National Endoscopic Database Research Articles

Sa1450 Safety and Risk Factors for Procedural Sedation in the 21st Century: a Review of Over 2 Million Patients From 2000-2011

Safety and Risk Factors for Procedural Sedation in the 21st Century: a Review of Over 2 Million Patients From 2000-2011 John J. Vargo*, Douglas O. Faigel, Paul Niklewski, James Martin, Jeffrey L. Williams, Jennifer L. Holub Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH; Gastroenterology & Hepatology, Mayo Clinic, Scottsdale, AZ; Ethicon Endo-Surgery, Cincinnati, OH; Department of Gastroenterology, Oregon Health and Science University, Portland, OR; Neuroscience, University of Cincinnati, Cincinnati, OH Background: The advent of propofol-mediated sedation and the use of anesthesia professionals (APanesthesiologist or nurse anesthetist) have changed the procedural sedation landscape over the past ten years. The identification of risk factors for serious adverse events during EGD and colonoscopy in this new landscape has not been well studied. Aim: To assess the prevalence and risk factors for serious interventions as related to procedural sedation. Design: Retrospective cohort study. A procedure specific multivariate logistic regression analysis was performed, with covariates including age, gender, ASA classification, sedationist, and procedure indications. Setting: Clinical Outcomes Research Initiative National Endoscopy Database, 2000-2011. Patients: Adults undergoing colonoscopy or EGD procedures in 84 academic, VA and community sites throughout the US. Main Outcome Measurement: The risk of serious intervention based on the use of hemostasis, CPR, hospital/ER admittance, sedation reversal, emergency surgery, stopped procedure, and blood transfusion. Results: 1,372,524 colonoscopy and 805,006 EGD patients were included with 70% seen in the community setting. The presence of an AP increased from 4.3% to 23.5% for colonoscopy and from 4.1% to 23.4% for EGD procedures during this 11 year period. Propofol use increased from 2.3% to 24.5% for colonoscopy and 1.8% to 21.5% for EGD. Fentanyl use increased (colonoscopy 27.1 to 65.5%, EGD 25.1 to 67.2%) and meperidine use decreased (colonoscopy 68.2 to 5.4%, EGD 60.2 to 5.4%). CPR remained stable across the 11 years at 0.005% for colonoscopy and 0.05% for EGD. Use of a reversal agent for colonoscopy decreased from 0.17% to 0.01% and from 0.20% to 0.02% for EGD. 18 deaths were reported for EGD (4 possibly due to sedation, bradycardia/hypoxemia). 8 deaths were reported for colonoscopy (1 possibly due to sedation, hypoxemia). The table shows older age, higher ASA classifications, narcotic administration, trainee involvement, certain non-screening indications, and presence of AP for EGD procedures are associated with increased risk of serious events. Limitations: The main outcome measurement assesses procedural interventions and is not limited to only interventions directly related to sedation. Fields pertaining to sedationist and procedure medications are not required in the CORI software, leading to some missing data. Conclusion: We identified sedation practice changes over this time period and risk factors for adverse outcomes related to procedural sedation. In this analysis of over 2.1 million patients across 11 years, it is clear that sedation during routine colonoscopy and EGD has an excellent safety profile for healthy patients when administered by endoscopists. Utilization of an anesthesia provider did not improve patient safety; in fact the endoscopist was safer for EGD procedures.

Burden of Gastrointestinal Disease in the United States: 2012 Update

Gastrointestinal (GI) diseases account for substantial morbidity, mortality, and cost. Statistical analyses of the most recent data are necessary to guide GI research, education, and clinical practice. We estimate the burden of GI disease in the United States. We collected information on the epidemiology of GI diseases (including cancers) and symptoms, along with data on resource utilization, quality of life, impairments to work and activity, morbidity, and mortality. These data were obtained from the National Ambulatory Medical Care Survey; National Health and Wellness Survey; Nationwide Inpatient Sample; Surveillance, Epidemiology, and End Results Program; National Vital Statistics System; Thompson Reuters MarketScan; Medicare; Medicaid; and the Clinical Outcomes Research Initiative's National Endoscopic Database. We estimated endoscopic use and costs and examined trends in endoscopic procedure. Abdominal pain was the most common GI symptom that prompted a clinic visit (15.9 million visits). Gastroesophageal reflux was the most common GI diagnosis (8.9 million visits). Hospitalizations and mortality from Clostridium difficile infection have doubled in the last 10 years. Acute pancreatitis was the most common reason for hospitalization (274,119 discharges). Colorectal cancer accounted for more than half of all GI cancers and was the leading cause of GI-related mortality (52,394 deaths). There were 6.9 million upper, 11.5 million lower, and 228,000 biliary endoscopies performed in 2009. The total cost for outpatient GI endoscopy examinations was $32.4 billion. GI diseases are a source of substantial morbidity, mortality, and cost in the United States.

