GI Physicians Research Articles

Enabling tobacco treatment for gastroenterology patients via a novel low-burden point-of-care model

Background & aimSmoking is a major risk factor for multiple gastrointestinal cancers, and adversely affects peptic ulcer disease, gastroesophageal reflux, pancreatitis and Crohn’s disease. Despite key recommendations for diagnosing and treating tobacco use disorder in healthcare settings, the degree to which this is implemented in Gastroenterology (GI) clinics is unknown. We aimed to assess our providers’ practices, identify barriers for implementing evidence-based smoking cessation treatments, and address these barriers by implementing a novel low-burden point of care Electronic health record-enabled evidence-based tobacco treatment (ELEVATE), in GI clinics.MethodsAn online survey was distributed to clinic gastroenterologists. ELEVATE module training was implemented in 1/2021. Data were evaluated during pre (7/2020-12/2020) and post (1/2021-12/2021) implementation periods to evaluate the reach and effectiveness of ELEVATE. Generalized estimating equations (GEE) were used to generate rate ratios (RR) to evaluate the intervention.Results91% (20/22) of GI physicians responded to our survey, and only 20% often assisted patients who smoke with counseling. Lack of a systematic program to offer help to patients was reported by 80% of providers as an extremely/very important barrier limiting their smoking cessation practices. The proportion of current patients who smoke receiving cessation treatment increased from pre-ELEVATE to post-ELEVATE (14.36–27.47%, RR = 1.90, 95% CI 1.60–2.26, p < .001). Post-ELEVATE, 14.4% (38/264) of patients with treatment quit smoking, compared to 7.9% (55/697) of patients without treatment (RR = 1.89, 95% CI 1.26–2.82, p = .0021).ConclusionSmoking practices are frequently assessed in GI clinics but barriers limiting cessation treatment exist. The use of a low burden point of care EHR enabled smoking cessation treatment module has led to a significant improvement in the treatment of smoking and subsequent cessation in our clinics. This study sheds light on an often under-recognized source of morbidity in GI patients and identifies an efficient, effective, and scalable strategy to combat tobacco use and improve clinical outcomes in our patients.

Telehealth Coverage for a Pediatric Gastroenterology Consult Service at a Regional Hospital: An Accepted, Useful, and Sustainable Model of Care

To evaluate a novel telehealth inpatient pediatric gastroenterology (GI) consult service at a regional children's hospital in regard to acceptance, utility, quality, sustainability, and provider resiliency. Patients requiring GI care at a regional children's hospital between July 2020 and June 2021 were treated by an in-person or telehealth physician with physician assistant support, randomly assigned based on a weekly preset staffing schedule. A retrospective, multidomain program evaluation was performed based on the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) and STEM (SPROUT Telehealth Evaluation and Management) frameworks, using statistical analysis to compare the patient cohorts and anonymous surveys to assess provider perceptions. In total, 1051 patient-days of GI care were provided for 348 patients, 17% by telehealth and 83% in-person. There were no significant differences in diagnosis, transfer, or readmission rates between the cohorts. No transfers occurred for reasons other than need to access specialized services not available at the regional hospital. Daily consult workload was slightly greater for telehealth physicians. Primary and consult team providers accepted the practice. The model continued beyond the first year. In total, 75% of local GI physicians reported greater Brief Resilience Scores in the context of shifting 20% of their inpatient call weeks to another campus's physicians. Episodic pediatric GI consult service coverage via telehealth at a regional hospital was well accepted, useful, and sustainable, with improved physician resilience and no adverse outcomes seen. Telehealth holds promise for leveraging pediatric subspecialty physicians across hospitals, allowing complex patients to be admitted closer to home while reducing inpatient coverage requirements for smaller physician groups.

P127 Inflammatory Bowel Disease-associated colorectal cancers: retrospective cohort study from a tertiary centre surveillance programme over 10 years

