Sa1089

Crohn's Disease Patients Need Timely Follow-up Intestinal Surgery: APotential Role for Integrated Medical-Surgical Post-Operative CareJennifer L. Bennett, Christina Y. Ha, Elizabeth Wick

Background: Coordination of Crohn's disease (CD) post-operative care is essential in orderto identify surgical site infections, initiate or resume medical therapy, and identify earlysigns of disease recurrence. The aim of this study is to evaluate the post-operative gastroenter-ology (GI) and surgical follow-up care received by CD patients at a tertiary IBD referralcenter. Methods: We performed an retrospective study of colorectal surgery patients capturedin the National Surgical Outcome Improvement Program (NSQIP) database that were admit-ted to a tertiary IBD referral center with a principal discharge ICD-9 code of 555.x betweenJanuary 2009 and January 2012. Variables of interest included pre-operative medical therapy,surgical history, and disease phenotype/ location. Primary outcomes of interest were timesto post-operative surgical and medical outpatient follow-up, post-operative prophylactictherapy and endoscopic recurrence. Endoscopic recurrence was defined as a Rutgeerts scoreof greater than i2 on colonoscopy within 6 months post-operatively. Results: During the 3-year study period, 114 CD patients underwent intestinal surgery. 70 patients (61.4%)were referrals from academic and 34 patients (28.6%) were referred from communitygastroenterologists. Duration from diagnosis to first surgery was 6.6 years (95% CI 4.5-8.7).Among the academic center referrals, the majority (88.6%) had stricturing or penetratingdisease, 28.6% were current smokers (n=20), and 40% (n=28) had prior surgical resections.Approximately half (48.6%) of patients were on biologics pre-operatively, with 42.9% onsteroids, 22.9% on immunomodulators, and 41.4% on antibiotics. The vast majority ofpost-operative patients (91.4%; n=64) had surgical follow-up within 4 weeks of dischargecompared to less than half (47.1%; n=33) with GI outpatient follow-up (p ,0.0001). How-ever, most patients started post-operative medical therapy within 6 months (n=51; 72.8%),with most patients starting or resuming anti-TNF therapy (n=33; 66.7%). Only 54.3% (n=38) of patients underwent post-operative colonoscopy within 6 months with a 21.1% post-operative recurrence rate by 6 months of discharge. All of the patients with post-operativerecurrence were on post-operative therapy, 37.5% on immunomodulators and 62.5% onbiologics. Conclusion: For CD patients requiring surgery, follow-up physician visits, initiationof medical therapy, and surveillance colonoscopy remain critical to providing quality post-operative care. The discrepancy in surgical compared to GI follow-up underscores the needfor coordination of care between the surgical and GI medical teams. Integrated GI andsurgical clinics for post-operative care may improve health care delivery and allow for earlierescalation of therapy, particularly among those at higher risk for aggressive disease recurrence.

Sa1090

Non-Neoplastic Polypectomy During Screening Colonoscopy: The Impact onPolyp Detection Rate (Pdr) and Its Correlation With Adenoma Detection Rate(ADR)Mary A. Atia, Neal C. Patel, Shiva K. Ratuapli, Michael D. Crowell, Sarah B. Umar,Suryakanth Gurudu, Douglas O. Faigel, Jonathan A. Leighton, Francisco C. Ramirez

