Clinical Approaches to Hospital Medicine: Advances, Updates and Controversies: Second Edition

This book provides an update on recent clinical practice and an in-depth view of selected topics relevant to hospital medicine. It is divided into four sections that explore clinical, administrative, systems and ethical issues. Each section places an emphasis on the opportunities, challenges and potential directions of this bourgeoning subspecialty. This new edition expands on topics covered in the previous edition, including the COVID-19 pandemic, racial disparities in healthcare delivery and providers, and pediatric hospital medicine. Other chapters explore worldwide practice patterns and practical application of philosophical tools in daily practice. This up-to-date resource provides hospitalists, advanced nurse practitioners, medical students and administrators with the latest research, trends and issues in hospital medicine. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Development of an Online Learning Module on Gastroenterology Issues in Global Health

Introduction: Global health (GH) education is expanding and 23.1% of US medical students acquire international health experience prior to postgraduate training. Digestive diseases carry a high global burden. However, few GH programs and professional societies consider the inclusion of gastroenterology into their standard curriculum. In addition, travel restrictions during the COVID-19 pandemic have brought traditional GH rotations to a halt and spurred new educational approaches. Our goal is to develop a comprehensive online learning module on gastroenterology issues in GH for medical students undertaking GH electives. Method(s): A team of faculty and residents was convened between the Center for Community and Global Health and the Division of Gastroenterology. GH curricula across institutions and core competencies across 2 professional societies were examined via literature review. A survey was conducted among 2nd (MS2) and 3rd year medical students (MS3) interested in GH to assess attitudes toward GI-related issues in GH curriculum. An online learning module was developed consisting of 10, video-based lessons each addressing specific GH competencies (Figure 1). Result(s): In total, 41% (28/69) of MS2 and MS3 interested in GH responded to the survey, with a similar distribution of MS2 (13/28) and MS3 (15/28). Nearly all (92.8%) reported that learning GI conditions in a GH curriculum is moderately or very important (Table 1). A majority (78.5%) also reported feeling at least somewhat anxious or more about managing GI conditions during GH electives. Few medical students reported feeling moderately or extremely prepared to identify risk factors for GI conditions in different settings (21.5%) and to define approaches to therapy in resource-limited settings (14.3%). Interestingly, a majority (71.4%) reported feeling not at all prepared or slightly prepared to deliver cost-effective care to challenging populations. Conclusion(s): Our survey responses demonstrated an unmet need for GI-related training and cost-conscious care in the GH curriculum. Developing an online learning module on GI conditions to supplement GH curriculum may be useful and feasible. A randomized controlled trial is underway to examine the effect of this online learning module on medical student knowledge and preparedness to address GI conditions in GH electives.

How Type of Office Visit Influences Attitudes and Preferences for Telemedicine?

Introduction: The COVID-19 pandemic caused significant changes in delivery of healthcare. Telemedicine emerged as a popular option. Numerous studies demonstrate a favorable opinion of telemedicine from patient and physician perspectives. What factors make it more efficient and effective This study explores how type of office visit impacts attitudes towards telemedicine and affects patient's preferences for future visits. Method(s): Surveys were delivered by mail or in person to 1,100 randomly selected patients of Sierra Nevada Gastroenterology, a community-based practice in Grass Valley, CA. Each patient (pt) had a telemedicine visit (TMV) from April 2020-October 2021. Three hundred twenty surveys were returned completed. Surveys contained a 5-point Likert scale set of questions rating the quality, communication, compassion, thoroughness and convenience of TMV. In person visits (IPV) were then directly compared to TMV for the same qualities. Demographics were recorded (Table 1). Surveys were separated into 3 categories based on type of visit: new complaint (NC), follow-up of existing problem (FU), procedure-related visit (PRV). Statistical analysis and chi-square test were used to determine statistical significance. Result(s): Quality, communication, thoroughness and compassion during TMV rated high with Likert scores of 4.3-4.7 (= 0 strongly agree) for all groups. Comparing the 3 groups (NC, FU, PRV) with chi-square testing, no statistical difference in ratings was seen. FU pts had the highest Likert scores in all categories. Pts with new complaints preferred IPV over TMV for quality, communication, thoroughness and compassion, which was rated statistically significantly higher (P< 0.05). TMV was favored for convenience in all groups with highest ranking in FU pts (73%). Conclusion(s): This study showed type of office visit did not affect satisfaction or ratings of TMV. However, type of visit did reveal preferences for either IPV or TMV. Pts with NC preferred IPV and felt compassion is important and delivered more effectively in person. This suggests non-verbal communication such as body language, facial expression and tone is conveyed more effectively in person than over phone or video calls. FU or PRV pts rated TMV as more convenient and preferable over IPV for future visits, suggesting that pts with stable or less acute problems prioritize convenience over other factors when selecting type of visit. Further studies are needed to determine what other factors will influence and improve quality of TMV.

