Faculty Bibliography

BACKGROUND: Endoscopy is commonly performed in patients with chronic human immunodeficiency virus (HIV)-related diarrhea after negative stool studies. The aim of this study was to determine the diagnostic yield and cost-effectiveness of endoscopy in this setting. METHODS: Consecutive HIV-infected patients with chronic unexplained diarrhea who were referred for diagnostic endoscopy were identified. Patient charts, pathology reports, and endoscopy records were reviewed. RESULTS: A total of 479 endoscopic procedures were performed in 307 patients. A pathogen was identified in 147 patients (47.9%); cytomegalovirus was the most frequent organism found (21.5%). The average cost of identifying a pathogen by endoscopy was $3822.94. Colonoscopy had a greater diagnostic yield than flexible sigmoidoscopy (38.7% vs. 22.4%, p = 0.009) and was more cost-effective. The yield of upper endoscopy was 29.6%. In patients with a CD4 count of less than 100/mm3, endoscopy had a higher diagnostic yield (62.8% vs. 8.3%, p < 0.0001) and a lower cost of identifying a pathogen ($2943.92 vs. $21,583.51) than in those with higher CD4 counts. CONCLUSIONS: Endoscopy frequently identifies a pathogen in HIV-related chronic diarrhea. Colonoscopy is the most cost-effective procedure. Endoscopic evaluation has a significantly higher diagnostic yield and is considerably more cost-effective in patients with a CD4 count of less than 100/mm3 than in those with higher CD4 counts

BACKGROUND: The impact on instrument quality and cost of the practice of reusing ERCP accessories has not been fully addressed. METHODS: Twenty-five new papillotomes and 15 new retrieval baskets were labeled and evaluated over time by staff blinded to the number of prior uses. Instruments were scored as to their function for the designated task. The cost of this practice was calculated from the purchase price of accessories and the costs of cleaning, sterilization, and disposal, and then compared with the estimated cost of a practice of one-time use of similar instruments. RESULTS: Twenty-five papillotomes were used 246 times (median 8; mean 9.8). Fifteen retrieval baskets were used 193 times (median 13; mean 12.9). The median survival of both papillotomes and baskets before being considered inadequate (score < 6 out of 10) was 9 uses. There were no complications attributable to using reused equipment. The projected yearly cost savings of using reusable versus disposable instruments was $94,095 for papillotomes and $61,809 for baskets, a 475% and 322% cost reduction, respectively. CONCLUSION: The papillotomes and baskets in this study could be reused reliably and safely multiple times, with considerable cost savings compared with the practice of using disposable instruments.