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

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.

To describe associations between patient factors and interest in and concerns about telehealth video visits among adults in midlife and older.A cross-sectional, nationally representative panel survey of US adults aged 50 to 80 years (N = 2256) in May 2019.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.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).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.

Background. 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. Methods. 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. Results. 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. Conclusion. 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.

Background Electronic medical record–based interventions such as best practice alerts, or reminders, have been proposed to improve evidence‐based medication prescribing. Formal implementation evaluation including long‐term sustainment are not commonly reported. Preprocedural medication management is often a complex issue for patients taking antithrombotic medications. Methods We implemented a best practice alert (BPA) that recommended referral to an anticoagulation clinic before outpatient elective gastrointestinal (GI) endoscopies. Eligible patients were taking an oral anticoagulant (warfarin or direct oral anticoagulant [DOAC]) and/or antiplatelet medications. Patients referred to the anticoagulation clinic were compared to those managed by the ordering provider. Outcomes assessed included guideline‐adherent drug management before endoscopy, documentation of a medication management plan, guideline‐adherent rates of bridging for high‐risk patients taking warfarin, and evaluation for sustained use of BPA. Results Eighty percent of patients (553/691) were referred to the anticoagulation clinic during the initial 13‐month study period. Most referrals came from gastroenterologists (397/553; 71.8%) followed by primary care providers (127/554; 22.9%). Patients referred had improved rates of guideline‐adherent medication management compared to those who were not referred (97.4% vs 91.0%; P = .001). Documentation of medication plan was significantly higher in the referred group (99.1% vs 59.4%; P ≤ .001). There were no differences in rates of appropriate bridging for patients taking warfarin. Implementation of the BPA also resulted in sustained, consistent use over an additional 18 months following the initial study period. Conclusion Implementation of a BPA before elective outpatient GI endoscopies was associated with improved rates of guideline‐adherent medication management and documented management plan, while streamlining preprocedural medication management.

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.

Potent antithrombotic agents are routinely prescribed after percutaneous coronary intervention (PCI) to reduce ischemic complications. However, in patients who are at an increased bleeding risk, this may pose significant risks. We sought to evaluate the association between a history of gastrointestinal bleeding (GIB) and outcomes after PCI. We linked clinical registry data from PCIs performed at 48 Michigan hospitals between 1/2013 and 3/2018 to Medicare claims. We used 1:5 propensity score matching to adjust for patient characteristics. In-hospital outcomes included bleeding, transfusion, stroke or death. Post-discharge outcomes included 90-day all-cause readmission and long-term mortality. Of 30,206 patients, 1.1% had a history of GIB. Patients with a history of GIB were more likely to be older, female, and have more cardiovascular comorbidities. After matching, those with a history of GIB (n = 312) had increased post-procedural transfusions (15.7% vs 8.4%; p0.001), bleeding (11.9% vs 5.2%; p0.001), and major bleeding (2.8% vs 0.6%; p = 0.004). Ninety-day readmission rates were similar among those with and without a history of GIB (34.3% vs 31.3%; p = 0.318). There was no significant difference in post-discharge survival (1 year: 78% vs 80%; p = 0.217; 5 years: 54% vs 51%; p = 0.189). In conclusion, after adjusting for baseline characteristics, patients with a history of GIB had increased risk of post-PCI in-hospital bleeding complications. However, a history of GIB was not significantly associated with 90-day readmission or long-term survival.

Introduction: Mismanagement of antithrombotic medications often leads to cancelled elective procedures. Pharmacist-led anticoagulation management prior to elective procedures is not well studied. Methods: We implemented a best practice advisory (BPA) that offered referral to a pharmacist-led medication management service prior to elective outpatient gastrointestinal endoscopies. Eligible patients were taking warfarin, a direct oral anticoagulant, and/or a P2Y12 inhibitor for management of atrial fibrillation (AF), venous thromboembolism (VTE), coronary artery disease (CAD), peripheral arterial disease (PAD), and/or mechanical heart valve. Patients referred to the antithrombotic service were compared to those managed by the ordering provider. Outcomes assessed included documentation of a medication management plan, guideline-appropriateness of drug cessation prior to endoscopy, and guideline-appropriate rates of enoxaparin bridging for high risk warfarin patients. Results: Seventy-four percent of patients (448/645) were referred to the antithrombotic service. These patients were more likely to have had VTE (33.0% vs. 18.2%), less likely to have CAD (31.9% vs. 40.9%; p=0.009 for indication category), and more likely to be prescribed warfarin (32.8% vs 20.9%, p Conclusion: Pre-procedural antithrombotic medication management by a pharmacist-led team for elective endoscopies was associated with more guideline-adherent management and better documentation of the medication plans.