Virtual Visits for Initial Evaluation of Constipation Are Associated With Reduced Outpatient Order Compliance

Introduction: In gastroenterology, telemedicine has emerged as a means for improving patient access to medical care while limiting viral transmission during the pandemic. The purpose of this study was to assess patient order compliance in the virtual vs. in-person setting during the COVID-19 pandemic for the initial evaluation of constipation. Method(s): Using natural language processing, we identified outpatient gastroenterology visits (virtual and in-person) for constipation from March 2020 through December 2021. We assessed the number of orders placed for patients during these encounters and determined compliance based on order completion. A generalized linear mixed effects model with fixed effects for visit type and random intercepts for intra-patient correlation was used. A multivariable model was built controlling for age, socioeconomic status, BMI, dementia, stroke, and congestive heart failure. Result(s): Among 4,930 patients who presented for initial constipation evaluation since the start of the pandemic, 3,515 patients were evaluated in-person and 1,415 patients were evaluated virtually. Comparing order compliance in patients seen during the pandemic, patients seen virtually were 66% less likely to complete orders in comparison to patients seen in-person (p < .001). Patients seen in a pandemic virtual setting were 43% less likely to complete imaging orders (p < 0.001), 78% less likely to complete procedure orders (p < 0.001), and 90% less likely to complete lab orders (p < 0.001) (Table). Increased lab compliance was associated with the highest socioeconomic status ($75,000-$200,000) with patients eight times more likely to complete lab orders (p=0.049) and three times more likely to complete orders overall (p=0.021). Conclusion(s): Compared with in-person visits, patients seen virtually for their first presentation of constipation were less likely to complete labs, imaging and procedure evaluation ordered. In-person visits were more successful in leading to patient order completion during the pandemic. These findings suggest that virtual visits for constipation, despite convenience, may compromise care delivery;such visits may thus require additional care coordination to achieve compliance with medical recommendations. (Figure Presented).

Appropriateness and Completion of Multitarget Stool DNA Testing in Primary and Subspecialty Care

