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Telemedicine: A Modern Application in the Treatment of Chronic Hepatitis C Infection
demonstrated that the 2001 acetaminophen legislation has significantly reduced admissions from AO in Ireland in the five years(2002-2006) following the legislation. This effect has also been maintained in the following five years. This study can potentially be used as a basis for legislation on other potential harmful substances for example minimum pricing for alcohol which the Irish government is currently reviewing. [i]O'Rourke et al. Ir J Med Sci. 2002 Jul-Sep;171(3):148-50 [ii]Nourjah et al. Pharmacoepidemiol Drug Safety 2006 Jun,15(6) [iii]S.I 150/2001 Medicinal products control of Paracetamol Regulations, 2001 [iv]Ismail MS et al. Gastroenterology, Vol. 146, Issue 5 s-129. May 2014
Flesch Reading Ease graph depicting mean readability scores for different websites analyzed for gastroesophageal reflux disease. Flesch Reading Ease reports a score over a wide range, with 90-100 being intended for 11 year old students, 60-70 being intended for 6th grade, and 0-30 for university graduates.
Mean number of admissions for acetaminophen overdose including p values
Flesch Reading Ease graph depicting mean readability scores for different websites analyzed for Barrett's esophagus. Flesch Reading Ease reports a score over a wide range, with 90-100 being intended for 11 year old students, 60-70 being intended for 6th grade, and 0-30 for university graduates.
Tu1060 THE EFFECT OF ACETAMINOPHEN (PARACETAMOL) LEGISLATION ON ADMISSIONS FOR ACETAMINOPHEN OVERDOSE IN IRELAND Mohd Syafiq Ismail, Brian Christopher, Clifford Kiat, Elizabeth Tatro, P. Aiden Mccormick, Ross MacNicholas, Diarmaid Houlihan
Number of admission for acetaminophen overdose per year in Ireland. Dotted line representing the 2001 legislation
Introduction Acetaminophen is one of the most common substances taken in overdose and ease of access to this drug has been described as a principal factor for it so commonly used[i]. Acetaminophen overdose (AO) can have catastrophic effects leading to fulminant liver failure and death. In the United States a study has estimated AO accounts for 56000 emergency room visits, 26000 hospitalizations and 458 deaths during the period of 19901998[ii]. In the year 2001, Ireland introduced a pack size legislation limiting access to 24 tablets in a pharmacy and 12 tablets in a non-pharmacy setting in a single transaction[iii]. One study has shown reduced number of admissions from AO in a single referral centre but to date no data has been collected to assess the impact at a national level[iv]. Aim The aim of this study is to assess whether the 2001 legislation has had an impact to reduce hospital admissions from AO in Ireland. Method Data was obtained from Healthcare Pricing Office under Health Service Executive Ireland. This office collects data from inpatient admissions to each hospital in Ireland. Discharge data for AO was obtained from the period of 1997 to 2011. The data from the five years before and after the legislation was compared(19972001vs.2002-2006). The data from the first five years following legislation(2002-2006) was then compared to a further five years(2007-2011) to assess whether the changes were maintained. Parametric data was compared using an unpaired t-test. A value of <0.05 was considered statistically significant. Results There were a total of 14225 patients admitted to over the 10 year period(1997-2006) with AO. 4674(32.85%) patients were male and 9551(67.14%) patients were female. Total number of admissions from 1997-2001 was 7647 and from 2002-2006 was 6414. There was a statistically significant difference between the mean number of admission between the two periods(1529±72.7vs1315.6± 140.78;p value 0.0166). From the year 2007-2011 a total of 5719 were admitted. A statistically significant difference was again noted when comparing mean number of admissions from 2002-2006 to 2007-2011(1315.6±140.78vs1143.80±85.73;p value 0.0481). Conclusion This study has
