PMCC PMCC

Search tips
Search criteria

Advanced
Results 1-25 (29)
 

Clipboard (0)
None

Select a Filter Below

Journals
Year of Publication
1.  Randomized trial in malignant biliary obstruction: Plastic vs partially covered metal stents 
AIM: To compare efficacy and complications of partially covered self-expandable metal stent (pcSEMS) to plastic stent (PS) in patients treated for malignant, infrahilar biliary obstruction.
METHODS: Multicenter prospective randomized clinical trial with treatment allocation to a pcWallstent® (SEMS) or a 10 French PS. Palliative patients aged ≥ 18, for infrahilar malignant biliary obstruction and a Karnofsky performance scale index > 60% from 6 participating North American university centers. Primary endpoint was time to stent failure, with secondary outcomes of death, adverse events, Karnofsky performance score and short-form-36 scale administered on a three-monthly basis for up to 2 years. Survival analyses were performed for stent failure and death, with Cox proportional hazards regression models to determine significant predictive characteristics.
RESULTS: Eighty-five patients were accrued over 37 mo, 42 were randomized to the SEMS group and 83 patients were available for analyses. Time to stent failure was 385.3 ± 52.5 d in the SEMS and 153.3 ± 19.8 d in the PS group, P = 0.006. Time to death did not differ between groups (192.3 ± 23.4 d for SEMS vs 211.5 ± 28.0 d for PS, P = 0.70). The only significant predictor was treatment allocation, relating to the time to stent failure (P = 0.01). Amongst other measured outcomes, only cholangitis differed, being more common in the PS group (4.9% vs 24.5%, P = 0.029). The small number of patients in follow-up limits longitudinal assessments of performance and quality of life. From an initially planned 120 patients, only 85 patients were recruited.
CONCLUSION: Partially covered SEMS result in a longer duration till stent failure without increased complication rates, yet without accompanying measurable benefits in survival, performance, or quality of life.
doi:10.3748/wjg.v19.i46.8638
PMCID: PMC3870509  PMID: 24379581
Randomized; Biliary; Obstruction; Stent; Plastic; Metal; Palliative; Common bile duct
2.  Prolonged treatment duration is required for successful Helicobacter pylori eradication with proton pump inhibitor triple therapy in Canada 
BACKGROUND:
Traditional seven-day proton pump inhibitor triple therapy for Helicobacter pylori eradication has recently shown disappointing results outside of Canada. Prolonging therapy may be associated with poorer compliance and, hence, may not have a better outcome in a real-world setting.
OBJECTIVE:
To compare the outcomes of seven- and 14-day triple therapy for first-line treatment of H pylori infection in an effectiveness setting in Canada.
METHODS:
A total of 314 consecutive treatment-naive, adult H pylori-infected patients were allocated to either a seven- or 14-day triple therapy regimen, with a subgroup of 172 consecutive patients quasi-randomized to treatment according to date of visit. Eradication was confirmed using either urea breath test or gastric biopsies. Analysis was by intention to treat.
RESULTS:
Eradication was achieved in a higher proportion of patients who underwent 14-day versus seven-day treatment regimens (overall: 85% versus 70% [P≤0.001]; subgroup: 83% versus 64% [P≤0.01]). Although successful eradication was also associated with older age and a diagnosis of ulcer disease, multivariate analysis revealed only longer treatment duration and lack of yogurt ingestion as independent predictors of successful eradication. There was a trend toward reduced success in the latter years of the study. Side effects were similar in both groups and were not prevented by yogurt ingestion.
CONCLUSIONS:
The currently recommended duration of proton pump inhibitor triple therapy in Canada should be increased from seven to 14 days, the latter having achieved an excellent result in this particular real-world setting. Yogurt added no benefit. Further study is required to compare 10-day with 14-day treatment regimens.
PMCID: PMC3956018  PMID: 23862170
Amoxicillin; Clarithromycin; Duration; Helicobacter pylori; Proton pump inhibitor; Triple therapy; Yogurt
3.  Current status of core and advanced adult gastrointestinal endoscopy training in Canada: Survey of existing accredited programs 
OBJECTIVE:
To determine the current status of core and advanced adult gastroenterology training in Canada.
