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Berry SK, Takakura W, Patel D, Govalan R, Ghafari A, Kiefer E, Huang SC, Bresee C, Nuckols TK, Melmed GY. A randomized controlled trial of a proactive analgesic protocol demonstrates reduced opioid use among hospitalized adults with inflammatory bowel disease. Sci Rep 2023; 13:22396. [PMID: 38104145 PMCID: PMC10725490 DOI: 10.1038/s41598-023-48126-0] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 11/22/2023] [Indexed: 12/19/2023] Open
Abstract
Most hospitalized patients with inflammatory bowel disease (IBD) experience pain. Despite the known risks associated with opioids in IBD including risk for misuse, overdose, infection, readmission, and even death, opioid use is more prevalent in IBD than any other chronic gastrointestinal condition. Most hospitalized IBD patients receive opioids; however, opioids have not been shown to improve pain during hospitalization. We conducted a randomized controlled trial in hospitalized patients with IBD to evaluate the impact of a proactive opioid-sparing analgesic protocol. Wearable devices measured activity and sleep throughout their hospitalization. Chronic opioid users, post-operative, and pregnant patients were excluded. The primary endpoint was a change in pain scores from admission to discharge. Secondary endpoints included opioid use, functional activity, sleep duration and quality, and length of stay. Of 329 adults with IBD evaluated for eligibility, 33 were enrolled and randomized to the intervention or usual care. Both the intervention and control group demonstrated significant decreases in pain scores from admission to discharge (- 2.6 ± 2.6 vs. - 3.0 ± 3.2). Those randomized to the intervention tended to have lower pain scores than the control group regardless of hospital day (3.02 ± 0.90 vs. 4.29 ± 0.81, p = 0.059), used significantly fewer opioids (daily MME 11.8 ± 15.3 vs. 30.9 ± 42.2, p = 0.027), and had a significantly higher step count by Day 4 (2330 ± 1709 vs. 1050 ± 1214; p = 0.014). There were no differences in sleep duration, sleep quality, readmission, or length-of-stay between the two groups. A proactive analgesic protocol does not result in worsening pain but does significantly reduce opioid-use in hospitalized IBD patients.Clinical trial registration number: NCT03798405 (Registered 10/01/2019).
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Affiliation(s)
- Sameer K Berry
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles, USA
| | - Will Takakura
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles, USA
| | - Devin Patel
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles, USA
| | | | - Afsoon Ghafari
- F. Widjaja Inflammatory Bowel Disease Institute, Karsh Division of Gastroenterology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Elizabeth Kiefer
- Research Informatics and Scientific Computing Core, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Shao-Chi Huang
- Research Informatics and Scientific Computing Core, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Catherine Bresee
- Biostatistics and Bioinformatics Core, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Teryl K Nuckols
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles, USA
| | - Gil Y Melmed
- F. Widjaja Inflammatory Bowel Disease Institute, Karsh Division of Gastroenterology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.
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Berry SK, Berry R, Recker D, Botbyl J, Pun L, Chey WD. A Randomized Parallel-group Study of Digital Gut-directed Hypnotherapy vs Muscle Relaxation for Irritable Bowel Syndrome. Clin Gastroenterol Hepatol 2023; 21:3152-3159.e2. [PMID: 37391055 DOI: 10.1016/j.cgh.2023.06.015] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/31/2023] [Accepted: 06/16/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND & AIMS Gut-directed hypnotherapy (GDH) is effective for treating irritable bowel syndrome (IBS), but access limits its widespread use. We report the first randomized controlled trial comparing the safety and efficacy of a self-administered, digital GDH treatment program with that of digital muscle relaxation (MR) in adults with IBS. METHODS After a 4-week run-in period, patients were randomized to 12 weeks of treatment with digital GDH (Regulora), or digital MR accessed via a mobile app on a smartphone or tablet. The primary endpoint was abdominal pain response, defined as ≥30% reduction from baseline in average daily abdominal pain intensity in the 4 weeks following treatment. Key secondary outcomes included mean change from baseline in abdominal pain, stool consistency, and stool frequency. RESULTS Of 378 randomized patients, 362 were treated and included in the efficacy analysis. A similar proportion of the GDH (30.4%) and MR (27.1%) groups met the primary endpoint, with no significant difference between the groups (P = .5352). Significantly more patients treated with GDH than MR were abdominal pain responders during the last 4 weeks of treatment (30.9% vs 21.5%; P = .0232) and over the entire treatment period (29.3% vs 18.8%; P = .0254). Improvements in abdominal pain, stool consistency, and stool frequency were consistent across IBS subtypes. No patients experienced serious adverse events or adverse events leading to study discontinuation. CONCLUSIONS Treatment with a digital GDH program led to an improvement in abdominal pain and stool symptoms in patients with IBS, supporting a role for this intervention as part of integrated care for IBS. CLINICALTRIALS gov identifier NCT04133519.