Introduction: Colorectal cancer (CRC) is the third most prevalent cancer in the United States, with a 4% lifetime incidence. While more clinicians have begun ordering multitarget stool DNA (mt-sDNA) testing due to the COVID-19 pandemic, adherence to guidelines on mt-sDNA and rates of subsequent follow-up testing has not been well studied. We assessed the appropriateness of mt-sDNA orders and rate of high-quality colonoscopy completion following a positive result in a large academic medical center. Method(s): We identified patients ordered for mt-sDNA in primary care and gastroenterology clinics at our institution between April 2020 and July 2021. For each case, we reviewed the appropriateness of mtsDNA testing, documentation of shared decision making, result of testing, and subsequent follow-up. Appropriateness was defined in accordance to the most recent American College of Gastroenterology guidelines on mt-sDNA use for CRC screening. Result(s): Of the 797 patients in our study, 685 (86%) met all appropriateness criteria for mt-sDNA testing (Table). Shared decision making was documented in 488 (62%) cases, and the most common reason for ordering mt-SDNA was hesitancy for colonoscopy. 483 patients (61%) completed mt-sDNA testing, of which 74 cases (15%) were positive. Rates of positivity were higher in cases of inappropriate (28%) rather than appropriate (13.7%) orders (p = 0.01). Colonoscopy was ordered in 73 cases (99%) and completed by 59 patients (80%). Of the 56 patients who underwent colonoscopy at our institution, most had documentation of a high-quality colonoscopy, defined as adequate prep (84%), cecal intubation (93%), visualization of the appendiceal orifice and ileocecal valve (94%), and right colon retroflexion (83%). Sixteen patients (29%) were found with advanced adenomas and 19 (34%) had other adenomas or sessile polyps. Among the 409 patients with negative tests, a 3-year follow-up recommendation was documented for 369 patients (90%). Conclusion(s): Most clinicians at our institution identified appropriate patients for mt-sDNA testing and provided appropriate follow-up< and the majority of patients who underwent colonoscopy had documentation of a high-quality colonoscopy. In contrast, there were suboptimal rates of mt-sDNA completion and documentation of shared decision making. Further studies are needed to identify barriers to documentation of shared-decision making and to completion of high-quality colonoscopies in patients being screened with mt-sDNA.

Barking up the Wrong Hepatobiliary Tree: A Case of Elevated CA19-9

Introduction: Incidental elevations in Carbohydrate Antigen 19-9 (CA19-9) can trigger extensive medical evaluations for malignancy. Though classically associated with pancreatic cancer, CA19-9 is a nonspecific manifestation of multiple benign and malignant disease processes. Case Description/Methods: An asymptomatic, healthy 50-year-old female presented to primary care for an elevated CA19-9 level obtained for pancreatic cancer screening in Asia in 2019. Her evaluation in 2019 included abdominopelvic CT and magnetic retrograde cholangiopancreatography, which were normal. She was offered endoscopic ultrasonography to further evaluate pancreaticobiliary etiologies but was lost to follow-up amid the COVID-19 pandemic. She returned to the US in 2021, and basic laboratory testing and routine cervical cancer screening were performed. She was referred to Gastroenterology (GI) for further evaluation. Cervical cytology revealed atypical endometrial cells, and endometrial biopsy by gynecology was concerning for gastric-type endocervical adenocarcinoma. Transvaginal ultrasound revealed a thickened endometrial stripe, and pan CT revealed duodenal thickening, for which GI performed bidirectional endoscopy without significant abnormalities and no pancreatic or metastatic disease. Repeat CA19- 9 increased. She was referred to gynecologic oncology, where cervical biopsy and pelvic MRI confirmed an endocervical mass. She was diagnosed with Stage IIB gastric-type endocervical adenocarcinoma and underwent hysterectomy and left salpingectomy with adjuvant chemoradiation. Discussion(s): CA19-9 is synthesized in multiple organ systems. Elevations in asymptomatic patients are rarely predictive of pancreatic cancer but may expose patients to unnecessary testing and inadvertent harms without identifying malignancy. Thus, CA19-9 is not recommended for pancreatic cancer screening. Incidental elevations do warrant repeat testing. Benign processes will yield stable or decreasing levels, while rising levels suggest progressive or malignant processes. If concern for pancreatic malignancy is low, a reasonable investigation includes chest X-ray or CT, metabolic studies, hemoglobin A1c, liver and thyroid function panels, abdominopelvic CT or gynecologic cancer evaluation, and any other age-indicated cancer screening. In this case, prior imaging studies suggested low concern for pancreatic cancer. Her subsequent evaluation aligned with this suggested work-up and revealed gynecologic cancer as the ultimate etiology for her elevated CA19-9.

