Gastrointestinal Consultation Research Articles

Associations between prior healthcare use, time to diagnosis, and clinical outcomes in inflammatory bowel disease: a nationally representative population-based cohort study

BackgroundTimely diagnosis and treatment of inflammatory bowel disease (IBD) may improve clinical outcomes.ObjectiveExamine associations between time to diagnosis, patterns of prior healthcare use, and clinical outcomes in IBD.DesignUsing the Clinical...

Gastrointestinal diagnoses in patients with eating disorders: A retrospective cohort study 2010-2020.

Gastrointestinal (GI) disorders are common in patients with eating disorders. However, the temporal relationship between GI and eating disorder symptoms has not been explored. We aimed to evaluate GI disorders among patients with eating disorders, their relative timing, and the relationship between GI diagnoses and eating disorder remission. We conducted a retrospective analysis of patients with an eating disorder diagnosis who had a GI encounter from 2010 to 2020. GI diagnoses and timing of eating disorder onset were abstracted from chart review. Coders applied DSM-5 criteria for eating disorders at the time of GI consult to determine eating disorder remission status. Of 344 patients with an eating disorder diagnosis and GI consult, the majority (255/344, 74.2%) were diagnosed with an eating disorder prior to GI consult (preexisting eating disorder). GI diagnoses categorized as functional/motility disorders were most common among the cohort (57.3%), particularly in those with preexisting eating disorders (62.5%). 113 (44.3%) patients with preexisting eating disorders were not in remission at GI consult, which was associated with being underweight (OR 0.13, 95% CI 0.04-0.46, p < 0.001) and increasing number of GI diagnoses (OR 0.47 per diagnosis, 95% CI 0.26-0.85, p = 0.01). Eating disorder symptoms precede GI consult for most patients, particularly in functional/motility disorders. As almost half of eating disorder patients are not in remission at GI consult. GI providers have an important role in screening for eating disorders. Further prospective research is needed to understand the complex relationship between eating disorders and GI symptoms.

GLP-1RA Essentials in Gastroenterology: Side Effect Management, Precautions for Endoscopy and Applications for Gastrointestinal Disease Treatment

Amidst the obesity and type II diabetes mellitus (T2DM) epidemics, glucagon-like peptide-1 receptor agonists (GLP-1RAs) stand out as a promising therapeutic ally, achieving notable success in glycemic control and weight management. While GLP-1RAs’ positive clinical outcomes are commendable, they introduce significant gastrointestinal (GI) challenges, emphasizing the pivotal role of gastroenterologists in understanding and managing these implications. Physicians should be vigilant of potential complications if endoscopy is indicated and considered. A protocol coined “The Three E’s: Education, Escalation, and Effective Management” is essential as the first defense against GLP-1RA-induced dyspepsia, necessitating routine GI consultations. Awareness and intervention of potential aspiration due to GLP-1RA-induced gastroparesis are vital in clinical management. Furthermore, the evolving recognition of GLP-1RAs’ beneficial effects on non-alcoholic steatohepatitis (NASH) suggests gastroenterologists will increasingly prescribe them. Thus, a comprehensive understanding of pharmacological properties and potential GI complications, including the undetermined cancer risk landscape, becomes paramount. This review accentuates the nuances of GLP-1RA therapy from a gastroenterological lens, juxtaposing the therapeutic potential, manageable side effects, and circumstantial challenges, ensuring that GI specialists remain at the forefront of holistic care in obesity and T2DM management.

A mixed-methods approach utilising electronic health records to examine antimicrobial prescription surrounding gastrointestinal clinical presentations in dogs and cats.

