Glenn Eisen

Patterns of endoscopy use in the United States

BACKGROUND & AIMS The aim of this study was to use a large national endoscopic database to determine why routine endoscopy is performed in diverse practice settings. METHODS A computerized endoscopic report generator was developed and disseminated to gastrointestinal (GI) specialists in diverse practice settings. After reports were generated, a data file was transmitted electronically to a central databank, where data were merged from multiple sites for analysis. RESULTS From April 1, 1997, to October 28, 1998, 276 physicians in 31 practice sites in 21 states provided 18,444 esophagogastroduodenoscopy (EGD) reports, 20,748 colonoscopy reports, and 9767 flexible sigmoidoscopy reports to the central databank. EGD was most commonly performed to evaluate dyspepsia and/or abdominal pain (23.7%), dysphagia (20%), symptoms of gastroesophageal reflux without dysphagia (17%), and suspected upper GI bleeding (16.3%). Colonoscopy was most often performed for surveillance of prior neoplasia (24%) and evaluation of hematochezia (19%) or positive fecal occult blood test (15%). Flexible sigmoidoscopy was most commonly performed for routine screening (40%) and evaluation of hematochezia (22%). There were significant differences between academic and nonacademic sites. CONCLUSIONS The endoscopic database can be an important resource for future research in endoscopy by documenting current practice patterns and changes in practice over time.

Reliability, validity, and responsiveness of severity of dyspepsia assessment (SODA) in a randomized clinical trial of a COX-2-specific inhibitor and traditional NSAID therapy.

OBJECTIVE:We aimed to assess the Severity of Dyspepsia Assessment (SODA) scales as measures of change in dyspepsia-related health in a blinded, randomized, controlled trial in arthritis patients treated with nonsteroidal anti-inflammatory drugs.METHODS:Three thousand nine hundred seven arthritis patients completed SODA at baseline and weeks 4, 13, 26, and 52 and/or at early termination. Using baseline and 4-wk data, reliability was evaluated with Cronbachs α and the intraclass correlation coefficient (ICC). Dyspepsia adverse events were defined based on a combined set of World Health Organization Adverse Reaction Terminology terms. The ability of SODA to measure change in dyspepsia-related health was evaluated by comparing SODA change scores by dyspepsia adverse event severity level and withdrawal status. Responsiveness was further evaluated by the area under the curve (AUC) from receiver operating characteristic curves using withdrawal due to dyspepsia as the criterion.RESULTS:The SODA scales—Pain Intensity (α= 0.93), Non Pain Symptoms (α= 0.82), and Satisfaction (α= 0.89)—demonstrated excellent internal consistency reliability using baseline data. Reproducibility was fair to good: Pain Intensity ICC = 0.49, Non Pain Symptoms ICC = 0.61, and Satisfaction ICC = 0.45. SODA change scores (4-wk score − baseline score) increased, or worsened, with increasing dyspepsia severity and differentiated between adjacent levels of dyspepsia severity for eight of nine adjacent comparisons (p < 0.05). SODA change scores also differentiated between those who did and did not withdraw (p < 0.001). Responsiveness was highest with the Pain Intensity scale (AUC = 0.78), followed by the Non Pain Symptoms (AUC = 0.74) and Satisfaction (AUC = 0.75) scales.CONCLUSIONS:SODA is a reliable, valid instrument for use as a measure of dyspepsia tolerability in future clinical trials involving cyclo-oxygenase-2-specific and/or traditional nonsteroidal anti-inflammatory drugs.

4464 Can the asa grade predict the risk of endoscopic complications

Background:The American Society of Anesthesiologists (ASA) grade has been used for over 50 years as a predictor of risk for perioperative morbidity and mortality. This measure has been incorporated into the CORI endoscopic database as a potential stratification tool for adverse outcomes related to endoscopy. There are 5 designated levels, ranging from Class Ihealthy patient without comorbidities, to Class V-moribund paient with little chance of survival. Purpose: To utilize a national endoscopic database (CORI) to asses the predicitve ability of the ASA grade for endoscopic complications. Methods:A physician network of 116 endoscopists at 32 sites entered data from 6/30/97-9/30/99. 141,572 endoscopic exams were performed on 104,311 unique patients. EGD, colonoscopy, ERCP and FS exams were used for this study. The ASA grade was entered in 81% of cases. Multivariate analysis, controlling for age and gender was performed to assess the association of ASA grade and risk for complications. This analysis was performed separately for total complications and bleeding and/or perforation. ASA grade V was not analyzed due to the low number of cases (50). Conclusions: The ASA grade strongly predicts the risk of overall complications and the subset with bleeding and/or perforation secondary to endoscopy. The risk of complications for grade IV patients appears 4-8X greater than grade I patients. The ASA grade may be used to stratify the risk of endoscopic complications and as an adjustment tool for patient case-mix.