Faculty Bibliography

Introduction: Patients with inflammatory bowel disease (IBD) have many unique health maintenance needs and often require therapy necessitating close monitoring. Gastroenterologists often serve as the primary care provider for these patients and therefore must be familiar with the health maintenance needs of IBD patients. In this study, we investigated whether implementing a multimodal educational intervention could improve providers' rates of addressing healthcare maintenance measures. Methods: A retrospective chart review was performed in 2013-2014 on 208 IBD patients to determine adherence to performance practice measures. From February-April 2016, fellows received a recurring in-service lecture and an IBD clinic note template outlining the 2011 healthcare maintenance recommendations by the American Gastroenterological Association. An iBook was also introduced, which provided a comprehensive overview of IBD practice guidelines. Retrospective chart review was then performed 1 year afterwards. For each patient, performance measures were assessed in both pre- and post-intervention notes in the following categories: vaccinations, bone health, therapy-specific maintenance, tobacco cessation counseling, and cancer screening. Each performance measure was given a score of 0 (not addressed), 1 (addressed), or N/A (irrelevant to subject). The primary outcome was improvement in rates of adherence to performance measures. The adherence rates for pre- and post-intervention groups were compared using a chi-squared test. Results: A total of 208 pre-intervention clinic visits and 40 post-intervention visits were included for analysis. After the interventions, the rate of healthcare maintenance measures addressed overall increased from 37% to 52% (p < .001) (Figure 1). There were statistically significant improvements in addressing bone health (29% to 63%, p < .001), vaccination (33% to 47%, p < .001), and therapy-specific measures (53% to 74%, p=.01). There were no statistically significant changes in addressing cancer screening (66% to 58%, p=.19) or smoking (23% to 30%, p=.59). Conclusion: The use of multiple educational interventions to enhance delivery of IBD healthcare maintenance resulted in improved adherence to healthcare maintenance measures. Targeted educational programs and a multi-modal approach may be an effective method for teaching GI fellows and reinforcing the importance of addressing these measures to optimize the care of their IBD patients

Introduction: Colonoscopy is the most commonly used test for colorectal cancer screening in the US, but patients often find the oral bowel preparation difficult, inconvenient, or intolerable. Suboptimal bowel prep occurs in 20-24% of colonoscopies, leading to inadequate examinations that necessitate additional procedures. Colonic irrigation is an FDA-approved method of colon cleansing using a warm water lavage, but few studies have evaluated it as preparation for colonoscopy. The purpose of this study is to evaluate colonic irrigation as an alternative to oral bowel prep in patients undergoing screening/ surveillance colonoscopy. Methods: We conducted a single-center, single-arm feasibility study using the Hydro-San Plus system. Patients followed a low-residue diet and took 2 doses of polyethylene glycol the day before the procedure. Colonoscopy was performed immediately following colonic irrigation. Boston Bowel Prep Scale (BBPS) and adverse events were recorded. A telephone questionnaire was administered within 7 days of the procedure. Results: Of the 21 patients enrolled, 48% had at a medical risk factor for poor prep (Table 1). Eighteen patients completed irrigation, of whom 12 (67%) had an adequate bowel prep, defined as BBPS>1 in all segments (Table 2). Two irrigations were not completed due to minor adverse events (discomfort from speculum insertion and rectal abrasion) and 1 was aborted for mechanical repair. There were no major adverse events. Patients with no risk factors for poor prep were 4 times more likely to have an adequate prep, although this was not statistically significant (P=0.14). Half of the patients felt that irrigation was easy (47%) and comfortable (53%), while most felt it was tolerable (71%) and convenient (82%). Among participants who had previous a colonoscopy with oral prep, the majority felt that irrigation was easier (85%), more tolerable (77%), and more convenient (85%) than oral prep. 82% of respondents said they would ask for irrigation again and only 12% said they would refuse if it were offered. Conclusion: Colonic irrigation is a safe and moderately efficacious alternative to oral bowel prep for screening/surveillance colonoscopy. A more potent oral pre-prep, especially for patients with risk factors for poor prep, may improve efficacy. Importantly, patient satisfaction with colonic irrigation appears to be higher than with oral bowel prep. (Table Presented)