Systemically-administered antimicrobials are often prescribed in canine and feline gastrointestinal clinical presentations. Responsible use of antimicrobials, particularly those considered Highest Priority Critically Important Antimicrobials (HPCIAs) is vital to tackle antimicrobial resistance. Although practice-level prescription guidance is available, further strategies based on a greater understanding of antimicrobial prescription at the population-level are needed. Here, we used a mixed-methods approach, harnessing veterinary electronic health records (EHRs) to characterise the use of antimicrobials in canine and feline gastrointestinal presentations, and to explore justification and reasoning around antimicrobial prescribing, particularly of HPCIAs. This observational study used 23,337 EHRs complemented with veterinary practitioner-completed questionnaires, from canine and feline gastrointestinal consultations from 225 volunteer UK veterinary practices between April 2014 and September 2018. A total of 83.4% (95% confidence interval (CI) 82.6-84.3) gastrointestinal presentations were reported as mild, with non-haemorrhagic diarrhoea and vomiting the most frequently reported clinical signs. Systemically-administered antimicrobials occurred in 28.6% of canine (95% CI 26.9-30.3) and 22.4% of feline (95% CI 20.4-24.4) gastrointestinal consultations, with HPCIA prescription occurring more frequently in cats. Results of multivariable analysis showed the presence of non-haemorrhagic diarrhoea (canine Odds Ratio (OR) 2.1, 95% CI 1.9-2.3; feline OR 1.8, 95% CI 1.5-2.1), haemorrhagic diarrhoea (canine OR 4.2, 95% CI 3.8-4.7; feline OR 3.1, 95% CI 2.4-3.8), and moderate/severe presentations (canine OR 1.9, 95% CI 1.7-2.8; feline OR 2.0, 95% CI 1.7-2.5) were positively associated with receiving a systemically-administered antimicrobial. Thematic analysis of clinical narrative content of 516 gastrointestinal consultations where HPCIAs were prescribed allowed the identification of ten factors underpinning reasoning or decision-making for HPCIA prescription: perceived animal/owner compliance; owner's expectations; perceived risk of infection; clinical signs; recent clinical history; perceived positive previous response to antimicrobial therapy; geriatric patients and euthanasia; concomitant conditions; diagnostic testing and the behavioral trend to trial antimicrobial therapy empirically in gastrointestinal cases. No explicit justification for HPCIA prescription was recorded in 77% of cases. Improving recorded justification represents a clear target for stewardship programmes. By utilising a complementary mixed-methods approach to EHRs, this study unlocks previously untapped data recorded within EHRs. These results can help inform targeted interventions, contributing towards enhanced antimicrobial stewardship.

Prospective study of the effect of auricular percutaneous electrical nerve field stimulation on quality of life in children with pain related disorders of gut-brain interaction.

Disorders of the Gut-Brain Interaction (DGBIs) account for 50% of pediatric gastrointestinal (GI) consultations. Children with DGBIs have worse quality of life (QoL) than those with organic GI disorders such as inflammatory bowel disease and gastroesophageal reflux disease. Pediatric DGBIs patients, especially those with chronic abdominal pain (AP), have impaired QoL and increased psychological distress in the form of anxiety and depression. Percutaneous Electrical Nerve Field Stimulation (PENFS) therapy has been shown to be effective in improving symptoms and functioning in children with DGBIs. The treatment's impact on these patients' QoL is unknown. This prospective study evaluated changes in QoL, gastrointestinal symptoms, functional disability, somatization, global health, anxiety, and depression in patients aged 11-18 years who received PENFS therapy (IB-stim, NeurAxis, Versailles, IN) for treatment of pain related DGBIs, once a week for four consecutive weeks. This study included 31 patients with an average age of 15.7 years (SD = 2); 80.6% were female. After PENFS therapy, patients reported significant reductions in abdominal pain, nausea severity, functional disability, somatization, and anxiety from baseline to week 4 (p < 0.05). Parents reported significant improvement in their child's QoL regarding physical function, psychosocial function, and generic core scale scores (p < 0.05). Parents also noted reduced abdominal pain, functional disability, and somatization. Average scores on the Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health scale significantly improved based on both patient and parent reports (p < 0.05). Our patients' QoL was significantly lower than healthy controls at baseline and after treatment (p < 0.05). Our research demonstrates that PENFS significantly enhances the QoL of children suffering from pain-related DGBIs, in addition to improvement in GI symptoms, daily functioning, somatization, global health, and psychological comorbidities. These findings demonstrate the effectiveness of PENFS and its potential to alleviate the suffering of countless children.