METHODS:
A survey consisting of 20 questions pertaining to core and advanced endoscopy training was circulated to 14 accredited adult gastroenterology residency program directors. For continuous variables, median and range were analyzed; for categorical variables, percentage and associated 95% CIs were analyzed.
RESULTS:
All 14 programs responded to the survey. The median number of core trainees was six (range four to 16). The median (range) procedural volumes for gastroscopy, colonoscopy, percutaneous endoscopic gastrostomy and sigmoidoscopy, respectively, were 400 (150 to 1000), 325 (200 to 1500), 15 (zero to 250) and 60 (25 to 300). Eleven of 13 (84.6%) programs used endoscopy simulators in their curriculum. Eight of 14 programs (57%) provided a structured advanced endoscopy training fellowship. The majority (88%) offered training of combined endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography. The median number of positions offered yearly for advanced endoscopy fellowship was one (range one to three). The median (range) procedural volumes for ERCP, endoscopic ultrasonography and endoscopic mucosal resection, respectively, were 325 (200 to 750), 250 (80 to 400) and 20 (10 to 63). None of the current programs offered training in endoscopic submucosal dissection or natural orifice transluminal endoscopic surgery.
CONCLUSION:
Most accredited adult Canadian gastroenterology programs met the minimal procedural requirements recommended by the Canadian Association of Gastroenterology during core training. However, a more heterogeneous experience has been observed for advanced training. Additional studies would be required to validate and standardize evaluation tools used during gastroenterology curricula.
PMCID: PMC3735729  PMID: 23712301
Curriculum; Education; Endoscopy; Gastroenterology
4.  Endoscopy reporting standards 
OBJECTIVES:
The Canadian Association of Gastroenterology (CAG) recently published consensus recommendations for safety and quality indicators in digestive endoscopy. The present article focuses specifically on the identification of key elements that should be found in all electronic endoscopy reports detailing recommendations adopted by the CAG consensus group.
METHODS:
A committee of nine individuals steered the CAG Safety and Quality Indicators in Endoscopy Consensus Group, which had a total membership of 35 voting individuals with knowledge on the subject relating to endoscopic services. A comprehensive literature search was performed with regard to the key elements that should be found in an electronic endoscopy report. A task force reviewed all published, full-text, adult and human studies in French or English.
RESULTS:
Components to be entered into the standardized report include identification of procedure, timing, procedural personnel, patient demographics and history, indication(s) for procedure, comorbidities, type of bowel preparation, consent for the procedure, pre-endoscopic administration of medications, type and dose of sedation used, extent and completeness of examination, quality of bowel preparation, relevant findings and pertinent negatives, adverse events and resulting interventions, patient comfort, diagnoses, endoscopic interventions performed, details of pathology specimens, details of follow-up arrangements, appended pathology report(s) and, when available, management recommendations. Summary information should be provided to the patient or family.
CONCLUSION:
Continuous quality improvement should be the responsibility of every endoscopist and endoscopy facility to ensure improved patient care. Appropriate documentation of endoscopic procedures is a critical component of such activities.
PMCID: PMC3735732  PMID: 23712304
Colonoscopy/standards; Electronic reporting; Research report/standards; Review
5.  Patient-identified quality indicators for colonoscopy services 
BACKGROUND:
Current quality improvement tools for endoscopy services, such as the Global Rating Scale (GRS), emphasize the need for patient-centred care. However, there are no studies that have investigated patient expectations and/or perceptions of quality indicators in endoscopy services.
OBJECTIVES:
To identify quality indicators for colonoscopy services from the patient perspective; to rate indicators of importance; to determine factors that influence indicator ratings; and to compare the identified indicators with those of the GRS.
METHODS:
A two-phase mixed methods study was undertaken in Montreal (Quebec), Calgary (Alberta) and Hamilton (Ontario) among patients ≥18 years of age who spoke and read English or French. In phase 1, focus group participants identified quality indicators that were then used to construct a survey questionnaire. In phase 2, survey questionnaires, which were completed immediately after colonoscopy, prompted respondents to rate the 20 focus group-derived indicators according to their level of importance (low, medium, high) and to list up to nine additional items. Multiple logistic regression analysis was used to determine the factors that influenced focus group-derived indicator ratings. Patient-identified indicators were compared with those used in the GRS to identify novel indicators.
