Patient recruitment for clinical trials has traditionally been conducted through in-person visits, limiting overall enrollment. Alternatively, decentralized trial recruitment allows potential subjects to be identified via the electronic health record (EHR) and approached through digital outreach channels. Our investigation evaluates the effectiveness of decentralized recruitment methods and digital communication channels to enhance patient engagement within Inflammatory Bowel Disease (IBD) patients. We designed an EHR-integrated decentralized trial for an NIH-funded multi-site IBD study at three centers. Using the Commure/Engage/Rx.health platform, we sent educational content and enrollment links via text and email. For bulk prescriptions, we identified potential participants by IBD diagnosis and upcoming appointments and conducted follow-up calls to address questions. One-to-one prescriptions targeted patients missed in bulk outreach, while self-enrollment was available through text codes on clinic fliers. We approached 7027 patients over 12 months and successfully enrolled 543 patients across three IBD centers (mean age 42.1 ± 15.6 years, 63.3% females, 75% White, 6.3% current smokers, 39.0% ulcerative colitis, 60.6% Crohn’s disease, 46.4% partnered) (Figure 1). 81.2% were recruited from bulk outreach methods. 0.3% of patients reported having a need for additional resources to successfully engage digitally. Age (P=0.02), gender (P< 0.01), and race (P< 0.01) were statistically significant in determining digital clinical trial enrollment and engagement. At UC Davis, 549 patients were approached, and 70 patients were enrolled with mean age 45.2± 17.2, 61.4% female, 89.7% White (p=0.04), 64.3% Crohn’s disease, 4.3% smoker, 51.4% partnered, and 60.0% recruited via bulk prescription. At Cleveland Clinic, 1746 patients were approached, and 133 patients were enrolled with mean age 44.0 ± 14.2 (p< 0.001), 74.4 female (p< 0.001), 85.5% White, 62.9% Crohn’s disease, 7.52% smoker, 52.6% partnered, and 82.0% recruited via bulk prescription. At Mount Sinai, 4052 patients were approached, and 340 patients were enrolled with mean age 41.3 ± 16.9, 59.4% female (p=0.001), 71.8% White, 59.1% Crohn’s disease, 1.76% smoker, 42.9% partnered, and 95.6% recruited via bulk prescription (p< 0.001). Recruitment of IBD patients using automated digital outreach is feasible. Bulk outreach of IBD cohorts proved to be the most effective recruitment method across all three sites, with the majority of patients recruited from home. These findings illustrate improvement in patient enrollment by incorporating decentralized digital recruitment, demonstrating its potential for application in future clinical trials involving IBD and other chronic diseases. Figure 1.

ABSTRACT Objectives: Patient recruitment is a critical factor for successful completion of a clinical trial. Decentralized trial recruitment allows potential subjects to be identified via the electronic health record (EHR) and approached through digital channels. We sought to understand the real-world effectiveness of decentralized trial recruitment leveraging electronic patient reported outcomes (ePROs) in patients with inflammatory bowel disease (IBD). Methods: As part of a National Institutes of Health (NIH) funded multi-site clinical trial, we designed an EHR-integrated decentralized trial recruitment process to contact eligible patients at three tertiary IBD centers. We leveraged the Commure Engage/Rx.health (Mountain View, California) digital health formulary and automation engine integrated with Epic Systems (Epic Systems, Verona, WI) to digitally approach patients in an automated manner (with human-in-the loop) to complete the online enrollment process and monitor adherence with ePROs. Results: Using digital outreach complemented by in-person engagement, we approached 6,687 eligible patients over 12 months and successfully enrolled 543 patients (mean age 40.7 +/- 15.7 years, 63.3% females, 39.4% ulcerative colitis, 60.6% Crohns disease). 81.2% were recruited from bulk outreach methods. Gender (P<0.01), and race (P<0.01) were significantly associated with digital clinical trial enrollment. Patients were continually monitored with ePROs throughout the duration of the study. Conclusions: This is one of the first studies to show the feasibility and successful recruitment of patients with IBD using automated digital outreach. We found a combination of outreach methods with human in the loop an effective strategy for clinical trial accrual. These findings suggest that ePROs can be successfully used in IBD centers to support treat-to-target strategy. ### Competing Interest Statement Potential Competing Interest: -Dr. Atreja holds a patent for the RxUniverse (Prescription Universe) software platform that is licensed from Icahn School of Medicine at Mount Sinai to Rx.Health, Inc. (New York, NY) and acquired by Commure Inc. (MountainView, CA). Ashish Atreja owns stock in Commure, Inc and has recused himself from data analysis. - Sarthak Kakkar, Sravya Kurra, Garauv Narang, and Priya Patel are employees of Commure Inc. (Mountain View, CA) and own stock. They have recused themselves from data analysis. ### Clinical Trial NCT04345393 ### Funding Statement Financial Support: The study is funded by NIH (5U01TR00299704U01, Principal Investigators Dr. Sands, Dr. Atreja, and Dr. Rizk) Translating Scientific Evidence into Practice using Digital Medicine and Electronic Patient Reported Outcomes ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: We performed a NIH-funded multi-site trial focused on patients with IBD to first enroll patients via a decentralized recruitment process and then to establish baseline levels of disease control while implementing precision-matched interventions to improve outcomes using ePRO assessments at three tertiary IBD referral centers across the United States: Mount Sinai, University of California, Davis (UC Davis Health), and Cleveland Clinic. We utilized a centralized institutional review board (IRB) at all sites via a SMART IRB framework. A single centralized IRB protocol was created using Advarra services. Each site then reviewed the centralized IRB for approval at their institution which included ethical aspects of implementing and studying the intervention. A common protocol was submitted to Advarra Central IRB which addressed any potential conflicts of interest. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors

