A Simulation Exercise to Raise Learners' Awareness of the Physical and Cognitive Changes in Older Adults.

OBJECTIVE: The growing number of older adults with cognitive impairment is increasing the need for healthcare services. However, there is a great shortage of geriatric trained primary care providers and psychiatrists. A positive attitude towards people with cognitive impairment is associated with better quality of life among residents of long-term care settings. This led us to develop a simulation exercise to raise learners' awareness of, and attentiveness to, physical and cognitive changes experienced by the aging population. METHODS: Fifty-one learners rotating through Psychiatry at the Michael E. DeBakey VA Medical Center received the 10-min training over 1 year. The Approaches to Dementia Questionnaire was used to measure attitudes towards older persons with cognitive impairment. Pre- and postsimulation data subscores for the Hope, Person-centered, and total score were calculated, and a paired sample t test was conducted. RESULTS: Results of the questionnaire showed statistically significant improvement in the Approaches to Dementia Questionnaire scores among participants after they completed the simulation exercise, indicating an increase in positive attitudes. The mean difference in the total score of the Approaches to Dementia Questionnaire was 3.22, with a 95% CI of 1.67 to 4.74, t = 4.20, df (47), p < .000, r = .64, and a medium effect size of d = .61. CONCLUSIONS: On the basis of these findings, the simulation exercise can be used for improving learners' attitudes towards those with cognitive impairment.

Surveillance endoscopy is associated with improved outcomes of oesophageal adenocarcinoma detected in patients with Barrett's oesophagus.

BACKGROUND: The effectiveness of surveillance endoscopy in patients with Barrett's oesophagus (BE) for reducing oesophageal adenocarcinoma (EAC)-related mortality in patients with BE is unclear. METHODS: This is a cohort study of patients with BE diagnosed in the National Veterans Affairs hospitals during 2004-2009 excluding those with conditions that affect overall survival. We identified those diagnosed with EAC after BE diagnosis through 2011 and conducted chart reviews to identify BE surveillance programme, and indication for EAC diagnosis, verify diagnosis, stage, therapy and cause of death. We examined the association between surveillance indication for EAC diagnosis with or without surveillance programme and EAC stage and treatment receipt in logistic regression models, and with time to death or cancer-related death using a Cox proportional hazards regression model. RESULTS: Among 29 536 patients with BE, 424 patients developed EAC during a mean follow-up of 5.0 years. A total of 209 (49.3%) patients with EAC were in BE surveillance programme and were diagnosed as a result of surveillance endoscopy. These patients were more likely to be diagnosed at an early stage (stage 0 or 1: 74.7% vs 56.2, p<0.001), survived longer (median 3.2 vs 2.3 years; p<0.001) and have lower cancer-related mortality (34.0% vs 54.0%, p<0.0001) and had a trend to receive oesophagectomy (51.2% vs 42.3%; p=0.07) than 215 patients diagnosed by non-BE surveillance endoscopy (17.2% of whom were BE surveillance failure). BE surveillance endoscopy was associated with a decreased risk of cancer-related death (HR 0.47, 0.35 to 0.64), which was largely explained by the early stage of EAC at the time of diagnosis. Similarly, the adjusted mortality for patients with cancer in a prior surveillance programme for overall death was 0.63 (0.47 to 0.84) compared with patients with cancer not in a surveillance programme. CONCLUSIONS: Surveillance endoscopy among patients with BE is associated with significantly better EAC outcomes including cancer-related mortality compared with other non-surveillance endoscopy.

Risk of upper gastrointestinal cancers in patients with gastroesophageal reflux disease after a negative screening endoscopy.

BACKGROUND & AIMS: Practice guidelines recommend a 1-time screening endoscopy for patients with gastroesophageal reflux disease (GERD) who are at high risk for Barrett's esophagus or malignancy. However, little is known about the risk of cancer in patients with negative findings from screening endoscopies. METHODS: We conducted a retrospective cohort study using data from 121 Veterans Health Administration facilities nationwide to determine the incidence rate of esophageal adenocarcinoma (EA) separately, as well as any upper gastrointestinal cancers, in patients with an initial negative screening endoscopy (esophagogastroduodenoscopy [EGD]). We included veteran patients with GERD diagnosed between 2004 and 2009 who had a negative screening EGD within 1 year of diagnosis. We estimated the incidence rate of EA, and any upper gastrointestinal cancer, in patients with GERD who had a negative screening EGD. We examined differences in demographic, clinical, and facility factors among patients with and without cancer. RESULTS: We identified 68,610 patients with GERD and a negative screening EGD (mean age, 55.5 y; 90% men; 67.5% white). During a mean follow-up period of 3.2 years, 10 patients developed EA and 29 patients developed any upper gastrointestinal malignancies, including EA. The incidence of subsequent EA in this group was 4.6/100,000 patient-years of follow-up evaluation, whereas the incidence of any upper gastrointestinal cancers was 13.2/100,000 patient-years of follow-up evaluation. Patients with a subsequent cancer were significantly older and had higher comorbidity scores than patients without cancer. Other clinical and facility factors did not differ significantly between these 2 groups. CONCLUSIONS: The risk of cancer is low, over a mean 3-year period, for patients with GERD who had a negative screening endoscopy. These findings justify recommendations for a 1-time screening endoscopy for patients with GERD.

