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Provenzale, Dawn Tranchino

Overview:

Dr. Provenzale is Director of GI Outcomes Research at Duke University and the Director of the Durham Epidemiologic Research and Information Center (ERIC). She directs a research program that integrates observational research, measurement of patient-centered outcomes and decision making to investigate patient-oriented research questions in gastrointestinal cancer screening, surveillance and quality of care. Dr. Provenzale also directs the training program for GI fellows committed to careers in health services research.

Research:

Ongoing projects include CanCORS, an NCI/VA funded consortium to measure quality of lung and colorectal cancer care in VA and non-VA settings, and the development and dissemination of CCQMS, a cancer care quality measurement system. Additional studies are developing a cancer tissue repository for microarray studies.

Positions:

Professor of Medicine

Medicine, Gastroenterology
School of Medicine

Member of the Duke Cancer Institute

Duke Cancer Institute
School of Medicine

Education:

M.D. 0

M.D. — Albany Medical College

Medical Resident, Medicine

University of North Carolina at Chapel Hill

Fellow In Gastroenterology, Medicine

Tufts University

Fellow In Clinical Decision Making, Medicine

Tufts University

Grants:

Duke Training Grant in Digestive Diseases and Nutrition

Administered By
Medicine, Gastroenterology
AwardedBy
National Institutes of Health
Role
Mentor
Start Date
July 01, 1988
End Date
June 30, 2017

Understanding recommendations for screening colonoscopy intervals

Administered By
Medicine, Gastroenterology
AwardedBy
National Institutes of Health
Role
Investigator
Start Date
September 15, 2013
End Date
May 31, 2017

IPA Teresa Day

Administered By
Medicine, Gastroenterology
AwardedBy
Durham Veterans Affairs Medical Center
Role
Principal Investigator
Start Date
June 01, 2013
End Date
May 31, 2015

IPA - Jane T. Kolimaga

Administered By
Medicine, Gastroenterology
AwardedBy
Durham Veterans Affairs Medical Center
Role
Principal Investigator
Start Date
January 01, 2011
End Date
October 12, 2012

IPA Agreement

Administered By
Medicine, Gastroenterology
AwardedBy
Veterans Administration Medical Center
Role
Principal Investigator
Start Date
November 01, 2008
End Date
October 31, 2010

Gastrointestinal Cancer Screening and Surveillance

Administered By
Medicine, Gastroenterology
AwardedBy
National Institutes of Health
Role
Principal Investigator
Start Date
September 29, 2000
End Date
September 30, 2010

Patient Reported Outcomes Quality Improvement Survey for the CCQMS

Administered By
Medicine, Gastroenterology
AwardedBy
National Institutes of Health
Role
Principal Investigator
Start Date
September 01, 2008
End Date
August 31, 2009

Cancer Care Quality Measurement System

Administered By
Medicine, Gastroenterology
AwardedBy
National Institutes of Health
Role
Principal Investigator
Start Date
September 24, 2007
End Date
September 23, 2008

IPA Agreement-Chris Newlin

Administered By
Medicine, Gastroenterology
AwardedBy
Department of Veterans Affairs
Role
Principal Investigator
Start Date
September 01, 2007
End Date
August 31, 2008

IPA Jane T. Kolimaga

Administered By
Medicine, Gastroenterology
AwardedBy
Veterans Administration Medical Center
Role
Principal Investigator
Start Date
November 01, 2006
End Date
August 31, 2008

Colorectal Cancer Screening Behavior in VA Population

Administered By
Medicine, General Internal Medicine
AwardedBy
National Institutes of Health
Role
Co Investigator
Start Date
January 15, 2005
End Date
December 31, 2007

IPA Teresa Day

Administered By
Medicine, Gastroenterology
AwardedBy
Veterans Administration Medical Center
Role
Principal Investigator
Start Date
December 01, 2005
End Date
November 30, 2007
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Publications:

Colorectal Cancer Statistics From the Veterans Affairs Central Cancer Registry.

Colorectal cancer (CRC) is a common and potentially deadly disease. Although the United States has robust cancer data reporting, information from the Department of Veterans Affairs (VA) healthcare system has often been underrepresented in national cancer data sources. We describe veterans with incident CRC in terms of their patient and tumor characteristics and mortality.Patients diagnosed or treated with CRC at any VA institution in the fiscal years 2009 to 2012 were identified using 3 data sources: (1) VA Central Cancer Registry (VACCR); (2) VA Corporate Data Warehouse; and (3) VA Reports and Measures Portal. The CRC frequencies within the VA population and survival curves were examined descriptively and compared with the national projections using Surveillance, Epidemiology, and End Results program data.A total of 12,551 veterans with CRC were included in the present analysis. The median age at diagnosis was 65.5 years. Approximately 97% (n = 12,229) of the CRC cases were diagnosed among men. Approximately 44% (n = 5517) of the patients were diagnosed with localized disease. The 3-year survival rate was associated with age (P < .01) and stage (P < .01) at diagnosis. We identified a possible decrease in VA CRC incidence over time.Although the VA CRC patient population was heavily skewed toward the male gender, the patient and tumor characteristics were similar between the incident CRC cases reported by the VACCR and those reported to the Surveillance, Epidemiology, and End Results program. This suggests that research findings resulting from the VACCR might have applicability beyond the VA healthcare system setting.

Authors
Zullig, LL; Smith, VA; Jackson, GL; Danus, S; Schnell, M; Lindquist, J; Provenzale, D; Weinberger, M; Kelley, MJ; Bosworth, HB
MLA Citation
Zullig, LL, Smith, VA, Jackson, GL, Danus, S, Schnell, M, Lindquist, J, Provenzale, D, Weinberger, M, Kelley, MJ, and Bosworth, HB. "Colorectal Cancer Statistics From the Veterans Affairs Central Cancer Registry." Clinical colorectal cancer 15.4 (December 2016): e199-e204.
PMID
27301717
Source
epmc
Published In
Clinical colorectal cancer
Volume
15
Issue
4
Publish Date
2016
Start Page
e199
End Page
e204
DOI
10.1016/j.clcc.2016.04.005

The Symptom Experience in Rectal Cancer Survivors.

As the number of rectal cancer survivors grows, it is important to understand the symptom experience after treatment. Although data show that rectal cancer survivors experience a variety of symptoms after diagnosis, little has been done to study the way these symptoms are grouped and associated.To determine symptom prevalence and intensity in rectal cancer survivors and if clusters of survivors exist, who share similar symptom-defined survivor subgroups that may vary based on antecedent variables.A secondary analysis of the Cancer Care and Outcomes Research and Surveillance database was undertaken. Cluster analysis was performed on 15-month postdiagnosis data to form post-treatment survivor subgroups, and these were examined for differences in demographic and clinical characteristics. Data were analyzed using cluster analysis, chi-square, and analysis of variance.A total of 275 rectal cancer survivors were included who had undergone chemotherapy, radiation therapy, and surgery. Most frequently reported symptoms included feeling "worn out" (87%), feeling "tired" (85%), and "trouble sleeping" (66%). Four symptom-defined survivor subgroups (minimally symptomatic n = 40, tired and trouble sleeping n = 138, moderate symptoms n = 42, and highly symptomatic n = 55) were identified with symptom differences existing among each subgroup. Age and being married/partnered were the only two antecedents found to differ across subgroups.This study documents differences in the symptom experience after treatment. The identification of survivor subgroups allows researchers to further investigate tailored, supportive care strategies to minimize ongoing symptoms in those with the greatest symptom burden.

Authors
Gosselin, TK; Beck, S; Abbott, DH; Grambow, SC; Provenzale, D; Berry, P; Kahn, KL; Malin, JL
MLA Citation
Gosselin, TK, Beck, S, Abbott, DH, Grambow, SC, Provenzale, D, Berry, P, Kahn, KL, and Malin, JL. "The Symptom Experience in Rectal Cancer Survivors." Journal of pain and symptom management 52.5 (November 2016): 709-718.
PMID
27697567
Source
epmc
Published In
Journal of Pain and Symptom Management
Volume
52
Issue
5
Publish Date
2016
Start Page
709
End Page
718
DOI
10.1016/j.jpainsymman.2016.05.027

Depression symptom trends and health domains among lung cancer patients in the CanCORS study

Authors
Sullivan, DR; Forsberg, CW; Ganzini, L; Au, DH; Gould, MK; Provenzale, D; Lyons, KS; Slatore, CG
MLA Citation
Sullivan, DR, Forsberg, CW, Ganzini, L, Au, DH, Gould, MK, Provenzale, D, Lyons, KS, and Slatore, CG. "Depression symptom trends and health domains among lung cancer patients in the CanCORS study." Lung Cancer 100 (October 2016): 102-109.
Source
crossref
Published In
Lung Cancer
Volume
100
Publish Date
2016
Start Page
102
End Page
109
DOI
10.1016/j.lungcan.2016.08.008

Genetic/familial high-risk assessment: Colorectal version 1.2016: Clinical practice guidelines in oncology

This is a focused update highlighting the most current NCCN Guidelines for diagnosis and management of Lynch syndrome. Lynch syndrome is the most common cause of hereditary colorectal cancer, usually resulting from a germline mutation in 1 of 4 DNA mismatch repair genes (MLH1, MSH2, MSH6, or PMS2), or deletions in the EPCAM promoter. Patients with Lynch syndrome are at an increased lifetime risk, compared with the general population, for colorectal cancer, endometrial cancer, and other cancers, including of the stomach and ovary. As of 2016, the panel recommends screening all patients with colorectal cancer for Lynch syndrome and provides recommendations for surveillance for early detection and prevention of Lynch syndrome-associated cancers.

Authors
Provenzale, D; Gupta, S; Ahnen, DJ; Bray, T; Cannon, JA; Cooper, G; David, DS; Early, DS; Erwin, D; Ford, JM; Giardiello, FM; Grady, W; Halverson, AL; Hamilton, SR; Hampel, H; Ismail, MK; Klapman, JB; Larson, DW; Lazenby, AJ; Lynch, PM; Mayer, RJ; Ness, RM; Regenbogen, SE; Samadder, NJ; Shike, M; Steinbach, G; Weinberg, D; Dwyer, M; Darlow, S
MLA Citation
Provenzale, D, Gupta, S, Ahnen, DJ, Bray, T, Cannon, JA, Cooper, G, David, DS, Early, DS, Erwin, D, Ford, JM, Giardiello, FM, Grady, W, Halverson, AL, Hamilton, SR, Hampel, H, Ismail, MK, Klapman, JB, Larson, DW, Lazenby, AJ, Lynch, PM, Mayer, RJ, Ness, RM, Regenbogen, SE, Samadder, NJ, Shike, M, Steinbach, G, Weinberg, D, Dwyer, M, and Darlow, S. "Genetic/familial high-risk assessment: Colorectal version 1.2016: Clinical practice guidelines in oncology." JNCCN Journal of the National Comprehensive Cancer Network 14.8 (August 1, 2016): 1010-1030.
Source
scopus
Published In
Journal of the National Comprehensive Cancer Network : JNCCN
Volume
14
Issue
8
Publish Date
2016
Start Page
1010
End Page
1030

Veterans health administration hepatitis B testing and treatment with anti-CD20 antibody administration.

To evaluate pretreatment hepatitis B virus (HBV) testing, vaccination, and antiviral treatment rates in Veterans Affairs patients receiving anti-CD20 Ab for quality improvement.We performed a retrospective cohort study using a national repository of Veterans Health Administration (VHA) electronic health record data. We identified all patients receiving anti-CD20 Ab treatment (2002-2014). We ascertained patient demographics, laboratory results, HBV vaccination status (from vaccination records), pharmacy data, and vital status. The high risk period for HBV reactivation is during anti-CD20 Ab treatment and 12 mo follow up. Therefore, we analyzed those who were followed to death or for at least 12 mo after completing anti-CD20 Ab. Pretreatment serologic tests were used to categorize chronic HBV (hepatitis B surface antigen positive or HBsAg+), past HBV (HBsAg-, hepatitis B core antibody positive or HBcAb+), resolved HBV (HBsAg-, HBcAb+, hepatitis B surface antibody positive or HBsAb+), likely prior vaccination (isolated HBsAb+), HBV negative (HBsAg-, HBcAb-), or unknown. Acute hepatitis B was defined by the appearance of HBsAg+ in the high risk period in patients who were pretreatment HBV negative. We assessed HBV antiviral treatment and the incidence of hepatitis, liver failure, and death during the high risk period. Cumulative hepatitis, liver failure, and death after anti-CD20 Ab initiation were compared by HBV disease categories and differences compared using the χ(2) test. Mean time to hepatitis peak alanine aminotransferase, liver failure, and death relative to anti-CD20 Ab administration and follow-up were also compared by HBV disease group.Among 19304 VHA patients who received anti-CD20 Ab, 10224 (53%) had pretreatment HBsAg testing during the study period, with 49% and 43% tested for HBsAg and HBcAb, respectively within 6 mo pretreatment in 2014. Of those tested, 2% (167/10224) had chronic HBV, 4% (326/7903) past HBV, 5% (427/8110) resolved HBV, 8% (628/8110) likely prior HBV vaccination, and 76% (6022/7903) were HBV negative. In those with chronic HBV infection, ≤ 37% received HBV antiviral treatment during the high risk period while 21% to 23% of those with past or resolved HBV, respectively, received HBV antiviral treatment. During and 12 mo after anti-CD20 Ab, the rate of hepatitis was significantly greater in those HBV positive vs negative (P = 0.001). The mortality rate was 35%-40% in chronic or past hepatitis B and 26%-31% in hepatitis B negative. In those pretreatment HBV negative, 16 (0.3%) developed acute hepatitis B of 4947 tested during anti-CD20Ab treatment and follow-up.While HBV testing of Veterans has increased prior to anti-CD20 Ab, few HBV+ patients received HBV antivirals, suggesting electronic health record algorithms may enhance health outcomes.

Authors
Hunt, CM; Beste, LA; Lowy, E; Suzuki, A; Moylan, CA; Tillmann, HL; Ioannou, GN; Lim, JK; Kelley, MJ; Provenzale, D
MLA Citation
Hunt, CM, Beste, LA, Lowy, E, Suzuki, A, Moylan, CA, Tillmann, HL, Ioannou, GN, Lim, JK, Kelley, MJ, and Provenzale, D. "Veterans health administration hepatitis B testing and treatment with anti-CD20 antibody administration." World journal of gastroenterology 22.19 (May 2016): 4732-4740.
Website
http://hdl.handle.net/10161/11950
PMID
27217704
Source
epmc
Published In
World journal of gastroenterology : WJG
Volume
22
Issue
19
Publish Date
2016
Start Page
4732
End Page
4740
DOI
10.3748/wjg.v22.i19.4732

Risk of Incident Colorectal Cancer and Death After Colonoscopy: A Population-based Study in Utah

Authors
Samadder, NJ; Curtin, K; Pappas, L; Boucher, K; Mineau, GP; Smith, K; Fraser, A; Wan, Y; Provenzale, D; Kinney, AY; Ulrich, C; Burt, RW
MLA Citation
Samadder, NJ, Curtin, K, Pappas, L, Boucher, K, Mineau, GP, Smith, K, Fraser, A, Wan, Y, Provenzale, D, Kinney, AY, Ulrich, C, and Burt, RW. "Risk of Incident Colorectal Cancer and Death After Colonoscopy: A Population-based Study in Utah." Clinical Gastroenterology and Hepatology 14.2 (February 2016): 279-286.e2.
Source
crossref
Published In
Clinical Gastroenterology and Hepatology
Volume
14
Issue
2
Publish Date
2016
Start Page
279
End Page
286.e2
DOI
10.1016/j.cgh.2015.08.033

The accuracy and completeness for receipt of colorectal cancer care using Veterans Health Administration administrative data.

The National Comprehensive Cancer Network and the American Society of Clinical Oncology have established guidelines for the treatment and surveillance of colorectal cancer (CRC), respectively. Considering these guidelines, an accurate and efficient method is needed to measure receipt of care.The accuracy and completeness of Veterans Health Administration (VA) administrative data were assessed by comparing them with data manually abstracted during the Colorectal Cancer Care Collaborative (C4) quality improvement initiative for 618 patients with stage I-III CRC.The VA administrative data contained gender, marital, and birth information for all patients but race information was missing for 62.1% of patients. The percent agreement for demographic variables ranged from 98.1-100%. The kappa statistic for receipt of treatments ranged from 0.21 to 0.60 and there was a 96.9% agreement for the date of surgical resection. The percentage of post-diagnosis surveillance events in C4 also in VA administrative data were 76.0% for colonoscopy, 84.6% for physician visit, and 26.3% for carcinoembryonic antigen (CEA) test.VA administrative data are accurate and complete for non-race demographic variables, receipt of CRC treatment, colonoscopy, and physician visits; but alternative data sources may be necessary to capture patient race and receipt of CEA tests.

Authors
Sherer, EA; Fisher, DA; Barnd, J; Jackson, GL; Provenzale, D; Haggstrom, DA
MLA Citation
Sherer, EA, Fisher, DA, Barnd, J, Jackson, GL, Provenzale, D, and Haggstrom, DA. "The accuracy and completeness for receipt of colorectal cancer care using Veterans Health Administration administrative data." BMC health services research 16 (January 2016): 50-.
Website
http://hdl.handle.net/10161/11721
PMID
26869265
Source
epmc
Published In
BMC Health Services Research
Volume
16
Publish Date
2016
Start Page
50
DOI
10.1186/s12913-016-1294-9

Physician Non-adherence to Colonoscopy Interval Guidelines in the Veterans Affairs Healthcare System.

Colonoscopy can decrease colorectal cancer (CRC) mortality, although performing this procedure more frequently than recommended could increase costs and risks to patients. We aimed to determine rates and correlates of physician non-adherence to guidelines for repeat colonoscopy screening and polyp surveillance intervals.We performed a multi-center, retrospective, observational study using administrative claims, physician databases, and electronic medical records (EMR) from 1455 patients (50-64 y old) who underwent colonoscopy in the Veterans Affairs healthcare system in fiscal year 2008. Patients had no prior diagnosis of CRC or inflammatory bowel disease, and had not undergone colonoscopy examinations in the previous 10 years. We compared EMR-documented, endoscopist-recommended intervals for colonoscopies with intervals recommended by the 2008 Multi-Society Task Force guidelines.The overall rate of non-adherence to guideline recommendations was 36% and ranged from 3% to 80% among facilities. Non-adherence was 28% for patients who underwent normal colonoscopies, but 45%-52% after colonoscopies that identified hyperplastic or adenomatous polyps. Most of all recommendations that were not followed recommended a shorter surveillance interval. In adjusted analyses, non-adherence was significantly higher for patients whose colonoscopies identified hyperplastic (odds ratio [OR] = 3.1; 95% CI, 1.7-5.5) or high-risk adenomatous polyps (OR = 3.0; 95% CI, 1.2-8.0), compared to patients with normal colonoscopy examinations, but not for patients with low-risk adenomatous polyps (OR = 1.8; 95% CI, 0.9-3.7). Nonadherence was also associated with bowel preparation quality, geographic region, Charlson comorbidity score, and colonoscopy indication.In a managed care setting with salaried physicians, endoscopists recommend repeat colonoscopy sooner than guidelines for more than one third of patients. Factors associated with non-adherence to guideline recommendations were colonoscopy findings, quality of bowel preparation, and geographic region. Targeting endoscopist about non-adherence to colonoscopy guidelines could reduce overuse of colonoscopy and associated healthcare costs.

Authors
Johnson, MR; Grubber, J; Grambow, SC; Maciejewski, ML; Dunn-Thomas, T; Provenzale, D; Fisher, DA
MLA Citation
Johnson, MR, Grubber, J, Grambow, SC, Maciejewski, ML, Dunn-Thomas, T, Provenzale, D, and Fisher, DA. "Physician Non-adherence to Colonoscopy Interval Guidelines in the Veterans Affairs Healthcare System." Gastroenterology 149.4 (October 2015): 938-951.
PMID
26122143
Source
epmc
Published In
Gastroenterology
Volume
149
Issue
4
Publish Date
2015
Start Page
938
End Page
951
DOI
10.1053/j.gastro.2015.06.026

Colorectal Cancer Screening, Version 1.2015.

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Colorectal Cancer Screening provide recommendations for selecting individuals for colorectal cancer screening, and for evaluation and follow-up of colon polyps. These NCCN Guidelines Insights summarize major discussion points of the 2015 NCCN Colorectal Cancer Screening panel meeting. Major discussion topics this year were the state of evidence for CT colonography and stool DNA testing, bowel preparation procedures for colonoscopy, and guidelines for patients with a positive family history of colorectal cancer.

Authors
Provenzale, D; Jasperson, K; Ahnen, DJ; Aslanian, H; Bray, T; Cannon, JA; David, DS; Early, DS; Erwin, D; Ford, JM; Giardiello, FM; Gupta, S; Halverson, AL; Hamilton, SR; Hampel, H; Ismail, MK; Klapman, JB; Larson, DW; Lazenby, AJ; Lynch, PM; Mayer, RJ; Ness, RM; Rao, MS; Regenbogen, SE; Shike, M; Steinbach, G; Weinberg, D; Dwyer, MA; Freedman-Cass, DA; Darlow, S
MLA Citation
Provenzale, D, Jasperson, K, Ahnen, DJ, Aslanian, H, Bray, T, Cannon, JA, David, DS, Early, DS, Erwin, D, Ford, JM, Giardiello, FM, Gupta, S, Halverson, AL, Hamilton, SR, Hampel, H, Ismail, MK, Klapman, JB, Larson, DW, Lazenby, AJ, Lynch, PM, Mayer, RJ, Ness, RM, Rao, MS, Regenbogen, SE, Shike, M, Steinbach, G, Weinberg, D, Dwyer, MA, Freedman-Cass, DA, and Darlow, S. "Colorectal Cancer Screening, Version 1.2015." Journal of the National Comprehensive Cancer Network : JNCCN 13.8 (August 2015): 959-968.
PMID
26285241
Source
epmc
Published In
Journal of the National Comprehensive Cancer Network : JNCCN
Volume
13
Issue
8
Publish Date
2015
Start Page
959
End Page
968

Patient characteristics associated with the level of patient-reported care coordination among male patients with colorectal cancer in the Veterans Affairs health care system.

The current study was performed to determine whether patient characteristics, including race/ethnicity, were associated with patient-reported care coordination for patients with colorectal cancer (CRC) who were treated in the Veterans Affairs (VA) health care system, with the goal of better understanding potential goals of quality improvement efforts aimed at improving coordination.The nationwide Cancer Care Assessment and Responsive Evaluation Studies survey involved VA patients with CRC who were diagnosed in 2008 (response rate, 67%). The survey included a 4-item scale of patient-reported frequency ("never," "sometimes," "usually," and "always") of care coordination activities (scale score range, 1-4). Among 913 patients with CRC who provided information regarding care coordination, demographics, and symptoms, multivariable logistic regression was used to examine odds of patients reporting optimal care coordination.VA patients with CRC were found to report high levels of care coordination (mean scale score, 3.50 [standard deviation, 0.61]). Approximately 85% of patients reported a high level of coordination, including the 43% reporting optimal/highest-level coordination. There was no difference observed in the odds of reporting optimal coordination by race/ethnicity. Patients with early-stage disease (odds ratio [OR], 0.60; 95% confidence interval [95% CI], 0.45-0.81), greater pain (OR, 0.97 for a 1-point increase in pain scale; 95% CI, 0.96-0.99), and greater levels of depression (OR, 0.97 for a 1-point increase in depression scale; 95% CI, 0.96-0.99) were less likely to report optimal coordination.Patients with CRC in the VA reported high levels of care coordination. Unlike what has been reported in settings outside the VA, there appears to be no racial/ethnic disparity in reported coordination. However, challenges remain in ensuring coordination of care for patients with less advanced disease and a high symptom burden. Cancer 2015;121:2207-2213. © 2015 American Cancer Society.

Authors
Jackson, GL; Zullig, LL; Phelan, SM; Provenzale, D; Griffin, JM; Clauser, SB; Haggstrom, DA; Jindal, RM; van Ryn, M
MLA Citation
Jackson, GL, Zullig, LL, Phelan, SM, Provenzale, D, Griffin, JM, Clauser, SB, Haggstrom, DA, Jindal, RM, and van Ryn, M. "Patient characteristics associated with the level of patient-reported care coordination among male patients with colorectal cancer in the Veterans Affairs health care system." Cancer 121.13 (July 2015): 2207-2213.
PMID
25782082
Source
epmc
Published In
Cancer
Volume
121
Issue
13
Publish Date
2015
Start Page
2207
End Page
2213
DOI
10.1002/cncr.29341

Population-based assessment of cancer survivors' financial burden and quality of life: a prospective cohort study.

The impact of financial burden among patients with cancer has not yet been measured in a way that accounts for inter-relationships between quality of life, perceived quality of care, disease status, and sociodemographic characteristics.In a national, prospective, observational, population- and health care systems-based cohort study, patients with colorectal or lung cancer were enrolled from 2003 to 2006 within 3 months of diagnosis. For this analysis, surviving patients who were either disease free or had advanced disease were resurveyed a median 7.3 years from diagnosis. Structural equation modeling was used to investigate relationships between financial burden, quality of life, perceived quality of care, and sociodemographic characteristics.Among 1,000 participants enrolled from five geographic regions, five integrated health care systems, or 15 Veterans Administration Hospitals, 89% (n = 889) were cancer free, and 11% (n = 111) had advanced cancer. Overall, 48% (n = 482) reported difficulties living on their household income, and 41% (n = 396) believed their health care to be "excellent." High financial burden was associated with lower household income (adjusted odds ratio [OR] = 0.61 per $20k per year, P < .001) and younger age (adjusted OR = 0.63 per 10 years; P < .001). High financial burden was also associated with poorer quality of life (adjusted beta = -0.06 per burden category; P < .001). Better quality of life was associated with fewer perceptions of poorer quality of care (adjusted OR = 0.85 per 0.10 EuroQol units; P < .001).Financial burden is prevalent among cancer survivors and is related to patients' health-related quality of life. Future studies should consider interventions to improve patient education and engagement with regard to financial burden.

Authors
Zafar, SY; McNeil, RB; Thomas, CM; Lathan, CS; Ayanian, JZ; Provenzale, D
MLA Citation
Zafar, SY, McNeil, RB, Thomas, CM, Lathan, CS, Ayanian, JZ, and Provenzale, D. "Population-based assessment of cancer survivors' financial burden and quality of life: a prospective cohort study." Journal of oncology practice 11.2 (March 2015): 145-150.
PMID
25515717
Source
epmc
Published In
Journal of Oncology Practice
Volume
11
Issue
2
Publish Date
2015
Start Page
145
End Page
150
DOI
10.1200/jop.2014.001542

Epidemiologic approaches to veterans' health.

The present issue of Epidemiologic Reviews is dedicated to better understanding the health of men and women who have served in the military. There are 13 articles that discuss a range of physical and mental health concerns among both military personnel who are currently serving and those who served in the past. The corresponding research provides insight into issues that are directly relevant and of keen interest to clinicians and investigators. The articles illustrate some of the obstacles to conducting rigorous epidemiologic research when seeking to inform the health issues of those who serve in the military and of veterans. Within the United States, they point to opportunities for the Department of Defense and Department of Veterans Affairs (VA) to address existing gaps in knowledge. The VA in particular can take advantage of its research infrastructure, altruistic veteran population, and clinical and administrative databases. In the era of multinational military interventions, international counterparts of the Department of Defense and VA should collaborate in the collection of data on relevant military exposures and also in the characterization of short- and long-term health effects related to service to better inform health needs. The work included in this issue is a call to the global research community to continue to invest resources to better characterize military service and its impact on health. Finally, these articles serve as a testament to the additional health burden carried by many of the women and men who have provided service to their country.

Authors
Gaziano, JM; Concato, J; Galea, S; Smith, NL; Provenzale, D
MLA Citation
Gaziano, JM, Concato, J, Galea, S, Smith, NL, and Provenzale, D. "Epidemiologic approaches to veterans' health." Epidemiologic reviews 37 (January 22, 2015): 1-6.
PMID
25613553
Source
epmc
Published In
Epidemiologic Reviews
Volume
37
Publish Date
2015
Start Page
1
End Page
6
DOI
10.1093/epirev/mxu013

Epidemiology and familial risk of synchronous and metachronous colorectal cancer: a population-based study in Utah.

BACKGROUND & AIMS: Patients diagnosed with colorectal cancer (CRC) are at risk for synchronous and metachronous lesions at the time of diagnosis or during follow-up evaluation. We performed a population-based study to evaluate the rate, predictors, and familial risk for synchronous and metachronous CRC in Utah. METHODS: All newly diagnosed cases of CRC between 1980 and 2010 were obtained from the Utah Cancer Registry and linked to pedigrees from the Utah Population Database. RESULTS: Of the 18,782 patients diagnosed with CRC, 134 were diagnosed with synchronous CRC (0.71%) and 300 were diagnosed with metachronous CRC (1.60%). The risk for synchronous CRC was significantly higher in men (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.02-2.06) and in patients aged 65 years or older (OR, 1.50; 95% CI, 1.02-2.21). Synchronous CRCs were located more often in the proximal colon (OR, 1.70; 95% CI, 1.20-2.41). First-degree relatives of cases with synchronous (OR, 1.86; 95% CI, 1.37-2.53), metachronous (OR, 2.34; 95% CI, 1.62-3.36), or solitary CRC (OR, 1.75; 95% CI, 1.63-1.88) were at increased risk for developing CRC, compared with relatives of CRC-free individuals. Four percent of first-degree relatives of patients with synchronous or metachronous cancer developed CRC at younger ages than the age recommended for initiating CRC screening (based on familial risk), and therefore would not have been screened. CONCLUSIONS: Of patients diagnosed with CRC, 2.3% are found to have synchronous lesions or develop metachronous CRC during follow-up evaluation. Relatives of these patients have a greater risk of CRC than those without a family history of CRC. These results highlight the importance of obtaining a thorough family history and adhering strictly to surveillance guidelines during management of high-risk patients.

Authors
Samadder, NJ; Curtin, K; Wong, J; Tuohy, TMF; Mineau, GP; Smith, KR; Pimentel, R; Pappas, L; Boucher, K; Garrido-Laguna, I; Provenzale, D; Burt, RW
MLA Citation
Samadder, NJ, Curtin, K, Wong, J, Tuohy, TMF, Mineau, GP, Smith, KR, Pimentel, R, Pappas, L, Boucher, K, Garrido-Laguna, I, Provenzale, D, and Burt, RW. "Epidemiology and familial risk of synchronous and metachronous colorectal cancer: a population-based study in Utah." Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association 12.12 (December 2014): 2078-84.e1-2-.
PMID
24768809
Source
epmc
Published In
Clinical Gastroenterology and Hepatology
Volume
12
Issue
12
Publish Date
2014
Start Page
2078-84.e1-2
DOI
10.1016/j.cgh.2014.04.017

Implementation of new clinical programs in the VHA healthcare system: the importance of early collaboration between clinical leadership and research.

Collaboration between policy, research, and clinical partners is crucial to achieving proven quality care. The Veterans Health Administration has expended great efforts towards fostering such collaborations. Through this, we have learned that an ideal collaboration involves partnership from the very beginning of a new clinical program, so that the program is designed in a way that ensures quality, validity, and puts into place the infrastructure necessary for a reliable evaluation. This paper will give an example of one such project, the Lung Cancer Screening Demonstration Project (LCSDP). We will outline the ways that clinical, policy, and research partners collaborated in design, planning, and implementation in order to create a sustainable model that could be rigorously evaluated for efficacy and fidelity. We will describe the use of the Donabedian quality matrix to determine the necessary characteristics of a quality program and the importance of the linkage with engineering, information technology, and clinical paradigms to connect the development of an on-the-ground clinical program with the evaluation goal of a learning healthcare organization. While the LCSDP is the example given here, these partnerships and suggestions are salient to any healthcare organization seeking to implement new scientifically proven care in a useful and reliable way.

Authors
Wu, RR; Kinsinger, LS; Provenzale, D; King, HA; Akerly, P; Barnes, LK; Datta, SK; Grubber, JM; Katich, N; McNeil, RB; Monte, R; Sperber, NR; Atkins, D; Jackson, GL
MLA Citation
Wu, RR, Kinsinger, LS, Provenzale, D, King, HA, Akerly, P, Barnes, LK, Datta, SK, Grubber, JM, Katich, N, McNeil, RB, Monte, R, Sperber, NR, Atkins, D, and Jackson, GL. "Implementation of new clinical programs in the VHA healthcare system: the importance of early collaboration between clinical leadership and research." Journal of general internal medicine 29 Suppl 4 (December 2014): 825-830.
PMID
25355086
Source
epmc
Published In
Journal of General Internal Medicine
Volume
29 Suppl 4
Publish Date
2014
Start Page
825
End Page
830
DOI
10.1007/s11606-014-3026-3

Implementation of a new screening recommendation in health care: the Veterans Health Administration's approach to lung cancer screening.

Authors
Kinsinger, LS; Atkins, D; Provenzale, D; Anderson, C; Petzel, R
MLA Citation
Kinsinger, LS, Atkins, D, Provenzale, D, Anderson, C, and Petzel, R. "Implementation of a new screening recommendation in health care: the Veterans Health Administration's approach to lung cancer screening." Annals of internal medicine 161.8 (October 2014): 597-598.
PMID
25111673
Source
epmc
Published In
Annals of internal medicine
Volume
161
Issue
8
Publish Date
2014
Start Page
597
End Page
598
DOI
10.7326/m14-1070

Utilization of Hospital-Based Chaplain Services Among Newly Diagnosed Male Veterans Affairs Colorectal Cancer Patients

The aim of the study was to examine utilization of chaplain services among Veterans Affairs patients with colorectal cancer (CRC). In 2009, the Cancer Care Assessment and Responsive Evaluation Studies questionnaire was mailed to VA CRC patients diagnosed in 2008 (67 % response rate). Multivariable logistic regression examined factors associated with chaplain utilization. Of 918 male respondents, 36 % reported utilizing chaplains. Chaplain services were more likely to be utilized by patients with higher pain levels (OR = 1.017; 95 % CI = 0.999-1.035), younger age (age OR = 0.979; 95 % CI = 0.964-0.996), and later cancer stage (early stage OR = 0.743; 95 % CI = 0.559-0.985). Chaplain services are most utilized by younger, sicker patients. © 2012 Springer Science+Business Media New York (Outside the USA).

