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The Boston Bowel Preparation Scale: Introduction of a Valid and Reliable Tool to the Dvamc Endoscopy Unit
Factors Associated with a Delay in Post-Surgical Biologic Therapy
AGA Abstracts
improve the quality of our EGD pathology in regards to Barrett's esophagus surveillance, gastric intestinal metaplasia, and Helicobacter pylori treatment.
Table A
412 BARRIERS TO POST-SURGICAL BIOLOGIC THERAPY IN CROHN'S DISEASE Shirley A. Cohen-Mekelburg, Stephanie Gold, Yecheskel Schneider, Madison Dennis, Clara Oromendia, Fabrizio Michelassi, Ellen Scherl, Adam F. Steinlauf Introduction: A significant proportion of patients with Crohn's disease (CD) will develop complications requiring surgery. However, surgery is not a cure for CD, and a majority will develop disease recurrence. Multiple studies have shown that infliximab and adalimumab can reduce rates of post-surgical recurrence, particularly with a preventative approach. Anecdotally, we see many CD patients returning to care after a surgical resection with recurrent symptoms which could have potentially been prevented with post-operative biologic therapy. We aimed to identify risk factors for delay in the initiation of post-operative biologic therapy in high-risk CD patients. Methods: We performed a retrospective chart review of CD patients who underwent a bowel resection from 1/2013-3/2016 at a tertiary care center. We excluded patients who lacked indications for post-operative prophylaxis and those with contraindications to biologic therapy. Delay in therapy was defined as initiation of biologic therapy more than 4 weeks after surgery. We explored a variety of characteristics of patients with and without delay both univariably (chi-square and Kruskal Wallis tests) and using multivariable logistic regression. Results: 174 subjects with CD who underwent resection were reviewed. 110 patients met inclusion criteria (Figure 1), of which 69% had a delay in post-operative prophylactic therapy. 23.6% were lost to follow-up, so information regarding a post-operative strategy was unavailable. Publicly insured patients had a 100% rate of delay in post-surgical biologic prophylaxis (p=0.035). Patients off all CD-specific therapy prior to surgery (p=0.007) were more likely to have a delay in postoperative biologic therapy. Patients on biologic therapy prior to surgery (p<0.001) and those living outside the vicinity of treatment facility (p=0.026) were less likely to have a delay in post-surgical biologic prophylaxis (Table 1). On multivariate logistic regression, delay among patients within the vicinity of treatment facility was not explained by other factors. Additionally, there was no difference in delay of post-surgical biologic therapy based on systemic factors (Table 1). Further, on sensitivity analysis, there was no significant differences based on whether patients were lost to follow up. Conclusions: To provide our CD patients with the highest quality care, we must identify barriers to timely post-operative biologic therapy. Insurance status, vicinity to treatment facility, and pre-operative CD therapy should be considered in targeting patients for future quality improvement efforts.
413 THE BOSTON BOWEL PREPARATION SCALE: INTRODUCTION OF A VALID AND RELIABLE TOOL TO THE DVAMC ENDOSCOPY UNIT Scharles Konadu, Alyson A. McGhan, Jill Moore Introduction According to the US Multisociety Task Force on Colorectal Cancer screening, reporting the quality of the bowel preparation is required to appropriately recommend interval screening or surveillance. The Boston Bowel Preparation Scale (BBPS) is a validated, standardized scoring scale to assess bowel preparation after cleansing and during withdrawal. As part of a quality improvement initiative in 2015, we developed a method to transition our Durham VA Medical Center (DVAMC) endoscopy unit from our previously used subjective bowel preparation scoring system (Excellent/Good/Fair/Poor) to the objective Boston Bowel Preparation Scale. Methods The DVAMC endoscopy unit is primarily a GI fellow based unit with faculty supervision. Our previous method for reporting bowel preparation quality was based on a subjective scoring system (Excellent/Good/Fair/Poor). In order to transition to the BBPS, first, we created an instructional handout which included details on the validity of the BBPS, illustrative examples of the scoring system, and a link to an instructional video (http://www.cori.org/bbps/instruction.php) for scoring. Then, we instructed the endoscopy nurses, GI fellows and faculty on how to use and record the BBPS. In March 2015, we implemented the use of the BPPS for all screening colonoscopies. We reviewed 270 randomly selected screening colonoscopy reports between April 2015 and May 2016 and assessed compliance to BBPS. Goal was for 80% compliance by all endoscopists, fellows and faculty. Mid study interventions included incorporating the BBPS into our EndoWorks report template in October 2015. Results In April 2015 compliance was 3.33%, in October 2015 60%, and after mid study intervention the compliance for November, December and January were 73%, 70% and 80%, respectively. Compliance was also reviewed in the 2016 months of March, April and May with rates of 80%, 86% and 83% respectively.
