ACG MAGAZINE | Vol. 2, No. 2 | Summer 2018

ACG MAGAZINE Summer 2018

MEMBERS. MEDICINE. MEANING.

GIVING RISE to

GI in RWANDA

ACG MOBILE: ACCESS KEY RESOURCES

at the point of care

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DOWNLOAD THE ACG MOBILE APP Download the app via Google Play or Apple App Store.

SUMMER 2018 // VOLUME 2, NUMBER 2

FEATURED CONTENTS

COVER STORY

GIVING RISE TO GI IN RWANDA

Drs. Steve Bensen and Frederick Makrauer describe their ongoing efforts to build GI education and training in Rwanda.

PAGE 26

SCREENING THE UNSCREENED

Dr. Karen Kim on the innovative, web-based platform her team developed to screen the unscreened.

PAGE 17

Photo courtesy of Eridana Harder, RN.

HOW COLON CANCER CHANGED MY LIFE

Davis William Atkins, 17, the son of Len Atkins and Norma Davis-Atkins, reflects on his father’s passing from stage IV colon cancer at age 48.

PAGE 37

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Attend an upcoming

ACG POSTGRADUATE COURSE 2018 Hepatology School and ACG Midwest Regional Postgraduate Course Sheraton Indianapolis City Centre Hotel | Indianapolis, IN August 24–26, 2018

2018 IBD School and ACG/VGS/ODSGNA Regional Postgraduate Course Williamsburg Lodge | Williamsburg, VA September 7–9, 2018

ACG 2018 Annual Meeting and Postgraduate Course Pennsylvania Convention Center | Philadelphia, PA October 5–10, 2018 • Practice Management | October 5, 2018 • GI Pharmacology | October 5, 2018 • Pathology and Imaging | October 5, 2018 • ACG’s Postgraduate Course | October 6–7, 2018 • ACG’s Annual Scientific Meeting | October 8–10, 2018

2018 Hepatology School and Southern Regional Postgraduate Course JW Marriott Hotel | Nashville, TN November 30–December 2, 2018

2019 IBD School & Western Regional Postgraduate Course Cosmopolitan Hotel | Las Vegas, NV January 18–20, 2019

2019 ACG/FGS Annual Spring Symposium Naples Grande Beach Resort | Naples, FL March 1–3, 2019

2019 ACG/LGS Regional Postgraduate Course Hilton New Orleans Riverside | New Orleans, LA March 7–10, 2019

North American Conference of GI Fellows (NACGF)* Hyatt Regency Grand Cypress | Orlando, FL March 22–24, 2019 *NACGF is by application only and free to selected participants.

2019 Hepatology School & Eastern Regional Postgraduate Course Marriott Marquis | Washington, DC June 7-9, 2019

FOR MORE INFO, VISIT: GI.ORG/ACG-COURSE-CALENDAR

SUMMER 2018 // VOLUME 2, NUMBER 2

CONTENTS

“My time in Rwanda has proven to be the highlight of my medical career. The most rewarding aspect of the experience for me has been the deep friendships and relationships I have established with my Rwandan colleagues.” ­—Steve P. Bensen, MD, “GIVING RISE TO GI IN RWANDA,” PG 26

6 // MESSAGE FROM THE PRESIDENT Dr. Irving Pike on the commitment ACG Governors showed during their DC Fly-In.

7 // NOVEL & NOTEWORTHY Members' career moves, magazine and book publishing news, & CRC awareness recognition.

13 // PUBLIC POLICY GOVERNORS’ VANTAGE POINT Chair Dr. Costas Kefalas recaps the day on Capitol Hill, while Vice Chair Dr. Doug Adler overviews the Governors’ meeting.

17 // GETTING IT RIGHT 17 SCREENING THE UNSCREENED Dr. Karen Kim on an innovative, web-based platform to screen the unscreened.

19 QUALITY How to build a quality institute in your practice, by Dr. Michael Morelli.

21 BUILDING SUCCESS Optimizing revenue cycle output.

24 LAW MIND Ann Bittinger, JD, addresses how to strategically approach negotiating contracts with payers.

26 // COVER STORY GIVING RISE TO GI IN RWANDA Drs. Steve Bensen and Frederick Makrauer describe their ongoing efforts to build GI education and training in Rwanda.

37 // ACG PERSPECTIVES 37 HOW COLON CANCER CHANGED MY LIFE Davis William Atkins, 17, reflects on his father’s passing from stage IV colon cancer at age 48.

39 FROM ACCRA TO ROCHESTER Dr. Bampoh on her time at Mayo Clinic.

40 FACING CHALLENGES, SEEKING BALANCE Female advanced endoscopists describe challenges and lessons learned.

45 // EDUCATION EDGAR ACHKAR VISITING PROFESSORS Taking ACG's commitment to GI training on the road.

49 // INSIDE THE JOURNALS 50 AJG Drs. Grace Elta and Vijay Shah offer author insights on new ACG Clinical Guidelines.

52 ACGCRJ Malignant Peritoneal Mesothelioma Presenting as Mucinous Ascites.

53 CTG BE is Associated with a Distinct Oral Microbiome, TLRs-Mediated Pathways Activate Inflammatory Responses in the Esophageal Mucosa of Adult EoE.

54 // REACHING THE CECUM A LOOK BACK: THE FLUSH TOILET Invented, ignored and revolutionized.

Cover: background courtesy of Eridana Harder, RN; framed photos courtesy of Dr. Steve Bensen, Connor Gordon and Eridana Harder, RN. Photo top courtesy of Dr. Steve Bensen and Connor Gordon.

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ACG MAGAZINE MAGAZINE STAFF

CONNECT WITH ACG

Executive Director Bradley C. Stillman, JD

youtube.com/ACGastroenterology

Editor in Chief; Vice President, Communications Anne-Louise B. Oliphant Managing Editor; Senior Writer Brian C. Davis Copy Editors; Staff Writers Jenny Dunnington, Sarah Richman, Lindsey Topp

facebook.com/AmCollegeGastro

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Art Director Emily Garel Graphic Designer Antonella Iseas

BOARD OF TRUSTEES President: Irving M. Pike, MD, FACG President-Elect: Sunanda V. Kane, MD, MSPH, FACG Vice President: Mark B. Pochapin, MD, FACG Secretary: Samir A. Shah, MD, FACG Treasurer: David A. Greenwald, MD, FACG Immediate Past President: Carol A. Burke, MD, FACG

CONTACT IDEAS & FEEDBACK We'd love to hear from you.

Send us your ideas, stories and comments.

ACGMag@gi.org

CONTACT ACG American College of Gastroenterology 6400 Goldsboro Rd., Suite 200 Bethesda, MD 20817 (301) 263-9000 | gi.org

Past President: Kenneth R. DeVault, MD, FACG Director, ACG Institute: Nicholas J. Shaheen, MD, MPH, FACG Co-Editors, The American Journal of Gastroenterology: Brian E. Lacy, MD, PhD, FACG

DIGITAL EDITIONS

GI.ORG/ACGMAGAZINE

Brennan M. R. Spiegel, MD, MSHS, FACG Chair, Board of Governors: Costas H. Kefalas, MD, MMM, FACG Vice Chair, Board of Governors: Douglas G. Adler, MD, FACG Trustee for Administrative Affairs: Delbert L. Chumley, MD, FACG

TRUSTEES William D. Chey, MD, FACG Immanuel K. H. Ho, MD, FACG Caroll D. Koscheski, MD, FACG Paul Y. Kwo, MD, FACG Jonathan A. Leighton, MD, FACG Amy S. Oxentenko, MD, FACG Daniel J. Pambianco, MD, FACG David T. Rubin, MD, FACG John R. Saltzman, MD, FACG

4 | GI.ORG/ACGMAGAZINE

American College of Gastroenterology is an international organization with more than 14,000 physician members representing some 85 countries. The College's vision is to be the pre-eminent professional organization that champions the evolving needs of clinicians in the delivery of high-quality, evidence-based and compassionate health care to gastroenterology patients. The mission of the College is to advance world-class care for patients with gastrointestinal disorders through excellence, innovation and advocacy in the areas of scientific investigation, education, prevention and treatment.

CONTRIBUTING WRITERS

Douglas G. Adler, MD, FACG

Sharlene D'Souza, MD

Frederick L. Makrauer, MD

Dr. Adler, of the University of Utah School of Medicine, is the Vice Chair of the ACG Board of Governors.

Dr. D’Souza, of Gastroenterology Consultants, PC in Medford, OR, is an advanced endoscopist and a member of ACG's Women in GI Committee.

Dr. Makrauer, of Brigham and Women’s Hospital, is Assistant Professor of Medicine at Harvard Medical School and Associate Program Director of Advanced Fellowship in IBD.

Davis William Atkins

Grace H. Elta, MD, FACG

Michael S. Morelli MD, CPE, FACG

Davis William Atkins, 17, the son of Len Atkins and Norma Davis-Atkins, reflects on his father’s passing from Stage IV colon cancer at age 48.

Dr. Elta is of the University of Michigan Medical Center in Ann Arbor, MI.

Sally Afua Bampoh, MD

Costas H. Kefalas, MD, MMM, FACG

The 2016 International GI Training Grant recipient, of Korle Bu Teaching Hospital in Accra, Ghana.

Dr. Kefalas serves as Chair of the ACG Board of Governors and practices with Akron Digestive Disease Consultants in Akron, OH.

Promila Banerjee, MD, FACG

Karen E. Kim, MD, MS

Dr. Banerjee is an advanced endoscopist in Northbrook, IL. She is Co-Chair of the Interventional Women in GI Subcommittee.

Dr. Kim is a Professor of Medicine at the University of Chicago.

Steve P. Bensen, MD

Dr. Morelli is President of Indianapolis Gastroenterology and Hepatology in Indianapolis, IN.

Richard L. Nemec, MD, FACG Dr. Nemec is of Winchester Gastroenterology Associates in Winchester, VA.

Swati Pawa, MD, FACG Dr. Pawa is Associate Professor of Medicine, Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, and is CoChair, Interventional Women in GI Subcommittee.

Shivangi T. Kothari, MD, FACG

Vijay H. Shah, MD, FACG

Dr. Bensen is Associate Professor of Medicine, Geisel School of Medicine at Dartmouth, Section of Gastroenterology, Dartmouth-Hitchcock Medical Center.

Dr. Kothari is Assistant Professor of Medicine and Associate Director of Endoscopy at the University of Rochester Medical Center.

She is Vice Chair of the ACG Women in GI Committee.

Dr. Shah is Chair, Division of Gastroenterology and Hepatology, at the Mayo Clinic in Rochester, MN.

Ann M. Bittinger, JD

Robert E. Kravetz, MD, MACG

Renee L. Williams, MD, FACG

Dr. Kravetz is passionate about the history of medicine and the history of the College. He is Past Chair, ACG Archives Committee, and was instrumental in the publication of the ACG 75th Anniversary history in 2007. Read about ACG’s History: gi.org/aboutacg/#Anniversary

Dr. Williams, of the New York University School of Medicine in New York, NY, is Chair of ACG’s Minority Affairs and Cultural Diversity Committee.

Ms. Bittinger is health law expert at Bittinger Law Firm in Jacksonville, FL. She is a regular contributor to ACG publications on her areas of expertise, including legal relationships between hospital systems and physicians or physician groups (bittingerlaw.com).

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MESSAGE FROM THE PRESIDEN

ACG GOVERNORS DEMONSTRATE UNIQUE COMMITMENT AND PREPARATION DURING FLY-IN The impact and energy of the 2018 ACG Governors’ Fly-In to Washington, DC began many weeks before the event and culminated in an experience that typifies the unique strengths of the College’s organizational structure as well as ACG’s fundamental commitment to advancing the interests of GI physicians and their patients.

Thanks to the leadership and vision of ACG Board of Governors Chair Dr. Costas Kefalas and Vice Chair Dr. Doug Adler and the organization and educational preparedness offered by ACG staff, our day on Capitol Hill was a tremendous success. The background material on ACG’s top policy priorities and key messages for our meetings with legislators and policymakers was offered in segments and broken down into major points so that it was complete and succinct at the same time. The pitch was perfect!!

As we gathered for a briefing the morning of our visits to Congress on April 19, the energy and commitment of the ACG Board of Governors was palpable in the room. Everyone was focused and confident concerning the day’s activities and our purpose.

My first visit with other ACG leaders included a unique opportunity arranged by the College to meet with Anand Shah, MD, MPH, the Chief Medical Officer for the Center for Medicare & Medicaid Innovation at CMS. While serving at CMS, Dr. Shah continues to actively practice radiation oncology one day per week at the National Cancer Institute.

He clearly remains in touch with reality in terms of practicing specialty medicine. Dr. Shah remarked that he was familiar with GIQuIC, mentioning that it was considered among the top two specialtydeveloped clinical data registries.

Dr. Shah’s division at CMS is charged with helping to develop, review and approve Advanced Payment Models (APMs) in Medicare. Dr. Shah encouraged ACG to present suggestions for such models—perhaps using GIQuIC as a vehicle to capture the information. The idea of a gastroenterology-specific APM is something I will be discussing with our Practice Management leadership and Drs. Pochapin and Greenwald, our appointees to the GIQuIC Board of Directors.

The College’s foresight to get moving on the quality movement as early as 2005 and to develop that commitment into a major national GI clinical

6 | GI.ORG/ACGMAGAZINE

“The Governors

allow ACG to do things nimbly and quickly, and importantly, serve as a conduit for leadership, letting us know what’s really important...” 

data registry has been a major plus for ACG, and we will continue to reap rewards. ACG and GIQuIC have been on the forefront of improving patient outcomes by measuring quality well before these became hot topics at the national level or were required for physicians to get reimbursed from Medicare.

The remainder of my day in Washington was spent visiting with policy experts with House Majority Leader U.S. Representative Kevin McCarthy (R-CA), House Minority Leader U.S. Representative Nancy Pelosi (D-CA), and U.S. Representative Paul Ryan (R-WI), the Speaker of the U.S. House of Representatives. I was also fortunate to visit my own congressman, U.S. Representative Mark DeSaulnier (D-CA). Everyone we spoke to seemed knowledgeable about the issue of the “polypectomy surprise,” which is an unintended consequence of a provision in the Affordable Care Act causing Medicare beneficiaries to be responsible for payment of coinsurance if their screening colonoscopies lead to therapeutic procedures, such as polypectomies or biopsies. There was consensus among congressional staff we met that this should be corrected. A resolution has bipartisan support, although we are far from the finish line. As an organization, ACG must keep at this issue.

Prior authorization requirements from commercial insurers including “step therapy” were topics with which the Hill staff were less familiar. ACG’s position is that therapeutic decisions must always be made between the treating physician and the patient. The step therapy issue also gave the College an appropriate opportunity to educate Hill staff on a concern that creates undue practice management burdens, threatens to interfere with doctor-patient decision-making, and importantly, impacts patients’ health outcomes and their quality of life.