Introduction: Given the use of potent antithrombotic agents during and after PCI, patients (pts) are at an increased risk of gastrointestinal bleeding (GIB). Hypothesis: We hypothesize that pts with a history of recent GIB have a higher risk of post-discharge readmission and mortality compared with those without a history of GIB. Methods: We linked clinical registry data from PCIs performed between 1/1/2013 and 3/31/2018 at 48 Michigan hospitals to Medicare claims. A recent history of GIB prior to PCI was defined in the clinical PCI registry as any occurrence of melena or hematemesis in the last 30 days or any history of GIB including peptic ulcer disease that may influence clinical management during this hospitalization. Primary outcomes of interest were 90-day readmission after PCI and long-term mortality. We used 1:5 propensity-matching to adjust for differences in characteristics between pts with and without a history of recent GIB. Log-rank testing was used to evaluate survival at 1 and 5 years. Fisher's exact testing was used to compare the rates of 90-day readmission after PCI. Results: Of 30,206 pts, 1.1% had a history of GIB. Pts with a history of GIB were more likely to be older, female, black, and have more cardiovascular comorbidities. After matching 1896 pts, those with a history of GIB (n=316) appeared to have decreased survival early after PCI (Fig); however, the differences in survival were not statistically significant at 1 yr (76.%3 vs. 80.1%; p=0.11) or 5 yrs (52.5% vs. 52.2%; p=0.50) (Fig). There was no significant difference in readmission rates among those with and without a history of GIB (33.5% vs. 30.2%; p=0.26). Conclusions: Pts with and without a history of recent GIB had similar risks of readmission and long-term mortality after PCI. Although a history of GIB has previously been shown to be associated with increased post-PCI bleeding complications, a recent history of GIB was not associated with long-term post-PCI outcomes.

Background: Proton pump inhibitors (PPIs) substantially reduce the risk of upper gastrointestinal bleeding (GIB) and are recommended for high-risk patients by professional cardiology societies but remain underused in clinical practice. By reducing hemorrhagic risk associated with dual antiplatelet therapy (DAPT), PPIs may affect the risk-benefit equation of varying durations of DAPT and should be considered in such clinical trials. We sought to determine the extent to which randomized controlled trials (RCTs) evaluating DAPT after percutaneous coronary intervention (PCI) provide guidance on the use of PPIs for GIB prevention. Methods: A previously completed systematic review was updated to identify all RCTs comparing varying durations of DAPT between June 1983 and October 2019. Primary publications, online supplements, clinical trial registries and additional publications linked to the trial registration number were reviewed for protocol information. Results: Of 21 included studies (n=58,625; Figure), none of the study protocols provided guidance on the use of PPIs by trial participants. One study stated that the decision to use PPIs was left to the discretion of the treating physician. Two studies specified that treating physicians could prescribe non-mandated medications concordant with standard of care but did not specifically mention PPIs. Only 5 studies reported rates of PPI use, which ranged from 25.6-69.1%. Conclusions: Trials of DAPT regimens did not provide guidance on the use of PPI gastroprotection, a guideline-supported strategy for prevention of bleeding from the GI tract, the most common site of bleeding in patients using DAPT. Guidance on and reporting of PPI use should be mandatory in future antithrombotic trials to enhance their safety and interpretability. Figure 1. PRISMA flow diagram

Objectives To explore how accurately over-the-counter (OTC) medications were documented in an academic nephrology clinic and the benefits of using a novel short questionnaire as part of medication reconciliation (MR). Methods We developed a 3-item tailored questionnaire with questions about use of aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and proton pump inhibitors (PPIs), which clinical leadership identified as medications of interest. Over the course of 20 days, medical assistants administered the questionnaire to clinic patients immediately after the standard MR. We summarized the rate of inaccurate medication documentation by individual drug and drug class, comparing the standard MR process with the questionnaire. We also calculated diagnostic performance characteristics of the questionnaire. We evaluated the severity of drug-drug interactions between OTC medications discovered using the OTC medication questionnaire and patients’ other prescription medications. Results Nearly 30% (n = 133 of 450) of the participants had at least 1 inaccurately documented OTC medication after the standard MR. The sensitivity and specificity of the standard MR were 79.2% and 93.5%, respectively, for aspirin; 14.5% and 99.5% for NSAIDs; and 80.4% and 97.3% for PPIs. Medication omissions were resolved in the electronic health record approximately two-thirds of the time using the questionnaire. At least 1 drug-drug interaction (DDI) involving active use of an OTC medication was identified in 9.6% of the patients. Of the DDIs, the most common portended effects were increased nephrotoxicity (52.9%), increased bleeding risk (22.9%), and enhanced antiplatelet activity (7.1%). Conclusion Despite the standard MR process, inaccurate documentation of commonly used OTC medications occurred in nearly one-third of outpatients in a nephrology clinic. A brief OTC medication questionnaire may be a scalable and effective strategy to address this problem.

