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Tu1072 Predicting Advanced Proximal Neoplasia in Asymptomatic Adults Without Knowing Distal Colorectal Findings: A New Scoring System With High Discrimination
AGA Abstracts
inhibition of methanogenesis in M. smithii. In this study, we examine the effects of lovastatin in a rat model of diet-induced constipation and M. smithii proliferation. Methods 30 adult, male Sprague-Dawley rats were placed on a high-fat diet (60.3% kcal from fat, Teklad highfat diet TD.06414, Harlan Laboratories Inc, Madison, WI) for 7 weeks. The rats were assessed for increased M. smithii by qPCR before and after the diet, and then divided into 3 groups. Group 1 was given lovastatin in its lactone form, group 2 was given lovastatin hydroxy acid (each 1.5 mg/rat), and the Group 3 was gavaged with a placebo. Each group was gavaged daily for 10 days. Three day stool collections were performed to assess average stool wetweight and daily variability prior to commencing the high-fat diet, after 7 weeks of highfat diet, and the finals days of the lovastatin gavage (still on high-fat diet). On day 10 of the gavage, rats were then euthanized and DNA was extracted from contents of ligated bowel segments (ileum, jejunum, duodenum, cecum and left colon). qPCR was performed using primers for total luminal bacteria and M. smithii. Results Confirming previous studies, highfat diet augmented stool M. smithii colonization in Sprague-Dawley rats (7.58x104±6.62x104 cfu/mL at baseline to 2.60x105±1.95x105 after 7 weeks of high-fat) (P<0.01). This was coupled with a reduction in the stool wet-weights (62.4% at baseline to 48.6% after 7 weeks) (P<0.01). At this point rats were divided into 3 groups. With respect to the total bacteria by qPCR, levels were not different between placebo and either lovastatin group. For M. smithii, the ratio of M. smithii to total bacteria was significantly reduced in rats given the lovastatin lactone in the ileum. M. smithii levels in the colon were unaffected. Most importantly, there was an increase in stool wet-weight noted in rats receiving lovastatin lactone gavage. Conclusions Lovastatin lactone improved stool water content in constipated rats with higher M. smithii. Although rats do not produce large enough quantities of methane to show the effect on methane, lovastatin lactone produced a reduction (but not elimination) of M. smithii in the ileum by the lovastatin lactone.
57.3 ± 6.5 yrs; 51% women), APN prevalence was 4.5%. Independently associated with APN were age, sex, cigarette smoking, marital status, metabolic syndrome, NSAID use, and physical activity. The model was well-calibrated (P=0.62) and had good discrimination (cstatistic=0.73). In low-, intermediate-, and high-risk groups that comprised 21%, 58%, and 21% of the sample, respectively, APN risks were 1.47% (95% CI, 0.67-2.77%) 3.0% (CI, 2.3-4.0%), and 11.6% (CI, 9.1-14.4%), respectively (P<0.0001), with no proximal CRCs in the low-risk group and only 1 in the intermediate-risk group. APN risk in low and intermediate risk groups combined was 2.6% (CI, 2.0-3.4%). When tested in the validation set (N=1455; mean age = 57.3 ± 7.0 yrs; 51% women), the model retained good statistical metrics (calibration P=0.85; c-statistic=0.83), with APN risks in low- (22%), intermediate(56%), and high-risk (22%) subgroups of 0.62% (CI, 0.08-2.23%) 2.2% (CI, 1.31-3.46%), and 13.0% (CI, 9.5-17.2%), respectively (P<0.0001). There were no proximal CRCs in the low-risk group, while two were in the intermediate-risk group. Conclusion: This new risk model effectively stratifies large proportions of average-risk persons into clinically-meaningful risk groups. Those at low APN risk (0.62-1.47%; 22% of average-risk) might be screened safely and efficiently without colonoscopy while those at high APN risk (11.6-13%; 22% of average-risk) should undergo initial colonoscopy. Tu1073 Relationship Between Patient Factors and End-Stage Liver Disease Readmission Rates in California Edward Sheen, Yifei Ma, Mindie H. Nguyen, Kim F. Rhoads BACKGROUND AND AIMS: Hospital readmissions are associated with worse patient outcomes and higher costs, but many readmissions are potentially preventable. Consequently, they are now a focus of national quality improvement efforts. Patients admitted to the hospital for end-stage liver disease (ESLD) complications have a particularly high rate of readmission after discharge, but little is known about the factors that may impact shortterm readmission rates in this population. Our goal is to examine patient factors associated with readmission within 30-days, using for the first time ever, a large statewide all-payer database. METHODS: We analyzed the 2012 California Office of Statewide Health Planning and