Sex and racial disparities in duodenal biopsy to evaluate for celiac disease

Celiac disease (CD) is common but underdiagnosed in the United States. Serological screening studies indicate that, although CD occurs at the same frequency in both sexes, women are diagnosed more frequently than men (2:1). CD is less frequently diagnosed among black patients, though the seroprevalence in this group is not known. To measure the rates of duodenal biopsy during EGD for symptoms consistent with CD. Retrospective cohort study. Clinical Outcomes Research Initiative National Endoscopy Database, spanning the years 2004 through 2009. Adults undergoing EGD for the indication of diarrhea, anemia, iron deficiency, or weight loss, in which the endoscopic appearance of the upper GI tract was normal. Performance of duodenal biopsy. Of 13,091 individuals (58% female patients, 9% black patients) who met the inclusion criteria, duodenal biopsy was performed in 43%, 45% of female patients and 39% of male patients (P < .0001). Black patients underwent duodenal biopsy in 28% of EGDs performed compared with 44% for white patients (P < .0001). On multivariate analysis, male sex (odds ratio [OR] 0.81; 95% CI, 0.75-0.88), older age (OR for 70 years and older compared with 20-49 years, 0.51; 95% CI, 0.46-0.57), and black patients (OR 0.55; 95% CI, 0.48-0.64) were associated with decreased odds of duodenal biopsy. Lack of histopathologic correlation with CD prevalence. In this multiregional endoscopy database spanning the period from 2004 through 2009, rates of duodenal biopsy increased modestly over time, but overall remained low in patients with possible clinical indications for biopsy. Nonperformance of duodenal biopsy during endoscopy may be contributing to the underdiagnosis of CD in the United States.

Polypectomy rate is a valid quality measure for colonoscopy: results from a national endoscopy database

The adenoma detection rate (ADR) is one of the main quality measures for colonoscopy, but it is burdensome to calculate and is not amenable to claims-based reporting. To validate the correlation between polypectomy rates (PRs) and ADRs by using a large group of endoscopists. Retrospective study. Community and academic endoscopy units in the United States. Sixty endoscopists and their patients. Proportion of patients with any adenoma and any polyp removed; correlation between ADRs and PRs. In total, 14,341 screening colonoscopies were included, and there was high correlation between endoscopists' PRs and ADRs in men ( r(s)= .91, P < .0001) and women (r(s) = .91, P < .0001). Endoscopists with PRs in the highest quartile had a significantly higher ADR than did those in the lowest quartile in men (44.6% vs 19.4%, P < .0001) and women (33.6% vs 11.6%, P < .0001). Endoscopists in the top polypectomy quartile also found more advanced adenomas than did endoscopists in the bottom quartile (men: 9.6% vs 4.6%, P = .0006; women: 6.3% vs 3.0%, P = .01). Benchmark PRs of 40% and 30% correlated with ADRs greater than 25% and 15% for men and women, respectively. Retrospective analysis of a subset of a national endoscopic database. Endoscopists' PRs correlate well with their ADRs. Given its clinical relevance, its simplicity, and the ease with which it can be incorporated into claims-based reporting programs, the PR may become an important quality measure.

