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DDW 2022 Author Disclosures: Sachin Wani: NO financial relationship with a commercial interest ;Jeffrey Williams: NO financial relationship with a commercial interest ;Jennifer Holub: NO financial relationship with a commercial interest ;Audrey Calderwood: YES financial relationship with a commercial interest;Dark Canyon Laboratoties:Advisory Committees or Review Panels ;Jason Dominitz: NO financial relationship with a commercial interest ;Prasad Iyer: YES financial relationship with a commercial interest;Exact Sciences:Consulting;Exact Sciences:Grant/Research Support;Pentax:Grant/Research Support;Pentax:Consulting;Ambu:Consulting;Symple Surgical:Consulting;Medtronic:Consulting ;Nicholas Shaheen: YES financial relationship with a commercial interest;Lucid:Grant/Research Support;Medtronic:Grant/Research Support;Steris:Grant/Research Support;Pentax:Grant/Research Support;CDx Medical:Consulting;Cernostics:Consulting;Interpace Diagnostics:Grant/Research Support;Phathom Pharmaceuticals:Consulting;Exact Sciences:Consulting;Aqua Medical:Consulting;Cook Medical:Consulting Background: The COVID-19 pandemic has disrupted endoscopy practices with significant reductions in procedural capacity creating unprecedented decreases in cancer screening and surveillance services. Using a national registry with matched endoscopy and pathology data, we aimed to assess the impact of the pandemic on the proportion of patients diagnosed with BE and BE-related dysplasia and adherence to established quality indicators in BE. Methods: We analyzed data from the GI Quality Improvement Consortium (GIQuIC) Registry, a national repository of endoscopy data. Procedure data from all EGDs in the registry during the study period, including procedure indication, demographics, endoscopy findings, pathology results and recommendations were assessed from 1/2018 – 5/2021. Three cohorts based on date of EGD performance were created: Pre-pandemic (1/2018-2/2020), Early Pandemic (3/2020-7/2020) and Late-pandemic (8/2020-5/2021). Observed and expected number of BE and dysplasia cases/month were calculated. Adherence to Seattle protocol was assessed by dividing the BE length by number of pathology jars submitted;a ratio of ≤2.0 with rounding down was considered adherent. Adherence to recommended surveillance for non-dysplastic BE (NDBE) was calculated by assessing the proportion recommended to undergo an EGD between 3-5 years. Results: Among 1,619,684 EGDs assessed, 94,081 (5.8%) met inclusion criteria (Table 1). These cases were largely performed by GIs and represented 394 practices and 2666 endoscopists nationwide with geographic distribution within the U.S. as follows: West 24%, Midwest 13%, South 40%, and Northeast 23%. Fewer endoscopies were performed by non-GIs during the early (1.5%) and late pandemic (1.5%) compared to pre-pandemic period (9.3%, p<0.001). The mean BE length was 2.3 (2.5) cm and distribution based on histology was NDBE 87.5%, low-grade dysplasia (LGD) 2.2%, indefinite for dysplasia (IND) 2.9%, high-grade dysplasia (HGD) 1.5%, and unknown 5.8%. Table and Figure highlight the significant reduction in the number of patients diagnosed with BE (47.9% and 24.1%) and BE-related dysplasia (HGD: 38.5% and 25.3%;LGD: 45% and 34%, any dysplasia: 43.9% and 31.3%) per month during the early and late pandemic periods. Over the pandemic, there was no decline in adherence rates to quality indicators in BE with an overall adherence rate to the Seattle protocol and appropriate recommended surveillance interval in NDBE of 83% and 68.4%, respectively. Conclusions: Results of this study demonstrate a significant decline in EGD volume with an associated reduction in the number of patients diagnosed with BE and related dysplasia during the COVID-19 pandemic. The absence of a compensatory increase in diagnoses in the late pandemic period is concerning with likely long-term deleterious downstream effects on esophageal adenocarcinoma morbidity and mortality. [Formula presented] [Formula presented]
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Background: The COVID-19 pandemic has temporarily reduced capacity in many endoscopyunits, creating long backlogs, which have the potential to worsen patient outcomes. Aims:To evaluate the impact of two evidence-based strategies for offloading colonoscopy demandduring and after the first wave of the pandemic: (1) An “Extend” strategy, in which theinterval for low-risk adenoma (LRA) patients who are currently “due” is extended from 5years to 7 years;(2) An “Exchange” strategy, in which all referrals for screening colonoscopyare changed to fecal immunochemical testing (FIT);(3) a combination of “Extend+Exchange.”Methods: We developed a discrete-event simulation of an endoscopy unit in an integratedhealthcare system with a caseload of 110 procedures weekly. We assumed capacity initiallyfell to 5% of pre-COVID levels for 10 weeks (as a result of the pandemic), and incrementallyincreased back to 100% by 30 weeks. Each week, 113 patients were referred with thefollowing indications, in order of priority: diagnostic colonoscopy (23% of referrals) and upper endoscopy (28%), high-risk adenoma (HRA) surveillance (10%), LRA surveillance(17%), and screening colonoscopy (22%). The highest priority patients were always seenfirst, while others joined a queue. Outcomes included average wait time, number of patientsseen, and queue size at model’s end. The base unit of time was weeks. Model length was150 weeks. One-way sensitivity analyses were performed for all variables. Each strategy wassimulated 500 times in C++ and compared to a base case in which no offloading strategieswere used. Results: In the base case, 3,023 patients remained in queue at 150 weeks, andthe average wait time was 22.5 weeks overall. The wait time for screening colonoscopy was69.9 weeks. With the Extend strategy, 1,293 patients remained in queue at 150 weeks, theaverage wait time was 14.2 weeks overall, and the wait time for screening colonoscopy was41.6 weeks. With Exchange, no patients remained in queue at 150 weeks, and the averagewait time was 9.9 weeks. Because no screening colonoscopies were done, there was no waittime for this indication. The Extend+Exchange strategy yielded similar results, but the averagewait time was 5.3 weeks. In all four strategies, nearly equivalent numbers of patients wereseen for HRA surveillance (range 2,496-2,511), diagnostic colonoscopy (range 4,547-5,062),and upper endoscopy (3,749-3,759), with similar wait times. None of the strategies hadwait times for upper endoscopy or diagnostic colonoscopy exceeding 5 weeks. Conclusions:Without offloading strategies, prolonged queues and wait times developed, especially forscreening colonoscopies. Substituting FIT for screening colonoscopy (Exchange) is the singlestrategy with the greatest potential to mitigate these problems, without which patients maysuffer harm caused by limited access.(Figure Presented)Figure 1. Average wait time by indication under usual care, and three evidence-based strategies for offloading endoscopy demand during the COVID-19 pandemic.