Background: High quality, high definition imaging may enhance irrelevant non-neoplastictissue (lymphoid aggregates and normal mucosa) that resembles a polyp. The frequency ofnon-neoplastic polypectomy (NNP) and its impact on PDR (a proposed surrogate of ADR)is unknown. The correlation between NNP rate and ADR has also not been investigated.Aim: To determine 1) the rate of NNP in screening colonoscopy; 2) the impact of NNP onPDR and, 3) the correlation of NNP with ADR. Methods: As part of a quality improvementprogram we reviewed the endoscopy and pathology reports for all patients undergoingscreening colonoscopy from October 2010 September 2011. PDR and ADR were calculatedfor each endoscopist and for the entire group. We then calculated a non-neoplastic polypdetection rate (proportion of patients with at least one non-neoplastic polyp). A subgroupof patients with ONLY NNP (no concomitant adenoma or hyperplastic polyps) was evaluatedto assess the impact on overall PDR. Pearson correlation coefficient was used to evaluatethe relationship between the quality metrics. Results: A total of 1797 screening colonoscopiesperformed using Olympus high definition colonoscopes (180-series) by 20 gastroenterologistswere reviewed. Overall, mean (SD) for PDR was 47.7% (12.0), and for ADR was 27.3%(6.9). The overall non-neoplastic polyp rate was 10.4% (7.1) with a range of 2.4%-28.4%.Among all polypectomies (n = 2061), 276 were for non-neoplastic polyps (13.4 %). Meansize of non-neoplastic polyps was 2.9mm (2.2) and its distribution was similar in the proximal(48.9%) and distal (51.1%) colon. One hundred patients had ONLY NNP representing anoverestimation of 5.6% (4) in the overall PDR (range 0-12%). The proportion of polyphistology per endoscopist is displayed in Figure 1. Endoscopists with a higher rate of NNPwere more likely to detect an adenoma (OR 1.58, CI 1.1-1.2). There was a trend towardsa positive correlation between ADR and NNP (r=0.363, p=0.058). Figure 2. Age and genderof the patient, presence of a fellow, and bowel preparation quality did not affect the rateof NNP. Conclusion: During screening colonoscopy, 13% of polyps removed are non-neoplastic, which may overestimate PDR by up to 12%. There is a positive correlationbetween adenoma detection and NNP. The etiology for this relationship is unclear. Themost likely explanation of the NNP rate in our group is the misinterpretation of enhancedmucosa by high definition imaging, but NNP may inflate PDR for some endoscopists.Additionally, removal of these lesions may lead to post-polypectomy complications andincrease the cost of the procedure unnecessarily. Further studies should evaluate NNP toassess its role as a quality metric.

S-199 AGA Abstracts

Figure 1. Distribution of Polyp Pathology per Endoscopist

Figure 2. Relationship between ADR and Nonneoplastic Polypectomy (NNP)

Sa1091

Clinical Values of Alarm Features and History of Prior Use of Anti-AcidMedication(S) for Predicting Significant Endoscopic Lesions in Patients WithChronic Upper Gastrointestinal (UGI) SymptomsTanisa Patcharatrakul, Prima Singhagowinta, Pinit Kullavanijaya, Sutep Gonlachanvit

