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Suresh MR, Nassani N, Servin-Abad LA, Walz DB, Davis PR, Boelter CW, Goettl TG, Beilman GJ, Freeman ML, Olson APJ, Bazerbachi F. Implementation of a same-day, round-trip interventional endoscopy service for rural and critical access hospital patients. J Hosp Med 2024; 19:971-976. [PMID: 38698607 DOI: 10.1002/jhm.13333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 02/29/2024] [Accepted: 03/07/2024] [Indexed: 05/05/2024]
Affiliation(s)
- Mithun R Suresh
- Department of Hospital Medicine, CentraCare-St. Cloud Hospital, St. Cloud, Minnesota, USA
| | - Najib Nassani
- Interventional Endoscopy Program, CentraCare-St. Cloud Hospital, St. Cloud, Minnesota, USA
| | - Luis A Servin-Abad
- Interventional Endoscopy Program, CentraCare-St. Cloud Hospital, St. Cloud, Minnesota, USA
| | - Deanne B Walz
- Interventional Endoscopy Program, CentraCare-St. Cloud Hospital, St. Cloud, Minnesota, USA
| | - Paul R Davis
- Department of Anesthesia, CentraCare-St. Cloud Hospital, St. Cloud, Minnesota, USA
| | | | - Tyler G Goettl
- Department of Surgery, CentraCare-Rice Memorial Hospital, Willmar, Minnesota, USA
| | - Greg J Beilman
- Department of Surgery, Minnesota Center for Resuscitative Trauma Care, University of Minnesota, Minneapolis, Minnesota, USA
| | - Martin L Freeman
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Andrew P J Olson
- Departments of Medicine and Pediatrics, Division of Hospital Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Fateh Bazerbachi
- Interventional Endoscopy Program, CentraCare-St. Cloud Hospital, St. Cloud, Minnesota, USA
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Interventional Endoscopy Program, CentraCare-St. Cloud Hospital, University of Minnesota, Minneapolis, Minnesota, USA
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Babbar S, Debordeaux M. Examining the Impact of a GI Hospitalist Model on the Outcomes of Double-Balloon Enteroscopy: A Single-Center Retrospective Study. Dig Dis Sci 2024; 69:3369-3374. [PMID: 38940976 DOI: 10.1007/s10620-024-08552-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 06/24/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND A GI hospitalist (GIH) is a physician who practices in the inpatient setting performing consultations and endoscopic procedures. Obscure small bowel bleeding is a common inpatient diagnosis that is difficult to manage and associated with longer hospitalizations. Having an onsite GIH physician with expertise in video capsule endoscopy (VCE) and double-balloon enteroscopy (DBE) has the potential to improve patient outcomes. AIMS This study will be the first to explore how implementing a GIH model and providing a GIH with training in DBE can affect the outcomes of patients with small bowel pathology. METHODS We performed a retrospective study of patients who received an inpatient DBE at an academic medical center before and after initiation of a GIH model and credentialing of a GIH in DBE. We compared outcomes, including procedure volumes, diagnostic and therapeutic yields, procedure duration, time to procedure, and length of stay. RESULTS There was a 46.5% increase in the number of DBEs performed by the GIH. The diagnostic yield increased from 56.3 to 74.0% (OR 2.2, 95% CI 1.2-4.2), and the proportion of DBEs with a therapeutic intervention increased from 38.0 to 65.4% (OR 3.1, 95% CI 1.4-7.0). The total procedure time increased from 77.8 to 96.4 min (p < 0.05) with a GIH. CONCLUSION Having a GIH perform inpatient DBEs was associated with an increased number of procedures, duration of procedures, diagnostic yield, and therapeutic interventions. The onsite presence of a GIH with competency in DBE improves the care of hospitalized patients with small bowel pathology.
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Affiliation(s)
- Shaili Babbar
- New York University Grossman School of Medicine, NYU Langone Health, 550 First Avenue, New York, NY, USA.