Authors
Zullig, LL; Jackson, GL; Provenzale, D; Griffin, JM; Phelan, S; Nieuwsma, JA; van Ryn, M
MLA Citation
Zullig, LL, Jackson, GL, Provenzale, D, Griffin, JM, Phelan, S, Nieuwsma, JA, and van Ryn, M. "Utilization of Hospital-Based Chaplain Services Among Newly Diagnosed Male Veterans Affairs Colorectal Cancer Patients." Journal of Religion and Health 53.2 (April 1, 2014): 498-510.
Source
scopus
Published In
Journal of Religion and Health
Volume
53
Issue
2
Publish Date
2014
Start Page
498
End Page
510
DOI
10.1007/s10943-012-9653-2

Characteristics of missed or interval colorectal cancer and patient survival: a population-based study.

BACKGROUND & AIMS: Colorectal cancers (CRCs) diagnosed within a few years after an index colonoscopy can arise from missed lesions or the development of a new tumor. We investigated the proportion, characteristics, and factors that predict interval CRCs that develop within 6-60 months of colonoscopy. METHODS: We performed a population-based cohort study of Utah residents who underwent colonoscopy examinations from 1995 through 2009 at Intermountain Healthcare or the University of Utah Health System, which provide care to more than 85% of state residents. Colonoscopy results were linked with cancer histories from the Utah Population Database to identify patients who underwent colonoscopy 6-60 months before a diagnosis of CRC (interval cancer). Logistic regression was performed to identify risk factors associated with interval cancers. RESULTS: Of 126,851 patients who underwent colonoscopies, 2659 were diagnosed with CRC; 6% of these CRCs (159 of 2659) developed within 6 to 60 months of a colonoscopy. Sex and age were not associated with interval CRCs. A higher percentage of patients with interval CRC were found to have adenomas at their index colonoscopy (57.2%), compared with patients found to have CRC detected at colonoscopy (36%) or patients who did not develop cancer (26%) (P < .001). Interval CRCs tended to be earlier-stage tumors than those detected at index colonoscopy, and to be proximally located (odds ratio, 2.24; P < .001). Patients with interval CRC were more likely to have a family history of CRC (odds ratio, 2.27; P = .008) and had a lower risk of death than patients found to have CRC at their index colonoscopy (hazard ratio, 0.63; P < .001). CONCLUSIONS: In a population-based study in Utah, 6% of all patients with CRC had interval cancers (cancer that developed within 6 to 60 months of a colonoscopy). Interval CRCs were associated with the proximal colon, earlier-stage cancer, lower risk of death, higher rate of adenoma, and family history of CRC. These findings indicate that interval colorectal tumors may arise as the result of distinct biologic features and/or suboptimal management of polyps at colonoscopy.

Authors
Samadder, NJ; Curtin, K; Tuohy, TMF; Pappas, L; Boucher, K; Provenzale, D; Rowe, KG; Mineau, GP; Smith, K; Pimentel, R; Kirchhoff, AC; Burt, RW
MLA Citation
Samadder, NJ, Curtin, K, Tuohy, TMF, Pappas, L, Boucher, K, Provenzale, D, Rowe, KG, Mineau, GP, Smith, K, Pimentel, R, Kirchhoff, AC, and Burt, RW. "Characteristics of missed or interval colorectal cancer and patient survival: a population-based study." Gastroenterology 146.4 (April 2014): 950-960.
PMID
24417818
Source
epmc
Published In
Gastroenterology
Volume
146
Issue
4
Publish Date
2014
Start Page
950
End Page
960
DOI
10.1053/j.gastro.2014.01.013

Facility-level analysis of PET scanning for staging among US veterans with non-small cell lung cancer.

PET scanning has been shown in randomized trials to reduce the frequency of surgery without cure among patients with potentially resectable non-small cell lung cancer (NSCLC). We examined whether more frequent use of PET scanning at the facility level improves survival among patients with NSCLC in real-world practice.In this prospective cohort study of 622 US veterans with newly diagnosed NSCLC, we compared groups defined by the frequency of PET scan use measured at the facility level and categorized as low (<25%), medium (25%-60%), or high (>60%).The median age of the sample was 69 years. Ninety-eight percent were men, 36% were Hispanic or nonwhite, and 54% had moderate or severe comorbidities. At low-, medium-, and high-use facilities, PET scan was performed in 13%, 40%, and 72% of patients, respectively (P<.0001). Baseline characteristics were similar across groups, including clinical stage based on CT scanning. More frequent use of PET scanning was associated with more frequent invasive staging (P<.001) and nonsignificant improvements in downstaging (P=.13) and surgery without cure (P=.12). After a median of 352 days of follow-up, 22% of the sample was still alive, including 22% at low- and medium-use facilities and 20% at high-use facilities. After adjustment and compared with patients at low-use facilities, the hazard of death was greater for patients at high-use facilities (adjusted hazard ratio [HR], 1.35; 95% CI, 1.05-1.74) but not different for patients at medium-use facilities (adjusted HR, 1.14; 95% CI, 0.88-1.46).In this study of veterans with NSCLC, markedly greater use of PET scanning at the facility level was associated with more frequent use of invasive staging and possible improvements in downstaging and surgery without cure, but greater use of PET scanning was not associated with better survival.

Authors
Gould, MK; Wagner, TH; Schultz, EM; Xu, X; Ghaus, SJ; Provenzale, D; Au, DH
MLA Citation
Gould, MK, Wagner, TH, Schultz, EM, Xu, X, Ghaus, SJ, Provenzale, D, and Au, DH. "Facility-level analysis of PET scanning for staging among US veterans with non-small cell lung cancer." Chest 145.4 (April 2014): 839-847.
PMID
24306819
Source
epmc
Published In
Chest
Volume
145
Issue
4
Publish Date
2014
Start Page
839
End Page
847
DOI
10.1378/chest.13-1073

Utilization of hospital-based chaplain services among newly diagnosed male Veterans Affairs colorectal cancer patients.

The aim of the study was to examine utilization of chaplain services among Veterans Affairs patients with colorectal cancer (CRC). In 2009, the Cancer Care Assessment and Responsive Evaluation Studies questionnaire was mailed to VA CRC patients diagnosed in 2008 (67 % response rate). Multivariable logistic regression examined factors associated with chaplain utilization. Of 918 male respondents, 36 % reported utilizing chaplains. Chaplain services were more likely to be utilized by patients with higher pain levels (OR = 1.017; 95 % CI = 0.999-1.035), younger age (age OR = 0.979; 95 % CI = 0.964-0.996), and later cancer stage (early stage OR = 0.743; 95 % CI = 0.559-0.985). Chaplain services are most utilized by younger, sicker patients.

Authors
Zullig, LL; Jackson, GL; Provenzale, D; Griffin, JM; Phelan, S; Nieuwsma, JA; van Ryn, M
MLA Citation
Zullig, LL, Jackson, GL, Provenzale, D, Griffin, JM, Phelan, S, Nieuwsma, JA, and van Ryn, M. "Utilization of hospital-based chaplain services among newly diagnosed male Veterans Affairs colorectal cancer patients." J Relig Health 53.2 (April 2014): 498-510.
PMID
23054482
Source
pubmed
Published In
Journal of Religion and Health
Volume
53
Issue
2
Publish Date
2014
Start Page
498
End Page
510
DOI
10.1007/s10943-012-9653-2

Patient-reported quality of supportive care among patients with colorectal cancer in the Veterans Affairs Health Care System.

High-quality supportive care is an essential component of comprehensive cancer care. We implemented a patient-centered quality of cancer care survey to examine and identify predictors of quality of supportive care for bowel problems, pain, fatigue, depression, and other symptoms among 1,109 patients with colorectal cancer.Patients with new diagnosis of colorectal cancer at any Veterans Health Administration medical center nationwide in 2008 were ascertained through the Veterans Affairs Central Cancer Registry and sent questionnaires assessing a variety of aspects of patient-centered cancer care. We received questionnaires from 63% of eligible patients (N = 1,109). Descriptive analyses characterizing patient experiences with supportive care and binary logistic regression models were used to examine predictors of receipt of help wanted for each of the five symptom categories.There were significant gaps in patient-centered quality of supportive care, beginning with symptom assessment. In multivariable modeling, the impact of clinical factors and patient race on odds of receiving wanted help varied by symptom. Coordination of care quality predicted receipt of wanted help for all symptoms, independent of patient demographic or clinical characteristics.This study revealed substantial gaps in patient-centered quality of care, difficult to characterize through quality measurement relying on medical record review alone. It established the feasibility of collecting patient-reported quality measures. Improving quality measurement of supportive care and implementing patient-reported outcomes in quality-measurement systems are high priorities for improving the processes and outcomes of care for patients with cancer.

Authors
van Ryn, M; Phelan, SM; Arora, NK; Haggstrom, DA; Jackson, GL; Zafar, SY; Griffin, JM; Zullig, LL; Provenzale, D; Yeazel, MW; Jindal, RM; Clauser, SB
MLA Citation
van Ryn, M, Phelan, SM, Arora, NK, Haggstrom, DA, Jackson, GL, Zafar, SY, Griffin, JM, Zullig, LL, Provenzale, D, Yeazel, MW, Jindal, RM, and Clauser, SB. "Patient-reported quality of supportive care among patients with colorectal cancer in the Veterans Affairs Health Care System." Journal of clinical oncology : official journal of the American Society of Clinical Oncology 32.8 (March 2014): 809-815.
PMID
24493712
Source
epmc
Published In
Journal of Clinical Oncology
Volume
32
Issue
8
Publish Date
2014
Start Page
809
End Page
815
DOI
10.1200/jco.2013.49.4302

Invited comment on Warrier et al: hereditary colorectal cancer screening and management practices by colorectal surgeons.

Authors
Karlitz, J; Provenzale, D
MLA Citation
Karlitz, J, and Provenzale, D. "Invited comment on Warrier et al: hereditary colorectal cancer screening and management practices by colorectal surgeons." Techniques in coloproctology 18.3 (March 2014): 313-314.
PMID
24127044
Source
epmc
Published In
Techniques in Coloproctology
Volume
18
Issue
3
Publish Date
2014
Start Page
313
End Page
314
DOI
10.1007/s10151-013-1080-1

Implementation of New Clinical Programs in the VHA Healthcare System: The Importance of Early Collaboration Between Clinical Leadership and Research

© 2014, Society of General Internal Medicine.Collaboration between policy, research, and clinical partners is crucial to achieving proven quality care. The Veterans Health Administration has expended great efforts towards fostering such collaborations. Through this, we have learned that an ideal collaboration involves partnership from the very beginning of a new clinical program, so that the program is designed in a way that ensures quality, validity, and puts into place the infrastructure necessary for a reliable evaluation. This paper will give an example of one such project, the Lung Cancer Screening Demonstration Project (LCSDP). We will outline the ways that clinical, policy, and research partners collaborated in design, planning, and implementation in order to create a sustainable model that could be rigorously evaluated for efficacy and fidelity. We will describe the use of the Donabedian quality matrix to determine the necessary characteristics of a quality program and the importance of the linkage with engineering, information technology, and clinical paradigms to connect the development of an on-the-ground clinical program with the evaluation goal of a learning healthcare organization. While the LCSDP is the example given here, these partnerships and suggestions are salient to any healthcare organization seeking to implement new scientifically proven care in a useful and reliable way.

Authors
Wu, RR; Kinsinger, LS; Provenzale, D; King, HA; Akerly, P; Barnes, LK; Datta, SK; Grubber, JM; Katich, N; McNeil, RB; Monte, R; Sperber, NR; Atkins, D; Jackson, GL
MLA Citation
Wu, RR, Kinsinger, LS, Provenzale, D, King, HA, Akerly, P, Barnes, LK, Datta, SK, Grubber, JM, Katich, N, McNeil, RB, Monte, R, Sperber, NR, Atkins, D, and Jackson, GL. "Implementation of New Clinical Programs in the VHA Healthcare System: The Importance of Early Collaboration Between Clinical Leadership and Research." Journal of General Internal Medicine 29.4 (January 1, 2014): 825-830.
Source
scopus
Published In
Journal of General Internal Medicine
Volume
29
Issue
4
Publish Date
2014
Start Page
825
End Page
830
DOI
10.1007/s11606-014-3026-3

Physician perceptions on colonoscopy quality: results of a national survey of gastroenterologists.

Background. Quality indicators for colonoscopy have been developed, but the uptake of these metrics into practice is uncertain. Our aims were to assess physician perceptions regarding colonoscopy quality measurement and to quantify the perceived impact of quality measurement on clinical practice. Methods. We conducted in-person interviews with 15 gastroenterologists about their perceptions regarding colonoscopy quality. Results from these interviews informed the development of a 34-question web-based survey that was emailed to 1,500 randomlyselected members of the American College of Gastroenterology. Results. 160 invitations were undeliverable, and 167 out of 1340 invited physicians (12.5%) participated in the survey. Respondents and nonrespondents did not differ in age, sex, practice setting, or years since training. 38.8% of respondents receive feedback on their colonoscopy quality. The majority of respondents agreed with the use of completion rate (90%) and adenoma detection rate (83%) as quality indicators but there was less enthusiasm for withdrawal time (61%). 24% of respondents reported usually or always removing diminutive polyps solely to increase their adenoma detection rate, and 20% reported prolonging their procedure time to meet withdrawal time standards. Conclusions. A minority of respondents receives feedback on the quality of their colonoscopy. Interventions to increase continuous quality improvement in colonoscopy screening are needed.

Authors
Gellad, ZF; Voils, CI; Lin, L; Provenzale, D
MLA Citation
Gellad, ZF, Voils, CI, Lin, L, and Provenzale, D. "Physician perceptions on colonoscopy quality: results of a national survey of gastroenterologists." Gastroenterology research and practice 2014 (January 2014): 510494-.
PMID
24734039
Source
epmc
Published In
Gastroenterology Research and Practice
Volume
2014
Publish Date
2014
Start Page
510494
DOI
10.1155/2014/510494

Epidemiology and Familial Risk of Synchronous and Metachronous Colorectal Cancer: A Population-Based Study in Utah

© 2014 AGA Institute.Background & Aims: Patients diagnosed with colorectal cancer (CRC) are at risk for synchronous and metachronous lesions at the time of diagnosis or during follow-up evaluation. We performed a population-based study to evaluate the rate, predictors, and familial risk for synchronous and metachronous CRC in Utah. Methods: All newly diagnosed cases of CRC between 1980 and 2010 were obtained from the Utah Cancer Registry and linked to pedigrees from the Utah Population Database. Results: Of the 18,782 patients diagnosed with CRC, 134 were diagnosed with synchronous CRC (0.71%) and 300 were diagnosed with metachronous CRC (1.60%). The risk for synchronous CRC was significantly higher in men (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.02-2.06) and in patients aged 65 years or older (OR, 1.50; 95% CI, 1.02-2.21). Synchronous CRCs were located more often in the proximal colon (OR, 1.70; 95% CI, 1.20-2.41). First-degree relatives of cases with synchronous (OR, 1.86; 95% CI, 1.37-2.53), metachronous (OR, 2.34; 95% CI, 1.62-3.36), or solitary CRC (OR, 1.75; 95% CI, 1.63-1.88) were at increased risk for developing CRC, compared with relatives of CRC-free individuals. Four percent of first-degree relatives of patients with synchronous or metachronous cancer developed CRC at younger ages than the age recommended for initiating CRC screening (based on familial risk), and therefore would not have been screened. Conclusions: Of patients diagnosed with CRC, 2.3% are found to have synchronous lesions or develop metachronous CRC during follow-up evaluation. Relatives of these patients have a greater risk of CRC than those without a family history of CRC. These results highlight the importance of obtaining a thorough family history and adhering strictly to surveillance guidelines during management of high-risk patients.

Authors
Samadder, NJ; Curtin, K; Wong, J; Tuohy, TMF; Mineau, GP; Smith, KR; Pimentel, R; Pappas, L; Boucher, K; Garrido-Laguna, I; Provenzale, D; Burt, RW
MLA Citation
Samadder, NJ, Curtin, K, Wong, J, Tuohy, TMF, Mineau, GP, Smith, KR, Pimentel, R, Pappas, L, Boucher, K, Garrido-Laguna, I, Provenzale, D, and Burt, RW. "Epidemiology and Familial Risk of Synchronous and Metachronous Colorectal Cancer: A Population-Based Study in Utah." Clinical Gastroenterology and Hepatology 12.12 (2014): 2078-2084.
Source
scival
Published In
Clinical Gastroenterology and Hepatology
Volume
12
Issue
12
Publish Date
2014
Start Page
2078
End Page
2084
DOI
10.1016/j.cgh.2014.04.017

An examination of racial differences in process and outcome of colorectal cancer care quality among users of the veterans affairs health care system

Background Veterans Affairs (VA) manages the largest US integrated health care system. Although quality of VA colorectal cancer (CRC) care is well chronicled, there is a paucity of research examining racial differences in this care. This study examines racial differences in 2 dimensions of quality of VA CRC care: processes (time to treatment) and outcomes (survival). Patients and Methods Retrospective data were from the VA External Peer Review Program (EPRP), a nationwide VA quality-monitoring program. Study patients were white and African American men diagnosed with nonmetastatic CRC between 2003 and 2006 who received definitive CRC surgery. We examined 3 quality indicators: time from (1) surgery to initiation of adjuvant chemotherapy (stages II-III disease), (2) surgery to surveillance colonoscopy (stages I-III disease), and (3) surgery to death (stages I-III disease). Unadjusted analyses used log-rank and Wilcoxon tests. Adjusted analyses used Cox proportional hazard models. Results In unadjusted analyses, there was no evidence of racial differences across the 3 quality measures. In adjusted Cox regression, there were no racial differences in time to initiation of chemotherapy (hazard ratio [HR], 0.82; P =.61) or surgery to death (HR, 0.94; P =.49). In adjusted Cox regression, among those receiving colonoscopy within 7 to 18 months after surgery, white patients experienced slightly shorter median times to surveillance colonoscopy than did African American patients (367 vs. 383 days; HR, 0.63; P =.02). Conclusion Other than a small racial difference in timing of surveillance colonoscopy, there was little evidence of racial differences in quality of CRC care among VA health care system users. © 2013 Elsevier Inc. All rights reserved.

Authors
Zullig, LL; Jackson, GL; Weinberger, M; Provenzale, D; Reeve, BB; Carpenter, WR
MLA Citation
Zullig, LL, Jackson, GL, Weinberger, M, Provenzale, D, Reeve, BB, and Carpenter, WR. "An examination of racial differences in process and outcome of colorectal cancer care quality among users of the veterans affairs health care system." Clinical Colorectal Cancer 12.4 (December 1, 2013): 255-260.
Source
scopus
Published In
Clinical colorectal cancer
Volume
12
Issue
4
Publish Date
2013
Start Page
255
End Page
260
DOI
10.1016/j.clcc.2013.06.004

Colorectal cancer screening.

Mortality from colorectal cancer can be reduced by early diagnosis and by cancer prevention through polypectomy. These NCCN Guidelines for Colorectal Cancer Screening describe various colorectal screening modalities and recommended screening schedules for patients at average or increased risk of developing colorectal cancer. In addition, the guidelines provide recommendations for the management of patients with high-risk colorectal cancer syndromes, including Lynch syndrome. Screening approaches for Lynch syndrome are also described.

Authors
Burt, RW; Cannon, JA; David, DS; Early, DS; Ford, JM; Giardiello, FM; Halverson, AL; Hamilton, SR; Hampel, H; Ismail, MK; Jasperson, K; Klapman, JB; Lazenby, AJ; Lynch, PM; Mayer, RJ; Ness, RM; Provenzale, D; Rao, MS; Shike, M; Steinbach, G; Terdiman, JP; Weinberg, D; Dwyer, M; Freedman-Cass, D
MLA Citation
Burt, RW, Cannon, JA, David, DS, Early, DS, Ford, JM, Giardiello, FM, Halverson, AL, Hamilton, SR, Hampel, H, Ismail, MK, Jasperson, K, Klapman, JB, Lazenby, AJ, Lynch, PM, Mayer, RJ, Ness, RM, Provenzale, D, Rao, MS, Shike, M, Steinbach, G, Terdiman, JP, Weinberg, D, Dwyer, M, and Freedman-Cass, D. "Colorectal cancer screening." Journal of the National Comprehensive Cancer Network : JNCCN 11.12 (December 2013): 1538-1575.
PMID
24335688
Source
epmc
Published In
Journal of the National Comprehensive Cancer Network : JNCCN
Volume
11
Issue
12
Publish Date
2013
Start Page
1538
End Page
1575

An examination of racial differences in process and outcome of colorectal cancer care quality among users of the veterans affairs health care system.

BACKGROUND: Veterans Affairs (VA) manages the largest US integrated health care system. Although quality of VA colorectal cancer (CRC) care is well chronicled, there is a paucity of research examining racial differences in this care. This study examines racial differences in 2 dimensions of quality of VA CRC care: processes (time to treatment) and outcomes (survival). PATIENTS AND METHODS: Retrospective data were from the VA External Peer Review Program (EPRP), a nationwide VA quality-monitoring program. Study patients were white and African American men diagnosed with nonmetastatic CRC between 2003 and 2006 who received definitive CRC surgery. We examined 3 quality indicators: time from (1) surgery to initiation of adjuvant chemotherapy (stages II-III disease), (2) surgery to surveillance colonoscopy (stages I-III disease), and (3) surgery to death (stages I-III disease). Unadjusted analyses used log-rank and Wilcoxon tests. Adjusted analyses used Cox proportional hazard models. RESULTS: In unadjusted analyses, there was no evidence of racial differences across the 3 quality measures. In adjusted Cox regression, there were no racial differences in time to initiation of chemotherapy (hazard ratio [HR], 0.82; P = .61) or surgery to death (HR, 0.94; P = .49). In adjusted Cox regression, among those receiving colonoscopy within 7 to 18 months after surgery, white patients experienced slightly shorter median times to surveillance colonoscopy than did African American patients (367 vs. 383 days; HR, 0.63; P = .02). CONCLUSION: Other than a small racial difference in timing of surveillance colonoscopy, there was little evidence of racial differences in quality of CRC care among VA health care system users.

Authors
Zullig, LL; Jackson, GL; Weinberger, M; Provenzale, D; Reeve, BB; Carpenter, WR
MLA Citation
Zullig, LL, Jackson, GL, Weinberger, M, Provenzale, D, Reeve, BB, and Carpenter, WR. "An examination of racial differences in process and outcome of colorectal cancer care quality among users of the veterans affairs health care system." Clin Colorectal Cancer 12.4 (December 2013): 255-260.
PMID
23988481
Source
pubmed
Published In
Clinical colorectal cancer
Volume
12
Issue
4
Publish Date
2013
Start Page
255
End Page
260
DOI
10.1016/j.clcc.2013.06.004

MicroRNA expression differentiates squamous epithelium from barrett's esophagus and esophageal cancer

Background: Current strategies fail to identify most patients with esophageal adenocarcinoma (EAC) before the disease becomes advanced and incurable. Given the dismal prognosis associated with EAC, improvements in detection of early-stage esophageal neoplasia are needed. Aim: We sought to assess whether differential expression of microRNAs could discriminate between squamous epithelium, Barrett's esophagus (BE), and EAC. Methods: We analyzed microRNA expression in a discovery cohort of human endoscopic biopsy samples from 36 patients representing normal squamous esophagus (n = 11), BE (n = 14), and high-grade dysplasia/EAC (n = 11). RNA was assessed using microarrays representing 847 human microRNAs followed by quantitative real-time polymerase chain reaction (qRT-PCR) verification of nine microRNAs. In a second cohort (n = 18), qRT-PCR validation of five miRNAs was performed. Expression of 59 microRNAs associated with BE/EAC in the literature was assessed in our training cohort. Known esophageal cell lines were used to compare miRNA expression to tissue miRNAs. Results: After controlling for multiple comparisons, we found 34 miRNAs differentially expressed between squamous esophagus and BE/EAC by microarray analysis. However, miRNA expression did not reliably differentiate non-dysplastic BE from EAC. In the validation cohort, all five microRNAs selected for qRT-PCR validation differentiated between squamous samples and BE/EAC. Microarray results supported 14 of the previously reported microRNAs associated with BE/EAC in the literature. Cell lines did not generally reflect miRNA expression found in vivo. Conclusions: These data indicate that miRNAs differ between squamous esophageal epithelium and BE/EAC, but do not distinguish between BE and EAC. We suggest prospective evaluation of miRNAs in patients at high risk for EAC. © 2013 Springer Science+Business Media New York.

Authors
Garman, KS; Owzar, K; Hauser, ER; Westfall, K; Anderson, BR; Souza, RF; Diehl, AM; Provenzale, D; Shaheen, NJ
MLA Citation
Garman, KS, Owzar, K, Hauser, ER, Westfall, K, Anderson, BR, Souza, RF, Diehl, AM, Provenzale, D, and Shaheen, NJ. "MicroRNA expression differentiates squamous epithelium from barrett's esophagus and esophageal cancer." Digestive Diseases and Sciences 58.11 (November 1, 2013): 3178-3188.
Source
scopus
Published In
Digestive Diseases and Sciences
Volume
58
Issue
11
Publish Date
2013
Start Page
3178
End Page
3188
DOI
10.1007/s10620-013-2806-7

MicroRNA expression differentiates squamous epithelium from Barrett's esophagus and esophageal cancer.

BACKGROUND: Current strategies fail to identify most patients with esophageal adenocarcinoma (EAC) before the disease becomes advanced and incurable. Given the dismal prognosis associated with EAC, improvements in detection of early-stage esophageal neoplasia are needed. AIM: We sought to assess whether differential expression of microRNAs could discriminate between squamous epithelium, Barrett's esophagus (BE), and EAC. METHODS: We analyzed microRNA expression in a discovery cohort of human endoscopic biopsy samples from 36 patients representing normal squamous esophagus (n = 11), BE (n = 14), and high-grade dysplasia/EAC (n = 11). RNA was assessed using microarrays representing 847 human microRNAs followed by quantitative real-time polymerase chain reaction (qRT-PCR) verification of nine microRNAs. In a second cohort (n = 18), qRT-PCR validation of five miRNAs was performed. Expression of 59 microRNAs associated with BE/EAC in the literature was assessed in our training cohort. Known esophageal cell lines were used to compare miRNA expression to tissue miRNAs. RESULTS: After controlling for multiple comparisons, we found 34 miRNAs differentially expressed between squamous esophagus and BE/EAC by microarray analysis. However, miRNA expression did not reliably differentiate non-dysplastic BE from EAC. In the validation cohort, all five microRNAs selected for qRT-PCR validation differentiated between squamous samples and BE/EAC. Microarray results supported 14 of the previously reported microRNAs associated with BE/EAC in the literature. Cell lines did not generally reflect miRNA expression found in vivo. CONCLUSIONS: These data indicate that miRNAs differ between squamous esophageal epithelium and BE/EAC, but do not distinguish between BE and EAC. We suggest prospective evaluation of miRNAs in patients at high risk for EAC.

Authors
Garman, KS; Owzar, K; Hauser, ER; Westfall, K; Anderson, BR; Souza, RF; Diehl, AM; Provenzale, D; Shaheen, NJ
MLA Citation
Garman, KS, Owzar, K, Hauser, ER, Westfall, K, Anderson, BR, Souza, RF, Diehl, AM, Provenzale, D, and Shaheen, NJ. "MicroRNA expression differentiates squamous epithelium from Barrett's esophagus and esophageal cancer." Dig Dis Sci 58.11 (November 2013): 3178-3188.
PMID
23925817
Source
pubmed
Published In
Digestive Diseases and Sciences
Volume
58
Issue
11
Publish Date
2013
Start Page
3178
End Page
3188
DOI
10.1007/s10620-013-2806-7

Examining potential colorectal cancer care disparities in the Veterans Affairs health care system.

PURPOSE: Racial disparities in cancer treatment and outcomes are a national problem. The nationwide Veterans Affairs (VA) health system seeks to provide equal access to quality care. However, the relationship between race and care quality for veterans with colorectal cancer (CRC) treated within the VA is poorly understood. We examined the association between race and receipt of National Comprehensive Cancer Network guideline-concordant CRC care. PATIENTS AND METHODS: This was an observational, retrospective medical record abstraction of patients with CRC treated in the VA. Two thousand twenty-two patients (white, n = 1,712; African American, n = 310) diagnosed with incident CRC between October 1, 2003, and March 31, 2006, from 128 VA medical centers, were included. We used multivariable logistic regression to examine associations between race and receipt of guideline-concordant care (computed tomography scan, preoperative carcinoembryonic antigen, clear surgical margins, medical oncology referral for stages II and III, fluorouracil-based adjuvant chemotherapy for stage III, and surveillance colonoscopy for stages I to III). Explanatory variables included demographic and disease characteristics. RESULTS: There were no significant racial differences for receipt of guideline-concordant CRC care. Older age at diagnosis was associated with reduced odds of medical oncology referral and surveillance colonoscopy. Presence of cardiovascular comorbid conditions was associated with reduced odds of medical oncology referral (odds ratio, 0.65; 95% CI, 0.50 to 0.89). CONCLUSION: In these data, we observed no evidence of racial disparities in CRC care quality. Future studies could examine causal pathways for the VA's equal, quality care and ways to translate the VA's success into other hospital systems.

Authors
Zullig, LL; Carpenter, WR; Provenzale, D; Weinberger, M; Reeve, BB; Jackson, GL
MLA Citation
Zullig, LL, Carpenter, WR, Provenzale, D, Weinberger, M, Reeve, BB, and Jackson, GL. "Examining potential colorectal cancer care disparities in the Veterans Affairs health care system." J Clin Oncol 31.28 (October 1, 2013): 3579-3584.
PMID
24002515
Source
pubmed
Published In
Journal of Clinical Oncology
Volume
31
Issue
28
Publish Date
2013
Start Page
3579
End Page
3584
DOI
10.1200/JCO.2013.50.4753

Clinical practice variation in the management of diminutive colorectal polyps: results of a national survey of gastroenterologists.

OBJECTIVES: We investigated physician beliefs and behaviors regarding diminutive colorectal polyps and the contribution of these beliefs to variable detection rates. METHODS: One hundred sixty-seven members of the American College of Gastroenterology took a Web-based survey. We compared respondents and nonrespondents using demographic and practice information from the American Medical Association Physician Masterfile. RESULTS: Respondents varied in their definition of diminutive polyps. Respondents acknowledged leaving diminutive polyps in place during colonoscopy in various scenarios. Years in practice, confidence in endoscopic histologic diagnosis, and never having seen advanced histology in a diminutive polyp were predictive of leaving polyps in place. The majority of respondents were at least somewhat agreeable to leaving diminutive polyps in place if guidelines endorsed this practice. CONCLUSIONS: Gastroenterologists vary in their removal of diminutive polyps. The results have implications for the interpretation and management of variable polyp detection rates.

Authors
Gellad, ZF; Voils, CI; Lin, L; Provenzale, D
MLA Citation
Gellad, ZF, Voils, CI, Lin, L, and Provenzale, D. "Clinical practice variation in the management of diminutive colorectal polyps: results of a national survey of gastroenterologists." Am J Gastroenterol 108.6 (June 2013): 873-878.
PMID
23735908
Source
pubmed
Published In
The American Journal of Gastroenterology (Elsevier)
Volume
108
Issue
6
Publish Date
2013
Start Page
873
End Page
878
DOI
10.1038/ajg.2012.316

Method issues in epidemiological studies of medically unexplained Symptom-based conditions in veterans

Symptom-based conditions such as chronic fatigue syndrome (CFS) and medically unexplained multi-symptom illness (MSI) are fairly common in the general population and are also important veteran's health concerns due to their higher frequency among U.S. veterans who served during the 1990-1991 Gulf War. CFS, MSI, and other symptom-based conditions are often associated with considerable morbidity due to fatigue, chronic pain, neurologic symptoms, and other symptoms that can impair the quality of life. This article discusses several important issues of methodology that arise in population studies of CFS and MSI. These include the exclusion criteria that have been used in population studies to define CFS-like illness and unexplained MSI, the potential for false positive and false negative assessments of illness status, the potential for sex differences, and the poorly understood natural history of these symptom-based conditions across the life span. As an empirical example of these methodology issues, we examined existing data from a 2005 follow-up survey. We found that 64.9% (762 of 1,175) of female Gulf War veterans and 53.4% (2,530 of 4,739) of male Gulf War veterans had 1 or more exclusionary medical conditions. The prevalence among veterans with one or more exclusionary medical conditions increased markedly by age among females and those with a low Income.

Authors
Coughlin, SS; McNeil, RB; Provenzale, DT; Dursa, EK; Thomas, CM
MLA Citation
Coughlin, SS, McNeil, RB, Provenzale, DT, Dursa, EK, and Thomas, CM. "Method issues in epidemiological studies of medically unexplained Symptom-based conditions in veterans." Journal of Military and Veterans' Health 21.2 (May 1, 2013): 4-10.
PMID
24683425
Source
scopus
Published In
Journal of Military and Veterans Health
Volume
21
Issue
2
Publish Date
2013
Start Page
4
End Page
10

Variability in resource use: diagnosing colorectal cancer.

OBJECTIVES: Efficient resource use is relevant in all healthcare systems. Although colorectal cancer is common, little has been published regarding the utilization of clinical resources in diagnosis. STUDY DESIGN: The primary aim was to evaluate the patterns and factors associated with clinical services used to diagnose colorectal cancer at 14 US Department of Veterans Affairs facilities. The secondary aim was to investigate whether using more clinical services was associated with time to diagnosis. METHODS: We reviewed medical records for 449 patients with colorectal cancer in an observational study. Study end points were the use of clinical diagnostic services grouped as laboratory tests, imaging studies, and subspecialty consultations. Cumulative logistic regression models were used to explore factors associated with each outcome. RESULTS: Facility variability contributed to the variability of resource use in all models. In adjusted analyses, older patients had higher use of laboratory tests (odds ratio [OR], 1.20; 95% confidence interval [CI], 1.02-1.43) and incidentally discovered colorectal cancer was associated with increased use of consultations (OR, 1.97; 95% CI, 1.27-3.05), imaging studies (OR, 1.70; 95% CI, 1.12-2.58), and laboratory tests (OR, 3.14; 95% CI, 2.06-4.77) compared with screen-detected cancers. There was a strong direct correlation between thenumber of diagnostic services performed and the median time to diagnosis (Spearman correlation coefficient, 0.99; P < .001). CONCLUSIONS: Variability in utilization of diagnostic clinical services was associated with patient age, patient presentation, and facility. Increased resource use was highly correlated with increased time to diagnosis.

