Operational Changes on Child and Adolescent Acute Psychiatric Treatment Programs During COVID-19.

This Letter to the Editor examines the operational changes on two child and adolescent acute psychiatric treatment programs during the COVID-19 pandemic. On an inpatient unit with roughly two-thirds of its beds in double-occupancy rooms, we found that average daily census and total admissions were lower in the early pandemic period compared to the pre-pandemic period, whereas length of stay was significantly longer. In contrast, a community-based acute treatment program with only single-occupancy rooms showed an increase in average daily census, and no significant change in admissions or length of stay during the early pandemic period compared to the pre-pandemic period. Recommendations include considering preparedness for infection-related public health emergencies in unit design.

The Perioperative Pain Self-Management (PePS) randomized controlled trial protocol: Preventing chronic post-surgical pain and prolonged opioid use.

BACKGROUND: Total joint arthroplasties are common orthopedic surgeries that carry risk for developing chronic post-surgical pain. In addition to pre- and post-operative pain severity, psychological distress (e.g., anxiety, pain catastrophizing) is a risk factor for chronic postsurgical pain. Cognitive behavioral therapy (CBT) for chronic pain is an empirically supported approach to managing chronic pain, functional impairment, and related distress. While CBT has been used extensively in patients with established chronic pain, using it as a preventive intervention targeting the transition from acute to chronic postsurgical pain is a novel application. OBJECTIVES: The Perioperative Pain Self-Management (PePS) program is a pain self-management intervention based on the principles of CBT. This innovative intervention is brief, flexible, and is delivered remotely. The current study aims to determine the efficacy of PePS compared to standard care on reducing the incidence of significant surgical site pain at 6-months post-surgery. The current study also aims to evaluate the context for subsequent implementation. METHODS: This study is a hybrid type I efficacy-preparing for implementation trial. It is a two-site, single-blind, two-arm, parallel, randomized control trial. Surgical patients will be randomized to either receive: 1) PePS plus standard care, or 2) Standard care. The primary end point will be surgical site pain severity at 6-months post-surgery. CONCLUSION: Results from this study are expected to result in support for a brief scalable intervention (PePS) that can prevent the development of chronic pain and prolonged post-surgical opioid use, as well as key details to inform subsequent implementation. CLINICALTRIALS: govIdentifier:NCT04979429.

Gender Differences in Colonoscopy: Implications for Clinical Practice and Female Gastroenterologists.

BACKGROUND AND AIMS: Performing colonoscopy can be technically challenging in female patients. Female patients may prefer having a female endoscopist. This preference, coupled with the fact that there are fewer female endoscopists, may result in gender differences in colonoscopy practice. We hypothesized that the duration of female colonoscopy is longer and that female endoscopists perform a higher proportion of female colonoscopy than male colleagues. We explored the potential revenue implications of gender differences in screening colonoscopy. METHODS: We analyzed procedure time and gender differences in 16,573 screening colonoscopies performed by 27 male and 7 female endoscopists over a three-year period in one large academic practice. We modeled the potential revenue impacts of differences in procedure duration, proportion of female colonoscopy and the frequency of detected adenomas. RESULTS: We found that screening colonoscopy takes 8.8% more time to complete in female patients compared to male patients for all endoscopists (p < 0.001), and that female endoscopists perform an average of 71.2% female exams compared to male endoscopists, who perform an average of 50.8% female exams (p < 0.001). Female patients had a lower detection adenoma rate (ADR), reducing the frequency of polypectomy and reimbursement in an RVU model. The observed gender differences could account for an estimated 9.6% revenue loss per 8-h session for a female gastroenterologist performing screening colonoscopy compared to a male counterpart. CONCLUSION: Longer colonoscopy duration in females, increased proportion of female colonoscopies for female endoscopists and lower ADR in females may contribute to the gender gap in physician pay in gastroenterology.

Interval Colorectal Cancer in Inflammatory Bowel Disease: The Role of Guideline Adherence.

