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Reynolds CA, Nair V, Villaflores C, Dominguez K, Arbanas JC, Treasure M, Skootsky S, Tseng CH, Sarkisian C, Patel A, Ghassemi K, Fendrick AM, May FP, Mafi JN. Developing an electronic health record measure of low-value esophagogastroduodenoscopy for GERD at a large academic health system. BMJ Open Qual 2023; 12:e002363. [PMID: 38135304 DOI: 10.1136/bmjoq-2023-002363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 12/03/2023] [Indexed: 12/24/2023] Open
Abstract
OBJECTIVES Low-value esophagogastroduodenoscopies (EGDs) for uncomplicated gastro-oesophageal reflux disease (GERD) can harm patients and raise patient and payer costs. We developed an electronic health record (EHR) 'eMeasure' to detect low-value EGDs. DESIGN Retrospective cohort of 518 adult patients diagnosed with GERD who underwent initial EGD between 1 January 2019 and 31 December 2019. SETTING Outpatient primary care and gastroenterology clinics at a large, urban, academic health centre. PARTICIPANTS Adult primary care patients at the University of California Los Angeles who underwent initial EGD for GERD in 2019. MAIN OUTCOME MEASURES EGD appropriateness criteria were based on the American College of Gastroenterology 2012 guidelines. An initial EGD was considered low-value if it lacked a documented guideline-based indication, including alarm symptoms (eg, iron-deficiency anaemia); failure of an 8-week proton pump inhibitor trial or elevated Barrett's oesophagus risk. We performed manual chart review on a random sample of 204 patients as a gold standard of the eMeasure's validity. We estimated EGD costs using Medicare physician and facility fee rates. RESULTS Among 518 initial EGDs performed (mean age 53 years; 54% female), the eMeasure identified 81 (16%) as low-value. The eMeasure's sensitivity was 42% (95% CI 22 to 61) and specificity was 93% (95% CI 89 to 96). Stratifying across clinics, 62 (74.6%) low-value EGDs originated from 2 (12.5%) out of 16 clinics. Total cost for 81 low-value EGDs was approximately US$75 573, including US$14 985 in patients' out-of-pocket costs. CONCLUSIONS We developed a highly specific eMeasure that showed that low-value EGDs occurred frequently in our healthcare system and were concentrated in a minority of clinics. These results can inform future QI efforts at our institution, such as best practice alerts for the ordering physician. Moreover, this open-source eMeasure has a much broader potential impact, as it can be integrated into any EHR and improve medical decision-making at the point of care.
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Affiliation(s)
- Courtney A Reynolds
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Vishnu Nair
- Department of Medicine, Stanford University, Stanford, California, USA
| | - Chad Villaflores
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Katherine Dominguez
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Julia Cave Arbanas
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Madeline Treasure
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Samuel Skootsky
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Chi-Hong Tseng
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Catherine Sarkisian
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Veterans' Administration Greater Los Angeles Healthcare System, Geriatric Research Education & Clinical Center (GRECC), birmingham, Alabama, USA
| | - Arpan Patel
- The Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Kevin Ghassemi
- The Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - A Mark Fendrick
- Department of Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Folasade P May
- UCLA Kaiser Permanente Center for Health Equity, Jonsson Comprehensive Cancer Center, Los Angeles, Calif, USA
| | - John N Mafi
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- RAND Health, RAND Corporation, Santa Monica, California, USA
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Guido PA, Treasure M, DeCherney GS. SUN-280 A Brute of a Case: Pituitary Apoplexy in a Patient Treated for Chronic Lymphocytic Leukemia with Ibrutinib. J Endocr Soc 2020. [PMCID: PMC7209631 DOI: 10.1210/jendso/bvaa046.740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background- Patients treated for chronic lymphocytic leukemia are frequently administered ibrutinib. Ibrutinib inhibits Bruton’s tyrosine kinase, blocks the B-cell receptor signaling pathway, thereby reducing downstream effects such as proliferation; effectively treating the malignancy. Adverse events such as bleeding have been reported and are suspected to be caused by inhibition of kinases in the platelet aggregation pathway. Clinical Case- A 60-year-old man with chronic lymphocytic leukemia, treated with ibrutinib for five months, was diagnosed with pituitary apoplexy and consequent panhypopituitarism. He presented with a severe headache one month prior to diagnosis. At this time, a non-contrast head CT was interpreted as unremarkable. On second presentation one month later, studies showed a serum sodium of 116 mmol/L (135-145 mmol/L), glucose of 43 mg/dL (65-179 mg/dL), and blood pressure of 95/52. An MRI brain demonstrated an enlarged pituitary with areas of intrinsic T1 hyperintense signal noted within the sella turcica suggestive of blood products. Serum cortisol rose from 0.3 to 8.9 ug/dL (4.5-22.7 ug/dL) one hour after IV injection of 250 mcg cosyntropin. Paired ACTH was < 5 pg/mL (7.2-63 pg/mL). Hydrocortisone was started and blood pressure, sodium, and glucose normalized. LH was 0.9 mIU/mL (3-10 mIU/mL), FSH was 4.7 mIU/mL (1.6-9.7 mIU/mL), and total testosterone was < 0.7 ng/dL (240-950 ng/dL). TSH was 0.115 uIU/mL (0.6-3-3 uIU/mL) with FT4 of 0.84 ng/dL (0.71-1.4 ng/dL). Prolactin was 2.4 ng/mL (4-18 ng/mL) and IGF-1 Z score was -1.28 (-2.0-2.0). Replacement levothyroxine and testosterone were started. Oncology stopped ibrutinib and switched therapy to rituximab and venetoclax. A pituitary MRI two months later showed significant improvement of the T1 hyperintensity (blood products) and a 1.1 cm adenoma was found. During the entire course of his illness his platelet counts ranged from 275 to 431 109/L (150-440 109/L). His INR was 1.14 and PT 13.2 sec (10.2-13.2 sec). He has recovered well on hormone replacement. Discussion- Pituitary apoplexy often has underlying risk factors, including pituitary adenomas and coagulopathies. To our knowledge apoplexy has not been reported in patients taking ibrutinib, though bleeding and platelet dysfunction have been well described. Knowledge of the possible side effects of newer anti-cancer drugs is increasingly important for the endocrinologist.
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Affiliation(s)
- Paul Anthony Guido
- University of North Carolina Department of Endocrinology, Diabetes, and Metabolism, Chapel Hill, NC, USA
| | - Madeline Treasure
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - G Stephen DeCherney
- University of North Carolina Department of Endocrinology, Diabetes, and Metabolism, Chapel Hill, NC, USA
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