Towards benchmarking in endoscopy; A multi-center database analysis

*4308 PUBLIC AWARENESS AND MODES OF EDUCATION ABOUT COLON CANCER SCREENING IN INNER-CITY POPULATIONS Scott M. Suchin, Montefiore Medical Ctr, Bronx, NY; Bhagyalakshmi L. Sastri, Jacobi Medical Ctr, Bronx, NY; Peter K. Slotwiner-Nie, Daniel Gelrud, Lawrence J. Brandt, Montefiore Medical Ctr, Bronx, NY Purpose: Colon cancer is the second most common cause of cancer-related mortality in the United States. While there are reliable and safe screening measures that may decrease mortality from colon cancer, many patients who are eligible for such screening do not get tested. The aims of this study were twofold. 1. To determine the exposure our clinic patients have had to the benefits of colon cancer screening (CCS) from the media (television, radio, newspaper, bus and subway advertisements, and the internet) and from their physician. 2. To determine whether participation in a CCS program was more influenced by information from the media or from physicians. We hope to use this information in making specific recommendations about where future efforts and funding should be allocated for patient education with respect to colon cancer prevention. Methods: All patients (216) attending the General Medical and GI Clinics at two inner-city hospitals between August and September, 2000 were invited to answer a questionnaire of predominantly close-ended, multiple-choice questions. Questions were asked pertaining to demographics, attitudes, and what exposure patients had had to information about CCS. Results: 131 patients ->50y of age completed questionnaires. Among those, 87.8% had heard about CCS tests from their doctor while 79.4% had heard about CCS from the media. The various media from which these patients claim to have heard about CCS include television(61.8%), radio(57.3%), newspaper(43.5%), bus and subway advertisements(33.6%), and the internet(4.6%). Among patients age >50y who planned to have a screening test within the following 6 months, 35.9% said it was on their physician's advice while only 2.3% said it was because of information received from the media. Conclusions: A majority of our patients heard about CCS from both their physician and from the media. However, a significantly larger percentage said that they would actually pursue CCS within the following 6 months because of their doctor's advice rather than because of information they received from the media. One may conclude that physicians are more influential in convincing patients to undergo CCS examinations. Future efforts and funding for patient education with respect to colon cancer prevention should be directed at the health care system p e r s e - - notably, towards educating health care professionals about the importance of their unique role in patient compliance with CCS guidelines.

*4309 OUTCOMES BASED ANALYSIS OF A MANAGED CARE VS GROUP PRACTICE MODEL IN THE MANAGEMENT OF U P P E R GASTROINTESTINAL HEMORRHAGE. Michael R. Freeling, Drew B. Schembre, Richard A. Kozarek, Fouad M. Attia, Virginia Mason Medical Ctr, Seattle, WA BACKGROUND: While previous studies have evaluated the effectiveness of protocol-based team approches in the management of gastrointestinal hemorrhage, and the impact of physician specialty on outcomes in acute upper gastrointestinal hemorrhage, to our knowledge no literature has yet been published comparing differences in outcome between Managed Care and Group Practice Models in the management of acute upper gastrointestinal hemorrhage. Virginia Mason Hospital provides an ideal environment for conducting a comparative analysis of this type since both groups of physicians utilize the same hospital, nursing staff, and ER for admitting purposes. METHODS: The hospital database was searched using ICD-9 codes for all patients admitted through the Emergency Department for the period February 01, 1999 through January 31, 2000 with a diagnosis of upper gastrointestinal bleed. The sample population was then stratified into Managed Care and Group practice patients respectively. A retrospective chart review was then conducted by a single reviewer. The cohorts were risk stratified using a simple Rockall risk assessment score and evaluated utilizing the following endpoints: mortality, time to endoscopy(TE), rebleeding rate(%RB), surgery(%SURG), # units transfused(PC), length of stay(LOS) and hospital charges(HC). RESULTS: From February 01, 1999 to January 31, 2000 23 Managed Care patients were matched to 25 patients treated by a Group Practice. The Rockall risk score was not significantly different between groups, and there were no mortalities in either group. CONCLUSION: There is no statistically significant difference in the evaluated outcomes between Managed Care and Group Practice models in the management of acute upper gastrointestinal hemorrhage.

MC

GP P value

TE(days)

PC(units )

%RB

%SURG

LOS(day s)

0.76 0.67 0.21

3.1 3.0 0.65

13.6 8.0 0.34

4.5 0,0 0.32

3.3 3,6 0.33

HC($) 10212 9247 0.53

MC - ManagedCare GP- GroupPractice

"4310 TOWARDS BENCHMARKING IN ENDOSCOPY; A MULTI-CENTER DATABASE ANALYSIS. Patrick Connor, James Vaughan, Medical Univ of South Carolina, Charleston, SC; Steve Schutz, David Grant USAF Medical Ctr, Travis Air Force Base, CA; Paul Jowell, Duke Univ Medical Ctr, Durham, NC; Joseph Leung, USC Davis, Sacramento, CA; Nick Nickl, Univ of Kentucky, Lexington, K'Y;Eric Libby, Medical Univ of South Carolina, Charleston, SC; Alan N G Barkun, McGill Univ, Montreal Canada; Peter B. Cotton, Medical Univ of South Carolina, Charleston, SC Background: Assessment of quality of performance in endoscopic procedures between centers is commonly made. Increasingly, objective measures are being called for and variations within centres are being questioned. Patients and purchasers expect and should be provided with, minimum acceptable standards with which to make balanced judgements regarding healthcare choices. Trainees should be aware of the objective standards increasingly required to assess performance. Methods: GI Trac is a database of all endoscopic procedures undertaken in 6 large endoscopy centres (4 university, 1 VA, 1 Military) by a total of 71 endoscopists. Over a median of 5 years, we analysed demographic, clinical and endoscopic data on all upper GI endoscopies (29,596), colonoscopies (18,731) and ERCPs (8040). Many procedure specific measures were compared between endoscopists and centres and the effect of level of activity on performance of each procedure was also assessed. Three examples are presented. Results: Rates of cecal intubation in colonoscopy was assessed. Mean rate was 90%, with variation across individual endoscopists of (+/- 2SD) 79 100, and across centers (+/- 2SD) 82 - 98. Comparison between those individuals performing >100 colonoscopies per yr. and those <100 per yr. was statistically significant (p=<0.0001). The same assessment was made for the ability to achieve stone extraction at ERCP. Mean rate was 72% (individual variation (+]- 2SD)47 96, inter-centre variation(+/- 2SD)53 91). No statistically significant difference was found between those performing <50 or >50 ERCP per yr. Finally, comparison was made looking at rate of bile duct cannulation in jaundiced patients. Mean rate 95% (individual variation (+/2SD)86 100, inter-centre variation (+/- 2SD) 89 - 100 and no significant difference was found between those performing <100 or >100 ERCPs per year. Conclusions: This data shows marked variation in the performance of three endoscopic procedures between centres and individual endoscopists. Attempt was made to account for level of expertise, but the surrogate marker used (current level of activity) may not be appropriate. Similar analyses, based on improved and acceptable data collection giving due regard to confounding factors, will aid in the provision of a framework for the development of benchmarks to assist training, continuing evaluation and quality improvement.