A survey of colonoscopic polypectomy practices among clinical gastroenterologists

BACKGROUND: Polypectomy techniques vary in clinical practice. The aim of this study was to determine patterns of polypectomy practices in a random sample of gastroenterologists. METHODS: A total of 300 gastroenterologists were selected randomly from the membership directory of a professional society. They were asked to complete a standardized survey by telephone, electronic mail, or facsimile. RESULTS: The offices of 285 physicians were contacted successfully. A total of 189 (63%) chose to participate. 152 (80%) of these physicians were in private practice, and 37 (20%) were in academic practice. The mean number of years in practice was 15.5 (range 1-46 years). Forceps techniques (cold or hot) dominated other polypectomy methods for polyps 1 to 3 mm in size ( p < 0.0001), whereas electrosurgical snare resection was dominate for polyps 7 to 9 mm in diameter ( p < 0.0001). No method of polypectomy was significantly more likely to be used for polyps 4 to 6 mm in size. The proportion of physicians who had used dye spraying was 8.5%; detachable snares, 20.1%; clips, 20.1%; and submucosal saline solution injection, 82%. Of those who had used submucosal saline solution injection, 29.7% had no rules for its use, and, in the remainder, there was marked variation regarding the criteria. For polyp stalks greater than 1 cm in diameter, 69% used no method to prevent bleeding. Of those who did use preventive techniques, 76% used epinephrine injection. The electrosurgical current used for polypectomy was pure coagulation in 46%, blend in 46%, and pure-cut in 3%; 4% varied the current. CONCLUSIONS: At present, polypectomy technique among clinical gastroenterologists is highly variable. Some newer ancillary techniques have had extremely limited use thus far.     

A survey of perceptions and practices of complementary alternative medicine among Canadian gastroenterologists

BACKGROUND:

Despite a high prevalence of complementary alternative medicine (CAM) use among inflammatory bowel disease (IBD) patients, there is a dearth of information about the attitudes and perceptions of CAM among the gastroenterologists who treat these patients.

OBJECTIVE:

To characterize the beliefs, perceptions and practices of gastroenterologists toward CAM use in patients with IBD.

METHODS:

A web-based survey was sent to member gastroenterologists of the Canadian Association of Gastroenterology. The survey included multiple-choice and Likert scale questions that queried physician knowledge and perceptions of CAM and their willingness to discuss CAM with patients.

RESULTS:

Fifty-three per cent of respondents considered themselves to be IBD subspecialists. The majority (86%) of gastroenterologists reported that less than one-half of their patient population had mentioned the use of CAM. Only 8% of physicians reported initiating a conversation about CAM in the majority of their patient encounters. Approximately one-half (51%) of respondents were comfortable with discussing CAM with their patients, with lack of knowledge being cited as the most common reason for discomfort with the topic. Most gastroenterologists (79%) reported no formal education in CAM. While there was uncertainty as to whether CAM interfered with conventional medications, most gastroenterologists believed it could be effective as an adjunct treatment.

CONCLUSION:

Our findings demonstrate that gastroenterologists were hesitant to initiate discussions about CAM with patients. Nearly one-half were uncomfortable or only somewhat comfortable with the topic, and most may benefit from CAM educational programs. Interestingly, most respondents appeared to be receptive to CAM as adjunct therapy alongside conventional IBD treatment.     

Survey of perceptions and practices among Canadian gastroenterologists regarding the prevention of venous thromboembolism for hospitalized inflammatory bowel disease patients

BACKGROUND:

Patients with inflammatory bowel disease (IBD) who are hospitalized with disease flares are known to be at an increased risk of venous thromboembolism (VTE). This is a preventable complication; however, there is currently no standardized approach to the prevention and management of VTE.

OBJECTIVES:

To characterize the opinions and general prophylaxis patterns of Canadian gastroenterologists and IBD experts.

METHODS:

A survey questionnaire was sent to Canadian gastroenterologists affiliated with a medical school or IBD referral centre. Participants were required to be practicing physicians who had completed all of their training and had been involved in the care of IBD patients within the previous 12 months. Various clinical scenarios were presented and demographic data were solicited.