Authors
Srygley, FD; Abbott, DH; Grambow, SC; Provenzale, D; Sandler, RS; Fischer, DA
MLA Citation
Srygley, FD, Abbott, DH, Grambow, SC, Provenzale, D, Sandler, RS, and Fischer, DA. "Variability in resource use: diagnosing colorectal cancer." The American journal of managed care 19.5 (May 2013): 370-376.
PMID
23781891
Source
epmc
Published In
American Journal of Managed Care
Volume
19
Issue
5
Publish Date
2013
Start Page
370
End Page
376

Using NCCN clinical practice guidelines in oncology to measure the quality of colorectal cancer care in the veterans health administration.

Clinical practice guidelines can be used to help develop measures of quality of cancer care. This article describes the use of a Cancer Care Quality Measurement System (CCQMS) to monitor these measures for colorectal cancer in the Veterans Health Administration (VHA). The CCQMS assessed practice guideline concordance primarily based on colon (14 indicators) and rectal (11 indicators) cancer care guidelines of the NCCN. Indicators were developed with input from VHA stakeholders with the goal of examining the continuum of diagnosis, neoadjuvant therapy, surgery, adjuvant therapy, and survivorship surveillance and/or end-of-life care. In addition, 9 measures of timeliness of cancer care were developed. The measures/indicators formed the basis of a computerized data abstraction tool that produced reports on quality of care in real-time as data were entered. The tool was developed for a 28-facility learning collaborative, the Colorectal Cancer Care Collaborative (C4), aimed at improving colorectal cancer (CRC) care quality. Data on 1373 incident stage I-IV CRC cases were entered over approximately 18 months and were used to target and monitor quality improvement activities. The primary opportunity for improvement involved surveillance colonoscopy and services in patients after curative-intent treatment. NCCN Clinical Practice Guidelines in Oncology were successfully used to develop a measurement system for a VHA research-operations quality improvement partnership.

Authors
Jackson, GL; Zullig, LL; Zafar, SY; Powell, AA; Ordin, DL; Gellad, ZF; Abbott, D; Schlosser, JM; Hersh, J; Provenzale, D
MLA Citation
Jackson, GL, Zullig, LL, Zafar, SY, Powell, AA, Ordin, DL, Gellad, ZF, Abbott, D, Schlosser, JM, Hersh, J, and Provenzale, D. "Using NCCN clinical practice guidelines in oncology to measure the quality of colorectal cancer care in the veterans health administration." J Natl Compr Canc Netw 11.4 (April 1, 2013): 431-441.
PMID
23584346
Source
pubmed
Published In
Journal of the National Comprehensive Cancer Network : JNCCN
Volume
11
Issue
4
Publish Date
2013
Start Page
431
End Page
441

Chemotherapy use and patient treatment preferences in advanced colorectal cancer: a prospective cohort study.

BACKGROUND: The objective of this study was to determine how patient preferences guide the course of palliative chemotherapy for advanced colorectal cancer. METHODS: Eligible patients with metastatic colorectal cancer (mCRC) were enrolled nationwide in a prospective, population-based cohort study. Data were obtained through medical record abstraction and patient surveys. Logistic regression analysis was used to evaluate patient characteristics associated with visiting medical oncology and receiving chemotherapy and patient characteristics, beliefs, and preferences associated with receiving >1 line of chemotherapy and receiving combination chemotherapy. RESULTS: Among 702 patients with mCRC, 91% consulted a medical oncologist; and among those, 82% received chemotherapy. Patients ages 65 to 75 years and aged ≥75 years were less likely to visit an oncologist, as were patients who were too sick to complete their own survey. In adjusted analyses, patients aged ≥75 years who had moderate or severe comorbidity were less likely to receive chemotherapy, as were patients who were too sick to complete their own survey. Patients received chemotherapy even if they believed that chemotherapy would not extend their life (90%) or that chemotherapy would not likely help with cancer-related problems (89%), or patients preferred treatment focusing on comfort even if it meant not living as long (90%). Older patients were less likely to receive combination first-line therapy. Patient preferences and beliefs were not associated with receipt of >1 line of chemotherapy or combination chemotherapy. CONCLUSIONS: The majority of patients received chemotherapy even if they expressed negative or marginal preferences or beliefs regarding chemotherapy. Patient preferences and beliefs were not associated with the intensity or number of chemotherapy regimens.

Authors
Zafar, SY; Malin, JL; Grambow, SC; Abbott, DH; Kolimaga, JT; Zullig, LL; Weeks, JC; Ayanian, JZ; Kahn, KL; Ganz, PA; Catalano, PJ; West, DW; Provenzale, D; Cancer Care Outcomes Research & Surveillance CanCORS Consortium,
MLA Citation
Zafar, SY, Malin, JL, Grambow, SC, Abbott, DH, Kolimaga, JT, Zullig, LL, Weeks, JC, Ayanian, JZ, Kahn, KL, Ganz, PA, Catalano, PJ, West, DW, Provenzale, D, and Cancer Care Outcomes Research & Surveillance CanCORS Consortium, . "Chemotherapy use and patient treatment preferences in advanced colorectal cancer: a prospective cohort study." Cancer 119.4 (February 15, 2013): 854-862.
PMID
22972673
Source
pubmed
Published In
Cancer
Volume
119
Issue
4
Publish Date
2013
Start Page
854
End Page
862
DOI
10.1002/cncr.27815

Influence of comorbidity on racial differences in receipt of surgery among US veterans with early-stage non-small-cell lung cancer.

PURPOSE: It is unclear why racial differences exist in the frequency of surgery for lung cancer treatment. Comorbidity is an important consideration in selection of patients for lung cancer treatment, including surgery. To assess whether comorbidity contributes to the observed racial differences, we evaluated racial differences in the prevalence of comorbidity and their impact on receipt of surgery. PATIENTS AND METHODS: A total of 1,314 patients (1,135 white, 179 black) in the Veterans Health Administration diagnosed with early-stage non-small-cell lung cancer in 2007 were included. The effect of comorbidity on surgery was determined by using generalized linear models with a logit link accounting for patient clustering within Veterans Administration Medical Centers. RESULTS: Compared with whites, blacks had greater prevalence of hypertension, liver disease, renal disease, illicit drug abuse, and poor performance status, but lower prevalence of respiratory disease. The impact of most individual comorbidities on receipt of surgery was similar between blacks and whites, and comorbidity did not influence the race-surgery association in a multivariable analysis. The proportion of blacks not receiving surgery as well as refusing surgery was greater than that among whites. CONCLUSION: Blacks had a greater prevalence of several comorbid conditions and poor performance status; however, the overall comorbidity score did not differ by race. In general, the effect of comorbidity on receipt of surgery was similar in blacks and whites. Racial differences in comorbidity do not fully explain why blacks undergo lung cancer surgery less often than whites.

Authors
Williams, CD; Stechuchak, KM; Zullig, LL; Provenzale, D; Kelley, MJ
MLA Citation
Williams, CD, Stechuchak, KM, Zullig, LL, Provenzale, D, and Kelley, MJ. "Influence of comorbidity on racial differences in receipt of surgery among US veterans with early-stage non-small-cell lung cancer." J Clin Oncol 31.4 (February 1, 2013): 475-481.
PMID
23269988
Source
pubmed
Published In
Journal of Clinical Oncology
Volume
31
Issue
4
Publish Date
2013
Start Page
475
End Page
481
DOI
10.1200/JCO.2012.44.1170

An assessment of survey measures used across key epidemiologic studies of United States Gulf War I Era veterans.

Over the past two decades, 12 large epidemiologic studies and 2 registries have focused on U.S. veterans of the 1990-1991 Gulf War Era. We conducted a review of these studies' research tools to identify existing gaps and overlaps of efforts to date, and to advance development of the next generation of Gulf War Era survey tools. Overall, we found that many of the studies used similar instruments. Questions regarding exposures were more similar across studies than other domains, while neurocognitive and psychological tools were the most variable. Many studies focused on self-reported survey results, with a range of validation practices. However, physical exams, biomedical assessments, and specimen storage were not common. This review suggests that while research may be able to pool data from past surveys, future surveys need to consider how their design can yield data comparable with previous surveys. Additionally, data that incorporate recent technologies in specimen and genetic analyses would greatly enhance such survey data. When combined with existing data on deployment-related exposures and post-deployment health conditions, longitudinal follow-up of existing studies within this collaborative framework could represent an important step toward improving the health of veterans.

Authors
McNeil, RB; Thomas, CM; Coughlin, SS; Hauser, E; Huang, GD; Goldstein, KM; Johnson, MR; Dunn-Thomas, T; Provenzale, DT
MLA Citation
McNeil, RB, Thomas, CM, Coughlin, SS, Hauser, E, Huang, GD, Goldstein, KM, Johnson, MR, Dunn-Thomas, T, and Provenzale, DT. "An assessment of survey measures used across key epidemiologic studies of United States Gulf War I Era veterans. (Published online)" Environ Health 12 (January 9, 2013): 4-. (Review)
PMID
23302181
Source
pubmed
Published In
Environmental Health
Volume
12
Publish Date
2013
Start Page
4
DOI
10.1186/1476-069X-12-4

Chemotherapy use and patient treatment preferences in advanced colorectal cancer: A prospective cohort study

Background: The objective of this study was to determine how patient preferences guide the course of palliative chemotherapy for advanced colorectal cancer. METHODS: Eligible patients with metastatic colorectal cancer (mCRC) were enrolled nationwide in a prospective, population-based cohort study. Data were obtained through medical record abstraction and patient surveys. Logistic regression analysis was used to evaluate patient characteristics associated with visiting medical oncology and receiving chemotherapy and patient characteristics, beliefs, and preferences associated with receiving >1 line of chemotherapy and receiving combination chemotherapy. RESULTS: Among 702 patients with mCRC, 91% consulted a medical oncologist; and among those, 82% received chemotherapy. Patients ages 65 to 75 years and aged ≥75 years were less likely to visit an oncologist, as were patients who were too sick to complete their own survey. In adjusted analyses, patients aged ≥75 years who had moderate or severe comorbidity were less likely to receive chemotherapy, as were patients who were too sick to complete their own survey. Patients received chemotherapy even if they believed that chemotherapy would not extend their life (90%) or that chemotherapy would not likely help with cancer-related problems (89%), or patients preferred treatment focusing on comfort even if it meant not living as long (90%). Older patients were less likely to receive combination first-line therapy. Patient preferences and beliefs were not associated with receipt of >1 line of chemotherapy or combination chemotherapy. CONCLUSIONS: The majority of patients received chemotherapy even if they expressed negative or marginal preferences or beliefs regarding chemotherapy. Patient preferences and beliefs were not associated with the intensity or number of chemotherapy regimens. Cancer 2013. © 2012 American Cancer Society. The authors investigate how patient preferences guide the course of palliative chemotherapy for advanced colorectal cancer. The majority of patients receive such treatment even if they express negative or marginal preferences or beliefs regarding chemotherapy. Copyright © 2012 American Cancer Society.

Authors
Zafar, SY; Malin, JL; Grambow, SC; Abbott, DH; Kolimaga, JT; Zullig, LL; Weeks, JC; Ayanian, JZ; Kahn, KL; Ganz, PA; Catalano, PJ; West, DW; Provenzale, D
MLA Citation
Zafar, SY, Malin, JL, Grambow, SC, Abbott, DH, Kolimaga, JT, Zullig, LL, Weeks, JC, Ayanian, JZ, Kahn, KL, Ganz, PA, Catalano, PJ, West, DW, and Provenzale, D. "Chemotherapy use and patient treatment preferences in advanced colorectal cancer: A prospective cohort study." Cancer 119.4 (2013): 854-862.
Source
scival
Published In
Cancer
Volume
119
Issue
4
Publish Date
2013
Start Page
854
End Page
862
DOI
10.1002/cncr.27815

The association of race with timeliness of care and survival among Veterans Affairs health care system patients with late-stage non-small cell lung cancer.

BACKGROUND: Non-small cell lung cancer is the leading cause of cancer-related mortality in the United States. Patients with late-stage disease (stage 3/4) have five-year survival rates of 2%-15%. Care quality may be measured as time to receiving recommended care and, ultimately, survival. This study examined the association between race and receipt of timely non-small cell lung cancer care and survival among Veterans Affairs health care system patients. METHODS: Data were from the External Peer Review Program, a nationwide Veterans Affairs quality-monitoring program. We included Caucasian or African American patients with pathologically confirmed late-stage non-small cell lung cancer in 2006 and 2007. We examined three quality measures: time from diagnosis to (1) treatment initiation, (2) palliative care or hospice referral, and (3) death. Unadjusted analyses used log-rank and Wilcoxon tests. Adjusted analyses used Cox proportional hazard models. RESULTS: After controlling for patient and disease characteristics using Cox regression, there were no racial differences in time to initiation of treatment (72 days for African American versus 65 days for Caucasian patients, hazard ratio 1.04, P = 0.80) or palliative care or hospice referral (129 days versus 116 days, hazard ratio 1.10, P = 0.34). However, the adjusted model found longer survival for African American patients than for Caucasian patients (133 days versus 117 days, hazard ratio 0.31, P < 0.01). CONCLUSION: For process measures of care quality (eg, time to initiation of treatment and referral to supportive care) the Veterans Affairs health care system provides racially equitable care. The small racial difference in survival time of approximately 2 weeks is not clinically meaningful. Future work should validate this possible trend prospectively, with longer periods of follow-up, in other veteran groups.

Authors
Zullig, LL; Carpenter, WR; Provenzale, DT; Weinberger, M; Reeve, BB; Williams, CD; Jackson, GL
MLA Citation
Zullig, LL, Carpenter, WR, Provenzale, DT, Weinberger, M, Reeve, BB, Williams, CD, and Jackson, GL. "The association of race with timeliness of care and survival among Veterans Affairs health care system patients with late-stage non-small cell lung cancer. (Published online)" Cancer Manag Res 5 (2013): 157-163.
PMID
23900515
Source
pubmed
Published In
Cancer Manag Res
Volume
5
Publish Date
2013
Start Page
157
End Page
163
DOI
10.2147/CMAR.S46688

Examining potential cancer care disparities in an equal access system: Quality of colorectal cancer care (CRC) in the Veterans Affairs (VA) health care system

Authors
Zullig, LL; Carpenter, WR; Abbott, DH; Provenzale, DT; Weinberger, M; Reeve, BB; Jackson, GL
MLA Citation
Zullig, LL, Carpenter, WR, Abbott, DH, Provenzale, DT, Weinberger, M, Reeve, BB, and Jackson, GL. "Examining potential cancer care disparities in an equal access system: Quality of colorectal cancer care (CRC) in the Veterans Affairs (VA) health care system." JOURNAL OF CLINICAL ONCOLOGY 30.34 (December 1, 2012).
Source
wos-lite
Published In
Journal of Clinical Oncology
Volume
30
Issue
34
Publish Date
2012

Impact of race on early-stage lung cancer treatment and survival

Authors
Williams, CD; Provenzale, DT; Stechuchak, KM; Kelley, MJ
MLA Citation
Williams, CD, Provenzale, DT, Stechuchak, KM, and Kelley, MJ. "Impact of race on early-stage lung cancer treatment and survival." JOURNAL OF CLINICAL ONCOLOGY 30.34 (December 1, 2012).
Source
wos-lite
Published In
Journal of Clinical Oncology
Volume
30
Issue
34
Publish Date
2012

The cost effectiveness of radiofrequency ablation for Barrett's esophagus.

BACKGROUND & AIMS: Radiofrequency ablation (RFA) reduces the risk of esophageal adenocarcinoma (EAC) in patients with Barrett's esophagus (BE) with high-grade dysplasia (HGD), but its effects in patients without dysplasia are debatable. We analyzed the effectiveness and cost effectiveness of RFA for the management of BE. METHODS: We constructed a decision analytic Markov model. We conducted separate analyses of hypothetical cohorts of patients with BE with dysplasia (HGD or low-grade [LGD]) and without dysplasia. In the analysis of the group with HGD, we compared results of initial RFA with endoscopic surveillance with surgery when cancer was detected. In analyzing the group with LGD or no dysplasia, we compared 3 strategies: endoscopic surveillance with surgery when cancer was detected (S1), endoscopic surveillance with RFA when HGD was detected (S2), and initial RFA followed by endoscopic surveillance (S3). RESULTS: Among patients with HGD, initial RFA was more effective and less costly than endoscopic surveillance. Among patients with LGD, when S3 was compared with S2, the incremental cost-effectiveness ratio was $18,231/quality-adjusted life-year, assuming an annual rate of progression rate from LGD to EAC of 0.5%/year. For patients without dysplasia, S2 was more effective and less costly than S1. In a comparison of S3 with S2, the incremental cost-effectiveness ratios were $205,500, $124,796, and $118,338/quality-adjusted life-year using annual rates of progression of no dysplasia to EAC of 0.12%, 0.33%, or 0.5% per year, respectively. CONCLUSIONS: By using updated data, initial RFA might not be cost effective for patients with BE without dysplasia, within the range of plausible rates of progression of BE to EAC, and be prohibitively expensive, from a policy perspective. RFA might be cost effective for confirmed and stable LGD. Initial RFA is more effective and less costly than endoscopic surveillance in HGD.

Authors
Hur, C; Choi, SE; Rubenstein, JH; Kong, CY; Nishioka, NS; Provenzale, DT; Inadomi, JM
MLA Citation
Hur, C, Choi, SE, Rubenstein, JH, Kong, CY, Nishioka, NS, Provenzale, DT, and Inadomi, JM. "The cost effectiveness of radiofrequency ablation for Barrett's esophagus." Gastroenterology 143.3 (September 2012): 567-575.
PMID
22626608
Source
pubmed
Published In
Gastroenterology
Volume
143
Issue
3
Publish Date
2012
Start Page
567
End Page
575
DOI
10.1053/j.gastro.2012.05.010

Cancer incidence among patients of the U.S. Veterans Affairs Health Care System.

OBJECTIVE: Approximately 40,000 incident cancer cases are reported in the Veterans Affairs Central Cancer Registry (VACCR) annually (approximately 3% of U.S. cancer cases). Our objective was to provide the first comprehensive description of cancer incidence as reported in VACCR. METHODS: Data were obtained from VACCR for incident cancers diagnosed in VA. Analyses focused on 2007 data. Cancer incidence among VA patients was compared to the general U.S. cancer population. RESULTS: In 2007, 97.5% of VA cancers were diagnosed among men. Approximately 78.5% of newly diagnosed patients were White, 19.0% Black, and 2.5% were another race. Median age at diagnosis was 66 years. The geographic distribution of cancer patients in VA aligns that of VA users. The most commonly diagnosed cancers were similar between VA and the U.S. male cancer population. The five most frequently diagnosed cancers among VA cancer patients were: prostate (31.8%), lung/bronchus (18.8%), colon/rectum (8.6%), urinary bladder (3.6%), and skin melanomas (3.4%). VA patients were diagnosed at an earlier stage of disease for the three most commonly diagnosed cancers--lung/bronchus, colon/rectum, and prostate--compared to the U.S. male cancer population. CONCLUSIONS: Registry data indicate that incident cancers in VA in 2007 approximately mirrored those observed among U.S. men.

Authors
Zullig, LL; Jackson, GL; Dorn, RA; Provenzale, DT; McNeil, R; Thomas, CM; Kelley, MJ
MLA Citation
Zullig, LL, Jackson, GL, Dorn, RA, Provenzale, DT, McNeil, R, Thomas, CM, and Kelley, MJ. "Cancer incidence among patients of the U.S. Veterans Affairs Health Care System." Mil Med 177.6 (June 2012): 693-701.
PMID
22730846
Source
pubmed
Published In
Military medicine
Volume
177
Issue
6
Publish Date
2012
Start Page
693
End Page
701

Transportation: a vehicle or roadblock to cancer care for VA patients with colorectal cancer?

BACKGROUND: Patients must have transportation to the treatment site before they can access appropriate cancer care. This article describes factors associated with patients experiencing transportation-related barriers to accessing cancer care. PATIENTS AND METHODS: The Cancer Care Assessment & Responsive Evaluation Studies (C-CARES) questionnaire was mailed to Veterans Affairs (VA) patients with colorectal cancer (CRC) during the fall of 2009. Eligible patients were diagnosed at any VA facility in 2008, they were men, and alive at the time of the mailing. A total of 1409 surveys were returned (approximately 67% response rate). To assess transportation barriers, patients were asked how often it was difficult to get transportation to or from treatment. Symptoms were assessed using validated Patient-Reported Outcomes Measurement Information System (PROMIS) scales for fatigue, pain, and depression. Multivariate logistic regression was used to examine determinants of transportation barriers. RESULTS: A minority of respondents (19%) reported transportation barriers. Patients experiencing pain (OR, 1.04; 95% CI, 1.02-1.06) had greater odds of transportation barriers than patients without this symptom. Patients who reported no primary social support (OR, 6.13; 95% CI, 3.10-12.14) or nonspousal support (OR, 2.00; 95% CI, 1.40-2.87) were more likely to experience transportation barriers than patients whose spouses provided social support. DISCUSSION: Patients with uncontrolled pain or less social support have greater odds of transportation barriers. The directional association between social support, symptoms, and transportation cannot be determined in this data. CONCLUSION: Inquiring about accessible transportation should become a routine part of cancer care, particularly for patients with known risk factors.

Authors
Zullig, LL; Jackson, GL; Provenzale, D; Griffin, JM; Phelan, S; van Ryn, M
MLA Citation
Zullig, LL, Jackson, GL, Provenzale, D, Griffin, JM, Phelan, S, and van Ryn, M. "Transportation: a vehicle or roadblock to cancer care for VA patients with colorectal cancer?." Clin Colorectal Cancer 11.1 (March 2012): 60-65.
PMID
21803001
Source
pubmed
Published In
Clinical colorectal cancer
Volume
11
Issue
1
Publish Date
2012
Start Page
60
End Page
65
DOI
10.1016/j.clcc.2011.05.001

A guide for success as a clinical investigator

Authors
Provenzale, D
MLA Citation
Provenzale, D. "A guide for success as a clinical investigator." Gastroenterology 142.3 (2012): 418-421.
PMID
22266151
Source
scival
Published In
Gastroenterology
Volume
142
Issue
3
Publish Date
2012
Start Page
418
End Page
421
DOI
10.1053/j.gastro.2012.01.009

Retraction for Garman et al: A genomic approach to colon cancer risk stratification yields biologic insights into therapeutic opportunities.

Authors
Garman, KS; Acharya, CR; Edelman, E; Grade, M; Gaedcke, J; Sud, S; Barry, W; Diehl, AM; Provenzale, D; Ginsburg, GS; Ghadimi, BM; Ried, T; Nevins, JR; Mukherjee, S; Hsu, D; Potti, A
MLA Citation
Garman, KS, Acharya, CR, Edelman, E, Grade, M, Gaedcke, J, Sud, S, Barry, W, Diehl, AM, Provenzale, D, Ginsburg, GS, Ghadimi, BM, Ried, T, Nevins, JR, Mukherjee, S, Hsu, D, and Potti, A. "Retraction for Garman et al: A genomic approach to colon cancer risk stratification yields biologic insights into therapeutic opportunities." Proc Natl Acad Sci U S A 108.42 (October 18, 2011): 17569-.
PMID
21969600
Source
pubmed
Published In
Proceedings of the National Academy of Sciences of USA
Volume
108
Issue
42
Publish Date
2011
Start Page
17569
DOI
10.1073/pnas.1115170108

Early dissemination of bevacizumab for advanced colorectal cancer: a prospective cohort study.

BACKGROUND: We describe early dissemination patterns for first-line bevacizumab given for metastatic colorectal cancer treatment. METHODS: We analyzed patient surveys and medical records for a population-based cohort with metastatic colorectal cancer treated in multiple regions and health systems in the United States (US). Eligible patients were diagnosed with metastatic colorectal cancer and initiated first-line chemotherapy after US Food & Drug Administration (FDA) bevacizumab approval in February 2004. First-line bevacizumab therapy was defined as receiving bevacizumab within 8 weeks of starting chemotherapy for metastatic colorectal cancer. We evaluated factors associated with first-line bevacizumab treatment using logistic regression. RESULTS: Among 355 patients, 31% received first-line bevacizumab in the two years after FDA approval, including 26% of men, 41% of women, and 16% of those ≥ 75 years. Use rose sharply within 6 months after FDA approval, then plateaued. 20% of patients received bevacizumab in combination with irinotecan; 53% received it with oxaliplatin. Men were less likely than women to receive bevacizumab (adjusted OR 0.55; 95% CI 0.32-0.93; p = 0.026). Patients ≥ 75 years were less likely to receive bevacizumab than patients < 55 years (adjusted OR 0.13; 95% CI 0.04-0.46; p = 0.001). CONCLUSIONS: One-third of eligible metastatic colorectal cancer patients received first-line bevacizumab shortly after FDA approval. Most patients did not receive bevacizumab as part of the regimen used in the pivotal study leading to FDA approval.

Authors
Zafar, SY; Malin, JL; Grambow, SC; Abbott, DH; Schrag, D; Kolimaga, JT; Zullig, LL; Weeks, JC; Fouad, MN; Ayanian, JZ; Wallace, R; Kahn, KL; Ganz, PA; Catalano, P; West, DW; Provenzale, D; Cancer Care and Outcomes Research and Surveillance (CanCORS) Consortium,
MLA Citation
Zafar, SY, Malin, JL, Grambow, SC, Abbott, DH, Schrag, D, Kolimaga, JT, Zullig, LL, Weeks, JC, Fouad, MN, Ayanian, JZ, Wallace, R, Kahn, KL, Ganz, PA, Catalano, P, West, DW, Provenzale, D, and Cancer Care and Outcomes Research and Surveillance (CanCORS) Consortium, . "Early dissemination of bevacizumab for advanced colorectal cancer: a prospective cohort study. (Published online)" BMC Cancer 11 (August 16, 2011): 354-.
PMID
21846341
Source
pubmed
Published In
BMC Cancer
Volume
11
Publish Date
2011
Start Page
354
DOI
10.1186/1471-2407-11-354

A genomic approach to colon cancer risk stratification yields biologic insights into therapeutic opportunities (Proceedings of the National Academy of Sciences of the United States of America (2008) 105, 49, (19432-19437) DOI: 10.1073/pnas.0806674105)

Authors
Garman, KS; Acharya, CR; Edelman, E; Grade, M; Gaedcke, J; Sud, S; Barry, W; Diehl, AM; Provenzale, D; Ginsburg, GS; Ghadimi, BM; Ried, T; Nevins, JR; Mukherjee, S; Hsu, D; Potti, A
MLA Citation
Garman, KS, Acharya, CR, Edelman, E, Grade, M, Gaedcke, J, Sud, S, Barry, W, Diehl, AM, Provenzale, D, Ginsburg, GS, Ghadimi, BM, Ried, T, Nevins, JR, Mukherjee, S, Hsu, D, and Potti, A. "A genomic approach to colon cancer risk stratification yields biologic insights into therapeutic opportunities (Proceedings of the National Academy of Sciences of the United States of America (2008) 105, 49, (19432-19437) DOI: 10.1073/pnas.0806674105)." Proceedings of the National Academy of Sciences of the United States of America 108.42 (2011): 17569--.
Source
scival
Published In
Proceedings of the National Academy of Sciences of USA
Volume
108
Issue
42
Publish Date
2011
Start Page
17569-
DOI
10.1073/pnas.1115170108

Use of psychosocial support services among male Veterans Affairs colorectal cancer patients.

The authors describe use of psychosocial services within +/- 3 months of diagnosis among male colorectal cancer (CRC) patients treated within the Veterans Affairs (VA) health care system. Analysis included 1,199 patients with CRC treated at 27 VA medical centers primarily diagnosed between the periods 2005 to 2007. Of the patients, 78.6% received some form of psychosocial support, including 50.5% social work, 58.9% chaplain, 6.2% psychologist, 7.1% psychiatry, 3.5% mental health nurse, and 4.4% other. Logistic regression results indicate that rectal cancer patients were less likely to receive psychosocial services (odds ratio = .65, 95% confidence interval [0.43, 0.97]). The majority of patients in the VA receive some type of psychosocial service at the time of CRC diagnosis.

Authors
Hamilton, NS; Jackson, GL; Abbott, DH; Zullig, LL; Provenzale, D
MLA Citation
Hamilton, NS, Jackson, GL, Abbott, DH, Zullig, LL, and Provenzale, D. "Use of psychosocial support services among male Veterans Affairs colorectal cancer patients." J Psychosoc Oncol 29.3 (2011): 242-253.
PMID
21590571
Source
pubmed
Published In
Journal of Psychosocial Oncology
Volume
29
Issue
3
Publish Date
2011
Start Page
242
End Page
253
DOI
10.1080/07347332.2011.563346

Disparities in lung cancer staging with positron emission tomography in the cancer care outcomes research and surveillance (cancors) study

Introduction: Disparities in treatment exist for nonwhite and Hispanic patients with non-small cell lung cancer, but little is known about disparities in the use of staging tests or their underlying causes. Methods: Prospective, observational cohort study of 3638 patients with newly diagnosed non-small cell lung cancer from 4 large, geographically defined regions, 5 integrated health care systems, and 13 VA health care facilities. Results: Median age was 69 years, 62% were men, 26% were Hispanic or nonwhite, 68% graduated high school, 50% had private insurance, and 41% received care in the VA or another integrated health care system. After adjustment, positron emission tomography (PET) use was 13% lower among nonwhites and Hispanics than non-Hispanic whites (risk ratio [RR] 0.87, 95% confidence interval [CI] 0.77-0.97), 13% lower among those with Medicare than those with private insurance (RR 0.87, 95% CI 0.76-0.99), and 24% lower among those with an elementary school education than those with a graduate degree (RR 0.76, 95% CI 0.57-0.98). Disparate use of PET was not observed among patients who received care in an integrated health care setting, but the association between race/ethnicity and PET use was similar in magnitude across all other subgroups. Further analysis showed that income, education, insurance, and health care setting do not explain the association between race/ethnicity and PET use. CONCLUSIONS:: Hispanics and nonwhites with non-small cell lung cancer are less likely to receive PET imaging. This finding is consistent across subgroups and not explained by differences in income, education, or insurance coverage. Copyright © 2011 by the International Association for the Study of Lung Cancer.

Authors
Gould, MK; Schultz, EM; Wagner, TH; Xu, X; Ghaus, SJ; Wallace, RB; Provenzale, D; Au, DH
MLA Citation
Gould, MK, Schultz, EM, Wagner, TH, Xu, X, Ghaus, SJ, Wallace, RB, Provenzale, D, and Au, DH. "Disparities in lung cancer staging with positron emission tomography in the cancer care outcomes research and surveillance (cancors) study." Journal of Thoracic Oncology 6.5 (2011): 875-883.
PMID
21572580
Source
scival
Published In
Journal of Thoracic Oncology
Volume
6
Issue
5
Publish Date
2011
Start Page
875
End Page
883
DOI
10.1097/JTO.0b013e31821671b6

Colorectal Cancer Screening

Colorectal cancer screening is an important mission for a practicing gastroenterologist. Several different screening modalities are available: fecal occult blood test, flexible sigmoidoscopy, colonoscopy, barium enema, and more recently, CT-colonography and stool DNA tests. The physician is charged with weighing the pros and cons of the different screening methods and selecting the most appropriate method for each patient. © 2010 Blackwell Publishing Ltd.

Authors
Garman, KS; Provenzale, D
MLA Citation
Garman, KS, and Provenzale, D. "Colorectal Cancer Screening." (August 31, 2010): 212-218. (Chapter)
Source
scopus
Publish Date
2010
Start Page
212
End Page
218
DOI
10.1002/9781444328417.ch31

Colonoscopy withdrawal time and risk of neoplasia at 5 years: results from VA Cooperative Studies Program 380.

OBJECTIVES: Withdrawal time (WT) has been proposed as a quality indicator for colonoscopy based on evidence that it is directly related to the rate of adenoma detection. Our objective was to test the hypothesis that baseline WT is inversely associated with the risk of finding neoplasia at interval colonoscopy. METHODS: In all, 3,121 subjects, aged 50-75 years, had screening colonoscopy between 1994 and 1997 at 13 Veteran Affairs Medical Centers. In all, 1,193 subjects returned by protocol for surveillance within 5.5 years. In the 304 patients without polyps at baseline, we evaluated the contribution of baseline WT to their risk of interval neoplasia using bivariate and logistic regression analysis. We also examined the correlation between mean WT, baseline adenoma detection rate, and interval neoplasia rate at the medical-center level. RESULTS: The average WT at the baseline exam in subjects with neoplasia on follow-up was 15.3 min as compared with 13.2 min in subjects without neoplasia (P=0.18). In a logistic regression model, WT was not associated with the risk of interval neoplasia (P=0.07). At the medical-center level, mean WT was not correlated with the probability of finding interval neoplasia (P=0.61) but was positively correlated with adenoma detection rate at baseline (P=0.03). CONCLUSIONS: In this study with a mean baseline WT &12 min, there was no detectable association between WT and risk of future neoplasia. The medical center-level WT was positively correlated with adenoma detection. Therefore, above a certain threshold, WT may no longer be an adequate quality measure for screening colonoscopy.

Authors
Gellad, ZF; Weiss, DG; Ahnen, DJ; Lieberman, DA; Jackson, GL; Provenzale, D
MLA Citation
Gellad, ZF, Weiss, DG, Ahnen, DJ, Lieberman, DA, Jackson, GL, and Provenzale, D. "Colonoscopy withdrawal time and risk of neoplasia at 5 years: results from VA Cooperative Studies Program 380." Am J Gastroenterol 105.8 (August 2010): 1746-1752.
PMID
20234348
Source
pubmed
Published In
The American Journal of Gastroenterology (Elsevier)
Volume
105
Issue
8
Publish Date
2010
Start Page
1746
End Page
1752
DOI
10.1038/ajg.2010.107

Quality of colonoscopy reporting in community practice.