RESULTS:
Three quality indicator themes were identified by 66 participants in 12 focus groups: communication, comfort and service environment. Of the 828 surveys distributed, 402 (48.6%) were returned and 65% of focus group-derived indicators were rated highly important by at least 55% of survey respondents. Indicator ratings differed according to age, sex, site and perceived colorectal cancer risk. Of the 29 patient-identified indicators, 17 (58.6%) were novel.
CONCLUSIONS:
Patients identified 17 novel quality indicators, suggesting that patients and health professionals differ in their perspectives with respect to quality in colonoscopy services.
PMCID: PMC3545623  PMID: 23378980
Colorectal cancer screening; Indicators; Quality
6.  Report on the Expert Forum on Using Information Technology to Facilitate Uptake and Impact of Colorectal Cancer Screening Guidelines 
The present report summarizes the proceedings of the pan-Canadian Expert Forum on Using Information Technology to Facilitate Uptake and Impact of Colorectal Cancer Screening Guidelines, which was held in Montreal, Quebec, November 18 to 19, 2011. The meeting assembled a multidisciplinary group of family physicians, gastroenterologists, nurses, patients, foundation representatives, screening program administrators and researchers to discuss the development of a mechanism or strategy that would permit the collection of comparable data by all colorectal cancer (CRC) screening programs, which would not only support the needs of each program but also provide a national perspective. The overarching theme of the meeting was ‘designing a national approach to computerized electronic data collection and dissemination for CRC screening that would improve knowledge transfer across the continuum of preventive health care’. The forum encouraged presentations on clinical, research and technical topics. The meeting fostered valuable cross-disciplinary communication and delivered the message that it is essential to develop a national health informatics approach for CRC screening data collection and dissemination to support provincial CRC screening programs.
PMCID: PMC3551566  PMID: 23248792
Colorectal cancer; Information technology; National registry; Report; Screening
7.  Different screening definitions have little impact on polypectomy rate estimates 
BACKGROUND:
Polypectomy rate is a surrogate quality indicator for screening colonoscopy. Various methods for identifying screening colonoscopies have been used and it is unclear how different definitions affect the estimated polypectomy rate.
OBJECTIVE:
To estimate polypectomy rates and how they vary according to the definition of a screening colonoscopy, using patient- and endoscopist-reported indications.
METHODS:
A cross-sectional analysis of endoscopists and their patients 50 to 75 years of age who underwent colonoscopy was conducted. Based on questionnaire responses, four patient indications were derived: perceived screening; perceived nonscreening; medical history indicating nonscreening; and combination of the three indications. Endoscopist indication was derived from a questionnaire completed immediately after colonoscopy. Polypectomy status was obtained from provincial physician billing records. Polypectomy rates were computed, while accounting for physician and hospital level clustering, using all four patient indications, endoscopist indication, and the agreement between patient and endoscopist indications. The effect of indications on polypectomy rate was estimated adjusting for age, sex and family history of colorectal cancer.
RESULTS:
A total of 2134 patients and 45 endoscopists were included. The proportion of colonoscopies classified as screening according to the nine indications ranged from 32.2% to 70.9%. Polypectomy rates ranged between 22.6% and 26.2% for screening colonoscopy, and between 27.1% and 30.8% for nonscreening colonoscopy. Adjusted ORs for indication ranged between 0.74 and 0.94.
DISCUSSION:
Although the proportion of colonoscopies identified as screening varied considerably among the indications, the estimated polypectomy rates were similar.
CONCLUSION:
The findings suggest that the way screening is defined does not greatly affect the estimates of polypectomy rate.
PMCID: PMC3495695  PMID: 23166901
Colonoscopy; Colorectal cancer screening; Indication; Polypectomy; Quality assurance
8.  Rate of serious complications of colonoscopy in Quebec 
BACKGROUND
The rate of serious complications is one marker of the quality of colonoscopy services.
OBJECTIVE:
To estimate the rate of serious complications of colonoscopy according to colonoscopy indication and polypectomy status.
