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Dig Dis Sci (2015) 60:3234–3241

DOI 10.1007/s10620-015-3781-y

ORIGINAL ARTICLE

Multicenter Study Assessing Physician Recommendations
Regarding the Continuation of Aspirin and/or NSAIDs
Prior to Gastrointestinal Endoscopy
Joseph D. Feuerstein1 • Elliot B. Tapper1 • Edward Belkin2 • Jeffrey J. Lewandowski3 •

Anand Singla4,5 • Saurabh Sethi1 • Sunil G. Sheth1 • Mandeep Sawheny1

Received: 21 April 2015 / Accepted: 20 June 2015 / Published online: 30 June 2015
Ó Springer Science+Business Media New York 2015

Abstract time in clinical practice, year of medical school graduation,
Background In 2009 the American Society for Gas- and location of medical school were all reviewed. The
trointestinal Endoscopy (ASGE) guidelines advised that primary outcome was number of questions answered cor-
both aspirin and NSAIDs be continued prior to low-risk rectly and predictors of correct responses.
gastrointestinal endoscopic procedures. We sought to Results The survey was administered to 941 participants
determine physician knowledge regarding these guidelines. with 12 declining to participate, while 80 % (740/929) of
Methods A survey questionnaire was developed based on the subjects completed the survey; 20 % (150/740)
the ASGE guidelines. Physicians were queried about respondents answered both questions correctly and 42 %
whether they would continue/stop aspirin in a patient with (310/740) answered one question correctly. There was no
cardiac disease and in a patient taking NSAIDs for arthritis significant difference between institutions (p = 0.6) or
whether they would continue/stop NSAIDs prior to endo- between attendings and trainees (p = 0.75). Multivariate
scopy. The survey was administered at three academic predictors of correct answers were self-reported familiarity
medical centers. Demographic information: level of train- with the guideline (-0.029; 95 % CI -0.003 to -0.056,
ing, board certification, teaching trainees, percentage of p \ 0.031), level of training (0.050; 95 % CI 0.012–0.088,
p = 0.010), and specialty (0.108; 95 % CI 0.058–0.159,
p \ 0.0001). Finally, there was an inverse, linear rela-
Electronic supplementary material The online version of this tionship between postgraduate year and percent questions
article (doi:10.1007/s10620-015-3781-y) contains supplementary correct.
material, which is available to authorized users.
1
& Joseph D. Feuerstein Division of Gastroenterology, Department of Medicine, Beth
jfeuerst@bidmc.harvard.edu Israel Deaconess Medical Center, Harvard Medical School,
110 Francis Street 8E Gastroenterology, Boston, MA 02215,
Elliot B. Tapper
USA
Etapper@bidmc.harvard.edu
2
Department of Medicine, University of Massachusetts
Edward Belkin
Memorial Medical Center, University of Massachusetts
Edward.Belkin@umassmemorial.org
Medical School, Worcester, MA, USA
Jeffrey J. Lewandowski 3
Department of Emergency Medicine, Beth Israel Deaconess
jlewando@bidmc.harvard.edu
Medical Center, Harvard Medical School, Boston, MA, USA
Anand Singla 4
Present Address: Division of Gastroenterology, Department
anand.singla@gmail.com
of Medicine, University of Washington, University of
Saurabh Sethi Washington School of Medicine, Seattle, WA, USA
Ssethi@bidmc.harvard.edu 5
Department of Medicine, Boston Medical Center, Boston
Sunil G. Sheth University School of Medicine, Boston, MA, USA
ssheth@bidmc.harvard.edu
Mandeep Sawheny
Msawhney@bidmc.harvard.edu

