Publications by authors named "Sameer D Saini"

117 Publications

A survey of internists' recommendations for aspirin in older adults and barriers to evidence-based use.

J Thromb Thrombolysis 2022 Jun 14. Epub 2022 Jun 14.

Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA.

Recent trials suggest that aspirin for primary prevention may do more harm than good for some, including adults over 70 years of age. We sought to assess how primary care providers (PCPs) use aspirin for the primary prevention in older patients and to identify barriers to use according to recent guidelines, which recommend against routine use in patients over age 70. We surveyed PCPs about whether they would recommend aspirin in clinical vignettes of a 75-year-old patient with a 10-year atherosclerotic cardiovascular disease risk of 25%. We also queried perceived difficulty following guideline recommendations, as well as perceived barriers and facilitators. We obtained responses from 372 PCPs (47.9% response). In the patient vignette, 45.4% of clinicians recommended aspirin use, which did not vary by whether the patient was using aspirin initially (p = 0.21); 41.7% believed aspirin was beneficial. Perceived barriers to guideline-based aspirin use included concern about patients being upset (41.6%), possible malpractice claims (25.0%), and not having a strategy for discussing aspirin use (24.5%). The estimated adjusted probability of rating the guideline as "hard to follow" was higher in clinicians who believed aspirin was beneficial (29.4% vs. 8.0%; p < 0.001) and who worried the patient would be upset if told to stop aspirin (26.7% vs. 12.5%; p = 0.001). Internists vary considerably in their recommendations for aspirin use for primary prevention in older patients. A high proportion of PCPs continue to believe aspirin is beneficial in this setting. These results can inform de-implementation efforts to optimize evidence-based aspirin use.
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http://dx.doi.org/10.1007/s11239-022-02669-7DOI Listing
June 2022

Association of Antisecretory Drugs with Upper Gastrointestinal Bleeding in Patients Using Oral Anticoagulants: A Systematic Review and Meta-Analysis.

Am J Med 2022 Jun 7. Epub 2022 Jun 7.

Yale School of Medicine, New Haven, Conn; VA Connecticut Healthcare System, West Haven, Conn.

Background: The role of antisecretory drugs for the prevention of upper gastrointestinal bleeding in patients using anticoagulants is unclear. We investigated this question in a systematic review and meta-analysis.

Methods: We searched Embase, PubMed, Web of Science, Scopus, the Cochrane Library, and clinicaltrials.gov thru April 2021 for controlled randomized trials and observational studies evaluating the association of proton pump inhibitors (PPIs) or H2-receptor antagonists with overt upper gastrointestinal bleeding in patients using anticoagulants. Independent duplicate review, data extraction, and risk of bias assessment were performed. Observational studies were included only if they provided results controlled for at least 2 variables. Meta-analyses were performed using random effects models.

Results: Six observational studies and 1 randomized trial were included. All but 1 study had low risk of bias. None of the studies excluded patients with concomitant aspirin or nonsteroidal anti-inflammatory drug use. For PPIs, the pooled relative risk of upper gastrointestinal bleeding was 0.67 (95% confidence interval 0.61, 0.74) with low statistical heterogeneity (I = 15%). Individual studies showed greater treatment effect in patients with higher risk for upper gastrointestinal bleeding (eg, nonsteroidal anti-inflammatory drug or aspirin use, elevated bleeding risk score). A single observational study evaluating the association of H2-receptor antagonists with upper gastrointestinal bleeding found a relative risk of 0.69 (95% confidence interval 0.24-2.02).

Conclusions: Evidence drawn mostly from observational studies with low risk of bias demonstrate that PPIs reduce upper gastrointestinal bleeding in patients prescribed oral anticoagulants. The benefit appears to be most clearcut and substantial in patients with elevated risk of upper gastrointestinal bleeding.
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http://dx.doi.org/10.1016/j.amjmed.2022.05.031DOI Listing
June 2022

Rising use of surveillance colonoscopy and potential impacts.

Am J Manag Care 2022 05;28(5):229-231

Veterans Affairs Center for Clinical Management Research, 2215 Fuller Rd, 111D, Ann Arbor, MI 48105. Email:

Objectives: To quantify temporal changes in colonoscopy indication and assess appropriateness of surveillance use in older adults.

Study Design: Retrospective longitudinal study of national Veterans Health Administration (VHA) data of all patients who underwent outpatient colonoscopy in 2005-2014.

Methods: After validating an electronic algorithm for classifying colonoscopy indication in VHA, we examined trends in colonoscopy indication over time and across patient characteristics.

Results: The proportion of colonoscopies performed for postpolypectomy surveillance increased significantly during the study period, particularly among older patients with limited life expectancy, raising concern for possible overuse.

Conclusions: Guidelines should make clear recommendations about when and how to discontinue postpolypectomy surveillance colonoscopy. Doing so would potentially reduce harms due to complications from low-value procedures and in turn moderate demand and thereby enhance overall procedural access for patients more likely to benefit.
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http://dx.doi.org/10.37765/ajmc.2022.89143DOI Listing
May 2022

Diffusion of an innovation: growth in video capsule endoscopy in the U.S. Medicare population from 2003 to 2019.

BMC Health Serv Res 2022 Mar 31;22(1):425. Epub 2022 Mar 31.

Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA.

Background: Video capsule endoscopy (VCE), approved by the U.S. Food and Drug Administration (FDA) in 2001, represented a disruptive technology that transformed evaluation of the small intestine. Adoption of this technology over time and current use within the U.S. clinical population has not been well described.

Methods: To assess the growth of capsule endoscopy within the U.S. Medicare provider population (absolute growth and on a population-adjusted basis), characterize the providers performing VCE, and describe potential regional differences in use. Medicare summary data from 2003 to 2019 were used to retrospectively analyze capsule endoscopy use in a multiple cross-sectional design. In addition, detailed provider summary files were used from 2012 to 2018 to characterize provider demographics.

Results: VCE use grew rapidly from 2003 to 2008 followed by a plateau from 2008 to 2019. There was significant variation in use of VCE between states, with up to 10-fold variation between states (14.6 to 156.1 per 100,000 enrollees in 2018). During this time, the adjusted VCE use on a population-adjusted basis declined, reflecting saturation of growth.

