Browsing by Author "Kaltenbach, Tonya"

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    Cost Effectiveness Analysis Evaluating Real-Time Characterization of Diminutive Colorectal Polyp Histology using Narrow Band Imaging (NBI)
    (2020-01) Patel, Swati G.; Scott, Frank I.; Das, Ananya; Rex, Douglas K.; McGill, Sarah; Kaltenbach, Tonya; Ahnen, Dennis J.; Rastogi, Amit; Wani, Sachin; Medicine, School of Medicine
    Background: Endoscopists and new computer-aided programs can achieve performance benchmarks for real-time diagnosis of colorectal polyps using Narrow-Band Imaging (NBI), though do not perform as well as endoscopists with expertise in advanced imaging. Previous cost-effectiveness studies on optical diagnosis have focused on expert performance, potentially over-estimating its benefits. Aim: Determine cost-effectiveness of an NBI ‘characterize, resect and discard (CRD)’ strategy using updated assumptions based on non-expert performance. Methods: Markov model was constructed to compare cost-effectiveness of the CRD strategy, where diminutive polyps characterized as non-adenomas with high confidence are not resected and adenomas are resected and discarded, versus standard of care (SOC) in which all polyps are resected with histologic analysis. Rates related to NBI performance, missed polyps, polyp progression, malignancy, and complications, as well as quality-adjusted life years (QALYs) were derived from the literature. Costs were age and insurer-specific. Mean QALYs and costs were calculated using first order Monte Carlo simulation. Deterministic and probabilistic sensitivity analyses were conducted. Results: The mean QALY estimates were similar for the CRD (8.563, 95% CI: 8.557-8.571) and SOC strategy (8.563, 8.557-8.571), but costs were reduced ($2,693.06 vs. $2,800.27, mean incremental cost savings: $107.21/person). Accounting for colonoscopy rates, the CRD strategy would save $708 million to $1.06 billion annually. The model was sensitive to the incidence of tubular adenomas; the results were otherwise robust in all other one-way and probabilistic analyses. Conclusions: An NBI CRD strategy is cost-effective when compared to the SOC, even when employed by non-experts. The appreciated benefit is primarily due to cost savings of the CRD strategy.
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    Individualized feedback on colonoscopy skills improves group colonoscopy quality in providers with lower adenoma detection rates
    (Thieme, 2022-03-14) Keswani, Rajesh N.; Wood, Mariah; Benson, Mark; Gawron, Andrew J.; Kahi, Charles; Kaltenbach, Tonya; Yadlapati, Rena; Gregory, Dyanna; Duloy, Anna; Medicine, School of Medicine
    Background and study aims:  Colonoscopy inspection quality (CIQ) assesses skills (fold examination, cleaning, and luminal distension) during inspection for polyps and correlates with adenoma detection rate (ADR) and serrated detection rate (SDR). We aimed to determine whether providing individualized CIQ feedback with instructional videos improves quality metrics performance. Methods:  We prospectively studied 16 colonoscopists who already received semiannual benchmarked reports of quality metrics (ADR, SDR, and withdrawal time [WT]). We randomly selected seven colonoscopies/colonoscopist for evaluation. Six gastroenterologists graded CIQ using an established scale. We created instructional videos demonstrating optimal and poor inspection techniques. Colonoscopists received the instructional videos and benchmarked CIQ performance. We compared ADR, SDR, and WT in the 12 months preceding (“baseline”) and following CIQ feedback. Colonoscopists were stratified by baseline ADR into lower (≤ 34 %) and higher-performing (> 34 %) groups. Results:  Baseline ADR was 38.5 % (range 26.8 %–53.8 %) and SDR was 11.2 % (2.8 %–24.3 %). The proportion of colonoscopies performed by lower-performing colonoscopists was unchanged from baseline to post-CIQ feedback. All colonoscopists reviewed their CIQ report cards. Post-feedback, ADR (40.1 % vs 38.5 %, P  = 0.1) and SDR (12.2 % vs. 11.2 %, P  = 0.1) did not significantly improve; WT significantly increased (11.4 vs 12.4 min, P  < 0.01). Among the eight lower-performing colonoscopists, group ADR (31.1 % vs 34.3 %, P  = 0.02) and SDR (7.2 % vs 9.1 %, P  = 0.02) significantly increased post-feedback. In higher-performing colonoscopists, ADR and SDR did not change. Conclusions: CIQ feedback modestly improves ADR and SDR among colonoscopists with lower baseline ADR but has no effect on higher-performing colonoscopists. Individualized feedback on colonoscopy skills could be used to improve polyp detection by lower-performing colonoscopists.
