Survey Finds Gender Disparities Impact Both Women Mentors and Mentees in Gastroenterology.

INTRODUCTION: Gastroenterologists at all levels of practice benefit from formal mentoring. Much of the current literature on mentoring in gastroenterology is based on expert opinion rather than data. In this study, we aimed to identify gender-related barriers to successful mentoring relationships from the mentor and mentee perspectives. METHODS: A voluntary, web-based survey was distributed to physicians at 20 academic institutions across the United States. Overall, 796 gastroenterology fellows and faculty received the survey link, with 334 physicians responding to the survey (42% response rate), of whom 299 (90%; 129 women and 170 men) completed mentorship questions and were included in analysis. RESULTS: Responses of women and men were compared. Compared with men, more women preferred a mentor of the same gender (38.6% women vs 4.2% men, P < 0.0001) but less often had one (45.5% vs 70.2%, P < 0.0001). Women also reported having more difficulty finding a mentor (44.4% vs 16.0%, P < 0.0001) and more often cited inability to identify a mentor of the same gender as a contributing factor (12.8% vs 0.9%, P = 0.0004). More women mentors felt comfortable advising women mentees about work-life balance (88.3% vs 63.8%, P = 0.0005). Nonetheless, fewer women considered themselves effective mentors (33.3% vs 52.6%, P = 0.03). More women reported feeling pressured to mentor because of their gender (39.5% vs 0.9% of men, P < 0.0001). Despite no gender differences, one-third of respondents reported negative impact of the COVID-19 pandemic on their ability to mentor and be mentored. DISCUSSION: Inequities exist in the experiences of women mentees and mentors in gastroenterology, which may affect career advancement and job satisfaction.

Quality measures for colonoscopy: a critical evaluation.

In a recent article in The New York Times, "The $2.7 Trillion Medical Bill,"(1) colonoscopy was singled out for its cost. In their response, the leading gastroenterology professional societies highlighted colonoscopy's effectiveness and cost-effectiveness for the prevention of colorectal cancer (CRC). Affirming colonoscopy's central role in CRC prevention, both as a frontline test and as the final common pathway for other CRC screening modalities, requires strategies to measure and improve colonoscopy quality, particularly by controlling operator-dependent factors. Although colonoscopy is a powerful CRC screening test,(2-6) several recent studies have highlighted decreased protection, mainly against right-sided CRC,(5,7-16) an observation that has been linked to performance quality.

Association between body mass index and quality of split bowel preparation.

BACKGROUND & AIMS: Little is known about the association between obesity and bowel preparation. We investigated whether body mass index (BMI) is an independent risk factor for inadequate bowel preparation in patients who receive split preparation regimens. METHODS: We performed a retrospective study of data from 2163 consecutive patients (mean age, 60.6 ± 10.5 y; 93.8% male) who received outpatient colonoscopies in 2009 at the Veterans Affairs Medical Center in Indianapolis, Indiana. All patients received a split preparation, categorized as adequate (excellent or good, based on the Aronchick scale) or inadequate. We performed a multivariable analysis to identify factors independently associated with inadequate preparation. RESULTS: Bowel preparation quality was inadequate for 44.2% of patients; these patients had significantly higher mean BMIs than patients with adequate preparation (31.2 ± 6.5 vs 29.8 ± 5.9, respectively; P < .0001) and Charlson comorbidity scores (1.5 ± 1.6 vs 1.1 ± 1.4; P < .0001). Independent risk factors for inadequate preparation were a BMI of 30 kg/m(2) or greater (odds ratio [OR], 1.46; 95% confidence interval [CI], 1.21-1.75; P < .0001), use of tobacco (OR, 1.28; 95% CI, 1.07-1.54; P = .0084) or narcotics (OR, 1.28; 95% CI, 1.04-1.57; P = .0179), hypertension (OR, 1.30; 95% CI, 1.07-1.57; P = .0085), diabetes (OR, 1.38; 95% CI, 1.12-1.69; P = .0021), and dementia (OR, 3.02; 95% CI, 1.22-7.49; P = .0169). CONCLUSIONS: BMI is an independent factor associated with inadequate split bowel preparation for colonoscopy. Additional factors associated with quality of bowel preparation include diabetes, hypertension, dementia, and use of tobacco and narcotics. Patients with BMIs of 30 kg/m(2) or greater should be considered for more intensive preparation regimens.

