Gastroenterology

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https://hdl.handle.net/20.500.14709/74

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P177 Structured pre-accreditation training improves the pass-rate of the bowel cancer screeners examination, enjoyment of colonoscopy, and key performance outcomes
(BMJ Publishing Group, 2024-07-01) Pohl, Keith; Smaldon, Chrissie; Taylor, Charlotte; Feeney, Mark; Dunckley, Paul; Dunckley, Paul; Medical and Dental
No abstract available
Quantifying the cost savings and health impacts of improving colonoscopy quality: an economic evaluation
(BMJ Publishing Group, 2024-06-26) McCarthy, Stephen; Rutter, Matthew; McMeekin, Peter; Catlow, Jamie; Sharp, Linda; Brookes, Matthew; Valori, Roland; Bhardwaj-Gosling, Rashmi; Lee, Tom; McNally, Richard; McCarthy, Andrew; Gray, Joanne; Valori, Roland; Medical and Dental
Objective: To estimate and quantify the cost implications and health impacts of improving the performance of English endoscopy services to the optimum quality as defined by postcolonoscopy colorectal cancer (PCCRC) rates. Design: A semi-Markov state-transition model was constructed, following the logical treatment pathway of individuals who could potentially undergo a diagnostic colonoscopy. The model consisted of three identical arms, each representing a high, middle or low-performing trust's endoscopy service, defined by PCCRC rates. A cohort of 40-year-old individuals was simulated in each arm of the model. The model's time horizon was when the cohort reached 90 years of age and the total costs and quality-adjusted life-years (QALYs) were calculated for all trusts. Scenario and sensitivity analyses were also conducted. Results: A 40-year-old individual gains 0.0006 QALYs and savings of £6.75 over the model lifetime by attending a high-performing trust compared with attending a middle-performing trust and gains 0.0012 QALYs and savings of £14.64 compared with attending a low-performing trust. For the population of England aged between 40 and 86, if all low and middle-performing trusts were improved to the level of a high-performing trust, QALY gains of 14 044 and cost savings of £249 311 295 are possible. Higher quality trusts dominated lower quality trusts; any improvement in the PCCRC rate was cost-effective. Conclusion: Improving the quality of endoscopy services would lead to QALY gains among the population, in addition to cost savings to the healthcare provider. If all middle and low-performing trusts were improved to the level of a high-performing trust, our results estimate that the English National Health Service would save approximately £5 million per year.
Cost-Effectiveness of Regular Surveillance Versus Endoscopy at Need for Patients With Barrett’s Esophagus: Economic Evaluation Alongside the Barrett’s Oesophagus Surveillance Study (BOSS) Randomized Controlled Trial
(Elsevier, 2025-05-15) Deidda, Manuela; Old, Oliver; Jankowski, Janusz; Attwood, Stephen; Stokes, Clive; Kendall, Catherine; Rasdell, Cathryn; Zimmermann, Alex; Massa, Sofia; Love, Sharon; Sanders, Scott; Hapeshi, Julie; Foy, Chris; Briggs, Andrew; Barr, Hugh; Moayyedi, Paul; Old, Oliver; Stokes, Clive; Kendall, Catherine; Rasdell, Cathryn; Hapeshi, Julie; Foy, Chris; Barr, Hugh; Medical and Dental; Additional Professional Scientific and Technical; Admin and Clerical
Background & aims: The Barrett's Oesophagus Surveillance Study (BOSS) was the first randomized study of surveillance. This study reports the costs and quality of life outcomes from the BOSS trial and models the outcomes and cost-effectiveness of surveillance beyond the follow-up period of the BOSS study. This trial showed similar stages and rates of esophageal cancer in both arms, but the regular surveillance arm did identify more high-grade dysplasia after a median of 12.8 years follow-up. Methods: We used a decision tree model based on results from BOSS to conduct a cost-effectiveness analysis of costs and quality-adjusted life years (QALYs). A Markov model was used to extrapolate costs and outcomes over a further 10 years after the trial had ended, representing a 22.8-year time horizon. The proportion with high-grade dysplasia and QALYs was derived from the randomized trial. Results: The total costs associated with 2-yearly surveillance was $5309 vs $3182 in the at-need arm. Total QALYs in the 2-yearly endoscopy arm were 8.647 compared with 8.629 in the at-need arm. Compared with at-need endoscopy, 2-yearly surveillance costs $115,563/QALY gained. In the sensitivity analyses around assumptions on the proportion of high-grade dysplasia that is undetected in the at-need endoscopy arm, surveillance had an incremental cost effectiveness ratio of $94,513/QALY for the best-case and $146,272/QALY for the worst-case scenario. Conclusion: Barrett's esophagus surveillance every 2 to 3 years is unlikely to be a cost-effective strategy. Guidelines should take this into account when deciding surveillance intervals.