OBJECTIVES:Unplanned "crash" dialysis starts are associated with worse outcomes and higher costs, a challenging problem for health systems participating in value-based care (VBC). We examined expenditures and utilization associated with these events in a large health system.STUDY DESIGN:Retrospective, single-center study at Cleveland Clinic, a large, integrated health system participating in VBC contracts, including a Medicare accountable care organization.METHODS:We analyzed beneficiaries who transitioned to dialysis between 2017 and 2020. Crash starts involved initiating inpatient hemodialysis (HD) with a central venous catheter (CVC). Optimal starts were initiated with either home dialysis or outpatient HD without a CVC. Suboptimal starts were initiated with outpatient HD with a CVC or inpatient HD without a CVC.RESULTS:A total of 495 patients initiated chronic dialysis: 260 crash starts, 130 optimal starts, and 105 suboptimal starts. Median predialysis 12-month cost was $67,059 for crash starts, $17,891 for optimal starts, and $7633 for suboptimal starts (P < .001). Median postdialysis 12-month cost was $71,992 for crash starts, $55,427 for optimal starts, and $72,032 for suboptimal starts (P = .001). Predialysis inpatient admission per 1000 beneficiaries was 1236 per 1000 for crash starts vs 273 per 1000 for optimal starts and 170 per 1000 for suboptimal starts (P < .001). Postdialysis inpatient admission for crash starts was 853 per 1000 vs 291 per 1000 for optimal starts and 184 per 1000 for suboptimal starts (P < .001).CONCLUSIONS:In a major health system, crash starts demonstrated the highest cost and hospital utilization, a pattern that persisted after dialysis initiation. Developing strategies to promote optimal starts will improve VBC contract performance.

BACKGROUND & AIMS: Despite the high prevalence of asymptomatic gallstones (AGs), there are limited data on their natural history. We aimed to determine the rate of symptom development in a contemporary population, determine factors associated with progression to symptomatic gallstones (SGs), and develop a clinical prediction model.METHODS: We used a retrospective cohort design. The time to first SG was shown using Kaplan-Meier curves. Multivariable competing risk (death) regression analysis was used to identify vari-ables associated with SGs. A prediction model for the development of SGs after 10 years was generated and calibration curves were plotted. Participants were patients with AGs based on ultrasound or computed tomography from the general medical population. RESULTS: From 1996 to 2016, 22,257 patients (51% female) with AGs were identified; 14.5% developed SG with a median follow-up period of 4.6 years. The cumulative incidence was 10.1% (& PLUSMN;0.22%) at 5 years, 21.5% (& PLUSMN;0.39%) at 10 years, and 32.6% (& PLUSMN;0.83%) at 15 years. In a multivariable model, the strongest predictors of developing SGs were female gender (hazard ratio [HR], 1.50; 95% CI, 1.39-1.61), younger age (HR per 5 years, 1.15; 95% CI, 1.14-1.16), multiple stones (HR, 2.42; 95% CI, 2.25-2.61), gallbladder polyps (HR, 2.55; 95% CI, 2.14-3.05), large stones (HR, 2.03; 95% CI, 1.80-2.29), and chronic hemolytic anemia (HR, 1.90; 95% CI, 1.33-2.72). The model showed good discrimination (C-statistic, 0.70) and calibration. CONCLUSIONS: In general medical patients with AGs, symptoms developed at approximately 2% per year. A predictive model with good calibration could be used to inform patients of their risk of SGs.