Improvement of Osteoporosis Screening among Inflammatory Bowel Disease Patients at Gastroenterology Fellows' Clinics.

INTRODUCTION: Individuals with inflammatory bowel disease (IBD) have an increased risk of osteoporosis compared to the general population. We aimed to improve the osteoporosis screening rate in the IBD patient population of the gastroenterology (GI) fellows' continuity clinics. METHODS: Baseline preintervention data were collected on patients seen from July through September of 2018. Four simplified criteria for osteoporosis screening were extrapolated from 3 national guidelines. Among patients who met any of these criteria, we determined the baseline screening rate. Fellows were then educated with a didactic session and handout material, and a standardized template was incorporated into clinic notes. Following this intervention, screening rates were reassessed from December 2018 through February 2019. RESULTS: During the preintervention phase, fellows saw 80 patients with IBD. Dual-energy X-ray absorptiometry (DEXA) scan was obtained in 44% of IBD patients who qualify for screening at the county hospital clinic compared to 21% of veterans' clinic IBD patients. In the postintervention period, screening rates remarkably improved to 100% in the county hospital clinic and to 75% in the veterans' clinic. Overall, the screening rate increased by 56% (P < 0.001). CONCLUSIONS: A large percentage of IBD patients at risk for osteoporosis did not have appropriate bone mass density testing. Educating GI fellows and adding a template to clinic notes were effective in significantly improving the number of patients at risk of osteoporosis to receive appropriate screening test, a DEXA scan. Similar educational interventions should be considered for providers caring for IBD patients to prevent complications of osteoporosis in these patients.

Educational Intervention Improves Proton Pump Inhibitor Stewardship in Outpatient Gastroenterology Clinics.

BACKGROUND: Improper chronic proton pump inhibitor (PPI) use has risen significantly in the last few decades. In our gastroenterology trainees' clinics, we aimed to optimize PPI usage. METHODS: We collected baseline data on patients' PPI use for 8 weeks. Based on gastroenterology society guidelines, we determined conditions for appropriate PPI use. If the indication could not be determined, it was categorized as "unknown". Generated from the three most frequent causes for inappropriate PPI use, interventions were developed to correct each issue. Following a brief educational session, trainees implemented these interventions over a subsequent 8-week interval. RESULTS: During our pre-intervention period, trainees evaluated 263 patients who were prescribed a PPI. In 49% of the cases, the use of PPI was deemed inappropriate. The most common reasons were: gastroesophageal reflux disease (GERD) which was never titrated to the lowest effective dose, twice daily dosing for Barrett's esophagus (BE) chemoprevention and unknown indication. During our intervention period, trainees evaluated 145 patients prescribed a PPI for GERD with well-controlled symptoms in 101 cases. PPI had not been titrated to lowest effective dose in 37 cases prompting intervention which was successful in 23 cases. PPI indication was unknown in 17 cases prompting a message to the prescribing provider to review appropriateness. Two cases of BE chemoprevention with twice daily dosing were appropriately reduced to daily dosing. Ultimately, after intervention, PPI use was deemed appropriate after intervention in 172 (77%) cases. CONCLUSIONS: Improper chronic PPI use was significant. Focusing intervention efforts on PPI use for GERD, BE and unknown indications substantially increased appropriateness of PPI use.

Improving Colorectal Cancer Screening Rates in Patients Referred to a Gastroenterology Clinic.

