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Yen T, Jones B, Espinoza JM, Singh S, Pell J, Duloy A, Wani S, Scott FI, Patel SG. Optimizing Endoscopy Procedure Documentation Improves Guideline-Adherent Care in Upper Gastrointestinal Bleeding. Dig Dis Sci 2023; 68:2264-2275. [PMID: 36645637 PMCID: PMC9841959 DOI: 10.1007/s10620-023-07823-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 01/03/2023] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND AIMS Upper GI bleeding (UGIB) is a common indication for inpatient esophagogastroduodenoscopy (EGD). Guideline adherence improves post-EGD care, including appropriate medication dosing/duration and follow-up procedures that reduce UGIB-related morbidity. We aimed to optimize and standardize post-EGD documentation to improve process and clinical outcomes in UGIB-related care. METHODS We performed a prospective quality improvement study of inpatient UGIB endoscopies at an academic tertiary referral center during 6/2019-7/2021. Guidelines were used to develop etiology/severity-specific electronic health record note templates. Participants (39 faculty/15 trainees) completed 10-min training in template content/use. We collected pre/post-intervention process data on "Minimal Standard Report" (MSR) documentation including patient disposition, diet, and medications. We also recorded documentation of re-bleed precautions and follow-up procedures. Study outcomes included guideline-based medication prescriptions, ordering of follow-up EGD, and post-discharge re-bleeding. Pre/post-intervention analysis was performed using chi-square tests. RESULTS From a pre-intervention baseline of 199 patients to 459 patients post-intervention, compliance improved with inpatient PPI (53.4-77.9%, p < 0.001) and discharge PPI (31.3-61.0%, p < 0.001) prescriptions. There was improvement in MSR completion (28.6-42.5%, p < 0.001). Compliance improved with octreotide prescriptions (75.0-93.6%, p = 0.002) and follow-up EGD order (61.3-87.1%, p < 0.001). There was no change in post-discharge re-bleeding. 82.6% of cases used templates. CONCLUSIONS Our project leveraged endoscopy software to standardize documentation, resulting in improved clinical care behavior and efficiency. Our intervention required low burden of maintenance, and sustainability with high utilization over 9 months. Similar endoscopy templates can be applied to other health systems and procedures to improve care.
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Affiliation(s)
- Timothy Yen
- grid.430503.10000 0001 0703 675XDivision of Gastroenterology & Hepatology, University of Colorado Anschutz School of Medicine, 12631 E 17Th Avenue, B158, Aurora, CO 80045 USA
| | - Blake Jones
- grid.430503.10000 0001 0703 675XDivision of Gastroenterology & Hepatology, University of Colorado Anschutz School of Medicine, 12631 E 17Th Avenue, B158, Aurora, CO 80045 USA
| | - Jeannine M. Espinoza
- grid.430503.10000 0001 0703 675XDivision of Gastroenterology & Hepatology, University of Colorado Anschutz School of Medicine, 12631 E 17Th Avenue, B158, Aurora, CO 80045 USA
| | - Sarguni Singh
- grid.430503.10000 0001 0703 675XDivision of Hospital Medicine, University of Colorado Anschutz School of Medicine, Aurora, CO USA
| | - Jonathan Pell
- grid.430503.10000 0001 0703 675XDivision of Hospital Medicine, University of Colorado Anschutz School of Medicine, Aurora, CO USA
| | - Anna Duloy
- grid.430503.10000 0001 0703 675XDivision of Gastroenterology & Hepatology, University of Colorado Anschutz School of Medicine, 12631 E 17Th Avenue, B158, Aurora, CO 80045 USA
| | - Sachin Wani
- grid.430503.10000 0001 0703 675XDivision of Gastroenterology & Hepatology, University of Colorado Anschutz School of Medicine, 12631 E 17Th Avenue, B158, Aurora, CO 80045 USA
| | - Frank I. Scott
- grid.430503.10000 0001 0703 675XDivision of Gastroenterology & Hepatology, University of Colorado Anschutz School of Medicine, 12631 E 17Th Avenue, B158, Aurora, CO 80045 USA
| | - Swati G. Patel
- grid.430503.10000 0001 0703 675XDivision of Gastroenterology & Hepatology, University of Colorado Anschutz School of Medicine, 12631 E 17Th Avenue, B158, Aurora, CO 80045 USA ,grid.422100.50000 0000 9751 469XRocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO USA
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Farah F, Patel SG, Espinoza JM, Jensen N, Katona BW, Muller C, Kupfer SS, Weiss JM, Hinton A, Stanich PP. Yield of upper gastrointestinal screening in colonic adenomatous polyposis of unknown etiology: a multicenter study. Endosc Int Open 2022; 10:E528-E533. [PMID: 35433207 PMCID: PMC9010079 DOI: 10.1055/a-1784-0166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 11/24/2021] [Indexed: 11/17/2022] Open
Abstract
Background and study aims The majority of patients with 10 or more cumulative colorectal adenomas have uninformative genetic testing and meet criteria for colonic adenomatous polyposis of unknown etiology (CPUE). The yield of upper gastrointestinal screening in patients with CPUE after multi-gene panel testing is unknown and our objective was to characterize this. Patient and methods A multicenter, retrospective analysis of screening upper endoscopies in adults with CPUE after multi-gene panel testing was performed. Those with a history of gastroduodenal neoplasia prior to CPUE diagnosis were excluded. Demographic and clinical variables were collected and compared. Results One hundred and twenty-eight patients with CPUE were included from five participating centers. Nine (7.0 %) had gastroduodenal neoplasia on initial screening upper endoscopy. Those with over 100 colorectal adenomas had a significantly higher rate of gastroduodenal neoplasia than those with 20-99 or 10-19 colorectal adenomas (44.4 % vs 4.1 % vs 4.4 %, P = 0.002). Similar results were seen when the analysis was restricted to only duodenal or ampullary adenomas. The only malignancy was a gastric cancer in a patient with 20 to 99 colorectal adenomas. When comparing patients with gastroduodenal neoplasia to those without, the only significantly different characteristic was the cumulative number of colorectal adenomas. Conclusions We found a 7 % rate of gastroduodenal neoplasia in patients with CPUE after multi-gene panel testing. Although patients with ≥ 100 colorectal adenomas had a significantly higher risk, over 4 % of patients with 10 to 99 colorectal adenomas had gastroduodenal neoplasia. Given this, we recommend a screening upper endoscopy at the time of a colonoscopy after CPUE diagnosis.