Journal Scan

Journal Scan

Endoscopic Findings in Patients Presenting with Dysphagia: Analysis of a National Endoscopy Database

Dysphagia is a common problem and an indication for upper endoscopy. There is no data on the frequency of the different endoscopic findings and whether they change according to demographics or by single versus repeat endoscopy. To determine the prevalence of endoscopic findings in patients with dysphagia and whether findings differ in regard to age, gender, ethnicity, and repeat procedure. This was a retrospective study using a national endoscopic database (CORI). A total of 30,377 patients underwent esophagogastroduodenoscopy (EGD) for dysphagia of which 4,202 patients were repeat endoscopies. Overall frequency of endoscopic findings was determined by gender, age, ethnicity, and single vs. repeat procedures. Esophageal stricture was the most common finding followed by normal, esophagitis/ulcer (EU), Schatzki ring (SR), esophageal food impaction (EFI), and suspected malignancy. Males were more likely to undergo repeat endoscopies and more likely to have stricture, EU, EFI, and suspected malignancy (P=0.001). Patients 60years or older had a higher prevalence of stricture, EU, SR, and suspected malignancy (P<0.0001). Esophageal stricture was most common in white non-Hispanic patients compared to other ethnic groups. In patients undergoing repeat EGD, stricture, SR, EFI, and suspected malignancy were more common (P<0.0001). The prevalence of endoscopic findings differs significantly by gender, age, and repeat procedure. The most common findings in descending order were stricture, normal, EU, SR, EFI, and suspected malignancy. For patients undergoing a repeat procedure, normal and EU were less common and all other abnormal findings were significantly more common.

Polypectomy at colonoscopy and sigmoidoscopy in England: a review of national data between 1997 and 2007

<h3>Introduction</h3> Currently, there is no national endoscopic database in England. Information regarding the volume of therapeutic endoscopic procedures such as polypectomy is obtained mainly from small prospective studies. This article examines the Hospital Episode Statistics (HES) database to assess the number of patients that have undergone a therapeutic polypectomy for a diagnosis of a benign colorectal polyp over a 10-year period. We also analyse 28-day re-admission and 30-day mortality rates post procedure across 174 English National Health Service (NHS) units. <h3>Methods</h3> All elective patients having undergone a therapeutic polypectomy for a benign colorectal polyp between 1 Jan 1997 and 31 December 2007 in English NHS units were identified from HES after cleaning and formatting the dataset. Trends in rates of colonoscopies and flexible sigmoidoscopies were evaluated as well as 28-day re-admission and mortality rates over time. The reliability of HES data has previously been demonstrated in general surgical and medical patient cohorts <h3>Results</h3> The HES dataset reports that, 334,753 polypectomy procedures were performed on 286,204 patients in English NHS Trusts over the 10-year period. Of these, 233,119 (69.6%) were colonoscopicand 101,634 (30.4%) were via flexible sigmoidoscopy. Over this period a 55.2% increase in the total number of endoscopic polypectomy procedures were performed (from 20,289 in 1997 to 31,503 in 2007). Over the study years, the unadjusted average readmission (range-2.08% &gt; 2.47%) and mortality rates (range −0.33% &gt; 0.63%) overall were not significantly different (p = 0.440, both). <h3>Conclusion</h3> This analysis is the first to report national lower GI polypectomy numbers. It appears to demonstrates that patients undergoing endoscopic polypectomy rose by 55% from 1997 to 2007. Improved coding and a genuine increase in polypectomy workload may underlie these findings. Given the volumes of polypectomies being undertaken, and that polypectomy accounts for most of the procedure related risk with lower GI endoscopy, this may strengthen the case for improved training and accreditation in polypectomy.

Accuracy of Medicare claims for identifying findings and procedures performed during colonoscopy

Administrative claims data are frequently used for quality measurement. To examine the accuracy of administrative claims for potential colonoscopy quality measures, including findings (polyp or tumor detection), procedures (biopsy or polypectomy), and incomplete colonoscopy. Cross-sectional study. Patients age 65 and older undergoing colonoscopy in the Clinical Outcomes Research Initiative National Endoscopic Database in 2006. We linked colonoscopy records for these patients to Medicare colonoscopy claims by using patient age, sex, date of procedure, and performing provider's Unique Physician Identification Number. Sensitivity, specificity, positive and negative predictive values of the Medicare claims for potential quality measures, including colonoscopy findings and procedures. We linked Medicare colonoscopy claims to 15,168 of the 30,011 Clinical Outcomes Research Initiative colonoscopy records. Sensitivity of the claims for colon polyps was 93.4%, with a specificity of 97.8%. Sensitivity of claims for other diagnoses, including colorectal tumors was suboptimal, although specificity was high. In contrast, sensitivity of claims for procedures-biopsy (with or without cautery) or polypectomy-was high (87.2%-97.6%), with specificity >97%. Claims had poor sensitivity for identification of incomplete colonoscopy. Potential for inaccurate matching of colonoscopy records and Medicare claims. Medicare claims have high sensitivity and specificity for polyp detection, biopsy, and polypectomy at colonoscopy, but sensitivity is low for other diagnoses such as tumor detection and for incomplete colonoscopy. Caution is needed when using Medicare claims data for certain important quality measures, in particular tumor detection and incomplete colonoscopy.