BACKGROUND: Factors associated with interval colorectal cancer (CRC) development in the inflammatory bowel disease (IBD) population remain unclear. AIMS: Among a cohort of patients with interval CRC, we aimed to evaluate IBD characteristics, colonoscopy quality indicators, and surveillance guideline adherence. METHODS: We performed a retrospective review of IBD- and non-IBD-associated interval CRCs diagnosed between January 2007 and December 2014 within a large US healthcare system. We evaluated risk factors for CRC among patients with IBD. We assessed adherence to surveillance guidelines according to the American Society for Gastrointestinal Endoscopy (IBD surveillance) and the US Multi-Society Task Force on Colorectal Cancer (polyp surveillance). We compared colonoscopy quality measures between patients with and without IBD. RESULTS: Among 5345 cases of colonic adenocarcinoma, we detected 15 IBD-associated cases of interval CRC and 230 non-IBD-associated cases of interval CRC. Compared to patients without IBD, IBD patients were younger (54.5 vs. 70.4 years; p < 0.0001) and experienced a shorter interval between index colonoscopy and CRC diagnosis (20.7 vs. 35.1 months; p = 0.0009). Fifty three percent (8/15) of interval CRCs in IBD patients were detected within surveillance guidelines. All IBD patients with interval CRC detected after guideline surveillance interval had high-risk features, including active inflammation, previous low-grade or indefinite dysplasia, multiple pseudopolyps on index colonoscopy, or a first-degree relative with CRC. There were no differences in colonoscopy quality measures between patients with and without IBD. CONCLUSIONS: This study stresses the importance of strict short-interval surveillance for IBD patients with high-risk features, including active inflammation on index colonoscopy.

A Digital Preprocedure Instruction Program for Outpatient Colonoscopy.

Introduction:Many patients struggle with colonoscopy preparation, which is complex and can be an uncomfortable as well as a time-consuming process. The confusion and anxiety from the preprocedure process may lead patients to delay their colonoscopy or skip it altogether. Digital health technology that focuses on patient engagement can play an important role in promoting colorectal cancer screening.Methods:A digital preprocedure instruction program was implemented for outpatient colonoscopy by sending critical reminders and instructions to patients through a series of short message service messages and/or emails. Eligible patients included English speakers on GoLYTELY®/NuLYTELY® or MiraLAX® preparation regimens with a valid cellphone or email address in the electronic health record. We examined the impact of digital instructions on bowel preparation quality, no-show and same-day cancellations over a 3-month period between an intervention group of 756 patients and a control group of 2,103 patients. Patients who enrolled in the digital instructions also received a patient satisfaction survey.Results:Our controlled study demonstrated the effectiveness of digital instructions to reduce no-show and same-day cancellation rates for outpatient colonoscopy from 10.40% to 6.08% (p < 0.001). Bowel preparation quality was not significantly different between the two groups (p = 0.23). However, 90% of patients who enrolled in the program rated their satisfaction with the digital reminders very highly.Discussion:A digital preprocedure instruction program can have a positive impact on operational efficiency, quality of care, and patient satisfaction. This study shows how digital health tools can effectively engage patients scheduled for a colonoscopy, increase appointment adherence, and, therefore, lead to better cancer screening.

Effect of video monitor size on polyp detection: a prospective, randomized, controlled trial.

BACKGROUND AND AIMS: The adenoma detection rate (ADR) is the most important quality metric for colonoscopy. Numerous factors are known to influence ADR. However, no data on the effect of monitor size on ADR exist. The aim of this study was to compare the ADR and polyp detection rate (PDR) achieved using 2 different-size video monitors (19-inch diagonal and 32-inch diagonal). METHODS: In a single-center, prospective, randomized clinical trial, endoscopists were randomized on a daily basis to perform routine ambulatory colonoscopies with either a 32-inch diagonal or a 19-inch diagonal video monitor. RESULTS: The study was conducted between October 2013 and April 2014 in an outpatient center of a tertiary referral hospital. Fifteen endoscopists performed 1795 outpatient colonoscopies (mean age, 55 years; 56% women; screening, 56%). There was no substantial difference in baseline patient characteristics between the 2 arms. The overall ADR (27.4% vs 27.9%; P = .80) and PDR (32.8% vs 34.4%; P = .50) were not significantly different between the 32-inch and 19-inch monitor group, respectively. The findings were not significantly altered when stratified by indication, cecal intubation, bowel preparation, operator experience, and time of endoscopy as well as in a multivariable model that included these variables as potential confounders (all P > .05). Overall, the ADR and PDR for each individual endoscopist did not appear to be influenced by monitor size. CONCLUSIONS: The results of this trial do not support the notion that larger video monitors improve ADR. Future efforts to increase ADR should focus on other aspects of colonoscopy. (Clinical trial registration number: NCT01952418.).

e-Consults in gastroenterology: An opportunity for innovative care.

