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The pros and cons of pathology lab ownership: What early career GI doctors need to know
From colonoscopies to endoscopic ultrasound, gastroenterology is fundamentally a procedure-based specialty. Given that reality, making a decision to have as much control as possible over the entire process just makes sense for many GI practices.
Back in 2008, I was in charge of the process to develop a pathology lab at Arizona Digestive Health, a physician group with 26 locations throughout the state, as part of our decision to form a supergroup with eight ambulatory surgery centers. For us, having ambulatory surgery centers had been a game changer. We learned we could double our efficiency with procedures when we controlled the process from start to finish. We began to consider other processes – in this case pathology – that we could improve.
Prior to running our own pathology lab, doctors who read our slides were general pathologists who did not always understand the language of gastroenterology. We had results that came back by fax that were often cumbersome to read and did not always give us the information we needed in the way we needed it. Consistency was a problem. We knew we needed a change.
I cannot lie – setting up and running your own pathology lab is not always easy. But with the right factors in place, here are some benefits to consider when you are making a decision about joining a practice.
Quality, efficiency can lead to opportunity
Our lab has three GI fellowship–trained pathologists reading our slides. That means they are highly specialized and know exactly what we are looking for in a pathology report. We have a 24-hour turnaround for results. A courier service delivers biopsy specimens from our endoscopy centers to our path lab every day, and each morning our gastropathologists have a stack of pathology slides waiting for them. It’s added predictability and stability to the process, and we get the level of quality, specificity, and uniformity we need in a report.
The efficiencies are beneficial and it has given us more leverage in our negotiations with payers. We know what our costs are and have great quality metrics as well as read rates that we can provide. This signals to health plans that quality is a top priority for us.
We have also gained a reputational benefit with patients. Although much of the work is happening behind the scenes for our patients, they get results faster and a consistency with costs. It also allows us to easily access the slides of patients we have been seeing for years, giving us a richer data set and more confidence in our diagnosis.
Now that we have our own lab, we can look at our pathology data and conduct studies that will benefit all patients. For example, a few of our GI fellows were able to work with our pathologists to conduct a study on adenoma detection rates, exhausting a tissue block when no adenoma was found on initial review. We found a significant increase in adenoma detection using this method; we plan to publish results soon. The ability to conduct this kind of research is worth considering when early career gastroenterologists are selecting a practice to join.
And last but not least, having our own pathology lab acts as a unifying force for our group, which is spread out across 26 offices. When diagnoses are available and we get a call from our pathologist, we know to pick up the phone immediately.
What to consider before jumping in
Setting up our own pathology lab from the ground up was a learning process. We had enough patient volume for the move to make sense, so it is possible that smaller practices might not be able to make the investment if they have lower patient volume or cannot control their specimen flow. One option is to set up a technical lab and contract out for the slide reading. We felt it was important for our pathologists to also be our practice partners, and time has proven this to be a good decision for us.
We designed a lab with our work flow in mind, and it helped to have a pathologist on board from the beginning who knows gastroenterology. We even created our own lab information system with the help of a software engineer. It took a little bit over a year from conception to a functioning comprehensive lab.
Of course, there are regulatory factors to consider – the federal physician self-referral (Stark) law and the federal Anti-Markup Rule – come to mind. But we made sure to get a legal opinion that allows us to comply with the law. That’s something anyone who wants to make a move in this direction should do.
Looking back over the experience, I would not do anything differently. Yes, there are startup costs and a learning curve. But the quality we get from having our own pathology lab dedicated to GI and the efficiencies we have gained are well worth it.
Dr. Berggreen is the president of Arizona Digestive Health and chief strategy officer of the GI Alliance. He is also a board member of the Digestive Health Physicians Association. He received his doctorate at Louisiana State University, New Orleans. He is the former site director of the Good Samaritan GI Fellowship Program and named one of Phoenix Magazine’s “Top Docs.”
From colonoscopies to endoscopic ultrasound, gastroenterology is fundamentally a procedure-based specialty. Given that reality, making a decision to have as much control as possible over the entire process just makes sense for many GI practices.
Back in 2008, I was in charge of the process to develop a pathology lab at Arizona Digestive Health, a physician group with 26 locations throughout the state, as part of our decision to form a supergroup with eight ambulatory surgery centers. For us, having ambulatory surgery centers had been a game changer. We learned we could double our efficiency with procedures when we controlled the process from start to finish. We began to consider other processes – in this case pathology – that we could improve.
Prior to running our own pathology lab, doctors who read our slides were general pathologists who did not always understand the language of gastroenterology. We had results that came back by fax that were often cumbersome to read and did not always give us the information we needed in the way we needed it. Consistency was a problem. We knew we needed a change.
I cannot lie – setting up and running your own pathology lab is not always easy. But with the right factors in place, here are some benefits to consider when you are making a decision about joining a practice.
Quality, efficiency can lead to opportunity
Our lab has three GI fellowship–trained pathologists reading our slides. That means they are highly specialized and know exactly what we are looking for in a pathology report. We have a 24-hour turnaround for results. A courier service delivers biopsy specimens from our endoscopy centers to our path lab every day, and each morning our gastropathologists have a stack of pathology slides waiting for them. It’s added predictability and stability to the process, and we get the level of quality, specificity, and uniformity we need in a report.
The efficiencies are beneficial and it has given us more leverage in our negotiations with payers. We know what our costs are and have great quality metrics as well as read rates that we can provide. This signals to health plans that quality is a top priority for us.
We have also gained a reputational benefit with patients. Although much of the work is happening behind the scenes for our patients, they get results faster and a consistency with costs. It also allows us to easily access the slides of patients we have been seeing for years, giving us a richer data set and more confidence in our diagnosis.
Now that we have our own lab, we can look at our pathology data and conduct studies that will benefit all patients. For example, a few of our GI fellows were able to work with our pathologists to conduct a study on adenoma detection rates, exhausting a tissue block when no adenoma was found on initial review. We found a significant increase in adenoma detection using this method; we plan to publish results soon. The ability to conduct this kind of research is worth considering when early career gastroenterologists are selecting a practice to join.
And last but not least, having our own pathology lab acts as a unifying force for our group, which is spread out across 26 offices. When diagnoses are available and we get a call from our pathologist, we know to pick up the phone immediately.
What to consider before jumping in
Setting up our own pathology lab from the ground up was a learning process. We had enough patient volume for the move to make sense, so it is possible that smaller practices might not be able to make the investment if they have lower patient volume or cannot control their specimen flow. One option is to set up a technical lab and contract out for the slide reading. We felt it was important for our pathologists to also be our practice partners, and time has proven this to be a good decision for us.
We designed a lab with our work flow in mind, and it helped to have a pathologist on board from the beginning who knows gastroenterology. We even created our own lab information system with the help of a software engineer. It took a little bit over a year from conception to a functioning comprehensive lab.
Of course, there are regulatory factors to consider – the federal physician self-referral (Stark) law and the federal Anti-Markup Rule – come to mind. But we made sure to get a legal opinion that allows us to comply with the law. That’s something anyone who wants to make a move in this direction should do.
Looking back over the experience, I would not do anything differently. Yes, there are startup costs and a learning curve. But the quality we get from having our own pathology lab dedicated to GI and the efficiencies we have gained are well worth it.
Dr. Berggreen is the president of Arizona Digestive Health and chief strategy officer of the GI Alliance. He is also a board member of the Digestive Health Physicians Association. He received his doctorate at Louisiana State University, New Orleans. He is the former site director of the Good Samaritan GI Fellowship Program and named one of Phoenix Magazine’s “Top Docs.”
From colonoscopies to endoscopic ultrasound, gastroenterology is fundamentally a procedure-based specialty. Given that reality, making a decision to have as much control as possible over the entire process just makes sense for many GI practices.
Back in 2008, I was in charge of the process to develop a pathology lab at Arizona Digestive Health, a physician group with 26 locations throughout the state, as part of our decision to form a supergroup with eight ambulatory surgery centers. For us, having ambulatory surgery centers had been a game changer. We learned we could double our efficiency with procedures when we controlled the process from start to finish. We began to consider other processes – in this case pathology – that we could improve.
Prior to running our own pathology lab, doctors who read our slides were general pathologists who did not always understand the language of gastroenterology. We had results that came back by fax that were often cumbersome to read and did not always give us the information we needed in the way we needed it. Consistency was a problem. We knew we needed a change.
I cannot lie – setting up and running your own pathology lab is not always easy. But with the right factors in place, here are some benefits to consider when you are making a decision about joining a practice.
Quality, efficiency can lead to opportunity
Our lab has three GI fellowship–trained pathologists reading our slides. That means they are highly specialized and know exactly what we are looking for in a pathology report. We have a 24-hour turnaround for results. A courier service delivers biopsy specimens from our endoscopy centers to our path lab every day, and each morning our gastropathologists have a stack of pathology slides waiting for them. It’s added predictability and stability to the process, and we get the level of quality, specificity, and uniformity we need in a report.
The efficiencies are beneficial and it has given us more leverage in our negotiations with payers. We know what our costs are and have great quality metrics as well as read rates that we can provide. This signals to health plans that quality is a top priority for us.
We have also gained a reputational benefit with patients. Although much of the work is happening behind the scenes for our patients, they get results faster and a consistency with costs. It also allows us to easily access the slides of patients we have been seeing for years, giving us a richer data set and more confidence in our diagnosis.
Now that we have our own lab, we can look at our pathology data and conduct studies that will benefit all patients. For example, a few of our GI fellows were able to work with our pathologists to conduct a study on adenoma detection rates, exhausting a tissue block when no adenoma was found on initial review. We found a significant increase in adenoma detection using this method; we plan to publish results soon. The ability to conduct this kind of research is worth considering when early career gastroenterologists are selecting a practice to join.
And last but not least, having our own pathology lab acts as a unifying force for our group, which is spread out across 26 offices. When diagnoses are available and we get a call from our pathologist, we know to pick up the phone immediately.
What to consider before jumping in
Setting up our own pathology lab from the ground up was a learning process. We had enough patient volume for the move to make sense, so it is possible that smaller practices might not be able to make the investment if they have lower patient volume or cannot control their specimen flow. One option is to set up a technical lab and contract out for the slide reading. We felt it was important for our pathologists to also be our practice partners, and time has proven this to be a good decision for us.
We designed a lab with our work flow in mind, and it helped to have a pathologist on board from the beginning who knows gastroenterology. We even created our own lab information system with the help of a software engineer. It took a little bit over a year from conception to a functioning comprehensive lab.
Of course, there are regulatory factors to consider – the federal physician self-referral (Stark) law and the federal Anti-Markup Rule – come to mind. But we made sure to get a legal opinion that allows us to comply with the law. That’s something anyone who wants to make a move in this direction should do.
Looking back over the experience, I would not do anything differently. Yes, there are startup costs and a learning curve. But the quality we get from having our own pathology lab dedicated to GI and the efficiencies we have gained are well worth it.
Dr. Berggreen is the president of Arizona Digestive Health and chief strategy officer of the GI Alliance. He is also a board member of the Digestive Health Physicians Association. He received his doctorate at Louisiana State University, New Orleans. He is the former site director of the Good Samaritan GI Fellowship Program and named one of Phoenix Magazine’s “Top Docs.”
New medical ethics series debuts
Dear colleagues,
The first issue of The New Gastroenterologist in 2020 consists of a particularly interesting array of articles and the introduction of a new medical ethics series!
This month’s “In Focus” article, brought to you by Jennifer Maratt (Indiana University) and Elena Stoffel (University of Michigan), provides a high yield overview of hereditary colorectal cancer and polyposis syndromes, with guidance on when a referral to a high risk cancer specialist and geneticist is warranted.
Daniel Mills (Cunningham, Meyer & Vedrine P.C.) gives us a valuable legal perspective of the role of electronic patient portals in the dissemination of information and medical advice to patients – such an important topic for everyone to be aware of as the nature of patient communication now strongly relies on electronic messaging.
R. Thomas Finn III (Palo Alto Medical Foundation) and David Leiman (Duke) nicely broach the issue of patient satisfaction. This is a timely topic as many institutions are not only publishing patient reviews online so that they are readily available to the public, but are also making financial incentives contingent on high patient ratings. The article discusses the evolution of the emphasis placed on patient satisfaction throughout the years with tips on how to navigate some of the distinct challenges within gastroenterology.
As part of our DHPA Private Practice Perspectives series, David Stokesberry (Digestive Disease Specialists Inc, Oklahoma City) discusses the nuts and bolts of ambulatory endoscopy centers and some of the challenges and benefits that accompany ownership of such centers.
An often overlooked aspect of gastroenterology training is nutrition. In our postfellowship pathways section, Dejan Micic (University of Chicago) outlines his decision to pursue a career in nutrition support, small bowel disorders, and the practice of deep enteroscopy.
Finally, this quarter’s newsletter features the start of a new section, which I am very excited to introduce – a case based series which will address issues in clinical medical ethics specific to gastroenterology. Lauren Feld (University of Washington) writes the inaugural piece for the section, providing a systematic approach to the patient with an existing do-not-resuscitate (DNR) order that is about to undergo endoscopy.
If you have interest in contributing or have ideas for future TNG topics, please contact me ([email protected]), or Ryan Farrell ([email protected]), managing editor of TNG.
Sincerely,
Vijaya L. Rao, MD
Editor in Chief
Dear colleagues,
The first issue of The New Gastroenterologist in 2020 consists of a particularly interesting array of articles and the introduction of a new medical ethics series!
This month’s “In Focus” article, brought to you by Jennifer Maratt (Indiana University) and Elena Stoffel (University of Michigan), provides a high yield overview of hereditary colorectal cancer and polyposis syndromes, with guidance on when a referral to a high risk cancer specialist and geneticist is warranted.
Daniel Mills (Cunningham, Meyer & Vedrine P.C.) gives us a valuable legal perspective of the role of electronic patient portals in the dissemination of information and medical advice to patients – such an important topic for everyone to be aware of as the nature of patient communication now strongly relies on electronic messaging.
R. Thomas Finn III (Palo Alto Medical Foundation) and David Leiman (Duke) nicely broach the issue of patient satisfaction. This is a timely topic as many institutions are not only publishing patient reviews online so that they are readily available to the public, but are also making financial incentives contingent on high patient ratings. The article discusses the evolution of the emphasis placed on patient satisfaction throughout the years with tips on how to navigate some of the distinct challenges within gastroenterology.
As part of our DHPA Private Practice Perspectives series, David Stokesberry (Digestive Disease Specialists Inc, Oklahoma City) discusses the nuts and bolts of ambulatory endoscopy centers and some of the challenges and benefits that accompany ownership of such centers.
An often overlooked aspect of gastroenterology training is nutrition. In our postfellowship pathways section, Dejan Micic (University of Chicago) outlines his decision to pursue a career in nutrition support, small bowel disorders, and the practice of deep enteroscopy.
Finally, this quarter’s newsletter features the start of a new section, which I am very excited to introduce – a case based series which will address issues in clinical medical ethics specific to gastroenterology. Lauren Feld (University of Washington) writes the inaugural piece for the section, providing a systematic approach to the patient with an existing do-not-resuscitate (DNR) order that is about to undergo endoscopy.
If you have interest in contributing or have ideas for future TNG topics, please contact me ([email protected]), or Ryan Farrell ([email protected]), managing editor of TNG.
Sincerely,
Vijaya L. Rao, MD
Editor in Chief
Dear colleagues,
The first issue of The New Gastroenterologist in 2020 consists of a particularly interesting array of articles and the introduction of a new medical ethics series!
This month’s “In Focus” article, brought to you by Jennifer Maratt (Indiana University) and Elena Stoffel (University of Michigan), provides a high yield overview of hereditary colorectal cancer and polyposis syndromes, with guidance on when a referral to a high risk cancer specialist and geneticist is warranted.
Daniel Mills (Cunningham, Meyer & Vedrine P.C.) gives us a valuable legal perspective of the role of electronic patient portals in the dissemination of information and medical advice to patients – such an important topic for everyone to be aware of as the nature of patient communication now strongly relies on electronic messaging.
R. Thomas Finn III (Palo Alto Medical Foundation) and David Leiman (Duke) nicely broach the issue of patient satisfaction. This is a timely topic as many institutions are not only publishing patient reviews online so that they are readily available to the public, but are also making financial incentives contingent on high patient ratings. The article discusses the evolution of the emphasis placed on patient satisfaction throughout the years with tips on how to navigate some of the distinct challenges within gastroenterology.
As part of our DHPA Private Practice Perspectives series, David Stokesberry (Digestive Disease Specialists Inc, Oklahoma City) discusses the nuts and bolts of ambulatory endoscopy centers and some of the challenges and benefits that accompany ownership of such centers.
An often overlooked aspect of gastroenterology training is nutrition. In our postfellowship pathways section, Dejan Micic (University of Chicago) outlines his decision to pursue a career in nutrition support, small bowel disorders, and the practice of deep enteroscopy.
Finally, this quarter’s newsletter features the start of a new section, which I am very excited to introduce – a case based series which will address issues in clinical medical ethics specific to gastroenterology. Lauren Feld (University of Washington) writes the inaugural piece for the section, providing a systematic approach to the patient with an existing do-not-resuscitate (DNR) order that is about to undergo endoscopy.
If you have interest in contributing or have ideas for future TNG topics, please contact me ([email protected]), or Ryan Farrell ([email protected]), managing editor of TNG.
Sincerely,
Vijaya L. Rao, MD
Editor in Chief
Colorectal polyps and cancer – when to refer to genetics
Introduction
Genetic predisposition to colorectal polyps and colorectal cancer (CRC) is more common than previously recognized. Approximately 5%-10% of all individuals diagnosed with CRC have a known genetic association. However, among those with early-onset CRC (diagnosed at age less than 50 years), recent studies show that up to 20% have an associated genetic mutation.1,2 In addition, the risk of CRC in patients with certain hereditary syndromes, such as familial adenomatous polyposis (FAP), approaches 80%-90% without timely management.3 This overall high risk of CRC and extracolonic malignancies in patients with a hereditary syndrome, along with the rising rates of early-onset CRC, underscores the importance of early diagnosis and management of a hereditary condition.
Despite increasing awareness of hereditary polyposis and nonpolyposis syndromes, referral rates for genetic counseling and testing remain low.4 As gastroenterologists we have several unique opportunities, in clinic and in endoscopy, to identify patients at risk for hereditary syndromes.
Risk stratification
Personal and family history
Reviewing personal medical history and family history in detail should be a routine part of our practice. This is often when initial signs of a potential hereditary syndrome can be detected. For example, if a patient reports a personal or family history of colorectal polyps or CRC, additional information that becomes important includes age at time of diagnosis, polyp burden (number and histologic subtype), presence of inflammatory bowel disease, and history of any extracolonic malignancies. Patients with multiple colorectal polyps (e.g. more than 10-20 adenomas or more than 2 hamartomas) and those with CRC diagnosed at a young age (younger than 50 years) should be considered candidates for genetic evaluation.5
Lynch syndrome (LS), an autosomal dominant condition caused by loss of DNA mismatch repair (MMR) genes, is the most common hereditary CRC syndrome, accounting for 2%-4% of all CRCs.3,6 Extracolonic LS-associated cancers to keep in mind while reviewing personal and family histories include those involving the gastrointestinal (GI) tract such as gastric, pancreatic, biliary tract, and small intestine cancers, and also non-GI tract cancers including endometrial, ovarian, urinary tract, and renal cancers along with brain tumors, and skin lesions including sebaceous adenomas, sebaceous carcinomas, and keratoacanthomas. Notably, after CRC, endometrial cancer is the second most common cancer among women with LS. Prior diagnosis of endometrial cancer should also prompt additional history-taking and evaluation for LS.
As the National Comprehensive Cancer Network (NCCN) highlights in its recent guidelines, several key findings in family history that should prompt referral to genetics for evaluation and testing for LS include: one or more first-degree relatives (FDR) with CRC or endometrial cancer diagnosed at less than 50 years of age, one or more FDR with CRC or endometrial cancer and another synchronous or metachronous LS-related cancer, two or more FDR or second-degree relatives (SDR) with LS-related cancer (including at least one diagnosed at age less than 50 years), and three or more FDR or SDR with LS-related cancers (regardless of age).5
Comprehensive assessment of family history should include all cancer diagnoses in first- and second-degree relatives, including age at diagnosis and cancer type, as well as ethnicity, as these inform the likelihood that the patient harbors a germline pathogenic variant associated with cancer predisposition.5 Given the difficulty of eliciting this level of detail, the family histories elicited in clinical settings are often limited or incomplete. Unknown family history should not be mistaken for unremarkable family history. Alternatively, if family history is unimpressive, this is not necessarily reassuring, as there can be variability in disease penetrance, including autosomal recessive syndromes that may skip generations, and de novo mutations do occur. In fact, among individuals with early-onset CRC diagnosed at age less than 50, only half of mutation carriers reported a family history of CRC in an FDR.2 Thus, individuals with concerning personal histories should undergo a genetic evaluation even if family history is not concerning.
Polyp phenotype
In addition to personal and family history, colon polyp history (including number, size, and histology) can provide important clues to identifying individuals with genetic predisposition to CRC. Table 1 highlights hereditary syndromes and polyp phenotypes associated with increased CRC risk. Based on consensus guidelines, individuals with a history of greater than 10-20 adenomas, 2 or more hamartomas, or 5 or more sessile serrated polyps should be referred for genetic testing.5,7 Serrated polyposis syndrome (SPS) is diagnosed based on at least one of the following criteria: 1) 5 or more serrated polyps, all at least 5 mm in size, proximal to the rectum including at least 2 that are 10 mm or larger in size, or 2) more than 20 serrated polyps distributed throughout the colon with at least 5 proximal to the rectum.8 Pathogenic germline variants in RNF43, a tumor suppressor gene, have been associated with SPS in rare families; however, in most cases genetic testing is uninformative and further genetic and environmental discovery studies are needed to determine the underlying cause.8,9
Risk prediction models
Models have been developed that integrate family history and phenotype data to help identify patients who may be at risk for LS. The Amsterdam criteria (more than 3 relatives with LS-associated cancers, more than 2 generations involving LS-associated cancers, and more than 1 cancer diagnosed before the age of 50; “3:2:1” criteria) were initially developed for research purposes to identify individuals who were likely to be carriers of mutations of LS based on CRC and later revised to include extracolonic malignancies (Amsterdam II).11 However, they have limited sensitivity for identifying high-risk patients. Similarly, the Bethesda guidelines have also been modified and revised to identify patients at risk for LS whose tumors should be tested with microsatellite instability (MSI), but also with limited sensitivity.12
Several risk prediction models have been developed that perform better than the Amsterdam criteria or Bethesda guidelines for determining which patients should be referred for genetic testing for LS. These include MMRPredict, MMRpro, and PREMM5.13-16 These models use clinical data (personal and family history of cancer and tumor phenotypes) to calculate the probability of a germline mutation in one of the mismatch repair (MMR) genes associated with LS. The current threshold at which to refer a patient for genetic counseling and testing is a predicted probability of 5% or greater using any one of these models, though some have proposed lowering the threshold to 2.5%.16,17
Universal tumor testing
Because of the limitations of relying on clinical family history, such as with the Amsterdam criteria and the Bethesda guidelines,18,19 as of 2014 the NCCN recommended universal tumor screening for DNA MMR deficiency associated with LS. This approach, also known as “universal testing,” has been shown to be cost effective and more sensitive in identifying at-risk patients than clinical criteria alone.20,21 Specifically, the NCCN recommends that tumor specimens of all patients diagnosed with CRC undergo testing for microsatellite instability (MSI) or loss of MMR proteins (MLH1, MSH2, MSH6, PMS2) expression by immunohistochemistry (IHC).5 Loss of MMR proteins or MSI-high findings should prompt a referral to genetics for counseling and consideration of testing for germline mutations. Universal testing of CRC and endometrial cancers is considered the most reliable way to screen patients for LS.