Importance Management of antithrombotic medications presents a challenge for many clinicians and patients before procedures. Anticoagulation clinic involvement may improve preprocedure coordination, satisfaction on the part of patients and clinicians, last-minute procedure cancellations, and patient safety. Objective To assess the implementation of an electronic medical record (EMR) best practice alert (BPA) and anticoagulation clinic referral process to assist with management of antithrombotic medication before gastrointestinal endoscopic procedures. Design, Setting, and Participants This multimodal evaluation of a quality improvement intervention using EMRs and survey data included patients using oral antithrombotic medications who were scheduled for elective gastrointestinal endoscopic procedures at an academic medical center along with the clinicians who ordered these procedures. Data were collected from November 1, 2017, through December 19, 2018. Data were analyzed in September 2019. Exposures Following a multidisciplinary intervention, a BPA and referral process for periprocedural antithrombotic medication management was implemented in November 2017. Main Outcomes and Measures The following implementation outcomes were assessed through EMR review and surveys through December 2018: use of BPAs, patient and clinician satisfaction with preprocedure anticoagulation management, procedure cancelation rates, reach, and spread by patient and clinician characteristics. Multilevel logistic regression was used to estimate variance in BPA use at the clinician level. Results A total of 2082 patients (mean [SD] age, 64.1 [11.9] years) and 144 clinicians were included in the analysis. The BPA was used broadly across the health system, resulting in anticoagulation clinic referral for 1389 patients (66.7%). Referral was more common for patients using anticoagulant vs antiplatelet medications (1041 of 1524 [68.3%] vs 346 of 556 [62.2%]; adjusted odds ratio [aOR], 1.51; 95% CI, 1.15-1.98) and for procedures ordered by gastroenterologists vs primary care clinicians (933 of 1241 [75.2%] vs 365 of 618 [59.1%]; aOR, 2.15; 95% CI, 1.46-3.17). Individual clinician behavior patterns explained 26.5% (95% CI, 18.7%-36.1%) of variation in anticoagulation clinic referrals. Implementation of the intervention was associated with high patient satisfaction and improvements in multidimensional measures of clinician satisfaction (clinician response rate, 44.2% [144 of 326]). In multivariable analysis, the odds of altered or canceled procedures because of medication mismanagement declined after implementation (8 of 50 [16.0%] vs 1 of 52 [1.9%]; aOR, 0.11; 95% CI, 0.01-0.96;P = .02). Conclusions and Relevance A newly implemented BPA and anticoagulation clinic referral process was broadly adopted and used, had high satisfaction by patients and clinicians, and was associated with fewer disruptions to planned procedures caused by medication mismanagement.

BACKGROUND: An effective patient-physician relationship (PPR) is essential to the care of patients with irritable bowel syndrome (IBS). After developing a PPR questionnaire for patients, we sought to develop and validate an IBS-specific instrument to measure physician expectations of the PPR. METHODS: We conducted focus groups about PPRs among 15 clinicians who treat patients with IBS from community and academic centers. Qualitative analysis was used to generate the Patient-Physician Relationship Scale-Physician RESULTS: The PPRS-Physician contained 35 questions pertaining to interpersonal and psychosocial features considered desirable or undesirable in a relationship with IBS patients. 1113 physicians (22%) completed the survey. Physicians were predominantly middle-aged (mean = 55.1 years), male (85.0%), white (74.5%), and practiced primarily within group settings (61.6%), with an average of 25.7% of their patients having IBS. Factor analysis revealed three relevant factors: interfering attributes, positive attributes, and personal connection. The scale ranged from possible 0 to 100 (mean = 83.8; SD = 8.38). Cronbach’s alpha reliability measure of the scale was 0.938, indicating high internal consistency. There was a significant moderate, positive correlation between JSPE and the PPRS (P < 0.001, r = 0.488), establishing concurrent validity. CONCLUSIONS: We describe the development and validation of the first questionnaire to measure physician expectations of the PPR. This instrument can be used clinically, and for future studies on physician communication.

