Does Provider Specialty Matter?

OBJECTIVES: Multiple practice guidelines discourage indiscriminate use of broad panels of allergen-specific IgE (sIgE) tests due to increased risk of false positives and misinterpretation of results. We provide an analytical framework to identify specialty-specific differences in ordering patterns and effectiveness, which can be used to improve test utilization. METHODS: Test results from a tertiary pediatric hospital were analyzed by ordering specialty to evaluate size of allergen workups. Positivity rates were analyzed to determine effectiveness in selecting tests with high positive pretest probabilities. Laboratory test menu components were also evaluated. RESULTS: Our findings demonstrate 29% of sIgE tests are ordered as part of broad workups (>20 sIgE tests/date of service) contrary to the recommended testing approach. Detailed descriptions of ordering patterns and positivity rates are provided. CONCLUSIONS: This study provides a framework for using a cross-sectional analytical approach to assess test utilization patterns and evaluate components of laboratory testing menus.

Allied Health Professional Support in Pediatric Inflammatory Bowel Disease: A Survey from the Canadian Children Inflammatory Bowel Disease Network-A Joint Partnership of CIHR and the CH.I.L.D. Foundation.

OBJECTIVES: The current number of healthcare providers (HCP) caring for children with inflammatory bowel disease (IBD) across Canadian tertiary-care centres is underinvestigated. The aim of this survey was to assess the number of healthcare providers (HCP) in ambulatory pediatric IBD care across Canadian tertiary-care centres. METHODS: Using a self-administered questionnaire, we examined available resources in academic pediatric centres within the Canadian Children IBD Network. The survey evaluated the number of HCP providing ambulatory care for children with IBD. RESULTS: All 12 tertiary pediatric gastroenterology centres participating in the network responded. Median full-time equivalent (FTE) of allied health professionals providing IBD care at each site was 1.0 (interquartile range (IQR) 0.6-1.0) nurse, 0.5 (IQR 0.2-0.8) dietitian, 0.3 (IQR 0.2-0.8) social worker, and 0.1 (IQR 0.02-0.3) clinical psychologists. The ratio of IBD patients to IBD physicians was 114 : 1 (range 31 : 1-537 : 1), patients to nurses/physician assistants 324 : 1 (range 150 : 1-900 : 1), dieticians 670 : 1 (range 250 : 1-4500 : 1), social workers 1558 : 1 (range 250 : 1-16000 : 1), and clinical psychologists 2910 : 1 (range 626 : 1-3200 : 1). CONCLUSIONS: There was a wide variation in HCP support among Canadian centres. Future work will examine variation in care including patients' outcomes and satisfaction across Canadian centres.

How Do US Gastroenterologists Use Over-the-Counter and Prescription Medications in Patients With Gastroesophageal Reflux and Chronic Constipation?

BACKGROUND: The aim of this study was to assess how US gastroenterologists perceive and utilize over-the-counter (OTC) and prescription medications for gastroesophageal reflux disease (GERD) and chronic constipation (CC). METHODS: A total of 3,600 randomly selected American Gastroenterological Association (AGA) members were mailed a 27-question survey that assessed their perceptions and use of OTC and prescription medications. The χ(2) test and Student's t-test were utilized for bivariate analysis. RESULTS: A total of 830 gastroenterologists (23.1%) completed the survey. For the typical acid reflux patient, 50% of gastroenterologists recommended OTC proton pump inhibitors (PPIs), 13% recommended an OTC histamine2 receptor antagonist, whereas 33% recommended a prescription PPI. However, in the typical CC patient, 97% of gastroenterologists initially utilized OTC treatments. The vast majority of gastroenterologists felt that OTC brand name and store brand PPIs (76%) and polyethylene glycol (PEG 3350; 90%) were equally effective. Despite this, a minority "always" or "very often" directed their patients to purchase a store brand PPI (35%) or laxative (40%). In addition, gastroenterologists tended to underestimate the cost savings associated with store brand medicines and had limited knowledge regarding the regulation of store brands. CONCLUSIONS: Among US gastroenterologists, OTC medications now dominate primary therapy of GERD and CC. Despite feeling that name brand and store brand PPIs and laxatives are equally effective, the majority of gastroenterologists recommend brand name medicines and underestimate the cost savings associated with store brands. In this age of accountable care, greater efforts to help physicians and patients to better utilize their health-care dollars is warranted.