IMPORTANCE The benefits from colorectal cancer (CRC) screeningmay take 10 to 15 years to accrue. Therefore, screening is recommended for older adults who are in good health. OBJECTIVE To determine the number of screening colonoscopies done in patients older than 75 years with a life expectancy of fewer than 10 years, diagnostic yield, and associated adverse events within 10 days and 30 days of the procedure. DESIGN This cross-sectional study with a nested cohort between January 2009 and January 2022 in an integrated health system assessed asymptomatic patients older than 75 years who underwent screening colonoscopy in the outpatient setting. Reports with incomplete data, any indication other than screening, patients who had a colonoscopy within the previous 5 years, and patients with a personal history of inflammatory bowel disease or CRC were excluded. EXPOSURES Life expectancy based on a prediction model from previous literature. MAIN OUTCOMES AND MEASURES The primary outcomewas the percentage of screened patients who had limited (<10 years) life expectancy. Other outcomes included colonoscopy findings and adverse events that developed within 10 days and 30 days of the procedure. RESULTS A total of 7067 patients older than 75 years were included. The median (IQR) age was 78 (77-79) years, 3967 (56%) were women, and 5431 (77%) were White with an average of 2 comorbidities (taken from a select group of comorbidities). The proportion of colonoscopies performed on patients with a life expectancy of fewer than 10 years aged 76 to 80 years was 30% in both sexes and increased with age-82% of men and 61% of women aged 81 to 85 years (71% total), and 100% of patients beyond the age of 85 years. Adverse events requiring hospitalizations were common at 10 days (13.58 per 1000) and increased with age, particularly among patients older than 85 years. The detection of advanced neoplasia varied from 5.4% among patients aged 76 to 80 years to 6.2% in those aged 81 to 85 years and 9.5% among patients older than 85 years (P =.02). Of the total population, 15 patients (0.2%) had invasive adenocarcinoma; among patients with a life expectancy of fewer than 10 years, 1 of 9 was treated, whereas 4 of 6 patients with a life expectancy of greater than or equal to 10 years were treated. CONCLUSIONS AND RELEVANCE In this cross-sectional study with a nested cohort, most screening colonoscopies performed in patients older than 75 years were in patients with limited life expectancy and associated with increased risk of complications. Colorectal cancer was exceedingly rare.

BACKGROUND:Inadequate bowel preparation (IBP) is associated with reduced adenoma detection. However, limited research has examined the impact of different commercial bowel preparations (CBPs) on IBP and adenoma detection. We aim to determine whether type of CBP used is associated with IBP or adenoma detection.METHODS:We retrospectively evaluated outpatient, screening or surveillance colonoscopies performed in the Cleveland Clinic health system between January 2011 and June 2017. IBP was defined by the Aronchick scale. Multilevel mixed-effects logistic regression was performed to assess the association between CBP type and IBP and adenoma detection. Fixed effects were defined as demographics, comorbidities, medication use, and colonoscopy factors. Random effect of individual endoscopist was considered.RESULTS:Of 153,639 colonoscopies, 75,874 records met inclusion criteria. Median age was 54; 50% were female; 17.7% had IBP, and adenoma detection rate was 32.6%. In adjusted analyses, compared to GoLYTELY, only NuLYTELY [OR 0.66 (95% CI 0.60, 0.72)] and SuPREP [OR 0.53 (95% CI 0.40, 0.69)] were associated with reduced IBP. Adenoma detection did not vary based on the type of bowel preparation used.CONCLUSIONS:Among patients referred for screening or surveillance colonoscopy, choice of CBP was not associated with adenoma detection. Decisions about CBP should be based on other factors, such as tolerability, cost, or safety.

