Transcript
Page 1: Patient Satisfaction Does Not Correlate With Established Colonoscopy Quality Metrics

© 2014 by the American College of Gastroenterology The American Journal of GASTROENTEROLOGY

Letters to the Editor 1089

Harvard Medical School , Boston , Massachusetts , USA . Correspondence: Joseph Feuerstein, MD , Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School , 330 Brookline Avenue E / Dana 501 , Boston, Massachusetts 02215 , USA . E-mail: [email protected]

Terminal Ileitis Found Upon Imaging: Is It Always Crohn ’ s Disease?

Teresa Pinto Pais , MD 1 , S ó nia Fernandes , MD 1 ,

Carlos Fernandes , MD 1 , Iolanda Ribeiro , MD 1

and Jo ã o Carvalho , MD 1

doi:10.1038/ajg.2014.114

To the Editor: Terminal ileitis (TI), defi ned

as infl ammation of the terminal ileum, is

a common condition in clinical practice

and is classically associated with Crohn ’ s

disease (CD). However, a wide variety

of diseases may be associated with ileitis

( 1,2 ). Diagnosis of the specifi c cause of

ileitis is of paramount importance because

misdiagnosis may result in critical delays or

errors in patient management ( 3 – 5 ). None-

theless, distinguishing between the various

forms of ileitis remains a test of clinical acu-

men. Accurate diagnosis is suggested by a

detailed history and physical examination,

by laboratory testing, and by ileocolonos-

copy and / or radiological evaluation.

To study the diff erent entities associated

with TI in clinical practice, we reviewed

all patients with confi rmed imaging of TI

on ultrasound admitted to our depart-

ment over four consecutive years. An

observational, descriptive, longitudinal

study was performed, with a retrospective

review of demographics, clinical presenta-

tion, laboratory data, treatment, and fol-

low-up. Abdominal ultrasonography was

performed in all patients and was comple-

mented with computed tomography when

necessary. Sonographic features compati-

ble with TI included hypoechogenic mural

thickening of the terminal ileum and hyp-

oechoic enlarged mesenteric lymph nodes

( 6 ). Th e diagnosis of ileal CD was based on

clinical, endoscopic, and histopathological

data. Acid-fast bacilli smear and culture

were performed in ileal biopsy specimens.

An infectious etiology was presumed when

there was clinical, analytical, and imag-

ing remission aft er empirical antibiotic

therapy, or when confi rmed by isolation

of pathogenic microorganisms in stool

cultures.

Th is study assessed 62 patients with a

median age of 38.2 years (18 – 82), with a

slight predominance of females (56.4 % ).

Th e main form of presentation was abdom-

inal pain (93.5 % ) and diarrhea (67.7 % ). All

patients presented with ultrasonographic

features of TI, which were corroborated

by computed tomography in 62.9 % . In this

study, infectious etiology was confi rmed

in 62.9 % ( n = 39) of patients, CD was

diagnosed in 32.2 % ( n = 20), and ileum

cancer in 4.9 % (ileal lymphoma — 2, ade-

nocarcinoma — 1). Fecal pathogens were

identifi ed in 7 patients: Campylobacter — 3,

Yersinia — 2, and Salmonella — 2. No para-

sitic or tuberculosis infection was identifi ed.

On comparing the groups with confi rmed

CD and infectious ileitis, we found in the

fi rst group higher median values of serum

infl ammatory parameters (C-reactive pro-

tein: 9.8 vs. 7.4 mg / dl; leukocyte count:

16.650 vs. 11.170 / μ l), lower hemoglobin

levels (10.45 vs. 13.5 g / dl, t- test, P =0.03),

and a longer inpatient period (10 vs. 5 days).

Patients diagnosed with CD maintain long-

term follow-up in our outpatient clinic.

In the current study, the diagnosis of CD

of the ileum was confi rmed histopatholog-

ically in 32.2 % of patients with imaging of

TI. We highlight that infl ammation of the

terminal ileum is not always CD, and infec-

tious etiology is a common cause (62.9 %

in our study). Th e diff erential diagnosis of

TI found on imaging, although sometimes

diffi cult, is of critical importance to avoid

further unnecessary diagnostic workup

and inappropriate treatment.

CONFLICT OF INTEREST Guarantor of the article: Teresa Pinto Pais,

MD.

Specifi c author contributions: Teresa Pinto

Pais was involved in planning and conduct-

ing the study, collecting and interpret-

ing data, and writing the paper. She has

approved the fi nal draft submitted. S ó nia

Fernandes was involved in planning the

study, interpreting data, and draft ing the

manuscript. She has approved the fi nal draft

submitted. Carlos Fernandes was involved

in collecting and interpreting data. He has

approved the fi nal draft submitted. Iolanda

Ribeiro was involved in collecting and

interpreting data. She has approved the fi nal

draft submitted. Jo ã o Carvalho was involved

in planning the study, interpreting data, and

draft ing the manuscript. He has approved

the fi nal draft submitted.

Financial support: None.

Potential competing interests: None.