A One Health real-time surveillance system for nowcasting Campylobacter gastrointestinal illness outbreaks, Norway, week 30 2010 to week 11 2022.

BackgroundCampylobacter is a leading cause of food and waterborne illness. Monitoring and modelling Campylobacter at chicken broiler farms, combined with weather pattern surveillance, can aid nowcasting of human gastrointestinal (GI) illness outbreaks. Near real-time sharing of data and model results with health authorities can help increase potential outbreak responsiveness.AimsTo leverage data on weather and Campylobacter on broiler farms to build a risk model for possible human Campylobacter outbreaks and to communicate risk assessments with health authorities.MethodsWe developed a spatio-temporal random effects model for weekly GI illness consultations in Norwegian municipalities with Campylobacter monitoring and weather data from week 30 2010 to 11 2022 to give 1-week nowcasts of GI illness outbreaks. The approach combined a municipality random effects baseline model for seasonally-adjusted GI illness with a second model for peak deviations from that baseline. Model results are communicated to national and local stakeholders through an interactive website: Sykdomspulsen One Health.ResultsLagged temperature and precipitation covariates, as well as 2-week-lagged positive Campylobacter sampling in broilers, were associated with higher levels of GI consultations. Significant inter-municipality variability in outbreak nowcasts were observed.ConclusionsCampylobacter surveillance in broilers can be useful in GI illness outbreak nowcasting. Surveillance of Campylobacter along potential pathways from the environment to illness such as via water system monitoring may improve nowcasting. A One Health system that communicates near real-time surveillance data and nowcast changes in risk to health professionals facilitates the prevention of Campylobacter outbreaks and reduces impact on human health.

S1519 The Rise in Number of Gastrointestinal Consultations Over Time: Differences Between Teaching and Non-Teaching Medicine Teams in a Community Residency Program

S1519 The Rise in Number of Gastrointestinal Consultations Over Time: Differences Between Teaching and Non-Teaching Medicine Teams in a Community Residency Program

Adherence to goal-directed therapy for patients with cirrhosis hospitalized with spontaneous bacterial peritonitis.

The American Association for the Study of Liver Diseases has developed a standard of care for the treatment of patients with spontaneous bacterial peritonitis (SBP). Evidence examining the adherence rate to these guideline recommendations is limited. This study aimed to determine the adherence rate to guideline-directed therapy for patients with cirrhosis hospitalized with SBP. This institutional review board-approved retrospective cohort study conducted at a large academic hospital evaluated the adherence rate to guideline-directed therapy in adult patients with cirrhosis hospitalized with SBP. Included hospitalized patients had a documented diagnosis of cirrhosis and acute SBP. The adherence rate to guideline-directed therapy was determined by receipt of paracentesis within 24 hours of admission, request of Gram stain and culture tests, avoidance of fresh frozen plasma, receipt of albumin on days 1 and 3, receipt of empiric antibiotics within 6 hours, receipt of SBP prophylaxis, receipt of deep vein thrombosis prophylaxis, and offer of pneumococcal vaccination. A total of 110 patients were included. Provider adherence to goal-directed therapy was poor, with criteria met for only 10 (9.1%) patients. The therapies with the lowest adherence rates included SBP prophylaxis on discharge (54.5%), receipt of albumin on day 3 (42.7%), and offer of pneumococcal vaccination during admission (43.6%). Patients with a gastrointestinal consult were more likely than those without a consult to obtain albumin on day 1 (69.4% vs 36.8%, P = 0.001) and albumin on day 3 (52.8% vs 23.7%, P = 0.004). This study demonstrated a lack of adherence to guideline-directed therapy for the management of SBP.

Colonoscopy Following an Abnormal Fecal Test Result from an Annual Colorectal Cancer Screening Program in a Federally Qualified Health Center.