BACKGROUND AND AIM: Deploy and evaluate a gastroenterology (GI) electronic consultation (e-consult) program. E-consults are a promising approach to enhance provider communication, facilitate timely specialty advice and may replace some outpatient visits. STUDY: As part of our health system's efforts to provide more cost-effective care under risk-based contracts, we implemented an e-consult program where referring providers submit patient-specific clinical questions electronically via an electronic referral system. A GI consultant then reviews the patient's record and provides a written recommendation back to the referring physician. For our program evaluation, we conducted chart reviews of each e-consult to understand how the program was being used and surveyed the participating providers and consultants. RESULTS: From September 2015 to March 2016, we received 144 e-consults, with most questions concerning GI symptoms or abnormal hepatology labs. Only 36% of e-consults recommended an in-person GI consult or procedure. In our survey of participating providers, referring providers strongly agreed that the GI e-consults promoted good patient care (88%) and were satisfied with the program (84%). The majority of GI consultants felt strongly that e-consults were useful for referring providers and their patients, but that current reimbursement and time allotted were not adequate. CONCLUSIONS: We report on the implementation of a GI e-consult program within an ACO, showing that many clinical questions could be answered using this mechanism. E-consults in gastroenterology have the potential to reduce unnecessary visits and/or procedures for patients who can be managed by their primary provider, potentially increasing access for other patients.

Improving the Quality of Inpatient Bowel Preparation for Colonoscopies.

BACKGROUND: Hospitalized patients completing bowel preparation for colonoscopy typically have preparations of poorer quality when compared to outpatient populations. AIMS: Our study aimed to evaluate the effectiveness of a performance improvement program in improving colonoscopy preparation for an inpatient population. METHODS: We identified a cohort of adult patients (n = 641) undergoing an inpatient colonoscopy during a 12-month period at an academic medical center and compared a multifactor intervention group to a historical baseline group. During this 12-month period, a performance improvement program including use of a dedicated gastrointestinal nurse facilitator, implementation of standardized order sets, and introduction of split bowel preparations in the inpatient setting was made available to the cohort group. RESULTS: The primary outcome was quality of bowel preparation for colonoscopy as rated by endoscopists using the modified Aronchick scale. When comparing the baseline group to the intervention group, the rate of acceptable preparations, characterized as excellent, good, or adequate, increased from 69.9 to 78.9%, which was statistically significant (p < 0.001). CONCLUSIONS: A comprehensive performance improvement program improved the quality of colonoscopy preparation among inpatients. The use of a dedicated gastrointestinal nurse facilitator, implementation of standardized order sets, and introduction of split bowel preparations are recommended in the inpatient setting for an effective bowel preparation.

Hospital readmissions in decompensated cirrhotics: Factors pointing toward a prevention strategy.

AIM: To reduce readmissions and improve patient outcomes in cirrhotic patients through better understanding of readmission predictors. METHODS: We performed a single-center retrospective study of patients admitted with decompensated cirrhosis from January 1, 2011 to December 31, 2013 (n = 222). Primary outcomes were time to first readmission and 30-d readmission rate due to complications of cirrhosis. Clinical and demographic data were collected to help describe predictors of readmission, along with care coordination measures such as post-discharge status and outpatient follow-up. Univariate and multivariate analyses were performed to describe variables associated with readmission. RESULTS: One hundred thirty-two patients (59.4%) were readmitted at least once during the study period. Median time to first and second readmissions were 54 and 93 d, respectively. Thirty and 90-d readmission rates were 20.7 and 30.1 percent, respectively. Predictors of 30-d readmission included education level, hepatic encephalopathy at index, ALT more than upper normal limit and Medicare coverage. There were no statistically significant differences in readmission rates when stratified by discharge disposition, outpatient follow-up provider or time to first outpatient visit. CONCLUSION: Readmissions are challenging aspect of care for cirrhotic patients and risk continues beyond 30 d. More initiatives are needed to develop enhanced, longitudinal post-discharge systems.