Non hepatic hyperammonaemia: a case series
(BMJ Publishing Group, 2024-11-07) Nye, Charles; di Mambro, Alex; Renowden, Shelley; Rice, Claire; Nye, Charles; di Mambro, Alex; Medical and Dental
Hyperammonaemia is a reversible cause of encephalopathy and can mimic of several neurological conditions. The diagnosis may be delayed, particularly if liver function tests are normal. We present a case series of adult non-hepatic hyperammonaemia patients highlighting the importance of testing ammonia levels in patients with cryptogenic neurological disease and the consideration of multiple causes including iatrogenic elevation secondary to sodium valproate, gastrointestinal and urinary causes of hyperammonaemia. None had a urea cycle disorder, as such there is little evidence on how best to manage these patients. We summarise the treatments used in these cases and the patient’s outcome.
Nationally Automated Colonoscopy Performance Feedback Increases Polyp Detection: The NED APRIQOT Randomized Controlled Trial
(Elsevier, 2024-05-15) Catlow, Jamie; Sharp, Linda; Wagnild, Janelle; Lu, Liya; Bhardwaj-Gosling, Rashmi; Ogundimu, Emmanuel; Kasim, Adetayo; Brookes, Matthew; Lee, Thomas; McCarthy, Stephen; Gray, Joanne; Sniehotta, Falko; Valori, Roland; Westwood, Claire; McNally, Richard; Ruwende , Josephine; Sinclair, Simon; Deane, Jill; Rutter, Matt; Valori, Roland; Medical and Dental
Background & aims: Postcolonoscopy colorectal cancer incidence and mortality rates are higher for endoscopists with low polyp detection rates. Using the UK's National Endoscopy Database (NED), which automatically captures real-time data, we assessed if providing feedback of case-mix-adjusted mean number of polyps (aMNP), as a key performance indicator, improved endoscopists' performance. Feedback was delivered via a theory-informed, evidence-based audit and feedback intervention. Methods: This multicenter, prospective, NED Automated Performance Reports to Improve Quality Outcomes Trial randomized National Health Service endoscopy centers to intervention or control. Intervention-arm endoscopists were e-mailed tailored monthly reports automatically generated within NED, informed by qualitative interviews and behavior change theory. The primary outcome was endoscopists' aMNP during the 9-month intervention. Results: From November 2020 to July 2021, 541 endoscopists across 36 centers (19 intervention; 17 control) performed 54,770 procedures during the intervention, and 15,960 procedures during the 3-month postintervention period. Comparing the intervention arm with the control arm, endoscopists during the intervention period: aMNP was nonsignificantly higher (7%; 95% CI, -1% to 14%; P = .08). The unadjusted MNP (10%; 95% CI, 1%-20%) and polyp detection rate (10%; 95% CI, 4%-16%) were significantly higher. Differences were not maintained in the postintervention period. In the intervention arm, endoscopists accessing NED Automated Performance Reports to Improve Quality Outcomes Trial webpages had a higher aMNP than those who did not (aMNP, 118 vs 102; P = .03). Conclusions: Although our automated feedback intervention did not increase aMNP significantly in the intervention period, MNP and polyp detection rate did improve significantly. Engaged endoscopists benefited most and improvements were not maintained postintervention; future work should address engagement in feedback and consider the effectiveness of continuous feedback.
National census of UK endoscopy services in 2023
(BMJ Publishing Group, 2024-10-29) Bendall, Oliver; Pohl, Keith; Siau, Keith; Dodds, Phedra; Feeney, Mark; Butler, Jessica; Bano, Madeline; Cullinan, Daniel; Griffiths, Helen; Mills, Sarah; Jarvis, Mark; Dunckley, Paul; Rutter, Matt; Dunckley, Paul; Medical and Dental
Background The Joint Advisory Group on Gastrointestinal Endoscopy (JAG) conducts a biennial census of UK endoscopy services. The 2023 census aimed to assess the current status of endoscopy services and compare them with pre-pandemic census benchmark data. Methods An electronic survey was sent to all JAG participating services in April 2023. Key domains included activity, waiting times, workforce and safety. Whole census and service level paired comparison was made with 2019 census data. Results There were 334 census responses representing 443 JAG-participating services (86.7% response rate). NHS services were operating at 110% of pre-pandemic activity levels. In the first 3 months of 2023, 53.6% of NHS services met urgent suspected cancer waiting time targets, 26.5% met routine waits and 26.2% met surveillance waits. The proportion of NHS services meeting all three targets decreased from 40.9% to 21.9% between 2019 and 2023. Compared with 2019, the proportion of independent sector activity has significantly increased. Insourcing activity has significantly increased and is being used by 57.9% of NHS services. Staff shortages were the most cited reasons for services not meeting waiting time targets or providing training. Absence through sickness rates for Band 2–6 nursing and healthcare support workers were significantly higher in 2023 compared with 2019 (p<0.001). Conclusion The 2023 census presents a system under strain. While overall activity is above pre-pandemic levels, this is set against workforce concerns, increasing staff absences and reliance on insourcing for additional activity. This census re-emphasises the need to proactively plan for rising demand, while maximising all current available resources.