For warfarin-treated patients with atrial fibrillation (AF) at low thromboembolic risk, recent studies have shown harm associated with periprocedural bridging using low–molecular-weight heparin. Clinician surveys have indicated a preference toward excessive bridging, especially among noncardiologists; however, little is known about actual practice patterns in these patients. We performed a retrospective evaluation of bridging in the setting of gastrointestinal endoscopy. We identified 938 patients with AF on warfarin who underwent esophagogastroduodenoscopy or colonoscopy between 2012 and 2016 at a tertiary health center. Urgent, inpatient, or advanced endoscopic procedures were excluded. Clinical variables were abstracted using a predefined data dictionary. Values were expressed as means and compared using a t test or a chi-squared test as appropriate. Three hundred seventy-four patients met criteria for analysis. Twenty-five percent of these patients received bridging therapy, including 11% of patients with CHADS(2) scores of 0 to 2 without valvular AF or previous venous thromboembolism. Of the clinical variables assessed, CHADS(2), CHA(2)DS(2)-VASc, and a history of stroke were the strongest predictors of bridging. Cardiologists were also significantly less likely to prescribe bridging than noncardiology providers (18% vs 30%, p = 0.011); this effect was significant when controlling for CHADS(2), CHA(2)DS(2)-VASc, or stroke history. In conclusion, patients with AF on warfarin receive excessive low–molecular-weight heparin bridging in the setting of endoscopy; the lower rates of bridging observed among cardiologists suggests a need for their increased involvement in this decision making.

Background This systematic review aims to assess the accuracy of hydrogen breath testing as a predictor of bowel preparation. Methods Studies were identified from MEDLINE, Embase, Web of Science, Cochrane Library and clinicaltrials.gov. Two investigators evaluated abstracts for inclusion criteria - report of correlation between hydrogen breath levels and bowel preparation quality, prospective design and non-emergent colonoscopy in adults. Included studies underwent duplicate data extraction using a standardized approach. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool assessed quality of the studies. Results One hundred fifty-nine publications were identified, and six unique studies met inclusion criteria. The number of patients analyzed ranged from 61 to 127. Three studies were performed in the USA, one in Japan and two in Italy. Three studies used a prebiotic in addition to a purgative, with the intention of enhancing the discriminating ability of hydrogen breath levels. Three studies assessed baseline hydrogen levels. In five of the six studies, hydrogen breath levels were predictive of inadequate bowel preparation. Suggested absolute hydrogen levels to distinguish adequate from inadequate bowel preparation ranged from 3 to 10 parts per million. Depending on the cutoff value, sensitivity ranged from 71% to 100% and specificity from 87% to 100%. There was significant heterogeneity among studies in breath testing protocol and breath analyzer used. Full-text studies had low risk of bias in most assessed domains. Conclusion Hydrogen breath levels predict bowel preparation adequacy but existing studies have significant limitations. Further studies should use standardized methods and consider the real-world practicality of self-administered home breath testing.

Many patients with symptoms of gastroesophageal reflux disease (GERD) not responding to a proton pump inhibitor (PPI) undergo an upper endoscopy. We hypothesized that an incomplete response to a PPI is not associated with findings of esophageal pathology on endoscopy, and that psychological distress is associated inversely with pathology.We enrolled consecutive individuals aged 40 to 79 years with prior heartburn or regurgitation. Logistic regression was used to estimate the effects of incomplete response of GERD symptoms and psychological distress on the odds of finding erosive esophagitis or Barrett's esophagus.A total of 625 patients completed the study. A total of 254 (66.8% of those taking PPI) had GERD symptoms incompletely responsive to a PPI and 352 (56.3%) had severe somatization. An incomplete response to a PPI was associated with psychological distress (P.001). Erosive esophagitis was found in 148 subjects (23.7%) and Barrett's esophagus in 58 (9.3%). Overall, an incomplete response to a PPI was not found to be associated with these pathologies (odds ratio, 1.17; 95% CI, 0.720-1.91). In contrast, greater psychological distress was associated inversely with erosive esophagitis or Barrett's esophagus (in particular, highest vs lowest tertile somatization: odds ratio, 0.590; 95% CI, 0.365-0.952).Patients undergoing upper endoscopy frequently have GERD symptoms incompletely responding to a PPI and a high burden of somatization. However, an incomplete response of GERD symptoms is a poor predictor for endoscopic pathology, and should not be relied upon for selecting patients for screening for Barrett's esophagus. Patients with high psychological distress are less likely to have esophageal pathology.

