Society: AGA

Introduction:
A family history of gastric cancer (GC) is a risk factor for developing this malignancy and portends an increased risk of precursor lesions such as gastric intestinal metaplasia (GIM). Recent American Gastroenterological Association guidelines cite having a family history of GC as an indication for surveillance of GIM; however, evidence on the threshold to initiate screening and surveillance in these individuals and the intervals at which it should continue is lacking. The aim of this study was to assess the effectiveness and cost-effectiveness of screening and surveillance strategies in individuals with a family history of GC.

Methods:
A computer-based Markov simulation model of the natural history of progression from normal gastric mucosa to gastric cancer in a population of Americans with a family history of gastric cancer was developed and calibrated in TreeAge (TreeAge Pro 2020, Williamstown, MA). The model start age was 18 and it had a time horizon until age 100 or death. Cycle length was one month. Model inputs were derived from published literature. The model was used to compare five screening and surveillance strategies: one-time upper endoscopy bundled with colonoscopy at age 45, with surveillance every 3 years or every 5 years if GIM is diagnosed; surveillance at 3- or 5-year intervals irrespective of pathology; and no screening/surveillance. The primary outcomes were total cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs). Secondary outcomes were cancer mortality and unadjusted life-years gained. A willingness to pay threshold of $100,000 per QALY was used to determine whether a strategy was cost-effective.

Results:
The cost-effective strategy was one-time upper endoscopy at age 45 with surveillance every 5 years if GIM is diagnosed. This corresponded to an ICER of $13,780/QALY, with an incremental gain of 0.23 QALYs compared to no screening/surveillance. The lifetime cancer mortality rate with this strategy was 1.93%, compared to 3.84% with no screening/surveillance. All other intervention strategies were dominated because they had higher costs and lower QALYs gained compared to the cost-effective strategy. Although cancer mortality was lowest with surveillance at 3-year intervals irrespective of pathology (0.29%), this was offset by lower incremental QALYs gained (0.031) compared to no screening/surveillance, and higher costs ($15,078).

Conclusions:
Based on our Markov model, one-time screening with surveillance every 5 years if GIM is diagnosed was effective and cost-effective in individuals with a family history of gastric cancer in the US context. While this can inform considerations regarding screening and surveillance recommendations, clinical studies will be vital to validating the potential benefits of preventative interventions in this high-risk population.

Table 1. Base-case analysis of a Markov model comparing screening and surveillance strategies in individuals with a family history of gastric cancer.

Table 1. Base-case analysis of a Markov model comparing screening and surveillance strategies in individuals with a family history of gastric cancer.

Introduction:
A high esophagogastroduodenoscopy (EGD) volume (~500 procedures per year) hospital in the southeastern United States had their automated endoscope reprocessor (AER) stop operating the day before twelve patients were scheduled for their procedures. Due to this situation, the facility would not be able to clean their reusable gastroscopes after procedure, thus rendering them unusable. To alleviate the potential backlog in patients, the facility utilized the Ambu aScope Gastro single-use gastroscope to perform all procedures as scheduled. To understand the impact of utilizing single-use more frequently in the facility, a cost analysis was performed to evaluate the impact of switching to single-use gastroscopes.
Methods:
Endoscope-related data from the facility was gathered including, but not limited to the following: procedure volume, quantity and price of gastroscopes and reprocessing equipment, scope reprocessing method, and repair costs. These variables were used to calculate a cost per use for the facility. An estimated number of additional procedures single-use gastroscopes may allow due to time and workflow efficiencies and average reimbursement amount were provided by the facility. Additional reimbursement and costs were calculated given the additional projected EGD procedures, and a final cost impact was calculated for a transition to single-use gastroscopes.
Results:
The cost analysis found that single-use gastroscopes would provide the facility a cost savings of $126.23 per procedure, or $37,867 a year. Per procedure, the facility would incur an additional equipment cost of $137.93, a reprocessing savings of $147.12, and a repair savings of $117.04 (Table 1). Due to increased workflow efficiencies, the facility projected an increase in the total amount of EGDs performed. This analysis assumed that single-use gastroscope could allow for 1 additional EGD a week, or 52 a year. With an average reimbursement of $15,500, the facility could see an additional $806,000 in yearly reimbursement for an additional cost of $14,469 (Table 2).
Conclusion:
Switching to single-use gastroscopes may not only provide facilities the ability to meet current demands in a time of need, but also promote cost savings as well as staff satisfaction and retention. Additionally, by allowing facilities to increase their procedure volume by improving workflow efficiency, single-use may also provide potential revenue generation. As the landscape of EGDs evolves, it will become even more important for facilities to evaluate their true cost per use and how single-use gastroscopes may impact it.

Background
Dyspepsia impacts over 20% of the global population and costs over $30 billion in healthcare-related and societal costs. American College of Gastroenterology (ACG) guidelines recommending a more judicious application of esophagogastroduodenoscopy (EGD) in the evaluation of dyspepsia in low-risk patients were published in 2017, but a prior single-center study showed adherence to this guidance is limited (Gupta et al. 2021). This study aimed to measure the uptake of ACG dyspepsia guidelines and factors associated with guideline adherence.

