Andrew Tinsley

A survey of current practice of venous thromboembolism prophylaxis in hospitalized inflammatory bowel disease patients in the United States.

Background: Inflammatory bowel disease (IBD) patients are at an increased risk of thrombosis, particularly when hospitalized. Several clinical practice guidelines now recommend pharmacologic prophylaxis for hospitalized ulcerative colitis and Crohn’s disease patients. It is unclear to what extent gastroenterologists are aware of these recommendations and whether they are administering pharmacologic venous thromboembolism (VTE) prophylaxis appropriately. Our aim was to explore current practice of VTE prophylaxis in hospitalized IBD patients in the United States. Methods: A survey was mailed electronically to gastroenterologists whose electronic mail address was listed in the American College of Gastroenterology (ACG) database. This survey included clinical vignettes outlining scenarios for consideration of VTE prophylaxis. Results: A total of 6227 surveys were sent to gastroenterologists nationwide, and 591 physicians chose to participate (response rate 9.5%). Respondents (80.6%) believed that hospitalized IBD patients have a higher risk of VTE than other inpatients. A total of 29.1% were unaware of any recommendations addressing pharmacologic prophylaxis included in ACG IBD guidelines and 34.6% would give pharmacologic VTE prophylaxis to a hospitalized patient with severe ulcerative colitis. Heparin VTE prophylaxis use was associated with gastroenterologists who indicated that their practices comprised more than 50% of patients with IBD (P=0.0001), being a physician at an academic hospital (P=0.0001) and providers having less than 5 years practice experience (P=0.003). Conclusions: Despite reasonable awareness of the increased risk of thrombosis in hospitalized IBD patients, many US gastroenterologists may not follow clinical practice guidelines and use pharmacologic VTE prophylaxis.

Validation of the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) in patients with inflammatory bowel disease

Aliment Pharmacol Ther 2011; 34: 1328–1336

Current practice and perception of screening for medication adherence in inflammatory bowel disease.

Background Adherence to medication in inflammatory bowel disease (IBD) improves outcomes. Current practices of screening for adherence to IBD medications are unknown. The goal of this study was to determine current practice and perception of screening for medication adherence among US-based gastroenterologists. Methods A survey was mailed electronically to gastroenterologists whose electronic-mail address was listed in the American College of Gastroenterology database. Physicians who cared for IBD patients were invited to answer. Results About 6830 surveys were sent to gastroenterologists nationwide, and 395 physicians who cared for IBD patients completed the survey. The true response rate is unknown, as the number of physicians caring for IBD patients in the database is unknown. About 77% (n=303) of physicians who responded stated they screen for adherence to medication. Of the 77% of physicians who screened for adherence, only 19% (n=58) use accepted measures of screening for adherence (pill counts, prescription refill rates, or adherence surveys). The remaining 81% used patient interview to screen for adherence, a measure considered least accepted to determine adherence, as it overestimates adherence. The average number of IBD patients observed in 1 week had no statistical significance in predilection for screening (P=0.82). Private practice physicians (P=0.05), younger physicians (P=0.03), and physicians with fewer years of experience (P=0.02) all were more likely to screen. About 95% of responders thought determining a low adherer to medicine was important because an intervention can increase adherence. Conclusions The majority of gastroenterologists surveyed recognize that adherence to medication is important and improves outcomes. The majority of physicians in this study are screening for nonadherence in IBD, but are not using accepted measures for adherence detection. If this study truly reflects the majority of physicians nationwide, changing the way physicians screen for adherence, may detect more low adherers to medication.

Ulcerative Colitis Is Associated With an Increased Risk of Venous Thromboembolism in the Postoperative Period The Results of a Matched Cohort Analysis

OBJECTIVES To determine the rates of venous thromboembolism (VTE) during admission and within 30 days of hospital discharge in inflammatory bowel (IBD) patients undergoing colonic resection using the ACS National Surgical Quality Improvement Project (NSQIP) database and to compare these rates to VTE rates in cohorts of patients undergoing colonic resection for several other colonic pathologies. BACKGROUND High rates of VTE have been demonstrated in hospitalized IBD patients. However, rates of postdischarge VTE in IBD patients are understudied. METHODS Demographic, operative, and outcomes data for 96,999 patients undergoing colonic resection for diverticulitis, colorectal cancer (CRC), benign neoplasms, ulcerative colitis (UC), and Crohns disease (CD) between 2005 and 2011 was obtained. Student t and χ tests were used for univariate analysis. A logistic multivariate analysis was performed with all significant variables. Propensity score matching was utilized to compare the VTE incidences between the groups. RESULTS Highest VTE risk was seen in obese patients [odds ratio (OR) = 1.41], those older than 73 years (OR = 1.58) and with bleeding disorders (OR = 1.44), American Society of Anesthesiology class III/IV (OR = 1.52/1.86), preoperative systemic inflammatory response syndrome (OR = 1.55), sepsis (OR = 1.48) or steroid use (OR = 1.63), and primary diagnosis of UC (OR = 2.10). The UC group had the highest incidence of VTE (2.74%), followed by CRC patients (1.74%). A 1.2% incidence was seen in the CD population, and 41.5% of the UC-VTEs were diagnosed after discharge. CONCLUSIONS This study affirms that inpatient UC patients undergoing colonic resection are at high risk for VTE and suggests that this risk persists into the postdischarge period. Thus, these patients should be given appropriate prophylaxis.