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Affiliation(s)
- Sameer K Berry
- New York Gastroenterology Associates, New York, New York
| | - Rani Berry
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, California.
| | | | | | - Lucy Pun
- Elevated Health, Huntington Beach, California
| | - William D Chey
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
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3
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Saleh ZM, Chey WD, Berry SK. Behavioral Health Digital Therapeutics for Patients With Irritable Bowel Syndrome: A Primer for Gastroenterologists. Am J Gastroenterol 2023; 118:1311-1313. [PMID: 36799911 DOI: 10.14309/ajg.0000000000002220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/13/2023] [Indexed: 02/18/2023]
Affiliation(s)
- Zachary M Saleh
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - William D Chey
- Division of Gastroenterology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Sameer K Berry
- Division of Gastroenterology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
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Byrne MF, Panaccione R, East JE, Iacucci M, Parsa N, Kalapala R, Reddy DN, Rughwani HR, Singh AP, Berry SK, Monsurate R, Soudan F, Laage G, Cremonese ED, St-Denis L, Lemaître P, Nikfal S, Asselin J, Henkel ML, Travis SP. Application of Deep Learning Models to Improve Ulcerative Colitis Endoscopic Disease Activity Scoring Under Multiple Scoring Systems. J Crohns Colitis 2022; 17:463-471. [PMID: 36254822 DOI: 10.1093/ecco-jcc/jjac152] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Lack of clinical validation and inter-observer variability are two limitations of endoscopic assessment and scoring of disease severity in patients with Ulcerative Colitis. We developed a deep learning (DL) model to improve, accelerate and automate UC detection, and predict the Mayo Endoscopic Subscore (MES) and the Ulcerative Colitis Endoscopic Index of Severity (UCEIS). METHODS A total of 134 prospective videos (1,550,030 frames) were collected and those with poor quality were excluded. The frames were labeled by experts based on MES and UCEIS scores. The scored frames were used to create a preprocessing pipeline and train multiple convolutional neural networks (CNNs) with proprietary algorithms in order to filter, detect and assess all frames. These frames served as the input for the DL model, with the output being continuous scores for MES and UCEIS (and its components). A graphical user interface was developed to support both labeling video sections and displaying the predicted disease severity assessment by the AI from endoscopic recordings. RESULTS Mean absolute error (MAE) and mean bias were used to evaluate the distance of continuous model's predictions from ground truth and its possible tendency to over/under-predict were excellent for MES and UCEIS. The quadratic weighted kappa used to compare the inter-rater agreement between experts' labels and the model's predictions showed strong agreement (0.87, 0.88 frame-level, 0.88, 0.90 section-level and 0.90, 0.78 at video-level, for MES and UCEIS, respectively). CONCLUSIONS We present the first fully automated tool that improves the accuracy of the MES and UCEIS, reduces the time between video collection and review, and improves subsequent quality assurance and scoring.