Universal testing by MSI or IHC may be performed on premalignant or malignant lesions. However, it is important to recognize that DNA MMR deficiency testing may not be as reliable when applied to colorectal polyps. Using data from three cancer registries (Dana-Farber Cancer Institute, University of Michigan, MD Anderson Cancer Center), Yurgelun and colleagues investigated the yield of MSI and IHC in colorectal polyps removed from patients with known LS.22 Overall, high-level MSI was found in only 41% of Lynch-associated adenomas and loss of MMR protein expression was evident in only 50%. While adenomas 8 mm in size or greater were more likely to have MSI-high or loss of MMR protein expression compared with those less than 8 mm in size, MMR-deficiency phenotype was less reliable in smaller adenomas. Consequently, results of MSI and/or IHC should therefore be interpreted with caution and in the context of the specimen upon which they are performed.
Considerations for clinical genetic testing
Genetic testing for cancer susceptibility should include informed consent and counseling for patients regarding potential risks and benefits. Clinicians ordering genetic testing should have the expertise necessary to interpret test results, which may be positive (pathogenic or likely pathogenic germline variant identified), or negative (no variants identified), or may yield one or more variants of uncertain clinical significance. Individuals found to carry a pathogenic or likely pathogenic germline variant associated with cancer susceptibility should be referred for additional genetic counseling and may require additional expert consultation for management of extracolonic cancer risks. It is important that individuals diagnosed with a hereditary cancer syndrome be informed that this diagnosis has implications for family members, who may also be at risk for the condition and may benefit from genetic testing.
Practical considerations
Given the difficulty in obtaining a detailed family history while in clinic or in endoscopy, several studies have investigated strategies that may be integrated into practice to identify high-risk patients without substantial burden on providers or patients. Kastrinos and colleagues identified the following three high-yield questions as part of a CRC Risk Assessment Tool that can be used while performing a precolonoscopy assessment: 1) Do you have a first-degree relative with CRC or LS-related cancer diagnosed before age 50?; 2) Have you had CRC or polyps diagnosed prior to age 50?; and 3) Do you have three or more relatives with CRC? The authors found that these three questions alone identified 77% of high-risk individuals.23 In addition, implementation of family history screening instruments using standardized surveys or self-administered risk prediction models at the time of colonoscopy have been shown to improve ascertainment of high-risk patients.24,25 Such strategies may become increasingly easier to implement with integration into patients’ electronic medical records.
Conclusions
Hereditary CRC syndromes are becoming increasingly important to identify, especially in an era where we are seeing rising rates of early-onset CRC. Early identification of high-risk features (Table 2) can lead to timely diagnosis with the goal to implement preventive strategies for screening and/or surveillance, ideally prior to development of cancers.
As gastroenterologists, we have several unique opportunities to identify these individuals and must maintain a high level of suspicion with careful attention when obtaining personal and family history details in clinic and in endoscopy.
Dr. Maratt is assistant professor, Indiana University, Richard L. Roudebush VA Medical Center, Indianapolis. Dr. Stoffel is assistant professor, University of Michigan; director of Cancer Genetic Clinic, Rogel Cancer Center, Ann Arbor. They have no conflicts of interest.
References
1. Pearlman R et al. JAMA Oncol. 2017;3(4):464-71.
2. Stoffel EM et al. Gastroenterology. 2018;154(4):897-905.
3. Kanth P et al. Am J Gastroenterol. 2017;112:1509-25.
4. Brennan B et al. Ther Adv Gastroenterol. 2017;10:361-71.
5. National Comprehensive Cancer Network. Available at: nccn.org.
6. Lynch HT et al. Nat Rev Cancer. 2015;15:181-94.
7. Syngal S et al. Am J Gastroenterol. 2015;110:223-62.
8. Mankaney G et al. Clin Gastroenterol Hepatol. 2020:(in press)
9. Yan HHN et al. Gut 2017;66:1645-56.
10. Ma H et al. Pathology. 2018;50:49-59.
11. Vasen H et al. Gastroenterology 1999;116:1453-6.
12. Umar A et al. J Natl Cancer Inst. 2004;96:261-8.
13. Kastrinos F et al. J Natl Cancer Inst. 2015;108(2):1-9.
14. Chen S et al. JAMA. 2006;296(12):1479-87.
15. Barnetson RA et al. N Engl J Med. 2006;354(26):2751-63.
16. Kastrinos F et al. J Clin Oncol. 2017;35:2165-72.
17. Kastrinos F et al. Fam Cancer. 2018;17:567-67.
18. Cohen SA et al. Annu Rev Genomics Hum Genet. 2019;20:293-307.
19. Matloff J et al. J Natl Compr Canc Netw. 2013;11:1380-5.
20. Ladabaum U et al. Ann Intern Med. 2011;155(2):69-79.
21. Hampel H et al. N Engl J Med. 2005;352(18):1851-60.
22. Yurgelun MB et al. Cancer Prev Res. 2012;5:574-82.
23. Kastrinos F et al. Am J Gastroenterol. 2009;104:1508-18.
24. Luba DG et al. Clin Gastroenterol Hepatol. 2018;16:49-58.
25. Guivatchian T et al. Gastrointest Endosc. 2017;86:684-91.
Introduction
Genetic predisposition to colorectal polyps and colorectal cancer (CRC) is more common than previously recognized. Approximately 5%-10% of all individuals diagnosed with CRC have a known genetic association. However, among those with early-onset CRC (diagnosed at age less than 50 years), recent studies show that up to 20% have an associated genetic mutation.1,2 In addition, the risk of CRC in patients with certain hereditary syndromes, such as familial adenomatous polyposis (FAP), approaches 80%-90% without timely management.3 This overall high risk of CRC and extracolonic malignancies in patients with a hereditary syndrome, along with the rising rates of early-onset CRC, underscores the importance of early diagnosis and management of a hereditary condition.
Despite increasing awareness of hereditary polyposis and nonpolyposis syndromes, referral rates for genetic counseling and testing remain low.4 As gastroenterologists we have several unique opportunities, in clinic and in endoscopy, to identify patients at risk for hereditary syndromes.
Risk stratification
Personal and family history
Reviewing personal medical history and family history in detail should be a routine part of our practice. This is often when initial signs of a potential hereditary syndrome can be detected. For example, if a patient reports a personal or family history of colorectal polyps or CRC, additional information that becomes important includes age at time of diagnosis, polyp burden (number and histologic subtype), presence of inflammatory bowel disease, and history of any extracolonic malignancies. Patients with multiple colorectal polyps (e.g. more than 10-20 adenomas or more than 2 hamartomas) and those with CRC diagnosed at a young age (younger than 50 years) should be considered candidates for genetic evaluation.5
Lynch syndrome (LS), an autosomal dominant condition caused by loss of DNA mismatch repair (MMR) genes, is the most common hereditary CRC syndrome, accounting for 2%-4% of all CRCs.3,6 Extracolonic LS-associated cancers to keep in mind while reviewing personal and family histories include those involving the gastrointestinal (GI) tract such as gastric, pancreatic, biliary tract, and small intestine cancers, and also non-GI tract cancers including endometrial, ovarian, urinary tract, and renal cancers along with brain tumors, and skin lesions including sebaceous adenomas, sebaceous carcinomas, and keratoacanthomas. Notably, after CRC, endometrial cancer is the second most common cancer among women with LS. Prior diagnosis of endometrial cancer should also prompt additional history-taking and evaluation for LS.
As the National Comprehensive Cancer Network (NCCN) highlights in its recent guidelines, several key findings in family history that should prompt referral to genetics for evaluation and testing for LS include: one or more first-degree relatives (FDR) with CRC or endometrial cancer diagnosed at less than 50 years of age, one or more FDR with CRC or endometrial cancer and another synchronous or metachronous LS-related cancer, two or more FDR or second-degree relatives (SDR) with LS-related cancer (including at least one diagnosed at age less than 50 years), and three or more FDR or SDR with LS-related cancers (regardless of age).5
Comprehensive assessment of family history should include all cancer diagnoses in first- and second-degree relatives, including age at diagnosis and cancer type, as well as ethnicity, as these inform the likelihood that the patient harbors a germline pathogenic variant associated with cancer predisposition.5 Given the difficulty of eliciting this level of detail, the family histories elicited in clinical settings are often limited or incomplete. Unknown family history should not be mistaken for unremarkable family history. Alternatively, if family history is unimpressive, this is not necessarily reassuring, as there can be variability in disease penetrance, including autosomal recessive syndromes that may skip generations, and de novo mutations do occur. In fact, among individuals with early-onset CRC diagnosed at age less than 50, only half of mutation carriers reported a family history of CRC in an FDR.2 Thus, individuals with concerning personal histories should undergo a genetic evaluation even if family history is not concerning.
Polyp phenotype
In addition to personal and family history, colon polyp history (including number, size, and histology) can provide important clues to identifying individuals with genetic predisposition to CRC. Table 1 highlights hereditary syndromes and polyp phenotypes associated with increased CRC risk. Based on consensus guidelines, individuals with a history of greater than 10-20 adenomas, 2 or more hamartomas, or 5 or more sessile serrated polyps should be referred for genetic testing.5,7 Serrated polyposis syndrome (SPS) is diagnosed based on at least one of the following criteria: 1) 5 or more serrated polyps, all at least 5 mm in size, proximal to the rectum including at least 2 that are 10 mm or larger in size, or 2) more than 20 serrated polyps distributed throughout the colon with at least 5 proximal to the rectum.8 Pathogenic germline variants in RNF43, a tumor suppressor gene, have been associated with SPS in rare families; however, in most cases genetic testing is uninformative and further genetic and environmental discovery studies are needed to determine the underlying cause.8,9
Risk prediction models
Models have been developed that integrate family history and phenotype data to help identify patients who may be at risk for LS. The Amsterdam criteria (more than 3 relatives with LS-associated cancers, more than 2 generations involving LS-associated cancers, and more than 1 cancer diagnosed before the age of 50; “3:2:1” criteria) were initially developed for research purposes to identify individuals who were likely to be carriers of mutations of LS based on CRC and later revised to include extracolonic malignancies (Amsterdam II).11 However, they have limited sensitivity for identifying high-risk patients. Similarly, the Bethesda guidelines have also been modified and revised to identify patients at risk for LS whose tumors should be tested with microsatellite instability (MSI), but also with limited sensitivity.12
Several risk prediction models have been developed that perform better than the Amsterdam criteria or Bethesda guidelines for determining which patients should be referred for genetic testing for LS. These include MMRPredict, MMRpro, and PREMM5.13-16 These models use clinical data (personal and family history of cancer and tumor phenotypes) to calculate the probability of a germline mutation in one of the mismatch repair (MMR) genes associated with LS. The current threshold at which to refer a patient for genetic counseling and testing is a predicted probability of 5% or greater using any one of these models, though some have proposed lowering the threshold to 2.5%.16,17
Universal tumor testing
Because of the limitations of relying on clinical family history, such as with the Amsterdam criteria and the Bethesda guidelines,18,19 as of 2014 the NCCN recommended universal tumor screening for DNA MMR deficiency associated with LS. This approach, also known as “universal testing,” has been shown to be cost effective and more sensitive in identifying at-risk patients than clinical criteria alone.20,21 Specifically, the NCCN recommends that tumor specimens of all patients diagnosed with CRC undergo testing for microsatellite instability (MSI) or loss of MMR proteins (MLH1, MSH2, MSH6, PMS2) expression by immunohistochemistry (IHC).5 Loss of MMR proteins or MSI-high findings should prompt a referral to genetics for counseling and consideration of testing for germline mutations. Universal testing of CRC and endometrial cancers is considered the most reliable way to screen patients for LS.
Universal testing by MSI or IHC may be performed on premalignant or malignant lesions. However, it is important to recognize that DNA MMR deficiency testing may not be as reliable when applied to colorectal polyps. Using data from three cancer registries (Dana-Farber Cancer Institute, University of Michigan, MD Anderson Cancer Center), Yurgelun and colleagues investigated the yield of MSI and IHC in colorectal polyps removed from patients with known LS.22 Overall, high-level MSI was found in only 41% of Lynch-associated adenomas and loss of MMR protein expression was evident in only 50%. While adenomas 8 mm in size or greater were more likely to have MSI-high or loss of MMR protein expression compared with those less than 8 mm in size, MMR-deficiency phenotype was less reliable in smaller adenomas. Consequently, results of MSI and/or IHC should therefore be interpreted with caution and in the context of the specimen upon which they are performed.
Considerations for clinical genetic testing
Genetic testing for cancer susceptibility should include informed consent and counseling for patients regarding potential risks and benefits. Clinicians ordering genetic testing should have the expertise necessary to interpret test results, which may be positive (pathogenic or likely pathogenic germline variant identified), or negative (no variants identified), or may yield one or more variants of uncertain clinical significance. Individuals found to carry a pathogenic or likely pathogenic germline variant associated with cancer susceptibility should be referred for additional genetic counseling and may require additional expert consultation for management of extracolonic cancer risks. It is important that individuals diagnosed with a hereditary cancer syndrome be informed that this diagnosis has implications for family members, who may also be at risk for the condition and may benefit from genetic testing.
Practical considerations
Given the difficulty in obtaining a detailed family history while in clinic or in endoscopy, several studies have investigated strategies that may be integrated into practice to identify high-risk patients without substantial burden on providers or patients. Kastrinos and colleagues identified the following three high-yield questions as part of a CRC Risk Assessment Tool that can be used while performing a precolonoscopy assessment: 1) Do you have a first-degree relative with CRC or LS-related cancer diagnosed before age 50?; 2) Have you had CRC or polyps diagnosed prior to age 50?; and 3) Do you have three or more relatives with CRC? The authors found that these three questions alone identified 77% of high-risk individuals.23 In addition, implementation of family history screening instruments using standardized surveys or self-administered risk prediction models at the time of colonoscopy have been shown to improve ascertainment of high-risk patients.24,25 Such strategies may become increasingly easier to implement with integration into patients’ electronic medical records.
Conclusions
Hereditary CRC syndromes are becoming increasingly important to identify, especially in an era where we are seeing rising rates of early-onset CRC. Early identification of high-risk features (Table 2) can lead to timely diagnosis with the goal to implement preventive strategies for screening and/or surveillance, ideally prior to development of cancers.
As gastroenterologists, we have several unique opportunities to identify these individuals and must maintain a high level of suspicion with careful attention when obtaining personal and family history details in clinic and in endoscopy.
Dr. Maratt is assistant professor, Indiana University, Richard L. Roudebush VA Medical Center, Indianapolis. Dr. Stoffel is assistant professor, University of Michigan; director of Cancer Genetic Clinic, Rogel Cancer Center, Ann Arbor. They have no conflicts of interest.
References
1. Pearlman R et al. JAMA Oncol. 2017;3(4):464-71.
2. Stoffel EM et al. Gastroenterology. 2018;154(4):897-905.
3. Kanth P et al. Am J Gastroenterol. 2017;112:1509-25.
4. Brennan B et al. Ther Adv Gastroenterol. 2017;10:361-71.
5. National Comprehensive Cancer Network. Available at: nccn.org.
6. Lynch HT et al. Nat Rev Cancer. 2015;15:181-94.
7. Syngal S et al. Am J Gastroenterol. 2015;110:223-62.
8. Mankaney G et al. Clin Gastroenterol Hepatol. 2020:(in press)
9. Yan HHN et al. Gut 2017;66:1645-56.
10. Ma H et al. Pathology. 2018;50:49-59.
11. Vasen H et al. Gastroenterology 1999;116:1453-6.
12. Umar A et al. J Natl Cancer Inst. 2004;96:261-8.
13. Kastrinos F et al. J Natl Cancer Inst. 2015;108(2):1-9.
14. Chen S et al. JAMA. 2006;296(12):1479-87.
15. Barnetson RA et al. N Engl J Med. 2006;354(26):2751-63.
16. Kastrinos F et al. J Clin Oncol. 2017;35:2165-72.
17. Kastrinos F et al. Fam Cancer. 2018;17:567-67.
18. Cohen SA et al. Annu Rev Genomics Hum Genet. 2019;20:293-307.
19. Matloff J et al. J Natl Compr Canc Netw. 2013;11:1380-5.
20. Ladabaum U et al. Ann Intern Med. 2011;155(2):69-79.
21. Hampel H et al. N Engl J Med. 2005;352(18):1851-60.
22. Yurgelun MB et al. Cancer Prev Res. 2012;5:574-82.
23. Kastrinos F et al. Am J Gastroenterol. 2009;104:1508-18.
24. Luba DG et al. Clin Gastroenterol Hepatol. 2018;16:49-58.
25. Guivatchian T et al. Gastrointest Endosc. 2017;86:684-91.
Introduction
Genetic predisposition to colorectal polyps and colorectal cancer (CRC) is more common than previously recognized. Approximately 5%-10% of all individuals diagnosed with CRC have a known genetic association. However, among those with early-onset CRC (diagnosed at age less than 50 years), recent studies show that up to 20% have an associated genetic mutation.1,2 In addition, the risk of CRC in patients with certain hereditary syndromes, such as familial adenomatous polyposis (FAP), approaches 80%-90% without timely management.3 This overall high risk of CRC and extracolonic malignancies in patients with a hereditary syndrome, along with the rising rates of early-onset CRC, underscores the importance of early diagnosis and management of a hereditary condition.
Despite increasing awareness of hereditary polyposis and nonpolyposis syndromes, referral rates for genetic counseling and testing remain low.4 As gastroenterologists we have several unique opportunities, in clinic and in endoscopy, to identify patients at risk for hereditary syndromes.
Risk stratification
Personal and family history
Reviewing personal medical history and family history in detail should be a routine part of our practice. This is often when initial signs of a potential hereditary syndrome can be detected. For example, if a patient reports a personal or family history of colorectal polyps or CRC, additional information that becomes important includes age at time of diagnosis, polyp burden (number and histologic subtype), presence of inflammatory bowel disease, and history of any extracolonic malignancies. Patients with multiple colorectal polyps (e.g. more than 10-20 adenomas or more than 2 hamartomas) and those with CRC diagnosed at a young age (younger than 50 years) should be considered candidates for genetic evaluation.5
Lynch syndrome (LS), an autosomal dominant condition caused by loss of DNA mismatch repair (MMR) genes, is the most common hereditary CRC syndrome, accounting for 2%-4% of all CRCs.3,6 Extracolonic LS-associated cancers to keep in mind while reviewing personal and family histories include those involving the gastrointestinal (GI) tract such as gastric, pancreatic, biliary tract, and small intestine cancers, and also non-GI tract cancers including endometrial, ovarian, urinary tract, and renal cancers along with brain tumors, and skin lesions including sebaceous adenomas, sebaceous carcinomas, and keratoacanthomas. Notably, after CRC, endometrial cancer is the second most common cancer among women with LS. Prior diagnosis of endometrial cancer should also prompt additional history-taking and evaluation for LS.
As the National Comprehensive Cancer Network (NCCN) highlights in its recent guidelines, several key findings in family history that should prompt referral to genetics for evaluation and testing for LS include: one or more first-degree relatives (FDR) with CRC or endometrial cancer diagnosed at less than 50 years of age, one or more FDR with CRC or endometrial cancer and another synchronous or metachronous LS-related cancer, two or more FDR or second-degree relatives (SDR) with LS-related cancer (including at least one diagnosed at age less than 50 years), and three or more FDR or SDR with LS-related cancers (regardless of age).5
Comprehensive assessment of family history should include all cancer diagnoses in first- and second-degree relatives, including age at diagnosis and cancer type, as well as ethnicity, as these inform the likelihood that the patient harbors a germline pathogenic variant associated with cancer predisposition.5 Given the difficulty of eliciting this level of detail, the family histories elicited in clinical settings are often limited or incomplete. Unknown family history should not be mistaken for unremarkable family history. Alternatively, if family history is unimpressive, this is not necessarily reassuring, as there can be variability in disease penetrance, including autosomal recessive syndromes that may skip generations, and de novo mutations do occur. In fact, among individuals with early-onset CRC diagnosed at age less than 50, only half of mutation carriers reported a family history of CRC in an FDR.2 Thus, individuals with concerning personal histories should undergo a genetic evaluation even if family history is not concerning.
Polyp phenotype
In addition to personal and family history, colon polyp history (including number, size, and histology) can provide important clues to identifying individuals with genetic predisposition to CRC. Table 1 highlights hereditary syndromes and polyp phenotypes associated with increased CRC risk. Based on consensus guidelines, individuals with a history of greater than 10-20 adenomas, 2 or more hamartomas, or 5 or more sessile serrated polyps should be referred for genetic testing.5,7 Serrated polyposis syndrome (SPS) is diagnosed based on at least one of the following criteria: 1) 5 or more serrated polyps, all at least 5 mm in size, proximal to the rectum including at least 2 that are 10 mm or larger in size, or 2) more than 20 serrated polyps distributed throughout the colon with at least 5 proximal to the rectum.8 Pathogenic germline variants in RNF43, a tumor suppressor gene, have been associated with SPS in rare families; however, in most cases genetic testing is uninformative and further genetic and environmental discovery studies are needed to determine the underlying cause.8,9
Risk prediction models
Models have been developed that integrate family history and phenotype data to help identify patients who may be at risk for LS. The Amsterdam criteria (more than 3 relatives with LS-associated cancers, more than 2 generations involving LS-associated cancers, and more than 1 cancer diagnosed before the age of 50; “3:2:1” criteria) were initially developed for research purposes to identify individuals who were likely to be carriers of mutations of LS based on CRC and later revised to include extracolonic malignancies (Amsterdam II).11 However, they have limited sensitivity for identifying high-risk patients. Similarly, the Bethesda guidelines have also been modified and revised to identify patients at risk for LS whose tumors should be tested with microsatellite instability (MSI), but also with limited sensitivity.12
Several risk prediction models have been developed that perform better than the Amsterdam criteria or Bethesda guidelines for determining which patients should be referred for genetic testing for LS. These include MMRPredict, MMRpro, and PREMM5.13-16 These models use clinical data (personal and family history of cancer and tumor phenotypes) to calculate the probability of a germline mutation in one of the mismatch repair (MMR) genes associated with LS. The current threshold at which to refer a patient for genetic counseling and testing is a predicted probability of 5% or greater using any one of these models, though some have proposed lowering the threshold to 2.5%.16,17
Universal tumor testing
Because of the limitations of relying on clinical family history, such as with the Amsterdam criteria and the Bethesda guidelines,18,19 as of 2014 the NCCN recommended universal tumor screening for DNA MMR deficiency associated with LS. This approach, also known as “universal testing,” has been shown to be cost effective and more sensitive in identifying at-risk patients than clinical criteria alone.20,21 Specifically, the NCCN recommends that tumor specimens of all patients diagnosed with CRC undergo testing for microsatellite instability (MSI) or loss of MMR proteins (MLH1, MSH2, MSH6, PMS2) expression by immunohistochemistry (IHC).5 Loss of MMR proteins or MSI-high findings should prompt a referral to genetics for counseling and consideration of testing for germline mutations. Universal testing of CRC and endometrial cancers is considered the most reliable way to screen patients for LS.