Hemospray® (hemostatic powder TC-325) as monotherapy for acute gastrointestinal bleeding: a multicenter prospective study
(Hellenic Society of Gastroenterology, 2024-06-20) Papaefthymiou, Apostolis; Aslam, Nasar; Hussein, Mohamed; Alzoubaidi, Durayd; Gross, Seth; De La Serna, Alvaro; Varbobitis, Ioannis; Hengehold, Tricia; Fraile López, Miguel; Ortiz Fernández-Sordo, Jacobo; Rey, Johannes; Hayee, Bu; Despott, Edward; Murino, Alberto; Moreea, Sulleman; Boger, Phil; Dunn, Jason; Mainie, Inder; Mullady, Daniel; Early, Dayna; Latorre, Melissa; Ragunath, Krish; Anderson, John; Bhandari, Pradeep; Goetz, Martin; Kiesslich, Ralf; Coron, Emmanuel; Rodríguez De Santiago, Enrique; Gonda, Tamas; O'Donnell, Michael; Norton, Benjamin; Telese, Andrea; Simons-Linares, Roberto; Haidry, Rehan; Anderson, John; Medical and Dental
Background: Hemostatic powders are used as second-line treatment in acute gastrointestinal (GI) bleeding (AGIB). Increasing evidence supports the use of TC-325 as monotherapy in specific scenarios. This prospective, multicenter study evaluated the performance of TC-325 as monotherapy for AGIB. Methods: Eighteen centers across Europe and USA contributed to a registry between 2016 and 2022. Adults with AGIB were eligible, unless TC-325 was part of combined hemostasis. The primary endpoint was immediate hemostasis. Secondary outcomes were rebleeding and mortality. Associations with risk factors were investigated (statistical significance at P≤0.05). Results: One hundred ninety patients were included (age 51-81 years, male: female 2:1), with peptic ulcer (n=48), upper GI malignancy (n=79), post-endoscopic treatment hemorrhage (n=37), and lower GI lesions (n=26). The primary outcome was recorded in 96.3% (95% confidence interval [CI]: 92.6-98.5) with rebleeding in 17.4% (95%CI 11.9-24.1); 9.9% (95%CI 5.8-15.6) died within 7 days, and 21.7% (95%CI 15.6-28.9) within 30 days. Regarding peptic ulcer, immediate hemostasis was achieved in 88% (95%CI 75-95), while 26% (95%CI 13-43) rebled. Higher ASA score was associated with mortality (OR 23.5, 95%CI 1.60-345; P=0.02). Immediate hemostasis was achieved in 100% of cases with malignancy and post-intervention bleeding, with rebleeding in 17% and 3.1%, respectively. Twenty-six patients received TC-325 for lower GI bleeding, and in all but one the primary outcome was achieved. Conclusions: TC-325 monotherapy is safe and effective, especially in malignancy or post-endoscopic intervention bleeding. In patients with peptic ulcer, it could be helpful when the primary treatment is unfeasible, as bridge to definite therapy.
P33 ERCP nurse specialist reduces late cancellations
(BMJ Publishing Group, 2024-07-01) Betancor Jimenez, Veronica; Sinha, Ashish; Brooklyn, Trevor; Betancor Jimenez, Veronica; Sinha, Ashish; Brooklyn, Trevor; Nursing and Midwifery Registered; Medical and Dental
No abstract available
Duty of Candour legislation in post-colonoscopy colorectal cancer: a prospective cohort study
(Thieme Gruppe, 2024-10-16) Saunsbury, Emma; Burr, Nicholas; Beaton, David; McSweeney, Kate; Mason-Higgins, Jo; Trudgill, Nigel; Morris, Eva; Valori, Roland; Mason-Higgins, Jo; Valori, Roland; Admin and Clerical; Medical and Dental
This study investigated the application of Duty of Candour (DoC) legislation in the context of post-colonoscopy colorectal cancers (PCCRCs). DoC mandates transparent disclosure of notifiable safety incidents to patients in the English National Health Service, including incidences leading to severe or moderate harm. This study aimed to analyze the application of DoC in PCCRCs, improve understanding of the legislation, and identify challenges in DoC implementation.A national audit of PCCRCs was conducted between September 2021 and May 2022. PCCRCs were identified using linked administrative datasets, and root-cause analyses were performed using structured templates. "Avoidability" and harm were categorized into specific levels, and guidance was provided on improving consistency in judgments.16% of 1724 PCCRCs resulted in major harm or death, of which 27% (75) were probably or definitely avoidable. Hospitals deemed DoC discharge necessary in only 53% of these cases. When including moderate harm, 11% of all PCCRCs would trigger DoC discharge, yet this was deemed necessary in only 45% of such cases.There is inconsistent application of DoC in PCCRC cases. Challenges include determining "avoidability" and harm, particularly when diagnosis is delayed. Clearer guidance and definitions of harm are needed to improve adherence to regulations.