RESULTS:

The majority of respondents were practicing in an academic setting (95%) and considered themselves to be IBD experts or subspecialists (71%). Eighty-three per cent reported providing VTE prophylaxis most, if not all of the time, and most (96%) used pharmacological prophylaxis alone, usually heparin or one of its analogues. There was less consistency among respondents with respect to whether IBD patients in remission, but admitted for another condition, should be given prophylaxis. There was also less agreement regarding the duration of anticoagulation in patients with confirmed VTE.

CONCLUSION:

There was a general consensus among academic gastroenterologists that IBD inpatients are at an increased risk for VTE and would benefit from VTE prophylaxis. However, areas of uncertainty still exist and the IBD community would benefit from evidence-based clinical practice guidelines to standardize the management of this important problem.     

Defensive medicine practices among gastroenterologists in Japan

INTRODUCTIONThe number of negligence claims against physicians is increasing continuously, not only in Western countries but also in Japan[1-9], where a 10-fold increase in malpractice litigations, from 102 to 1019 cases per year, was observed between 196…     

A survey of Canadian gastroenterologists about the management of Barrett's esophagus.

The aims of the present study were to determine practice patterns of Canadian gastroenterologists for screening patients with Barrett's esophagus and to compare current practice patterns with published guidelines. A secondary goal was to evaluate whether gastroenterologists recommend a "once in a lifetime" endoscopy for patients with chronic gastroesophageal reflux disease. A structured questionnaire regarding screening for Barrett's esophagus was sent to members of the Canadian Association of Gastroenterology. The overall response rate was 51% (203 of 396). Of the 203 respondents, 165 (81%) performed endoscopies in adults and form the basis of this report. The majority of Canadian gastroenterologists followed published guidelines, with 62% screening patients without dysplasia every two years. Patients with low grade dysplasia were screened more frequently, with 54% of respondents performing endoscopy every six months, and 35% on a yearly basis. Biopsy protocols showed the greatest variation, with 46% of gastroenterologists taking four-quadrant biopsies at 2 cm intervals along the columnar-lined (Barrett's) esophagus. Seventy-six per cent of gastroenterologists agreed that all patients with chronic gastroesophageal reflux should have a "once in a lifetime" endoscopy to screen for Barrett's esophagus. The majority of Canadian gastroenterologists follow current guidelines for the management of Barrett's esophagus and support the concept of "once in a lifetime" endoscopy.     

Medical management of inflammatory bowel disease among Canadian gastroenterologists

BACKGROUND:

Little is known about physician perceptions of and practices in using infliximab – a biological agent that was approved in Canada for the treatment of Crohn’s disease in 2001, and for ulcerative colitis in 2006.

OBJECTIVES:

To describe Canadian gastroenterologists’ use and perceptions of infliximab in the treatment of refractory inflammatory bowel disease (IBD), and to identify factors that may influence a gastroenterologist’s decision to initiate infliximab therapy.

METHODS:

A postal questionnaire was distributed to all practicing clinicians captured in the 2007 membership of the Canadian Association of Gastroenterology. Each physician was contacted up to a maximum of three times.

RESULTS:

Of 466 questionnaires mailed out, responses were received from 336 (72%), with 292 respondents (63%) returning fully completed surveys. For 80% of respondents, IBD patients comprised less than 30% of their clinical practice. Most prescribed infliximab at an initial dose of 5 mg/kg (97%), prescribed loading doses at 0, 2 and 6 weeks (88%), premedicated with corticosteroids (74%), administered maintenance infusions at eight-week intervals (89%), co-administered immunosuppressive agents (81%) and continued infliximab ‘indefinitely’ as long as it was effective and well tolerated (76%). Most gastroenterologists (>70%) identified lack of drug insurance coverage and provincial funding criteria as important barriers to prescribing infliximab.

CONCLUSIONS:

Most Canadian gastroenterologists exhibited similar practice patterns with respect to the use of infliximab for induction and maintenance therapy of IBD. Common barriers to the initiation of infliximab therapy were identified.     