OBJECTIVES To assess patient preferences for colorectal cancer screening with stool-based tests after initial colonoscopy with suboptimal bowel preparation. METHODS An online scenario-based survey of adults aged 45 to 75 years at average risk for colorectal cancer was performed. RESULTS When presented with a hypothetical scenario of screening colonoscopy with suboptimal bowel preparation, 59% of respondents chose stool-based testing as a next step, 29% preferred a repeat colonoscopy within a year, and 12% preferred a repeat colonoscopy in 10 years (N = 1,080). CONCLUSIONS Clinicians should consider offering stool-based screening tests as an alternative to repeat colonoscopy after suboptimal bowel preparation.

BACKGROUND: Implementation of evidence-based practices often requires tailoring implementation strategies to local contextual factors, including available resources, expertise, and cultural norms. Using an exemplar case, we describe how health systems engineering methods can be used to understand system-level variation that must be accounted for prior to broad implementation. METHODS: Within the context of a single-center quality improvement activity, a multi-disciplinary stakeholder team used health systems engineering methods to describe how pre-endoscopy antithrombotic management was executed, and implemented a redesigned process to improve clinical care. The research team then conducted multiple stakeholder focus groups at four different health-care systems to describe and compare current processes for pre-endoscopy antithrombotic medication management. Detailed work flow maps for each health-care system were developed, analyzed, and integrated to develop an overarching current work flow map, identify key process steps, and describe areas of process variation. RESULTS: Five key process steps were identified across the four health systems: (1) place an endoscopy order, (2) screen for antithrombotic use, (3) coordinate medication management, (4) instruct the patient, and (5) confirm appropriate medication management before procedure. Across health systems, we found a high degree of variation in each step (e.g., who performed, use of technology, systematic vs. ad hoc process). This variation was influenced by two key system-level contextual factors: (1) degree of health system integration and (2) role and training level of available staff. These key steps, areas of variation, and contextual factors were integrated into an assessment tool designed to facilitate tailoring of a future implementation and dissemination strategy. CONCLUSIONS: Tools from health systems engineering can be used to identify key work flow process steps, variations in how those steps are executed, and influential contextual factors. This process and the associated assessment tool may facilitate broader implementation tailoring. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-020-06121-5) contains supplementary material, which is available to authorized users.

Little is known about how reports on the adverse effects of proton pump inhibitors (PPIs) impact patients' perceptions of these drugs and medication use. We sought to determine patients' level of concern about PPI adverse effects and its association with attempts to discontinue these drugs.This study is an online survey of US adults who use PPIs for gastroesophageal reflux disease. Topics included awareness of and concern about PPI adverse effects, prior discussion with providers, and attempts to stop PPI because of concern about adverse effects. For the primary analysis, we used logistic regression to identify associations between having attempted to stop PPI and concern about PPI-related adverse effects, a provider's recommendation to stop, risk of upper gastrointestinal bleeding (UGIB), age, and gender.Among 755 patient participants, mean age was 49 years (s.d. 16), 71% were women, and 24% were at high risk of UGIB. Twenty percent of patients were able to write in ≥1 reported adverse effect, and 46% endorsed awareness of ≥1 adverse effect when presented with a list, most commonly chronic kidney disease (17%). Thirty-three percent of patients were slightly concerned, 32% somewhat concerned, and 14% extremely concerned about adverse effects. Twenty-four percent of patients had discussed PPI risks and benefits with a provider, and 9% had been recommended to stop. Thirty-nine percent had attempted to stop their PPI, most (83%) without a provider recommendation. Factors associated with an attempt at stopping PPI included: (i) provider recommendation to stop (odds ratio [OR] 3.26 [1.82-5.83]); (ii) concern about adverse effects (OR 5.13 [2.77-9.51] for slightly, 12.0 [6.51-22.2] for somewhat, and 19.4 [9.75-38.7] for extremely concerned); and (iii) female gender (OR 1.64 [1.12-2.39]). Patients at high risk of UGIB were as likely to have attempted to stop as others (OR 0.98 [0.66-1.44]).Concern about PPIs is common and strongly associated with attempts at discontinuation, even without a provider's recommendation. Notably, individuals at high risk of UGIB, who benefit from PPIs, were equally likely to have tried stopping PPIs as others. Providers should proactively discuss the risks and benefits of PPIs with their patients, who may otherwise make unwise decisions about PPI management on their own.