Individuals with an abnormal fecal immunochemical test (FIT) result have an elevated risk of colorectal cancer, and the risk increases if the follow-up colonoscopy is delayed. Of note, rates of follow-up colonoscopy are alarmingly low in federally qualified health centers (FQHCs), US health care settings that serve a majority racial and ethnic minority patient population. We assessed factors associated with colonoscopy after an abnormal FIT result and used chart-abstracted data to assess reasons (including process measures) for lack of follow-up as part of an annual, mailed-FIT outreach program within a large, Latino-serving FQHC. As part of the National Institutes of Health-funded PROMPT study, we identified patients with an abnormal FIT result and used logistic regression to assess associations between patient demographics and receipt of follow-up colonoscopy, controlling for patients' preferred language. We report on time (days) to referral and time to colonoscopy. For charts with an abnormal FIT result but no evidence of colonoscopy, we performed a manual abstraction and obtained the reason for the absence of colonoscopy. When there was no evidence of colonoscopy in a patient's electronic health record (EHR), we performed an automated query of the administrative claims database to identify colonoscopy outcomes. We identified 324 patients with abnormal FIT results from July to October 2018. These patients were mostly publicly insured (Medicaid 53.1%, Medicare 14.5%), 81.8% were aged 50 to 64 years, 55.3% were female, 80.3% were Hispanic/Latino, and 67.3% preferred to speak Spanish. We found that 108/324 (33.3%) patients completed colonoscopy within 12 months, and the median time to colonoscopy was 94 days (IQR: 68-176). Common barriers to colonoscopy completion, obtained from chart-abstracted data, were: no documentation following referral to gastrointestinal (GI) specialist or GI consultation (41.6%), no referral to GI specialist following abnormal fecal test (34.2%), and absence of a valid insurance authorization (6.5%). Multi-level strategies are needed to provide optimal care across the cancer continuum for FQHC patients. In order to reduce the risk of CRC and realize the return on fecal testing investment, concerted system-level efforts are urgently needed to improve rates of follow-up colonoscopy among FQHC patients and redress racial and ethnic disparities in CRC screening outcomes.

Management of acute upper gastrointestinal bleeding: Urgent versus early endoscopy.

For decades, timing of endoscopy has been a controversy in the management of patients who present with upper gastrointestinal bleeding (GIB). The advent of endoscopic hemostatic therapy led to reduced further bleeding, surgery and mortality. Observational studies suggest that in patients at low risk of further bleeding, early endoscopy establishes diagnosis and allows their prompt hospital discharge. In the high-risk patients, early endoscopy with hemostatic treatment can stop bleeding and improve outcomes. Sample size in early randomized controlled trials (RCTs) was small. They included low-risk patients or patients with poorly defined risks. We designed a RCT to test the hypothesis that in high-risk patients (defined by those with an admission Glasgow Blatchford Score of 12 or greater), endoscopy within 6 h of gastrointestinal consultation, when compared to the standard of care i.e. endoscopy within 24 h, would improve outcomes.The primary outcomes, all-cause mortality at 30 days did not differ between groups; 23 of 258 (8.9%) in the urgent-endoscopy group and 17 of 258 (6.6%) in the early-endoscopy group died (difference 2.3%, 95% confidence interval -2.3 to 6.9%). Further bleeding was similar (10.9% vs. 7.8%) between groups. A higher rate in endoscopic hemostatic treatment was observed in the urgent-endoscopy group (60.1% vs. 48.4%). In patients with peptic ulcers, active bleeding or visible vessels were found on initial endoscopy in 105 of the 158 patients (66.4%) and in 76 of 159 (47.8%) in the respective group. In the majority of patients with GIB, endoscopy earlier than 24 h is not indicated.

S621 GI Consultation Before TEE: A Necessary Step for Clearance in the Inpatient Setting?