METHODS:
A prospective cohort study of patients scheduled for colonoscopy who were recruited from seven endoscopy facilities across Montreal (Quebec) was conducted. Before colonoscopy, patients completed a brief questionnaire and provided their health insurance numbers. Colonoscopy indication was based on patient-reported medical history. Polypectomy status was obtained from provincial physician billing records (Régie de l’assurance maladie du Québec). Diagnoses and procedures associated with hospitalization in the 30 days following colonoscopy were obtained from the provincial hospitalization database (MedEcho).
RESULTS:
Of the 2134 patients enrolled (mean age 60.9 years, 50.1% male), 33 (1.55% [95% CI 1.06% to 2.16%]) were hospitalized within 30 days. One patient experienced bleeding following a colonoscopy that involved polypectomy and was diagnosed with carcinoma in situ of the rectum. Based on self-reported rectal bleeding in the previous six months, the colonoscopy was nonscreening. The provincial hospitalization data showed no occurrences of perforation, diverticulitis, myocardial infarction/stroke or death; thus, the rate of serious colonoscopy complications was 0.05% (95% CI 0.00% to 0.26%).
DISCUSSION:
The rate of serious colonoscopy complications requiring hospitalization was low and comparable with what is reported in the literature. The serious complication occurred subsequent to polypectomy and in a nonscreening colonoscopy.
CONCLUSION:
The findings support the relative safety of screening colonoscopy in persons without large bowel diseases and symptoms. However, future research to determine the rate of serious complications not requiring hospitalization is warranted to reassure decision makers of the safety of colonoscopy for colorectal cancer screening.
PMCID: PMC3441168  PMID: 22993732
Colonoscopy; Complications; Screening
9.  The potential impact of contemporary developments in the management of patients with gastroesophageal reflux disease undergoing an initial gastroscopy 
BACKGROUND:
Recent developments may alter the approach to patients presenting with gastroesophageal reflux disease (GERD)-like symptoms. A newly proposed Montreal consensus definition of Barrett’s esophagus includes all types of esophageal columnar metaplasia, with or without intestinal-type metaplasia. There is also increasing recognition of eosinophilic esophagitis (EE) in patients with GERD-like symptoms.
OBJECTIVE:
To quantify the impact of these developments on a multiphysician general gastroenterology practice in a tertiary care medical centre.
METHODS:
Medical charts of all patients having an initial gastroscopy for GERD-like symptoms over a one-year period were reviewed retrospectively, and audits of their endoscopic images and esophageal biopsies were performed.
RESULTS:
Of the 353 study participants, typical symptoms of heartburn and acid reflux were present in 87.7% and 23.2%, respectively. Less commonly, patients presented with atypical symptoms (eg, dysphagia in 9.4%). At endoscopy, 26% were found to have erosive esophagitis and 12% had endoscopically suspected esophageal metaplasia. Histological evaluation was available for 65 patients. Ten of the 65 biopsied patients (15%) met traditional criteria for Barrett’s esophagus (ie, exhibiting intestinal-type metaplasia), whereas 49 (75%) fulfilled the newly proposed consensus definition of Barrett’s esophagus. Five patients (7.7%) met the study criteria for EE (more than 20 eosinophils per high-power field), four of whom had not been previously recognized.
CONCLUSIONS:
Among patients presenting with GERD-like symptoms, the prevalence of Barrett’s esophagus may increase markedly if the Montreal definition is adopted. In addition, growing awareness of EE may lead to an increase in the prevalence of this diagnosis. Prospective studies of the management implications of these findings are warranted.
PMCID: PMC2694588  PMID: 19214284
Barrett’s esophagus; Eosinophilic esophagitis; Gastroesophageal reflux disease (GERD)
10.  Why do mortality rates for nonvariceal upper gastrointestinal bleeding differ around the world? A systematic review of cohort studies 
BACKGROUND:
Discrepancies exist in reported mortality rates of nonvariceal upper gastrointestinal bleeding (NVUGIB).
OBJECTIVE:
To perform a systematic review assessing possible reasons for these disparate findings and to more reliably compare them.
METHODS:
The MEDLINE, EMBASE and ISI Web of Knowledge databases were searched for studies reporting mortality rates in NVUGIB involving adults and published in English. To ensure robust and contemporary estimates, studies spanning 1996 to January 2011 that included more than 1000 patients were selected.