To study the value of alarm features and history of anti-acid medication(s) use for predictingsignificant endoscopic lesions. Methods: 554 consecutive patients(375F, age 48±14) whohad at least weekly of any disturbing UGI symptoms for . 3 months and scheduledfor esophagogastroduodenoscopy(EGD) were included. All were interviewed regarding GIsymptoms, use of PPI, H2RA, analgesic and aspirin as well as alarm features including weightloss, loss of appetite, awakening pain, hematemesis, and melena. Gastric ulcer(GU), duodenalulcer(DU), gastric cancer, and esophagitis(LA grade.B)were considered as significant lesions.Patients without these lesions were classified as functional dyspepsia(FD), FD subgroups,overlapping FD+IBS or FD+GERD, and others UGI symptoms according to their symptomprofiles. Results: 74 patients(13.4%) had significant endoscopic lesions including 48 GU,6DU, 13 GU+DU, 3 esophagitis, 2 DU or GU+esophagitis, and 2 gastric cancer. These lesionswere significantly increased with age .50 years [OR(95%CI)= 1.2(1.07-1.19);p,0.001),presence of awakening pain [OR=1.1(1.01-1.17);p, 0.01] and presence of melena [OR=1.1(1.04-1.34);p,0.01] by multivariate analysis. Sensitivity, specificity, PPV and NPV ofhaving significant lesions were 63%, 61%, 20%, and 91% for age .50; 29%, 82%, 20%,and 88% for awakening pain, and 14%, 94%, 26%, and 87% for the presence of melena,respectively. The prevalence of each type of significant lesion in patients with age .50 yr,awakening pain and melena were similar (p.0.05). 32% of the patients had positive rapidurease test. 414 patients used H2RA and/or PPI within one month prior to EGD. 11 patientsused aspirin and 89 patients used analgesic regularly. H.pylori infections, the use of PPI/H2RA, regular use of aspirin and analgesic, other alarm features, and each of the UGIsymptoms were not significantly associated with the presence of significant endoscopiclesions. History of markedly symptoms improvement with acid suppressions were similarbetween the patients with and without significant lesions (41/53vs.287/361, p .0.05).Patients with overlapping FD with GERD or IBS(n=93) had significantly more prevalenceof awakening pain(38%vs.13%), loss of appetite(27%vs.12%), and weight loss(39%vs.18%)than patients with FD alone(p, 0.01). In FD alone patients, weight loss and loss appetitewere significantly more prevalent in PDS than EPS patients [weight loss 21/77vs.20/152,loss of appetite 14/77vs.12/152, respectively; p, 0.005)]. Conclusions: In patients withUGI symptoms, significant endoscopic lesions were associated with age .50 years, awakeningpain and presence ofmelena.Weight loss and loss of appetite were associatedwith overlappingfunctional GI disorders. The history of PPI or H2RA use in the last 1 month seems to provideno significant benefit on predicting significant endoscopic lesions.

Sa1092

Adherence to Anti-TNF Therapy in Outpatients With Inflammatory BowelDiseaseMike V. Have, Bas Oldenburg, Adrian A. Kaptein, Peter D. Siersema, Herma Fidder

Background: Non-adherence is associated with poor health outcomes and increased healthcare costs. Although anti-TNF agents are increasingly used in the medical management ofpatients with inflammatory bowel disease (IBD), data regarding the adherence rates for theseagents and risk factors for non-adherence are limited. Aims: To assess adherence to infliximab(IFX) and adalimumab (ADA) and risk factors for non-adherence in outpatients with IBD.

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sMethods: In this multicenter observational study, consecutive IBD patients visiting theoutpatient clinic were included. Patients completed the validated Modified Morisky Adher-ence Scale-8 with a score on this scale of ,6 indicating low adherence. Clinical diseaseactivity was assessed by the modified Harvey Bradshaw Index (Crohn's disease) or theSimple Clinical Colitis Activity Index (ulcerative colitis). We also assessed demographic andbehavioural characteristics, including medication beliefs (Beliefs about Medicines Question-naire) and illness beliefs (Brief-Illness Perception Questionnaire). A hierarchical logisticalregression analysis was performed to determine factors associated with low adherence.Results: Seventy-three patients were included (27 IFX, 46 ADA), median age 35 years (IQR24-51), 27 males (37%). Median disease duration was 11 years (IQR 3-18). Clinical diseaseactivity was present in 19 patients (26%). Fifteen of 46 patients on ADA (33%) and 6 of27 patients on IFX (22%) reported a low adherence (p = 0.32). Attitudinal analysis showedthat while 38% of the patients was "accepting" maintenance therapy, including anti-TNFtherapy (high necessity, low concerns), more than half of patients (58%) was "ambivalent"about maintenance therapy (high necessity, high concerns). Factors independently associatedwith low adherence were high perceived personal control over the illness (OR 1.38, 95%CI 1.01-1.89), symptoms attributed to the illness (OR 0.60, 95% CI 0.39-0.93), and strongbeliefs about how the illness affects one's emotional well-being (OR 1.61, 95% CI 1.12-2.32). Non-adherence was not significantly affected by young age, male gender, diseaseactivity or concerns about potential adverse effects of anti-TNF therapy. Conclusions: Theoverall non-adherence rate of anti-TNF therapy is comparable to rates found in oral medica-tion. A substantial proportion of patients were ambivalent about maintenance therapy,including anti-TNF therapy and several illness beliefs were significantly associated with non-adherence. As illness beliefs are potentially modifiable factors, they may provide a relevanttarget for interventions aimed at improving adherence and health outcomes.