Universal testing by MSI or IHC may be performed on premalignant or malignant lesions. However, it is important to recognize that DNA MMR deficiency testing may not be as reliable when applied to colorectal polyps. Using data from three cancer registries (Dana-Farber Cancer Institute, University of Michigan, MD Anderson Cancer Center), Yurgelun and colleagues investigated the yield of MSI and IHC in colorectal polyps removed from patients with known LS.22 Overall, high-level MSI was found in only 41% of Lynch-associated adenomas and loss of MMR protein expression was evident in only 50%. While adenomas 8 mm in size or greater were more likely to have MSI-high or loss of MMR protein expression compared with those less than 8 mm in size, MMR-deficiency phenotype was less reliable in smaller adenomas. Consequently, results of MSI and/or IHC should therefore be interpreted with caution and in the context of the specimen upon which they are performed.
Considerations for clinical genetic testing
Genetic testing for cancer susceptibility should include informed consent and counseling for patients regarding potential risks and benefits. Clinicians ordering genetic testing should have the expertise necessary to interpret test results, which may be positive (pathogenic or likely pathogenic germline variant identified), or negative (no variants identified), or may yield one or more variants of uncertain clinical significance. Individuals found to carry a pathogenic or likely pathogenic germline variant associated with cancer susceptibility should be referred for additional genetic counseling and may require additional expert consultation for management of extracolonic cancer risks. It is important that individuals diagnosed with a hereditary cancer syndrome be informed that this diagnosis has implications for family members, who may also be at risk for the condition and may benefit from genetic testing.
Practical considerations
Given the difficulty in obtaining a detailed family history while in clinic or in endoscopy, several studies have investigated strategies that may be integrated into practice to identify high-risk patients without substantial burden on providers or patients. Kastrinos and colleagues identified the following three high-yield questions as part of a CRC Risk Assessment Tool that can be used while performing a precolonoscopy assessment: 1) Do you have a first-degree relative with CRC or LS-related cancer diagnosed before age 50?; 2) Have you had CRC or polyps diagnosed prior to age 50?; and 3) Do you have three or more relatives with CRC? The authors found that these three questions alone identified 77% of high-risk individuals.23 In addition, implementation of family history screening instruments using standardized surveys or self-administered risk prediction models at the time of colonoscopy have been shown to improve ascertainment of high-risk patients.24,25 Such strategies may become increasingly easier to implement with integration into patients’ electronic medical records.
Conclusions
Hereditary CRC syndromes are becoming increasingly important to identify, especially in an era where we are seeing rising rates of early-onset CRC. Early identification of high-risk features (Table 2) can lead to timely diagnosis with the goal to implement preventive strategies for screening and/or surveillance, ideally prior to development of cancers.
As gastroenterologists, we have several unique opportunities to identify these individuals and must maintain a high level of suspicion with careful attention when obtaining personal and family history details in clinic and in endoscopy.
Dr. Maratt is assistant professor, Indiana University, Richard L. Roudebush VA Medical Center, Indianapolis. Dr. Stoffel is assistant professor, University of Michigan; director of Cancer Genetic Clinic, Rogel Cancer Center, Ann Arbor. They have no conflicts of interest.
References
1. Pearlman R et al. JAMA Oncol. 2017;3(4):464-71.
2. Stoffel EM et al. Gastroenterology. 2018;154(4):897-905.
3. Kanth P et al. Am J Gastroenterol. 2017;112:1509-25.
4. Brennan B et al. Ther Adv Gastroenterol. 2017;10:361-71.
5. National Comprehensive Cancer Network. Available at: nccn.org.
6. Lynch HT et al. Nat Rev Cancer. 2015;15:181-94.
7. Syngal S et al. Am J Gastroenterol. 2015;110:223-62.
8. Mankaney G et al. Clin Gastroenterol Hepatol. 2020:(in press)
9. Yan HHN et al. Gut 2017;66:1645-56.
10. Ma H et al. Pathology. 2018;50:49-59.
11. Vasen H et al. Gastroenterology 1999;116:1453-6.
12. Umar A et al. J Natl Cancer Inst. 2004;96:261-8.
13. Kastrinos F et al. J Natl Cancer Inst. 2015;108(2):1-9.
14. Chen S et al. JAMA. 2006;296(12):1479-87.
15. Barnetson RA et al. N Engl J Med. 2006;354(26):2751-63.
16. Kastrinos F et al. J Clin Oncol. 2017;35:2165-72.
17. Kastrinos F et al. Fam Cancer. 2018;17:567-67.
18. Cohen SA et al. Annu Rev Genomics Hum Genet. 2019;20:293-307.
19. Matloff J et al. J Natl Compr Canc Netw. 2013;11:1380-5.
20. Ladabaum U et al. Ann Intern Med. 2011;155(2):69-79.
21. Hampel H et al. N Engl J Med. 2005;352(18):1851-60.
22. Yurgelun MB et al. Cancer Prev Res. 2012;5:574-82.
23. Kastrinos F et al. Am J Gastroenterol. 2009;104:1508-18.
24. Luba DG et al. Clin Gastroenterol Hepatol. 2018;16:49-58.
25. Guivatchian T et al. Gastrointest Endosc. 2017;86:684-91.
February 2020 – ICYMI
Gastroenterology
November 2019
Clip closure after resection of large colorectal lesions with substantial risk of bleeding. Albéniz E et al. 2019 Nov;157(5):1213-21.e4. doi. 10.1053/j.gastro.2019.07.037.
Tumor seeding during colonoscopy as a possible cause for metachronous colorectal cancer. Backes Y et al. 2019 Nov;157(5):1222-32.e4. doi. 10.1053/j.gastro.2019.07.062.
December 2019
How to “DEAL” with disruptive physician behavior. Junga Z et al. 2019 Dec;157(6):1469-72. doi. 10.1053/j.gastro.2019.10.021.
Effect of sex, age, and positivity threshold on fecal immunochemical test accuracy: A systematic review and meta-analysis. Selby K et al. 2019 Dec;(6):1494-505. doi. 10.1053/j.gastro.2019.08.023.
January 2020
How to approach burnout among gastroenterology fellows. DeCross AJ 2020 Jan;158(1):32-5. doi. 10.1053/j.gastro.2019.11.032.
Efficacy and safety of peppermint oil in a randomized, double-blind trial of patients with irritable bowel syndrome. Weerts ZZRM et al. 2020 Jan;158(1):123-36. doi. 10.1053/j.gastro.2019.08.026.
Validation of a machine learning model that outperforms clinical risk scoring systems for upper gastrointestinal bleeding. Shung DL et al. 2020 Jan;158(1):160-7. doi. 10.1053/j.gastro.2019.09.009.
Efficacy and safety of early vs elective colonoscopy for acute lower gastrointestinal bleeding. Niikura R et al. 2020 Jan;158(1):168-75.e6. doi. 10.1053/j.gastro.2019.09.010.
Clinical Gastroenterology and Hepatology
November 2019
Medical professional liability in gastroenterology: Understanding the claims landscape and proposed mechanisms for reform. Adams MA and John I. Allen. 2019 Nov;17(12):2392-6.e1. doi. 10.1016/j.cgh.2019.07.002.
Optimizing use of nonalcoholic fatty liver disease fibrosis score, Fibrosis-4 score, and liver stiffness measurement to identify patients with advanced fibrosis. Chan W-K et al. 2019 Nov;17(12):2570-80.e37. doi. 10.1016/j.cgh.2019.03.006.
December 2019
Clinical and molecular features of post-colonoscopy colorectal cancers. Samadder NJ et al. 2019 Dec;17(12):2731-9.e2. doi. 10.1016/j.cgh.2019.02.040.
Neurologic deficits in patients with newly diagnosed celiac disease are frequent and linked with autoimmunity to transglutaminase 6. Hadjivassiliou M et al. 2019 Dec;17(12):2678-86.e2. doi. 10.1016/j.cgh.2019.03.014.
Increased risk of death in first year after liver transplantation among patients with nonalcoholic steatohepatitis vs liver disease of other etiologies. Nagai S et al. 2019 Dec;17(12):2759-68.e5. doi. 10.1016/j.cgh.2019.04.033.
January 2020
Incorporating high value care into gastroenterology fellowship training. Shah BJ and Janice H. Jou. 2020 Jan;18(1):11-3. doi. 10.1016/j.cgh.2019.10.040.
Association of obesity with colonic diverticulosis in women. Peery AF et al. 2020 Jan;18(1):107-14.e1. doi. 10.1016/j.cgh.2019.04.058.
Endocuff vision reduces inspection time without decreasing lesion detection: A clinical randomized trial. Rex DK et al. 2020 Jan;18(1):158-62.e1 doi. 10.1016/j.cgh.2019.01.015.
Gastroenterology
November 2019
Clip closure after resection of large colorectal lesions with substantial risk of bleeding. Albéniz E et al. 2019 Nov;157(5):1213-21.e4. doi. 10.1053/j.gastro.2019.07.037.
Tumor seeding during colonoscopy as a possible cause for metachronous colorectal cancer. Backes Y et al. 2019 Nov;157(5):1222-32.e4. doi. 10.1053/j.gastro.2019.07.062.
December 2019
How to “DEAL” with disruptive physician behavior. Junga Z et al. 2019 Dec;157(6):1469-72. doi. 10.1053/j.gastro.2019.10.021.
Effect of sex, age, and positivity threshold on fecal immunochemical test accuracy: A systematic review and meta-analysis. Selby K et al. 2019 Dec;(6):1494-505. doi. 10.1053/j.gastro.2019.08.023.
January 2020
How to approach burnout among gastroenterology fellows. DeCross AJ 2020 Jan;158(1):32-5. doi. 10.1053/j.gastro.2019.11.032.
Efficacy and safety of peppermint oil in a randomized, double-blind trial of patients with irritable bowel syndrome. Weerts ZZRM et al. 2020 Jan;158(1):123-36. doi. 10.1053/j.gastro.2019.08.026.
Validation of a machine learning model that outperforms clinical risk scoring systems for upper gastrointestinal bleeding. Shung DL et al. 2020 Jan;158(1):160-7. doi. 10.1053/j.gastro.2019.09.009.
Efficacy and safety of early vs elective colonoscopy for acute lower gastrointestinal bleeding. Niikura R et al. 2020 Jan;158(1):168-75.e6. doi. 10.1053/j.gastro.2019.09.010.
Clinical Gastroenterology and Hepatology
November 2019
Medical professional liability in gastroenterology: Understanding the claims landscape and proposed mechanisms for reform. Adams MA and John I. Allen. 2019 Nov;17(12):2392-6.e1. doi. 10.1016/j.cgh.2019.07.002.
Optimizing use of nonalcoholic fatty liver disease fibrosis score, Fibrosis-4 score, and liver stiffness measurement to identify patients with advanced fibrosis. Chan W-K et al. 2019 Nov;17(12):2570-80.e37. doi. 10.1016/j.cgh.2019.03.006.
December 2019
Clinical and molecular features of post-colonoscopy colorectal cancers. Samadder NJ et al. 2019 Dec;17(12):2731-9.e2. doi. 10.1016/j.cgh.2019.02.040.
Neurologic deficits in patients with newly diagnosed celiac disease are frequent and linked with autoimmunity to transglutaminase 6. Hadjivassiliou M et al. 2019 Dec;17(12):2678-86.e2. doi. 10.1016/j.cgh.2019.03.014.
Increased risk of death in first year after liver transplantation among patients with nonalcoholic steatohepatitis vs liver disease of other etiologies. Nagai S et al. 2019 Dec;17(12):2759-68.e5. doi. 10.1016/j.cgh.2019.04.033.
January 2020
Incorporating high value care into gastroenterology fellowship training. Shah BJ and Janice H. Jou. 2020 Jan;18(1):11-3. doi. 10.1016/j.cgh.2019.10.040.
Association of obesity with colonic diverticulosis in women. Peery AF et al. 2020 Jan;18(1):107-14.e1. doi. 10.1016/j.cgh.2019.04.058.
Endocuff vision reduces inspection time without decreasing lesion detection: A clinical randomized trial. Rex DK et al. 2020 Jan;18(1):158-62.e1 doi. 10.1016/j.cgh.2019.01.015.
Gastroenterology
November 2019
Clip closure after resection of large colorectal lesions with substantial risk of bleeding. Albéniz E et al. 2019 Nov;157(5):1213-21.e4. doi. 10.1053/j.gastro.2019.07.037.
Tumor seeding during colonoscopy as a possible cause for metachronous colorectal cancer. Backes Y et al. 2019 Nov;157(5):1222-32.e4. doi. 10.1053/j.gastro.2019.07.062.
December 2019
How to “DEAL” with disruptive physician behavior. Junga Z et al. 2019 Dec;157(6):1469-72. doi. 10.1053/j.gastro.2019.10.021.
Effect of sex, age, and positivity threshold on fecal immunochemical test accuracy: A systematic review and meta-analysis. Selby K et al. 2019 Dec;(6):1494-505. doi. 10.1053/j.gastro.2019.08.023.
January 2020
How to approach burnout among gastroenterology fellows. DeCross AJ 2020 Jan;158(1):32-5. doi. 10.1053/j.gastro.2019.11.032.
Efficacy and safety of peppermint oil in a randomized, double-blind trial of patients with irritable bowel syndrome. Weerts ZZRM et al. 2020 Jan;158(1):123-36. doi. 10.1053/j.gastro.2019.08.026.
Validation of a machine learning model that outperforms clinical risk scoring systems for upper gastrointestinal bleeding. Shung DL et al. 2020 Jan;158(1):160-7. doi. 10.1053/j.gastro.2019.09.009.
Efficacy and safety of early vs elective colonoscopy for acute lower gastrointestinal bleeding. Niikura R et al. 2020 Jan;158(1):168-75.e6. doi. 10.1053/j.gastro.2019.09.010.
Clinical Gastroenterology and Hepatology
November 2019
Medical professional liability in gastroenterology: Understanding the claims landscape and proposed mechanisms for reform. Adams MA and John I. Allen. 2019 Nov;17(12):2392-6.e1. doi. 10.1016/j.cgh.2019.07.002.
Optimizing use of nonalcoholic fatty liver disease fibrosis score, Fibrosis-4 score, and liver stiffness measurement to identify patients with advanced fibrosis. Chan W-K et al. 2019 Nov;17(12):2570-80.e37. doi. 10.1016/j.cgh.2019.03.006.
December 2019
Clinical and molecular features of post-colonoscopy colorectal cancers. Samadder NJ et al. 2019 Dec;17(12):2731-9.e2. doi. 10.1016/j.cgh.2019.02.040.
Neurologic deficits in patients with newly diagnosed celiac disease are frequent and linked with autoimmunity to transglutaminase 6. Hadjivassiliou M et al. 2019 Dec;17(12):2678-86.e2. doi. 10.1016/j.cgh.2019.03.014.
Increased risk of death in first year after liver transplantation among patients with nonalcoholic steatohepatitis vs liver disease of other etiologies. Nagai S et al. 2019 Dec;17(12):2759-68.e5. doi. 10.1016/j.cgh.2019.04.033.
January 2020
Incorporating high value care into gastroenterology fellowship training. Shah BJ and Janice H. Jou. 2020 Jan;18(1):11-3. doi. 10.1016/j.cgh.2019.10.040.
Association of obesity with colonic diverticulosis in women. Peery AF et al. 2020 Jan;18(1):107-14.e1. doi. 10.1016/j.cgh.2019.04.058.
Endocuff vision reduces inspection time without decreasing lesion detection: A clinical randomized trial. Rex DK et al. 2020 Jan;18(1):158-62.e1 doi. 10.1016/j.cgh.2019.01.015.
AGA News
AGA’s flagship research grant goes to ...
The AGA Research Scholar Award, funded by the AGA Research Foundation, is our premier funding mechanism, providing $100,000 per year for 3 years to early-career faculty working toward independent careers in digestive disease research. Our AGA Research Scholar Award recipients have a proven track record of receiving substantial funding and leadership roles in GI following the receipt of their AGA award. Read about our most recent class of RSA recipients – we’re confident they are future leaders in our field. Learn more about the AGA Research Foundation at www.gastro.org/foundation.
Parambir Dulai, MD
University of California, San Diego
Project title: Development and validation of machine learning optimized predictive models for response to different biologic agents in patients with Crohn’s disease and ulcerative colitis.
Dr. Dulai is using his grant to build and refine a decision-support platform to help providers and patients navigate the complex landscape of choosing between available biologics for the treatment of inflammatory bowel disease (IBD).
Amy Hemperly, DO
University of California, San Diego
AGA-Rady Children’s Institute for Genomic Medicine Research Scholar Award in Pediatric Genomics
Project title: Integration of pharmacogenomics and pharmacometabolomics with pharmacokinetics for biomarker discovery in pediatric inflammatory bowel disease
Dr. Hemperly’s research assesses the influence of genetic variations and metabolic and microbial changes on response to anti–tumor necrosis factor (anti-TNF) therapy in pediatric IBD patients. This work will ultimately elucidate factors that improve a patient’s response to therapy.
Rodney Infante, MD, PhD
University of Texas Southwestern Medical Center, Dallas
Project title: Regulation of gastrointestinal cancer cachexia by a tumor-adipose-hypothalamic axis
Dr. Infante and his lab will use the AGA grant to improve our understanding of the mechanism and clinical relevance of cachexia-associated anorexia and tissue wasting in order to identify effective therapeutic targets.
Suraj Patel, MD, PhD
Massachusetts General Hospital, Boston
Project title: Hepatic IRF3 is a transcriptional regulator of steatosis and insulin resistance in NAFLD
Dr. Patel’s research focuses on the role of innate immunity in cellular metabolism and insulin resistance. Specifically, he’s interested in determining how chronic inflammation fuels the genetic and epigenetic changes we see in overnutritional states such as nonalcoholic fatty liver disease (NAFLD).
Jason Pitarresi, PhD
University of Pennsylvania Health System, Philadelphia
AGA-Bern Schwartz Family Fund Research Scholar Award in Pancreatic Cancer
Project title: PTHLH drives epithelial-to-mesenchymal transition and metastasis in pancreatic cancer
With this funding, Dr. Pitarresi will continue on his quest to identify novel drivers of pancreatic cancer development and metastasis with use of genetically engineered mouse models and patient-derived 3D organoids. Dr. Pitarresi is hoping that anti-PTHLH may fill a treatment void and ultimately increase the quality of life in these patients.
Eric Shah, MD, MBA
Dartmouth-Hitchcock Medical Center, Lebanon, N.H.
AGA-Shire Research Scholar Award in Functional GI and Motility Disorders*
Project title: Office-based anorectal testing to diagnose evacuation disorders and predict outcomes with biofeedback therapy: The rectal expulsion device (RED)
Dr. Shah’s research aims to validate a diagnostic test to triage patients with chronic constipation to the most effective treatment in general GI practice. This work will ultimately help patients with motility and functional bowel conditions and their providers reach a confident diagnosis and understand their treatment options.
*Funded by Shire Plc, now part of Takeda
Shailja Shah, MD, MPH
Vanderbilt University Medical Center, Nashville, Tenn.
Project title: Defining host-specific genetic and non-genetic determinants of Helicobacter pylori eradication failure using a large prospective cohort and genomic biobank
Dr. Shah’s research is focused on personalizing the clinical management of H. pylori such that eradication efforts can be optimized and targeted to the less than 1-3% of the estimated 4.4 billion individuals infected with H. pylori who are most at risk for complications, such as gastric cancer, and avoided in those who are unlikely to benefit and may even experience harm from eradication therapy.
Xiao Tan, MD, PhD
Massachusetts General Hospital, Boston
AGA-Takeda Pharmaceuticals Research Scholar Award in Inflammatory Bowel Disease
Project title: Paper-based diagnostics of microbial and host biomarkers to predict responsiveness to IBD therapy
Dr. Tan will develop low-cost, point-of-care microbiome diagnostics to ultimately help physicians’ make diagnoses, monitor, and select treatment for patients with IBD.
Michael Thompson, MD, PhD
Washington University, Saint Louis, Mo.
Project title: Mechanisms of altered bile acid homeostasis and non-alcoholic fatty liver disease in offspring exposed to maternal obesity
Dr. Thompson’s research is focused on how perinatal exposures impact risk for metabolic liver disease in offspring.
My day on Capitol Hill
By Richard K. Sterling, MD, MSC, AGAF
When initially asked to represent AGA on Capitol Hill for the Global Liver Institute (GLI) congressional briefing on liver cancer and the LIVER Act on Oct. 31, I felt both honored and somewhat frightened. Honored that AGA thought enough of me as a hepatologist to represent them and frightened, not because it was Halloween, but because I would be speaking to members of Congress and their staff on issues that may impact policy and thousands if not millions of Americans. Along with myself, were Donna Cryer, founder and CEO of the GLI; John Groopman, PhD, an epidemiologist from Johns Hopkins focusing on liver disease; and two patients with liver disease who had a compelling story to tell. In addition, our briefing and Capitol Hill advocacy day included patients with a history of liver cancer and members of the Hepatitis B Foundation.
In preparation, Andrew Scott from the GLI helped me in identifying the target audience and in developing slides to present to Congress members and their aides that would show those at risk for liver cancer, the increasing incidence of the disease, and the importance of diagnosis at an early stage when curative treatment options are readily available. Travel and hotel logistics were taken care of by Kathleen Teixeira and AGA staff, and it was comforting to see them in the audience.
The briefing took place in the Cannon office building and was standing room only. After a brief introduction by Andrew Scott, I was the first speaker followed by our patient advocates and Dr. Groopman. The LIVER Act (H.R. 3016) is sponsored by Congresswomen Nydia Velazquez (D-NY) and would drive several public health initiatives that would help people of all ages, lifestyles, and ethnic backgrounds to reduce their risk for liver cancer and related illnesses by enhancing the federal government’s prevention, education, and disease surveillance capabilities while empowering local entities to promote treatment and raise awareness. It also supports increased funding to both the Centers for Disease Control and Prevention and the National Institutes of Health for liver disease and liver cancer research.
We had plenty of time for questions from the audience and I saw a lot of nodding from many present acknowledging that they had friends or family who had liver disease. Although our briefing was happening at the same time as the vote on formalizing the impeachment inquiry (you can hear the buzzing going off and the red lights flashing that the vote was about to happen; see Facebook; HepBFoundation video), congressional staff did not leave.
After the meeting, the patient advocates along with members of the GLI, Hepatitis B Foundation, and others met one-on-one with additional members of congress and their staff. While on the train home, I had time to reflect on the day and hoped that our message would be advanced through congress.
AGA, along with our sister societies (American Association for the Study of Liver Diseases and American College of Gastroenterology) are our voice and advocates for advancing legislation through congress. Days like today allow our members to get involved. It is an exciting way to help our congressional representatives take action on what matters most to us: improved patient care, supporting research, promoting education, and reducing the overall burden to accomplish these important goals.
While some say Virginia is for Lovers, I say Virginia is for Livers (#LoveYourLiver). For more on this and the Liver Biliary Council offerings at Digestive Disease Week, follow me on twitter (@RichSterlingMD).
Dr. Sterling is professor of medicine, chief of hepatology, division of gastroenterology, hepatology and nutrition, Virginia Commonwealth University, Richmond; vice-chair, AGA Liver Biliary Section, DDW Council.
New AGA guideline: Management of GIM
AGA released a new clinical practice guideline in Gastroenterology with recommendations for the management of patients with gastric intestinal metaplasia (GIM) detected as part of routine upper endoscopy for reasons including work up of endoscopically identified gastropathy/presumed gastritis, dyspepsia, or exclusion of Helicobacter pylori.
Guideline recommendations
1. In patients with GIM, AGA recommends testing for H. pylori followed by eradication over no testing and eradication. (Strong recommendation: moderate-quality evidence)
2. In patients with GIM, AGA suggests against routine use of endoscopic surveillance. (Conditional recommendation: very-low-quality evidence)
Comment: Patients with GIM at higher risk for gastric cancer who put a high value on potential but uncertain reduction in gastric cancer mortality, and who put a low value on potential risks of surveillance endoscopies, may reasonably elect for surveillance.
Patients with GIM specifically at higher risk of gastric cancer include those with the following:
- Incomplete versus complete GIM.
- Extensive versus limited GIM.
- Family history of gastric cancer.
Patients at overall increased risk for gastric cancer include the following:
- Racial/ethnic minorities.
- Immigrants from high incidence regions.
3. In patients with GIM, AGA suggests against routine repeat short-interval endoscopy with biopsies for the purpose of risk stratification. (Conditional recommendation: very-low-quality evidence)
Comment: Based on shared decision making, patients with GIM and high-risk stigmata, those with concerns about completeness of baseline endoscopy, and/or those who are at overall increased risk for gastric cancer (racial/ethnic minorities, immigrants from regions with high gastric cancer incidence, or individuals with family history of first-degree relative with gastric cancer) may reasonably elect for repeat endoscopy within 1 year for risk stratification.
This guideline will be published in the February print issue of Gastroenterology with additional resources to help you implement in your practice.
A GI society update on MOC reform
Our work was suspended when American Board of Internal Medicine (ABIM) announced the creation of a new longitudinal assessment option for maintenance of certification across all specialties.
GI society leaders are in touch with ABIM. Here’s an update on what we know: The ABIM board of directors committed to evolve its program to provide a longitudinal assessment option for Maintenance of Certification (MOC), offering a self-paced pathway for physicians to acquire and demonstrate ongoing knowledge. The traditional, long-form assessment will also remain an option because some physicians have expressed a preference for a point-in-time exam taken less frequently.
Our next steps include seeking clarity from ABIM including the following:
1. The milestones in the process to create the new pathway.
2. When the new pathway will be available to diplomates.
3. Consideration and integration of the GI societies’ principles in the development of the new pathway for recertification, including these considerations:
- MOC needs to be simpler, less intrusive, and less expensive.
- We continue to support alternatives to the high-stakes, every-10-year recertification exam.
- We do not support single source or time-limited assessments because they do not represent the current realities of medicine in the digital age.
- We support the concept that, for the many diplomates who specialize within certain areas of gastroenterology and hepatology, MOC should not include high-stakes assessments of areas in which the diplomate may not practice.
- We support the principles of lifelong learning, as evidenced by ongoing CME activities, rather than lifelong testing.
4. The role the GI societies, as representatives for thousands of U.S. members who are ABIM diplomates, play in the creation and implementation of the new pathway.
AASLD, ACG, AGA, and American Society for Gastrointestinal Endoscopy want to be fully informed and fully respected partners in an endeavor that touches upon one of the toughest challenges facing our members and the single issue we hear about most often requesting our help.
We will continue to update our members as we learn the answers to these questions from ABIM.
Together, our first priority on the MOC issue remains ensuring that GI diplomates have a pathway for recertification that meets your needs.
Watch your step (therapy) – understanding ‘fail first’
Sometimes known as “fail first,” step therapy is a tool used by insurance companies that requires patients to fail medications before agreeing to cover a health care provider’s initial treatment recommendation.
Often affecting patients with inflammatory bowel disease (IBD), step therapy focuses on the use of insurer-preferred treatments rather than effective, patient-centric therapies. In addition to causing many patient hardships, this protocol allows insurance companies to come between the provider-patient relationship and dictate a patient’s course of treatment.
To help clinicians navigate this challenging landscape, AGA is pleased to offer a new step therapy webpage that details the step therapy protocol and opportunities to advocate for patient protections.
Additional education modules – including videos, podcasts and other resources – are also available for several states that have implemented safe step therapy laws, including Illinois, New York, and Texas.
Visit the Navigating State Step Therapy Laws program page to learn more about the following:
- What is the step therapy protocol?
- How does step therapy impact a health care provider’s ability to provide patient care?
- Which states have implemented step therapy laws?
- How do state step therapy laws provide physician rights and patient protection?
- Tips to share with your patients.
- What are AGA’s advocacy efforts – and how can I help?
Education modules for additional states will be available in early 2020.
AGA’s Navigating State Step Therapy Laws program is funded by an unrestricted educational grant from Takeda and Pfizer.
AGA’s flagship research grant goes to ...
The AGA Research Scholar Award, funded by the AGA Research Foundation, is our premier funding mechanism, providing $100,000 per year for 3 years to early-career faculty working toward independent careers in digestive disease research. Our AGA Research Scholar Award recipients have a proven track record of receiving substantial funding and leadership roles in GI following the receipt of their AGA award. Read about our most recent class of RSA recipients – we’re confident they are future leaders in our field. Learn more about the AGA Research Foundation at www.gastro.org/foundation.
Parambir Dulai, MD
University of California, San Diego
Project title: Development and validation of machine learning optimized predictive models for response to different biologic agents in patients with Crohn’s disease and ulcerative colitis.
Dr. Dulai is using his grant to build and refine a decision-support platform to help providers and patients navigate the complex landscape of choosing between available biologics for the treatment of inflammatory bowel disease (IBD).
Amy Hemperly, DO
University of California, San Diego
AGA-Rady Children’s Institute for Genomic Medicine Research Scholar Award in Pediatric Genomics
Project title: Integration of pharmacogenomics and pharmacometabolomics with pharmacokinetics for biomarker discovery in pediatric inflammatory bowel disease
Dr. Hemperly’s research assesses the influence of genetic variations and metabolic and microbial changes on response to anti–tumor necrosis factor (anti-TNF) therapy in pediatric IBD patients. This work will ultimately elucidate factors that improve a patient’s response to therapy.
Rodney Infante, MD, PhD
University of Texas Southwestern Medical Center, Dallas
Project title: Regulation of gastrointestinal cancer cachexia by a tumor-adipose-hypothalamic axis
Dr. Infante and his lab will use the AGA grant to improve our understanding of the mechanism and clinical relevance of cachexia-associated anorexia and tissue wasting in order to identify effective therapeutic targets.
Suraj Patel, MD, PhD
Massachusetts General Hospital, Boston
Project title: Hepatic IRF3 is a transcriptional regulator of steatosis and insulin resistance in NAFLD
Dr. Patel’s research focuses on the role of innate immunity in cellular metabolism and insulin resistance. Specifically, he’s interested in determining how chronic inflammation fuels the genetic and epigenetic changes we see in overnutritional states such as nonalcoholic fatty liver disease (NAFLD).
Jason Pitarresi, PhD
University of Pennsylvania Health System, Philadelphia
AGA-Bern Schwartz Family Fund Research Scholar Award in Pancreatic Cancer
Project title: PTHLH drives epithelial-to-mesenchymal transition and metastasis in pancreatic cancer
With this funding, Dr. Pitarresi will continue on his quest to identify novel drivers of pancreatic cancer development and metastasis with use of genetically engineered mouse models and patient-derived 3D organoids. Dr. Pitarresi is hoping that anti-PTHLH may fill a treatment void and ultimately increase the quality of life in these patients.
Eric Shah, MD, MBA
Dartmouth-Hitchcock Medical Center, Lebanon, N.H.
AGA-Shire Research Scholar Award in Functional GI and Motility Disorders*
Project title: Office-based anorectal testing to diagnose evacuation disorders and predict outcomes with biofeedback therapy: The rectal expulsion device (RED)
Dr. Shah’s research aims to validate a diagnostic test to triage patients with chronic constipation to the most effective treatment in general GI practice. This work will ultimately help patients with motility and functional bowel conditions and their providers reach a confident diagnosis and understand their treatment options.
*Funded by Shire Plc, now part of Takeda
Shailja Shah, MD, MPH
Vanderbilt University Medical Center, Nashville, Tenn.
Project title: Defining host-specific genetic and non-genetic determinants of Helicobacter pylori eradication failure using a large prospective cohort and genomic biobank
Dr. Shah’s research is focused on personalizing the clinical management of H. pylori such that eradication efforts can be optimized and targeted to the less than 1-3% of the estimated 4.4 billion individuals infected with H. pylori who are most at risk for complications, such as gastric cancer, and avoided in those who are unlikely to benefit and may even experience harm from eradication therapy.
Xiao Tan, MD, PhD
Massachusetts General Hospital, Boston
AGA-Takeda Pharmaceuticals Research Scholar Award in Inflammatory Bowel Disease
Project title: Paper-based diagnostics of microbial and host biomarkers to predict responsiveness to IBD therapy
Dr. Tan will develop low-cost, point-of-care microbiome diagnostics to ultimately help physicians’ make diagnoses, monitor, and select treatment for patients with IBD.
Michael Thompson, MD, PhD
Washington University, Saint Louis, Mo.
Project title: Mechanisms of altered bile acid homeostasis and non-alcoholic fatty liver disease in offspring exposed to maternal obesity
Dr. Thompson’s research is focused on how perinatal exposures impact risk for metabolic liver disease in offspring.
My day on Capitol Hill
By Richard K. Sterling, MD, MSC, AGAF
When initially asked to represent AGA on Capitol Hill for the Global Liver Institute (GLI) congressional briefing on liver cancer and the LIVER Act on Oct. 31, I felt both honored and somewhat frightened. Honored that AGA thought enough of me as a hepatologist to represent them and frightened, not because it was Halloween, but because I would be speaking to members of Congress and their staff on issues that may impact policy and thousands if not millions of Americans. Along with myself, were Donna Cryer, founder and CEO of the GLI; John Groopman, PhD, an epidemiologist from Johns Hopkins focusing on liver disease; and two patients with liver disease who had a compelling story to tell. In addition, our briefing and Capitol Hill advocacy day included patients with a history of liver cancer and members of the Hepatitis B Foundation.
In preparation, Andrew Scott from the GLI helped me in identifying the target audience and in developing slides to present to Congress members and their aides that would show those at risk for liver cancer, the increasing incidence of the disease, and the importance of diagnosis at an early stage when curative treatment options are readily available. Travel and hotel logistics were taken care of by Kathleen Teixeira and AGA staff, and it was comforting to see them in the audience.
The briefing took place in the Cannon office building and was standing room only. After a brief introduction by Andrew Scott, I was the first speaker followed by our patient advocates and Dr. Groopman. The LIVER Act (H.R. 3016) is sponsored by Congresswomen Nydia Velazquez (D-NY) and would drive several public health initiatives that would help people of all ages, lifestyles, and ethnic backgrounds to reduce their risk for liver cancer and related illnesses by enhancing the federal government’s prevention, education, and disease surveillance capabilities while empowering local entities to promote treatment and raise awareness. It also supports increased funding to both the Centers for Disease Control and Prevention and the National Institutes of Health for liver disease and liver cancer research.
We had plenty of time for questions from the audience and I saw a lot of nodding from many present acknowledging that they had friends or family who had liver disease. Although our briefing was happening at the same time as the vote on formalizing the impeachment inquiry (you can hear the buzzing going off and the red lights flashing that the vote was about to happen; see Facebook; HepBFoundation video), congressional staff did not leave.
After the meeting, the patient advocates along with members of the GLI, Hepatitis B Foundation, and others met one-on-one with additional members of congress and their staff. While on the train home, I had time to reflect on the day and hoped that our message would be advanced through congress.
AGA, along with our sister societies (American Association for the Study of Liver Diseases and American College of Gastroenterology) are our voice and advocates for advancing legislation through congress. Days like today allow our members to get involved. It is an exciting way to help our congressional representatives take action on what matters most to us: improved patient care, supporting research, promoting education, and reducing the overall burden to accomplish these important goals.
While some say Virginia is for Lovers, I say Virginia is for Livers (#LoveYourLiver). For more on this and the Liver Biliary Council offerings at Digestive Disease Week, follow me on twitter (@RichSterlingMD).
Dr. Sterling is professor of medicine, chief of hepatology, division of gastroenterology, hepatology and nutrition, Virginia Commonwealth University, Richmond; vice-chair, AGA Liver Biliary Section, DDW Council.
New AGA guideline: Management of GIM
AGA released a new clinical practice guideline in Gastroenterology with recommendations for the management of patients with gastric intestinal metaplasia (GIM) detected as part of routine upper endoscopy for reasons including work up of endoscopically identified gastropathy/presumed gastritis, dyspepsia, or exclusion of Helicobacter pylori.
Guideline recommendations
1. In patients with GIM, AGA recommends testing for H. pylori followed by eradication over no testing and eradication. (Strong recommendation: moderate-quality evidence)
2. In patients with GIM, AGA suggests against routine use of endoscopic surveillance. (Conditional recommendation: very-low-quality evidence)
Comment: Patients with GIM at higher risk for gastric cancer who put a high value on potential but uncertain reduction in gastric cancer mortality, and who put a low value on potential risks of surveillance endoscopies, may reasonably elect for surveillance.
Patients with GIM specifically at higher risk of gastric cancer include those with the following:
- Incomplete versus complete GIM.
- Extensive versus limited GIM.
- Family history of gastric cancer.
Patients at overall increased risk for gastric cancer include the following:
- Racial/ethnic minorities.
- Immigrants from high incidence regions.
3. In patients with GIM, AGA suggests against routine repeat short-interval endoscopy with biopsies for the purpose of risk stratification. (Conditional recommendation: very-low-quality evidence)
Comment: Based on shared decision making, patients with GIM and high-risk stigmata, those with concerns about completeness of baseline endoscopy, and/or those who are at overall increased risk for gastric cancer (racial/ethnic minorities, immigrants from regions with high gastric cancer incidence, or individuals with family history of first-degree relative with gastric cancer) may reasonably elect for repeat endoscopy within 1 year for risk stratification.
This guideline will be published in the February print issue of Gastroenterology with additional resources to help you implement in your practice.
A GI society update on MOC reform
Our work was suspended when American Board of Internal Medicine (ABIM) announced the creation of a new longitudinal assessment option for maintenance of certification across all specialties.
GI society leaders are in touch with ABIM. Here’s an update on what we know: The ABIM board of directors committed to evolve its program to provide a longitudinal assessment option for Maintenance of Certification (MOC), offering a self-paced pathway for physicians to acquire and demonstrate ongoing knowledge. The traditional, long-form assessment will also remain an option because some physicians have expressed a preference for a point-in-time exam taken less frequently.
Our next steps include seeking clarity from ABIM including the following:
1. The milestones in the process to create the new pathway.
2. When the new pathway will be available to diplomates.
3. Consideration and integration of the GI societies’ principles in the development of the new pathway for recertification, including these considerations:
- MOC needs to be simpler, less intrusive, and less expensive.
- We continue to support alternatives to the high-stakes, every-10-year recertification exam.
- We do not support single source or time-limited assessments because they do not represent the current realities of medicine in the digital age.
- We support the concept that, for the many diplomates who specialize within certain areas of gastroenterology and hepatology, MOC should not include high-stakes assessments of areas in which the diplomate may not practice.
- We support the principles of lifelong learning, as evidenced by ongoing CME activities, rather than lifelong testing.
4. The role the GI societies, as representatives for thousands of U.S. members who are ABIM diplomates, play in the creation and implementation of the new pathway.
AASLD, ACG, AGA, and American Society for Gastrointestinal Endoscopy want to be fully informed and fully respected partners in an endeavor that touches upon one of the toughest challenges facing our members and the single issue we hear about most often requesting our help.
We will continue to update our members as we learn the answers to these questions from ABIM.
Together, our first priority on the MOC issue remains ensuring that GI diplomates have a pathway for recertification that meets your needs.
Watch your step (therapy) – understanding ‘fail first’
Sometimes known as “fail first,” step therapy is a tool used by insurance companies that requires patients to fail medications before agreeing to cover a health care provider’s initial treatment recommendation.
Often affecting patients with inflammatory bowel disease (IBD), step therapy focuses on the use of insurer-preferred treatments rather than effective, patient-centric therapies. In addition to causing many patient hardships, this protocol allows insurance companies to come between the provider-patient relationship and dictate a patient’s course of treatment.
To help clinicians navigate this challenging landscape, AGA is pleased to offer a new step therapy webpage that details the step therapy protocol and opportunities to advocate for patient protections.
Additional education modules – including videos, podcasts and other resources – are also available for several states that have implemented safe step therapy laws, including Illinois, New York, and Texas.
Visit the Navigating State Step Therapy Laws program page to learn more about the following:
- What is the step therapy protocol?
- How does step therapy impact a health care provider’s ability to provide patient care?
- Which states have implemented step therapy laws?
- How do state step therapy laws provide physician rights and patient protection?
- Tips to share with your patients.
- What are AGA’s advocacy efforts – and how can I help?
Education modules for additional states will be available in early 2020.
AGA’s Navigating State Step Therapy Laws program is funded by an unrestricted educational grant from Takeda and Pfizer.
AGA’s flagship research grant goes to ...
The AGA Research Scholar Award, funded by the AGA Research Foundation, is our premier funding mechanism, providing $100,000 per year for 3 years to early-career faculty working toward independent careers in digestive disease research. Our AGA Research Scholar Award recipients have a proven track record of receiving substantial funding and leadership roles in GI following the receipt of their AGA award. Read about our most recent class of RSA recipients – we’re confident they are future leaders in our field. Learn more about the AGA Research Foundation at www.gastro.org/foundation.
Parambir Dulai, MD
University of California, San Diego
Project title: Development and validation of machine learning optimized predictive models for response to different biologic agents in patients with Crohn’s disease and ulcerative colitis.
Dr. Dulai is using his grant to build and refine a decision-support platform to help providers and patients navigate the complex landscape of choosing between available biologics for the treatment of inflammatory bowel disease (IBD).
Amy Hemperly, DO
University of California, San Diego
AGA-Rady Children’s Institute for Genomic Medicine Research Scholar Award in Pediatric Genomics
Project title: Integration of pharmacogenomics and pharmacometabolomics with pharmacokinetics for biomarker discovery in pediatric inflammatory bowel disease
Dr. Hemperly’s research assesses the influence of genetic variations and metabolic and microbial changes on response to anti–tumor necrosis factor (anti-TNF) therapy in pediatric IBD patients. This work will ultimately elucidate factors that improve a patient’s response to therapy.
Rodney Infante, MD, PhD
University of Texas Southwestern Medical Center, Dallas
Project title: Regulation of gastrointestinal cancer cachexia by a tumor-adipose-hypothalamic axis
Dr. Infante and his lab will use the AGA grant to improve our understanding of the mechanism and clinical relevance of cachexia-associated anorexia and tissue wasting in order to identify effective therapeutic targets.
Suraj Patel, MD, PhD
Massachusetts General Hospital, Boston
Project title: Hepatic IRF3 is a transcriptional regulator of steatosis and insulin resistance in NAFLD
Dr. Patel’s research focuses on the role of innate immunity in cellular metabolism and insulin resistance. Specifically, he’s interested in determining how chronic inflammation fuels the genetic and epigenetic changes we see in overnutritional states such as nonalcoholic fatty liver disease (NAFLD).
Jason Pitarresi, PhD
University of Pennsylvania Health System, Philadelphia
AGA-Bern Schwartz Family Fund Research Scholar Award in Pancreatic Cancer
Project title: PTHLH drives epithelial-to-mesenchymal transition and metastasis in pancreatic cancer
With this funding, Dr. Pitarresi will continue on his quest to identify novel drivers of pancreatic cancer development and metastasis with use of genetically engineered mouse models and patient-derived 3D organoids. Dr. Pitarresi is hoping that anti-PTHLH may fill a treatment void and ultimately increase the quality of life in these patients.
Eric Shah, MD, MBA
Dartmouth-Hitchcock Medical Center, Lebanon, N.H.
AGA-Shire Research Scholar Award in Functional GI and Motility Disorders*
Project title: Office-based anorectal testing to diagnose evacuation disorders and predict outcomes with biofeedback therapy: The rectal expulsion device (RED)
Dr. Shah’s research aims to validate a diagnostic test to triage patients with chronic constipation to the most effective treatment in general GI practice. This work will ultimately help patients with motility and functional bowel conditions and their providers reach a confident diagnosis and understand their treatment options.
*Funded by Shire Plc, now part of Takeda
Shailja Shah, MD, MPH
Vanderbilt University Medical Center, Nashville, Tenn.
Project title: Defining host-specific genetic and non-genetic determinants of Helicobacter pylori eradication failure using a large prospective cohort and genomic biobank
Dr. Shah’s research is focused on personalizing the clinical management of H. pylori such that eradication efforts can be optimized and targeted to the less than 1-3% of the estimated 4.4 billion individuals infected with H. pylori who are most at risk for complications, such as gastric cancer, and avoided in those who are unlikely to benefit and may even experience harm from eradication therapy.
Xiao Tan, MD, PhD
Massachusetts General Hospital, Boston
AGA-Takeda Pharmaceuticals Research Scholar Award in Inflammatory Bowel Disease
Project title: Paper-based diagnostics of microbial and host biomarkers to predict responsiveness to IBD therapy
Dr. Tan will develop low-cost, point-of-care microbiome diagnostics to ultimately help physicians’ make diagnoses, monitor, and select treatment for patients with IBD.
Michael Thompson, MD, PhD
Washington University, Saint Louis, Mo.
Project title: Mechanisms of altered bile acid homeostasis and non-alcoholic fatty liver disease in offspring exposed to maternal obesity
Dr. Thompson’s research is focused on how perinatal exposures impact risk for metabolic liver disease in offspring.
My day on Capitol Hill
By Richard K. Sterling, MD, MSC, AGAF
When initially asked to represent AGA on Capitol Hill for the Global Liver Institute (GLI) congressional briefing on liver cancer and the LIVER Act on Oct. 31, I felt both honored and somewhat frightened. Honored that AGA thought enough of me as a hepatologist to represent them and frightened, not because it was Halloween, but because I would be speaking to members of Congress and their staff on issues that may impact policy and thousands if not millions of Americans. Along with myself, were Donna Cryer, founder and CEO of the GLI; John Groopman, PhD, an epidemiologist from Johns Hopkins focusing on liver disease; and two patients with liver disease who had a compelling story to tell. In addition, our briefing and Capitol Hill advocacy day included patients with a history of liver cancer and members of the Hepatitis B Foundation.
In preparation, Andrew Scott from the GLI helped me in identifying the target audience and in developing slides to present to Congress members and their aides that would show those at risk for liver cancer, the increasing incidence of the disease, and the importance of diagnosis at an early stage when curative treatment options are readily available. Travel and hotel logistics were taken care of by Kathleen Teixeira and AGA staff, and it was comforting to see them in the audience.
The briefing took place in the Cannon office building and was standing room only. After a brief introduction by Andrew Scott, I was the first speaker followed by our patient advocates and Dr. Groopman. The LIVER Act (H.R. 3016) is sponsored by Congresswomen Nydia Velazquez (D-NY) and would drive several public health initiatives that would help people of all ages, lifestyles, and ethnic backgrounds to reduce their risk for liver cancer and related illnesses by enhancing the federal government’s prevention, education, and disease surveillance capabilities while empowering local entities to promote treatment and raise awareness. It also supports increased funding to both the Centers for Disease Control and Prevention and the National Institutes of Health for liver disease and liver cancer research.
We had plenty of time for questions from the audience and I saw a lot of nodding from many present acknowledging that they had friends or family who had liver disease. Although our briefing was happening at the same time as the vote on formalizing the impeachment inquiry (you can hear the buzzing going off and the red lights flashing that the vote was about to happen; see Facebook; HepBFoundation video), congressional staff did not leave.
After the meeting, the patient advocates along with members of the GLI, Hepatitis B Foundation, and others met one-on-one with additional members of congress and their staff. While on the train home, I had time to reflect on the day and hoped that our message would be advanced through congress.
AGA, along with our sister societies (American Association for the Study of Liver Diseases and American College of Gastroenterology) are our voice and advocates for advancing legislation through congress. Days like today allow our members to get involved. It is an exciting way to help our congressional representatives take action on what matters most to us: improved patient care, supporting research, promoting education, and reducing the overall burden to accomplish these important goals.
While some say Virginia is for Lovers, I say Virginia is for Livers (#LoveYourLiver). For more on this and the Liver Biliary Council offerings at Digestive Disease Week, follow me on twitter (@RichSterlingMD).
Dr. Sterling is professor of medicine, chief of hepatology, division of gastroenterology, hepatology and nutrition, Virginia Commonwealth University, Richmond; vice-chair, AGA Liver Biliary Section, DDW Council.
New AGA guideline: Management of GIM
AGA released a new clinical practice guideline in Gastroenterology with recommendations for the management of patients with gastric intestinal metaplasia (GIM) detected as part of routine upper endoscopy for reasons including work up of endoscopically identified gastropathy/presumed gastritis, dyspepsia, or exclusion of Helicobacter pylori.
Guideline recommendations
1. In patients with GIM, AGA recommends testing for H. pylori followed by eradication over no testing and eradication. (Strong recommendation: moderate-quality evidence)
2. In patients with GIM, AGA suggests against routine use of endoscopic surveillance. (Conditional recommendation: very-low-quality evidence)
Comment: Patients with GIM at higher risk for gastric cancer who put a high value on potential but uncertain reduction in gastric cancer mortality, and who put a low value on potential risks of surveillance endoscopies, may reasonably elect for surveillance.
Patients with GIM specifically at higher risk of gastric cancer include those with the following:
- Incomplete versus complete GIM.
- Extensive versus limited GIM.
- Family history of gastric cancer.
Patients at overall increased risk for gastric cancer include the following:
- Racial/ethnic minorities.
- Immigrants from high incidence regions.
3. In patients with GIM, AGA suggests against routine repeat short-interval endoscopy with biopsies for the purpose of risk stratification. (Conditional recommendation: very-low-quality evidence)
Comment: Based on shared decision making, patients with GIM and high-risk stigmata, those with concerns about completeness of baseline endoscopy, and/or those who are at overall increased risk for gastric cancer (racial/ethnic minorities, immigrants from regions with high gastric cancer incidence, or individuals with family history of first-degree relative with gastric cancer) may reasonably elect for repeat endoscopy within 1 year for risk stratification.
This guideline will be published in the February print issue of Gastroenterology with additional resources to help you implement in your practice.
A GI society update on MOC reform
Our work was suspended when American Board of Internal Medicine (ABIM) announced the creation of a new longitudinal assessment option for maintenance of certification across all specialties.
GI society leaders are in touch with ABIM. Here’s an update on what we know: The ABIM board of directors committed to evolve its program to provide a longitudinal assessment option for Maintenance of Certification (MOC), offering a self-paced pathway for physicians to acquire and demonstrate ongoing knowledge. The traditional, long-form assessment will also remain an option because some physicians have expressed a preference for a point-in-time exam taken less frequently.
Our next steps include seeking clarity from ABIM including the following:
1. The milestones in the process to create the new pathway.
2. When the new pathway will be available to diplomates.
3. Consideration and integration of the GI societies’ principles in the development of the new pathway for recertification, including these considerations:
- MOC needs to be simpler, less intrusive, and less expensive.
- We continue to support alternatives to the high-stakes, every-10-year recertification exam.
- We do not support single source or time-limited assessments because they do not represent the current realities of medicine in the digital age.
- We support the concept that, for the many diplomates who specialize within certain areas of gastroenterology and hepatology, MOC should not include high-stakes assessments of areas in which the diplomate may not practice.
- We support the principles of lifelong learning, as evidenced by ongoing CME activities, rather than lifelong testing.
4. The role the GI societies, as representatives for thousands of U.S. members who are ABIM diplomates, play in the creation and implementation of the new pathway.
AASLD, ACG, AGA, and American Society for Gastrointestinal Endoscopy want to be fully informed and fully respected partners in an endeavor that touches upon one of the toughest challenges facing our members and the single issue we hear about most often requesting our help.
We will continue to update our members as we learn the answers to these questions from ABIM.
Together, our first priority on the MOC issue remains ensuring that GI diplomates have a pathway for recertification that meets your needs.
Watch your step (therapy) – understanding ‘fail first’
Sometimes known as “fail first,” step therapy is a tool used by insurance companies that requires patients to fail medications before agreeing to cover a health care provider’s initial treatment recommendation.
Often affecting patients with inflammatory bowel disease (IBD), step therapy focuses on the use of insurer-preferred treatments rather than effective, patient-centric therapies. In addition to causing many patient hardships, this protocol allows insurance companies to come between the provider-patient relationship and dictate a patient’s course of treatment.
To help clinicians navigate this challenging landscape, AGA is pleased to offer a new step therapy webpage that details the step therapy protocol and opportunities to advocate for patient protections.
Additional education modules – including videos, podcasts and other resources – are also available for several states that have implemented safe step therapy laws, including Illinois, New York, and Texas.
Visit the Navigating State Step Therapy Laws program page to learn more about the following:
- What is the step therapy protocol?
- How does step therapy impact a health care provider’s ability to provide patient care?
- Which states have implemented step therapy laws?
- How do state step therapy laws provide physician rights and patient protection?
- Tips to share with your patients.
- What are AGA’s advocacy efforts – and how can I help?
Education modules for additional states will be available in early 2020.
AGA’s Navigating State Step Therapy Laws program is funded by an unrestricted educational grant from Takeda and Pfizer.
Calendar
For more information about upcoming events and award deadlines, please visit http://agau.gastro.org and http://www.gastro.org/research-funding.
UPCOMING EVENTS
Feb 20; Mar. 24, 2020
Coding and Reimbursement Solutions by McVey Associates, Inc.
Improve the efficiency and performance of your practice by staying current on the latest reimbursement, coding, and compliance changes.
Knoxville, Tenn. (2/20); Birmingham, Ala. (3/24)
Mar. 7-8, 2020
Gut Microbiota for Health World Summit 2020
The focus of the 2020 program will include dietary and nondietary factors shaping the gut microbiome, the microbiome as orchestrator for the immune system, and drug interactions and the microbiome. The summit is sponsored by the European Society for Neurogastroenterology & Motility and the American Gastroenterological Association.
Madrid, Spain
Mar. 10-11; 11-12; 25-26; Apr. 15-16; May 13-14, 2020
Two-Day, In-Depth Coding Seminar by McVey Associates, Inc.
Become a certified GI coder with a two-day, in-depth training course provided by McVey Associates, Inc.
Orlando, Fla. (3/10-11); Novi, Mich. (3/11-12); Charlotte, N.C. (3/25-26); Columbus, Ohio (4/15-16); Chicago, Ill. (5/13-14)
Mar. 21; Apr. 15, 2020
Regional Practice Skills Workshop
AGA Regional Practice Skills workshops are free in-person, half-day courses that provide trainees and early-career gastroenterologists with practical insights about GI business issues that will shape their professional development. Faculty will discuss employment models, reimbursement strategies, health economics and policy, billing issues, contract negotiations, and other subjects to help attendees navigate the rapidly shifting GI business environment. All workshops are open to both members and nonmembers.
Ann Arbor, Mich. (3/21); Philadelphia, Penn. (4/15)
May 2-5, 2020
Digestive Disease Week® (DDW)
Digestive Disease Week® (DDW) is the world’s leading educational forum for academicians, clinicians, researchers, students, and trainees working in gastroenterology, hepatology, GI endoscopy, gastrointestinal surgery, and related fields. Whether you work in patient care, research, education, or administration, the DDW program offers something for you.
Chicago, Ill.
May 2-3, 2020
2020 AGA Postgraduate Course
The AGA Postgraduate Course is a comprehensive 1.5-day program highlighting groundbreaking advances in the delivery of high-quality, patient-centered GI care. Offering general and breakout sessions, learning lunches, and case-based and panel discussions, attendees will gain a deeper understanding of how to diagnose and treat a variety of disease states and digestive disorders.
June 3-6, 2020
2020 AGA Tech Summit
Visit https://techsummit.gastro.org/ for more details.
San Francisco, Calif.
Aug. 14-15, 2020
James W. Freston Single-Topic Conference: Gastrointestinal Organoids and Engineered Organ Systems
The 2020 Freston Conference will focus on GI organoids and engineered organ systems.
Chicago, Ill.
Aug. 14-16, 2020
2020 Principles of GI for the NP and PA
Principles of GI is designed by leading advanced practice providers, GI experts, and physicians to mirror real-life settings for nurse practitioners and physician assistants that lead to GI clinical success.
Denver, Colo.
AWARDS DEADLINES
AGA Fellow Abstract Award
This $500 travel award supports recipients who are MD, PhD, or equivalent fellows giving abstract-based oral or poster presentations at Digestive Disease Week® (DDW). The top-scoring abstract will be designated the Fellow Abstract of the Year and receive a $1,000 award.
Application Deadline: Feb. 26, 2020
AGA Student Abstract Award
This $500 travel award supports recipients who are graduate students, medical students, or medical residents (residents up to postgraduate year three) giving abstract-based oral or poster presentations at Digestive Disease Week® (DDW).
Application Deadline: Feb. 26, 2020
AGA-Moti L. & Kamla Rustgi International Travel Awards
This $750 travel award supports recipients who are young (i.e., 35 years of age or younger at the time of DDW) basic, translational, or clinical investigators residing outside North America to support travel and related expenses to attend Digestive Disease Week® (DDW).
Application Deadline: Feb. 26, 2020
For more information about upcoming events and award deadlines, please visit http://agau.gastro.org and http://www.gastro.org/research-funding.
UPCOMING EVENTS
Feb 20; Mar. 24, 2020
Coding and Reimbursement Solutions by McVey Associates, Inc.
Improve the efficiency and performance of your practice by staying current on the latest reimbursement, coding, and compliance changes.
Knoxville, Tenn. (2/20); Birmingham, Ala. (3/24)
Mar. 7-8, 2020
Gut Microbiota for Health World Summit 2020
The focus of the 2020 program will include dietary and nondietary factors shaping the gut microbiome, the microbiome as orchestrator for the immune system, and drug interactions and the microbiome. The summit is sponsored by the European Society for Neurogastroenterology & Motility and the American Gastroenterological Association.
Madrid, Spain
Mar. 10-11; 11-12; 25-26; Apr. 15-16; May 13-14, 2020
Two-Day, In-Depth Coding Seminar by McVey Associates, Inc.
Become a certified GI coder with a two-day, in-depth training course provided by McVey Associates, Inc.
Orlando, Fla. (3/10-11); Novi, Mich. (3/11-12); Charlotte, N.C. (3/25-26); Columbus, Ohio (4/15-16); Chicago, Ill. (5/13-14)
Mar. 21; Apr. 15, 2020
Regional Practice Skills Workshop
AGA Regional Practice Skills workshops are free in-person, half-day courses that provide trainees and early-career gastroenterologists with practical insights about GI business issues that will shape their professional development. Faculty will discuss employment models, reimbursement strategies, health economics and policy, billing issues, contract negotiations, and other subjects to help attendees navigate the rapidly shifting GI business environment. All workshops are open to both members and nonmembers.
Ann Arbor, Mich. (3/21); Philadelphia, Penn. (4/15)
May 2-5, 2020
Digestive Disease Week® (DDW)
Digestive Disease Week® (DDW) is the world’s leading educational forum for academicians, clinicians, researchers, students, and trainees working in gastroenterology, hepatology, GI endoscopy, gastrointestinal surgery, and related fields. Whether you work in patient care, research, education, or administration, the DDW program offers something for you.
Chicago, Ill.
May 2-3, 2020
2020 AGA Postgraduate Course
The AGA Postgraduate Course is a comprehensive 1.5-day program highlighting groundbreaking advances in the delivery of high-quality, patient-centered GI care. Offering general and breakout sessions, learning lunches, and case-based and panel discussions, attendees will gain a deeper understanding of how to diagnose and treat a variety of disease states and digestive disorders.
June 3-6, 2020
2020 AGA Tech Summit
Visit https://techsummit.gastro.org/ for more details.
San Francisco, Calif.
Aug. 14-15, 2020
James W. Freston Single-Topic Conference: Gastrointestinal Organoids and Engineered Organ Systems
The 2020 Freston Conference will focus on GI organoids and engineered organ systems.
Chicago, Ill.
Aug. 14-16, 2020
2020 Principles of GI for the NP and PA
Principles of GI is designed by leading advanced practice providers, GI experts, and physicians to mirror real-life settings for nurse practitioners and physician assistants that lead to GI clinical success.
Denver, Colo.
AWARDS DEADLINES
AGA Fellow Abstract Award
This $500 travel award supports recipients who are MD, PhD, or equivalent fellows giving abstract-based oral or poster presentations at Digestive Disease Week® (DDW). The top-scoring abstract will be designated the Fellow Abstract of the Year and receive a $1,000 award.
Application Deadline: Feb. 26, 2020
AGA Student Abstract Award
This $500 travel award supports recipients who are graduate students, medical students, or medical residents (residents up to postgraduate year three) giving abstract-based oral or poster presentations at Digestive Disease Week® (DDW).
Application Deadline: Feb. 26, 2020
AGA-Moti L. & Kamla Rustgi International Travel Awards
This $750 travel award supports recipients who are young (i.e., 35 years of age or younger at the time of DDW) basic, translational, or clinical investigators residing outside North America to support travel and related expenses to attend Digestive Disease Week® (DDW).
Application Deadline: Feb. 26, 2020
For more information about upcoming events and award deadlines, please visit http://agau.gastro.org and http://www.gastro.org/research-funding.
UPCOMING EVENTS
Feb 20; Mar. 24, 2020
Coding and Reimbursement Solutions by McVey Associates, Inc.
Improve the efficiency and performance of your practice by staying current on the latest reimbursement, coding, and compliance changes.
Knoxville, Tenn. (2/20); Birmingham, Ala. (3/24)
Mar. 7-8, 2020
Gut Microbiota for Health World Summit 2020
The focus of the 2020 program will include dietary and nondietary factors shaping the gut microbiome, the microbiome as orchestrator for the immune system, and drug interactions and the microbiome. The summit is sponsored by the European Society for Neurogastroenterology & Motility and the American Gastroenterological Association.
Madrid, Spain
Mar. 10-11; 11-12; 25-26; Apr. 15-16; May 13-14, 2020
Two-Day, In-Depth Coding Seminar by McVey Associates, Inc.
Become a certified GI coder with a two-day, in-depth training course provided by McVey Associates, Inc.
Orlando, Fla. (3/10-11); Novi, Mich. (3/11-12); Charlotte, N.C. (3/25-26); Columbus, Ohio (4/15-16); Chicago, Ill. (5/13-14)
Mar. 21; Apr. 15, 2020
Regional Practice Skills Workshop
AGA Regional Practice Skills workshops are free in-person, half-day courses that provide trainees and early-career gastroenterologists with practical insights about GI business issues that will shape their professional development. Faculty will discuss employment models, reimbursement strategies, health economics and policy, billing issues, contract negotiations, and other subjects to help attendees navigate the rapidly shifting GI business environment. All workshops are open to both members and nonmembers.
Ann Arbor, Mich. (3/21); Philadelphia, Penn. (4/15)
May 2-5, 2020
Digestive Disease Week® (DDW)
Digestive Disease Week® (DDW) is the world’s leading educational forum for academicians, clinicians, researchers, students, and trainees working in gastroenterology, hepatology, GI endoscopy, gastrointestinal surgery, and related fields. Whether you work in patient care, research, education, or administration, the DDW program offers something for you.
Chicago, Ill.
May 2-3, 2020
2020 AGA Postgraduate Course
The AGA Postgraduate Course is a comprehensive 1.5-day program highlighting groundbreaking advances in the delivery of high-quality, patient-centered GI care. Offering general and breakout sessions, learning lunches, and case-based and panel discussions, attendees will gain a deeper understanding of how to diagnose and treat a variety of disease states and digestive disorders.
June 3-6, 2020
2020 AGA Tech Summit
Visit https://techsummit.gastro.org/ for more details.
San Francisco, Calif.
Aug. 14-15, 2020
James W. Freston Single-Topic Conference: Gastrointestinal Organoids and Engineered Organ Systems
The 2020 Freston Conference will focus on GI organoids and engineered organ systems.
Chicago, Ill.
Aug. 14-16, 2020
2020 Principles of GI for the NP and PA
Principles of GI is designed by leading advanced practice providers, GI experts, and physicians to mirror real-life settings for nurse practitioners and physician assistants that lead to GI clinical success.
Denver, Colo.
AWARDS DEADLINES
AGA Fellow Abstract Award
This $500 travel award supports recipients who are MD, PhD, or equivalent fellows giving abstract-based oral or poster presentations at Digestive Disease Week® (DDW). The top-scoring abstract will be designated the Fellow Abstract of the Year and receive a $1,000 award.
Application Deadline: Feb. 26, 2020
AGA Student Abstract Award
This $500 travel award supports recipients who are graduate students, medical students, or medical residents (residents up to postgraduate year three) giving abstract-based oral or poster presentations at Digestive Disease Week® (DDW).
Application Deadline: Feb. 26, 2020
AGA-Moti L. & Kamla Rustgi International Travel Awards
This $750 travel award supports recipients who are young (i.e., 35 years of age or younger at the time of DDW) basic, translational, or clinical investigators residing outside North America to support travel and related expenses to attend Digestive Disease Week® (DDW).
Application Deadline: Feb. 26, 2020
Endoscopy in a do-not-resuscitate patient: Practical and ethical considerations
Editor’s Note: I am very excited to introduce a section to The New Gastroenterologist that will address topics in clinical medical ethics we frequently face as gastroenterologists. There are several inherent ethical issues in gastroenterology that are not often explicitly discussed, such as periprocedural code status, informed consent, transplantation, performance of endoscopy in the critically ill, and nutrition support in the setting of end of life care. Often the most difficult decisions we make as clinicians are fraught with ethical implications which can be daunting and difficult to navigate. The goal of this section is to address these issues in a case-based format to offer some guidance to young gastroenterologists grappling with similar scenarios.
This month’s issue features the inaugural piece for this series, written by Dr. Lauren Feld (University of Washington), which discusses a clinical scenario in which a patient with a preexisting do-not-resuscitate (DNR) order is about to undergo endoscopy. The article provides a systematic approach to periprocedural code status and highlights existing guidelines that are generally not well known among gastroenterologists.
Vijaya L. Rao, MD
Editor in Chief
An 89-year old female with history of heart failure with reduced ejection fraction, chronic obstructive pulmonary disease, and dementia is admitted to the intensive care unit (ICU) with melena and acute post-hemorrhagic anemia. The family member designated as the patient’s power of attorney (POA) agrees that her code status upon admission will be do-not-resuscitate and do-not-intubate (DNR/DNI) without plan for invasive procedures. However, she has continued overt bleeding with concomitant hemodynamic instability. The POA and ICU team are now asking for urgent endoscopic evaluation, but do not agree to temporary code reversal for the duration of the procedure.
This vignette highlights an important distinction between a patient’s goals of care and the code status. While these two terms are often erroneously used interchangeably, “code status” refers to a patient’s wishes in the event of cardiopulmonary arrest, while “goals of care” refers to a more comprehensive understanding of what care fits within a patient’s values. Patients or their families may still desire interventions such as procedures, but not wish to have a resuscitation attempt in the event of cardiopulmonary arrest. This leads to the commonly encountered clinical scenario in which a patient planning to undergo endoscopy has an active DNR order.
Frequently, DNR orders are temporarily rescinded prior to invasive procedures. There are several reasons this occurs. First, patients or decision makers may decide that the improved rates of survival in intraprocedural arrests changes their risk-benefit assessment about resuscitation procedures. Secondly, proceduralists may feel an ethical duty to resuscitate a patient if the cause of the arrest is considered iatrogenic and potentially reversible. In addition, proceduralists may worry about legal or professional risk if a patient suffers cardiopulmonary arrest during a procedure and an attempt at resuscitation does not occur.
While this is a frequently encountered clinical scenario, there is wide variation in clinical practice. This variation led to the creation of guidelines set forth by the American Society of Anesthesiologists in 1993 and subsequently adopted by the American College of Surgeons. These guidelines recommend a discussion between the physician and the patient prior to the procedure, utilizing shared decision-making around three options: 1) a full attempt at resuscitation; 2) a limited attempt at resuscitation defined with regard to specific procedures; and 3) a limited attempt at resuscitation defined with regard to the patient’s goals and values.
However, these guidelines are both not well known and frequently not applied amongst clinicians and ancillary staff. Patients are frequently told that they must reverse their DNR order to full code prior to undergoing endoscopy. Dissemination of a systematic approach to a patient with a DNR order who requires endoscopy is important to ensure patients have autonomy over their medical decision-making, while also ensuring that health care professionals feel comfortable with their decisions.
The first step when encountering this scenario is to ensure that the procedure is indicated in this particular patient. While guidelines and algorithms have a substantial role in deciding the appropriate work-up for a presenting complaint such as a presumed upper gastrointestinal bleed, the art of medicine lies in the role of the physicians to decide if an invasive procedure is indicated in their specific patients. This decision should be based on the patients’ presenting clinical scenario, their overall comorbidities, their values, and their goals of care.