I am deeply grateful for the tremendous effort by the ACG Board of Governors to come to Washington, taking time away from patients, practices and families to have their voices heard on Capitol Hill and represent their gastroenterology colleagues. The Fly-In was a great experience because the Governors put so much into it. The ACG Fly-In is particularly meaningful and impactful in the current climate facing medicine when it is imperative for physicians to be advocates before legislators and federal policymakers. The number of Governors who attend and the number of meetings on the Hill has been growing year after year, showcasing the amazing advantage of the Board of Governors structure for the College. The Governors allow ACG to do things nimbly and quickly, and importantly, serve as a conduit for leadership, letting us know what’s really important to the membership.

Thank you, ACG Governors, for doing the tremendous work you do, and keep it going.

­­—Irving M. Pike, MD, FACG

N wotoerthy ACG MAGAZINE is a forum for College news—a place to showcase the interests and accomplishments of ACG members, as well as notable GI news and innovation. In this issue, we feature members making career moves, publishing magazine articles and books, hosting national radio shows about CRC, earning national recognition for their awareness efforts, and more. Email your news and any ideas for future issues of ACG MAGAZINE to ACGMag@gi.org

Novel & Noteworthy | 7

// N&N [BOOKS] [ON THE BIG SCREEN]

FIGHT CRC PARTNERS WITH “POOP TALK” DOCUMENTARY

Poop.

“It’s one of the those things…Everyone does it…No one talks about it…Until now,” reads the tagline in the trailer for “Poop Talk,” a documentary released in select theaters and via Video On Demand on February 16.

The documentary “gives an inside look at all things poop—from uncensored, embarrassing moments to scientific explanations recounted by 50 experts and comedians,” according to an email from patient advocacy organization Fight Colorectal Cancer (CRC).

In January, Fight CRC announced a partnership with Poop Talk that is designed to promote the film, in the hopes of increasing discussion about poop and combating the stigma that it is a “taboo topic.” In the first 48 hours following the partnership announcement, CRC advocates could pre-order Poop Talk at a 50% discount.

The documentary features Kumail Nanjiani, Nikki Glaser, Pete Holmes, Eric Stonestreet, comedians and brothers Randy and Jason Sklar, and many other recognizable faces.

DAVID A. JOHNSON, MD, MACG

WATCH the Poop Talk trailer: bit.ly/Poop-Talk-Trailer DOWNLOAD Poop Talk on iTunes: bit.ly/Poop-Talk-DL [AUTHORSHIP]

DOUGLAS G. ADLER, MD, FACG, VICE CHAIR, ACG BOARD OF GOVERNORS Dr. Adler published a first-person article entitled “No Easy Fix,” in the March 2018 issue of Discover magazine. The subject of the story is “Rebecca”—a real patient whose name has been changed— who is struggling to maintain her weight loss after undergoing gastric bypass and initially losing a significant amount of weight.

In telling Rebecca’s story, Adler conveys that bariatric surgery alone is not a simple solution for weight loss. Rather, even with successful surgery, complications may emerge, dedicated dieting

and exercise are essential, and managing emotions can be challenging as physical changes occur.

Adler simplifies bariatric surgery for the lay reader with succinct descriptions and easy-to-follow diagrams, which illustrate the different types of bariatric surgeries. Articulating complex topics for a lay audience is one of several topics Adler addressed in a Q&A published in the Summer 2017 issue of ACG MAGAZINE, in which Adler detailed his life-long interest in writing and publishing.

Zinio Reader

PURCHASE the March 2018 Discover digital edition to read the full story about Rebecca: bit.ly/Discover-18

 LEARN MORE: bit.ly/DAJ-Sleep

READ “Writing for New & Familiar Audiences,” in the Summer 2017 issue of ACG MAGAZINE: bit.ly/Adler17

1 of 2

8 | GI.ORG/ACGMAGAZINE

http://www.zinio.com/mag-reader/h5r-reader.jsp#/readsvg/416441009/16

In March, Nova Science Publishers released Sleep Effect on Gastrointestinal Health and Disease: Translational Opportunities for Promoting Health and Optimizing Disease Management, a book edited by ACG Past President Dr. David Johnson, Professor of Medicine and Chief of Gastroenterology at Eastern Virginia Medical School in Norfolk, VA. While dysfunctional sleep has a “profound” effect on GI health and disease, it is “typically not recognized or addressed by clinicians,” the co-editors write in a description of the book.

They describe sleep and the GI system as having a “dynamic bidirectional relationship.” A GI disease can worsen or be the “primary underlying cause of a sleep disorder.” In addition, recognizing sleep disorders and implementing sleep-directed management “can help optimize the treatment of numerous gastrointestinal diseases,” the co-editors write.

The goal of the book is to increase awareness of the essential role of sleep.

“Clearly, it is time for us all to open our eyes and realize the value of closing them,” the coeditors conclude.

Johnson co-edited the book with William C. Orr, PhD, FACG, J. Catesby Ware, PhD, Parth Parekh, MD, and Edward C. Oldfield IV, MD.

2/8/2018, 12:02 PM

[AWARDEES]

[MILESTONES]

THE NATIONAL COLORECTAL CANCER ROUNDTABLE (NCCRT) RECOGNIZED DRS. GRAY AND PACE AS 2018 80% BY 2018 NATIONAL ACHIEVEMENT AWARD HONOREES. The Awards honor individuals and organizations who are dedicating their time, talent and expertise to advancing needed initiatives that support the shared 80% by 2018 CRC screening goal.

Darrell M. Gray, II, MD, MPH, and The Ohio State University won the Health System category for the work of the Provider and Community Engagement (PACE) Program for Health Equity in CRC Prevention, a comprehensive program which, among many efforts, offers low-to-no-cost colonoscopies to the uninsured and underinsured, hosts an annual cancer disparities conference, and leads grocery store tours and cooking demonstrations.

NCCRT awarded Samuel C. Pace, MD, FACG, in the Survivor/Physician Champion category. Pace, a retired gastroenterologist who was diagnosed with CRC in 2011, spearheads CRC awareness initiatives in Mississippi, including a 70% by 2020 statewide screening goal and a colon cancer awareness license plate. Pace previously served as ACG Governor for Mississippi.  LEARN MORE about the other awardees and program: bit.ly/NCCRT18 NCCRT 80% by 2018 National Achievement Award Honorees Dr. Samuel Pace (top) and Dr. Darrell Gray, II, and The Ohio State University are recognized on a big screen in Times Square. Images provided by Fight Colorectal Cancer.

BRIAN E. LACY, MD, PHD, FACG Dr. Lacy started at Mayo Clinic, Florida in January 2018 as Senior Associate Consultant. Prior to joining Mayo, Lacy worked at Dartmouth from 2003 until the end of 2018.

“I loved being at Dartmouth,” Lacy told ACG. He cited his wonderful colleagues, great patients, and his work during his time there.

As for his new opportunity, Lacy said he is “incredibly excited,” referencing the “incredibly bright, hard-working clinician-scientists” he’s surrounded by and great leaders such as Michael F. Picco, MD, PhD, FACG, ACG Past President Kenneth R. DeVault, MD, FACG, and Gianrico Farrugia, MD. “Mayo’s dedication to patient care and research represents an amazing opportunity for me as I hope to bring some new ideas that will extend our knowledge of functional bowel disorders,” Lacy said.

Dr. Lacy serves as Co-Editor-inChief of The American Journal of Gastroenterology.

[ON THE AIR]

SIRIUSXM SPECIAL PROGRAM ON COLORECTAL CANCER FEATURING ACG LEADERS

As we neared the end of March Colorectal Cancer (CRC) Awareness Month, several ACG leaders punctuated their awareness efforts by hosting a live SiriusXM radio show on CRC awareness and prevention from 4:00-6:00 pm Eastern on Thursday, March 22.

The show ran on SiriusXM’s “Doctor Radio” channel (Channel 110), and was broadcast from the Doctor Radio studio located in the lobby of the NYU Langone Medical Center.

ACG Vice President Mark B. Pochapin, MD, FACG, hosted the radio show, which featured ACG President Irving M. Pike, MD, FACG, Treasurer David A. Greenwald, MD, FACG, Board of Governors Vice Chair Douglas G. Adler, MD, FACG, Public Relations Committee Chair Sophie M. Balzora, MD, FACG, Minority Affairs and Cultural Diversity Committee Chair Renee L. Williams, MD, FACG, Regional Councilor Aasma Shaukat, MD, FACG, ACG Governor for Manhattan Brian P. Bosworth, MD, FACG, and ACG Governor for Connecticut Jeffry L. Nestler, MD, FACG. The show included a surprise guest: Jonathan LaPook, MD, CBS News Chief Medical Correspondent and Professor of Medicine at NYU Langone.

ACG is thankful to SiriusXM and Doctor Radio for broadcasting this show dedicated to CRC awareness and prevention. SiriusXM subscribers can listen to a recording of the show through SiriusXM On Demand.

Novel & Noteworthy | 9

ACG CALENDA

MAY 31

Scopy Award

MARCH

16–18

JUNE

25

SUBMISSION DEADLINE More info: gi.org/SCOPY

ACG 2018

APRIL

13 7–9

SEPTEMBER

Call for Abstracts

IBD SCHOOL AND ACG/VGS/ODSGNA REGIONAL POSTGRADUATE COURSE  Williamsburg, VA

DEADLINE

More info: gi.org/regional-meetings

Submit your abstract:

conferenceabstracts.com/acg2018.html

AUGUST

24

ACG 2018

ANNUAL SCIENTIFIC MEETING & POSTGRADUATE COURSE

AC G 2O18

October 5–10, 2018

Pennsylvania Convention Center Philadelphia, PA

acgmeetings.gi.org HEPATOLOGY SCHOOL AT MIDWEST REGIONAL

O CTO B E R 5 – 1 O, 2 O 1 8 The Premier GI Clinical Meeting & Postgraduate Course

 Indianapolis, IN More info: gi.org/regional-meetings

AUGUST

25–26

NOVEMBER

30

ACG MIDWEST REGIONAL POSTGRADUATE COURSE

 Indianapolis, IN More info: gi.org/regional-meetings

10 | GI.ORG/ACGMAGAZINE

DECEMBER

1–2

HEPATOLOGY SCHOOL AT SOUTHERN REGIONAL  Nashville, TN

SOUTHERN REGIONAL POSTGRADUATE COURSE  Nashville, TN

More info: gi.org/regional-meetings

DECEMBER

7

ACG INSTITUTE

RESEARCH GRANTS DEADLINE More info: gi.org/grant-announcements

IMPORTANT SAFETY INFORMATION SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution is an osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. Most common adverse reactions (>2%) are overall discomfort, abdominal distention, abdominal pain, nausea, vomiting and headache.

Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. Use caution when prescribing for patients with a history of seizures, arrhythmias, impaired gag reflex, regurgitation or aspiration, severe active ulcerative colitis, impaired renal function or patients taking medications that may affect renal function or electrolytes. Use can cause temporary elevations in uric acid. Uric acid fluctuations in patients with gout may precipitate an acute flare. Administration of osmotic laxative products may produce mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Patients with impaired water handling who experience severe vomiting should be closely monitored including measurement of electrolytes. Advise all patients to hydrate adequately before, during, and after use. Each bottle must be diluted with water to a final volume of 16 ounces and ingestion of additional water as recommended is important to patient tolerance.

BRIEF SUMMARY: Before prescribing, please see Full Prescribing Information and Medication Guide for SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution.

INDICATIONS AND USAGE: An osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. WARNINGS AND PRECAUTIONS: SUPREP Bowel Prep Kit is an osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. Use caution when prescribing for patients with a history of seizures, arrhythmias, impaired gag reflex, regurgitation or aspiration, severe active ulcerative colitis, impaired renal function or patients taking medications that may affect renal function or electrolytes. Pre-dose and post-colonoscopy ECGs should be considered in patients at increased risk of serious cardiac arrhythmias. Use can cause temporary elevations in uric acid. Uric acid fluctuations in patients with gout may precipitate an acute flare.

Administration of osmotic laxative products may produce mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Patients with impaired water handling who experience severe vomiting should be closely monitored including measurement of electrolytes. Advise all patients to hydrate adequately before, during, and after use. Each bottle must be diluted with water to a final volume of 16 ounces and ingestion of additional water as recommended is important to patient tolerance. Pregnancy: Pregnancy Category C. Animal reproduction studies have not been conducted. It is not known whether this product can cause fetal harm or can affect reproductive capacity. Pediatric Use: Safety and effectiveness in pediatric patients has not been established.

Geriatric Use: Of the 375 patients who took SUPREP Bowel Prep Kit in clinical trials, 94 (25%) were 65 years of age or older, while 25 (7%) were 75 years of age or older. No overall differences in safety or effectiveness of SUPREP Bowel Prep Kit administered as a split-dose (2-day) regimen were observed between geriatric patients and younger patients. DRUG INTERACTIONS: Oral medication administered within one hour of the start of administration of SUPREP may not be absorbed completely. ADVERSE REACTIONS: Most common adverse reactions (>2%) are overall discomfort, abdominal distention, abdominal pain, nausea, vomiting and headache. Oral Administration: Split-Dose (Two-Day) Regimen: Early in the evening prior to the colonoscopy: Pour the contents of one bottle of SUPREP Bowel Prep Kit into the mixing container provided. Fill the container with water to the 16 ounce fill line, and drink the entire amount. Drink two additional containers filled to the 16 ounce line with water over the next hour. Consume only a light breakfast or have only clear liquids on the day before colonoscopy. Day of Colonoscopy (10 to 12 hours after the evening dose): Pour the contents of the second SUPREP Bowel Prep Kit into the mixing container provided. Fill the container with water to the 16 ounce fill line, and drink the entire amount. Drink two additional containers filled to the 16 ounce line with water over the next hour. Complete all SUPREP Bowel Prep Kit and required water at least two hours prior to colonoscopy. Consume only clear liquids until after the colonoscopy.

STORAGE: Store at 20°-25°C (68°-77°F). Excursions permitted between 15°-30°C (59°-86°F). Rx only. Distributed by Braintree Laboratories, Inc. Braintree, MA 02185

For additional information, please call 1-800-874-6756 or visit www.suprepkit.com

©2017 Braintree Laboratories, Inc.

HH13276B-U

May 2017

1 MOST PRESCRIBED,

#

BRANDED BOWEL PREP KIT1

A CLEAN SWEEP

EFFECTIVE RESULTS IN ALL COLON SEGMENTS2

· SUPREP® Bowel Prep Kit has been FDA-approved as a split-dose oral regimen3 · >90% of patients had no residual stool in all colon segments2* †

These cleansing results for the cecum included 91% of patients2*

†

SUPREP Bowel Prep Kit also achieved ≥64% no residual fluid in 4 out of 5 colon segments (ascending, transverse, descending, and sigmoid/rectum)2* †

Aligned with Gastrointestinal Quality Improvement Consortium (GIQuIC) performance target of ≥85% quality cleansing for outpatient colonoscopies.4

*This clinical trial was not included in the product labeling. †Based on investigator grading.