The incidence of esophageal adenocarcinoma in a national veterans cohort with Barrett's esophagus.

OBJECTIVES: The increasing incidence of esophageal adenocarcinoma (EA) in the United States may have leveled off in recent years. The risk of EA among patients with Barrett's esophagus (BE) seems to be decreasing in several European cohorts, but these estimates are unknown in the United States. We aimed to determine the risk of developing EA in a national cohort of BE patients in the US Veterans Health Administration and to account for the use of endoscopic ablation and esophagectomy. METHODS: This was a retrospective cohort study from a total of 121 facilities in the Veterans Health Administration. Veteran patients with BE diagnosed between 1 October 2003 and 30 September 2009 were included and followed until esophageal cancer diagnosis, death or 30 September 2011. All EA diagnoses were verified in detailed structured reviews of medical records. RESULTS: We identified 29,536 patients with BE who met our eligibility criteria. Most were men (96.9%) and White (83.2%), with a mean age of 61.8 years. During 144,949 person-years of follow-up, 466 patients developed EA, yielding an incidence rate of 3.21 per 1,000 person-years (95% confidence interval (CI) 2.94-3.52). Excluding those who developed EA within 1 year of their index BE date lowered the incidence rate to 1.75 per 1,000 person-years. However, including additional patients who underwent endoscopic ablation or esophagectomy for HGD or EA increased the incidence rate to 4.79 (95% CI 4.44-5.16). CONCLUSIONS: The incidence of EA in a US national cohort of mostly male veterans may be lower than previous estimates. Almost half of the EA cases were diagnosed within 1 year of their BE index date.

Clinical and psychosocial variables associated with behavioral intentions to undergo surveillance endoscopy.

BACKGROUND: Many patients with Barrett's esophagus do not adhere to guideline-recommended endoscopic surveillance. Among patient factors related to cancer prevention behaviors, patients' stated behavioral intention is a strong predictor of behavior performance. Little is known about the patient factors associated with having a strong behavioral intention to pursue surveillance endoscopy. This study explores the association of clinical and psychosocial variables and behavioral intention to pursue surveillance endoscopy among patients with Barrett's Esophagus and no or low-grade dysplasia. METHODS: Potential subjects were screened using electronic medical records of a regional Veterans Affairs Medical Center and a pathologically confirmed Barrett's esophagus registry. Eligible participants were recruited by a mailer or phone call and completed a questionnaire to measure six distinct psychosocial factors, their behavioral intention to undergo surveillance endoscopy, and various demographic and clinical variables. Univariate and multivariate linear regression identified the relation of behavioral intention with each of six psychosocial variables. RESULTS: One-hundred and one subjects consented and returned surveys. The analytical sample for this study consists of the 94% of surveys with complete responses to the behavior intention items. Three of the six psychosocial domains were statistically significant predictors of intention in both univariate and adjusted univariate analysis (salience/coherence ß = 0.59, 95% CI = 0.45-0.76, P <0.01; self-efficacy ß = 0.30, 95% CI = 0.10-0.51, P <0.01; and social influence ß = 0.20, 95% CI = 0.08-0.33, P <0.01). In a multivariate analysis only salience/coherence (ß = 0.65, 95% CI = 0.42-0.88, P <0.01) remained statistically significant predictor of intention. CONCLUSION: This study established the validity of a scale to measure psychosocial variables associated with behavioral intentions to undergo surveillance endoscopy. Results demonstrate the importance of assessing self-efficacy, social influences, and bottom-line belief in the value of surveillance endoscopy when evaluating a patient's likelihood of completing surveillance endoscopy.

Patient experiences with surveillance endoscopy: a qualitative study.

BACKGROUND: Prior studies examining patterns of esophagogastroduodenoscopy (EGD) surveillance in patients with Barrett's esophagus (BE) demonstrate variable adherence to practice guidelines. In prior studies, memories of endoscopic experiences shaped overall perceptions and subsequent adherence behaviors, but the specific elements of that experience are unclear. We sought to identify specific elements of the EGD experience that frame overall perceptions of surveillance. METHODS: We conducted structured in-depth, qualitative interviews with BE patients with a range of severity (non-dysplastic, low-grade and high-grade dysplasia) who recently completed an EGD. Data collection continued until we reached thematic saturation (n = 20). We applied principles of framework analysis to identify emerging themes regarding patients' salient EGD experiences. We validated our coding scheme through multidisciplinary consensus meetings comprised of clinician (gastroenterologist and internist) and non-clinician investigators (sociologist and public health expert). RESULTS: Patient experiences can be conceptualized within a temporal model: prior to, during, and after endoscopy. The most memorable aspects of the EGD experience include physician-patient communication prior to EGD, wait time at the endoscopy center, interpersonal interactions at the time of the EGD, level of pain or discomfort with the procedure, level of trust in the physician following EGD, and gaining a sense of control over BE. CONCLUSIONS: We identified six salient memories before, during, and after the procedure that shape patients' perceptions of the EGD experience. We offer recommendations for measuring patient experiences using a composite of validated survey items. Future studies should test the relation of patient experience measures and adherence to surveillance EGD.