RESULTS:
Eighteen of 3077 studies were selected. Ten studies used administrative databases and the remaining eight used registries. The mortality rates reported in these studies ranged from 1.1% in Japan to 11% in Denmark. There were variations in reported mortality rates among countries and also within countries. Reasons for these disparities included a spectrum of quality in reporting as well as heterogeneous definitions of case ascertainment, differing patient populations with regard to severity of presentation and associated comorbidities, varying durations of follow-up and different health care system-related practices.
CONCLUSIONS:
Wide differences in reported NVUGIB mortality rates are attributable to differences in adopted methodologies and populations studied. More uniform standards in reporting are needed; only then can true observed variations enable a better understanding of causes of death and pave the way to improved patient outcomes.
PMCID: PMC3414476  PMID: 22891179
Acetylsalicylic acid; Acute gastrointestinal bleeding; Bleeding peptic ulcer; Gastrointestinal endoscopy
11.  The costs of colonoscopy in a Canadian hospital using a microcosting approach 
BACKGROUND:
Colonoscopy has become accepted as one of the most effective methods of screening patients for colorectal cancer, and is used to remove the majority of colonic adenomas.
OBJECTIVE:
Because of the paucity of such estimates in the literature and the significant number of candidates for this procedure, the present study was performed to estimate the direct hospital costs of both diagnostic and therapeutic (polypectomy) colonoscopy.
METHODS:
A microcosting methodology was used to itemize the costs of colonoscopy. Variable and fixed costs were divided into labour, supplies, equipment and overhead costs. A third-party payer perspective was adopted. All costs are expressed in 2007 Canadian dollars.
RESULTS:
The cost of a diagnostic colonoscopy was $157 and the cost of a therapeutic colonoscopy was $199. Overhead costs represented approximately 30% of these amounts. When physician fees were added, these costs rose to $352 and $467, respectively.
CONCLUSION:
Because the overhead costs represent a large proportion of the total costs, allocation methods for these costs should be improved to allow for a more precise determination of the total costs of a colonoscopy. These estimates are useful when analyzing the cost-effectiveness of a strategy that uses colonoscopy when screening for colorectal cancer.
PMCID: PMC2660815  PMID: 18560635
Colonoscopy; Cost; Microcosting
12.  The Stretta procedure versus proton pump inhibitors and laparoscopic Nissen fundoplication in the management of gastroesophageal reflux disease: A cost-effectiveness analysis 
BACKGROUND:
The Stretta procedure is an endoscopic therapy for gastroesophageal reflux disease.
OBJECTIVE:
To evaluate the cost-effectiveness of the Stretta procedure and that of competing strategies in the long-term management of gastroesophageal reflux disease.
METHODS:
A Markov model was designed to estimate costs and health outcomes in Canadian patients with gastroesophageal reflux disease over five years, from a Ministry of Health perspective. Strategies included the use of daily proton pump inhibitors (PPIs), laparoscopic Nissen fundoplication (LNF) and the Stretta procedure. Probabilities and utilities were derived from the literature. Costs are expressed in 2006 Canadian dollars. Units of effectiveness were symptom-free months (SFMs) and quality-adjusted life years (QALYs), using a five-year time horizon.
RESULTS:
In the analysis that used SFMs, the strategy using PPIs exhibited the lowest costs ($40 per SFM) and the greatest number of SFMs, thus dominating both the LNF and Stretta systems. But the cost-effectiveness analysis using QALYs as the measure of effectiveness showed that PPIs presented the lowest cost-effectiveness ratio, while both the LNF and Stretta strategies were associated with very high incremental costs (approximately $353,000 and $393,000, respectively) to achieve an additional QALY. However, the PPI strategy did not dominate the two other strategies, which were associated with better effectiveness.
CONCLUSIONS:
If SFMs are used as the measure of effectiveness, PPIs dominate the Stretta and LNF strategies. However, if QALYs are used, the PPIs still present the lowest cost and LNF gives the best effectiveness. Regardless of the units of effectiveness or utility used in the present cost analysis, an approach of prescribing PPIs appears to be the preferred strategy.
PMCID: PMC2660813  PMID: 18560633
GERD; Proton pump inhibitors; Stretta procedure
14.  Disparities in Outcomes following Admission for Cholangitis 
PLoS ONE  2013;8(3):e59487.