Abstract Background Patients with IBD have increased risk for developing colorectal cancer (CRC), with poorer survival, compared to those without IBD. Despite surveillance colonoscopy, IBD post-colonoscopy CRC (PCCRC) rates are unacceptably high at 28-45%. We define surveillance colonoscopy quality, IBD-dysplasia and IBD-CRC prevalence, IBD-CRC characteristics, and IBD PCCRC rates at a tertiary IBD centre. Methods The GI Reporting Tool (Unisoft Medical Systems) was searched for IBD surveillance colonoscopy reports from April 2008–December 2018. Electronic medical records were reviewed. IBD phenotype and diagnosis date was confirmed on the Lothian IBD Registry. Follow-up was until September 2022. Results 1892 colonoscopies from 1262 patients were included. Median follow-up was 7.1 (4.4, 9.5) years. 885/1262 (70.1%) had UC, 344/1262 (27.3%) had Crohn’s, and 33/1262 (2.6%) had IBD-U. Median disease duration at colonoscopy was 16.8 (11, 24.6) years. 1825/1892 (96.5%) colonoscopies achieved caecal intubation, 1735/1840 (94.3%) adhered to biopsy guidelines and 704/1892 (37%) used chromoendoscopy. Histological inflammation was identified in 873/1823 (47.9%) cases; 57.2% in the right colon. Bowel preparation was poor in 194/1892 (10.3%) procedures and the most documented reason for not performing chromoendoscopy. Poor bowel preparation was associated with 23/60 (38.3%) poorly tolerated and 29/52 (55.8%) incomplete colonoscopies. Moviprep was superior to Picolax (p&amp;lt;0.001). GI physicians were more likely to use chromoendoscopy (p&amp;lt;0.001), biopsy per guideline (p&amp;lt;0.001), and identify dysplasia (p=0.012) compared to surgical colleagues. Dysplasia was identified in 145/1892 (7.7%) colonoscopies: 84/1892 (4.4%) sporadic, 22/1892 (1.2%) IBD-associated, and 39/1892 (2.1%) unspecified. IBD-CRC is rare, at 0.8 cases per 1000 patient years. Within the study period, 20/1262 (1.6%) patients had CRC diagnosed. 17/20 (85%) had UC and 3/20 (15%) had Crohn’s. 15/17 (88%) UC patients had E3 disease. 11/20 (55%) presented with lymph node or distant metastasis. 8/20 (40%) tumours had mucinous differentiation; only 1/15 (6.7%) was well differentiated. IBD-CRC patients had longer disease duration (28.3 (19.7, 37.8) years) compared to patients without CRC (22.25 (16.42, 29.85) years) at follow-up (p=0.028). The 3-year PCCRC rate was 15%. Conclusion IBD-CRC is rare however IBD PCCRC rates are unacceptably high. While this may reflect disease biology, a new approach to IBD surveillance is urgently needed. Interventions could include dedicated IBD surveillance lists, patient education around bowel preparation, and pre-screening for inflammation (e.g. faecal calprotectin). Cancer registry database linkage is now essential for us to identify IBD-CRC cases not identified by surveillance.

Trends in female representation in gastroenterology fellowships in the United States.

Women have historically been underrepresented in gastroenterology (GI). Currently they compose only a small percentage of practicing GI physicians in the United States. Despite the rise in women graduating medical school, the percentage of current female GI fellows has remained low in recent years. In this study, we sought to examine the trends of female representation in GI over the past 10 years, to further elucidate the disparity, and to illustrate if any major changes have occurred. The findings were compared to those for other specialties to shed light on the relationship between them. This retrospective study used data on the gender of residents obtained through the Accreditation Council for Graduate Medical Education Data Resource Books from 2009-2019. Chi-square statistical testing was used to compare representation percentages across groups. Significance was determined at the P<0.05 level, while P<0.01 was also reported. Over a 10-year period from 2009-2019, an average of 33.6% of GI fellowship positions were filled by women, an increase of only 3.3% since 2009. Chi-square analysis of proportions across groups demonstrated a significantly lower percentage of female representation in GI in comparison to other specialties. Despite an increase in the number of women entering and graduating from medical school within the last decade, the number of female gastroenterologists remains a poor reflection of it. GI continues to have a significantly lower female representation than other specialties over the last decade.

Feasibility of a low FODMAPs diet without initial dietician intervention in the management of patients with irritable bowel syndrome: a prospective study.

Efficiency of a low FODMAPs diet (LFD) to relieve symptoms in patients with irritable bowel syndrome (IBS) has been proved in several studies. Our study aimed to evaluate the management of IBS-patients when explanations about LFD are given by the physician without dietician intervention. Patients with IBS were evaluated prospectively after explanations about the LFD were given with the help of a leaflet. A first questionnaire evaluating trigger foods and diet acceptability was submitted to the patient after the consultation. Six weeks later, a second questionnaire evaluated patient's understanding and adherence to the diet, the evolution of symptoms, and the need for a specific dietetic support. Thirty-five patients were included (69% female; mean age 45±15). Seventy-four percent of the patients thought that their symptoms were related to food ingestion, and 97% were ready to go on a diet to improve their symptoms. During the second visit, 91% of the patients reported understanding correctly the explanations, 52% followed LFD regularly, 28% sometimes and 20% did not follow LFD at all or barely. Multiple non-adherence factors were reported. All symptoms, except constipation, decreased significantly six weeks after starting LFD. Finally, 77% of the patients reported satisfaction with care and 69% were willing to be supported by a dietician. Most IBS patients understood explanations given by GI physicians, but low compliance to the diet and a wish for dietician support was highlighted, suggesting that a dietician intervention should be scheduled when LFD is implemented.