Frequency and efficacy of additional investigations following incomplete colonoscopies: A population-based analysis.

BACKGROUND: Limited data are available on the follow-up of patients with incomplete colonoscopy following positive faecal occult blood testing. Our study aimed to determine the proportion of and reasons for incomplete colonoscopies, the proportion of patients who completed colonic evaluations, the methods used and the subsequent findings. METHODS: A total of 9483 colonoscopies performed after positive testing in a colorectal cancer screening programme setting were included. The study was prospective for index colonoscopy findings and partly retrospective for follow-up. RESULTS: Overall 297 colonoscopies were incomplete (3.2%). A secondary colonic evaluation was deemed necessary in 245 patients, of which 126 underwent an additional examination (51.4%). Radiology was the primary method used for complete colonic evaluation, whereas a repeat colonoscopy was performed in only 6.4%; the examination was normal in 119 patients (94.4%). A mucosal high-grade neoplasia was removed in 1, and multiple (≥3) adenomas were removed in 2 patients. CONCLUSIONS: The present screening programme with biennial faecal occult blood testing revealed a high colonoscopy completion rate, a low rate of secondary colonic evaluation, infrequent use of colonoscopy for completion, and a low detection rate of significant neoplasia.

Characteristics and management of patients with chronic hepatitis B in an integrated care setting.

BACKGROUND: Few population-based studies have described characteristics and management of patients with chronic hepatitis B (CHB) in the USA. METHODS: We retrospectively studied adults with CHB in the Northern California Kaiser Permanente Medical Care Program (KPNC) from July 2009 to December 2010 (n = 12,016). Laboratory tests, treatment patterns, and hepatocellular carcinoma (HCC) surveillance were ascertained during a "recent" 18-month study window (July 2009-December 2010), or as "ever" based on records dating to 1995. RESULTS: The mean age was 49 years; 51 % were men, 83 % Asian, and 87 % KPNC members >5 years. Overall, 51 % had ≥ 1 liver-related visit, 14 % with gastroenterology or infectious disease specialists, and 37 % with primary care providers (PCP) only. Less than 40 % of patients had both hepatitis B virus (HBV) DNA and ALT testing conducted recently, while 56 % of eligible patients had received HCC surveillance. Recent laboratory testing and HCC surveillance were more frequent in patients seen by a specialist versus PCP only (90 vs. 47 % and 92 vs. 73 %, respectively, p values <0.001). During the study period, 1,649 (14 %) received HBV treatment, while 5 % of untreated patients had evidence of treatment eligibility. Among 599 patients newly initiated on HBV therapy, 76 % had guideline-based indications for treatment. CONCLUSIONS: Most patients initiated on HBV treatment met eligibility, and very few patients with evidence of needing treatment were left untreated. However, monitoring of ALT and HBV DNA levels, as well as HCC surveillance, were not frequent, underestimating the proportion of patients that warranted HBV therapy. Viral monitoring and cancer surveillance are therefore important targets for improving the scope of CHB care in the community setting.

Inflammatory bowel disease in the 21(st) century in China: turning challenges into opportunities.

Inflammatory bowel disease (IBD) has been an international hot spot for research for a long period of time. In China, the prevalence of IBD is rapidly increasing in recent years, mimicking the same fast growing footsteps of the developed world. Chinese literature of the 20(th) century shows that the total number of IBD cases increased by approximately 2.5-fold over the previous decade, in particular a 15.7-fold in patients with Crohn's disease (CD). Articles on basic research have increased 4.3-fold, with a particular 9.9-fold increase on immunological mechanisms. The predominantly Traditional Chinese Medicine (TCM) related clinical trials implied tendency to use a combination of Western Medicine and TCM in the management of Chinese IBD patients. IBD research and collaborations overseas have been markedly promoted since the Chinese Organization for the Study of Inflammatory Bowel Disease (COIBD) was founded at the beginning of the 21(st) century. From the second decade of the century onwards, we need to focus on the research hot spots to catch up with the rapid advances worldwide. Big challenges and present achievements provide us with great opportunities for further developments of the study on IBD. The development of some novel target pathogenic factors of the disease will provide us with more effective roll for modern management and optimistic treatment of IBD during this century.