Acid-Related Upper Endoscopy Findings in Patients with Diabetes Versus Non-diabetic Patients

The relationship between diabetes, GERD symptoms and acid-related mucosal damage has not been well studied. To better quantify risk of acid-related mucosal damage among patients with and without diabetes. A prospective study using 10 sites from the Clinical Outcomes Research Initiative (CORI) National Endoscopy Database surveyed patients undergoing EGD by telephone within 30 days on medical history, symptoms and demographics. Varices and feeding tube indications were excluded. Acid-related damage was defined as any of these findings recorded in CORI: Barrett's esophagus; esophageal inflammation (unless non-acid-related etiology); healed ulcer, duodenal, gastric or esophageal ulcer; stricture; and mucosal abnormality with erosion or ulcer. Of 1,569 patients, 16% had diabetes, 95% being type 2. Diabetic patients were significantly more likely to be male, older and have a higher body mass index, and less likely to report frequent heartburn and non-steroidal anti-inflammatory drug use. No significant differences were found in acid reflux and proton pump inhibitor (PPI) use between groups. In unadjusted analyses, diabetic patients had a similar risk for acid-related damage than non-diabetic patients (OR 1.09; 95% CI: 0.83, 1.42) which persisted after adjusting for gender, age, acid reflux, acid indication and PPI use (OR 1.04; 95% CI: 0.79, 1.39). No difference in risk of acid-related mucosal damage was found, even after adjustment for potential confounders. Our data do not support the need for a lower threshold to perform endoscopy in diabetic patients.

M1575: The Frequency and Determinants of Polyps in Children: Results From a National Endoscopic Database

M1575: The Frequency and Determinants of Polyps in Children: Results From a National Endoscopic Database

S1552: A Comparison of Lower Gastrointestinal (GI) Bleeding and Screening Colonoscopy Patient Cohorts: Data From the CORI National Endoscopic Database

There are limited data describing patients (pts) presenting with acute lower GI bleeding (LGIB) who undergo colonoscopy. There are no comparative data with patient populations undergoing colonoscopy for alternative indications.

Serious Complications Within 30 Days of Screening and Surveillance Colonoscopy Are Uncommon

The risk of serious complications after colonoscopy has important implications for the overall benefits of colorectal cancer screening programs. We evaluated the incidence of serious complications within 30 days after screening or surveillance colonoscopies in diverse clinical settings and sought to identify potential risk factors for complications. Patients age 40 and over undergoing colonoscopy for screening, surveillance, or evaluation based an abnormal result from another screening test were enrolled through the National Endoscopic Database (CORI). Patients completed a standardized telephone interview approximately 7 and 30 days after their colonoscopy. We estimated the incidence of serious complications within 30 days of colonoscopy and identified risk factors associated with complications using logistic regression analyses. We enrolled 21,375 patients. Gastrointestinal bleeding requiring hospitalization occurred in 34 patients (incidence 1.59/1000 exams; 95% confidence interval [CI], 1.10-2.22). Perforations occurred in 4 patients (0.19/1000 exams; 95% CI, 0.05-0.48), diverticulitis requiring hospitalization in 5 patients (0.23/1000 exams; 95% CI, 0.08-0.54), and postpolypectomy syndrome in 2 patients (0.09/1000 exams; 95% CI, 0.02-0.30). The overall incidence of complications directly related to colonoscopy was 2.01 per 1000 exams (95% CI, 1.46-2.71). Two of the 4 perforations occurred without biopsy or polypectomy. The risk of complications increased with preprocedure warfarin use and performance of polypectomy with cautery. Complications after screening or surveillance colonoscopy are uncommon. Risk factors for complications include warfarin use and polypectomy with cautery.