References: 1. IMS Health, NPA Weekly, May 2017. 2. Rex DK, DiPalma JA, Rodriguez R, McGowan J, Cleveland M. A randomized clinical study comparing reduced-volume oral sulfate solution with standard 4-liter sulfate-free electrolyte lavage solution as preparation for colonoscopy. Gastrointest Endosc. 2010;72(2):328-336. 3. SUPREP Bowel Prep Kit [package insert].

Braintree, MA: Braintree Laboratories, Inc; 2012. 4. Rex DK, Schoenfeld PS, Cohen J, et al. Quality indicators for colonoscopy. Gastrointest Endosc. 2015;81(1):31-53.

©2017 Braintree Laboratories, Inc.

HH13276B-U

May 2017

PUBLIC

POLICY Legislative Priorities on

CAPITOL HILL //GOVERNORS' VANTAGE POINT

ONCE AGAIN, THE DEDICATION OF MORE THAN 50 ACG GOVERNORS AND SENIOR LEADERSHIP WAS ON FULL DISPLAY as they participated in more than 250

 Costas H. Kefalas, MD, MMM, FACG Chair, ACG Board of Governors Akron Digestive Disease Consultants, Akron, OH

unique meetings on Capitol Hill during the annual ACG Board of Governors Fly-In to Washington, DC on April 19, 2018. The Governors advocated on behalf of the College’s legislative and public policy agenda in meetings with members of the U.S. House of Representatives and the U.S. Senate.

Joining the Governors were non-Governor College leaders including ACG officers President Irving M. Pike, MD, FACG, Vice President Mark B. Pochapin, MD, FACG, Treasurer David A. Greenwald, MD, FACG, and Secretary Samir A. Shah, MD, FACG. Adding their voices to the Fly-In were also the Chair of the ACG Legislative & Public Policy Council, Whitfield L. Knapple, MD, FACG, and Council members R. Bruce Cameron, MD, FACG, and Ramona O. Rajapakse, MD. 

Public Policy | 13

// PUBLIC POLICY: GOVERNORS' VANTAGE POINT

Many months of preparation preceded the day’s visits to Capitol Hill. First, ACG staff and the ACG Legislative & Public Policy Council membership, led by Dr. Knapple, helped define the key legislative initiatives that the College is pursuing in 2018. From there, the Governors and senior leaders were well prepared over the course of four weeks with policy briefs and other documents.

When the day of advocacy finally came, the ACG Governors took the following messages to Congress:  Support Legislation that Improves Colorectal Cancer Screening Access for Medicare Beneficiaries

The ACG Governors thanked the more than 50% of legislators who have co-sponsored the “Removing Barriers to Colorectal Cancer Screening Act” (S.479 & H.R.1017) and encouraged the non-co-sponsoring legislators to do so as well. This bill corrects a glitch that allows cost-sharing for a screening colonoscopy turned therapeutic, with the removal of polyps.  Support Legislation in the U.S. House of Representatives that Provides Exemptions to the Current “Step Therapy” Requirements

H.R. 2077, the “Restoring the Patient’s Voice Act,” would allow patients enrolled in health insurance plans covered under the Employee Retirement Income Security Act access to the medication originally prescribed by the provider, rather than being forced to try and fail with other drugs first. Prior authorizations are just one example of burdensome commercial insurance requirements that consume significant administrative resources, but do not improve quality of patient care or decrease overall health care costs.

Thank You ACG Governors!

The ACG Board of Governors is a unique body within the College. It represents ACG membership both to the ACG Board of Trustees, and to legislators and policymakers in Washington, DC. I have been privileged to lead these dedicated leaders to two Capitol Hill Fly-Ins. I extend my sincere gratitude to all Governors and senior leaders who took time away from their patients and families to come to Washington, DC. The Governors continue to represent you and your interests. Please contact your Governor today. You can find contact information for your ACG Governor at gi.org/governors upon login to the ACG website.

14 | GI.ORG/ACGMAGAZINE

ACG Governors Meet During Fly-In on Capitol Hill The ACG Board of Governors also met and had a tremendously productive meeting, discussing a wide range of topics of concern from all regions of the country. The Board of Governors meeting had several guest speakers, most notably ACG Vice President Mark B. Pochapin, MD, FACG, who shared his personal views on leadership in medicine.

Overall the 2018 ACG Board of Governors Legislative Fly-in and Meeting was a tremendous success. Many thanks to Board Chair Dr. Costas H. Kefalas, Dr. Whit Knapple, Dr. Pochapin, and ACG staff including Brad Conway, Brad Stillman, Maria Susano, Valencia Waller and Jil Staszewski for all of their hard work for this critical meeting sponsored by the ACG.



 Douglas G. Adler, MD, FACG Vice Chair, ACG Board of Governors University of Utah School of Medicine, Salt Lake City, UT

Public Policy | 15

Accessible. Relevant. Practical.

The information you need to improve your practice.

The ACG Practice Management Committee’s mission is to equip College members with accessible tools to overcome management challenges, improve operations, enhance productivity, and support physician leadership in their private and physician-led clinical practices.

Learn from practicing colleagues through monthly articles on topics important to you. Articles include a topic overview, suggestions, examples, and a list of resources or references.

Toolbox topics will include

• Alternative Payment Models (APMs)

• Patient Satisfaction Surveys & Engagement

• Merit-Based Incentive Program Systems (MIPS)

• Reviewing & Updating Informed Consent

• Medicare Compliance & Preparation for RAC Audits

• Developing an Infection Control Plan

• Reviewing & Maximizing Revenue Cycle Efforts

• Professional Society Opportunities & Involvement

• Reviewing & Negotiating Insurance Contracts

• Quality Improvement Projects in Your Practice

"Pressures are high as gastroenterologists make important management decisions that profoundly affect their business future, their private lives, and their ability to provide care to patients." —Louis J. Wilson, MD, FACG

Start Building Success Today.

GI.ORG/TOOLBOX 16 | GI.ORG/ACGMAGAZINE

it Right GETTING

GETTING

IT

How Can We

Screen the Unscreened?

DESPITE ADVANCES IN COLORECTAL CANCER (CRC) SCREENING, FAR TOO MANY INDIVIDUALS ARE NOT BEING SCREENED. The problem is particularly acute at the 1,250 federally qualified



Karen E. Kim, MD, MS Professor of Medicine University of Chicago

health centers (FQHCs) with 8,000 service sites nationwide who provide the highest proportion of primary care to our nation’s most vulnerable and underserved populations.

In 2016, FQHCs provided primary care services to more than 25 million patients, 65% being racial/ethnic minority populations and 23% uninsured. Unfortunately, among these vulnerable populations, CRC screening rates at FQHCs are significantly lower at 35% compared with the national average of 62%. There are numerous system- and providerlevel barriers which contribute to these low screening rates including cost, access and poor communication. Many FQHC providers use FOBT/FIT as the initial screening option, but follow-up for those found to have a positive test is often delayed or never results in a completed diagnostic exam. The lack of specialty access for colonoscopy services within our nation’s safety net systems is a significant problem, with the average wait of 18 months to complete a diagnostic colonoscopy. This alone can significantly contribute to disparities in CRC mortality, with studies showing that a one-year delay in follow-up for a positive FIT can lead to a two-fold increase in CRC risk. How can we close this gap to reduce the unnecessary burden of disease? 

Getting it Right | 17

// GETTING IT RIGHT

ILColonCARES.orgsolves solves the fragmentation.

ILColonCARES.org theproblem problemofofsystem system fragmentation.

ILColonCARES.org solves the problem of system fragmentation.

Clinic

Hospital

Clinic Clinic

Hospital Hospital

schedules appointments schedules at Point of Service schedules appointments at

fills colonoscopy fills slots

fills slots colonoscopy colonoscopy slots

appointments at Point of Service Point of Service

Patient

Patient Patient

gets screened gets

gets screened screened

Completion of colonoscopy and REDUCE Colorectal Cancer Burden

Completion of colonoscopy and REDUCE Colorectal Cancer Burden Completion of colonoscopy and REDUCE Colorectal Cancer Burden

Our fragmented health care system plays an important role in impeding access to colonoscopy services. A recent 5 report showed that 80% of serious medical errors could be attributed to miscommunication among medical staff, with more than 50% due to poor provider-to-provider communication.

In fact, more than 50% of referring providers have no communication with the specialist, while 50% of specialists do not send information back to their referring providers. The challenges of failed communication can be attributed to multiple causes, the most important being unintegrated health care systems.

The most significant outcome from this poor communication falls on the shoulder of our patients. Studies show that only one out of every two referrals results in an actual appointment, and 40% of these cases are failed scheduling.

In fact, we know that when patients in need of colonoscopy services are not given an appointment before they leave

5 5

their doctor’s office, more than 50% will not complete their exam. This has a significant downstream effect, with between 14-24% of all colonoscopy slots being unfilled. The end result is patients who remain unscreened and hospitals who are wasting resources.

To address these barriers, me and my team received funds from the Centers for Disease Control and Prevention to develop an innovative web-based platform—ILColonCARES.org—to connect FIT-positive patients from FQHCs with colonoscopy slots at local hospitals. ILColonCARES.org is HIPAA compliant and was designed to link non-networked health care systems to specialty services. This portal overcomes system fragmentation to successfully complete colonoscopy services across systems by: (1) providing access to care for patients; (2) establishing point-ofcare scheduling; and (3) facilitating bidirectional communication. The IL Colon CARES program handles

ILColonCARES.org is an end-to-end solution for linkage to specialty care services.

Innovative web-based HIPAA-compliant software: •

•

References

Miglioretti DL, Rutter CM, Bradford SC, Zauber AG, Kessler LG,

healthcare systems

Feuer EJ, Grossman DC. Improvement in the diagnostic evaluation

Provides physician-to-physician

organization. Med Care. 2008; 46(9 Suppl 1):S91-96.

communication

Forrest CB, Nutting P, Werner JJ, Starfield B, von Schrader S, Rohde

Linkage to specialty care services with follow-

results from the Ambulatory Sentinel Practice Network referral study.

up reporting

of a positive fecal occult blood test in an integrated health care

C. Managed health plan effects on the specialty referral process: Med Care 2003; 41(2):242-53.

O’Malley AS; Reschovsky JD. Referral and consultation communication between primary care and specialist physicians finding common ground. Arch Intern Med. 2011; 171(1):56-65.

4

18 | GI.ORG/ACGMAGAZINE

Images courtesy of Dr. Karen Kim.

•

Connects out-of-network (decentralized)

two very different user bases: (1) FQHC providers in need of colonoscopy slots for their FOBT/FIT-positive patients, to make appointments for their patients and send clinic notes; and (2) hospital partners who post their open slots, accept referrals and appointments, capture notes from the providers, and communicate findings. A key innovation of this portal is the ability for point-of-service scheduling. Point-of-service scheduling has been shown to significantly increase receipt of services. Partner hospitals upload their available colonoscopy slots to the website, including the date and time, two weeks in advance. Clinics can see the open colonoscopy slots, schedule their patients, provide bowel prep instructions, and upload any medical information into the portal before their patients leave their clinic visit.

Once the patient completes their procedure, hospitals upload the colonoscopy report, any pertinent findings, quality metrics (e.g. bowel preparation, number of polyps found, withdrawal time) and interval follow-up into the portal to close the communication loop. ILColonCARES.org is an innovative platform which has broad application for increasing endoscopy capacity, reducing unfilled slots, and ensuring everyone receives high-quality, timely CRC screening and follow-up care.

Creating & Implementing a

QUALITY INSTITUTE

Dr. Andrew Crane serves as the Quality Institute's Physician Champion. Photos courtesy of Dr. Michael Morelli.

in Your Practice

Michael S. Morelli MD, CPE, FACG President, Indianapolis Gastroenterology and Hepatology, Indianapolis, IN



ALL PHYSICIANS

want to provide high-quality care to their patients. It is part of a universal mission in the medical profession, although accomplishing that goal is more difficult than simply professing it.

In today's medical environment, it is incumbent upon physicians to actually prove the quality of care they claim and strive to give. Patients, insurance companies, health care systems, and the Centers for Medicare and Medicaid Services (CMS) all demand this.

Thus, proving quality care is important for many reasons including improving patient outcomes, lowering cost of care, attracting more patient referrals, improving satisfaction rates among patients and referring physicians, and improving reimbursement.

Providing—and proving—this high-quality care requires a culture devoted to quality, baseline metrics and benchmarks to measure and aspire to, and an information technology (IT) and work force infrastructure to document and submit measures.

A CULTURE OF QUALITY IN INDIANAPOLIS In 2015, our group developed the Quality Institute at Indianapolis Gastroenterology and Hepatology (IGH), with the goal of developing a dedicated and structured approach to providing high-quality care to our patients. This essentially became another department of our practice, no different in a sense from the Revenue Cycle Management Department, Scheduling Department, Medical Records Department, etc.  Getting it Right | 19

// GETTING IT RIGHT

I met with our partners at a board meeting and discussed my idea and the merits of the program. Although they understood this project would require time and money, they readily agreed to pursue it.

Andrew W. Crane, MD, agreed to take the role of Physician Champion. Clinical Nursing Manager Cheryl Michael agreed to be the Nurse Liaison for the program and to do much of the ground work. We met with our IT vendor to discuss how they could help us devise the program and put the infrastructure in place to measure our quality metrics. With time and frequent meetings, the program has really taken off and become a source of pride in our practice. The creation of the Quality Institute has allowed us to devise efficient ways to measure and report quality in both our endoscopy services and clinicbased services in the areas of inflammatory bowel disease and liver disease. We market the work of the Institute on our website and have shared what we are doing with referring physicians, patients, self-insured companies, hospital systems, and thirdparty payers, with great feedback.

Strategies & Tactics

You Can Use in Your Practice The steps we took to create the Quality Institute at IGH that your group can replicate include the following:

Get buy-in from your group to appreciate the importance of this program, understanding that it will cost time, human resources and money.

Choose a Physician Champion of the program.

This may require extra compensation for this person depending on how your group compensates its members.

If feasible, choose one other physician to help the Physician Champion oversee the entire program.

Involve your IT vendor to help develop the measurement tools and reporting capability of your progress.

Market results to patients, referring doctors, self-insured companies and standard insurance companies.

Submit your results as a part of your MIPS composite score.

Choose metrics and benchmarks based on your scope of practice.

Choose a Nursing Champion to act as a liaison from the Physician Champion to the other physicians and to the IT vendor.

This may require extra compensation.

Measure.

Report results.

20 | GI.ORG/ACGMAGAZINE

Institute a quality improvement plan to get better at what you are measuring.

