Faculty Bibliography

BACKGROUND AND AIMS/OBJECTIVE:The biological environment varies across the colorectum and may therefore affect neoplastic growth differently in the proximal and distal colon. The aim of the study was to evaluate the risk for recurrent adenomas and their anatomic location based on adenoma location at baseline colonoscopy. METHODS:Data were extracted from 3 adenoma prevention trials (n = 2430). Participants had at least 1 adenoma at baseline colonoscopy and underwent subsequent surveillance colonoscopy, at which time metachronous adenomas could be detected. We calculated the risk ratio (RR) and the 95% confidence interval (CI) for metachronous adenomas by location of the baseline lesion and considered the impact of advanced neoplasia and multiplicity. RESULTS:At baseline, 522 patients (21.5%) had adenomas only in the proximal colon, 1266 patients (52.1%) had adenomas only in the distal colorectum, and 642 (26.4%) had adenomas in both regions. Overall, 877 patients (36.5%) had metachronous adenomas during the follow-up period. Those with only proximal adenomas at baseline had a higher risk of metachronous adenomas compared with patients with only distal adenomas (RR, 1.17; 95% CI, 1.01-1.35). A greater proximal risk was found after restricting the analysis to patients with multiple proximal adenomas versus multiple distal adenomas (RR, 1.35; 95% CI, 1.10-1.67). The risk of recurrent adenomas on the same side was 48% higher for patients with only proximal adenomas at baseline compared with those with only distal adenomas at baseline (RR, 1.48; 95% CI, 1.22-1.80). CONCLUSIONS:Patients with proximal adenomas only have a modestly greater risk of adenoma recurrence than patients with adenomas limited to the distal colon, and have a greater likelihood of adenoma recurrence on the same side compared with patients with distal adenomas. This observation suggests that biological factors may differentially affect neoplasia growth across the colon.

BACKGROUND:Inflammatory bowel diseases (IBDs) are group of chronic inflammatory illnesses with a remitting and relapsing course that may result in appreciable morbidity and high medical costs secondary to repeated hospitalizations. The study's objectives were to identify the reasons for hospitalization among patients with inflammatory bowel diseases, and compare inpatient courses and readmission rates for IBD-related admissions versus non-IBD-related admissions. METHODS:A retrospective chart review was performed on all patients with IBD admitted to the Minneapolis VA Medical Center between September 2010 and September 2012. RESULTS:A total of 111 patients with IBD were admitted during the 2-year study period. IBD flares/complications accounted for 36.9 % of the index admissions. Atherothrombotic events comprised the second most common cause of admissions (14.4 %) in IBD patients. Patients with an index admission directly related to IBD were significantly younger and had developed IBD more recently. Unsurprisingly, the IBD admission group had significantly more gastrointestinal endoscopies and abdominal surgeries, and was more likely to be started on medication for IBD during the index stay. The median length of stay (LOS) for the index hospitalization for an IBD flare or complication was 4 (2-8) days compared with 2 (1-4) days for the other patients (P = 0.001). A smaller percentage of the group admitted for an IBD flare/complication had a shorter ICU stay compared with the other patients (9.8 % vs. 15.7 %, respectively); however, their ICU LOSs tended to be longer (4.5 vs. 2.0 days, respectively, P = 0.17). Compared to the other admission types, an insignificantly greater percentage of the group whose index admission was related to an IBD flare or complication had at least one readmission within 6 months of discharge (29 % versus 21 %; P = 0.35). The rate of admission was approximately 80 % greater in the group whose index admission was related to an IBD flare or complication compared to the other types of admission (rate ratio 1.8, 95 % confidence interval 0.96 to 3.4), although this difference did not reach statistical significance (P = 0.07). CONCLUSION/CONCLUSIONS:Identifying the reasons for the patients' index admission, IBD flares versus all other causes, may provide valuable information concerning admission care and the subsequent admission history.

This study assessed whether postal follow-up to a web-based physician survey improves response rates, response quality, and representativeness. We recruited primary care and gastroenterology chiefs at 125 Veterans Affairs medical facilities to complete a 10-min web-based survey on colorectal cancer screening and diagnostic practices in 2010. We compared response rates, response errors, and representativeness in the primary care and gastroenterology samples before and after adding postal follow-up. Adding postal follow-up increased response rates by 20-25 percentage points; markedly greater increases than predicted from a third e-mail reminder. In the gastroenterology sample, the mean number of response errors made by web responders (0.25) was significantly smaller than the mean number made by postal responders (2.18), and web responders provided significantly longer responses to open-ended questions. There were no significant differences in these outcomes in the primary care sample. Adequate representativeness was achieved before postal follow-up in both samples, as indicated by the lack of significant differences between web responders and the recruitment population on facility characteristics. We conclude adding postal follow-up to this web-based physician leader survey improved response rates but not response quality or representativeness.

BACKGROUND:This study assessed the contribution of organizational structures and processes identified from facility surveys to follow-up for positive fecal occult blood tests [FOBT-positive (FOBT(+))]. METHODS:We identified 74,104 patients with FOBT(+) results from 98 Veterans Health Administration (VHA) facilities between August 16, 2009 and March 20, 2011, and followed them until September 30, 2011, for completion of colonoscopy. We identified patient characteristics from VHA administrative records, and organizational factors from facility surveys completed by primary care and gastroenterology chiefs. We estimated predictors of colonoscopy completion within 60 days and six months using hierarchical logistic regression models. RESULTS:Thirty percent of patients with FOBT(+) results received colonoscopy within 60 days and 49% within six months. Having gastroenterology or laboratory staff notify gastroenterology providers directly about FOBT(+) cases was a significant predictor of 60-day [odds ratio (OR), 1.85; P = 0.01] and six-month follow-up (OR, 1.25; P = 0.008). Additional predictors of 60-day follow-up included adequacy of colonoscopy appointment availability (OR, 1.43; P = 0.01) and frequent individual feedback to primary care providers about FOBT(+) referral timeliness (OR, 1.79; P = 0.04). Additional predictors of six-month follow-up included using guideline-concordant surveillance intervals for low-risk adenomas (OR, 1.57; P = 0.01) and using group appointments and combined verbal-written methods for colonoscopy preparation instruction (OR, 1.48; P = 0.0001). CONCLUSION/CONCLUSIONS:Directly notifying gastroenterology providers about FOBT(+) results, using guideline-concordant adenoma surveillance intervals, and using colonoscopy preparations instruction methods that provide both verbal and written information may increase overall follow-up rates. Enhancing follow-up within 60 days may require increased colonoscopy capacity and feedback to primary care providers. IMPACT/CONCLUSIONS:These findings may inform organizational-level interventions to improve FOBT(+) follow-up.