Conclusions: Growth of VCE use over time follows an S-shaped diffusion of innovation curve demonstrating a successful diffusion of innovation within gastroenterology. The lack of additional growth since 2008 suggests that current levels of use are well matched to overall population need within the constraints of reimbursement. Future studies should examine whether this lack of growth has implications for access and healthcare inequities.
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http://dx.doi.org/10.1186/s12913-022-07780-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8969398PMC
March 2022

Engaging Stakeholders in Identifying Access Research Priorities for the Department of Veterans Affairs.

J Gen Intern Med 2022 04 29;37(Suppl 1):14-21. Epub 2022 Mar 29.

Division of General Internal Medicine, University of Colorado School of Medicine, Academic Office One, 12631 E 17th Avenue, Aurora, CO, 80045, USA.

Background: The Veterans Access Research Consortium (VARC), a Department of Veterans Affairs (VA) Consortium of Research focused on access to healthcare, has been funded by VA's Health Services Research and Development Service (HSR&D) to develop a research roadmap for healthcare access. The goal of the roadmap is to identify operationally aligned research questions that are most likely to lead to meaningful improvements in Veterans' healthcare access.

Objectives: To describe the process of soliciting diverse stakeholder perspectives about key priorities on which VA's HSR&D access agenda should focus and identify the results of that process.

Methods: We used a modified Delphi approach to engage researchers and VA operational partners in a process to develop recommendations regarding the access-related research questions VA should prioritize. We then collaborated with three Veteran Engagement Groups (VEGs) across the country to solicit Veterans' reactions to the Delphi results and their perspectives about access-related issues affecting access to VA health care.

Results: The Delphi panel consisted of 22 research and operational experts, both internal and external to VA. The Delphi process resulted in five research questions identified by the panelists as highest priority for VA to pursue, each representing one of the following domains: (1) measurement of access, (2) barriers to access, (3) equity and subpopulations, (4) effective interventions to improve access, and (5) consequences of poor/better access. Veterans' perspectives focused primarily on the barriers to access domain. Veterans indicated several barriers that might be addressed through research or operational initiatives, including poor communication about services, weak connections to and partnerships with local community care facilities, and poor provision of telehealth resources and education.

Conclusions: Engaging multiple methods to solicit stakeholder perspectives enables more nuanced understanding of access-related priorities for VA. Future research should consider utilizing such an approach to identify additional research and/or operational priorities.
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http://dx.doi.org/10.1007/s11606-021-07195-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8993958PMC
April 2022

Impact of Coronavirus Disease 2019 on Screening Colonoscopy Utilization in a Large Integrated Health System.

Gastroenterology 2022 06 24;162(7):2098-2100.e2. Epub 2022 Feb 24.

Center for Clinical Management Research, Department of Veterans Affairs, VA Ann Arbor Healthcare System and, Division of Gastroenterology, University of Michigan Health System and, Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan.

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http://dx.doi.org/10.1053/j.gastro.2022.02.034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8867975PMC
June 2022

AGA Clinical Practice Update on De-Prescribing of Proton Pump Inhibitors: Expert Review.

Gastroenterology 2022 04 17;162(4):1334-1342. Epub 2022 Feb 17.

Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan; Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.

Description: Proton pump inhibitors (PPIs) are among the most commonly used medications in the world. Developed for the treatment and prevention of acid-mediated upper gastrointestinal conditions, these agents are being used increasingly for indications where their benefits are less certain. PPI overprescription imposes an economic cost and contributes to polypharmacy. In addition, PPI use has been increasingly linked to a number of adverse events (PPI-associated adverse events [PAAEs]). Therefore, de-prescribing of PPIs is an important strategy to lower pill burden while reducing real costs and theoretical risks. The purpose of this clinical update was to provide Best Practice Advice (BPA) statements about how to approach PPI de-prescribing in ambulatory patients.

Methods: Our guiding principle was that, although PPIs are generally safe, patients should not use any medication when there is not a reasonable expectation of benefit based on scientific evidence or prior treatment response. Prescribers are responsible for determining whether PPI use is absolutely or conditionally indicated and, when uncertainty exists, to incorporate patient perspectives into PPI decision making. We collaboratively outlined a high-level "process map" of the conceptual approach to de-prescribing PPIs in a clinical setting. We identified the following 3 key domains that required BPA guidance: documentation of PPI indication; identifying suitable candidates for consideration of de-prescribing; and optimizing successful de-prescribing. Co-authors drafted 1 or more potential BPAs, supported by literature review, for each domain. All co-authors reviewed, edited, and selected or rejected draft BPAs for inclusion in the final list submitted to the American Gastroenterological Association Governing Board. Because this was not a systematic review, we did not carry out a formal rating of the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: All patients taking a PPI should have a regular review of the ongoing indications for use and documentation of that indication. This review should be the responsibility of the patient's primary care provider. BEST PRACTICE ADVICE 2: All patients without a definitive indication for chronic PPI should be considered for trial of de-prescribing. BEST PRACTICE ADVICE 3: Most patients with an indication for chronic PPI use who take twice-daily dosing should be considered for step down to once-daily PPI. BEST PRACTICE ADVICE 4: Patients with complicated gastroesophageal reflux disease, such as those with a history of severe erosive esophagitis, esophageal ulcer, or peptic stricture, should generally not be considered for PPI discontinuation. BEST PRACTICE ADVICE 5: Patients with known Barrett's esophagus, eosinophilic esophagitis, or idiopathic pulmonary fibrosis should generally not be considered for a trial of de-prescribing. BEST PRACTICE ADVICE 6: PPI users should be assessed for upper gastrointestinal bleeding risk using an evidence-based strategy before de-prescribing. BEST PRACTICE ADVICE 7: Patients at high risk for upper gastrointestinal bleeding should not be considered for PPI de-prescribing. BEST PRACTICE ADVICE 8: Patients who discontinue long-term PPI therapy should be advised that they may develop transient upper gastrointestinal symptoms due to rebound acid hypersecretion. BEST PRACTICE ADVICE 9: When de-prescribing PPIs, either dose tapering or abrupt discontinuation can be considered. BEST PRACTICE ADVICE 10: The decision to discontinue PPIs should be based solely on the lack of an indication for PPI use, and not because of concern for PAAEs. The presence of a PAAE or a history of a PAAE in a current PPI user is not an independent indication for PPI withdrawal. Similarly, the presence of underlying risk factors for the development of an adverse event associated with PPI use should also not be an independent indication for PPI withdrawal.
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http://dx.doi.org/10.1053/j.gastro.2021.12.247DOI Listing
April 2022

Development of a multicomponent implementation strategy to reduce upper gastrointestinal bleeding risk in patients using warfarin and antiplatelet therapy, and protocol for a pragmatic multilevel randomized factorial pilot implementation trial.

