Tailored surgery in chronic pancreatitis after implementation of a multidisciplinary team assessment; a prospective observational study.

INTRODUCTION: Optimal management of chronic pancreatitis involves several specialties. Selection of patients for surgery may benefit from evaluation by a multidisciplinary team (MDT), similar to cancer care. The aim of this study was to evaluate outcomes in patients selected for surgery after MDT decision. METHODS: A prospective, observational study of consecutive patients operated for pain due to chronic pancreatitis after implementation of a MDT. The main outcome was Quality of life (QoL) assessed by EORTC-QLQ C30 and pain relief in patients followed >3 months. Complications were registered and predictive factors for pain relief analyzed. RESULTS: Of 269 patients evaluated by the MDT, 60 (22%) underwent surgery. Postoperative surgical complications occurred in five patients (8.3%) and reoperation within 30 days in two. There was no 90-days mortality. Complete or partial pain relief was achieved in 44 of 50 patients followed >3 months (88%). Preoperative duration of pain predicted lower probability of success. Postoperative improvement in QoL was most prominent for pain, appetite and nausea. CONCLUSIONS: After MDT evaluation, one in five patients was selected for surgery. Pain relief was obtained in a majority of patients with improved QoL. A tailored approach through a MDT seems warranted and efficient.

Priority and prejudice: does low socioeconomic status bias waiting time for endoscopy? A blinded, randomized survey.

INTRODUCTION: An unwanted socioeconomic health gap is observed in Western countries with easily accessible, government-financed health care systems. Survival rates from several malignancies differ between socioeconomic clusters and the disparities remain after adjusting for major co-morbidities and health related behavior. The possibility of biased conduct among health care workers has been proposed as a contributing factor, but evidence is sparse. METHODS: A blinded, randomized online questionnaire survey was conducted among specialists in gastroenterology in Norway. Each respondent was asked to give priority for colonoscopy to three different referrals. By randomized sequence, half the referrals contained a discreet piece of information indicating low socioeconomic status (SES). The SES information given was focused on known low-status clusters in Norway, namely the morbidly obese and receivers of disability pensions. RESULTS: There were 107 respondents giving a response rate of 67%. A lower priority was consistently given to the referrals containing information on low SES, but the difference only reached statistical significance (p = .018) for one of the referrals. CONCLUSION: Information on low SES may influence how referrals for endoscopy are prioritized.

Assessment of the effect of an Interactive Dynamic Referral Interface (IDRI) on the quality of referral letters from general practitioners to gastroenterologists: a randomised cross-over vignette trial.

OBJECTIVES: We evaluated whether interactive, electronic, dynamic, diagnose-specific checklists improve the quality of referral letters in gastroenterology and assessed the general practitioners' (GPs') acceptance of the checklists. DESIGN: Randomised cross-over vignette trial. SETTING: Primary care in Norway. PARTICIPANTS: 25 GPs. INTERVENTION: The GPs participated in the trial and were asked to refer eight clinical vignettes in an internet-based electronic health record simulator. A referral support, consisting of dynamic diagnose-specific checklists, was created for the generation of referral letters to gastroenterologists. The GPs were randomised to refer the eight vignettes with or without the checklists. After a minimum of 3 months, they repeated the referral process with the alternative method. MAIN OUTCOME MEASURES: Difference in quality of the referral letters between referrals with and without checklists, measured with an objective Thirty Point Score (TPS).Difference in variance in the quality of the referral letters and GPs' acceptance of the electronic dynamic user interface. RESULTS: The mean TPS was 15.2 (95% CI 13.2 to 16.3) and 22.0 (95% CI 20.6 to 22.8) comparing referrals without and with checklist assistance (p<0.001), respectively. The coefficient of variance was 23.3% for the checklist group and 39.6% for the non-checklist group. Two-thirds (16/24) of the GPs thought they had included more relevant information in the referrals with checklists, and considered implementing this type of checklists in their clinical practices, if available. CONCLUSIONS: Dynamic, diagnose-specific checklists improved the quality of referral letters significantly and reduced the variance of the TPS, indicating a more uniform quality when checklists were used. The GPs were generally positive to the checklists.

