A212 AGA ABSTRACTS
1300
USE OF COLONOSCOPY FOLLOWING COLORECTAL CAN-
CER SURGERY: A POPULATION-BASED STUDY IN A SETTING
OF UNIVERSAL HEALTH CARE.
Robert 1. Hilsden, Heather Bryant, Lloyd R. Sutherland, Anthony La
Fields, Penny Ma Brasher, Univ of Calgary, Calgary, AB, Canada; Alberta
Cancer Board, Calgary, AB, Canada; Alberta Cancer Board, Edmonton,
AB, Canada.
Purpose:To determine whether the use of colonoscopy following poten-
tially curative surgery for colorectal cancer (CRC) in a Canadian province
is associated with patient, treatment or surgeon factors. Methods: Patients
(:C-30 yrs) diagnosed with a first, stage A-C CRC from 1983-95, who had
curative-intent surgery, survived :c-9 months and were covered by the
Alberta Health Care Insurance Plan (AHCIP) were selected from the
Alberta Cancer Registy. Data on colonoscopy use was obtained through
linkage to AHCIP physician payment databases. Cancer clinic charts were
reviewed to obtain additional tumor, treatment and outcome data. Patients
were censored from the analysis at the time of death, disease recurrence or
loss of AHCIP coverage. Piece-wise Cox regression models were used to
test associations between predictor variables and time to first colonoscopy.
Results: The analysis sample was composed of 3916 patients (44% female,
47% diagnosed 1983-89). 51.5% had at least one post-operative colonos-
copy. Kaplan-Meier survival curves showed an abrupt increase in the risk
of undergoing a colonoscopy at about I year after surgery. The use of
colonoscopy increased after 1989. When comparing survival curves for
different groups characterized by treatment or surgeon characteristics,
differences were usually only seen beginning 12 months after surgery.
Patients diagnosed between 1990-95 who were more likely to undergo a
post-operative colonoscopy included those who had undergone a pre-
operative one (Hazard Ratio 1.41, 95% CI 1.17-1.69), those seen more
frequently in a provincial cancer clinic (1.45, 1.23 - 1.70) and those whose
surgeon performed colonoscopies (1.37, 1.19-1.58) Patients who were less
likely included those who underwent an abdominoperineal resection (0.71,
0.59-0.85) and older age groups (70-79 yrs old: HR 0.38; 80+ yrs old: HR
0.13 compared with 30-54 yrs old). Before 1990, men were more likely
then women to undergo a post-operative colonoscopy (1.25,1.01-1.53), but
this difference did not persist in 1990-95. Conclusion: (1) The use of
colonoscopy after colorectal cancer surgery has increased over a 12 year
period in Alberta. (2) Several patient, treatment, and surgeon factors are
associated with the likelihood of undergoing a post-operative colonoscopy.
(3) Most of these factors would not be predicted based on prevailing
guidelines for surveillance colonoscopy.
1301
IS STEP-DOWN FROM PPIS FEASIBLE? PROSPECTIVE EVAL-
UATION OF A PRACTICE GUIDELINE FOR GASTROESOPHA-
GEAL REFLUX DISEASE.
John M. Inadomi, Roula Jamal, Glen H. Murata, Richard M. Hoffman,
Laurence A. Lavezo, Justina Vigil, Kathleen M. Swanson, Amnon Son-
nenberg, VA Health Service Research and Development Service, Ann
Arbor, MI; VA Med Ctr, Albuquerque, NM.
Background: Published guidelines for the management of gastroesophageal
reflux disease (GERD) advocate "step-down" of asymptomatic patients
from proton-pump inhibitors (PPIs) to less costly maintenance medication.
The feasibility of this strategy, however, has not been demonstrated.
Purpose: To evaluate the outcome of PPI discontinuation in patients with
uncomplicated GERD. Methods: GERD patients on PPIs were recruited
from primary care clinics and managed prospectively through a sub-
specialty clinic staffed by clinical pharmacists. Inclusions:GERD patients
asymptomatic> 12 weeks on PPIs. Exclusions:GERD complications (stric-
tures, Barrett s metaplasia, bleeding or anemia), extra-esophageal manifes-
tations of GERD, or persistent symptoms. Eligible subjects received half
their usual dose of PPI for 2 weeks; if symptoms recurred the original dose
of PPI was re-instituted, otherwise PPIs were discontinued and subjects
were followed at 3-month intervals. If symptoms recurred, histarninej-
receptor antagonists (H2RAs) and/or prokinetic agents were administered
for 2 weeks; if symptoms persisted PPIs were re-instituted, otherwise
subjects continued non-PPI therapy. Outcome measures were 1. Medica-
tion required to alleviate symptoms, 2. Predictors of PPI requirement, 3.
Total costs of management. Results: 154 patients were evaluated, of whom
73 (47.4%) were eligible and attempted PPI discontinuation. After a mean
follow-up of 332 days, 41/73 (56.2%) did not require re-institution of PPIs.