123

and M. A Likert of care and risk of adverse events. Web sites. Albeit based asked to answer them based on their current knowledge and on low-quality evidence.) based on a thorough review of the clinical practice guidelines. ther or not they would recommend for or against continuing cer-related death in the USA [1]. therapy is withheld even for temporary reasons [6–9]. No changes were physicians for endoscopic procedures regarding the advised.. referring physician. This was the second part IOM Institute of Medicine of a survey questionnaire that queried physicians regarding NSAIDs Non-steroidal anti-inflammatory drugs pre-procedure use of antibiotics.Dig Dis Sci (2015) 60:3234–3241 3235 Conclusion Physician knowledge of guidelines regarding recommendations to continue/discontinue aspirin and/or the use of aspirin and NSAIDs prior to endoscopy is sub. Keywords Endoscopy  Aspirin  NSAIDs  Guidelines  Quality Methods Abbreviations ASA Aspirin A survey questionnaire was developed using the ASGE ASGE American Society for Gastrointestinal guidelines published in 2009 for antithrombotic agents prior Endoscopy to gastrointestinal endoscopy [10]. The decision regarding the management 1. NSAIDs prior to the procedure.S. These referrals are generated by A 54-year-old man is being referred for a screening primary care physicians who send their patients directly to colonoscopy. (ASGE) published a guideline regarding the use of Physicians were queried with the hypothetical questions and antithrombotic agents prior to endoscopy [10]. Multiple studies have shown a significant risk of involvement in teaching trainees. Open access endoscopy aspirin and/or NSAIDs prior to gastroscopy or colonoscopy. sources prior to answering questions. serves as the conduit to remove impediments to colorectal The two questions were as follows: cancer screening [2]. polypectomy bleeding rates in the patients on aspirin/ The survey was piloted at a tertiary care medical center NSAIDs compared to those not on these drugs [11]. The ques- tions for the second part of the survey were designed by three authors (J. 123 . The only additional information pro- 2. We also evaluated whether optimal. scale of 1–5 (1 = unfamiliar and 5 = very familiar) was Aspirin therapy is used both in primary and secondary used to assess familiarity with the guideline. History of arthritis on ibuprofen 400 mg twice a day: vided regarding medication usage/discontinuation prior to Yes or no. a larger study of patients undergoing questions but were not specifically asked to refer to any polypectomy found that there was no difference in post.G. Demographic prevention of myocardial infarction and ischemic stroke information including: level of training. we sought to evaluate the current knowl. the guideline recommends that how they would advise their patients. that was not included in this study. the American Society of Gastrointestinal Endoscopy Supplementary Table 1 for the survey questionnaire. S. See 2009... year of graduation from medical school. neither medication needs may lead to unforeseen consequences that affect the quality to be stopped for a low-risk screening colonoscopy. textbooks) as they might do in clinical practice to answer the Subsequently.S. In and location of medical school were all reviewed. percentage of time spent in myocardial infarction and ischemic stroke when aspirin clinical practice. Interventions are necessary to improve knowledge any other variables related to the physician’s medical of the current pre-procedure guidelines. History of coronary artery disease on aspirin 81 mg of medications prior to endoscopy often resides with the daily: Yes or no. Results of this section of the survey have been previously published [12].g. training and clinical practice would predict knowledge of societal guidelines. board certification.D. Inappropriate continuation and/or cessation of medications Based on the 2009 guidelines. Physicians were per- both aspirin and non-steroidal anti-inflammatory drugs mitted to use any resources (e. provide recommendations regarding the clarity and accu- edge and practices of gastroenterologist and referring racy of the questions and answers. Two pre-proce- Introduction dure questions of theoretical patients with varying past medical histories were developed to survey clinicians whe- Colorectal cancer continues to be a leading cause of can. guidelines. colonoscopy is in the bowel preparation instructions. or (NSAIDs) may be continued for all endoscopic procedures.F. Would you recommend cessation of the fol- colonoscopy without gastroenterology evaluation prior to lowing drug prior to colonoscopy: the procedure [2]. [3–5]. Eight gastroenterology Given the importance and deleterious effects of stopping fellows were given the survey questionnaire and asked to aspirin therapy.