T1052 Acid-Related Upper Endoscopy Findings in Subjects with Diabetes Versus Non-Diabetics

From the few studies in the literature, it has been suggested that diabetics may be less likely to experience symptoms of gastroesophageal reflux disease but more likely to have acidrelated mucosal damage. To better quantify risk of acid-related damage among diabetics and non-diabetics undergoing esophagogastroduodenoscopy (EGD), we conducted a prospective study using the Clinical Outcomes Research Initiative (CORI) National Endoscopy Database. Methods: Data were collected at 10CORI sites on all patients undergoing EGD fromDecember 2006 to November 2007 unless evaluation was for a varices indication or feeding tube (PEG) placement. Within 30 days after EGD, eligible patients were contacted by telephone and questioned on their medical history, symptoms, medications and demographic data. Diabetics provided further details about their condition. Participants were considered to have an acidrelated finding if at least one of the following findings was entered on the CORI report: Barrett's esophagus; esophageal inflammation (unless etiology was not acid-related); healed ulcer; duodenal, gastric or esophageal ulcer; stricture; and mucosal abnormality with the sub-categorization of erosion or ulcer. Results: Of 2,090 eligible patients, 1,569 (75.1%) were included in the final analysis. 256 (16%) had diabetes, the majority being Type II (95%). Diabetics were significantly more likely to be male (65% vs 55%; p=.01), older (mean age 63 vs 58 years; p<.0001) and have a higher body mass index (mean 31 vs 28; p<.0001) than non-diabetics. The prevalence of acid reflux (self-reported) was similar among diabetics (70%) and non-diabetics (71%), however diabetics were significantly less likely to report frequent heartburn symptoms (at least 2-3 times per week) compared with nondiabetics (21% vs 30%; p=.01). Proton pump inhibitor (PPI) use did not differ between groups (56% in diabetics vs 55% in non-diabetics; p=.69), whereas diabetics were less likely to report non-steroidal anti-inflammatory drug use (11% vs 16%; p=.03). In unadjusted analyses, diabetics had similar risk for acid-related finding as non-diabetics (OR 1.09; 95% CI: 0.83, 1.42) which persisted after adjusting for gender, age, acid reflux, acid indication for EGD and PPI use (OR 1.04; 95% CI:0.79, 1.39). Conclusion: Diabetics were overrepresented in the cohort (16%) relative to the estimated prevalence of treated diabetics in the United States (7%), suggesting they may be more likely than non-diabetics to undergo EGD. However, no difference in risk of acid-related finding was observed between diabetics and non-diabetics, even after adjustment for potential confounders in multivariate models.

T1053 GERD Prevalence: A Population-Based Survey of An African American Community

From the few studies in the literature, it has been suggested that diabetics may be less likely to experience symptoms of gastroesophageal reflux disease but more likely to have acidrelated mucosal damage. To better quantify risk of acid-related damage among diabetics and non-diabetics undergoing esophagogastroduodenoscopy (EGD), we conducted a prospective study using the Clinical Outcomes Research Initiative (CORI) National Endoscopy Database. Methods: Data were collected at 10CORI sites on all patients undergoing EGD fromDecember 2006 to November 2007 unless evaluation was for a varices indication or feeding tube (PEG) placement. Within 30 days after EGD, eligible patients were contacted by telephone and questioned on their medical history, symptoms, medications and demographic data. Diabetics provided further details about their condition. Participants were considered to have an acidrelated finding if at least one of the following findings was entered on the CORI report: Barrett's esophagus; esophageal inflammation (unless etiology was not acid-related); healed ulcer; duodenal, gastric or esophageal ulcer; stricture; and mucosal abnormality with the sub-categorization of erosion or ulcer. Results: Of 2,090 eligible patients, 1,569 (75.1%) were included in the final analysis. 256 (16%) had diabetes, the majority being Type II (95%). Diabetics were significantly more likely to be male (65% vs 55%; p=.01), older (mean age 63 vs 58 years; p<.0001) and have a higher body mass index (mean 31 vs 28; p<.0001) than non-diabetics. The prevalence of acid reflux (self-reported) was similar among diabetics (70%) and non-diabetics (71%), however diabetics were significantly less likely to report frequent heartburn symptoms (at least 2-3 times per week) compared with nondiabetics (21% vs 30%; p=.01). Proton pump inhibitor (PPI) use did not differ between groups (56% in diabetics vs 55% in non-diabetics; p=.69), whereas diabetics were less likely to report non-steroidal anti-inflammatory drug use (11% vs 16%; p=.03). In unadjusted analyses, diabetics had similar risk for acid-related finding as non-diabetics (OR 1.09; 95% CI: 0.83, 1.42) which persisted after adjusting for gender, age, acid reflux, acid indication for EGD and PPI use (OR 1.04; 95% CI:0.79, 1.39). Conclusion: Diabetics were overrepresented in the cohort (16%) relative to the estimated prevalence of treated diabetics in the United States (7%), suggesting they may be more likely than non-diabetics to undergo EGD. However, no difference in risk of acid-related finding was observed between diabetics and non-diabetics, even after adjustment for potential confounders in multivariate models.