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Affiliation(s)
- Filsan Farah
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
| | - Swati G. Patel
- Division of Gastroenterology, University of Colorado Anschutz Medical Center, Aurora, Colorado, United States
- Division of Gastroenterology, Rocky Mountain Regional Veterans Affairs Medical Center, Denver, Colorado, United States
| | - Jeannine M. Espinoza
- Division of Gastroenterology, University of Colorado Anschutz Medical Center, Aurora, Colorado, United States
- Division of Gastroenterology, Rocky Mountain Regional Veterans Affairs Medical Center, Denver, Colorado, United States
| | - Nicholas Jensen
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Bryson W. Katona
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Charles Muller
- Section of Gastroenterology, Hepatology and Nutrition, University of Chicago, Chicago, Illinois, United States
| | - Sonia S. Kupfer
- Section of Gastroenterology, Hepatology and Nutrition, University of Chicago, Chicago, Illinois, United States
| | - Jennifer M. Weiss
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
| | - Alice Hinton
- Division of Biostatistics, The Ohio State University, Columbus, Ohio, United States
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
| | - Peter P. Stanich
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
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Parekh A, Hochheimer CJ, Espinoza JM, Karlitz JJ, Lewis CL, Wani S, Patel SG. Primary Care Provider Knowledge and Practice in Risk Assessment for Early Age Onset Colorectal Cancer: Opportunities for Improvement. J Cancer Prev 2021; 26:298-303. [PMID: 35047456 PMCID: PMC8749316 DOI: 10.15430/jcp.2021.26.4.298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/09/2021] [Accepted: 12/22/2021] [Indexed: 12/30/2022] Open
Abstract
Colorectal cancer (CRC) incidence and mortality are rising in individuals under age 50, termed early age onset (EAO) CRC. Lower endoscopy is recommended for all patients with unexplained iron deficiency anemia (IDA) or hematochezia to assess the EAO-CRC. For those without symptoms, professional societies recommend decreasing the age to start screening from 50 to 45. Primary care provider (PCP) knowledge and practices around EAO-CRC risk assessment and screening are unknown. We conducted a survey study in May, 2020 of multi-specialty PCPs from three large medical systems to assess PCP knowledge, risk stratification practices and barriers/facilitators they face to offer CRC screening in patients < 50. We conducted univariate analysis to assess factors associated with knowledge and diagnostic practices. Response rate was 27.7% (196/708). Although 77.6% of respondents were aware that EAO-CRC incidence is increasing, only 42.9% knew that EAO-CRC mortality is also increasing. Of note, 91.8% recommend starting average risk screening at age 50. For 40- to 49-year-old patients present with unexplained IDA or hematochezia, 71.9% and 50.5% of respondents, respectively, recommend a diagnostic colonoscopy. Trainees were less likely to be aware of rising EAO-CRC mortality (odds ratio, 0.42; 95% CI, 0.21 to 0.82) and non-internal medicine providers were less likely to recommend CRC screening in those with a first-degree relative with CRC (odds ratio, 0.82; 95% CI, 0.72 to 0.93). Ongoing education efforts will be required to improve recognition and management of high-risk symptoms, particularly among non-internists and trainees.
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Affiliation(s)
- Anjali Parekh
- Division of Gastroenterology & Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Camille J Hochheimer
- Center for Innovative Design & Analysis, University of Colorado School of Public Health, Aurora, CO, USA
| | - Jeannine M Espinoza
- Division of Gastroenterology & Hepatology, Denver Health Hospital Authority, Denver, CO, USA
| | - Jordan J Karlitz
- Division of General Internal Medicine, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Carmen L Lewis
- Division of General Internal Medicine, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Sachin Wani
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
| | - Swati G Patel
- Division of General Internal Medicine, University of Colorado Anschutz Medical Center, Aurora, CO, USA
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