ORIGINAL ARTICLE
Current knowledge of antibiotic prophylaxis guidelines regarding GI open-access endoscopic procedures is inadequate Joseph David Feuerstein, MD,1 Saurabh Sethi, MD,1 Elliot B. Tapper, MD,1 Edward Belkin, MD,2 Jeffrey J. Lewandowski, BA,3 Anand Singla, MD,4 Sunil G. Sheth, MD,1 Mandeep Sawhney, MD1 Boston, Massachusetts, USA
Background: The American Heart Association (AHA) guidelines from 2007 and the American Society for Gastrointestinal Endoscopy (ASGE) guidelines from 2008 recommended against antibiotic prophylaxis before GI endoscopic procedures to prevent bacterial endocarditis. Objective: To determine physician knowledge regarding these guidelines and to identify physician subgroups for which knowledge was suboptimal. Design: A survey questionnaire was developed based on AHA and ASGE guidelines regarding antibiotics before endoscopy. Physicians were queried about 10 theoretical scenarios as to whether or not they would recommend before-procedure antibiotics. Setting: The survey was administered at 3 academic medical centers. Participants: Attending physicians and trainees in primary care and subspecialties. Interventions: Survey. Main Outcome Measurements: Percentage of the survey questions answered correctly and predictors of correct response. Results: The survey was administered to 941 participants of whom 12 declined to participate. Eighty percent (n Z 740/929) of participants completed the survey. The median number of correct answers was 70% (interquartile range [IQR] 50%-90%) and was similar at each institution (P Z .6). A total of 7.3% (n Z 54) of respondents answered all questions correctly. There was no significant difference in correct responses between attending physicians and trainees or between study centers (median 7, IQR 5-9; P Z .75). Gastroenterologists were more likely to answer questions correctly than other subspecialists or primary care physicians (P ! .0001). On multivariate analysis, physician knowledge correlated directly with self-reported familiarity with guidelines (0.21; 95% confidence interval [CI], 0.08-0.34; P Z .002) and specialty (0.56; 95% CI, 0.30-0.82; P ! .001) and inversely with year of medical school graduation (0.22; 95% CI, 0.07-0.37; P Z .005). Limitations: Survey study that used theoretical scenarios. Conclusion: Physician knowledge of guidelines regarding antibiotic use before endoscopy is suboptimal. Further interventions are needed to improve the knowledge of before-procedure guidelines. (Gastrointest Endosc 2015;-:1-8.)
Open-access endoscopy allows patients to be referred by physicians other than gastroenterologists for GI procedures and has evolved as a means to improve the efficiency of
scheduling for colorectal cancer screening.1 Most openaccess referrals are from primary care physicians who can send patients directly to endoscopy without gastroenterology
Abbreviations: AHA, American Heart Association; ASGE, American Society for Gastrointestinal Endoscopy.
Current affiliations: Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (1), Department of Medicine, University of Massachusetts Memorial Medical Center, University of Massachusetts Medical School, Worcester, Massachusetts (2),
DISCLOSURE: All authors disclosed no financial relationships relevant to this article. Copyright ª 2015 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 http://dx.doi.org/10.1016/j.gie.2015.01.018 Received July 25, 2014. Accepted January 4, 2015.
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consultation.1 The referring physician assumes responsibility for discussing before-endoscopy medical issues, including the use of antibiotic prophylaxis, if indicated. Appropriate antibiotic prescribing practices are a key factor in ensuring quality and safe endoscopy, and inappropriate antibiotic usage may impart unintended consequences that can affect the quality of care and increase risks of adverse events. Endoscopy is believed to be associated with very low rates of bacteremia. In 1997, after a series of studies estimated the rate of bacteremia after gastroscopy to range from 0% to 8% (mean 4.4%) and from 0% to 25% (mean 4.4%) after colonoscopy,2,3 the American Heart Association (AHA) guidelines recommended prophylactic antibiotics before all endoscopic procedures to reduce the risk of bacterial endocarditis. More recent studies, however, noted that the risk of endocarditis from GI procedures was reported in only 15 case reports.2,4 In response, the AHA revised their guidelines to no longer recommend antibiotic prophylaxis before endoscopic procedures. In their recommendations, the AHA noted that overall risk of a transient bacteremia from daily activities such as tooth brushing, flossing, toothpicks, and chewing food all cause transient bacteremia at higher rates than endoscopy, with a range from 7% to 68%.2 Furthermore, it is now recognized that use of prophylactic antibiotics incurs risks of anaphylaxis and other adverse events, including the development of Clostridium difficile infection as well as antibiotic resistance.5 We reviewed the current American Society for Gastrointestinal Endoscopy (ASGE) guidelines to determine the standard of care for antibiotics before endoscopy. The current guidelines do not recommend antibiotics for routine colonoscopy or gastroscopy, except in cases of gastrostomy tube placement and in patients with cirrhosis experiencing upper GI bleeding.2 The current guidelines differ from the past guidelines and no longer recommend antibiotic usage solely to reduce the risk of endocarditis.2 Given the change in evidence and importance of maintaining a safe medical system for endoscopic practice, we sought to evaluate the overall knowledge and practices of gastroenterologists and referring physicians for endoscopic procedures regarding the recommendations for or against use of antibiotics before endoscopic procedures. We also sought to determine any variables related to physician medical training and clinical practice that would predict better knowledge of current guidelines.
METHODS A survey questionnaire was developed by using the ASGE guidelines published in 2008 for antibiotic prophylaxis before GI endoscopy and the AHA prevention of infective endocarditis guidelines.2,5 The guidelines were reviewed by 4 authors (J.D.F., S.S., S.G.S., M.S.) to develop unambiguous questions. Ten before-endoscopy questions 2 GASTROINTESTINAL ENDOSCOPY Volume
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of theoretical patients with varying medical histories were developed to survey clinicians as to whether or not they would recommend for or against antibiotic use before gastroscopy or colonoscopy. A Likert scale of 1 to 5 was used to assess familiarity with the current guidelines. Demographic information regarding level of training, board certification, involvement in teaching trainees, percentage of time spent in clinical practice, year of graduation from medical school, and location of medical school were all assessed. Supplementary Table 1 (Appendix 1, available online at www.giejournal.org) shows the survey questionnaire. Physicians were asked to answer the questions based on their current knowledge and how they would advise their patients. Physicians were allowed to use additional resources (eg, Web sites or textbooks) if needed to answer the questions. However, physicians were not specifically advised to review and/or check other resources before answering the questions. The survey was first piloted at an academic medical center not included in this study. Eight gastroenterology fellows were asked to answer the survey questions and provide recommendations regarding clarity and accuracy of the questions and answers. No changes were advised. The survey was administered at 3 major academic medical centers in Massachusetts. One center is a 496-bed safety-net hospital affiliated with Boston University, another is a 649-bed Harvard-affiliated academic medical center in Boston, and the third is a 417-bed academic center serving Western Massachusetts and affiliated with the University of Massachusetts. Each site has a robust internal medicine residency program and internal medicine subspecialties. The 3 sites were chosen given their distinct patient populations and missions. Paper and online versions of the survey were created. Surveys were either handed out at conferences or sent via e-mail invitation by using the Research Electronic Data Capture (REDCap) survey database (Vanderbilt University, Nashville, Tenn).6 Study data were collected and managed by using REDCap electronic data capture tools hosted at Beth Israel Deaconess Medical Center. REDCap is a secure, Web-based application designed to support data capture for research studies, provide an intuitive interface for validated data entry, and audit trails for tracking data manipulation and export procedures and procedures for importing data from external sources.6 Up to 3 e-mail reminders were sent. All respondents were included except for those responding to the survey e-mail declining the invitation or those with an away message defaulted during the survey invitation period. All data were obtained anonymously. Statistical analysis included univariate and multiple logistic regression performed by using JMP Pro 10.0.0 (2012, SAS Institute, Inc, Cary, NC). Predictors of correct survey responses were first assessed by using univariate analysis, with a P value of .10 on chi-square testing used as the prespecified threshold for inclusion into the multivariate www.giejournal.org
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941 surveys administered
Institution A
Institution B
Institution C
487 surveys administered
276 surveys administered
178 surveys administered
216 responded (79%)
150 responded (84%)
7 Attendings declined
2 Attendings declined
1 Attending & 1 Resident autoaway emails for all emails
1 Attending autoaway email for all emails
374 responded (78%)
Figure 1. Inclusion and exclusion of participants.
analysis. Previously specified subgroup analyses included stratification by level of training. In the graphic representation of mean correct responses by graduation year, the line of best fit was produced by using a quadratic transformation. To study the association between participant characteristics and knowledge of guidelines, a regression model was created. Proportion of correct answers served as the outcome variable. Participant characteristics included level of training, board certification, involvement in teaching trainees, percentage of time spent in clinical practice, year of graduation from medical school, and location of medical school. These were all entered into the model as independent variables. Variable collinearity was assessed with variance inflation factor analysis, with a previously specified upper bound of 10 to denote collinearity. However, no variable’s value was O1.5. Year of medical school graduation was a nonlinear continuous variable that was transformed into a nominal variable after graphic depiction revealed a binary fit for graduation in the decade between 2000 and 2010 compared with all others. Variables significant at a P value ! .10 were then entered into a multivariate regression model. This study was approved by the institutional review boards at each of the 3 study medical centers. All authors had access to the study data and approved the final manuscript.