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Affiliation(s)
- Michael F Byrne
- Division of Gastroenterology, Department of Medicine. Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada.,Satisfai Health, Vancouver, British Columbia, Canada
| | - Remo Panaccione
- Division of Gastroenterology, University of Calgary, Calgary, Canada
| | - James E East
- Translational Gastroenterology Unit and Oxford NIHR Biomedical Research Centre, Nuffield Department of Clinical Medicine, Experimental Medicine Division, University of Oxford, John Radcliffe Hospital, Headley Way, Headington, Oxford, United Kingdom
| | - Marietta Iacucci
- Institute of Translational Medicine, Division of Gastroenterology, Birmingham, United Kingdom
| | - Nasim Parsa
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA.,Satisfai Health, Vancouver, British Columbia, Canada
| | - Rakesh Kalapala
- Asian Institute of Gastroenterology (AIG Hospitals), Gachibowli, Hyderabad, India
| | - Duvvur N Reddy
- Asian Institute of Gastroenterology (AIG Hospitals), Gachibowli, Hyderabad, India
| | | | - Aniruddha P Singh
- Asian Institute of Gastroenterology (AIG Hospitals), Gachibowli, Hyderabad, India
| | - Sameer K Berry
- Division of Gastroenterology & Hepatology, University of Michigan, Ann Arbor, MI, USA
| | | | | | | | | | | | | | | | | | | | - Simon P Travis
- Translational Gastroenterology Unit and Oxford NIHR Biomedical Research Centre, Nuffield Department of Clinical Medicine, Experimental Medicine Division, University of Oxford, John Radcliffe Hospital, Headley Way, Headington, Oxford, United Kingdom
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Berinstein JA, Cohen-Mekelburg SA, Greenberg GM, Wray D, Berry SK, Saini SD, Fendrick AM, Adams MA, Waljee AK, Higgins PD. A Care Coordination Intervention Improves Symptoms But Not Charges in High-Risk Patients With Inflammatory Bowel Disease. Clin Gastroenterol Hepatol 2022; 20:1029-1038.e9. [PMID: 34461298 PMCID: PMC8882693 DOI: 10.1016/j.cgh.2021.08.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/17/2021] [Accepted: 08/23/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) is associated with substantial symptom burden, variability in clinical outcomes, and high direct costs. We sought to determine if a care coordination-based strategy was effective at improving patient symptom burden and reducing healthcare costs for patients with IBD in the top quintile of predicted healthcare utilization and costs. METHODS We performed a randomized controlled trial to evaluate the efficacy of a patient-tailored multicomponent care coordination intervention composed of proactive symptom monitoring and care coordinator-triggered algorithms. Enrolled patients with IBD were randomized to usual care or to our care coordination intervention over a 9-month period (April 2019 to January 2020). Primary outcomes included change in patient symptom scores throughout the intervention and IBD-related charges at 12 months. RESULTS Eligible IBD patients in the top quintile for predicted healthcare utilization and expenditures were identified. A total of 205 patients were enrolled and randomized to our intervention (n = 100) or to usual care (n = 105). Patients in the care coordinator arm demonstrated an improvement in symptoms scores compared with usual care (coefficient, -0.68, 95% confidence interval, -1.18 to -0.18; P = .008) without a significant difference in median annual IBD-related healthcare charges ($10,094 vs $9080; P = .322). CONCLUSIONS In this first randomized controlled trial of a patient-tailored care coordination intervention, composed of proactive symptom monitoring and care coordinator-triggered algorithms, we observed an improvement in patient symptom scores but not in healthcare charges. Care coordination programs may represent an effective value-based approach to improve symptoms scores without added direct costs in a subgroup of high-risk patients with IBD. (ClinicalTrials.gov, Number: NCT04796571).
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Affiliation(s)
- Jeffrey A. Berinstein
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Shirley A. Cohen-Mekelburg
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA,VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | | | - Daniel Wray
- Twine Clinical Consulting, LLC Park City, UT, USA
| | - Sameer K. Berry
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA
| | - Sameer D. Saini
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA,VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - A. Mark Fendrick
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA,Center for Value-Based Insurance Design, University of Michigan, Ann Arbor, MI, USA
| | - Megan A. Adams
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA,VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Akbar K. Waljee
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA,VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Peter D.R. Higgins
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA
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6