Mucosa-Associated Lymphoid Tissue Lymphoma of the Rectum Incidentally Found in a Patient with Ulcerative Colitis

Introduction: Mucosa-associated lymphoid tissue (MALT) lymphomas are extra-nodal marginal zone B-cell lymphomas, most commonly found in the stomach, associated with Helicobacter pylori infections, and generally not linked with inflammatory bowel disease. Rectal MALT lymphoma is very uncommon and often associated with painful defecation, change in bowel habits, or rectal pressure/prolapse. Here, we present a rare case of an asymptomatic female with ulcerative colitis (UC) found to have benign-appearing rectal polyps during a routine screening colonoscopy. Case Description/Methods: The patient is a 56-year-old female with a history of left-sided UC, diagnosed in 1993, with one flare after receiving the 2nd dose of the Moderna COVID-19 vaccine, taking oral Olsalazine 500 mg twice daily, low-dose Prednisone, and mesalamine suppositories as needed presenting for screening colonoscopy. The patient was asymptomatic, citing regular non-bloody bowel movements and normal stool consistency. Colonoscopy revealed two 7 mm sessile, non-bleeding rectal polyps, surrounded by congested, erythematous, friable, and ulcerated mucosa in the rectosigmoid colon. Cold forceps biopsies were taken. Hematopathology evaluation of the routine colon biopsy samples revealed chronic nonspecific colitis while pathology of the rectal polyps showed marked lymphoplasmacytic infiltrate and extra-nodal marginal zone lymphoma of MALT. Ancillary studies, immunohistochemistry, and molecular studies for B-cell gene rearrangement confirmed extra-nodal marginal zone lymphoma of MALT with prominent plasmacytic differentiation. The patient was informed and close follow-up in Gastroenterology clinic was arranged. (Figure) Discussion: Rectal MALT lymphoma is rare with unclear management options. Treatments of UC include watchful waiting, surgical resection, endoscopic mucosal resection, radiation, and/or chemotherapy. Helicobacter pylori infections, though strongly linked with gastric MALT lymphoma, have not been shown to be strongly correlated with rectal MALT lymphoma. Given that patients with UC have chronic UCassociated colonic inflammation, lymphoma is often difficult to distinguish visually during colonoscopy, frequently masked by ulcerations and pseudo-polyps. In cases like these, more definitive treatments such as surgical resection could therefore be warranted. Long-term follow-up data is sparse and definitive management remains a clinical conundrum, thus these patients require reliable long-term multidisciplinary close follow-up. (Figure Presented).

Temporal Analysis of Medicare Physician Reimbursement for Common Gastroenterology Procedures From 2007 to 2022

Introduction: As the U.S. population ages, gastroenterologists will provide care for an increasing number of older patients - many of whom use Medicare. In recent years there have been significant policy changes surrounding Medicare reimbursement for physicians. Understanding reimbursement trends can help reveal the financial impact of these policies on gastroenterologists. Our study aims to analyze the trends in Medicare reimbursement of common gastrointestinal (GI) services from 2007 to 2022. Method(s): The top 10 GI procedures and their respective CPT codes were identified through a joint list published by the American College of Gastroenterology, American Society of Gastrointestinal Endoscopy, and American Gastroenterological Association. The top 5 5 CPT codes relating to office/inpatient visits provided by gastroenterologists to Medicare Part B beneficiaries was identified using data from CMS. The Physician Fee Schedule Look-Up Tool from CMS was queried for the selected CPT codes from 2007 to 2022, to determine the facility reimbursement rate by Medicare for each service. The reimbursement data were adjusted to January 2022 U.S. dollars using the U.S. Department of Labor's Bureau of Labor Statistics' consumer price index inflation calculator. Result(s): The unadjusted physician reimbursement for GI procedures exhibited an average decrease of 7.0% (95% CI, 29.9% to 24.1%) from 2007 to 2022. After adjusting for inflation, the mean decrease in physician reimbursement for procedures was 33.0% (95% CI, 235.1% to 230.9%). The mean annual growth rate in reimbursement was 22.6% (95% CI, 22.8% to 22.4%). The unadjusted physician reimbursement for inpatient and outpatient visits exhibited an average increase of 32.1% (95% CI, 4.8% to 59.3%). After adjusting for inflation, physician reimbursement for patient visits exhibited a mean decrease of 4.92% (Figure 1). Conclusion(s): The analysis revealed a steady decline in adjusted and non-adjusted reimbursement between 2007 and 2022. Decreasing Medicare reimbursement may impact health outcomes, healthcare access, and patient satisfaction. Reimbursement policies must be scrutinized particularly in the light of high inflation and increased costs due to additional costs associated with care during the COVID-19 pandemic, staffing shortages, and increased staffing salaries. (Figure Presented).

