Racial and Ethnic Disparities in Opioid Prescriptions for Patients with Abdominal Pain: Analysis of the National Ambulatory Medical Care Survey.

BACKGROUND: Disparities in pain control have been extensively studied in the hospital setting, but less is known regarding the racial/ethnic disparities in opioid prescriptions for patients with abdominal pain in ambulatory clinics. METHODS: We examined opioid prescriptions during visits by patients presenting with abdominal pain between the years of 2006 and 2015, respectively, in the National Ambulatory Medical Care Survey database. Data weights for national-level estimates were applied. RESULTS: We identified 4006 outpatient visits, equivalent to 114 million weighted visits. Rates of opioid use was highest among non-Hispanic White patients (12%), and then non-Hispanic Black patients (11%), and was the lowest in Hispanic patients (6%). Hispanic patients had lower odds of receiving opioid prescriptions compared to non-Hispanic White patients (OR = 0.49; 95% CI, 0.31-0.77, p = 0.002) and all non-Hispanic patients (OR 0.48; 95% CI 0.30-0.75; p = 0.002). No significant differences were noted in non-opioid analgesia prescriptions (p = 0.507). A higher frequency of anti-depressants/anti-psychotic prescriptions and alcohol use was recorded amongst the non-Hispanic patients (p = 0.027 and p = 0.001, respectively). CONCLUSIONS: Rates of opioid prescriptions for abdominal pain patients were substantially lower for the Hispanic patients compared with the non-Hispanic patients, despite having a decreased rate of high-risk features, such as alcohol use and depression. The root cause of this disparity needs further research to ensure equitable access to pain management.

Advanced endoscopy fellowship training in the United States: recent trends in American Society for Gastrointestinal Endoscopy advanced endoscopy fellowship match, trainee experience, and postfellowship employment.

BACKGROUND AND AIMS: The American Society for Gastrointestinal Endoscopy (ASGE) advanced endoscopy fellowship (AEF) match offers a structured application process for AEF training in the United States. Our aim was to describe recent trends in AEF match, trainee experience, and postfellowship employment. METHODS: ASGE AEF match data from 2012 to 2020 were reviewed. Online surveys were sent to advanced endoscopy trainees in 2019 and 2020 to explore their perceptions about AEF training and postfellowship jobs. RESULTS: Data for 2020 showed 19% of matched applicants were women, 55% foreign medical graduates, and 17.5% U.S. visa holders. The number of AEF match applicants increased by 15.6% (90 in 2012 to 104 in 2020) and number of AEF programs increased by 23.5% (51 in 2012 to 63 in 2020). The average applicant match rate was 57% (range, 52.8%-60.6%) and position match rate 87.9% (range, 79.1%-94.6%). Ninety-one percent of trainees (n = 58) rated the quality of their training as very good/excellent; 75% of trainees participated in >300 ERCPs and 64.1% in >300 EUS cases. Seventy percent of trainees reported that advanced endoscopic procedures comprised ≤50% of their procedure volume in their first job, and 71.9% believed it was not easy to find a job after fellowship; however, 97% believed they would make the same decision to pursue AEF training again. CONCLUSIONS: There has been a steady increase in the number of advanced endoscopy applicants and training positions over recent years. Most graduating fellows reported 50% or less of their upcoming clinical practice would involve advanced endoscopic procedures. Future studies are needed to further clarify employment opportunities and personnel needs for advanced endoscopists.

A Longitudinal Study of Adenoma Detection Rate in Gastroenterology Fellowship Training.