RESULTS In total, 941 surveys were administered. A total of 9 attending physicians declined to participate, and 2 attending physicians and 1 trainee had an automatic out-of-office e-mail response during the survey period www.giejournal.org
and were excluded. Of the remaining 929 surveys, 740 respondents completed the survey. When broken down by institution, responses were 78% (n Z 374/479) from institution A, 79% (n Z 216/273) from institution B, and 84% (150/178) from institution C. There was no significant difference among institutions regarding survey completion (P Z .59). Figure 1 shows inclusion and exclusion criteria.
Demographics Table 1 shows complete demographic characteristics. Eighty percent (740/930) of eligible respondents answered the survey completely. Forty-eight percent (357/740) of respondents were attending physicians. The median year of graduation from medical school was 2006 (range 19542013). Eighty-four percent (598/712) of respondents reported graduating from a United States medical school, and 89% (319/357) of attending physicians reported board certification in internal medicine. The Likert score was 3 (range 1-5) for median self-reported familiarity with the current guideline recommendations regarding antibiotics before endoscopy.
Responses The median of correct responses for the entire survey was 7 (interquartile range [IQR] 5-9). The median correct responses were as follows: institution A, 7 (IQR 5-9); institution B, 7 (IQR 6-9); and institution C, 7 (IQR 5-8). There was no significant difference between the correct answers from the 3 institutions (P Z .6). Only 54 (7.3%) respondents answered all 10 questions correctly. A total of 139 (18.7%) answered 90% correctly, 90 (12.2%) answered 80% correctly, 123 (16.6%) answered 70% correctly, 130 (17.6%) answered 60% correctly, 114 (15.4%) Volume
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TABLE 1. Demographics information of survey respondents
Total n [ 740 (%)
Attending physicians n [ 357 (%)
Trainees n [ 383 (%)
Medical center A
374 (51)
213 (57)
161 (43)
Medical center B
216 (29)
73 (34)
143 (66)
Variable
Medical center C
150 (20)
71 (47)
79 (53)
2006 (1954-2013)
1995 (1954-2010)
2010 (1995-2013)
U.S. medical school graduates
598 (84)
293 (49)
305 (51)
International medical school graduates
114 (16)
60 (53)
54 (47)
Attending physician internal medicine board certification
NA
319 (89)
NA
Year of graduation from medical school, median (range)
Internal medicine/primary care
463 (64)
171 (37)
292 (63)
Cardiology
53 (7)
29 (55)
24 (45)
Family medicine
46 (6)
26 (57)
20 (43)
Geriatrics
19 (3)
14 (74)
5 (26)
Infectious diseases
38 (5)
24 (63)
14 (37)
Gastroenterology
66 (9)
49 (74)
17 (26)
Hospital medicine
43 (6)
42 (98)
1 (2)
Pulmonary medicine
1 (0)
1 (100)
0 (0)
NA, not applicable.
answered 50% correctly, 62 (8.4%) answered 40% correctly, 23 (3.1%) answered 30% correctly, and 5 (0.7%) answered 20% correctly. Figure 2 gives the answers to each question by attending physicians and trainees. Supplementary Tables 2 and 3 (available online at www.giejournal.org) show the correct answers by level of training, institution, and Likert score.
Attending physicians versus trainees There was no significant difference between the median of correct responses to the questions between attending physicians (median 7, IQR 5-9) and trainees (median 7, IQR 5-9) (P Z .75). Similarly, there was no significant difference when data were analyzed between attendings and trainees based on institution (institution A, P Z .5; institution B, P Z .6; institution C, P Z .6).
Specialty Data were further analyzed by specialty and level of training (eg, attending physician vs trainee). The highest median scores for attending physicians were 9 among gastroenterologists (IQR 7-10) followed by 7 for infectious disease specialists, hospitalists, and cardiologists. In contrast, the highest median scores for trainees were 10 for gastroenterology trainees and 9 for infectious disease specialists and geriatrics trainees. Supplementary Table 4 (available online at www.giejournal.org) gives a breakdown by specialty. 4 GASTROINTESTINAL ENDOSCOPY Volume
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When we analyzed the data compared with that of gastroenterologists, attending gastroenterologists answered a median of 8 (IQR 7-9) questions correctly compared with a median of 7 (IQR 5-8) among those other than gastroenterology attending physicians (P! .0001). Similarly, gastroenterology fellows answered a median of 10 (IQR 7.5-10) questions correctly compared with a median of 7 (IQR 5-8) among trainees in other specialties (P ! .0001).
Predictors of response All demographic data were analyzed for predictors of the outcome variable of all questions answered correctly. In analysis of the 740 responses, univariate analysis was significant for self-reported familiarity with current guidelines (0.32; 95% confidence interval [CI], 0.20-0.44; P ! .0001), specialty (0.72; 95% CI, 0.48-0.96; P ! .0001), and year of graduation from medical school (0.26; 95% CI, 0.11-0.41; P Z .0009). Multivariate analysis revealed statistical significance for self-reported familiarity with current guidelines (0.21; 95% CI, 0.08-0.34; P Z .002), specialty (0.56; 95% CI, 0.30-0.82; P! .0001), and year of graduation from medical school (0.22; 95% CI, 0.07-0.37; P Z .005) (Table 2).
Predictors of response by level of training In post hoc analysis, data were analyzed for differences among attending physicians and trainees. Significant findings on univariate analysis for attending physician respondents were self-reported individual familiarity with current guidelines (0.39; 95% CI, 0.22-0.57; P ! .0001), www.giejournal.org
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100%
90%
80%
70%
60%
50%
99% 100%
99% 100%
96% 95% 83% 83%
40%
84% Trainees
74%
71%
AƩendings
61%
30% 54% 44%
20%
41%
42%
38%
36% 30%
35%
10%
0% No medical history
Hip Dysphagia RheumaƟc Bacterial Bacterial Mechanical Vascular graŌ Coronary replacement heart disease endocardiƟs endocardiƟs aorƟc valve placed 1 year artery 6 months with mitral 6 months ago placed 6 ago disease with 6 months ago valve stenosis ago. DilaƟon months ago angioplasty of known and stent esophageal placement 6 stricture is months ago planned
Esophageal cancer with dysphagia - a PEG tube is going to be placed
Figure 2. Answers to survey questions by attending physicians and trainees.