Sexual abuse history in GI illness, how do gastroenterologists deal with it?

INTRODUCTION: Data support an increased prevalence of sexual abuse (SA) among patients with gastrointestinal (GI) complaints. Sexual abuse causes multiple symptoms related to pelvic floor and stress mediated brain-gut dysfunctions. Treating these patients asks for a holistic approach, using centrally targeted interventions. However, gastroenterologists have never been surveyed regarding their practice patterns and constraints about inquiring into SA. AIM: To evaluate whether gastroenterologists address SA in their daily practice and to evaluate their knowledge regarding the implications of SA in GI illness. METHODS: A 42-item anonymous questionnaire was mailed to all 402 members of the Dutch Society of Gastroenterology (gastroenterologists and fellows in training). The questionnaire addressed SA and pelvic-floor-related complaints. MAIN OUTCOME MEASURES: The results of this survey. RESULTS: One hundred eighty-three of the 402 (45.2%) questionnaires were returned. Overall, 4.7% of the respondents asked their female patients regularly about SA; in males, this percentage was 0.6%. Before performing a colonoscopy, these percentages were even smaller (2.4% and 0.6%, respectively). When patients presented with specific complaints, such as chronic abdominal pain or fecal incontinence, 68% of the gastroenterologists asked females about SA and 29% of the males (P < 0.01). The majority of respondents stated it as rather important to receive more training on how to inquire about SA and its implications for treatment. CONCLUSION: Gastroenterologists do not routinely inquire about a history of SA and they rarely ask about it before performing colonoscopy. There is a need for training to acquire the skills and knowledge to deal with SA.

The prevalence of medical nomadism of the followed patients in rheumatology.

The nomads are defined as patients related to multiple practicians of the same speciality or different specialities for the same symptomatology during a certain period. The objectives of this investigation were to evaluate the prevalence of medical nomadism of the followed patients in rheumatology and compare their profile with those patients followed in neurology and gastroenterology. A multicentric transverse study (September 2009-March 2010) was conducted in three departments of CHU Ibn Sina Rabat-Salé, Morocco; rheumatology, gastroenterology and neurology. Only patients seen in external consultations were included. Patients' socio-economic and demographic background (familial status, instruction level, monthly revenue, social assistance) were recorded, as well as the clinical parameters related to the pathology (pathology, duration of the illness, diagnosis final time). A questionnaire containing variables on the patients' state concerning diagnosis, satisfaction degree of the patients and other variables evaluated the notion of taking medication and the practice of alternative medicine. Medical nomadism has been defined by the consultation for the same symptomatology of three different practicians, either of the same speciality or of different specialities during the study period of 6 months. There were 250 patients included in this study (150 patients in rheumatology, 50 in gastroenterology and 50 in neurology), the mean age was 46 ± 13 years and females dominated (65.6%). The average duration of the evolution was 7 ± 5 years, 35% of the patients were illiterate, 30% had a primary school education, 22% had a secondary school education and 13% had a university-level education. Sixty-two percent of the patients were jobless, 27% were workers, 9% were the functionary and 2% were the based liberal. Fifty-six percent had no social assistance. Rheumatoid arthritis and degenerative pathology were the most frequent diagnoses in rheumatology, being 20% and 40%, respectively. In gastroenterology, the most frequent pathologies were functional colopathy (25%) and proctology (20%), and migraine (42%) in neurology. The global prevalence of nomadism was 51%; 36% in rheumatology, 58% in neurology and 86% in gastroenterology. The associated factors of nomadism phenomena in rheumatology were: the satisfaction degree of the patient (P = 0.001), the wrong beliefs (P = 0.007), the practice of alternative medicine (P = 0.009), the pathology (P = 0.01) and the psychic profile (P = 0.001). Our study suggests that medical nomadism is frequent. It seems to be more frequent in the gastroenterology area, was linked with the degree of the patients' satisfaction, the alternative medicine practice and the type of the pathologies. Other studies of a high level would be necessary.