BACKGROUND: Quality endoscopy reporting is essential when community endoscopists perform colonoscopies for veterans who cannot be scheduled at a Veterans Administration (VA) facility. OBJECTIVE: To examine the quality of colonoscopy reports received from community practices and to determine factors associated with more complete reporting, by using national documentation guidelines. DESIGN: Cross-sectional analysis. SETTING: Reports submitted to the Durham VA Medical Center, Durham, North Carolina, from 2007 to 2008. PATIENTS: Subjects who underwent fee-basis colonoscopy. MAIN OUTCOME MEASUREMENTS: Scores created by comparing community reports with published documentation guidelines. Three scores were created, one for each category of information: Universal Elements (found on all endoscopy reports), Indication Elements (specific to the procedure indication), and Finding Elements (specific to examination findings). RESULTS: For the 135 included reports, the summary scores were Universal Elements, 57.6% (95% confidence interval [CI], 55%-60%); Indication Elements, 73.7% (95% CI, 69%-78%); and Finding Elements, 75.8% (95% CI, 73%-79%). Examples of poor reporting included patient history (20.7%), last colonoscopy date (18.0%), average versus high risk screening (32.0%), withdrawal time (5.9%), and cecal landmark photographs (45.2%). Only the use of automated reporting software was associated with more thorough reporting. LIMITATIONS: Modest sample size, mostly male participants, frequent pathologic findings, limited geography, and lack of complete reporting by a minority of providers. CONCLUSIONS: The overall completeness of colonoscopy reports was low, possibly reflecting a lack of knowledge of reporting guidelines or a lack of agreement regarding important colonoscopy reporting elements. Automated endoscopy software may improve reporting compliance but may not completely standardize reporting quality.

Authors
Palmer, LB; Abbott, DH; Hamilton, N; Provenzale, D; Fisher, DA
MLA Citation
Palmer, LB, Abbott, DH, Hamilton, N, Provenzale, D, and Fisher, DA. "Quality of colonoscopy reporting in community practice." Gastrointest Endosc 72.2 (August 2010): 321-327.e1.
PMID
20591430
Source
pubmed
Published In
Gastrointestinal Endoscopy
Volume
72
Issue
2
Publish Date
2010
Start Page
321
End Page
327.e1
DOI
10.1016/j.gie.2010.03.002

Community-associated Clostridium difficile infection: experience of a veteran affairs medical center in southeastern USA.

BACKGROUND: There is increasing recognition of the importance of community-associated Clostridium difficile infection (CA-CDI) despite little being known about its epidemiology. METHODS: We performed routine, active laboratory surveillance for CDI at the Durham Veterans Affairs Medical Center between January and December 2005 and extracted data from the electronic medical record for this investigation. Bivariable analyses were performed using the chi-square test, and continuous variables were compared using two sample t test and Wilcoxon rank sums. RESULTS: We identified 108 CDI cases during the study period; 38 (35%) had onset of disease in the community and, of these, 31 (82%) met the definition for CA-CDI. A comparison of CA- versus healthcare facility-associated (HCFA)-CDI revealed that CA-CDI patients were younger (median age 58 vs. 69 years, respectively; p = 0.01), with the majority being <65 years, but had similar co-morbidities to HCFA-CDI patients. CA-CDI patients were reportedly exposed less frequently to an antimicrobial or a proton pump inhibitor than HCFA-CDI patients, while the latter showed a trend towards a higher 60-day all-cause mortality (3 vs. 17%, respectively; p = 0.06). CONCLUSIONS: CA-CDI is the primary reason for community-onset CDI in our community. Compared to patients with HCFA-CDI, those with CA-CDI were younger, had fewer reported exposures to antimicrobials or PPIs, and had lower mortality. Further study is needed to identify unrecognized risk factors of CDI in the community.

Authors
Naggie, S; Frederick, J; Pien, BC; Miller, BA; Provenzale, DT; Goldberg, KC; Woods, CW
MLA Citation
Naggie, S, Frederick, J, Pien, BC, Miller, BA, Provenzale, DT, Goldberg, KC, and Woods, CW. "Community-associated Clostridium difficile infection: experience of a veteran affairs medical center in southeastern USA." Infection 38.4 (August 2010): 297-300.
PMID
20454827
Source
pubmed
Published In
Infection
Volume
38
Issue
4
Publish Date
2010
Start Page
297
End Page
300
DOI
10.1007/s15010-010-0025-0

Quality of nonmetastatic colorectal cancer care in the Department of Veterans Affairs.

PURPOSE: The Veterans Affairs (VA) healthcare system treats approximately 3% of patients with cancer in the United States each year. We measured the quality of nonmetastatic colorectal cancer (CRC) care in VA as indicated by concordance with National Comprehensive Cancer Network practice guidelines (six indicators) and timeliness of care (three indicators). PATIENTS AND METHODS: A retrospective medical record abstraction was done for 2,492 patients with incident stages I to III CRC diagnosed between October 1, 2003, and March 31, 2006, who underwent definitive CRC surgery. Patients were treated at one or more of 128 VA medical centers. The proportion of patients receiving guideline-concordant care and time intervals between care processes were calculated. RESULTS: More than 80% of patients had preoperative carcinoembryonic antigen determination (ie, stages II to III disease) and documented clear surgical margins (ie, stages II to III disease). Between 72% and 80% of patients had appropriate referral to a medical oncologist (ie, stages II to III disease), preoperative computed tomography scan of the abdomen and pelvis (ie, stages II to III disease), and adjuvant fluorouracil-based chemotherapy (ie, stage III disease). Less than half of patients with stages I to III CRC (43.5%) had a follow-up colonoscopy 7 to 18 months after surgery. The mean number of days between major treatment events included the following: 26.6 days (standard deviation [SD], 38.2; median, 20 days) between diagnosis and initiation of treatment (in stages II to III disease); 64.8 [corrected] days (SD, 54.9; median, 50 days) between definitive surgery and start of adjuvant chemotherapy (in stages II to III disease); and 444.2 [corrected] days (SD, 182.1; median, 393 days) between definitive surgery and follow-up colonoscopies (in stages I to III disease). CONCLUSION: Although there is opportunity for improvement in the area of cancer surveillance, the VA performs well in meeting established guidelines for diagnosis and treatment of CRC.

Authors
Jackson, GL; Melton, LD; Abbott, DH; Zullig, LL; Ordin, DL; Grambow, SC; Hamilton, NS; Zafar, SY; Gellad, ZF; Kelley, MJ; Provenzale, D
MLA Citation
Jackson, GL, Melton, LD, Abbott, DH, Zullig, LL, Ordin, DL, Grambow, SC, Hamilton, NS, Zafar, SY, Gellad, ZF, Kelley, MJ, and Provenzale, D. "Quality of nonmetastatic colorectal cancer care in the Department of Veterans Affairs." J Clin Oncol 28.19 (July 1, 2010): 3176-3181.
PMID
20516431
Source
pubmed
Published In
Journal of Clinical Oncology
Volume
28
Issue
19
Publish Date
2010
Start Page
3176
End Page
3181
DOI
10.1200/JCO.2009.26.7948

Colorectal cancer: national and international perspective on the burden of disease and public health impact.

Colorectal cancer is a significant cause of morbidity and mortality in the United States and throughout the world. The importance of this disease to gastroenterologists cannot be understated, given that screening and surveillance colonoscopy are dominant segments of clinical practice. The United States is the only country in the world where incidence and mortality rates from colorectal cancer are reported to be decreasing significantly, but health disparities in cancer screening, treatment, and survival persist. Health disparities are also evident worldwide, where the impact of this disease is staggering. In fact, rates of cancer are increasing in many parts of the world. Eliminating barriers to cancer screening and treatment could lead to substantial gains in quality and quantity of life and decrease the burden of colorectal cancer on public health. Programmatic and opportunistic screening programs have already had a measurable impact on disease burden, although the optimal screening strategy remains a matter of debate. Screening programs vary throughout the world, and further refinement will require a tailored approach because of differences in politics and fiscal reality among individual countries. Despite the strong impact of colorectal cancer on public health, there is cause for optimism and room for hope.

Authors
Gellad, ZF; Provenzale, D
MLA Citation
Gellad, ZF, and Provenzale, D. "Colorectal cancer: national and international perspective on the burden of disease and public health impact." Gastroenterology 138.6 (June 2010): 2177-2190. (Review)
PMID
20420954
Source
pubmed
Published In
Gastroenterology
Volume
138
Issue
6
Publish Date
2010
Start Page
2177
End Page
2190
DOI
10.1053/j.gastro.2010.01.056

Determinants of medical system delay in the diagnosis of colorectal cancer within the Veteran Affairs Health System.

BACKGROUND AND AIMS: The goals of this study are to evaluate determinants of the time in the medical system until a colorectal cancer diagnosis and to explore characteristics associated with stage at diagnosis. METHODS: We examined medical records and survey data for 468 patients with colorectal cancer at 15 Veterans Affairs medical centers. Patients were classified as screen-detected, bleeding-detected, or other (resulting from the evaluation of another medical concern). Patients who presented emergently with obstruction or perforation were excluded. We used Cox proportional hazards models to determine predictors of time in the medical system until diagnosis. Logistic regression models were used to determine predictors of stage at diagnosis. RESULTS: We excluded 21 subjects who presented emergently, leaving 447 subjects; the mean age was 67 years and 98% were male, 66% Caucasian, and 43% stage I or II. Diagnosis was by screening for 39%, bleeding symptoms for 27%, and other for 34%. The median times to diagnosis were 73-91 days and were not significantly different by diagnostic category. In the multivariable model for time to diagnosis, older age, having comorbidities, and Atlantic region were associated with a longer time to diagnosis. In the multivariable model for stage-at-diagnosis, only the diagnostic category was associated with stage; the screen-detected category was associated with decreased risk of late-stage cancer. CONCLUSIONS: Our results point to several factors associated with a longer time from the initial clinical event until diagnosis. This increased time in the health care system did not clearly translate into more advanced disease at diagnosis.

Authors
Fisher, DA; Zullig, LL; Grambow, SC; Abbott, DH; Sandler, RS; Fletcher, RH; El-Serag, HB; Provenzale, D
MLA Citation
Fisher, DA, Zullig, LL, Grambow, SC, Abbott, DH, Sandler, RS, Fletcher, RH, El-Serag, HB, and Provenzale, D. "Determinants of medical system delay in the diagnosis of colorectal cancer within the Veteran Affairs Health System." Dig Dis Sci 55.5 (May 2010): 1434-1441.
PMID
20238248
Source
pubmed
Published In
Digestive Diseases and Sciences
Volume
55
Issue
5
Publish Date
2010
Start Page
1434
End Page
1441
DOI
10.1007/s10620-010-1174-9

Developing and sustaining quality improvement partnerships in the VA: the Colorectal Cancer Care Collaborative.

OBJECTIVE: The Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) seeks to develop partnerships between VA health services researchers and clinical managers, with the goal of designing and evaluating interventions to improve the quality of VA health care. METHODS: In the present report we describe one such initiative aimed at enhancing the continuum of colorectal cancer (CRC) care, including diagnosis, treatment and surveillance-the Colorectal Cancer Care Collaborative (C4). RESULTS: We describe the process and thinking that led to two parallel quality improvement "collaboratives" that addressed (1) CRC screening and diagnostic follow-up and (2) the guideline concordance and timeliness of CRC treatment. Additionally, we discuss ongoing effort to spread lessons learned during the first stages of the project, which initially occurred at only a subset of VA facilities, throughout the VA health care system. The description of this initiative is organized around key questions that must be answered when developing, sustaining and spreading multi-component quality improvement interventions. CONCLUSION: We conclude with a discussion of lessons learned that we believe would apply to similar initiatives elsewhere, even if they address different clinical issues in health care settings with different organizational structures.

Authors
Jackson, GL; Powell, AA; Ordin, DL; Schlosser, JE; Murawsky, J; Hersh, J; Ponte, G; Zullig, LL; Erb, F; Parlier, R; Haggstrom, DA; Koets, N; Mills, PD; Francis, J; Kelley, MJ; Davies, ML; Provenzale, D; VA Colorectal Cancer Care Planning Committee Members,
MLA Citation
Jackson, GL, Powell, AA, Ordin, DL, Schlosser, JE, Murawsky, J, Hersh, J, Ponte, G, Zullig, LL, Erb, F, Parlier, R, Haggstrom, DA, Koets, N, Mills, PD, Francis, J, Kelley, MJ, Davies, ML, Provenzale, D, and VA Colorectal Cancer Care Planning Committee Members, . "Developing and sustaining quality improvement partnerships in the VA: the Colorectal Cancer Care Collaborative." J Gen Intern Med 25 Suppl 1 (January 2010): 38-43.
PMID
20077150
Source
pubmed
Published In
Journal of General Internal Medicine
Volume
25 Suppl 1
Publish Date
2010
Start Page
38
End Page
43
DOI
10.1007/s11606-009-1155-x

Reply

Authors
Gellad, ZF; Provenzale, D
MLA Citation
Gellad, ZF, and Provenzale, D. "Reply." Gastroenterology 139.3 (2010): 1065--.
Source
scival
Published In
Gastroenterology
Volume
139
Issue
3
Publish Date
2010
Start Page
1065-
DOI
10.1053/j.gastro.2010.07.037

Variation in estimates of limited ealth Literacy by Assessment Instruments and Non-Response Bias

Objectives: This paper compares estimates of poor health literacy using two widely used assessment tools and assesses the effect of non-response on these estimates. Study Design and Setting: A total of 4,868 veterans receiving care at four VA medical facilities between 2004 and 2005 were stratified by age and facility and randomly selected for recruitment. Interviewers collected demographic information and conducted assessments of health literacy (both REALM and S-TOFHLA) from 1,796 participants. Prevalence estimates for each assessment were computed. Non-respondents received a brief proxy questionnaire with demographic and self-report literacy questions to assess non-response bias. Available administrative data for non-participants were also used to assess non-response bias. Results: Among the 1,796 patients assessed using the S-TOFHLA, 8% had inadequate and 7% had marginal skills. For the REALM, 4% were categorized with 6th grade skills and 17% with 7-8th grade skills. Adjusting for non-response bias increased the S-TOFHLA prevalence estimates for inadequate and marginal skills to 9.3% and 11.8%, respectively, and the REALM estimates for∈6th and 7-8th grade skills to 5.4% and 33.8%, respectively. Conclusions: Estimates of poor health literacy varied by the assessment used, especially after adjusting for non-response bias. Researchers and clinicians should consider the possible limitations of each assessment when considering the most suitable tool for their purposes. © 2010 Society of General Internal Medicine.

Authors
Griffin, JM; Partin, MR; Noorbaloochi, S; Grill, JP; Saha, S; Snyder, A; Nugent, S; Simon, AB; Gralnek, I; Provenzale, D; Ryn, MV
MLA Citation
Griffin, JM, Partin, MR, Noorbaloochi, S, Grill, JP, Saha, S, Snyder, A, Nugent, S, Simon, AB, Gralnek, I, Provenzale, D, and Ryn, MV. "Variation in estimates of limited ealth Literacy by Assessment Instruments and Non-Response Bias." Journal of General Internal Medicine 25.7 (2010): 675-681.
PMID
20224964
Source
scival
Published In
Journal of General Internal Medicine
Volume
25
Issue
7
Publish Date
2010
Start Page
675
End Page
681
DOI
10.1007/s11606-010-1304-2

NCCN clinical practice guidelines in oncology. Colorectal cancer screening.

Authors
Burt, RW; Barthel, JS; Dunn, KB; David, DS; Drelichman, E; Ford, JM; Giardiello, FM; Gruber, SB; Halverson, AL; Hamilton, SR; Ismail, MK; Jasperson, K; Lazenby, AJ; Lynch, PM; Jr, EWM; Mayer, RJ; Ness, RM; Provenzale, D; Rao, MS; Shike, M; Steinbach, G; Terdiman, JP; Weinberg, D
MLA Citation
Burt, RW, Barthel, JS, Dunn, KB, David, DS, Drelichman, E, Ford, JM, Giardiello, FM, Gruber, SB, Halverson, AL, Hamilton, SR, Ismail, MK, Jasperson, K, Lazenby, AJ, Lynch, PM, Jr, EWM, Mayer, RJ, Ness, RM, Provenzale, D, Rao, MS, Shike, M, Steinbach, G, Terdiman, JP, and Weinberg, D. "NCCN clinical practice guidelines in oncology. Colorectal cancer screening." Journal of the National Comprehensive Cancer Network : JNCCN 8.1 (2010): 8-61.
PMID
20064289
Source
scival
Published In
Journal of the National Comprehensive Cancer Network : JNCCN
Volume
8
Issue
1
Publish Date
2010
Start Page
8
End Page
61

Colorectal cancer screening: Clinical practice guidelines in oncology™

Colorectal cancer (CRC) is the third most frequently diagnosed cancer in men and women in the United States. Patients with localized colon cancer have a 90% 5-year survival rate, and CRC mortality can be reduced through early diagnosis and cancer prevention with polypectomy. Therefore, the goal of CRC screening is to detect cancer at an early, curable stage and to detect and remove clinically significant adenomas. Screening tests that can detect both early cancer and adenomatous polyps are encouraged, although the panel recognizes that patient preference and resource accessibility play a large role in test selection. Current technology falls into 2 broad categories: structural and stool! fecal-based tests. Although some techniques are better established than others, the guidelines panelists agree that any screening is better than none. Important updates for 2010 include the addition of surveillance guidelines and definitions for several polyposis syndromes, including Peutz-Jeghers syndrome and juvenile polyposis syndrome, and modifications to screening modality and schedule recommendations. © Journal of the National Comprehensive Cancer Network 2010.

Authors
Burt, RW; Barthel, JS; Dunn, KB; David, DS; Drelichman, E; Ford, JM; Giardiello, FM; Gruber, SB; Halverson, AL; Hamilton, SR; Ismail, MK; Jasperson, K; Lazenby, AJ; Lynch, PM; Jr, EWM; Mayer, RJ; Ness, RM; Provenzale, D; Rao, MS; Shike, M; Steinbach, G; Terdiman, JP; Weinberg, D
MLA Citation
Burt, RW, Barthel, JS, Dunn, KB, David, DS, Drelichman, E, Ford, JM, Giardiello, FM, Gruber, SB, Halverson, AL, Hamilton, SR, Ismail, MK, Jasperson, K, Lazenby, AJ, Lynch, PM, Jr, EWM, Mayer, RJ, Ness, RM, Provenzale, D, Rao, MS, Shike, M, Steinbach, G, Terdiman, JP, and Weinberg, D. "Colorectal cancer screening: Clinical practice guidelines in oncology™." JNCCN Journal of the National Comprehensive Cancer Network 8.1 (2010): 8-60.
Source
scival
Published In
Journal of the National Comprehensive Cancer Network : JNCCN
Volume
8
Issue
1
Publish Date
2010
Start Page
8
End Page
60

Time from positive screening fecal occult blood test to colonoscopy and risk of neoplasia.

There is no guideline defining the optimal time from a positive screening fecal occult blood test to follow-up colonoscopy. We reviewed records of 231 consecutive primary care patients who received a colonoscopy within 18 months of a positive fecal occult blood test. We examined the relationship between time to colonoscopy and risk of neoplasia on colonoscopy using a logistic regression analysis adjusting for potential confounders such as age, race, and gender. The mean time to colonoscopy was 236 days. Longer time to colonoscopy (OR = 1.10, P = 0.01) and older age (OR 1.04, P = 0.01) were associated with higher odds of neoplasia. The association of time with advanced neoplasia was positive, but not statistically significant (OR 1.07, P = 0.14). In this study, a longer interval to colonoscopy after fecal occult blood test was associated with an increased risk of neoplasia. Determining the optimal interval for follow-up is desirable and will require larger studies.

Authors
Gellad, ZF; Almirall, D; Provenzale, D; Fisher, DA
MLA Citation
Gellad, ZF, Almirall, D, Provenzale, D, and Fisher, DA. "Time from positive screening fecal occult blood test to colonoscopy and risk of neoplasia." Dig Dis Sci 54.11 (November 2009): 2497-2502.
PMID
19093199
Source
pubmed
Published In
Digestive Diseases and Sciences
Volume
54
Issue
11
Publish Date
2009
Start Page
2497
End Page
2502
DOI
10.1007/s10620-008-0653-8

Validation of a questionnaire to assess self-reported colorectal cancer screening status using face-to-face administration.

PURPOSE: The aim of this study was to assess the accuracy of a National Cancer Institute (NCI)-developed colorectal cancer screening questionnaire. METHODS: We conducted 36 cognitive interviews and made iterative changes to the questionnaire to improve comprehension. The revised questionnaire was administered face-to-face to 201 participants. The primary outcome was agreement between questionnaire responses and medical records for whether or not a participant was up-to-date for any colorectal cancer screening test. RESULTS: Comprehension of descriptions and questions was generally good; however, the barium enema description required several revisions. The sensitivity of the questionnaire for up-to-date screening status was 94%, specificity 63%, and concordance 88%. CONCLUSIONS: The modified questionnaire was highly sensitive for determining if a person was up-to-date for any colorectal cancer screening test, although the specificity was low. Given the difficulty of obtaining all relevant records, self-report using this questionnaire is a reasonable option for identifying people who have undergone testing.

Authors
Fisher, DA; Voils, CI; Coffman, CJ; Grubber, JM; Dudley, TK; Vernon, SW; Bond, JH; Provenzale, D
MLA Citation
Fisher, DA, Voils, CI, Coffman, CJ, Grubber, JM, Dudley, TK, Vernon, SW, Bond, JH, and Provenzale, D. "Validation of a questionnaire to assess self-reported colorectal cancer screening status using face-to-face administration." Dig Dis Sci 54.6 (June 2009): 1297-1306.
PMID
18726152
Source
pubmed
Published In
Digestive Diseases and Sciences
Volume
54
Issue
6
Publish Date
2009
Start Page
1297
End Page
1306
DOI
10.1007/s10620-008-0471-z

Improving colorectal cancer screening and care in the Veterans Affairs Healthcare system.

The Veterans Health Administration (VHA) has recently launched several nationwide initiatives to improve the quality of its colorectal cancer (CRC) screening and care. The timeliness of follow-up diagnostic tests in patients who have positive noncolonoscopic CRC screening tests is one of the target areas of these initiatives. Multiple aspects of colon cancer care are being monitored, and the degree of adherence to accepted quality measures is being assessed. The purpose of this review is to describe the background leading to these initiatives and their expected impact on CRC screening and management in the VHA.

Authors
Chao, HH; Schwartz, AR; Hersh, J; Hunnibell, L; Jackson, GL; Provenzale, DT; Schlosser, J; Stapleton, LM; Zullig, LL; Rose, MG
MLA Citation
Chao, HH, Schwartz, AR, Hersh, J, Hunnibell, L, Jackson, GL, Provenzale, DT, Schlosser, J, Stapleton, LM, Zullig, LL, and Rose, MG. "Improving colorectal cancer screening and care in the Veterans Affairs Healthcare system." Clin Colorectal Cancer 8.1 (January 2009): 22-28. (Review)
PMID
19203893
Source
pubmed
Published In
Clinical colorectal cancer
Volume
8
Issue
1
Publish Date
2009
Start Page
22
End Page
28
DOI
10.3816/CCC.2009.n.004

Erratum: A genomic approach to colon cancer risk stratification yields biologic insights into therapeutic opportunities (Proceedings of the National Academy of Sciences of the United States of America (2008) 105:49 (19432-19437) Doi: 10.1073/pnas.0806674105)

Authors
Garman, KS; Acharya, CR; Edelman, E; Grade, M; Gaedcke, J; Sud, S; Barry, W; Diehl, AM; Provenzale, D; Ginsburg, GS; Ghadimi, BM; Ried, T; Nevins, JR; Mukherjee, S; Hsu, D; Potti, A
MLA Citation
Garman, KS, Acharya, CR, Edelman, E, Grade, M, Gaedcke, J, Sud, S, Barry, W, Diehl, AM, Provenzale, D, Ginsburg, GS, Ghadimi, BM, Ried, T, Nevins, JR, Mukherjee, S, Hsu, D, and Potti, A. "Erratum: A genomic approach to colon cancer risk stratification yields biologic insights into therapeutic opportunities (Proceedings of the National Academy of Sciences of the United States of America (2008) 105:49 (19432-19437) Doi: 10.1073/pnas.0806674105)." Proceedings of the National Academy of Sciences of the United States of America 106.16 (2009): 6878--.
Source
scival
Published In
Proceedings of the National Academy of Sciences of USA
Volume
106
Issue
16
Publish Date
2009
Start Page
6878-
DOI
10.1073/pnas.0902004106

Cancer control-planning and monitoring population-based systems

Cancer is a growing global health issue, and many countries are ill-prepared to deal with their current cancer burden let alone the increased burden looming on the horizon. Growing and aging populations are projected to result in dramatic increases in cancer cases and cancer deaths particularly in low- and middle-income countries. It is imperative that planning begin now to deal not only with those cancers already occurring but also with the larger numbers expected in the future. Unfortunately, such planning is hampered, because the magnitude of the burden of cancer in many countries is poorly understood owing to lack of surveillance and monitoring systems for cancer risk factors and for the documentation of cancer incidence, survival and mortality. Moreover, the human resources needed to fight cancer effectively are often limited or lacking. Cancer diagnosis and cancer care services are also inadequate in low-and middle-income countries. Late-stage presentation of cancers is very common in these settings resulting in less potential for cure and more need for symptom management. Palliative care services are grossly inadequate in low- and middle-income countries, and many cancer patients die unnecessarily painful deaths. Many of the challenges faced by low- and middle-income countries have been at least partially addressed by higher income countries. Experiences from around the world are reviewed to highlight the issues and showcase some possible solutions.

Authors
Harford, JB; Edwards, BK; Nandakumar, A; Ndom, P; Capocaccia, R; Coleman, MP; Vinson, CA; Stinchcomb, DG; Leitao, AR; Pinheiro, Z; Camanho, PP; Vichi, EJ; Sepulveda, C; Samiei, M; Makinen, M; Sabata, MSD; Sheikh, M; Gort, M; Siesling, S; Otter, R; Rutten, LJ; Moser, RP; Davis, KL; Davis, T; Luna, GT; Beckjord, E; Hesse, B; Moser, RP; Davis, KL; Rutten, LJ; Beckjord, E; Hesse, B; Davis, KL; Price, RA; Koshiol, J; Tiro, J; Habbema, D; Ballegooijen, MV; Allemani, C; Sant, M; Galán, Y; Fernández, L et al.
MLA Citation
Harford, JB, Edwards, BK, Nandakumar, A, Ndom, P, Capocaccia, R, Coleman, MP, Vinson, CA, Stinchcomb, DG, Leitao, AR, Pinheiro, Z, Camanho, PP, Vichi, EJ, Sepulveda, C, Samiei, M, Makinen, M, Sabata, MSD, Sheikh, M, Gort, M, Siesling, S, Otter, R, Rutten, LJ, Moser, RP, Davis, KL, Davis, T, Luna, GT, Beckjord, E, Hesse, B, Moser, RP, Davis, KL, Rutten, LJ, Beckjord, E, Hesse, B, Davis, KL, Price, RA, Koshiol, J, Tiro, J, Habbema, D, Ballegooijen, MV, Allemani, C, Sant, M, Galán, Y, and Fernández, L et al. "Cancer control-planning and monitoring population-based systems." Tumori 95.5 (2009): 568-578.
PMID
19999948
Source
scival
Published In
Tumori
Volume
95
Issue
5
Publish Date
2009
Start Page
568
End Page
578

A genomic approach to colon cancer risk stratification yields biologic insights into therapeutic opportunities.

Gene expression profiles provide an opportunity to dissect the heterogeneity of solid tumors, including colon cancer, to improve prognosis and predict response to therapies. Bayesian binary regression methods were used to generate a signature of disease recurrence in patients with resected early stage colon cancer validated in an independent cohort. A 50-gene signature was developed that effectively distinguished early stage colon cancer patients with a low or high risk of disease recurrence. RT-PCR analysis of the 50-gene signature validated 9 of the top 10 differentially expressed genes. When applied to two independent validation cohorts of 55 and 73 patients, the 50-gene model accurately predicted recurrence. Standard Kaplan-Meier survival analysis confirmed the prognostic accuracy (P < 0.01, log rank), as did multivariate Cox proportional hazard models. We tested potential targeted therapeutic options for patients at high risk for disease recurrence and found a clinically important relationship between sensitivity to celecoxib, LY-294002 (PI3kinase inhibitor), retinol, and sulindac in colon cancer cell lines expressing the poor prognostic phenotype (P < 0.01, t test), which performed better than standard chemotherapy (5-FU and oxaliplatin). We present a genomic strategy in early stage colon cancer to identify patients at highest risk of recurrence. An ability to move beyond current staging by refining the estimation of prognosis in early stage colon cancer also has implications for individualized therapy.

Authors
Garman, KS; Acharya, CR; Edelman, E; Grade, M; Gaedcke, J; Sud, S; Barry, W; Diehl, AM; Provenzale, D; Ginsburg, GS; Ghadimi, BM; Ried, T; Nevins, JR; Mukherjee, S; Hsu, D; Potti, A
MLA Citation
Garman, KS, Acharya, CR, Edelman, E, Grade, M, Gaedcke, J, Sud, S, Barry, W, Diehl, AM, Provenzale, D, Ginsburg, GS, Ghadimi, BM, Ried, T, Nevins, JR, Mukherjee, S, Hsu, D, and Potti, A. "A genomic approach to colon cancer risk stratification yields biologic insights into therapeutic opportunities." Proc Natl Acad Sci U S A 105.49 (December 9, 2008): 19432-19437.
PMID
19050079
Source
pubmed
Published In
Proceedings of the National Academy of Sciences of USA
Volume
105
Issue
49
Publish Date
2008
Start Page
19432
End Page
19437
DOI
10.1073/pnas.0806674105

Comorbidity, age, race and stage at diagnosis in colorectal cancer: a retrospective, parallel analysis of two health systems.

BACKGROUND: Stage at diagnosis plays a significant role in colorectal cancer (CRC) survival. Understanding which factors contribute to a more advanced stage at diagnosis is vital to improving overall survival. Comorbidity, race, and age are known to impact receipt of cancer therapy and survival, but the relationship of these factors to stage at diagnosis of CRC is less clear. The objective of this study is to investigate how comorbidity, race and age influence stage of CRC diagnosis. METHODS: Two distinct healthcare populations in the United States (US) were retrospectively studied. Using the Cancer Care Outcomes Research and Surveillance Consortium database, we identified CRC patients treated at 15 Veterans Administration (VA) hospitals from 2003-2007. We assessed metastatic CRC patients treated from 2003-2006 at 10 non-VA, fee-for-service (FFS) practices. Stage at diagnosis was dichotomized (non-metastatic, metastatic). Race was dichotomized (white, non-white). Charlson comorbidity index and age at diagnosis were calculated. Associations between stage, comorbidity, race, and age were determined by logistic regression. RESULTS: 342 VA and 340 FFS patients were included. Populations differed by the proportion of patients with metastatic CRC at diagnosis (VA 27% and FFS 77%) reflecting differences in eligibility criteria for inclusion. VA patients were mean (standard deviation; SD) age 67 (11), Charlson index 2.0 (1.0), and were 63% white. FFS patients were mean age 61 (13), Charlson index 1.6 (1.0), and were 73% white. In the VA cohort, higher comorbidity was associated with earlier stage at diagnosis after adjusting for age and race (odds ratio (OR) 0.76, 95% confidence interval (CI) 0.58-1.00; p = 0.045); no such significant relationship was identified in the FFS cohort (OR 1.09, 95% CI 0.82-1.44; p = 0.57). In both cohorts, no association was found between stage at diagnosis and either age or race. CONCLUSION: Higher comorbidity may lead to earlier stage of CRC diagnosis. Multiple factors, perhaps including increased interactions with the healthcare system due to comorbidity, might contribute to this finding. Such increased interactions are seen among patients within a healthcare system like the VA system in the US versus sporadic interactions which may be seen with FFS healthcare.

Authors
Zafar, SY; Abernethy, AP; Abbott, DH; Grambow, SC; Marcello, JE; Herndon, JE; Rowe, KL; Kolimaga, JT; Zullig, LL; Patwardhan, MB; Provenzale, DT
MLA Citation
Zafar, SY, Abernethy, AP, Abbott, DH, Grambow, SC, Marcello, JE, Herndon, JE, Rowe, KL, Kolimaga, JT, Zullig, LL, Patwardhan, MB, and Provenzale, DT. "Comorbidity, age, race and stage at diagnosis in colorectal cancer: a retrospective, parallel analysis of two health systems. (Published online)" BMC Cancer 8 (November 25, 2008): 345-.
PMID
19032772
Source
pubmed
Published In
BMC Cancer
Volume
8
Publish Date
2008
Start Page
345
DOI
10.1186/1471-2407-8-345

Are we use of chemotherapy for elderly stage III colon cancer patients? An analysis from the Cancer Care Outcomes & Research Surveillance Consortium (CanCORS)

Authors
Kahn, KL; Adams, JL; Chrischilles, EE; Harrington, DP; Weeks, JC; Ayanian, JZ; Kiefe, CI; Provenzale, DT; Fletcher, RH
MLA Citation
Kahn, KL, Adams, JL, Chrischilles, EE, Harrington, DP, Weeks, JC, Ayanian, JZ, Kiefe, CI, Provenzale, DT, and Fletcher, RH. "Are we use of chemotherapy for elderly stage III colon cancer patients? An analysis from the Cancer Care Outcomes & Research Surveillance Consortium (CanCORS)." JOURNAL OF CLINICAL ONCOLOGY 26.15 (May 20, 2008).
Source
wos-lite
Published In
Journal of Clinical Oncology
Volume
26
Issue
15
Publish Date
2008

Health Economics

Authors
Provenzale, D; Lipscomb, J
MLA Citation
Provenzale, D, and Lipscomb, J. "Health Economics." (April 15, 2008): 51-64. (Chapter)
Source
scopus
Publish Date
2008
Start Page
51
End Page
64
DOI
10.1002/9780470692189.ch8

Frequency and predictors of de novo hepatocellular carcinoma in patients awaiting orthotopic liver transplantation during the model for end-stage liver disease era.