Impact of physician compliance with colonoscopy surveillance guidelines on interval colorectal cancer.

BACKGROUND AND AIMS: Interval colorectal cancer (iCRC) incidence is the criterion standard benchmark for measuring the effectiveness of colonoscopy. Colonoscopy surveillance guidelines are designed to minimize iCRC cases. Our aims were to describe characteristics of iCRC patients and to assess whether development of iCRC is related to colonoscopy surveillance guideline intervals. METHODS: We performed a retrospective cohort study of postcolonoscopy iCRC cases in a large healthcare system. Guideline-based colonoscopy intervals were calculated based on the 2012 U.S. Multi-Society Task Force for Colorectal Cancer colonoscopy surveillance guidelines. Backward stepwise linear regression was used to determine predictors of iCRC before guideline-recommended follow-up intervals. RESULTS: We identified 245 iCRC cases (mean age, 69.4 years; 56.3% male) out of 5345 colon cancers evaluated for a prevalence of 4.60%. On index colonoscopy, 75.1% had an adequate preparation, 93.0% reached the cecum, and 52.5% had polyps. iCRC developed before the guideline-recommended interval in 59.1% of patients (94/159). Independent predictive factors of this finding were inadequate preparation (OR, .012; 95% CI, .003-.06; P < .0001) and ≥3 polyps on index colonoscopy (OR, .2; 95% CI, .078-.52; P = .0009). An endoscopist-recommended follow-up interval past the guideline-recommended interval was seen in 23.9% of cases (38/159). Most (34/38, 89.5%) of these iCRCs had inadequate preparation and were diagnosed after the guideline-based follow-up interval. CONCLUSIONS: Current colonoscopy surveillance guidelines may be inadequate to prevent many iCRC cases. Physician noncompliance with guideline-based surveillance intervals may increase in iCRC cases, especially in patients with an initially inadequate bowel preparation.

Adverse Event and Complication Management in Gastrointestinal Endoscopy.

Gastrointestinal endoscopy is a remarkably safe set of diagnostic and therapeutic techniques, and yet a small number of significant complications and adverse events are expected. Serious complications may have a material effect on the patient's health and well-being. They need to be anticipated and prevented if possible and managed effectively when identified. When complications occur they need to be discussed frankly with patients and their families. Informed consent, prevention, early detection, reporting, and systems improvement are critical aspects of effective complication management. Optimal complication management may improve patient satisfaction and outcome, as well as preserving the reputation and confidence of the endoscopist, and may minimize litigation.

Diagnostic and Therapeutic Yield of Endoscopy in Patients with Elevated INR and Gastrointestinal Bleeding.