Gastroenterology Fellowship Virtual Interviews: Applicant and Faculty Perceptions on Virtual Interview Advantages and Barriers

Introduction: During the COVID-19 pandemic, virtual interviews for resident and fellowship applicants became the standard. However, studies evaluating the experience of virtual interviews format are lacking. Accordingly, we sought to survey both gastroenterology fellowship applicants and interviewing faculty members about their experiences with the virtual interview process. Method(s): Interviewees and faculty at 13 different gastroenterology fellowship programs at academic medical centers across the United States completed a post-interview survey. The online survey was conducted during the 2020 ERAS fellowship interview season via Google Forms. The survey responses were anonymously collected and reported. Result(s): A total of 177 gastroenterology fellowship applicants and 83 faculty members completed the electronic surveys. Most participants reported a positive experience with 91% and 84% of applicants and faculty respectively, scoring at least 4 points on a 5-point scale. Eighty-8 percent and 85% of applicants and faculty respectively, reported that they had enough insight about the applicant or the fellowship program during the interview. Over 67% of applicants reported cost-savings of greater than $1,000 per interview. Thirty-6 percent of applicants reported that they missed the personal interaction with the current gastroenterology fellows in the respective programs and the experience of physically touring the facility. Twenty-7 percent and 25% of applicants and faculty experienced technical difficulties during the interview process, respectively. Thirty-one percent and 22% of applicants and faculty would like for the virtual interviews to be the standard of future fellowship interviews, while 35% and 42% of applicants and faculty would consider it in the future, respectively. Figure 1 shows the ranking process for both applicants and faculty. Conclusion(s): Virtual interviews were perceived as effective and cost-saving by both gastroenterology fellowship applicants and faculty members. The virtual experience was widely accepted by most applicants and faculty, with high potential to become the standard of fellowship interview process in the future. However, a substantial portion experienced technical difficulty. Further improvements in technology are needed to optimize the process and increase the acceptance of the virtual interview experience. (Figure Presented).

Improving Barrett's Diagnosis and Surveillance Service at a District General Hospital in the United Kingdom

Introduction: Barrett's oesophagus is a well identified precursor for oesophageal adenocarcinoma, with the risk of malignant transformation being 0.5% annually. It is therefore crucial that diagnosis and surveillance standards meet national guidelines. This audit was carried out to assess if our District General Hospital was meeting the standards set by the British Society of Gastroenterology with regards to Barrett's diagnosis and surveillance. Method(s): Data was collected looking at 143 OGDs carried out for Barrett's diagnosis and surveillance at a District General Hospital in the United Kingdom from 01/01/2018 to 30/06/2018. The OGD reports were compared against recommended national standards set by the British Society of Gastroenterology. A proforma was created and was put into use from August 2020. It was utilized by all endoscopists when carrying out OGDs for Barrett's diagnosis and surveillance. The proforma was added to the end of the hospital's standard endoscopy report. Following the intervention and use of the proforma, the second cycle of the audit was carried out looking at 58 OGDs completed between 05/08/2020-27/02/2021 to see if they met the standards set out by the British Society of Gastroenterology. The Barrett's surveillance service and the volume of OGDs carried out following the introduction of the proforma was affected by the Covid-19 pandemic. Result(s): The first cycle of the audit found that only 34% of OGDs had a Prague classification documented correctly. 0% of OGDs had the correct biopsy protocol followed and 12.6% of endoscopies did not have any biopsies taken. 26% of patients had no follow up or surveillance endoscopy interval documented or organised. Following the intervention, it was found that 96% of endoscopies now had a Prague classification documented, an increase of 62%. There was a 65% increase in correct biopsy technique being followed and 100% of OGD reports now had surveillance interval documented if deemed appropriate. Conclusion(s): The audit clearly displays that following our intervention there was a significant improvement in the quality of Barrett's diagnostic and surveillance endoscopies, when compared to national guidelines. Given its potential for malignant transformation, correct surveillance is exceptionally important to improve patient care and reduce mortality. The introduction of a proforma drastically improved the standard of the service provided at our District General Hospital and is one that can be transferable to other hospitals.

