Quality indicators for pediatric colonoscopy: results from a multicenter consortium.

BACKGROUND AND AIMS: Currently, there are no quality measures specific to children undergoing GI endoscopy. We aimed to determine the baseline quality of pediatric colonoscopy by using the Pediatric Endoscopy Database System-Clinical Outcomes Research Initiative (PEDS-CORI), a central registry. METHODS: We conducted prospective data collection by using a standard computerized report generator and central registry (PEDS-CORI) to examine key quality indicators from 14 pediatric centers between January 2000 and December 2011. Specific quality indicators, including bowel preparation, ileal intubation rate, documentation of American Society of Anesthesiologists Physical Status Classification System (ASA) class, and procedure time, were compared during the study period. RESULTS: We analyzed 21,807 colonoscopy procedures performed in patients with a mean age of 11.5 ± 4.8 years. Of the 21,807 reports received during the study period, 56% did not include bowel preparation quality, and 12.7% did not include ASA classification. When bowel preparation was reported, the quality was described as excellent, good, or fair in 90.3%. The overall ileal intubation rate was 69.4%, and 15.6% reported cecal intubation only, calculated to be 85% cecum or ileum intubation. Thus, 15% of colonoscopy procedures did not report reaching the cecum or ileum. When excluding the proportion of procedures not intended to reach the ileum (31.5%), the overall ileal intubation rate increased to 84.0%. The rate of ileum examination varied from 85% to 95%, depending on procedure indication. CONCLUSIONS: Colonoscopy reports from our central registry revealed significant variations and inconsistent documentation in pediatric colonoscopy. Our study identifies areas for quality improvement and highlights the need for developing accepted quality measures specific to pediatric endoscopy.

Implementable strategies and exploratory considerations to reduce costs associated with anti-TNF therapy in inflammatory bowel disease.

A health care system is needed where care is based on the best available evidence and is delivered reliably, efficiently, and less expensively (best care at lower cost). In gastroenterology, anti-tumor necrosis factor agents represent the most effective medical therapeutic option for patients with moderate-to-severe inflammatory bowel disease (IBD), but are very expensive and account for nearly a quarter of the cost of IBD care, representing a major area of present and future impact in direct health care costs. The ImproveCareNow Network, consisting of over 55 pediatric IBD centers, seeks ways to improve the value of care in IBD, curtailing unnecessary costs and promoting better health outcomes through systematic and incremental quality improvement initiatives. This report summarizes the key evidence to facilitate the cost-effective use of anti-tumor necrosis factor agents for patients with IBD. Our review outlines the scientific rationale for initiating cost-reducing measures in anti-tumor necrosis factor use and focuses on 3 implementable strategies and 4 exploratory considerations through practical clinical guidelines, as supported by existing evidence. Implementable strategies can be readily integrated into today's daily practice, whereas exploratory considerations can guide research to support future implementation.

Abdominal migraine: an under-diagnosed cause of recurrent abdominal pain in children.

OBJECTIVE: Our objective was to demonstrate that, despite recognition by both the gastroenterology and headache communities, abdominal migraine (AM) is an under-diagnosed cause of chronic, recurrent, abdominal pain in childhood in the USA. BACKGROUND: Chronic, recurrent abdominal pain occurs in 9-15% of all children and adolescents. After exclusion of anatomic, infectious, inflammatory, or other metabolic causes, "functional abdominal pain" is the most common diagnosis of chronic, idiopathic, abdominal pain in childhood. Functional abdominal pain is typically categorized into one, or a combination of, the following 4 groups: functional dyspepsia, irritable bowel syndrome, AM, or functional abdominal pain syndrome. International Classification of Headache Disorders--(ICHD-2) defines AM as an idiopathic disorder characterized by attacks of midline, moderate to severe abdominal pain lasting 1-72 hours with vasomotor symptoms, nausea and vomiting, and included AM among the "periodic syndromes of childhood that are precursors for migraine." Rome III Gastroenterology criteria (2006) separately established diagnostic criteria and confirmed AM as a well-defined cause of recurrent abdominal pain. METHODS: Following institutional review board approval, a retrospective chart review was conducted on patients referred to an academic pediatric gastroenterology practice with the clinical complaint of recurrent abdominal pain. ICHD-2 criteria were applied to identify the subset of children fulfilling criteria for AM. Demographics, diagnostic evaluation, treatment regimen and outcomes were collected. RESULTS: From an initial cohort of 600 children (ages 1-21 years; 59% females) with recurrent abdominal pain, 142 (24%) were excluded on the basis of their ultimate diagnosis. Of the 458 patients meeting inclusion criteria, 1824 total patient office visits were reviewed. Three hundred eighty-eight (84.6%) did not meet criteria for AM, 20 (4.4%) met ICHD-2 formal criteria for AM and another 50 (11%) had documentation lacking at least 1 criterion, but were otherwise consistent with AM (probable AM). During the observation period, no children seen in this gastroenterology practice had received a diagnosis of AM. CONCLUSION: Among children with chronic, idiopathic, recurrent abdominal pain, AM represents about 4-15%. Given the spectrum of treatment modalities now available for pediatric migraine, increased awareness of cardinal features of AM by pediatricians and pediatric gastroenterologists may result in improved diagnostic accuracy and early institution of both acute and preventative migraine-specific treatments.

