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Use of sustained GERD medication therapy, physician prescribing patterns, and medical costs among surgically managed GERD patients
NS). There was no difference in clinical outcome among the two groups - ncluding: mortality 2% vs. 4%, hospital stay 5.8 vs 6.6 days, ICU stay 1.8 vs. 2.4 days, transfusion requirements 4.2 vs. 5 units, early rebleedng 22% vs. 30%, surgery 14% vs. 12%, fate rebleeding 16% vs. 14% (mean follow-up of 62 and 58 months). There was a trend toward lower transfusion requirements in the urgent colonoscopy group, however, this did not reach statistical significance. Conclusion: Although urgent colonoscopy identified a definitive source of bleeding more often than a standard care algorithm in patients with acute LGIB, the approaches are equivalent with regard to important outcomes. Thus, decisions concemng care should be based on ndividual experience and local expertise.
143 Ethnic Variations in the Prevalence of Esophageal Endoscopic Findings: A Population-hased Study Hashem B. E1-Serag, Lnda Rabeneck, Robert M. Genta, Nancy Petersen, David Y. Graham Background Caucasians in the US have a 5-fold greater incidence of esophageal adenocartinoma, and a 2-3 times greater prevalence of Barrett's esophagus than blacks. It remains unknown whether this ethnic discrepancy reflects lower prevalence of GERD symptoms in blacks, or lesser esophageal damage for the same degree of symptoms. Methods We camed out a population-based study to determine the prevalence of endoscopic esophageal findings in the ethnically diverse population (55% black) of employees at the Houston VAMC. Gastroesophageal Reflux Questionnaires were distributed followed by an invitation to undergo upper endoscopy. All endoscopic procedures and biopsy protocols were standardized and performed by a single endoscopist who was blinded to the results of the questionnaires. All biopsy specimens were interpreted by a single pathologist blinded to the results of the questionnaire and endoscopy. The presence of erosive esophagitis (EE) was examined n multivariable logistic regression analyses that included age, gender, ethnicity, GERD symptoms, medications, BMI, H. pylori nfection, and the presence and distribution of gastritis. Results 520/915 (57%) returned complete questionnaires, 226/520 underwent upper endoscopy with gastric biopsies. 108 (48%) were black, and 145 (64%) were female. This was the first endoscopy for >70% of participants. A greater proportion of those who underwent endoscopy had frequent heartburn (36% vs. 21%) and used PPI, H2RA, or antacids than those who did n~ have endoscopy. Overall, EE was found in 50/226 (22%); 31 were grade A. Nine had CLE (8 were < 2 cm) of whom only one had Barrett's esophagus (0.4%). The prevalence of EE in whites was greater than blacks (41% vs 16%). In those with frequent heartburn or regurgitation, EE was present n 45% of whites and 19% of blacks, respectively. In the logistic regression that controlled for age and BMI, black ethnicity was associated with a lower risk of EE (0.2, 0.1-0.5, p<0.001). BMI>25 was the only other independent risk factor for EE. There were no significant associations between the presence or severity of EE and H. pylori, or the presence of corpus gastritis. Conclusions: 1. Bhcks in the US have a lower prevalence of esophagitis than whites for the same frequency of GERD symptoms. Further studies should examine the reason(s) for this finding. 2. EE grade A is relatively common even n asymptomatic persons, while Barrett's esophagus is rare even among those with frequent symptoms. 3. Overweight is an ndependent risk factor of EE.
141
Use of Sustained GERD Medication Therapy, Physician Prescribing Patterns, and Medical Costs among Surgically Managed GERD Patients Elise M. Pelletier, David A. Johnson, Erin M. Sullivan Purpose. To examine the use of sustained GERD medication therapy, physician prescribing patterns, and medical costs among patients following surgical treatment for GERD. Methods. A retrospective study using administrative and medical claims data from a national database of publicly and privately insured beneficiaries was performed. Adult patients with a GERD diagnosis who underwent a surgical fundopfication between April 1997 and December 1998 were included. Use of sustained GERD medication therapy (defined as three consecutive prescriptions for an H2 antagonist, PPI, or gastric motility ~gent after fundoplication), physician prescribing patterns, and medical costs were examined during the two years follovang the date of surgery ("index date"). Results. The study included 231 surgical patients (mean age 51 years). One hundred nine patients (47%) received at least 1 GERD medication post-index date, and 40 patients (17%) met the study definition for sustained GERD medication use after surgery. Twenty-three percent of these patients began sustaine~ GERD medication therapy within 1 month of surgery and continued therapy for an average of 224 days. Within 12 months, 68% had begun sustained GERD medication therapy. Surgeons were the primary prescribers of sustained GERD medication therapy during the first month after surgery (85%), and accounted for 67% and 51% of all sustained GERD prescriptions during the first post-operative 6 and 12 months. PCPs/gastroenterologists accounted for only 23% and 28% of the prescriptions during the same 2 time periods. During the 2 years following fundoplication, mean overall medical costs were significantly higher for patients with sustamed GERD medication therapy post-index date compared to those with slSoradic or no drug therapy ($19,569 versus $11,281, p<0.0001). Significantly higher GERD-related treatment and diagnostic medical costs and GERD-related and non-GERD-related pharmacy costs contributed to this difference. Conclusions. 1. Despite surgical fundoplication to eliminate GERD symptoms, there is a surprisingly high percentage of patients who continue to need sustained GERD medication therapy. 2. Surgeons were the most frequent prescribers of GERD medication therapy during the first 12 months after surgery. 3. Additional studies to evaluate GERD medication use following GERD surgery are warranted.