REFERENCES 1 . Dilauro S , Crum-Cianfl one NF . Ileitis: when it

is not Crohn’s disease . Curr Gastroenterol Rep 2010 ; 12 : 249 – 58 .

2 . Greaves ML , Pochapin M . Asymptomatic ileitis: past, present, and future . J Clin Gastroenterol 2006 ; 40 : 281 – 5 .

3 . Lee YJ , Yang SK , Byeon JS et al. Analysis of colonoscopic fi ndings in the diff erential diagno-sis between intestinal tuberculosis and Crohn’s disease . Endoscopy 2006 ; 38 : 592 – 7 .

4 . Jeong SH , Lee KJ , Kim YB et al. Diagnostic value of terminal ileum intubation during colonoscopy . J Gastroenterol Hepatol 2008 ; 23 : 51 – 5 .

5 . Chang HS , Lee D , Kim JC et al. Isolated termi-nal ileal ulcerations in asymptomatic individu-als: natural course and clinical signifi cance . Gastrointest Endosc 2010 ; 72 : 1226 – 32 .

6 . Ledermann HP , B ö rner N , Strunk H et al. Bowel wall thickening on transabdominal sonography . Am J Roentgenol 2000 ; 174 : 107 – 17 .

1 Department of Gastroenterology and Hepatology, Centro Hospitalar de Gaia / Espinho , Vila Nova de Gaia , Portugal . Correspondence: Teresa Pinto Pais, MD , Department of Gastroenterology and Hepatology, Centro Hospitalar de Gaia / Espinho, Rua Concei ç ã o Fernandes , 4434-502 Vila Nova de Gaia , Portugal . E-mail: [email protected]

Patient Satisfaction Does Not Correlate With Established Colonoscopy Quality Metrics

Rena Yadlapati , MD 1 , Andrew Gawron , MD 1 , 2

and Rajesh N. Keswani , MD 1

doi:10.1038/ajg.2014.115

To the Editor: Quality metrics for colonos-

copy are increasingly being measured and

reported, as procedure quality correlates

Page 2: Patient Satisfaction Does Not Correlate With Established Colonoscopy Quality Metrics

The American Journal of GASTROENTEROLOGY VOLUME 109 | JULY 2014 www.amjgastro.com

1090 Letters to the Editor

with its eff ectiveness in reducing colorec-

tal cancer incidence and mortality ( 1,2 ).

Patient satisfaction ratings (PSRs) are also

publicly reported and may be eventually

tied to reimbursement in clinical practice.

PSRs are additionally being utilized in con-

cert with other measures to determine pro-

vider performance and health-care quality

( 3 – 6 ). However, previous studies have

failed to validate a relationship between

PSRs and surgical procedure quality ( 4 ). As

a result, we sought to investigate whether

patient satisfaction correlates with estab-

lished indicators of colonoscopy quality, an

area that has not been studied previously.

We performed a retrospective review of

PSRs and colonoscopy quality for endo-

scopists at a single-center tertiary care

teaching institution from September 2012

to August 2013. Endoscopists were included

if they were attending gastroenterologists

and performed more than 50 colonoscop-

ies over 1 year. Th is study was approved by

the Institutional Review Board.

All patients undergoing endoscopic

procedures at our institution are asked to

complete an 11-question outpatient vali-

dated survey developed by Press Ganey

Associates (South Bend, IN) assessing

their procedure experience ( 6 ). Th e PSR

is measured by calculating the percent-

age of responses with a score of 5 (rep-

resenting “ very good ” ) on a scale of 1 – 5.

Physician quality indicators for screening

colonoscopies including adenoma detec-

tion rate (ADR), withdrawal time (WT)

in normal screening colonoscopies, and

cecal intubation rate are also measured.

Th e relationship between patient satisfac-

tion and quality indicators was determined

using Spearman ’ s rank-order correlation.

Statistical analyses were performed using

STATA 12.0 (College Station, TX).

During the 1-year period 1,688 patient

satisfaction surveys were collected and 6,761

screening colonoscopies were performed.

Th e mean screening colonoscopy volume

per physician was 687 (229 – 1179) ± 301.

Twenty-one endoscopists (5F:16M) were

included in this study: 48 % were in private

practice and 52 % were in academic practice.

Th ere was no signifi cant diff erence in PSRs

and practice type. Median time in clinical

practice aft er training was 15 years (inter-

quartile range = 22), and did not correlate

with patient satisfaction ( r = − 0.11).

Th e overall mean PSR was 75.6 % (64 –

84 % ) ± 5.5 % . Th e mean ADR, WT, and cecal

intubation rate were 29 % (12 – 51 % ) ± 10.8 % ,

10.5 (3.1 – 19.2) ± 4.5 min, and 98.6 % (96.3 –

100 % ) ± 1.2 % , respectively. Th ere was weak

or no correlation between PSRs and ADR

( r = 0.22), WT ( r = 0.02), and cecal intu-

bation rate ( r = 0.24). We found a strong

positive correlation between ADR and WT

( r = 0.60; Table 1 ).

