Unsedated endoscopy: A study at a V.A. medical center

a shorter median LOS (p<.002) and lower median charges (p = .036) than patients admitted later in the week (Thursday, Friday, Saturday, or Sunday). (See table) The 516 patients admitted on a Friday, Saturday, or Sunday accrued $916,842 ($1,777 per patient) more in charges than if they were admitted on a Monday. The age, gender, and ICU days did not impact the LOS or the hospital charges. CONCLUSION:Late week or weekendGI admissions to the hospital are associatedwith longer LOS and higher charges. Offering more extensive weekend services or directing admissions to the days at the beginning of the week may decrease LOS and hospital charges.

LOS1 CHARGE S2

MON

TUES

WED

THURS FRI

SAT

SUN

4 (1-37) $14,37 2

4 (1-66) $14,14 4

4 (1-39) $13,70 2

5 (1-57) $14,88 4

5 (1-65) $17,45 5

5 (1-31) $15,249

5 (148) $15,80 0

1Median(Range)LOS in days 2MedianCharges 2068

The Impact of Timing of Colonossopy on Length of Hospital Stay in Patients with Acute Lower Gastrointestinal Bleeding Lisa L. Strate, 8righam and Women's Hosp, Boston, MA; Roger Davis, Beth Israel Deaconess Medical Ctr, Boston, MA; Jeffrey Schnipper, MA Gen Hosp, Boston, MA; Sapoa Syngal, Brigham and Women's Hosp, Boston, MA Background: Previous studies suggest that urgent colonoscopy (performed within 12hrs of admission) for massive diverticular hemorrhage can reduce hospital length of stay (LOS). However,these findings may not be generalizableto patients with other sources or seve~es of lower gastrointestinal bleeding (LGIB). Aim: To determine if time to colonscopy impacts hospital LOS in patients admitted with all causes of acute LGIB. Methods: 252 consecutive patients were identified using ICD-9 codes consistent with LGIB. Ingatieots and patients with evidence of UGIB, or scant or chronic LGI8 were excluded. Data were collected using a standardizedinstrument. Dateand time of admission, interventions and discharge were taken from emergencydepartmentand computerizedendoscopyand dischargerecords,raspoctively. Time to colonoscopy was analyzed as a time-varying covariste. Cox proportional hazards regression using variableswith univahatesignificance (p<0.25) was usedto elucidateindependent predictors of LOS. Results: Subjects were 57% female. The mean age was 56+16yrs. 85% had at least 1 comorbid condition. The meaninitial Hct was 35%. Predominantsources of bleedingwere diverticuli (27%), hemorrhoids (11%), ischemiccolitis (10%), post-polypeotorny (7%)and malignancy (6%). No source was identified in 13%. 141 patients (57%) underwent inpatient colonoscopy: 13 were done in <12hrs of admission, 54 in 12-24hrs, 45 in 24-48hrs and 26 in >48 hrs. After controlling for the other independentpredictors, time to colonoscopy was significantly correlated with LOS (HR 1.6,95%CI 1.2-2.0,p<0.001). The adjusted median LOS by colonoscopy time were: <24hrs- 2.1 days, 24-48hrs- 2.5 days, >48hrs- 4.3 days. However, endoscopictherapy and hemosfasiswere not relatedto LOS (p>0.25). Conclusion: Time to colonoscopy is an independentpredictor of hospital LOS. However,this appears to be related to diagnostic yield and not therapeutic intervention. 2069 Unsedeted Endoscopy:A Study at a V.A. Medical Center Masoud Firoozi, Marianne Kasian, ElaineAdelson, George D. Gourgootis, Richard D. Michelstein, David R. 8eswick, Randall W. Snyder, Ramesh M Shah, VeteransAffairs Medical Ctr, Wilkes-Barre, PA

