Guideline

Open-access endoscopy

Digestive endoscopy is a resource-intensive activity with a conspicuous carbon footprint and an estimated rate of inappropriateness. However, the carbon costs of inappropriate endoscopic procedures still remain obscure. Here we evaluated the environmental impact of inappropriate endoscopic examinations.

We calculated the carbon cost of a standard endoscopic procedure (EGD and colonoscopy [CLS]), taking into account the items (eg, disposable materials, personal protective equipment) and energy required for the endoscopy procedure itself and the cleaning process. The rates of inappropriateness and the mortality cost of carbon (MCC) of endoscopic examinations in different scenarios were calculated.

EGD and CLS presented a carbon cost of 5.43 kg and 6.71 kg of CO₂, respectively. Different scenarios were evaluated, according to the number of endoscopic procedures performed in Italy per 1000 inhabitants and the reported data on their inappropriateness. The carbon cost of inappropriate EGD and CLS in Italy was 4133 CO₂ metric tons per year (MCC, .93), ranging from 3527 to 4749, and equivalent to 1,760,446 L of gasoline consumed. Applying the same data to the European population, the estimated carbon footprint of inappropriate digestive endoscopy in Europe was 30,804 metric tons.

The environmental impact of inappropriate endoscopic procedures in Europe is remarkable. These results highlight the need to adopt novel strategies aimed at reducing both the carbon footprint of digestive endoscopy and the rate of inappropriate procedures.

Informed consent should allow patients the appropriate time and conditions to make decisions about their care. However, consent is often obtained immediately prior to a colonoscopy. We conducted a quality improvement study to assess how a preprocedure consent video 2 days prior to an outpatient colonoscopy impacts patient satisfaction.

Patients undergoing outpatient colonoscopy at a large academic medical center opted in to a text messaging platform for procedural information. Our intervention was an informed consent video 2 days before the colonoscopy. Our primary outcome was a composite patient satisfaction score. Pre and postintervention scores were compared using ordinal or multinomial logistic models to calculate odds ratios (OR) or relative risk ratios and 95% confidence intervals (CI), adjusting for age and sex.

1109 and 1452 patients completed ≥1 survey question in the pre and postintervention phases, respectively. Overall patient satisfaction did not differ between groups [OR for a 1-point increment in satisfaction score between post- vs preintervention groups = 1.05; 95% CI: 0.90–1.22; P = .51]. Compared to preintervention, postintervention respondents were more likely to report higher satisfaction with time available to talk with their physician (OR of a 1-point increase in individual question response = 1.29; 95% CI: 1.09–1.54; P = .004). Compared to preintervention, more physicians in the postintervention phase rated satisfaction with consent process efficiency as “very satisfied” or “satisfied” (P < .001).

An informed consent video prior to colonoscopy resulted in similar overall patient satisfaction. However, post-intervention, patients were more likely to report sufficient time to talk with their physician, and physicians reported higher satisfaction with consent efficiency.

Endoscopy is an essential component of gastroenterology, allowing for the diagnosis and management of a variety of gastrointestinal diseases. Although most endoscopies are considered to be low risk procedures, several factors including the sedation, patient, and procedure play a role in determining overall risk. Patient assessment prior to endoscopy is essential to risk-stratification and provides an opportunity to review comorbidities, adjust medications if necessary, and identify an optimal sedation plan. Several best practice recommendations and guidelines have been developed to ensure that safe, high-quality endoscopies are performed to minimize risks and optimize outcomes. The purpose of this review is to highlight best practices related to pre-endoscopic evaluation and, when available, review quality indicators.

Payments from pharmaceutical and medical device manufacturers to authors of clinical practice guidelines (CPGs) may influence practice recommendations. It is therefore important to evaluate the completeness of financial conflict of interest (FCOI) declarations among CPG authors.

We performed a cross-sectional analysis of industry payments to authors of endoscopy guidelines published by 5 GI societies between 2014 and 2017. For each author we identified payments using the disclosure section of CPGs and the Centers for Medicare & Medicaid Services Open Payments (CMS-OP) database. We calculated the prevalence, monetary value, and type of declared and undeclared payments among authors. Payments were assessed for the calendar year of and before publication.

Thirty-seven CPGs were included in the analysis comprising 569 author entries (91 unique individuals; 66.43% men, 92.6% physicians, 66.4% academically affiliated). Four hundred fifty-one episodes (79%) involved FCOIs, 451 (79%) had undisclosed FCOIs in the CMS-OP, and 445 (77%) had FCOIs relevant to a CPG recommendation. The median undisclosed payment value was $4807.26 (interquartile range, $334.84-$20,579.75). Male authors (odds ratio, 2.23; 95% confidence interval, 1.47-3.39) and academically affiliated authors (odds ratio, 8.87; 95% confidence interval, 5.57-14.13) were significantly more likely to have undeclared payments (P < .001). No CPGs met all National Academy of Medicine criteria.