Tu1061 TELEMEDICINE: A MODERN APPLICATION IN THE TREATMENT OF CHRONIC HEPATITIS C INFECTION Melissa Vitolo, Stefanie Purdon, Erik Kimble, Armen Henderson, Marie Antoine, Elizabeth Vilches-Olivera, Andrew C. Elden, Maria D. Hernandez, Marco A. Ladino Introduction As technology has advanced in recent decades, telemedicine has joined the forefront of practice modalities to facilitate communication with patients with barriers to care. Telemedicine is the use of telecommunications technology to allow health care professionals to evaluate and manage patients remotely. We sought to evaluate the effectiveness of telemedicine in the context of hepatitis C (HCV) treatment. The Miami VA Healthcare System serves veterans in three South Florida counties. In order to overcome geographical barriers and facilitate patient access to direct antiviral agents (DAA), a Provider-Patient Tele-Hepatology clinic using a secured videoconference was implemented. Material and Methods We retrospectively identified patients evaluated in the Tele-Hepatology clinic at the Miami VA Medical Center between 2014 and 2016. All patients were undergoing treatment for chronic hepatitis C infection. The initial visit was held in the main medical center, where an in-person evaluation was held to discuss compliance, indications, and contraindications to therapy. Patients were selected for Tele-Hepatology follow up based on geographic location. Those living greater than 40 miles from the main medical center were offered follow up via telecommunication methods. Patients were required to travel to a telemedicine clinic in a
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AGA Abstracts
AGA Abstracts
with other subsections with a mean grade level of 11.88±1.36 which was significantly higher than the symptoms subsection which had the least mean reading grade level (9.87±1.94) when compared with SMOG & GF (p<0.05). For BE, complications subsection had the highest mean grade level (12±1.06), while causes subsection recorded the least (8.94±1.36). ANOVA and post-hoc analysis showed that ASGE & ACG had significantly higher grade level than WebMD & Healthline, which had the least readability grade level. The complications section was usually the most difficult section when compared with other subsections. Conclusion: Patient material is above the recommended 6th grade level across all websites. Greater emphasis on clear & simple language is needed to increase quality & comprehension of online patient education resources in the selected websites.
AGA Abstracts
remote location, where they had a 15-30 minute visit via video conference. The interaction between patient and provider was in real time using a secured system. The outcome was successful compliance to therapy and satisfaction using the Tele-Hepatology clinic. Results A total of 38 patients were evaluated between 2014-2016 in Tele-Hepatology clinic. There were 97% males and 3% females. Average age was 64 years old. The DAA regimens included 32 patients on sofosbuvir in the following combinations: 14 patients with ledipasvir, 8 patients with simeprevir, and 15 patients with ribavirin. Six patients were on a combination treatment of ombitasvir/paritaprevir/ritonavir/dasabuvir and 4 of these received this in conjunction with ribavirin. Patients attended an average of two Tele-Hepatology visits over the course of their treatment. A sustained viral response (SVR) was achieved in 97.4% of patients. Common adverse medication effects were reported and addressed during these visits. A medication compliance rate of 100% was attained. Conclusions Tele-Hepatology evaluation for HCV DAA therapy with DAA here have been shown to produce effective rates of SVR and medication compliance as compared to those found in standard clinical practice. In patients who would benefit from treatment for chronic HCV but have limitations to necessary follow-up, telemedicine may offer a unique opportunity to access a hepatology specialist. Table 1: Patient Characteristics and Response to DAA Therapy