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    Patients Prescribed Direct-acting Oral Anticoagulants Have Low Risk of Post-Polypectomy Complications
    (Elsevier, 2019) Yu, Jessica X.; Oliver, Melissa; Lin, Jody; Chang, Matthew; Limketkai, Berkeley N.; Soetikno, Roy; Bhattacharya, Jay; Kaltenbach, Tonya; Medicine, School of Medicine
    Background & Aims Use of direct-acting oral anticoagulants (DOACs) is increasing, but little is known about the associated risks in patients undergoing colonoscopy with polypectomy. We aimed to determine the risk of post-polypectomy complications in patients prescribed DOACs. Methods We performed a retrospective analysis using the Clinformatics Data Mart Database (a de-identified administrative database from a large national insurance provider) to identify adults who underwent colonoscopy with polypectomy or endoscopic mucosal resection (EMR) from January 1, 2011, through December 31, 2015. We collected data from 11,504 patients prescribed antithrombotic agents (1590 DOAC, 3471 warfarin, and 6443 clopidogrel) and 599,983 patients not prescribed antithrombotics of interest (controls). We compared 30-day post-polypectomy complications, including gastrointestinal bleeding (GIB), cerebrovascular accident (CVA), myocardial infarction (MI), and hospital admissions, of patients prescribed DOACs, warfarin, or clopidogrel vs controls. Results Post-polypectomy complications were uncommon but occurred in a significantly higher proportion of patients receiving any antithrombotic vs controls (P<0.001). The percentage of patients in the DOAC group with GIB was 0.63% (95% CI, 0.3%–1.2%) vs 0.2% (95% CI, 0.2%–0.3%) in controls. The percentage of patients with CVA in the DOAC group was 0.06% (95% CI, 0.01%–0.35%) vs 0.04% (95% CI, 0.04%–0.05%) in controls. After we adjusted for bridge anticoagulation, EMR, Charlson comorbidity index (CCI), and CHADS2 (congestive heart failure, hypertension, age over 75, diabetes, stroke [double weight]) score, patients prescribed DOACs no longer had a statistically significant increase in the odds of GIB (odds ratio [OR], 0.90; 95% CI, 0.44–1.85), CVA (OR, 0.45; 95% CI, 0.06–3.28), MI (OR, 1.07; 95% CI, 0.14–7.72), or hospital admission (OR, 0.86; 95% CI, 0.64–1.16). Clopidogrel, warfarin, bridge anticoagulation, higher CHADS2, CCI, and EMR were associated with increased odds of complications. Conclusion In our retrospective analysis of a large national dataset, we found that patients prescribed DOACs did not have significantly increased adjusted odds of post-polypectomy GIB, MI, CVA, or hospital admission. Bridge anticoagulation, higher CHADS2 score, CCI, and EMR were risk factors for GIB, MI, CVA, and hospital admissions. Studies are needed to determine the optimal peri-procedural dose for high-risk patients.
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    Recommendations for Follow-Up After Colonoscopy and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer
    (Elsevier, 2020-03) Gupta, Samir; Lieberman, David; Anderson, Joseph C.; Burke, Carol A.; Dominitz, Jason A.; Kaltenbach, Tonya; Robertson, Douglas J.; Shaukat, Aasma; Syngal, Sapna; Rex, Douglas K.; Medicine, School of Medicine
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    Recommendations on Surveillance and Management of Biallelic Mismatch Repair Deficiency (BMMRD) Syndrome: A Consensus Statement by the US Multi-Society Task Force on Colorectal Cancer
    (Elsevier, 2017-05) Durno, Carol; Boland, C. Richard; Cohen, Shlomi; Dominitz, Jason A.; Giardiello, Frank M.; Johnson, David A.; Kaltenbach, Tonya; Levin, T. R.; Lieberman, David; Robertson, Douglas J.; Rex, Douglas K.; Department of Medicine, School of Medicine
    The US Multi-Society Task Force on Colorectal Cancer, with invited experts, developed a consensus statement and recommendations to assist health care providers with appropriate management of patients with biallelic mismatch repair deficiency (BMMRD) syndrome, also called constitutional mismatch repair deficiency syndrome. This position paper outlines what is known about BMMRD, the unique genetic and clinical aspects of the disease, and reviews the current management approaches to this disorder. This article represents a starting point from which diagnostic and management decisions can undergo rigorous testing for efficacy. There is a lack of strong evidence and a requirement for further research. Nevertheless, providers need direction on how to recognize and care for BMMRD patients today. In addition to identifying areas of research, this article provides guidance for surveillance and management. The major challenge is that BMMRD is rare, limiting the ability to accumulate unbiased data and develop controlled prospective trials. The formation of effective international consortia that collaborate and share data is proposed to accelerate our understanding of this disease.