Methods
Patients aged 18-59 years who underwent outpatient EGD for dyspepsia or epigastric pain at 2 hospital-based endoscopy centers between 1/2018-12/2019 were included. Patients with a prior EGD, upper gastrointestinal surgery, or who had alarm symptoms were excluded. The co-primary outcomes were (1) the proportion of inappropriate EGDs, defined as those without H. pylori testing or a proton pump inhibitor [PPI] trial prior to EGD and (2) the proportion of potentially avoidable EGDs, defined as endoscopic and histologic findings of gastritis or H. pylori infection. Demographic and procedural factors associated with inappropriate or potentially avoidable endoscopies were explored in univariate analysis using chi square and in multivariable logistic regression.

Results
521 EGDs met our inclusion and exclusion criteria. The mean age of the patients undergoing EGDs was 43.2 years (SD: 11.1). Majority of patients were female (68.5%) and had commercial insurance (56%). 42% were Hispanic and 25% of EGDs had a fellow involved. 8.4% had an H. pylori test and 29.2% had a documented PPI prescription in the 2 years prior to EGD. 66% of EGDs were inappropriate and 39% were potentially avoidable by ACG guidelines. In univariable analysis, White race, non-Hispanic ethnicity, commercial insurance, tertiary care facility location, and lack of fellow involvement were each associated with inappropriate EGDs. Tertiary care facility location (OR 0.88, CI 0.57-1.34) and lack of fellow involvement (OR 0.46, CI 0.29-0.73) were independently associated with inappropriate EGDs when controlling for race, ethnicity, and insurance status in the multivariable analysis.

Discussion
In our cohort, adherence to ACG guidelines was low and a significant proportion of endoscopies were potentially avoidable. Fellow involvement was associated with guideline adherence despite prior work suggesting a limited impact of trainees on guideline adherence (Perez et al. 2012). Difficulty in completing H. pylori testing and treatment, varying levels of physician acceptance, as well as patient and provider beliefs regarding endoscopic evaluation are likely additional factors impacting guideline adherence but could not be measured in this study. Further analysis of the trainee effect is needed to improve adherence to the dyspepsia guidelines.

Background: While validated instruments have been developed for symptom and quality of life in eosinophilic esophagitis (EoE), no studies have measured the EoE-specific health state utility required to calculate quality-adjusted life-years in health economics studies.

Aims: To estimate the health state utility value in participants with EoE and to assess its association with clinical, endoscopic, and histopathologic characteristics.

Methods: We performed a prospective cross-sectional study of current health state valuation of adult patients with EoE diagnosed per consensus guidelines. Enrollment and interviews were conducted within three weeks prior to a clinically scheduled upper endoscopy. The primary outcome was health state utility measured by a rigorous time trade-off process (TTO) modelled after EuroQOL standards with a 10-year horizon and with a dynamic visual aid. Symptoms were assessed pre-procedure with the Eosinophilic Esophagitis Symptom Activity Index (EEsAI) patient-reported outcome (PRO) score. Endoscopic findings were assessed by the EoE Endoscopic Reference Score (EREFS), and peak eosinophil counts (eos/hpf) were recorded from esophageal biopsies. Patients were stratified a priori based on histologic disease control (inactive defined as <15 eos/hpf, compared to active with ≥15 eos/hpf).

Results: The 51 enrolled participants (mean age 38, 56% male, 98% white) had similar clinical characteristics regardless of histologic disease activity and were on a variety of EoE therapies (Table 1). The mean TTO health state utility was 0.91 (95% CI 0.86-0.95). Health state utility was numerically similar among the active and inactive participants (0.90 vs 0.90, p = 0.99), but TTO estimates were numerically worse in those patients that required dilation (0.90 vs 0.95) or had a lower minimum stricture diameter (0.89 vs 0.92), but these were not statistically significant (Table 2). With each one-point improvement in EEsAI PRO score, the health state valuation increased by a mean 0.27 percentage points (95% CI 0.08 - 0.47), and EEsAI scores ≥20 had significant lower valuation than scores <20 (0.88 vs 0.94, p<0.01).

Conclusions: EoE has a large impact on patient valuation of their current health state utility. Health state utility estimates in EoE were worse than most reported estimates for GERD (0.88 – 0.99. While utility valuation did not vary by measures of histologic or endoscopic control, it was numerically worse with esophageal dilation and lower minimum stricture diameter. The strongest predictor of health state valuation was the EEsAI PRO score. Future health economics studies should use an overall health state utility of EoE of 0.91 for EoE. The quality-of-life impacts of EoE are significant from a health economics perspective.

BACKGROUND: Cirrhotic patients are at high risk of developing hepatocellular carcinoma (HCC). Adherence to HCC surveillance guidelines with abdominal ultrasound (US) and alpha-fetoprotein (AFP) every six months is associated with detecting early-stage HCC and providing potentially curative treatment options. However, HCC surveillance guidelines are underused. Literature shows that less than 10% of cirrhotic patients seen in community-based primary care clinics undergo HCC surveillance. Hence, developing effective interventions to improve HCC surveillance is crucial for detecting HCC in the early stages in patients with cirrhosis.