144
Rapid Diagnosis Of Spontaneous Bacterial Peritonitis With A Urine Reagent . Strip (Nephur-Test | Thierry Sapey Sr., Eric Fort, Christine Laurin, Denis Kabissa, Paul Strock, Perrine Duranthon, Michel-Henry Mendler Background/aims: the aim of this study was to assess the diagnostic accuracy of a rapid urine reagent strip (nephur-test| for bedside diagnosis of spontaneous bacterial peritonitis (SBP) n cirrhotics. Methods: During six months, 80 non-selected paracemesis samples were obtained prospectively from 35 cirrhotic patients. 27 were male, 8 female. Mean age was 61 years (35-86). 3 were child A, 12 Child B, and 20 Child C. Cirrhosis was due to alcohol in 34, and HCV in 1.14 patients had long-term antibiotic SBP prophylaxLs (40%). Multiple samples were obtained from each patient during their bospitalisation. In cases of SBP (Polymorphonuclear (PMN) ascites count greater than 250/mm3), repeat samples were obtaned 2 days after antibiotic treatment. All ascites samples were tested with the nephurtest| urine reagent strip at bedside and compared to leukocyte and PMN counts, ascites culture (aerobic/anaerobic) and biochemical analysis in all patients. Based on a colorimetric scale read at 60 seconds, the test was considered negative or positive (violet, >500 leukocyte/ p,l). The accuracy of the reagent strip n the diagnosis of SBP as compared to ascitic fluid analysis was determined. Results: 75 ascites samples negative for SBP tested negative by the nephur-test | Four of the 35 patients had SBP and the nephur-test | was positive in 3/4. After 48 hours of antibiotics, 1/4 still had SBP and the nephur-test | remained positive. In 2/4 the PMN count dropped below 250/mm3 and the nephnr-test | tested negative. The 1/ 4 SBP patient who was nephur-test | negative died within 48 hours from bacterial pneumonia. Overall, this urine reagent strip was 80% sensitive, 100% specific, had a 99% negative predictive value and a 100% positive predictive value and was 99% accurate in the diagnosis of SBP. In our hospital, the cost of a nephnr-test | is 0.155--ukocyte and PMN count, ascites culture and biochemical analysis is 555. Conclusion: Rapid bedside screening for SBP with a urine reagent strip such as the nephur-test | could prove to be accurate and cost-effective. This type of screen could prove to be useful in situations of emergency or limited resources, resuhng in the initiation of fife-saving antibiotic therapy while fluid analysis is pending.
