in taking care of patients. Much has been studied and published about the high costs of HCV treatment. Medications, blood work and hospitalization costs if needed, are significant. On the other hand, physician compensation is only a small proportion. Providers spend a significant amount of time and energy during the treatment course along with responsibility and liability. Physicians are only compensated up to two office visits a month under most insurances. Financially, this may be manageable in a large academic center setting but not in private practice. Providers will face difficulty in light of emerging therapies and complex treatment plans. Physician factors should be considered and solutions sought, otherwise much of Hepatitis C will remain untreated.
Sa1167 Determinants of Health-Related Quality of Life in Crohn's Disease: A Systematic Review and Meta-Analysis Mike V. Have, Karen S. van der Aalst, Adrian A. Kaptein, Max Leenders, Peter D. Siersema, Bas Oldenburg, Herma Fidder Background and aims: Health-related quality of life (HRQOL) is increasingly recognized as an important patient-reported outcome, although rarely implemented into clinical practice. A comprehensive understanding of the determinants of Crohn's Disease patients' HRQOL may facilitate clinicians in clinical decision making, defining risk groups and allowing more accurate prediction of HRQOL. Therefore, we systematically assessed the determinants of HRQOL in adult CD patients. Methods: The databases PubMed, EMBASE, the Cochrane Library, PsycINFO and CINAHL were searched for English abstracts related to socio-demographic, psychological, clinical and treatment-related determinants of HRQOL in CD. Two independent reviewers extracted study characteristics and assessed the methodological quality according the criteria of Hayden et al. Main outcome was the number of studies showing a statistically significant association between the above-mentioned determinants and HRQOL. A meta-analysis was performed to quantify the relationship between disease activity and HRQOL. Results: Of the 2,060 articles identified, 24 original studies were included. The majority of studies originated from Europe (15/24; 63%) and had a cross-sectional design (15/24; 63%). Sample sizes varied between 52 and 628 patients, with a majority of females (3576/ 5735; 62%) and with mean/median ages ranging from 29 to 45 years. Most studies had a moderate to high quality. Data on psychological determinants were limited. Work disability, increased disease activity, number of relapses, corticosteroid use and hospitalization rate were significantly associated with a lower HRQOL in the majority of included studies. Use of biologicalspositively influenced HRQOL. The pooled data on the association between disease activity and HRQOL resulted in a weighed mean correlation coefficient of -0.61 (CI -0.65 to -0.57). Conclusions: HRQOL of adult CD patients is consistently determined by markers of active disease, including work disability, increased disease activity, number of relapses, corticosteroid use and hospitalization rate. However, these determinants are not very helpful for clinicians when dealing with asymptomatic CD patients or when choosing between treatments with a comparable clinical efficacy. In addition, as disease activity contributed to only 37% of CD patients' HRQOL, there remains a need for additional, possibly modifiable, determinants.
Sa1169 Incidence of Venous Thromboembolism in Gastrointestinal Bleeding Neel Malhotra, Nilesh Chande Background: Patients with acute gastrointestinal (GI) bleeding represent a challenging population to manage with respect to the safety of anticoagulant therapy for prophylaxis against venous thromboembolism during hospital admission. Methods: Over a two-year period, 1014 patients with acute upper or lower GI bleeding were hospitalized at our centre. Inclusion criteria included those admitted with a primary diagnosis of a GI bleed along with any endoscopic confirmed source. Patients who developed GI bleeding while already admitted for another reason were excluded. Only the initial event was considered in those with recurrent hospitalizations. The primary end point was the development of venous thromboembolism (deep venous thrombosis or pulmonary embolism) within one year after presentation. Results: Among those excluded, 359 patients developed GI bleeding after admission and 121 had no definitive source of bleed identified. Data for 504 patients admitted with GI bleeding was eligible for review. Prior to admission, 324 patients were on some form of anticoagulation (mostly aspirin, n=256). Upper gastrointestinal bleeding was more common than lower (n=350 vs. n=154). 397 patients (78.8%) were not given VTE prophylaxis during their hospitalization. Of those that were, 36 patients (7.2%) were given prophylactic dalteparin or heparin for the duration of their stay. A further 38 patients (7.6%) were given VTE prophylaxis for a portion of their hospitalization. 113 patients had at least one other risk factor for VTE including recent or subsequent surgery, past thrombotic events or malignancy, however only 24 of these patients received VTE prophylaxis. The total number of VTE events was 20 (3.97%). However, the incidence of thrombosis in those with other
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AGA Abstracts