specialty (0.63; 95% CI, 0.34-0.34; P ! .0001), and current teaching and/or supervising of trainees (0.30; 95% CI, 0.030.58; P Z .03). In multivariate analysis, both self-reported individual familiarity with current guidelines (0.28; 95% CI, 0.09-0.47; P Z .005) and specialty (0.41; 95% CI, 0.09-0.73; P Z .01) remained significant (Table 2). In evaluation among trainees, the following variables were significant on univariate analysis: self-reported individual familiarity with current guidelines (0.33; 95% CI, 0.15-0.50; P Z .0004), specialty (1.08; 95% CI, 0.64-1.53; P ! .0001), year of graduation from medical school (0.35; 95% CI, 0.15-0.56; P ! .0009), and the current postgraduate year level of training (0.31; 95% CI, 0.20-0.41; P ! .0001). In multivariate analysis, only specialty (0.65; 95% CI, 0.19-1.12; P Z .006) and current postgraduate year level of training (0.25; 95% CI, 0.11-0.39; P Z .0007) remained significant (Table 2). We found a strong association between year of graduation from medical school and our primary outcome of answering all the questions correctly. The longer the interval since graduation from medical school, the less likely physicians were to answer correctly (Supplementary Fig. 1, available online at www.giejournal.org). The odds of correctly answering questions increased by 3% (95% CI, 0.0160.052; P Z .0002) for every subsequent year of graduation since 1950. Figure 3A shows the inflection point at year 1995 to 2000. In contrast, in evaluation of trainees, there was a direct relationship with postgraduate year and odds of answering questions correctly. Each postgraduate year was associated with a 3% (95% CI, 0.20-0.41; P ! .0001) increased odds of answering questions correctly (Fig. 3B). www.giejournal.org
DISCUSSION Our study indicates poor knowledge of the current recommendations regarding the use of antibiotics before endoscopy, despite updating of the published guidelines in 2008. In the most routine scenario, in patients with no significant medical history, nearly all physicians correctly opted against using antibiotics, but in patients with any relevant comorbidities, the knowledge was clearly inadequate. The incorrect answers were similar among attending physicians and trainees and at the 3 different academic medical centers where the survey was administered. As a group, gastroenterologists answered the most questions correctly. The only subgroup with a near-perfect response to the clinical scenarios was gastroenterology fellows. This group incorporates trainees who started and completed residency training during the time period when the new guidelines changed and recommended against antibiotic use. This group also trained in the era of increased awareness of antibiotic resistance and adverse events like Clostridium difficile infection. The Institute of Medicine defines practice guidelines as, “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”7 Guidelines are meant to review the current medical literature and succinctly provide the clinician with evidence-based recommendations to better care for their patients.7 Practice guidelines are meant to create a safer medical system.8,9 However, when guidelines are not followed, the safety of the healthcare system may be at risk. In our study, the decision to Volume
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TABLE 2. Univariate and multivariate analysis of predictors of correct responses to all survey questions Univariate analysis
Multivariate analysis
Coefficient (b)
95% CI
P value
Coefficient (b)
95% CI
P value
Self-reported individual familiarity with current guidelines
0.32
0.20-0.44
P ! .0001
0.21
0.08-0.34
P Z .002
Level of training (attending physician vs trainee)
0.05
-0.19-0.09
P Z .50
Specialty (compared with gastroenterologists)
0.72
0.48-0.96
P ! .0001
0.56
0.30-0.82
P ! .0001
Year of graduation from medical school
0.26
0.11-0.41
P Z .0009
0.22
0.07-0.37
P Z .005
Location of medical school (U.S. vs international)
0.11
-0.08-0.31
P Z .24
Self-reported individual familiarity with current guidelines
0.39
0.22-0.57
P ! .0001
0.28
0.09-0.47
P Z .005
Specialty (compared with gastroenterologists)
0.63
0.34-0.34
P ! .0001
0.41
0.09-0.73
P Z .01
Year of graduation from medical school
0.16
-0.06-0.39
P Z .15
Location of medical school (U.S. vs international)
0.14
-0.13-0.42
P Z .31
Percentage of time spent in direct patient care
-0.01
-0.14-0.11
P Z .80
Current teaching/supervising residents or fellows
0.30
0.03-0.58
P Z .03
0.16
-0.11-0.43
P Z .24
Board certification in internal medicine
0.19
-0.15-0.53
P Z .30
Self-reported individual familiarity with current guidelines
0.33
0.15-0.50
P Z .0004
0.12
-0.08-0.31
P Z .23
Specialty (compared with gastroenterologists)
1.08
0.64-1.53
P ! .0001
0.65
0.19-1.12
P Z .006
Year of graduation from medical school
0.35
0.15-0.56
P ! .0009
0.07
-0.19-0.33
P Z .60
Location of medical school (U.S. vs international)
0.09
-0.18-0.36
P Z .50
Level of training (postgraduate year)
0.31
0.20-0.41
P ! .0001
0.25
0.11-0.39
P Z .0007
All respondents
Attending physicians
Trainees
CI, Confidence interval.
deviate from these practice guidelines is unclear. Comments provided by respondents are included in Supplementary Table 5 (available online at www.giejournal.org). Some respondents noted a distrust of the guideline development process, and therefore, they do not view guidelines as standard of care. Others cited a lack of current knowledge in the guidelines and need to look them up as needed, and other respondents believed beforeendoscopy antibiotics should not be the responsibility of the referring physician. Although our study did not assess the actual causes of deviations from practice guidelines, 6 GASTROINTESTINAL ENDOSCOPY Volume
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possible causes include educational deficits, failure to publicize and/or justify updated practice guidelines, or views that current guidelines are flawed.10 Further studies are necessary to evaluate the root causes underlying this problem and to initiate steps to improve compliance with current practice guidelines. It is often presumed that with increasing number of years in practice, physician knowledge and expertise increases. However, Choudhry et al11 reviewed studies assessing knowledge and quality of care based on physician age or years since graduation. Fifty-two percent of the www.giejournal.org
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The Number of Correct Answers is Inversely Related to Time in Practice
The Number of Correct Answers is Proportional to Post-Graduate Year Among Trainees
OUTCOME
10
(OUTCOME) OUTCOME
10 9 Number of Correct Responses
Number of Correct Answers
9 8 7 6 5 4
A
8 7 6 5 4
3
3
2
2 1950
1960
1990 2000 1970 1980 Year of Medical School Graduation
2010
B
0
1
2
3
4 5 Post-Graduate Year
6
7
8
9
Figure 3. A, Year of graduation from medical school and odds of answering questions correctly. B, Trainee postgraduate year of training and odds of answering questions correctly.
studies reviewed reported a decrease in physician performance with increasing age and years since medical school graduation in all areas evaluated: overall knowledge; compliance with standards of care for diagnosis, screening, or prevention; compliance with standards of care for therapy; and health outcomes. Ultimately, Choudhry et al11 concluded that physicians who have been in practice more years as well as older physicians have less factual knowledge and are less likely to follow accepted standards of care.11 Similarly, in our study, physicians who trained before 2000 performed worse than physicians who trained after 2000. Interestingly, in our study we noted that physicians who were still developing their “toolbox” of care also did poorly when they were within 3 years of graduating from medical school (Fig. 3B). To rectify this problem, it is critical for physicians to continue earning continued medical education throughout their career to update their toolbox with new recommendations. In our study, guiding forces for physician decisions to deviate from practice guidelines regarding antibiotic prophylaxis is unclear. Although our survey did not address this issue directly, studies have noted that adult learning approaches dictate that adults are more likely to adopt change if they experience a problem.10 In endoscopy, the old recommendations were based on case reports of adverse events and physician experience.2,5 Adoption of current practice guidelines requires physicians to forgo individual experience for more extensively reviewed literature. This requires adoption and acceptance from physicians and patients despite antibiotics being viewed by many as protecting against harm. One of the most difficult practices to change is to reduce the degree of intervention being provided.12 Nonetheless, depending on the underlying cause of poor compliance with guidelines, there are multiple ways to improve care. As noted in our study, overall familiarity of guidelines was predictive of www.giejournal.org
correct answers. To that end, educational sessions on updates to practice guidelines and institutions instituting policies consistent with practice guidelines may improve compliance. Additionally, electronic record systems can be used to trigger alerts that antibiotics are no longer recommended when patients are referred for endoscopic procedures. Alternatively, providing incentives and auditing compliance can improve care. Last, directly educating patients about the guidelines also has been successful.10,13 The most effective methods, though, are multifaceted approaches and include a combination of these methods.13 Our study has few limitations. It is a survey study and does not incorporate actual clinical practice. However, the scenario questions should have been answered correctly. Our study was multicentered, so individual institution practice bias should not have affected our study results. This study does not take into consideration patient preference or recommendations from nurses at the endoscopy intake interview. Currently, there is poor knowledge among physicians other than gastroenterologists regarding the clinical practice guidelines for antibiotic use before endoscopy. Further studies are necessary to determine the causes of this knowledge gap among referring physicians. In order to improve the safety of endoscopy, improved knowledge and compliance with current practice guidelines is critical. REFERENCES 1. Eisen GM, Baron TH, Dominitz JA, et al. Open access endoscopy. Gastrointest Endosc 2002;56:793-5. 2. Banerjee S, Shen B, Baron TH, et al. Antibiotic prophylaxis for GI endoscopy. Gastrointest Endosc 2008;67:791-8. 3. Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis: recommendations by the American Heart Association. Circulation 1997;96:358-66.