Implement Sci Commun 2022 Jan 28;3(1). Epub 2022 Jan 28.

Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.

Background: The concomitant use of anticoagulant and antiplatelet medications increases the risk of upper gastrointestinal (GI) bleeding. Two underused evidence-based practices (EBPs) can reduce the risk: de-prescribe unnecessary antiplatelet therapy or initiate a proton pump inhibitor. We describe the development of a multicomponent intervention to increase use of these EBPs in patients treated with warfarin and followed by an anticoagulation monitoring service (AMS), and the design of a pilot pragmatic implementation trial.

Methods: A participatory planning group iteratively used Implementation Mapping and the Multiphase Optimization Strategy to develop implementation strategies and plan the trial. Informed by qualitative interviews with patients and clinicians, we drew on several implementation science theories, as well as self-determination theory, to design interventions. For patients, we developed an activation guide to help patients discuss the EBPs with their clinicians. For clinicians, we developed two electronic health record (EHR)-based interventions: (1) clinician notification (CN) consists of a templated message that identifies a patient as high risk, summarizes the EBPs, and links to a guidance statement on appropriate use of antiplatelet therapy. (2) Clinician notification with nurse facilitation (CN+NF) consists of a similar notification message but includes additional measures by nursing staff to support appropriate and timely decision-making: the nurse performs a chart review to identify any history of vascular disease, embeds indication-specific guidance on antiplatelet therapy in the message, and offers to assist with medication order entry and patient education. We will conduct a pilot factorial cluster- and individual-level randomized controlled trial with a primary objective of evaluating feasibility. Twelve clinicians will be randomized to receive either CN or CN+NF for all their patients managed by the AMS while 50 patients will be individually randomized to receive either the activation guide or usual care. We will explore implementation outcomes using patient and clinician interviews along with EHR review.

Discussion: This pilot study will prepare us to conduct a larger optimization study to identify the most potent and resource conscious multicomponent implementation strategy to help AMSs increase the use of best practices for upper GI bleeding risk reduction.

Trial Registration: ClinicalTrials.gov NCT05085405 . Registered on October 19, 2021-retrospectively registered.
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http://dx.doi.org/10.1186/s43058-022-00256-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8796614PMC
January 2022

Barriers to Guideline-Based Use of Proton Pump Inhibitors to Prevent Upper Gastrointestinal Bleeding.

Ann Fam Med 2022 Jan-Feb;20(1):5-11

Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan.

Purpose: Gastrointestinal (GI) bleeding is one of the most common serious adverse drug events. Guidelines recommend proton pump inhibitor (PPI) gastroprotection to prevent upper GI bleeding in high-risk patients, but this practice is underused.

Methods: To explore prescribing practices and barriers to the use of PPI gastroprotection, including dynamics within and across specialties, we conducted semistructured interviews with physicians in 4 specialties at a single institution. We performed thematic analysis of barriers, organized around the theoretical domains framework.

Results: The sample included 5 primary care physicians (PCPs), 4 cardiologists, 3 gastroenterologists, and 3 vascular surgeons. Most PCPs, gastroenterologists, and vascular surgeons seldom prescribed PPI gastroprotection. Cardiologists varied most in their use of PPI gastroprotection, with some prescribing it consistently and others never. Major barriers related to the following 3 themes: (1) knowledge, (2) decision processes, and (3) professional role. Knowledge of guidelines was greatest among cardiologists and gastroenterologists and low among PCPs and vascular surgeons, and PCPs tended to focus on adverse effects associated with PPIs, which made them reluctant to prescribe them. For cardiologists, prevention of bleeding was usually a priority, but they sometimes deferred prescribing to others. For the other 3 specialties, PPI gastroprotection was a low priority. There was unclear delineation of responsibility for prescribing gastroprotection between specialties.

Conclusions: Major barriers to PPI gastroprotection relate to knowledge, decision processes, and professional role, which operate differentially across specialties. Multicomponent interventions will likely be necessary to improve guideline-based use of PPIs to prevent upper GI bleeding..
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http://dx.doi.org/10.1370/afm.2734DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8786436PMC
March 2022

Endoscopist-directed sedation rarely fails: implications for the value of anesthesia assistance for routine GI endoscopy.

Am J Manag Care 2021 12 1;27(12):e413-e419. Epub 2021 Dec 1.

Division of Gastroenterology, University of Michigan Health System, 2215 Fuller Rd, Gastroenterology 111-D, Ann Arbor, MI 48105. Email:

Objectives: Use of anesthesia-assisted (AA) sedation for routine gastrointestinal (GI) endoscopy has increased markedly. Clinical uncertainty about which patients are most likely to benefit from AA sedation contributes to this increased use. We aimed to estimate the prevalence of failed endoscopist-directed sedation and to identify patients at elevated risk of failing standard sedation.

Study Design: Retrospective longitudinal study of national Veterans Health Administration (VA) data of all patients who underwent esophagogastroduodenoscopy and/or colonoscopy in 2009-2013.

Methods: Using multivariable logistic regression, we sought to identify patient and procedural risk factors for failed sedation. Failed sedation cases were identified electronically and validated by chart review.

Results: Of 302,247 standard sedation procedures performed at VA facilities offering AA sedation, we identified 313 cases of failed sedation (prevalence, 0.10%). None of the factors found to be associated with increased risk of failed sedation (eg, high-dose opioid use, younger age) had an odds ratio greater than 3. Even among the highest-risk patients (top decile), the prevalence of failed sedation was only 0.29%.