Introduction
Few have examined determinants of adverse outcomes in patients presenting with ascending cholangitis. The objective of this study was to examine factors associated with in-hospital mortality, prolonged length of stay (LOS) and increased hospital charges (HC) in patients presenting with acute cholangitis.
Methods
Within the Health Care Utilization Project Nationwide Inpatient Sample (NIS), we focused on patients, 18 years and older, admitted to the emergency department with cholangitis as primary diagnosis (1998–2009). Models were fitted to predict likelihood of in-hospital mortality, prolonged LOS and increased HC. Covariates included race, day of admission, insurance status, socio-economical status and other patient and hospital characteristics.
Results
Overall, weighted estimates of 248,942 patients were admitted with acute cholangitis between 1998 and 2009, of which 13,534 (5.4%) died during the admission. Multivariable analyses revealed that relative to Caucasian patients, African American, Hispanic and Asian and Pacific Islander patients were more likely to die (OR = 1.61, p<0.001, OR = 1.20, p = 0.01 and OR = 1.26, p = 0.008), to experience a prolonged LOS (OR = 1.77, p<0.001, OR = 1.30, p<0.001, 1.34, p<0.001), and to incur high HC (OR = 1.83, p<0.001, OR = 1.51, p<0.001, OR = 1.56, p<0.001). Moreover, Medicaid and Medicare patients were more likely to die (OR = 1.64, p<0.001, OR = 1.24, p<0.001), to experience a prolonged LOS (1.74, p<0.001, OR = 1.25, p<0.001) and to incur high HC (OR = 1.23, p = 0.002, OR = 1.12, p = 0.002) compared to privately insured patients. In subgroup analysis, there were no differences for Medicare patients age 65 years and over. However, those under 65, most of whom have disability or end stage renal disease, were more likely to experience the negative outcomes.
Conclusion
Race and insurance status represent independent predictors of in-hospital mortality and adverse outcomes in patients presenting with cholangitis. Whether these disparities are due to biological predisposition or unequal quality of care requires further investigation. Regardless, efforts should be made to reduce these outcome disparities.
doi:10.1371/journal.pone.0059487
PMCID: PMC3612050  PMID: 23555680
15.  Effectiveness of disseminating consensus management recommendations for ulcer bleeding: a cluster randomized trial 
Background:
International guidelines for the management of nonvariceal upper gastrointestinal bleeding have not been widely adopted in clinical practice. We sought to determine whether a national, multifaceted intervention could improve adherence to guidelines, especially for patients at high risk of nonvariceal upper gastrointestinal bleeding.
Methods:
In this randomized trial, we stratified hospitals by region and size and allocated sites to either the control or experimental group. Health care workers in the experimental group were given published guidelines, generic algorithms, stratification scoring systems and written reminders and attended multidisciplinary guideline education groups and case-based workshops. These interventions were implemented over a 12-month period after randomization, with performance feedback and benchmarking. The primary outcome of adherence rates to key guidelines in endoscopic and pharmacologic management, determined by chart review, was adjusted according to site characteristics and possible within-site dependencies. We also report the rates of adherence to other recommendations.
Results:
Forty-three sites were randomized to the experimental (n = 21) or control (n = 22) groups. In our primary analysis, we compared patients before (experimental group: n = 402 patients; control group: n = 424 patients) and after (experimental group: n = 361 patients; control group: n = 389 patients) intervention. Patient-level analysis revealed no significant difference in adherence rates to the guidelines after the intervention (experimental group: 9.8%; control group: 4.8%; p = 0.99) after adjustment for the rate of adherence before the intervention (experimental group: 13.2%; control group: 7.1%). The adherence rates to other guidelines were similar and decreased over time, varying between 5% and 93%.
Interpretation:
This national knowledge translation–based trial suggests poor adherence to guidelines on nonvariceal upper gastrointestinal bleeding. Adherence was not improved by an educational intervention, which highlights both the complexity and poor predictability of attempting to alter the behaviour of health care providers (Trial registration: ClinicalTrials.gov, no. MCT-88113).
doi:10.1503/cmaj.120095
PMCID: PMC3576461  PMID: 23318399
17.  Accuracy of administrative claims data for polypectomy 
Background:
The frequency of polypectomy is an important indicator of quality assurance for population-based colorectal cancer screening programs. Although administrative databases of physician claims provide population-level data on the performance of polypectomy, the accuracy of the procedure codes has not been examined. We determined the level of agreement between physician claims for polypectomy and documentation of the procedure in endoscopy reports.