Background: Inflammatory bowel diseases (IBD) are costly, chronic illnesses. Key cost-drivers of IBD health care expenditures include pharmaceuticals and unplanned care, but evolving treatment approaches have shifted these factors. We aimed to assess changes in cost of care, determine shifts in IBD cost-drivers, and examine differences by socioeconomic and insurance status over time. Methods: The Medical Expenditure Panel Survey (MEPS), a nationally representative database that collects data on health care utilization and expenditures from a nationally representative sample since 1998, was utilized. Adult subjects with IBD were identified by ICD-9 codes. To determine changes in per-patient costs or cost-drivers unique to IBD, a control population of rheumatoid arthritis (RA) subjects was generated and matched in 1:1 case to control. Total annual health care expenditures were obtained and categorized as outpatient, inpatient, emergency, or pharmacy related. Temporal cohorts from 1998 to 2015 were created to assess change over time. Per-patient expenditures were compared by disease state and temporal cohort using weighted generalized linear models. Results: A total of 641 IBD subjects were identified and matched to 641 RA individuals. From 1998 to 2015, median total annual health care expenditures nearly doubled (adjusted estimate 2.20; 95% CI, 1.6-3.0) and were 36% higher in IBD compared with RA. In IBD, pharmacy expenses increased 7% to become the largest cost-driver (44% total expenditures). Concurrently, inpatient spending in IBD decreased by 40%. There were no significant differences in the rate of change of cost-drivers in IBD compared with RA. Conclusions: Per-patient health care costs for chronic inflammatory conditions have nearly doubled over the last 20 years. Increases in pharmaceutical spending in IBD may be accompanied by reduction in inpatient care. Additional studies are needed to explore patient-, disease-, system-, and industry-level cost mitigation strategies.

Introduction: Research suggests that neighborhood-level factors are associated with long-term health; however, there is a dearth of research evaluating this association among patients (pts) undergoing percutaneous coronary intervention (PCI), a population that is usually optimally treated with respect to long-term risk management. Hypothesis: We hypothesize that pts living in the most disadvantaged areas have a higher risk of post-discharge mortality after PCI compared with pts not living in the most disadvantaged areas. Methods: Using a clinical registry of pts with valid zip codes who underwent PCI between 1/2013 - 3/2018 at 47 Michigan hospitals linked to Medicare claims, we compared long-term outcomes between pts in the highest ADI decile (i.e. most disadvantaged) with the remainder. The Area Deprivation Index (ADI) is a zip-code-level composite measure of neighborhood disadvantage. Unadjusted mortality was depicted on a Kaplan-Meier plot. We used a Cox model to assess the association between the ADI and mortality after adjusting for pt factors. Results: Among 26,164 pts, 9.9% lived in the most disadvantaged zip codes and were more likely to be younger, of black race, have both Medicare and Medicaid insurance, and have more cardiovascular comorbidities. Unadjusted rates of mortality were higher among pts living in the most disadvantaged areas compared with the remainder (5-yr mortality: 64.5% vs 70.9%; Fig). After adjusting for pt factors, those living in the most disadvantaged areas had a significantly increased risk of long-term mortality (HR 1.16; 95% CI 1.08 - 1.25), a risk equivalent to an 8% reduction in one’s ejection fraction (HR for 8% EF reduction: 1.16; 95% CI 1.14 - 1.17). Conclusions: Medicare pts living in the most disadvantaged areas have a higher risk of post-PCI long-term mortality compared with the remainder. Policies targeting the deleterious health effects of neighborhood disadvantage and social risk are needed to improve survival after PCI.