| | - Melissa Debordeaux
- Division of Gastroenterology & Hepatology, Department of Medicine, NYU Langone Health, New York, NY, USA
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Lewis JD, Brensinger CM, Parlett LE, Hurtado-Lorenzo A, Kappelman MD. Provider Specialization in Inflammatory Bowel Diseases: Quality of Care and Outcomes. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00499-3. [PMID: 38844254 DOI: 10.1016/j.cgh.2024.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 05/05/2024] [Accepted: 05/07/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND & AIMS Management of inflammatory bowel diseases (IBD) is complex and variation in care has been well-documented. However, the drivers of practice variation remain unexplored. We examined variation based on the treating gastroenterologist's IBD focus (proportion of outpatient visits for IBD). METHODS We conducted a retrospective cohort of newly diagnosed patients with IBD using data from Optum's deidentified Clinformatics Data Mart Database (2000-2020). The exposure variable was whether the treating gastroenterologist had an IBD focus (>90th percentile of IBD visits/total outpatient visits). We used adjusted regression models to evaluate associations between provider IBD focus and process measures (use of mesalamine, corticosteroid, biologic, and narcotic medications and endoscopic or radiographic imaging) and clinical outcomes (time to IBD-related hospitalization and bowel resection surgery). We tested for change in treatment patterns over time by including an interaction term for study era (2004-2012 vs 2013-2020). RESULTS The study included 772 children treated by 493 providers and 2864 adults treated by 2076 providers. In children, none of the associations between provider focus and process or outcome measures were significant. In adults, care from an IBD-focused provider was associated with more use of biologics, combination therapy, and imaging and endoscopy, and less mesalamine use for Crohn's disease (P < .05 for all comparisons) but not with other process measures. Biologics were prescribed more frequently and narcotics less frequently during the later era (P < .05 for both). Hospitalization and surgery rates were not associated with IBD focus or era. CONCLUSIONS IBD care for adults varies by provider specialization. Given the evolving complexity, novel methods may be needed to standardize care.
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Affiliation(s)
- James D Lewis
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Colleen M Brensinger
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Michael D Kappelman
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Baron TH. Experience is "what separates the good and the great": implications of ERCP volume on patient outcomes. Gastrointest Endosc 2024; 99:960-961. [PMID: 38762307 DOI: 10.1016/j.gie.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/06/2024] [Accepted: 03/07/2024] [Indexed: 05/20/2024]
Affiliation(s)
- Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina in Chapel Hill, Chapel Hill, North Carolina, USA
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Teles de Campos S, Diniz P, Castelo Ferreira F, Voiosu T, Arvanitakis M, Devière J. Assessing the impact of center volume on the cost-effectiveness of centralizing ERCP. Gastrointest Endosc 2024; 99:950-959.e4. [PMID: 38061478 DOI: 10.1016/j.gie.2023.11.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/03/2023] [Accepted: 11/21/2023] [Indexed: 05/20/2024]
Abstract
BACKGROUND AND AIMS ERCP is a complex endoscopic procedure in which the center's procedure volume influences outcomes. With the increasing healthcare expenses and limited resources, promoting cost-effective care becomes essential for healthcare provision. This study was a cost-effectiveness analysis to evaluate the hypothesis that high-volume (HV) centers perform ERCP with higher quality at lower costs than low-volume (LV) centers. METHODS A baseline case compared the current distribution of ERCPs among HV and LV centers with a hypothetical scenario in which all ERCPs are performed at HV centers. A cost-effectiveness analysis was constructed, followed by 1- and 2-way sensitivity analyses, and probabilistic sensitivity analysis using Monte Carlo simulations. RESULTS In the baseline case, the incremental cost-effectiveness ratio was -$151,270 per year, due to the hypothetical scenario's lower costs and slightly higher quality-adjusted life years. The model was most sensitive to changes in transportation costs (109.34%), probability of significant adverse events (AEs) after successful ERCP at LV centers (42.12%), utility after ERCP with significant AEs (30.10%), and probability of significant AEs after successful ERCP at HV centers (23.53%); only transportation costs above $3655 changed the study outcome, however. The current ERCP distribution would only be cost-effective if LV centers achieved higher success (≥92.4% vs 89.3%), with much lower significant AEs (≤.5% vs 6.7%). The study's main findings remained unchanged while combining all model parameters in the probabilistic sensitivity analysis. CONCLUSIONS Our findings show that HV centers have high-performance rates at lower costs, raising the need to consider the principle of centralization of ERCPs into HV centers to improve the quality of care.
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Affiliation(s)
- Sara Teles de Campos
- Gastroenterology Department, Digestive Unit, Champalimaud Foundation, Lisbon, Portugal; Université Libre Bruxelles, Brussels, Belgium; Department of Bioengineering and iBB, Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Fondation Michel Cremer, Universidade de Lisboa, Lisbon, Portugal.
