Letters to the Editor

Harvard Medical School, Boston, Massachusetts, USA. Correspondence: Joseph Feuerstein, MD, Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue E/Dana 501, Boston, Massachusetts 02215, USA. E-mail: [email protected]

Terminal Ileitis Found Upon Imaging: Is It Always Crohn’s Disease? Teresa Pinto Pais, MD1, Sónia Fernandes, MD1, Carlos Fernandes, MD1, Iolanda Ribeiro, MD1 and João Carvalho, MD1 doi:10.1038/ajg.2014.114

To the Editor: Terminal ileitis (TI), defined as inflammation of the terminal ileum, is a common condition in clinical practice and is classically associated with Crohn’s disease (CD). However, a wide variety of diseases may be associated with ileitis (1,2). Diagnosis of the specific cause of ileitis is of paramount importance because misdiagnosis may result in critical delays or errors in patient management (3–5). Nonetheless, distinguishing between the various forms of ileitis remains a test of clinical acumen. Accurate diagnosis is suggested by a detailed history and physical examination, by laboratory testing, and by ileocolonoscopy and/or radiological evaluation. To study the different entities associated with TI in clinical practice, we reviewed all patients with confirmed imaging of TI on ultrasound admitted to our department over four consecutive years. An observational, descriptive, longitudinal study was performed, with a retrospective review of demographics, clinical presentation, laboratory data, treatment, and follow-up. Abdominal ultrasonography was performed in all patients and was complemented with computed tomography when necessary. Sonographic features compatible with TI included hypoechogenic mural thickening of the terminal ileum and hypoechoic enlarged mesenteric lymph nodes (6). The diagnosis of ileal CD was based on clinical, endoscopic, and histopathological data. Acid-fast bacilli smear and culture © 2014 by the American College of Gastroenterology

were performed in ileal biopsy specimens. An infectious etiology was presumed when there was clinical, analytical, and imaging remission after empirical antibiotic therapy, or when confirmed by isolation of pathogenic microorganisms in stool cultures. This study assessed 62 patients with a median age of 38.2 years (18–82), with a slight predominance of females (56.4%). The main form of presentation was abdominal pain (93.5%) and diarrhea (67.7%). All patients presented with ultrasonographic features of TI, which were corroborated by computed tomography in 62.9%. In this study, infectious etiology was confirmed in 62.9% (n = 39) of patients, CD was diagnosed in 32.2% (n = 20), and ileum cancer in 4.9% (ileal lymphoma—2, adenocarcinoma—1). Fecal pathogens were identified in 7 patients: Campylobacter—3, Yersinia—2, and Salmonella—2. No parasitic or tuberculosis infection was identified. On comparing the groups with confirmed CD and infectious ileitis, we found in the first group higher median values of serum inflammatory parameters (C-reactive protein: 9.8 vs. 7.4 mg/dl; leukocyte count: 16.650 vs. 11.170/μl), lower hemoglobin levels (10.45 vs. 13.5 g/dl, t-test, P=0.03), and a longer inpatient period (10 vs. 5 days). Patients diagnosed with CD maintain longterm follow-up in our outpatient clinic. In the current study, the diagnosis of CD of the ileum was confirmed histopathologically in 32.2% of patients with imaging of TI. We highlight that inflammation of the terminal ileum is not always CD, and infectious etiology is a common cause (62.9% in our study). The differential diagnosis of TI found on imaging, although sometimes difficult, is of critical importance to avoid further unnecessary diagnostic workup and inappropriate treatment. CONFLICT OF INTEREST Guarantor of the article: Teresa Pinto Pais, MD. Specific author contributions: Teresa Pinto Pais was involved in planning and conducting the study, collecting and interpreting data, and writing the paper. She has approved the final draft submitted. Sónia Fernandes was involved in planning the study, interpreting data, and drafting the

manuscript. She has approved the final draft submitted. Carlos Fernandes was involved in collecting and interpreting data. He has approved the final draft submitted. Iolanda Ribeiro was involved in collecting and interpreting data. She has approved the final draft submitted. João Carvalho was involved in planning the study, interpreting data, and drafting the manuscript. He has approved the final draft submitted. Financial support: None. Potential competing interests: None.