Expand the program to encompass more areas of your practice. For example, expand from simply endoscopy to the clinic and create disease management protocols for liver disease and inflammatory bowel disease.

Optimizing Revenue Cycle Output BUILDING SUCCESS

Patient Scheduling & Registration

Insurance Verification

Patient Statements

Co-Pay Collection

A/R Follow Up

Denial Appeals

Patient Exam

IT IS CRITICAL THAT YOUR PRACTICE BE PAID FOR ALL THE EFFORT AND CARE THAT YOU PROVIDE FOR YOUR PATIENTS. Identifying and

correcting problems in your revenue cycle management (RCM) should be a highpriority project. I developed this article for the ACG Practice Management Toolbox to guide you through the process of assessing, testing, and optimizing your revenue cycle (RC) performance.

 Payment Processing

Coding & Charge Entry

Claim Submission

What is Image source: http://www.ihealth-solutions.com/wp-content/uploads/2014/04/revenue-cycle-full.png.

the Revenue Cycle?

Revenue cycle (RC) refers to all processes involved in the collection of revenue earned through the delivery of care to the patient. The RC is not truly a cycle, but a set of interrelated events which begin prior to provider-patient contact and finish with the receipt of revenue and posting the revenue to an account.

Although making a claim and sending a bill is a component of the revenue cycle, it is only a small piece.

Components of

the Revenue Cycle The components of the revenue cycle can be divided into three main headings as to the time sequence of events:

Richard L. Nemec, MD, FACG Winchester Gastroenterology Associates, Winchester, VA

Claim Review

1

PRIOR TO PATIENT CONTACT Why is this important?

FACT: Up to 60% of claim denials are due to registration errors.

• Pre-registration: Collecting and verifying the insurance information and verification prior to patient arrival.

• Registration: Confirmation of demographics and co-pay collection.

2 PROVIDERPATIENT CONTACT

Why is this important?

Failure here can result in audits, penalties, undercharges and loss of revenue.

3

AFTER PROVIDER-PATIENT CONTACT Why is this important? This is how and when you get paid!

• Coding: Properly coding the diagnoses (ICD-10) and services provided (CPT) so that the practitioner is fully compensated for all of his/her services.

• Claims management: Submitting claims of billable fees to the insurance company • Payment collection: Collecting payments after claims submission.

• Payment failure: When payment is NOT made.

• Denial management • Accounts receivables/ Collections

Getting it Right | 21

// GETTING IT RIGHT

Systems Supporting the Revenue Cycle Although we can discuss the components of the Revenue Cycle, just as important are the business systems (people, process, capital equipment) that support it.

CORPORATE STRUCTURE AND LEADERSHIP: Although every corporate structure is unique, the leadership within that structure is essential to a highly effective RCM. The leadership drives the corporate vision as to the importance and necessity of RCM. The leadership needs to determine the responsibilities of each of the other three business components that support the resource cycle (RC): personnel/staff, information technology (IT) systems and external contractors. The leadership needs to develop the policies and procedures to coordinate all three of these entities.

Practical Suggestions:

Optimizing Revenue Cycle Output

HEALTH CARE PROVIDERS: are often the most overlooked component of RCM. However, accurate and clear documentation in the health care record are essential to adequate charge capture and coding. Inadequate or incomplete documentation may result in claim denials or down coding to a lower level of service (with less revenue). Failure to use key diagnostic terms may make it time-consuming, difficult or nearly impossible for billing personnel to convert information in the health care record into a billable claim.

SUPPORT PERSONNEL: Obviously the training and experience of multiple different personnel in multiple different positions directly impact the efficiency of the revenue cycle. Although most of the emphasis tends to be on those staff in the back office, those who work in pre-registration or registration are also important by accurately initiating the revenue cycle and thereby lessening the rate of claim denials downstream.

INFORMATION TECHNOLOGY (IT) SYSTEMS: Probably the first IT system purchased by a practice was the one to support the billing function. As time progressed electronic systems have developed for charge capture, health care record, claims submission, claims scrubbing (clerical error detection), receipt processing, etc. Seamless coordination and full integration between these oftentimes disparate and legacy systems highly impact the efficiency of the revenue cycle (and your staff).

Analyzing & Testing

the Revenue Cycle

(Reviewing Key Performance Indicators) In order to properly manage the revenue cycle, some testing/analysis is required. To assess your overall success in the revenue cycle, measure and monitor the four key performance indicators (KPIs).

22 | GI.ORG/ACGMAGAZINE

1

AGING REPORT: % of accounts receivable (A/R) pending after 120 days. Goal is 12% or less

Step 1 Review the below checklist: This list assesses current status and looks for obvious areas for improvement

EXTERNAL CONTRACTORS: Many practices are already dependent upon external contractors to support a few or many of the business processes of the revenue cycle. As may have happened with IT support, there may be a hodge-podge of different contractors.

Some vendors (generally those associated with electronic health care record systems) provide more integrated revenue cycle management support systems.

2

MEAN DAYS IN A/R: Mean # of days between date of service and date of payment receipt.

Goal is < 35

CORPORATE STRUCTURE AND LEADERSHIP: ❒ Does your leadership have the necessary skill sets to manage the RC? ❒ Is your leadership engaged in promoting this important function? ❒ Do you need to seek outside help to guide you through this process or can you develop the plan of action and milestones? ❒ Does your leadership have the determination to push this project forward, particularly when there are generally high upfront costs prior to the ROI (return on investment)? ❒ Does your leadership measure, review and react to the results of the four KPIs for the revenue cycle?

3

ADJUSTED COLLECTION RATE: The ratio between actual collections and the expected collections (adjusted for write offs): Goal is > 95%

4

DENIAL RATE: % of claims denied. Goal is < 5%

PROVIDERS: ❒ Are your health care providers (HCPs) cognizant of documentation requirements for E&M (evaluation and management) codes? ❒ Do your HCPs document in the health care record in such a fashion that allows easy conversion to chargeable visit? ❒ Who does the initial charge capture: the HCP? The back office? ❒ Do you have any physician leaders that can drive the agenda through the HCP staff?

FRONT OFFICE SUPPORT PERSONNEL: This includes all personnel who predominantly contact the patient prior to the delivery of service. ❒ What is the experience and skill set level of those personnel who work in pre-registration or registration? ❒ Do you have a high turnover rate?

Why? ❒ How are new personnel incorporated? ❒ Is there sufficient emphasis and time for training? By whom? ❒ Are the expectations of the staff performance communicated clearly?

BACK OFFICE SUPPORT PERSONNEL: This includes personnel predominantly involved in the portion of the revenue cycle after the delivery of service.

See all the questions for Front Office Support, with the following additions: ❒ Do you have personnel dedicated to coding, claims management, and denial management? ❒ Are your coders GI certified coders? ❒ Do your coders keep up to date with latest ICD-10? ❒ Do you have sufficient coders for the demand? ❒ Do you use external service for this (at what cost?)

IT SYSTEMS/SOFTWARE: ❒ Do you have an electronic health care record (EHR)? ❒ Do you have practice management (PM) system/software? ❒ Do you use electronic methods for benefits analysis/insurance verification? ❒ Do you process your claims electronically? ❒ Do you use electronic claims auditing tools (“scrubbers”) to ensure only clean claims are sent? ❒ Are payments received and posted electronically? ❒ Do you use a clearinghouse? ❒ MOST importantly, to what extent are these systems integrated: seamlessly? With interfaces? Not at all? If interfaces: how reliable are these systems?

Step 2 Identify and implement a RC improvement project: From the checklist, identify the most glaring area in need of improvement, then take steps to implement the improvement. Prioritize changes made based on financial impact.

EXTERNAL CONTRACTORS: ❒ Do you use external contractors for any of the components of the revenue cycle (see listing at beginning of this document)? ❒ How well is/are the external contractor(s) integrated with your software systems: EHR? PM? Other software? ❒ Do you use a global RCM contractor? ❒ Do you know the direct costs of this RCM contractor? ❒ Are they providing what YOU need/want or simply their cookiecutter RCM product?

Identify New and Undiscovered Areas

for Revenue Cycle Improvement KPI that needs improvement

Look to this RC component first!

Aging report

Back office

Mean days in A/R

Back office

Adjusted collection rate

Front office

Denial rate

Front office

Practice Strategies and References

to Improve Your Revenue Cycle

To get the most out of this article, please explore my handpicked references and



resources which illustrate practical approaches to the eight most common revenue cycle areas in need of improvement in medical practice. I provide examples ranging from the weak, absent or non-functional leadership team to practical advice on improving front-office and back-office operations, including claims, coding and collections. For each example, I have identified resources and references to guide in implementing an improvement strategy.

LEARN MORE: bit.ly/Rev-Cycle

Getting it Right | 23

// GETTING IT RIGHT

LAW MIND: IT’S NOT ALL ABOUT THAT RATE

APPROACH NEGOTIATIONS

with PAYERS How to

PHYSICIANS MUST IMPLEMENT A LONG-TERM, STRATEGIC APPROACH TO NEGOTIATING CONTRACTS WITH PAYERS. Gone are the days of trying to get a

few dollars more per CPT code or a few numbers higher as a percentage of Medicare. Today, it’s about more than the rate. Successful physician groups are building strategic alignment with payers to provide quality care for reasonable prices.

 Ann M. Bittinger, JD, represents physicians and physician groups in transactions with other entities and with compliance with federal health care laws and in structuring their independent practices.

Questions? Email ann@bittingerlaw.com

24 | GI.ORG/ACGMAGAZINE

Analyze Your Group As in any successful negotiation, first you need to know what you bring to the table. I’m surprised how many clients can’t tell me how much their top three payers pay them for a colonoscopy, or how much those payers are supposed to pay them per their contract. Often those two numbers are not the same. First, get your house in order. Understand what the contracts say versus what the payers are paying you. If you’ve been underpaid for a while, that lemon can be turned into lemonade by using that fact as justification that the insurer should pay you more going forward.

How long does it take payers to pay claims? Which payers dispute claims or haggle about medical necessity, pre-authorizations and the like?

A good practice chief executive officer will interview billing staff to learn the nuances of each payer before going to the negotiating table with the payer. This is important because often payers will not give an across-theboard increase but will carve out a few CPT codes and grant an increase on those, while leaving others the same or lowering them.

Also, what’s your payer mix? What is your private pay versus Medicare percentages of patients? Within the private payers, what payers represent what percentages? Within government payers, what percent are Medicare versus a Medicare managed care plan?

When you analyze this information, you will see trends. Once you lay the contracted charges and payments analysis on top of the payer mix percentages, you will identify which payer will give you the most bang for your buck, so to speak, to target for negotiations. This process can take anywhere from one to six months.

In addition, analyze procedures versus E&M coding for office visits versus diagnostics (and another subset of services you may provide).

Would you be willing to sacrifice a lower rate for imaging, for example, to get a higher rate on procedures? Would the net outcome be an increase?

Expect the payers to offer a change like this in response to an offer by you for an increase: in other words, a “Yes, we agree to an increase on some but we are lowering something else.”

Clients often want to focus on costs of running the practice. While this is good from a practice management standpoint, my experience is that payers are not swayed by costs. Their first response is typically: “Well your biggest cost is physician payroll, so pay your physicians less.” Additionally, sharing physician salary information without the information being subject to a non-disclosure agreement is not a sound decision. Generally, the negotiations include confidential information, trade secrets or other information about the practice—which is not uncommon in some payer-physician arrangements—so you want the payer to sign a nondisclosure agreement.

Other than charges, collections and payer mix data, I suggest that clients analyze their groups in additional ways prior to the negotiations. What makes your group a better partner with the payer than the other groups? Do you submit claims cleaner and faster than your competitors? Do you have good relationships with the payer? Are the geographic locations of your clinics appealing to the payers’ patient mixes? Is there something about your endoscopy center that sets your group apart from other centers or hospitals? Identify and accentuate a value proposition.

Once you’ve done this analysis and are ready for presentation to the payer, set your sights on a reasonable goal, but don’t make the first offer and don’t draw a line in the sand during the negotiations. The payer-physician dynamic is changing. Groups need to be ready to think creatively about how to structure payments.

Keep in mind that the payer may know more about your practice than you do. Most major payers have sophisticated systems to analyze physician data. In the meetings I discuss in part II of this article, which is available now on the ACG Blog, it may be helpful to listen to the payer’s representative talk about what they see in the data that they have about your group, and compare that with what your data reveals.



TO-DO LIST BEFORE NEGOTIATING

Determine your payer mix:

Which payers represent what percentage of your collections?

Determine what each payer is actually paying you: Check CPT codes against EOBs or other data.

Compare what different payers are paying: Identify outliers or trends.

Identify codes or procedures that could be targeted for improvement: Group different services together and set a goal for increase.

Align incentives with the payers:

Research what payers’ hot-button issues are and try to address them.

“

...Sharing physician salary information without the information being subject to a nondisclosure agreement is not a sound decision.

”

Identify your strengths:

Create a marketing document that shows how you are a good partner with the payer (clean claims, geographic locations).

CONTINUE READING

this installment of LAW MIND on the ACG BLOG. Ms. Bittinger tells you what hidden clause to look out for in contracts, the most important legal provision in a payer-group contract, and how to approach a meeting with a payer: bit.ly/LawMind18

Set financial and timeframe goals: Set a goal as to what you want to achieve and by when.

Getting it Right | 25

// COVER STORY

RWA

 GIVING RISE TO GI IN 26 | GI.ORG/ACGMAGAZINE

WANDA Q&A WITH DR. STEVE BENSEN AND DR. FRED MAKRAUER

Cover Story | 27

// COVER STORY

IT WAS AN EXPERIENCE HE HAD LONG HOPED WOULD BE A PART OF HIS MEDICAL CAREER, BUT HE DISCOVERED THAT THE RIGHT OPPORTUNITY WAS NOT EASY TO FIND.

28 | GI.ORG/ACGMAGAZINE

S

teve P. Bensen, MD, had searched for a global health experience, but he lacked the “tropical medicine” or infectious disease background. So when a former medical school classmate and now colleague asked him to serve as a visiting gastroenterologist in Rwanda, he jumped at the offer. This was a chance to teach Rwandan medical students and residents about GI—something he does every day at the Geisel School of Medicine at Dartmouth.

Rwanda is a small country of 12 million in the heart of East Africa whose health care system had been decimated by its 1994 genocide. In a 100-day span, 800,000 Rwandans were killed, including many of the country’s physicians, nurses and other health care professionals. Bensen was the first gastroenterologist to participate in the Human Resources for Health Program (HRH), a consortium that sent teams of doctors, nurses and other health professionals for extended stays working with Rwandan counterparts to rebuild their health care system.

“It’s been an experience that has forever changed me, offering a different perspective that has become a mid-career avenue for a renewed sense of purpose,” —Dr. Bensen

Photo top and on pages 26-27 courtesy of Eridana Harder, RN. Photo right courtesy of Dr. Steve Bensen and Connor Gordon.