Clinicians' attitudes towards endoscopic ultrasound: a survey of four European countries.

OBJECTIVE: Despite the documented effectiveness of endoscopic ultrasound (EUS) in research studies, data on the utilization of this technology in clinical practice are scarce. The aim of this study was to assess EUS availability and accessibility as well as EUS utilization among clinicians from different European countries. MATERIAL AND METHODS: A direct mail survey was sent to members of the national gastroenterological associations in Sweden, Norway, Greece, and the United Kingdom. RESULTS: Out of 2361 clinicians with valid addresses, 593 (25.1%) responded. Overall, EUS was available to 43% of clinicians within their practice but availability varied from 23% in Greece to 56% in the United Kingdom. More than 50% of respondents evaluating patients with esophageal cancer, rectal cancer, or pancreaticobiliary disorders had utilized EUS during the previous year, but utilization varied considerably among different countries, being more frequent in the United Kingdom. In logistic regression analyses, factors independently related to EUS utilization were mainly EUS availability and accessibility as well as perceived utility of EUS (p <0.05 for all). Respondents considered the lack of trained endosonographers (79%) and high cost (52%) as the main barriers to wider EUS use. CONCLUSIONS: The majority of responding clinicians use EUS but overall utilization varies considerably among different countries. There is considerable variation in EUS service availability and accessibility among countries which, together with perceived usefulness of EUS, is a major determinant of EUS utilization. A shortage of trained endosonographers and the high cost are major barriers to wider EUS use. The findings of this study might help to define policies aimed at development of EUS services.

Inter-observer agreement in the assessment of endoscopic findings in ulcerative colitis.

BACKGROUND: Endoscopic findings are essential in evaluating the disease activity in ulcerative colitis. The aim of this study was to evaluate how endoscopists assess individual endoscopic features of mucosal inflammation in ulcerative colitis, the inter-observer agreement, and the importance of the observers' experience. METHODS: Five video clips of ulcerative colitis were shown to a group of experienced and a group of inexperienced endoscopists. Both groups were asked to assess eight endoscopic features and the overall mucosal inflammation on a visual analogue scale. The following statistical analyses were used; Contingency tables analysis, kappa analysis, analysis of variance, Pearson linear correlation analysis, general linear models, and agreement analysis. All tests were carried out two-tailed, with a significance level of 5%. RESULTS: The inter-observer agreement ranged from very good to moderate in the experienced group and from very good to fair in the inexperienced group. There was a significantly better inter-observer agreement in the experienced group in the rating of 6 out of 9 features (p < 0.05). The experienced and inexperienced endoscopists scored the "ulcerations" significantly different. (p = 0.05). The inter-observer variation of the mean score of "erosions", "ulcerations" and endoscopic activity index in mild disease, and the scoring of "erythema" and "oedema" in moderate-severe disease was significantly higher in the inexperienced group.A correlation was seen between all the observed endoscopic features in both groups of endoscopists. Among experienced endoscopists, a set of four endoscopic variables ("Vascular pattern", "Erosions", "Ulcerations" and Friability") explained 92% of the variation in EAI. By including "Granularity" in these set 91% of the variation in EAI was explained in the group of inexperienced endoscopists. CONCLUSION: The inter-observer agreement in the rating of endoscopic features characterising ulcerative colitis is satisfactory in both groups of endoscopists but significantly higher in the experienced group. The difference in the mean score between the two groups is only significant for "ulcerations". The endoscopic variables "Vascular pattern", "Erosions", "Ulcerations" and Friability" explained the overall endoscopic activity index. Even though the present result is quite satisfactory, there is a potential of improvement. Improved grading systems might contribute to improve the consistency of endoscopic descriptions.