Increasing Access or Improving Mortality in Endoscopy
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Debate: Increasing Access or Improving
Mortality in Endoscopy
Elective v Acute
Dr Sanchoy Sarkar FRCP. PhD
Endoscopy Services Lead
Consultant Gastroenterologist
Senior Lecturer
Content
• Improving Mortality
• Futility
• Adversely Effecting Mortality
Improving Mortality
EMERGENCY-IN-PATIENT
UPPER ENDOSCOPY
GASTROSCOPY
ELECTIVE-OPD or DAY-CASE
LOWER ENDOSCOPY:
COLONOSCOPY/FLEXI
Therapeutic
EMERGENCY & IN-PATIENT
ENDOSCOPY SERVICES
Upper GI Bleed BSG Audit
206 Hospitals: UK
• On call: Half hospitals BUT mortality 20% lower if present
• High Risk Patients (Scope 12hrs)
– 1/2 scoped 24hrs
• High risk Bleed lesions- treatment– ¾ Given any endoscopic treatment
– Only 1/3 given optimal
• Inappropriate Drugs
– ¼ used correct use
GUT 2010(59) 1022-1029
When Things Done Badly
“Goals & Opportunities are Missed !!’
Evolving Endoscopy Services (20 yrs)
93 99 06 07 09 11 12 13 93 99 06 07 09 11 12 13
Middle Grade
24/7 Rota
Consultant
plus
Middle Grade
24/7 Rota
In-Patient Lists
Day time
Daily
In-patient
Day-Time
Evening Lists In-patient
Coordinator
Saturday
lists
Consultant
Endoscopists
x3
Bowel
Cancer
Screening
Fellow
3 Session
Day
Flexi
Screening
Consultant
Expansion
Sunday
Lists
BCSP
Centre
Na
tio
na
l Tr
ain
ing
Ce
ntr
e
Surv
Colonoscopy
nurse
Expertise & Infra-structure • Endoscopy Training Centre & Tertiary Referral Centre
• Personnel– SpR/Fellow
– Consultant On-Call Rota & Consultant Endoscopists
• Equipment– Endoscopic Equipment
– Haemostatic Equipment (Technologies)
• Facilities– Theatre/Endoscopy Unit Access
– High Dependency Bleed Unit & Gastro Ward Base
• Service provision– 24/7 On Call Service (Consultant & Middle Grade)
– In-Patient Lists (Day & Evening)
– Weekend In-Patient Lists
• Back-Up– Interventional Radiology
– Specialty Based Surgery
UGI Bleeding Mortality
Comparison National & RLH
Mortality 1993 2007 2009 2011
National 14% 10% N/A N/A
RLH 5% 3% 0% 0%
ELECTIVE ENDOSCOPY
Lower Endoscopy- Screening
Diagnostic
Therapeutic
Screening Improving Mortality
• Colonoscopy + FOBT
– Reduce incidence CRC by 20%
– Reduce CRC mortality by 28%
• Flexi-Sigmoidoscopy
– Reduced incidence by 33%
– Reduced CRC mortality 43%
– Saved lives (1 in 200)
Futility- E.g. Colonoscopy Surveillance
0
4
8
12
16
30 day
6 month
Sarkar et al: Frontline Gastroenterology 2011
%
Fit Un-Fit (not scoped)
Pathology Mortality
None due to CRC
Elective Endoscopy
Emergency Readmissions & Mortality
If you have access to this article through your institution, you can view this article in OvidSP.
European Journal of Gastroenterology & Hepatology:December 2012 - Volume 24 - Issue 12 - p 1438–1446doi: 10.1097/MEG.0b013e3283582db0Original Articles: Endoscopy
A multicentre study to determine the incidence,demographics, aetiology and outcomes of 6-dayemergency readmission following day-case endoscopy
Sarkar, Sanchoya; Geraghty, Joea; Moore, Andrew R.a; Lal, Simonc;
Ramesh, Jayapald; Bodger, Keithb; CERT-N: Collaboration inEndoscopy, Research & Training-North-West
Readmission Rate 0.5% but if readmitted Mortality 6.8%
Adverse Events
TOTAL % Rate Standards Details/Comments
PerforationsOGD-Therapy 1 0.1 1/1000
OGD-Diagnostic 1 0.02 1/6000
Colonoscopy-
Diagnostic 0 0 N/A
Colonoscopy-Therapy 2 0.14 1/725
Flexi-Diagnostic 3 0.08 1/1800 (
BleedingERCP-Sphincterotomy 4 0.26 1/100
Post-polypectomy-
EMR 4 0.2 1/450
OGD-Diagnostic 1 0.002 1/6000 (
Hidden Health Costs
Other Complications No % Rate Comment
CVS-Resp 16 0.1 1/1000
Arrest 2 All OGD
Aspiration 2 All OGD
Pneumonia 3 All Colon
MI/ACS/Angina 8 0.05 1/2000
CVA 1
Preciptated
Obstruction 7 0.1 1/850 All after diagnostic OGD
Bowel Prep 4 0.1 1/900
Conclusions
• Improve Mortality
– Emergency/In-Patients: Therapeutic Upper Endoscopy– Elective: Asymptomatic: Lower GI Endoscopy
• Adversely Effect Mortality
– Futility & Risk to Benefit Ratio– Hidden Costs; Patient safety– APPROPRIATENESS
Thank You
Sanchoy.Sarkar@rlbuht.nhs.uk
www.liverpoolgastroenterology.nhs.uk
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