Development (OSHPD) Patient Discharge Database (PDD), which is an all-payer database containing records for every discharge from a general, acute, non-federal hospital in California; the OSPHD Hospital Annual Financial Data file; and a custom prepared American Hospital Association database. Each patient was followed from index through each subsequent admission using an individual record linkage number. Multivariate logistic regression models were used to study the relationships between patient factors and the likelihood of 30-day all cause readmission, while controlling for comorbid conditions. RESULTS: A total of 59,704 ESLD patients admitted to the hospital in 2012 were identified. Table 1 reports the relationship between patient factors and readmission within 30-days. Male gender (OR= 1.04, p<0.03) was independently associated with increased odds of readmission, as were black (OR=1.33, p<0.001), Hispanic (OR=1.1, p<0.001), and Asian Pacific Islander race (OR=1.08, p<0.03). Medi-Cal (California's Medicaid program) (OR=1.39, p<0.001) and Medicare (OR=1.33, p<0.001) coverage were also independently associated with increased odds of readmission. Lack of health insurance (OR=0.86, p<0.003) and increasing length of stay (OR=0.98, p<0.001), were associated with lower odds of readmission. CONCLUSIONS: Male gender as well as black, Hispanic, and Asian Pacific Islander race were independent predictors of ESLD readmission within 30 days, as were Medi-Cal and Medicare coverage. Lack of insurance and increasing length of stay were independently associated with lower odds of readmission. Current payment reform policies are increasingly using payment reductions to penalize hospitals with high readmission rates in order to provide financial incentives to improve systems of care. However, unlike hospital characteristics, patient factors are usually much more difficult to modify, if at all. If the predominant drivers of ESLD readmissions are actually patient, rather than hospital facility characteristics, then our findings suggest that current policy may not be effective, and may even yield unintended consequences, particularly for resource poor facilities.
Mo2052 Non-Gastrointestinal Pain Is Increased in Irritable Bowel Syndrome (IBS) but Does Not Account for Abdominal Pain Olafur S. Palsson, Steve Heymen, William E. Whitehead Multiple studies have reported an excess of non-gastrointestinal (non-GI) body symptoms in IBS, but pain throughout the body has not been systematically assessed in the disorder. We aimed to (1) quantify non-GI pain in IBS and (2) examine whether general pain tendency can explain IBS abdominal pain. Methods: A nationwide U.S. community Internet survey of 328 adults was conducted, stratified to ensure equal gender ratio and age group and minority inclusion. The survey included the "Whole Body Pain Index" (WBPI), a new questionnaire constructed for measuring body-wide pain in an ongoing NIH-funded headache treatment trial. Subjects report on the WBPI their maximum pain in 28 body areas over the past 7 days on a 4-point scale from "none" to "severe". The survey also contained the Rome III IBS diagnostic questions in the new response formats planned for Rome IV (Gastroenterology 2013;144(5) Suppl.1:S-916), demographic questions, the Brief Symptom Inventory 18 (BSI18), and a question on doctor diagnosis of IBS. Respondents inconsistent on two repeated quality-check questions (n=18) were eliminated from analysis, leaving 310 response sets (51.3% females; age range 18-86 years, mean 46.7; 61.6% white race, 18.7% blacks, 19.7% hispanics). Subjects were divided into an IBS group meeting Rome III criteria (n=66; 18% diagnosed by doctor) and a control group (n=226) not meeting IBS criteria and without IBS doctor diagnosis. Whole-body non-GI pain was calculated by excluding the four GI body areas (intestines, stomach, rectum, throat) on the WBPI from scoring. Results: The IBS group reported twice as many non-GI body pain areas on average (Mean +/- SEM: 10.2 +/- 0.8 vs. 4.8 +/- 0.3; p<0.0001), and higher mean pain severity in each painful area (1.52 +/- 0.05 vs. 1.37 +/- 0.03; p=0.01) compared to controls. In the IBS group, most common painful body areas in the past week were head (80%) and lower back (74%); both more common than pain in the intestines (71%). Age and sex were unrelated to non-GI pain amount. IBS abdominal pain frequency correlated significantly with number of non-GI body areas with pain (Spearman rho=0.50) and mean pain severity in those areas (rho=0.24), and also with somatization scores on the BSI-18 (rho=0.43); all correlations p<0.0001. However, the difference in abdominal pain frequency between IBS subjects and controls remained highly significant (p<0.0001) when number of non-GI