Gavin C. Harewood

Economic analysis of combined endoscopic and endobronchial ultrasound in the evaluation of patients with suspected non-small cell lung cancer.

Lung cancer remains the most common cause of cancer-related death in the United States. This study evaluated the costs of alternative diagnostic evaluations for patients with suspected non-small cell lung cancer (NSCLC). Researchers used a cost-minimization model to compare various diagnostic approaches in the evaluation of patients with NSCLC. It was less expensive to use an initial endoscopic ultrasound (EUS) with fine needle aspiration (FNA) to detect a mediastinal lymph node metastasis (

Band ligation of gastric antral vascular ectasia is a safe and effective endoscopic treatment.

18,603 per patient), compared with combined EUS FNA and endobronchial ultrasound (EBUS) with FNA (

Co-prescription of gastro-protectants in hospitalized patients: an analysis of what we do and what we think we do.

18,753). The results were sensitive to the prevalence of malignant mediastinal lymph nodes; EUS FNA remained least costly, if the probability of nodal metastases was <32.9%, as would occur in a patient without abnormal lymph nodes on computed tomography (CT). While EUS FNA combined with EBUS FNA was the most economical approach, if the rate of nodal metastases was higher, as would be the case in patients with abnormal lymph nodes on CT. Both of these strategies were less costly than bronchoscopy or mediastinoscopy. The pre-test probability of nodal metastases can determine the most cost-effective testing strategy for evaluation of a patient with NSCLC. Pre-procedure CT may be helpful in assessing probability of mediastinal nodal metastases.

Randomised clinical trial: a ‘nudge’ strategy to modify endoscopic sedation practice

Gastric antral vascular ectasia (GAVE) or ‘watermelon stomach’ is a rare and often misdiagnosed cause of occult upper gastrointestinal bleeding. Treatment includes conservative measures such as transfusion and endoscopic therapy. A recent report suggests that endoscopic band ligation (EBL) offers an effective alternative treatment. The aim of the present study is to demonstrate our experiences with this novel technique, and to compare argon plasma coagulation (APC) with EBL in terms of safety and efficacy.

Utilization of resource leveling to optimize ERCP efficiency.

Background Proton pump inhibitors (PPIs) reduce the risk of upper gastrointestinal hemorrhage (UGIH) associated with the use of many medications. Goals To examine how clinicians perceive such risk and whether PPI coprescribing is based on an accurate assessment. Study Methods Clinicians in a single teaching hospital were asked to estimate risk of UGIH and comment on PPI coprescription in hypothetical patients. Records of 160 hospital in-patients (median age; 74 y) were then reviewed to examine PPI prescribing and risk factors for UGIH. Results In general, clinicians estimated UGIH risk accurately and reported low thresholds for PPI coprescription. Prescribing records showed regular PPI use increased between admission and discharge of patients from 61/160 (38%) to 93/160 (58%). Ten percent had a prior history of peptic ulcer disease. Proton pump inhibitor prescription was significantly associated with the use of aspirin and clopidogrel. Half of the patients with multiple risk factors for UGIH on admission and almost a third at discharge were not coprescribed a PPI. Conclusions Clinicians generally estimate correctly the risk of UGIH and report a low threshold for prescribing gastro-protection. Despite this, prescribing practice does not consistently take account of relative risk of UGIH. Targeted PPI coprescribing on the basis of risk factors would lead to more rational PPI use.

Intra-aortic mural thrombosis and splenic infarction in association with ulcerative colitis

Aliment Pharmacol Ther 2011; 34: 229–234

Sleep deprivation leads to reduction in polyp detection among endoscopy trainees

BackgroundOptimizing endoscopy efficiency is becoming increasingly important. This study profiled ERCP availability and assessed resource leveling as a strategy to enhance efficiency.DesignAll ERCPs performed at an academic teaching hospital between January 2007 and December 2008 were reviewed. Procedure timeliness (time between admission and ERCP) and demand were analyzed to assess resource utilization.ResultsData were recorded for 393 ERCPs. Profiling identified an unequal distribution of waiting times from admission to procedure due to restricted ERCP availability. Use of resource leveling methodology demonstrated that a small increase in procedure availability (one additional half day per week) would significantly reduce the hospital stay of ERCP patients.ConclusionsResource leveling can be applied to balance procedure provision with demand to cope with fluctuations in demand. The impact of resource leveling can be truly measured only by implementing these changes and prospectively studying the effect.