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Sheehan JL, Jacob J, Berinstein EM, Greene-Higgs L, Steiner CA, Berry SK, Shannon C, Cohen-Mekelburg SA, Higgins PDR, Berinstein JA. The Relationship Between Opioid Use and Healthcare Utilization in Patients With Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis. Inflamm Bowel Dis 2022; 28:1904-1914. [PMID: 35230420 PMCID: PMC9924039 DOI: 10.1093/ibd/izac021] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pain is commonly experienced by patients with inflammatory bowel disease (IBD). Unfortunately, pain management is a challenge in IBD care, as currently available analgesics are associated with adverse events. Our understanding of the impact of opioid use on healthcare utilization among IBD patients remains limited. METHODS A systematic search was completed using PubMed, Embase, the Cochrane Library, and Scopus through May of 2020. The exposure of interest was any opioid medication prescribed by a healthcare provider. Outcomes included readmissions rate, hospitalization, hospital length of stay, healthcare costs, emergency department visits, outpatient visits, IBD-related surgeries, and IBD-related medication utilization. Meta-analysis was conducted on study outcomes reported in at least 4 studies using random-effects models to estimate pooled relative risk (RR) and 95% confidence interval (CI). RESULTS We identified 1969 articles, of which 30 met inclusion criteria. Meta-analysis showed an association between opioid use and longer length of stay (mean difference, 2.25 days; 95% CI, 1.29-3.22), higher likelihood of prior IBD-related surgery (RR, 1.72; 95% CI, 1.32-2.25), and higher rates of biologic use (RR, 1.38; 95% CI, 1.13-1.68) but no difference in 30-day readmissions (RR, 1.17; 95% CI, 0.86-1.61), immunomodulator use (RR, 1.13; 95% CI, 0.89-1.44), or corticosteroid use (RR, 1.36; 95% CI, 0.88-2.10) in patients with IBD. On systematic review, opioid use was associated with increased hospitalizations, healthcare costs, emergency department visits, outpatient visits, and polypharmacy. DISCUSSION Opioids use among patients with IBD is associated with increased healthcare utilization. Nonopioid alternatives are needed to reduce burden on the healthcare system and improve patient outcomes.
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Affiliation(s)
- Jessica L Sheehan
- Address correspondence to: Jessica L. Sheehan, MD, MS, 1500 E. Medical Center Drive, Ann Arbor, MI 48109, USA ()
| | - Janson Jacob
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Elliot M Berinstein
- Department of Medicine, St. Joseph Mercy Ann Arbor Hospital, Ypsilanti, MI, USA
| | | | - Calen A Steiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Colorado, Aurora, Colorado, USA
| | - Sameer K Berry
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Carol Shannon
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, Michigan, USA
| | - Shirley A Cohen-Mekelburg
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA,VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI, USA,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
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Hall NJ, Berry SK, Aguilar J, Brier E, Shah P, Cheng D, Herman J, Stein T, Spiegel BMR, Almario CV. Impact of an Online Gastrointestinal Symptom History Taker on Physician Documentation and Charting Time: Pragmatic Controlled Trial. JMIR Form Res 2021; 5:e23599. [PMID: 33944789 PMCID: PMC8132977 DOI: 10.2196/23599] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 01/18/2021] [Accepted: 04/11/2021] [Indexed: 11/28/2022] Open
Abstract
Background A potential benefit of electronic health records (EHRs) is that they could potentially save clinician time and improve documentation by auto-generating the history of present illness (HPI) in partnership with patients prior to the clinic visit. We developed an online patient portal called AEGIS (Automated Evaluation of Gastrointestinal [GI] Symptoms) that systematically collects patient GI symptom information and then transforms the data into a narrative HPI that is available for physicians to review in the EHR prior to seeing the patient. Objective This study aimed to compare whether use of an online GI symptom history taker called AEGIS improves physician-centric outcomes vs usual care. Methods We conducted a pragmatic controlled trial among adults aged ≥18 years scheduled for a new patient visit at 4 GI clinics at an academic medical center. Patients who completed AEGIS were matched with controls in the intervention period who did not complete AEGIS as well as controls who underwent usual care in the pre-intervention period. Of note, the pre-intervention control group was formed as it was not subject to contamination bias, unlike for post-intervention controls. We then compared the following outcomes among groups: (1) documentation of alarm symptoms, (2) documentation of family history of GI malignancy, (3) number of follow-up visits in a 6-month period, (4) number of tests ordered in a 6-month period, and (5) charting time (difference between appointment time and time the encounter was closed). Multivariable regression models were used to adjust for potential confounding. Results Of the 774 patients who were invited to complete AEGIS, 116 (15.0%) finished it prior to their visit. The 116 AEGIS patients were then matched with 343 and 102 controls in the pre- and post-intervention periods, respectively. There were no statistically significant differences among the groups for documentation of alarm symptoms and GI cancer family history, number of follow-up visits and ordered tests, or charting time (all P>.05). Conclusions Use of a validated online HPI-generation portal did not improve physician documentation or reduce workload. Given universal adoption of EHRs, further research examining how to optimally leverage patient portals for improving outcomes are needed.