Rates of pharmacologic venous thromboembolism prophylaxis in hospitalized patients with active ulcerative colitis: Results from a tertiary care center

BACKGROUND Inflammatory bowel disease (IBD) patients are at increased risk for venous thromboembolism (VTE) compared to the general population. Practice guidelines recommend pharmacologic prophylaxis for IBD inpatients. AIM Our aim was to determine the rates of pharmacologic VTE prophylaxis in ulcerative colitis (UC) inpatients at a tertiary referral center. We also assessed potential predictors of pharmacologic prophylaxis. METHODS We conducted a retrospective cohort study of 377 UC patients between January 1st, 2007 and December 31st, 2011. The medical record of each patient was examined to determine whether pharmacologic VTE prophylaxis was ordered and administered. We conducted multiple logistic regression to determine predictors of pharmacologic prophylaxis. RESULTS The overall VTE pharmacologic prophylaxis rate was 67.6%. The rate of patients admitted to the medical service was 57.4% compared to 93.5% for those admitted to surgery. In medical patients who received pharmacologic VTE prophylaxis, 34.0% of ordered doses were not given compared to 17.4% of doses in surgical patients (P<0.001). In the multiple logistic regression analysis, having an additional VTE risk factor (OR 2.46, 95% CI 1.41-4.30), extensive colitis (OR 2.26, 95% CI 1.32-3.87) or being admitted to a surgical service (OR 12.03, 95% CI 5.29-27.38) was associated with VTE pharmacologic prophylaxis. CONCLUSIONS A substantial proportion of medical patients admitted with UC were not ordered for VTE pharmacologic prophylaxis despite current guidelines. Even in patients who were ordered for pharmacologic prophylaxis, one third of doses were not given. Inappropriate prophylaxis may lead to unnecessary morbidity and mortality.

Early readmission in patients hospitalized for ulcerative colitis: incidence and risk factors

Abstract Objective. Early readmission rates are becoming an integral measure of the quality of care for hospitalized patients with chronic diseases. The incidence and predictors of early readmission in patients with inflammatory bowel disease (IBD) are uncertain. Risk factors for readmission over the first few weeks may differ from those that influence re-hospitalization at later time points. We examined the incidence and predictors of both 30-day and 90-day readmissions among ulcerative colitis (UC) patients. Materials and methods. A retrospective, cohort study was performed including all severe UC patients admitted to a tertiary-care hospital between January 2007 and December 2011. All-cause readmissions to the medical or surgical service within 30 and 90 days were recorded to allow the calculation of early readmission rates. We used multiple logistic regression to analyze demographic, hospital-related, general medical and IBD-specific factors as potential risk factors for readmission. Results. There were a total of 229 patients discharged following hospitalization for severe UC. The 30- and 90-day readmission rates were 11.7% and 20.5%, respectively. Forty-seven percent of early readmissions were for colectomy. In the 30-day analysis, only the presence of extensive colitis (odds ratio 3.59; 95% confidence interval [CI] 1.41–9.13) compared with left-sided disease was independently associated with readmission. Extensive colitis (3.09, 95% CI 1.33–7.08), albumin on admission (0.56, 0.31–0.99) and being admitted to a housestaff service (2.87, 95% CI 1.14–6.54), were independent predictors of readmission at 90 days. Conclusions. Early readmission is common in IBD. Independent risk factors for early readmission included extensive colitis, admission albumin, and being admitted to a housestaff service.

Knowledge, Attitudes, and Beliefs Regarding the Role of Nutrition in IBD Among Patients and Providers.