CI 1.33-2.36), Asian race (OR 1.75, CI 1.18-2.59), Medicaid insurance (OR 3.50, CI 2.455.00), and No Insurance (OR 3.51, CI 2.30-5.36) were risk factors for not receiving Delayed CCY on multivariate analysis. In the 60 days following discharge, 12.1% of patients who did not receive CCY had a RBE compared to 1.1% of patients who had Index CCY (Figure 1A, p<0.0001). In the 180 days following discharge, 19.1% of the No CCY cohort had a RBE, compared to 8.9% in the Delayed CCY cohort, and 1.7% in the Index CCY cohort (Figure 1B, p<0.0001). Conclusions: Almost half of patients who present with choledocholithiasis requiring ES and stone extraction do not undergo CCY within 60 days of discharge. Asian race and Medicaid insurance are risk factors for not receiving Index CCY. Hispanic and Asian race, Medicaid insurance, and No Insurance are strong risk factors for not receiving Delayed CCY. RBEs are 11-fold more likely to occur with No CCY, and 5-fold more likely to occur with Delayed CCY compared to Index CCY in the 180 days following discharge. Clinicians should consider referral for CCY at index admission as a substantial number of patients will either develop interval RBE or be lost to follow-up. Table 1: Odds Ratio (OR) and Confidence Intervals (CI) for Variables Predicting Not Receiving Cholecystectomy
SVR: Sustained Virologic Response, Std Dev: Standard Deviation; [CI]; Confidence Intervals represented in brackets Table 2: DAA Therapy for Genotypes 1 and 2 Therapy
* Multivariate model statistics: c = 0.693, intercept = -1.4071, likelihood ratio for testing global null hypothesis, χ2 = 542.2 (p < 0.0001). ** Multivariate model statistics: c = 0.704, intercept = -0.6979, likelihood ratio for testing global null hypothesis, χ2 = 209.6 (p < 0.0001). DAA: Direct Acting Antiviral; SOF: sofosbuvir, LED: ledipasvir, DAC: daclastavir, RIB: ribavirin, SIM: simeprevir; VK: ombitasvir/paritaprevir/ritonavir/dasabuvir
Tu1062 PRACTICE PATTERNS OF CHOLECYSTECTOMY FOLLOWING ERCP WITH ENDOSCOPIC SPHINCTEROTOMY FOR CHOLEDOCHOLITHIASIS IN THE UNITED STATES Robert J. Huang, Monique T. Barakat, Mohit Girotra, Subhas Banerjee Background: Previous studies have shown that cholecystectomy (CCY) following an episode of choledocholithiasis requiring ERCP with endoscopic sphincterotomy (ES) and stone extraction reduces risk of recurrent biliary event (RBE, defined as recurrent choledocholithiasis, cholangitis, cholecystitis or biliary pancreatitis) compared to expectant management. Furthermore, early CCY (at index admission) may be superior to delayed CCY. Consistency in performing CCY in this patient group in the United States has not been studied. Methods: We utilized the longitudinal, all-capture state inpatient and emergency department databases from California, Florida, and New York from 2009 to 2014. We identified all patients hospitalized with a diagnosis of choledocholithiasis and cholelithiasis without cholecystitis, who underwent ES with stone clearance. We determined if patients underwent CCY at index admission (Index CCY), elective CCY within 60 days of discharge (Delayed CCY), or did not undergo CCY within 60 days of discharge (No CCY), and analyzed rates of RBE for each of these CCY classes. We determined risk factors for not receiving Index or Delayed CCY. Results: 4,798 patients met inclusion and exclusion criteria. 41.0% of patients had Index CCY, 10.8% of patients had Delayed CCY, and 48.2% of patients had No CCY. Increasing age (OR 1.24, CI 1.18-1.29), increasing comorbidity (OR 1.10, CI 1.07-1.13), Asian race (OR 1.50, CI 1.16-1.93), and Medicaid insurance (OR 1.25, CI 1.03-1.52) were risk factors for not receiving Index CCY in multivariate analysis. Increasing age (OR 1.18, CI 1.10-1.27), increasing comorbidity (OR 1.10, CI 1.06-1.15), Hispanic race (OR 1.77,
AGA Abstracts
Figure 1A: Risk of recurrent biliary event in 60 days following index discharge, based on index cholecystectomy status (blue - index cholecystectomy, red - no index cholecystectomy). Patients censored at either time of elective cholecystectomy, or at 60 days from index hospitalization discharge. 95% confidence intervals in color bands. Figure 1B: Risk of recurrent biliary event in 180 days following index discharge, based on cholecystectomy status (blue - index cholecystectomy, green - delayed cholecystectomy, red - no cholecystectomy). All patients censored at 180 days. 95% confidence intervals in color bands.