pain areas, non-GI pain severity and somatization were all controlled for in Analysis of Covariance. Conclusions: Individuals meeting IBS criteria have more widespread and severe non-GI pain on average than other people. This general tendency toward increased pain cannot account for the higher amount of abdominal pain that is key to IBS diagnosis, but may point to broader pain sensitization in the disorder. [Support: Salix Pharmaceuticals and NIH R01 AT007813] Tu1072 Predicting Advanced Proximal Neoplasia in Asymptomatic Adults Without Knowing Distal Colorectal Findings: A New Scoring System With High Discrimination Thomas F. Imperiale, Patrick O. Monahan, Timothy E. Stump, David F. Ransohoff Background: Published risk prediction models for advanced proximal neoplasia (APN) require knowing distal colorectal findings, which is not useful for colorectal cancer (CRC) screening programs that are not sigmoidoscopy-based. A separate model is needed to determine who requires initial colonoscopy (high APN risk) vs. who, because of low APN risk, might be screened initially with sig +/- stool blood testing. Objective: To derive and test a scoring system for APN among average-risk adults that does not require knowing distal colorectal findings. Methods: From 2004-2011, patients undergoing first time screening colonoscopy completed a survey of demographics, personal and family medical history, lifestyle factors, and physical measures. Responses were linked to the most advanced endoscopic finding in proximal (splenic flexure) and distal segments of the colorectum. APN was defined as any adenoma or serrated polyp >=1 cm, one with villous histology or high-grade dysplasia, or CRC. On a derivation subset, logistic regression identified factors independently associated with APN. Based on equation coefficients, points were assigned to each factor, and risk for APN was examined for each score. Scores with comparable risk magnitudes were collapsed into risk categories. The regression equation and scoring system were locked down and tested on the validation set. Results: Among 2859 patients in the derivation set (mean age
AGA Abstracts
Tu1074 Gastrointestinal Bleeding in Baby Boomers: Implications for Healthcare Resource Utilization Neena S. Abraham, Yu-Hui Chang Background: Patients born following World War II are the fastest growing segment of the US population. In 2011 this birth cohort started turning 65, shifting the age demographic of the US population toward an increasingly older population. This epidemiologic trend is
S-780
inhibition of methanogenesis in M. smithii. In this study, we examine the effects of lovastatin in a rat model of diet-induced constipation and M. smithii proliferation. Methods 30 adult, male Sprague-Dawley rats were placed on a high-fat diet (60.3% kcal from fat, Teklad highfat diet TD.06414, Harlan Laboratories Inc, Madison, WI) for 7 weeks. The rats were assessed for increased M. smithii by qPCR before and after the diet, and then divided into 3 groups. Group 1 was given lovastatin in its lactone form, group 2 was given lovastatin hydroxy acid (each 1.5 mg/rat), and the Group 3 was gavaged with a placebo. Each group was gavaged daily for 10 days. Three day stool collections were performed to assess average stool wetweight and daily variability prior to commencing the high-fat diet, after 7 weeks of highfat diet, and the finals days of the lovastatin gavage (still on high-fat diet). On day 10 of the gavage, rats were then euthanized and DNA was extracted from contents of ligated bowel segments (ileum, jejunum, duodenum, cecum and left colon). qPCR was performed using primers for total luminal bacteria and M. smithii. Results Confirming previous studies, highfat diet augmented stool M. smithii colonization in Sprague-Dawley rats (7.58x104±6.62x104 cfu/mL at baseline to 2.60x105±1.95x105 after 7 weeks of high-fat) (P<0.01). This was coupled with a reduction in the stool wet-weights (62.4% at baseline to 48.6% after 7 weeks) (P<0.01). At this point rats were divided into 3 groups. With respect to the total bacteria by qPCR, levels were not different between placebo and either lovastatin group. For M. smithii, the ratio of M. smithii to total bacteria was significantly reduced in rats given the lovastatin lactone in the ileum. M. smithii levels in the colon were unaffected. Most importantly, there was an increase in stool wet-weight noted in rats receiving lovastatin lactone gavage. Conclusions Lovastatin lactone improved stool water content in constipated rats with higher M. smithii. Although rats do not produce large enough quantities of methane to show the effect on methane, lovastatin lactone produced a reduction (but not elimination) of M. smithii in the ileum by the lovastatin lactone.
