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1.
Artigo em Inglês | MEDLINE | ID: mdl-34481951

RESUMO

BACKGROUND & AIMS: Inflammatory bowel disease (IBD) care and outcomes exhibit substantial variability, suggesting quality gaps. We aimed to identify interventions to narrow these gaps. METHODS: We performed a systematic review of Medline, Embase, and Web of Science through May 2021 to find manuscripts and abstracts reporting quality improvement (QI) interventions in IBD. We included studies with interventions that addressed acute care utilization, vaccination, or Crohn's and Colitis Foundation quality indicators for care processes, including pre-therapy testing, tobacco cessation, colorectal cancer surveillance, Clostridium difficile infection screening in flares, sigmoidoscopy in patients hospitalized with ulcerative colitis, and use of steroid-sparing therapy. The primary objective was to identify successful QI interventions. Risk of bias assessment was conducted using the Joanna Briggs Institute critical appraisal checklist. RESULTS: Twenty-three manuscripts and 23 meeting abstracts met inclusion criteria. Influenza and pneumococcal vaccination were the most studied indicators (24 references), followed by emergency room and/or hospital utilization, tobacco cessation, and pre-therapy testing (17, 11, and 10 references, respectively). Electronic medical record-based interventions were the most frequent, whereas other initiatives used strategies that included changes to care structure or delivery, vaccination protocols, or physician and patient education. Successful interventions matched the complexity of the metric to the intervention including making changes to care structure or delivery, empowered non-physician staff, and used electronic medical record changes to prompt clinicians. CONCLUSIONS: The quality of IBD care can be improved with diverse interventions that range from simple to complex. However, these interventions are not universally successful. Clinicians should emulate successful interventions and design new initiatives to narrow gaps in care quality.

2.
Inflamm Bowel Dis ; 2021 Jul 22.
Artigo em Inglês | MEDLINE | ID: mdl-34291800

RESUMO

BACKGROUND: Data describing the effect of obesity on antitumor necrosis factor (anti-TNF) treatment response are inconsistent. Visceral adipose tissue (VAT) is a superior marker of adiposity to body mass index. However, its effect on treatment response is unclear. We aimed to evaluate the effect of VAT on anti-TNF treatment response. METHODS: Inflammatory bowel disease (IBD) patients starting anti-TNF agents between January 1, 2009, and July 31, 2019, were included. 3-dimensional measurements of VAT volume and visceral fat index (visceral:subcutaneous adipose tissue ratio; VFI) were obtained from computed tomography (CT) scans. Subjects were categorized by predefined volume cutoffs (<1500cm3, 1500-2999cm3, ≥3000cm3) and VFI (<0.33, 0.33-0.66, ≥0.67). Primary outcomes included a composite treatment response end point at 6 and 12 months. Secondary outcomes were surgery at 6 and 12 months. Multivariable logistic regression was used to calculate adjusted odds ratio (aOR) and 95% confidence interval (CI). RESULTS: The final cohort included 176 patients. No significant differences in treatment response at 6 months was observed. At 12 months, compared with volume <1500cm3, patients with volume 1500-2999cm3 had higher odds of response (aOR, 3.52; 95% CI, 1.16-10.71; P = .023), whereas volume ≥3000cm3 did not. Compared with VFI<0.33, VFI ≥0.67 had higher odds of surgery at 6 (aOR, 48.22; 95% CI, 4.73-491.57; P = .023) and 12 months (aOR, 20.94; 95% CI, 3.14-139.67; P = .004). Post hoc analysis suggested VAT may affect drug pharmacokinetics. CONCLUSIONS: We found VAT volume is associated with anti-TNF treatment response in a nondose dependent manner, and VFI may inform risk of surgery after anti-TNF initiation. If confirmed by prospective studies, VAT volumetrics are potentially useful biomarkers to inform IBD treatment decisions.

6.
Ann Gastroenterol ; 32(3): 273-277, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31040624

RESUMO

Background: Although esophagogastroduodenoscopy (EGD) is usually the first procedure trainees learn, it is not known whether the involvement of a trainee affects the procedure's complication rate, a key quality and safety indicator. The purpose of this study was to determine whether the complication rate of fellow-performed upper endoscopy differs from that of attending gastroenterologists, and whether that difference varies with the level of training. Methods: Emergency room visits within 14 days of an outpatient EGD deemed to be probably or definitely related to the EGD were categorized as complications. Complication rates were calculated for attending- and trainee-performed gastrointestinal endoscopies, the latter stratified by level of training. Results: Forty-five attendings and 43 fellows performed 21,899 EGDs during the study period. There were 43 complications (1.96 per 1000 EGDs). Procedures performed by any fellow were more likely to have a complication than those performed by an attending (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.17-4.6). This difference was driven by a higher rate of complications among fellows who had completed general gastroenterology training and were in advanced training (OR 3.8, 95%CI 1.76-8.04); all of these complications involved trainees in interventional endoscopy. Fellows in any year of general gastroenterology training were not more likely to cause complications than attendings. Conclusions: The rate of complications from EGDs performed by fellows in their general gastroenterology training does not differ from that of attending endoscopists. The complication rate of advanced trainees exceeded that of attendings, but this is likely to be attributable to the higher-risk interventions undertaken by fellows in interventional endoscopy.