REFERENCES 1. Dilauro S, Crum-Cianflone NF. Ileitis: when it is not Crohn’s disease. Curr Gastroenterol Rep 2010;12:249–58. 2. Greaves ML, Pochapin M. Asymptomatic ileitis: past, present, and future. J Clin Gastroenterol 2006;40:281–5. 3. Lee YJ, Yang SK, Byeon JS et al. Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohn’s disease. Endoscopy 2006;38:592–7. 4. Jeong SH, Lee KJ, Kim YB et al. Diagnostic value of terminal ileum intubation during colonoscopy. J Gastroenterol Hepatol 2008;23:51–5. 5. Chang HS, Lee D, Kim JC et al. Isolated terminal ileal ulcerations in asymptomatic individuals: natural course and clinical significance. Gastrointest Endosc 2010;72:1226–32. 6. Ledermann HP, Börner N, Strunk H et al. Bowel wall thickening on transabdominal sonography. Am J Roentgenol 2000;174:107–17. 1

Department of Gastroenterology and Hepatology, Centro Hospitalar de Gaia/Espinho, Vila Nova de Gaia, Portugal. Correspondence: Teresa Pinto Pais, MD, Department of Gastroenterology and Hepatology, Centro Hospitalar de Gaia/Espinho, Rua Conceição Fernandes, 4434-502 Vila Nova de Gaia, Portugal. E-mail: [email protected]

Patient Satisfaction Does Not Correlate With Established Colonoscopy Quality Metrics Rena Yadlapati, MD1, Andrew Gawron, MD1,2 and Rajesh N. Keswani, MD1 doi:10.1038/ajg.2014.115

To the Editor: Quality metrics for colonoscopy are increasingly being measured and reported, as procedure quality correlates The American Journal of GASTROENTEROLOGY

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Table 1. Colonoscopy variables and their correlation with PSRs Variable ADR WT (min) Cecal intubation (%)

Mean (range)±s.d.

Correlation with PSRs (r)

29.2 (11.5–51.2)±10.7

0.17

10.5 (3.1–19.2)±4.5

0.88

98.6 (96.0–99.0)±1.18

0.26

ADR, adenoma detection rate; PSR, patient satisfaction rating; WT, withdrawal time.

Table 2. Colonoscopy quality indicators and PSRs for male and female endoscopists Male endoscopists (n =16)

Female endoscopists (n =5)

P value

29.8 (11.6–51.2)±11.8

27.6 (20.0–37.4)±6.9

0.69

WT, mean

10.1 (3.1–19.2)±4.6

11.8 (7.7–19.0)±4.3

0.46

Cecal intubation rate, mean

98.7 (96.3–99.9)±1.3

98.4 (97.9–99.3)±0.6

0.68

77 (71–84)±4.5

70 (64–76)±4.5

< 0.01

ADR, mean

PSR, mean

ADR, adenoma detection rate; PSR, patient satisfaction rating; WT, withdrawal time.

with its effectiveness in reducing colorectal cancer incidence and mortality (1,2). Patient satisfaction ratings (PSRs) are also publicly reported and may be eventually tied to reimbursement in clinical practice. PSRs are additionally being utilized in concert with other measures to determine provider performance and health-care quality (3–6). However, previous studies have failed to validate a relationship between PSRs and surgical procedure quality (4). As a result, we sought to investigate whether patient satisfaction correlates with established indicators of colonoscopy quality, an area that has not been studied previously. We performed a retrospective review of PSRs and colonoscopy quality for endoscopists at a single-center tertiary care teaching institution from September 2012 to August 2013. Endoscopists were included if they were attending gastroenterologists and performed more than 50 colonoscopies over 1 year. This study was approved by the Institutional Review Board. All patients undergoing endoscopic procedures at our institution are asked to complete an 11-question outpatient validated survey developed by Press Ganey Associates (South Bend, IN) assessing their procedure experience (6). The PSR is measured by calculating the percentage of responses with a score of 5 (repThe American Journal of GASTROENTEROLOGY