57.3 ± 6.5 yrs; 51% women), APN prevalence was 4.5%. Independently associated with APN were age, sex, cigarette smoking, marital status, metabolic syndrome, NSAID use, and physical activity. The model was well-calibrated (P=0.62) and had good discrimination (cstatistic=0.73). In low-, intermediate-, and high-risk groups that comprised 21%, 58%, and 21% of the sample, respectively, APN risks were 1.47% (95% CI, 0.67-2.77%) 3.0% (CI, 2.3-4.0%), and 11.6% (CI, 9.1-14.4%), respectively (P<0.0001), with no proximal CRCs in the low-risk group and only 1 in the intermediate-risk group. APN risk in low and intermediate risk groups combined was 2.6% (CI, 2.0-3.4%). When tested in the validation set (N=1455; mean age = 57.3 ± 7.0 yrs; 51% women), the model retained good statistical metrics (calibration P=0.85; c-statistic=0.83), with APN risks in low- (22%), intermediate(56%), and high-risk (22%) subgroups of 0.62% (CI, 0.08-2.23%) 2.2% (CI, 1.31-3.46%), and 13.0% (CI, 9.5-17.2%), respectively (P<0.0001). There were no proximal CRCs in the low-risk group, while two were in the intermediate-risk group. Conclusion: This new risk model effectively stratifies large proportions of average-risk persons into clinically-meaningful risk groups. Those at low APN risk (0.62-1.47%; 22% of average-risk) might be screened safely and efficiently without colonoscopy while those at high APN risk (11.6-13%; 22% of average-risk) should undergo initial colonoscopy. Tu1073 Relationship Between Patient Factors and End-Stage Liver Disease Readmission Rates in California Edward Sheen, Yifei Ma, Mindie H. Nguyen, Kim F. Rhoads BACKGROUND AND AIMS: Hospital readmissions are associated with worse patient outcomes and higher costs, but many readmissions are potentially preventable. Consequently, they are now a focus of national quality improvement efforts. Patients admitted to the hospital for end-stage liver disease (ESLD) complications have a particularly high rate of readmission after discharge, but little is known about the factors that may impact shortterm readmission rates in this population. Our goal is to examine patient factors associated with readmission within 30-days, using for the first time ever, a large statewide all-payer database. METHODS: We analyzed the 2012 California Office of Statewide Health Planning and Development (OSHPD) Patient Discharge Database (PDD), which is an all-payer database containing records for every discharge from a general, acute, non-federal hospital in California; the OSPHD Hospital Annual Financial Data file; and a custom prepared American Hospital Association database. Each patient was followed from index through each subsequent admission using an individual record linkage number. Multivariate logistic regression models were used to study the relationships between patient factors and the likelihood of 30-day all cause readmission, while controlling for comorbid conditions. RESULTS: A total of 59,704 ESLD patients admitted to the hospital in 2012 were identified. Table 1 reports the relationship between patient factors and readmission within 30-days. Male gender (OR= 1.04, p<0.03) was independently associated with increased odds of readmission, as were black (OR=1.33, p<0.001), Hispanic (OR=1.1, p<0.001), and Asian Pacific Islander race (OR=1.08, p<0.03). Medi-Cal (California's Medicaid program) (OR=1.39, p<0.001) and Medicare (OR=1.33, p<0.001) coverage were also independently associated with increased odds of readmission. Lack of health insurance (OR=0.86, p<0.003) and increasing length of stay (OR=0.98, p<0.001), were associated with lower odds of readmission. CONCLUSIONS: Male gender as well as black, Hispanic, and Asian Pacific Islander race were independent predictors of ESLD readmission within 30 days, as were Medi-Cal and Medicare coverage. Lack of insurance and increasing length of stay were independently associated with lower odds of readmission. Current payment reform policies are increasingly using payment reductions to penalize hospitals with high readmission rates in order to provide financial incentives to improve systems of care. However, unlike hospital characteristics, patient factors are usually much more difficult to modify, if at all. If the predominant drivers of ESLD readmissions are actually patient, rather than hospital facility characteristics, then our findings suggest that current policy may not be effective, and may even yield unintended consequences, particularly for resource poor facilities.