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4. Nelson DB. Infectious disease complications of GI endoscopy: Part I, endogenous infections. Gastrointest Endosc 2003;57:546-56. 5. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007;116: 1736-54. 6. Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap)da metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Informat 2009;42:377-81. 7. Committee on Clinical Practice Guidelines. Institute of Medicine. Guidelines for clinical practice: from development to use. Washington, DC: The National Academies Press; 1992. 8. World Health Organization. Guidelines for WHO guidelines, v. 10. Geneva: World Health Organization; 2003. p.1-23; Global Programme on Evidence for Health Policy http://whqlibdoc.who.int/hq/2003/EIP_ GPE_EQC_2003_1.pdf. Accessed October 15, 2014. 9. Committee on Quality of Health Care in America; Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century, 1st ed. Washington, DC: National Academies Press; 2001.
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10. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet 2003;362:1225-30. 11. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med 2005;142:260-73. 12. Greer AL. The state of the art versus the state of the science. The diffusion of new medical technologies into practice. Int J Technol Assess Health Care 1988;4:5-26. 13. Bero LA, Grilli R, Grimshaw JM, et al. Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. BMJ 1998;317:465-8.
Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (3), Department of Medicine and Division of Gastroenterology, University of Washington, University of Washington School of Medicine, Seattle, Washington, USA (4). Reprint requests: Dr Joseph D. Feuerstein, Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street 8E Gastroenterology, Boston, MA 02215. If you would like to chat with an author of this article, you may contact Dr Feuerstein at [email protected].
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APPENDIX 1
Supplementary Table 1. Complete survey questionnaire with correct answers in yellow boxes
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Supplementary Table 1. (Continued)
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SUPPLEMENTARY TABLE 2. Correct answers by training and medical center No. of questions answered correctly, no. 0-1
All respondents n [ 740(%)
Attending physicians n [ 357(%)
Trainees n [ 383(%)
Center A n [ 374(%)
Center B n [ 216(%)
Center C n [ 150(%)
0
0
0
0
0
0
2
5 (1)
3 (1)
2 (1)
3 (1)
1 (0)
1 (1)
3
23 (3)
14 (4)
9 (2)
12 (3)
7 (3)
4 (3)
4
62 (8)
33 (9)
29 (8)
37 (10)
14 (6)
11 (7)
5
114 (15)
50 (14)
64 (17)
60 (16)
29 (13)
25 (17)
6
130 (18)
63 (18)
67 (17)
60 (16)
45 (21)
25 (17)
7
123 (17)
62 (17)
61 (16)
58 (16)
32 (15)
33 (22)
8
89 (12)
35 (10)
54 (14)
39 (10)
33 (15)
17 (12)
9
139 (19)
72 (20)
67 (17)
79 (21)
37 (17)
23 (15)
10
54 (7)
24 (7)
30 (8)
26 (7)
18 (8)
10 (7)
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SUPPLEMENTARY TABLE 3. Correct answers based on Likert score Likert score
Median no. correct
Median no. correct for attending physicians
Median no. correct for trainees
Trainee level of training, postgraduate year
Median no. correct
1
6
6
7
1
2
2
7
6
7
2
2
3
7
6
7
3
2
4
8
8
9
4
3
5
8
9
7
5
3
6
3
7
4
8
2
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SUPPLEMENTARY TABLE 4. Answers based on specialty and level of training All respondents, n [ 728 % Correct per No. specialty Internal medicine/ primary care
463
60
Median no. correct (range) 6 (2-10)
Attending physicians, n [ 355 % Correct per No. specialty 171
Median no. correct (range)
60
6 (3-10)
Trainees, n [ 373 % Correct per No. specialty 292
65
Median no. correct (range) 6.5 (2-10)
Cardiology
53
70
7 (4-10)
29
70
7 (4-10)
24
70
7 (4-10)
Family medicine
46
60
6 (2-10)
26
60
6 (2-10)
20
70
7 (3-10)
Geriatrics
19
60
6 (2-9)
14
50
5 (2-9)
5
90
9 (3-9)
Infectious diseases
38
75
7.5 (3-10)
24
70
7 (3-10)
14
90
9 (5-10)
Gastroenterology
65
90
9 (2-10)
48
80
8 (2-10)
17
100
10 (6-10)
Hospital medicine
43
70
7 (3-10)
42
70
7 (3-10)
1
80
8 (8)
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SUPPLEMENTARY TABLE 5. Comments by survey respondents Category of comment
Comments
Lack of active knowledge of current guidelines
Although I don’t know the answer to some of these, I would generally look it up on Up To Date. I look this up if I have any doubt. Admittedly, it was hard not to “cheat” and look on Up To Date or AGA society guidelines. I would presume that many general internists do not keep all of this information in their minds, but know where/how to look it up easily. I realized I really don’t know the guidelines. I would look these things up if I encountered some of these situations. In reading this I realize that I am no longer sure whether colonoscopy is currently considered a bacteremia-prone procedure. I answered assuming it was, but I realize that may not be the case, and will now check. I know WHERE to find the answers, but for most of these scenarios I would want to look up best current practices before giving a patient a recommendation. I would love some information on the current guidelinesdonce I started to answer the questions I realized I wasn’t that familiar with them. I would look up for questions. I would look this up on Up To Date Many of these questions I would normally look up and not necessarily expect a general medicine doctor to remember off hand. I usually try to look up guidelines before I tell patients what to do, so would in all of the above cases.
Lack of trust in guidelines
I realize my responses may not reflect the most recent AHA guidelines for antibiotic prophylaxis, and are driven more from clinical experience, and off line discussions with some of those involved with the guidelines. The use of antibiotics has on a practical level not always followed what I understood to be guidelines, and this may have affected my understanding and recall of the guidelines. Current guidelines may be too conservative. I do not always follow the guidelines for endocarditis prophylaxis with respect to very high risk patients undergoing colonoscopy with probable biopsy (known polyps), especially if they have been taking prophylaxis for decades (eg, mechanical valve, prior endocarditis with severe valvular disease). Sometimes fear trumps the current guidelines; depends on whether your last patient developed endocarditis vs anaphylaxis from the antibiotic! YesdI think this is not a well-designed questionnaire because the clinical context is frequently NOT so black and white, and both the history and the recommendations may vary. My practice for years is to contact the relevant specialists who actually know the complicated patients by e-mail to decide on pre-procedure prescription. And orthopedists vary greatly on recommendations for antibiotics after hip and knee replacements in spite of the standard recommendations. FYI, I have cared for a very sick patient population for years and have had no patients develop endocarditis or joint infections following GI procedures. My point is, customized analysis is preferable to a minimized checklist for high risk patients. Guidelines are generally not based on good data.
Someone else is responsible for before-procedure decisions
I thought a lot of this is discussed when a patient schedules the procedure. I think it would be advisable to refer to GI first prior to procedure. They are specialists and the ones doing the procedures. I defer decisions regarding antibiotic agents to the endoscopist, so do not use the guidelines in my practice. I have no idea what the guidelines are on this subject and would love to have it left to the gastroenterologists.
Miscellaneous comments
I answered these questions based upon guidelines as I understand them for endocarditis and prosthetic joint infections. There may be procedure-specific guidelines related to local infection that would not be patient specific and would be, I think, purely under GI control. ARE there clear “evidence based” guidelines for most of this stuff or are they “CRICO” based guidelines??? Seems to be ongoing differences between orthopedic recommendations and cardiology recommendations. Doesn’t make sense. Ok, So I guess I really don’t know these guidelines at all. Please teach us primary care physicians about what to do with antibiotics before procedures. It would be good for me to know more about the guidelines! I need to learn this stuff better! Interesting. U.S. guidelines vague regarding antibiotic prophylaxis. British [’NICE]: None.