Tu1063 DESPITE HIGH INTEREST IN TELEMEDICINE VIDEO VISITS FOR MAINTENANCE IBD CARE, FEW PATIENTS ARE WILLING TO PAY MORE FOR INCREASED CONVENIENCE Jack W. Bevins, Shail M. Govani, Akbar K. Waljee, Peter D. Higgins, Ryan W. Stidham BACKGROUND: Synchronous telemedicine services offer the potential to address geographic and access barriers to specialty care for inflammatory bowel disease (IBD). Our aim was to assess patients' interest, comfort and expectations for remote video visits replacing
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Flesch Reading Ease graph depicting mean readability scores for different websites analyzed for gastroesophageal reflux disease. Flesch Reading Ease reports a score over a wide range, with 90-100 being intended for 11 year old students, 60-70 being intended for 6th grade, and 0-30 for university graduates.
Mean number of admissions for acetaminophen overdose including p values
Flesch Reading Ease graph depicting mean readability scores for different websites analyzed for Barrett's esophagus. Flesch Reading Ease reports a score over a wide range, with 90-100 being intended for 11 year old students, 60-70 being intended for 6th grade, and 0-30 for university graduates.
Tu1060 THE EFFECT OF ACETAMINOPHEN (PARACETAMOL) LEGISLATION ON ADMISSIONS FOR ACETAMINOPHEN OVERDOSE IN IRELAND Mohd Syafiq Ismail, Brian Christopher, Clifford Kiat, Elizabeth Tatro, P. Aiden Mccormick, Ross MacNicholas, Diarmaid Houlihan
Number of admission for acetaminophen overdose per year in Ireland. Dotted line representing the 2001 legislation
Introduction Acetaminophen is one of the most common substances taken in overdose and ease of access to this drug has been described as a principal factor for it so commonly used[i]. Acetaminophen overdose (AO) can have catastrophic effects leading to fulminant liver failure and death. In the United States a study has estimated AO accounts for 56000 emergency room visits, 26000 hospitalizations and 458 deaths during the period of 19901998[ii]. In the year 2001, Ireland introduced a pack size legislation limiting access to 24 tablets in a pharmacy and 12 tablets in a non-pharmacy setting in a single transaction[iii]. One study has shown reduced number of admissions from AO in a single referral centre but to date no data has been collected to assess the impact at a national level[iv]. Aim The aim of this study is to assess whether the 2001 legislation has had an impact to reduce hospital admissions from AO in Ireland. Method Data was obtained from Healthcare Pricing Office under Health Service Executive Ireland. This office collects data from inpatient admissions to each hospital in Ireland. Discharge data for AO was obtained from the period of 1997 to 2011. The data from the five years before and after the legislation was compared(19972001vs.2002-2006). The data from the first five years following legislation(2002-2006) was then compared to a further five years(2007-2011) to assess whether the changes were maintained. Parametric data was compared using an unpaired t-test. A value of <0.05 was considered statistically significant. Results There were a total of 14225 patients admitted to over the 10 year period(1997-2006) with AO. 4674(32.85%) patients were male and 9551(67.14%) patients were female. Total number of admissions from 1997-2001 was 7647 and from 2002-2006 was 6414. There was a statistically significant difference between the mean number of admission between the two periods(1529±72.7vs1315.6± 140.78;p value 0.0166). From the year 2007-2011 a total of 5719 were admitted. A statistically significant difference was again noted when comparing mean number of admissions from 2002-2006 to 2007-2011(1315.6±140.78vs1143.80±85.73;p value 0.0481). Conclusion This study has