Background:Starting in Jan. 2000, we haveoffered patientsthe option of unsedatedendoscopy. We would like to report our preliminary results over a 9-month period. Subjects:All competent male patients who were referred during Jan. 2000 through Sept. 2000 were interviewed. 795 patients were seen, ages 50 to 89. Methods: All patients were well educatedabout the risks and benefits of both options. IV sedationwas administered during the procedure it the patient felt uncomfortable.Patientswere questionedabouttheir satisfactionat the end of the procedure. Results: During the 9 months of the study, a total of 795 procedures were performed on qualified patients. A total of 381 EGD's were done: 216 sedated, 165 onsedated.Volunteer rate for unsedatedEGD was 43%. B patients (4%) from the unsedatedgroup were converted to sedation during the procedure. All EGD's were completed on both groups. 12 patients (7%) from the unsadatedgroup were dissatisfied postop. For colonoscopy, a total of 454 cases were done. 148 (32%) patients volunteeredfor the unsedatedexam. 14 patients (9%) from the unsedatedgroup were convertedto sedation during the procedure. 15 patients from the unsedatedgroup were dissatisfied, resulting in a satisfaction rate of 89%. We compared the complete exam rate in both unsedatedand sedatedgroups. The results were comparable: 95% in both groups, Conclusion: Unsedatedendoscopycould be completed successfully with no IV sedation, with a high satisfaction rate. Consideration should be given to unsedated endoscopy, particularly in elderly, male patients on whom serious complication could be avoided in this manner.

EGD Colonoscopy

Satisfaction Rate Completed Exam Rate (unsedated) Completion Rate (sedated)

Total

Sedated

Unsedated

Converted

381 454

216 306

165 (43%) 148 (32%)

8 (4%) 14 (9%)

EGD 93%

Colonoscopy 89%

100%

95%

100%

95%

2070 Caregiver Out-Of-PocketExpenses And Loss Of ProductivityAssociated With Outpatient Management Of Upper Gastrointestinal Hemorrhage. Agarwal Rohitas, Goel Sachin, Tamir 8en-Menachem, Robert Mortock, Henry Ford Hosp, Detroit, MI

BACKGROUND:Recentstudies suggest that outpatient managementof upper gastrointestinal hemorrhage (UGIH) for patients at low risk of recurrent hemorrhageis safe and may be costeffective. Shiffing care to the outpatient setting may shift some costs to patients and their families. Herein,we report the results of a survey-basedinvestigation of the economic burden of outpatient UGIH mangemeot on the patient's family/caregiver. METHODS:Caregivers of 71 adults with UGIH managedas outpatients consentedto participate. A previously validated survey instrument (Gastroenterology,2000; 118:1296) was mailed to participants.TJ~efollowlog information was collected: demographics, employment status, out of pocket expenses, travel times and distances, and days of work lost. Out of pocket expenseswere defined as money spent on food and travel by the caregiver. Travel costs were calculated at $0.31 per mile. The value of lost work time was calculated as the product of the number of work days lost aod the salary.A caregiver'sannual salary was estimatedfrom the median income reported at their ;dp code of residence. RESULTS:The mean age of the caregivers was 49 yr(SD 16). 56% were females. 43% of caregiverswere employedfull time, 36% were homemakers, 5% wore unemployed and 16% were retired. The caregivers brought patients to the clinic for a mean of 1.2 visits (SD 0.5); (median and IQ range 1; 1-1). The mean distance traveled to the clinic was 19 miles (SD=18). The mean time spent at the clinic was 215 minutes (SD=113). The employed caregivers missed a mean of 1.4 days of work(SD 1); (median and IQ range 1,1-2). The averageamount spent for food by the caregiver was $7 (SD $8.5); (range 0-$40). The calculated average driving expenses were $5.89. The mean of the zipcode based median incomes was $42,304 (SD=$19,055); (median=S39,087). The mean value of lost work time per caregiver was $246 (SD $111). Three caregivers had to arrange for child-care in order to bring the patient to clinic. CONCLUSION:In this population, out-ofpocket expensesincurred by the caragiver are minimal. The cost of the caregiver's lost work time is more substantial, and will vary by their income. The latter costs, and other expenses such as childcareservices needto be consideredwhen performing cost analysesof outpatient management of LIGIH. 2o71