Year of demic medical centers in Massachusetts.6). there was no significant difference 123 . There was no statistically significant Exclusion Criteria difference between institutions and survey completion rates (p = 0. percentage of time spent in clinical practice. Pre-specified subgroup anal. at center C answered both questions correctly (p = 0. Independent answers based on institution. attending physicians declined to partake in the study and tion designed to support data capture for research studies. One center is a medical school graduation was a nonlinear continuous 496-bed safety-net hospital affiliated with Boston Univer.0. (Fig. 1). Variable collinearity was There was no significant difference between the median cor- assessed with variance inflation factor analysis with a pre.10 on Chi-squared testing as the threshold for inclusion into the multivariate model. 19 % graduation year. In questions correctly and 42 % (310/740) answered one the graphical representation of mean correct responses by question correctly. Proportion of correct trainees. SAS Institute Inc.. the sources [13]. nees (p = 0. and the third is a between 2000 and 2010 compared with all others.59). sent. training. and procedures for importing data from external pleted the survey. and 84 % (150/178) from institution C.75). Study data were collected and managed using REDCap tools hosted at Beth Israel Deaconess Nine hundred and forty-one surveys were sent out. populations they serve and their missions. and location of medical school (US vs International). 20 % (150/740) of respondents answered both yses included stratification by reported level of training. web-based applica.1 were included into a western Massachusetts affiliated with the University of multivariate regression model. graduation was 2006 (range 1954–2013). Overall. and Likert variables of participant characteristics included: level of score. A regression model was devel. Supplementary tables 2 and 3 show the correct answers was used as the outcome variable. and 29 % (44/150) quadratic transformation. Similarly.) Predictors of correct survey responses were first analyzed with univariate analysis using a p of Responses 0. year of Attending Versus Trainees graduation from medical school. Vari- 417-bed tertiary care medical center that primarily serves ables significant at a p value \0. three out-of-office emails (two attendings and one trainee) providing an intuitive interface for validated data entry. the line of best fit was developed via (72/374) at center A. 79 % (216/273) from institution B.0 (2012 provided in Table 1. 16 % at center B. Majority of the physicians studied at a medical school in the USA (89 % Statistical Analysis 319/357). Full study demographics are regression was performed using JMPÒ Pro 10. were received during the study period and were excluded audit trails for tracking data manipulation and export pro. board certification. REDCap is a secure. 2 for answers to each question by attendings and teristics and knowledge of guidelines. rect responses to the questions between attendings and trai- specified upper bound of ten to denote collinearity. Nine Medical Center. no variable’s value was greater than 1. Eighty percent (740/929) of respondents com- cedures. oped to study the association between participant charac. A total of up to three email reminders were response rates were: 78 % (374/479) from institution A. When analyzed by institution. Physicians who declined to participate or those with an Fifty-two percent (383/740) of study participants were away email message defaulted during the survey invitation physicians in training. Surveys were either handed out at Results clinical conferences or sent out through email invitation using Research Electronic Data Capture (REDCap) survey Demographics database [13]. Median year of medical school period were excluded. Each site has a large internal medicine The Institutional Review Boards at each of the three residency program and internal medicine subspecialties. When broken down by center. See Fig. Massachusetts. The survey was created in both a paper handout format and online template. All data were obtained anonymously. variable that was transformed into a nominal variable after sity. study centers approved this study.5. involvement in teaching trai- nees. another is a 649-bed Harvard-University-affiliated graphical depiction showed a binary fit for graduation tertiary care medical center in Boston. level of training.3236 Dig Dis Sci (2015) 60:3234–3241 The survey was administered at three tertiary care aca. However. The median self-reported familiarity with guideline recommendations for aspirin and NSAIDs Likert Statistical analysis using univariate and multiple logistic score was 3 (range 1–5). All authors had access to The three sites were chosen given the distinct patient the study data and approved the final manuscript.

Overall.06].e. physicians in family medicine (mean 51 %). primary care (Supplementary tables 5. internal medicine (mean 45 %).Dig Dis Sci (2015) 60:3234–3241 3237 Fig.02 (attending [ trainee). Univariate analysis ken down by attending or trainee (Supplementary table 4). the responses were highest for primary care physicians. Likewise. internal medicine 28 %. but Data were further analyzed by specialty and level of all groups answered this question correctly more frequently training (i. In contrast. and geriatricians (mean 45 %) Predictors of Response were most likely to make recommendations consistent with current guidelines..10. 6). geriatricians 26 %) but with sim- ilarly higher averages compared with 8 % for gastroen- Specialty terologist. institution B p = 0. institution C p = 0. was significant for self-reported familiarity with the 123 . aspirin. answering all the questions correctly. gastroenterologists reported All demographic data were analyzed for predictors of a mean of 22 % correct. 1 Inclusion and exclusion of participants 941 surveys administered Institution A Institution B Institution C 487 surveys sent out 276 surveys sent out 178 surveys sent out 7 Attendings declined 2 Attendings declined 1 Attending & 1 Resident 1 Attending autoaway email autoaway emails for all for all emails emails 374 completed survey(78%) 216 completed survey(79%) 150 completed survey(85%) Table 1 Demographic information of survey respondents—might stay the same Total Attendings Trainees n = 740 (%) n = 357 (%) n = 383 (%) Medical center A 374 (51) 213 (57) 161 (43) Medical center B 216 (29) 73 (34) 143 (66) Medical center C 150 (20) 71 (47) 79 (53) Median year graduation from medical school (range) 2006 (1954–2013) 1995 (1954–2010) 2010 (1995–2013) US medical school graduates 598 (84) 293 (49) 305 (51) International medical graduates 114 (16) 60 (53) 54 (47) Attending internal medicine board certification NA 319 (89) NA Internal medicine/primary care 463 (64) 171 (37) 292 (63) Cardiology 53 (7) 29 (55) 24 (45) Family medicine 46 (6) 26 (57) 20 (43) Geriatrics 19 (3) 14 (74) 5 (26) Infectious diseases 38 (5) 24 (63) 14 (37) Gastroenterology 66 (9) 49 (74) 17 (26) Hospitalist 43 (6) 42 (98) 1 (2) Pulmonary 1 (0) 1 (100) 0 (0) when analyzed between attendings and trainees based on When looking at the data regarding continuation of institution [institution A p = 0. for the question regarding NSAIDs. attending and trainee). The data were similar when bro. the mean was lower (family medicine 39 %.