Measuring the Value of Colonoscopists’ Performance

BackgroundArterial thrombosis is a very rare, but recognised complication of inflammatory bowel disease that can result in significant morbidity and mortality.Case presentationWe present the case of a 48-year-old female with previously well-controlled ulcerative colitis who presented with severe left upper quadrant abdominal pain. Imaging investigations subsequently revealed a large intra-aortic mural thrombus extending into the coeliac axis complicated by splenic infarction. This occurred in the absence of other prothrombotic states such as thrombophilias or vasculitis.ConclusionThis case highlights the frequently overlooked association between inflammatory bowel disease and arterial thrombosis.

Creating a lean endoscopist: Does operations management have a role in endoscopy?

the mean size of tumors that were treated using ESD in our pilot study was 26.8 mm with resultant mucosal defects of at least 30 mm in most cases. In our earlier multicenter study analyzing 1111 colorectal ESD cases, the incidence of delayed bleeding was 1.5% (17/1111), which we regard as being higher than the incidence of such bleeding after polypectomies and conventional EMRs performed on smaller lesions.3 The effectiveness of our closure technique for large mucosal defects after colorectal ESDs, therefore, still needs to be demonstrated in a randomized clinical trial. We also consider the closure technique to be a useful preventive method for delayed perforations, particularly in ESDs involving damage to the muscle layer. Delayed perforations seldomly occur (0.4%; 4/1111),3 although they are occasionally inolved in cases of fatal peritonitis. In addition, the closure echnique can reinforce a fragile bowel wall against the train of normal peristaltic action with a view toward olorectal ESD potentially becoming a 1-day treatment in he future. Finally, the closure technique is thought to be ppropriate, even for small perforations that may be diffiult to close by using the conventional clipping method ecause of a fragile or frayed muscle layer. As demonstrated in our study, the mean procedure time as 15 minutes. This is a reasonable amount in our estiation because closure of large mucosal defects can ometimes be more difficult and time-consuming when sing conventional clipping. Currently, the new closure echnique is not necessary in every case of colorectal ESD, ut we recommend the technique in high-risk cases inluding those in which the patient is a regular user of an ntithrombotic agent or the muscle layer is damaged durng ESD. To demonstrate the true effectiveness of this echnique, however, we strongly support further evaluaion in a randomized clinical trial involving a larger numer of patients.

Pricing Practices of Gastroenterologists in New York

The article by Gohel at al not only addresses the relevant relationship between polypectomy rate (PR) and adenoma detection rate (ADR) but also provides important clinical insights into the value of colonoscopy performance among a large cohort of endoscopists. With the growing emphasis on value-based payment, the value of clinicians’ performance is now subject to greater scrutiny. In healthcare, value is defined as quality of care adjusted for cost. In the context of colonoscopy practice, one approach to expressing value is the ratio of adenoma detection, a measure of quality, to polyp detection, which can serve as a surrogate estimate of procedure cost. The principal cost components of a colonoscopy are technical facility charge, endoscopist professional charge, pathology charge, and anesthesia charge. In endoscopy units in which sedation is administered by the endoscopist, thereby avoiding any additional anesthesiologist professional fee, the number of histology specimen containers used, which generally correlates closely with PR, represents the major source of variable costs per procedure. Therefore, with these assumptions in mind, the ratio of ADR to PR can be used to estimate the value of a colonoscopist’s performance, ie, quality/cost. In the article by Gohel et al, the overall mean ADR/PR ratio for the 65 colonoscopists studied was 58%, with a broad variation from 0% to 97% and standard deviation of 20%. The coefficient of variation (ratio of the standard deviation to the mean) was 34%; by convention, a coefficient of variation >15% represents broad spread, thereby indicating a high level of variation in value of endoscopists’ performances. Figure 1 illustrates the relationship between ADR and PR for the author’s study group. The horizontal line separates endoscopists with ADR above and below the mean (25%). As shown, the cohort of endoscopists who achieve an acceptable level of quality (ADR >25%) can be further classified as higher value or lower value performers on the basis of whether they have high PR (thereby incurring high pathology charges) or low PR (incurring lesser pathology charges). Although there are many measures of colonoscopy quality other than ADR and many contributors to cost other than pathology charges, the data provided by Gohel et al illustrate one approach to numerically quantifying the value of colonoscopy performance. With the introduction of the Affordable Care Act and the shift toward value-based reimbursement in place of a fee-for-service model of payment, value measurement, not just in endoscopy but in all aspects of clinical care, will assume increasing importance.