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Supplementary Figure 1. Correct answers based on year of medical school graduation
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Current knowledge of antibiotic prophylaxis guidelines regarding GI open-access endoscopic procedures is inadequate Joseph David Feuerstein, MD,1 Saurabh Sethi, MD,1 Elliot B. Tapper, MD,1 Edward Belkin, MD,2 Jeffrey J. Lewandowski, BA,3 Anand Singla, MD,4 Sunil G. Sheth, MD,1 Mandeep Sawhney, MD1 Boston, Massachusetts, USA
Background: The American Heart Association (AHA) guidelines from 2007 and the American Society for Gastrointestinal Endoscopy (ASGE) guidelines from 2008 recommended against antibiotic prophylaxis before GI endoscopic procedures to prevent bacterial endocarditis. Objective: To determine physician knowledge regarding these guidelines and to identify physician subgroups for which knowledge was suboptimal. Design: A survey questionnaire was developed based on AHA and ASGE guidelines regarding antibiotics before endoscopy. Physicians were queried about 10 theoretical scenarios as to whether or not they would recommend before-procedure antibiotics. Setting: The survey was administered at 3 academic medical centers. Participants: Attending physicians and trainees in primary care and subspecialties. Interventions: Survey. Main Outcome Measurements: Percentage of the survey questions answered correctly and predictors of correct response. Results: The survey was administered to 941 participants of whom 12 declined to participate. Eighty percent (n Z 740/929) of participants completed the survey. The median number of correct answers was 70% (interquartile range [IQR] 50%-90%) and was similar at each institution (P Z .6). A total of 7.3% (n Z 54) of respondents answered all questions correctly. There was no significant difference in correct responses between attending physicians and trainees or between study centers (median 7, IQR 5-9; P Z .75). Gastroenterologists were more likely to answer questions correctly than other subspecialists or primary care physicians (P ! .0001). On multivariate analysis, physician knowledge correlated directly with self-reported familiarity with guidelines (0.21; 95% confidence interval [CI], 0.08-0.34; P Z .002) and specialty (0.56; 95% CI, 0.30-0.82; P ! .001) and inversely with year of medical school graduation (0.22; 95% CI, 0.07-0.37; P Z .005). Limitations: Survey study that used theoretical scenarios. Conclusion: Physician knowledge of guidelines regarding antibiotic use before endoscopy is suboptimal. Further interventions are needed to improve the knowledge of before-procedure guidelines. (Gastrointest Endosc 2015;-:1-8.)
Open-access endoscopy allows patients to be referred by physicians other than gastroenterologists for GI procedures and has evolved as a means to improve the efficiency of
scheduling for colorectal cancer screening.1 Most openaccess referrals are from primary care physicians who can send patients directly to endoscopy without gastroenterology
Abbreviations: AHA, American Heart Association; ASGE, American Society for Gastrointestinal Endoscopy.
Current affiliations: Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (1), Department of Medicine, University of Massachusetts Memorial Medical Center, University of Massachusetts Medical School, Worcester, Massachusetts (2),
DISCLOSURE: All authors disclosed no financial relationships relevant to this article. Copyright ª 2015 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 http://dx.doi.org/10.1016/j.gie.2015.01.018 Received July 25, 2014. Accepted January 4, 2015.
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(footnotes continued on last page of article)
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consultation.1 The referring physician assumes responsibility for discussing before-endoscopy medical issues, including the use of antibiotic prophylaxis, if indicated. Appropriate antibiotic prescribing practices are a key factor in ensuring quality and safe endoscopy, and inappropriate antibiotic usage may impart unintended consequences that can affect the quality of care and increase risks of adverse events. Endoscopy is believed to be associated with very low rates of bacteremia. In 1997, after a series of studies estimated the rate of bacteremia after gastroscopy to range from 0% to 8% (mean 4.4%) and from 0% to 25% (mean 4.4%) after colonoscopy,2,3 the American Heart Association (AHA) guidelines recommended prophylactic antibiotics before all endoscopic procedures to reduce the risk of bacterial endocarditis. More recent studies, however, noted that the risk of endocarditis from GI procedures was reported in only 15 case reports.2,4 In response, the AHA revised their guidelines to no longer recommend antibiotic prophylaxis before endoscopic procedures. In their recommendations, the AHA noted that overall risk of a transient bacteremia from daily activities such as tooth brushing, flossing, toothpicks, and chewing food all cause transient bacteremia at higher rates than endoscopy, with a range from 7% to 68%.2 Furthermore, it is now recognized that use of prophylactic antibiotics incurs risks of anaphylaxis and other adverse events, including the development of Clostridium difficile infection as well as antibiotic resistance.5 We reviewed the current American Society for Gastrointestinal Endoscopy (ASGE) guidelines to determine the standard of care for antibiotics before endoscopy. The current guidelines do not recommend antibiotics for routine colonoscopy or gastroscopy, except in cases of gastrostomy tube placement and in patients with cirrhosis experiencing upper GI bleeding.2 The current guidelines differ from the past guidelines and no longer recommend antibiotic usage solely to reduce the risk of endocarditis.2 Given the change in evidence and importance of maintaining a safe medical system for endoscopic practice, we sought to evaluate the overall knowledge and practices of gastroenterologists and referring physicians for endoscopic procedures regarding the recommendations for or against use of antibiotics before endoscopic procedures. We also sought to determine any variables related to physician medical training and clinical practice that would predict better knowledge of current guidelines.
METHODS A survey questionnaire was developed by using the ASGE guidelines published in 2008 for antibiotic prophylaxis before GI endoscopy and the AHA prevention of infective endocarditis guidelines.2,5 The guidelines were reviewed by 4 authors (J.D.F., S.S., S.G.S., M.S.) to develop unambiguous questions. Ten before-endoscopy questions 2 GASTROINTESTINAL ENDOSCOPY Volume
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of theoretical patients with varying medical histories were developed to survey clinicians as to whether or not they would recommend for or against antibiotic use before gastroscopy or colonoscopy. A Likert scale of 1 to 5 was used to assess familiarity with the current guidelines. Demographic information regarding level of training, board certification, involvement in teaching trainees, percentage of time spent in clinical practice, year of graduation from medical school, and location of medical school were all assessed. Supplementary Table 1 (Appendix 1, available online at www.giejournal.org) shows the survey questionnaire. Physicians were asked to answer the questions based on their current knowledge and how they would advise their patients. Physicians were allowed to use additional resources (eg, Web sites or textbooks) if needed to answer the questions. However, physicians were not specifically advised to review and/or check other resources before answering the questions. The survey was first piloted at an academic medical center not included in this study. Eight gastroenterology fellows were asked to answer the survey questions and provide recommendations regarding clarity and accuracy of the questions and answers. No changes were advised. The survey was administered at 3 major academic medical centers in Massachusetts. One center is a 496-bed safety-net hospital affiliated with Boston University, another is a 649-bed Harvard-affiliated academic medical center in Boston, and the third is a 417-bed academic center serving Western Massachusetts and affiliated with the University of Massachusetts. Each site has a robust internal medicine residency program and internal medicine subspecialties. The 3 sites were chosen given their distinct patient populations and missions. Paper and online versions of the survey were created. Surveys were either handed out at conferences or sent via e-mail invitation by using the Research Electronic Data Capture (REDCap) survey database (Vanderbilt University, Nashville, Tenn).6 Study data were collected and managed by using REDCap electronic data capture tools hosted at Beth Israel Deaconess Medical Center. REDCap is a secure, Web-based application designed to support data capture for research studies, provide an intuitive interface for validated data entry, and audit trails for tracking data manipulation and export procedures and procedures for importing data from external sources.6 Up to 3 e-mail reminders were sent. All respondents were included except for those responding to the survey e-mail declining the invitation or those with an away message defaulted during the survey invitation period. All data were obtained anonymously. Statistical analysis included univariate and multiple logistic regression performed by using JMP Pro 10.0.0 (2012, SAS Institute, Inc, Cary, NC). Predictors of correct survey responses were first assessed by using univariate analysis, with a P value of .10 on chi-square testing used as the prespecified threshold for inclusion into the multivariate www.giejournal.org
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Antibiotic prophylaxis before endoscopy
941 surveys administered
Institution A
Institution B
Institution C
487 surveys administered
276 surveys administered
178 surveys administered
216 responded (79%)
150 responded (84%)
7 Attendings declined
2 Attendings declined
1 Attending & 1 Resident autoaway emails for all emails
1 Attending autoaway email for all emails
374 responded (78%)
Figure 1. Inclusion and exclusion of participants.
analysis. Previously specified subgroup analyses included stratification by level of training. In the graphic representation of mean correct responses by graduation year, the line of best fit was produced by using a quadratic transformation. To study the association between participant characteristics and knowledge of guidelines, a regression model was created. Proportion of correct answers served as the outcome variable. Participant characteristics included level of training, board certification, involvement in teaching trainees, percentage of time spent in clinical practice, year of graduation from medical school, and location of medical school. These were all entered into the model as independent variables. Variable collinearity was assessed with variance inflation factor analysis, with a previously specified upper bound of 10 to denote collinearity. However, no variable’s value was O1.5. Year of medical school graduation was a nonlinear continuous variable that was transformed into a nominal variable after graphic depiction revealed a binary fit for graduation in the decade between 2000 and 2010 compared with all others. Variables significant at a P value ! .10 were then entered into a multivariate regression model. This study was approved by the institutional review boards at each of the 3 study medical centers. All authors had access to the study data and approved the final manuscript.