7.
J Hosp Med ; 14(12): 766-773, 2019 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-31112499

RESUMO

Acute severe ulcerative colitis (ASUC) is a potentially life-threatening presentation of ulcerative colitis that in nearly all cases requires inpatient management and coordinated care from hospitalists, gastroenterologists, and surgeons. Even with ideal care, a substantial proportion of patients will ultimately require colectomy, but most patients can avoid surgery with intravenous corticosteroid treatment and if needed, appropriate rescue therapy with infliximab or cyclosporine. In-hospital management requires not only therapies to reduce the inflammation at the heart of the disease process, but also to avoid complications of the disease and its treatment. Care for ASUC must be anticipatory, with patient education and evaluation starting at the time of admission in advance of the possible need for urgent medical or surgical rescue therapy. Here we outline a general approach to the treatment of patients hospitalized with ASUC, highlighting the common pitfalls and critical points in management.


Assuntos
Colite Ulcerativa/diagnóstico por imagem , Colite Ulcerativa/terapia , Gerenciamento Clínico , Hospitalização/tendências , Índice de Gravidade de Doença , Doença Aguda , Administração Intravenosa , Corticosteroides/administração & dosagem , Humanos
8.
J Clin Gastroenterol ; 53(8): e316-e321, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-30001290

RESUMO

BACKGROUND AND AIMS: Informed consent is a vital preprocedural step for endoscopy but there are substantial variations in its delivery. We therefore sought to assess a multifaceted intervention to improve the consent process. METHODS: Gastroenterologists at a tertiary center were educated on the recommended components of informed consent. Following this, 3 cohorts of patients undergoing colonoscopy were surveyed before and after consent. In one cohort, the effect of optimized verbal consent alone was assessed. In the second and third groups, the effects of the addition of either a handout or a video describing colonoscopy and its risks were evaluated. The primary outcomes were the changes between preconsent and postconsent survey responses regarding confidence in understanding the procedure's purpose, likelihood of adverse events, and levels of anxiety. RESULTS: In total, 240 patients were included with 79 to 81 patients per group. There were no significant differences among the groups' survey responses. Compared with patients receiving verbal consent alone, fewer patients in the handout and video groups increased their perceived risk of adverse events following consent, but this difference did not reach significance (P=0.08). Examining all groups together, anxiety levels changed significantly after consent (P=0.003), with 31% of patients reducing their anxiety level, 8% increasing it, and 62% having no change. CONCLUSIONS: The consent process appears to decrease patient anxiety about colonoscopy. When used in conjunction with a high-quality verbal consent, written or video educational adjuncts provided on the day of colonoscopy likely have no effect on patient perceptions.


Assuntos
Colonoscopia , Conhecimentos, Atitudes e Prática em Saúde , Consentimento Livre e Esclarecido , Educação de Pacientes como Assunto , Adulto , Idoso , Estudos de Coortes , Colonoscopia/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários
9.
Am J Surg Pathol ; 40(4): 554-62, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26645729

RESUMO

Radiofrequency ablation (RFA), with or without endoscopic mucosal resection (EMR), is a safe, effective, and durable treatment option for Barrett esophagus (BE)-associated dysplasia (DYS), but few studies have identified predictors of treatment failure in BE-associated intramucosal adenocarcinoma (IMC). The aim of this study was to determine the rate of IMC eradication when using RFA±EMR and to identify clinical and pathologic predictors of treatment failure. A retrospective review of medical records and a central review of index histologic parameters were performed for 78 patients who underwent RFA±EMR as the primary treatment for biopsy-proven IMC at 4 academic tertiary medical centers. Complete eradication (CE) (absence of IMC/DYS on first follow-up endoscopy) was achieved in 86% of patients, and durable eradication (DE) (CE with no recurrence of IMC/DYS until last follow-up) was achieved in 78% of patients, with significant variation between the 4 study sites (P=0.03 and 0.09 by analysis of variance for DE and CE, respectively). Use of EMR before RFA significantly reduced the risk for treatment failure for IMC/DYS (hazard ratio, 0.15; 95% confidence interval, 0.05-0.48; P=0.001), whereas IMC involving ≥50% of the columnar metaplastic area on index examination significantly increased the risk for treatment failure (hazard ratio, 4.24; 95% confidence interval, 1.53-11.7; P=0.005). Endoscopic and pathologic factors associated with treatment failure in BE-associated IMC treated with RFA±EMR may help identify the subset of IMC patients for whom a more aggressive initial approach may be justified.