Diagnosis and treatment of functional gastrointestinal disorders in the Asia-Pacific region: a survey of current practices.

BACKGROUND AND AIMS: Functional gastrointestinal disorders (FGIDs), namely functional dyspepsia (FD) and irritable bowel syndrome (IBS) are common disorders important to public health in the Asia-Pacific region. Our objectives were to determine the current practices in diagnosis and management of these disorders in the Asia-Pacific region. METHODS: Forty-three physicians and researchers in FGID who attended the first Asian Pacific Topic Conference at Tokyo in November 2010 were invited to answer a questionnaire. Twenty-three Japanese doctors and twenty doctors from other Asia-Pacific Societies answered the questionnaire, which consisted of 60 multiple-choice questions concerning physician's preferences in diagnosis and management of FGIDs. RESULTS: Overall, there were similarities in diagnostic approach, such as differential diagnosis, exclusion of organic diseases, psychophysiological assessment, medical advice or medication with psychological drugs, not only among different Asia-Pacific region but also between FD and IBS. Several notable differences were seen. For example, general practitioners did not commonly use the term FD or diagnose FD by themselves, while the term IBS was widely used and frequently diagnosed. Sub-categorization was more common in IBS than FD. There was also a difference between Japan and other Asia-Pacific region; upper GI endoscopy and blood examination were more common in Japan, while eradication of Helicobacter pylori was more frequently done in other countries. Anti-secretory drugs for FD and mild laxatives or anti-diarrheal drug for IBS were frequently used, and prokinetics were used for all patients with FD or IBS. Interestingly, drugs developed in Japan and Chinese herbal medicines were more frequently prescribed in Japan. CONCLUSION: Information obtained in this survey is useful for understanding the most common clinical approaches for FGIDs in the Asia-Pacific region.

Physician attitudes and practices of enteral nutrition as primary treatment of paediatric Crohn disease in North America.

BACKGROUND: The use of exclusive enteral nutrition (EEN) in children with Crohn disease has not been universally adopted by North American paediatric gastroenterologists. This is in stark contrast to their European counterparts. The present study aimed to define attitudes and practice patterns of EEN use by members of the North American Society for Paediatric Gastroenterology, Hepatology, and Nutrition. METHODS: Members were contacted by e-mail and provided with access to a Web-based survey. RESULTS: Surveys were completed by 326 of 1162 (30.7%) eligible North American Society for Paediatric Gastroenterology, Hepatology, and Nutrition members from North America (86% United States, 14% Canada). Thirty-one percent of respondents reported never using EEN, 55% reported sparse use, and 12% reported regular use. Physicians in Canada reported significantly more use than those in United States (P < 0.001). Currently working and previously working in a centre where EEN was used were highly correlated with both the perceived appropriateness of EEN and the regularity of its use (P < 0.01). More American physicians than Canadian physicians reported that concurrent medical therapy was necessary to induce remission (P < 0.001). Canadian respondents were more likely to use maintenance therapy than American respondents (P = 0.02). Compliance issues were seen as the main disadvantages of EEN and as the major barrier to increased use by nonregular users. CONCLUSIONS: There are significant variations in the patterns of use and the acceptance of EEN between Canada and the United States, with Canadian physicians showing a greater use of EEN. The use of EEN appears influenced by the extent to which physicians are exposed to its use both in their training and in their current practice setting.

Teaching in small portions dispersed over time enhances long-term knowledge retention.