RESULTS In total, 941 surveys were administered. A total of 9 attending physicians declined to participate, and 2 attending physicians and 1 trainee had an automatic out-of-office e-mail response during the survey period www.giejournal.org
and were excluded. Of the remaining 929 surveys, 740 respondents completed the survey. When broken down by institution, responses were 78% (n Z 374/479) from institution A, 79% (n Z 216/273) from institution B, and 84% (150/178) from institution C. There was no significant difference among institutions regarding survey completion (P Z .59). Figure 1 shows inclusion and exclusion criteria.
Demographics Table 1 shows complete demographic characteristics. Eighty percent (740/930) of eligible respondents answered the survey completely. Forty-eight percent (357/740) of respondents were attending physicians. The median year of graduation from medical school was 2006 (range 19542013). Eighty-four percent (598/712) of respondents reported graduating from a United States medical school, and 89% (319/357) of attending physicians reported board certification in internal medicine. The Likert score was 3 (range 1-5) for median self-reported familiarity with the current guideline recommendations regarding antibiotics before endoscopy.
Responses The median of correct responses for the entire survey was 7 (interquartile range [IQR] 5-9). The median correct responses were as follows: institution A, 7 (IQR 5-9); institution B, 7 (IQR 6-9); and institution C, 7 (IQR 5-8). There was no significant difference between the correct answers from the 3 institutions (P Z .6). Only 54 (7.3%) respondents answered all 10 questions correctly. A total of 139 (18.7%) answered 90% correctly, 90 (12.2%) answered 80% correctly, 123 (16.6%) answered 70% correctly, 130 (17.6%) answered 60% correctly, 114 (15.4%) Volume
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TABLE 1. Demographics information of survey respondents
Total n [ 740 (%)
Attending physicians n [ 357 (%)
Trainees n [ 383 (%)
Medical center A
374 (51)
213 (57)
161 (43)
Medical center B
216 (29)
73 (34)
143 (66)
Variable
Medical center C
150 (20)
71 (47)
79 (53)
2006 (1954-2013)
1995 (1954-2010)
2010 (1995-2013)
U.S. medical school graduates
598 (84)
293 (49)
305 (51)
International medical school graduates
114 (16)
60 (53)
54 (47)
Attending physician internal medicine board certification
NA
319 (89)
NA
Year of graduation from medical school, median (range)
Internal medicine/primary care
463 (64)
171 (37)
292 (63)
Cardiology
53 (7)
29 (55)
24 (45)
Family medicine
46 (6)
26 (57)
20 (43)
Geriatrics
19 (3)
14 (74)
5 (26)
Infectious diseases
38 (5)
24 (63)
14 (37)
Gastroenterology
66 (9)
49 (74)
17 (26)
Hospital medicine
43 (6)
42 (98)
1 (2)
Pulmonary medicine
1 (0)
1 (100)
0 (0)
NA, not applicable.
answered 50% correctly, 62 (8.4%) answered 40% correctly, 23 (3.1%) answered 30% correctly, and 5 (0.7%) answered 20% correctly. Figure 2 gives the answers to each question by attending physicians and trainees. Supplementary Tables 2 and 3 (available online at www.giejournal.org) show the correct answers by level of training, institution, and Likert score.
Attending physicians versus trainees There was no significant difference between the median of correct responses to the questions between attending physicians (median 7, IQR 5-9) and trainees (median 7, IQR 5-9) (P Z .75). Similarly, there was no significant difference when data were analyzed between attendings and trainees based on institution (institution A, P Z .5; institution B, P Z .6; institution C, P Z .6).
Specialty Data were further analyzed by specialty and level of training (eg, attending physician vs trainee). The highest median scores for attending physicians were 9 among gastroenterologists (IQR 7-10) followed by 7 for infectious disease specialists, hospitalists, and cardiologists. In contrast, the highest median scores for trainees were 10 for gastroenterology trainees and 9 for infectious disease specialists and geriatrics trainees. Supplementary Table 4 (available online at www.giejournal.org) gives a breakdown by specialty. 4 GASTROINTESTINAL ENDOSCOPY Volume
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When we analyzed the data compared with that of gastroenterologists, attending gastroenterologists answered a median of 8 (IQR 7-9) questions correctly compared with a median of 7 (IQR 5-8) among those other than gastroenterology attending physicians (P! .0001). Similarly, gastroenterology fellows answered a median of 10 (IQR 7.5-10) questions correctly compared with a median of 7 (IQR 5-8) among trainees in other specialties (P ! .0001).
Predictors of response All demographic data were analyzed for predictors of the outcome variable of all questions answered correctly. In analysis of the 740 responses, univariate analysis was significant for self-reported familiarity with current guidelines (0.32; 95% confidence interval [CI], 0.20-0.44; P ! .0001), specialty (0.72; 95% CI, 0.48-0.96; P ! .0001), and year of graduation from medical school (0.26; 95% CI, 0.11-0.41; P Z .0009). Multivariate analysis revealed statistical significance for self-reported familiarity with current guidelines (0.21; 95% CI, 0.08-0.34; P Z .002), specialty (0.56; 95% CI, 0.30-0.82; P! .0001), and year of graduation from medical school (0.22; 95% CI, 0.07-0.37; P Z .005) (Table 2).
Predictors of response by level of training In post hoc analysis, data were analyzed for differences among attending physicians and trainees. Significant findings on univariate analysis for attending physician respondents were self-reported individual familiarity with current guidelines (0.39; 95% CI, 0.22-0.57; P ! .0001), www.giejournal.org
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100%
90%
80%
70%
60%
50%
99% 100%
99% 100%
96% 95% 83% 83%
40%
84% Trainees
74%
71%
AƩendings
61%
30% 54% 44%
20%
41%
42%
38%
36% 30%
35%
10%
0% No medical history
Hip Dysphagia RheumaƟc Bacterial Bacterial Mechanical Vascular graŌ Coronary replacement heart disease endocardiƟs endocardiƟs aorƟc valve placed 1 year artery 6 months with mitral 6 months ago placed 6 ago disease with 6 months ago valve stenosis ago. DilaƟon months ago angioplasty of known and stent esophageal placement 6 stricture is months ago planned
Esophageal cancer with dysphagia - a PEG tube is going to be placed
Figure 2. Answers to survey questions by attending physicians and trainees.
