Dyanna L. Gregory

Incidence and Prevalence of Achalasia in Central Chicago, 2004–2014, Since the Widespread Use of High-Resolution Manometry

BACKGROUND & AIMS Reported global incidence and prevalence values for achalasia vary widely, from 0.03 to 1.63 per 100,000 persons per year and from 1.8 to 12.6 per 100,000 persons per year, respectively. This study aimed to reconcile these low values with findings from a major referral center, in central Chicago (which began using high‐resolution manometry in 2004 and used it in all clinical studies since 2005), and has determined the incidence and prevalence of achalasia to be much greater. METHODS We collected data from the Northwestern Medicine Enterprise Data Warehouse database (tertiary care setting) of adults residing in Chicago with an encounter diagnosis of achalasia from 2004 through 2014. Patient files were reviewed to confirm diagnosis and residential address. US Census Bureau population data were used as the population denominator. We assumed that we encountered every incident case in the city to calculate incidence and prevalence estimates. Data were analyzed for the city at large and for the 13 zip codes surrounding the Northwestern Memorial Hospital (NMH), the NMH neighborhood. RESULTS We identified 379 cases (50.9% female) that met the full inclusion criteria; of these, 246 were incident cases. Among these, 132 patients resided in the NMH neighborhood, 89 of which were incident cases. Estimated yearly incidences were stable over the study period, ranging from 0.77 to 1.35 per 100,000 citywide (average, 1.07 per 100,000) and from 1.41 to 4.60 per 100,000 in the NMH neighborhood (average, 2.92 per 100,000). The corresponding prevalence values increased progressively, from 4.68 to 14.42 per 100,000 citywide and from 15.64 to 32.58 per 100,000 in the NMH neighborhood. CONCLUSIONS The incidence and prevalence of achalasia in central Chicago diagnosed using state‐of‐the‐art technology and diagnostic criteria are at least 2‐ to 3‐fold greater than previous estimates. Additional studies are needed to determine the generalizability of these data to other regions.

Evaluating the reliability and construct validity of the Eckardt symptom score as a measure of achalasia severity

Achalasia is a disease of mechanical esophageal dysfunction characterized by dysphagia, chest pain, regurgitation, and malnutrition. The Eckardt symptom score (ESS) is the gold standard self‐report assessment tool. Current guidelines outline a three‐step approach to patient reported outcomes measure design. Developed prior to these policies, the ESS has not undergone rigorous testing of its reliability and validity.

Design and participant characteristics for a randomized effectiveness trial of an intensive lifestyle intervention to reduce cardiovascular risk in adults with type 2 diabetes: The I-D-HEALTH study

Intervening in Diabetes with Healthy Eating, Activity and Linkages To Healthcare (I-D-HEALTH) is a community-based randomized trial evaluating the effectiveness of a group-based adaption of the Look AHEAD intensive lifestyle intervention. Most potentially eligible patients were identified through electronic medical record queries or referral to a diabetes resource hub. Trial enrollees had a usual source of primary care, elevated body mass index (BMI) and type 2 diabetes. I-D-HEALTH participants were randomized to either standard care alone or standard care plus free-of-charge access to a group-based lifestyle intervention (GLI) offered by the YMCA. GLI participation was encouraged, but not required, for the latter group. The primary outcome is percent weight change over 6, 12 and 24months. Secondary outcomes include direct intervention costs and direct medical and non-medical expenditures, as well as changes in systolic blood pressure, hemoglobin A1c and cholesterol. Among 331 I-D-HEALTH participants, 167 were randomized to standard care and 164 to GLI. The mean age (±standard deviation) in each group was 57.1years (±12.2) and 57.6years (±10.5), respectively. Mean BMI was 34.9kg/m(2) (±7.3) among standard care participants and 36.2kg/m(2) (±7.8) among GLI participants. In both groups, approximately one third of participants were non-Hispanic Whites. We detected no significant differences between groups in mean systolic blood pressure, hemoglobin A1c or total cholesterol (P >0.05 for all characteristics above). The I-D-HEALTH study enrolled a diverse sample of adults with diabetes and offers a unique opportunity to evaluate the effectiveness of offering a community-based intensive lifestyle intervention.