As the medical complexity of the patient increases, the risks of the procedure increase and it is ultimately up to the endoscopist to frame the informed consent conversation such that the patient and family understand the potential risks and benefits in their specific case.
With a patient who has a desire to avoid aggressive resuscitation attempts, the physician, patient, and family should weigh the risks and benefits of the procedure, and carefully examine if the indication is sufficient. For the patient outlined in the case, her dementia limits her decision-making capacity, and the clinical team is working with a surrogate decision-maker, her POA, to understand the patient’s wishes and goals. Her POA reports upon admission that invasive procedures may not be in line with her previously expressed values or in her best interest. However, with the development of an acute decompensation due to a presumed GI bleed, a potentially reversible cause, the POA requests an endoscopy to attempt to intervene. Occasionally, a patient with clear goals of care can have a change in these goals when a decompensation occurs. The gastroenterologist should assess if this represents a true desire for invasive procedures, or if this is a response to pressure from other members of the clinical team or family, or if palliative needs are not being met. In this patient, her POA desires an endoscopy because her likely upper GI bleed may be contributing to an acute decompensation, but does not wish for other aggressive measures if she should suffer cardiopulmonary arrest. Although upper endoscopy is a generally safe and well-tolerated procedure, this patient’s cardiopulmonary comorbidities increase the risk of the procedure; therefore, the gastroenterology team should proceed with a candid, detailed discussion of risks, benefits, and alternatives with the patient’s POA.
If the decision is made to proceed with endoscopy, the next step is to address the patient’s code status surrounding the procedure. This conversation should focus on three key goals: 1) allow the physician to gain understanding of the patient or surrogate’s perspectives on goals of care; 2) provide the patient or surrogate with an understanding of the risks and potential outcomes of the procedure, as well as resuscitation options; and 3) ultimately arrive at a mutual consensus regarding the patient’s periprocedural code status. Plans for postprocedural care should also be discussed.
While gastroenterology societies do not have specific guidelines surrounding this situation, there are several steps clinicians can take to ensure patient safety and autonomy are preserved:
- Physicians should avoid one-size-fits-all policies, such as the expectation that patients routinely return to full code for procedures.
- The patient and/or decision-makers should have a discussion regarding the risks during the procedure and potential reversibility of these risks.
- The patient should be presented with the option to either reverse to full code, refuse specific resuscitative measures such as defibrillation or intubation, or be allowed to explain his or her own views on goals of care and allow the procedural team to use their clinical judgment should an emergency arise.
- Physicians should be specific regarding the duration of the code status change. For example, in a patient who has reversed the code status to allow a full resuscitation attempt, the team and patient should discuss how long the patient will remain intubated after the procedure.
- This discussion should be documented carefully in the chart to assist with dissemination amongst the medical team.
This process will ensure that clear guidelines are defined such that everyone, including the patient’s potential decision makers, understand to what they are agreeing.
While physicians and care teams are primarily concerned with providing high-quality and individualized care to patients, it is true that concerns surrounding medicolegal risk are present. Careful informed consent and informed refusal conversations will reduce risk. Indeed, in a patient who has a DNR order, physicians are more likely to be at risk performing resuscitation efforts than withholding them. Communication between patients, families, and physicians remains the foundation for a trusting relationship and decreased litigation risk.
For this patient, engaging her POA in an honest and thorough discussion about her goals of care, as well as the risks of both performing and not performing the upper endoscopy are critical to her care. If her POA wishes to proceed with the procedure and have her remain DNR during the procedure, this should be documented and adhered to. Ultimately, the best outcome for this patient will occur with an individualized risk-benefit assessment and open, frequent communication among the care team and her POA.
Dr. Feld is a gastroenterology and hepatology fellow in the department of gastroenterology and hepatology, University of Washington, Seattle. She has no conflicts of interest.
Editor’s Note: I am very excited to introduce a section to The New Gastroenterologist that will address topics in clinical medical ethics we frequently face as gastroenterologists. There are several inherent ethical issues in gastroenterology that are not often explicitly discussed, such as periprocedural code status, informed consent, transplantation, performance of endoscopy in the critically ill, and nutrition support in the setting of end of life care. Often the most difficult decisions we make as clinicians are fraught with ethical implications which can be daunting and difficult to navigate. The goal of this section is to address these issues in a case-based format to offer some guidance to young gastroenterologists grappling with similar scenarios.
This month’s issue features the inaugural piece for this series, written by Dr. Lauren Feld (University of Washington), which discusses a clinical scenario in which a patient with a preexisting do-not-resuscitate (DNR) order is about to undergo endoscopy. The article provides a systematic approach to periprocedural code status and highlights existing guidelines that are generally not well known among gastroenterologists.
Vijaya L. Rao, MD
Editor in Chief
An 89-year old female with history of heart failure with reduced ejection fraction, chronic obstructive pulmonary disease, and dementia is admitted to the intensive care unit (ICU) with melena and acute post-hemorrhagic anemia. The family member designated as the patient’s power of attorney (POA) agrees that her code status upon admission will be do-not-resuscitate and do-not-intubate (DNR/DNI) without plan for invasive procedures. However, she has continued overt bleeding with concomitant hemodynamic instability. The POA and ICU team are now asking for urgent endoscopic evaluation, but do not agree to temporary code reversal for the duration of the procedure.
This vignette highlights an important distinction between a patient’s goals of care and the code status. While these two terms are often erroneously used interchangeably, “code status” refers to a patient’s wishes in the event of cardiopulmonary arrest, while “goals of care” refers to a more comprehensive understanding of what care fits within a patient’s values. Patients or their families may still desire interventions such as procedures, but not wish to have a resuscitation attempt in the event of cardiopulmonary arrest. This leads to the commonly encountered clinical scenario in which a patient planning to undergo endoscopy has an active DNR order.
Frequently, DNR orders are temporarily rescinded prior to invasive procedures. There are several reasons this occurs. First, patients or decision makers may decide that the improved rates of survival in intraprocedural arrests changes their risk-benefit assessment about resuscitation procedures. Secondly, proceduralists may feel an ethical duty to resuscitate a patient if the cause of the arrest is considered iatrogenic and potentially reversible. In addition, proceduralists may worry about legal or professional risk if a patient suffers cardiopulmonary arrest during a procedure and an attempt at resuscitation does not occur.
While this is a frequently encountered clinical scenario, there is wide variation in clinical practice. This variation led to the creation of guidelines set forth by the American Society of Anesthesiologists in 1993 and subsequently adopted by the American College of Surgeons. These guidelines recommend a discussion between the physician and the patient prior to the procedure, utilizing shared decision-making around three options: 1) a full attempt at resuscitation; 2) a limited attempt at resuscitation defined with regard to specific procedures; and 3) a limited attempt at resuscitation defined with regard to the patient’s goals and values.
However, these guidelines are both not well known and frequently not applied amongst clinicians and ancillary staff. Patients are frequently told that they must reverse their DNR order to full code prior to undergoing endoscopy. Dissemination of a systematic approach to a patient with a DNR order who requires endoscopy is important to ensure patients have autonomy over their medical decision-making, while also ensuring that health care professionals feel comfortable with their decisions.
The first step when encountering this scenario is to ensure that the procedure is indicated in this particular patient. While guidelines and algorithms have a substantial role in deciding the appropriate work-up for a presenting complaint such as a presumed upper gastrointestinal bleed, the art of medicine lies in the role of the physicians to decide if an invasive procedure is indicated in their specific patients. This decision should be based on the patients’ presenting clinical scenario, their overall comorbidities, their values, and their goals of care.
As the medical complexity of the patient increases, the risks of the procedure increase and it is ultimately up to the endoscopist to frame the informed consent conversation such that the patient and family understand the potential risks and benefits in their specific case.
With a patient who has a desire to avoid aggressive resuscitation attempts, the physician, patient, and family should weigh the risks and benefits of the procedure, and carefully examine if the indication is sufficient. For the patient outlined in the case, her dementia limits her decision-making capacity, and the clinical team is working with a surrogate decision-maker, her POA, to understand the patient’s wishes and goals. Her POA reports upon admission that invasive procedures may not be in line with her previously expressed values or in her best interest. However, with the development of an acute decompensation due to a presumed GI bleed, a potentially reversible cause, the POA requests an endoscopy to attempt to intervene. Occasionally, a patient with clear goals of care can have a change in these goals when a decompensation occurs. The gastroenterologist should assess if this represents a true desire for invasive procedures, or if this is a response to pressure from other members of the clinical team or family, or if palliative needs are not being met. In this patient, her POA desires an endoscopy because her likely upper GI bleed may be contributing to an acute decompensation, but does not wish for other aggressive measures if she should suffer cardiopulmonary arrest. Although upper endoscopy is a generally safe and well-tolerated procedure, this patient’s cardiopulmonary comorbidities increase the risk of the procedure; therefore, the gastroenterology team should proceed with a candid, detailed discussion of risks, benefits, and alternatives with the patient’s POA.
If the decision is made to proceed with endoscopy, the next step is to address the patient’s code status surrounding the procedure. This conversation should focus on three key goals: 1) allow the physician to gain understanding of the patient or surrogate’s perspectives on goals of care; 2) provide the patient or surrogate with an understanding of the risks and potential outcomes of the procedure, as well as resuscitation options; and 3) ultimately arrive at a mutual consensus regarding the patient’s periprocedural code status. Plans for postprocedural care should also be discussed.
While gastroenterology societies do not have specific guidelines surrounding this situation, there are several steps clinicians can take to ensure patient safety and autonomy are preserved:
- Physicians should avoid one-size-fits-all policies, such as the expectation that patients routinely return to full code for procedures.
- The patient and/or decision-makers should have a discussion regarding the risks during the procedure and potential reversibility of these risks.
- The patient should be presented with the option to either reverse to full code, refuse specific resuscitative measures such as defibrillation or intubation, or be allowed to explain his or her own views on goals of care and allow the procedural team to use their clinical judgment should an emergency arise.
- Physicians should be specific regarding the duration of the code status change. For example, in a patient who has reversed the code status to allow a full resuscitation attempt, the team and patient should discuss how long the patient will remain intubated after the procedure.
- This discussion should be documented carefully in the chart to assist with dissemination amongst the medical team.
This process will ensure that clear guidelines are defined such that everyone, including the patient’s potential decision makers, understand to what they are agreeing.
While physicians and care teams are primarily concerned with providing high-quality and individualized care to patients, it is true that concerns surrounding medicolegal risk are present. Careful informed consent and informed refusal conversations will reduce risk. Indeed, in a patient who has a DNR order, physicians are more likely to be at risk performing resuscitation efforts than withholding them. Communication between patients, families, and physicians remains the foundation for a trusting relationship and decreased litigation risk.
For this patient, engaging her POA in an honest and thorough discussion about her goals of care, as well as the risks of both performing and not performing the upper endoscopy are critical to her care. If her POA wishes to proceed with the procedure and have her remain DNR during the procedure, this should be documented and adhered to. Ultimately, the best outcome for this patient will occur with an individualized risk-benefit assessment and open, frequent communication among the care team and her POA.
Dr. Feld is a gastroenterology and hepatology fellow in the department of gastroenterology and hepatology, University of Washington, Seattle. She has no conflicts of interest.
Editor’s Note: I am very excited to introduce a section to The New Gastroenterologist that will address topics in clinical medical ethics we frequently face as gastroenterologists. There are several inherent ethical issues in gastroenterology that are not often explicitly discussed, such as periprocedural code status, informed consent, transplantation, performance of endoscopy in the critically ill, and nutrition support in the setting of end of life care. Often the most difficult decisions we make as clinicians are fraught with ethical implications which can be daunting and difficult to navigate. The goal of this section is to address these issues in a case-based format to offer some guidance to young gastroenterologists grappling with similar scenarios.
This month’s issue features the inaugural piece for this series, written by Dr. Lauren Feld (University of Washington), which discusses a clinical scenario in which a patient with a preexisting do-not-resuscitate (DNR) order is about to undergo endoscopy. The article provides a systematic approach to periprocedural code status and highlights existing guidelines that are generally not well known among gastroenterologists.
Vijaya L. Rao, MD
Editor in Chief
An 89-year old female with history of heart failure with reduced ejection fraction, chronic obstructive pulmonary disease, and dementia is admitted to the intensive care unit (ICU) with melena and acute post-hemorrhagic anemia. The family member designated as the patient’s power of attorney (POA) agrees that her code status upon admission will be do-not-resuscitate and do-not-intubate (DNR/DNI) without plan for invasive procedures. However, she has continued overt bleeding with concomitant hemodynamic instability. The POA and ICU team are now asking for urgent endoscopic evaluation, but do not agree to temporary code reversal for the duration of the procedure.
This vignette highlights an important distinction between a patient’s goals of care and the code status. While these two terms are often erroneously used interchangeably, “code status” refers to a patient’s wishes in the event of cardiopulmonary arrest, while “goals of care” refers to a more comprehensive understanding of what care fits within a patient’s values. Patients or their families may still desire interventions such as procedures, but not wish to have a resuscitation attempt in the event of cardiopulmonary arrest. This leads to the commonly encountered clinical scenario in which a patient planning to undergo endoscopy has an active DNR order.
Frequently, DNR orders are temporarily rescinded prior to invasive procedures. There are several reasons this occurs. First, patients or decision makers may decide that the improved rates of survival in intraprocedural arrests changes their risk-benefit assessment about resuscitation procedures. Secondly, proceduralists may feel an ethical duty to resuscitate a patient if the cause of the arrest is considered iatrogenic and potentially reversible. In addition, proceduralists may worry about legal or professional risk if a patient suffers cardiopulmonary arrest during a procedure and an attempt at resuscitation does not occur.
While this is a frequently encountered clinical scenario, there is wide variation in clinical practice. This variation led to the creation of guidelines set forth by the American Society of Anesthesiologists in 1993 and subsequently adopted by the American College of Surgeons. These guidelines recommend a discussion between the physician and the patient prior to the procedure, utilizing shared decision-making around three options: 1) a full attempt at resuscitation; 2) a limited attempt at resuscitation defined with regard to specific procedures; and 3) a limited attempt at resuscitation defined with regard to the patient’s goals and values.
However, these guidelines are both not well known and frequently not applied amongst clinicians and ancillary staff. Patients are frequently told that they must reverse their DNR order to full code prior to undergoing endoscopy. Dissemination of a systematic approach to a patient with a DNR order who requires endoscopy is important to ensure patients have autonomy over their medical decision-making, while also ensuring that health care professionals feel comfortable with their decisions.
The first step when encountering this scenario is to ensure that the procedure is indicated in this particular patient. While guidelines and algorithms have a substantial role in deciding the appropriate work-up for a presenting complaint such as a presumed upper gastrointestinal bleed, the art of medicine lies in the role of the physicians to decide if an invasive procedure is indicated in their specific patients. This decision should be based on the patients’ presenting clinical scenario, their overall comorbidities, their values, and their goals of care.
As the medical complexity of the patient increases, the risks of the procedure increase and it is ultimately up to the endoscopist to frame the informed consent conversation such that the patient and family understand the potential risks and benefits in their specific case.
With a patient who has a desire to avoid aggressive resuscitation attempts, the physician, patient, and family should weigh the risks and benefits of the procedure, and carefully examine if the indication is sufficient. For the patient outlined in the case, her dementia limits her decision-making capacity, and the clinical team is working with a surrogate decision-maker, her POA, to understand the patient’s wishes and goals. Her POA reports upon admission that invasive procedures may not be in line with her previously expressed values or in her best interest. However, with the development of an acute decompensation due to a presumed GI bleed, a potentially reversible cause, the POA requests an endoscopy to attempt to intervene. Occasionally, a patient with clear goals of care can have a change in these goals when a decompensation occurs. The gastroenterologist should assess if this represents a true desire for invasive procedures, or if this is a response to pressure from other members of the clinical team or family, or if palliative needs are not being met. In this patient, her POA desires an endoscopy because her likely upper GI bleed may be contributing to an acute decompensation, but does not wish for other aggressive measures if she should suffer cardiopulmonary arrest. Although upper endoscopy is a generally safe and well-tolerated procedure, this patient’s cardiopulmonary comorbidities increase the risk of the procedure; therefore, the gastroenterology team should proceed with a candid, detailed discussion of risks, benefits, and alternatives with the patient’s POA.
If the decision is made to proceed with endoscopy, the next step is to address the patient’s code status surrounding the procedure. This conversation should focus on three key goals: 1) allow the physician to gain understanding of the patient or surrogate’s perspectives on goals of care; 2) provide the patient or surrogate with an understanding of the risks and potential outcomes of the procedure, as well as resuscitation options; and 3) ultimately arrive at a mutual consensus regarding the patient’s periprocedural code status. Plans for postprocedural care should also be discussed.
While gastroenterology societies do not have specific guidelines surrounding this situation, there are several steps clinicians can take to ensure patient safety and autonomy are preserved:
- Physicians should avoid one-size-fits-all policies, such as the expectation that patients routinely return to full code for procedures.
- The patient and/or decision-makers should have a discussion regarding the risks during the procedure and potential reversibility of these risks.
- The patient should be presented with the option to either reverse to full code, refuse specific resuscitative measures such as defibrillation or intubation, or be allowed to explain his or her own views on goals of care and allow the procedural team to use their clinical judgment should an emergency arise.
- Physicians should be specific regarding the duration of the code status change. For example, in a patient who has reversed the code status to allow a full resuscitation attempt, the team and patient should discuss how long the patient will remain intubated after the procedure.
- This discussion should be documented carefully in the chart to assist with dissemination amongst the medical team.
This process will ensure that clear guidelines are defined such that everyone, including the patient’s potential decision makers, understand to what they are agreeing.
While physicians and care teams are primarily concerned with providing high-quality and individualized care to patients, it is true that concerns surrounding medicolegal risk are present. Careful informed consent and informed refusal conversations will reduce risk. Indeed, in a patient who has a DNR order, physicians are more likely to be at risk performing resuscitation efforts than withholding them. Communication between patients, families, and physicians remains the foundation for a trusting relationship and decreased litigation risk.
For this patient, engaging her POA in an honest and thorough discussion about her goals of care, as well as the risks of both performing and not performing the upper endoscopy are critical to her care. If her POA wishes to proceed with the procedure and have her remain DNR during the procedure, this should be documented and adhered to. Ultimately, the best outcome for this patient will occur with an individualized risk-benefit assessment and open, frequent communication among the care team and her POA.
Dr. Feld is a gastroenterology and hepatology fellow in the department of gastroenterology and hepatology, University of Washington, Seattle. She has no conflicts of interest.
Developing a career in nutrition support and small-bowel disorders
The role of diet and nutrition is becoming increasingly recognized in the cause, management, and prevention of disease. Despite the clear importance of the role of nutrition in the field of medicine, among health professionals, formal training in nutrition support is lacking. A lack of nutrition training has been recognized in multiple subspecialty fields1 and is highlighted by a shortage of physicians trained to manage disease-related malnutrition.2 Gastroenterologists, in particular, have a special responsibility related to nutrition in disorders of the gastrointestinal tract and are in a unique position to recognize and manage disorders of maldigestion and malabsorption. Unfortunately, surveys of both U.S. and Canadian fellows have demonstrated deficiencies in the training of nutrition support and management of enteral and parenteral nutrition (PN).3,4
Current status of nutrition training
The impact of diet and nutrition on health and disease is universally recognized but unfortunately lagging with respect to formal training at all levels of medical education. A survey of program directors from primary care, surgery, and anesthesia showed only 26% of respondent programs had a formal curriculum in nutrition education.1 Specific to gastroenterology, a majority of trainees and recent graduates perceived that nutrition education was an important aspect of their training; however, only 50% of respondents had training in nutrition support with 36% reporting mandatory training.3
The Gastroenterology Core Curriculum, most recently updated in 2007 – and sponsored by the American Association for the Study of Liver Diseases, American College of Gastroenterology, the American Society for Gastrointestinal Endoscopy, and the American Gastroenterological Association – includes six domains of nutrition training within the training track: nutrition assessment, basic nutrition requirements, specific gastrointestinal disorders and other allied diseases, enteral nutrition, PN, and diet therapy. Level 1 training is expected for all gastroenterology fellows. Level 2 is comprised, on average, of an additional 12 months with described objectives, either occurring outside of a standard gastroenterology fellowship or coinciding with a dedicated third year of training. Although training durations for level 1 are not defined, level 2 recommends at least 6 months of experience working with an inpatient nutrition support team (NST) and the management of outpatients in nutrition and weight management clinics.5
Role of a nutrition support team
Training in nutrition is a heterogeneous field, with a wide range that covers understanding metabolism in health and disease, micronutrient and macronutrient requirements, nutrient digestion and absorption, and the best route and provision of nutrition support. Therefore, a critical aspect of education includes access to a dedicated NST. Such teams were common and necessary in the late 1900s with the inception of specialized nutrition therapy. However, with an increase in the use of home infusion therapies, NSTs were dismantled in favor of shifting responsibility to decentralized home infusion companies. A dedicated NST often will include some combination of pharmacists with an interest in the safe compounding of parenteral formulas, nurses with experience in the home management of intravenous therapies and catheters, and dietitians with dedicated interests in intestinal failure, recognition of malnutrition, and provision of calories. Collectively, a highly functioning NST also provides dedicated multidisciplinary training to health professionals of varying backgrounds.
My entry into the field of nutrition support
Entering a fellowship in gastroenterology should be pursued with an open mind. We all have varying experiences in the management of patients with gastrointestinal conditions, both in the inpatient and outpatient arenas through residency training. My early experiences in fellowship at the University of Chicago centered on the management of patients with inflammatory bowel disease (IBD) and with research interests related to the clinical course of IBD. I was also fortunate to be part of a fellowship program offering both level 1 and level 2 training with a longstanding track record of graduating fellows responsible for the running of NSTs at their local institutions. Categorical fellows spend 3 months of training on a rotation with combined inpatient and outpatient responsibilities focusing on the management of patients with intestinal failure, inpatient management of complications from PN support, and an outpatient clinic focused on small-bowel disorders (celiac disease, small-bowel bleeding, and intestinal malabsorption). This experience led me to pursue level 2 training at Northwestern University with a combined focus on small-bowel diseases and enteroscopy.
These collective experiences in fellowship and postfellowship training grounded my ideas on the role of nutrition pervading many gastrointestinal conditions from acute and chronic pancreatitis and IBD to rare conditions such as enteropathy associated with immune deficiencies and autoimmune enteropathy. Now, as a junior faculty member with a focus in nutrition support and small-bowel disorders, my clinical responsibilities include a dedicated half-day in the management of outpatients (parenteral and enteral nutrition), inpatient rounding with our dedicated NST focusing on the initiation of PN, management of home PN complications, and dedicated procedural time focusing on enteral access techniques (percutaneous gastrostomy/jejunostomy tubes) and small-bowel enteroscopy. To my surprise, entry into the field of nutrition support and small-bowel disorders has been filled with excitement and a growing list of collaborations and opportunities. While initial work in the management of PN has been in existence since the 1970s and earlier with respect to the development of safe administration techniques, most of my current work transcends specialties as we develop appropriateness criteria related to PN support in collaboration with a wide range of specialties that include surgery, oncology, and palliative care.
Seeking opportunities for additional training
As the field of gastroenterology grows outward in various directions, mastery of subjects has led to subspecialization in specific areas including interventional gastroenterology, pancreatology, IBD, and motility disorders. The field is primed for broader access to specialty training in nutrition support and small-bowel disorders. Exposure to dedicated training in nutrition and nutrition-related disorders is vital as part of a categorical fellowship, but can also be complemented via visiting observerships, access to formal level 2 training programs, and external programs related to promoting nutrition education.
Since 2001, formal nutrition fellowship programs offering level 2 training have been compiled by the National Board of Physician Nutrition Specialists, although attraction of interested fellows has been lacking.2 The Nestlé Nutrition Institute Clinical Nutrition Fellowship, endorsed by the American Society for Parenteral and Enteral Nutrition and the AGA, is an ongoing program that pairs interested trainees with expert program faculty through onsite clinical rotations lasting a total of 4 weeks.2 Attendance at national and international conferences can supplement a fellows training in nutrition, and an increased focus on nutrition lectures should be a priority of meeting education committees to increase the exposure of trainees to leaders in the field.
Conclusion
A career in nutrition support and small-bowel disorders is incredibly rewarding as it incorporates the basic physiologic processes of digestion and absorption with a wide array of pathologic conditions. Incorporation of the basic principles of intestinal absorption allows for a greater understanding of the role of the low–fermentable oligo-, di-, monosaccharides and polyols (FODMAP) diet in the management of irritable bowel syndrome to the varying principles of diets currently under study for the management of IBD. Outside of this spectrum, working with an NST allows for the management of complex cases of malnutrition resulting from disorders ranging from cancer to various postsurgical intestinal alterations. Although observerships and external training programs allow for an introduction into the field, formal level 2 training, combining both work with a NST and small-bowel enteroscopy, allows for exposure to the full range of disorders of the small bowel. As patients continue to seek disease management options rooted in diet, the demand for gastroenterologists with subspecialty training in nutritional disorders will continue to grow and will require further support across training programs to incorporate additional training into categorical fellowships.
References
1. Daley BJ et al. JPEN J Paren Enteral Nutr. 2016;40(1):95-9. doi: 10.1177/0148607115571155.
2. Kiraly LN et al. Nutr Clin Pract. 2014;29(3):332-7. doi: 10.1177/0884533614525212.
3. Hu J et al. Nutr Clin Pract. 2018 Apr;33(2):191-7. doi: 10.1177/0884533617700852.
4. Scolapio JS et al. J Clin Gastroenterol. 2008 Feb;42(2):122-7. doi: 10.1097/MCG.0b013e3181595b6a.
5. American Association for the Study of Liver Diseases et al. The Gastroenterology Core Curriculum, 3rd ed. Gastroenterology. 2007;132(5):2012-8. doi: 10.1053/j.gastro.2007.03.079.
Dr. Micic is assistant professor of medicine, department of internal medicine, section of gastroenterology, hepatology, and nutrition, University of Chicago.
The role of diet and nutrition is becoming increasingly recognized in the cause, management, and prevention of disease. Despite the clear importance of the role of nutrition in the field of medicine, among health professionals, formal training in nutrition support is lacking. A lack of nutrition training has been recognized in multiple subspecialty fields1 and is highlighted by a shortage of physicians trained to manage disease-related malnutrition.2 Gastroenterologists, in particular, have a special responsibility related to nutrition in disorders of the gastrointestinal tract and are in a unique position to recognize and manage disorders of maldigestion and malabsorption. Unfortunately, surveys of both U.S. and Canadian fellows have demonstrated deficiencies in the training of nutrition support and management of enteral and parenteral nutrition (PN).3,4
Current status of nutrition training
The impact of diet and nutrition on health and disease is universally recognized but unfortunately lagging with respect to formal training at all levels of medical education. A survey of program directors from primary care, surgery, and anesthesia showed only 26% of respondent programs had a formal curriculum in nutrition education.1 Specific to gastroenterology, a majority of trainees and recent graduates perceived that nutrition education was an important aspect of their training; however, only 50% of respondents had training in nutrition support with 36% reporting mandatory training.3
The Gastroenterology Core Curriculum, most recently updated in 2007 – and sponsored by the American Association for the Study of Liver Diseases, American College of Gastroenterology, the American Society for Gastrointestinal Endoscopy, and the American Gastroenterological Association – includes six domains of nutrition training within the training track: nutrition assessment, basic nutrition requirements, specific gastrointestinal disorders and other allied diseases, enteral nutrition, PN, and diet therapy. Level 1 training is expected for all gastroenterology fellows. Level 2 is comprised, on average, of an additional 12 months with described objectives, either occurring outside of a standard gastroenterology fellowship or coinciding with a dedicated third year of training. Although training durations for level 1 are not defined, level 2 recommends at least 6 months of experience working with an inpatient nutrition support team (NST) and the management of outpatients in nutrition and weight management clinics.5
Role of a nutrition support team
Training in nutrition is a heterogeneous field, with a wide range that covers understanding metabolism in health and disease, micronutrient and macronutrient requirements, nutrient digestion and absorption, and the best route and provision of nutrition support. Therefore, a critical aspect of education includes access to a dedicated NST. Such teams were common and necessary in the late 1900s with the inception of specialized nutrition therapy. However, with an increase in the use of home infusion therapies, NSTs were dismantled in favor of shifting responsibility to decentralized home infusion companies. A dedicated NST often will include some combination of pharmacists with an interest in the safe compounding of parenteral formulas, nurses with experience in the home management of intravenous therapies and catheters, and dietitians with dedicated interests in intestinal failure, recognition of malnutrition, and provision of calories. Collectively, a highly functioning NST also provides dedicated multidisciplinary training to health professionals of varying backgrounds.
My entry into the field of nutrition support
Entering a fellowship in gastroenterology should be pursued with an open mind. We all have varying experiences in the management of patients with gastrointestinal conditions, both in the inpatient and outpatient arenas through residency training. My early experiences in fellowship at the University of Chicago centered on the management of patients with inflammatory bowel disease (IBD) and with research interests related to the clinical course of IBD. I was also fortunate to be part of a fellowship program offering both level 1 and level 2 training with a longstanding track record of graduating fellows responsible for the running of NSTs at their local institutions. Categorical fellows spend 3 months of training on a rotation with combined inpatient and outpatient responsibilities focusing on the management of patients with intestinal failure, inpatient management of complications from PN support, and an outpatient clinic focused on small-bowel disorders (celiac disease, small-bowel bleeding, and intestinal malabsorption). This experience led me to pursue level 2 training at Northwestern University with a combined focus on small-bowel diseases and enteroscopy.
These collective experiences in fellowship and postfellowship training grounded my ideas on the role of nutrition pervading many gastrointestinal conditions from acute and chronic pancreatitis and IBD to rare conditions such as enteropathy associated with immune deficiencies and autoimmune enteropathy. Now, as a junior faculty member with a focus in nutrition support and small-bowel disorders, my clinical responsibilities include a dedicated half-day in the management of outpatients (parenteral and enteral nutrition), inpatient rounding with our dedicated NST focusing on the initiation of PN, management of home PN complications, and dedicated procedural time focusing on enteral access techniques (percutaneous gastrostomy/jejunostomy tubes) and small-bowel enteroscopy. To my surprise, entry into the field of nutrition support and small-bowel disorders has been filled with excitement and a growing list of collaborations and opportunities. While initial work in the management of PN has been in existence since the 1970s and earlier with respect to the development of safe administration techniques, most of my current work transcends specialties as we develop appropriateness criteria related to PN support in collaboration with a wide range of specialties that include surgery, oncology, and palliative care.
Seeking opportunities for additional training
As the field of gastroenterology grows outward in various directions, mastery of subjects has led to subspecialization in specific areas including interventional gastroenterology, pancreatology, IBD, and motility disorders. The field is primed for broader access to specialty training in nutrition support and small-bowel disorders. Exposure to dedicated training in nutrition and nutrition-related disorders is vital as part of a categorical fellowship, but can also be complemented via visiting observerships, access to formal level 2 training programs, and external programs related to promoting nutrition education.
Since 2001, formal nutrition fellowship programs offering level 2 training have been compiled by the National Board of Physician Nutrition Specialists, although attraction of interested fellows has been lacking.2 The Nestlé Nutrition Institute Clinical Nutrition Fellowship, endorsed by the American Society for Parenteral and Enteral Nutrition and the AGA, is an ongoing program that pairs interested trainees with expert program faculty through onsite clinical rotations lasting a total of 4 weeks.2 Attendance at national and international conferences can supplement a fellows training in nutrition, and an increased focus on nutrition lectures should be a priority of meeting education committees to increase the exposure of trainees to leaders in the field.
Conclusion
A career in nutrition support and small-bowel disorders is incredibly rewarding as it incorporates the basic physiologic processes of digestion and absorption with a wide array of pathologic conditions. Incorporation of the basic principles of intestinal absorption allows for a greater understanding of the role of the low–fermentable oligo-, di-, monosaccharides and polyols (FODMAP) diet in the management of irritable bowel syndrome to the varying principles of diets currently under study for the management of IBD. Outside of this spectrum, working with an NST allows for the management of complex cases of malnutrition resulting from disorders ranging from cancer to various postsurgical intestinal alterations. Although observerships and external training programs allow for an introduction into the field, formal level 2 training, combining both work with a NST and small-bowel enteroscopy, allows for exposure to the full range of disorders of the small bowel. As patients continue to seek disease management options rooted in diet, the demand for gastroenterologists with subspecialty training in nutritional disorders will continue to grow and will require further support across training programs to incorporate additional training into categorical fellowships.
References
1. Daley BJ et al. JPEN J Paren Enteral Nutr. 2016;40(1):95-9. doi: 10.1177/0148607115571155.
2. Kiraly LN et al. Nutr Clin Pract. 2014;29(3):332-7. doi: 10.1177/0884533614525212.
3. Hu J et al. Nutr Clin Pract. 2018 Apr;33(2):191-7. doi: 10.1177/0884533617700852.
4. Scolapio JS et al. J Clin Gastroenterol. 2008 Feb;42(2):122-7. doi: 10.1097/MCG.0b013e3181595b6a.
5. American Association for the Study of Liver Diseases et al. The Gastroenterology Core Curriculum, 3rd ed. Gastroenterology. 2007;132(5):2012-8. doi: 10.1053/j.gastro.2007.03.079.
Dr. Micic is assistant professor of medicine, department of internal medicine, section of gastroenterology, hepatology, and nutrition, University of Chicago.
The role of diet and nutrition is becoming increasingly recognized in the cause, management, and prevention of disease. Despite the clear importance of the role of nutrition in the field of medicine, among health professionals, formal training in nutrition support is lacking. A lack of nutrition training has been recognized in multiple subspecialty fields1 and is highlighted by a shortage of physicians trained to manage disease-related malnutrition.2 Gastroenterologists, in particular, have a special responsibility related to nutrition in disorders of the gastrointestinal tract and are in a unique position to recognize and manage disorders of maldigestion and malabsorption. Unfortunately, surveys of both U.S. and Canadian fellows have demonstrated deficiencies in the training of nutrition support and management of enteral and parenteral nutrition (PN).3,4
Current status of nutrition training
The impact of diet and nutrition on health and disease is universally recognized but unfortunately lagging with respect to formal training at all levels of medical education. A survey of program directors from primary care, surgery, and anesthesia showed only 26% of respondent programs had a formal curriculum in nutrition education.1 Specific to gastroenterology, a majority of trainees and recent graduates perceived that nutrition education was an important aspect of their training; however, only 50% of respondents had training in nutrition support with 36% reporting mandatory training.3
The Gastroenterology Core Curriculum, most recently updated in 2007 – and sponsored by the American Association for the Study of Liver Diseases, American College of Gastroenterology, the American Society for Gastrointestinal Endoscopy, and the American Gastroenterological Association – includes six domains of nutrition training within the training track: nutrition assessment, basic nutrition requirements, specific gastrointestinal disorders and other allied diseases, enteral nutrition, PN, and diet therapy. Level 1 training is expected for all gastroenterology fellows. Level 2 is comprised, on average, of an additional 12 months with described objectives, either occurring outside of a standard gastroenterology fellowship or coinciding with a dedicated third year of training. Although training durations for level 1 are not defined, level 2 recommends at least 6 months of experience working with an inpatient nutrition support team (NST) and the management of outpatients in nutrition and weight management clinics.5
Role of a nutrition support team
Training in nutrition is a heterogeneous field, with a wide range that covers understanding metabolism in health and disease, micronutrient and macronutrient requirements, nutrient digestion and absorption, and the best route and provision of nutrition support. Therefore, a critical aspect of education includes access to a dedicated NST. Such teams were common and necessary in the late 1900s with the inception of specialized nutrition therapy. However, with an increase in the use of home infusion therapies, NSTs were dismantled in favor of shifting responsibility to decentralized home infusion companies. A dedicated NST often will include some combination of pharmacists with an interest in the safe compounding of parenteral formulas, nurses with experience in the home management of intravenous therapies and catheters, and dietitians with dedicated interests in intestinal failure, recognition of malnutrition, and provision of calories. Collectively, a highly functioning NST also provides dedicated multidisciplinary training to health professionals of varying backgrounds.
My entry into the field of nutrition support
Entering a fellowship in gastroenterology should be pursued with an open mind. We all have varying experiences in the management of patients with gastrointestinal conditions, both in the inpatient and outpatient arenas through residency training. My early experiences in fellowship at the University of Chicago centered on the management of patients with inflammatory bowel disease (IBD) and with research interests related to the clinical course of IBD. I was also fortunate to be part of a fellowship program offering both level 1 and level 2 training with a longstanding track record of graduating fellows responsible for the running of NSTs at their local institutions. Categorical fellows spend 3 months of training on a rotation with combined inpatient and outpatient responsibilities focusing on the management of patients with intestinal failure, inpatient management of complications from PN support, and an outpatient clinic focused on small-bowel disorders (celiac disease, small-bowel bleeding, and intestinal malabsorption). This experience led me to pursue level 2 training at Northwestern University with a combined focus on small-bowel diseases and enteroscopy.
These collective experiences in fellowship and postfellowship training grounded my ideas on the role of nutrition pervading many gastrointestinal conditions from acute and chronic pancreatitis and IBD to rare conditions such as enteropathy associated with immune deficiencies and autoimmune enteropathy. Now, as a junior faculty member with a focus in nutrition support and small-bowel disorders, my clinical responsibilities include a dedicated half-day in the management of outpatients (parenteral and enteral nutrition), inpatient rounding with our dedicated NST focusing on the initiation of PN, management of home PN complications, and dedicated procedural time focusing on enteral access techniques (percutaneous gastrostomy/jejunostomy tubes) and small-bowel enteroscopy. To my surprise, entry into the field of nutrition support and small-bowel disorders has been filled with excitement and a growing list of collaborations and opportunities. While initial work in the management of PN has been in existence since the 1970s and earlier with respect to the development of safe administration techniques, most of my current work transcends specialties as we develop appropriateness criteria related to PN support in collaboration with a wide range of specialties that include surgery, oncology, and palliative care.
Seeking opportunities for additional training
As the field of gastroenterology grows outward in various directions, mastery of subjects has led to subspecialization in specific areas including interventional gastroenterology, pancreatology, IBD, and motility disorders. The field is primed for broader access to specialty training in nutrition support and small-bowel disorders. Exposure to dedicated training in nutrition and nutrition-related disorders is vital as part of a categorical fellowship, but can also be complemented via visiting observerships, access to formal level 2 training programs, and external programs related to promoting nutrition education.
Since 2001, formal nutrition fellowship programs offering level 2 training have been compiled by the National Board of Physician Nutrition Specialists, although attraction of interested fellows has been lacking.2 The Nestlé Nutrition Institute Clinical Nutrition Fellowship, endorsed by the American Society for Parenteral and Enteral Nutrition and the AGA, is an ongoing program that pairs interested trainees with expert program faculty through onsite clinical rotations lasting a total of 4 weeks.2 Attendance at national and international conferences can supplement a fellows training in nutrition, and an increased focus on nutrition lectures should be a priority of meeting education committees to increase the exposure of trainees to leaders in the field.
Conclusion
A career in nutrition support and small-bowel disorders is incredibly rewarding as it incorporates the basic physiologic processes of digestion and absorption with a wide array of pathologic conditions. Incorporation of the basic principles of intestinal absorption allows for a greater understanding of the role of the low–fermentable oligo-, di-, monosaccharides and polyols (FODMAP) diet in the management of irritable bowel syndrome to the varying principles of diets currently under study for the management of IBD. Outside of this spectrum, working with an NST allows for the management of complex cases of malnutrition resulting from disorders ranging from cancer to various postsurgical intestinal alterations. Although observerships and external training programs allow for an introduction into the field, formal level 2 training, combining both work with a NST and small-bowel enteroscopy, allows for exposure to the full range of disorders of the small bowel. As patients continue to seek disease management options rooted in diet, the demand for gastroenterologists with subspecialty training in nutritional disorders will continue to grow and will require further support across training programs to incorporate additional training into categorical fellowships.
References
1. Daley BJ et al. JPEN J Paren Enteral Nutr. 2016;40(1):95-9. doi: 10.1177/0148607115571155.
2. Kiraly LN et al. Nutr Clin Pract. 2014;29(3):332-7. doi: 10.1177/0884533614525212.
3. Hu J et al. Nutr Clin Pract. 2018 Apr;33(2):191-7. doi: 10.1177/0884533617700852.
4. Scolapio JS et al. J Clin Gastroenterol. 2008 Feb;42(2):122-7. doi: 10.1097/MCG.0b013e3181595b6a.
5. American Association for the Study of Liver Diseases et al. The Gastroenterology Core Curriculum, 3rd ed. Gastroenterology. 2007;132(5):2012-8. doi: 10.1053/j.gastro.2007.03.079.
Dr. Micic is assistant professor of medicine, department of internal medicine, section of gastroenterology, hepatology, and nutrition, University of Chicago.
Pitfalls in physician-patient communication via patient access support portals
Technology can be used to enhance communication, increase patient safety, and improve overall patient care. For example, many physicians have arranged for remote access to medical records and established a unique system of communication via a patient access support portal. A patient portal is a secure online website that provides patients 24-hour, on-demand access to their health information. Patient portals, while popular and oftentimes quite helpful, are not without drawbacks. Communication by electronic means with your patient can be viewed by some as impersonal and can make patients less tolerant to what they perceive to be a mistake, error, or unwanted outcome. A decrease in face-to-face contact and communication with your patient also gives you less time to resolve any conflict or disagreement. While communication via a patient access support portal has the potential to free up medical staff for direct patient care, such communication also carries liability risk.
Patient access support portal
A physician’s legal responsibility to communicate in a timely and accurate manner does not change, irrespective of the form of communication. However, communication via a patient access portal does have some unique features that must be considered by the practitioner. Practitioners must remember that any communication via the patient portal creates a permanent record, which can and will be used in the event of litigation. For example, when responding to a patient inquiry about a specific complaint, treatment provided, or test result, it will be presumed that the physician had access to the patient’s full medical record and that the full record will be utilized in making a response. Accessing the patient’s chart will leave an audit trail that will provide what is known as metadata, which in the context of electronic medical records, is what allows technicians to verify that the patient record was accessed, and it provides details as to when, and for how long it was accessed. These records are frequently pursued in litigation, so you must understand that parties can often re-create an intricate and accurate timeline of events. While state courts are divided on the issue of whether metadata contained within electronic medical records is discoverable, recent federal court decisions have held that such data is discoverable pursuant to the Federal Rules of Civil Procedure. Thus, once a patient has communicated with you via the portal, you will be responsible for responding in an appropriate and prompt fashion. For these reasons, it is imperative that you create an agreement with your patients as to how the portal will be used and clearly set forth the rules for such use.
Patient portal policies and procedures
In creating patient portal user agreements (See "Sample User Agreement," attached below), it is crucial that an agreement clearly identify the policies and procedures for use. A patient portal user agreement should:
- Set forth the rules and regulations for portal use.
- Include a verification procedure that requires the patients to confirm that they have the legal capacity to consent to the terms of use. This is especially important when treating patients with mental disability, elderly patients with dementia, minors, and any other individuals who may not legally consent.
- Include a verification procedure that requires the patients to confirm that they understand and agree to abide by the user agreement rules.
- Include a detailed list that informs users of the risks and benefits of communicating via the patient portal.
- Stress that communication through the patient portal is for nonemergent matters only.
- Set forth permissible topics for use, such as communicating with the physician or staff, obtaining test results or records, and setting, changing, or canceling appointments.
- Clearly indicate certain topics that should not be discussed via the patient portal, including mental health issues.
- Reiterate that communication via the patient portal is only one option, and that all other standard methods of communication remain available. In doing so, provide office telephone numbers, hotlines, and email addresses for convenience.
- Inform the patients that they should call the office with any questions or concerns regarding use of the patient portal.
- Include a statement that the patient should call 911 or proceed directly to the nearest hospital for any and all urgent or emergent medical matters.
Other considerations
There are, however, equally critical considerations to be made that go beyond the core details of the user agreement. For instance, use of the patient access portal should be limited to only current or active patients, and you should stress to patients the importance of keeping their contact information updated and accurate. This is especially vital in situations in which a patient is unresponsive to communication via the portal, as your staff will need to follow up via other means of communication. It is also imperative to ensure the patient portal is programmed to promptly alert you or your staff following an inquiry from the patient as the patient will likely expect an immediate response.
Notably, communication via the patient portal must still comply with the Health Insurance Portability and Accountability Act (HIPAA). This means that only authorized users are able to access records within the patient portal. To ensure compliance with HIPAA, all users should be instructed in the appropriate practices of maintaining patient privacy. This includes barring the use of shared passwords amongst multiple individuals, requiring that users enable an auto log-off setting, and programming work stations to turn off automatically after brief periods of nonuse. Further, all communications in the patient portal should be encrypted to prevent the patient’s sensitive information from being accessed in the event of an attempted security breach.
Finally, depending upon the practice, there may be instances in which someone other than the patient’s physician would be reading and responding to patient queries. In these situations, the patient should be informed of such potential. This way, if the communication is intended only for the physician, the patient will be afforded the opportunity to call the physician directly rather than communicate via the patient portal.
While the use of patient access portals is becoming far more prevalent, as they offer many practical benefits ranging from increased convenience and efficiency to enhanced patient care, they also carry the potential for increased liability exposure. As such, it is vital that physicians weigh all potential risks and benefits that are inherent in the use of patient access portals prior to making the decision to implement such technology.
Mr. Mills is an equity partner in Cunningham, Meyer & Vedrine, Chicago.
Technology can be used to enhance communication, increase patient safety, and improve overall patient care. For example, many physicians have arranged for remote access to medical records and established a unique system of communication via a patient access support portal. A patient portal is a secure online website that provides patients 24-hour, on-demand access to their health information. Patient portals, while popular and oftentimes quite helpful, are not without drawbacks. Communication by electronic means with your patient can be viewed by some as impersonal and can make patients less tolerant to what they perceive to be a mistake, error, or unwanted outcome. A decrease in face-to-face contact and communication with your patient also gives you less time to resolve any conflict or disagreement. While communication via a patient access support portal has the potential to free up medical staff for direct patient care, such communication also carries liability risk.