Methods:
We conducted a retrospective cohort study involving patients aged 50–80 years who underwent colonoscopy at seven study sites in Montréal, Que., between January and March 2007. We obtained data on physician claims for polypectomy from the Régie de l’Assurance Maladie du Québec (RAMQ) database. We evaluated the accuracy of the RAMQ data against information in the endoscopy reports.
Results:
We collected data on 689 patients who underwent colonoscopy during the study period. The sensitivity of physician claims for polypectomy in the administrative database was 84.7% (95% confidence interval [CI] 78.6%–89.4%), the specificity was 99.0% (95% CI 97.5%–99.6%), concordance was 95.1% (95% CI 93.1%–96.5%), and the kappa value was 0.87 (95% CI 0.83–0.91).
Interpretation:
Despite providing a reasonably accurate estimate of the frequency of polypectomy, physician claims underestimated the number of procedures performed by more than 15%. Such differences could affect conclusions regarding quality assurance if used to evaluate population-based screening programs for colorectal cancer. Even when a high level of accuracy is anticipated, validating physician claims data from administrative databases is recommended.
doi:10.1503/cmaj.100897
PMCID: PMC3153545  PMID: 21670107
18.  A one-year economic evaluation of six alternative strategies for the management of uninvestigated upper gastrointestinal symptoms in Canadian primary care 
BACKGROUND:
The cost-effectiveness of initial strategies in managing Canadian patients with uninvestigated upper gastrointestinal symptoms remains controversial.
OBJECTIVE:
To assess the cost-effectiveness of six management approaches to uninvestigated upper gastrointestinal symptoms in the Canadian setting.
METHODS:
The present study analyzed data from four randomized trials assessing homogeneous and complementary populations of Canadian patients with uninvestigated upper gastrointestinal symptoms with comparable outcomes. Symptom-free months, quality-adjusted life-years (QALYs) and direct costs in Canadian dollars of two management approaches based on the Canadian Dyspepsia Working Group (CanDys) Clinical Management Tool, and four additional strategies (two empirical antisecretory agents, and two prompt endoscopy) were examined and compared. Prevalence data, probabilities, utilities and costs were included in a Markov model, while sensitivity analysis used Monte Carlo simulations. Incremental cost-effectiveness ratios and cost-effectiveness acceptability curves were determined.
RESULTS:
Empirical omeprazole cost $226 per QALY ($49 per symptom-free month) per patient. CanDys omeprazole and endoscopy approaches were more effective than empirical omeprazole, but more costly. Alternatives using H2-receptor antagonists were less effective than those using a proton pump inhibitor. No significant differences were found for most incremental cost-effectiveness ratios. As willingness to pay (WTP) thresholds rose from $226 to $24,000 per QALY, empirical antisecretory approaches were less likely to be the most cost-effective choice, with CanDys omeprazole progressively becoming a more likely option. For WTP values ranging from $24,000 to $70,000 per QALY, the most clinically relevant range, CanDys omeprazole was the most cost-effective strategy (32% to 46% of the time), with prompt endoscopy-proton pump inhibitor favoured at higher WTP values.
CONCLUSIONS:
Although no strategy was the indisputable cost-effective option, CanDys omeprazole may be the strategy of choice over a clinically relevant range of WTP assumptions in the initial management of Canadian patients with uninvestigated dyspepsia.
PMCID: PMC2947002  PMID: 20711528
Antisecretory therapy; Cost-effectiveness; Dyspepsia; Economic modelling; Endoscopy; Helicobacter pylori
19.  Barriers to the implementation of practice guidelines in managing patients with nonvariceal upper gastrointestinal bleeding: A qualitative approach 
BACKGROUND/OBJECTIVE:
Guidelines for the management of patients with nonvariceal upper gastrointestinal bleeding (NVUGIB) are inconsistently applied by health care providers, potentially resulting in suboptimal care and patient outcomes. A needs assessment was performed to assess health care providers’ barriers to the implementation of these guidelines in Canada.