Prevalence of Colon Polyps >9 mm Detected By Colonoscopy Screening in Asymptomatic Hispanic and Asian/Pacific Islander Patients: Results from the National Endoscopic Database

Prevalence of Colon Polyps >9 mm Detected By Colonoscopy Screening in Asymptomatic Hispanic and Asian/Pacific Islander Patients: Results from the National Endoscopic Database

Endoscopic Findings in Patients Presenting with Dysphagia: Analysis of a National Endoscopy Database

Background: Dysphagia is a common indication for upper endoscopy. The different endoscopic findings are well known but the prevalence of these findings is not. There is also no data on the prevalence according to demographics or by single vs repeat EGD. Purpose: To determine the prevalence of endoscopic findings in patients (pts) presenting with dysphagia and if these findings differ with regards to age, gender, ethnicity and repeat procedure. Methods: The Clinical Outcomes Research Initiative (CORI) data base was queried from 1/2000 - 9/2006 for upper endoscopies performed for dysphagia. The overall frequency of endoscopic findings was determined and by gender, age, ethnicity and single vs. multiple procedures. Findings were grouped into normal esophagus, esophagitis/esophageal ulcer (EU), esophageal food impaction (EFI), suspected malignancy, stricture and Schatzki ring (SR). Chi-square analysis was used to analyze categorical variables. Results: 30,377 total pts were identified. For race/ethnicity analyses, a total of 29,337 was used. Esophageal stricture was the most common finding followed by normal, EU, SR, EFI and suspected malignancy. Males were more likely to undergo multiple endoscopies than females (15.3% vs 12.8%, p=0.001). Women were more likely to have a normal exam (37.2% vs 25.4%, p<0.0001). Men were more likely to have EU, EFI, stricture & suspected malignancy (p< 0.001 for all comparisons). The prevalence of SR among males and females was not different (p = 0.90). Pts over 60 (vs<60) had a higher prevalence of suspected malignancy (1.3% vs 0.4%), stricture (45.9% vs 35.6%) & SR (14.7% vs 11.9%) (p<0.0001 for all comparisons). (Esophageal stricture was most common in white non-Hispanic pts compared to other ethnic groups. Asian/pacific islander pts were most likely to have normal exams (65.5% vs 30.7%) and a lower prevalence of stricture (9.4% vs 42.3%) and SR (3.7% vs 13.8%) compared to whites. 4202 (13.8%) pts had multiple endoscopies for dysphagia during the time period. Males were more likely to undergo multiple EGD's than females (15.3% vs 12.8%, p=0.001). Normal and EU were more frequent in single EGD. Stricture, EFI, suspected malignancy and SR were more frequent in pts undergoing multiple EGD's (p<0.0001 for all comparisons). Conclusion: The prevalence of endoscopic findings among pts with dysphagia differs significantly by gender, age, and repeat procedure. For all pts, the most common findings in descending order were: stricture, normal, EU, SR, EFI, and suspected malignancy. For pts undergoing repeat procedure, normal and esophagitis were significantly less and all abnormal findings were significantly more common.