Tu1061 TELEMEDICINE: A MODERN APPLICATION IN THE TREATMENT OF CHRONIC HEPATITIS C INFECTION Melissa Vitolo, Stefanie Purdon, Erik Kimble, Armen Henderson, Marie Antoine, Elizabeth Vilches-Olivera, Andrew C. Elden, Maria D. Hernandez, Marco A. Ladino Introduction As technology has advanced in recent decades, telemedicine has joined the forefront of practice modalities to facilitate communication with patients with barriers to care. Telemedicine is the use of telecommunications technology to allow health care professionals to evaluate and manage patients remotely. We sought to evaluate the effectiveness of telemedicine in the context of hepatitis C (HCV) treatment. The Miami VA Healthcare System serves veterans in three South Florida counties. In order to overcome geographical barriers and facilitate patient access to direct antiviral agents (DAA), a Provider-Patient Tele-Hepatology clinic using a secured videoconference was implemented. Material and Methods We retrospectively identified patients evaluated in the Tele-Hepatology clinic at the Miami VA Medical Center between 2014 and 2016. All patients were undergoing treatment for chronic hepatitis C infection. The initial visit was held in the main medical center, where an in-person evaluation was held to discuss compliance, indications, and contraindications to therapy. Patients were selected for Tele-Hepatology follow up based on geographic location. Those living greater than 40 miles from the main medical center were offered follow up via telecommunication methods. Patients were required to travel to a telemedicine clinic in a
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AGA Abstracts
AGA Abstracts
with other subsections with a mean grade level of 11.88±1.36 which was significantly higher than the symptoms subsection which had the least mean reading grade level (9.87±1.94) when compared with SMOG & GF (p<0.05). For BE, complications subsection had the highest mean grade level (12±1.06), while causes subsection recorded the least (8.94±1.36). ANOVA and post-hoc analysis showed that ASGE & ACG had significantly higher grade level than WebMD & Healthline, which had the least readability grade level. The complications section was usually the most difficult section when compared with other subsections. Conclusion: Patient material is above the recommended 6th grade level across all websites. Greater emphasis on clear & simple language is needed to increase quality & comprehension of online patient education resources in the selected websites.
AGA Abstracts
remote location, where they had a 15-30 minute visit via video conference. The interaction between patient and provider was in real time using a secured system. The outcome was successful compliance to therapy and satisfaction using the Tele-Hepatology clinic. Results A total of 38 patients were evaluated between 2014-2016 in Tele-Hepatology clinic. There were 97% males and 3% females. Average age was 64 years old. The DAA regimens included 32 patients on sofosbuvir in the following combinations: 14 patients with ledipasvir, 8 patients with simeprevir, and 15 patients with ribavirin. Six patients were on a combination treatment of ombitasvir/paritaprevir/ritonavir/dasabuvir and 4 of these received this in conjunction with ribavirin. Patients attended an average of two Tele-Hepatology visits over the course of their treatment. A sustained viral response (SVR) was achieved in 97.4% of patients. Common adverse medication effects were reported and addressed during these visits. A medication compliance rate of 100% was attained. Conclusions Tele-Hepatology evaluation for HCV DAA therapy with DAA here have been shown to produce effective rates of SVR and medication compliance as compared to those found in standard clinical practice. In patients who would benefit from treatment for chronic HCV but have limitations to necessary follow-up, telemedicine may offer a unique opportunity to access a hepatology specialist. Table 1: Patient Characteristics and Response to DAA Therapy
CI 1.33-2.36), Asian race (OR 1.75, CI 1.18-2.59), Medicaid insurance (OR 3.50, CI 2.455.00), and No Insurance (OR 3.51, CI 2.30-5.36) were risk factors for not receiving Delayed CCY on multivariate analysis. In the 60 days following discharge, 12.1% of patients who did not receive CCY had a RBE compared to 1.1% of patients who had Index CCY (Figure 1A, p<0.0001). In the 180 days following discharge, 19.1% of the No CCY cohort had a RBE, compared to 8.9% in the Delayed CCY cohort, and 1.7% in the Index CCY cohort (Figure 1B, p<0.0001). Conclusions: Almost half of patients who present with choledocholithiasis requiring ES and stone extraction do not undergo CCY within 60 days of discharge. Asian race and Medicaid insurance are risk factors for not receiving Index CCY. Hispanic and Asian race, Medicaid insurance, and No Insurance are strong risk factors for not receiving Delayed CCY. RBEs are 11-fold more likely to occur with No CCY, and 5-fold more likely to occur with Delayed CCY compared to Index CCY in the 180 days following discharge. Clinicians should consider referral for CCY at index admission as a substantial number of patients will either develop interval RBE or be lost to follow-up. Table 1: Odds Ratio (OR) and Confidence Intervals (CI) for Variables Predicting Not Receiving Cholecystectomy