Conclusions: Failed sedation among patients undergoing routine outpatient GI endoscopy with standard sedation is very rare, even among patients at highest risk. This suggests that concerns regarding failed sedation due to commonly cited factors such as chronic opioid use and obesity do not justify forgoing standard sedation in favor of AA sedation in most patients. It also suggests that use of AA sedation is generally unnecessary. Reinstatement of endoscopist-directed sedation, rather than AA sedation, as the default sedation standard is warranted to reduce low-value care and prevent undue financial burdens on patients.
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http://dx.doi.org/10.37765/ajmc.2021.88796DOI Listing
December 2021

A Brighter Red Section.

Am J Gastroenterol 2021 12;116(12):2316-2317

Veteran's Affairs Center for Clinical Management Research, Veteran's Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.

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http://dx.doi.org/10.14309/ajg.0000000000001561DOI Listing
December 2021

Interest in and concerns about telehealth among adults aged 50 to 80 years.

Am J Manag Care 2021 10;27(10):415-422

University of Michigan, 3912 Taubman Center, 1500 E Medical Center Dr, SPC 5352, Ann Arbor, MI 48109-5362. Email:

Objectives: To describe associations between patient factors and interest in and concerns about telehealth video visits among adults in midlife and older.

Study Design: A cross-sectional, nationally representative panel survey of US adults aged 50 to 80 years (N = 2256) in May 2019.

Methods: Multivariable logistic regression was used to estimate the adjusted prevalence of interest in different types of video telehealth visits and concerns about telehealth for individuals with different characteristics.

Results: Individuals aged 65 to 80 (vs 50-64) years were more likely to be interested in a first-time telehealth visit (37.3% vs 31.5%; P < .05) and to be concerned about not feeling personally connected to their provider (52.8% vs 46.5%; P < .05). Women (vs men) were less likely to be interested in a first-time visit (29.3% vs 38.2%; P < .001) and more likely to be concerned about technical difficulties (52.3% vs 42.1%; P < .001). Black, non-Hispanic individuals (vs White, non-Hispanic individuals) were more likely to be interested in first-time (45.2% vs 29.8%; P < .001) and return (67.7% vs 56.2%; P < .01) visits. Individuals comfortable using video chat (vs never users) were more likely to be interested in a telehealth visit for any reason (all P < .001) and less likely to have concerns about privacy, difficulty seeing/hearing, technical difficulties, not feeling personally connected, and lower quality of care (all P < .01).

Conclusions: Interest in and concerns about telehealth vary along the lines of sociodemographic factors and experience using the internet for video communication. These findings have implications for the design of interventions and policies to promote equitable access to health care as it increasingly moves online.
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http://dx.doi.org/10.37765/ajmc.2021.88759DOI Listing
October 2021

Patients' Willingness to Share Limited Endoscopic Resources: A Brief Report on the Results of a Large Regional Survey.

MDM Policy Pract 2021 Jul-Dec;6(2):23814683211045648. Epub 2021 Sep 28.

Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan.

In some health care systems, patients face long wait times for screening colonoscopy. We sought to assess whether patients at low risk for colorectal cancer (CRC) would be willing to delay their own colonoscopy so higher-risk peers could undergo colonoscopy sooner. We surveyed 1054 Veterans regarding their attitudes toward repeat colonoscopy and risk-based prioritization. We used multivariable regression to identify patient factors associated with willingness to delay screening for a higher-risk peer. Despite a physician recommendation to stop screening, 29% of respondents reported being "not at all likely" to stop. However, 94% reported that they would be willing to delay their own colonoscopy for a higher-risk peer. Greater trust in physician and greater health literacy were positively associated with willingness to wait, while greater perceived threat of CRC and Black or Latino race/ethnicity were negatively associated with willingness to wait. Despite high enthusiasm for repeat screening, patients were willing to delay their own colonoscopy for higher-risk peers. Appealing to altruism could be effective when utilizing scarce resources.
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http://dx.doi.org/10.1177/23814683211045648DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8488065PMC
September 2021

Testing Practices, Interpretation, and Diagnostic Evaluation of Iron Deficiency Anemia by US Primary Care Physicians.

JAMA Netw Open 2021 10 1;4(10):e2127827. Epub 2021 Oct 1.

Department of Internal Medicine, University of Michigan, Ann Arbor.

Importance: Recognition of iron deficiency anemia (IDA) is important to initiate timely evaluation for gastrointestinal tract cancer. Retrospective studies have reported delays in diagnostic evaluation of IDA as a common factor associated with delayed diagnosis of colorectal cancer.

Objective: To assess how US primary care physicians (PCPs) approach testing for anemia, interpret iron laboratory studies, and refer patients with IDA for gastrointestinal endoscopy.

Design, Setting, And Participants: This survey study, conducted in August 2019, included members of the American College of Physicians Internal Medicine Insiders Panel, a nationally representative group of American College of Physicians membership, who self-identified as PCPs. Participants completed a vignette-based survey to assess practices related to screening for anemia, interpretation of laboratory-based iron studies, and appropriate diagnostic evaluation of IDA.

Main Outcomes And Measures: Descriptive statistics based on survey responses were evaluated for frequency of anemia screening, correct interpretation of iron laboratory studies, and proportion of patients with new-onset IDA referred for gastrointestinal tract evaluation.

Results: Of 631 PCPs who received an invitation to participate in the survey, 356 (56.4%) responded and 31 (4.9%) were excluded, for an adjusted eligible sample size of 600, yielding 325 completed surveys (response rate, 54.2%). Of the 325 participants who completed surveys, 180 (55.4%) were men; age of participants was not assessed. The mean (SD) duration of clinical experience was 19.8 (11.2) years (range, 1.0-45.0 years). A total of 250 participants (76.9%) screened at least some patients for anemia. Interpretation of iron studies was least accurate in a scenario of a borderline low ferritin level (40 ng/mL) with low transferrin saturation (2%); 86 participants (26.5%) incorrectly responded that this scenario did not indicate IDA, and 239 (73.5%) correctly identified this scenario as IDA. Of 312 participants, 170 (54.5%) recommended bidirectional endoscopy (upper endoscopy and colonoscopy) for new IDA for women aged 65 years; of 305 respondents, 168 (55.1%) recommended bidirectional endoscopy for men aged 65 years.