Background and Aims: Colonoscopy is commonly performed for colorectal cancer screening in the United States. Reports are often generated in a non-standardized format and are not always integrated into electronic health records. Thus, this information is not readily available for streamlining quality management, participating in endoscopy registries, or reporting of patient- and center-specific risk factors predictive of outcomes. We aim to demonstrate the use of a new hybrid approach using natural language processing of charts that have been elucidated with optical character recognition processing (OCR/NLP hybrid) to obtain relevant clinical information from scanned colonoscopy and pathology reports, a technology co-developed by Cleveland Clinic and eHealth Technologies (West Henrietta, NY, USA). Methods: This was a retrospective study conducted at Cleveland Clinic, Cleveland, Ohio, and the University of Minnesota, Minneapolis, Minnesota. A randomly sampled list of outpatient screening colonoscopy procedures and pathology reports was selected. Desired variables were then collected. Two researchers first manually reviewed the reports for the desired variables. Then, the OCR/NLP algorithm was used to obtain the same variables from 3 electronic health records in use at our institution: Epic (Verona, Wisc, USA), ProVation (Minneapolis, Minn, USA) used for endoscopy reporting, and Sunquest PowerPath (Tucson, Ariz, USA) used for pathology reporting. Results: Compared with manual data extraction, the accuracy of the hybrid OCR/NLP approach to detect polyps was 95.8%, adenomas 98.5%, sessile serrated polyps 99.3%, advanced adenomas 98%, inadequate bowel preparation 98.4%, and failed cecal intubation 99%. Comparison of the dataset collected via NLP alone with that collected using the hybrid OCR/NLP approach showed that the accuracy for almost all variables was >99%. Conclusions: Our study is the first to validate the use of a unique hybrid OCR/ NLP technology to extract desired variables from scanned procedure and pathology reports contained in image format with an accuracy > 95%.

BACKGROUND AND AIMS Previous small to mid-sized studies have found an inconsistent relationship between diverticulosis and colon polyps. We assessed the odds of polyps in patients with left-sided diverticulosis (LDV) compared to patients without LDV, and if a predilection for polyps in the distal colon (DC) versus the proximal colon (PC) existed. METHODS In this case-control, retrospective study records of all patients in the Cleveland Clinic undergoing average-risk, screening colonoscopy between January 2011-August 2017 were identified. Baseline characteristics were described. Multivariate logistic regression analysis was performed to identify odds of polyps in PC and DC after adjusting for clinical and colonoscopic factors. RESULTS 50,703 patients (mean age=60 years; 48% male) were included; 38.9% of patients had LDV. Compared to patients without LDV, those with LDV more often had adenomas (33.2% vs 27.8%; p <0.001), hyperplastic polyps (HPs) (18.3% vs 16.2%; p <0.001), and sessile serrated polyps (SSPs) (4.8% vs 4.3%; P=0.011). LDV was associated with adenomas in the DC (OR, 1.59; 95%CI, 1.52, 1.67) more than the PC (OR, 1.15; 95%CI, 1.10, 1.21), with HPs equally in the PC (OR, 1.27; 95%CI, 1.20, 1.34) and DC (OR, 1.28; 95%CI, 1.19, 1.38), and with SSPs in the DC only (OR, 1.50; 95%CI, 1.34, 1.67). CONCLUSIONS LDV is associated with a significantly increased risk of adenomas, HPs, and SSPs, but the association was stronger for adenomas in the DC. Careful inspection of the DC should be encouraged in patients with LDV. More research is needed to understand this phenomenon.

Introduction: Optimal management of asymptomatic gallstones (AG) remains controversial and factors associated with endoscopic or surgical intervention have not been documented. Our aim was to perform big data analysis to identify associated factors and develop a risk stratification tool (RST) to aid in patient consultations. Methods: A validated natural language algorithm was used to screen radiological reports to identify patients with AG. For this cohort each individual electronic medical record (EMR) was screened using a second algorithm to identify patients who subsequently underwent intervention including cholecystectomy (C), endoscopic retrograde cholangiopancreatography (ERCP), or percutaneous cholecystostomy (PC). The indication for each intervention be it for chronic or acute cholecystitis, acute pancreatitis, cholangitis, or gallbladder cancer was recorded. Kaplan Meier curves were constructed to analyze time to intervention, and both cumulative incidence ratios and hazard estimates were calculated. Forward stepwise cox-regression identified factors associated with future intervention and these were used to develop the RST. Area under the receiver operating characteristics (AUROC) curves were calculated and internally validated using 1000 boot-strapped resamples. Results: 2,257 patients were identified between 1996-2016. Median follow-up was 4.5 years (inter-quartile range [IQR]: 1.8-7.9 years). 1762 patients (7.9%) underwent intervention [C (n=1273); PC (n=66); ERCP (n=592)] within a median of 3.9 years (IQR 1.4-6.9 years) of initial presentation. The cumulative incidence of intervention increased linearly up to 25% at 15 years. Factors associated with intervention are summarized in Table 1. The AUROC of the RST was 0.66 (95%CI, 0.64-0.67) for the initial sample and a 1000 boot-strapped resample yielded an AUROC of 0.66 (95%CI, 0.64-0.67) indicating good internal validity. Conclusions: Intervention following diagnosis of AG is common, increasing linearly from initial presentation to 25% at 15 years. An RST, if externally validated, may identify associated risk factors and provide prognostic information for counseling of patients presenting with AG. Table 1Factors predicting intervention in patients presenting with asymptomatic gallstones.