S3427 Online Patient Ratings of Gastroenterologists in the United States

Introduction: The purpose of this study was to analyze the various factors affecting the online ratings of gastroenterologists on leading physician websites in the United States Methods: A search for all gastroenterology (GI) fellowship programs was performed on the Accreditation Council for Graduate Medical Education website and programs were identified. Online search was performed to identify all gastroenterologists affiliated at the institutions. Academic rank and subspecialty within GI (general, hepatology, IBD or advanced endoscopy) were recorded from the online curriculum vitae. The three most popular physician rating websites - healthgrades.com, vitals.com and rateMDs.com, were accessed to record the average patient rating of the GI physicians. All three websites provide an aggregate rating out of 5. Age and gender were recorded from healthgrades.com. Results: A total of 2362 gastroenterologists’ profiles were identified, of which 664 (28.1%) were females and 1686 (71.4%) males (data was missing for 12). Average patient ratings were available for 1631 GI physicians on healthgrades.com, 1623 GI physicians on vitals.com and 617 GI physicians on rateMDs.com. The mean (standard deviation and median) patient ratings were 4.0 (1.0, median 4.3), 4.1 (SD 0.9, median 4.3) and 3.8 (SD 1.1, median 4.0), on healthgrades, vitals and rateMDs respectively. There was no significant difference in patient ratings on all websites amongst GI physicians when grouped by gender, subspecialty or academic rank (p >0.05 for all groups). Spearman test showed statistically significant correlation between vitals and healthgrades (r=0.300, p< 0.005), healthgrades and rateMDs (r=0.314, p< 0.005) and vitals and rateMDs (r=0.257, p< 0.005). There was no significant correlation between patient ratings and the number of publications, citations or h-index of the GI physicians. There was a weak but statistically significant inverse correlation between age and patient ratings on healthgrades (r = -0.97, p< 0.005) and vitals (r = -0.92, p< 0.005), and a nonsignificant negative correlation on rateMDs (r = -0.046, P=0.267). Conclusion: Majority of gastroenterologists have been rated on physician online rating websites. The average ratings were found to be inversely correlated with age. Factors including academic rank, academic productivity, gender or subspecialty were not found not to be affecting the average ratings.Table 1.: Comparison of various factors affecting the online ratings of gastroenterologists on leading physician websites in the United States.Figure 1.: Flowchart depicting methods of the study.

S1210 Identification of Patients With Nonalcoholic Steatohepatitis in a Predominately African American Urban Medical Center

Introduction: Patients with nonalcoholic steatohepatitis (NASH), a subset of nonalcoholic fatty liver disease (NAFLD), can progress to advanced fibrosis and cirrhosis. The identification of the stage of fibrosis is critical as it correlates with hepatic related outcomes and influences clinical management. Non-invasive methods are increasingly being used to diagnose and stage NAFLD patients who are at risk of developing NASH. The purpose of this study was to examine the accuracy of NASH diagnoses as well as the demographics and management of patients with NASH at a predominately African American (AA) urban medical institution. Methods: Medical records of patients with the NASH ICD-code (75.81) from the years 2017-2020 were obtained from the institutional EMR. The accuracy of the NASH diagnosis was assessed either by biopsy findings or evidence of advanced liver fibrosis/cirrhosis using available non-invasive lab and/or imaging parameters (NFS, FIB-4, APRI, Fibroscan, ultrasound and/or CT) in patients after excluding other common causes of chronic liver disease. Further analysis assessed whether patients with advanced fibrosis were managed according to current clinical guidelines. Results: A total of 77 records with sufficient information to determine the accuracy of NASH were examined, only 55% had an accurate diagnosis. Those NASH patients were predominately female (65%), but despite the high AA prevalence in the population, only 36% were African American (AA) (Table 1). Biopsy revealed fibrosis in 87% of AA NASH patients but only 62% of Non-AA NASH patients. Bariatric surgery was performed on only 30% of NASH patients. Despite using the highest score of two evaluations at least one year apart, all three lab-based fibrosis assessments were suboptimal for identifying NASH patients (Table 1). GI physicians saw 70% of NASH patients, and those patients were receiving appropriate weight loss counseling as well as screening for hepatocellular carcinoma and variceal screening if they had cirrhosis. Conclusion: There is room for improvement in the accurate classification and management of NASH patients, particularly regarding lab-based assessments. The reason for the unexpectedly low prevalence of AA NAFLD patients with NASH needs to be investigated further. The majority of those who had progressed to show signs of advanced fibrosis were followed by GI with appropriate screening with respect to adverse outcomes.Figure 1.: Presentation images.Table 1.: Monthly run chart data for vitamin D order rate/completion rate and DEXA order rate and completion rate.

S1120 When Your Lab Didn’t Read the Guidelines: The Ability of Physicians in a Teaching Hospital Clinic to Identify Abnormal Alanine Aminotransferase (ALT) Values