142 Risk Factors for the Onset of Abdominal Pain in Children: A Prospective
Population Based Study Smita L. S Halder, Gareth T. Jones, Alan J. Silman, David G. Thompson, Gary J. Macfarfane Background: Recurrent abdominal pain (RAP) is a common functional disorder n children and its underlying aetiology remains unclear. RAP often coexists with somatic symptoms such as headache. Cross sectional studies have shown that children who suffer from RAP are more likely to have behavioural problems, and to suffer from anxiety and depression, but these studies are unable to distngnish whether these factors are causes or effects of pain. The aim of this current study was to determine whether psychosocial factors and a history of somatic symptoms predict the future onset of abdominal pain. Methods: From a large questionnaire-based cross sectional survey, 675 children aged 11-14 yrs from schools in North West England were identified as being free of abdominal pain. Usng a validated questionnaire, information was collected from these subjects on psychosocial difficuhtes and behaviour as well as on other common somatic complaints: headache, sore throat and daytime tiredness. A one year follow up questionnaire determined whether these children had developed new onset abdominal pain defined as pain on at least 1 day n the past month. Risk factors were identified using Poisson regression and are expressed as age and sex adjusted Relative Risks (RR) with 95% Confidence Intervals. Results: 570 children (84.4%) were followed up of whom 243 (42.6%) reported new onset abdominal pain. Pain was more common in girls (52.3%) than boys (35.5%), but did not vary by age group and was unrelated to menstrual status High levels of total psychosocial difficulties were predictive of pain onset (1.4; 1.03-2.0), whereas positive behaviour was protective (0.7; 0.5-0.9). Reporting other somatic complaints at baseline also predicted new onset abdominal pain; headache: 1.4 (1.1-1.8); sore throat: 1.2 (0.96-1.6); and daytime tiredness: 1.4 (1.1-1.9). Using a definition of more frequent pain (pain > 7 days) as the outcome (new onset rate 3.2%), stronger risk associations were observed e.g. the RR associated with high total difficulties ncreased to 8.1 (2.8-23.7). Conclusions: This is the first population'based study examinng predictors of abdominal pain in children. Female sex, and adverse behavioural and emotional factors are strong predictors of onset of future abdominal pain in subjects free of pain at baseline. Conversely, positive behaviour is protective against abdominal pain development. Consistent with results from adults, this study provides evidence that abdominal pain in children may he a manifestation of somatisation.
AGA Abstracts
145 10-Day Outpatient Treatment Protocol for Management of Acute Colonic Diverticulitis Akira Mizuki, Hiroshi Nagata, Masayuki Tatemiti, Nobuhiro Tsukada, Satoru Kaneda, Hiromasa lshii Background/aims: In the meeting of DDW 2001, we preliminarily reported treatment modality of acute colonic diverticulitis (ACD) using oral antibiotics and sports drink in outpatient clinic. In this paper, we have collected more subjects, determined the re-attack rate, and compared the cost of treatments. Methods: Based on the findings of uhrasonography (US), 4 grades of ACD were determined: grade I, an imaged nflamed diverticulum (lID); grade II, lID with panicufitis; grade Ill, lID with an abscess within 2 cm in diameter and grade IV, IID with an abscess larger than 2 cm in diameter or perforation to the abdominal cavity. The treatment protocol consistmg of cefpodoxime proxetile 200 mg given orally twice daily for 10 days and sports drink for the first 3 days was given to the patients with grade I to grade Ill (mild to moderate) ACD. Physical and laboratory examinations were repeated to determine feasibility to take liquid diet and ordinary diet on the 4th and 7th day, respectively. Patients who had been successfully treated were followed to determine the re.attack rate.
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143 Ethnic Variations in the Prevalence of Esophageal Endoscopic Findings: A Population-hased Study Hashem B. E1-Serag, Lnda Rabeneck, Robert M. Genta, Nancy Petersen, David Y. Graham Background Caucasians in the US have a 5-fold greater incidence of esophageal adenocartinoma, and a 2-3 times greater prevalence of Barrett's esophagus than blacks. It remains unknown whether this ethnic discrepancy reflects lower prevalence of GERD symptoms in blacks, or lesser esophageal damage for the same degree of symptoms. Methods We camed out a population-based study to determine the prevalence of endoscopic esophageal findings in the ethnically diverse population (55% black) of employees at the Houston VAMC. Gastroesophageal Reflux Questionnaires were distributed followed by an invitation to undergo upper endoscopy. All endoscopic procedures and biopsy protocols were standardized and performed by a single endoscopist who was blinded to the results of the questionnaires. All biopsy specimens were interpreted by a single pathologist blinded to the results of the questionnaire and endoscopy. The presence of erosive esophagitis (EE) was examined n multivariable logistic regression analyses that included age, gender, ethnicity, GERD symptoms, medications, BMI, H. pylori nfection, and the presence and distribution of gastritis. Results 520/915 (57%) returned complete questionnaires, 226/520 underwent upper endoscopy with gastric biopsies. 108 (48%) were black, and 145 (64%) were female. This was the first endoscopy for >70% of participants. A greater proportion of those who underwent endoscopy had frequent heartburn (36% vs. 21%) and used PPI, H2RA, or antacids than those who did n~ have endoscopy. Overall, EE was found in 50/226 (22%); 31 were grade A. Nine had CLE (8 were < 2 cm) of whom only one had Barrett's esophagus (0.4%). The prevalence of EE in whites was greater than blacks (41% vs 16%). In those with frequent heartburn or regurgitation, EE was present n 45% of whites and 19% of blacks, respectively. In the logistic regression that controlled for age and BMI, black ethnicity was associated with a lower risk of EE (0.2, 0.1-0.5, p<0.001). BMI>25 was the only other independent risk factor for EE. There were no significant associations between the presence or severity of EE and H. pylori, or the presence of corpus gastritis. Conclusions: 1. Bhcks in the US have a lower prevalence of esophagitis than whites for the same frequency of GERD symptoms. Further studies should examine the reason(s) for this finding. 2. EE grade A is relatively common even n asymptomatic persons, while Barrett's esophagus is rare even among those with frequent symptoms. 3. Overweight is an ndependent risk factor of EE.