Background and Aim We identified patients without medical record evidence of up-to-date colorectal cancer (CRC) screening and sent an invitation letter to self-schedule a colonoscopy without requiring prior primary care or gastroenterologist consultation. The aim of the study was to evaluate the response rate to the letter and factors associated with colonoscopy completion. Methods A computer algorithm invited patients not up to date with CRC screening, with an INR < 1.5, and living within 300 miles of the Cleveland Clinic main campus through a letter. Patients scheduled a colonoscopy through a dedicated phone line without any prior physician consultation. Clinical, demographic, and socioeconomic variables were extracted from the EMR through natural language algorithms. We analyzed the percentage of patients who completed a colonoscopy within 6 months of sending the letter and factors associated with colonoscopy completion. Results A total of 145,717 letters were sent. 1451 patients were deceased and excluded from analysis. 3.8% (5442) of letter recipients completed a colonoscopy. The strongest factors associated with colonoscopy completion on multivariate analysis included family history of polyps (OR 3.1, 95% CI 2.3, 4.2) or CRC (OR 2.1, 95% CI 1.7, 2.5). Other factors included younger age, male gender, married status, closer distance to endoscopy center, number of visits in the year prior, statin use, and diabetes. There were no immediate procedural complications. Conclusions Patient-initiated colonoscopy in response to letter invitation for CRC screening is effective and safe with safeguards established a priori. Consultation with a gastroenterologist or primary care physician is not necessary prior to colonoscopy. To our knowledge, this is the first study to evaluate patient-initiated colonoscopy for CRC cancer screening.

Importance Research demonstrates adenoma detection rate (ADR) and proximal sessile serrated polyp detection rate (pSSPDR) are associated with endoscopist characteristics including sex, specialty, and years in practice. However, many studies have not adjusted for other risk factors associated with colonic neoplasia. Objective To assess the association between endoscopist characteristics and polyp detection after adjusting the factors included in previous studies as well as other factors. Design, Setting, and Participants This cohort study was conducted in the Cleveland Clinic health system with data from individuals undergoing screening colonoscopies between January 2015 and June 2017. The study analyzed data using methods from previous studies that have demonstrated significant associations between endoscopist characteristics and ADR or pSSPDR. Multilevel mixed-effects logistic regression was performed to examine 7 endoscopist characteristics associated with ADRs and pSSPDRs after controlling for patient demographic, clinical, and colonoscopy-associated factors. Exposures Seven characteristics of endoscopists performing colonoscopy. Main Outcomes and Measures The ADR and pSSPDR, with a hypothesis created after data collection began. Results A total of 16 089 colonoscopies were performed in 16 089 patients by 56 clinicians. Of these, 8339 patients were male (51.8%), and the median (range) age of the cohort was 59 (52-66) years. Analyzing the data by the methods used in 4 previous studies yielded an association between endoscopist and polyp detection; surgeons (OR, 0.49 [95% CI, 0.28-0.83]) and nongastroenterologists (OR, 0.50 [95% CI 0.29-0.85]) had reduced odds of pSSPDR, which was similar to results in previous studies. In a multilevel mixed-effects logistic regression analysis, ADR was not significantly associated with any endoscopist characteristic, and pSSPDR was only associated with years in practice (odds ratio, 0.86 [95% CI, 0.83-0.89] per increment of 10 years; P < .001) and number of annual colonoscopies performed (odds ratio, 1.05 [95% CI, 1.01-1.09] per 50 colonoscopies/year; P = .02). Conclusions and Relevance The differences in ADRs that were associated with 7 of 7 endoscopist characteristics and differences in pSSPDRs that were associated with 5 of 7 endoscopist characteristics in previous studies may have been associated with residual confounding, because they were not replicated in this analysis. Therefore, these characteristics should not influence the choice of endoscopist for colorectal cancer screening. However, clinicians further from their training and those with lower colonoscopy volumes have lower adjusted pSSPDRs and may need additional training to help increase pSSPDRs.