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Affiliation(s)
- Natalie J Hall
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Sameer K Berry
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Jack Aguilar
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Elizabeth Brier
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Parth Shah
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Derek Cheng
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Jeremy Herman
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Theodore Stein
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Brennan M R Spiegel
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Division of Health Services Research, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Division of Informatics, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, United States
| | - Christopher V Almario
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Division of Health Services Research, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Division of Informatics, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, United States
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Kane AD, Paterson J, Pokhrel S, Berry SK, Monkhouse D, Brand JW, Ingram M, Danjoux GR. Peri-operative COVID-19 infection in urgent elective surgery during a pandemic surge period: a retrospective observational cohort study. Anaesthesia 2020; 75:1596-1604. [PMID: 33090469 DOI: 10.1111/anae.15281] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2020] [Indexed: 12/23/2022]
Abstract
Maintaining safe elective surgical activity during the global coronavirus disease 2019 (COVID-19) pandemic is challenging and it is not clear how COVID-19 may impact peri-operative morbidity and mortality in this population. Therefore, adaptations to normal care pathways are required. Here, we establish if implementation of a bespoke peri-operative care bundle for urgent elective surgery during a pandemic surge period can deliver a low COVID-19-associated complication profile. We present a single-centre retrospective cohort study from a tertiary care hospital of patients planned for urgent elective surgery during the initial COVID-19 surge in the UK between 29 March and 12 June 2020. Patients asymptomatic for COVID-19 were screened by oronasal swab and chest imaging (chest X-ray or computed tomography if aged ≥ 18 years), proceeding to surgery if negative. COVID-19 positive patients at screening were delayed. Postoperatively, patients transitioning to COVID-19 positive status by reverse transcriptase polymerase chain reaction testing were identified by an in-house tracking system and monitored for complications and death within 30 days of surgery. Out of 557 patients referred for surgery (230 (41.3%) women; median (IQR [range]) age 61 (48-72 [1-89])), 535 patients (96%) had COVID-19 screening, of which 13 were positive (2.4%, 95%CI 1.4-4.1%). Out of 512 patients subsequently undergoing surgery, 7 (1.4%) developed COVID-19 positive status (1.4%, 95%CI 0.7-2.8%) with one COVID-19-related death (0.2%, 95%CI 0.0-1.1%) within 30 days. Out of these seven patients, four developed pneumonia, of which two required invasive ventilation including one patient with acute respiratory distress syndrome. Low rates of COVID-19 infection and mortality in the elective surgical population can be achieved within a targeted care bundle. This should provide reassurance that elective surgery can continue, where possible, despite high community rates of COVID-19.
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Affiliation(s)
- A D Kane
- Department of Anaesthesia, James Cook University Hospital, Middlesbrough, UK
| | - J Paterson
- Department of Anaesthesia, James Cook University Hospital, Middlesbrough, UK
| | - S Pokhrel
- Department of Anaesthesia, James Cook University Hospital, Middlesbrough, UK
| | - S K Berry
- Department of Anaesthesia, James Cook University Hospital, Middlesbrough, UK
| | - D Monkhouse
- Department of Intensive Care Medicine, James Cook University Hospital, Middlesbrough, UK
| | - J W Brand
- Department of Cardiothoracic Intensive Care Medicine and Anaesthesia, James Cook University Hospital, Middlesbrough, UK
| | - M Ingram
- Department of Cardiothoracic Intensive Care Medicine and Anaesthesia, James Cook University Hospital, Middlesbrough, UK
| | - G R Danjoux
- Department of Cardiothoracic Intensive Care Medicine and Anaesthesia, James Cook University Hospital, Middlesbrough, UK.,Hull York Medical School and School of Health and Social Science, Teesside University, Middlesbrough, UK
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Berry SK, Takakura W, Bresee C, Melmed GY. Pain in Inflammatory Bowel Disease Is Not Improved During Hospitalization: The Impact of Opioids on Pain and Healthcare Utilization. Dig Dis Sci 2020; 65:1777-1783. [PMID: 31654314 DOI: 10.1007/s10620-019-05906-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 10/15/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Most patients with IBD experience pain, especially during acute disease exacerbations. Opioid use continues to be more prevalent in IBD than any other chronic gastrointestinal condition, and the majority of IBD patients consume narcotics during hospitalization despite the risks of infection and death. METHODS We performed a retrospective review of 57 subjects aimed at quantifying pain and opiate consumption for IBD-related