BACKGROUND: A primary goal of education is to promote long-term knowledge storage and retrieval. OBJECTIVE: A prospective interventional study design was used to investigate our research question: Does a dispersed curriculum promote better short- and long-term retention over a massed course? METHODS: Participants included 20 gastroenterology residents from the University of Calgary (N = 10) and University of Toronto (N = 10). Participants completed a baseline test of nutrition knowledge. The nutrition course was imparted to University of Calgary residents for 4 h occurring 1 h weekly over 4 consecutive weeks: dispersed delivery (DD). At the University of Toronto the course was taught in one 4h academic half-day: massed delivery (MD). Post-curriculum tests were administered at 1 week and 3 months to assess knowledge retention. RESULTS: The baseline scores were 46.39 +/- 6.14% and 53.75 +/- 10.69% in the DD and MD groups, respectively. The 1 week post-test scores for the DD and MD groups were 81.67 +/- 8.57%, p < 0.001 and 78.75 +/- 4.43, p < 0.001 which was significantly higher than baseline. The 3-month score was significantly higher in the DD group, but not in the MD group (65.28 +/- 9.88%, p = 0.02 vs. 58.93 +/- 12.06%, p = 0.18). The absolute pre-test to 1-week post-test difference was significantly higher at 35.28 +/- 7.65% among participants in the DD group compared to 25.0 +/- 11.80% in the MD group, p = 0.048. Similarly, the absolute pre-test to 3-month post-test difference was significantly higher at 18.9 +/- 6.7% among the participants in the DD group, compared to 6.8 +/- 11.8% in the MD group, p = 0.021. CONCLUSIONS: Long-term nutrition knowledge is improved with DD compared with MD.

Audit of constipation in a gastroenterology referral center.

This study was designed to assess the various subtypes of functional constipation in a referral gastrointestinal center of a Latino-American country. All patients referred for evaluation of constipation during a 10-year period were audited, and those with functional constipation according to Rome I criteria classified by physiologic tests of colonic transit, as well as tests of anorectal and pelvic floor function. More than 70% of patients with functional constipation had evidence of pelvic floor dysfunction, whereas those with slow transit and constipation-predominant irritable bowel syndrome subtypes were less frequently represented. Even in a setting different from those most frequently reported in the literature, pelvic floor dysfunction represents the most common cause of functional constipation. Simple, physiologic testing is needed and useful for the diagnosis. This fact has therapeutic implications, especially because many such patients may benefit from biofeedback.

Use of complementary and alternative medicine in Germany - a survey of patients with inflammatory bowel disease.

BACKGROUND: Previous studies have suggested an increasing use of complementary and alternative medicine (CAM) in patients with inflammatory bowel disease (IBD). The aim of our study was to evaluate the use of CAM in German patients with IBD. METHODS: A questionnaire was offered to IBD patients participating in patient workshops which were organized by a self-help association, the German Crohn's and Colitis Association. The self-administered questionnaire included demographic and disease-related data as well as items analysing the extent of CAM use and satisfaction with CAM treatment. Seven commonly used CAM methods were predetermined on the questionnaire. RESULTS: 413 questionnaires were completed and included in the analysis (n = 153 male, n = 260 female; n = 246 Crohn's disease, n = 164 ulcerative colitis). 52 % of the patients reported CAM use in the present or past. In detail, homeopathy (55%), probiotics (43%), classical naturopathy (38%), Boswellia serrata extracts (36%) and acupuncture/Traditional Chinese Medicine (TCM) (33%) were the most frequently used CAM methods. Patients using probiotics, acupuncture and Boswellia serrata extracts (incense) reported more positive therapeutic effects than others. Within the statistical analysis no significant predictors for CAM use were found. 77% of the patients felt insufficiently informed about CAM. CONCLUSION: The use of CAM in IBD patients is very common in Germany, although a large proportion of patients felt that information about CAM is not sufficient. However, to provide an evidence-based approach more research in this field is desperately needed. Therefore, physicians should increasingly inform IBD patients about benefits and limitations of CAM treatment.

Colorectal cancer screening: practices and attitudes of gastroenterologists, internists and surgeons.