INTRODUCTION:Inadequate bowel preparation (IBP) is a common problem in hospitalized patients; however, little is known about how to prevent IBP. In a large, multihospital system, we evaluated the association between modifiable factors and IBP rate.METHODS:We reviewed data from adult (≥18 years) inpatients undergoing colonoscopy between January 2011 and June 2017. Colonoscopies performed in the intensive care unit or lacking descriptions of bowel preparation quality were excluded. Multivariate logistic regression analysis was performed to identify factors associated with IBP. A counterfactual analysis was performed to assess the potential contribution of modifiable factors to IBP.RESULTS:Of 8,819 patients that were included (median age of 64 years; 50.5% female), 51% had IBP. Patients with IBP stayed in the hospital one day longer than those with adequate bowel preparation (P < .001). Modifiable factors associated with IBP include opiate use within three days of colonoscopy (OR, 1.31; 95% CI, 1.18, 1.45), colonoscopy performed after 12:00 pm (OR, 1.25; 95% CI, 1.1, 1.41), and solid diet the day before colonoscopy (OR, 1.37; 95% CI, 1.18, 1.59). In the counterfactual analysis, if all patients avoided these three conditions, adjusted IBP rates were reduced by 5.6%.CONCLUSIONS:Among hospitalized patients undergoing colonoscopy, IBP rates are high and associated with an increased length of stay. Avoiding opiates before colonoscopy, performing colonoscopy before noon, and maintaining patients on a liquid diet or nil per os might significantly reduce IBP rates.

INTRODUCTION: Patients with recurrent non-variceal upper gastrointestinal bleed (NVUGIB) undergo repeat EGD, and for any further bleeding episode, consideration of angiography or interventional radiology (IR) with arterial embolization is employed. However, there is minimal evidence to support these recommendations promulgated by the national societies (refer to guideline). We sought to compare the effectiveness of repeat EGD with IR in achieving hemostasis in patients with recurrent NVUGIB after initial endoscopy. METHODS: This is a single-center retrospective cohort study. Between 2008-2018 consecutive ICU patients who underwent an EGD for diagnosis of NVUGIB (melena, hematochezia, hematemesis, coffee-ground emesis) were included. Continuous bleeding was defined by no hemostasis achieved, while recurrent bleeding was defined as re-bleeding within 30 days of hemostasis after index EGD. When hemostasis was not achieved, patients were stratified into treatment modalities of repeat EGD, IR without embolization, empiric embolization or lesion embolization. Generalized linear mixed models were used to evaluate if treatment effects re-bleeding when all bleeding episodes were analyzed. RESULTS: A total of 1067 patients were eligible for analysis. Mean age was 63 years and 44% were female. Following initial EGD, 90% (n = 960) of patients achieved hemostasis, 16% (n = 157) had recurrent bleeding and 10% (n = 107) had continuous bleeding without initial hemostasis. When compared to patients who underwent EGD and IR, patients with repeat EGD only had significantly higher Charlson Comorbidity Index (4.8 ± 3.2 vs. 3.4 ± 2.4; P < 0.001) and fewer re-bleeding episodes (P < 0.001). When all episodes of recurrent and continuous bleeding were analyzed, EGD had a three times higher likelihood of hemostasis when compared to IR without embolization (OR 2.9, 95%CI 1.05-7.7; P = 0.039). There is no significant difference between EGD and IR with empiric or lesion embolization or when all forms of IR were combined. CONCLUSION: Repeat EGD is three times more likely than IR without embolization in achieving hemostasis for all episodes of recurrent or continued NVUGIB after an initial endoscopy. However, EGD and IR with embolization appear equally effective modalities in achieving hemostasis after recurrent or continuous NVUGIB. The study is the first to directly compare EGD with IR and validates consensus recommendations of repeating upper endoscopy when hemostasis is not initially achieved as well as utilizing IR when necessary.

Biliary dilation suggests obstruction and prompts further work up. Our experience with endoscopic ultrasound and endoscopic retrograde cholangiopancreatography in the symptomatic post-bariatric surgery population revealed many patients with radiographically dilated bile ducts, but endoscopically normal studies. It is unclear if this finding is phenomenological or an effect of surgery. Additionally, it is unknown whether the type of bariatric surgery alters biliary pathophysiology. Thus, we studied whether a change occurs in biliary diameter following Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG).