BACKGROUND AND AIMS: Electronic consultations (e-consults) are asynchronous, provider-to-provider exchanges that allow specialists to provide clinical guidance without an in-person visit. Referring clinicians submit focused questions through the electronic health record, and specialists review relevant history and data to make recommendations. At many academic centers, waits for specialty appointments exceed months, limiting timely care and underscoring the need for alternative referral pathways. We evaluated the implementation, utilization, and provider experiences of a gastroenterology e-consult program at Massachusetts General Hospital. METHODS: We analyzed all gastroenterology e-consults from January 2023 through September 2024, extracting completion rates, turnaround times, and clinical indications from 2416 encounters. Anonymous 5-point Likert surveys assessed satisfaction, perceived utility, and implementation barriers among referring providers and consulting gastroenterologists. RESULTS: Of 2416 e-consults involving 2038 unique patients, 2112 (87%) were completed, with a mean turnaround time of 2.6 business days. Hepatology and abnormal imaging findings comprised nearly half of all requests. Referring providers reported high satisfaction and educational value, with most indicating that e-consults reduced unnecessary visits and testing. Consultants recognized clinical utility but cited inadequate reimbursement and difficulty meeting turnaround targets. CONCLUSION: Gastroenterology e-consults can operate effectively at scale, particularly for objective, data-driven questions such as abnormal liver function tests and imaging findings. However, the satisfaction gap between referring providers and consultants, driven largely by reimbursement and workload pressures, threatens long-term sustainability. Addressing these challenges through payment models that reflect cognitive work and streamlined workflows will be essential to maintain specialist engagement while expanding access to care.

BACKGROUND:Icosapent ethyl (IPE), an ethyl ester of eicosapentaenoic acid (EPA; C20:5n-3), is thought to have immunomodulatory properties and may protect against colorectal cancer. OBJECTIVES:This study aimed to assess the effect of IPE on changing total marine omega-3 (n-3) polyunsaturated fatty acid (PUFA) and individual fatty acid composition in colorectal tissue. METHODS:We conducted a prospective, single-arm clinical trial of 4 g/d IPE (VASCEPA) treatment for 8 to 12 wk among patients with a recent history of adenoma. We collected pretreatment and posttreatment colorectal biopsies through flexible sigmoidoscopy and participants' diet and lifestyle via questionnaires. The primary outcome was the change in total marine ω-3 PUFA in colorectal tissue measured by gas-liquid chromatography. We examined changes in individual fatty acids exploratorily. RESULTS:Among a total of 81 patients enrolled, 72 had paired pretreatment and posttreatment tissue fatty acid data. After intervention, the tissue composition [median (interquartile range)] of total marine ω-3 PUFA increased from 2.10% (0.96%) to 5.21% (1.97%), with a fold change of 2.40 (0.82). With a slight decrease in ω-6 PUFA [fold change = 0.96 (0.27)], the ratio of marine ω-3 to ω-6 PUFA increased [fold change = 2.58 (0.81)]. Among individual fatty acids, EPA increased the most [fold change = 5.88 (3.63)]. The cumulative amount of IPE treatment, rather than daily dosage, showed a positive correlation with changes in tissue EPA composition (Spearman's ρ = 0.23, P = 0.051). The treatment effect on tissue EPA changes appeared to be stronger for participants with lower than higher dietary EPA intake at baseline, although the interaction tests did not reach statistical significance (P for interaction = 0.26). CONCLUSIONS:IPE treatment substantially increased incorporation of marine ω-3 PUFA, particularly EPA, into the colorectal tissue while reducing tissue ω-6 PUFA composition. This trial was registered at clinicaltrials.gov as NCT04216251.

Objectives Uncertainty tolerance is an important characteristic thought to influence medical judgments and decisions. However, patients’ tolerance of different types of uncertainty may vary and have different effects. The current study explored how tolerance of different types of uncertainty relates to decision-related outcomes among older adults considering colorectal cancer (CRC) screening. Methods A secondary analysis of data from a cluster randomized clinical trial of an intervention to improve shared decision making (SDM) for older adults considering CRC screening was conducted. Patients completed a questionnaire following clinic visits, including measures of tolerance of uncertainty due to ambiguity (Ambiguity Aversion in Medicine) and complexity (Geller Tolerance of Ambiguity), as well as key decision-related cognitive, affective, and behavioral variables: perceived benefit of screening, concern about harms of screening, and CRC screening intention. Multilevel regression analyses were used to evaluate the associations between tolerance of uncertainty and decision-related variables as well as various patient characteristics. Results The sample (N=448) ranged in age from 76 to 85 (M=80, SD=3), and 53.7% were female, 94% were white, and 72% had at least a 4-year college degree. Higher tolerance of ambiguity, but not complexity, was associated with higher perceived benefit of screening (b=-0.077, p<0.001). Higher tolerance of ambiguity (b=0.08, p<0.01) and complexity (b=0.06, p<0.05) were associated with lower concern about harms of screening, although neither were associated with CRC screening intentions. Conclusions Tolerance of uncertainty due to ambiguity and complexity have different associations with key cognitive and affective variables related to older adults’ CRC screening decisions, but not screening intentions. Patients’ tolerance of different types of uncertainty may influence their responses to medical decisions involving uncertainty. Practice Implications By assessing different types of uncertainty tolerance, clinicians may be able to better tailor their approach to patient communication and SDM to improve decision quality.

BackgroundConcordance, or alignment of care with patients' preferences, is a key component of high-quality decision making. Some patients may not have a clear preference, and others may not receive care aligned with their preference-both situations indicating a lack of concordance. The reasons behind these situations remain poorly understood. This study explores the reasons for lack of concordance in colorectal cancer screening among older adults.MethodsInterviews were conducted with 160 older adults from the Promoting Informed Decisions About Colorectal Cancer Screening in Older Adults trial (NCT03959696) who did not meet the criteria for concordance. A thematic analysis of 152 analyzable interviews was performed to explore reasons for lack of concordance.ResultsFour themes summarize the different reasons for the lack of concordance: 1) provider discussion and the need for more guidance (e.g., patients reported very limited discussion and desire for more information), 2) age-related considerations (e.g., patients acknowledge that at their age, screening may no longer be needed), 3) changes in health condition (e.g., patients report other health issues that take priority over screening), and 4) the impact of COVID-19 and practical barriers (e.g., patients report a desire to avoid hospitals and procedures).ConclusionsThe lack of concordance stemming from limited discussion, guidance, or lack of clear preference signal low decision quality, whereas the lack of concordance from changing patient preferences over time has implications for timing of measurement. To improve concordance, patients need support to clarify their preferences as well as support to implement their preferred approach.HighlightsLimited provider discussion, age-related factors, changing health priorities, and COVID-19-related or practical challenges were identified as key contributors to lack of concordance.Achieving high concordance will require helping patients clarify their preferences, strengthening shared decision making, and providing implementation support.Researchers also need to be aware of evolving preferences and implications for timing of preference measurements.

INTRODUCTION:Dairy consumption has been linked to the development of autoimmune diseases. We aimed to examine the association between dairy intake and risk of incident inflammatory bowel disease. METHODS:We conducted a prospective cohort study of 197,763 participants without a baseline diagnosis of inflammatory bowel disease in 1986 in Nurses' Health Study, 1991 in Nurses' Health Study II (NHSII), and 1986 in Health Professionals Follow-up Study. Data on dairy intake were collected every 2-4 years using a validated semi-quantitative food frequency questionnaire and modeled according to quintiles for total intake and quartiles for components of dairy. We used Cox proportional hazard modeling to estimate adjusted hazard ratios and 95% CIs. RESULTS:Through the end of follow-up in 2016 in Nurses' Health Study and Health Professionals Follow-up Study, and 2017 in Nurses' Health Study II, we documented 347 Crohn's disease cases and 428 cases of ulcerative colitis (UC). In our primary analysis, we observed an inverse association between baseline dairy intake (P trend = 0.04) and risk of UC (adjusted hazard ratio of 0.72 [95% CI 0.52-1.00 comparing extremes of quintiles]). Among dairy components, baseline yogurt consumption (hazard ratio = 0.70; 95%CI 0.5-0.99; P trend = 0.05) was most strongly associated with decreased risk of UC. There was no consistent association between dairy intake and risk of Crohn's disease. DISCUSSION:In 3 large prospective cohort studies, we observed a suggestive inverse association between baseline dairy intake, particularly from yogurt, and risk of UC. Future studies are needed to confirm these results.

INTRODUCTION:Electronic health records (EHRs) provide cancer screening reminders to patients and clinicians, but they are not always accurate. Updating the EHR after a colonoscopy for colorectal cancer screening is typically performed manually by the endoscopist when pathology results are available but may be error prone. We evaluated an electronic tool embedded in patient result letters that automatically updated the EHR follow-up time interval after a colonoscopy. METHODS:A randomized controlled trial of endoscopists from 1 institution who performed colonoscopies on patients undergoing a screening or surveillance colonoscopy. Intervention endoscopists were trained to use the electronic tool in their result letters to patients. Control endoscopists continued with their usual care. The primary outcome was the accuracy of the follow-up surveillance colonoscopy time interval in the EHR compared with the time interval specified in the patient result letter. RESULTS:Overall, 43 endoscopists were randomly assigned to intervention (n = 22) or control (n = 21) groups. Characteristics of patients in the intervention (n = 2,365) and control (n = 1,422) were similar. A result letter was sent to 1,498 (63.3%) intervention and 814 (57.2%) control patients ( P < 0.001). Among all patients sent a result letter, the accuracy of the follow-up colonoscopy surveillance time interval between the result letter and the EHR was significantly higher for the intervention (92.4% vs 76.2%, P < 0.001). Intervention endoscopists were more satisfied with the process of reporting results after a colonoscopy (88.2% vs 60.0%, P = 0.11). DISCUSSION:For patients undergoing a colonoscopy for colorectal cancer screening, an electronic tool embedded in the result letter that automatically updated the EHR significantly improved the accuracy of the follow-up time interval compared with usual care.

We investigated the relationship between nut and legume intake and risk of Crohn's disease (CD) and ulcerative colitis (UC). We conducted a prospective cohort study of 223 283 adults from the Nurses' Health Study (NHS), NHSII, and Health Professionals Follow-Up Study (1986-2017), excluding those with inflammatory bowel disease (IBD) at baseline. Food frequency questionnaires were used to calculate nut and legume intake. Inflammatory bowel disease was self-reported on questionnaires and confirmed via blinded record review. Using Cox proportional hazards models, we calculated adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for CD and UC according to categories of nut and legume intake. In over 5 460 315 person-years of follow-up (CD = 371, UC = 481), neither nut nor legume intake was associated with CD or UC risk. Compared to those who never consumed nuts, those who consumed nuts ≥2 times/week had an aHR = 0.96 (95% CI, 0.63-1.47; Ptrend = 0.57) for CD and 1.30 (95% CI, 0.92-1.84; Ptrend = 0.36) for UC. Compared to those who consumed legumes 0-3 times/month, those who consumed legumes ≥4 times/week had an aHR of 1.26 (95% CI, 0.78-2.04; Ptrend = 0.59) for CD and 0.72 (95% CI, 0.44-1.18; Ptrend = 0.20) for UC. Baseline BMI modified the relationship between nut intake and CD risk (Pint = 0.03). In those with BMI ≥25, the aHR for CD was 0.14 (95% CI, 0.03-0.56; P = .006) per additional serving/day of nuts compared with 0.88 (95% CI, 0.45-1.74; P = .72) for those with BMI <25. Nut and legume intake were not associated with CD or UC risk. However, higher nut intake decreased CD risk in overweight or obese individuals. Thus, personalized-risk stratification, rather than generalized dietary recommendations, may be important for IBD prevention strategies.