Conclusions And Relevance: In this survey study, US PCPs' self-reported testing practices for anemia suggest overuse of screening laboratory tests, misinterpretation of iron studies, and underuse of bidirectional endoscopy for evaluation of new-onset IDA. Both misinterpretation of iron studies and underuse of bidirectional endoscopy can lead to delayed diagnosis of gastrointestinal tract cancers and warrant additional interventions.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.27827DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8486982PMC
October 2021

Primary care and referring physician perspectives on non-alcoholic fatty liver disease management: a nationwide survey.

Therap Adv Gastroenterol 2021 20;14:17562848211042200. Epub 2021 Sep 20.

Centura Health Porter Adventist Hospital, Denver, CO 80210, USA.

Introduction: The optimal approach to screening and risk stratification for non-alcoholic fatty liver disease is challenging given disease burden and variable progression. The aim of this study was to assess primary care physician and referring physician practice patterns regarding non-alcoholic fatty liver disease.

Methods: An anonymous nationwide survey was administered to primary care physicians, endocrinologists, and cardiologists in a: (1) tertiary academic hospital, (2) community hospital, and (3) the American College of Physicians Insider Panel. Survey domains assessed non-alcoholic fatty liver disease knowledge, recommendations for screening, risk stratification, treatment, and referral patterns.

Results: A total of 440 providers completed the survey (35.2% completion rate;  = 82 academic hospital,  = 21 community hospital,  = 337 American College of Physicians). Half were male (51.7%), 78% from internal medicine, with 5% subspecialists. Providers were knowledgeable regarding prevalence and risk factors for non-alcoholic fatty liver disease. 58% would support screening for non-alcoholic fatty liver disease and used liver enzymes to do so. Only 22.5% used serum biomarkers and 23% used transient elastography for risk stratification. Primary reason for referral was advanced fibrosis/cirrhosis. 80% reported barriers to treating non-alcoholic fatty liver disease. There was no consistent diet recommended.

Conclusion: In this nationwide survey, we demonstrated that while overall disease knowledge was good, there was an important disconnect between current guidelines and real-world clinical practice. There is also significant heterogeneity in practice patterns for first-line therapy of non-alcoholic fatty liver disease and the majority of provider's report barriers to treating non-alcoholic fatty liver disease. These findings highlight the potential role for reevaluating screening and risk stratification recommendations in primary care to better align with needs in that setting.
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http://dx.doi.org/10.1177/17562848211042200DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8460969PMC
September 2021

Automated Measurements of Body Composition in Abdominal CT Scans Using Artificial Intelligence Can Predict Mortality in Patients With Cirrhosis.

Hepatol Commun 2021 11 7;5(11):1901-1910. Epub 2021 Jul 7.

Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA.

Body composition measures derived from already available electronic medical records (computed tomography [CT] scans) can have significant value, but automation of measurements is needed for clinical implementation. We sought to use artificial intelligence to develop an automated method to measure body composition and test the algorithm on a clinical cohort to predict mortality. We constructed a deep learning algorithm using Google's DeepLabv3+ on a cohort of de-identified CT scans (n = 12,067). To test for the accuracy and clinical usefulness of the algorithm, we used a unique cohort of prospectively followed patients with cirrhosis (n = 238) who had CT scans performed. To assess model performance, we used the confusion matrix and calculated the mean accuracy of 0.977 ± 0.02 (0.975 ± 0.018 for the training and test sets, respectively). To assess for spatial overlap, we measured the mean intersection over union and mean boundary contour scores and found excellent overlap between the manual and automated methods with mean scores of 0.954 ± 0.030, 0.987 ± 0.009, and 0.948 ± 0.039 (0.983 ± 0.013 for the training and test set, respectively). Using these automated measurements, we found that body composition features were predictive of mortality in patients with cirrhosis. On multivariate analysis, the addition of body composition measures significantly improved prediction of mortality for patients with cirrhosis over Model for End-Stage Liver Disease alone (P < 0.001). Conclusion: The measurement of body composition can be automated using artificial intelligence and add significant value for incidental CTs performed for other clinical indications. This is proof of concept that this methodology could allow for wider implementation into the clinical arena.
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http://dx.doi.org/10.1002/hep4.1768DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8557320PMC
November 2021

A Care Coordination Intervention Improves Symptoms But Not Charges in High-Risk Patients With Inflammatory Bowel Disease.

Clin Gastroenterol Hepatol 2022 05 28;20(5):1029-1038.e9. Epub 2021 Aug 28.

Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan.

Background: Inflammatory bowel disease (IBD) is associated with substantial symptom burden, variability in clinical outcomes, and high direct costs. We sought to determine if a care coordination-based strategy was effective at improving patient symptom burden and reducing healthcare costs for patients with IBD in the top quintile of predicted healthcare utilization and costs.

Methods: We performed a randomized controlled trial to evaluate the efficacy of a patient-tailored multicomponent care coordination intervention composed of proactive symptom monitoring and care coordinator-triggered algorithms. Enrolled patients with IBD were randomized to usual care or to our care coordination intervention over a 9-month period (April 2019 to January 2020). Primary outcomes included change in patient symptom scores throughout the intervention and IBD-related charges at 12 months.

Results: Eligible IBD patients in the top quintile for predicted healthcare utilization and expenditures were identified. A total of 205 patients were enrolled and randomized to our intervention (n = 100) or to usual care (n = 105). Patients in the care coordinator arm demonstrated an improvement in symptoms scores compared with usual care (coefficient, -0.68, 95% confidence interval, -1.18 to -0.18; P = .008) without a significant difference in median annual IBD-related healthcare charges ($10,094 vs $9080; P = .322).

Conclusions: In this first randomized controlled trial of a patient-tailored care coordination intervention, composed of proactive symptom monitoring and care coordinator-triggered algorithms, we observed an improvement in patient symptom scores but not in healthcare charges. Care coordination programs may represent an effective value-based approach to improve symptoms scores without added direct costs in a subgroup of high-risk patients with IBD. (ClinicalTrials.gov, Number: NCT04796571).
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http://dx.doi.org/10.1016/j.cgh.2021.08.034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8882693PMC
May 2022

Regression and Random Forest Machine Learning Have Limited Performance in Predicting Bowel Preparation in Veteran Population.