resenting “very good”) on a scale of 1–5. Physician quality indicators for screening colonoscopies including adenoma detection rate (ADR), withdrawal time (WT) in normal screening colonoscopies, and cecal intubation rate are also measured. The relationship between patient satisfaction and quality indicators was determined using Spearman’s rank-order correlation. Statistical analyses were performed using STATA 12.0 (College Station, TX). During the 1-year period 1,688 patient satisfaction surveys were collected and 6,761 screening colonoscopies were performed. The mean screening colonoscopy volume per physician was 687 (229–1179)±301. Twenty-one endoscopists (5F:16M) were included in this study: 48% were in private practice and 52% were in academic practice. There was no significant difference in PSRs and practice type. Median time in clinical practice after training was 15 years (interquartile range = 22), and did not correlate with patient satisfaction (r = − 0.11). The overall mean PSR was 75.6% (64– 84%)±5.5%. The mean ADR, WT, and cecal intubation rate were 29% (12–51%)±10.8%, 10.5 (3.1–19.2)±4.5 min, and 98.6% (96.3– 100%)±1.2%, respectively. There was weak or no correlation between PSRs and ADR (r = 0.22), WT (r = 0.02), and cecal intubation rate (r = 0.24). We found a strong

positive correlation between ADR and WT (r = 0.60; Table 1). There was a moderate, statistically significant, inverse correlation between PSR and physician sex (r = − 0.57, P < 0.01). However, there was no significant difference when comparing female with male physician ADR, WT, or cecal intubation rate (Table 2). In addition, female endoscopists saw a disproportionately greater number of female patients compared with male endoscopists (75% vs. 55%, P < 0.01). This is the first study to suggest that patient satisfaction is not related to established colonoscopy quality indicators. Our analyses did, however, reproduce a correlation between widely accepted quality indicators such as ADR and WT (7). Although PSRs may reflect an institution’s ability to provide good service as part of the patient experience, our study challenges their role as a measure of colonoscopy quality. Patient satisfaction is likely influenced by several factors that are unrelated to procedure quality. For instance, it is possible that polyp detection and removal results in longer procedure time and emotional distress, which could negatively affect patient satisfaction. This study also suggests a correlation between PSRs and physician gender. These are interesting areas that require further investigation. In conclusion, this analysis demonstrates that patient satisfaction is not a reliable metric of colonoscopy quality, and further work should be carried out before patient satisfaction is promoted as a surrogate measure for colonoscopy quality. CONFLICT OF INTEREST Guarantor of the article: Rena Yadlapati, MD. Specific author contributions: Rena Yadlapati and Andrew Gawron: study concept and design, acquisition of data, analysis and interpretation of data, drafting of manuscript, approval of final draft submitted; Raj Keswani: Principal Investigator, study supervision, study concept and design, acquisition of data, analysis and interpretation of data, drafting of manuscript, approval of final draft submitted. Financial support: None. Potential competing interests: None. VOLUME 109 | JULY 2014 www.amjgastro.com

Letters to the Editor

REFERENCES 1. Zauber AG WS, O′Brien MJ, LansdorpVogelaar I et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med 2012;366:687–96. 2. Lieberman DA, Weiss DG, Bond JH et al. Use of colonoscopy to screen asymptomatic adults for colorectal cancer. Veterans Affairs Cooperative Study Group 380. N Engl J Med 2000;343:162–8. 3. Centers for Medicare & Medicaid Services. Medicare program: hospital inpatient value-based purchasing program. Fed Regist 2011;76:2454–91.

© 2014 by the American College of Gastroenterology

4. Lyu H, Wick EC, Housman M et al. Patient satisfaction as a possible indicator of quality surgical care. JAMA Surg 2013;148: 362–7. 5. Pascoe GC. Patient satisfaction in primary health care: a literature review and analysis. Eval Program Plann 1983;6:185–210. 6. Hospital Consumer Assessment of Healthcare Providers and Systems 2013 (Accessed 29 December 2013, at http://www.hcahpsonline. org/home.aspx). 7. Barclay RL, Vicari JJ, Doughty AS et al. Colonoscopic withdrawal times and adenoma

detection during screening colonoscopy. N Engl J Med 2006;355:2533–41. 1

Divisions of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA; 2Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA. Correspondence: Rena Yadlapati, MD, Divisions of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA. E-mails: [email protected] and [email protected]

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Patient satisfaction does not correlate with established colonoscopy quality metrics.

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