Sa1093

Do We Need to Repeat Upper Endoscopy After First Endoscopy PresentsReflux Esophagitis?Michael Abeles, Boris Sapoznikov, Sara Welinsky, Rachel Gingold Belfer, Yaron Niv, LitalBoker Keinan, Irena Liphshitz, Zohar Levi

Background: Patients with a primary endoscopic diagnosis of Reflux Esophagitis (RE) areoften advised to repeat upper endoscopy. We aimed to assess the adherence for repeatendoscopy and evaluate the outcomes at our center. Methods: Included all patients with afirst endoscopy revealing RE from 2003 to 2011. The endoscopic diagnosis of reflux esophagi-tis was extracted from the electronic medical records database, and all cases were trackedfor further endoscopy, pathology results and for any record of gastro-esophageal cancerthrough the National cancer Registry (NCR). Results: Included 958 cases: 62.5% had LosAngeles (LA)-A, 17.7% had LA-B and 19.7 % had LA-C/D. Of all cases, 616 (64.3%) hadrepeat endoscopy. The proportion of repeat endoscopy was not correlated with severity ofRE (p=0.4). Pathology confirmed that Barrett's Esophagus (BE) was found in 49/368 (13.3%)of LA-A, 23/126 (18.3%) of LA-B and 20/122 (16.4%) of LA-C/D (p=0.35). BE with dysplasiawas found in 11/368 (3.0%) of LA-A, 4/126 (3.2%) of LA-B and 4/122 (3.3%) of LA-C/D(p=0.98). BE with cancer was found in 2/368 (0.5%) of LA-A and none in LA-B and LA-C/D (p=0.64). No further gastro-esophageal cancer was detected by the NCR. Conclusions:Repeat endoscopy was performed in about two thirds of patients who were formerly foundto have RE. Interestingly, most of the cases of Barrett's Esophagus with and without dysplasiaoccurred in the group of mild RE. Repeat endoscopy is strongly advised to all patients withall degrees of RE.

Sa1094

A Sustained Reduction of Inappropriate Proton Pump Inhibitor Use Through aProcess Improvement Initiative At an Academic Teaching HospitalRena Shah, Andrew Lichtmann, Dana Russell, Tristan Grogan, Nasim Afsarmanesh, DanielUslan

Background: Proton pump inhibitors (PPIs) are one of the most widely used medications.Studies have shown 60% of inpatient PPI use is inappropriate. Inpatient PPI use is associatedwith risks such as Clostridium difficile infection (CDI) and nosocomial pneumonia. Weimplemented a process improvement initiative to decrease inappropriate PPI use on aninternal medicine teaching service. Methods: We utilized quality improvement tools andlean methodology to implement our initiative. First, we retrospectively reviewed 100 internalmedicine patients to determine the baseline rate of inappropriate PPI use. Appropriatenesswas determined according to the American Society of Health System Pharmacists' guidelinesfor PPI utilization. We administered a survey to housestaff regarding PPI indications andside effects. Next we developed an A3 report and performed a root cause analysis to identifyareas contributing to inappropriate PPI use. We implemented an initiative focused onhousestaff education. We led didactic sessions, distributed informational pocketcards andencouraged housestaff to qualify PPI use on their progress notes. We also incorporatedformal indications for PPI use onto electronic ordersets and worked with pharmacy todevelop a formal PPI review process in the hospital. Initially, a pilot phase was conductedwith medicine team C. The rate of inappropriate PPI use and qualification of PPI use onprogress notes was monitored on a daily basis for 14 days. Next we expanded the initiativeto the entire internal medicine service and followed patients for 6 weeks. Results: Accordingto the baseline data, 63% of internal medicine inpatients were placed on a PPI and 35% ofPPI utilization was inappropriate. Housestaff scored an average of 34% on the survey. Theroot cause analysis identified multiple areas for intervention including lack of physicianawareness of PPI indications and risks, preset PPI checkboxes on ordersets and absence ofa formal hospital PPI review process (Figure 1). In the pilot phase, inappropriate PPI usedecreased from 35% to 1.6% (p,0.001) and qualification of PPI use increased from 0% to74%. During the expansion phase, inappropriate PPI use decreased from 35% to 15% (p=0.0018) (Figure 2). Conclusion: Through a formal quality improvement process, we achieveda significant and sustainable decrease in inappropriate PPI use on an inpatient internalmedicine service. An integral component was housestaff education and incorporation of PPIqualification into daily progress notes. Decrease in inappropriate PPI use led to a decrease