Patient access support portal
A physician’s legal responsibility to communicate in a timely and accurate manner does not change, irrespective of the form of communication. However, communication via a patient access portal does have some unique features that must be considered by the practitioner. Practitioners must remember that any communication via the patient portal creates a permanent record, which can and will be used in the event of litigation. For example, when responding to a patient inquiry about a specific complaint, treatment provided, or test result, it will be presumed that the physician had access to the patient’s full medical record and that the full record will be utilized in making a response. Accessing the patient’s chart will leave an audit trail that will provide what is known as metadata, which in the context of electronic medical records, is what allows technicians to verify that the patient record was accessed, and it provides details as to when, and for how long it was accessed. These records are frequently pursued in litigation, so you must understand that parties can often re-create an intricate and accurate timeline of events. While state courts are divided on the issue of whether metadata contained within electronic medical records is discoverable, recent federal court decisions have held that such data is discoverable pursuant to the Federal Rules of Civil Procedure. Thus, once a patient has communicated with you via the portal, you will be responsible for responding in an appropriate and prompt fashion. For these reasons, it is imperative that you create an agreement with your patients as to how the portal will be used and clearly set forth the rules for such use.
Patient portal policies and procedures
In creating patient portal user agreements (See "Sample User Agreement," attached below), it is crucial that an agreement clearly identify the policies and procedures for use. A patient portal user agreement should:
- Set forth the rules and regulations for portal use.
- Include a verification procedure that requires the patients to confirm that they have the legal capacity to consent to the terms of use. This is especially important when treating patients with mental disability, elderly patients with dementia, minors, and any other individuals who may not legally consent.
- Include a verification procedure that requires the patients to confirm that they understand and agree to abide by the user agreement rules.
- Include a detailed list that informs users of the risks and benefits of communicating via the patient portal.
- Stress that communication through the patient portal is for nonemergent matters only.
- Set forth permissible topics for use, such as communicating with the physician or staff, obtaining test results or records, and setting, changing, or canceling appointments.
- Clearly indicate certain topics that should not be discussed via the patient portal, including mental health issues.
- Reiterate that communication via the patient portal is only one option, and that all other standard methods of communication remain available. In doing so, provide office telephone numbers, hotlines, and email addresses for convenience.
- Inform the patients that they should call the office with any questions or concerns regarding use of the patient portal.
- Include a statement that the patient should call 911 or proceed directly to the nearest hospital for any and all urgent or emergent medical matters.
Other considerations
There are, however, equally critical considerations to be made that go beyond the core details of the user agreement. For instance, use of the patient access portal should be limited to only current or active patients, and you should stress to patients the importance of keeping their contact information updated and accurate. This is especially vital in situations in which a patient is unresponsive to communication via the portal, as your staff will need to follow up via other means of communication. It is also imperative to ensure the patient portal is programmed to promptly alert you or your staff following an inquiry from the patient as the patient will likely expect an immediate response.
Notably, communication via the patient portal must still comply with the Health Insurance Portability and Accountability Act (HIPAA). This means that only authorized users are able to access records within the patient portal. To ensure compliance with HIPAA, all users should be instructed in the appropriate practices of maintaining patient privacy. This includes barring the use of shared passwords amongst multiple individuals, requiring that users enable an auto log-off setting, and programming work stations to turn off automatically after brief periods of nonuse. Further, all communications in the patient portal should be encrypted to prevent the patient’s sensitive information from being accessed in the event of an attempted security breach.
Finally, depending upon the practice, there may be instances in which someone other than the patient’s physician would be reading and responding to patient queries. In these situations, the patient should be informed of such potential. This way, if the communication is intended only for the physician, the patient will be afforded the opportunity to call the physician directly rather than communicate via the patient portal.
While the use of patient access portals is becoming far more prevalent, as they offer many practical benefits ranging from increased convenience and efficiency to enhanced patient care, they also carry the potential for increased liability exposure. As such, it is vital that physicians weigh all potential risks and benefits that are inherent in the use of patient access portals prior to making the decision to implement such technology.
Mr. Mills is an equity partner in Cunningham, Meyer & Vedrine, Chicago.
Technology can be used to enhance communication, increase patient safety, and improve overall patient care. For example, many physicians have arranged for remote access to medical records and established a unique system of communication via a patient access support portal. A patient portal is a secure online website that provides patients 24-hour, on-demand access to their health information. Patient portals, while popular and oftentimes quite helpful, are not without drawbacks. Communication by electronic means with your patient can be viewed by some as impersonal and can make patients less tolerant to what they perceive to be a mistake, error, or unwanted outcome. A decrease in face-to-face contact and communication with your patient also gives you less time to resolve any conflict or disagreement. While communication via a patient access support portal has the potential to free up medical staff for direct patient care, such communication also carries liability risk.
Patient access support portal
A physician’s legal responsibility to communicate in a timely and accurate manner does not change, irrespective of the form of communication. However, communication via a patient access portal does have some unique features that must be considered by the practitioner. Practitioners must remember that any communication via the patient portal creates a permanent record, which can and will be used in the event of litigation. For example, when responding to a patient inquiry about a specific complaint, treatment provided, or test result, it will be presumed that the physician had access to the patient’s full medical record and that the full record will be utilized in making a response. Accessing the patient’s chart will leave an audit trail that will provide what is known as metadata, which in the context of electronic medical records, is what allows technicians to verify that the patient record was accessed, and it provides details as to when, and for how long it was accessed. These records are frequently pursued in litigation, so you must understand that parties can often re-create an intricate and accurate timeline of events. While state courts are divided on the issue of whether metadata contained within electronic medical records is discoverable, recent federal court decisions have held that such data is discoverable pursuant to the Federal Rules of Civil Procedure. Thus, once a patient has communicated with you via the portal, you will be responsible for responding in an appropriate and prompt fashion. For these reasons, it is imperative that you create an agreement with your patients as to how the portal will be used and clearly set forth the rules for such use.
Patient portal policies and procedures
In creating patient portal user agreements (See "Sample User Agreement," attached below), it is crucial that an agreement clearly identify the policies and procedures for use. A patient portal user agreement should:
- Set forth the rules and regulations for portal use.
- Include a verification procedure that requires the patients to confirm that they have the legal capacity to consent to the terms of use. This is especially important when treating patients with mental disability, elderly patients with dementia, minors, and any other individuals who may not legally consent.
- Include a verification procedure that requires the patients to confirm that they understand and agree to abide by the user agreement rules.
- Include a detailed list that informs users of the risks and benefits of communicating via the patient portal.
- Stress that communication through the patient portal is for nonemergent matters only.
- Set forth permissible topics for use, such as communicating with the physician or staff, obtaining test results or records, and setting, changing, or canceling appointments.
- Clearly indicate certain topics that should not be discussed via the patient portal, including mental health issues.
- Reiterate that communication via the patient portal is only one option, and that all other standard methods of communication remain available. In doing so, provide office telephone numbers, hotlines, and email addresses for convenience.
- Inform the patients that they should call the office with any questions or concerns regarding use of the patient portal.
- Include a statement that the patient should call 911 or proceed directly to the nearest hospital for any and all urgent or emergent medical matters.
Other considerations
There are, however, equally critical considerations to be made that go beyond the core details of the user agreement. For instance, use of the patient access portal should be limited to only current or active patients, and you should stress to patients the importance of keeping their contact information updated and accurate. This is especially vital in situations in which a patient is unresponsive to communication via the portal, as your staff will need to follow up via other means of communication. It is also imperative to ensure the patient portal is programmed to promptly alert you or your staff following an inquiry from the patient as the patient will likely expect an immediate response.
Notably, communication via the patient portal must still comply with the Health Insurance Portability and Accountability Act (HIPAA). This means that only authorized users are able to access records within the patient portal. To ensure compliance with HIPAA, all users should be instructed in the appropriate practices of maintaining patient privacy. This includes barring the use of shared passwords amongst multiple individuals, requiring that users enable an auto log-off setting, and programming work stations to turn off automatically after brief periods of nonuse. Further, all communications in the patient portal should be encrypted to prevent the patient’s sensitive information from being accessed in the event of an attempted security breach.
Finally, depending upon the practice, there may be instances in which someone other than the patient’s physician would be reading and responding to patient queries. In these situations, the patient should be informed of such potential. This way, if the communication is intended only for the physician, the patient will be afforded the opportunity to call the physician directly rather than communicate via the patient portal.
While the use of patient access portals is becoming far more prevalent, as they offer many practical benefits ranging from increased convenience and efficiency to enhanced patient care, they also carry the potential for increased liability exposure. As such, it is vital that physicians weigh all potential risks and benefits that are inherent in the use of patient access portals prior to making the decision to implement such technology.
Mr. Mills is an equity partner in Cunningham, Meyer & Vedrine, Chicago.
Ambulatory surgery centers 101: What new GIs need to know
Almost 20 years ago, I joined Digestive Disease Specialists in Oklahoma, where I am an owner in two ambulatory endoscopy centers (AECs). Through this experience, I’ve learned a thing or two about the advantages of these centers and what to consider when joining a practice that has ownership in an endoscopy center or an ambulatory surgery center (ASC).
ASCs – or in my case AECs – are highly specialized, modern health care facilities in which physicians provide safe, high-quality procedures to millions of Americans each year, including diagnostic and preventive procedures. ASCs and AECs allow us to provide a more convenient and cost-effective alternative to performing GI procedures in a hospital. As you can imagine, these facilities are a vital part of being an independent gastroenterologist.
Quality care at a lower cost
When looking into practices with ownership in surgery centers, quality of care is one of the most critical considerations. Each center must enter into an agreement with Medicare and meet its certification requirements, which are similar to those required for hospital outpatient departments. We also undergo accreditation by the Accreditation Association for Ambulatory Healthcare. And while not everyone participates in quality registries such as GIquic – which helps us define and refine our endoscopic outcomes – our AEC does because we put patient care first.
This focus on quality leads to better care. A 2016 study of Medicare claims in the Journal of Health Economics shows that ASCs and AECs, on average, provide higher-quality care for outpatient procedures than hospitals.1
We get into medicine because we care about patients and want to provide them with the best and most convenient care possible. Because we don’t have to operate in the context of a large hospital, we can be nimbler when it comes to patient needs. As is true in other areas, the more you specialize, the more effective and efficient you can become performing certain procedures. For instance, our practice is highly specialized in endoscopy. As a result, we can be highly efficient in the turnaround time in between patient procedures. This helps people get back to their daily lives as soon as possible, whereas patients may spend a lot more time waiting to have their procedure in the hospital setting.
Performing procedures in an ASC or AEC also helps us keep costs down, and we spend a lot of time educating policymakers about the role independent physicians play in lowering health care costs. According to a recent study in Health Affairs, hospital-based outpatient care prices grew at four times the rate of physician prices from 2007 to 2014.2 And the National Institute for Health Care Reform found that the average Medicare facility payment for a basic colonoscopy was more than twice as much in a hospital setting.3
The challenges and benefits of running an ASC or AEC
With consolidation of hospitals and insurance companies, operating an independent ASC or AEC has become more challenging. The players are bigger, providing more competition. Where we practice in Oklahoma, we are the only independent gastroenterologists. The way we have kept up is by diversifying the ancillary services we offer. This includes infusion center services, pathology, anesthesia, and research alongside our standard endoscopic and office/hospital-based practice.
As doctors, we are not typically trained on the business side of medicine, but when you own an ASC, you need to learn to be your own boss. You will need to understand the details of how the business operates, from relevant state and federal regulations to the supportive services that make the center run smoothly.
Gastroenterologists who are new to the field can and should ask questions of any practice they are considering joining about the buy-in process for ASCs and the path to becoming a partner. One of the things to consider is what kind of planning has gone into determining how many investors there are in the ASC. It is possible to have too many physician partners, but having too few could also present challenges. If there are too many physician owners, ownership interests could be diluted. On the flip side, if there aren’t many physician owners, it will be more expensive to buy in and there will be greater risk.
Another question to ask is if the practice partners with a hospital for its ASC or AEC. About one in four surgery centers have a hospital partner. This can be helpful with managed care contracting and concerns physicians may have about being excluded from having hospital privileges. Partnering with a hospital is not an indication of a successful center given there are still many surgery centers with hospital partners that are not run well or underperform.
While I have outlined some of the challenges of owning an ASC or AEC, physician ownership can be very attractive under the right circumstances. There are many benefits including having more control over your life. You get to set your own schedules and determine your patient load.
When physicians own the surgery center, we can control the schedule and the environment in the operating room. In a hospital, there is not much we can do if the operating room is not running efficiently. If our cases are bumped, the care of our patients is undermined. In our own surgery center, we can ensure that these things do not happen. We are able to provide our patients the best care possible.
When I look back over my time in our AEC, I wouldn’t change anything. Even though there may be challenges in running an AEC, I would advise young gastroenterologists to consider this path. Nothing worthwhile is easy, but the ability to provide the best care to our patients is its own reward.
References
1. Munnich E et al. J Health Economics, January 2018;57:147-67. https://doi.org/10.1016/j.jhealeco.2017.11.004.
2. Cooper Z et al. https://doi.org/10.1377/hlthaff.2018.05424. Health Affairs 2019;38(2).
3. Reschovsky J et al. NIHCR Research Brief No. 16. http://nihcr.org/wp-content/uploads/2016/07/Research_Brief_No._16.pdf. National Institute for Health Care Reform; June 2014.
Dr. Stokesberry is a practicing gastroenterologist at Digestive Disease Specialists in Oklahoma City and serves as an executive committee member of the Digestive Health Physicians Association.
Almost 20 years ago, I joined Digestive Disease Specialists in Oklahoma, where I am an owner in two ambulatory endoscopy centers (AECs). Through this experience, I’ve learned a thing or two about the advantages of these centers and what to consider when joining a practice that has ownership in an endoscopy center or an ambulatory surgery center (ASC).
ASCs – or in my case AECs – are highly specialized, modern health care facilities in which physicians provide safe, high-quality procedures to millions of Americans each year, including diagnostic and preventive procedures. ASCs and AECs allow us to provide a more convenient and cost-effective alternative to performing GI procedures in a hospital. As you can imagine, these facilities are a vital part of being an independent gastroenterologist.
Quality care at a lower cost
When looking into practices with ownership in surgery centers, quality of care is one of the most critical considerations. Each center must enter into an agreement with Medicare and meet its certification requirements, which are similar to those required for hospital outpatient departments. We also undergo accreditation by the Accreditation Association for Ambulatory Healthcare. And while not everyone participates in quality registries such as GIquic – which helps us define and refine our endoscopic outcomes – our AEC does because we put patient care first.
This focus on quality leads to better care. A 2016 study of Medicare claims in the Journal of Health Economics shows that ASCs and AECs, on average, provide higher-quality care for outpatient procedures than hospitals.1
We get into medicine because we care about patients and want to provide them with the best and most convenient care possible. Because we don’t have to operate in the context of a large hospital, we can be nimbler when it comes to patient needs. As is true in other areas, the more you specialize, the more effective and efficient you can become performing certain procedures. For instance, our practice is highly specialized in endoscopy. As a result, we can be highly efficient in the turnaround time in between patient procedures. This helps people get back to their daily lives as soon as possible, whereas patients may spend a lot more time waiting to have their procedure in the hospital setting.
Performing procedures in an ASC or AEC also helps us keep costs down, and we spend a lot of time educating policymakers about the role independent physicians play in lowering health care costs. According to a recent study in Health Affairs, hospital-based outpatient care prices grew at four times the rate of physician prices from 2007 to 2014.2 And the National Institute for Health Care Reform found that the average Medicare facility payment for a basic colonoscopy was more than twice as much in a hospital setting.3
The challenges and benefits of running an ASC or AEC
With consolidation of hospitals and insurance companies, operating an independent ASC or AEC has become more challenging. The players are bigger, providing more competition. Where we practice in Oklahoma, we are the only independent gastroenterologists. The way we have kept up is by diversifying the ancillary services we offer. This includes infusion center services, pathology, anesthesia, and research alongside our standard endoscopic and office/hospital-based practice.
As doctors, we are not typically trained on the business side of medicine, but when you own an ASC, you need to learn to be your own boss. You will need to understand the details of how the business operates, from relevant state and federal regulations to the supportive services that make the center run smoothly.
Gastroenterologists who are new to the field can and should ask questions of any practice they are considering joining about the buy-in process for ASCs and the path to becoming a partner. One of the things to consider is what kind of planning has gone into determining how many investors there are in the ASC. It is possible to have too many physician partners, but having too few could also present challenges. If there are too many physician owners, ownership interests could be diluted. On the flip side, if there aren’t many physician owners, it will be more expensive to buy in and there will be greater risk.
Another question to ask is if the practice partners with a hospital for its ASC or AEC. About one in four surgery centers have a hospital partner. This can be helpful with managed care contracting and concerns physicians may have about being excluded from having hospital privileges. Partnering with a hospital is not an indication of a successful center given there are still many surgery centers with hospital partners that are not run well or underperform.
While I have outlined some of the challenges of owning an ASC or AEC, physician ownership can be very attractive under the right circumstances. There are many benefits including having more control over your life. You get to set your own schedules and determine your patient load.
When physicians own the surgery center, we can control the schedule and the environment in the operating room. In a hospital, there is not much we can do if the operating room is not running efficiently. If our cases are bumped, the care of our patients is undermined. In our own surgery center, we can ensure that these things do not happen. We are able to provide our patients the best care possible.
When I look back over my time in our AEC, I wouldn’t change anything. Even though there may be challenges in running an AEC, I would advise young gastroenterologists to consider this path. Nothing worthwhile is easy, but the ability to provide the best care to our patients is its own reward.
References
1. Munnich E et al. J Health Economics, January 2018;57:147-67. https://doi.org/10.1016/j.jhealeco.2017.11.004.
2. Cooper Z et al. https://doi.org/10.1377/hlthaff.2018.05424. Health Affairs 2019;38(2).
3. Reschovsky J et al. NIHCR Research Brief No. 16. http://nihcr.org/wp-content/uploads/2016/07/Research_Brief_No._16.pdf. National Institute for Health Care Reform; June 2014.
Dr. Stokesberry is a practicing gastroenterologist at Digestive Disease Specialists in Oklahoma City and serves as an executive committee member of the Digestive Health Physicians Association.
Almost 20 years ago, I joined Digestive Disease Specialists in Oklahoma, where I am an owner in two ambulatory endoscopy centers (AECs). Through this experience, I’ve learned a thing or two about the advantages of these centers and what to consider when joining a practice that has ownership in an endoscopy center or an ambulatory surgery center (ASC).
ASCs – or in my case AECs – are highly specialized, modern health care facilities in which physicians provide safe, high-quality procedures to millions of Americans each year, including diagnostic and preventive procedures. ASCs and AECs allow us to provide a more convenient and cost-effective alternative to performing GI procedures in a hospital. As you can imagine, these facilities are a vital part of being an independent gastroenterologist.
Quality care at a lower cost
When looking into practices with ownership in surgery centers, quality of care is one of the most critical considerations. Each center must enter into an agreement with Medicare and meet its certification requirements, which are similar to those required for hospital outpatient departments. We also undergo accreditation by the Accreditation Association for Ambulatory Healthcare. And while not everyone participates in quality registries such as GIquic – which helps us define and refine our endoscopic outcomes – our AEC does because we put patient care first.
This focus on quality leads to better care. A 2016 study of Medicare claims in the Journal of Health Economics shows that ASCs and AECs, on average, provide higher-quality care for outpatient procedures than hospitals.1
We get into medicine because we care about patients and want to provide them with the best and most convenient care possible. Because we don’t have to operate in the context of a large hospital, we can be nimbler when it comes to patient needs. As is true in other areas, the more you specialize, the more effective and efficient you can become performing certain procedures. For instance, our practice is highly specialized in endoscopy. As a result, we can be highly efficient in the turnaround time in between patient procedures. This helps people get back to their daily lives as soon as possible, whereas patients may spend a lot more time waiting to have their procedure in the hospital setting.
Performing procedures in an ASC or AEC also helps us keep costs down, and we spend a lot of time educating policymakers about the role independent physicians play in lowering health care costs. According to a recent study in Health Affairs, hospital-based outpatient care prices grew at four times the rate of physician prices from 2007 to 2014.2 And the National Institute for Health Care Reform found that the average Medicare facility payment for a basic colonoscopy was more than twice as much in a hospital setting.3
The challenges and benefits of running an ASC or AEC
With consolidation of hospitals and insurance companies, operating an independent ASC or AEC has become more challenging. The players are bigger, providing more competition. Where we practice in Oklahoma, we are the only independent gastroenterologists. The way we have kept up is by diversifying the ancillary services we offer. This includes infusion center services, pathology, anesthesia, and research alongside our standard endoscopic and office/hospital-based practice.
As doctors, we are not typically trained on the business side of medicine, but when you own an ASC, you need to learn to be your own boss. You will need to understand the details of how the business operates, from relevant state and federal regulations to the supportive services that make the center run smoothly.
Gastroenterologists who are new to the field can and should ask questions of any practice they are considering joining about the buy-in process for ASCs and the path to becoming a partner. One of the things to consider is what kind of planning has gone into determining how many investors there are in the ASC. It is possible to have too many physician partners, but having too few could also present challenges. If there are too many physician owners, ownership interests could be diluted. On the flip side, if there aren’t many physician owners, it will be more expensive to buy in and there will be greater risk.
Another question to ask is if the practice partners with a hospital for its ASC or AEC. About one in four surgery centers have a hospital partner. This can be helpful with managed care contracting and concerns physicians may have about being excluded from having hospital privileges. Partnering with a hospital is not an indication of a successful center given there are still many surgery centers with hospital partners that are not run well or underperform.
While I have outlined some of the challenges of owning an ASC or AEC, physician ownership can be very attractive under the right circumstances. There are many benefits including having more control over your life. You get to set your own schedules and determine your patient load.
When physicians own the surgery center, we can control the schedule and the environment in the operating room. In a hospital, there is not much we can do if the operating room is not running efficiently. If our cases are bumped, the care of our patients is undermined. In our own surgery center, we can ensure that these things do not happen. We are able to provide our patients the best care possible.
When I look back over my time in our AEC, I wouldn’t change anything. Even though there may be challenges in running an AEC, I would advise young gastroenterologists to consider this path. Nothing worthwhile is easy, but the ability to provide the best care to our patients is its own reward.
References
1. Munnich E et al. J Health Economics, January 2018;57:147-67. https://doi.org/10.1016/j.jhealeco.2017.11.004.
2. Cooper Z et al. https://doi.org/10.1377/hlthaff.2018.05424. Health Affairs 2019;38(2).
3. Reschovsky J et al. NIHCR Research Brief No. 16. http://nihcr.org/wp-content/uploads/2016/07/Research_Brief_No._16.pdf. National Institute for Health Care Reform; June 2014.
Dr. Stokesberry is a practicing gastroenterologist at Digestive Disease Specialists in Oklahoma City and serves as an executive committee member of the Digestive Health Physicians Association.