In the current system of allocation, patients awaiting orthotopic liver transplantation (OLT) remain at risk of developing de novo hepatocellular carcinoma (HCC) and removal from the waiting list. Using the United Network for Organ Sharing database, we calculated the rate and identified predictors of de novo HCC in patients listed for OLT between February 2002 and December 2004. Among 8566 patients, 1167 (13.6%) developed de novo HCC. Predictors of increased odds of de novo HCC were older age, male gender, Asian race, other race, hepatitis C, and hepatitis B. A sensitivity analysis of 2067 patients waiting at least 6 months found that 16.2% developed de novo HCC. Older age [odds ratio (OR) 1.05; 95% confidence interval (CI) 1.03, 1.07], male gender (OR 2.01; 95% CI 1.49, 2.71), Asian race (OR 2.39; 95% CI 1.20, 4.76), other race (OR 1.94; 95% CI 1.40, 2.68), hepatitis C (OR 2.36; 95% CI 1.76, 3.16), and hepatitis B (OR 1.96; 95% CI 1.19, 3.23) remained predictors of increased odds of de novo HCC, and alcoholic liver disease (OR 1.40; 95% CI 1.06, 1.86) emerged as a predictor of increased odds of de novo HCC. A significant proportion of patients listed for OLT develop de novo HCC. Identifying predictors of HCC in these patients may facilitate timely HCC screening and diagnosis.

Authors
Brady, CW; Smith, AD; Stechuchak, KM; Coffman, CJ; Tuttle-Newhall, JE; Provenzale, D; Muir, AJ
MLA Citation
Brady, CW, Smith, AD, Stechuchak, KM, Coffman, CJ, Tuttle-Newhall, JE, Provenzale, D, and Muir, AJ. "Frequency and predictors of de novo hepatocellular carcinoma in patients awaiting orthotopic liver transplantation during the model for end-stage liver disease era." Liver Transpl 14.2 (February 2008): 228-234.
PMID
18236402
Source
pubmed
Published In
Liver Transplantation
Volume
14
Issue
2
Publish Date
2008
Start Page
228
End Page
234
DOI
10.1002/lt.21346

Comorbidity, age, race and stage at diagnosis in colorectal cancer: a retrospective, parallel analysis of two health systems.

BACKGROUND: Stage at diagnosis plays a significant role in colorectal cancer (CRC) survival. Understanding which factors contribute to a more advanced stage at diagnosis is vital to improving overall survival. Comorbidity, race, and age are known to impact receipt of cancer therapy and survival, but the relationship of these factors to stage at diagnosis of CRC is less clear. The objective of this study is to investigate how comorbidity, race and age influence stage of CRC diagnosis. METHODS: Two distinct healthcare populations in the United States (US) were retrospectively studied. Using the Cancer Care Outcomes Research and Surveillance Consortium database, we identified CRC patients treated at 15 Veterans Administration (VA) hospitals from 2003-2007. We assessed metastatic CRC patients treated from 2003-2006 at 10 non-VA, fee-for-service (FFS) practices. Stage at diagnosis was dichotomized (non-metastatic, metastatic). Race was dichotomized (white, non-white). Charlson comorbidity index and age at diagnosis were calculated. Associations between stage, comorbidity, race, and age were determined by logistic regression. RESULTS: 342 VA and 340 FFS patients were included. Populations differed by the proportion of patients with metastatic CRC at diagnosis (VA 27% and FFS 77%) reflecting differences in eligibility criteria for inclusion. VA patients were mean (standard deviation; SD) age 67 (11), Charlson index 2.0 (1.0), and were 63% white. FFS patients were mean age 61 (13), Charlson index 1.6 (1.0), and were 73% white. In the VA cohort, higher comorbidity was associated with earlier stage at diagnosis after adjusting for age and race (odds ratio (OR) 0.76, 95% confidence interval (CI) 0.58-1.00; p = 0.045); no such significant relationship was identified in the FFS cohort (OR 1.09, 95% CI 0.82-1.44; p = 0.57). In both cohorts, no association was found between stage at diagnosis and either age or race. CONCLUSION: Higher comorbidity may lead to earlier stage of CRC diagnosis. Multiple factors, perhaps including increased interactions with the healthcare system due to comorbidity, might contribute to this finding. Such increased interactions are seen among patients within a healthcare system like the VA system in the US versus sporadic interactions which may be seen with FFS healthcare.

Authors
Zafar, SY; Abernethy, AP; Abbott, DH; Grambow, SC; Marcello, JE; 2nd, JEH; Rowe, KL; Kolimaga, JT; Zullig, LL; Patwardhan, MB; Provenzale, DT
MLA Citation
Zafar, SY, Abernethy, AP, Abbott, DH, Grambow, SC, Marcello, JE, 2nd, JEH, Rowe, KL, Kolimaga, JT, Zullig, LL, Patwardhan, MB, and Provenzale, DT. "Comorbidity, age, race and stage at diagnosis in colorectal cancer: a retrospective, parallel analysis of two health systems." BMC cancer 8 (2008): 345--.
Source
scival
Published In
BMC Cancer
Volume
8
Publish Date
2008
Start Page
345-
DOI
10.1186/1471-2407-8-345

Compliance with referral for hepatitis C evaluation among veterans.

GOALS: The goals of this study were to quantify the rate and to identify predictors of compliance with outpatient hepatitis C evaluation. BACKGROUND: Challenges in hepatitis C management include patient compliance with multiple clinic visits, laboratory tests, and radiologic studies throughout the management of hepatitis C. However, the success of hepatitis C management begins with the patient's compliance with referral for hepatitis C evaluation. STUDY: The administrative databases and medical records of patients who were newly referred to the Durham Veterans Affairs Medical Center for hepatitis C evaluation between 2002 and 2004 were reviewed. RESULTS: A total of 376 veterans were identified as being newly referred to the Durham Veterans Affairs Medical Center gastroenterology and liver clinics for hepatitis C evaluation. The mean age of referred patients was 51.2+/-6.1 years, and 94.7% were men. The majority of patients (87%) were compliant with referral for hepatitis C evaluation. In multivariable logistic regression adjusting for age, race, marital status, history of psychiatric disease, history of substance abuse, origin of referral, and wait time, keeping other outpatient appointments was a significant predictor of compliance with referral for hepatitis C evaluation (odds ratio 6.00; 95% confidence interval 1.52, 23.67). CONCLUSIONS: Veterans have a high rate of compliance with referral for hepatitis C evaluation, and their compliance is likely reflective of their motivation to maintain general health care. Future studies assessing other factors, such as patient educational level and socioeconomic status, may help to elucidate more fully the factors impacting compliance with hepatitis C management.

Authors
Brady, CW; Coffman, CJ; Provenzale, D
MLA Citation
Brady, CW, Coffman, CJ, and Provenzale, D. "Compliance with referral for hepatitis C evaluation among veterans." J Clin Gastroenterol 41.10 (November 2007): 927-931.
PMID
18090163
Source
pubmed
Published In
Journal of Clinical Gastroenterology
Volume
41
Issue
10
Publish Date
2007
Start Page
927
End Page
931
DOI
10.1097/MCG.0b013e31802dc55f

Five-year colon surveillance after screening colonoscopy.

BACKGROUND & AIMS: Outcomes of colon surveillance after colorectal cancer screening with colonoscopy are uncertain. We conducted a prospective study to measure incidence of advanced neoplasia in patients within 5.5 years of screening colonoscopy. METHODS: Three thousand one hundred twenty-one asymptomatic subjects, age 50 to 75 years, had screening colonoscopy between 1994 and 1997 in the Department of Veterans Affairs. One thousand one hundred seventy-one subjects with neoplasia and 501 neoplasia-free controls were assigned to colonoscopic surveillance over 5 years. Cohorts were defined by baseline findings. Relative risks for advanced neoplasia within 5.5 years were calculated. Advanced neoplasia was defined as tubular adenoma greater than > or =10 mm, adenoma with villous histology, adenoma with high-grade dysplasia, or invasive cancer. RESULTS: Eight hundred ninety-five (76.4%) patients with neoplasia and 298 subjects (59.5%) without neoplasia at baseline had colonoscopy within 5.5 years; 2.4% of patients with no neoplasia had interval advanced neoplasia. The relative risk in patients with baseline neoplasia was 1.92 (95% CI: 0.83-4.42) with 1 or 2 tubular adenomas <10 mm, 5.01 (95% CI: 2.10-11.96) with 3 or more tubular adenomas <10 mm, 6.40 (95% CI: 2.74-14.94) with tubular adenoma > or =10 mm, 6.05 (95% CI: 2.48-14.71) for villous adenoma, and 6.87 (95% CI: 2.61-18.07) for adenoma with high-grade dysplasia. CONCLUSIONS: There is a strong association between results of baseline screening colonoscopy and rate of serious incident lesions during 5.5 years of surveillance. Patients with 1 or 2 tubular adenomas less than 10 mm represent a low-risk group compared with other patients with colon neoplasia.

Authors
Lieberman, DA; Weiss, DG; Harford, WV; Ahnen, DJ; Provenzale, D; Sontag, SJ; Schnell, TG; Chejfec, G; Campbell, DR; Kidao, J; Bond, JH; Nelson, DB; Triadafilopoulos, G; Ramirez, FC; Collins, JF; Johnston, TK; McQuaid, KR; Garewal, H; Sampliner, RE; Esquivel, R; Robertson, D
MLA Citation
Lieberman, DA, Weiss, DG, Harford, WV, Ahnen, DJ, Provenzale, D, Sontag, SJ, Schnell, TG, Chejfec, G, Campbell, DR, Kidao, J, Bond, JH, Nelson, DB, Triadafilopoulos, G, Ramirez, FC, Collins, JF, Johnston, TK, McQuaid, KR, Garewal, H, Sampliner, RE, Esquivel, R, and Robertson, D. "Five-year colon surveillance after screening colonoscopy." Gastroenterology 133.4 (October 2007): 1077-1085.
PMID
17698067
Source
pubmed
Published In
Gastroenterology
Volume
133
Issue
4
Publish Date
2007
Start Page
1077
End Page
1085
DOI
10.1053/j.gastro.2007.07.006

Predicting poor outcome from acute upper gastrointestinal hemorrhage.

BACKGROUND: Uncertainty about the outcome of acute upper gastrointestinal bleeding often results in a longer-than-necessary hospital stay. METHODS: We derived and internally validated clinical prediction rules (CPRs) to predict outcome from upper gastrointestinal bleeding. This multisite, prospective cohort study involved consecutive patients admitted for acute upper gastrointestinal bleeding. Multivariate logistic regression was used to derive CPRs on two thirds of the cohort (derivation set) that predicted bleeding-specific outcomes (rebleeding, need for urgent surgery, or hospital death [poor outcome 1]) and bleeding-specific outcomes plus new or worsening comorbidity (poor outcome 2). Both CPRs were then tested on the remaining third of the cohort (validation set). RESULTS: A total of 391 individuals (99% men; mean age, 63.4 years) were enrolled, of which 4.6% rebled and 3.1% died. Independent predictors of poor outcome 1 were APACHE (Acute Physiology and Chronic Health Evaluation) II score of 11 or greater, esophageal varices, and stigmata of recent hemorrhage. Predictors of poor outcome 2 were these 3 factors plus unstable comorbidity on admission. Of patients with no risk factors, only 1 (1.1%) of 92 experienced poor outcome 1 and only 6 (6.2%) of 97 experienced poor outcome 2. Risks in the validation set were comparable. The CPRs identified 37.8% and 32.2% of patients in the derivation and validation sets, respectively, who were eligible for a shorter hospital stay. CONCLUSIONS: Patients admitted with acute upper gastrointestinal bleeding were unlikely to have a poor outcome if these risk factors were absent. These CPRs might make hospital management more efficient by identifying low-risk patients for whom early hospital discharge is possible.

Authors
Imperiale, TF; Dominitz, JA; Provenzale, DT; Boes, LP; Rose, CM; Bowers, JC; Musick, BS; Azzouz, F; Perkins, SM
MLA Citation
Imperiale, TF, Dominitz, JA, Provenzale, DT, Boes, LP, Rose, CM, Bowers, JC, Musick, BS, Azzouz, F, and Perkins, SM. "Predicting poor outcome from acute upper gastrointestinal hemorrhage." Arch Intern Med 167.12 (June 25, 2007): 1291-1296.
PMID
17592103
Source
pubmed
Published In
Archives of internal medicine
Volume
167
Issue
12
Publish Date
2007
Start Page
1291
End Page
1296
DOI
10.1001/archinte.167.12.1291

Colorectal cancer screening in young patients with poor health and severe comorbidity.

BACKGROUND: Young patients with poor health and a high risk of mortality from comorbid diseases have less chance of deriving a survival benefit from colorectal cancer screening. The aim of this study was to examine the relationship between colorectal cancer screening, self-reported health status, and comorbidity in a cohort of young patients, defined as patients between the ages of 50 and 64 years. METHODS: This was a single-center study conducted at a Veterans Affairs Medical Center from October 1, 1996, to March 30, 2004. Colorectal cancer screening information was obtained from 861 outpatients who completed the 36-Item Short-Form Health Survey (measure of health status) and the Kaplan-Feinstein Index (comorbidity score). Rates of screening were examined by age, physical component summary score, and severity of comorbid illnesses. RESULTS: Of the veterans, 45.9% had undergone screening within 5 years of their index visit. Screening rates were high among patients with moderate (44.9%) and severe (45.8%) comorbidities. When stratified by age group and physical component summary quartile, there was a trend toward increasing screening rates with better health status in the 50- to 54- and 55- to 59-year age groups. In the 60- to 64-year age group, high screening rates for patients with poorer health were observed: physical component summary quartiles 1 and 2, 55.7% and 54.2%, respectively. Fifty-two patients died during the 5-year follow-up; 37 (71.2%) had undergone screening for colorectal cancer. CONCLUSIONS: Young patients with potentially reduced life expectancy are being screened for colorectal cancer at relatively high rates. Comprehensive assessment of health status and comorbidity should guide cancer screening decisions, especially in individuals with reduced life expectancy who may obtain the least benefit from screening.

Authors
Sultan, S; Conway, J; Edelman, D; Dudley, T; Provenzale, D
MLA Citation
Sultan, S, Conway, J, Edelman, D, Dudley, T, and Provenzale, D. "Colorectal cancer screening in young patients with poor health and severe comorbidity." Arch Intern Med 166.20 (November 13, 2006): 2209-2214.
PMID
17101938
Source
pubmed
Published In
Archives of internal medicine
Volume
166
Issue
20
Publish Date
2006
Start Page
2209
End Page
2214
DOI
10.1001/archinte.166.20.2209

Do patient preferences influence decisions on treatment for patients with steroid-refractory ulcerative colitis?

BACKGROUND & AIMS: Patients with steroid-refractory ulcerative colitis face a difficult treatment decision between colectomy and therapy with infliximab or cyclosporine. The aim of this study was to understand how individual patient preferences for the various treatment outcomes influence the optimal treatment decision for a given patient. METHODS: A Markov model was used to simulate treatment with total colectomy with an ileo pouch-anal anastomosis (TC/IPAA), cyclosporine (CSA), infliximab (INFLX), and infliximab followed by cyclosporine for treatment failures (INFLX-->CSA). Utility weights for treatment outcomes were elicited from 48 patients using both time trade-off and visual rating scale methods. Preference sets were applied to the model to identify the therapy that maximized quality-adjusted life years (QALYs) for each patient. Sensitivity analyses were performed to assess model robustness. RESULTS: Optimal treatment was highly variable among patients (INFLX-->CSA = 42%, 20/48; TC/IPAA = 37%, 18/48; CSA = 21%, 10/48; INFLX = 0%, 0/48). However, when average preference weights from our sample were applied to the model, medical treatments were superior to TC (CSA = .26 QALYs gained vs TC/IPAA; INFLX-->CSA = .25 QALYs gained vs TC/IPAA). CONCLUSIONS: Patient preferences have a clear impact on the optimal treatment for steroid-refractory ulcerative colitis. Although averaged preferences support the use of medical interventions, a third of individual patients may benefit most from proceeding directly to colectomy. Failure to fully assess individual preferences may result in suboptimal treatment for these patients.

Authors
Arseneau, KO; Sultan, S; Provenzale, DT; Onken, J; Bickston, SJ; Foley, E; Connors, AF; Cominelli, F
MLA Citation
Arseneau, KO, Sultan, S, Provenzale, DT, Onken, J, Bickston, SJ, Foley, E, Connors, AF, and Cominelli, F. "Do patient preferences influence decisions on treatment for patients with steroid-refractory ulcerative colitis?." Clin Gastroenterol Hepatol 4.9 (September 2006): 1135-1142.
PMID
16829206
Source
pubmed
Published In
Clinical Gastroenterology and Hepatology
Volume
4
Issue
9
Publish Date
2006
Start Page
1135
End Page
1142
DOI
10.1016/j.cgh.2006.05.003

TPMT genotype screening for patients about to begin azathioprine treatment--a look at costs and potential benefits.

Authors
Provenzale, D; Onken, JE
MLA Citation
Provenzale, D, and Onken, JE. "TPMT genotype screening for patients about to begin azathioprine treatment--a look at costs and potential benefits." Inflamm Bowel Dis 11.12 (December 2005): 1119-1120.
PMID
16306775
Source
pubmed
Published In
Inflammatory Bowel Diseases
Volume
11
Issue
12
Publish Date
2005
Start Page
1119
End Page
1120

The perception of cancer risk in patients with prevalent Barrett's esophagus enrolled in an endoscopic surveillance program.

BACKGROUND & AIMS: Patients with Barrett's esophagus (BE) have a risk of esophageal adenocarcinoma of approximately 0.5% per year. Patients may have difficulty understanding this risk. This study assessed the perceived risk of cancer in patients with BE, and correlated their risk estimates with their health care use behaviors. METHODS: We performed a survey of patients with BE participating in an endoscopic surveillance program at 2 sites: a university teaching hospital and a Veterans' Administration hospital. A questionnaire also elicited their demographics as well as their sources of health information. Health care behaviors, including physician visits and endoscopic surveillance behaviors, were assessed. Patients were classified as either overestimators or nonoverestimators of risk. Characteristics of overestimators, as well as health care use patterns, were assessed. RESULTS: One hundred eighteen patients met entry criteria, and 92 (78%) completed all the questionnaires. Sixty-eight percent of patients overestimated their 1-year risk of cancer, with a mean estimated 1-year cancer risk being 13.6%. The lifetime risk also was overestimated by 38% of patients. Patients who overestimated risk were more likely to be Veterans' Administration medical center patients, have more symptomatic reflux, and were more likely to use the Internet to get health care information. There was no significant difference in physician visits between overestimators and nonestimators (1.2 visits per year vs 1.0, P = .20), nor in endoscopy use (5.7 endoscopies per 5-year period vs 5.0, P = .42). CONCLUSIONS: The majority of patients with prevalent BE participating in an endoscopic surveillance program overestimated their chances of developing adenocarcinoma of the esophagus. Efforts to improve education of such patients with BE are warranted.

Authors
Shaheen, NJ; Green, B; Medapalli, RK; Mitchell, KL; Wei, JT; Schmitz, SM; West, LM; Brown, A; Noble, M; Sultan, S; Provenzale, D
MLA Citation
Shaheen, NJ, Green, B, Medapalli, RK, Mitchell, KL, Wei, JT, Schmitz, SM, West, LM, Brown, A, Noble, M, Sultan, S, and Provenzale, D. "The perception of cancer risk in patients with prevalent Barrett's esophagus enrolled in an endoscopic surveillance program." Gastroenterology 129.2 (August 2005): 429-436.
PMID
16083700
Source
pubmed
Published In
Gastroenterology
Volume
129
Issue
2
Publish Date
2005
Start Page
429
End Page
436
DOI
10.1016/j.gastro.2005.05.055

Impact of functional support on health-related quality of life in patients with colorectal cancer.

BACKGROUND: It has been shown that social integration and the availability of social support influence quality of life. However, little is known about the relation between social support and mental and physical health in patients with colorectal cancer. In the current study, the authors examined the effects of social network size, as well as emotional and instrumental support, on health-related quality of life (HRQOL) in patients with colorectal cancer. METHODS: Six hundred thirty-six veterans with colorectal cancer were asked to complete a telephone interview, which included a measure of social support (the Berkman-Syme Index) and the Medical Outcomes Study Short Form 12-Item Survey. Mean physical composite scale (PCS) and mental composite scale (MCS) scores were compared across groups. RESULTS: No difference in mean PCS or MCS scores was found between patients who had larger social networks and patients who had smaller social networks. The availability of emotional and instrumental support was associated with higher MCS scores, whereas the availability of instrumental support was associated with lower PCS scores. CONCLUSIONS: Irrespective of network size, the availability of emotional support and instrumental support had an impact on HRQOL in patients with colorectal cancer. More emphasis needs to be placed on understanding how various types of social support, individually and collectively, influence physical and mental health in patients with colorectal cancer.

Authors
Sultan, S; Fisher, DA; Voils, CI; Kinney, AY; Sandler, RS; Provenzale, D
MLA Citation
Sultan, S, Fisher, DA, Voils, CI, Kinney, AY, Sandler, RS, and Provenzale, D. "Impact of functional support on health-related quality of life in patients with colorectal cancer." Cancer 101.12 (December 15, 2004): 2737-2743.
PMID
15536617
Source
pubmed
Published In
Cancer
Volume
101
Issue
12
Publish Date
2004
Start Page
2737
End Page
2743
DOI
10.1002/cncr.20699

Risk factors for advanced disease in colorectal cancer.

OBJECTIVES: The goal of this study was to identify predictors of presenting with late-stage colorectal cancer with a focus on potentially modifiable factors. METHODS: This was a multicenter, case-based study of patients with colorectal cancer. Detailed information about the cancer was abstracted from the tumor registries, pathology reports, and medical records. The remaining information was obtained by telephone interview. Inclusion criteria were age 40-85 yr with a first diagnosis of histologically proven colorectal cancer between July 1, 1997 and January 1, 2001. Simple contingency table methods were used to examine the relationship between potential risk factors for early versus advanced-stage disease. Logistic regression was performed to simultaneously control for potential confounding factors. RESULTS: There was complete information for 549 respondents. Approximately, 43% of the sample presented with late-stage colorectal cancer. In univariate analysis, lacking a usual source of health care (doctor's office or clinic), no participation in any colorectal cancer screening test in the prior 10 yr, symptoms of blood in stool, and unexplained weight loss were associated with late-stage colorectal cancer. In the logistic regression model, only lacking a usual source of healthcare and unexplained weight loss were associated with late-stage colorectal cancer with odds ratios (95% confidence intervals) of 0.4 (0.2-0.6) and 1.9 (1.2-3.0), respectively. CONCLUSIONS: These results suggest that system changes in the VA health-care system that increase access to and improve utilization of primary care may reduce presentation with late-stage colorectal cancer and thus, reduce mortality from colorectal cancer in veterans.

Authors
Fisher, DA; Martin, C; Galanko, J; Sandler, RS; Noble, MD; Provenzale, D
MLA Citation
Fisher, DA, Martin, C, Galanko, J, Sandler, RS, Noble, MD, and Provenzale, D. "Risk factors for advanced disease in colorectal cancer." Am J Gastroenterol 99.10 (October 2004): 2019-2024.
PMID
15447766
Source
pubmed
Published In
The American Journal of Gastroenterology (Elsevier)
Volume
99
Issue
10
Publish Date
2004
Start Page
2019
End Page
2024
DOI
10.1111/j.1572-0241.2004.40010.x

AGA future trends report: CT colonography.

BACKGROUND & AIMS: Computed tomographic colonography (CTC) was first described more than a decade ago. Recent advances in imaging hardware and software and results of clinical trials based on new methods for performing and interpreting images suggest that CTC may now be assessed as a method for colorectal cancer screening. METHODS: The Research Policy Committee of the American Gastroenterological Association assembled a task force to review the results of recent clinical trials and quantitative mathematical models pertaining to CTC. The goal of the task force was to assess the current knowledge about CTC and to evaluate the issues that will define its impact. RESULTS: Limitations in evaluating the current state of CTC technology include a wide variation in results of clinical trials. There are as yet insufficient data on the use of CTC in routine clinical practice. Limitations in the use of quantitative mathematical models make predictions based on such models of limited value. The cancer risk and therefore clinical importance of small colorectal polyps detected by CTC and/or nonpolypoid neoplasia not detected by CTC remains largely unknown. CONCLUSIONS: CTC is attractive as a colon imaging modality. It is therefore anticipated that CTC will have a significant impact on the practice of gastroenterology. However, the magnitude of the impact is currently unknown. Whether the ongoing implementation of CTC will increase or decrease the number of referrals for colonoscopy or shift the procedure from colorectal cancer screening to therapeutic interventions (e.g., polypectomy) is unknown at the present time. Multidisciplinary collaboration between gastroenterology and radiology to promote effective implementation and ongoing quality assurance will be important.

Authors
van Dam, J; Cotton, P; Johnson, CD; McFarland, BG; Pineau, BC; Provenzale, D; Ransohoff, D; Rex, D; Rockey, D; Wootton, FT; American Gastroenterological Association,
MLA Citation
van Dam, J, Cotton, P, Johnson, CD, McFarland, BG, Pineau, BC, Provenzale, D, Ransohoff, D, Rex, D, Rockey, D, Wootton, FT, and American Gastroenterological Association, . "AGA future trends report: CT colonography." Gastroenterology 127.3 (September 2004): 970-984. (Review)
PMID
15362051
Source
pubmed
Published In
Gastroenterology
Volume
127
Issue
3
Publish Date
2004
Start Page
970
End Page
984

Understanding cancer treatment and outcomes: the Cancer Care Outcomes Research and Surveillance Consortium.

Authors
Ayanian, JZ; Chrischilles, EA; Fletcher, RH; Fouad, MN; Harrington, DP; Kahn, KL; Kiefe, CI; Lipscomb, J; Malin, JL; Potosky, AL; Provenzale, DT; Sandler, RS; van Ryn, M; Wallace, RB; Weeks, JC; West, DW
MLA Citation
Ayanian, JZ, Chrischilles, EA, Fletcher, RH, Fouad, MN, Harrington, DP, Kahn, KL, Kiefe, CI, Lipscomb, J, Malin, JL, Potosky, AL, Provenzale, DT, Sandler, RS, van Ryn, M, Wallace, RB, Weeks, JC, and West, DW. "Understanding cancer treatment and outcomes: the Cancer Care Outcomes Research and Surveillance Consortium." J Clin Oncol 22.15 (August 1, 2004): 2992-2996.
PMID
15284250
Source
pubmed
Published In
Journal of Clinical Oncology
Volume
22
Issue
15
Publish Date
2004
Start Page
2992
End Page
2996
DOI
10.1200/JCO.2004.06.020

An overview of economic analysis for the practising gastroenterologist and hepatologist.

In this era of limited resources and regulation of health care, it is important for the practising clinician to understand the process of economic evaluation of health care practices. This review provides an overview of economic analysis for the practising gastroenterologist and hepatologist, including information about costs and charges, and an explanation of the common types of economic analyses, and criteria for critically evaluating economic analyses in the literature.

Authors
Provenzale, D
MLA Citation
Provenzale, D. "An overview of economic analysis for the practising gastroenterologist and hepatologist." Eur J Gastroenterol Hepatol 16.6 (June 2004): 513-517. (Review)
PMID
15167151
Source
pubmed
Published In
European Journal of Gastroenterology and Hepatology
Volume
16
Issue
6
Publish Date
2004
Start Page
513
End Page
517

Screening flexible sigmoidoscopy using an upper endoscope is better tolerated by women.

BACKGROUND: Flexible sigmoidoscopy (FS) is a commonly used method for colorectal cancer screening. Women are more likely than men to have a FS with a limited depth of insertion, in part due to differences of anatomy and perception of pain. AIM: The objective of this prospective single-blinded randomized clinical study is to assess satisfaction in women undergoing screening FS using an upper endoscope (E, diameter 9.8 mm) versus a standard sigmoidoscope (S, diameter 13.3 mm) as measured by pain and discomfort and overall satisfaction using a validated survey instrument. Secondary endpoints of FS efficacy included the depth of insertion of the instrument, frequency of polyp detection, and complication rate. RESULTS: A total of 160 asymptomatic women undergoing screening FS were entered over a 4-month period (July through November 2002). All procedures were performed by two experienced physician assistants. The two groups were of similar age (E = 57.5, S = 58.2, p= 0.579) and had a similar rate of previous abdominal surgery (E = 51.2%, S = 45.0%, p= 0.428) or hysterectomy (E = 34.2%, S = 26.3%, p= 0.274). Depth of insertion of the scope was 54.5 cm (+/-9.2 cm) with the E and 51.6 cm (+/- 10.3 cm) with the S (p= 0.058). Polyps were found more frequently in the study group (18.3%) compared with the control group (p= 10.2%) though this did not reach statistical significance (p= 0.131). Overall satisfaction with FS was similar in both groups (p= 0.694) but pain and discomfort were less in the patients undergoing FS using the E (p= 0.006). Controlling for age and previous surgery the differences in pain scores remained significant (p= 0.035). Endoscopist assessment of procedure difficulty (p= 0.726) and complication rates (p= 0.614) was equivalent. Controlling for the presence of polyps, the total duration for the procedure was 7.2 min in the E group and 5.7 min in the S group (p= 0.008). There were no significant differences between women with and without hysterectomy on either overall satisfaction or pain and discomfort. CONCLUSION: Screening FS in women using an upper endoscope is a feasible approach to colorectal cancer screening. Patients screened with an upper endoscope reported less pain and discomfort compared to standard sigmoidoscope while overall satisfaction did not differ. The trend toward increased polyp detection in patients undergoing FS with an upper endoscope may be related to a more thorough examination due to less patient discomfort and/or an increased depth of insertion of the upper endoscope. Thinner, more flexible endoscopes should be considered when performing screening FS in women.

Authors
Farraye, FA; Horton, K; Hersey, H; Trnka, Y; Heeren, T; Provenzale, D
MLA Citation
Farraye, FA, Horton, K, Hersey, H, Trnka, Y, Heeren, T, and Provenzale, D. "Screening flexible sigmoidoscopy using an upper endoscope is better tolerated by women." Am J Gastroenterol 99.6 (June 2004): 1074-1080.
PMID
15180728
Source
pubmed
Published In
The American Journal of Gastroenterology (Elsevier)
Volume
99
Issue
6
Publish Date
2004
Start Page
1074
End Page
1080
DOI
10.1111/j.1572-0241.2004.30215.x

A glossary of economic terms.

Authors
Chiba, N; Gralnek, IM; Moayyedi, P; Provenzale, D; Inadomi, JM; Willan, AR; Briggs, AH; Kim, WR
MLA Citation
Chiba, N, Gralnek, IM, Moayyedi, P, Provenzale, D, Inadomi, JM, Willan, AR, Briggs, AH, and Kim, WR. "A glossary of economic terms." Eur J Gastroenterol Hepatol 16.6 (June 2004): 563-565.
PMID
15167157
Source
pubmed
Published In
European Journal of Gastroenterology and Hepatology
Volume
16
Issue
6
Publish Date
2004
Start Page
563
End Page
565

Screening in liver disease: report of an AASLD clinical workshop.

This report summarizes an AASLD Clinical Workshop that was presented at Digestive Diseases Week 2003 on screening in liver diseases. As newer diagnostic tests become available, many liver diseases and complications of liver disease can be detected at an early asymptomatic stage. In many cases, early detection can lead to earlier treatment and an improved outcome. However, screening for liver diseases in asymptomatic persons has the potential for adverse consequences, including discrimination and stigmatization. The cost of screening programs is significant, and access to screening tests varies in different countries. Future screening programs require careful planning and implementation to balance the benefits, risks, and cost-effectiveness. This review outlines the concepts of screening and their application to a broad range of liver diseases.

Authors
Adams, PC; Arthur, MJ; Boyer, TD; DeLeve, LD; Di Bisceglie, AM; Hall, M; Levin, TR; Provenzale, D; Seeff, L
MLA Citation
Adams, PC, Arthur, MJ, Boyer, TD, DeLeve, LD, Di Bisceglie, AM, Hall, M, Levin, TR, Provenzale, D, and Seeff, L. "Screening in liver disease: report of an AASLD clinical workshop." Hepatology 39.5 (May 2004): 1204-1212. (Review)
PMID
15122748
Source
pubmed
Published In
Hepatology
Volume
39
Issue
5
Publish Date
2004
Start Page
1204
End Page
1212
DOI
10.1002/hep.20169

Race and colorectal cancer screening: a population-based study in North Carolina.

OBJECTIVE: National and state data document racial differences in colorectal cancer (CRC) mortality and incidence. Screening for CRC reduces cancer incidence and deaths. Racial differences in colorectal cancer screening behavior may contribute to the racial disparity in incidence and mortality. The purpose of this study was to determine if colorectal cancer screening rates are different between blacks and whites while controlling for potential confounders. STUDY DESIGN: Cross-sectional survey. DATA SOURCE(S)/STUDY SETTING: We used data from the North Carolina Colon Cancer Study, a population-based case-control study conducted in 33 counties of North Carolina. We analyzed data from 598 control subjects who were eligible for colorectal cancer screening. METHODS: Trained nurses conducted face-to-face interviews from October 1996 through October 2000. RESULTS: Overall, 50% of the respondents were compliant with CRC screening guidelines. In the multivariable logistic regression model having a regular doctor and participation in a general medical exam were significantly associated with current screening status with odds ratios (OR) (95% confidence interval (CI)) of 3.8 (1.7-8.3) and 3.7 (2.1-6.7), respectively. Older age was a significant predictor of current screening status with an OR (95% CI) of 2.9 (1.7-4.8) for those 60-69 compared to respondents 50-59 and OR 3.2 (1.9-5.5) for those 70 and older compared to respondents 50-59. After adjusting for age, having a regular doctor and participation in general medical exams, race was not significantly associated with current CRC screening status, with an OR of 1.1 (95% CI 0.7-1.6). CONCLUSION: CRC screening rates in North Carolina were low. Race was not a significant determinant of screening behavior and therefore does not explain the racial disparity in incidence or survival. Older age, having a regular doctor and participating in general medical exams were significant predictors of CRC screening. RELEVANCE: This study reinforces the fact that screening rates in North Carolina are low despite the strong evidence that colorectal cancer screening reduces cancer deaths.