admissions over a 3-month period. For each patient, the average and maximum of each day's pain scores were used to measure changes in pain from admission to discharge using mixed model regression, with opiate use as a time-dependent covariate. RESULTS The daily average pain score over the entire hospitalization was 4.23 ± 2.09, and the maximum pain score was 8.28 ± 1.75. Among opioid users (n = 51), the daily average pain score was 4.65 ± 2.16 and the maximum pain score was 7.53 ± 2.56. Across all cases from admission to discharge, there was less than a 1-point change in daily average pain (- 0.96 ± 2.03, p = 0.0009), and no change in maximum pain (- 0.89 ± 3.59, p = 0.0671). Opioid users, a subset of the overall cohort, had a similar less than one-point drop in daily average pain (- 0.94 ± - 0.29, p = 0.0024) and no change in daily maximum pain scores (- 0.81 ± - 0.47, p = 0.0914). Patients on average used 20 ± 25 mg morphine equivalents per day. Opioid-naïve patients used similar doses to those who used opioids prior to admission (PTA). Almost half of all cases (47%) were discharged with an opioid prescription, the majority (71%) of whom were not on opioids PTA. CONCLUSIONS Pain in IBD is not well controlled through hospitalization, with less than a 1-point change from admission to discharge, despite significant opioid consumption. Alternative analgesic methods should be explored, given the significant impact of narcotics on long-term outcomes including mortality and quality of life.
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Affiliation(s)
- Sameer K Berry
- General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Will Takakura
- General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Catherine Bresee
- Biostatistics Core, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Gil Y Melmed
- Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, 8730 Alden Drive, Steven Spielberg Building, Suite 2-East, Los Angeles, CA, 90048, USA.
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Affiliation(s)
- Sameer K. Berry
- Division of Gastroenterology and HepatologyUniversity of Michigan Medical SchoolAnn ArborMI
| | - Robert J. Fontana
- Division of Gastroenterology and HepatologyUniversity of Michigan Medical SchoolAnn ArborMI
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Abstract
Inflammatory bowel disease (IBD), which includes Crohn's disease and ulcerative colitis, is a chronic, debilitating, and expensive condition affecting millions of people globally. There is significant variation in the quality of care for patients with IBD across North America, Europe, and Asia; this variation suggests poor quality of care due to overuse, underuse, or misuse of health services and disparity of outcomes. Several initiatives have been developed to reduce variation in care delivery and improve processes of care, patient outcomes, and reduced healthcare costs. These initiatives include the development of quality indicator sets to standardize care across organizations, and learning health systems to enable data sharing between doctors and patients, and sharing of best practices among providers. These programs have been variably successful in improving patient outcomes and reducing healthcare utilization. Further studies are needed to demonstrate the long-term impact and applicability of these efforts in different geographic areas around the world, as regional variations in patient populations, societal preferences, and costs should inform local quality improvement efforts.
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Affiliation(s)
- Sameer K Berry
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Gil Y Melmed
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Abstract
PURPOSE OF REVIEW This article serves as an overview of several quality improvement initiatives in inflammatory bowel disease (IBD). RECENT FINDINGS IBD is associated with significant variation in care, suggesting poor quality of care. There have been several efforts to improve the quality of care for patients with IBD. Quality improvement (QI) initiatives in IBD are intended to be patient-centric, improve outcomes for individuals and populations, and reduce costs-all consistent with "the triple aim" put forth by the Institute for Healthcare Improvement (IHI). Current QI initiatives include the development of quality measure sets to standardize processes and outcomes, learning health systems to foster collaborative improvement, and patient-centered medical homes specific to patients with IBD in shared risk models of care. Some of these programs have demonstrated early success in improving patient outcomes, reducing costs, improving patient satisfaction, and facilitating patient engagement. However, further studies are needed to evaluate and compare the effects of these programs over time on clinical outcomes in order to demonstrate long-term value and sustainability.
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Affiliation(s)
- Sameer K Berry
- Department of Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA
| | - Corey A Siegel
- Department of Medicine, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH, 03766, USA
| | - Gil Y Melmed
- Department of Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA. .,Inflammatory Bowel Disease Center, 8730 Alden Drive, Second Floor East, Los Angeles, CA, 90048, USA.
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