Thrombosis in a bleeding disorder: case of thromboembolism in factor VII deficiency.

Congenital factor VII deficiency (FVIID) is a rare disorder with a wide range of bleeding manifestations. The disorder does not protect patients against occurrence of thrombosis, and deep vein thrombosis can occur in the setting of surgery and recombinant factor VIIa replacement.

Open access colonoscopy: Critical appraisal of indications, quality metrics and outcomes.

INTRODUCTION: In an era of cost containment and measurement of value, screening for colon cancer represents a clear target for better accountability. Bundling payment is a real possibility and will likely have to rely on open-access colonoscopy (OAC). OAC is a method to allow patients to undergo endoscopy without prior evaluation by a gastroenterologist. We conducted a cross-sectional study to evaluate the indications and outcomes among patients scheduled for OAC or traditional colonoscopy at a tertiary medical center. We hypothesized that outcomes in OAC patients would be similar to those from traditional referral modes. METHOD: Using a standardized data abstraction form, we documented indications for colonoscopy, clinical outcomes (complications, emergency room visits, phone calls), and compliance with quality indicators (QI) in a random sample of 1000 patients who underwent an outpatient colonoscopy at an academic medical center in 2013. We compared baseline characteristics and outcomes between two cohorts: OAC vs. patients who were scheduled after previous evaluation by a gastroenterologist or physician assistant or non-open access colonoscopy (NOAC). RESULTS: Patients in the OAC group were more likely to be male, non-Hispanic, to be privately insured, and to have screening (vs. diagnostic) indication. However they were significantly less likely than those in the NOAC group to have a procedure performed once scheduled, (45.5% vs. 66.9%, p<0.001), due to no-show (24/178 or 13.5% vs. 60/822 or 7.3%), cancellation (56/178 or 31.5 vs. 156/822 or 19.0%), and non-compliance (9/178 or 5.1% vs. 20/822 or 2.4%). There were no clinically meaningful differences between groups with respect to outcomes such as polyp detection (35.6% OE vs. 39.5% NOE, p=0.54), postoperative call to GI practice (5.5% vs. 2.5%, p=0.41), or QI metrics such as documentation of prep quality (99.8% vs. 98.8%, p=0.24). CONCLUSION: Patients undergoing OAC are more likely to have a screening colonoscopy but with overall similar clinical outcomes and compliance with QI to patients scheduled as NOAC. OAC remains handicapped by high cancellation and no-show rates.