Authors
Fisher, DA; Dougherty, K; Martin, C; Galanko, J; Provenzale, D; Sandler, RS
MLA Citation
Fisher, DA, Dougherty, K, Martin, C, Galanko, J, Provenzale, D, and Sandler, RS. "Race and colorectal cancer screening: a population-based study in North Carolina." N C Med J 65.1 (January 2004): 12-15.
PMID
15052704
Source
pubmed
Published In
North Carolina Medical Journal
Volume
65
Issue
1
Publish Date
2004
Start Page
12
End Page
15

Colorectal cancer screening and treatment: review of outcomes research.

BACKGROUND: Colorectal cancer is the second leading cause of cancer deaths in the United States each year. Screening is effective in reducing colorectal cancer mortality; however, compliance with screening is poor, and factors associated with its compliance are poorly understood. The outcomes of treatment of colorectal cancer (surgery, radiation therapy, and chemotherapy) may have profound effects on quality of life (QOL). Furthermore, colorectal cancer screening and treatment may be expensive, and the costs are important from a policy perspective. This review examines patient-centered outcomes research related to colorectal cancer screening and treatment and outlines the work that has been done in several areas, including patient preferences, QOL, and economic analysis. METHODS: The literature on the health outcomes associated with colorectal cancer screening and treatment was reviewed. A MEDLINE search of English language articles published from January 1, 1990 through February 2001, was conducted and was supplemented by a review of references of obtained articles. Criteria for study inclusion were identified a priori. A standardized data abstraction form was developed. Summary statistical analyses were performed on the results. RESULTS: Six hundred eighty-six articles were selected for review. In total, 530 articles were excluded because they either did not include patient-centered outcomes, were duplicate articles, or could not be obtained. There were 156 articles included in the analysis; 67 addressed screening, 18 examined surveillance of high-risk groups, 22 concerned treatment of local disease, 10 examined treatment of local and metastatic disease, and 19 considered treatment of metastatic disease only. One study examined end-of-life care. In 19 studies, the phase of care was unspecified. CONCLUSIONS: Standardized, disease-specific QOL instruments should be applied in clinical trials so that the results may be compared across different types of interventions. Valid and reliable methods that accurately capture patient preferences regarding screening and treatment should be developed.

Authors
Provenzale, D; Gray, RN
MLA Citation
Provenzale, D, and Gray, RN. "Colorectal cancer screening and treatment: review of outcomes research." J Natl Cancer Inst Monogr 33 (2004): 45-55. (Review)
PMID
15504919
Source
pubmed
Published In
Journal of the National Cancer Institute. Monographs
Issue
33
Publish Date
2004
Start Page
45
End Page
55
DOI
10.1093/jncimonographs/lgh005

The epidemiology of gastroesophageal reflux disease.

Symptoms of gastroesophageal reflux disease (GERD) are among the most common encountered in primary practice. Reported symptoms certainly under-represent the true prevalence of this disease in the population, because many patients do not seek care for symptoms of GERD and many physicians do not specifically ask about such symptoms when performing the review of systems. We describe the epidemiology of GERD. We begin by considering the prevalence of GERD as a function of the disease definition used. We then discuss the epidemiology of nonerosive reflux disease. After that, we consider the population risk factors for GERD. Next, we briefly touch on the epidemiology of GERD complications, including erosive esophagitis, strictures, and Barrett esophagus. We will end with a brief discussion of population screening of those with GERD for Barrett esophagus.

Authors
Shaheen, N; Provenzale, D
MLA Citation
Shaheen, N, and Provenzale, D. "The epidemiology of gastroesophageal reflux disease." Am J Med Sci 326.5 (November 2003): 264-273. (Review)
PMID
14615667
Source
pubmed
Published In
American Journal of the Medical Sciences
Volume
326
Issue
5
Publish Date
2003
Start Page
264
End Page
273

Mortality and follow-up colonoscopy after colorectal cancer.

OBJECTIVE: There have been no studies that demonstrate surveillance colonoscopy decreases mortality in patients with a history of colorectal cancer. The purpose of this study was to compare the mortality of patients with colorectal cancer who received at least one colonoscopy after their diagnosis with patients who had no further procedures after adjusting for age, race, chemotherapy, radiation therapy, and comorbidity using the national Veterans Affairs (VA) databases. METHODS: We studied a cohort of 3546 patients within the VA national databases with a new diagnosis of colorectal cancer during fiscal year 1995-1996. Patients with inflammatory bowel disease, metastatic disease at presentation, or who died within 1 yr of initial diagnosis were excluded. We collected data for demographics, comorbidities, colonoscopies, chemotherapy, and radiation therapy. The primary outcome was adjusted 5-yr mortality. RESULTS: In the adjusted analysis, the risk of death was decreased by 43% (hazard ratio = 0.57, 95% CI = 0.51-0.64) in the group who had at least one follow-up colonoscopy compared with patients who had no follow-up colonoscopies. CONCLUSIONS: This study strongly supports a mortality benefit for follow-up colonoscopy in patients with a history of nonmetastatic colorectal cancer.

Authors
Fisher, DA; Jeffreys, A; Grambow, SC; Provenzale, D
MLA Citation
Fisher, DA, Jeffreys, A, Grambow, SC, and Provenzale, D. "Mortality and follow-up colonoscopy after colorectal cancer." Am J Gastroenterol 98.4 (April 2003): 901-906.
PMID
12738475
Source
pubmed
Published In
The American Journal of Gastroenterology (Elsevier)
Volume
98
Issue
4
Publish Date
2003
Start Page
901
End Page
906
DOI
10.1111/j.1572-0241.2003.07376.x

Gastroenterologist specialist care and care provided by generalists--an evaluation of effectiveness and efficiency.

OBJECTIVE: In this era of cost containment, gastroenterologists must demonstrate that they provide effective and efficient care. The aim of this study was to evaluate the process and outcomes of care provided by gastroenterologists and generalist physicians (internists, family physicians, general surgeons) for GI conditions. METHODS: We conducted a systematic literature review using a MEDLINE search of English language articles (January 1980 to September 1998). A total of 2157 articles were identified; 10 met inclusion criteria for systematic review. In addition, there were nine articles that described the results of physician surveys, and examined the process of care among gastroenterologists and generalist physicians. RESULTS: Care provided by gastroenterologists for GI bleeding and diverticulitis resulted in significantly shorter length of hospital stay. Gastroenterologists diagnosed celiac disease more accurately than generalists, and more adequately diagnosed colorectal cancer and prescribed antimicrobials for peptic ulcer disease. There was no difference between gastroenterologists and generalists in terms of colonoscopy procedure time, and family physicians detected a greater number of cancers. Furthermore, there was no difference in the outcomes of gastroesophageal reflux disease therapy in patients seen by gastroenterologists, versus those educated by nurses. The survey articles suggested that gastroenterologists were more likely to test and treat for Helicobacter pylori in patients with peptic ulcer disease, and were more likely recommended for medical versus surgical therapy. Gastroenterologists had a lower threshold for ordering ERCP before cholecystectomy than surgeons, but had similar responses regarding indications for surgery in inflammatory bowel disease. Finally, primary care physicians were less likely to associate symptoms of profuse watery diarrhea with cryptosporidium infection compared with gastroenterologists and infectious disease specialists. CONCLUSIONS: We reached the following conclusions: 1) The results suggest that gastroenterologists deliver effective and efficient care for GI bleeding and diverticulitis and provide more effective diagnosis in certain disorders. 2) Studies are limited by retrospective design, small sample size, and lack of control groups. 3) To fully evaluate care by gastroenterologists, prospective comparisons with greater attention to methodology are needed.

Authors
Provenzale, D; Ofman, J; Gralnek, I; Rabeneck, L; Koff, R; McCrory, D
MLA Citation
Provenzale, D, Ofman, J, Gralnek, I, Rabeneck, L, Koff, R, and McCrory, D. "Gastroenterologist specialist care and care provided by generalists--an evaluation of effectiveness and efficiency." Am J Gastroenterol 98.1 (January 2003): 21-28. (Review)
PMID
12526931
Source
pubmed
Published In
The American Journal of Gastroenterology (Elsevier)
Volume
98
Issue
1
Publish Date
2003
Start Page
21
End Page
28
DOI
10.1111/j.1572-0241.2003.07208.x

Re: Mortality and Follow-Up Colonoscopy after Colorectal Cancer [1] (multiple letters)

Authors
Hilsden, RJ; Fisher, DA; Jeffreys, A; Grambow, SC; Provenzale, D
MLA Citation
Hilsden, RJ, Fisher, DA, Jeffreys, A, Grambow, SC, and Provenzale, D. "Re: Mortality and Follow-Up Colonoscopy after Colorectal Cancer [1] (multiple letters)." American Journal of Gastroenterology 98.12 (2003): 2801-2803.
PMID
14687835
Source
scival
Published In
American Journal of Gastroenterology
Volume
98
Issue
12
Publish Date
2003
Start Page
2801
End Page
2803

An examination of factors predicting prioritization for liver transplantation.

With the recent transition of the liver transplant allocation system to the Model for End-Stage Liver Disease, a major change is its reliance entirely on objective criteria. In previous reports, potential donor families and members of the transplant community have questioned the fairness of the subjective nature of previous systems. Therefore, we examined the United Network for Organ Sharing database to determine if the previous allocation system benefited a particular group in prioritization for transplant. We included adult patients with chronic liver disease listed for transplant in the year 2000. Patients who had ever been listed as status 2A or 2B were analyzed. A multivariable analysis examined the patient characteristics that predicted being uplisted to status 2A. Of the 9244 patients, 2376 (25.7%) had received a liver transplant as a status 2A or had been listed as status 2A. In the multivariate analysis, the strongest patient characteristics that predicted status 2A were listing in the western United States and shorter duration of registration. Other predictors include blood type O, college education, unemployment, and coverage with private insurance or a health maintenance organization/preferred provider organization. In addition, patients with Laennec's cirrhosis were less likely to be uplisted to status 2A. Age, gender, and race were not predictors of uplisting to status 2A. In conclusion, these data show the wide range of practice patterns with the use of status 2A, and these findings suggest that certain patient groups might have received preference in the previous liver transplant allocation system.

Authors
Muir, AJ; Sanders, LL; Heneghan, MA; Kuo, PC; Wilkinson, WE; Provenzale, D
MLA Citation
Muir, AJ, Sanders, LL, Heneghan, MA, Kuo, PC, Wilkinson, WE, and Provenzale, D. "An examination of factors predicting prioritization for liver transplantation." Liver Transpl 8.10 (October 2002): 957-961.
PMID
12360441
Source
pubmed
Published In
Liver Transplantation
Volume
8
Issue
10
Publish Date
2002
Start Page
957
End Page
961
DOI
10.1053/jlts.2002.35545

Quality of life in patients with Barrett's esophagus undergoing surveillance.

OBJECTIVES: Practice guidelines recommend surveillance for Barrett's esophagus (BE) because of the risk of esophageal cancer. The quality of life of patients undergoing surveillance is unknown. The objectives of this study were to develop a new utility instrument to measure quality of life of patients undergoing BE surveillance and determine if Quality of Life in Reflux and Dyspepsia (QOLRD) scores correlate with utility ratings. METHODS: Fifteen patients were administered 16 scenarios describing possible BE surveillance outcomes. Each scenario was rated from 0 (equivalent to being dead) to 10 (equivalent to being in perfect health). Each patient also completed the QOLRD, a validated instrument. A t test was performed to compare the QOLRD means with published means. The Spearman's rank correlation coefficient was calculated for the median QOLRD score and the median utility rating. RESULTS: QOLRD means ranged from 5.80 to 6.65 (previously published means 4.3-5.4). Lower scores denoted a worsened quality of life. The difference was significant (p < 0.001). The correlation coefficient of median QOLRD score (6.8) and median utility rating (4.0) was 0.10 (p = 0.71). CONCLUSIONS: This population of BE patients had significantly higher QOLRD scores than a previously published population referred for endoscopy. Quality of life using the utility measure was reduced. The utility measure did not correlate with the disease-specific instrument, suggesting that the concerns of patients undergoing surveillance are distinct from their reflux symptoms.

Authors
Fisher, D; Jeffreys, A; Bosworth, H; Wang, J; Lipscomb, J; Provenzale, D
MLA Citation
Fisher, D, Jeffreys, A, Bosworth, H, Wang, J, Lipscomb, J, and Provenzale, D. "Quality of life in patients with Barrett's esophagus undergoing surveillance." Am J Gastroenterol 97.9 (September 2002): 2193-2200.
PMID
12358232
Source
pubmed
Published In
The American Journal of Gastroenterology (Elsevier)
Volume
97
Issue
9
Publish Date
2002
Start Page
2193
End Page
2200
DOI
10.1111/j.1572-0241.2002.05972.x

Upper endoscopy as a screening and surveillance tool in esophageal adenocarcinoma: a review of the evidence.

Esophageal adenocarcinoma is a rare cancer that is increasing rapidly in incidence. Because gastroesophageal reflux disease (GERD) is a risk factor for the development of this cancer, endoscopic screening of individuals with GERD symptoms and endoscopic surveillance of those who are found to have Barrett's esophagus (BE), the presumed precursor to adenocarcinoma, have been proposed. Although no direct data support endoscopic screening or surveillance, several lines of indirect evidence are available. We apply a set of criteria for the evaluation of screening programs to endoscopic screening of subjects with reflux and endoscopic surveillance of subjects with BE. A critical examination of the data supporting these practices shows that considerable gaps exist in our knowledge regarding endoscopy as a screening test in GERD, making us unable to support this practice based on current evidence. Although no controlled trials exist to substantiate the effectiveness of surveillance programs for subjects with BE, some stronger indirect evidence does support this practice. However, further studies are necessary to substantiate the effectiveness and cost-effectiveness of endoscopic surveillance in BE. Based on the currently available data, consideration should be given to expanding the intervals between endoscopic surveillance sessions.

Authors
Shaheen, NJ; Provenzale, D; Sandler, RS
MLA Citation
Shaheen, NJ, Provenzale, D, and Sandler, RS. "Upper endoscopy as a screening and surveillance tool in esophageal adenocarcinoma: a review of the evidence." Am J Gastroenterol 97.6 (June 2002): 1319-1327. (Review)
PMID
12094844
Source
pubmed
Published In
The American Journal of Gastroenterology (Elsevier)
Volume
97
Issue
6
Publish Date
2002
Start Page
1319
End Page
1327
DOI
10.1111/j.1572-0241.2002.05767.x

A descriptive evaluation of eligibility for therapy among veterans with chronic hepatitis C virus infection.

GOAL: To assess the number of chronic hepatitis C patients eligible for therapy. BACKGROUND: Recent studies have shown improved response rates to treatment of chronic hepatitis C infection. However, treatment with interferon alfa has major side effects, and many patients may not be eligible for therapy. STUDY: One hundred consecutive patients with positive hepatitis C serologies at the Durham Veterans Affairs Medical Center were evaluated. Medical records were reviewed, and the patients were interviewed. Patients were considered ineligible for therapy if they had severe mental illness, hazardous alcohol consumption, current drug abuse, decompensated cirrhosis, dementia, terminal illness, diabetic ketoacidosis, and severe cardiac or pulmonary disease or if they were homeless. RESULTS: Of the 100 patients, 92% were male and 51% were African American. The mean age was 47.3 +/- 5.6 years. Only 32 of the 100 patients were eligible for therapy. Hazardous alcohol consumption was present in 44%. Major depressive symptoms were present in 12%. CONCLUSIONS: The minority of chronic hepatitis C patients were eligible for therapy. Significant rates of hazardous alcohol consumption and psychiatric disorders were present. For these patients to complete or become eligible for therapy, a multidisciplinary approach with psychiatric and substance abuse treatment will be necessary.

Authors
Muir, AJ; Provenzale, D
MLA Citation
Muir, AJ, and Provenzale, D. "A descriptive evaluation of eligibility for therapy among veterans with chronic hepatitis C virus infection." J Clin Gastroenterol 34.3 (March 2002): 268-271.
PMID
11873110
Source
pubmed
Published In
Journal of Clinical Gastroenterology
Volume
34
Issue
3
Publish Date
2002
Start Page
268
End Page
271

Esophageal adenocarcinoma arising from Barrett's metaplasia has regional variations in the west.

Authors
Jankowski, JA; Provenzale, D; Moayyedi, P
MLA Citation
Jankowski, JA, Provenzale, D, and Moayyedi, P. "Esophageal adenocarcinoma arising from Barrett's metaplasia has regional variations in the west." Gastroenterology 122.2 (February 2002): 588-590. (Letter)
PMID
11845805
Source
pubmed
Published In
Gastroenterology
Volume
122
Issue
2
Publish Date
2002
Start Page
588
End Page
590

The cost-effectiveness of aspirin for chemoprevention of colorectal cancer.

Authors
Provenzale, D
MLA Citation
Provenzale, D. "The cost-effectiveness of aspirin for chemoprevention of colorectal cancer." Gastroenterology 122.1 (January 2002): 230-233. (Review)
PMID
11781299
Source
pubmed
Published In
Gastroenterology
Volume
122
Issue
1
Publish Date
2002
Start Page
230
End Page
233

Cost-effectiveness of screening the average-risk population for colorectal cancer.

This article reviews several of the recent models addressing the cost-effectiveness of colorectal cancer screening in the average-risk individual (Table 1). How can clinicians and policy makers use this information for decision making regarding colorectal cancer screening? The cost-effectiveness ratios reported by themselves do not identify cost-effective practices. They must be placed in a decision context that is expressed in one of two forms. In the first form, an explicit threshold or maximum amount that a policy maker is willing to spend is stated (e.g., $40,000 per LY gained, as has been quoted as an acceptable amount for a prevention program). In the second form of decision context, a list of medical practices and their associated cost-effectiveness ratios, also known as a league table (Table 2) is used as a basis for comparison with the practice under evaluation (e.g., colorectal cancer screening). The practice with the lowest cost-effectiveness ratio is the most cost-effective practice on the list. Practices with lower cost-effectiveness ratios are considered cost-effective compared with those with higher ratios. Table 2 lists incremental cost-effectiveness ratios for common medical practices. The models discussed in this article suggested that colorectal cancer screening using annual FOBT, flexible sigmoidoscopy at 3 or 5 years, the combination of FOBT and flexible sigmoidoscopy, barium enema, colonoscopy, and even virtual colonoscopy had incremental cost-effectiveness ratios ranging from $6300 to $92,900 per LY saved with most of the cost-effectiveness ratio ranging from $10,000 to $40,000 per LY saved. These ratios are similar to the cost of another widely accepted practice, breast cancer screening with annual mammography in women age 50 and older ($22,000 per LY gained). Colorectal cancer screening with any of the modalities discussed is considered less cost-effective than screening for hemochromatosis, which has an incremental cost-effectiveness ratio of $3665 per LY saved. Based on these ratios, however, screening for colorectal cancer is considered cost-effective compared with cervical cancer screening in women age 20 and older with pap smear every 3 years, which has an incremental cost-effectiveness ratio of $250,000 per LY gained. The clinician can use these incremental cost-effectiveness ratios to evaluate the risks and benefits of alternative practices for the individual, and the policy maker with a limited health care budget can use these ratios to set priorities for funding based on the costs and the expected gains in life expectancy for colorectal cancer screening and for alternative health care programs.

Authors
Provenzale, D
MLA Citation
Provenzale, D. "Cost-effectiveness of screening the average-risk population for colorectal cancer." Gastrointest Endosc Clin N Am 12.1 (January 2002): 93-109.
PMID
11916165
Source
pubmed
Published In
Gastrointestinal Endoscopy Clinics of North America
Volume
12
Issue
1
Publish Date
2002
Start Page
93
End Page
109

Patient-centered outcomes in colorectal cancer screening and treatment

Outcomes research has been identified for all phases of colorectal cancer care. The reports that have been summarized reflect the variable quality and application of outcomes research to colorectal cancer screening and treatment. There were several articles that examined screening for colorectal cancer, and compliance with screening. In general, compliance with screening was associated with education level, socioeconomic status, belief in the efficacy of screening and treatment for colorectal cancer, and physician recommendation of screening tests. Economic analyses represented a substantial portion of the screening articles. There is general agreement among these articles that, compared to other screening programs such as breast cancer screening,6 colorectal cancer screening, regardless of the test employed, is cost-effective. Regarding surveillance of high-risk groups, compliance with follow-up among those with a history of resected colorectal cancer is greater among those whose surgery was performed with curative intent. In this group, mortality is associated with compliance and stage at time of diagnosis. For those with an inherited risk for colorectal cancer (e.g., hereditary nonpolyposis colorectal cancer (HNPCC), familial adenomatous polyposis (FAP)), genetic testing is more common among those who have increased anxiety about cancer, perceived increased risk, and a desire to plan for their own and their children's futures. Treatment for colorectal cancer was the subject of nearly half of the articles in this review. Quality of life was a focus of many of these articles. Methods for measuring quality of life were diverse and genetic for the most part. However, certain observations are noteworthy. Most studies found little correlation between HRQL and other disease outcomes such as survival or disease-free survival. While this may truly reflect that treatment for colorectal cancer, particularly chemotherapy, does not affect HRQL, an alternative explanation is that the largely generic measures used to assess it were insensitive to the quality of life concerns of patients undergoing treatment for colorectal cancer. Regarding care at the end of life, one study170 revealed that, although functional status remained high up to the last month on life, pain was a frequent symptom in the last 6 months of life. The articles for which the phase of care was unspecified examined a variety of topics including the testing of alternative methods for measuring quality of life, caregiver burden, impact of age on HRQL, and others. Their diversity reflects the diversity of patient and caregiver centered outcomes. Finally, the development of colorectal cancer-specific quality of life instruments in the latter part of the decade provides the opportunity to more adequately address patient-specific concerns related to colorectal cancer care. This review has considered patient centered outcomes of colorectal cancer screening and treatment. The last decade revealed a move towards incorporating these important outcomes into assessments of screening programs and treatment regimens. The lack of standardization of measures makes comparisons somewhat difficult, but the development of disease-specific instruments to measure quality of life provides an opportunity to standardize future measurements and study methods. Research that focuses on standard approaches to economic analysis and measurement of HRQL, and that addresses patient satisfaction and compliance with screening for colorectal cancer, may provide us with critical information about effective and cost-effective modalities to increase both length and quality of life.

Authors
Provenzale, D; Gray, RN; Fisher, DA; Schmidt, T
MLA Citation
Provenzale, D, Gray, RN, Fisher, DA, and Schmidt, T. "Patient-centered outcomes in colorectal cancer screening and treatment." Evidence-Based Gastroenterology 3.1 (2002): 12-25.
Source
scival
Published In
Evidence-Based Gastroenterology
Volume
3
Issue
1
Publish Date
2002
Start Page
12
End Page
25

Procedural success and complications of large-scale screening colonoscopy

Background: Indirect evidence and modeling analyses suggest that colonoscopy may be the most cost-effective way to screen the average-risk population for colorectal neoplasia. However, the success and safety of primary colonoscopic screening has not been prospectively evaluated in a multicenter trial. Methods: Asymptomatic subjects age 50 to 75 years who had not undergone examination of the colon within 10 years were recruited from the general medicine clinics of 13 Department of Veterans Affairs Medical Centers. Eligible patients underwent colonoscopy by study coinvestigators, at which time all polyps were measured, photographed, and removed. Patients were contacted at 24 hours and 1 week to track procedure-related complications. Results: Primary screening colonoscopy was performed in a cohort of 3196 asymptomatic subjects. A "good" preparation was reported in 81% of patients, and colonoscopy to the cecum was successful in 97.2% of cases. Mean insertion time to the cecum and total procedure times were 10.5 (8.7) and 30.6 (19.1) minutes, respectively. No preprocedural patient characteristics were identified that were predictive of an incomplete procedure. At least one polyp was resected in 1672 patients. There was no perforation and no death attributed to colonoscopy. Major morbidity considered to be definitely related to colonoscopy occurred in 9 of 3196 procedures (0.3%): lower GI bleeding requiring intervention (6), myocardial infarction and/or cerebrovascular accident (2), and thrombophlebitis (1). In subjects undergoing only diagnostic procedures, the major complication rate was 0.1%. Conclusions: Screening colonoscopy can be performed in multiple centers with a high degree of success and safety in large numbers of asymptomatic, average-risk men.

Authors
Nelson, DB; McQuaid, KR; Bond, JH; Lieberman, DA; Weiss, DG; Johnston, TK; Harford, WV; Ahnen, DJ; Provenzale, D; Sontag, SJ; Schnell, TG; Campbell, DR; Durbin, TE; Lee, JG; Triadafilopoulos, G; Ramirez, FC; Collins, JF; Fennerty, MB; Garewal, H; Sampliner, RE; Morales, TG; Fass, R; Smith, RE; Maheshwari, Y
MLA Citation
Nelson, DB, McQuaid, KR, Bond, JH, Lieberman, DA, Weiss, DG, Johnston, TK, Harford, WV, Ahnen, DJ, Provenzale, D, Sontag, SJ, Schnell, TG, Campbell, DR, Durbin, TE, Lee, JG, Triadafilopoulos, G, Ramirez, FC, Collins, JF, Fennerty, MB, Garewal, H, Sampliner, RE, Morales, TG, Fass, R, Smith, RE, and Maheshwari, Y. "Procedural success and complications of large-scale screening colonoscopy." Gastrointestinal Endoscopy 55.3 (2002): 307-314.
PMID
11868001
Source
scival
Published In
Gastrointestinal Endoscopy
Volume
55
Issue
3
Publish Date
2002
Start Page
307
End Page
314
DOI
10.1067/mge.2002.121883

Management of primary sclerosing cholangitis

Authors
Lee, Y-M; Kaplan, MM; Vakil, N; Arlow, FL; Carey, WD; Cheney, CP; Chokhavatia, SS; Farraye, FA; Hanauer, SB; Holtzmuller, KC; Kowdley, KV; Lichtenstein, GR; Meyer, GW; Pratt, DS; Provenzale, D; Tsuchida, AM; Waring, JP; Wiersema, MJ; Wo, JM; Zuckerman, MJ
MLA Citation
Lee, Y-M, Kaplan, MM, Vakil, N, Arlow, FL, Carey, WD, Cheney, CP, Chokhavatia, SS, Farraye, FA, Hanauer, SB, Holtzmuller, KC, Kowdley, KV, Lichtenstein, GR, Meyer, GW, Pratt, DS, Provenzale, D, Tsuchida, AM, Waring, JP, Wiersema, MJ, Wo, JM, and Zuckerman, MJ. "Management of primary sclerosing cholangitis." American Journal of Gastroenterology 97.3 (2002): 528-534.
PMID
11922543
Source
scival
Published In
The American Journal of Gastroenterology (Elsevier)
Volume
97
Issue
3
Publish Date
2002
Start Page
528
End Page
534
DOI
10.1016/S0002-9270(01)04147-8

Early diagnosis and prevention of sporadic colorectal cancer.

Authors
Lambert, R; Provenzale, D; Ectors, N; Vainio, H; Dixon, MF; Atkin, W; Werner, M; Franceschi, S; Watanabe, H; Tytgat, GN; Axon, AT; Neuhaus, H
MLA Citation
Lambert, R, Provenzale, D, Ectors, N, Vainio, H, Dixon, MF, Atkin, W, Werner, M, Franceschi, S, Watanabe, H, Tytgat, GN, Axon, AT, and Neuhaus, H. "Early diagnosis and prevention of sporadic colorectal cancer." Endoscopy 33.12 (December 2001): 1042-1064. (Review)
PMID
11740647
Source
pubmed
Published In
Endoscopy
Volume
33
Issue
12
Publish Date
2001
Start Page
1042
End Page
1064
DOI
10.1055/s-2001-18938

Improvement of gastroesophageal reflux disease after initiation of a low-carbohydrate diet: five brief case reports.

The 5 individuals described in these case reports experienced resolution of GERD symptoms after self-initiation of a low-carbohydrate diet. Their observations suggest that carbohydrate restriction may have contributed to their symptom relief. However, this conclusion is confounded by concurrent reduction of caffeine intake in 3 of the individuals and reduction of acidic and high-osmolal food intake in all of them. Observations from some of these individuals suggest that carbohydrates may be a precipitating factor for GERD symptoms and that other classic exacerbating foods such as coffee and fat may be less pertinent when a low-carbohydrate diet is followed. However, these conclusions are preliminary. These findings primarily suggest that prospective research should be performed on the effect of low-carbohydrate diets on GERD symptoms. Trials that control for all of the confounders mentioned above and that contain objective endpoints are needed to further investigate these issues.

Authors
Yancy, WS; Provenzale, D; Westman, EC
MLA Citation
Yancy, WS, Provenzale, D, and Westman, EC. "Improvement of gastroesophageal reflux disease after initiation of a low-carbohydrate diet: five brief case reports." Altern Ther Health Med 7.6 (November 2001): 120-119.
PMID
11712463
Source
pubmed
Published In
Alternative therapies in health and medicine
Volume
7
Issue
6
Publish Date
2001
Start Page
120
End Page
119

Clinical and demographic predictors of Barrett's esophagus among patients with gastroesophageal reflux disease: a multivariable analysis in veterans.

BACKGROUND: The subgroup of patients with gastroesophageal reflux disease (GERD) that should undergo endoscopy to rule out Barrett's esophagus (BE) has not been well defined. GOALS: To examine demographic and clinical variables predictive of BE before endoscopy. STUDY: A validated GERD questionnaire was administered to 107 patients with biopsy-proven BE and to 104 patients with GERD but no BE shown by endoscopy. Frequent symptoms were defined as symptoms that occurred at least once or more each week. Severity of symptoms was rated on a scale from 1 to 4 (mild to very severe). Univariate analysis and multivariable logistic regression were performed to determine whether demographic characteristics and the duration, severity, and frequency of GERD symptoms were associated with the identification of BE. RESULTS: Eighty-five percent of the GERD patients and 82% of the BE patients completed the questionnaire. There was no difference between the groups in terms of race, gender, or proton pump inhibitor use. The BE patients were older (median age, 64 vs. 57 years, p = 0.04). In multivariable logistic regression, an age of more than 40 years ( p = 0.008), the presence of heartburn or acid regurgitation ( p = 0.03), and heartburn more than once a week ( p = 0.007) were all independent predictors of the presence of BE. Interestingly, patients with BE were less likely to report severe GERD symptoms ( p = 0.0008) and nocturnal symptoms ( p = 0.03). Duration of symptoms, race, alcohol, and smoking history were not associated with BE. CONCLUSIONS: Upper endoscopy should be performed in GERD patients more than 40 years of age who report heartburn once or more per week. The severity of symptoms and the presence of nocturnal symptoms are not reliable indicators of the presence of BE.

Authors
Eloubeidi, MA; Provenzale, D
MLA Citation
Eloubeidi, MA, and Provenzale, D. "Clinical and demographic predictors of Barrett's esophagus among patients with gastroesophageal reflux disease: a multivariable analysis in veterans." J Clin Gastroenterol 33.4 (October 2001): 306-309.
PMID
11588545
Source
pubmed
Published In
Journal of Clinical Gastroenterology
Volume
33
Issue
4
Publish Date
2001
Start Page
306
End Page
309

A prospective evaluation of health-related quality of life after ileal pouch anal anastomosis for ulcerative colitis.

OBJECTIVES: The ileal pouch anal anastomosis is a safe and effective procedure but is also associated with pouchitis, small bowel obstruction, and incontinence. We prospectively evaluated the health-related quality of life using generic and disease-specific measures in a cohort of patients with ulcerative colitis undergoing ileal pouch anal anastomosis. METHODS: Health-related quality of life measures included the Time Trade-off, Rating Form of IBD Patient Concerns, and the Short-Form 36. Assessments occurred preoperatively and 1, 6, and 12 months postoperatively. RESULTS: Time Trade-off scores had significantly improved at the 1-month postoperative assessment and approached perfect health at the 12-month postoperative assessment. The Rating Form of IBD Patient Concerns revealed a significant reduction in patient concerns at 1 month, and this difference persisted at 6 and 12 months. Seven of the eight subscales of the Short-Form 36 revealed improved health-related quality of life postoperatively. CONCLUSIONS: Health-related quality of life improved after ileal pouch anal anastomosis when assessed with both generic and disease-specific measures. Improvements were observed as early as 1 month postoperatively. These results may guide patients and physicians as they consider and prepare for the impact of ileal pouch anal anastomosis.

Authors
Muir, AJ; Edwards, LJ; Sanders, LL; Bollinger, RR; Koruda, MJ; Bachwich, DR; Provenzale, D
MLA Citation
Muir, AJ, Edwards, LJ, Sanders, LL, Bollinger, RR, Koruda, MJ, Bachwich, DR, and Provenzale, D. "A prospective evaluation of health-related quality of life after ileal pouch anal anastomosis for ulcerative colitis." Am J Gastroenterol 96.5 (May 2001): 1480-1485.
PMID
11374686
Source
pubmed
Published In
The American Journal of Gastroenterology (Elsevier)
Volume
96
Issue
5
Publish Date
2001
Start Page
1480
End Page
1485
DOI
10.1111/j.1572-0241.2001.03801.x

Factors associated with acceptance and full publication of GI endoscopic research originally published in abstract form.

BACKGROUND: Many abstracts submitted to annual scientific meetings never come to full publication in peer-reviewed journals. The objective of this study was to determine factors associated with the fate of endoscopic research abstracts submitted to the annual scientific meeting of the American Society for Gastrointestinal Endoscopy (ASGE). METHODS: All abstracts (n = 461) submitted to the annual meeting of the ASGE in May of 1994 were retrospectively reviewed. The following databases were searched for evidence of publication of abstracts in full-manuscript form: Medline, HealthSTAR, Current Contents, CINHAL, and Cancerlit. All abstracts were reviewed between May 4, 1998 and June 30, 1998. Univariate and multivariate analysis were performed to determine the association between abstract characteristics and acceptance for presentation at the meeting and for publication. RESULTS: Fifty-five percent (247/451) of submitted abstracts were accepted for presentation. In univariate analysis, pediatric studies, prospective studies, randomized studies, and studies from university-affiliated medical centers (UAMC), were more likely to be accepted for presentation (p < 0.05). In multivariate analysis, the variables: pediatric studies (p = 0.01), prospective studies (p = 0.005), randomized studies (p = 0.06), and studies from UAMC (p = 0.01) predicted acceptance of abstracts for presentation at the meeting. The overall publication rate was 25.1%. The publication rates 1, 2, 3, and 4 years after the meeting were 6.7%, 16.2%, 22.8%, and 25.1%, respectively. Multivariate Cox proportional hazards analysis showed that accepted abstracts (p = 0.0003) studies reporting positive results (p = 0.0015), and studies from outside the United States (p = 0.036) were more likely to be published in manuscript form. CONCLUSIONS: The overall publication rate of abstracts reporting endoscopic research is 25%, lower than that in any published report from other medical societies. Abstracts from the United States were less likely to be published in full-manuscript form. Although there was no positive outcome bias for acceptance of abstracts for presentation at the meeting, there was bias toward publication of statistically significant results. Further investigations are warranted to determine the variation in the publication of research results according to country of origin and to determine factors that hinder publication of GI endoscopic research in manuscript form.