17/73 (23.3%) had recurrent symptoms on half-dose PPI, while another
15/73 (20.5%) had recurrent symptoms that required PPI re-institution after
initial successful discontinuation with a median time to recurrence of 14
days (range 3-210 days). Of the 41 subjects managed without PPIs, 21
required H2RAs, 5 promotility agents, 4 both and II remained asymptom-
atic without medication. Multivariate logistic regression analysis revealed
a dominant symptom of heartburn (vs. dyspepsia or acid regurgitation) and
younger age to be significant predictors for PPI requirement. Guideline
implementation resulted in a net cost savings of $39,344 in the cohort.
Conclusions: The majority of uncomplicated GERD patients rendered
asymptomatic with PPIs can be maintained with alternative therapy. The
majority of those who require PPIs declare themselves within 2 weeks of
discontinuation. Practice guidelines implemented through subspecialty
clinics can decrease management costs.
GASTROENTEROLOGY Vol. 118, No.
1302
MEDICAL RESOURCE UTILIZATION OF CHRONIC CONSTIPA·
TION PATIENTS IN A LARGE GENERAL PRACTICE POPULA-
TION.
Michael P. Jones, Dominique Dubois, Guy Nuyts, Nicholas 1. Talley, Univ
of Sydney, Sydney, Australia; Janssen Research Fdn, Beerse, Belgium.
BACKGROUND Chronic constipation (CC) is a common problem among
general practice patients, and may impair patients' quality-of-life. The
present study aims to describe the medical resources used and to identify
the most important cost drivers of chronic constipation. METHODS A
sample of CC patients (n =7251 )was obtained from the UK General Prac-
tice Research Database among patients with diagnoses in 1997/98, as well
as a control sample (n=7103). Measureable medical resources included GP
consultations, hospital admissions, investigations and medications. RE-
SULTS Patient history ranged from 0.5-12 years. CC patients had a higher
prevalence of co-existing diseases, and used more medications and inves-
tigations compared with the control sample (Figure, NB * indicates
xl,OOO). Drivers of GP consultations were (numbers are relative rates, all
statistically significant); all patients: faecal impaction (FI,2.1), GI obstruc-
tion (GIO,2.1), Multiple Sclerosis (MS,1.7) and opioids use(OP,1.6); in
patients aged 10-59 years: Parkinson's disease (PD,4.2), MS (3.8), FI (2.6)
and GIO (2.2); patients 60+: GIO (2.1), FI (2.0) and OP (1.6). Drivers of
hospital admissions were; all: GIO (12.4), MS (3.1), FI (3.1) and opioids
(2.2); in patients aged 10-59 years: GIO (17.9), MS (12.6), diabetes (4.7)
and FI (2.4); 60+: GIO (10.7), FI (3.2), faecal incontinence (2.2) and
opioids (1.9). During periods of recurrent constipation resource use was
high, compared to controls (Figure): total GP consults CC=30/yr, hospital
admissions CC=0.6/yr, laxatives CC= 16/yr. CONCLUSION CC patients
in a general practice setting have a higher medical resource utilisation than
controls. This study has identified the main drivers for resource use: In the
the elderly, constipation induced complications drive the resource utiliza-
tion, while in the younger PD or MS are the main drivers.
12,---------------------,
10
Cohort
Parameter
1303
INITIAL REPORT OF A RANDOMIZED, PROSPECTIVE STUDY
OF PROPHYLACTIC PROPRANOLOL COMPARED TO RUBBER
BAND LIGATION FOR PREVENTION OF FIRST VARICEAL
HEMORRHAGE IN CIRRHOTICS WITH LARGE ESOPHAGEAL
VARICES.
Rome Jutabha, Dennis M. Jensen, Paul Martin, Thomas J. Savides, Flo-
rence Lam, Mary Ellen Jensen, Gwen Alofaituli, Jeffrey Gornbein, UCLA
Sch of Medicine, Los Angeles, CA; UCSD Med Ctr, San Diego, CA;
UCLA Health Sci Ctr, Los Angeles, CA; UCLA Biomathematics, Los
Angeles, CA.
As prophylaxis to prevent first variceal hemorrhage (1 Sl EVH), the current
standard of practice for cirrhotics with large esophageal varices is to treat
with beta-blockers (e.g. propranolol). Daily l3-blockers are inconvenient,
not all patients respond to them, and compliance is a long-term problem.
The purpose of this study is to test the hypothesis that rubber band ligation
(RBL) will be as effective, safe, and cost effective as propranolol for
prevention of first variceal hemorrhage. Methods. This is an ongoing,
randomized prospective multicenter trial of propranolol (doses titrated to
decrease the resting pulse by 25%) vs. RBL (in successive endoscopic
treatments to obliterate the varices in the distal6-7cm of the esophagus). 35
cirrhotics with large EV and no history of UGI or EVH were randomized,
17 to propranolol and 18 to RBL. Treatments were continued until 1Sl UGI
hemorrhage, serious adverse event (AE), or liver transplantation (OLT).
Direct costs of therapies, complications, and EVH were estimated from
Medicare re-embursements and fixed and variable charges for services up
to OLT. Results. The most common etiologies of cirrhosis were hepatitis C
(63%), B (17%), and alcohol (19%). Child Class was similar with A or B
in 77%. Refer to the table for outcomes. There were no deaths. Differences
in outcomes or cost are not significant. Conclusions. For stable cirrhotics
with large esophageal varices and no history of UGI hemorrhage who are
potential candidates for liver transplantation: I) Rates of first variceal