BACKGROUND: Current guidelines suggest that a gastroenterology fellow in training needs to perform 140 colonoscopies to achieve competency. Data are limited regarding adenoma detection rate (ADR) in fellowship. AIMS: To assess how fellow ADR correlates with number of colonoscopies performed. METHODS: We performed a retrospective study examining consecutive colonoscopies performed by gastroenterology fellows. Fellow ADR before and after the 140 procedure benchmark was compared to colonoscopies performed by attending only with whom these fellows trained. A threshold for ideal procedure count was performed using ROC analysis. RESULTS: We analyzed 2021 average-risk colonoscopies performed by 10 gastroenterology fellows under the supervision of an attending physician. When fellows had performed <140 colonoscopies, the ADR was 27 % compared with an ADR of 36 % when fellows had performed >140 colonoscopies under attending supervision (p = 0.02). The ADR of fellows who had performed >140 colonoscopies under attending supervision was greater than that of attending-only colonoscopies (36 vs. 25 %, p < 0.0001). A threshold of >325 (male patients) and 539 (female patients) colonoscopies was determined to be ideal for achieving adequate ADR based on ROC analysis. CONCLUSIONS: Our data suggest that ADR increases after fellows perform >140 colonoscopies under attending supervision, and thereafter surpasses the ADR of attending-only colonoscopies. Some of the differences may be driven by detection of small adenomas. The findings of this study suggest that a higher threshold for number of colonoscopies performed under attending supervision may be needed to achieve adequate ADR during fellowship prior to independent practice.

Capnographic Monitoring of Moderate Sedation During Low-Risk Screening Colonoscopy Does Not Improve Safety or Patient Satisfaction: A Prospective Cohort Study.

OBJECTIVES: Appropriate monitoring during sedation has been recognized as vital to patient safety in procedures outside of the operating room. Capnography can identify hypoventilation prior to hypoxemia; however, it is not clear whether the addition of capnography improves safety or is cost effective during routine colonoscopy, a high volume, low-risk procedure. Our aim was to evaluate the value of EtCO2 monitoring during colonoscopy with moderate sedation. METHODS: We conducted a prospective study of sedation safety and patient satisfaction before and after the introduction of EtCO2 monitoring during outpatient colonoscopy with midazolam and fentanyl using the validated PROcedural Sedation Assessment Survey (PROSAS). Complications of sedation and PROSAS scores were compared among colonoscopies with and without capnography. RESULTS: A total of 966 patients participated in our study, 465 in the pre-EtCO2 group and 501 in the EtCO2 group. On multivariate analysis, patients and nurses reported higher levels of procedural discomfort after adoption of capnography (1.71 vs. 1.00, P<0.001). No serious adverse events were seen, and minor sedation-related adverse events occurred with similar frequency in both groups (8.2% pre-EtCO2 vs. 11.2% EtCO2, P=0.115). The cost of implementing EtCO2 in our unit was $40,169.95 and added $11.68 per case. CONCLUSIONS: Colonoscopy with moderate sedation is a low-risk procedure, and the addition of EtCO2 did not improve safety or patient satisfaction but did increase cost. These data suggest that routine capnography in this setting may not be cost effective and that EtCO2 might be reserved for patients at higher risk of adverse events.

Fellowship Colonoscopy Training and Preparedness for Independent Gastroenterology Practice.

GOALS: To objectively assess when gastroenterology (GI) fellows achieve technical competency to perform colonoscopy independently. BACKGROUND: New guidelines to assess the procedural competency of GI fellows in training have been developed. Although comprehensive, they do not account for the quality metrics to which independently practicing gastroenterologists are held. STUDY: We performed a prospective study examining consecutive colonoscopies performed by GI fellows from November 2013 through March 2014 at an academic medical center. Using a brief postprocedure questionnaire and the online medical record, we measured rates of independent fellow cecal intubation rate (CIR), insertion time to the cecum (cecal IT), and independent polypectomy rate. Our secondary outcomes were adenoma detection rate and polyp detection rate. RESULTS: A total of 898 colonoscopies performed by 10 GI fellows were analyzed. In the multivariate analysis, CIR [odds ratio (OR)=1.29, P=0.012], cecal IT (ß-coefficient=0.19, P=0.006), and rates of unassisted independent snare polypectomy (OR=1.36, P<0.001) all improved significantly with increased number of procedures performed (OR and ß-coefficient per 100 colonoscopies performed). After performing 500 colonoscopies, fellows achieved a mean CIR>90%, cecal IT between 7 and 10 minutes, and independent polypectomy rate of 90% with further improvement in cecal IT to <7 minutes, and independent snare polypectomy of >95% after 700 cases. CONCLUSIONS: Current procedural recommendations for fellowship training may underestimate the technical skill necessary for independent GI practice upon completion of fellowship. Technical proficiency in snare polypectomy may lag behind proficiency in cecal intubation.