Authors
Eloubeidi, MA; Wade, SB; Provenzale, D
MLA Citation
Eloubeidi, MA, Wade, SB, and Provenzale, D. "Factors associated with acceptance and full publication of GI endoscopic research originally published in abstract form." Gastrointest Endosc 53.3 (March 2001): 275-282.
PMID
11231383
Source
pubmed
Published In
Gastrointestinal Endoscopy
Volume
53
Issue
3
Publish Date
2001
Start Page
275
End Page
282

Quality of life measurement in gastroenterology: what is available?

Monitoring and enhancement of a patient's health-related quality of life (HRQL) is an important element of research and medical care. In a previous article, we provided an overview of HRQL measurement. Now we will review the structure and properties of the most commonly used generic and digestive disease-specific HRQL instruments and illustrates their use in the gastroenterology and hepatology literature. Generic measures have been used to study specific diseases as well as to compare HRQL in GI and nongastrointestinal disease. Disease specific instruments have been developed for inflammatory bowel disease, irritable bowel syndrome, dyspepsia, gastroesophageal reflux disease, liver disease, and GI malignancy. Further work is needed to compare disease-specific instruments and to define the most appropriate uses of HRQL measurement in clinical trial and community practice settings.

Authors
Yacavone, RF; Locke, GR; Provenzale, DT; Eisen, GM
MLA Citation
Yacavone, RF, Locke, GR, Provenzale, DT, and Eisen, GM. "Quality of life measurement in gastroenterology: what is available?." Am J Gastroenterol 96.2 (February 2001): 285-297. (Review)
PMID
11232666
Source
pubmed
Published In
The American Journal of Gastroenterology (Elsevier)
Volume
96
Issue
2
Publish Date
2001
Start Page
285
End Page
297
DOI
10.1111/j.1572-0241.2001.03509.x

Surveillance issues in inflammatory bowel disease: ulcerative colitis.

This review article on the surveillance of patients with ulcerative colitis provides an overview of the criteria for evaluating screening and surveillance programs and applies the criteria to the available evidence to determine the effectiveness of the surveillance of patients with ulcerative colitis. We examine the clinical outcomes associated with surveillance, the additional clinical time required to confirm the diagnosis of dysplasia and cancer, compliance with surveillance and follow-up, and the effectiveness of the individual components of a surveillance program, including colonoscopy and pathologist's interpretation. The disability associated with colectomy is considered, as are the cost and acceptability of surveillance programs. Patients with long-standing ulcerative colitis are at risk for developing colorectal cancer. Recommended surveillance colonoscopy should be supported. New endoscopic and histopathologic techniques to improve the identification of high-risk patients may enhance the effectiveness and cost-effectiveness of surveillance practices.

Authors
Provenzale, D; Onken, J
MLA Citation
Provenzale, D, and Onken, J. "Surveillance issues in inflammatory bowel disease: ulcerative colitis." J Clin Gastroenterol 32.2 (February 2001): 99-105.
PMID
11205664
Source
pubmed
Published In
Journal of Clinical Gastroenterology
Volume
32
Issue
2
Publish Date
2001
Start Page
99
End Page
105

Screening strategies in gastroesophageal reflux disease: early identification of esophageal carcinoma.

Authors
Shaheen, NJ; Provenzale, D
MLA Citation
Shaheen, NJ, and Provenzale, D. "Screening strategies in gastroesophageal reflux disease: early identification of esophageal carcinoma." Adv Intern Med 47 (2001): 137-157. (Review)
PMID
11795073
Source
pubmed
Published In
Advances in internal medicine
Volume
47
Publish Date
2001
Start Page
137
End Page
157

Economic considerations in the treatment of gastroesophageal reflux disease: a review.

Gastroesophageal reflux disease is a common problem. Most patients with erosive GERD require long-term treatment, without which relapse is common. The cost of ongoing medical care for GERD is substantial, and patients with symptomatic GERD have impaired quality of life. Treatment strategies for GERD should aim to improve patient outcome at a reasonable cost. Cost-effectiveness methodology facilitates the integration of costs and patient outcomes, enabling the clinician to choose the most cost-effective therapy in a variety of clinical circumstances. The published studies reviewed in this paper show that proton pump inhibitors are the most cost-effective initial and maintenance medical therapy for GERD under most circumstances. However, variations in drug acquisition costs, such as may occur in managed care practice settings, may lead to H2-receptor antagonists being preferred under some circumstances. In the long-term management of GERD, laparoscopic surgery is effective, but its high initial cost makes it less cost-effective than proton pump inhibitors in the early treatment years. Also, recent data suggest that the long-term morbidity is higher than previously suspected. Finally, appropriate application of cost-effectiveness analyses to clinical practice requires critical appraisal of model design and the perspective adopted. The purpose of this article is to describe the interpretation and application of the results of cost-effectiveness analyses in clinical practice, and to examine the published literature on the cost-effectiveness of treatment options for GERD.

Authors
O'Connor, JB; Provenzale, D; Brazer, S
MLA Citation
O'Connor, JB, Provenzale, D, and Brazer, S. "Economic considerations in the treatment of gastroesophageal reflux disease: a review." Am J Gastroenterol 95.12 (December 2000): 3356-3364. (Review)
PMID
11151862
Source
pubmed
Published In
The American Journal of Gastroenterology (Elsevier)
Volume
95
Issue
12
Publish Date
2000
Start Page
3356
End Page
3364
DOI
10.1111/j.1572-0241.2000.03345.x

Health-related quality of life and severity of symptoms in patients with Barrett's esophagus and gastroesophageal reflux disease patients without Barrett's esophagus.

OBJECTIVES: The aims of this study were: 1) to compare the health-related quality of life (HRQL) of patients with Barrett's esophagus (BE) to that of patients with GERD who did not have BE; 2) to compare HRQL of gastroesophageal reflux disease (GERD) patients to that of normative data for the US general population; and 3) to examine the impact of GERD symptom frequency and severity on HRQL. METHODS: The SF-36 and a validated GERD questionnaire were administered to 107 patients with biopsy-proven BE and to 104 patients with GERD but no BE by endoscopy. Frequent symptoms were defined as symptoms that occurred at least once weekly. Severity of symptoms was rated on a scale from 1 to 4 (mild to very severe). RESULTS: In all, 85% of the GERD patients and 82% of BE patients completed the questionnaires. There was no difference in the scores of the eight subscales of the SF-36 between BE patients and those with GERD but without BE (p > 0.05). However, both groups scored below average on all subscales of the SF-36 compared to published US norms for an age- and gender-matched group. Using multivariable linear regression, the social functioning subscale of the SF-36 correlated with the presence of heartburn or acid regurgitation, severity of acid regurgitation, frequency of heartburn, frequency of acid regurgitation, and number of comorbidities. Similarly, the physical functioning subscale correlated with age, frequency of heartburn, and number of comorbidities. The bodily pain subscale correlated with the frequency of heartburn and number of comorbidities. The bodily pain subscale correlated with the frequency of heartburn and the severity of dysphagia, whereas the role emotional subscale correlated with the frequency of heartburn and the presence of dysphagia. CONCLUSIONS: Although there were no differences in HRQL between BE and GERD patients, both groups scored below average on the subscales of the SF-36 compared to normal controls. GERD symptom frequency and severity were associated with bodily pain and with impaired social, emotional, and physical functioning, suggesting a profound impact on daily living.

Authors
Eloubeidi, MA; Provenzale, D
MLA Citation
Eloubeidi, MA, and Provenzale, D. "Health-related quality of life and severity of symptoms in patients with Barrett's esophagus and gastroesophageal reflux disease patients without Barrett's esophagus." Am J Gastroenterol 95.8 (August 2000): 1881-1887.
PMID
10950030
Source
pubmed
Published In
The American Journal of Gastroenterology (Elsevier)
Volume
95
Issue
8
Publish Date
2000
Start Page
1881
End Page
1887
DOI
10.1111/j.1572-0241.2000.02235.x

Hospital credentialing and quality of care.

The purpose of this study was to evaluate the impact of hospital credentialing standards on surgical outcomes for selected procedures. The study used hospital credentialing practices from a 1996 survey of North Carolina community hospitals, with surgical outcomes derived from a statewide database of inpatient surgical discharges in 1995. Hospital mortality, complications and elevated lengths of stay were used as outcome indicators in an analysis of 6 surgical procedures. Multivariate logit analysis was used to calculate the effects of hospital credentialing stringency and nine credentialing practices on outcomes, controlling for patient demographic characteristics, type of admission, severity of illness and hospital characteristics. Teaching hospitals adopted more stringent credentialing practices, with almost no difference between metropolitan and nonmetropolitan nonteaching facilities in their use of various credentialing policies. Surgical outcomes typically were not related to stringency of the hospital credentialing environment. Generally, the effect of specific practices was inconsistent (associated with improved outcomes for certain procedures and significantly worse outcomes for others) or counterintuitive (showing worse outcomes for selected surgical procedures where effects were statistically significant). More stringent hospital credentialing does not appear likely to improve patient outcomes.

Authors
Sloan, FA; Conover, CJ; Provenzale, D
MLA Citation
Sloan, FA, Conover, CJ, and Provenzale, D. "Hospital credentialing and quality of care." Soc Sci Med 50.1 (January 2000): 77-88.
PMID
10622696
Source
pubmed
Published In
Social Science & Medicine
Volume
50
Issue
1
Publish Date
2000
Start Page
77
End Page
88

CT-guided treatment of ultrasonically invisible hepatocellular carcinoma

New techniques of CT-guided management were introduced to ablate ultrasonically invisible hepatocellular carcinomas. In six patients with HCC, a total of six nodules (8-30 mm in diameter) were treated under the guidance of CT. These lesions were not visualized by sonography but were visualized as Lipiodol spots on CT after chemoembolization. Tumor localization was successful in all patients without difficulty, using a thin needle or hookwire under the guidance of CT. Two patients underwent subsequent hepatic resection and/or microwave coagulation therapy (MCT) through a small incision after hookwire placement. Four patients received percutaneous MCT (n = 2) or ethanol injection (PEI) (n = 2) at the time of localization. The postoperative CT with contrast enhancement indicated that tumor ablation was complete in four of the five nodules treated with MCT or PEI. However, in one nodule (30 mm in diameter) treated with PEI, tumor ablation was not complete. There were no complications. There has been no local tumor recurrence 6-46 months after treatment in any of the patients. In conclusion, these CT-guided procedures were effective in treating ultrasonically invisible hepatocellular carcinomas that otherwise would have remained untreated. (C) 2000 by Am. Coll. of Gastroenterology.

Authors
Eloubeidi, MA; Provenzale, D
MLA Citation
Eloubeidi, MA, and Provenzale, D. "CT-guided treatment of ultrasonically invisible hepatocellular carcinoma." American Journal of Gastroenterology 95.8 (2000): 2102-2106.
Source
scival
Published In
The American Journal of Gastroenterology (Elsevier)
Volume
95
Issue
8
Publish Date
2000
Start Page
2102
End Page
2106
DOI
10.1016/S0002-9270(00)01067-4

A prospective trial of colchicine and methotrexate in the treatment of primary biliary cirrhosis.

BACKGROUND & AIMS: The aim of this study was to determine if colchicine or methotrexate improves blood test results, symptoms, and/or liver histology in patients with primary biliary cirrhosis. METHODS: Patients with histologically confirmed primary biliary cirrhosis whose serum alkaline phosphatase (ALP) levels were at least 2 times above normal and who were not yet candidates for liver transplantation received colchicine or methotrexate and were followed up for 2 years. RESULTS: In patients receiving colchicine (n = 43), mean pruritus score decreased from 1.63 to 1.12 (P = 0.04), ALP level from 494 to 355 U/L (P < 0.0001), and alanine aminotransferase (ALT) level from 79 to 61 U/L (P < 0.0001). In patients receiving methotrexate (n = 42), pruritus score decreased from 1.25 to 0.44 (P = 0.0001), ALP from 478 to 235 U/L (P < 0.0001), and ALT from 96 to 61 U/L (P = 0.0001). Methotrexate but not colchicine significantly improved liver histology (P = 0.005) and serum immunoglobulin G levels (P = 0.0002). Methotrexate improved most blood test results more than colchicine. Serum bilirubin levels increased slightly with each drug, and albumin levels decreased slightly. CONCLUSIONS: Both colchicine and methotrexate improved biochemical test results and symptoms in primary biliary cirrhosis, but the response to methotrexate was greater.

Authors
Kaplan, MM; Schmid, C; Provenzale, D; Sharma, A; Dickstein, G; McKusick, A
MLA Citation
Kaplan, MM, Schmid, C, Provenzale, D, Sharma, A, Dickstein, G, and McKusick, A. "A prospective trial of colchicine and methotrexate in the treatment of primary biliary cirrhosis." Gastroenterology 117.5 (November 1999): 1173-1180.
PMID
10535881
Source
pubmed
Published In
Gastroenterology
Volume
117
Issue
5
Publish Date
1999
Start Page
1173
End Page
1180

Economic analysis of endoscopic procedures.

Economic analysis is becoming an important tool for the evaluation of new technologies. In this era of rapidly rising health care costs, we are required to demonstrate that our procedures are effective and cost-efficient. This article provides a glossary of terms for the evaluation and performance of an economic analysis and outlines the steps for performing an economic evaluation of an endoscopic procedure. The reader is provided with the skills to critically evaluate economic analyses of endoscopic technologies, and to determine their relevance to their practice.

Authors
Provenzale, D
MLA Citation
Provenzale, D. "Economic analysis of endoscopic procedures." Gastrointest Endosc Clin N Am 9.4 (October 1999): 573-vi. (Review)
PMID
10495223
Source
pubmed
Published In
Gastrointestinal Endoscopy Clinics of North America
Volume
9
Issue
4
Publish Date
1999
Start Page
573
End Page
vi

Health-related quality of life: a primer for gastroenterologists.

The evolution of health care has required physicians to evaluate more critically the impact of interventions on their patients' well-being. Prior clinical interventions focused primarily on biochemical and histological endpoints. These outcomes frequently were tenuously linked to patient benefit. Recently there has been a movement toward patient-oriented outcomes, including health-related quality of life (HRQL). The medical literature now frequently describes the effects of therapies on HRQL. Gastroenterologists need to understand the concepts behind HRQL and the use and utility of the various instruments employed to measure this outcome. The purpose of this article is: 1) to define the concept of health-related quality of life (HRQL); 2) to assess when measurement of HRQL can guide clinical decision-making; 3) to describe the desired properties of an HRQL instrument; and 4) to distinguish types of HRQL instruments. We discuss the varied definitions of HRQL and the clinical scenarios in which they are important. The psychometric properties of HRQL instruments, including validity, reliability, responsiveness, sensitivity, and coverage are defined and discussed. The types of instruments such as health profile, time trade-off, and standard gamble are contrasted. Finally, we compare generic and disease-specific instruments regarding their uses, strengths, and weaknesses. HRQL reflects patients' perceptions of disease and its impact on health status. It is becoming an increasingly important endpoint in therapeutic trials. By understanding its components and how it can meaningfully be measured, gastroenterologists may be better able to optimize the benefit patients receive from their medical interventions.

Authors
Eisen, GM; Locke, GR; Provenzale, D
MLA Citation
Eisen, GM, Locke, GR, and Provenzale, D. "Health-related quality of life: a primer for gastroenterologists." Am J Gastroenterol 94.8 (August 1999): 2017-2021. (Review)
PMID
10445522
Source
pubmed
Published In
The American Journal of Gastroenterology (Elsevier)
Volume
94
Issue
8
Publish Date
1999
Start Page
2017
End Page
2021
DOI
10.1111/j.1572-0241.1999.01272.x

Prevalence of dyspepsia, heartburn, and peptic ulcer disease in veterans.

OBJECTIVE: Medications used to treat gastrointestinal symptoms account for a substantial share of pharmacy expenses for veterans affairs medical centers. Prior studies have shown that the prevalence of peptic ulcer disease is higher in veterans than in nonveterans. Our aim was to determine the prevalence of upper gastrointestinal symptoms among patients seeking health care in the Department of Veterans Affairs outpatient clinics. METHODS: A total of 1582 veterans completed a previously validated bowel symptom questionnaire in the following clinics: gastroenterology (n = 693), walk-in (n = 403), general medicine (n = 379), and women's health (n = 107). RESULTS: Overall response was 78%. Dyspepsia was reported in 30%, 37%, 44%, and 53% of patients in general medicine, walk-in, women's health, and gastroenterology clinics, respectively. Heartburn, at least weekly, was reported in 21%, 21%, 28%, and 40% of patients in general medicine, walk-in, women's health, and gastroenterology clinics, respectively. Prior peptic ulcer disease (PUD) was reported in 29%, 26%, 22%, and 44% of patients in general medicine, walk-in, women's health, and gastroenterology clinics, respectively. Dyspepsia, heartburn, and PUD were significantly associated with increased physician visits and lower general health. CONCLUSIONS: Dyspepsia and heartburn are common symptoms among veterans. Lifetime prevalence of PUD is high among veterans. Gastrointestinal symptoms have a significant impact on health care utilization and general health. These prevalence estimates provide a basis for studies of resource utilization and for cost-effectiveness analyses of the treatment of gastrointestinal disorders in the veteran population. Moreover, the high prevalence of symptoms helps to explain the high utilization of gastrointestinal medications.

Authors
Dominitz, JA; Provenzale, D
MLA Citation
Dominitz, JA, and Provenzale, D. "Prevalence of dyspepsia, heartburn, and peptic ulcer disease in veterans." Am J Gastroenterol 94.8 (August 1999): 2086-2093.
PMID
10445532
Source
pubmed
Published In
The American Journal of Gastroenterology (Elsevier)
Volume
94
Issue
8
Publish Date
1999
Start Page
2086
End Page
2093
DOI
10.1111/j.1572-0241.1999.01282.x

A cost analysis of outpatient care for patients with Barrett's esophagus in a managed care setting.

OBJECTIVES: Although Barrett's esophagus (BE) may be associated with severe gastroesophageal reflux disease (GERD), there are currently no studies that evaluate resource utilization in Barrett's patients. The aims of this study were 1) to determine the cost and number of endoscopies and clinic visits to the GI clinic for GERD or its complications in patients with BE; 2) to determine the pattern and cost of medication use in patients with BE; and 3) to compare medication use by patients with BE to that of patients with insulin-requiring diabetes mellitus (DM). METHODS: Using the cost distribution report data and the pharmacy acquisition costs from the Durham VAMC, we calculated the monthly cost of endoscopies, clinic visits related to GERD, and medication use in 53 patients with BE between 1/1/94 and 1/1/97. We also calculated the average cost of medication use for 55 patients with insulin-requiring DM. RESULTS: All patients with BE were male. Their median age was 64.0 yr (IQR 57-68). Of them, 92% were white; 23% had low-grade dysplasia (LGD). Patients with LGD were more likely to have more than three endoscopies in 3 yr than were those with no LGD (OR 6.3, 95% CI 1.11-35.67). There was no difference in clinic visits in the patients with and without dysplasia (OR 0.335, 95% CI 0.093-1.206). A total of 139 endoscopies and 172 clinic visits were observed. Outpatient care for patients with BE costs approximately $103/month or $1241/yr. Endoscopies and clinic visits accounted for 31.1% and 5.9% of the monthly medical cost, respectively. Medications accounted for 63% of the total cost of care. Prokinetic agents accounted for 0.8% of the total cost of medications, whereas histamine receptor antagonists (H2 blockers) and proton pump inhibitors (PPIs) accounted for 34.6% and 64.6%, respectively. Medication cost per month in patients with BE was approximately $65, similar to that of patients with insulin-requiring DM ($63). CONCLUSIONS: Our conclusions were as follows: 1) Outpatient care for patients with BE costs approximately $1241/yr or ($103/month). 2) Medication use per month accounted for more than half of the total cost; PPIs accounted for 64.6% of total medication cost, suggesting that reflux was severe. 3) Consistent with current surveillance strategies, patients with LGD had more frequent endoscopy than patients with no dysplasia. 4) Medication cost per month in patients with BE is similar to that in patients with DM, another group with a chronic disorder. 5) Those who make health policy can use these results to compare the cost of care of patients with BE to the cost for those with other chronic medical disorders.

Authors
Eloubeidi, MA; Homan, RK; Martz, MD; Theobald, KE; Provenzale, D
MLA Citation
Eloubeidi, MA, Homan, RK, Martz, MD, Theobald, KE, and Provenzale, D. "A cost analysis of outpatient care for patients with Barrett's esophagus in a managed care setting." Am J Gastroenterol 94.8 (August 1999): 2033-2036.
PMID
10445524
Source
pubmed
Published In
The American Journal of Gastroenterology (Elsevier)
Volume
94
Issue
8
Publish Date
1999
Start Page
2033
End Page
2036
DOI
10.1111/j.1572-0241.1999.01274.x

Barrett's esophagus: a new look at surveillance based on emerging estimates of cancer risk.

OBJECTIVE: Surveillance of Barrett's patients is recommended, to detect dysplasia and early cancer. The reported risk for developing cancer varies substantially, however. Our previous analysis used an average cancer incidence of 1/75 patient-years (PY). Recent reports suggest that the risk may range from 1/251 to 1/208 PY in combined series of patients with long segment Barrett's esophagus (LSBE, >3 cm), and short segment Barrett's esophagus (SSBE), and up to 1% annually in patients with SSBE. Our goal was to consider these new estimates of cancer risk in a cost-utility analysis of surveillance of patients with Barrett's esophagus. METHODS: Using our previously published model, we incorporated an average of the recent estimates of cancer risk (0.4% annually, 1/227 PY), and our primary data on quality of life after esophagectomy. We included actual variable (direct) costs and used a discount rate of 5%. From the perspective of an HMO, the model evaluates surveillance every 1-5 yr and no surveillance, with esophagectomy performed if high grade dysplasia is diagnosed, and calculates the incremental cost-utility ratios for each strategy. RESULTS: The results suggest that, at our baseline, annual cancer risk surveillance every 5 yr is the only viable strategy. More frequent surveillance costs more and yields a lower life expectancy. The incremental cost-utility ratio for surveillance every 5 yr is $98,000/quality-adjusted life year (QALY) gained, comparable to the incremental cost-effectiveness ratios of accepted practices (heart transplantation and screening for tuberculosis in selected populations, $160,000/LY gained and $216,000/LY gained, respectively). CONCLUSIONS: Surveillance of Barrett's patients should extend life, with incremental cost-utility ratios that compare favorably with some accepted medical practices. Policy makers can compare the cost of surveillance to that of other accepted practices to determine their willingness to fund surveillance.

Authors
Provenzale, D; Schmitt, C; Wong, JB
MLA Citation
Provenzale, D, Schmitt, C, and Wong, JB. "Barrett's esophagus: a new look at surveillance based on emerging estimates of cancer risk." Am J Gastroenterol 94.8 (August 1999): 2043-2053.
PMID
10445526
Source
pubmed
Published In
The American Journal of Gastroenterology (Elsevier)
Volume
94
Issue
8
Publish Date
1999
Start Page
2043
End Page
2053
DOI
10.1111/j.1572-0241.1999.01276.x

Economic considerations for the hepatologist.

This is an era of rapid change in health care systems and clinical practice. In the face of increasing national health care expenditures, physicians are confronted with an increased demand to justify practices and to show the value of their services. Hepatologists are being required to show that their practices are both effective and cost-effective. This has led to an expanding body of literature examining the cost-effectiveness of medical practices. To evaluate these economic analyses the reader must be familiar with the concepts used in economic analysis and have a clear understanding of both how these analyses are performed and how the results can be applied to clinical practice. The purpose of this article is to provide the reader with the essential concepts for evaluating economic analyses in the medical literature and to provide published criteria for performing and critiquing an economic analysis. The terms used in economic analysis are outlined and defined. The criteria for performing an economic analysis are listed. Examples are given to emphasize the key points.

Authors
Provenzale, D
MLA Citation
Provenzale, D. "Economic considerations for the hepatologist." Hepatology 29.6 Suppl (June 1999): 13S-17S.
PMID
10386077
Source
pubmed
Published In
Hepatology
Volume
29
Issue
6 Suppl
Publish Date
1999
Start Page
13S
End Page
17S

Does this patient have Barrett's esophagus? The utility of predicting Barrett's esophagus at the index endoscopy.

OBJECTIVES: Few studies have evaluated the ability of the endoscopist to predict the presence of Barrett's esophagus (BE) at index endoscopy. The goals of this study were to determine the operating characteristics of endoscopy in diagnosing BE, and to determine the clinical and endoscopic predictors of BE in suspected BE patients at the index endoscopy. METHODS: From September 1993 to October 1997, endoscopic reports were examined to identify patients with suspected BE. All esophageal pathology reports during the same period were evaluated for the presence of specialized intestinal metaplasia. RESULTS: During the study period, 4053 endoscopies were performed on 2393 patients. Eight percent of all procedures were performed for suspected or confirmed BE. Fifty-three patients were known to have BE and thus their reports were excluded from this analysis. Five hundred seventy of the remaining patients had esophageal biopsies performed, and were included in this analysis. Among these 570 patients, 146 were suspected to have BE on endoscopy, while 424 were not suspected to have BE at the time of endoscopy. There were no differences among the two groups in terms of gender, race, and dyspepsia as an indication for the endoscopy. However, suspected BE patients were slightly younger and were more likely to have heartburn, but were less likely to have dysphagia as an indication for the endoscopy. The sensitivity and specificity of the endoscopists' assessments were 82% (95% confidence interval [CI], 72-92) and 81% (95% CI, 78-84), respectively. The positive predictive value and the negative predictive value were 34% and 97%, respectively. The positive likelihood ratio was 4.32 (95% CI, 3.49-5.31) and the negative likelihood ratio was 0.22 (95% CI, 0.13-0.38). Univariate analysis showed that endoscopists diagnosed BE in those with long-segment BE (LSBE) more accurately than in those with short-segment BE (SSBE) (55% vs 25% p = 0.001; odds ratio [OR] = 3.63, 95% CI, 1.71-7.70). Barrett's esophagus was correctly diagnosed in 38.5% of white patients but in only 14.7% of black patients (p = 0.01; OR = 3.63, 95% CI, 1.31-10.13). Multivariable logistic regression identified only the length of the columnar-appearing segment (p = 0.002; OR = 3.33, 95% CI, 1.54-7.17) and race (p = 0.08; OR = 2.31, 95% CI, 0.88-6.03) to be associated with the presence of BE on biopsy. CONCLUSIONS: Barrett's esophagus is frequently suspected at endoscopy; SSBE was more frequently suspected than LSBE, but was correctly diagnosed only 25% of the time, versus 55% for LSBE. Endoscopists diagnosed BE with a sensitivity of 82% and a specificity of 81%. However, the positive predictive value was only 34%, whereas the negative predictive value was 97%. The length of the columnar-appearing segment is the strongest predictor of BE at endoscopy. Alternative methods are needed to better identify BE patients endoscopically, especially those with SSBE.

Authors
Eloubeidi, MA; Provenzale, D
MLA Citation
Eloubeidi, MA, and Provenzale, D. "Does this patient have Barrett's esophagus? The utility of predicting Barrett's esophagus at the index endoscopy." Am J Gastroenterol 94.4 (April 1999): 937-943.
PMID
10201460
Source
pubmed
Published In
The American Journal of Gastroenterology (Elsevier)
Volume
94
Issue
4
Publish Date
1999
Start Page
937
End Page
943
DOI
10.1111/j.1572-0241.1999.990_m.x

Economic considerations for the hepatologist

This is an era of rapid change in health care systems and clinical practice. In the face of increasing national health care expenditures, physicians are confronted with an increased demand to justify practices and to show the value of their services. Hepatologists are being required to show that their practices are both effective and cost-effective. This has led to an expanding body of literature examining the cost-effectiveness of medical practices. To evaluate these economic analyses the reader must be familiar with the concepts used in economic analysis and have a clear understanding of both how these analyses are performed and how the results can be applied to clinical practice. The purpose of this article is to provide the reader with the essential concepts for evaluating economic analyses in the medical literature and to provide published criteria for performing and critiquing an economic analysis. The terms used in economic analysis are outlined and defined. The criteria for performing an economic analysis are listed. Examples are given to emphasize the key points.

Authors
Provenzale, D
MLA Citation
Provenzale, D. "Economic considerations for the hepatologist." Hepatology 29.6 SUPPL. (1999): 13S-17S.
Source
scival
Published In
Hepatology
Volume
29
Issue
6 SUPPL.
Publish Date
1999
Start Page
13S
End Page
17S

Hospital credentialing for laparoscopic cholecystectomy: is stricter better?

OBJECTIVE: Hospital credentialing standards for laparoscopic cholecystectomy were established to improve surgical outcomes, but standards vary by hospital. We hypothesized that more stringent credentialing would result in better outcomes. DESIGN: Univariate and multivariate logistic analyses were performed using a 1996 survey on hospital credentialing practices. Surgical-outcome data were obtained from statewide hospital discharge abstracts and hospital chart reviews. Multivariate logistic analysis was used to calculate the effects of hospital credentialing stringency and nine credentialing practices on operative and postoperative outcomes (including death), controlling for patient and hospital characteristics. SETTING: Short-stay community hospitals performing laparoscopic cholecystectomy. PATIENTS: Statewide hospital discharge data included 1995 inpatient discharges for laparoscopic cholecystectomy. Medical-records review included 843 laparoscopic cholecystectomy patients selected from 14 North Carolina hospitals with widely different credentialing practices. RESULTS: Surgical complications from laparoscopic cholecystectomies appeared unrelated to stringency of the hospital credentialing environment. Important factors predicting complications included hospital volume and other hospital characteristics such as the number of registered nurses per patient day. CONCLUSIONS: Given current levels of training, performance, and credentialing standards, tightening of credentialing practices may not improve patient outcomes for laparoscopic cholecystectomy.

Authors
Conover, CJ; Sloan, FA; Provenzale, D; Oddone, E; Jowell, PS; Mah, ML
MLA Citation
Conover, CJ, Sloan, FA, Provenzale, D, Oddone, E, Jowell, PS, and Mah, ML. "Hospital credentialing for laparoscopic cholecystectomy: is stricter better?." Clin Perform Qual Health Care 6.4 (October 1998): 155-162.
PMID
10351281
Source
pubmed
Published In
Clinical performance and quality health care
Volume
6
Issue
4
Publish Date
1998
Start Page
155
End Page
162

Race, treatment, and survival among colorectal carcinoma patients in an equal-access medical system.

BACKGROUND: The aim of this study was to assess the influence of race on the treatment and survival of patients with colorectal carcinoma. METHODS: This retrospective cohort study included all white or black male veterans given a new diagnosis of colorectal carcinoma in 1989 at Veterans Affairs Medical Centers nationwide. After adjusting for patient demographics, comorbidity, distant metastases, and tumor location, the authors determined the likelihood of surgical resection, chemotherapy, radiation therapy, and death in each case. RESULTS: Of the 3176 veterans identified, 569 (17.9%) were black. Bivariate analyses and logistic regression revealed no significant differences in the proportions of patients undergoing surgical resection (70% vs. 73%, odds ratio 0.92, 95% confidence interval 0.74-1.15), chemotherapy (23% vs. 23%, odds ratio 0.99, 95% confidence interval 0.78-1.24), or radiation therapy (17% vs. 16%, odds ratio 1.10, 95% confidence interval 0.85-1.43) for black versus white patients. Five-year relative survival rates were similar for black and white patients (42% vs. 39%, respectively; P=0.16), though the adjusted mortality risk ratio was modestly increased (risk ratio 1.13, 95% confidence interval 1.01-1.28). CONCLUSIONS: Overall, race was not associated with the use of surgery, chemotherapy, or radiation therapy in the treatment of colorectal carcinoma among veterans seeking health care at Veterans Affairs Medical Centers. Although mortality from all causes was higher among black veterans with colorectal carcinoma, this finding may be attributed to underlying racial differences associated with survival. This study suggests that when there is equal access to care, there are no differences with regard to race.

Authors
Dominitz, JA; Samsa, GP; Landsman, P; Provenzale, D
MLA Citation
Dominitz, JA, Samsa, GP, Landsman, P, and Provenzale, D. "Race, treatment, and survival among colorectal carcinoma patients in an equal-access medical system." Cancer 82.12 (June 15, 1998): 2312-2320.
PMID
9635522
Source
pubmed
Published In
Cancer
Volume
82
Issue
12
Publish Date
1998
Start Page
2312
End Page
2320

Effectiveness and patient satisfaction with nurse-directed treatment of Barrett's esophagus.

OBJECTIVE: Using clinical practice guidelines, a registered nurse adjusted antireflux medications, evaluated esophageal biopsy reports, determined the interval between surveillance endoscopies, and provided education for patients with Barrett's esophagus. No previous reports have assessed the effectiveness or patient satisfaction associated with registered nurse-provided primary care. Because estimates of the incidence of dysplasia and adenocarcinoma vary widely, we also prospectively followed a cohort of patients with Barrett's esophagus. METHODS: Charts were reviewed to determine the frequency of variation from guidelines, the annual incidence of dysplasia and adenocarcinoma, and frequency of reflux symptoms. Patients were mailed a questionnaire to assess satisfaction with their medical care and with the nurse. RESULTS: Variation by the nurse from the guidelines on surveillance endoscopy (1.9%) and the treatment of reflux (1.3%) was rare. Most patients were very satisfied (score of 6 on 0-6-point Likert scale) with overall medical care (88%), and patient education (76%), and most patients did not think that increased physician involvement would improve their care (93%). Ninety-seven percent of patients had control of reflux symptoms. Two patients with long segment Barrett's esophagus (n = 67) developed high grade dysplasia over 323 patient-yr of follow-up (1 of 162 patient-yr for an annual incidence of 0.6%). No patients with short segment Barrett's esophagus (n = 56) developed high grade dysplasia or adenocarcinoma over 172 patient-years of follow-up. CONCLUSION: The registered nurse in our clinical setting effectively administered clinical practice guidelines for the management of Barrett's esophagus without clinically significant morbidity or patient dissatisfaction. Before these results can be generalized to other settings, further studies will need to be performed.