Importance Decisions about whether to stop colorectal cancer (CRC) screening tests in older adults can be difficult and may benefit from shared decision-making (SDM). Objective To evaluate the effect of physician training in SDM and electronic previsit reminders (intervention) vs reminders only (comparator) on receipt of the patient-preferred approach to CRC screening and on overall CRC screening rates of older adults at 12 months. Design, Setting, and Participants This was a secondary analysis of the Promoting Informed Decisions About Colorectal Cancer Screening in Older Adults (PRIMED) cluster randomized clinical trial. In the PRIMED trial, primary care physicians (PCPs) from 36 primary care practices in Massachusetts and Maine were enrolled between May 1 and August 30, 2019, and were randomized to the intervention group or the comparator group. Patients aged 76 to 85 years who were overdue for CRC screening and did not have a prior diagnosis of CRC enrolled between October 21, 2019, and April 8, 2021. Data analysis was performed between May 24, 2022, and May 10, 2023. Interventions Primary care physicians in the intervention group completed an SDM training course and received previsit reminders of patients eligible for CRC testing discussion, whereas PCPs in the comparator group received reminders only. Main Outcomes and Measures The primary outcome was concordance, or the percentage of patients who received their preferred screening approach. Postvisit surveys were administered to assess patient preference for testing, and electronic health record review was used to assess CRC testing at 12 months. Heterogeneity of treatment effect analyses examined interaction between study groups and different factors on concordance rates. Results This study included 59 physicians and 466 older adults. Physicians had a mean (SD) age of 52.7 (9.4) years and a mean (SD) of 21.6 (10.2) years in practice; 30 (50.8%) were women and 16 (27.1%) reported prior training in SDM. Patients had a mean (SD) age of 80.3 (2.8) years; 249 (53.4%) were women and 238 (51.1%) reported excellent or very good overall health. Patients preferred stool-based tests (161 [34.5%]), followed by colonoscopy (116 [24.8%]) or no further screening (97 [20.8%]); 75 (16.1%) were not sure. The distribution of patient preferences was similar across groups (P = .36). At 12 months, test uptake was also similar for both the intervention group (29 [12.3%] for colonoscopy, 62 [26.3%] for stool-based tests, and 145 [61.4%] for no testing) and the comparator group (32 [13.9%] for colonoscopy, 35 [15.2%] for stool-based tests, and 163 [70.9%] for no testing; P = .08). Approximately half of patients in the intervention group received their preferred approach vs the comparator group (115 of 226 [50.9%] vs 103 of 223 [46.2%]; P = .47). Heterogeneity of treatment effect analyses found significantly higher rates with the intervention vs the comparator for patients with a strong intention to follow through with the preferred approach (adjusted odds ratio [AOR], 1.79 [95% CI, 1.11-2.89]; P = .02, P = .05 for interaction) and for patients who reported more than 5 minutes (AOR, 3.27 [95% CI, 1.25-8.59]; P = .02, P = .05 for interaction) of discussion with their PCP regarding screening. Higher rates were also observed among patients who reported 2 to 5 minutes of discussion with their PCP, although this finding was not significant (AOR, 1.89 [95% CI, 0.93-3.84]; P = .08, P = .05 for interaction). Conclusions and Relevance In this secondary analysis of a cluster randomized clinical trial, approximately half of older patients received their preferred approach to CRC screening. Physician training in SDM did not result in higher concordance rates overall but may have benefitted some subgroups. Future work to refine and evaluate clinical decision support (in the form of an electronic advisory or reminder) as well as focused SDM skills training for PCPs may promote high-quality, preference-concordant decisions about CRC testing for older adults.

OBJECTIVE:Understand how physicians' uncertainty tolerance (UT) in clinical care relates to their personal characteristics, perceptions and practices regarding shared decision making (SDM). METHODS:As part of a trial of SDM training about colorectal cancer screening, primary care physicians (n = 67) completed measures of their uncertainty tolerance in medical practice (Anxiety subscale of the Physician's Reactions to Uncertainty Scale, PRUS-A), and their SDM self-efficacy (confidence in SDM skills). Patients (N = 466) completed measures of SDM (SDM Process scale) after a clinical visit. Bivariate regression analyses and multilevel regression analyses examined relationships. RESULTS:Higher UT was associated with greater physician age (p = .01) and years in practice (p = 0.015), but not sex or race. Higher UT was associated with greater SDM self-efficacy (p < 0.001), but not patient-reported SDM. CONCLUSION:Greater age and practice experience predict greater physician UT, suggesting that UT might be improved through training, while UT is associated with greater confidence in SDM, suggesting that improving UT might improve SDM. However, UT was unassociated with patient-reported SDM, raising the need for further studies of these relationships. PRACTICE IMPLICATIONS:Developing and implementing training interventions aimed at increasing physician UT may be a promising way to promote SDM in clinical care.

INTRODUCTION:A link between inflammatory bowel disease (IBD), stressful life events, and psychological factors has previously been reported. Our objective was to examine the relationship between emotional, physical, and sexual abuse of childhood and risk of IBD using a large cohort of female health professionals. METHODS:We included participants in the Nurses' Health Study II who completed the Physical and Emotional Abuse Subscale of the Childhood Trauma Questionnaire and the Sexual Maltreatment Scale of the Parent-Child Conflict Tactics Scale in 2001. Diagnosis of IBD was determined by self-report and confirmed independently by 2 physicians through review of medical records. We used Cox proportional hazard modeling to estimate the risk of Crohn's disease (CD) and ulcerative colitis (UC) while adjusting for covariates. RESULTS:Among 68,167 women followed from 1989 until 2017, there were 146 incident cases of CD and 215 incident cases of UC. Compared with women with no history of abuse, the adjusted hazard ratios of CD were 1.16 (95% confidence interval [CI] 0.67-2.02) for mild, 1.58 (95% CI 0.92-2.69) for moderate, and 1.95 (95% CI 1.22-3.10) for severe abuse ( Ptrend = 0.002). We did not observe an association between childhood abuse and risk of UC. DISCUSSION:Women who reported early life severe abuse had an increased risk of CD. These data add to the growing body of evidence on the critical role of early life stressors in development of CD.