Now more than four years since that visit, Bensen has completed a total of four trips. He considers himself “hooked” and views his experiences in Rwanda as “the highlight of my medical career.”

In several conversations with ACG MAGAZINE, Bensen shows passion and fervor for the work his team has done—and will do—in Rwanda. Most of his stories conclude not when success is realized, but with his vision for expanding these successes in the future.

In this Q&A, Bensen is joined by Frederick L. Makrauer, MD, of Brigham and Women's Hospital and Harvard Medical School. Makrauer discusses the work he and Bensen are doing to develop a GI fellowship program for Rwanda. They talk about the state of medical care and GI care,

what makes the program successful, and how GI physicians and other health care professionals can participate.

“You end up getting more out of the experience than you’re giving,” Bensen said.

What prompted you to take your first trip to Rwanda?

SB: I first went to Rwanda four years ago. I was

lucky enough to be talked into spending three months there by Lisa Adams, who is now the Dean of Global Health for Dartmouth College and Medical School. After my first stint I was hooked and have been returning every year since. It’s been an experience that has forever changed me, offering a different perspective that has become a mid-career avenue for a renewed sense of purpose.

Lisa asked me to participate as a visiting gastroenterologist with the HRH in Rwanda, a program she helped to establish and had brought to Dartmouth. HRH is a seven-year partnership involving the Rwandan Ministry of Health, the Clinton Foundation, and 11 other U.S. medical schools that is committed to rebuilding the Rwandan medical education and health care system. HRH has been successful in increasing the number of medical school graduates and physicians who have completed residency training in medicine, surgery, anesthesia, pediatrics and OB/ GYN. Before HRH there were just six residency-trained internists in the country; that number has grown to 70 today.

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Rwanda

A small country of 12 million in the heart of East Africa whose health care system had been decimated by its 1994 genocide. In a 100-day span, 800,000 Rwandans were killed, including many of the country’s physicians, nurses and other health care professionals.

FM: The founders of a cardiac

surgical non-governmental organization in Rwanda alerted me that the country was eager to address the need for expertise in gastroenterology and hepatology.

The opportunity to build a much-needed program from the ground up with extremely talented colleagues passionately committed to its success has made acceptance of the invitation very easy. Now there, I am constantly reminded of the benefits of learning and listening before choosing a solution or drafting a protocol.

What are the common GI diseases in Rwanda?

Rwanda has made enormous strides over the past 10 years in recreating a health care system. In some ways we can learn from them. There is now universal health care coverage, and health care is free for the poorest 25% of Rwandans.

Rwanda suffers from a significant burden of gastrointestinal disease.

30 | GI.ORG/ACGMAGAZINE

In 2017, during Rwandan Endoscopy Week (REW), 200 EGDs, 39 colonoscopies and five ERCPs were completed—the first ERCPs ever performed in Rwanda. 33% of EGDs revealed significant findings including peptic ulcer disease (16%), suspected gastric malignancy (4%), esophageal varices (4.5%), and gastric outlet obstruction (2.5%).

Significant findings on colonoscopy included hemorrhoid disease (23%), suspected colorectal cancer (7.7%), and ulcerative colitis (one case).

SB: Rwanda suffers from a significant burden of gastrointestinal disease. Conditions such as gastrointestinal malignancies, H. pylori-related peptic ulcer disease, advanced liver disease and its complications, noncirrhotic portal hypertension, acute and chronic diarrheal illness, malnutrition, and the gastrointestinal manifestations of the most common infectious diseases, such as HIV and tuberculosis, which are underdiagnosed and inadequately treated.

What medical resources—for example, endoscopic equipment— do Rwandan doctors use?

SB: The lack of endoscopic

equipment, coupled with a lack of training and expertise in therapeutic endoscopy, hinders gastrointestinal specialized care.

There are three referral hospitals where endoscopic equipment is available. Dedicated nurses and doctors at these facilities make the best of what they have to provide care. The equipment is often donated, used scopes from abroad, and maintenance of this equipment is a challenge. Likewise, consumables such as balloon dilators, variceal band ligators and biopsy forceps are in short supply.

What is the state of medical and gastroenterology care?

SB: Rwanda has made enormous strides

over the past 10 years in recreating a health care system. In some ways we can learn from them. There is now universal health care coverage, and health care is free for the poorest 25% of Rwandans. An article in The New York Times highlighted that in some ways Rwanda has a more equitable health care system than the United States, although they lack our resources. We can learn a lot about resourcefulness from the Rwandans.

After the genocide, Rwanda first focused on rebuilding a rich network of community health care workers to provide basic primary care. This is where you get the most bang for the buck. They are now focused on training nurses and midwives, and doctors in the fundamental specialties such as IM, general surgery, pediatrics and OB/GYN, however there are no subspecialty training or training programs in areas such as radiology, pathology, psychiatry or the surgical subspecialties. From a GI standpoint, there are only a handful of internists who can perform diagnostic endoscopic procedures and have expertise in the treatment of gastrointestinal conditions.

What is the background on the GI fellowship program? Dr. Makrauer, how did you become involved?

SB: There is palpable enthusiasm amongst Rwandan IM residents and young internists for advanced subspecialty training in GI, which does not currently exist.

The internists with whom I have been working propose a two-year subspecialty fellowship training program in gastroenterology that would develop the next generation of leaders in gastrointestinal health care and research, and that could serve as a model for other medical subspecialty fellowship programs.

Through the Rwandan doctors I was connected with Dr. Makrauer from the Brigham, who was also busy at work facilitating the creation of a fellowship training program.

FM: In 2015, the University of Rwanda School of Medicine invited me to join their faculty in designing an urgently needed, sustainable GI fellowship program and providing faculty with the necessary skills in teaching and clinical research. I accepted without hesitation, fulfilling a dream of

Photo at right courtesy of Eridana Harder, RN.

How about you, Dr. Makrauer?

“The MVP of the trip was not a physician but our biomedical engineer, Ben Sault. He worked tirelessly to make the most of all kinds of equipment.

When a hospital found out he was on site, he was pulled in all directions…” —Dr. Bensen

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// COVER STORY

 Watch the full video: bit.ly/Rwanda-Video

sharing the principles of clinical care, teaching and curriculum development with the global health community.

How has that process progressed?

FM: The realities of limited funding and separation by distance and time zones made it imperative that teaching and learning occur through multiple technologies. The availability of worldwide broadband access, and the use of already-functioning applications for both weekly videoconferencing and a “virtual classroom” have quickly cemented strong, international professional relationships and the mutual respect necessary to resolve the program mission, governance and funding. Rwandan leadership of all phases of development is embraced as critical by all parties. All faculty recognize the value of bidirectional training opportunities for enhanced learning and scholarship.

32 | GI.ORG/ACGMAGAZINE

“The ultimate success of this initiative will rely heavily on local leadership, close international collaboration, and teams of technicians and engineers in addition to nurses and physicians.”

—Dr. Bensen

Has the program been approved by the government?

SB: The program is just about approved through the Rwandan Ministry of Health.

Have your colleagues joined you on trips to Rwanda? Have your Rwandan counterparts made trips to the states?

SB: My first two visits to Rwanda were threemonth stays through HRH. My first visit had such an impact on me. I was 49 the first time I went, and I wished I had done it much earlier. I wanted others to have this experience. For my second visit, I brought several Geisel medical students and our third-year GI fellow.

Lisa made a point early on to all of us involved in HRH that it was important for physicians to have this type of experience at some point in their career, and she supported us in bringing over students. However she firmly believed that it was not fair to just

Photos at left on page 32 courtesy of Eridana Harder, RN. Photo on pages 32-33 courtesy of Dr. Steve Bensen and Connor Gordon.

be sending Dartmouth students and trainees to Rwanda. We should establish “exchanges,” through which our learners rotating through Rwanda should be matched by Rwandan trainees and physicians coming to the United States. I bought into that idea once I appreciated how valuable it was on both sides to share this cultural and professional exchange.

We have brought over about 15 Rwandan resident physicians and faculty for extended stays at Dartmouth, and a similar number of Dartmouth medical students and postgraduate trainees have been to Rwanda. We all benefit. Deep friendships and professional relationships have been established through these exchanges.

The Rwandan residents we brought to Dartmouth a few years ago are now medical leaders in their country, some serving as the only IM doctors at large district hospitals. Others serve as junior

faculty training medical students and residents at the four teaching hospitals.

“…I am constantly reminded of the benefits of learning and listening before choosing a solution or drafting a protocol” —Dr. Makrauer

You are involved in Rwandan Endoscopy Week (REW).

What goes on during that week?

SB: This idea arose from my Rwandan colleagues, Drs. Vincent Dusabejambo and Eric Rutaganda, who wished to advance endoscopy in Rwanda. They and a few others formed the Rwandan Society of Endoscopy (RSE) a few years back.

REW is a collaborative effort born of relationships formed through HRH, RSE and previously established bilateral international physician exchanges. The goals are to provide direct patient care, train providers in therapeutic endoscopic skills, and advance gastroenterology as a subspecialty intensively over a short period of time. In 2017, REW was advertised to the public through national media and to referring providers at district hospitals. We deployed integrated US/Rwandan teams to the four referral hospitals with endoscopic capabilities. Six GI physicians, two nurses, two technicians and a biomedical engineer from the Cover Story | 33

// COVER STORY

34 | GI.ORG/ACGMAGAZINE

United States collaborated with RSE members—15 physicians and 18 endoscopy nurses.

GI consultations were performed on all patients referred for endoscopy to ensure appropriateness of procedures. Demographic data, procedural indication and results were collected with the online tool Google Forms.

The majority of endoscopes were donated; many were outdated and not functioning optimally. The biomedical engineer repaired non-functioning devices; technicians provided training on the care of equipment; and nurses exchanged knowledge of patient sedation and monitoring. In all, the teams completed 200 EGDs, 39 colonoscopies and five ERCPs— the first ERCPs ever performed in Rwanda.

Consistent with local practice, no sedation was administered but for the five ERCPs and several colonoscopies. Thirty-three percent of EGDs revealed significant findings including peptic ulcer disease (16%), suspected gastric malignancy (4%), esophageal varices (4.5%), and gastric outlet obstruction (2.5%).

Instruction in interventional procedures included banding of esophageal varices, placement of esophageal stents, PEG tubes, and balloon dilation. Significant findings on colonoscopy included hemorrhoid disease (23%), suspected colorectal cancer (7.7%), and ulcerative colitis (one case).

The ultimate success of this initiative will rely heavily on local leadership, close international collaboration, and teams of technicians and engineers in addition to nurses and physicians.

In addition to physicians, what other health care professionals are critical to the team’s success?

SB: The endoscopy techs and nurses were key to REW’s success. Everyone pitched in to work long hours and provide much-needed care. The MVP of the trip was not a physician but our biomedical engineer, Ben Sault.

He worked tirelessly to make the most of all kinds of equipment. When a hospital

found out he was on site, he was pulled in all directions, fixing equipment such as ventilators and PICU incubators in addition to endoscopic equipment.

The monitor at the hospital in Butare, which had worked for years, went down. Dozens of patients were lined up for procedures. We felt helpless. We trucked Ben down from Kigali, which is three hours away. He found an older unit in a storage room that he rigged to work, literally saving the day. They still use the unit today.

Another day we were given a room in the operative theater. Dr. Stuart Gordon and our advanced biliary team of tech Kristen Sprenger and nurse Eridana Harder cranked out the first ERCPs in east Africa—five in total over an 18–hour period. The Rwandan nurses and doctors stayed with us the whole time—until we completed the last case.

What has your experience in Rwanda meant to you?

SB: My time in Rwanda has proven to be the highlight of my medical career. The most rewarding aspect of the experience for me has been the deep friendships and relationships I have established with my Rwandan colleagues.

What’s next?

SB: We are planning for the 2018 REW. We hope to extend REW to include more formal educational sessions and symposia the week before and after the intensive procedure week. We hold weekly teleconferences with RSE leaders, Dr. Makrauer and others in the Netherlands and Australia to move the GI fellowship program forward.

We will be recruiting faculty from the United States and abroad who are willing to serve as visiting faculty for three-to-four-week blocks starting in September. We want others to have the meaningful experience we have had. The Rwandans could use our help, so it is a win-win proposition.

“My time in Rwanda has proven to be the highlight of my medical career.

The most rewarding aspect of the experience for me has been the deep friendships and

relationships I have established with my Rwandan colleagues.”

—Dr. Bensen

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// COVER STORY

GET INVOLVED HOW CAN ACG MEMBERS GET INVOLVED? Do you need physicians and other health care professionals?

SB: We would love to hear from ACG members interested in an international experience.

We could use both academic physicians and those in private practice, as well as endoscopy techs, nurses and biomedical engineers.

Andy Robinson, MD, who was in private practice in New Hampshire and recently retired, came to REW. He was amazing, using his years of experience to train two young Rwandan internists in upper endoscopy over the week at a remote district hospital. His team, with the most limited equipment and inexperienced group of Rwandans, performed the most procedures, with more than 70 unsedated upper endoscopies over four days. These patients had waited months to be seen, but no one could treat them.

Now there are two Rwandan doctors continuing what was started during REW.

 If any ACG member physicians, endoscopy nurses and techs, or biomedical engineers are interested, they can contact me at Steve.P.Bensen@hitchcock.org for more information.

36 | GI.ORG/ACGMAGAZINE

Photos on pages 34-36 courtesy of Eridana Harder, RN.

later we found out he had cancer. At the time, I didn’t care much because my Granny had previously had breast cancer and she survived, so I figured the same would happen to my dad. I was only 12 at the time, so I figured cancer was like a cold that would come and go. During one of my Dad’s hospital visits, the doctors told us his tumor was shrinking. My family and I were happy, and I believed everything was going to be alright.

Then a month later, my parents and I left the doctor’s office crying because the doctors told us the tumor had grown and spread, and there was nothing else they could do. The entire car ride home I remember laying my head on my Dad’s lap and crying.

The next few months were rough for me because I woke up every morning in constant fear that my Dad would be gone. I had to watch a man for whom I had the utmost respect—who carried me in his arms, who loved me more than anyone in the world, who I saw as “Superman”—become eaten and consumed by cancer. The one thing about it is that he always kept his optimism.

How Colon Cancer

CHANGED my

Photo courtesy of Norma Davis-Atkins.

 Davis William Atkins, the son of Len Atkins and Norma DavisAtkins, shares this personal reflection on his father’s passing from stage IV colon cancer at age 48. Ms. Davis-Atkins is now advocating for earlier screening.

My family is planning on moving to a new home. I’m switching schools. We’re planning a family trip to Florida. I’m looking to the horizon with excitement, as my life is taking new turns.

Then it happens out of the blue: my Dad is diagnosed with colon cancer. The only things running through my mind are “How did this happen?” and “Why did my dad get picked by the cancer monster?” So many emotions run through my entire body—I’m angry, sad and confused all at the same time. It’s like in the movies when a character starts to spin more and more until they get so dizzy, then the screen turns black.