Training and certifying gastroenterologists as physician nutrition specialists

Because nutrition is an integral aspect of the science and practice of gastroenterology, all gastroenterology fellows should receive training in core aspects of nutrition (level 1 training). Some gastroenterologists also wish to train more extensively in nutrition (level 2) and become physician nutrition specialists. The Intersociety Professional Nutrition Education Consortium, composed of representatives from eight national societies with significant nutrition interests, including the American Gastroenterological Association, and three credentialing bodies, has developed a paradigm and training requirements for physician-nutrition specialists that recognizes their varied backgrounds and areas of interest. Opportunities exist for gastroenterology fellows to obtain physician nutrition specialist training within their gastroenterology fellowships and to be eligible to take the Certification Examination for Physician Nutrition Specialists offered by the new American Board of Physician Nutrition Specialists.* This article reviews the development of consensus on subspecialty training for physicians in nutrition; it also encourages directors of gastroenterology fellowships to develop training opportunities and gastroenterology fellows to consider identifying nutrition as an area of emphasis for their careers.     

Use of fecal occult blood test in hospitalized patients: Survey of physicians practicing in a large central Canadian health region and Canadian gastroenterologists

BACKGROUND:

Although the fecal occult blood test (FOBT) was developed for colorectal cancer screening in the outpatient setting, it continues to be used among hospitalized patients. No previous study has evaluated the knowledge, beliefs and attitudes of practicing physicians on the use of FOBT among hospitalized patients and compared practices among physicians with different medical specialty training.

OBJECTIVE:

To survey physicians in the Winnipeg Regional Health Authority (WRHA) and Canadian gastroenterologists (GIs) on the use of FOBT in hospitals.

METHODS:

A survey was distributed by e-mail to internists (n=198), emergency medicine (EM) physicians (n=118), general surgeons (n=47) and family medicine (FM) physicians with admitting privileges (n=29) in the WRHA. Canadian GIs were surveyed through the membership database of the Canadian Association of Gastroenterology (CAG) (n=449). The survey included items regarding demographics of the respondents and their current use of FOBT in hospitals.

RESULTS:

Response rates ranged from 18% among CAG members to 69% among FM physicians in the WRHA. General internal medicine, general surgeon and GI respondents were less likely to order a FOBT and less likely to believe that an FOBT was useful in assessing emergency room or hospitalized patients when compared with FM and EM respondents (P<0.001). The most common indications for ordering a FOBT were black stools and anemia with and without iron deficiency. Two-thirds of EM physicians preferred point-of-care testing rather than laboratory reporting of FOBT.

CONCLUSIONS:

The present survey suggests that FOBTs are commonly used in hospitals by EM and FM physicians for indications such as anemia and black stools.     

A survey of Canadian gastroenterologists about the use of methotrexate in patients with Crohn's disease.

BACKGROUND: Methotrexate (MTX) is effective in remission induction and maintenance in steroid-dependent Crohn's disease (CD), but is often considered to be a second-line immunosuppressive agent, to be used in cases of failure or intolerance to azathioprine (AZA) or 6-mercaptopurine (6-MP). This may be related to concerns about hepatotoxicity, but this adverse effect is rare in monitored CD patients taking MTX. Still, there are no guidelines for monitoring patients with CD on MTX, and physicians must decide based on rheumatological literature about how to monitor their patients. PURPOSE: To determine the patterns of MTX use in patients with CD by Canadian gastroenterologists, examining the reasons for choosing MTX versus AZA/6-MP, the doses and routes of administration of MTX, and how patients on MTX are monitored, including the use of liver biopsy. METHODS: A self-report survey was sent to physician members of the Canadian Association of Gastroenterology, with a second mailing three months later to increase response rate. RESULTS: Of 490 surveys mailed, a 54.9% response rate was achieved. Of adult gastroenterologists, 60.7% stated they never use MTX as a first-line immunosuppressive agent, and 33.3% never use MTX at all. The most common reasons for choosing MTX were a contraindication to the use of AZA/6-MP (43.7%) and patient preference (22.5%). MTX is used intramuscularly in 41.5%, subcutaneously in 31.8%, and orally in 26.7% of patients. The most common dose used for remission induction was 25 mg/week (84.2%; range 7.5 mg/week to 50 mg/week; three responders used more frequent dosing than weekly) and for remission maintenance was 15 mg/week (55.4%; range 7.5 mg/week to 50 mg/week; three responders used more frequent dosing than weekly). Most responders checked a liver profile and complete blood count at baseline and serially. Of those who used MTX, 26.5% routinely performed liver biopsy after an accumulated dose of MTX had been taken (usually 1 g to 2 g), 57.7% sometimes performed liver biopsy, and 16.8% never performed liver biopsy. Of pediatric gastroenterologists, 17.6% never used MTX, but those who used it prescribed it subcutaneously (80.0%) more often than intramuscularly (17.5%) or orally (2.5%). CONCLUSIONS: MTX was used as a first-line immunosuppressive agent in patients with CD by a minority of Canadian gastroenterologists. When used, there is variability in how MTX is prescribed and monitored. Although hepatotoxicity is rare, liver biopsy was performed frequently and probably often unnecessarily.     