BACKGROUND: Gastrointestinal bleeding is a well-known risk of systemic anticoagulation. However, bleeding in the setting of supratherapeutic anticoagulation may have a milder natural history than unprovoked bleeding. It is a common clinical gestalt that endoscopy is common, but bleeding source identification or intervention is uncommon, yet few data exist to inform this clinical impression. Consequently, we sought to examine our institutional experience with gastrointestinal bleeding in the setting of supratherapeutic international normalized ratio (INR) with the aim of identifying predictors of endoscopically identifiable lesions, interventions, and outcomes. METHODS: A retrospective review was conducted at a tertiary referral academic medical center to identify patients presenting with gastrointestinal bleeding in the setting of warfarin and a supratherapeutic INR (>3.5) who underwent an endoscopic procedure. Relevant clinical covariates, endoscopic findings, need for intervention, and outcomes were collected by review of the medical record. Logistic regression adjusting for potential confounders identified predictors of endoscopically significant lesions as well as intervention and outcomes. RESULTS: A total of 134 patients with INR 3.5 or greater (mean 5.5, range 3.5-17.1) presented with symptoms of gastrointestinal bleeding, most commonly as melena or symptomatic anemia. Antiplatelet agents were used by 54% of patients, and 60% of patients were on concomitant acid suppression on admission. Procedures included esophagogastroduodenoscopy (upper endoscopy; EGD) (n = 128), colonoscopy (n = 73), and video capsule endoscopy (n = 32). Active bleeding at first EGD or colonoscopy was found in only 19 patients (18%), with endoscopic intervention in only 26 patients (25%). At a critical threshold of INR 7.5 at presentation, the likelihood of finding an endoscopically significant lesion fell to <20%. On multivariate logistic regression, concomitant antiplatelet therapy (odds ratio [OR] 2.59; 95% confidence interval [CI], 1.13-5.94), timing of EGD within 12 hours of presentation (OR 3.71; 95% CI, 1.05-13.08), and INR level (OR 0.79; 95% CI, 0.64-0.98) were the only significant independent predictors of identifying a source of bleeding. A risk score incorporating these covariates performed modestly in identifying risk of significant finding on EGD (area under the curve 0.68). We found no association between identification of a significant lesion at EGD and future readmission for gastrointestinal bleeding. CONCLUSION: This study demonstrates that the relationship between INR elevation and identification of a bleeding source or endoscopic intervention at EGD are indeed antiparallel. Concomitant antiplatelet therapy increases the likelihood of bleeding source identification and intervention, as does EGD within 12 hours of presentation. However, regardless of source identification or endoscopic intervention, important clinical outcomes were unchanged, suggesting that decisions about endoscopy should be made on a case-by-case basis, particularly in patients with INR > 7.5. Future prospective studies on appropriate indications and timing of endoscopy in such patients are warranted.

Interval colorectal cancer after colonoscopy.

BACKGROUND: As more patients are screened for colorectal cancer a small but significant number of interval cancers develop after colonoscopy for colorectal cancer screening. MATERIALS AND METHODS: We reviewed records of 75,314 adult patients who underwent colonoscopy for screening or diagnostic purposes between 1998 and 2006 inclusively, and identified 77 who developed interval cancers within the next 5 years. We reviewed their original endoscopic findings to determine the clinical and endoscopic factors that might predict a greater risk for future cancers. RESULTS: Patients aged ≥ 60 years had a higher risk of an interval neoplasm (P < .0001). Interval cancers were more common on the right side of the colon and in the hepatic flexure (both P < .0001). We did not observe an increased rate of interval cancers in patients with poor preparation (P = .799); however, examination completion rates did affect the rate of interval cancers (P = .016). CONCLUSION: Better identification of higher risk patients and assurance of follow-up examinations might increase the percentage of colon cancers discovered at an early stage. Special attention to careful examination of the right colon is key.

The safety of nurse-administered procedural sedation compared to anesthesia care in a historical cohort of advanced endoscopy patients.

BACKGROUND: In April 2010, in response to a change in Centers for Medicare and Medicaid Services regulation placing deep sedation under hospital anesthesia services, our institution began providing anesthesia care for all advanced endoscopic procedures. Because it remains unknown whether anesthesia care reduces sedation-related complications or improves quality of care versus nurse-administered sedation for endoscopic retrograde cholangiopancreatography and endoscopic ultrasound patients, we retrospectively compared complications in a 5-year historical cohort before and after the policy change. METHODS: We reviewed a historical cohort of 9598 consecutive endoscopic retrograde cholangiopancreatography and endoscopic ultrasound examinations for adult patients at a single institution during a 5-year period (October 2007-October 2012). We compared procedures performed before and after the policy change for the incidence of sedation, endoscopic, and total complications, and for major morbidity and mortality. RESULTS: The incidence of reported sedation-related complications was 0.38% (17 of 4514) before the policy change and 0.08% (4 of 5084) after the policy change, which was statistically significant (P = 0.002, diff = 0.3, 95% confidence interval, 0.11%-0.53%). Endoscopic complications were not significantly different before versus after: 0.66% vs 0.87% (P = 0.293, diff = 0.2, 95% confidence interval, -0.16% to 0.56%). Total complications (1.11% vs 1.00%, P = 0.618) and major morbidity and mortality (0.27% vs 0.33%, P = 0.581) did not differ between the 2 time periods. CONCLUSIONS: Anesthesia care for advanced endoscopy in a high-risk population significantly reduced sedation complications compared with nurse-administered sedation. Endoscopic complications were unchanged. The sedation risk reduction did not reduce major morbidity, mortality, or total complications.