| | - Pedro Diniz
- Department of Bioengineering and iBB, Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Fondation Michel Cremer, Universidade de Lisboa, Lisbon, Portugal; Associate Laboratory i4HB, Institute for Health and Bioeconomy, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal
| | - Frederico Castelo Ferreira
- Department of Bioengineering and iBB, Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Fondation Michel Cremer, Universidade de Lisboa, Lisbon, Portugal; Associate Laboratory i4HB, Institute for Health and Bioeconomy, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal
| | - Theodor Voiosu
- Gastroenterology Department, Colentina Clinical Hospital, Carol Davila Faculty of Medicine, Bucharest, Romania
| | - Marianna Arvanitakis
- Université Libre Bruxelles, Brussels, Belgium; Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Brussels, Belgium
| | - Jacques Devière
- Gastroenterology Department, Digestive Unit, Champalimaud Foundation, Lisbon, Portugal; Université Libre Bruxelles, Brussels, Belgium; Department of Bioengineering and iBB, Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Fondation Michel Cremer, Universidade de Lisboa, Lisbon, Portugal; Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Brussels, Belgium
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García-Cano J, Viñuelas Chicano M, Valiente González L. ERCP for common bile duct stones in the elderly: refine the procedure to improve outcomes. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024. [PMID: 38469806 DOI: 10.17235/reed.2024.10352/2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
Removal of common bile duct stones in patients with a previous cholecystectomy was one of the first indications for ERCP with biliary sphincterotomy. Thanks to a minimally invasive procedure, patients were prevented from having a new operation. Subsequently, as the technique proved to be successful, ERCP was extended to all patients with choledocholithiasis, regardless of whether or not they had gallbladder. Also contributing was the fact that, at least in the beginnings, surgical interventions on the bile duct with laparoscopic cholecystectomy were more difficult. Nowadays, many surgeons prefer to perform cholecystectomy with a bile duct clean of stones. In this issue of the Spanish Journal of Gastroenterology, Gardenyes et al. present a study on ERCP for common bile duct stones in elderly patients. The novelty of this study is not only to analyze the ERCP procedure, which we already knew has similar success and complication rates to younger patients, but also to focus on the long-term outcome, considering the frailty that frequently accompanies aging. The study concludes that older patients may benefit from enhanced care protocols to reduce medical adverse events and improve outcomes. For us gastroenterologists and endoscopists, another conclusion that can be drawn from this study is that we should not be satisfied that ERCP in older patients has the same success and complication rates as in younger patients, but rather we should strive to ensure that the results are even better.
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Monino L, Moreels TG. Patient Radiation Exposure during Enteroscopy-Assisted Endoscopic Retrograde Cholangiopancreatography in Surgically Altered Anatomy (with Video). Diagnostics (Basel) 2024; 14:142. [PMID: 38248019 PMCID: PMC10814473 DOI: 10.3390/diagnostics14020142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/01/2024] [Accepted: 01/03/2024] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND Fluoroscopy must be used cautiously during endoscopic retrograde cholangiopancreatography (ERCP). Radiation exposure data in patients with surgically altered anatomy undergoing enteroscopy-assisted ERCP (EA-ERCP) are scarce. METHODS 34 consecutive EA-ERCP procedures were compared with 68 conventional ERCP (C-ERCP) procedures. Patient and procedure characteristics and radiation data were collected. RESULTS Surgical reconstructions were gastrojejunostomy, Roux-en-Y hepaticojejunostomy, Roux-en-Y total gastrectomy, Roux-en-Y gastric bypass and Whipple's duodenopancreatectomy. Procedures were restricted to biliary indications. Mean fluoroscopy time was comparable in both groups (370 ± 30 s EA-ERCP vs. 393 ± 40 s C-ERCP, p = 0.7074), whereas total mean radiation dose was lower in EA-ERCP (83 ± 6 mGy) compared to C-ERCP (110 ± 11 mGy, p = 0.0491) and dose area product (DAP) was higher in EA-ERCP (2216 ± 173 µGy*m2) compared to C-ERCP (1600 ± 117 µGy*m2, p = 0.0038), as was total procedure time (77 ± 5 min vs. 39 ± 3 min, p < 0.0001). Enteroscope insertion to reach the bile duct during EA-ERCP took 28 ± 4 min, ranging from 4 to 90 min. These results indicate that C-ERCP procedures are generally more complex, needing magnified fluoroscopy, whereas EA-ERCP procedures take more time for enteroscope insertion under wide field fluoroscopic guidance (increased DAP) with less complex ERCP manipulation (lower total radiation dose). CONCLUSIONS Radiation exposure during EA-ERCP in surgically altered anatomy is different as compared to C-ERCP. EA-ERCP takes longer with a higher DAP because of the enteroscope insertion, but with lower total radiation dose because these ERCP procedures are usually less complex.