Background:Malnutrition is common in inflammatory bowel disease (IBD). Identifying patients who are malnourished or at risk for malnutrition may lead to early intervention and improve patient outcomes. To date, little is known about the role of nutritional assessment and management in IBD care. We aimed to evaluate knowledge, attitudes, and beliefs regarding nutrition in IBD among patients and providers. Methods:Surveys were mailed electronically to patients and providers identified through their membership in the Crohns & Colitis Foundation of America. In addition, patient and provider focus groups were conducted to explore nutrition-related themes. These surveys and focus groups were designed to evaluate knowledge and perceived importance of nutrition, patient–provider interactions regarding nutrition and use of nutritional resources. Results:There were 223 provider respondents (65.5% gastroenterologists, 15.2% nurses, and 6.7% dietitians). Forty-one percent of the gastroenterologists rated their knowledge of nutrition in IBD as “very good” compared with 87% of dietitians and 16% of nurses (P < 0.001). Thirty-three percent of the gastroenterologists reported not routinely screening their IBD patients for malnutrition. The patient survey had 567 respondents with 27% rating their knowledge of nutrition in IBD as “very good.” In the focus groups, a lack of adequate IBD nutritional resources was evident along with a desire for improved access to nutrition specialists. Conclusions:Significant gaps in knowledge relating to nutrition in IBD seem to exist. Targeted educational initiatives and improved access to nutritional experts are warranted. In addition, a standardized process for the assessment of malnutrition among patients with IBD should be developed.

Characteristics, goals, and motivations of applicants pursuing a fourth-year advanced endoscopy fellowship

BACKGROUND The number of applications to advanced endoscopy fellowships has increased in past years. There is limited knowledge regarding why gastroenterology fellows pursue interventional/advanced endoscopy (AE) as a career. OBJECTIVE To explore the characteristics, goals, and motivations of applicants applying for AE fellowships. DESIGN A total of 101 applicants of the 2011 AE fellowship match were sent a survey via electronic mail 4 weeks after the match. PARTICIPANTS A total of 65 applicants participated. INTERVENTION Study questionnaire. RESULTS The response rate was 64.4% (95% certainty ± 5%). By the first year of gastroenterology fellowship, 67% had decided to apply for an AE fellowship. Half stated that pursuing a career in AE was a difficult decision; primary concerns included the additional year of training and the delay in income. A total of 69% of applicants intended to pursue academics. Applicants listed endoscopic procedures (92%), exposure to mentors in the field (46%), and demand for the skill set (43%) as the most significant sources of motivation in pursuing AE. Influential factors in an applicants decision to choose a program included high procedure volume (69%), reputation of the program (63%), and a desirable geographic location (61%). Applicants who reported difficulty in choosing AE as a career were less inclined to pursue academia as compared with those with no difficulty deciding (54.8% vs 84.4%; P = .006). These same applicants were similarly less motivated to pursue research (3.1% vs 34.3%; P = .002). Applicants who favored academia versus private practice listed mentors in the field (54% vs 25%; P = .031) and research interest (27.3% vs 0%; P = .012) as significant factors. LIMITATIONS One-year sample of applicants. CONCLUSION Although a majority of applicants decided to pursue careers in AE during the first year of gastroenterology fellowship, making the decision was difficult for half of the applicants. Motivations for choosing AE as a career differed among applicants interested in academics versus private practice.

Refractory Peristomal Pyoderma Gangrenosum Successfully Treated With Intravenous Immunoglobulin: A Case Report

Refractory Peristomal Pyoderma Gangrenosum Successfully Treated With Intravenous Immunoglobulin: A Case Report

An Electronic Alert System Is Associated With a Significant Increase in Pharmacologic Venous Thromboembolism Prophylaxis Rates Among Hospitalized Inflammatory Bowel Disease Patients.

Background: Utilization of pharmacologic venous thromboembolism (VTE) prophylaxis in inflammatory bowel disease (IBD) patients seems to be suboptimal with reported rates as low as 50% in some studies. Implementation of an electronic alert system seems to be an effective tool for increasing VTE prophylaxis rates in medical inpatients. To date, no studies have assessed whether this approach is associated with improved rates of pharmacologic VTE prophylaxis specifically in IBD patients. Aims: To determine the efficacy of an electronic alert in improving VTE prophylaxis rates in hospitalized IBD patients. Methods: We conducted a retrospective cohort study of 576 hospitalized IBD patients. The medical record of each patient was then examined to determine whether pharmacologic VTE prophylaxis was both ordered and administered, the timing of pharmacologic VTE prophylaxis, and reasons for any missed doses. Results: The VTE pharmacologic prophylaxis rate was improved from 60% to 81.2% following the implementation of the electronic alert system (p < .001). An increase in prophylaxis rates was seen in both medical (26.3% vs. 62.8%, p < .001) and surgical services (83.7% vs. 95.5%, p < .001). In patients who received pharmacologic VTE prophylaxis, 16% of all ordered doses were not administered and 57.3% of missed doses were the result of patient refusal. Hospitalization after implementation of the electronic alert system (odds ratio [OR] 4.71, 95% confidence interval [CI] 2.94–7.57) and admission to a surgical service (OR 14.3, 95% CI 8.62–24.39) were predictive of VTE pharmacologic prophylaxis orders. Conclusions: The introduction of an electronic alert system was associated with a significant increase in rates of pharmacologic VTE prophylaxis. However, orders were often delayed and doses not always administered. The most common reason that ordered doses were not given was patient refusal.