Introduction: Although esophagogastroduodenoscopy (EGD) before transesophageal echocardiogram (TEE) is common in patients with known gastrointestinal (GI) disease, there is a lack of objective evidence to support this practice. The goal of our study is to elucidate whether presence or absence of GI history and/or symptoms significantly affect the clearance for TEE. Methods: This is a retrospective cohort study performed at a tertiary care center. It included all adult patients admitted for whom an inpatient EGD was ordered and performed prior to TEE from 7/1/2008 - 4/1/2021 for the purposes of medical clearance. Data on Gastroenterology consults ordered with the indication for clearance for TEE were collected. Furthermore, indication for TEE, hospital day numbers between GI consult, EGD and TEE performance were recorded. Data was summarized using descriptive statistics and cumulative frequencies. Results: In total, 83 patients were identified. Of these, 16.9% (n=14) had no prior GI history, 31.3% (n=26) had a diagnosis of cirrhosis with or without EV, 2.4% (n=2) had a history of cirrhosis with EV with prior banding, 15.7% (n=13) had a history of dysphagia of unknown etiology, 9.6% (n=8) had a history of esophageal strictures and 24.1% (n=20) were categorized as other (Figure 1A). With regards to GI symptoms, 44.6% (n=37) had no GI symptoms, 33.7% (n=28) had dysphagia, 8.4% (n=7) had GI bleed, and 13.3% (n=11) were categorized as other (Figure 1B). The average time from admit to GI consult was 5.1 days with an average of 2.3 days from GI consult to EGD, and an average of 7.3 days from admit to EGD performance. Meanwhile, the time from admit to TEE was 9.3 days. Conclusion: The findings from this study showed that performing an EGD prior to TEE prolonged hospital stay significantly and EGD is not electively required prior to TEE. EGD did not change the management or need for TEE despite a high-risk population. Only 3 instances were identified in which a TEE was not initially performed due to inability to pass the TEE probe, prompting a GI consult. Subsequently, all 3 EGD’s were completed without complications and no contraindications to TEE were reported. Eliminating the need for EGD prior to TEE would improve hospital costs, decrease inpatient hospital nights, decrease anesthesia exposure and, finally, avoid delaying treatment plans.Figure 1.: A: GI Medical History; Legend: No GI history (16.9 %), Cirrhosis +/- EV (31.3 %), Cirrhosis with EV with prior banding (9.6 %), Dysphagia of unknown etiology (15.7 %), Esophageal strictures (2.4 %), Other (24.1%). B: Reported GI Symptoms; Legend: No GI symptoms (44.6 %), Dysphagia (33.7 %), GI bleeding (melena, hematochezia, hematemesis) (8.4 %), Other (13.3 %).

Medication use and polypharmacy in patients referred to a tertiary gastroenterology practice.

Introduction. Commonly prescribed medications are associated with various gastrointestinal (GI) side effects but few data are available on prescription medication use and polypharmacy in a gastroenterology outpatient practice. We aimed to examine the prevalence of polypharmacy, defined as the simultaneous use of 5 or more medications.Methods. A descriptive correlational study of consecutive outpatient consultations in 988 patients referred to a tertiary gastroenterology practice. Main outcome measurements were frequency of prescription medication use and polypharmacy.Results. The most common GI symptoms were abdominal pain (72%), nausea (57%), and constipation (53%). The frequency of polypharmacy was 10%. Eighty percent of patients took at least one medication and 60% took two or more. The most frequently used medication classes were proton pump inhibitors (43%), followed by benzodiazepines (30%), selective serotonin-reuptake or norepinephrine-reuptake inhibitors (28%), non-steroidal anti-inflammatory drugs (27%), and opioids (21%).Conclusion. There was a higher use of prescription medicine including antidepressants, and a lower frequency of polypharmacy in our study cohort compared to the general population. The use of medications may have contributed to the symptoms leading to our study's population GI consultation.

HP QI Abstract: Improving Helicobacter pylori Testing in Patients With Acute Upper GI Bleeding Due to Peptic Ulcer Disease