Assuntos
Adenocarcinoma/cirurgia , Esôfago de Barrett/cirurgia , Neoplasias Esofágicas/cirurgia , Adulto , Idoso , Carcinoma in Situ/cirurgia , Ablação por Cateter , Estudos de Coortes , Esofagoscopia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Membrana Mucosa/cirurgia , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
10.
Gastrointest Endosc ; 80(1): 71-7, 2014 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-24565071

RESUMO

BACKGROUND: Radiofrequency ablation (RFA) has become an accepted form of endoscopic treatment for Barrett's esophagus (BE), yet reported response rates are variable. There are no accepted quality measures for performing RFA, and provider-level characteristics may influence RFA outcomes. OBJECTIVE: To determine whether endoscopist RFA volume is associated with rates of complete remission of intestinal metaplasia (CRIM) after RFA in patients with BE. DESIGN: Retrospective analysis of longitudinal data. SETTING: Three tertiary-care medical centers. PATIENTS: Patients with BE treated with RFA. INTERVENTION RFA MAIN OUTCOME MEASUREMENTS: For each endoscopist, we recorded RFA volume, defined as the number of unique patients treated as well as corresponding CRIM rates. We calculated a Spearman correlation coefficient relating these 2 measures. RESULTS: We identified 417 patients with BE treated with RFA who had at least 1 post-RFA endoscopy with biopsies. A total of 73% of the cases had pretreatment histology of high-grade dysplasia or adenocarcinoma. The procedures were performed by 7 endoscopists, who had a median RFA volume of 62 patients (range 20-188). The overall CRIM rate was 75.3% (provider range 62%-88%). The correlation between endoscopist RFA volume and CRIM rate was strong and significant (rho = 0.85; P = .014). In multivariable analysis, higher RFA volume was significantly associated with CRIM (P for trend .04). LIMITATIONS: Referral setting may limit generalizability. Limited number of endoscopists analyzed. CONCLUSION: Endoscopist RFA volume correlates with rates of successful BE eradication. Further studies are required to confirm these findings and to determine whether RFA volume is a valid predictor of treatment outcomes in BE.


Assuntos
Esôfago de Barrett/cirurgia , Ablação por Cateter , Esofagoscopia , Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos , Adulto , Idoso , Idoso de 80 Anos ou mais , Ablação por Cateter/métodos , Esofagoscopia/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Centros de Atenção Terciária , Resultado do Tratamento
11.
Gastroenterology ; 145(1): 79-86.e1, 2013 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-23499759

RESUMO

BACKGROUND & AIMS: Radiofrequency ablation (RFA) is an established treatment for dysplastic Barrett's esophagus (BE). Although short-term end points of ablation have been ascertained, there have been concerns about recurrence of intestinal metaplasia (IM) after ablation. We aimed to estimate the incidence and identify factors that predicted the recurrence of IM after successful RFA. METHODS: We analyzed data from 592 patients with BE treated with RFA from 2003 through 2011 at 3 tertiary referral centers. Complete remission of intestinal metaplasia (CRIM) was defined as eradication of IM (in esophageal and gastroesophageal junction biopsy specimens), documented by 2 consecutive endoscopies. Recurrence was defined as the presence of IM or dysplasia after CRIM in surveillance biopsies. Two experienced gastrointestinal pathologists confirmed pathology findings. RESULTS: Based on histology analysis, before RFA, 71% of patients had high-grade dysplasia or esophageal adenocarcinoma, 15% had low-grade dysplasia, and 14% had nondysplastic BE. Of patients treated, 448 (76%) were assessed after RFA. Fifty-five percent of patients underwent endoscopic mucosal resection before RFA. The median time to CRIM was 22 months, with 56% of patients in CRIM by 24 months. Increasing age and length of BE segment were associated with longer times to CRIM. Twenty-four months after CRIM, the incidence of recurrence was 33%; 22% of all recurrences observed were dysplastic BE. There were no demographic or endoscopic factors associated with recurrence. Complications developed in 6.5% of subjects treated with RFA; strictures were the most common complication. CONCLUSIONS: Of patients with BE treated by RFA, 56% were in complete remission after 24 months. However, 33% of these patients had disease recurrence within the next 2 years. Most recurrences were nondysplastic and endoscopically manageable, but continued surveillance after RFA is essential.


Assuntos
Esôfago de Barrett/cirurgia , Ablação por Cateter , Esofagoscopia/métodos , Esôfago/patologia , Idoso , Esôfago de Barrett/patologia , Junção Esofagogástrica/patologia , Feminino , Humanos , Masculino , Metaplasia , Pessoa de Meia-Idade , Membrana Mucosa/cirurgia , Recidiva
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