Introduction: ACG guidelines define normal ALT as 29 to 33 for males and 19 to 25 for females. An elevated ALT, even if borderline, warrants consideration as to the cause, and monitoring for worsening. However, different laboratories use different reference values for normal, and many report ALTs greater than 25 or 33 as normal. Our hospital’s lab reports ALT 6-55 as normal. In this study, we aimed to assess physicians’ identification of abnormal ALT values, particularly in instances when the lab did not identify it as abnormal (by bolding). Methods: We reviewed the charts of 4965 patients seen in Internal Medicine (IM) and GI clinics to identify patients with elevated ALTs. Only the first instance of elevated ALT was included for each patient. We excluded patient who had a history of liver disease. We identified the patients who had ALTs that were abnormal but not marked as such by the laboratory. For each patient, we reviewed the clinic notes to find any comment or plan for work-up. Results: Results are summarized in the chart and table. 1018 patients with elevated ALT and no history of liver disease were identified and included. Elevated ALT was identified by the physician in 29.1% of patients. Of elevated ALT values that were less than 55, only 31/491 were identified. Of these 31 patients, 11 were not seen again and 5 had no additional testing. One patient underwent liver biopsy. The rest had an ultrasound and serologic testing. After work-up, two patients were presumed to have alcoholic liver disease, 5 NAFLD, one was diagnosed with choledocholithiasis, and 3 were diagnosed with DILI. Furthermore, there was a significant difference in the identification of abnormal ALTs between 50-55 (not bolded) and ALTs between 56-64 (bolded): ALT of 50-55 was identified as abnormal in 16.4% of visits, while ALT of 56-64 in 39.7% (P-value .005). Of note, GI physicians were significantly more likely to identify elevated ALT values than IM physicians (see table). Conclusion: Physicians were more likely to identify an abnormal ALT if it was bolded. In both clinics, non-bolded ALTs were largely ignored. Amongst the patients whose non-bolded elevated ALT were identified, most received additional testing and were found or presumed to have modifiable etiologies. This study demonstrates the need for physicians to better familiarize themselves with normal ranges of liver tests, and consider the need for further evaluation or monitoring when an ALT value is abnormal even if their laboratory does not identify it as such.Table 1Figure 1.: Identification of Elevated ALT as Abnormal. Blue bar shows GI clinic; Orange bar shows IM clinic; Gray bar shows Total

Development of AGA’s Policy Agenda During the COVID-19 Pandemic

Development of AGA’s Policy Agenda During the COVID-19 Pandemic

S3195 Probiotics or Againstbiotics: The Use of Probiotics in Inflammatory Bowel Disease

INTRODUCTION: The use of probiotics for inflammatory bowel disease (IBD) is controversial. Currently, the American College of Gastroenterology only recommends the specific probiotic VSL#3 for treatment and prevention of pouchitis. Recently, the American Academy of Family Physicians placed a Grade 1A recommendation for probiotic use in all patients with IBD. Differing recommendations can lead to uncertainty about the use of probiotics. This study evaluated probiotic use in IBD patients at a university medical center. METHODS: An IRB approved, retrospective chart review of all IBD patients seen at a university gastroenterology clinic during the past decade was conducted. Patient age, gender, self-described ethnicity, IBD type, medications and probiotic use were obtained. The GI physician gender and whether a primary care or GI physician documented probiotic use were noted. A confidential data based was created. Statistical analysis was performed with significance set at P < 0.05. RESULTS: Medical records of 392 IBD patients (218 females, 174 males; mean age 44.4 years) were reviewed. 204 were white, 99 African American, 11 Asian, 78 undefined. 279 had ulcerative colitis (52 with a J-pouch), 96 Crohn’s disease and 19 microscopic colitis. 52 of 393 (13.3%) IBD patients used probiotics, including 11 of the 52 (21.2%) patients with a J-pouch. Females were significantly more likely to use probiotics compared to males (17.0% vs 8.62%, P = 0.016). White patients were more likely than patients of other ethnicities to use probiotics. (P = 0.051).There was no significant difference in probiotic use based upon IBD type or medications. Patients of female GI physicians compared to male GI physicians were significantly more likely to use probiotics (19.5% vs. 10.8%, P = 0.031). GI physicians compared to primary care physicians more frequently documented probiotic use in IBD patients (92.3% vs 19.2%; P = 0.0001). CONCLUSION: Probiotics are increasingly being used by IBD patients. This study revealed that females and whites were more likely to incorporate probiotics into their IBD treatment regimen. In addition, patients of female physicians were more likely to use probiotics. GI physicians more often documented probiotic use in IBD patients compared to primary care physicians. While this study is limited based on single institution design, it provides a foundation for further research. Increased investigations are needed to evaluate the efficacy and use of probiotics in IBD.

S1246 The Development of an Evidence-Based Management Algorithm for Iatrogenic Endoscopic Perforations and Its Impact on Physician Knowledge: A Quality Improvement Project