BACKGROUND: The Canadian Task Force on Preventive Health Care has recommended the use of annual or biennial fecal occult blood testing (FOBT) and flexible sigmoidoscopy in the periodic health examination of asymptomatic people over 50 years of age. Therefore, we decided to ascertain the current colorectal cancer (CRC) screening practices and attitudes of surgeons, gastroenterologists and internists. METHODS: In June 2002 (with a final mailing in December 2002), a questionnaire was sent to all gastroenterologists, internists and surgeons in Alberta. It included items on demographic and practice characteristics, CRC screening practices and opinions about CRC screening. RESULTS: Responses were received from 42 gastroenterologists, 83 internists and 68 surgeons. Overall, 141 of 187 respondents (75.4%, 95% confidence interval [CI] 68.6%-81.4%) recommended that average-risk adults undergo CRC screening. Internists were less likely to recommend screening than either gastroenterologists or surgeons (95% CI for the difference 7.2%-32.8%). The most commonly recommended screening test was colonoscopy (70%), followed by FOBT (65%), flexible sigmoidoscopy (47%) and air-contrast barium enema (31%). Colonoscopy was the only test recommended by 7 (22.6%) of 33 gastroenterologists, 9 (16.4%) of 59 surgeons and 3 (6.1%) of 49 internists. Respondents were more likely to list barriers to the use of colonoscopy (mean 5 barriers) for screening than for either FOBT or flexible sigmoidoscopy (mean 2 barriers for both tests). Only 3 respondents indicated that they themselves would not undergo screening. Colonoscopy was the only screening test that 135 (70.0%) of the 193 would themselves undergo. CONCLUSIONS: The majority of Alberta specialists recommend CRC screening for average-risk adults. Colonoscopy was the most commonly recommended test, despite the perception of more barriers to that technique and the 2001 guidelines prepared by the Canadian Task Force for Preventive Health Care, which did not support colonoscopy.

[Consumption of medicinal herbs in patients attending a gastroenterology outpatient clinic]. / Consumo de hierbas medicinales en los pacientes de consultas externas de digestivo.

The consumption of medicinal herbs is one of the most important topics in alternative and complementary medicine. The widespread use of these substances among the general population gives rise to the possibility of therapeutic or toxic effects in patients seeking conventional medical assistance. To determine the frequency of medicinal herb use, the species consumed and the profile of medicinal herb consumers among patients with gastrointestinal disorders, patients attending the gastroenterology outpatient clinic of the Francesc de Borja district hospital (Gandía, Spain) over a 5-month period were interviewed and 539 valid questionnaires were obtained. A total of 34.7% of the interviewees had taken medicinal herbs at some time and 26.9% had used them in the last year. Self-prescription was reported by 67.1%. Medicinal herbs were mainly obtained in the pharmacy or herbalist's (74.7%). The results of medicinal herb therapy were considered good or excellent by 80.3% of the interviewees, average by 18.6% and poor by 1.1%. In the univariate analysis, medicinal herb consumption was positively associated with female sex (p < 0.001), a university education (p < 0.05), consumption of psychotropic drugs (p < 0.005), use of trencar l'enfit (TE, a common practice of magic medicine in Valencia) (p < 0.001), functional gastrointestinal disorders (p < 0.005) and a diagnosis of lower gastrointestinal disorder (p < 0.01). In the multivariate analysis, the variables that remained statistically significant were female sex (p < 0.005), university education (p < 0.01), use of TE and a diagnosis of lower gastrointestinal disorder. Fifty-seven botanical varieties were used. The most frequent varieties were Santolina chamaecyparissus (18.8%), Tilia platyphyllos (6.5%), Thymus vulgaris (6%), Equisetum ramosissimum (4.7%), Mentha pulegium (4.4%) and Valeriana officinalis (4.4%). The results show that consumption of medicinal herbs is frequent among patients attending the gastroenterology outpatient clinic of a district hospital. The probable profile of those showing maximum consumption is: female sex, university education, lower gastrointestinal disorder, functional gastrointestinal disorder, psychotropic drug consumption and use of TE.

Proton pump inhibitors. Compliance with a mandated step-up program.