Recognizing concerns about the accuracy of the CMS-OP, there are substantial discrepancies between industry-reported payments and author self-disclosure. Additionally, there is a high prevalence of undisclosed payments by pharmaceutical and medical device manufacturers to these authors. Given the potential impact of these discrepancies and undisclosed payments on CPGs, more accurate reporting and alternative strategies for managing FCOI are needed.

Pancreaticobiliary endoscopy focuses on the diagnosis and therapy of conditions involving the pancreas and biliary tree, and distinguishes itself from luminal endoscopy by a greater use of side-viewing endoscopes and echoendoscopes and the use of fluoroscopy. With advances in endoscopic equipment and growing experience, pancreaticobiliary endoscopy has evolved to encompass a wide range of diagnostic and therapeutic procedures of increasing complexity. Accordingly, the practice of pancreaticobiliary endoscopy requires meticulous preparation and training. This chapter reviews the various aspects of preparation for pancreaticobiliary endoscopy. These aspects are conveniently organized under patient-, physician-, and endoscopy unit–related preparation, with an emphasis on existing guidelines and published evidence. Preprocedure visits, the role of open-access endoscopy, informed consent, and interdisciplinary communication are discussed in the patient-related preparation section. Physician training, credentialing, and guidelines for the acquisition and adoption of new techniques are highlighted in the provider preparation section. Suggestions for unit layout, ergonomics, fluoroscopy, staff training, and postprocedure care are provided in the endoscopy unit–related preparation section. Attention to these often-overlooked details before and after the procedure increases the chance of a successful endoscopy and an excellent outcome for the patient.

La dispepsia es un trastorno frecuente tanto en Atención Primaria (AP) como Especializada (AE). Se recomienda realizar una gastroscopia al inicio del estudio si existen datos de alarma, aunque su accesibilidad desde AP es variable.

Desarrollamos un proyecto piloto estableciendo una agenda de gastroscopia precoz para pacientes con dispepsia y datos de alarma en AP, ampliándolo posteriormente a toda el área sanitaria. El objetivo fue evaluar los requerimientos, el impacto y la valoración desde AP de esta prestación. Recogimos variables demográficas, sintomáticas y endoscópicas de los pacientes remitidos y las derivaciones a AE desde el centro piloto. Se realizó una encuesta de satisfacción entre los facultativos de AP.

Se evaluaron el proyecto piloto, de un año de duración, y el primer año de implantación de la agenda, con un total de 355 pacientes (edad mediana 56,4 años; RIQ 45,5-64,3). El 61,2% (56,1-66,3%) eran mujeres. La demora hasta la exploración fue de 1,5 semanas (RIQ 1,5-2,5). El 82,7% (78,4-86,3%) de las gastroscopias fueron indicadas correctamente. La mediana mensual de solicitudes fue de 1,1 por cada 10.000 adultos (rango 0,8-1,6). Las derivaciones mensuales a consultas de AE desde el centro piloto disminuyeron en 11 sujetos (IC 95% 5,9-16), respecto a la mediana previa de 58 (RIQ 48-64,5). El 98,4% de los encuestados consideraron la agenda útil en su práctica habitual.

La disponibilidad de una agenda de gastroscopia precoz en AP para pacientes con dispepsia y datos de alarma disminuye el número de derivaciones a AE.

Dyspepsia is a common disorder in both Primary (PC) and Specialised Care (SC). Gastroscopy is recommended at the start of the study if there are warning signs, although it is not always available in PC.

We developed a pilot project establishing an early gastroscopy programme for patients with dyspepsia and warning signs in PC, subsequently extending it to the entire healthcare area. The aim was to evaluate the requirements, impact and opinion of this service at the PC level. Demographic, symptomatic and endoscopic variables on the patients referred to SC from the pilot centre were recorded. A satisfaction survey was conducted among the PC physicians.

The one-year pilot study and the first year of implementation of the programme were evaluated. A total of 355 patients were included (median age 56.4 years; IQR 45.5-64.3); 61.2% (56.1-66.3%) were women. The waiting time for examination was 1.5 weeks (IQR 1.5-2.5). Gastroscopy was correctly indicated in 82.7% (78.4-86.3%) of patients. The median number of requests per month was 1.1 per 10,000 adults (range 0.8-1.6). Monthly referrals to SC clinics from the pilot centre fell by 11 subjects (95% CI 5.9-16) with respect to the previous median of 58 (IQR 48-64.5). Almost all those polled (98.4%) considered the programme useful in routine practice.

The availability of an early gastroscopy programme in PC for patients with dyspepsia and warning signs reduced the number of referrals to SC.