INTRODUCTION: Iatrogenic endoscopic perforations can lead to serious complications and death. If identified immediately, perforations can be closed endoscopically with a 90% success rate. Knowledge of acute management of iatrogenic perforations may decrease the associated morbidity and mortality. Therefore, the objectives of this study were to: (1) develop an evidence-based acute iatrogenic endoscopic perforation (AIEP) management algorithm that is available for quick reference in the GI lab; and (2) to study its impact on physicians’ knowledge. METHODS: AIEP management algorithm was created using the most current recommendations by ASGE/ESGE and additional input from advanced endoscopists, nurses, and anesthesiologists was obtained in an open discussion forum. Figure 1 shows the final AIEP management algorithm. We assessed change in physician knowledge using a pre-post study design. To accomplish this, we created a 10-item questionnaire (Figure 2) that assessed physicians' knowledge on the appropriate identification and treatment of an acute iatrogenic perforation. The questionnaire was filled out before (pre-test) and after (post-test) GI physicians and fellows read a standardized one-page educational material based on the aforementioned perforation algorithm. RESULTS: 29 subjects (8 fellows and 21 practicing gastroenterologists) participated in the assessments. Overall pre-test and post-test accuracies were 75% and 95% (P < 0.01), respectively. On pre-test, the biggest gaps in knowledge were seen in questions 3 and 4 (most sensitive imaging test to diagnose perforations and most common site of perforation during routine colonoscopy) among the fellows, and question 7 (TTS clips for max 10mm perforation closures) for the GI physicians. The fellows' pre-test and post-test accuracies were 67.5% and 96% (P < 0.01), and the practicing gastroenterologists' pre-test and post-test accuracies were 78% and 95% (P < 0.01) (Figure 3), respectively. CONCLUSION: Using standardized methodology and a multidisciplinary approach, an AIEP management algorithm was created in an effort to improve patient care and alleviate physician stress. Additionally, we showed that a brief one-page educational material can significantly improve physician knowledge on the appropriate identification and treatment of perforations. Future studies are required to evaluate if maintaining such algorithms as quick reference guides in the endoscopy suite can improve outcomes of patients in the event of an AIEP.Figure 1.: Ten question pre- and post-training assessment for acute iatrogenic endoscopic perforations, a quality improvement study in the GI lab.Figure 2.: Management algorithm for acute iatrogenic endoscopic perforations.Figure 3.: Panel A and B show the pre- and post-test accuracies per question for fellows and practicing gastroenterologists, respectively.

S3100 Racial Disparity of Gender Difference in Prevalence of Adenomatous Polyps

INTRODUCTION: The risk for colorectal cancer (CRC) varies based on multiple risk factors including race and gender. Although male gender and African American (AA) race are more likely to be diagnosed with colon cancer, it is not clear where in the adenoma progression to cancer these risks are manifested. Variations of the prevalence of adenomatous polyps in different patient populations have the potential to affect screening recommendations. Using patients from an urban medical center endoscopy suite, we evaluated the influence of race on adenoma detection rate by gender. METHODS: We identified 709 patients whose screening colonoscopy was performed by academic gastroenterologists. The study was limited to academic GI physicians since in our institution, their rate of adenoma detection was higher (46% of patients) as compared to non-Academic GI physicians (24%) and surgeons (14%). A retrospective electronic chart review was conducted for the 630 (89%) AA and 79 (11%) non-AA. There was no difference in age by race or gender (59 years of age; range 46-73 years). The BMI (kg/m2) was slightly higher in females as compared to males (31.2+/-0.4 vs 28.7+/-0.39 P < 0.001) but was not different by race (30.2 vs 28.6). ADR was the number of patients with at least 1 adenoma divided by the total number of patients. RESULTS: ADR was higher in AA males as compared to females(51% vs 35%; Odds Ratio = 1.9 P < 0.001 Pearson chi-square). In contrast, the ADR was similar by gender for non-AA (38% vs 40%; OR = 0.9 P > 0.05) (Table 1). The role of body weight on gender differences was variable with the major gender difference being in overweight (BMI 25-30) AA patients. When evaluated for effect of age, the AA males were more likely to have adenomas detected as compared to females both above and below the age of 60 years. CONCLUSION: This study demonstrated that in contrast to Non-AA, African American males are more likely to have an adenoma as compared to females in screening populations. The reason Non-AA individuals do not have a gender difference is puzzling given the known risk of gender for CRC. However, larger sample of Non-AA patients may generate a statistical difference. Other reasons might be related to geographical difference in the prevalence of the adenomas or the fact most of our population was in the middle range of BMI (ie overweight).Table 1.: Odd’s Ratio and ADR for Male and Female Patients by Race

S0511 Do We Know If Our Constipated Patients Are Taking Opiates?

INTRODUCTION: Constipation is the one of the most common reasons for obtaining gastroenterology consultation. Use of opioid medications is a frequent contributor to constipation, and the opioid epidemic has increased awareness about this public health concern. Many states have mandated centralized monitoring of opioid prescriptions to limit abuse. The aim of this study was to determine how physician knowledge of opioid use affects care of patients with constipation. METHODS: Adult patients who presented to our outpatient GI clinic with a diagnosis of constipation from 2016–2019 were identified. Diagnosis of constipation was defined by ICD-10 codes listed in Table 1. Those with active malignancy were excluded. Opioid use was defined as any opioid prescription within 3 months prior to the first clinic visit as listed in our state’s prescription drug monitoring program (PDMP). Data extracted from the chart included demographics and medication details. Physician knowledge of opioid use was determined if opioid use was mentioned in the progress note, if PDMP was checked during visit, if PDMP audit trail was used or if an opioid was on the active medication list. Data was analyzed using SPSS v25. RESULTS: A total of 233 patients met inclusion criteria. Demographic information is reported in Table 2. Of all the patients presenting for an initial visit for constipation, 55% were on opioids 3 months before their first appointment. When examining progress notes compared to the “gold standard” PDMP, GI physicians were unaware of the opioid use in 70% of these patients. Patients taking opioids known to the provider were more likely to be prescribed constipation medication on initial consult compared to unknown opioids though this was not significant (53% vs 46%, P = 0.40). Basic demographic factors were not significant predictors of whether a patient was on opioids in the preceding 3 months. 71 patients underwent lower endoscopy between 1st and 2nd visit. Opioid use was associated with a lower chance of having a procedure with a trend towards significance (OR = 0.597, P = 0.07). CONCLUSION: At our safety-net hospital, in an area plagued by opioid abuse, a significant number of patients were taking opioids. Furthermore, GI providers were unaware of this use in the majority of cases though this did not seem to affect prescribing patterns. Provider education is needed to increase the accuracy of the EMR, and further studies are needed to identify the effect of the opioid crisis on GI patients.Table 1.: ICD-10 Codes and DescriptionsTable 2.: Demographics of Patients Presenting with Constipation (n = 233)