Authors
Schoenfeld, P; Johnston, M; Piorkowski, M; Jones, DM; Eloubeidi, M; Provenzale, D
MLA Citation
Schoenfeld, P, Johnston, M, Piorkowski, M, Jones, DM, Eloubeidi, M, and Provenzale, D. "Effectiveness and patient satisfaction with nurse-directed treatment of Barrett's esophagus." Am J Gastroenterol 93.6 (June 1998): 906-910.
PMID
9647016
Source
pubmed
Published In
The American Journal of Gastroenterology (Elsevier)
Volume
93
Issue
6
Publish Date
1998
Start Page
906
End Page
910
DOI
10.1111/j.1572-0241.1998.00274.x

Performing a cost-effectiveness analysis: surveillance of patients with ulcerative colitis.

OBJECTIVE: To illustrate the principles of cost-effectiveness analysis, this third article in the "Primer on Economic Analysis for the Gastroenterologist" applies published criteria for appraising an economic analysis to a study of the cost-effectiveness of surveillance of patients with ulcerative colitis. METHODS: We review and apply the 10 standard criteria for critical appraisal and evaluation of cost-effectiveness analyses. SUMMARY: We outlined the development and critique of a decision analytic model that examines the cost-effectiveness of surveillance of patients with ulcerative colitis, and we compared the cost-effectiveness of surveillance of patients with ulcerative colitis to other well-accepted medical practices.

Authors
Provenzale, D; Wong, JB; Onken, JE; Lipscomb, J
MLA Citation
Provenzale, D, Wong, JB, Onken, JE, and Lipscomb, J. "Performing a cost-effectiveness analysis: surveillance of patients with ulcerative colitis." Am J Gastroenterol 93.6 (June 1998): 872-880.
PMID
9647011
Source
pubmed
Published In
The American Journal of Gastroenterology (Elsevier)
Volume
93
Issue
6
Publish Date
1998
Start Page
872
End Page
880
DOI
10.1111/j.1572-0241.1998.00314.x

Research and the Internet [6] (multiple letters)

Authors
Hilsden, RJ; Scott, CM; Verhoef, MJ; Soetikno, RM; Lenert, LA; Provenzale, D
MLA Citation
Hilsden, RJ, Scott, CM, Verhoef, MJ, Soetikno, RM, Lenert, LA, and Provenzale, D. "Research and the Internet [6] (multiple letters)." American Journal of Gastroenterology 93.3 (1998): 484-485.
PMID
9517674
Source
scival
Published In
American Journal of Gastroenterology
Volume
93
Issue
3
Publish Date
1998
Start Page
484
End Page
485

Clinical and endoscopic predictors of barrett's esophagus (BE) at the index endoscopy

Background: There are currently no studies evaluating the factors predictive of BE at the time of endoscopy. Aim: To determine the clinical and endoscopic predictors of BE at the time of index endoscopy. Methods: From September 1993 to October 1997 endoscopic reports were examined to identify patients suspected to have BE. One hundred forty six patients not previously known to have BE were identified and their pathology reports were reviewed. Univariate analysis and multivariate logistic regression were performed. The presence of BE on pathology was used as the outcome variable while age, race and heartburn as an indication for the endoscopy, and the length of the columnar appearing segment were used as predictor variables. Results: Eight percent of all procedures and 12% of outpatient procedures were performed for suspected or confirmed BE. The prevalence of BE was 7.5%. and the incidence was 4.35%. BE was suspected in 13% of all outpatients. Of 146 patients suspected to have BE, 71% were classified as short segment BE (SSBE, ≤ 2 cm) by the endoscopist. Of those who had confirmed BE, 90% were white and 10% were black. SSBE LSBE SEX MALE (%) 98 98 RACE WHITE (%) 72 86 HEARTBURN (%) 46 48 AGE ± SD 59 ± 13 61 ± 15 LENGTH (CMS) 1.73 ± 0.46 5.64 ± 3.26 PROVEN BE (%) 25 55 Univariate analysis showed that endoscopists predicted BE in those with LSBE more accurately than those with SSBE (55% vs 25% p=0.001), (OR = 3.63, 95% CI 1.71-7.7). Barrett's esophagus was accurately predicted in 38.5% of white patients but in only 14.7 % of black patients (p=0.01), (OR = 3.63, 95% CI 1.31-10.13). Heartburn as an indication for the endoscopy and age greater than 50 years were not predictive of BE (P= 0.685 and 0.74 respectively). Multivariate logistic regression identified only the length of the columnar appearing segment as significant p=0.002 (OR = 3.33 95% CI 1.54-7.17), with race trending towards significance (p=0.08) (OR = 2.31 95% CI 0.88-6.03) (white patients were more likely to be diagnosed with BE). Conclusions: 1) The endoscopic diagnosis of BE patients remains a challenge especially for those with SSBE. 2)The length of the columnar appearing segment is the strongest predictor of BE at endoscopy.

Authors
Eloubeidi, M; Provenzale, D
MLA Citation
Eloubeidi, M, and Provenzale, D. "Clinical and endoscopic predictors of barrett's esophagus (BE) at the index endoscopy." Gastrointestinal Endoscopy 47.4 (1998): AB67-.
Source
scival
Published In
Gastrointestinal Endoscopy
Volume
47
Issue
4
Publish Date
1998
Start Page
AB67

Patient preferences and quality of life associated with colorectal cancer screening.

OBJECTIVES: The goal of this study was to describe the attitudes of patients toward colorectal cancer screening, colon cancer, and colostomy. METHODS: Using the time trade-off technique, we interviewed four groups of patients at a veterans' hospital: 1) 46 patients with colorectal cancer, 2) 24 patients undergoing screening sigmoidoscopy, 3) 114 subjects participating in a screening colonoscopy study, and 4) 62 patients who have never undergone endoscopic screening for colorectal cancer. Using this technique, we measured quality of life for six scenarios pertaining to screening for colorectal cancer, the patient's current health, colorectal cancer, and colostomy. RESULTS: Unscreened patients were willing to give up significantly more time to avoid screening sigmoidoscopy and colonoscopy (median 91 days and 183 days, respectively) than were patients undergoing screening sigmoidoscopy (median 0 days and 7 days, respectively), screening colonoscopy (median 0 days and 0 days, respectively), or patients with colorectal cancer (median 0 days and 0 days, respectively). Cancer patients rated their current health state lower than volunteers for screening. Colon cancer and colostomy were rated similarly by all four groups. Substantial variation in patient attitudes was present in all groups. CONCLUSIONS: Patients are generally very accepting of endoscopic screening for colorectal cancer. However, decisions regarding recommendations for colorectal cancer screening must take into account the variability in patient preferences. Effective alternative strategies should be available for those whose preferences do not comply with standard recommendations. The effect of patient education and physician recommendations on subjects' attitudes toward screening warrants further investigation.

Authors
Dominitz, JA; Provenzale, D
MLA Citation
Dominitz, JA, and Provenzale, D. "Patient preferences and quality of life associated with colorectal cancer screening." Am J Gastroenterol 92.12 (December 1997): 2171-2178.
PMID
9399747
Source
pubmed
Published In
The American Journal of Gastroenterology (Elsevier)
Volume
92
Issue
12
Publish Date
1997
Start Page
2171
End Page
2178

Health-related quality of life after ileoanal pull-through evaluation and assessment of new health status measures.

BACKGROUND & AIMS: Health-related quality of life (HRQL) after proctocolectomy is a critical parameter for management decisions in patients with chronic pancolitis. The aim of this study was to evaluate the HRQL of patients with ileoanal pull-through and to validate new, easy-to-administer HRQL measures. METHODS: The Sickness Impact Profile (SIP), Short Form 36 (SF-36), Rating Form of Inflammatory Bowel Disease (IBD) Patient Concerns (RFIPC), and the time trade-off (TTO) were used to measure HRQL of pull-through patients. The SF-36 and the RFIPC were validated. RESULTS: HRQL of patients with ileoanal pull-through was better than that of a national sample of patients with IBD (SIP and RFIPC) and similar to that of a normal population (SF-36). Physical and psychosocial subscales of the SF-36 correlated with the SIP, affirming the construct validity of the SF-36. The RFIPC results correlated with the SIP and SF-36 results, suggesting that it is also a valid health status measure for these patients. TTO results correlated with the physical subscales of the SIP and SF-36, reflecting the impact of physical health on this group. CONCLUSIONS: HRQL of patients with ileoanal pull-through is excellent. The SF-36 and RFIPC are valid health status measures that can be used by clinicians and researchers in these patients.

Authors
Provenzale, D; Shearin, M; Phillips-Bute, BG; Drossman, DA; Li, Z; Tillinger, W; Schmitt, CM; Bollinger, RR; Koruda, MJ
MLA Citation
Provenzale, D, Shearin, M, Phillips-Bute, BG, Drossman, DA, Li, Z, Tillinger, W, Schmitt, CM, Bollinger, RR, and Koruda, MJ. "Health-related quality of life after ileoanal pull-through evaluation and assessment of new health status measures." Gastroenterology 113.1 (July 1997): 7-14.
PMID
9207256
Source
pubmed
Published In
Gastroenterology
Volume
113
Issue
1
Publish Date
1997
Start Page
7
End Page
14

Studying ulcerative colitis over the World Wide Web.

OBJECTIVES: The Internet may provide a cost-effective means to collect outcomes data needed to improve the quality and efficiency of medical care. We explored the feasibility and methodology of a longitudinal outcomes study of Internet users who have ulcerative colitis (UC). METHODS: We created an open-enrollment electronic survey of Internet users who have UC and recorded the number of respondents, their demographics, and their willingness to participate. RESULTS: In a 2-month period, 582 users browsed the survey, 172 (30%) completed the questionnaire, and 162 (95%) reported willingness to enroll this study. Eighty-three percent were willing to release their medical records to verify their diagnosis. Most (> 70%) had the same E-mail address over 2 yr, suggesting that long-term follow-up could be performed electronically. In comparison with the male predominance of Internet users, respondents had gender distribution similar to that of patients who have UC. In comparison with the general population, respondents have higher education and higher household income. CONCLUSIONS: The Internet community could serve as a resource for general population outcome studies. Selection bias due to limited availability and use of the networked computers may affect results. The Internet community, however, is expanding rapidly, so it should become more representative of the general population.

Authors
Soetikno, RM; Provenzale, D; Lenert, LA
MLA Citation
Soetikno, RM, Provenzale, D, and Lenert, LA. "Studying ulcerative colitis over the World Wide Web." Am J Gastroenterol 92.3 (March 1997): 457-460.
PMID
9068469
Source
pubmed
Published In
The American Journal of Gastroenterology (Elsevier)
Volume
92
Issue
3
Publish Date
1997
Start Page
457
End Page
460

The ODD score: an opportunity to develop a definitive measure for assessing endoscopic outcomes.

Authors
Provenzale, D
MLA Citation
Provenzale, D. "The ODD score: an opportunity to develop a definitive measure for assessing endoscopic outcomes." Gastrointest Endosc 45.2 (February 1997): 213-215.
PMID
9041018
Source
pubmed
Published In
Gastrointestinal Endoscopy
Volume
45
Issue
2
Publish Date
1997
Start Page
213
End Page
215

Patient preferences and quality of life associated with colorectal cancer screening

Objectives: The goal of this study was to describe the attitudes of patients toward colorectal cancer screening, colon cancer, and colostomy. Methods: Using the time trade-off technique, we interviewed four groups of patients at a veterans' hospital: 1) 46 patients with colorectal cancer. 2) 24 patients undergoing screening sigmoidoscopy, 3) 114 subjects participating in a screening colonoscopy study; and 4) 62 patients who have never undergone endoscopic screening for colorectal cancer. Using this technique, we measured quality of life for six scenarios pertaining to screening for colorectal cancer, the patient's current health, colorectal cancer, and colostomy. Results: Unscreened patients were willing to give up significantly more time to avoid screening sigmoidoscopy and colonoscopy (median 91 days and 183 days, respectively) than were patients undergoing screening sigmoidoscopy (median 0 days and 7 days, respectively), screening colonoscopy (median 0 days and 0 days, respectively), or patients with colorectal cancer (median 0 days and 0 days, respectively). Cancer patients rated their current health state lower than volunteers for screening. Colon cancer and colostomy were rated similarly by all four groups. Substantial variation in patient attitudes was present in all groups. Conclusions: Patients are generally very accepting of endoscopic screening for colorectal cancer. However, decisions regarding recommendations for colorectal cancer screening must take into account the variability in patient preferences. Effective alternative strategies should be available for those whose preferences do not comply with standard recommendations. The effect of patient education and physician recommendations on subjects' attitudes toward screening warrants further investigation.

Authors
Dominitz, JA; Provenzale, D
MLA Citation
Dominitz, JA, and Provenzale, D. "Patient preferences and quality of life associated with colorectal cancer screening." American Journal of Gastroenterology 92.12 (1997): 2171-2178.
Source
scival
Published In
The American Journal of Gastroenterology (Elsevier)
Volume
92
Issue
12
Publish Date
1997
Start Page
2171
End Page
2178

A reader's guide to economic analysis in the GI literature.

UNLABELLED: To evaluate economic analyses and determine their value for clinical practice, the reader must have a clear understanding of how these analyses are performed and how the results can be applied to clinical practice. This second article in the "Primer on Economic Analysis for the Gastroenterologist" focuses on the critical assessment of economic evaluations in the gastrointestinal literature. OBJECTIVES: The purpose of this article is (1) to review the criteria for the critical appraisal of an economic analysis, and (2) to apply these criteria to two recent articles that examine the cost-effectiveness of screening for hemochromatosis. METHODS: The criteria for the critical appraisal of an economic analysis are outlined. To demonstrate the application of these criteria to the gastroenterology literature, they are used to evaluate two recent articles that examine the cost-effectiveness of screening for hemochromatosis. SUMMARY/CONCLUSIONS: The reader of economic analyses in the gastroenterology literature is provided with a framework for the evaluation of such analyses and how they apply to gastroenterology. A systematic method for examining economic analyses and determining their value for the reader is illustrated.

Authors
Provenzale, D; Lipscomb, J
MLA Citation
Provenzale, D, and Lipscomb, J. "A reader's guide to economic analysis in the GI literature." Am J Gastroenterol 91.12 (December 1996): 2461-2470.
PMID
8946967
Source
pubmed
Published In
The American Journal of Gastroenterology (Elsevier)
Volume
91
Issue
12
Publish Date
1996
Start Page
2461
End Page
2470

Cost-effectiveness: definitions and use in the gastroenterology literature.

UNLABELLED: In this era of rapid change in our health care system, we will be required to demonstrate that our practices and procedures in gastroenterology are both effective and cost-effective. In the face of rising national health care expenditures, the medical profession confronts an increased demand to justify practices and to demonstrate the value of its services. This has led to both an expansive literature examining the cost-effectiveness of practices and procedures and an alarming disparity in the definition and use of the term "cost-effectiveness." Many reports may be lacking appropriate documentation of costs and benefits, the critical components for the determination of cost-effectiveness. OBJECTIVE: The purpose of this article was to define what is meant by a "cost-effective" intervention, with special reference to gastroenterology. METHODS: The varied use of the term "cost-effective" in the gastroenterology literature is illustrated. Accepted definitions of the term are provided, and suggested uses are outlined. The value judgements that must be made in funding decisions are presented, and the parameters that may be used to determine the cost-effectiveness of a procedure or practice are discussed. SUMMARY: Cost-effectiveness as it applies to GI medicine is defined, and appropriate and inappropriate uses of the term are illustrated. It is only through effective communication and precise definitions that we will be able to determine the cost-effectiveness of our practices in gastroenterology.

Authors
Provenzale, D; Lipscomb, J
MLA Citation
Provenzale, D, and Lipscomb, J. "Cost-effectiveness: definitions and use in the gastroenterology literature." Am J Gastroenterol 91.8 (August 1996): 1488-1493.
PMID
8759647
Source
pubmed
Published In
The American Journal of Gastroenterology (Elsevier)
Volume
91
Issue
8
Publish Date
1996
Start Page
1488
End Page
1493

Endoscopy, nonsteroidal anti-inflammatory drug, and omeprazole regimen in colorectal cancer prevention [2]

Authors
Morgan, G; Provenzale, D; Wong, JB
MLA Citation
Morgan, G, Provenzale, D, and Wong, JB. "Endoscopy, nonsteroidal anti-inflammatory drug, and omeprazole regimen in colorectal cancer prevention [2]." Gastroenterology 110.4 (1996): 1323--.
PMID
8613028
Source
scival
Published In
Gastroenterology
Volume
110
Issue
4
Publish Date
1996
Start Page
1323-
DOI
10.1053/gast.1996.v110.agast961323

Prophylactic colectomy or surveillance for chronic ulcerative colitis? A decision analysis.

BACKGROUND & AIMS: The treatment of patients with long-standing ulcerative colitis involving the entire colon is controversial. The aim of this study was to examine the effectiveness of surveillance colonoscopy or prophylactic colectomy on colon cancer mortality in patients with chronic ulcerative colitis. METHODS: Using decision analysis, computer cohort simulation of patients with ulcerative colitis was performed to evaluate 17 strategies including no colonoscopic surveillance, surveillance at varying intervals, and prophylactic proctocolectomy with ileal pouch-anal anastomosis. The model examined which biopsy results (low-grade dysplasia, high-grade dysplasia, or cancer) should lead to proctocolectomy and ileal pouch-anal anastomosis. Published data on the incidence of cancer with ulcerative colitis, the sensitivity and specificity of colonoscopy with biopsy, the risks of colonoscopy and surgery, and the prognosis with colon cancer were used. RESULTS: For a 30-year-old patient with pancolitis for 10 years, the model suggests that prophylactic colectomy would increase life expectancy by 2-10 months compared with surveillance and by 1.1-1.4 years compared with no surveillance. Surveillance would improve life expectancy by 7 months to 1.2 years compared with no surveillance. In sensitivity analysis, results were most affected by the cumulative incidence of cancer in patients with chronic ulcerative colitis. CONCLUSIONS: Either surveillance or prophylactic colectomy should increase life expectancy in patients with ulcerative colitis.

Authors
Provenzale, D; Kowdley, KV; Arora, S; Wong, JB
MLA Citation
Provenzale, D, Kowdley, KV, Arora, S, and Wong, JB. "Prophylactic colectomy or surveillance for chronic ulcerative colitis? A decision analysis." Gastroenterology 109.4 (October 1995): 1188-1196.
PMID
7557085
Source
pubmed
Published In
Gastroenterology
Volume
109
Issue
4
Publish Date
1995
Start Page
1188
End Page
1196

The business of dentistry.

Authors
Provenzale, D
MLA Citation
Provenzale, D. "The business of dentistry." CDS Rev 88.2 (March 1995): 8-.
PMID
7641290
Source
pubmed
Published In
CDS review
Volume
88
Issue
2
Publish Date
1995
Start Page
8

A primer on outcomes research for the gastroenterologist: Report of the American Gastroenterological Association Task Force on Outcomes Research

Authors
Sandler, RS; Everhart, J; Fenster, F; Jensen, D; Johanson, J; Lieberman, D; McMahon, L; Provenzale, D; Rabeneck, L; Ransohoff, D
MLA Citation
Sandler, RS, Everhart, J, Fenster, F, Jensen, D, Johanson, J, Lieberman, D, McMahon, L, Provenzale, D, Rabeneck, L, and Ransohoff, D. "A primer on outcomes research for the gastroenterologist: Report of the American Gastroenterological Association Task Force on Outcomes Research." Gastroenterology 109.1 (1995): 302-306.
Source
scival
Published In
Gastroenterology
Volume
109
Issue
1
Publish Date
1995
Start Page
302
End Page
306
DOI
10.1016/0016-5085(95)90297-X

Interstitial pneumonitis after low-dose methotrexate therapy in primary biliary cirrhosis.

Interstitial pneumonitis is an uncommon complication of low-dose methotrexate therapy in patients with psoriasis but occurs in 3%-5% of patients with rheumatoid arthritis. We found a higher incidence of interstitial pneumonitis in patients with primary biliary cirrhosis (14%) and describe its clinical manifestations, treatment, and possible etiology. Blood tests, arterial blood gas determinations, chest radiographs, bronchoscopy, tear production, autoantibody tests, and serum immunoglobulin levels were obtained in six women who developed interstitial pneumonitis while receiving methotrexate in a double-blind prospective trial of methotrexate vs. colchicine in 87 patients with primary biliary cirrhosis. Six of 43 patients (14%) who received methotrexate compared with no patients receiving colchicine developed interstitial pneumonitis 19-61 weeks after starting treatment. The pneumonitis was characterized by dyspnea, hypoxemia, and bilateral lung infiltrates, all of which responded within 24 hours to the administration of intravenous glucocorticoids. There was no correlation between the pneumonitis and pre-existing lung disease, the severity of the primary biliary cirrhosis, the titer of antimitochondrial antibody, or other diseases associated with primary biliary cirrhosis. Patients with primary biliary cirrhosis receiving low-dose methotrexate (15 mg/wk) are more susceptible to interstitial pneumonitis than patients with psoriasis or rheumatoid arthritis. The pneumonitis appears to be a hypersensitivity reaction and responds rapidly to intravenous glucocorticoid therapy.

Authors
Sharma, A; Provenzale, D; McKusick, A; Kaplan, MM
MLA Citation
Sharma, A, Provenzale, D, McKusick, A, and Kaplan, MM. "Interstitial pneumonitis after low-dose methotrexate therapy in primary biliary cirrhosis." Gastroenterology 107.1 (July 1994): 266-270.
PMID
8020670
Source
pubmed
Published In
Gastroenterology
Volume
107
Issue
1
Publish Date
1994
Start Page
266
End Page
270

A guide for surveillance of patients with Barrett's esophagus.

OBJECTIVE: Barrett's esophagus (columnar metaplasia of the distal esophagus due to chronic gastroesophageal reflux) affects nearly 700,000 people in the United States, and carries a risk of esophageal adenocarcinoma that is 30-125 times that of an age-matched population. Patients who develop high grade dysplasia are at greatest risk. Current recommendations are for endoscopic surveillance to detect dysplasia and to diagnose carcinoma while it is in an early and possibly treatable stage. In addition, some authorities recommend esophagectomy for high grade dysplasia, whereas others reserve esophagectomy only for those with cancer. There are no controlled trials demonstrating that surveillance increases life expectancy in patients with Barrett's esophagus. Furthermore, endoscopic surveillance of this large group with Barrett's esophagus may be costly, and associated with considerable morbidity. Therefore, our objective was to assess the effectiveness and cost-effectiveness of endoscopic surveillance in patients with Barrett's esophagus. METHODS: Design--Decision analysis using a computer cohort simulation (Markov). We examined 12 strategies: (A) no endoscopic surveillance. Esophagectomy is performed only if cancer is detected by biopsy. (B) no surveillance. Esophagectomy is performed if high grade dysplasia is detected by biopsy: (C1-C5) surveillance at intervals from 1 to 5 yr, with esophagectomy if cancer is diagnosed, and (D1-D5) surveillance at intervals from 1 to 5 yr with esophagectomy if high grade dysplasia is diagnosed. We measured life expectancy, quality-adjusted life expectancy, and incremental cost-effectiveness ratios for each strategy. Data Sources--Medline Search and bibliographies of retrieved articles; expert opinion when published data were not available. RESULTS AND CONCLUSIONS: Annual surveillance with esophagectomy for high grade dysplasia prevents cancer and is the preferred strategy, if only length of life (life expectancy) is considered. For those who consider both length and quality of life, endoscopy every 2-3 yr will provide the greatest quality-adjusted life expectancy. When costs are considered, endoscopy every 5 yr also increases life expectancy and has an incremental cost-effectiveness ratio similar to common medical practices. The cumulative incidence of cancer and the quality of life with an esophagectomy had the greatest impact on the decision for surveillance and the optimal surveillance strategy.

Authors
Provenzale, D; Kemp, JA; Arora, S; Wong, JB
MLA Citation
Provenzale, D, Kemp, JA, Arora, S, and Wong, JB. "A guide for surveillance of patients with Barrett's esophagus." Am J Gastroenterol 89.5 (May 1994): 670-680.
PMID
8172136
Source
pubmed
Published In
The American Journal of Gastroenterology (Elsevier)
Volume
89
Issue
5
Publish Date
1994
Start Page
670
End Page
680

Evidence for diminished B12 absorption after gastric bypass: oral supplementation does not prevent low plasma B12 levels in bypass patients.

Vitamin and mineral assays were performed on blood in 20 gastric bypass patients preoperatively and 6 and 12 months postoperatively. Values were compared with serial food records in nine patients. Postoperatively, all patients were prescribed a supplement containing the recommended dietary allowances (RDA) for vitamins and minerals. Weight, calorie and protein intake, and total serum protein decreased over the study interval (p less than 0.01). Dietary intakes of vitamins B1, B2, B6, folate, iron and zinc fell (p less than 0.01), but total intake (i.e., diet + supplement) did not decrease with the exception of iron. Blood indicators of these nutrients were normal preoperatively and did not decline. However, plasma vitamin B12 levels decreased from 385 pg/ml preoperatively to 234 pg/ml at 1 year (p = 0.0064), despite an increase in total vitamin B12 intake from 2.6 to 11.7 micrograms/day (p = 0.1173). Five patients (27.8%) had abnormally low plasma vitamin B12 levels at 1 year postoperatively; four were taking at least the RDA for vitamin B12 as supplements. Although oral supplementation containing the RDA for micronutrients can prevent abnormal blood indicators of most vitamins and minerals, it is insufficient to maintain normal plasma B12 levels in about 30% of gastric bypass patients.

Authors
Provenzale, D; Reinhold, RB; Golner, B; Irwin, V; Dallal, GE; Papathanasopoulos, N; Sahyoun, N; Samloff, IM; Russell, RM
MLA Citation
Provenzale, D, Reinhold, RB, Golner, B, Irwin, V, Dallal, GE, Papathanasopoulos, N, Sahyoun, N, Samloff, IM, and Russell, RM. "Evidence for diminished B12 absorption after gastric bypass: oral supplementation does not prevent low plasma B12 levels in bypass patients." J Am Coll Nutr 11.1 (February 1992): 29-35.
PMID
1541791
Source
pubmed
Published In
Journal of the American College of Nutrition
Volume
11
Issue
1
Publish Date
1992
Start Page
29
End Page
35

Distal and proximal colon adenomas [1]

Authors
Hassig, WM; Ibrahim, MAH; Arlow, FL; Carey, WD; Achkar, E; Lewis, JH; Provenzale, D; Sandler, RS
MLA Citation
Hassig, WM, Ibrahim, MAH, Arlow, FL, Carey, WD, Achkar, E, Lewis, JH, Provenzale, D, and Sandler, RS. "Distal and proximal colon adenomas [1]." Annals of Internal Medicine 114.7 (1991): 603-604.
PMID
2001093
Source
scival
Published In
Annals of Internal Medicine
Volume
114
Issue
7
Publish Date
1991
Start Page
603
End Page
604

Risk for colon adenomas in patients with rectosigmoid hyperplastic polyps.

OBJECTIVE: To determine whether hyperplastic polyps found in the rectosigmoid area of the colon are associated with proximal adenomas, and to judge whether patients with distal hyperplastic polyps found during sigmoidoscopy might benefit from full colonoscopy. DESIGN: Data on patients having colonoscopy collected prospectively according to a set protocol. The size and location of all polyps were noted, and all polyps were biopsied. SETTING: Two university hospitals. PATIENTS: One thousand eight hundred and thirty-six consecutive patients referred for colonoscopy between 31 December 1987 and 31 August 1989. RESULTS: Of the 970 patients who met eligibility requirements, 274 (28.3%) had adenomas and 108 (11.1%) had hyperplastic polyps. The proportion of patients with distal hyperplastic polyps and proximal adenomas (31.9%) was similar to the proportion of those without distal hyperplastic polyps (23.0%) (crude odds ratio, 1.57; 95% CI, 0.77 to 3.06). After adjusting for age and sex, the results were unchanged (adjusted odds ratio, 1.53; CI, 0.82 to 2.88). Patients with distal adenomas, on the other hand, were three times more likely to have proximal adenomas than those without distal adenomas (adjusted odds ratio, 3.42; CI, 1.99 to 5.88). CONCLUSIONS: Distal hyperplastic polyps are not strong predictors of risk for proximal adenomas. Based on the magnitude of the risk difference, we do not believe that finding a hyperplastic polyp during sigmoidoscopy justifies doing a full colonoscopy to search for proximal adenomas. Because rectosigmoid adenomas are associated with proximal adenomas, however, small polyps seen during sigmoidoscopy should be biopsied to determine their type. Colonoscopy should be reserved for patients who are proved to have adenomas.

Authors
Provenzale, D; Garrett, JW; Condon, SE; Sandler, RS
MLA Citation
Provenzale, D, Garrett, JW, Condon, SE, and Sandler, RS. "Risk for colon adenomas in patients with rectosigmoid hyperplastic polyps." Ann Intern Med 113.10 (November 15, 1990): 760-763.
PMID
2240878
Source
pubmed
Published In
Annals of internal medicine
Volume
113
Issue
10
Publish Date
1990
Start Page
760
End Page
763

Psychoses associated with propranolol withdrawal.

Authors
Golden, RN; Hoffman, J; Falk, D; Provenzale, D; Curtis, TE
MLA Citation
Golden, RN, Hoffman, J, Falk, D, Provenzale, D, and Curtis, TE. "Psychoses associated with propranolol withdrawal." Biol Psychiatry 25.3 (February 1, 1989): 351-354.
PMID
2914157
Source
pubmed
Published In
Biological Psychiatry
Volume
25
Issue
3
Publish Date
1989
Start Page
351
End Page
354

Colon adenomas in patients with hyperplastic polyps.

Although hyperplastic polyps are generally believed to have no malignant potential, recent work has suggested that they might be more common in patients with adenomas. We evaluated whether hyperplastic polyps could serve as a marker for patients who might benefit from colonoscopy. We retrospectively reviewed 1,588 consecutive colonoscopy reports and hospital charts on 1,407 different patients examined between May 1983 and August 1985: 242 patients had adenomas, and 94 had hyperplastic polyps. Of patients with hyperplastic polyps 93.6% had concomitant adenomas, as compared with 35.7% of those without, p less than 0.001. Adenomas proximal to the rectosigmoid were found in 61.7% of patients with hyperplastic polyps and in 25.3% of those without, p less than 0.001. Patients with hyperplastic polyps in the rectosigmoid had proximal adenomas more frequently (64.7%) than did those without rectosigmoid hyperplastic polyps (29.4%), p less than 0.001. We conclude that patients with hyperplastic polyps are more likely to have adenomas, and patients with rectosigmoid hyperplastic polyps are more likely to have proximal adenomas. Based on these preliminary data, we believe that the finding of hyperplastic polyps in the rectosigmoid might justify full colonoscopy and that this should be studied further.

Authors
Provenzale, D; Martin, ZZ; Holland, KL; Sandler, RS
MLA Citation
Provenzale, D, Martin, ZZ, Holland, KL, and Sandler, RS. "Colon adenomas in patients with hyperplastic polyps." J Clin Gastroenterol 10.1 (February 1988): 46-49.
PMID
3356885
Source
pubmed
Published In
Journal of Clinical Gastroenterology
Volume
10
Issue
1
Publish Date
1988
Start Page
46
End Page
49

Development of a scoring system to predict mortality from upper gastrointestinal bleeding.

Despite the widespread application of endoscopy in acute upper gastrointestinal bleeding, there is little evidence of improved survival among those who undergo the procedure. To select high-risk patients who might benefit most from diagnostic and therapeutic endoscopy, the authors developed and validated a scoring system based on prognostic indicators of increased mortality. The scoring system was developed from the best clinical predictors of mortality, determined in a prospective study of consecutive bleeding patients. The model was then tested in a prospective validation phase at three hospitals. Three main factors in the model predict mortality: bleeding, including hematochezia, drop in hematocrit of 5%, short duration of bleeding, absence of melena, and hypotension; liver disease, manifested by prolonged prothrombin time and encephalopathy; and renal disease. Patients determined to be at high risk for death using the scoring system might be candidates for aggressive management and for therapeutic endoscopy.

Authors
Provenzale, D; Sandler, RS; Wood, DR; Levinson, SL; Frakes, JT; Sartor, RB; Jackson, AL; Kinard, HB; Wagner, EH; Powell, DW
MLA Citation
Provenzale, D, Sandler, RS, Wood, DR, Levinson, SL, Frakes, JT, Sartor, RB, Jackson, AL, Kinard, HB, Wagner, EH, and Powell, DW. "Development of a scoring system to predict mortality from upper gastrointestinal bleeding." Am J Med Sci 294.1 (July 1987): 26-32.
PMID
3496791
Source
pubmed
Published In
American Journal of the Medical Sciences
Volume
294
Issue
1
Publish Date
1987
Start Page
26
End Page
32

Longitudinal Changes in Depression Symptoms and Survival Among Patients With Lung Cancer: A National Cohort Assessment

Authors
Sullivan, DR; Forsberg, CW; Ganzini, L; Au, DH; Gould, MK; Provenzale, D; Slatore, CG
MLA Citation
Sullivan, DR, Forsberg, CW, Ganzini, L, Au, DH, Gould, MK, Provenzale, D, and Slatore, CG. "Longitudinal Changes in Depression Symptoms and Survival Among Patients With Lung Cancer: A National Cohort Assessment (Published online)." Journal of Clinical Oncology.
Source
crossref
Published In
Journal of Clinical Oncology
DOI
10.1200/JCO.2016.66.8459
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