I was at the Wilson County Fair with my parents, a friend of mine and his parents. I was playing around with my friend until my Mom told me that my Dad was having pain. I noticed he was holding his side. He had more pains more often after that; weeks

LIFE

By Davis William Atkins

The morning my Dad died, I believed that my life was over. I never thought it would happen to my family, but it did. Afterward, it was like I had gone through a transformation with all the therapy sessions, the depression medicine, the hate I felt toward my family, that people I did not even know kept apologizing about me losing my Dad, and the multiple doctors’ appointments I had regarding my own health. I felt lost, and with all the changes going on in my life, I had no idea who to talk to or what to do with myself.

One day I realized that my Dad would want me to move on with my life and become the greatest person I could be. It took some time to put my life back together, but with help from my Mom, aunt, uncle and grandmothers, I figured out my life piece by piece.

I have many ambitions, starting with the colleges I want to apply to/attend, because I am hoping to make my Dad proud. I carry my Dad’s name with pride, knowing I am going to make him and my entire family proud.

I am now 17 years old and, as I have gotten older, I have discovered more things. I had a colonoscopy when I was 13, and my Mom had to explain to me why I was having a procedure like

ACG Perspectives | 37

// ACG PERSPECTIVES

HOW DID NORMA DAVISATKINS’ STORY COME TO ACG? Renee L. Williams, MD, FACG, New York University School of Medicine, New York, NY, Chair, ACG Minority Affairs and Cultural Diversity Committee

that. At first, I thought it was pointless, but now I realize the importance of it. The whole point was to keep me safe for the future.

What we hadn’t realized before was that my Dad had cancer for a long time and had never gotten checked out because he had no symptoms and was not old enough for a colonoscopy; my Mom and doctors did not want to make the same mistake with me. I now believe this is a good thing for me and it could be for a lot of other people, too.

The point of getting that procedure early, from what I understand, is that it can keep someone informed and updated on whether they may have cancer hidden in their body, especially for people with cancer in their family.

Sharing Norma Davis-Atkins and Davis William Atkins’ story is a collaboration of ACG’s Public Relations and Minority Affairs and Cultural Diversity Committees.

38 | GI.ORG/ACGMAGAZINE

"...I woke up every morning in constant fear that my Dad would be gone.

I had to watch a man for whom I had the utmost respect—who carried me in his arms, who loved me more than anyone in the world, who I saw as Superman— become eaten and consumed by cancer."

Ms. Davis-Atkins sent me a very touching email in which she revealed that her husband had died a few years earlier from colorectal cancer at the age of 48. She was interested in advocacy and wanted to know if I had any advice. I immediately contacted her via telephone because I wanted to speak with her directly after reading her email.

She mentioned that she wanted to get more involved in advocacy and felt that if her husband had been screened at age 45 he may still be alive today. She shared that it was only a few months from diagnosis to death and he left behind their son, who was 12 years old at the time. I spoke to her about my role in the College and asked if she would be comfortable sharing her story via social media to promote earlier screening in African Americans and screening in general. She agreed, I put her in contact with our media team, and the rest is in the graphics.  Download and share the graphics: bit.ly/Atkins-Age-45-Rec

From

ACCRA, GHANA to ROCHESTER, MINNESOTA MY MAYO CLINIC EXPERIENCE

Sally Afua Bampoh, MD Korle Bu Teaching Hospital, Accra, Ghana

Photos courtesy of Dr. Sally Afua Bampoh.

 MY COUNTRY, GHANA, HAS A HIGH BURDEN OF CHRONIC HEPATITIS B INFECTION,

with increasing incidence of complications like hepatocellular carcinoma and cirrhosis, the bulk of which are managed at my hospital, the Korle Bu Teaching Hospital, which is the premiere hospital in the country and located in the capital city, Accra. There is also an increase in the number of patients presenting with other gastrointestinal (GI) conditions like inflammatory bowel disease. However, there are very few qualified gastroenterologists, with most of them being trained in other countries. The Ghana College of Physicians and Surgeons only began sub-specialty training a few years ago.

As a gastroenterology trainee, my desire was to be exposed to novel areas in GI and hepatology, gain insight into the use of available modern technology, and to encourage the necessary authorities to acquire such tools. I also sought to improve my knowledge in research and to form a collaboration with foreign faculty to help research into various diseases affecting my country, develop solutions for these conditions, and contribute to available data on prevailing conditions.

This led me to apply for the position of a visiting fellow in the USA. Mayo Clinic Rochester was the obvious choice because I had previously come into contact with Dr. Lewis Roberts, who had done a lot of research into hepatobiliary cancers. With the help of the ACG, which awarded me with the 2016 International GI Training Grant, my trip to the Mayo Clinic became a reality.

On the September 19, 2016, I reported at the Mayo Clinic as a Visiting International Fellow for six months, a period that was divided equally between clinical and research periods. The Division of Gastroenterology and Hepatology at Mayo is well structured into smaller, specialized clinics, which makes the training in all aspects of GI easy. During the clinical period, I rotated through these specialized clinics and observed conditions that were not common in my part of the world, and learned how such conditions were managed. My best times during the clinical period were the days spent in the procedure rooms learning about ERCP, EUS, therapeutic endoscopies, manometry, etc. The clinical period helped reform me as a doctor and improved my relationship with my patients, which improves outcomes. The last three months of my training were spent in research, where I was involved in the ongoing clinical research on hepatocellular cancers. I was trained on developing and initiating research ideas and also on how to analyze data. This was very beneficial as I was having challenges with my dissertation, which is a mandatory requirement for my fellowship training. The knowledge acquired during this period empowered me to complete my proposal on “Non-

Alcoholic Fatty Liver Disease in Type 2 Diabetes,” and the actual work began in December 2017.

Indeed, the period spent at Mayo Clinic exposed me to a world of modern technology and advanced research, and this has been beneficial to my practice as a doctor and as a trainee in GI and hepatology. I also got the opportunity to attend conferences aimed at mentoring and career progression in clinical practice and education.

To the countless number of people who contributed to making this dream a reality, I express my heartfelt appreciation. I am grateful especially to ACG (in full please), Prof. Jacob Plange-Rhule, Rector of the Ghana College of Physicians and Surgeons, Dr. Mitch Mah’moud of Duke University, Dr. Mark Topazian of Mayo Clinic Rochester, and Jo Meyers and Rebecca Williams of Mayo Clinic. A special thank you to all the fellows and research coordinators I worked with, especially Dr. Thoetchai Peeraphatdit (Bee). Lastly, to my mentor Dr. Lewis Roberts of Mayo Clinic, who still encourages me and has formed collaboration with my unit in Ghana to research into various conditions. I say ”AYEKOO" to all these persons and all those I could not mention.

ACG Perspectives | 39

// ACG PERSPECTIVES

Facing Challenges & Seeking Balance FOR FEMALE ADVANCED ENDOSCOPISTS IT TAKES A VILLAGE  “A POIGNANT QUESTION COMES TO MIND when I think about the level of commitment it takes to thrive as an interventional gastroenterologist, while at the same time wanting to grow your family, not surpassing your child bearing age, and achieving a real work-life balance,” reflects Shivangi T. Kothari, MD, FACG, Vice Chair of ACG’s Women in GI Committee, an advanced endoscopist, and the mother of two young sons.

“My husband is also an interventional endoscopist [Truptesh H. Kothari, MD], but it helps tremendously that he totally understands the rocky ride I go through after a tough day at work. My parents helped out with the kids during the early years, and that’s how my husband and I were able to complete our interventional trainings. So, it’s true, it does take a village!”

Building support networks in personal and professional spheres—like Dr. Kothari—is a recurring theme for all of the female advanced endoscopists who graciously shared their reflections with ACG MAGAZINE. They recount common challenges facing female physicians generally, but reflect insightfully on the unique physical and professional demands of interventional endoscopy for women in GI. While they chose to pursue a path that is associated with long hours, repetitive stress injuries for endoscopists, and higher complication rates, nevertheless these women find their work deeply rewarding.

40 | GI.ORG/ACGMAGAZINE

“One of the most helpful things is having a good support system—both medical and non-medical.

Over the years, I have met many amazing women therapeutic endoscopists, whom I frequently turn to for support.”

—Sharlene L. D’Souza, MD, Medford, OR 

1

2

Why do you love interventional GI, and why did you choose it?

Dr. Kothari: A new case or new challenge presents every single day, and I still experience the same adrenaline rush and excitement as my first day as an interventional gastroenterologist. For me, there is a unique and satisfying sense of achievement after performing every interventional endoscopic procedure.

Dr. D’Souza: Procedures such as ERCP, EUS, placement of enteral stents, or mucosal resections are very cerebral and organized, but also require flexibility if the procedure is difficult or if plans A, B and C aren’t viable options. I like the fact that no two procedures are the same and each one challenges me in different ways.­

3

4

5



Dr. Banerjee: I love the challenges posed by GI tumors. I imagine myself to be the "007" when it comes to using my interventional GI skills to solve diagnostic dilemmas. I love the privilege of utilizing my interventional skills to keep patients out of the OR and avoid risky surgery.

What is uniquely challenging about advanced endoscopy as a path in GI for women?

Dr. D’Souza: Our field is technically challenging, mentally stimulating, sometimes emotionally draining—but, at the end of the day, it is immensely rewarding.

Dr. Banerjee: The main challenge I face today is the juggling act of integrating career and family

life. The long hours, higher probability of being called after hours, and the physical demands of the profession can add to the challenges of balancing personal and professional lives…Upon having kids, I quickly learned to delegate, become the CEO of home, and manage my energy (rather than time) more efficiently.

Dr. Pawa: Endoscopy can be challenging on the joints and arms, causing shoulder pain, lower back pain, and elbow, hand and neck pain. There is a risk of overuse syndromes because of repetitive movements and potentially awkward postures. It is worse for interventional endoscopists, as we perform the most technically challenging procedures and for longer hours. It is therefore important to incorporate ergonomic design principles in your practice. 

“The key is to identify and balance personal and professional goals, nurture wellness strategies, and perform regular reassessments of your priorities.”

—Swati Pawa, MD, FACG, New Brunswick, NJ, Co-Chair, Interventional Women in GI Subcommittee

ACG Perspectives | 41

// ACG PERSPECTIVES

1

3

“Follow your heart.

Learn to say ‘No,’ stop overextending yourself, and respect your needs.

When we engage in a healthy amount of self-care, self-love and self-respect, the rest around us falls into place.”

—Promila Banerjee, MD, FACG, Northbrook, IL, Co-Chair, Interventional Women in GI Subcommittee 

2

What lessons have you learned that might make the way easier for other women to follow?

Dr. D’Souza: My advice for women going into this field would be to actively seek out other women who will be good mentors, role models and colleagues that you can turn to for support. We all have shared experiences and it is always helpful to hear how someone else navigated through difficult ones.

Dr. Banerjee: Just as we schedule work into our daily lives, remember to

42 | GI.ORG/ACGMAGAZINE

schedule physical workout time, play time with kids or pets, "me" time, and time for your significant other.

Dr. Pawa: A rigorous work/endoscopy schedule over several years has forced me to reflect on the importance of balance in my life. I have since realized that attempting to be a “Superwoman” can lead to enormous stress and personal sacrifice and is simply not necessary. It is important to add variety to your routine by diversifying in education, teaching or research while continuing to maintain your skill set in advanced endoscopy.

“RULES to Live By” Shivangi T. Kothari, MD, FACG

 I have implemented a few “rules”



4 5

“I have benefited from the incredible support of my spouse and family.

Having the support of an understanding partner has been the foundation that allowed me to achieve my goal of pursuing interventional endoscopy, especially as a female in gastroenterology."

—Shivangi T. Kothari, MD, FACG, Rochester, NY, Vice Chair, ACG Women in GI Committee

6 Photos on pages 40-41: 1-2- courtesy of Sharlene L. D’Souza, MD; 3- courtesy of Shivangi T. Kothari, MD, FACG; 4- courtesy of Swati Pawa, MD, FACG; 5- courtesy of Promila Banerjee, MD, FACG. Photos on pages 42-43: 1- courtesy of Promila Banerjee, MD, FACG; 2- courtesy of Swati Pawa, MD, FACG; 3-4courtesy of Shivangi T. Kothari, MD, FACG; 5- courtesy of Promila Banerjee, MD, FACG; 6- courtesy of Swati Pawa, MD, FACG.

in my life to try to keep the right balance between my work and my personal life—not taking work home is the most important to me.

It took a while for me to realize that my kids, family and home need my undivided attention. For young gastroenterologists thinking about their careers, I strongly suggest not pushing your personal life to the side by bringing work home. I’m not suggesting that you leave your work hanging, but make sure you improve your ability to multitask and increase your efficiency.

Even though my husband and I share a profession, we never “talk shop” at home. This gives us the time to discuss and share our views on other topics. I am fortunate to be the mother of two young boys. I do my best to spend as much time with them as I can—even if it’s as simple as helping my oldest with his homework, playing games or reading him to sleep. I recommend to my peers that if you are planning a career in interventional GI, then focus equally on planning your family.

Another rule I feel has helped me is carving time out for just me and my hobbies. In all the roles that I live, sometimes I feel I don’t give myself enough time. After having my son, I decided to consciously make some more “me time.” I am a trained Indian classical dancer and had lost touch with my dancing over the years. Now I have started dancing again—it helps me unwind and helps with the post-baby weight loss.

The most salient lesson I have to share with other interventional GI colleagues and female physicians is this: never compromise your personal and family time. I spent a bit of energy learning this the hard way. I’ve realized if I can figure out how to balance my work-life ratio, ultimately my productivity increases at work, and my satisfaction and happiness increase; this helps me to focus more on my work and my personal life.

ACG Perspectives | 43

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THE AMERICAN COLLEGE OF GASTROENTEROLOGY 44 | GI.ORG/ACGMAGAZINE

Photo top: ACG Past President Stephen B Hanauer, MD, FACG (center), during his visit to Cleveland Clinic Florida.

EDUCATION

THE ACG EDGAR ACHKAR “Everyone here was thrilled with his [Dr. Hanauer's] visit.

Even though he is an outstanding speaker and I have heard him speak multiple times, the interaction in a smaller audience exceeded my expectations as we were able to learn more about his approach to patients and thought process behind it.” —Dr. Castro

VISITING PROFESSORSHIP PROVIDING NOTEWORTHY SPEAKERS FOR TRAINING IN YOUR COMMUNITIES THE GOAL OF THE ACG EDGAR ACHKAR VISITING PROFESSORSHIP PROGRAM is to enable GI

fellowship programs to have high-quality visiting professors to bolster the training program by providing lectures, small group discussions, and one-on-one visits with trainees and faculty. This issue of ACG MAGAZINE provides additional confirmed dates for this year's visiting professors and features the first five visits of 2018: Nicholas J. Shaheen, MD, MPH, FACG, at the University of Minnesota; Peter D.R. Higgins, MD, PhD, MSc, at the UCLA David Geffen School of Medicine; Satish S.C. Rao, MD, PhD, FACG, at Virginia Commonwealth University; Kris V. Kowdley, MD, FACG, at the University of Arizona College of Medicine Phoenix; and ACG Past President Stephen B. Hanauer, MD, FACG, at Cleveland Clinic Florida. 