141
Use of Sustained GERD Medication Therapy, Physician Prescribing Patterns, and Medical Costs among Surgically Managed GERD Patients Elise M. Pelletier, David A. Johnson, Erin M. Sullivan Purpose. To examine the use of sustained GERD medication therapy, physician prescribing patterns, and medical costs among patients following surgical treatment for GERD. Methods. A retrospective study using administrative and medical claims data from a national database of publicly and privately insured beneficiaries was performed. Adult patients with a GERD diagnosis who underwent a surgical fundopfication between April 1997 and December 1998 were included. Use of sustained GERD medication therapy (defined as three consecutive prescriptions for an H2 antagonist, PPI, or gastric motility ~gent after fundoplication), physician prescribing patterns, and medical costs were examined during the two years follovang the date of surgery ("index date"). Results. The study included 231 surgical patients (mean age 51 years). One hundred nine patients (47%) received at least 1 GERD medication post-index date, and 40 patients (17%) met the study definition for sustained GERD medication use after surgery. Twenty-three percent of these patients began sustaine~ GERD medication therapy within 1 month of surgery and continued therapy for an average of 224 days. Within 12 months, 68% had begun sustained GERD medication therapy. Surgeons were the primary prescribers of sustained GERD medication therapy during the first month after surgery (85%), and accounted for 67% and 51% of all sustained GERD prescriptions during the first post-operative 6 and 12 months. PCPs/gastroenterologists accounted for only 23% and 28% of the prescriptions during the same 2 time periods. During the 2 years following fundoplication, mean overall medical costs were significantly higher for patients with sustamed GERD medication therapy post-index date compared to those with slSoradic or no drug therapy ($19,569 versus $11,281, p<0.0001). Significantly higher GERD-related treatment and diagnostic medical costs and GERD-related and non-GERD-related pharmacy costs contributed to this difference. Conclusions. 1. Despite surgical fundoplication to eliminate GERD symptoms, there is a surprisingly high percentage of patients who continue to need sustained GERD medication therapy. 2. Surgeons were the most frequent prescribers of GERD medication therapy during the first 12 months after surgery. 3. Additional studies to evaluate GERD medication use following GERD surgery are warranted.
144
Rapid Diagnosis Of Spontaneous Bacterial Peritonitis With A Urine Reagent . Strip (Nephur-Test | Thierry Sapey Sr., Eric Fort, Christine Laurin, Denis Kabissa, Paul Strock, Perrine Duranthon, Michel-Henry Mendler Background/aims: the aim of this study was to assess the diagnostic accuracy of a rapid urine reagent strip (nephur-test| for bedside diagnosis of spontaneous bacterial peritonitis (SBP) n cirrhotics. Methods: During six months, 80 non-selected paracemesis samples were obtained prospectively from 35 cirrhotic patients. 27 were male, 8 female. Mean age was 61 years (35-86). 3 were child A, 12 Child B, and 20 Child C. Cirrhosis was due to alcohol in 34, and HCV in 1.14 patients had long-term antibiotic SBP prophylaxLs (40%). Multiple samples were obtained from each patient during their bospitalisation. In cases of SBP (Polymorphonuclear (PMN) ascites count greater than 250/mm3), repeat samples were obtaned 2 days after antibiotic treatment. All ascites samples were tested with the nephurtest| urine reagent strip at bedside and compared to leukocyte and PMN counts, ascites culture (aerobic/anaerobic) and biochemical analysis in all patients. Based on a colorimetric scale read at 60 seconds, the test was considered negative or positive (violet, >500 leukocyte/ p,l). The accuracy of the reagent strip n the diagnosis of SBP as compared to ascitic fluid analysis was determined. Results: 75 ascites samples negative for SBP tested negative by the nephur-test | Four of the 35 patients had SBP and the nephur-test | was positive in 3/4. After 48 hours of antibiotics, 1/4 still had SBP and the nephur-test | remained positive. In 2/4 the PMN count dropped below 250/mm3 and the nephnr-test | tested negative. The 1/ 4 SBP patient who was nephur-test | negative died within 48 hours from bacterial pneumonia. Overall, this urine reagent strip was 80% sensitive, 100% specific, had a 99% negative predictive value and a 100% positive predictive value and was 99% accurate in the diagnosis of SBP. In our hospital, the cost of a nephnr-test | is 0.155--ukocyte and PMN count, ascites culture and biochemical analysis is 555. Conclusion: Rapid bedside screening for SBP with a urine reagent strip such as the nephur-test | could prove to be accurate and cost-effective. This type of screen could prove to be useful in situations of emergency or limited resources, resuhng in the initiation of fife-saving antibiotic therapy while fluid analysis is pending.