Dig Dis Sci 2022 Jul 24;67(7):2827-2841. Epub 2021 Jun 24.

Department of Internal Medicine, University of Michigan, 3912 Taubman Center, 1500 E. Medical Center Dr., SPC 5362, Ann Arbor, MI, 48109-5362, USA.

Background: Inadequate bowel preparation undermines the quality of colonoscopy, but patients likely to be affected are difficult to identify beforehand.

Aims: This study aimed to develop, validate, and compare prediction models for bowel preparation inadequacy using conventional logistic regression (LR) and random forest machine learning (RFML).

Methods: We created a retrospective cohort of patients who underwent outpatient colonoscopy at a single VA medical center between January 2012 and October 2015. Candidate predictor variables were chosen after a literature review. We extracted all available predictor variables from the electronic medical record, and bowel preparation from the endoscopy database. The data were split into 70% training and 30% validation sets. Multivariable LR and RFML were used to predict preparation inadequacy as a dichotomous outcome.

Results: The cohort included 6,885 Veterans, of whom 964 (14%) had inadequate preparation. Using LR, the area under the receiver operating characteristic curve (AUC) for the validation cohort was 0.66 (95% CI 0.62, 0.69) and the Brier score, in which a lower score indicates better performance, was 0.11. Using RFML, the AUC for the validation cohort was 0.61 (95% CI 0.58, 0.65) and the Brier score was 0.12.

Conclusions: LR and RFML had similar performance in predicting bowel preparation, which was modest and likely insufficient for use in practice. Future research is needed to identify additional predictor variables and to test other machine learning algorithms. At present, endoscopy units should focus on universal strategies to enhance preparation adequacy.
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http://dx.doi.org/10.1007/s10620-021-07113-zDOI Listing
July 2022

Surveillance Cessation for Barrett's Esophagus: A Survey of Gastroenterologists.

Am J Gastroenterol 2021 08;116(8):1730-1733

Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA.

Introduction: Regular endoscopic surveillance is the gold standard Barrett's esophagus (BE) surveillance, yet harms of surveillance for some patients may outweigh the benefits. We sought to characterize physicians' BE surveillance cessation recommendations.

Methods: We surveyed gastroenterologists about their BE surveillance recommendations varying patient age, comorbidity, and BE length.

Results: Clinicians varied in recommendations for repeat surveillance. Patient age showed the largest variation among decisions, whereas BE length varied the least.

Discussion: Age and comorbidities seem to influence BE surveillance cessation decisions, but with variation. Clear cessation guidelines balancing the risks and benefits for BE surveillance are warranted.
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http://dx.doi.org/10.14309/ajg.0000000000001323DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9152734PMC
August 2021

Trials of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention Lack Strategies to Ensure Appropriate Gastroprotection.

Am J Gastroenterol 2021 04;116(4):821-824

1Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA; 2VA Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan, USA; 3Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA; 4Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, USA; 5UCLA Health Department of Medicine, Los Angeles, California, USA.

Introduction: Gastrointestinal bleeding is a morbid complication of dual antiplatelet therapy (DAPT). We evaluated the extent to which contemporary trials of DAPT included steps to ensure appropriate use of proton pump inhibitor (PPI) gastroprotection and reported rates of PPI use.

Methods: A methodological review of randomized trials comparing varying durations of DAPT after percutaneous coronary intervention.

Results: Among 21 trials, none incorporated protocol procedures or guidance for prescribing PPIs. Five reported rates of PPI use (range 25.6-69.1%).

Discussion: PPI gastroprotection is overlooked in major trials of DAPT. Appropriate use of PPI gastroprotection represents an important opportunity to improve patient safety.
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http://dx.doi.org/10.14309/ajg.0000000000001134DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8119932PMC
April 2021

Increased Driving Distance to Screening Colonoscopy Negatively Affects Bowel Preparation Quality: an Observational Study.

J Gen Intern Med 2021 06 31;36(6):1666-1672. Epub 2021 Mar 31.

Division of Gastroenterology, Department of Internal Medicine, University of Illinois at Chicago College of Medicine, Chicago, IL, USA.

Background: To prepare for colonoscopy, patients must consume a bowel purgative and travel from their home to the site of their procedure. The timing of bowel purgative ingestion predicts bowel preparation quality. Currently, it is not known if driving distance impacts bowel preparation quality or adenoma detection.

Objective: This study investigates the effect of driving distance on bowel preparation and adenoma detection.

Design: This is a cross-sectional retrospective analysis of outpatient screening colonoscopy procedures that were completed at an academic medical center.

Participants: A total of 5089 patients who completed screening colonoscopy across 3 procedure units were analyzed.

Main Measures: Description of bowel preparation was dichotomized to either adequate or inadequate. Patient residential addresses were converted into geographic coordinates for geospatial analysis of driving distance to their colonoscopy site.

Key Results: Median driving distance was 13.1 miles. Eighty-nine percent of patients had an adequate bowel preparation. The rate of adenoma detection was 37%. On multivariable logistic regression adjusting for age, sex, race, insurance, endoscopist, and site, increasing driving distance (10-mile increments) was negatively associated with adequate bowel preparation (odds ratio = 0.91; 95% confidence interval 0.85 to 0.97), while adenoma detection was positively associated with adequate bowel preparation (odds ratio = 1.53; 95% confidence interval 1.24 to 1.88) but not with driving distance (odds ratio = 1.02; 95% confidence interval 0.98 to 1.06). Driving distances of 30 miles or less were associated with adequate bowel preparation (odds ratio = 1.37; 95% confidence interval 1.09 to 1.72).

Conclusions: Increasing driving distance to screening colonoscopy was negatively associated with adequate bowel preparation but not adenoma detection. Among an academic medical center population, the likelihood of adequate bowel preparation was highest in patients traveling 30 miles or less to their screening colonoscopy. Patient driving distance to colonoscopy is an important consideration in optimizing screening colonoscopy quality.
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http://dx.doi.org/10.1007/s11606-020-06464-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8175497PMC
June 2021

Prevalence of Appropriate Testing for Incident Anemia in the US Department of Veterans Affairs.