Survey of the opinions, knowledge, and practices of gastroenterologists regarding colorectal cancer screening and use of the fecal occult blood test

OBJECTIVES: Primary care physicians and internal medicine residents have poor understanding of colorectal cancer screening and the use of fecal occult blood tests. If acceptance and implementation of colorectal cancer screening is to improve, gastroenterologists may have to take a more leading role in the education of their primary care colleagues, physicians in training, and the general public. However, before this can be recommended, it is necessary to determine how closely gastroenterologists follow currently recommended guidelines and how they use fecal occult blood tests. METHODS: We mailed a two-page, structured questionnaire about colorectal cancer screening and use of fecal occult blood tests to 8000 randomly selected gastroenterologists in the United States. RESULTS: We received responses from 24% of the gastroenterologists. Almost all used fecal occult blood tests in the office setting, 86% on stool obtained at rectal examination. The test was frequently used for reasons other than colorectal cancer screening, and often without adequate patient instruction on dietary and medication restrictions. Of the respondents, 98% commenced screening at age < or = 50 yr, whereas 37% either continued screening into advanced age or never stopped. Annual fecal occult blood testing with flexible sigmoidoscopy every 5 yr was the screening strategy recommended by 71% of the respondents, whereas 25% recommended colonoscopy every 10 yr. However, 77% of the gastroenterologists chose colonoscopy for personal colorectal cancer screening. CONCLUSIONS: Gastroenterologists usually give appropriate advice on colorectal cancer screening but often misuse fecal occult blood tests. This may produce excessively high false-positive screening rates, leading to unnecessary diagnostic testing without apparent benefit.     

Long-term management of patients with celiac disease: Current practices of gastroenterologists in Canada

BACKGROUND:

Long-term follow-up of patients with celiac disease is important for monitoring their clinical status, dietary compliance and complications.

AIM:

To examine the current practices of Canadian gastroenterologists providing long-term care to patients with celiac disease.

METHODS:

All gastroenterologists in Canada (n=585) were surveyed regarding their practice demographics, familiarity with celiac disease practice guidelines, and follow-up clinical examination and investigations.

RESULTS:

Of the 585 surveys mailed to gastroenterologists, 567 were expected to be returned. A total of 242 completed surveys (43%) were received. Of these, 237 (184 adult, 51 pediatric and two mixed) had an active practice that included patients with celiac disease. Long-term follow-up care was provided routinely by 76% of respondents. Follow-up consisted of annual clinic visits (67%), dietary review (77%), reinforcement of the need for adherence to a gluten-free diet (90%) and recommending membership in an advocacy group (65%). Physical examination was performed by 78%; most ordered laboratory tests including serology (65%).Adult gastroenterologists performed routine follow-up intestinal biopsy more often than their pediatric counterparts (46% versus 10%), but performed serology less frequently (48% versus 86%). Pediatric patients were more likely to be followed by a multidisciplinary team. All pediatric gastroenterologists were familiar with at least one celiac disease practice guideline, whereas 15% of adult gastroenterologists were not familiar with any practice guideline. The majority of gastroenterologists who did not routinely provide follow-up expected care to be provided by the patient’s primary physician (86%).