Education | 45

// EDUCATION

“Fellows appreciated Dr. Higgins' earnest opinions/advice to young GI trainees on finding mentors, identifying a career path, and developing future career plans... His participation at journal club was also phenomenal. He brought a lot to the discussion.”

—UCLA fellows

“The interaction between Dr. Kowdley and the fellows. Fellows left the conference with answers to some of their tough liver cases. ” —Dr. Alishahi on the biggest impact of Dr. Kowdley's visit to the University of Arizona College of Medicine Phoenix.

46 | GI.ORG/ACGMAGAZINE

2018 ACG EDGAR ACHKAR VISITING PROFESSORSHIPS

“Your [Dr. Shaheen's] visit was the best visiting faculty experience for us and particularly for the GI fellows that I have witnessed.

Feedback from fellows was simply the best possible.”

—Dr. Freeman

NICHOLAS J. SHAHEEN, MD, MPH, FACG University of Minnesota FEBRUARY 1–2 PETER D.R. HIGGINS, MD, PHD, MSC UCLA David Geffen School of Medicine FEBRUARY 21–23 SATISH S.C. RAO, MD, PHD, FACG Virginia Commonwealth University FEBRUARY 22–23 KRIS V. KOWDLEY, MD, FACG University of Arizona College of Medicine Phoenix MARCH 1–2 STEPHEN B. HANAUER, MD, FACG Cleveland Clinic Florida MARCH 5–6

“Inspiring and gratifying personally for me to help problem solve, inculcate a sense of compassion and discovery in peers and fellows, and expose them to latest advances in diagnosis and treatment of anorectal motility disorders. ” —Dr. Rao

SAPNA SYNGAL, MD, MPH, FACG Emory University School of Medicine MARCH 26–27 SACHIN B. WANI, MD University of Nebraska APRIL 12–13 DAVID T. RUBIN, MD, FACG UConn Health MAY 2 CHRISTOPHER C. THOMPSON, MD, MSC, FACG University of Alberta JUNE 12 JOHN J. VARGO, II, MD, MPH, FACG Vanderbilt University JUNE 21 SUNANDA V. KANE, MD, MSPH, FACG SUNY Downstate SEPTEMBER 13 JOHN E. PANDOLFINO, MD, MSCI, FACG Genesys Regional Medical Center NOVEMBER 6–7 MILLIE D. LONG, MD, MPH, FACG Beaumont-Botsford Campus DATE TBD

Education | 47

AJG Special Issue!

THE GUT MICROBIOME The gut microbiome, a rich and diverse community comprised of trillions of organisms, plays a critical role in health and disease.

Recent research has shown how alterations in gut microbiome homeostasis can lead to a variety of gastrointestinal disorders.

Gastroenterologists and hepatologists are confronted with this topic daily when evaluating patients with irritable bowel syndrome, C. difficile colitis, inflammatory bowel disease, nutritional disorders, obesity, and a variety of liver disorders.

The American Journal of Gastroenterology requests your high-quality, clinically relevant research about the role of the microbiome in all areas of gastroenterology and hepatology. We will collect the very best original research and clinical reviews into a special issue highlighting the relationship between the microbiome, health, and disease.

Please clearly state in your cover letter that your manuscript is intended for the special Microbiome Issue of AJG. Depending upon the response to this request, some accepted manuscripts may be published in other upcoming issues of AJG.

48 | GI.ORG/ACGMAGAZINE

Submit Your Manuscript!

Submit manuscripts to:

mc.manuscriptcentral.com/ajg

DEADLINE:

AUGUST 15, 2018

Please address questions to Lindsey Topp, Managing Editor: ltopp@gi.org www.nature.com/ajg

Inside the

JOURNALS

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Long-Term Bowel Disease cantly InfluencesUtilization in osis Type Signifi n Healthcare Ileocecal Anastom Quality of Life, and dent of Inflammatio Patients Indepen Functional Status, Crohn’s Disease , Andrew Postoperative M. Buchholz J. Bauer, Bettina Recurrence Claudia Ramos-

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n, Anthony G. Hashash, Regueiro, Brian Mahesh Gajendra E. Koutroubakis, Jana J. Cruz, Miguel Janet Harrison, R. Watson, Ioannis Kenneth K. Lee, Ruy Arthur Barrie, Shah, , Jason Swoger, Rivers, Nilesh Benjamin Click, Marc Schwartz William M. Rivers, Babichenko, Zuckerbraun, Javier Salgado, Umapathy, Dmitriy Douglas J. Hartman, , Chandraprakash Alyce M. Andersonand David G. Binion Michael A. Dunn

FACG TS INSIDE , MD, MSHS, OF CONTEN Brennan Spiegel MD, FACG and E. Lacy, PhD, EDITORS: Brian

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Cover_AJG

1

KEY CLINICAL TAKEAWAYS FROM TWO NEW GUIDELINES published in The American Journal of Gastroenterology this year are explored in AJG Author Insights from Dr. Grace Elta on the diagnosis and management of pancreatic cysts, and Dr. Vijay Shah on alcoholic liver disease.

Dr. Elta and co-authors provide guidance on surgical management as well as surveillance of asymptomatic cysts. You will find links to the full text of the guidelines and to an AJG Author Podcast with Dr. Elta.

In their update on the management of alcoholrelated etiologies, Dr. Vijay Shah and co-authors note the importance of early diagnosis and focus on jaundice, liver biopsy, liver transplantation in alcoholic hepatitis, and pharmacologic management. In an AJG Author Podcast, Dr. Shah discusses the definition of alcohol use disorder, as well as diagnostic tests for suspected cirrhosis and alcoholic hepatitis.

From the steady flow of new papers published in Clinical and Translational Gastroenterology, we feature articles with potential impact on clinical care of Barrett’s esophagus and eosinophilic esophagitis in adults. ACG MAGAZINE highlights thought-provoking cases from ACG Case Reports Journal, which continues with a case from the Florida State University College of Medicine and the University of Florida, Gainesville. ed by

Inside the Journals | 49

// THE AMERICAN JOURNAL OF GASTROENTEROLOGY

ACG Clinical

GUIDELINES [AUTHOR INSIGHT]

PANCREATIC CYSTS: AN INCREASINGLY COMMON CONCERN Grace H. Elta, MD, FACG, Brintha K. Enestvedt, MD, MBA, Bryan G. Sauer, MD, MSc, FACG (GRADE Methodologist), Anne Marie Lennon, MD, PhD, FACG

 PANCREATIC CYSTS ARE BEING DIAGNOSED MUCH MORE OFTEN and are present in up to 40% of individuals over the age of 70! Given that pancreatic cancer incidence is not changing, this increase in cyst diagnosis is most likely due to the improved quality and more frequent performance of CT and MRI exams. Most pancreatic cysts are found incidentally and are asymptomatic. The most common cysts are side branch intra-ductal papillary mucinous neoplasms (IPMNs). Although side branch-IPMNs do have malignant potential, the vast majority will never develop into pancreatic cancer.

The surveillance efficacy for the prevention of pancreatic cancer is unknown and it is costly. Hence the management conundrum and the many differences in existing national and international pancreatic cyst guidelines.

The new ACG Guideline on the Diagnosis and Management of Pancreatic Cysts is available online.

The first step in pancreatic cyst management is to determine cyst type.

They can be neoplastic or non-neoplastic (pseudocysts), with the neoplastic ones further categorized as mucinous, IPMNs and mucinous cystic neoplasms (MCNs), vs. non-mucinous, which are primarily serous cystadenomas. Other rare pancreatic cyst types are also discussed in the guideline.

MRI/MRCP and CT scan are the most commonly used imaging modalities, although both suffer in diagnostic accuracy for determining cyst type, with accuracy of 4050%. The addition of endoscopic ultrasound with FNA may help diagnose pancreatic cyst type when the diagnosis is unclear from clinical history and imaging.

The second step is to determine if the cyst is causing symptoms—which is rare—or carries any features worrisome for cancer (see Table 3). Because many incidental

50 | GI.ORG/ACGMAGAZINE

pancreatic cysts are found in elderly individuals, it is also important at this step to assess whether the patient is a surgical candidate and would be interested in pursuing surgery. Pancreatic surgery carries significant morbidity and some mortality. If the patient is not fit for surgery, no further evaluation or surveillance should occur.

Patients with symptomatic neoplastic cysts or imaging features worrisome for cancer should be referred to a multi-disciplinary pancreatic cancer center. Many of these patients may not require surgery, but a careful, multi-discipline opinion is valuable.

When the diagnosis of cyst type or the decision to operate remains unclear, EUS with cyst sampling can be helpful. Elevated cyst fluid CEA (>192 ng/ml) is suggestive of a mucinous cyst; if this is still nondiagnostic, analysis of cyst fluid KRAS and GNAS mutations can be used in diagnosing mucinous cysts. However, like cyst fluid CEA, they are not helpful in diagnosing cancer or high-grade dysplasia. EUS is also quite accurate at differentiating cyst wall nodules from mucin collections. Cyst fluid cytology showing dysplasia or cancer is very helpful, although most specimens are paucicellular and non-diagnostic. The role of cyst fluid genomics, cyst wall biopsy or confocal microscopy remains uncertain at this time.

The treatment of symptomatic or worrisome cysts continues to be surgery. The possible

role of cyst ablation techniques requires more study.

Once an asymptomatic pancreatic cyst is determined to most likely be a mucinous cyst, a discussion with the patient about potential surveillance should occur. The low risk of malignancy and unknown benefit of surveillance should be made clear. If the patient wishes to proceed and there are no high-risk features, MRI/MRCP is the usual choice for surveillance; EUS is an excellent alternative if the patient is unable or unwilling to undergo MRI. CT can also be utilized, although it is usually avoided due to radiation dose. Cyst surveillance intervals continue to be determined by cyst diameter, even though cyst size is only one measure of risk. This guideline gives practical recommendations on how often surveillance should occur. It also recommends that surveillance intervals may be lengthened after size stability is established. Given evidence that the risk of cancer does not diminish with time, surveillance should be continued until the patient is no longer a surgical candidate.

 Read the Guideline rdcu.be/I71Q Listen to the AJG Author Podcast gi.org/ajgpodcasts/Elta

TABLE 3. HIGH-RISK CHARACTERISTICS FOR MUCINOUS PANCREATIC CYSTS Symptoms Jaundice secondary to the cyst Acute pancreatitis secondary to the cyst Elevated serum CA 19-9 when no benign cause for elevation is present Imaging findings Mural nodule or solid component within the cyst or pancreatic parenchyma Main pancreatic duct diameter of >5 mm Change in main duct caliber with upstream atrophy Size > 3 cm Increase in cyst size > 3 mm/year Cytology High-grade dysplasia or pancreatic cancer

[AUTHOR INSIGHT]

ALCOHOLIC LIVER DISEASE Vijay H. Shah, MD, FACG, Ashwani K. Singal, MD, MS, FACG, Ramon Bataller, MD, PhD, FACG, Joseph Ahn, MD, MS, FACG (GRADE Methodologist), Patrick S. Kamath, MD

 LIVER CIRRHOSIS IS THE 12TH LEADING CAUSE OF MORTALITY IN THE UNITED STATES and at least one half of cases of liver cirrhosis relate to an alcohol-related etiology.

With recent advances in management of viral hepatitis-related cirrhosis, it is important for providers to be up to date in management of alcohol-related etiologies because this problem is likely to continue for the foreseeable future.

alcohol, it is prudent to check AST, ALT and, if elevated, then to perform an ultrasound of the liver as initial testing.

JAUNDICE In individuals who present with jaundice in the setting of excess alcohol consumption, it is important to consider alcoholic hepatitis in the differential diagnosis. Laboratory profile will usually reveal AST/ALT ratio of greater than 1.5 with transaminase levels generally less than 300.

LIVER BIOPSY The guideline outlines an approach to liver biopsy in which liver biopsy can be pursued in the setting where testing is not definitive for alcoholic hepatitis and/or when testing suggests potential alternative etiologies.

ASSESSING PROGRESS IN ALCOHOLIC HEPATITIS

EARLY DIAGNOSIS The first step in diagnosing alcohol-related liver disease is to try to make the diagnosis at an earlier stage than cirrhosis. This requires asking about alcohol use and addiction and providing input, guidance and feedback to the patient at the time of initial screening. A number of tools are available for this, and the key is to ask the questions. Not all patients who consume excess amounts of alcohol actually develop alcoholic liver disease, probably only about 20-30% of patients do so. There may be some genetic factors that predispose individuals as well as other co-variables such as obesity and co-existing forms of liver insults such as viral hepatitis. In individuals who consume excess amounts of

After the diagnosis of alcoholic hepatitis is made, it is important to use available nomograms to assess prognosis. The Maddrey Discriminant Function score is the most time-tested nomogram, however, many providers are moving to more modern nomograms, especially MELD score. A MELD score over 20 denotes severe alcoholic hepatitis that may warrant pharmacologic therapy.

provide a small survival benefit but only for one-month survival. Therefore, they could be utilized in cases where there are not contraindications to corticosteroids. However, clearly better therapies are needed for the future and an emphasis on abstinence needs to be pursued to improve survival beyond one month.

LIVER TRANSPLANTATION There has been recent momentum in the area of liver transplantation for patients with alcoholic hepatitis, however, it should be emphasized that the majority of patients with alcoholic hepatitis do not fit the criteria for liver transplantation. It should be considered only in individuals who have very strong social support, lack of psychiatric comorbidities, are presenting with their first bout of alcoholic hepatitis, have not failed prior to treatment efforts for addiction, and who have not responded to pharmacotherapy for their alcoholic hepatitis.

This constitutes a small percentage of the patients with alcoholic hepatitis.