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AGA Abstracts
AGA Abstracts
We found higher compliance rates from fellows (90%) compared to attendings (67%). Figure 1. All patients with a BBPS of 5 or below received a recommendation for repeat colonoscopy within one year. Conclusion We implemented the use of the BBPS for the report of bowel preparation quality in screening colonoscopy. We achieved our compliance goal of 80% by the end of study period with the use of our instructional handouts, education of all providers, and incorporation of the scale into our Endoworks report template. Appropriate interval colonoscopy recommendations were made based on bowel prep score. There were several challenges to the implementation of the BBPS including rotating GI fellows in the DVAMC endoscopy unit, changes in the faculty who were working within our endoscopy unit, and incorporating the scale into a non-customizable EMR. Limits of the study include small sample size and manual rather than automated recording of BBPS score within Endoworks.
Table 1
Figure 1
414 A GOOD BOWEL PREP, CAN WE AS PHYSICIANS DO BETTER? Noemi J. Baffy, Diana L. Franco, Michael D. Crowell, Francisco C. Ramirez, Sarah B. Umar Background Colorectal cancer (CRC) is a leading cause of cancer death in the US and high quality colonoscopy is key to efficient CRC screening and detection. Studies have shown that 18% to 31% of patients have inadequate bowel preparation (BP) and nearly 20% of these patients fail to follow instructions. We hypothesized that educating physicians who order colon purgatives with general tips on good quality bowel cleansing will improve the adequacy of preparation. Aims The aim of this quality improvement project was to determine whether a teaching intervention for ordering primary care physicians improves patient BP quality and changes prescribing habits. Methods This was a prospective cohort study. Physicians ordering colonoscopies in primary care practices were provided with a brief teaching session and informational card regarding the available bowel cleansing agents and useful tips for a good BP. Patients undergoing a screening or diagnostic colonoscopy 3 months pre-and post-intervention were identified from endoscopy records. Outpatient charts were reviewed to record demographics and additional data on patient factors. Analysis of variance or the Student t-test was used to compare groups. The Chi-squared test was used to assess differences in distributions of categorical variables. Results A total of 192 patients underwent screening or diagnostic colonoscopies three months preceding the teaching intervention compared to 175 patients afterwards. Gender, body mass index, ethnicity and patient factors (Table 1) were similar between the two groups except for a slightly older population (mean age 64.8 vs 60.8) present in the pre-intervention group. BP quality overall was good in both groups as assessed by the total Boston Bowel Prep Score (BBPS, 6.64 vs. 6.66) and only 9 compared to 8 patients had inadequate preparation (BBPS < 5) pre- and postintervention, respectively (NS). Additional measures of quality such as segmental BBPS scores and withdrawal time did not show a marked improvement after intervention. The majority of physicians prescribed large volume purgatives with the preferred split dosing (Table 2). The presence of patient factors such as diabetes, narcotic use, chronic constipation, prior colon surgery was associated with inadequate BP (BBPS <5) (p=0.0029). Discussion Inadequate BP is a common problem with potential impact on CRC screening quality. In our cohort, provider education had no measurable impact on BP quality, which was already adequate in most patients prior to our proposed intervention. However, our negative findings on the role of provider education may not translate into all practice settings. Furthermore, patient related risk factors were associated with worse BP quality, indicating the importance of tailoring our colon prep prescribing practices by these parameters in order to achieve high quality colonoscopy
AGA Abstracts
Table 2
415 ADHERENCE TO THE AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES (AASLD) GUIDELINES FOR REPEATING ENDOSCOPY IN PATIENTS WITH BANDING FOR VARICEAL HEMORRHAGE OR PRIMARY PROPHYLAXIS Elias Spyrou, Melissa Latorre, Jeremy Kaplan, Anish Patel, Rita-Maria Abdelmessih, David Markowitz Background: In 2012 the American Association for the Study of Liver Diseases (AASLD) issued guidelines recommending that patients treated with endoscopic variceal ligation (EVL) for either bleeding or prophylaxis, should have a repeat endoscopy (EGD) and EVL every 1-2 weeks until obliteration. To our knowledge, adherence to these guidelines has not been assessed. Our primary aim is to measure adherence to this recommendation and to identify variables that are associated with adherence. Methods: This is a retrospective