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Affiliation(s)
| | - Tom G. Moreels
- Department of Gastroenterology & Hepatology, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium;
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Teles de Campos S, Boskoski I, Voiosu T, Arvanitakis M, Costamagna G, Devière J. Face and content validity of a biological papilla designed for the Boškoski-Costamagna ERCP simulator. Gastrointest Endosc 2023; 98:822-829.e1. [PMID: 37390863 DOI: 10.1016/j.gie.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/09/2023] [Accepted: 06/14/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND AND AIMS A biological papilla made of chicken heart tissue, incorporated into the Boškoski-Costamagna ERCP Trainer simulator, was recently designed to allow training in sphincterotomy. This study aimed to evaluate the face and content validity of this tool. METHOD Participants from 2 groups (nonexperienced and experienced [<600 or >600 lifetime ERCPs, respectively]) were invited to perform standardized assignments on the model: sphincterotomy and precut for both groups and papillectomy for the experienced group. Following these assignments, all participants filled out a questionnaire to rate their appreciation of the realism of the model, and experienced endoscopists were also asked to evaluate its didactic value using a 5-point Likert scale. RESULTS A total of 19 participants were included (nonexperienced, n = 10; experienced, n = 9). Parameters regarding the realism of the tool in terms of general appearance, sphincterotomy, precut, and papillectomy were overall considered realistic (4 of 5), with good agreement rates in terms of overall realism between groups. Experienced operators reported the highest realism for "positioning the scope and needle-knife in the field of view" and "during precut," "cutting in small increments during precut," and "controlling the scope during papillectomy," and they highly agreed that this papilla should be included for training novice and intermediate trainees in sphincterotomy, precut, and papillectomy. CONCLUSIONS Our results show good face validity and excellent content validity of this biological papilla combined with the Boškoski-Costamagna ERCP Trainer. This new tool provides a useful, inexpensive, versatile, and easy tool for training regarding sphincterotomy, precut, and papillectomy. Future studies should explore whether including this model in real-life training improves the learning curve of endoscopy trainees.
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Affiliation(s)
- Sara Teles de Campos
- Gastroenterology Department, Digestive Unit, Champalimaud Foundation, Lisbon, Portugal; Université Libre de Bruxelles, Brussels, Belgium.
| | - Ivo Boskoski
- Gastroenterology and Digestive Endoscopy, Fondazione Policlinico Gemelli, Rome, Italy
| | - Theodor Voiosu
- Gastroenterology Department, Colentina Clinical Hospital, Carol Davila Faculty of Medicine, Bucharest, Romania
| | - Marianna Arvanitakis
- Université Libre de Bruxelles, Brussels, Belgium; Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasmus University Hospital, Brussels, Belgium
| | - Guido Costamagna
- Gastroenterology and Digestive Endoscopy, Fondazione Policlinico Gemelli, Rome, Italy
| | - Jacques Devière
- Gastroenterology Department, Digestive Unit, Champalimaud Foundation, Lisbon, Portugal; Université Libre de Bruxelles, Brussels, Belgium; Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasmus University Hospital, Brussels, Belgium
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Rivas A, Pherwani S, Mohamed R, Smith ZL, Elmunzer BJ, Forbes N. ERCP-related adverse events: incidence, mechanisms, risk factors, prevention, and management. Expert Rev Gastroenterol Hepatol 2023; 17:1101-1116. [PMID: 37899490 DOI: 10.1080/17474124.2023.2277776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/27/2023] [Indexed: 10/31/2023]
Abstract
INTRODUCTION Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly performed procedure for pancreaticobiliary disease. While ERCP is highly effective, it is also associated with the highest adverse event (AE) rates of all commonly performed endoscopic procedures. Thus, it is critical that endoscopists and caregivers of patients undergoing ERCP have clear understandings of ERCP-related AEs. AREAS COVERED This narrative review provides a comprehensive overview of the available evidence on ERCP-related AEs. For the purposes of this review, we subdivide the presentation of each ERCP-related AE according to the following clinically relevant domains: definitions and incidence, proposed mechanisms, risk factors, prevention, and recognition and management. The evidence informing this review was derived in part from a search of the electronic databases PubMed, Embase, and Cochrane, performed on 1 May 20231 May 2023. EXPERT OPINION Knowledge of ERCP-related AEs is critical not only given potential improvements in peri-procedural quality and related care that can ensue but also given the importance of reviewing these considerations with patients during informed consent. The ERCP community and researchers should aim to apply standardized definitions of AEs. Evidence-based knowledge of ERCP risk factors should inform patient care decisions during training and beyond.
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Affiliation(s)
- Angelica Rivas
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Simran Pherwani
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rachid Mohamed
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Zachary L Smith
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Nauzer Forbes
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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