Peptic ulcer disease (PUD) is a common cause of acute upper gastrointestinal (GI) bleeding with a significant impact on healthcare costs in the United States.1 Helicobacter pylori is a main risk factor for PUD, with high rates of rebleeding (27% to 81%) that have been shown to be reduced to less than 5% with eradication therapy.2 Guidelines recommend that all patients with PUD be tested for H pylori and if positive undergo treatment and subsequent testing to confirm eradication.3 In a recent study by Hung et al, 81% of inpatients presenting with upper GI bleeding due to PUD were tested for H pylori, an improvement from <60% historically, but still disappointingly low.4 We similarly reviewed inpatient consults for GI bleeding at the Michael E. DeBakey VA Medical Center in Houston, Texas from December 2017 to February 2018 and found 19 patients with PUD of whom only 13 (68%) were tested for H pylori, providing an important opportunity for improvement. We aimed to increase testing for H pylori in patients who present with acute upper GI bleeding due to PUD from our baseline of 68% to 90% over the course of 6 months. We also aimed to improve rates of treatment and confirmation of eradication in those who test positive for H pylori. We changed the burden of testing for H pylori from the inpatient GI consult fellow or medicine team to the attending gastroenterologist who identified the peptic ulcer during endoscopy. We implemented a comprehensive H pylori menu (Figure 1) into the electronic medical record (EMR) in November 2018 and announced it at the quarterly gastroenterology faculty meeting. Once a peptic ulcer was identified, the endoscopist would either biopsy the stomach or order the H pylori antibody test via the EMR. We identified 31 patients with acute GI bleeding due to PUD during follow up from January 2019 to September 2019. All 31 patients were tested for H pylori, a significant increase when compared to our baseline data of 68%. Though our follow up data were impressive in terms of testing for H pylori in patients with PUD, our rates of treatment and eradication in those found to be H pylori positive remained low at 46% (6/13) and 33% (2/6), respectively. This compares to a 25% (1/4) treatment rate in the pre-intervention group (the one patient treated had confirmatory eradication testing). Low rates of treatment may be in part due to time to results for biopsy and serology, which may not be available until after discharge. Our promising improvement in testing serve as an important, but imperfect surrogate measure for the more important outcome of treatment, which while increased from prior were still unacceptably low. We plan to conduct further quality improvement projects more specifically targeting treatment and confirmation of eradication.

PPIs and Beyond: A Framework for Managing Anticoagulation-Related Gastrointestinal Bleeding in the Era of COVID-19.

Coronavirus disease of 2019 (COVID-19) can be associated with high morbidity and mortality; patients with severe clinical manifestations may develop significant coagulopathy as well as unexpected thromboembolic complications. In response, centers are increasingly treating selected patients with intermediate-dose prophylactic or even therapeutic dose anticoagulation in order to prevent potentially catastrophic thrombotic complications. With this changing practice, the authors suspect that inpatient gastrointestinal consult teams across the country will be frequently managing COVID-19 patients with gastrointestinal bleeding (GIB). In order to reduce potentially avoidable hospital readmissions for GIB while improving patient outcomes, it is imperative to appropriately risk-stratify patients prior to initiation of anticoagulation. In this review, we discuss how to appropriately identify high-risk patients for GIB and how to mitigate GIB risk with proton-pump inhibitor co-therapy, medication reconciliation, and Helicobacter pylori testing and treating in this complex and morbid population.

Chronic Hiccups.

Nearly 4000 patients will be admitted to hospital in the US this year for hiccups. Hiccups are controlled by a complex reflex arc between peripheral receptors and the brainstem. Any disruption along this pathway may produce hiccups. Typically, hiccups resolve spontaneously but in certain pathologies symptoms may persist. Persistent hiccups may be considered a sign of underlying pathology. The most common cause involves GERD. Based on etiologies, studies have shown that first-line therapy should use a proton pump inhibitor (PPI) and involve appropriate gastrointestinal consultation. If symptoms persist, other etiologies such as central causes need to be explored. We review the pathophysiology of hiccups including multiple causes and the appropriate work up for each. We review several studies examining new treatments, both pharmacological and interventional, that may help patients. Initial therapy should still involve a PPI but several new therapies may be beneficial.

Proton Pump Inhibitors in the Elderly Hospitalized Patient: Evaluating Appropriate Use and Deprescribing.