Advanced disease, diuretic use, and marital status predict hospital admissions in an ambulatory cirrhosis cohort.

BACKGROUND AND AIMS: Hospital admissions in cirrhotic patients are a source of significant health care expenditure. Most studies to date have focused on readmissions in patients with decompensated cirrhosis. We sought to describe predictors of hospital admissions in an ambulatory cirrhosis cohort consisting of both compensated and decompensated patients to identify patients who could benefit from intensified outpatient chronic disease management. METHODS: We performed a retrospective cohort study of 395 cirrhotic patients followed at an academic medical center liver clinic. Inclusion criteria were documented cirrhosis and longitudinal care at our center during 2006-2008. Patients were followed until December 2011, death, or liver transplantation. The primary outcomes were non-elective cirrhosis-related hospital admissions within 1 year and time to admission. The secondary outcome was 2-year cirrhosis-related mortality. The study was approved by the Partners Human Research Committee (protocol 2012P001912). RESULTS: Seventy-eight patients (19.7 %) had at least one cirrhosis-related hospital admission within 1 year. The following were significant predictors in the multivariable model: model for end-stage liver disease score ≥15 [OR 2.22, 95 % CI (1.21-4.07), p = 0.01], diagnosis of hepatocellular carcinoma [3.64 (1.42-9.35), 0.007], diuretic use [2.27 (1.23-4.17), 0.008], at least one cirrhosis-related admission during the baseline year [2.17 (1.21-3.89), 0.01], and being unmarried [1.92 (1.10-3.35), 0.02]. CONCLUSIONS: Advanced disease, diuretic use, and marital status were associated with cirrhosis-related hospital admissions in patients followed at an academic medical center liver clinic. Our findings suggest that patients with inadequately or overzealously treated ascites, as well as those with limited social supports, could benefit from intensified outpatient management.

Automated before-procedure electronic health record screening to assess appropriateness for GI endoscopy and sedation.

BACKGROUND: Endoscopists are performing greater numbers of procedures, often on patients with complex conditions, in ambulatory settings because of changing patient demographics and referral patterns. To assist with the pre-procedure assessment of such patients, we deployed an advanced electronic health record tool, the Queriable Patient Inference Dossier (QPID), to review clinical histories and generate e-mail alerts to providers, based on clinical guidelines. OBJECTIVE: Study the feasibility of an automated pre-procedure alert system for outpatient endoscopy. DESIGN: We retrospectively reviewed 5 physicians' use of the application and their responses to the alerts. SETTING: A hospital-based endoscopy unit and its two satellite outpatient clinics, Boston area, Massachusetts. PATIENTS: Adult outpatients referred for endoscopy with moderate sedation. INTERVENTION: Pre-procedure alerts automatically sent 7 days before the procedure, highlighting any conditions/clinical history that may affect management of the patient. MAIN OUTCOME MEASUREMENTS: Physician use of the pre-procedure alert system and its effect on patient management. RESULTS: We studied 1682 procedures that met inclusion criteria for review by QPID and 364 alerts (1.6% of the eligible procedures). Nearly 80% of the alerts were reviewed and responded to by the physicians, and 70 total alerts resulted in a change in patient management (4.2% of eligible procedures). LIMITATIONS: The small size of the study group and the low rate of adverse events during the study period limit our findings. We thus plan to conduct a larger follow-up study to demonstrate changes in safety and efficiency. CONCLUSION: Use of advanced electronic health record technologies, such as QPID, may improve provider efficiency and patient outcomes in endoscopy units.

Using computerized provider order entry application to improve compliance with co-signature of verbal orders.

Verbal orders that are not cosigned in a timely manner represent potential quality, safety, and medical-legal concerns. Computerized Provider Order Entry Systems (CPOEs) provide unique opportunities to understand, describe, and improve compliance with guidelines that require the timely co-signature of verbal orders. We describe our baseline compliance and improvements that were achieved through a series of CPOE interventions and related provider feedback and education.