Introduction: Colonoscopy is the most commonly used colorectal cancer (CRC) screening modality in the US. Although national screening rates have increased over time, disparities by race/ethnicity, socioeconomic status, and geography are well documented. We sought to further characterize the relationship between sociodemographic factors and up-to-date CRC screening in a diverse urban center using the 2014 New York City Community Health Survey (NYCCHS). Methods: Data was collected from the 2014 NYCCHS, a telephone survey administered annually to adult New Yorkers in which up-to-date CRC screening was assessed by asking participants if they received a colonoscopy within the past 10 years. We examined screening rates in various racial/ethnic groups. We also evaluated the association between ten sociodemographic variables of interest-age, sex, race/ ethnicity, birthplace, home language, time living in the US, education, employment, income, and borough of residence-and CRC screening. Analysis was conducted using univariable and multivariable logistic regression and restricted to participants aged 50 and older. Results: The up-to-date CRC screening rate was 71% overall, 73% for non-Hispanic whites and Hispanics, 68% for non-Hispanic blacks, and 63% for Asians. Among Hispanic subgroups, rates ranged from 76% for Dominicans to 50% for Mexicans. Among Asian subgroups, rates ranged from 75% for Filipinos to 54% for Indians (Figure). All ten sociodemographic variables had statistically significant associations with screening on univariable analysis (Table). In the multivariable model, screening was associated with age greater than 65, Chinese home language, and not being in the labor force. Individuals who had lived in the US for less than 5 years, did not attend college, had income less than 200% of the poverty line, and resided outside of Manhattan were significantly less likely to receive up-to-date screening. Conclusion: Among New Yorkers older than age 50, the up-to-date CRC screening rate was 10% lower in Asians compared to whites. Screening rates varied substantially among Asian and Hispanic subgroups. In a multivariable model, the likelihood of receiving screening was significantly less among recent immigrants, individuals with low socioeconomic status, and those living outside of Manhattan. Targeted interventions to promote CRC screening in these groups may reduce existing sociodemographic disparities and improve overall screening rates

Introduction: Patients and families are often asked to make decisions regarding feeding tube placement during a medical crisis. The risks, benefits, and alternative treatment choices are not communicated by a standard method, and the consultants placing the tubes are often invited to join the discussion at a late stage. Our aim is to improve this process with a focus on patient and family preferences and patient safety, by educating medicine residents about feeding tubes and providing them with a shared decision making tool utilizing an electronic book (iBook). Methods: We created a one hour noon conference program for residents in which we reviewed information about enteral feeding, including types of tubes, placement methods, indications, contraindications, complications, and feeding tube use in selected medical conditions, with a focus on dementia. During this session the iBook was introduced for use in discussions with patients and families. Pre- and postintervention surveys were given to the residents to determine their knowledge and comfort level with the content. Gastroenterology fellows were also surveyed to determine if there was a difference in the nature of the feeding tube consults before and after the intervention. We used the chi-squared or Fisher's exact test to compare dichotomous outcomes in the pre- and post- intervention groups. Results: Among residents, there was a statistically significant increase in the proportion of individuals who answered that they were very comfortable/competent in all six questions regarding feeding tube placement after the intervention (p < 0.01 for all). Among fellows, there was perceived improvement in resident and patient knowledge regarding feeding tube placement as well as appropriateness of consults after the intervention, however these were not statistically significant due to the small sample size. There was a perceived decrease in the frequency of appropriate feeding tube placements after the intervention, which was also statistically non-significant. None of the residents reported that they had used the iBook with patients. Conclusion: Residents are often the first physicians to discuss feeding tube placement with patients and families in the acute inpatient setting, however many report that they are not equipped to lead this discussion. Formal education about feeding tubes improves resident comfort/competence in this area and should be incorporated into medicine housestaff curricula

PURPOSE: Colorectal cancer (CRC) incidence and mortality in the United States have steadily declined since the 1980s, but racial and socioeconomic disparities remain. The influence of geographic factors is poorly understood and may be affected by evolving insurance coverage and screening test uptake. We characterized temporal trends in the association between geographic and sociodemographic factors and CRC outcomes. METHODS: We used the 1973-2010 SEER-Medicare files to identify patients aged >/=65 years with and without CRC. Beneficiary residential ZIP codes were used to extract local-level data. We constructed multivariable logistic regression models for CRC incidence and mortality using geographic and sociodemographic variables in 4 time periods: (1) 1973-1997; (2) 1998-2001; (3) 2002-2006; and (4) 2007-2010. FINDINGS: We analyzed 1,093,758 records, including 336,321 CRC cases. Compared to urban residence, small rural residence was strongly associated with increased CRC incidence (OR 1.50, 95% CI: 1.43-1.57) and mortality (OR 1.35, 95% CI: 1.26-1.45) in 1973-1997, but the associations diminished by 2007-2010 (OR 1.09, 95% CI: 1.04-1.15 for incidence; OR 1.10, 95% CI: 1.01-1.20 for mortality). The disparity between blacks and whites increased over time for both incidence (OR 1.09, 95% CI: 1.05-1.13 in 1973-1997 vs OR 1.32, 95% CI: 1.27-1.37 in 2007-2010) and mortality (OR 1.22, 95% CI: 1.16-1.28 in 1973-1997 vs OR 1.34, 95% CI: 1.26-1.42 in 2007-2010). High socioeconomic status was associated with greater incidence and mortality in 1973-1997, but it became protective after 1998. CONCLUSIONS: Although disparities persist among Medicare beneficiaries, the relationship between geographic and sociodemographic factors and CRC incidence and mortality has evolved over time.