Improved Assessment of Bolus Clearance in Patients With Achalasia Using High-Resolution Impedance Manometry

Background & Aims: Esophageal retention is typically evaluated by timed‐barium esophagram in patients treated for achalasia. Esophageal bolus clearance can also be evaluated using high‐resolution impedance manometry. We evaluated the associations of conventional and novel high‐resolution impedance manometry metrics, esophagram, and patient‐reported outcomes (PROs) in achalasia. Methods: We performed a prospective study of 70 patients with achalasia (age, 20–81 y; 30 women) treated by pneumatic dilation or myotomy who underwent follow‐up evaluations from April 2013 through December 2015 (median, 12 mo after treatment; range, 3–183 mo). Patients were assessed using timed‐barium esophagrams, high‐resolution impedance manometry, and PROs, determined from Eckardt scores (the primary outcome) and the brief esophageal dysphagia questionnaire. Barium column height was measured from esophagrams taken 5 minutes after ingestion of barium (200 mL). Impedance‐manometry was analyzed for bolus transit (dichotomized) and with a customized MATLAB program (The MathWorks, Inc, Natick, MA) to calculate the esophageal impedance integral (EII) ratio. Results: Optimal cut points to identify a good PRO (defined as Eckardt score of ≤3) were esophagram barium column height of 3 cm (identified patients with a good PRO with 63% sensitivity and 75% specificity) and an EII ratio of 0.41 (identified patients with a good PRO with 83% sensitivity and 75% specificity). Complete bolus transit identified patients with a good PRO with 28% sensitivity and 75% specificity. Of the 25 patients who met these cut points for both esophagram barium column height and EII ratio, 23 (92%) had a good PRO. Of the 17 patients who met neither cut point, 14 (82%) had a poor PRO (Eckardt score above 3). Conclusions: In a prospective study of 70 patients with achalasia, we found EII ratio identified patients with good PROs with higher levels of sensitivity (same specificity) than timed‐barium esophagram or impedance‐manometry bolus transit assessments. The EII ratio should be added to achalasia outcome evaluations that involve high‐resolution impedance manometry as an independent measure and to complement timed‐barium esophagram.

The Reflux Improvement and Monitoring (TRIM) Program Is Associated With Symptom Improvement and Weight Reduction for Patients With Obesity and Gastroesophageal Reflux Disease.

Objectives:Current healthcare systems do not effectively promote weight reduction in patients with obesity and gastroesophageal reflux disease (GERD). The Reflux Improvement and Monitoring (TRIM) program provides personalized, multidisciplinary, health education and monitoring over 6 months. In this study we aimed to (i) measure the effectiveness of TRIM on GERD symptoms, quality of life, and weight, and (ii) examine patient health beliefs related to TRIM.Methods:This prospective mixed methods feasibility study was performed at a single center between September 2015 and February 2017, and included adult patients with GERD and a body mass index ≥30 kg/m2. Quantitative analysis consisted of a pre- to post-intervention analysis of TRIM participants (+TRIM Cohort) and a multivariable longitudinal mixed model analysis of +TRIM vs. patients who declined TRIM (−TRIM Cohort). Primary outcomes were change in patient-reported GERD symptom severity (GerdQ) and quality of life (GerdQ-DI), and change in percent excess body weight (%EBW). Qualitative analysis was based on two focus groups of TRIM participants.Results:Among the +TRIM cohort (n=52), mean baseline GerdQ scores (8.7±2.9) decreased at 3 months (7.5±2.2; P<0.01) and 6 months (7.4±1.9; P=0.02). Mean GerdQ-DI scores decreased, but did not reach statistical significance. Compared with the −TRIM cohort (n=89), reduction in %EBW was significantly greater at 3, 6, and 12 months among the +TRIM cohort (n=52). In qualitative analysis, patients unanimously appreciated the multidisciplinary approach and utilized weight loss effectively to improve GERD symptoms.Conclusions:In this mixed methods feasibility study, participation in TRIM was associated with symptom improvement, weight reduction, and patient engagement.

Electronic Clinical Decision Support Tools for Obesity and Gastroesophageal Reflux Disease: The Provider’s Perspective

Electronic clinical decision support (CDS) in the medical record is a potentially powerful tool to improve patient outcomes. Although CDS is increasingly utilized, limited data exist on the utilization, strengths, and drawback of CDS tools in the management of gastrointestinal disease [1–3]. We recently described the design and effective implementation of The Reflux Improvement and Monitoring (TRIM) program, which leveraged CDS to provide a 6-month patient-centered weight loss counseling program tailored to patients with gastroesophageal reflux disease (GERD) and administered by trained health educators [4]. While we reported patient health beliefs regarding TRIM, we did not explore provider perspectives. In this study, we aimed to assess provider factors and perspectives related to the CDS and TRIM in order to better inform future CDS implementation. In this study, we first prospectively examined the association between provider level factors and CDS acceptance defined as the percentage of CDS firings that led to a signed referral order between October 2015 and September 2017 in general internal medicine (GIM) and gastroenterology (GI) outpatient clinics at a single academic medical center. Next, we evaluated provider satisfaction with and perceptions of the CDS through a survey study. Surveys were distributed in email or paper form to 102 providers in the GIM and GI clinics between March and May 2017. The 13-item survey utilized Likert and modified Likert scales, multiple choice selection, and free response. Among 2361 unique triggered CDS alerts for patients with obesity and GERD, 503 (21.3%) were accepted and led to referral orders being placed for TRIM. Female providers were significantly more likely to refer compared to male providers (OR 1.9, CI 1.5–2.3; p < 0.01) and GI providers were significantly more likely to refer compared to GIM providers (OR 2.5, CI 2.0–3.1, p < 0.001). Provider age did not influence likelihood of referral. Survey response rate was 42% (43/102). The majority of providers (76%) agreed or strongly agreed that TRIM was an effective intervention for their patients with obesity and GERD. Providers were most likely to offer TRIM to patients that displayed high motivation for weight loss, and with more severe obesity. The top reported barrier to referral for GIM providers was a lack of time to consider the CDS, which appeared for them mixed in with other CDS in a dedicated section of the patient chart. When asked what would encourage them to refer more patients to TRIM, 60% of GIM providers selected satisfied patient/provider testimonials, and 40% selected having TRIM referral orders available outside of the CDS. Only 11% believed that having CDS appear more often would encourage them to refer more patients, suggesting that increased CDS must be balanced against the potential for alert fatigue. This post-hoc analysis provides the following important lessons for future CDS implementation: (1) satisfied patient and provider testimonials should be integrated into program promotion, (2) promotion should be particularly emphasized to providers in departments outside of the implementers’ home department, and (3) empowering and educating providers to place referrals outside of CDS is essential.