study, which involved reviewing medical records of patients who had undergone EGD and EVL for variceal hemorrhage or primary prophylaxis at our academic medical center. The purpose of the study was to determine whether patients had a repeat EGD for EVL as per guidelines, and it was performed over a 4 year period (7/1/2012 to 6/30/2016). Data collected included: age, gender, marital status, type of insurance, prior known varices at the time of index EGD/ EVL, use of beta blocker at time of index EGD/EVL, date of index EGD, date of follow-up EGD, type of sedation used during initial EGD/EVL, etiology of cirrhosis and/or portal hypertension, type of provider (fellow, transplant hepatologist, gastroenterologist), whether follow-up EGD date was provided, whether follow-up appointment was provided, laboratory data and based on our collected data we calculated MELD score, Child-Pugh score, and Child-Pugh class at index EGD. Results: We identified 152 patients who had at least one EVL, with 99 (65%) having a documented follow-up EGD. After comparing patients who did and did not have a follow-up EGD, there were statistically significant differences in etiology of portal hypertension and liver disease, survival, MELD, Child-Pugh Class (Image 1). Amongst patients who had a follow-up EGD, only 15 (15.1%) had an EGD within 2 weeks. The remaining 84 patients (84.9%) had an average time to follow-up EGD of 242 days (range: 16-2664). On multivariable analysis, providing a follow-up EGD date was the only factor that was significant for obtaining an EGD within 2 weeks (OR=20.5, 95% CI: 2.79 - 170.9) after accounting for other variables listed above. Conclusions: There is suboptimal adherence to the guidelines recommending a repeat EGD in 2 weeks for patients who underwent EVL. This analysis suggests that adherence to guidelines may be improved by documenting and scheduling a specific follow-up date within 2 weeks.
S-100
AGA Abstracts
improve the quality of our EGD pathology in regards to Barrett's esophagus surveillance, gastric intestinal metaplasia, and Helicobacter pylori treatment.
Table A
412 BARRIERS TO POST-SURGICAL BIOLOGIC THERAPY IN CROHN'S DISEASE Shirley A. Cohen-Mekelburg, Stephanie Gold, Yecheskel Schneider, Madison Dennis, Clara Oromendia, Fabrizio Michelassi, Ellen Scherl, Adam F. Steinlauf Introduction: A significant proportion of patients with Crohn's disease (CD) will develop complications requiring surgery. However, surgery is not a cure for CD, and a majority will develop disease recurrence. Multiple studies have shown that infliximab and adalimumab can reduce rates of post-surgical recurrence, particularly with a preventative approach. Anecdotally, we see many CD patients returning to care after a surgical resection with recurrent symptoms which could have potentially been prevented with post-operative biologic therapy. We aimed to identify risk factors for delay in the initiation of post-operative biologic therapy in high-risk CD patients. Methods: We performed a retrospective chart review of CD patients who underwent a bowel resection from 1/2013-3/2016 at a tertiary care center. We excluded patients who lacked indications for post-operative prophylaxis and those with contraindications to biologic therapy. Delay in therapy was defined as initiation of biologic therapy more than 4 weeks after surgery. We explored a variety of characteristics of patients with and without delay both univariably (chi-square and Kruskal Wallis tests) and using multivariable logistic regression. Results: 174 subjects with CD who underwent resection were reviewed. 110 patients met inclusion criteria (Figure 1), of which 69% had a delay in post-operative prophylactic therapy. 23.6% were lost to follow-up, so information regarding a post-operative strategy was unavailable. Publicly insured patients had a 100% rate of delay in post-surgical biologic prophylaxis (p=0.035). Patients off all CD-specific therapy prior to surgery (p=0.007) were more likely to have a delay in postoperative biologic therapy. Patients on biologic therapy prior to surgery (p<0.001) and those living outside the vicinity of treatment facility (p=0.026) were less likely to have a delay in post-surgical biologic prophylaxis (Table 1). On multivariate logistic regression, delay among patients within the vicinity of treatment facility was not explained by other factors. Additionally, there was no difference in delay of post-surgical biologic therapy based on systemic factors (Table 1). Further, on sensitivity analysis, there was no significant differences based on whether patients were lost to follow up. Conclusions: To provide our CD patients with the highest quality care, we must identify barriers to timely post-operative biologic therapy. Insurance status, vicinity to treatment facility, and pre-operative CD therapy should be considered in targeting patients for future quality improvement efforts.