BACKGROUND: Despite high-quality evidence demonstrating that screening reduces mortality from breast, cervical, colorectal, and lung cancers, a substantial portion of the population remains inadequately screened. There is a critical need to identify interventions that increase the uptake and adoption of evidence-based screening guidelines for preventable cancers at the community practice level. Text messaging (short message service, SMS) has been effective in promoting behavioral change in various clinical settings, but the overall impact and reach of text messaging interventions on cancer screening are unknown. OBJECTIVE: The objective of this systematic review was to assess the effect of text messaging interventions on screening for breast, cervical, colorectal, and lung cancers. METHODS: We searched multiple databases for studies published between the years 2000 and 2017, including PubMed, EMBASE, and the Cochrane Library, to identify controlled trials that measured the effect of text messaging on screening for breast, cervical, colorectal, or lung cancers. Study quality was evaluated using the Cochrane risk of bias tool. RESULTS: Our search yielded 2238 citations, of which 31 underwent full review and 9 met inclusion criteria. Five studies examined screening for breast cancer, one for cervical cancer, and three for colorectal cancer. No studies were found for lung cancer screening. Absolute screening rates for individuals who received text message interventions were 0.6% to 15.0% higher than for controls. Unadjusted relative screening rates for text message recipients were 4% to 63% higher compared with controls. CONCLUSIONS: Text messaging interventions appear to moderately increase screening rates for breast and cervical cancer and may have a small effect on colorectal cancer screening. Benefit was observed in various countries, including resource-poor and non-English-speaking populations. Given the paucity of data, additional research is needed to better quantify the effectiveness of this promising intervention.

BACKGROUND AND AIMS: Although the incidence of gastric cancer in the United States is relatively low, the incidence of gastric cancer is higher than for esophageal cancer, for which clear guidelines for screening and surveillance exist. With the increasing availability of endoscopic therapy, such as endoscopic submucosal dissection, for treating advanced dysplasia and early gastric cancer, establishing guidelines for screening and surveillance of patients who are at high risk of developing gastric cancer has the potential to diagnose and treat gastric cancer at an earlier stage and improve mortality from gastric cancer. The aims of this article were to review the data regarding the risk factors for developing gastric cancer, methods for gastric cancer screening, and results of national screening programs. METHODS: A review of the existing literature related to the aims was performed. RESULTS: Risk factors for gastric cancer that were identified include race/ethnicity (East Asian, Russian, or South American), first-degree relative diagnosed with gastric cancer, positive Helicobacter pylori status, and presence of atrophic gastritis or intestinal metaplasia. Endoscopy has the highest rate of detecting gastric cancer compared with other gastric cancer screening methods. The national screening program in Japan has demonstrated a mortality reduction from gastric cancer based on cohort data. CONCLUSIONS: Gastric cancer screening with endoscopy should be considered in individuals who are immigrants from regions associated with a high risk of gastric cancer (East Asia, Russia, or South America) or who have a family history of gastric cancer. Those with findings of atrophic gastritis or intestinal metaplasia on screening endoscopy should undergo surveillance endoscopy every 1 to 2 years. Large prospective multicenter studies are needed to further identify additional risk factors for developing gastric cancer and to assess whether gastric cancer screening programs for high-risk populations in the United States would result in improved mortality.

BACKGROUND: The AIMS65 score and the Glasgow-Blatchford risk score (GBRS) are validated preendoscopic risk scores for upper gastrointestinal hemorrhage (UGIH). GOALS: To compare the 2 scores' performance in predicting important outcomes in UGIH. STUDY: A prospective cohort study in 2 tertiary referral centers and 1 community teaching hospital. Adults with UGIH were included. The AIMS65 score and GBRS were calculated for each patient. The primary outcome was inpatient mortality. Secondary outcomes were 30-day mortality, in-hospital rebleeding, 30-day rebleeding, length of stay, and a composite endpoint of in-hospital mortality, transfusions, or need for intervention (endoscopic, radiologic, or surgical treatment). The area under the receiver operating characteristic curve (AUROC) was calculated for each score and outcome. RESULTS: A total of 298 patients were enrolled. The AIMS65 score was superior to the GBRS in predicting in-hospital mortality (AUROC, 0.85 vs. 0.66; P<0.01) and length of stay (Somer's D, 0.21 vs. 0.13; P=0.04). The scores were similar in predicting 30-day mortality (AUROC, 0.74 vs. 0.65; P=0.16), in-hospital rebleeding (AUROC, 0.69 vs. 0.62; P=0.19), 30-day rebleeding (AUROC, 0.63 vs. 0.63; P=0.90), and the composite outcome (AUROC, 0.57 vs. 0.59; P=0.49). The optimal cutoffs for predicting in-hospital mortality were an AIMS65 score of 3 and a GBRS score of 10. For predicting rebleeding, the optimal cutoffs were 2 and 10, respectively. CONCLUSIONS: The AIMS65 score is superior to the GBRS for predicting in-hospital mortality and hospital length of stay for patients with UGIH. The AIMS65 score and GBRS are similar in predicting 30-day mortality, rebleeding, and a composite endpoint.