Background: Proton pump inhibitors (PPIs) are often prescribed for elderly patients without appropriate indication, or for longer durations than recommended. Objective: To review appropriateness of PPI use prior to and in hospital, and deprescribing rates across different hospital units. Methods: Retrospective analysis of patients ≥65 years admitted to 5 acute care units: intensive care unit, acute care for elderly, orthopedics, surgery, and medicine. Patients who were "non-naive" (prehospital PPI use) or "naive" (new PPI initiated in hospital) users were included. For both groups, demographics, reason for admission, length of stay, comorbidities, name and number of home medications, PPI name, dose and indication, and PPI discharge instructions were collected. For naive patients, duration of in-hospital use and prescriber specialty was recorded. Results: Among non-naive patients (n = 377), for 37 patients (10%), the indication for a PPI was not appropriate, and for 92 patients (24%), the indication was unclear. Most patients had their home PPI continued while in hospital (87%) and at discharge (90%). Among naive (n = 93) patients, for 8 patients (9%), the indication for a PPI was not appropriate, and for 25 (27%) patients, the indication was unclear. PPI was prescribed to only 16 (18%) by the gastrointestinal consult service. Most patients had their new PPI continued at discharge (74%); only 7 (9%) were discharged with a plan to reassess PPI indication. Conclusion: PPIs are infrequently deprescribed during hospital admission, despite inappropriate or unclear indications for use. Thorough medication reconciliation, documentation of PPI indication and duration, and institutional focus on deprescribing are encouraged.

Integrating geriatric assessment into routine gastrointestinal (GI) consultation: The Cancer and Aging Resilience Evaluation (CARE)

BackgroundIntegrating Geriatric Assessment (GA) in the management of older adults with cancer is recommended, yet rarely practiced in routine oncologic care. Our objective was to assess the feasibility of integrating routine GA in the management of older adults with gastrointestinal (GI) malignancies and characterize impairments in this population. MethodsPatients ≥60yo referred for consultation to the GI Oncology clinic were asked to complete the Cancer and Aging Resilience Evaluation (CARE) on their first visit. CARE was adapted from the Cancer and Aging Research Group GA with modifications to create a completely patient-reported version of the GA. Feasibility was defined as completion of CARE by ≥80% of eligible patients during the initial consultation. ResultsOf the eligible 354 new patients seen in the GI Oncology Clinic, 323 (91.2%) completed the CARE survey. Most patients (83.1%) felt the length of time to complete was appropriate (median time of 10 min [IQR 10–15.7 min]). GA impairments were prevalent: 54.7% reported dependence in Instrumental Activities of Daily Living, 15.5% reported dependence in Activities of Daily Living, 20.9% reported ≥1 fall, 35.9% reported a performance status ≥2, 55.7% were limited in walking one block, 74.0% reported polypharmacy (≥4 medications), and 36.4% had ≥3 comorbidities. ConclusionsPerforming a GA in the routine care of older adults with GI malignancies is feasible, and GA impairments are common among this population. A fully patient-reported GA such as the CARE may facilitate broader incorporation of GA in the routine clinic work flow.

Integrating geriatric assessment into routine gastrointestinal (GI) consultation: The Cancer and Aging Resilience Evaluation (CARE).

667 Background: Integrating Geriatric Assessment (GA) in the management of older adults with cancer is recommended, yet rarely practiced in routine oncologic care. In this report, we describe the feasibility of integrating the routine incorporation of GA in the management of older adults with GI malignancies and characterize GA impairments. Methods: CARE was adapted from the Cancer and Aging Research Group GA with modifications to create a completely patient-reported version. The CARE assesses self-reported functional status, physical function, nutrition, social support, anxiety/depression, cognitive function, comorbidities, and social activities. Patients ≥ 60yo referred for consultation to the GI Oncology clinic were asked to complete the CARE (paper/pencil) on their first visit. The completed CARE was collected during nurse triage and submitted to the clinical team prior to the physician encounter. Feasibility was defined as completion of the CARE by ≥ 80% of eligible patients during the initial consultation. Results: Between September 2017 and August 2018, 199 eligible new patients attended the GI Oncology Clinic, 192 (96.5%) were approached, and 181 (90.4%) completed the CARE. Most patients (79.6%) felt the length of time to complete was appropriate (median time of 10 minutes [IQR 10-15 minutes]). The mean age was 70y (range 60-96), 54.3% were male, and 75.1% were non-Hispanic white. Common tumor types included colon (27.8%), pancreatic (21.2%), and rectal (10.2%) cancer; predominately advanced stage diseases (stage III: 26.9%; stage IV: 40.0%). GA impairments were prevalent: 48.6% reported dependence in Instrumental Activities of Daily Living, 18.0% reported dependence in Activities of Daily Living, 22.5% reported ≥ 1 fall, 29.4% reported a performance status ≥ 2, 51.3% were limited in walking one block, 75.7% reported polypharmacy (≥ 4 medications), and 84.3% had ≥ 1 comorbidity. Conclusions: Performing a GA in the routine care of older adults with GI malignancies is feasible, and GA impairments are common among older adults with GI malignancies. A fully patient-reported GA such as the CARE may facilitate broader incorporation of GA in the routine clinic work flow.