The Simplified Acute Pl~iolow Score (SAPSII): Is there a role in assessing palionb ~ medically rstredop/upper gastrointestinal bleeding? David P. Hurlstooe, David S. Sanders, Martyn J. Carter, Bethan Goodman-Jones,Jane Batten, Alan J. Lot~, Royal HaJiamshireHosp, Sheffield United Kingdom Introdcotion: Surgical interventionis effective in treating medicallyrefractory uppergastrointestinal haemorrhage(UGIH). Selectionof patientssuitablefor surgery, who will tolerateanaesthesia may be difficult and often involves subjective clinical judgement. The Simplified Acute Physiology Scores (SAPSII) is a validated predictor of mortality in the intensive care setting. Aim: We compared the SAPSII between LIGIH patients who were accepted or declined for surgical intervention. Subjects and Methods: All patients referred for surgical intervention from July 1996-99, (n = 99, meanage69.5years,58.5%male)with non-varicealUGIH(predominantly peptic ulcer disease) in a single hospital. Classificationwas according to their surgical assessment:,acceptedor declined.SAPSIIwere retrospectivelyassessedat the time of referral for surgical intervention. This was converted into a mortality probability using multiple regression analysis.The clinical outcome was defined as either survival to discharge or death whilst an in-patieot. Results:The Mean SAPSll score for death = 35.7 (Range28-46, median = 37). Mean SAPSII for survivors = 30.1 (Range 15-53, median =31). No patient with a SAPSll < 28 died. The 2 groups did not differ with respect to their SAPSII (t = 0.8, p = 0.44). Patients who were declined for surgery had a x2 increase in death compared to those accepted (p = 0.08: odds ratio 2.3, 95% CI 0.8-6.2). The observedmortality was consistent with mortality predicted in the operative group but for those declinedtheir actual mortality x2 that predicted. Conclusion: This is the 1st study to assess SAPSII in UGIH. Subjective clinical assessment may deprive some patients of a potentially life saving operation. Mortality predictions using SAPSIIsuggeststhat clinical selectioncriteria for patientsundergoingsurgery may be inconsistent

Number Mean SAPSIIscore (range=15~) Modabty pco40mMIIty Pre-di~harge mmtal~/¢~)

Accepted

Declined

65 31.7

34 30.2

16% 1o (13%)

15% 1o (30%)

2072 Long-Term Efficacy Of Octreotide In The Prevention Of Recurrent Bleeding From Gastrointestinal Angiodysplasla. Felix Junquera, SebastianVidela, EstebanSaperas,Jaime Vilaseca, Hosp Gee Vail d'Hebron, BarcelonaSpain; Faust Feu, Hosp Clin i Provincial, BarcelonaSpain; Michel Papo, Hosp Joan XXIII, Tarragona Spain; Josep Maria Bordas, Hosp Clin i Provincial, Barcelona Spain; Jose R. Armengol, Hosp Gen Vail d'Hebron, BarcelonaSpain; Josep Maria Pique, Hosp Clin i Provincial, BarcelonaSpain; Juan R. Maiagelada,Hosp Gun Vail d'l-lebron, BarcelonaSpain

Background/Objective:Angiodyspiasiais a major source of recurrent gastrointestinalbleeding. Casereports and small uncontrolledstudies have suggestedthat octreotide may be therapeuticefy helpful. Thus, we investigatedthe long-term efficacy of octreotidetherapy in the prevention of reblesding from gastrointestinal angiodysplasia. Methods: A unisenter prospective open pilot clinical trial was paralelly conducted to a multicenter randomized placebo (external control) controlled clinical trial of hormonal therapy in the prevention of rebleeding from

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