Colorectal cancer (CRC) is the third most common cancer and the second leading cause of cancer-related death in the United States. Colonoscopy and fecal immunochemistry testing (FIT) are the primary recommended CRC screening modalities. The purpose of this study is to improve rates of CRC screening in Veterans and County hospital patients referred to gastroenterology fellow's clinics. A total of 717 patients between ages of 49 and 75 years were seen. Previous CRC screening was not performed in 109 patients (15.2%) because of not being offered (73.4%) or declining (26.6%) screening. Patients who received previous CRC screening compared with no previous screening were older (mean age 62.3 years vs. 60.3 years, p < .003), white (88.6% vs. 78.3%, p < .027), and more likely to be Veterans patients (90.8% vs. 77.5%, p < .001). After systematically discussing options for screening with 78 of the 109 unscreened patients, 56 of them (71.8%) underwent screening with either colonoscopy (32) or FIT (24). Patients seen by fellows in their last year of training agreed to undergo screening more often than those seen by other fellows (100% vs. 66.2%, p < .033). Systematic discussions about both colonoscopy and FIT can improve the overall rates of CRC screening.

Should We Measure Adenoma Detection Rate for Gastroenterology Fellows in Training?

BACKGROUND: Adenoma detection rate (ADR) is a proven quality metric for colonoscopy. The value of ADR for the evaluation of gastroenterology fellows is not well established. The aim of this study is to calculate and evaluate the utility of ADR as a measure of competency for gastroenterology fellows. METHODS: Colonoscopies for the purposes of screening and surveillance, on which gastroenterology fellows participated at the Richard L. Roudebush VAMC (one of the primary training sites at Indiana University), during a 9-month period, were included. ADR, cecal intubation rate, and indirect withdrawal time were measured. These metrics were compared between the levels of training. RESULTS: A total of 591 screening and surveillance colonoscopies were performed by 14 fellows. This included six, four and four fellows, in the first, second and third year of clinical training, respectively. Fellows were on rotation at the VAMC for a mean of 1.9 months (range 1 to 3 months) during the study period. The average ADR was 68.8% (95% CI 65.37 - 72.24). The average withdrawal time was 27.59 min (95% CI 23.45 - 31.73). The average cecal intubation rate was 99% (95% CI 98-100%). There was no significant difference between ADRs, cecal intubation rates, and withdrawal times at different levels of training; however, a trend toward swifter withdrawal times with advancing training was noted. CONCLUSIONS: ADR appears not to be a useful measure of competency for gastroenterology fellows. Consideration should be given to alternative metrics that could avoid bias and confounders.

Colonoscopy quality assessment.

Colonoscopy is the cornerstone of colorectal cancer screening programs. There is significant variability in the quality of colonoscopy between endoscopists. Colonoscopy quality assessment tracks various metrics to improve the effectiveness of colonoscopy, aiming at reducing the incidence and mortality from colorectal cancer. Adenoma detection rate is the prime metric, because it is associated with the risk of interval cancer. Implementing processes to measure and improve the adenoma detection rate is essential to improve the quality of colonoscopy.

Metformin-induced cholestatic hepatitis.

OBJECTIVE: To report a case of metformin-induced cholestatic hepatitis. METHODS: We present a detailed case report, including laboratory and biopsy findings. In addition, similar cases from the literature are reviewed. RESULTS: In a 68-year-old man with newly diagnosed diabetes mellitus, metformin therapy was begun. The dosage initially was 500 mg twice daily and later was increased to 850 mg twice a day. Four weeks after met-formin treatment was initiated, jaundice, pruritus, and liver enzyme abnormalities were noted. The patient underwent an extensive work-up, including a hepatitis screen, ultrasonography, magnetic resonance imaging, and endoscopic retrograde cholangiopancreatography, all of which showed normal findings. A liver biopsy revealed severe cholestasis and mild portal inflammation. Treatment with metformin was discontinued, and the liver enzymes normalized except for a persistently increased level of alkaline phosphatase, most likely related to a prolonged cholestatic effect of metformin. CONCLUSION: Although rare, metformin can be responsible for inducing liver damage, and patients and physicians should be aware of this side effect.