JAMA Netw Open 2021 01 4;4(1):e2034406. Epub 2021 Jan 4.

Division of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor.

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http://dx.doi.org/10.1001/jamanetworkopen.2020.34406DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7838922PMC
January 2021

Identifying Recommendations for Stopping or Scaling Back Unnecessary Routine Services in Primary Care.

JAMA Intern Med 2020 11;180(11):1500-1508

Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan.

Importance: Much of health care involves established, routine use of medical services for chronic conditions or prevention. Stopping these services when the evidence changes or if the benefits no longer outweigh the risks is essential. Yet, most guidelines focus on escalating care and provide few explicit recommendations to stop or scale back (ie, deintensify) treatment and testing.

Objective: To develop a systematic, transparent, and reproducible approach for identifying, specifying, and validating deintensification recommendations associated with routine adult primary care.

Design, Setting, And Participants: A focused review of existing guidelines and recommendations was completed to identify and prioritize potential deintensification indications. Then, 2 modified virtual Delphi expert panels examined the synthesized evidence, suggested ways that the candidate recommendations could be improved, and assessed the validity of the recommendations using the RAND/UCLA Appropriateness Method. Twenty-five physicians from Veterans Affairs and US academic institutions with knowledge in relevant clinical areas (eg, geriatrics, primary care, women's health, cardiology, and endocrinology) served as panel members.

Main Outcomes And Measures: Validity of the recommendations, defined as high-quality evidence that deintensification is likely to improve patient outcomes, evidence that intense testing and/or treatment could cause harm in some patients, absence of evidence on the benefit of continued or repeated intense treatment or testing, and evidence that deintensification is consistent with high-quality care.

Results: A total of 409 individual recommendations were identified representing 178 unique opportunities to stop or scale back routine services (eg, stopping population-based screening for vitamin D deficiency and decreasing concurrent use of opioids and benzodiazepines). Thirty-seven recommendations were prioritized and forwarded to the expert panels. Panelists reviewed the evidence and suggested modifications, resulting in 44 recommendations being rated. Overall, 37 recommendations (84%) were considered to be valid, as assessed by the RAND/UCLA Appropriateness Method.

Conclusions And Relevance: In this study, a total of 178 unique opportunities to deintensify routine primary care services were identified, and 37 of these were validated as high-priority deintensification recommendations. To date, this is the first study to develop a model for identifying, specifying, and validating deintensification recommendations that can be implemented and tracked in clinical practice.
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http://dx.doi.org/10.1001/jamainternmed.2020.4001DOI Listing
November 2020

Association of Continuity of Care With Outcomes in US Veterans With Inflammatory Bowel Disease.

JAMA Netw Open 2020 09 1;3(9):e2015899. Epub 2020 Sep 1.

Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor.

Importance: Health care fragmentation is associated with inefficiency and worse outcomes. Continuity of care (COC) models were developed to address fragmentation.

Objective: To examine COC and selected outcomes in US veterans with inflammatory bowel disease (IBD).

Design, Setting, And Participants: This retrospective cohort study used the Veterans Health Administration (VHA) Corporate Data Warehouse to identify veterans with IBD who received care in the VHA health care system between January 1, 2002, and December 31, 2014. Included patients were veterans with IBD who had a primary care physician and at least 4 outpatient visits with key physicians (gastroenterologist, primary care physician, and surgeon) within the first year after an index IBD encounter. Data were analyzed from November 2018 to May 2020.

Exposures: Care continuity was measured with the Bice-Boxerman COC index to define care density and dispersion within year 1 after the initial presentation.

Main Outcomes And Measures: A Cox proportional hazards regression model was used to quantify the association between a low level of COC in year 1 (defined as ≤0.25 on a 0 to 1 scale) and subsequent IBD-related outcomes in years 2 and 3 (outpatient flare, hospitalization, and surgical intervention).

Results: Among the 20 079 veterans with IBD who met the inclusion criteria, 18 632 were men (92.8%) and the median (interquartile range [IQR]) age was 59 (48-66) years. In the first year of follow-up, substantial variation in the dispersion of care was observed (median [IQR] COC, 0.24 [0.13-0.46]). In a Cox proportional hazards regression model, a low level of COC was associated with a higher likelihood of outpatient flares that required corticosteroids (adjusted hazard ratio [aHR], 1.11; 95% CI, 1.01-1.22), hospitalizations (aHR, 1.25; 95% CI, 1.06-1.47), and surgical interventions (aHR, 1.72; 95% CI, 1.43-2.07).

Conclusions And Relevance: Results of this cohort study showed a wide variation in dispersion of IBD care and an association between a lower level of COC and active IBD and worse outcomes. The findings suggest that investigating the barriers to COC in integrated systems that have invested in care coordination is key to not only better understanding COC but also identifying opportunities to improve care fragmentation.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.15899DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489806PMC
September 2020

A National Survey of Adoption of the 2018 American Cancer Society Colorectal Cancer Screening Guideline in Primary Care.

Clin Gastroenterol Hepatol 2021 09 29;19(9):1973-1975.e1. Epub 2020 Aug 29.

Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; VA HSR&D Center for Clinical Management Research, Ann Arbor, Michigan.

Recent data have shown increasing incidence of colorectal cancer (CRC) among those younger than 50 years of age. In response, the American Cancer Society (ACS) introduced new guidelines in May 2018 that recommend initiation of CRC screening in average-risk adults at age 45, which is 5 years earlier than existing recommendations from the US Preventive Services Task Force and US Multi-Society Task Force on Colorectal Cancer. Most screening colonoscopies are ordered directly by primary care providers (PCPs) via "direct" or "open.
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http://dx.doi.org/10.1016/j.cgh.2020.08.060DOI Listing
September 2021

Deprescribing Proton Pump Inhibitors.

JAMA Intern Med 2020 12;180(12):1711-1712

Department of Internal Medicine, University of Michigan, Ann Arbor.