012–0.0001). medicine is currently practiced [14].052 to -0. 95 % CI 0. 18]. and year of graduation from medical school potential complications. Despite these findings and practice guidelines advising continued use of aspirin. the more familiar physicians thought they were with the practice guideline.106.102. medical heuristics. reported similar findings citing lack of awareness of ings were self-reported individual familiarity with current guidelines. physicians still do not Discussion appear to be adhering to these recommendations.041–0. their aspirin continuously even prior to endoscopy in nearly p \ 0.108. 95 % CI 0. While our study did not assess predictors of non- analysis. Nonetheless. it is possible that underlying the gastroen- and current teaching/supervising trainees (0. and current teaching/supervising trainees likely to recommend for the cessation of both aspirin and (0. they may be more attune to the importance of 0% Continue aspirin before endoscopy Continue nsaids before endoscopy taking aspirin on a daily basis compared with gastroen- terologists. Ulti- mately. of aspirin before endoscopy. primary care physicians 70% including internal medicine. 95 % CI without the use of any antiplatelet agents. and inertia from guideline (-0. level of training (0. 95 % CI Evidence-based medicine is one of the tenets of how -0. 95 % CI 0.030. gastroenterologists were most p \ 0. differences between attendings and trainees.082–0.001) compliance. and 123 .100. 95 % physicians still use anecdotal experience to influence their CI 0.048. decision making. [16] predictors of answering both questions correctly for attend. clinical inertia.056. 95 % CI 0.010). In contrast. in our study.152. 95 % CI terologists’ preference to stop both aspirin and NSAIDs 0.011. It is. Surprisingly. Interesting.0001) (Table 2). 17. specialty (0.0001). and geria- tricians correctly advised patients in more cases to continue 60% their medications as per the current guidelines. 30% 64% The success of aspirin in preventing myocardial 52% infarction in both primary and secondary prevention is well 20% studied [6–9]. However. ported familiarity with the guideline (-0. Univariate and prior anecdotal experience [15].0004). family medicine. Interest- 50% ingly.002). p = 0.004–0.030–0. a substantial number of p 0.138. carries a 1. in order to effectively institute change and adher- Despite the presence of compelling evidence regarding the ence to practice guidelines the following three principles safety of continuing both aspirin and NSAIDs prior to are critical: knowledge of the guidelines. our survey study found physicians foster new ideas and acceptance of new practices.001 to 0.058–0.003.054. patients would still erroneously stop their aspirin with p \ 0. prior practice as reasons why guidelines are not adhered to.002).074.0012). 95 % CI -0.64/1000 risk of bleeding.022–0.0001). therefore.007 to -0. colonoscopy -0. before endoscopy may be related to anecdotal experience Predictors of correct responses among trainees was the of a complication from postprocedure bleeding. Even more concerning is the fact (-0. level of training (0. 95 % CI -0.033 to -0.017).067. Attending 90% 92 % of gastroenterologists recommended against the use Trainee of aspirin prior to procedures and 64 % advised to stop 80% NSAIDs as well. Cabana et al.029. p = 0.032. have indicated that aspirin usage does not change this risk [11. 95 % CI -0. p \ 0.088. familiarity.031). A study of influences that explained non- adherence to NSAIDs prescribing guidelines found the Predictors of Response by Level of Training following predictive factors: lack of familiarity with guidelines. specialty (0. lack of agreement. 50 % of cases. perceived limited validity of guidelines. p 0. specialty (0. Multi.194. limited Post hoc analysis was performed on the data looking for applicability of them.3238 Dig Dis Sci (2015) 60:3234–3241 100% still recommend cessation of these drugs.050.056. 95 % CI 0. p = 0. p = 0.082. p \ 0. Figure 3 shows inverse.163.035) remained significant (Table 2). p = 0.059–0. 2 Percent correct answers to survey questions physicians in aggregate recommended that patients use guideline (-0. not surprising that primary care Fig. the less likely they were to answer 40% the theoretical scenarios correctly. p = 0.005. Given that primary care physicians prescribe 28% 10% 21% the aspirin and see the complications related to myocardial infarction. and multiple studies ear relationship between PGY and percent questions correct. attitudes which endoscopic procedures. In multivariate NSAIDs.159. that gastroenterologists frequently advised against the use variate analysis revealed statistical significance for self-re. and specialty (0. many 95 % CI 0.107. lin.003 to -0.133. Even level of postgraduate year (PGY) training (-0.