SVR: Sustained Virologic Response, Std Dev: Standard Deviation; [CI]; Confidence Intervals represented in brackets Table 2: DAA Therapy for Genotypes 1 and 2 Therapy
* Multivariate model statistics: c = 0.693, intercept = -1.4071, likelihood ratio for testing global null hypothesis, χ2 = 542.2 (p < 0.0001). ** Multivariate model statistics: c = 0.704, intercept = -0.6979, likelihood ratio for testing global null hypothesis, χ2 = 209.6 (p < 0.0001). DAA: Direct Acting Antiviral; SOF: sofosbuvir, LED: ledipasvir, DAC: daclastavir, RIB: ribavirin, SIM: simeprevir; VK: ombitasvir/paritaprevir/ritonavir/dasabuvir
Tu1062 PRACTICE PATTERNS OF CHOLECYSTECTOMY FOLLOWING ERCP WITH ENDOSCOPIC SPHINCTEROTOMY FOR CHOLEDOCHOLITHIASIS IN THE UNITED STATES Robert J. Huang, Monique T. Barakat, Mohit Girotra, Subhas Banerjee Background: Previous studies have shown that cholecystectomy (CCY) following an episode of choledocholithiasis requiring ERCP with endoscopic sphincterotomy (ES) and stone extraction reduces risk of recurrent biliary event (RBE, defined as recurrent choledocholithiasis, cholangitis, cholecystitis or biliary pancreatitis) compared to expectant management. Furthermore, early CCY (at index admission) may be superior to delayed CCY. Consistency in performing CCY in this patient group in the United States has not been studied. Methods: We utilized the longitudinal, all-capture state inpatient and emergency department databases from California, Florida, and New York from 2009 to 2014. We identified all patients hospitalized with a diagnosis of choledocholithiasis and cholelithiasis without cholecystitis, who underwent ES with stone clearance. We determined if patients underwent CCY at index admission (Index CCY), elective CCY within 60 days of discharge (Delayed CCY), or did not undergo CCY within 60 days of discharge (No CCY), and analyzed rates of RBE for each of these CCY classes. We determined risk factors for not receiving Index or Delayed CCY. Results: 4,798 patients met inclusion and exclusion criteria. 41.0% of patients had Index CCY, 10.8% of patients had Delayed CCY, and 48.2% of patients had No CCY. Increasing age (OR 1.24, CI 1.18-1.29), increasing comorbidity (OR 1.10, CI 1.07-1.13), Asian race (OR 1.50, CI 1.16-1.93), and Medicaid insurance (OR 1.25, CI 1.03-1.52) were risk factors for not receiving Index CCY in multivariate analysis. Increasing age (OR 1.18, CI 1.10-1.27), increasing comorbidity (OR 1.10, CI 1.06-1.15), Hispanic race (OR 1.77,
AGA Abstracts
Figure 1A: Risk of recurrent biliary event in 60 days following index discharge, based on index cholecystectomy status (blue - index cholecystectomy, red - no index cholecystectomy). Patients censored at either time of elective cholecystectomy, or at 60 days from index hospitalization discharge. 95% confidence intervals in color bands. Figure 1B: Risk of recurrent biliary event in 180 days following index discharge, based on cholecystectomy status (blue - index cholecystectomy, green - delayed cholecystectomy, red - no cholecystectomy). All patients censored at 180 days. 95% confidence intervals in color bands.
Tu1063 DESPITE HIGH INTEREST IN TELEMEDICINE VIDEO VISITS FOR MAINTENANCE IBD CARE, FEW PATIENTS ARE WILLING TO PAY MORE FOR INCREASED CONVENIENCE Jack W. Bevins, Shail M. Govani, Akbar K. Waljee, Peter D. Higgins, Ryan W. Stidham BACKGROUND: Synchronous telemedicine services offer the potential to address geographic and access barriers to specialty care for inflammatory bowel disease (IBD). Our aim was to assess patients' interest, comfort and expectations for remote video visits replacing
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