A closer look at same-day bidirectional endoscopy

Same-day bidirectional endoscopy (BDE) is commonly used in clinical practice. Our purpose was to determine the frequency, patient demographics, indications, and significant endoscopic findings for patients undergoing BDE. Retrospective study with a national endoscopic database. Diverse clinical practice settings in the United States, including 75% from private practice. A total of 591,074 adult patients had upper or lower endoscopy; 66,265 patients (11.2%) with same-day BDE and a subgroup (n = 9067) with a common indication for both upper and lower examinations are the subjects of this analysis. Age, sex, and procedure indication were analyzed in all subjects. Significant endoscopic findings were measured in patients with a single indication of anemia, a positive fecal occult blood test (FOBT), or abdominal pain/dyspepsia (pain) for both upper and lower endoscopy. The Clinical Outcomes Research Initiative (CORI) national endoscopic database was analyzed to determine the number of patients who underwent same-day BDE between 2000 and 2004. Patients with a single indication of anemia, positive fecal occult blood test (FOBT), or abdominal pain/dyspepsia (pain) on both EGD and colonoscopy were included for the analysis of endoscopic findings. Significant upper GI findings were defined as suspected malignancy, arteriovenous malformation (AVM), ulcer, Barrett's esophagus, and stricture. Significant lower GI findings included suspected malignancy, polyp >9 mm, and AVM. A total of 591,074 patients had upper and/or lower endoscopy; 66,265 patients (11.2%) had same-day BDE. The majority of patients were female (52.1%), and the mean age of patients with BDE was 60.8 years. A total of 6538 patients (9.9%) had anemia, 1169 (1.8%) had a positive FOBT, and 1360 (2.1%) had pain as the sole indication for both examinations. After adjustment for age and sex, significant findings were higher in patients with anemia than in those with pain (odds ratio 1.89; 95% CI, 1.59-2.26) and for patients with positive FOBT versus pain (odds ratio 1.83; 95% CI, 1.48-2.26). Retrospective analysis with possible bias. Fewer patients with pain had significant findings compared to the other two groups (P value <.0001). More than 10% of patients undergoing upper or lower endoscopy receive same-day BDE. BDE commonly revealed important conditions in patients with anemia or positive FOBT. Bidirectional endoscopy commonly revealed important pathology in patients with anemia or positive FOBT. Patients with pain had a lower prevalence of serious findings compared to the other groups studied. The benefits of BDE in patients with pain are uncertain and require additional investigation.

Barrett's Esophagus on Repeat Endoscopy: Should We Look More Than Once?

Barrett's esophagus (BE) is the precursor lesion for esophageal adenocarcinoma. The major risk factor for BE is chronic gastroesophageal reflux disease (GERD). Screening patients with longstanding GERD for BE with upper esophagogastroduodenoscopy (EGD) has become the standard practice, and guidelines from national gastrointestinal (GI) societies recommend only a single screening EGD because of limited evidence, suggesting that BE develops early in the course of GERD. We hypothesized that BE may be present in patients in whom initial endoscopy was negative, either due to a missed diagnosis or due to the later development of BE. The purpose of the study was to determine how often BE is identified on repeat endoscopy performed after an initial negative examination. The Clinical Outcomes Research Initiative (CORI) National Endoscopic Database was searched for all patients who had more than one EGD during the 5-yr period between January 1, 2000, and December 31, 2004. Patients who had either procedure for an indication of surveillance of BE were excluded. The primary outcome was a finding of newly suspected BE on repeat examination after an initial negative examination. In total, 24,406 patients underwent more than one endoscopy during the study period. Five hundred sixty-one (2.3%) were found to have suspected BE on repeat EGD following an initial negative examination. More men than women had BE on repeat examination (3.1%vs 1.2%, P < 0.0001). BE on repeat examination was more common in patients with reflux as an indication for endoscopy than in patients with any other indication (5%vs 1.6%, P< or =0.0001). In reflux patients with esophagitis on initial examination, 9.9% were found to have suspected BE on repeat examination versus 1.8% of reflux patients with no esophagitis on initial examination (P < 0.0001). BE is rarely found on second endoscopy performed less than 5 yr after an initial negative examination except in patients with esophagitis on the first endoscopy. Repeat EGD for Barrett's screening should not be performed out of concern for a missed diagnosis except when BE may have been obscured by overlying esophageal inflammation.