METHODS:
Semistructured telephone interviews were conducted by trained research personnel with 22 selectively sampled health care professionals actively treating and managing NVUGIB patients, including emergency room physicians (ER), intensivists (ICU), gastroenterologists (GI), gastroenterology nurses and hospital administrators. Participants were chosen from a representative sample of six Canadian community- and academic-based hospitals that participated in a national Canadian audit on the management of NVUGIB.
RESULTS:
Participants reported substantive gaps in the implementation of NVUGIB guidelines that included the following: lack of knowledge of the specifics of the NVUGIB guidelines (ER, ICU, nurses); limited belief in the value of guidelines, especially in areas where evidence is lacking (ER, ICU); limited belief in the value of available tools to support implementation of guidelines (GI); lack of knowledge of the roles and responsibilities of health care professions and disciplines, and lack of effective collaboration skills (ER, ICU and GI); variability of knowledge and skills of health care professionals within professions (eg, variability of nurses’ knowledge and skills in endoscopic procedures); and perceived overuse of intravenous proton pump inhibitor treatment, with limited concern regarding cost or side effect implications (all participants).
CONCLUSIONS:
In the present study population, ER, ICU and nurses did not adhere to NVUGIB guidelines because they were neither aware of nor familiar with them, whereas the GI lack of adherence to NVUGIB guidelines was influenced more by attitudinal and contextual barriers. These findings can guide the design of multifaceted educational and behavioural interventions when attempting to effectively disseminate existing guidelines, and for guideline implementation into practice.
PMCID: PMC2886569  PMID: 20485702
Acid suppressive therapy; Drug therapy; Endoscopy; Gastric; Peptic; Proton pump inhibitors; Stomach
21.  Does blood urea nitrogen level predict severity and high-risk endoscopic lesions in patients with nonvariceal upper gastrointestinal bleeding? 
BACKGROUND:
Nonvariceal upper gastrointestinal bleeding (UGIB) is a serious medical condition requiring prompt resuscitation and early endoscopic therapy in those with high-risk endoscopic lesions (HRLs). There are little or no data correlating sole blood urea nitrogen (BUN) level with the severity of nonvariceal UGIB or the presence of HRLs in the adult population.
OBJECTIVES:
To determine if the BUN level on presentation correlates with parameters of severity of UGIB (need for blood transfusion or intensive care unit [ICU] admission) or to the subsequent finding of HRL, and in so doing identify patients who will require early endoscopic intervention.
METHODS:
The Canadian Registry of patients with Upper Gastrointestinal Bleeding undergoing Endoscopy was used to identify patients enrolled from the McGill University Health Centre (Montreal, Quebec) who presented with or developed acute nonvariceal UGIB while admitted. All comparisons were performed using Student’s t test or Wilcoxon’s signed rank test, as appropriate. Logistic regression modelling using a stepwise method was performed to identify independent predictors of severe nonvariceal UGIB and HRL.
RESULTS:
Two hundred nine patients were enrolled in the study. The mean age was 67±18 years and 59.8% were male. The mean BUN level was 13.4±9.4 mmol/L. Univariate analysis demonstrated that the BUN level was a significant predictor of ICU admission (BUN 14.7±10.4 mmol/L versus 12.0±8.0 mmol/L, P=0.035). However, when adjusted for systolic blood pressure, BUN level became a weaker predictor of ICU admission, just failing to achieve statistical significance (OR 1.03, 95% CI 1.00 to 1.06; P=0.08). Univariate analysis also demonstrated that BUN level was not a statistically significant predictor of blood transfusion requirement (BUN 14.1±10.6 mmol/L versus 13.6±8.6 mmol/L, P=0.508), nor of HRL (BUN 14.2±10.7 mmol/L versus 12.9±8.6 mmol/L, P=0.605).
CONCLUSION:
In patients with nonvariceal UGIB, the BUN level at initial presentation is a weak predictor of the severity of UGIB as defined by ICU admission, but is not helpful in identifying patients with a HRL.
PMCID: PMC2662899  PMID: 18414716
BUN; High-risk lesions (endoscopic); Predictors; Upper gastrointestinal bleed

Results 1-25 (29)