S1265 Smoking Cessation Care in a Tertiary Center’s Gastroenterology (GI) Clinics: Role of the Electronic Health Record (EHR), Providers’ Practices and Barriers to Success

INTRODUCTION: Smoking has an unfavorable effect in various gastrointestinal ailments including peptic ulcer disease and Crohn's disease, and is a risk factor for multiple gastrointestinal cancers. Despite key recommendations for diagnosing and treating tobacco use disorder in healthcare settings, the degree to which this is implemented in GI clinics is unknown. We aim to study the smoking cessation care in our GI clinics across different timeframes with different EHRs, assess our providers' practices and identify perceived barriers for implementing smoking cessation treatments. METHODS: Retrospective cohort study of patients presenting to our institution's outpatient GI clinics. Data was extracted from the period 1–5/2018 while Allscripts was in place, and compared to the period 6–12/2018 after transitioning to EPIC. In addition, our GI attending physicians were invited to complete a survey regarding their smoking cessation care practices. RESULTS: Data for a total of 15,431 patients was extracted. 83% of patients were assessed for smoking pre-EPIC, in comparison to 98% of the patients who had visited our clinics post-EPIC (P < 0.0001). Although more smokers were identified in the cohort of patients pre-EPIC (15.7% vs 14.3%, P = 0.02), more patients were on treatment for smoking cessation post-EPIC (6.5% vs 2.7%, P < 0.0001). 77% attending GI physicians responded to the anonymous survey, and nearly half of them stated they always asked their patients if they smoked. However, 29% of the physicians stated they sometimes or often would assess their patients' willingness to quit at the time of the visit, and 58.8% had never assisted patients by prescribing smoking cessation medications. 82% of the providers reported “Patients not interested” as an extremely/very important barrier, followed by the “Lack of a systematic program to outreach,” reported by 76% of providers as an extremely/very important barrier. CONCLUSION: A significantly higher number of patients were assessed for smoking after the transition to EPIC EHR, largely attributable to EPIC's Best Practice Alert (BPA). Although patients' perceived lack of interest in smoking cessation was regarded as a major barrier to smoking cessation treatment among providers, about one third of providers have never or rarely assessed their patients' willingness to quit smoking. This study sheds light on an often under-recognized source of morbidity in our GI patients, and identifies potential avenues to improve smoking cessation care, including utilization of the EHR.Table 1.: Smoking prevalence and treatment among GI patients pre EPIC vs post EPICFigure 1.: Survey Question: In the past month, how frequently did you assess if patients are willing to attempt to quit at this time?Figure 2.: Survey Question: Please rate the importance of the following that might limit your smoking cessation treatment practice: Lack of a systematic program to outreach and offer help to patients who smoke.

S1256 TeleHealth in GI: A United States Survey to Assess Its Impact Amidst COVID-19 Pandemic

INTRODUCTION: TeleHealth has garnered a lot of attention amidst the COVID-19 pandemic, and embraced by GI community throughout the United States. While these changes provided healthcare facilities an opportunity to rapidly adopt the remote healthcare delivery model, the uptake and challenges accompanying this practice change are largely unknown. METHODS: A web-based survey was disseminated amongst gastroenterology/hepatology providers (attending physicians, fellows, nurse practitioners, physician assistants), via en masse emails, social media promotion and direct contact by authors, to assess the impact of TeleHealth adoption on clinical practice and GI training programs. RESULTS: 230 respondents (71.7% physicians, 21.3% fellows) completed the survey, with 67.8% academic responses. During COVID era, average weekly half-day clinics increased slightly for GI physicians (P = 0.14), but average number of patients dropped (10.2–6.5; P < 0.001). Respondents from academic centers reported significantly higher use of TeleMedicine (via-phone) (35.8% vs. 25.3%; P = 0.012), in comparison to higher in-person visits in non-academic settings (15.7% vs. 8.7%; P = 0.008). Use of TeleHealth (via-video) was not different between the two settings (P = 0.75). In terms of regional variations, a statistically higher TeleMedicine (via-phone) use was observed in NorthEast (vs. SouthEast, P = 0.005 or West, P = 0.004); top three reasons included less technically inclined population, less platform connectivity burden and fewer privacy concerns. SouthEast had significantly higher in-person visits than NorthEast (P < 0.001). Fellows' participation dropped to less than 50% in attending clinics, and 34.5% fellows noted a compromise in outpatient GI educational mission with adoption of TeleHealth. 95.2% of our respondents foresee future utilization of TeleHealth if adequately reimbursed. CONCLUSION: While our results suggest an almost universal adoption of TeleHealth, we observe a noteworthy variation in its utilization by region and practice type. Furthermore, our survey demonstrates that GI training has suffered significantly with this platform, given lack of consistent supervision in fellows' continuity clinics, and decreased participation in attending clinics. Moreover, our results also emphasize barriers to TeleHealth’s widespread utilization, where lack of adequate equipment/training, patient demographics and reimbursement policies are the foremost challenges.Table 1.: Comparison of outpatient clinics (half-day clinic sessions per week) and patient volume (patients seen per half-day clinic session) before and during COVID-19Figure 1.: Barriers to utilization of TeleHealth and TeleMedicine.