413 THE BOSTON BOWEL PREPARATION SCALE: INTRODUCTION OF A VALID AND RELIABLE TOOL TO THE DVAMC ENDOSCOPY UNIT Scharles Konadu, Alyson A. McGhan, Jill Moore Introduction According to the US Multisociety Task Force on Colorectal Cancer screening, reporting the quality of the bowel preparation is required to appropriately recommend interval screening or surveillance. The Boston Bowel Preparation Scale (BBPS) is a validated, standardized scoring scale to assess bowel preparation after cleansing and during withdrawal. As part of a quality improvement initiative in 2015, we developed a method to transition our Durham VA Medical Center (DVAMC) endoscopy unit from our previously used subjective bowel preparation scoring system (Excellent/Good/Fair/Poor) to the objective Boston Bowel Preparation Scale. Methods The DVAMC endoscopy unit is primarily a GI fellow based unit with faculty supervision. Our previous method for reporting bowel preparation quality was based on a subjective scoring system (Excellent/Good/Fair/Poor). In order to transition to the BBPS, first, we created an instructional handout which included details on the validity of the BBPS, illustrative examples of the scoring system, and a link to an instructional video (http://www.cori.org/bbps/instruction.php) for scoring. Then, we instructed the endoscopy nurses, GI fellows and faculty on how to use and record the BBPS. In March 2015, we implemented the use of the BPPS for all screening colonoscopies. We reviewed 270 randomly selected screening colonoscopy reports between April 2015 and May 2016 and assessed compliance to BBPS. Goal was for 80% compliance by all endoscopists, fellows and faculty. Mid study interventions included incorporating the BBPS into our EndoWorks report template in October 2015. Results In April 2015 compliance was 3.33%, in October 2015 60%, and after mid study intervention the compliance for November, December and January were 73%, 70% and 80%, respectively. Compliance was also reviewed in the 2016 months of March, April and May with rates of 80%, 86% and 83% respectively.
S-99
AGA Abstracts
AGA Abstracts
We found higher compliance rates from fellows (90%) compared to attendings (67%). Figure 1. All patients with a BBPS of 5 or below received a recommendation for repeat colonoscopy within one year. Conclusion We implemented the use of the BBPS for the report of bowel preparation quality in screening colonoscopy. We achieved our compliance goal of 80% by the end of study period with the use of our instructional handouts, education of all providers, and incorporation of the scale into our Endoworks report template. Appropriate interval colonoscopy recommendations were made based on bowel prep score. There were several challenges to the implementation of the BBPS including rotating GI fellows in the DVAMC endoscopy unit, changes in the faculty who were working within our endoscopy unit, and incorporating the scale into a non-customizable EMR. Limits of the study include small sample size and manual rather than automated recording of BBPS score within Endoworks.