specialty (0.63; 95% CI, 0.34-0.34; P ! .0001), and current teaching and/or supervising of trainees (0.30; 95% CI, 0.030.58; P Z .03). In multivariate analysis, both self-reported individual familiarity with current guidelines (0.28; 95% CI, 0.09-0.47; P Z .005) and specialty (0.41; 95% CI, 0.09-0.73; P Z .01) remained significant (Table 2). In evaluation among trainees, the following variables were significant on univariate analysis: self-reported individual familiarity with current guidelines (0.33; 95% CI, 0.15-0.50; P Z .0004), specialty (1.08; 95% CI, 0.64-1.53; P ! .0001), year of graduation from medical school (0.35; 95% CI, 0.15-0.56; P ! .0009), and the current postgraduate year level of training (0.31; 95% CI, 0.20-0.41; P ! .0001). In multivariate analysis, only specialty (0.65; 95% CI, 0.19-1.12; P Z .006) and current postgraduate year level of training (0.25; 95% CI, 0.11-0.39; P Z .0007) remained significant (Table 2). We found a strong association between year of graduation from medical school and our primary outcome of answering all the questions correctly. The longer the interval since graduation from medical school, the less likely physicians were to answer correctly (Supplementary Fig. 1, available online at www.giejournal.org). The odds of correctly answering questions increased by 3% (95% CI, 0.0160.052; P Z .0002) for every subsequent year of graduation since 1950. Figure 3A shows the inflection point at year 1995 to 2000. In contrast, in evaluation of trainees, there was a direct relationship with postgraduate year and odds of answering questions correctly. Each postgraduate year was associated with a 3% (95% CI, 0.20-0.41; P ! .0001) increased odds of answering questions correctly (Fig. 3B). www.giejournal.org
DISCUSSION Our study indicates poor knowledge of the current recommendations regarding the use of antibiotics before endoscopy, despite updating of the published guidelines in 2008. In the most routine scenario, in patients with no significant medical history, nearly all physicians correctly opted against using antibiotics, but in patients with any relevant comorbidities, the knowledge was clearly inadequate. The incorrect answers were similar among attending physicians and trainees and at the 3 different academic medical centers where the survey was administered. As a group, gastroenterologists answered the most questions correctly. The only subgroup with a near-perfect response to the clinical scenarios was gastroenterology fellows. This group incorporates trainees who started and completed residency training during the time period when the new guidelines changed and recommended against antibiotic use. This group also trained in the era of increased awareness of antibiotic resistance and adverse events like Clostridium difficile infection. The Institute of Medicine defines practice guidelines as, “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”7 Guidelines are meant to review the current medical literature and succinctly provide the clinician with evidence-based recommendations to better care for their patients.7 Practice guidelines are meant to create a safer medical system.8,9 However, when guidelines are not followed, the safety of the healthcare system may be at risk. In our study, the decision to Volume
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TABLE 2. Univariate and multivariate analysis of predictors of correct responses to all survey questions Univariate analysis
Multivariate analysis
Coefficient (b)
95% CI
P value
Coefficient (b)
95% CI
P value
Self-reported individual familiarity with current guidelines
0.32
0.20-0.44
P ! .0001
0.21
0.08-0.34
P Z .002
Level of training (attending physician vs trainee)
0.05
-0.19-0.09
P Z .50
Specialty (compared with gastroenterologists)
0.72
0.48-0.96
P ! .0001
0.56
0.30-0.82
P ! .0001
Year of graduation from medical school
0.26
0.11-0.41
P Z .0009
0.22
0.07-0.37
P Z .005
Location of medical school (U.S. vs international)
0.11
-0.08-0.31
P Z .24
Self-reported individual familiarity with current guidelines
0.39
0.22-0.57
P ! .0001
0.28
0.09-0.47
P Z .005
Specialty (compared with gastroenterologists)
0.63
0.34-0.34
P ! .0001
0.41
0.09-0.73
P Z .01
Year of graduation from medical school
0.16
-0.06-0.39
P Z .15
Location of medical school (U.S. vs international)
0.14
-0.13-0.42
P Z .31
Percentage of time spent in direct patient care
-0.01
-0.14-0.11
P Z .80
Current teaching/supervising residents or fellows
0.30
0.03-0.58
P Z .03
0.16
-0.11-0.43
P Z .24
Board certification in internal medicine
0.19
-0.15-0.53
P Z .30
Self-reported individual familiarity with current guidelines
0.33
0.15-0.50
P Z .0004
0.12
-0.08-0.31
P Z .23
Specialty (compared with gastroenterologists)
1.08
0.64-1.53
P ! .0001
0.65
0.19-1.12
P Z .006
Year of graduation from medical school
0.35
0.15-0.56
P ! .0009
0.07
-0.19-0.33
P Z .60
Location of medical school (U.S. vs international)
0.09
-0.18-0.36
P Z .50
Level of training (postgraduate year)
0.31
0.20-0.41
P ! .0001
0.25
0.11-0.39
P Z .0007
All respondents
Attending physicians
Trainees
CI, Confidence interval.
deviate from these practice guidelines is unclear. Comments provided by respondents are included in Supplementary Table 5 (available online at www.giejournal.org). Some respondents noted a distrust of the guideline development process, and therefore, they do not view guidelines as standard of care. Others cited a lack of current knowledge in the guidelines and need to look them up as needed, and other respondents believed beforeendoscopy antibiotics should not be the responsibility of the referring physician. Although our study did not assess the actual causes of deviations from practice guidelines, 6 GASTROINTESTINAL ENDOSCOPY Volume
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possible causes include educational deficits, failure to publicize and/or justify updated practice guidelines, or views that current guidelines are flawed.10 Further studies are necessary to evaluate the root causes underlying this problem and to initiate steps to improve compliance with current practice guidelines. It is often presumed that with increasing number of years in practice, physician knowledge and expertise increases. However, Choudhry et al11 reviewed studies assessing knowledge and quality of care based on physician age or years since graduation. Fifty-two percent of the www.giejournal.org
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The Number of Correct Answers is Inversely Related to Time in Practice
The Number of Correct Answers is Proportional to Post-Graduate Year Among Trainees
OUTCOME
10
(OUTCOME) OUTCOME
10 9 Number of Correct Responses
Number of Correct Answers
9 8 7 6 5 4
A
8 7 6 5 4
3
3
2
2 1950
1960
1990 2000 1970 1980 Year of Medical School Graduation
2010
B
0
1
2
3
4 5 Post-Graduate Year
6
7
8
9
Figure 3. A, Year of graduation from medical school and odds of answering questions correctly. B, Trainee postgraduate year of training and odds of answering questions correctly.
studies reviewed reported a decrease in physician performance with increasing age and years since medical school graduation in all areas evaluated: overall knowledge; compliance with standards of care for diagnosis, screening, or prevention; compliance with standards of care for therapy; and health outcomes. Ultimately, Choudhry et al11 concluded that physicians who have been in practice more years as well as older physicians have less factual knowledge and are less likely to follow accepted standards of care.11 Similarly, in our study, physicians who trained before 2000 performed worse than physicians who trained after 2000. Interestingly, in our study we noted that physicians who were still developing their “toolbox” of care also did poorly when they were within 3 years of graduating from medical school (Fig. 3B). To rectify this problem, it is critical for physicians to continue earning continued medical education throughout their career to update their toolbox with new recommendations. In our study, guiding forces for physician decisions to deviate from practice guidelines regarding antibiotic prophylaxis is unclear. Although our survey did not address this issue directly, studies have noted that adult learning approaches dictate that adults are more likely to adopt change if they experience a problem.10 In endoscopy, the old recommendations were based on case reports of adverse events and physician experience.2,5 Adoption of current practice guidelines requires physicians to forgo individual experience for more extensively reviewed literature. This requires adoption and acceptance from physicians and patients despite antibiotics being viewed by many as protecting against harm. One of the most difficult practices to change is to reduce the degree of intervention being provided.12 Nonetheless, depending on the underlying cause of poor compliance with guidelines, there are multiple ways to improve care. As noted in our study, overall familiarity of guidelines was predictive of www.giejournal.org
correct answers. To that end, educational sessions on updates to practice guidelines and institutions instituting policies consistent with practice guidelines may improve compliance. Additionally, electronic record systems can be used to trigger alerts that antibiotics are no longer recommended when patients are referred for endoscopic procedures. Alternatively, providing incentives and auditing compliance can improve care. Last, directly educating patients about the guidelines also has been successful.10,13 The most effective methods, though, are multifaceted approaches and include a combination of these methods.13 Our study has few limitations. It is a survey study and does not incorporate actual clinical practice. However, the scenario questions should have been answered correctly. Our study was multicentered, so individual institution practice bias should not have affected our study results. This study does not take into consideration patient preference or recommendations from nurses at the endoscopy intake interview. Currently, there is poor knowledge among physicians other than gastroenterologists regarding the clinical practice guidelines for antibiotic use before endoscopy. Further studies are necessary to determine the causes of this knowledge gap among referring physicians. In order to improve the safety of endoscopy, improved knowledge and compliance with current practice guidelines is critical. REFERENCES 1. Eisen GM, Baron TH, Dominitz JA, et al. Open access endoscopy. Gastrointest Endosc 2002;56:793-5. 2. Banerjee S, Shen B, Baron TH, et al. Antibiotic prophylaxis for GI endoscopy. Gastrointest Endosc 2008;67:791-8. 3. Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis: recommendations by the American Heart Association. Circulation 1997;96:358-66.