Video-Based Assessments of Colonoscopy Inspection Quality Correlate With Quality Metrics and Highlight Areas for Improvement

Background & Aims: Adenoma detection rate (ADR) and serrated polyp detection rate (SDR) vary significantly among colonoscopists. Colonoscopy inspection quality (CIQ) is the quality with which a colonoscopist inspects for polyps and may explain some of this variation. We aimed to determine the relationship between CIQ and historical ADRs and SDRs in a cohort of colonoscopists and assess whether there is variation in CIQ components (fold examination, cleaning, and luminal distension) among colonoscopists with similar ADRs and SDRs. Methods: We conducted a prospective observational study to assess CIQ among 17 high‐volume colonoscopists at an academic medical center. Over 6 weeks, we video‐recorded >28 colonoscopies per colonoscopist and randomly selected 7 colonoscopies per colonoscopist for evaluation. Six raters graded CIQ using an established scale, with a maximum whole colon score of 75. Results: We evaluated 119 colonoscopies. The median whole‐colon CIQ score was 50.1/75. Whole‐colon CIQ score (r=0.71; P<.01) and component scores (fold examination r=0.74; cleaning r=0.67; distension r=0.77; all P<.01) correlated with ADR. Proximal colon CIQ score (r=0.67; P<.01) and component scores (fold examination r=0.71; cleaning r=0.62; distension r=0.65; all P<.05) correlated with SDR. CIQ component scores differed significantly between colonoscopists with similar ADRs and SDRs for most of the CIQ skills. Conclusion: In a prospective observational study, we found CIQ and CIQ components to correlate with ADR and SDR. Colonoscopists with similar ADRs and SDRs differ in their performance of the 3 CIQ components—specific, actionable feedback might improve colonoscopy technique.

An automated inpatient split-dose bowel preparation system improves colonoscopy quality and reduces repeat procedures

Background/Goals: Inpatient colonoscopy preparations are often inadequate, compromising patient safety and procedure quality, while resulting in greater hospital costs. The aims of this study were to: (1) design and implement an electronic inpatient split-dose bowel preparation order set; (2) assess the intervention’s impact upon preparation adequacy, repeated colonoscopies, hospital days, and costs. Study: We conducted a single center prospective pragmatic quasiexperimental study of hospitalized adults undergoing colonoscopy. The experimental intervention was designed using DMAIC (define, measure, analyze, improve, and control) methodology. Prospective data collected over 12 months were compared with data from a historical preintervention cohort. The primary outcome was bowel preparation quality and secondary outcomes included number of repeated procedures, hospital days, and costs. Results: On the basis of a Delphi method and DMAIC process, we created an electronic inpatient bowel preparation order set inclusive of a split-dose bowel preparation algorithm, automated orders for rescue medications, and nursing bowel preparation checks. The analysis data set included 969 patients, 445 (46%) in the postintervention group. The adequacy of bowel preparation significantly increased following intervention (86% vs. 43%; P<0.01) and proportion of repeated procedures decreased (2.0% vs. 4.6%; P=0.03). Mean hospital days from bowel preparation initiation to discharge decreased from 8.0 to 6.9 days (P=0.02). The intervention resulted in an estimated 1-year cost-savings of

Endoscopic resection is cost-effective compared with laparoscopic resection in the management of complex colon polyps: an economic analysis

46,076 based on a reduction in excess hospital days associated with repeated and delayed procedures. Conclusions: Our interdisciplinary initiative targeting inpatient colonoscopy preparations significantly improved quality and reduced repeat procedures, and hospital days. Other institutions should consider utilizing this framework to improve inpatient colonoscopy value.