S0554 The First Year Fellow Effect: Adenoma Detection Rate (ADR) Associated With Gastroenterology Trainees

INTRODUCTION: There is conflicting data on the impact of trainees on adenoma detection during screening and surveillance colonoscopies. The aim of our study was to determine whether the participation of a gastroenterology fellow during colonoscopy affects adenoma detection based on the first 6 months of the fellow year of training. METHODS: In this retrospective cohort study, we extracted data of 575 screening colonoscopies by academic gastroenterologists in the last 6 months of 2017. There were 5 attending physicians and 7 fellows. Variables included patient demographics (age, gender, race), colonoscopy indication (surveillance vs. screening), bowel preparation quality (adequate vs. inadequate), cecum intubation, adenoma detection, presence and/or year of fellow in the last 6 months of 2017. Adenoma detection rate was defined as the presence of at least one adenoma /number of colonoscopies. RESULTS: At our institution, academic physicians have a better ADR for screening (46%) as compared to non-Academic GI physicians (46%) and surgeons. Fellows were involved in 297 screening colonoscopies out of the 574 procedures performed by academic GI (57%). The mean patient age was 58.4 years, and most patients were African American (88 %) and female (54%). There were no significant differences with respect to age, gender, race, indication for colonoscopy, or quality of bowel prep. There was a slight difference with cecum intubation between fellows and attendings (96% vs. 99%, P = 0.03). The overall adenoma detection was similar with fellow participation compared to non-fellow (45% vs. 40%, P = 0.19). Results by year of fellowship and screening colonoscopies are shown in Figure 1. The only setting where fellow participation influenced the detection of adenoma was in the first 6 months of fellowship for screening colonoscopies which were lower with fellows compared to the other groups (P = 0.048). CONCLUSION: Fellow involvement had minimal impact on adenoma detection, although first year fellows appear to have a slightly lower detection rate than in later years. Our data accentuates the first-year fellow effect by using only the first 6 months of each fellow’s respective year. Patient demographics, colonoscopy indication and bowel prep did not contribute a significant role in these findings. The reasons for conflicting literature remain unknown.Figure 1.: The % of patients with an adenoma (ADR) as a function of the year of GI fellowship. Also presented on the graph is the ADR for attending faculty when no fellow was present.

Analysis of payments to GI physicians in the United States: Open payments data study.

Background and AimThe purpose of this study was to review and analyze the nature of industry payments to gastroenterology and hepatology (GI) physicians.MethodsWe conducted a retrospective study of open payments (OP) data for the year 2017. Payments to individual physicians were aggregated using a unique physician profile identification number. General payments to Centers for Medicare and Medicaid Services regions were also analyzed. The nature of financial transactions in general payments was reported overall and per physician payment. Research, ownership, and general payments were aggregated and analyzed by drug/device companies.ResultsDuring the study period, more GI physicians received contributions in the form of general payments compared to ownership or research payments. A small percentage of physicians received contributions greater than $100 000. The most frequent contributions were for food and beverages. Only 10 manufacturers made about 71% ($43 271 938) of general payments.ConclusionsWe found that only a small number of GI physicians received a significant portion of industry payments. A large portion of those payments came from drug or device companies. The impact of these payments on gastroenterologists needs to be examined further.

A66 GEOGRAPHIC VARIATION AND INCREASED INVOLVEMENT OF INTERVENTIONAL RADIOLOGISTS IN THE MANAGEMENT OF REFRACTORY ASCITES: A POPULATION BASED STUDY

