J. Barry O'Connor

A prospective study of factors that determine cecal intubation time at colonoscopy.

BACKGROUND For outpatient colonoscopy, the time required to intubate the cecum is variable. The aim of this study was to determine factors associated with cecal intubation time. METHODS A total of 693 consecutive outpatient colonoscopies performed from January to October 2002 at a tertiary care medical center were studied prospectively. Data gathered included time required to reach the cecum; patient age, gender, and body mass index; history of abdominal surgery; quality of bowel preparation; presence/absence of diverticula; and endoscopist experience. RESULTS Complete data were available for 587 patients. Mean age was 59 years, 48% were men, and mean body mass index was 28. Median cecal intubation time was 9 minutes. Linear regression analysis was performed. Cecal intubation time is prolonged by the following factors: older patient age, female gender, lower body mass index, poor bowel preparation, and lower endoscopist annual case volume. CONCLUSIONS This large, prospective study identified 5 factors that prolong the time required for cecal intubation at colonoscopy. These factors may be used to individualize scheduling of colonoscopy according to the time required.

The cost-effectiveness of treatment strategies for achalasia

Achalasia is a disorder characterized by abnormal motility of the esophageal body and the lower esophageal sphincter, resulting in dysphagia, regurgitation, and chest pain. Treatment options for achalasia include Botulinum toxin injection, pneumatic balloon dilation, and surgical esophagomyotomy. The aim of this study was to determine the cost-effectiveness of these three strategies in the treatment of achalasia in adults. We constructed a Markov cost-effectiveness model comparing Botox injection, pneumatic balloon dilation, and laparoscopic esophagomyotomy as initial treatments of achalasia. Costs and probabilities were derived from the published literature. The utility for symptomatic achalasia was derived from a sample of patients with achalasia. Sensitivity analyses were performed. Over a five-year time horizon, pneumatic dilation was the most cost-effective treatment strategy for achalasia, with an incremental cost-effectiveness ratio of

A cost-minimization analysis of alternative treatment strategies for achalasia

1348 per quality-adjusted life-year compared to Botox. Although laparoscopic esophagomyotomy was more effective than the other treatment options, it was not cost-effective because of its high initial cost. In conclusion, pneumatic dilation is the most cost-effective treatment option for adults with achalasia. Further studies should examine the long-term relapse rates following treatment with Botox and more precisely determine the quality of life of symptomatic achalasia.

The cost-effectiveness of strategies to assess gastroesophageal reflux as an exacerbating factor in asthma

Abstract OBJECTIVE: The aim of this study is to compare the costs per cure of alternative strategies for the treatment of achalasia. METHODS: A cost-minimization model compared three strategies for otherwise healthy adults of any age with achalasia: 1) laparoscopic Heller myotomy with fundoplication (LHM); 2) pneumatic dilation (PD), with LHM reserved for treatment failures; 3) botulinum toxin (Botox) injection of the lower esophageal sphincter, with PD reserved for treatment failures. Probabilities of short- and long-term efficacy, treatment failure, symptomatic recurrence rates, and complications were derived from the published literature. Only direct costs were considered during the 5-yr time horizon. RESULTS: Respective reference case costs per cure of PD, Botox, and LHM strategies were

Economic considerations in the treatment of gastroesophageal reflux disease: a review.

3,111,

Massive gastrointestinal hemorrhage due to rupture of a donor pancreatic artery pseudoaneurysm in a pancreas transplant patient.

3,723, and

A continuous quality improvement initiative reduces inappropriate prescribing of prophylactic antibiotics for endoscopic procedures.

10,792. Despite short- and long-term efficacy of 96% and 94%, respectively, the LHM strategy was most costly. Initial PD remained less costly than initial Botox, provided that rates of PD efficacy and perforation were ≥70% and CONCLUSIONS: For otherwise healthy patients with achalasia, initial PD is the least costly strategy provided that the PD perforation rate remains

Most GERD symptoms are not due to acid reflux in patients with very low 24–hour acid contact times

OBJECTIVES:We sought to evaluate the cost-effectiveness of diagnostic strategies to determine whether or not acid reflux exacerbates asthma, and to identify which asthma response probabilities are most important in a cost-effective workup of this problem.MethodsWe performed a cost-effectiveness analysis, comparing 11 diagnostic strategies to assess the role that acid reflux plays in asthma. Probabilities and costs were derived from the published literature. Average and incremental costs, effectiveness, and cost-effectiveness were calculated for each strategy. Sensitivity analyses were performed.ResultsThe most cost-effective diagnostic approach is to begin with omeprazole 20 mg/day for 3 months, followed by 24-h pH testing on drug in nonresponders. If 24-h pH testing is positive, increase the omeprazole dose every 3 months until the patient responds or a maximum of 60 mg/day is given. This strategy costs

Marked improvement in Nocturnal gastroesophageal reflux in a large cohort of patients with obstructive sleep apnea treated with continuous positive airway pressure

730 per case correctly diagnosed. When the cost of pH testing exceeds

Use of the Web for medical information by a gastroenterology clinic population

586 or the cost of omeprazole 20 mg/day is <