Table 1
Figure 1
414 A GOOD BOWEL PREP, CAN WE AS PHYSICIANS DO BETTER? Noemi J. Baffy, Diana L. Franco, Michael D. Crowell, Francisco C. Ramirez, Sarah B. Umar Background Colorectal cancer (CRC) is a leading cause of cancer death in the US and high quality colonoscopy is key to efficient CRC screening and detection. Studies have shown that 18% to 31% of patients have inadequate bowel preparation (BP) and nearly 20% of these patients fail to follow instructions. We hypothesized that educating physicians who order colon purgatives with general tips on good quality bowel cleansing will improve the adequacy of preparation. Aims The aim of this quality improvement project was to determine whether a teaching intervention for ordering primary care physicians improves patient BP quality and changes prescribing habits. Methods This was a prospective cohort study. Physicians ordering colonoscopies in primary care practices were provided with a brief teaching session and informational card regarding the available bowel cleansing agents and useful tips for a good BP. Patients undergoing a screening or diagnostic colonoscopy 3 months pre-and post-intervention were identified from endoscopy records. Outpatient charts were reviewed to record demographics and additional data on patient factors. Analysis of variance or the Student t-test was used to compare groups. The Chi-squared test was used to assess differences in distributions of categorical variables. Results A total of 192 patients underwent screening or diagnostic colonoscopies three months preceding the teaching intervention compared to 175 patients afterwards. Gender, body mass index, ethnicity and patient factors (Table 1) were similar between the two groups except for a slightly older population (mean age 64.8 vs 60.8) present in the pre-intervention group. BP quality overall was good in both groups as assessed by the total Boston Bowel Prep Score (BBPS, 6.64 vs. 6.66) and only 9 compared to 8 patients had inadequate preparation (BBPS < 5) pre- and postintervention, respectively (NS). Additional measures of quality such as segmental BBPS scores and withdrawal time did not show a marked improvement after intervention. The majority of physicians prescribed large volume purgatives with the preferred split dosing (Table 2). The presence of patient factors such as diabetes, narcotic use, chronic constipation, prior colon surgery was associated with inadequate BP (BBPS <5) (p=0.0029). Discussion Inadequate BP is a common problem with potential impact on CRC screening quality. In our cohort, provider education had no measurable impact on BP quality, which was already adequate in most patients prior to our proposed intervention. However, our negative findings on the role of provider education may not translate into all practice settings. Furthermore, patient related risk factors were associated with worse BP quality, indicating the importance of tailoring our colon prep prescribing practices by these parameters in order to achieve high quality colonoscopy
AGA Abstracts
Table 2
415 ADHERENCE TO THE AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES (AASLD) GUIDELINES FOR REPEATING ENDOSCOPY IN PATIENTS WITH BANDING FOR VARICEAL HEMORRHAGE OR PRIMARY PROPHYLAXIS Elias Spyrou, Melissa Latorre, Jeremy Kaplan, Anish Patel, Rita-Maria Abdelmessih, David Markowitz Background: In 2012 the American Association for the Study of Liver Diseases (AASLD) issued guidelines recommending that patients treated with endoscopic variceal ligation (EVL) for either bleeding or prophylaxis, should have a repeat endoscopy (EGD) and EVL every 1-2 weeks until obliteration. To our knowledge, adherence to these guidelines has not been assessed. Our primary aim is to measure adherence to this recommendation and to identify variables that are associated with adherence. Methods: This is a retrospective study, which involved reviewing medical records of patients who had undergone EGD and EVL for variceal hemorrhage or primary prophylaxis at our academic medical center. The purpose of the study was to determine whether patients had a repeat EGD for EVL as per guidelines, and it was performed over a 4 year period (7/1/2012 to 6/30/2016). Data collected included: age, gender, marital status, type of insurance, prior known varices at the time of index EGD/ EVL, use of beta blocker at time of index EGD/EVL, date of index EGD, date of follow-up EGD, type of sedation used during initial EGD/EVL, etiology of cirrhosis and/or portal hypertension, type of provider (fellow, transplant hepatologist, gastroenterologist), whether follow-up EGD date was provided, whether follow-up appointment was provided, laboratory data and based on our collected data we calculated MELD score, Child-Pugh score, and Child-Pugh class at index EGD. Results: We identified 152 patients who had at least one EVL, with 99 (65%) having a documented follow-up EGD. After comparing patients who did and did not have a follow-up EGD, there were statistically significant differences in etiology of portal hypertension and liver disease, survival, MELD, Child-Pugh Class (Image 1). Amongst patients who had a follow-up EGD, only 15 (15.1%) had an EGD within 2 weeks. The remaining 84 patients (84.9%) had an average time to follow-up EGD of 242 days (range: 16-2664). On multivariable analysis, providing a follow-up EGD date was the only factor that was significant for obtaining an EGD within 2 weeks (OR=20.5, 95% CI: 2.79 - 170.9) after accounting for other variables listed above. Conclusions: There is suboptimal adherence to the guidelines recommending a repeat EGD in 2 weeks for patients who underwent EVL. This analysis suggests that adherence to guidelines may be improved by documenting and scheduling a specific follow-up date within 2 weeks.
S-100