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Background: The COVID-19 pandemic has presented tremendous hurdles to the continuation of preventative services worldwide, including surveillance for HCC for patients with cirrhosis. The Veterans Health Administration (VA) Hepatic Innovation Team Learning Collaborative (HIT) aims to improve care for Veterans with cirrhosis nationally. This evaluation aimed to assess 1) the approaches that sites used to providing cirrhosis care (implementation strategies) during the pandemic and 2) the implementation strategies associated with improved HCC surveillance rates during the pandemic. Methods: VA hepatology clinicians were surveyed about the use of 73 implementation strategies used to improve cirrhosis care in fiscal year (FY) 2020 and whether strategy use was affected by COVID-19. Descriptive and bivariate statistics defined frequencies and associations with HCC surveillance in the year. Results: Survey responses were received from 72 (55%) VA sites caring for over 42,000 Veterans with cirrhosis. Over the course of the pandemic in FY20, the HCC surveillance rate nationally declined from 51% to a nadir of 39%, with an overall rate of 40% at the end of FY20. Sites reported using a median of 10 (IQR 4-20) of 73 implementation strategies to improve cirrhosis care in FY20. Implementation strategy use shifted during the pandemic such that, relative to pre-COVID, sites engaged in more academic collaborations, local technical assistance, and networking to problem solve and less outreach to patients, clinical performance data, site visits, and external facilitation. Implementation strategy selection was associated with HCC surveillance;sites using more implementation strategies had significantly higher HCC surveillance rates (p=.046). Six of 73 individual implementation strategies were significantly associated with increased HCC surveillance: 1) use clinical reminders or note templates, 2) create new clinical teams, 3) use data experts, 4) tailor care to meet local needs, 5) learn from experts in cirrhosis care, and 6) use interdisciplinary workgroups to provide input into cirrhosis policies and practices. Conclusion: While VA experienced an expected national decline in HCC surveillance during FY20, sites used a variety of shifting strategies to adapt to the changing environment. A subset of implementation strategies, including interdisciplinary team formation and using medical record tools and data, was associated with higher surveillance rates during the pandemic.
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BACKGROUND: Older age and comorbid burden are both associated with adverse outcomes in SARS-CoV-2, but it is not known whether the association between comorbid burden and adverse outcomes differs in older and younger adults. OBJECTIVE: To compare the relationship between comorbid burden and adverse outcomes in adults with SARS-CoV-2 of different ages (18-64, 65-79 and ≥ 80 years). DESIGN, SETTING, AND PARTICIPANTS: Observational longitudinal cohort study of 170,528 patients who tested positive for SARS-CoV-2 in the US Department of Veterans Affairs (VA) Health Care System between 2/28/20 and 12/31/2020 who were followed through 01/31/2021. MEASUREMENTS: Charlson Comorbidity Index (CCI); Incidence of hospitalization, intensive care unit (ICU) admission, mechanical ventilation, and death within 30 days of a positive SARS-CoV-2 test. RESULTS: The cumulative 30-day incidence of death was 0.8% in cohort members < 65 years, 7.1% in those aged 65-79 years and 20.6% in those aged ≥80 years. The respective 30-day incidences of hospitalization were 8.2, 21.7 and 29.5%, of ICU admission were 2.7, 8.6, and 11% and of mechanical ventilation were 1, 3.9 and 3.2%. Median CCI (interquartile range) ranged from 0.0 (0.0, 2.0) in the youngest, to 4 (2.0, 7.0) in the oldest age group. The adjusted association of CCI with all outcomes was attenuated at older ages such that the threshold level of CCI above which the risk for each outcome exceeded the reference group (1st quartile) was lower in younger than in older cohort members (p < 0.001 for all age group interactions). LIMITATIONS: The CCI is calculated based on diagnostic codes, which may not provide an accurate assessment of comorbid burden. CONCLUSIONS: Age differences in the distribution and prognostic significance of overall comorbid burden could inform clinical management, vaccination prioritization and population health during the pandemic and argue for more work to understand the role of age and comorbidity in shaping the care of hospitalized patients with SARS-CoV-2.