CONCLUSIONS:

Most gastroenterologists in Canada who responded to the survey provided long-term follow-up care to patients with celiac disease. The diverse practices reported underscore the need to develop consensus-based guidelines for long-term care of these patients.     

Measurement of faecal fat excretion: an evaluation of attitudes and practices of Australian gastroenterologists

BACKGROUND: Although faecal fat excretion over 72 h is the gold standard for quantifying fat malabsorption, there has been a push from chemical pathology laboratories to discontinue this test, arguing that it is unreliable and of limited clinical value. AIMS: To assess attitudes, knowledge and practices of Australian gastroenterologists in relation to the test and to gauge opinion as to whether it should remain available. METHODS: A self-administered questionnaire was developed to assess attitudes towards, patterns of use and understanding of 72-h faecal fat collections. This was posted to all members of the Gastroenterological Society of Australia. RESULTS: Of 429 eligible gastroenterologists, 124 (29%) responded. Eighty-two per cent utilized the test; 62% at least once per year. Main indications were suspected steatorrhoea (55%), unexplained chronic diarrhoea (39%) or weight loss (29%). Thirty-eight per cent ordered the test to determine stool volume. Only 26% attempted to appropriately fat load patients and approximately half did not recognize the potential influence of medications and stool volume. This was also reflected in poor interpretation of results in specific clinical scenarios. Of those who use the test at least once per year, 97% wanted its continued availability and 51% felt their practice would be significantly affected if the test was discontinued. CONCLUSIONS: Although continued availability of 72-h faecal fat estimation is supported by many Australian gastroenterologists, the test appears to be often performed and interpreted suboptimally. Rather than discard the test, efforts should more appropriately be directed to improving baseline knowledge to ensure its optimal performance and interpretation.     

Defensive medicine practices among gastroenterologists in Lombardy: Between lawsuits and the economic crisis

BackgroundDefensive medicine is becoming more frequent behaviour and has an impact on the economic ‘health’ of national healthcare systems.AimThe aim of this study was to clarify the impact of defensive medicine on gastroenterological practices in Lombardy.MethodsGastroenterologists attending the Lombardy Annual Gastroenterological Conference received a questionnaire based on multiple choice tests and visual analogue scales. The questionnaire was divided into three parts evaluating the respondent's characteristics, the number of procedures prescribed, and the percentage of those performed with a defensive purpose.ResultsSixty-four of 107 participants (60%) completed the questionnaire, 94% of whom reported practising defensive medicine. The percentage of defensively requested procedures amounted to 18% of all digestive endoscopies, 8.9% of abdominal ultrasonography scans, 4.9% of abdominal computed tomography or magnetic resonance scans, and 12.2% of all consultations. The total number of defensive procedures prescribed per month by the participants was 878, and 31.7% of the performed procedures (n = 4897) were reported to defensively based. On the basis of the 2012 regional reimbursement fees, the yearly cost of defensive procedures prescribed and/or performed by all gastroenterologists in Lombardy was estimated to be € 8,637,835.ConclusionsOur findings indicate that defensive medicine profoundly affects current medical practices among gastroenterologists, and has a considerable economic impact.     

The Canadian Celiac Health Survey

The purpose of this study was to characterize the diagnostic process, frequency of associated disorders, family history, and impact of a gluten-free diet in individuals with celiac disease. All members of the Canadian Celiac Association (n=5240) were surveyed with a questionnaire. Respondents included 2681 adults with biopsy-proven celiac disease. The mean age was 56 years. Most common presenting symptoms included abdominal pain (83%), diarrhea (76%), and weight loss (69%). The mean delay in diagnosis was 11.7 years. Diagnoses made prior to celiac disease included anemia (40%), stress (31%), and irritable bowel syndrome (29%). Osteoporosis was common. Prior to diagnosis, 27% of respondents consulted three or more doctors about their symptoms. Delays in diagnosis of celiac disease remain a problem. Associated medical conditions occur frequently. More accurate food labeling is needed. Improved awareness of celiac disease and greater use of serological screening tests may result in earlier diagnosis and reduced risk of associated conditions.