METHODS: A pre-and post-quality improvement (QI) intervention study was conducted in community-based primary care clinics comprising four full-time and eight part-time clinics in Southern California. Cirrhotic patients were identified through the computer program developed using the International Classification of Diseases (ICD) 10^th code. Electronic medical record (EMR) alerts were created for HCC surveillance to prompt providers to order surveillance tests (abdominal US, AFP) every six months and incorporated with patient education using a concise brochure in English and Spanish. Additionally, data-driven analytical HCC surveillance QI measures were developed to monitor the surveillance status and prompt patient outreach to those who lacked HCC surveillance.

RESULTS: The primary outcome was the receipt of the US and AFP for HCC surveillance during the 6 months from September 2021 to March 2022. The baseline HCC surveillance rate was 6.7% (5/75). Cirrhotic patients were automatically enrolled in the HCC surveillance program throughout the project. The project team monitored monthly surveillance measure reports and referred patients who lacked the surveillance for outreach. After six months of project implementation, the post-intervention surveillance rate increased to 22.4 % (19/85), 3.3 times higher than the pre-intervention. In sub-analysis for matched patients (appearing in both pre-post-intervention periods, n=43), the post-surveillance rate increased to 39.5 % (17/43) from 11.6% (5/43) at baseline (P=.001).

CONCLUSIONS: Implementing the data-driven analytical HCC QI measures and EMR alerts incorporating patient education and outreach significantly improved HCC surveillance rates among cirrhotic patients. System-based multilevel interventions presented in this QI study are effective strategies to improve HCC surveillance, especially targeting PCPs in community-based primary care settings to reduce disparities in HCC surveillance. In addition, data-driven QI measures and EMR alerts are inexpensive, easy to use, and practical, which can be applied in GI/Hepatology and primary care clinics for early detection of HCC among cirrhotic patients.

Introduction
Gastrointestinal (GI) bleeding is one of the most common medical emergencies, with upper GI bleed accounting for $750 million/year for hospitalizations. While the ACG Clinical Guidelines on upper and lower GI bleeding recommend endoscopic evaluation within 24 hours of presentation, this is a conditional recommendation with low quality evidence. The timing of endoscopy for patients presenting on weekends varies, and current literature lacks data on length of stay changes with weekend endoscopy. This study aims to evaluate the number of hospital days saved for patients undergoing inpatient endoscopic evaluation on Saturdays at a large tertiary center.

Methods
This is a retrospective, single-centered study evaluating a pilot program at University of Chicago implementing Saturday endoscopies to decrease length of stay. All endoscopies performed on a Saturday from May 2022 to November 2022 were evaluated. Factors such as bed type, reason for consult, Glasgow-Blatchford score, and if treatment was performed were obtained via chart review. GI-related admissions included GI symptoms and anemia. Total length of stay and days saved were also recorded. Cost of admission was averaged as $2,000/day, and the cost of endoscopy nurses and technicians was calculated as $410 per Saturday morning.

Results
Over the 6-month study period, 21 Saturdays had scheduled endoscopies with staff compensation calculated as $8,610. Tables 1 and 2 describe the patient characteristics. A total of 41 EGDs and 18 colonoscopies were performed on Saturdays. Two patients (2/59, 3.4%) were in an intensive care unit (both getting EGD), and the rest were admitted on the floor. GI bleed accounted for 29 EGDs (70.7%) and 15 colonoscopies (83.3%). Other common diagnoses included dysphagia, food impaction, and diarrhea. Of the 29 patients evaluated for upper GI bleed, the average Glasgow-Blatchford score was 10, and 22/29 (79.3%) presented with overt GI bleed. Treatment occurred in 9/41 (22.0%) EGDs, 5 of which were for GI bleed, and in 2/18 (11.1%) colonoscopies. 3/18 (16.7%) colonoscopies had poor prep. 21 admission days ($42,000) were saved by performing a Saturday EGD and 15 days ($30,000) with colonoscopy, resulting in a total of $72,000 in savings via decreased length of stay. Overall, 36 admission days and $63,390 ($72,000 admission days– $8,610 staff compensation) were saved.

Conclusions
Saturday endoscopies at a large tertiary center is feasible and potentially cost effective. Cost savings would vary depending on the bed type and degree of endoscopic treatments. Nontangible considerations such as GI fellow discontinuity of care and increased workload leading to staff burnout should also be monitored. Further studies are warranted for comprehensive evaluation over a longer duration.

<b>Table 1.</b> Characteristics of patients undergoing EGD on a Saturday.

Table 1. Characteristics of patients undergoing EGD on a Saturday.

<b>Table 2.</b> Characteristics of patients undergoing colonoscopy on a Saturday.

Table 2. Characteristics of patients undergoing colonoscopy on a Saturday.

Robert Zabala

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