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    Right-Sided Location Not Associated With Missed Colorectal Adenomas in an Individual-Level Reanalysis of Tandem Colonoscopy Studies
    (Elsevier, 2019) Zimmermann-Fraedrich, Katharina; Sehner, Susanne; Rex, Douglas K.; Kaltenbach, Tonya; Soetniko, Roy; Wallace, Michael; Leung, Wai K.; Guo, Chuanguo; Gralnek, Ian M.; Brand, Eelco C.; Groth, Stefan; Schachschal, Guido; Ikematsu, Hiroaki; Siersema, Peter D.; Rösch, Thomas; Medicine, School of Medicine
    Background & Aims Interval cancers occur more frequently in the right colon. One reason could be that right-sided adenomas are frequently missed in colonoscopy examinations. We reanalyzed data from tandem colonoscopies to assess adenoma miss rates in relation to location and other factors. Methods We pooled data from 8 randomized tandem trials comprising 2218 patients who had diagnostic or screening colonoscopies (adenomas detected in 49.8% of patients). We performed a mixed-effects logistic regression with patients as cluster effects with different independent parameters. Factors analyzed included location (left vs right, splenic flexure as cutoff), adenoma size, form, and histologic features. Analyses were controlled for potential confounding factors such as patient sex and age, colonoscopy indication, and bowel cleanliness. Results Right-side location was not an independent risk factor for missed adenomas (odds ratio [OR] compared with the left side, 0.94; 95% CI, 0.75–1.17). However, compared with adenomas ≤5 mm, the OR for missing adenomas of 6–9 mm was 0.62 (95% CI, 0.44–0.87), and the OR for missing adenomas of ≥10 mm was 0.51 (95% CI, 0.33–0.77). Compared with pedunculated adenomas, sessile (OR, 1.82; 95% CI, 1.16–2.85) and flat adenomas (OR, 2.47; 95% CI, 1.49–4.10) were more likely to be missed. Histologic features were not significant risk factors for missed adenomas (OR for adenomas with high-grade intraepithelial neoplasia, 0.68; 95% CI, 0.34–1.37 and OR for sessile serrated adenomas, 0.87; 95% CI, 0.47–1.64 compared with low-grade adenomas). Men had a higher number of adenomas per colonoscopy (1.27; 95% CI, 1.21–1.33) than women (0.86; 95% CI, 0.80–0.93). Men were less likely to have missed adenomas than women (OR for missed adenomas in men, 0.73; 95% CI, 0.57–0.94). Conclusions In an analysis of data from 8 randomized trials, we found that right-side location of an adenoma does not increase its odds for being missed during colonoscopy but that adenoma size and histologic features do increase risk. Further studies are needed to determine why adenomas are more frequently missed during colonoscopies in women than men.
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    Spotlight: US Multi-Society Task Force on Colorectal Cancer Recommendations for Follow-up After Colonoscopy and Polypectomy
    (Elsevier, 2020-03) Gupta, Samir; Lieberman, David; Anderson, Joseph C.; Burke, Carol A.; Dominitz, Jason A.; Kaltenbach, Tonya; Robertson, Douglas J.; Shaukat, Aasma; Syngal, Sapna; Rex, Douglas K.; Medicine, School of Medicine
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    Use of Endoscopic Impression, Artificial Intelligence, and Pathologist Interpretation to Resolve Discrepancies Between Endoscopy and Pathology Analyses of Diminutive Colorectal Polyps
    (Elsevier, 2020-02) Shahidi, Neal; Rex, Douglas K.; Kaltenbach, Tonya; Rastogi, Amit; Ghalehjegh, Sina Hamidi; Byrne, Michael F.; Medicine, School of Medicine