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http://dx.doi.org/10.1001/jamainternmed.2020.2441DOI Listing
December 2020

Eliciting patient views on the allocation of limited healthcare resources: a deliberation on hepatitis C treatment in the Veterans Health Administration.

BMC Health Serv Res 2020 May 1;20(1):369. Epub 2020 May 1.

Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, 2800 Plymouth Road, North Campus Research Complex, Bldg. 14, G016, Ann Arbor, MI, 48109-2800, USA.

Background: In response to the development of highly effective but expensive new medications, policymakers, payors, and health systems are considering novel and pragmatic ways to provide these medications to patients. One approach is to target these treatments to those most likely to benefit. However, to maximize the fairness of these policies, and the acceptance of their implementation, the values and beliefs of patients should be considered. The provision of treatments for chronic hepatitis C (CHC) in the resource-constrained context of the Veterans Health Administration (VHA) offered a real-world example of this situation, providing the opportunity to test the value of using Democratic Deliberation (DD) methods to solicit the informed opinions of laypeople on this complex issue.

Methods: We recruited Veterans (n = 30) from the VHA to attend a DD session. Following educational presentations from content experts, participants engaged in facilitated small group discussions to: 1) identify strategies to overcome CHC treatment barriers and 2) evaluate, vote on, and modify/improve two CHC treatment policies - "first come, first served" (FCFS) and "sickest first" (SF). We used transcripts and facilitators' notes to identify key themes from the small group discussions. Additionally, participants completed pre- and post-DD surveys.

Results: Most participants endorsed the SF policy over the FCFS policy, emphasizing the ethical and medical appropriateness of treating the sickest first. Concerns about SF centered on the difficulty of implementation (e.g., how is "sickest" determined?) and unfairness to other Veterans. Proposed modifications focused on: 1) the need to consider additional health factors, 2) taking behavior and lifestyle into account, 3) offering education and support, 4) improving access, and 5) facilitating better decision-making.

Conclusions: DD offered a robust and useful method for addressing the allocation of the scarce resource of CHC treatment. Participants were able to develop a modified version of the SF policy and offered diverse recommendations to promote fairness and improve quality of care for Veterans. DD is an effective approach for incorporating patient preferences and gaining valuable insights for critical healthcare policy decisions in resource-limited environments.
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http://dx.doi.org/10.1186/s12913-020-05211-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7193376PMC
May 2020

Trends in Wait Time for Outpatient Colonoscopy in the Veterans Health Administration, 2008-2015.

J Gen Intern Med 2020 06 24;35(6):1776-1782. Epub 2020 Mar 24.

Center for Clinical Management Research, Department of Veterans Affairs, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.

Background: The Veterans Health Administration (VA) recently has been scrutinized for prolonged wait times for routine medical care, including elective outpatient procedures such as colonoscopy. Wait times for colonoscopy following positive fecal occult blood test (FOBT) are associated with worse clinical outcomes only if greater than 6 months.

Objective: We aimed to investigate time trends in wait time for outpatient colonoscopy in VA and factors influencing wait time.

Design: Retrospective cohort study using mixed-effects regression of VA administrative data from the Corporate Data Warehouse.

Participants: Veterans who underwent outpatient colonoscopy for positive FOBT in 2008-2015 at 124 VA endoscopy facilities.

Main Measures: The main outcome measure was wait time (in days) between positive FOBT and colonoscopy completion, stratified by year and adjusted for sedation type, year, and potentially influential patient- and facility-level factors.

Key Results: In total, 125,866 outpatient colonoscopy encounters for positive FOBT occurred during the study period. The number of colonoscopies for this indication declined slightly over time (17,586 in 2008 vs. 13,245 in 2015; range 13,425-19,814). In 2008, median wait time across sites was 50 days (interquartile range [IQR] = 33, 75). There was no secular trend in wait times (2015 median = 52 days, IQR = 34, 77). Examining the adjusted effect of patient- and facility-level factors on wait time, no clinically meaningful difference was found.

Conclusions: Wait times for colonoscopy for positive FOBT have been stable over time. Despite the perception of prolonged VA wait times, wait times for outpatient colonoscopy for positive FOBT are well below the threshold at which clinically meaningful differences in patient outcomes have been observed.
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http://dx.doi.org/10.1007/s11606-020-05776-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7280466PMC
June 2020

Physicians' Perceptions of Proton Pump Inhibitor Risks and Recommendations to Discontinue: A National Survey.

Am J Gastroenterol 2020 05;115(5):689-696

Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.

Objective: To provide contemporary estimates of internists' perceptions of adverse effects associated with proton pump inhibitors (PPIs) and self-reported clinical use.

Methods: We invited 799 internists, including specialists and postgraduate trainees, to complete an online survey. Topics included perceptions of PPI adverse effects (AEs) and effectiveness for upper gastrointestinal bleeding (UGIB) prevention, changes in prescribing, and management recommendations for patients using PPIs for gastroesophageal reflux disease or UGIB prevention. We used logistic regression to identify factors associated with appropriate PPI continuation in the scenario of a patient at high risk for UGIB.

Results: Among 437 respondents (55% response rate), 10% were trainees and 72% specialized in general medicine, 70% were somewhat/very concerned about PPI AEs, and 76% had somewhat/very much changed their prescribing. A majority believed PPIs increase the risk for 6 of 12 AEs queried. Fifty-two percent perceived PPIs to be somewhat/very effective for UGIB prevention. In a gastroesophageal reflux disease scenario in which PPI can be safely discontinued, 86% appropriately recommended PPI discontinuation. However, in a high-risk UGIB prevention scenario in which long-term PPI use is recommended, 79% inappropriately recommended discontinuation. In this latter scenario, perceived effectiveness for bleeding prevention was strongly associated with continuing PPI (odds ratio 7.68, P < 0.001 for moderately; odds ratio 17.3, P < 0.001 for very effective). Other covariates, including concern about PPI AEs, had no significant association.

Discussion: Most internists believe PPIs cause multiple AEs and recommend discontinuation even in patients at high risk for UGIB. Future interventions should focus on ensuring that PPIs are prescribed appropriately according to individual risks and benefits.
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http://dx.doi.org/10.14309/ajg.0000000000000558DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7196016PMC
May 2020
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