An evaluation of endoscopic indications and findings related to nonvariceal upper-GI hemorrhage in a large multicenter consortium

The majority of studies on upper-GI hemorrhage (UGIH) to date have been based on clinical experience at academic centers. There is limited information about patients with UGIH who are evaluated by endoscopy at nonacademic settings, which comprise the majority of endoscopic practices in the United States. The aims of this retrospective study were to use a large national endoscopy database to describe the population of patients who received an EGD for nonvariceal upper-GI hemorrhage at diverse clinical practice sites and to characterize their endoscopic diagnoses. Between 2000 and 2004, the Clinical Outcomes Research Initiative (CORI) database received endoscopic reports from 72 diverse practice sites in the United States. All adult patients who underwent an EGD during this period at a CORI site for the indications of hematemesis, melena, or "suspected upper-GI bleed" were identified. Variceal bleeding was excluded. The nonvariceal UGIH cohort was described, and this group's endoscopic findings were characterized by the prevalence, indication, and location of an EGD (inpatient vs outpatient). A repeat EGD within a 2-week period was also evaluated. A total of 243,427 EGDs were performed during the study period; 12,392 (4.9% of all EGDs) were performed for evaluation of hematemesis, melena, or "suspected" upper-GI bleed. Patients in this cohort were more likely to be older, men, and nonwhite compared with their nonbleeding counterparts. Melena was the most common indication for an EGD. The most common endoscopic finding was an ulcer (32.7%), followed by erosion (18.8%). A "normal" EGD was reported on 17.2% of EGDs. Among patients with ulcers, gastric ulcers were more common that duodenal ulcers (54.4% vs 37.1%), whereas clean-based ulcers comprised 52% of all ulcers. Ulcers and Mallory-Weiss tears were significantly more common on inpatient procedures. Ulcers identified on outpatient EGDs were more likely to be clean based. A repeat endoscopy was performed on 4% of the cohort within a 2-week follow-up period, hematemesis was the most common indication for a repeat EGD, and 24.3% of the cohort had a documented therapeutic intervention on their initial EGD. Among inpatients, 6.0% had a repeat EGD within two weeks for an UGIH indication compared with only 1.4% of outpatients (P < .0001). These results allow association of EGD findings with patient presentation. Furthermore, it allows us to characterize endoscopic findings in a particular patient population (those patients with UGIH) in clinical practice, outside of traditional academic medical centers. The CORI database is a valuable resource for characterizing the epidemiology of endoscopic findings and, in particular, patient populations and across diverse practice settings, thus, enabling the development of hypotheses for future studies.

Patterns of endoscopy in the United States: analysis of data from the Centers for Medicare and Medicaid Services and the National Endoscopic Database

Patterns of GI endoscopy are influenced by the underlying epidemiology of GI disease, as well as by policy and practice guidelines. To compare practice patterns of GI endoscopy between two large national databases of the United States. Descriptive database analysis. A 5% sample of the entire U.S. Medicare population (Centers for Medicare and Medicaid Services, CMS data files) and endoscopic data repository of U.S. gastroenterology practices (Clinical Outcomes Research Initiative, CORI database) from 1999 to 2003. The study population included 1,121,215 Medicare and 635,573 CORI patients undergoing various types of GI endoscopy. EGD, colonoscopy, and flexible sigmoidoscopy. Patient demographics, endoscopic diagnoses, time trends of diagnoses. A colonoscopy was the most common endoscopic procedure performed (CMS 53%, CORI 58%), followed by an EGD (37%, 32%), and a flexible sigmoidoscopy (10%, 10%). In the CMS data, women accounted for 59% of the EGDs, 57% of the colonoscopies, and 56% of the flexible sigmoidoscopies, and in the CORI data, the corresponding numbers were 57%, 55%, and 54%, respectively. Compared with their distribution in the U.S. census population, nonwhite patients in both databases underwent relatively more EGDs and fewer colonoscopies. The most common upper-GI diagnosis was GERD, followed by GI bleeding, gastric ulcer, and duodenal ulcer. The most common lower-GI diagnosis was colorectal polyp. Over the period of 1999 to 2003, the rates of colorectal cancer diagnosed with colonoscopy declined. Only a limited amount of information about individual patients was retrievable from the electronic databases. A colonoscopy is now the most common endoscopic procedure in the United States. Women undergo both upper and lower endoscopic procedures more often than men. Nonwhite patients are underrepresented in the use of colonoscopy relative to the prevalence of nonwhite persons in the U.S. population. Increased use of a colonoscopy for colon screening and surveillance has been associated with a decreased rate of cancer diagnosis.