Background Periprocedural antithrombotic medication management is a complex, often confusing process for patients and their providers. Communication difficulties often lead to suboptimal medication management, resulting in delayed or canceled procedures. Methods We conducted telephone surveys with patients taking chronic antithrombotic medications who had recently undergone an endoscopy procedure. In the survey, we sought to better understand the periprocedural process for patients taking antithrombotic medications. We conducted a content analysis of patients’ unstructured responses from the periprocedural patient phone calls. We used a multistep group coding process to analyze responses. Relationships between different themes and categories were analyzed using original quotes and retrieving thematic segments from the transcripts. Results The survey was administered to 81 patients; 74/81 respondents (91%) said they understood the plan to manage their antithrombotics, but 21/81 respondents (26%) were not completely satisfied with the coordination, communication, and management of their medications. Five primary themes emerged from the content analysis as patient-centered design features affecting periprocedural care: (1) patients require accurate and timely information; (2) a patient's prior experience with antithrombotic therapy affects their understanding of the process; (3) patients prefer receiving their information from a single source, and (4) also prefer different methods of instruction; (5) finally, patients expect their clinician(s) to be available through the periprocedural management process. Conclusion To optimize the periprocedural medication management communication process, patients desire timeliness, accuracy, and adaptiveness to prior patient experience while offering a single, consistently available point of contact.

OBJECTIVES: To understand how physicians from various specialties perceive coordination of care when managing peri-procedural anticoagulation. STUDY DESIGN: Cross-sectional survey of cardiologists, gastroenterologists, and primary care physicians (PCPs) in an integrated health system (N=251). METHODS: The survey began with a vignette of a patient with atrial fibrillation co-managed by his PCP, cardiologist, and an anticoagulation clinic who must hold warfarin for a colonoscopy. Respondents’ experiences and opinions around responsibilities and institutional support for managing peri-procedural anticoagulation were elicited using multiple choice questions. We examined differences in responses across specialties using chi-square analysis. RESULTS: The response rate was 51% (n=127). 52% were PCPs, 28% cardiologists, and 21% gastroenterologists. Nearly half (47.2%) of respondents believed that the cardiologist should be primarily responsible for managing peri-procedural anticoagulation, while fewer identified the PCP (25.2%), anticoagulation clinic (21.3%), or gastroenterologist (6.3%; p=0.09). Respondents across specialties had significantly different approaches to deciding how to manage the clinical case presented (p

Irritable bowel syndrome (IBS) is viewed as a diagnosis of exclusion by most providers. The aim of our study was to perform a systematic review and meta-analysis to evaluate the utility of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), fecal calprotectin, and fecal lactoferrin to distinguish between patients with IBS and inflammatory bowel disease (IBD) and healthy controls (HCs).A systematic online database search was performed. Included studies were prospective, adult, diagnostic cohort studies with any of the four tests. The means and s.d. values of biomarker logarithms were estimated based on studies that gave medians and either confidence intervals for the median, interquartile ranges, or ranges. We used a Naive Bayes approach to estimate the probability of being a HC, having IBS, or having IBD based on the biomarker values.Systematic review identified 1,252 citations. After cross-referencing medical subject headings, detailed evaluation identified 140 potentially relevant journal articles/abstracts for CRP, ESR, calprotectin, and lactoferrin of which 4, 4, 8, and 2 fulfilled our inclusion criteria, respectively. None of the biomarkers reliably distinguished between IBS and healthy controls. At a CRP level of ≤0.5 or calprotectin level of ≤40 μg/g, there was a ≤1% probability of having IBD. Individual analysis of ESR and lactoferrin had little clinical utility.CRP and calprotectin of ≤0.5 or 40, respectively, essentially excludes IBD in patients with IBS symptoms. The addition of CRP and calprotectin to symptom-based criteria may improve the confident diagnosis of IBS.

With increased prescription of opioids has come increased recognition of adverse consequences, including narcotic bowel syndrome (NBS). Characterized by incompletely controlled abdominal pain despite continued or increasing doses of opioids, NBS is estimated to occur in 4.2-6.4% of patients chronically taking opioids. Patients with NBS have a high degree of comorbid psychiatric illness, catastrophizing and disability; comorbid substance abuse must also be considered among this population. NBS should be distinguished from opioid-induced bowel disorder, which results from the effects of opioids on gastrointestinal motility and secretion. By contrast, the mechanisms of NBS are probably centrally mediated and include glial cell activation, bimodal opioid modulation in the dorsal horn, descending facilitation of pain and the glutaminergic system. Few treatments have been rigorously studied. A trial of opioid detoxification resulted in complete detoxification for the vast majority of patients with reduction in pain symptoms; however, despite improvement in pain, approximately half of patients returned to opioid use within 3 months. Improved strategies are needed to identify patients who will respond to detoxification and remain off opioids. Comorbid psychiatric and substance abuse disorders are barriers to durable response after detoxification and should be actively sought out and treated accordingly. An effective patient-physician relationship is essential.