SARS-CoV-2 Infection Precipitates the Discovery of Underlying Liver Disease: A Case Report.

Since the onset of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, numerous sequelae of this devastating virus have come to light. One organ known to be impacted by SARS-CoV-2 is the liver, as many SARS-CoV-2 patients demonstrate elevated liver enzymes on routine laboratory tests. In this case report, we present a patient with SARS-CoV-2 whose liver enzymes remained persistently elevated throughout his hospitalization. Due to the duration of his elevated liver enzymes, etiologies outside of SARS-CoV-2 were explored. This workup revealed that the patient had alpha-1 antitrypsin (A1AT) deficiency. Thus, this case serves to remind clinicians to continue investigating lab abnormalities despite a presumed etiology, such as SARS-CoV-2, so as not to miss the presentation of new diagnoses.

Telehealth for Pediatric Gastroenterology Care Now: The Transition to Telehealth and the Impact of Webinar-Based Didactics.

With the coronavirus disease 2019 public health emergency (PHE), telehealth (TH) became essential for continued delivery of care. Members of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) formed the Telehealth for Pediatric Gastrointestinal Care Now (TPGCN) working group and rapidly organized a telemedicine webinar to provide education and guidance. We aim to describe the webinar development and prospectively assess the effectiveness of this webinar-based educational intervention. Methods: NASPGHAN members who registered for the TPGCN webinar received pre- and post-webinar surveys. Outcome measures included a modified Telehealth Acceptance Model (TAM) survey and a Student Evaluation of Educational Quality (SEEQ) standardized instrument. Results: Seven hundred seventy-six NASPGHAN members participated in the webinar, 147 (33%) completed the pre-webinar survey; of these, 25 of 147 (17%) completed a post-webinar survey. Before the PHE, 50.3% of the pre-webinar survey participants had no TH knowledge. Webinar participants trended to have increased acceptance of TH for follow-up visits (pre-webinar, 68% versus post-webinar, 81%; P = 0.15) and chronic disease care (pre-webinar, 57% vs post-webinar, 81%; P = 0.01). The overall acceptance of TH as shown by TAM pre-webinar was 1.74 ± 0.8, which improved to 1.62 ± 0.8 post-webinar (lower scores indicate greater acceptance; P < 0.001). SEEQ results indicate that webinar material was understandable (post-webinar, 95%). Participants found breakout sessions informative and enjoyable (post-webinar, 91%). Conclusion: The TPGCN TH webinar was an effective educational intervention that fostered increased TH usage for follow-up and chronic care visits, improved TAM scores, and was well received by participants as seen by high SEEQ scores. Sustained and expanded pediatric gastrointestinal TH usage beyond the coronavirus disease 2019 PHE is expected.

Pancolitis Post COVID-19 Infection: A Case Report.

Gastrointestinal tract (GIT) symptoms are increasingly reported as the presenting symptoms of coronavirus disease 2019 (COVID-19). These symptoms vary from diarrhea to severe colitis or bleeding. This paper reports a rare case of pancolitis as a consequence of GIT involvement secondary to active COVID-19 in a previously healthy 52-year-old lady. The diagnosis was confirmed by a CT scan of the abdomen and the patient was hospitalized and treated conservatively and discharged home after three days of hospital admission. She was followed up in the outpatient surgical clinic in two weeks with no more gastrointestinal symptoms and a normal physical examination. Careful consideration of gastrointestinal symptoms in the context of COVID-19 and a prompt diagnosis will facilitate early recognition and management and avoid any sinister complications.