Mo2052 Non-Gastrointestinal Pain Is Increased in Irritable Bowel Syndrome (IBS) but Does Not Account for Abdominal Pain Olafur S. Palsson, Steve Heymen, William E. Whitehead Multiple studies have reported an excess of non-gastrointestinal (non-GI) body symptoms in IBS, but pain throughout the body has not been systematically assessed in the disorder. We aimed to (1) quantify non-GI pain in IBS and (2) examine whether general pain tendency can explain IBS abdominal pain. Methods: A nationwide U.S. community Internet survey of 328 adults was conducted, stratified to ensure equal gender ratio and age group and minority inclusion. The survey included the "Whole Body Pain Index" (WBPI), a new questionnaire constructed for measuring body-wide pain in an ongoing NIH-funded headache treatment trial. Subjects report on the WBPI their maximum pain in 28 body areas over the past 7 days on a 4-point scale from "none" to "severe". The survey also contained the Rome III IBS diagnostic questions in the new response formats planned for Rome IV (Gastroenterology 2013;144(5) Suppl.1:S-916), demographic questions, the Brief Symptom Inventory 18 (BSI18), and a question on doctor diagnosis of IBS. Respondents inconsistent on two repeated quality-check questions (n=18) were eliminated from analysis, leaving 310 response sets (51.3% females; age range 18-86 years, mean 46.7; 61.6% white race, 18.7% blacks, 19.7% hispanics). Subjects were divided into an IBS group meeting Rome III criteria (n=66; 18% diagnosed by doctor) and a control group (n=226) not meeting IBS criteria and without IBS doctor diagnosis. Whole-body non-GI pain was calculated by excluding the four GI body areas (intestines, stomach, rectum, throat) on the WBPI from scoring. Results: The IBS group reported twice as many non-GI body pain areas on average (Mean +/- SEM: 10.2 +/- 0.8 vs. 4.8 +/- 0.3; p<0.0001), and higher mean pain severity in each painful area (1.52 +/- 0.05 vs. 1.37 +/- 0.03; p=0.01) compared to controls. In the IBS group, most common painful body areas in the past week were head (80%) and lower back (74%); both more common than pain in the intestines (71%). Age and sex were unrelated to non-GI pain amount. IBS abdominal pain frequency correlated significantly with number of non-GI body areas with pain (Spearman rho=0.50) and mean pain severity in those areas (rho=0.24), and also with somatization scores on the BSI-18 (rho=0.43); all correlations p<0.0001. However, the difference in abdominal pain frequency between IBS subjects and controls remained highly significant (p<0.0001) when number of non-GI pain areas, non-GI pain severity and somatization were all controlled for in Analysis of Covariance. Conclusions: Individuals meeting IBS criteria have more widespread and severe non-GI pain on average than other people. This general tendency toward increased pain cannot account for the higher amount of abdominal pain that is key to IBS diagnosis, but may point to broader pain sensitization in the disorder. [Support: Salix Pharmaceuticals and NIH R01 AT007813] Tu1072 Predicting Advanced Proximal Neoplasia in Asymptomatic Adults Without Knowing Distal Colorectal Findings: A New Scoring System With High Discrimination Thomas F. Imperiale, Patrick O. Monahan, Timothy E. Stump, David F. Ransohoff Background: Published risk prediction models for advanced proximal neoplasia (APN) require knowing distal colorectal findings, which is not useful for colorectal cancer (CRC) screening programs that are not sigmoidoscopy-based. A separate model is needed to determine who requires initial colonoscopy (high APN risk) vs. who, because of low APN risk, might be screened initially with sig +/- stool blood testing. Objective: To derive and test a scoring system for APN among average-risk adults that does not require knowing distal colorectal findings. Methods: From 2004-2011, patients undergoing first time screening colonoscopy completed a survey of demographics, personal and family medical history, lifestyle factors, and physical measures. Responses were linked to the most advanced endoscopic finding in proximal (splenic flexure) and distal segments of the colorectum. APN was defined as any adenoma or serrated polyp >=1 cm, one with villous histology or high-grade dysplasia, or CRC. On a derivation subset, logistic regression identified factors independently associated with APN. Based on equation coefficients, points were assigned to each factor, and risk for APN was examined for each score. Scores with comparable risk magnitudes were collapsed into risk categories. The regression equation and scoring system were locked down and tested on the validation set. Results: Among 2859 patients in the derivation set (mean age
AGA Abstracts
Tu1074 Gastrointestinal Bleeding in Baby Boomers: Implications for Healthcare Resource Utilization Neena S. Abraham, Yu-Hui Chang Background: Patients born following World War II are the fastest growing segment of the US population. In 2011 this birth cohort started turning 65, shifting the age demographic of the US population toward an increasingly older population. This epidemiologic trend is
S-780