Practice patterns of surveillance endoscopy in a Veterans Affairs database of 29,504 patients with Barrett's esophagus.

BACKGROUND: Practice guidelines recommend surveillance endoscopy every 2 to 3 years among patients with Barrett's esophagus (BE) to detect early neoplastic lesions. Although surveys report that >95% of gastroenterologists recommend or practice BE surveillance, the extent and patterns of surveillance in clinical practice are unknown. OBJECTIVE: To identify the extent and determinants of endoscopic surveillance among BE patients. DESIGN: Retrospective cohort study. SETTING: A total of 121 Veterans Affairs facilities nationwide. PATIENTS: Veteran patients with BE diagnosed from 2003 to 2009, with follow-up through September 30, 2010. INTERVENTION: Not an interventional study. MAIN OUTCOME MEASUREMENTS: The proportions of patients with BE who received any EGD after the index BE EGD date. In the subgroup of patients with at least 6 years of follow-up, we also calculated proportions for regular (EGD during both 3-year intervals), irregular (EGD in only 1 interval), and no surveillance. We examined differences in demographics and clinical and facility factors among these groups in unadjusted and adjusted analyses. RESULTS: We identified 29,504 patients with BE; 97% were men, 83% white, and their mean age was 61.8 years. During a 3.8-year median follow-up period, 45.4% of patients with BE received at least one EGD. Among the subgroup of 4499 patients with BE who had at least 6 years of follow-up, 23.0% had regular surveillance, and 26.7% had irregular surveillance. There was considerable facility-level variation in percentages with surveillance EGD across the 112 facilities and by geographic region of these facilities. Demographic and clinical factors did not explain these variations. Patients with at least one EGD were significantly more likely to be white; to be aged <65 years, with a low level of comorbidity; to have GERD, obesity, dysphagia, or esophageal strictures; to have more outpatient visits; and to be seen in smaller hospitals (<87 beds) than those without any EGD. LIMITATIONS: There might be misclassification of BE and surveillance EGD. Lack of pathology data on dysplasia, which dictates surveillance intervals. CONCLUSION: Endoscopic surveillance for BE is considerably less commonly practiced in Veterans Affairs facilities than is self-reported by physicians. Although several clinical factors are associated with variations in surveillance, facility-level factors play a large role. The comparative effectiveness of the different practice-based surveillance patterns needs to be examined.

Patient-centered, comparative effectiveness of esophageal cancer screening: protocol for a comparative effectiveness research study to inform guidelines for evidence-based approach to screening and surveillance endoscopy.

BACKGROUND: The comparative effectiveness (CE) of endoscopic screening (versus no screening) for Barrett's esophagus (BE) in patients with GERD symptoms, or among different endoscopic surveillance strategies in patients with BE, for the early detection of esophageal adenocarcinoma (EA) is unknown. Furthermore, it is unclear if patients or providers have or will adopt any of these strategies (screening only, screening and surveillance, vs. none), irrespective of their effectiveness. Endoscopic screening and surveillance is expensive and can be risky. Therefore, it is imperative to establish the CE and acceptability about the risks and outcomes related to these practices to better inform expert recommendations and provider-patient decisions. METHODS/RESULTS: We propose a mixed methods study which will involve: (1) an analysis of secondary databases (VA and VA-Medicare linked datasets for 2004-09) to examine CE of endoscopic screening and surveillance in an observational study cohort (an estimated 680,000 patients with GERD; 25,000-30,000 with BE; and 3,000 with EA); (2) a structured electronic medical record (EMR) review on a national sample of patients using VA EMRs to verify all EA cases, identify cancer stage, cancer-targeted therapy, and validate the screening and surveillance endoscopy; and (3) qualitative in depth interviews with patients and providers to elicit preferences, norms, and behaviors to explain clinical contexts of these findings and address gaps arising from the CE study. CONCLUSION: This study will compare clinical strategies for detecting and monitoring BE, a pre-cancerous lesion. Additionally, by eliciting acceptability of these strategies for patients and providers, we will be able to propose effective and feasible strategies that are likely to be implemented in routine use. Findings will inform recommendations for clinical practice guidelines. Our innovative approach is consistent with the methodological standards of patient-centered outcomes research, and our findings will offer a significant contribution to the literature on cancer surveillance.