OBJECTIVE In the face of financial constraints, diabetic patients may forgo prescribed medications, causing negative health effects. This study examined how cost and noncost factors are associated with patterns of cost-related nonadherence to medications (CRN). RESEARCH DESIGN AND METHODS This was a cross-sectional survey of patients using medications for both diabetes and chronic pain (n = 245). Patients reported their income, out-of-pocket medication costs, education level, depressive symptoms, and medication-related beliefs and whether they cut back because of cost on 1) both diabetes and pain medications, 2) diabetes medications only, 3) pain medications only, or 4) neither. Multinomial logistic regression was used to model patients' adjusted odds ratios (AORs) of falling into these four possible categories. RESULTS Of the patients, 9% cut back on medications for both conditions, 13% cut back on diabetes medications alone, and 9% cut back on pain medications alone. Income 50 USD (AOR = 3.9, P = 0.02) increased patients' odds of CRN for both conditions versus neither. Low-income patients also were more likely to selectively forgo pain medications (AOR = 9.1, P = 0.001) but not diabetes medications (AOR = 2.1, P = 0.12). More depressive symptoms (AOR = 1.6, P = 0.006) and negative medication-related beliefs (AOR = 1.7, P = 0.02) increased patients' odds of cutting back selectively on medications for diabetes but not pain. CONCLUSIONS Patients who forgo medications for both diabetes and chronic pain appear to be influenced primarily by economic pressures, whereas patients who cut back selectively on their diabetes treatments are influenced by their mood and medication beliefs. Our findings point toward more targeted strategies to assist diabetic patients who experience CRN.

Importance Irritable bowel syndrome (IBS) affects 7% to 21% of the general population. It is a chronic condition that can substantially reduce quality of life and work productivity. Objectives To summarize the existing evidence on epidemiology, pathophysiology, and diagnosis of IBS and to provide practical treatment recommendations for generalists and specialists according to the best available evidence. Evidence Review A search of Ovid (MEDLINE) and Cochrane Database of Systematic Reviews was performed for literature from 2000 to December 2014 for the terms pathophysiology , etiology , pathogenesis , diagnosis , irritable bowel syndrome , and IBS . The range was expanded from 1946 to December 2014 for IBS , irritable bowel syndrome , diet , treatment , and therapy . Findings The database search yielded 1303 articles, of which 139 were selected for inclusion. IBS is not a single disease but rather a symptom cluster resulting from diverse pathologies. Factors important to the development of IBS include alterations in the gut microbiome, intestinal permeability, gut immune function, motility, visceral sensation, brain-gut interactions, and psychosocial status. The diagnosis of IBS relies on symptom-based criteria, exclusion of concerning features (symptom onset after age 50 years, unexplained weight loss, family history of selected organic gastrointestinal diseases, evidence of gastrointestinal blood loss, and unexplained iron-deficiency anemia), and the performance of selected tests (complete blood cell count, C-reactive protein or fecal calprotectin, serologic testing for celiac disease, and age-appropriate colorectal cancer screening) to exclude organic diseases that can mimic IBS. Determining the predominant symptom (IBS with diarrhea, IBS with constipation, or mixed IBS) plays an important role in selection of diagnostic tests and treatments. Various dietary, lifestyle, medical, and behavioral interventions have proven effective in randomized clinical trials. Conclusions and Relevance The diagnosis of IBS relies on the identification of characteristic symptoms and the exclusion of other organic diseases. Management of patients with IBS is optimized by an individualized, holistic approach that embraces dietary, lifestyle, medical, and behavioral interventions.

This study examines remuneration spending by drug-using participants in residential drug abuse research.Ninety-four adult males who participated in residential, non-treatment drug abuse research studies earned remuneration based on length of stay and specific research procedures. Remuneration could be in cash after discharge or for in-kind purchases and bill payments. Spending of remuneration was extracted from charts and evaluated with multivariate analyses.Participants received average remuneration of 1,454 dollars, taking 59% in cash. Other categories included cigarettes (60.6% of subjects), toiletries (60.6%), clothing (54.3%), and housing (52.1%). Primary drug of abuse, total remuneration, monthly income, length of stay on the residential research unit, age, and education were significantly associated with in-kind remuneration choices. Less total remuneration, intoxication in the month prior to study, higher IQ, and non-white race were associated with taking more in cash.Residential drug abuse research participants prefer cash to in-kind research remuneration, and their choices reflected drug use and economic status.