Repeat endoscopy affects patient management in pediatric inflammatory bowel disease.

OBJECTIVES: Endoscopy is commonly performed in the diagnosis of children with inflammatory bowel disease (IBD). The utility of repeat endoscopy for the management of pediatric IBD has not been subject to investigation. The frequency and determinants of changes in medical management resulting from endoscopy are unknown. METHODS: We conducted a cross-sectional cohort study to assess the frequency and determinants of management change in all children (0-21 years) who underwent endoscopy for the surveillance or evaluation of established IBD between July 2002 and July 2006 at 2 referral centers in the United States. Patients were sampled from the Pediatric Endoscopy Database System Clinical Outcomes Research Initiative and a chart review was performed to identify demographic features (age, gender), blood work (hemoglobin, albumin, erythrocyte sedimentation rate, C-reactive protein), and endoscopy results (endoscopic and histologic). An endoscopic score was used to assess mucosal injury. Subjects were divided into two groups for comparative analysis: (i) patients with management changes based on endoscopic or histologic findings, and (ii) patients without changes. RESULTS: We analyzed 285 endoscopic procedures (137 colonoscopies, 109 esophagogastroduodenoscopy (EGD) with colonoscopy, 25 sigmoidoscopies, 8 EGDs, 6 EGDs with sigmoidoscopy) performed in 230 children (mean age 14.5) with established IBD, including 147 with Crohn's disease, 80 with ulcerative colitis, and 3 with indeterminant colitis. Management changes were documented in 119 (42%) procedures, including 58 (20%) immediately after endoscopy, 52 (18%) after histology review, and 9 (3%) after both. Management changes included new medications in 86 cases, discontinuation of a medication in 3 cases, hospital admission in 11, and surgical consult in 14. No significant differences between groups occurred with regard to age, gender, endoscopy type, or infliximab use. The presence of anemia, hypoalbuminemia, or elevated markers of inflammation (ESR, CRP) did not correlate with management outcome. Management changes after endoscopy were more frequent in patients with Crohn's disease as compared to patients with ulcerative colitis. Patients with mucosal injury were more likely to have a management change than those with mucosal healing (80% vs. 20%; P<0.001). CONCLUSIONS: The overall rate of management change after endoscopic evaluation in children with IBD is approximately 42%. Addition of a new medication is the most common intervention. Blood work and patient symptoms before the procedure did not predict management outcome; however, mucosal healing may be an important end point. Our findings suggest that endoscopy is valuable for the evaluation of children with IBD.

Pattern of growth after pediatric living-donor small bowel transplantation.

The aim of our study was to analyze growth in children who underwent LDSB. The question was whether these children obtain linear growth and improvement of the Z-score for height and weight after the transplant. Three children with a mean age of 24 months underwent living-donor intestinal transplantation with 150 cm of terminal ileum. At a mean follow-up of 27 months height increased from 82.5 to 97.5 cm although Z-score for height did not improve, -2.679 to -2.675. Mean weight increased from 11.4 to 14.2 kg while Z-score for weight went from -1.916 to -2.409. Although these data are pertinent to only three children and the follow-up is slightly longer than two yr, it appears that while long-term survival and independency from TPN is achieved, only linear growth might be expected and catch-up growth does not occur.