 Read the Guideline rdcu.be/I8ac

PHARMACOLOGIC THERAPY In terms of pharmacologic therapy, recent studies have shown that pentoxifylline is unlikely to be providing benefit in patients with alcoholic hepatitis and should no longer be used in that setting. Corticosteroids do

Listen to the AJG Author Podcast gi.org/ajgpodcasts/shah

Alcoholic Liver Disea Alcoholic Liver Disea Alcoholic Liver Liver Disea Disea Alcoholic FIGURE 1. DISEASE SPECTRUM OF ALCOHOLIC LIVER DISEASE hepatitis Alcoholic hepatitis Alcoholic hepatitis Alcoholichepatitis hepatitis Alcoholic RISK FACTORS: Risk factors: Risk factors: Risk factors: Risk factors: Amount alcohol

Amount alcohol Amount alcohol Amount alcohol alcohol Amount Obesityalcohol Obesity Obesity Obesity Obesity PNPLA3 variations PNPLA3 variations variations PNPLA3 PNPLA3 variations variations PNPLA3 variations Smoking, coffee Smoking, coffee Smoking, coffee Smoking,coffee coffee coffee Smoking, Viral hepatitis hepatitis Viral Viral hepatitis Viralhepatitis hepatitis hepatitis Viral

Chronic Chronic Chronic Chronic Chronic alcohol 90–95% alcohol 90–95% alcohol 90–95% 90–95% alcohol 90–95% alcohol abuse abuse abuse abuse abuse Normal liver Normal liver Normalliver liver Normal Normal liver

20–40% 20–40% 20–40% 20–40%

8–20% 8–20% 8–20% 8–20% 8–20%

20–40%

Steatosis Steatosis Steatosis Steatosis Steatosis

Fibrosis Fibrosis Fibrosis Fibrosis Fibrosis

3–10% 3–10% 3–10% 3–10% 3–10% 3–10%

Cirrhosis Cirrhosis Cirrhosis Cirrhosis Cirrhosis

HCC HCC HCC HCC HCC HCC

gure 1. Disease Disease spectrum of alcoholic liver disease. gure spectrum of alcoholic liver disease. gure Diseasespectrum spectrumof ofalcoholic alcoholicliver liverdisease. disease. ure 111...Disease

Inside the Journals | 51

Making theCASE

// ACG CASE REPORTS JOURNAL

Malignant Peritoneal Mesothelioma Presenting as Mucinous Ascites

Zachary Field, BS, Andreas Zori, MD, Vikas Khullar, MD, Manoela Mota, MD, Michael Feely, DO, and Roberto J. Firpi, MD, MS

A rare case of a 46-year-old man presenting with mucinous ascites secondary to malignant peritoneal mesothelioma (MPM) that was diagnosed via colonoscopy with biopsies. Both the findings and the clinical presentation were unique. While it is widely known that asbestos exposure is commonly associated with pleural mesothelioma, 6–10% of malignant mesotheliomas arise from the peritoneum. To date, only four cases of MPM with the primary tumor site in the colon have been described in the literature.  Read the full case: bit.ly/ACGCRJ-May18

 View more images and all published cases without a subscription: acgcasereports.gi.org

52 | GI.ORG/ACGMAGAZINE

Highlights

Fig. 2 Distribution of relative abundance of phyla in saliva from subjects with and without BE. Subjects with BE had significantly increased relative abundance of Firmicutes and decreased Proteobacteria

Barrett’s Esophagus is Associated with a Distinct Oral Microbiome

By Julian A. Abrams, MD, MPH, Columbia University Medical Center, New York, NY

There is currently a great deal of interest in developing simple, non-endoscopic techniques to identify patients who have Barrett’s Esophagus (BE) and who are at highest risk for esophageal cancer. In this preliminary study, we found that the bacterial makeup of saliva can distinguish patients with and without BE. These results need to be confirmed in larger and different populations. However, we feel that this is a very exciting finding, as saliva collection and analysis could potentially serve as a simple, office-based method to identify patients with BE.  Read the full article: Arias et al. Clinical and Translational Gastroenterology bit.ly/CTG-May18-1

Page 11 of 14

Fig. 3 Cladogram demonstrating a phylogenetic tree with numerous differentially abundant taxa in saliva from subjects with and without demonstrating a phylogenetic numerous differentially abundant nodes3: onCladogram the inner ring represent phyla, and the nodes on the outertree ring with represent genera BE. The Fig.

taxa in saliva from subjects with and without BE.

(full table of differentially abundant taxa is shown in Supplementary Table 4). A model with a combination of the two taxa produced an AUROC of 0.93 (95% CI:

0.81–1.00) (Supplementary Figure 2). The optimal cutoff for this model was associated with 90.0% sensitivity and 87.5% specificity.

Toll-like Receptors-Mediated Pathways Activate Inflammatory Responses in the Esophageal Mucosa of Adult Eosinophilic Esophagitis

Official journal of the American College of Gastroenterology

By Alfredo J. Lucendo, MD, PhD, Madrid and Tomelloso, Spain

F

Eosinophilic esophagitis (EoE) is a common cause of chronic esophageal symptoms that is recognized as a form of allergy to food antigens; avoiding food triggers constitutes a first-line therapy for patients.

Toll-like receptors (TLRs) expressed in the mucosa surfaces distinguish between pathogen and commensal Page 11 of 14 components of the microbiota, and are involved in several immune-mediated conditions.

An upregulated expression of several TLRs was found in the esophageal mucosa of patients with active EoE compared to healthy controls, which returned to normal after remission induced dietary Fig. 6 The esophagus and the duodenum display a differential gene expression profile. a Principal component analysis by (PCA) and btherapy.

HeatmapsThe expression downstream inflammatory were determined using all genes detailed in Table 2 from both the esophagus and the duodenum from of active (aEoE) and quiescent (qEoE) mediators patients andand effector molecules was also upregulated. In all cases, healthy controls changes reversed after disease remission induced by dietary therapy. The activation of TLR-mediated signaling documented in our series of patients. Moreover, tran- of esophageal epithelial cells in immune defense and pathways in the esophageal mucosa of patients with scription factors and subsequent effectors of the TLRs maintenance of tolerance has not yet been fully EoE supports a relevant role for the microbiota in the signaling pathway are also upregulated in EoE, and investigated. pathophysiology of the disease.

O

terology

CLINICAL AND TRANSLATIONAL

// CLINICAL AND TRANSLATIONAL GASTROENTEROLOGY

O F R EC

TE

D

PR

O

Bronchial asthma and EoE share multiple resemblances, restored to control after effective dietary treatment. In triggered by contrast, the duodenal mucosa shows no inflammatory including an altered Th2-type  immune Read the response full article: the involvement of eosinoactivity despite comparable profile expression of the same potentially innocuous antigens, bit.ly/CTG-May18-2 TLR genes. This study adds to the cumulative literature phils and mast cells in the pathophysiology17, the transmural investigating the role of TLRs in different gastrointestinal inflammation that promotes smooth muscle dysfunction and inflammatory conditions, including inflammatory bowel fibrous remodeling8,56, and clinico-pathological response to disease29,45,46, celiac disease30,47, food allergy48, and sev- topic steroids and avoidance of antigen triggers exposure13,57,58. However, and despite all these similarities, as well eral atopic disorders49,50.  In recent years, multiple studies have investigated the as the fact that the prevalence of bronchial asthma among CTG is a free, fully open-access journal, Fig. 6. The esophagus and the duodenum display a differential gene expression profile. a differential gene expression profile. a expression Principal profile component analysis (PCA) and b Heatmaps signaling pathways byinTLRs in the allergic air- EoE patients is three times higher than in the non-EoE Having detected an altered gene mediated samples from patients with active available to all readers worldwide.

51,52 59 om both the esophagus and the duodenum from active regulate (aEoE) quiescent (qEoE) patients andpopulation , no study has assessed yet the role of TLRs on EoE regarding controls with, awhere healthy esophagus, which and decreased following SFED-induced way disease they immune responses Read the journal: nature.com/ctg remission, we studied whether that was reflected in a differential gene expression fingerprint. and are connected to the activity of high affinity IgEwe EoE, as in the case of bronchial asthma52,53. Hence, and given Given that TLR expression was also higher in the non-inflamed duodenum of EoE patients, first analyzed all the data revealing that the samples sort together based on the tissue (Fig. 6) receptor (FcεRI) expressed on mast cells, acting as a that it has been recently reported that TLR receptors are irrespective of the source of the patients. of esophageal in immune defense Moreover, tran-connector between epithelial the innate cells and adaptive immune sys- andexpressed in the healthy esophagus40,60, we decided to charof role tolerance has 4not been rs of the TLRstems.maintenance A predominant for TLR-2, and yet 9 has beenfullyacterize their expression in the context of EoE by describing investigated. d in EoE, andrecognized in bronchial asthma53,54. In contrast, the how TLR-1, TLR-2, TLR-4, and TLR-9 are expanded in the Inside the Journals | 53 Bronchial asthma and gastrointestinal EoE share multiple y treatment. Infunctioning its modulaof TLRs in the tractresemblances, has just inflamed mucosa from active EoE patients, and

M CECUM THE CECU HING THE REACHING REAC

By Robert E. Kravetz, MD, MACG Scottsdale, AZ

A LOOK BACK

THE FLUSH TOILET

This archival reflection originally appeared in The American Journal of Gastroenterology in March 2009.

D

isposal of human waste has been an issue since humans have inhabited the Earth. Prehistoric man relieved himself out of doors; much later, Native Americans and early American settlers also used rivers, woods and shrubs to fulfill their toilet needs in the same primitive way. There is archaeological evidence, however, of domestic communal toilets from many ancient civilizations dating back to 2500 BC. At the height of the Roman Empire, there was a highly developed water system and one for waste management with underground sewers and indoor privies in each home. After the decline of the Empire, the entire system collapsed, and by the Middle Ages in Europe, and well into the eighteenth

54 | GI.ORG/ACGMAGAZINE

century, waste disposal meant throwing the material out of the window or door onto the street and into the gutter.

In 1596, Sir John Harrington of England invented the first flush toilet, but the public mocked and ignored his invention.

Nearly 200 years passed before, in 1775, Alexander Cummings received the first patent for a water closet. By the 1800s, the golden age of toilets had begun. Thomas Crapper is erroneously thought to have invented the toilet, but his contribution was a series of plumbing-related patents that revolutionized its operation.

The accompanying illustration shows a nineteenthcentury toilet from an English catalog—a very elaborate fixture indeed!

IMPORTANT SAFETY INFORMATION SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution is an osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. Most common adverse reactions (>2%) are overall discomfort, abdominal distention, abdominal pain, nausea, vomiting and headache.

Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. Use caution when prescribing for patients with a history of seizures, arrhythmias, impaired gag reflex, regurgitation or aspiration, severe active ulcerative colitis, impaired renal function or patients taking medications that may affect renal function or electrolytes. Use can cause temporary elevations in uric acid. Uric acid fluctuations in patients with gout may precipitate an acute flare. Administration of osmotic laxative products may produce mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Patients with impaired water handling who experience severe vomiting should be closely monitored including measurement of electrolytes. Advise all patients to hydrate adequately before, during, and after use. Each bottle must be diluted with water to a final volume of 16 ounces and ingestion of additional water as recommended is important to patient tolerance.

BRIEF SUMMARY: Before prescribing, please see Full Prescribing Information and Medication Guide for SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution.

INDICATIONS AND USAGE: An osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. WARNINGS AND PRECAUTIONS: SUPREP Bowel Prep Kit is an osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. Use caution when prescribing for patients with a history of seizures, arrhythmias, impaired gag reflex, regurgitation or aspiration, severe active ulcerative colitis, impaired renal function or patients taking medications that may affect renal function or electrolytes. Pre-dose and post-colonoscopy ECGs should be considered in patients at increased risk of serious cardiac arrhythmias. Use can cause temporary elevations in uric acid. Uric acid fluctuations in patients with gout may precipitate an acute flare.

Administration of osmotic laxative products may produce mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Patients with impaired water handling who experience severe vomiting should be closely monitored including measurement of electrolytes. Advise all patients to hydrate adequately before, during, and after use. Each bottle must be diluted with water to a final volume of 16 ounces and ingestion of additional water as recommended is important to patient tolerance. Pregnancy: Pregnancy Category C. Animal reproduction studies have not been conducted. It is not known whether this product can cause fetal harm or can affect reproductive capacity. Pediatric Use: Safety and effectiveness in pediatric patients has not been established.

Geriatric Use: Of the 375 patients who took SUPREP Bowel Prep Kit in clinical trials, 94 (25%) were 65 years of age or older, while 25 (7%) were 75 years of age or older. No overall differences in safety or effectiveness of SUPREP Bowel Prep Kit administered as a split-dose (2-day) regimen were observed between geriatric patients and younger patients. DRUG INTERACTIONS: Oral medication administered within one hour of the start of administration of SUPREP may not be absorbed completely. ADVERSE REACTIONS: Most common adverse reactions (>2%) are overall discomfort, abdominal distention, abdominal pain, nausea, vomiting and headache. Oral Administration: Split-Dose (Two-Day) Regimen: Early in the evening prior to the colonoscopy: Pour the contents of one bottle of SUPREP Bowel Prep Kit into the mixing container provided. Fill the container with water to the 16 ounce fill line, and drink the entire amount. Drink two additional containers filled to the 16 ounce line with water over the next hour. Consume only a light breakfast or have only clear liquids on the day before colonoscopy. Day of Colonoscopy (10 to 12 hours after the evening dose): Pour the contents of the second SUPREP Bowel Prep Kit into the mixing container provided. Fill the container with water to the 16 ounce fill line, and drink the entire amount. Drink two additional containers filled to the 16 ounce line with water over the next hour. Complete all SUPREP Bowel Prep Kit and required water at least two hours prior to colonoscopy. Consume only clear liquids until after the colonoscopy.

STORAGE: Store at 20°-25°C (68°-77°F). Excursions permitted between 15°-30°C (59°-86°F). Rx only. Distributed by Braintree Laboratories, Inc. Braintree, MA 02185

For additional information, please call 1-800-874-6756 or visit www.suprepkit.com

©2017 Braintree Laboratories, Inc.

HH13276B-U

May 2017

1 MOST PRESCRIBED, BRANDED BOWEL PREP KIT1 #

2

FIVE-STAR EFF1CACY WITH SUPREP ® Distinctive results in all colon segments • SUPREP Bowel Prep Kit has been FDA-approved as a split-dose oral regimen3 • 98% of patients receiving SUPREP Bowel Prep Kit had “good” or “excellent” bowel cleansing2* †

• >90% of patients had no residual stool in all colon segments2*

†

These cleansing results for the cecum included 91% of patients2*

†

Aligned with Gastrointestinal Quality Improvement Consortium (GIQuIC) performance target of ≥85% quality cleansing for outpatient colonoscopies.4 *This clinical trial was not included in the product labeling. †Based on investigator grading.

References: 1. IMS Health, NPA Weekly, May 2017. 2. Rex DK, DiPalma JA, Rodriguez R, McGowan J, Cleveland M. A randomized clinical study comparing reduced-volume oral sulfate solution with standard 4-liter sulfate-free electrolyte lavage solution as preparation for colonoscopy. Gastrointest Endosc.

2010;72(2):328-336. 3. SUPREP Bowel Prep Kit [package insert]. Braintree, MA: Braintree Laboratories, Inc; 2012. 4. Rex DK, Schoenfeld PS, Cohen J, et al.

Quality indicators for colonoscopy. Gastrointest Endosc. 2015;81(1):31-53.

©2017 Braintree Laboratories, Inc. All rights reserved.

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