030 -0. 123 .Dig Dis Sci (2015) 60:3234–3241 3239 Table 2 Univariate and multivariate analysis of predictors of correct responses to all survey questions Univariate analysis Multivariate analysis Coefficient 95 % CI p value Coefficient 95 % CI p value (b) (b) All respondents Self-reported individual familiarity with current -0.302 guidelines Specialty (compared to gastroenterologists) 0.016 to -0.004 to 0.106 0.056 0. teaching in 2010.002 IMG international medical graduate. improvements in knowledge and its appli- agree with the recommendation to stop the medications.063 Current teaching/supervising residents or fellows 0.001 Year of graduation from medical school -0.012 -0.159 \0.133 0. As medical education shifts toward the Carnegie possible risk of bleeding if they view the medications as foundation recommendations with integrated problem- nonessential.248 What is your level of training (PGY level) -0.082–0.025 to 0.102 0.170 0. and absence of external barriers to perform recom.010 Specialty (compared to gastroenterologists) 0.054 0.012–0.138 0. it is important to overcome these barriers and ance with these new recommendations [16].058–0.048 -0.071 to 0.012 -0. thereby leading the gastroenterologist to based learning. This may be an explanation for our tice.059–0.022 -0. Each of these domains is potential reasons training were more versed in the actual guidelines and less why gastroenterologists who are actually performing the influenced by clinical experience influencing their decision.003 -0.633 Location of medical school (US vs IMG) 0. institute practices that are based on strong evidence such as Another potential reason for why gastroenterologists the safety of continuing aspirin and NSAIDs prior to rou- may recommend for cessation of aspirin and NSAIDs is a tine endoscopy.007 to -0.152 \0.193 \0.003 to 0.056 0.004–0.519 Attendings Self-reported individual familiarity with current -0.046 0. US United States Statistically significant variables are given in bold behaviors which allow for change and encourage compli. Nevertheless.022–0.025 -0. experience [22. self-efficacy.030 -0.075 Percentage of time spent in direct patient care 0.002 0.108 0. procedures may recommend against continuing medica.029 -0. disagreement in the validity of the guidelines.018 -0.067 -0. Recent Interestingly.001 to 0. The classic model of guideline recommendation given the lack of supporting medical school teaching has revolved around the Flexner evidence [19–21].001 to 0.163 0.0001 Year of graduation from medical school -0.0001 -0.090 to 0. ability to overcome inertia of previous prac.082 0.107 0.05 to -0.041–0. in our study.063 guidelines Specialty (compared to gastroenterologists) 0.021 0.101 0.035 Board certification in internal medicine -0.005 0. 23].011 0.033 to -0.001 to 0.052 0.005 0. [16] reported on seven key recommendations from 1910 [22.005 to 0.031 guidelines Level of training (attending vs trainee) 0. This established the barriers to physician adherence to practice guidelines: 4-year curriculum and focus on textbook factual memo- awareness. the less likely they were to make the appropriate recommendations are based on expert opinion which may recommendations prior to endoscopy compared with those lead one to have a differing opinion and deviate from the who had just finished medical school.017 -0.25 Location of medical school (US vs IMG) 0.0004 0.002 0. integration of formal knowledge with the clinical experi- Patients may prefer to stop the medications given the ence [23]. the farther into one’s PGY studies have noted that many of the practice guidelines training.032 -0.040 0.003 to -0.050 0.0001 0.048 0.0001 0. Cabana et al. finding that physicians closest to their medical school mendations.030–0. outcome rization followed by a residency that is rooted in clinical expectancy.001 -0. familiarity.453 Trainees Self-reported individual familiarity with current -0. 23].081 to 0. In the Carnegie foundation report for the advancement of tions that theoretically could increase the risk of bleeding.074 0.002 -0.100 0. PGY postgraduate year.084 -0.088 0.002 0. they encouraged a shift to focus more on Another important barrier is patient preference [16].050 0.058 Location of medical school (US vs IMG) -0. agreement.035 -0. cation into clinical practice will likely improve.

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