Abstract Background The disease burden from cirrhosis is increasing worldwide. Refractory ascites (RA) is a complication of cirrhosis associated with poor prognosis if liver transplant is not an option. Serial large volume paracentesis (LVP) is the standard of care in the management of refractory ascites (RA) and outpatient LVP has been shown to be safe and cost effective. Epidemiologic data is lacking regarding the incidence of RA, or how patients with RA are managed in routine clinical practice. Aims To describe secular trends in the incidence of RA in Ontario from 2000–2017, and to describe physician provider types performing LVPs in the RA population in Ontario. Methods This retrospective, population-based cohort study uses routinely collected healthcare data from Ontario, Canada, housed at ICES. From January 1, 2000 to Dec 31, 2017 all adult patients with cirrhosis were identified using a validated case definition, and those with RA were identified based on the need for serial LVP. All LVP procedures were described based on patient demographics, local health integration network (LHIN), physician type (Gastroenterology [GI], Internal Medicine [IM], Interventional Radiology [IR], Emergency Medicine [ER], other) and albumin administration. Annual incidence rates (IR) of RA in patients with cirrhosis were calculated and compared using Poisson regression to calculate incident rate ratios (IRRs). Annual LVP volume by provider type and LHIN were calculated and differences were compared using chi-squared analysis. Results The overall incidence of RA in patients with cirrhosis remained relatively stable over the study period (IRR 1.01, 95% CI 1.00–1.02 P&amp;lt;.001). The highest incidence of RA was in those with viral hepatitis and alcohol-related cirrhosis. A total of 90,126 LVPs were identified (median age 61 years [IQR 53–70], 69% male, median LVP per patient 24 [IQR 11–48], 15.8% received albumin infusion). The absolute numbers of LVPs more than tripled over the study period (12,047 in 1997–2002 vs. 37,437 in 2013–2017). GI performed the majority of LVPs (40.1%) followed by IR (22.4%), and IM (8.4%), but there was substantial variation based on location (Fig 1). Overall, the proportion performed by IR increased during the study (7.8% in 1997–2002 vs 30.8% in 2013–2017, P &amp;lt;.001) while the proportion performed by GI decreased (50% 1997–2002 vs 33.1% 2013–2017, P&amp;lt;.001). Conclusions The number of LVPs performed for RA have increased dramatically in Ontario over the past two decades, with the proportion being performed by GI physicians decreasing, while IR is increasing. Substantial variability exists across LHINs on the use of LVP, which may reflect differences in access to resources for LVP, or physician practice. Appropriate albumin use with LVP remains an area for potential quality improvement initiatives in the future. Funding Agencies AASLD Foundation Clinical Translational and Outcomes Research Award in Liver Disease (for supervisor JF)

Lactose Intolerance and Milk Protein Allergy

Real or perceived lactose intolerance (LI) and true cow’s milk allergy (CMA) are common reasons for dairy avoidance but are underdiagnosed and under-treated. Dairy avoidance is associated with nutrient deficiencies and unintended health consequences that disproportionately affect minorities. Surveyed GI physicians report that at least 30% of their patients had LI and 16% had food allergies including CMA. In a 2019 survey, approximately 10.8% of adults have symptoms consistent with a food allergy and CMA was the second most common allergy reported. LI and CMA are more common in ethnic and racial minorities and occur more often in women. Treatment options are poorly implemented, in part, due to decreased awareness of the current guidelines. Dairy food consumption reduces risk for chronic disease states and remains first-line intervention for LI. Dairy avoidance and nutrient supplementation are effective in managing CMA. Methods to guide dairy food reintroduction, improve LI education, with ethnic and racial considerations and facilitate early identification of CMA are needed. The optimal nutrient supplementation strategy remains undefined.

515 Are All Endoscopic-Related Musculoskeletal Injuries Created Equal?: Results of a National Gender-Based Survey

INTRODUCTION: Endoscopy- related injury (ERI) is common in gastroenterologists. This study aimed to evaluate the prevalence of self-reported ERI, patterns of injury and knowledge of ergonomic strategies in endoscopists who are ACG physician members. METHODS: A 38-item survey was developed and initially piloted at three academic medical centers. Through the ACG Women in GI Committee and ACG Governing Board sponsorship, the survey was administered to ACG physician members. Statistical analysis was performed using SAS Enterprise Guide 7.0 (SAS Institute Inc., Cary, NC); chi-square tests and descriptive analysis evaluating associations between multiple variables and ERI. RESULTS: Of the 14759 total surveys sent, 5940 were opened, and only completed surveys were included (n = 1133). ERI was reported by 71% of the respondents including 49% of trainees. More than half of the respondents reported pain in the thumbs (64%), hand/fingers (59%), neck (57%), and lower back (54 %). The most common causes of ERI reported were torqueing with the right hand (64%), adjusting tip angulation with left hand (53%), standing for prolonged periods of time (59%), and standing in awkward positions while supporting an endoscope (58 %). While no differences were noted in characteristics associated with overall ERI, including sex (P = 0.77), performance of interventional endoscopy or a focus in another GI domain (P = 0.55) women were more likely to have upper extremity pain and upper back pain (see Table 2). There were statistically significant differences between genders in the mechanisms of ERI (see Table 3). Most respondents did not receive training during fellowship (68%), or discuss ergonomic strategies in their current practice (63%). Those without training in ergonomics were more likely to report ERI (P = 0.02). 81 % of respondents noted a desire for more training in ergonomic strategies to reduce ERI. CONCLUSION: The results of this study show an overwhelming occurrence of ERI in all GI physicians and in nearly half of the trainee respondents. Preliminary analysis shows a significant difference between men and women with regards to specific areas of ERI and contributing mechanisms. Results strongly support training and a desire for continued education in ergonomic strategies as a preventative strategy. Education and prevention of ERI represent rich opportunities for improving key aspects of clinical practice, reducing burden on physicians, and decreasing interruptions to clinical care.