“That was then, this is now” improving public health syndromic surveillance baselines

ObjectiveTo improve the ability of syndromic surveillance systems to detectunusual events.IntroductionSyndromic surveillance systems are used by Public Health England(PHE) to detect changes in health care activity that are indicative ofpotential threats to public health. By providing early warning andsituational awareness, these systems play a key role in supportinginfectious disease surveillance programmes, decision making andsupporting public health interventions.In order to improve the identification ofunusualactivity, wecreated new baselines to modelseasonally expectedactivity inthe absence of outbreaks or other incidents. Although historicaldata could be used to model seasonality, changes due to publichealth interventions or working practices affected comparability.Specific examples of these changes included a major change in theway telehealth services were provided in England and the rotavirusvaccination programme introduced in July 2013 that changed theseasonality of gastrointestinal consultations. Therefore, we needed toincorporate these temporal changes in our baselines.MethodsWe used negative binominal regression to model daily syndromicsurveillance, allowing for day of week and public holiday effects.To account for step changes in data caused by changes in healthcaresystem working practices or public health interventions we introducedspecific independent variables into the models. Finally, we smoothedthe regression models to provide short term forecasts of expectedtrends.The new baselines were applied to PHE’s four syndromicsurveillance systems for daily surveillance and public-facing weeklybulletins.ResultsWe replaced traditional surveillance baselines (based on simpleaverages of historical data) with the regression models for dailysurveillance of 53 syndromes across four syndromic surveillancesystems. The improved models captured current seasonal trends andmore closely reflected actual data outside of outbreaks.ConclusionsSyndromic surveillance baselines provide context forepidemiologists to make decisions about seasonal disease activity andemerging public health threats. The improved baselines developedhere showed whether current activity was consistent with expectedactivity, given all available information, and improved interpretationwhen trends diverged from expectations.

Do Consultants Follow Up on Tests They Recommend? Insights from an Academic Inpatient Gastrointestinal Consult Service.

Inpatient care is a fundamental part of gastroenterology training and involves the recommendation, performance, and interpretation of diagnostic tests. However, test results are not always communicated to patients or treating providers. We determined the process of communication of test results and recommendations in our inpatient gastroenterology (GI) consult service. Test recommendations on 304 consecutive new GI consults (age 60.2±1.0year) over a 2-month period were recorded. Demographic factors (age, race, gender, zip code, insurance status) were extracted from the electronic medical record (EMR). Charts were independently reviewed 6months later to determine results of recommended tests, follow-up of actionable test results, 30-day readmission rates, and predictors of suboptimal communication. Of 490 recommended tests, 437 (89.2%) were performed, and 199 (45.5%) had actionable findings. Of these, 48 (24.1%) did not have documented follow-up. Failure of follow-up was higher for upper endoscopy (31.9%) compared to colonoscopy (18.0%, p=0.07). Women (p=0.07), patients on Medicare (p=0.05), and procedures supervised by advanced GI fellows (p=0.06) were less likely to receive follow-up. Median income and identification of a primary provider did not influence follow-up rates; 30-day readmission rates were not impacted. Female gender, insurance (Medicare) status, and attending type remained independent predictors of failure of follow-up on multivariate regression (p≤0.03). Failure to follow up test results on inpatient services at a large academic center was unacceptably high. Maximizing personnel participation together with diligence and technology (EMR) will be required to improve communication.