BACKGROUND An effective patient-physician relationship (PPR) is essential to the care of patients with irritable bowel syndrome (IBS). We sought to develop and validate an IBS-specific instrument to measure expectations of the PPR. METHODS We conducted structured focus groups about PPRs with 12 patients with IBS. Qualitative analysis was used to generate a questionnaire (the Patient-Physician Relationship Scale [PPRS]), which was modified with input from content experts and usability testing. For validation, we administered it online to US adults with IBS. Participants also completed the Functional Bowel Disorder Severity Index, the Rome III Adult Functional gastrointestinal (GI) Disorder Criteria Questionnaire, and modified versions of the Communication Assessment Tool (CAT-15) and Patient-Doctor Relationship Questionnaire (PDRQ-9). We performed principal components factor analysis for the PPRS. KEY RESULTS The PPRS contained 32 questions with responses on a 7-item Likert scale. Themes included interpersonal features, clinical care expectations, and aspects of communication. One thousand and fifty-four eligible individuals completed the survey (88% completion rate). Most participants were middle aged (mean 48 years, SD 16.3), white (90%), and female (86%). Factor analysis showed only one relevant factor, relating to quality of PPR. The final scale ranged from possible-96 to +96 (mean 62.0, SD 37.6). It correlated moderately with the CAT-15 (r=.40, P

Background Bowel preparation is inadequate in a large proportion of colonoscopies, leading to multiple clinical and economic harms. While most patients receive some form of education before colonoscopy, there is no consensus on the best approach. Aims This systematic review aimed to evaluate the efficacy of patient education interventions to improve bowel preparation. Methods We searched the Cochrane Database, CINAHL, EMBASE, Ovid, and Web of Science. Inclusion criteria were: (1) a patient education intervention; (2) a primary aim of improving bowel preparation; (3) a validated bowel preparation scale; (4) a prospective design; (5) a concurrent control group; and, (6) adult participants. Study validity was assessed using a modified Downs and Black scale. Results 1,080 abstracts were screened. Seven full text studies met inclusion criteria, including 2,660 patients. These studies evaluated multiple delivery platforms, including paper-based interventions (three studies), videos (two studies), re-education telephone calls the day before colonoscopy (one study), and in-person education by physicians (one study). Bowel preparation significantly improved with the intervention in all but one study. All but one study were done in a single center. Validity scores ranged from 13 to 24 (maximum 27). Four of five abstracts and research letters that met inclusion criteria also showed improvements in bowel preparation. Statistical and clinical heterogeneity precluded meta-analysis. Conclusion Compared to usual care, patient education interventions appear efficacious in improving the quality of bowel preparation. However, because of the small scale of the studies and individualized nature of the interventions, results of these studies may not be generalizable to other settings. Healthcare practices should consider systematically evaluating their current bowel preparation education methods before undertaking new interventions.

This study examined the impact of a 6-month, empowerment-based diabetes self-management support (DSMS) intervention on clinical outcomes, self-care behaviors, and quality of life (QOL) compared to a 6-month control period.This control-intervention cohort study recruited 77 African-American adults with type 2 diabetes. Baseline, 6-month, and 12-month assessments measured A1C, weight, body mass index (BMI), blood pressure, lipids, self-care behaviors, and QOL. During the control period, participants received weekly educational newsletters. During the intervention period, participants attended weekly DSMS groups as frequently as they needed. Sessions were guided by participants' self-management questions and concerns, and also emphasized experiential learning, coping, problem-solving, and goal-setting.The control period found significant improvements for diastolic BP (p0.05), serum cholesterol (p0.001), following a healthy diet (p0.01), and monitoring blood glucose (p0.01). The intervention period found significant additional improvements for A1C (p0.001), weight (p0.05), BMI (p0.05), and LDL (p0.001). Compared to the control period, participation in the intervention led to a significant reduction in A1C (p0.01).Findings suggest that an empowerment-based, DSMS intervention is promising for improving and/or maintaining diabetes-related health, particularly A1C.Incorporating empowerment principles in DSMS interventions may be useful for supporting patients' self-management efforts in "real-world" settings.