Clinical endoscopist up-skilling using an existing training programme for general practitioners in Gastroenterology – Experiences from the South West
(BMJ Publishing Group, 2024-07-01) Pohl, Keith; Howden, Adam; Feeney, Mark; Taylor, Charlotte; Dunckley, Paul; Howden, Adam; Dunckley, Paul; Medical and Dental
Abstract Introduction Despite making up only 12% of the endoscopist workforce, Clinical Endoscopists (CEs) undertake almost a quarter of endoscopies nationwide. April 2023 saw the end of the Health Education England (HEE) nationally co-ordinated clinical endoscopist training programme, with funding diverted to individual training academies. The South West Endoscopy Training Academy (SWETA) supports CEs in acute trusts across the South West of England in both their training and continued professional development. SWETA also funds a regional training programme for General Practitioners (GPs) with Extended Roles (GPwER), which is currently training 5 GPs. Alongside their clinical training, the GPs complete a comprehensive online educational programme. To enhance their knowledge base and clinical decision making, this online educational programme has been offered to qualified CEs. We present their feedback and knowledge attainment from the programme. Methods Clinical endoscopists from across the SW were invited to join the GPwER Upper and Lower GI online modules. Each module consists of a pre-module assessment to gauge knowledge, live online lectures, interactive case-studies, written assignments and an end-of-module assessment. Data collected from delegates includes pre- and post- module assessment scores, module completion rates, and subjective feedback from delegates on the online platform, course organisation and the impact of the training on knowledge and confidence. Wilcoxon rank test is used to identify significant differences in assessment scores from before and after each module. Feedback data is presented narratively. Results 10 CEs joined the Upper GI module, and 12 joined the Lower GI module. 80% (n=8) completed the Upper GI, and 83% (n=10) completed the Lower GI module. The mean pre-module assessment score among the CEs was 52.38% in the Upper GI module and 45.20% in the lower GI module. The online training led to significantly improved mean scores of 74.13% (p=0.014) and 70.80% (p=0.009) respectively. Both modules received unanimously positive feedback, with all elements rated at least 4.5 out of 5. In particular, candidates felt that the modules had increased their knowledge of common presentations and conditions, and that the knowledge gained would directly enhance their daily clinical practice. The online platform and course organisation was also unanimously praised. Conclusions Clinical endoscopists provide an essential service, performing high-quality endoscopy across the UK. We describe a novel way of enhancing their clinical knowledge and decision-making by utilising an existing training programme for GPwERs. By allowing CEs to complete elements of this programme we have demonstrated objective and subjective improvements in their clinical knowledge without any additional cost or time outlay. Furthermore our online platform is highlighted as an accessible and easy way of accessing training.
P185 Artificial intelligence in colonoscopy: real world experience from the southwest endoscopy group
(BMJ Publishing Group, 2024-07-01) Anderson, Rebecca; Materacki, Luke; Zeino, Zeino; Dharmasiri, Suranga; Anderson, Rebecca; Materacki, Luke; Medical and Dental
Introduction Between 2011 and 2013 post-colonoscopy colorectal cancer (PCCRC) rates in NHS England were 6.5%.1Artificial Intelligence (AI) has been shown to improve polyp detection rates (PDR) and reduce miss rates.2 AI-assisted polyp detection systems (AI-PDS) are likely to play a key role if we are to achieve an aspirational PCCRC target of 3.6%. This study looks at real world usability and experience of deployment at 3 NHS Trusts. Methods Three AI-PDS (A, B & C) were consecutively evaluated at each site for 2 months (site 3 did not assess C). A and B fed into the existing monitor but C had its own screen. Only B required network connection. At least 3 endoscopists were recruited at each site. Each unit received training prior to evaluation. At the end of each assessment, endoscopists and unit managers completed a survey reviewing usability and deployment experience respectively. Results Thirty endoscopist surveys and 8 manager surveys were returned. Responses are summarised in table 1

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