S-200AGA Abstracts

in polypharmacy and the data suggests it could ultimately lead to a decrease in associatedrisks such as hospital acquired CDI.

Root cause analysis to identify areas in clinical practice that lead to inappropriate PPI use.The starred boxes represent areas for intervention.

A) Overall inappropriate use decreased from 35% during the baseline phase to 1.6% duringthe Pilot Phase. This was a highly statistically significant change (P-value , 0.001). B)Overall inappropriate use decreased from 35% during the Baseline Phase to 15% duringthe Expansion Phase. This was a statistically significant change (P-value = 0.0018).

Sa1095

Assessment of Quality Indicators for Colonoscopy At Two Large AcademicInstitutions After InterventionLauren M. Shea, Melissa Osborn, Jay M. Anderson, Robin Rutherford, MohammadWehbi, Julia Massaad

Background: Colorectal cancer (CRC) is the second leading cause of cancer death in theUnited States. Colonoscopy is the gold standard of screening for CRC. Despite strong evidencethat this test has decreased mortality from CRC, there is marked variation in the performanceand reporting of this testing modality, and a great emphasis in the literature on QUALITYcolonoscopy. In 2009, we conducted a retrospective review to assess the performance andreporting techniques of 11 of our endoscopists. After analysis of the data, each endoscopistwas given face to face feedback on their performance and reporting techniques. Followingthat, we conducted a prospective study to see what changes/improvements were displayedin the endoscopists' performance and reporting techniques. Aim: to determine if there wasa change/ improvement in the performance as well as the reporting of endoscopists afterthey were provided with feedback on their prior performance status. Methods: For each of12 gastroenterologists, we reviewed 200 colonoscopy reports performed between May, 2010and February, 2012. 6 gastroenterologists participated in the retrospective study. The other6 were aware that their performance was being monitored. The reports reviewed includedexams performed for average risk screening, guaiac positive stool, history of polyps, orfamily history of CRC. Each report was analyzed for documentation of patient demographics,indication for the procedure, quality of the preparation, extent of the exam, polyp descriptorsand withdrawal time. The data were collected using Access (Microsoft) and analyzed withSAS 9.1. Results: Among the 2270 reports reviewed, more than 99% included patient ageand gender, procedural indication, quality of the preparation, and extent of the exam. 47.7%recorded race. The overall cecal intubation rate was 97.3%. Polyps were found in 49.7%of patients. The adenoma detection rate was 33.7% among all patients. 99% of the reportsincluded the polyp morphology. 1872 reports used standard descriptive terms to describethe quality of the preparation (68.6% good, 20% fair/adequate, 4.8% fair/inadequate, poor6.3%). Withdrawal time was documented 85.8% of the time. Conclusions: This studyprovides evidence of improvement in endoscopy performance and quality of reportingafter providing feedback to endoscopists, and standardizing the data collecting system. Ascompared to the retrospective study, there was improvement in recording cecal landmarks(.95%) and withdrawal time 85.8%. The patient's race was reported in 47.7% of reportsas compared to 0.05% in the retrospective study. The overall adenoma detection rateincreased from 25.4% to 33.7%. Conclusion: Standardization of colonoscopy reporting, andfeedback on performance are necessary for the improvement in the performance and reportingof colonoscopies.