Th ere was a moderate, statistically sig-

nifi cant, inverse correlation between PSR

and physician sex ( r = − 0.57, P < 0.01).

However, there was no signifi cant diff er-

ence when comparing female with male

physician ADR, WT, or cecal intubation

rate ( Table 2 ). In addition, female endo-

scopists saw a disproportionately greater

number of female patients compared with

male endoscopists (75 % vs. 55 % , P < 0.01).

Th is is the fi rst study to suggest that

patient satisfaction is not related to estab-

lished colonoscopy quality indicators. Our

analyses did, however, reproduce a correla-

tion between widely accepted quality indi-

cators such as ADR and WT ( 7 ). Although

PSRs may refl ect an institution ’ s ability to

provide good service as part of the patient

experience, our study challenges their role

as a measure of colonoscopy quality.

Patient satisfaction is likely infl uenced

by several factors that are unrelated to pro-

cedure quality. For instance, it is possible

that polyp detection and removal results in

longer procedure time and emotional dis-

tress, which could negatively aff ect patient

satisfaction. Th is study also suggests a cor-

relation between PSRs and physician gen-

der. Th ese are interesting areas that require

further investigation.

In conclusion, this analysis demon-

strates that patient satisfaction is not a

reliable metric of colonoscopy quality,

and further work should be carried out

before patient satisfaction is promoted

as a surrogate measure for colonoscopy

quality.

CONFLICT OF INTEREST Guarantor of the article: Rena Yadlapati,

MD.

Specifi c author contributions: Rena

Yadlapati and Andrew Gawron: study concept

and design, acquisition of data, analysis and

interpretation of data, draft ing of manu-

script, approval of fi nal draft submitted; Raj

Keswani: Principal Investigator, study super-

vision, study concept and design, acquisition

of data, analysis and interpretation of data,

draft ing of manuscript, approval of fi nal

draft submitted.

Financial support: None.

Potential competing interests: None.

Table 1 . Colonoscopy variables and their correlation with PSRs

Variable Mean (range) ± s.d. Correlation with PSRs ( r )

ADR 29.2 (11.5 – 51.2) ± 10.7 0.17

WT (min) 10.5 (3.1 – 19.2) ± 4.5 0.88

Cecal intubation ( % ) 98.6 (96.0 – 99.0) ± 1.18 0.26

ADR, adenoma detection rate; PSR, patient satisfaction rating; WT, withdrawal time.

Table 2 . Colonoscopy quality indicators and PSRs for male and female endoscopists

Male endoscopists ( n =16) Female endoscopists ( n =5) P value

ADR, mean 29.8 (11.6 – 51.2) ± 11.8 27.6 (20.0 – 37.4) ± 6.9 0.69

WT, mean 10.1 (3.1 – 19.2) ± 4.6 11.8 (7.7 – 19.0) ± 4.3 0.46

Cecal intubation rate, mean 98.7 (96.3 – 99.9) ± 1.3 98.4 (97.9 – 99.3) ± 0.6 0.68

PSR, mean 77 (71 – 84) ± 4.5 70 (64 – 76) ± 4.5 < 0.01

ADR, adenoma detection rate; PSR, patient satisfaction rating; WT, withdrawal time.

Page 3: Patient Satisfaction Does Not Correlate With Established Colonoscopy Quality Metrics

© 2014 by the American College of Gastroenterology The American Journal of GASTROENTEROLOGY

Letters to the Editor 1091

REFERENCES 1 . Zauber AG WS , O ′ Brien MJ , Lansdorp-

Vogelaar I et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths . N Engl J Med 2012 ; 366 : 687 – 96 .

2 . Lieberman DA , Weiss DG , Bond JH et al. Use of colonoscopy to screen asymptomatic adults for colorectal cancer. Veterans Aff airs Cooperative Study Group 380 . N Engl J Med 2000 ; 343 : 162 – 8 .

3 . Centers for Medicare & Medicaid Services . Medicare program: hospital inpatient value-based purchasing program . Fed Regist 2011 ; 76 : 2454 – 91 .

4 . Lyu H , Wick EC , Housman M et al. Patient satisfaction as a possible indicator of quality surgical care . JAMA Surg 2013 ; 148 : 362 – 7 .

5 . Pascoe GC . Patient satisfaction in primary health care: a literature review and analysis . Eval Program Plann 1983 ; 6 : 185 – 210 .

6 . Hospital Consumer Assessment of Healthcare Providers and Systems 2013 (Accessed 29 December 2013, at http://www.hcahpsonline.org/home.aspx ) .

7 . Barclay RL , Vicari JJ , Doughty AS et al. Colonoscopic withdrawal times and adenoma

detection during screening colonoscopy . N Engl J Med 2006 ; 355 : 2533 – 41 .

1 Divisions of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University , Chicago , Illinois , USA ; 2 Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University , Chicago , Illinois , USA . Correspondence: Rena Yadlapati, MD, Divisions of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University , Chicago , Illinois 60611 , USA . E-mails: [email protected] and [email protected]


Recommended