142 Risk Factors for the Onset of Abdominal Pain in Children: A Prospective
Population Based Study Smita L. S Halder, Gareth T. Jones, Alan J. Silman, David G. Thompson, Gary J. Macfarfane Background: Recurrent abdominal pain (RAP) is a common functional disorder n children and its underlying aetiology remains unclear. RAP often coexists with somatic symptoms such as headache. Cross sectional studies have shown that children who suffer from RAP are more likely to have behavioural problems, and to suffer from anxiety and depression, but these studies are unable to distngnish whether these factors are causes or effects of pain. The aim of this current study was to determine whether psychosocial factors and a history of somatic symptoms predict the future onset of abdominal pain. Methods: From a large questionnaire-based cross sectional survey, 675 children aged 11-14 yrs from schools in North West England were identified as being free of abdominal pain. Usng a validated questionnaire, information was collected from these subjects on psychosocial difficuhtes and behaviour as well as on other common somatic complaints: headache, sore throat and daytime tiredness. A one year follow up questionnaire determined whether these children had developed new onset abdominal pain defined as pain on at least 1 day n the past month. Risk factors were identified using Poisson regression and are expressed as age and sex adjusted Relative Risks (RR) with 95% Confidence Intervals. Results: 570 children (84.4%) were followed up of whom 243 (42.6%) reported new onset abdominal pain. Pain was more common in girls (52.3%) than boys (35.5%), but did not vary by age group and was unrelated to menstrual status High levels of total psychosocial difficulties were predictive of pain onset (1.4; 1.03-2.0), whereas positive behaviour was protective (0.7; 0.5-0.9). Reporting other somatic complaints at baseline also predicted new onset abdominal pain; headache: 1.4 (1.1-1.8); sore throat: 1.2 (0.96-1.6); and daytime tiredness: 1.4 (1.1-1.9). Using a definition of more frequent pain (pain > 7 days) as the outcome (new onset rate 3.2%), stronger risk associations were observed e.g. the RR associated with high total difficulties ncreased to 8.1 (2.8-23.7). Conclusions: This is the first population'based study examinng predictors of abdominal pain in children. Female sex, and adverse behavioural and emotional factors are strong predictors of onset of future abdominal pain in subjects free of pain at baseline. Conversely, positive behaviour is protective against abdominal pain development. Consistent with results from adults, this study provides evidence that abdominal pain in children may he a manifestation of somatisation.
AGA Abstracts
145 10-Day Outpatient Treatment Protocol for Management of Acute Colonic Diverticulitis Akira Mizuki, Hiroshi Nagata, Masayuki Tatemiti, Nobuhiro Tsukada, Satoru Kaneda, Hiromasa lshii Background/aims: In the meeting of DDW 2001, we preliminarily reported treatment modality of acute colonic diverticulitis (ACD) using oral antibiotics and sports drink in outpatient clinic. In this paper, we have collected more subjects, determined the re-attack rate, and compared the cost of treatments. Methods: Based on the findings of uhrasonography (US), 4 grades of ACD were determined: grade I, an imaged nflamed diverticulum (lID); grade II, lID with panicufitis; grade Ill, lID with an abscess within 2 cm in diameter and grade IV, IID with an abscess larger than 2 cm in diameter or perforation to the abdominal cavity. The treatment protocol consistmg of cefpodoxime proxetile 200 mg given orally twice daily for 10 days and sports drink for the first 3 days was given to the patients with grade I to grade Ill (mild to moderate) ACD. Physical and laboratory examinations were repeated to determine feasibility to take liquid diet and ordinary diet on the 4th and 7th day, respectively. Patients who had been successfully treated were followed to determine the re.attack rate.
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