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4. Nelson DB. Infectious disease complications of GI endoscopy: Part I, endogenous infections. Gastrointest Endosc 2003;57:546-56. 5. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007;116: 1736-54. 6. Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap)da metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Informat 2009;42:377-81. 7. Committee on Clinical Practice Guidelines. Institute of Medicine. Guidelines for clinical practice: from development to use. Washington, DC: The National Academies Press; 1992. 8. World Health Organization. Guidelines for WHO guidelines, v. 10. Geneva: World Health Organization; 2003. p.1-23; Global Programme on Evidence for Health Policy http://whqlibdoc.who.int/hq/2003/EIP_ GPE_EQC_2003_1.pdf. Accessed October 15, 2014. 9. Committee on Quality of Health Care in America; Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century, 1st ed. Washington, DC: National Academies Press; 2001.
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10. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet 2003;362:1225-30. 11. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med 2005;142:260-73. 12. Greer AL. The state of the art versus the state of the science. The diffusion of new medical technologies into practice. Int J Technol Assess Health Care 1988;4:5-26. 13. Bero LA, Grilli R, Grimshaw JM, et al. Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. BMJ 1998;317:465-8.
Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (3), Department of Medicine and Division of Gastroenterology, University of Washington, University of Washington School of Medicine, Seattle, Washington, USA (4). Reprint requests: Dr Joseph D. Feuerstein, Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street 8E Gastroenterology, Boston, MA 02215. If you would like to chat with an author of this article, you may contact Dr Feuerstein at [email protected].
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Antibiotic prophylaxis before endoscopy
APPENDIX 1
Supplementary Table 1. Complete survey questionnaire with correct answers in yellow boxes
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Supplementary Table 1. (Continued)
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SUPPLEMENTARY TABLE 2. Correct answers by training and medical center No. of questions answered correctly, no. 0-1
All respondents n [ 740(%)
Attending physicians n [ 357(%)
Trainees n [ 383(%)
Center A n [ 374(%)
Center B n [ 216(%)
Center C n [ 150(%)
0
0
0
0
0
0
2
5 (1)
3 (1)
2 (1)
3 (1)
1 (0)
1 (1)
3
23 (3)
14 (4)
9 (2)
12 (3)
7 (3)
4 (3)
4
62 (8)
33 (9)
29 (8)
37 (10)
14 (6)
11 (7)
5
114 (15)
50 (14)
64 (17)
60 (16)
29 (13)
25 (17)
6
130 (18)
63 (18)
67 (17)
60 (16)
45 (21)
25 (17)
7
123 (17)
62 (17)
61 (16)
58 (16)
32 (15)
33 (22)
8
89 (12)
35 (10)
54 (14)
39 (10)
33 (15)
17 (12)
9
139 (19)
72 (20)
67 (17)
79 (21)
37 (17)
23 (15)
10
54 (7)
24 (7)
30 (8)
26 (7)
18 (8)
10 (7)
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SUPPLEMENTARY TABLE 3. Correct answers based on Likert score Likert score
Median no. correct
Median no. correct for attending physicians
Median no. correct for trainees
Trainee level of training, postgraduate year
Median no. correct
1
6
6
7
1
2
2
7
6
7
2
2
3
7
6
7
3
2
4
8
8
9
4
3
5
8
9
7
5
3
6
3
7
4
8
2
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SUPPLEMENTARY TABLE 4. Answers based on specialty and level of training All respondents, n [ 728 % Correct per No. specialty Internal medicine/ primary care
463
60
Median no. correct (range) 6 (2-10)
Attending physicians, n [ 355 % Correct per No. specialty 171
Median no. correct (range)
60
6 (3-10)
Trainees, n [ 373 % Correct per No. specialty 292
65
Median no. correct (range) 6.5 (2-10)
Cardiology
53
70
7 (4-10)
29
70
7 (4-10)
24
70
7 (4-10)
Family medicine
46
60
6 (2-10)
26
60
6 (2-10)
20
70
7 (3-10)
Geriatrics
19
60
6 (2-9)
14
50
5 (2-9)
5
90
9 (3-9)
Infectious diseases
38
75
7.5 (3-10)
24
70
7 (3-10)
14
90
9 (5-10)
Gastroenterology
65
90
9 (2-10)
48
80
8 (2-10)
17
100
10 (6-10)
Hospital medicine
43
70
7 (3-10)
42
70
7 (3-10)
1
80
8 (8)
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SUPPLEMENTARY TABLE 5. Comments by survey respondents Category of comment
Comments
Lack of active knowledge of current guidelines
Although I don’t know the answer to some of these, I would generally look it up on Up To Date. I look this up if I have any doubt. Admittedly, it was hard not to “cheat” and look on Up To Date or AGA society guidelines. I would presume that many general internists do not keep all of this information in their minds, but know where/how to look it up easily. I realized I really don’t know the guidelines. I would look these things up if I encountered some of these situations. In reading this I realize that I am no longer sure whether colonoscopy is currently considered a bacteremia-prone procedure. I answered assuming it was, but I realize that may not be the case, and will now check. I know WHERE to find the answers, but for most of these scenarios I would want to look up best current practices before giving a patient a recommendation. I would love some information on the current guidelinesdonce I started to answer the questions I realized I wasn’t that familiar with them. I would look up for questions. I would look this up on Up To Date Many of these questions I would normally look up and not necessarily expect a general medicine doctor to remember off hand. I usually try to look up guidelines before I tell patients what to do, so would in all of the above cases.
Lack of trust in guidelines
I realize my responses may not reflect the most recent AHA guidelines for antibiotic prophylaxis, and are driven more from clinical experience, and off line discussions with some of those involved with the guidelines. The use of antibiotics has on a practical level not always followed what I understood to be guidelines, and this may have affected my understanding and recall of the guidelines. Current guidelines may be too conservative. I do not always follow the guidelines for endocarditis prophylaxis with respect to very high risk patients undergoing colonoscopy with probable biopsy (known polyps), especially if they have been taking prophylaxis for decades (eg, mechanical valve, prior endocarditis with severe valvular disease). Sometimes fear trumps the current guidelines; depends on whether your last patient developed endocarditis vs anaphylaxis from the antibiotic! YesdI think this is not a well-designed questionnaire because the clinical context is frequently NOT so black and white, and both the history and the recommendations may vary. My practice for years is to contact the relevant specialists who actually know the complicated patients by e-mail to decide on pre-procedure prescription. And orthopedists vary greatly on recommendations for antibiotics after hip and knee replacements in spite of the standard recommendations. FYI, I have cared for a very sick patient population for years and have had no patients develop endocarditis or joint infections following GI procedures. My point is, customized analysis is preferable to a minimized checklist for high risk patients. Guidelines are generally not based on good data.
Someone else is responsible for before-procedure decisions
I thought a lot of this is discussed when a patient schedules the procedure. I think it would be advisable to refer to GI first prior to procedure. They are specialists and the ones doing the procedures. I defer decisions regarding antibiotic agents to the endoscopist, so do not use the guidelines in my practice. I have no idea what the guidelines are on this subject and would love to have it left to the gastroenterologists.
Miscellaneous comments
I answered these questions based upon guidelines as I understand them for endocarditis and prosthetic joint infections. There may be procedure-specific guidelines related to local infection that would not be patient specific and would be, I think, purely under GI control. ARE there clear “evidence based” guidelines for most of this stuff or are they “CRICO” based guidelines??? Seems to be ongoing differences between orthopedic recommendations and cardiology recommendations. Doesn’t make sense. Ok, So I guess I really don’t know these guidelines at all. Please teach us primary care physicians about what to do with antibiotics before procedures. It would be good for me to know more about the guidelines! I need to learn this stuff better! Interesting. U.S. guidelines vague regarding antibiotic prophylaxis. British [’NICE]: None.
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Supplementary Figure 1. Correct answers based on year of medical school graduation
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