Assessment of quality indicators among nurse practitioners performing upper endoscopy.

Background and study aims Limited international data have shown that non-physicians can safely perform upper endoscopy, but no such study has been performed in the United States. Our aim was to assess the quality of outpatient upper endoscopies performed by nurse practitioners (NPs).Patients and methods Retrospective chart review of upper endoscopies performed by 3 NPs between 2010 and 2013 was performed. Comparisons among all NPs performing upper endoscopy and assessment of individual NP performance over time with respect to quality indicators were performed.Results Three NPs performed 333 upper endoscopies (distribution of 166, 44, and 123, respectively). Of the cases, 98.2 %s were successfully completed to the second portion of the duodenum. In most cases, photo-documentation of required anatomical landmarks was performed: GE junction (84.2 %), GE junction in retroflexed view (84.2 %), antrum (82.1 %) and duodenum (80.9 %). Photo-documentation improved with increasing experience. NPs appropriately performed biopsies for specific medical conditions: 10/11 (90.9 %) gastric ulcers were biopsied and 63/66 (95.5) of patients with iron deficiency had duodenal biopsies performed for celiac disease. A physician endoscopist was required during the procedure 22.5 % of the time. Important parameters such as documenting informed consent (100 %) and documenting a discharge plan (99.4 %) in the procedure reports were overwhelming present. There was a single adverse event during the study period.Conclusion In the first US study of NPs performing upper endoscopy, they were able to perform high-quality and safe upper endoscopies. These findings support incorporation of non-physicians alongside physicians to help meet the growing demand for endoscopic services across the United States

13-year mortality trends among hospitalized patients with inflammatory bowel disease

BACKGROUND: Studies document increasing rates of hospitalization among patients with inflammatory bowel disease, but temporal trends for in-hospital mortality among patients with inflammatory bowel disease are not characterized. We sought to determine whether in-hospital mortality changed over a 13-year period among nationwide hospitalizations associated with inflammatory bowel disease. We additionally sought to identify factors correlated with mortality. METHODS: We used the National Hospital Discharge Survey, a large nationally representative database, for the years 1994 through 2006. Age- and mortality-adjusted rates of in-hospital mortality and standardized mortality ratios were calculated for four time periods. Logistic regression analysis was used to assess associations between advancing time and mortality in adjusted analyses. RESULTS: 150 (0.9%) of 17,393 hospitalizations for patients with inflammatory bowel disease ended in death. Age-adjusted in-hospital mortality decreased from 3.6 deaths per 1,000 hospital days in 1994–96 to 2.4 per 1,000 in 2003–06; standardized mortality ratio decreased from 0.33 to 0.27. Similar trends were seen for patients with ulcerative colitis, but mortality did not change over time among patients with Crohn’s disease. Multivariable logistic regression analysis confirmed the significance of these changes in mortality, with 17% decreased odds of in-hospital death per three-year period (P = 0.012). Subject age (OR 1.06 per year, P < 0.001), Charlson comorbidity index (OR 1.29 per 1-point increase, P < 0.001), and diagnosis of ulcerative colitis (versus Crohn’s disease, OR 1.41, P = .042) were also associated with in-hospital mortality. CONCLUSIONS: The odds of in-hospital mortality among hospitalized patients with inflammatory bowel disease decreased by 17% per 3-year period from 1994 to 2006 in analysis adjusted for age and comorbidity status, in this large, nationally representative database. Multiple factors likely contribute to these trends

Performance of a cognitive load inventory during simulated handoffs: Evidence for validity.

BackgroundAdvancing patient safety during handoffs remains a public health priority. The application of cognitive load theory offers promise, but is currently limited by the inability to measure cognitive load types.ObjectiveTo develop and collect validity evidence for a revised self-report inventory that measures cognitive load types during a handoff.MethodsBased on prior published work, input from experts in cognitive load theory and handoffs, and a think-aloud exercise with residents, a revised Cognitive Load Inventory for Handoffs was developed. The Cognitive Load Inventory for Handoffs has items for intrinsic, extraneous, and germane load. Students who were second- and sixth-year students recruited from a Dutch medical school participated in four simulated handoffs (two simple and two complex cases). At the end of each handoff, study participants completed the Cognitive Load Inventory for Handoffs, Paas' Cognitive Load Scale, and one global rating item for intrinsic load, extraneous load, and germane load, respectively. Factor and correlational analyses were performed to collect evidence for validity.ResultsConfirmatory factor analysis yielded a single factor that combined intrinsic and germane loads. The extraneous load items performed poorly and were removed from the model. The score from the combined intrinsic and germane load items associated, as predicted by cognitive load theory, with a commonly used measure of overall cognitive load (Pearson's r = 0.83, p &lt; 0.001), case complexity (beta = 0.74, p &lt; 0.001), level of experience (beta = -0.96, p &lt; 0.001), and handoff accuracy (r = -0.34, p &lt; 0.001).ConclusionThese results offer encouragement that intrinsic load during handoffs may be measured via a self-report measure. Additional work is required to develop an adequate measure of extraneous load

Race and Inflammatory Bowel Disease in an Urban Healthcare System

Inflammatory bowel disease (IBD) is increasingly common among non-Caucasian populations, but interracial differences in disease characteristics and management are not well-characterized. We tested the hypothesis that disease characteristics and management vary by race among IBD patients in an ethnically diverse healthcare system. A retrospective study of the safety net healthcare system of San Francisco, CA, from 1996 to 2009 was undertaken. Patient records with International Classification of Diseases, 9th Revision (ICD9) codes 555.xx, 556.xx, and 558.xx were reviewed. Adult patients with confirmed IBD diagnoses were included. Interracial variations in disease characteristics and management were assessed broadly; focused between-race comparisons identified specific differences. The 228 subjects included 77 (33.4%) with Crohn’s disease (CD), 150 (65.8%) with ulcerative colitis, and 1 (0.4%) with IBD, type unclassified. The race distribution included 105 (46.1%) white, 34 (14.9%) black, 35 (15.4%) Hispanic, and 51 (22.4%) Asian subjects. Asians and Hispanics were diagnosed at older ages (41.0 and 37.1 years, respectively) and had shorter disease durations (5.4 and 5.2 years, respectively) than whites (30.5 years at diagnosis and 8.6 years duration, P &lt; 0.05) and blacks (31.7 years at diagnosis and 12.1 years duration, P &lt; 0.05). CD was more common among blacks (50% of subjects) than Asians (25.5% of subjects, P = 0.015). The Montreal classification of IBD was similar among races. Hispanics were less likely than others to be treated with 5-aminosalicylates (5-ASA), immunomodulators, and steroids. Medical and surgical management was otherwise similar among races. Modest race-based differences in IBD characteristics exist in this racially diverse healthcare system, but the management of IBD is similar among race groups