OBJECTIVE: To assess compliance with a step-up approach to proton pump inhibitor (PPI) therapy before implementation of a new provincial policy to promote histamine-type 2 receptor antagonist (H2RA) use before PPI therapy. DESIGN: Population-based, retrospective, open cohort study using prescribing and medical procedure data from January 1, 1995, to April 30, 1999. SETTING: Health administration databases for the universal health care system in Ontario. PARTICIPANTS: Approximately 1.4 million residents of Ontario older than 65 years. MAIN OUTCOME MEASURES: Proportion of patients who received a trial of H2RA therapy or gastrointestinal diagnostic testing 12 months before starting PPI therapy in 1996. RESULTS: Among the 25,870 patients who met study criteria in 1996, about 63% had received H2RAs 12 months before starting PPI therapy and 73% had had a trial of H2RAs or gastrointestinal diagnostic testing. Repeat analysis for January through April 1999, following the new policy implementation, showed that about 72% of patients had had a trial of H2RAs within 12 months of starting PPI therapy. CONCLUSION: A modest gain (9%) in compliance with using H2RA therapy within 12 months before starting PPI therapy was seen following introduction of the step-up intervention. In future, costs and benefits of potential interventions should be carefully considered before implementing new policies.

Gastroenterology in the Trent Region in 1992 and a review of changes since 1975.

A survey of all gastroenterologists in the Trent Region (population 4.7 million) showed that in 1992 the number of upper gastrointestinal endoscopies had continued to rise considerably. There were 8.6 per thousand of the population. Colonoscopies had also increased to 1.4 per thousand. There had been a large fall in barium meal examinations to 4.8 per thousand. Barium enema examinations had increased slightly to 5.3 per thousand. The number of endoscopic retrograde cholangiopancreatographies (ERCPs) and variceal sclerotherapies had also increased by 54% and 21% respectively since 1986 and were available in most of the 20 hospitals. Percutaneous endoscopic gastrostomy had been introduced at most hospitals. Emergency endoscopy was readily available at night in only half the hospitals. Fourteen hospitals offered formal open access endoscopy. Intravenous sedation was used routinely in 12 hospitals. The rate for perforation at routine upper gastrointestinal endoscopy was 1 in 4500 and for death was 1 in 20,000. There were serious deficiencies in provision of facilities or staff, or both at 14 hospitals. The total number of gastroenterologists had only increased from 25 to 26 since 1986. Thus endoscopy workload continues to increase and diversify often without adequate staffing, facilities, and funding.

Do gastroenterologists themselves follow the American Cancer Society recommendations for colorectal cancer screening?

OBJECTIVE: Colorectal cancer is a leading cause of mortality from cancer in the United States. Unfortunately, many patients already have advanced disease by the time symptoms occur. Screening of asymptomatic persons offers the potential of detecting the disease at its early and curable stages. The American Cancer Society (ACS) screening recommendations are the most widely employed in this country. We sought to determine whether gastroenterologists themselves follow the ACS recommendations, and if not, to determine their reasons for not doing so. We also looked at gastroenterologists' use of diets and supplements that might reduce the likelihood of colorectal cancer. METHOD: A questionnaire was mailed out to all gastroenterologists with U.S. addresses listed in the American College of Gastroenterology membership directory. RESULTS: Of 1466 respondents, 330 were excluded because they were at high risk for colorectal cancer or were not gastroenterologists. This left 875 gastroenterologists age 40 years and over and 261 gastroenterologists under age 40 for analysis. Overall, 68% of respondents felt the ACS recommendations were adequate; 32% did not. Of those who disagreed with the ACS recommendations, 58% preferred screening colonoscopy, and 22% preferred flexible sigmoidoscopy without annual fecal occult blood testing. Of gastroenterologists age 40 and over, 38% strictly followed the ACS recommendations themselves, 39% partially, and 23% did not follow them. Fifty percent of those who did not strictly follow the recommendations believed they were adequate but procrastinated or "did not have the time" to follow them. Overall, 82% of gastroenterologists said they used a high fiber diet, 68% used a diet low in fat, 18% used a calcium supplement, and 25% used aspirin regularly. CONCLUSIONS: Although two-thirds of gastroenterologists agreed with the ACS recommendations, only 38% themselves followed them strictly. Of the approximately one-third of gastroenterologists who considered them inadequate, a majority preferred screening colonoscopy. Gastroenterologists were more aggressive in following dietary practices that might help prevent colorectal cancer development than they were in undergoing screening.