Vitamin D may have a role in immune regulation and be associated with inflammatory bowel disease (IBD) expression. IBD patients are more likely to be vitamin D deficient than the general population. However, it is uncertain if vitamin D monitoring in IBD is consistently performed. This study evaluated the frequency of vitamin D testing in IBD patients at a university gastroenterology practice. A chart review of consecutive IBD patients during a 6 month period was performed. Patient age, gender, ethnicity were obtained. Vitamin D levels within the past year were noted. In vitamin D deficient (<30 ng/ml) patients, the frequency of supplementation was assessed. Database was created maintaining patient confidentiality. Analysis was performed using Fisher Exact test (significance set at p<0.05). This study was approved by the IRB. Records of 268 patients (118 men, 150 women; mean age 43) were evaluated, with 158 Crohn’s, 109 ulcerative colitis and 1 indeterminate colitis. 207 (77.24%) had vitamin D levels. There was a significant difference (p=0.049) of vitamin D testing in women (122/150; 81.33%) and men (85/118; 72.03%). In the 138 (66.67%) vitamin D deficient patients, whites (61; 79.49%) were more often deficient (p=0.003) than nonwhites (63/60.78%). 64 of 138 (45.6%) vitamin D deficient patients received supplementation, with no difference based upon gender (p=0.864) or ethnicity (p=1.000). While vitamin D may have a role in IBD, there are limited studies evaluating whether physicians obtain vitamin D levels. This study revealed inconsistent vitamin D monitoring and infrequent supplementation in deficient patients. Notably, women were more often tested than men and whites were more often deficient than non-whites. This study is limited based upon reliance upon documentation and single institution design, but it offers a foundation for future research. Increased efforts are needed to ensure consistency in vitamin D testing in all patients to optimize management.
Introduction: Proton pump inhibitors (PPI) are amongst the most widely prescribed classes of medication in the United States, commonly prescribed by primary care providers and specialists from a variety of disciplines. Indications for the initiation and maintenance of PPI therapy are well established. However, because they are so widely prescribed, responsibility for the management of PPIs is often diffused over numerous providers. This study evaluated the rates of PPI de-escalation in patients receiving PPIs from GI versus non-GI prescribers. Methods: A retrospective chart review of randomly selected medical records during a 1 year period of patients on >6 months PPI therapy seen by a faculty gastroenterologist at an urban university medical center was conducted. Data was collected regarding the indication, length, and prescriber of PPIs and whether there was a documented PPI de-escalation discussion. De-escalation was defined as attempts at reduction in dose, reduction in frequency, or complete PPI discontinuation. Patients prescribed PPIs for Barrett's esophagus or gastrointestinal bleeding were excluded. A Microsoft Excel database maintaining subject confidentiality was used. Statistical analysis was conducted using a two-tailed Fisher's Exact Test with significance set at p < 0.05. Results: A total of 600 charts were initially reviewed, of which, 324 were included in the analysis. PPIs were primarily prescribed by GI providers in 141 patients and non-GI providers in 183 patients. Of the 141 patients prescribed PPIs by their GI provider, 41 (29%) had an attempt to de-escalate therapy. Of the 183 patients prescribed PPIs by a non-GI provider, 25 (16%) had a de-escalation discussion. There was a significant increase in documented attempts at PPI de-escalation in patients whose PPIs were primarily prescribed by GI providers versus non-GI providers (p=0.0008). Conclusion: PPIs are highly effective, safe, and commonly prescribed. However, these medications are not without risks and there is evidence to suggest that patients with uncomplicated GERD who have obtained symptomatic relief with PPIs, should undergo attempts at de-escalation of therapy. Our data suggest that gastroenterologists are more likely to have a discussion about PPI de-escalation if the patient's primary PPI prescriber is a GI provider as compared to a non-GI provider (29% vs 16%, p = 0.0008). Increased efforts at PPI de-escalation should be made in all patients if appropriate.
The role of complementary and alternative medicine (CAM) have been used as adjunctive treatment in inflammatory bowel disease (IBD). It is estimated that 30–50% of IBD patients have used CAMs at some point in their disease course. However, it has been estimated that <50% of CAM users discuss this therapeutic strategy with their gastroenterologists. This study evaluated the frequency at which physicians discuss CAM with their IBD patients. A medical record review of consecutive IBD patients seen at a university gastroenterology practice during a 6 month period was performed. Patient age, gender, ethnicity and disease type (Crohn’s disease, ulcerative colitis, indeterminate colitis) were obtained. Records were reviewed for use of or discussion about CAM. A database was created maintaining patient confidentiality. The study was approved by the university IRB. Medical records of 268 patients (118 men, 150 women) with a mean age of 43 were reviewed. There were 158 Crohn’s, 109 ulcerative colitis (UC), 1 indeterminate colitis. There were 143 white, 80 African-Americans, 6 Hispanic, 10 Asian and 29 with unspecified ethnicity. Five patients (1.87%) had documentation of CAM use (3 with probiotics, 2 with herbal supplements). All patients with documentation of CAM use were white. There was no difference in the frequency of CAM use based upon gender (p=0.6577; 3 males, 2 females) or disease type (p=0.4012; 3 UC, 2 Crohn’s disease). CAM use in IBD is frequently used, but infrequently discussed with patients. This study suggests that IBD patients rarely used CAM. However, it is possible that there is patient reluctance to disclose CAM use due to perceived lack of physician awareness or acceptance. Additionally, physicians may infrequently discuss or document CAM treatments. It is important that there are efforts to increase CAM discussion among IBD patients to fully appreciate therapeutic strategies used by patients.
Introduction: Proton pump inhibitors (PPI) are amongst some of the most widely prescribed classes of medication in the United States. Indications for initiating therapy with PPIs are well established, as are recommendations to help guide duration of therapy. Long term treatment with these agents may be warranted in some narrowly defined situations. Patients with uncomplicated gastroesophageal reflux (GERD), who have showed improvement while on PPIs, attempts should be made to reduce or discontinue their use. Methods: A retrospective chart review of randomly selected records during a 1 year period of patients prescribed a PPI >6 months seen by a gastroenterologist at an urban university medical center was conducted. Information was collected on patient ethnicity, length and indication for PPI use, and documented discussion about PPI de-escalation. De-escalation attempts were defined as documentation of discussion for reduction in dose, reduction in frequency, or complete PPI discontinuation. Patients prescribed PPIs for Barrett's esophagus and gastrointestinal bleeding were excluded. A Microsoft Excel database maintaining subject confidentiality was created. Statistical analysis was conducted using a two-tailed Fisher's Exact Test with a significance set at p < 0.05. Results: A total of 600 charts were initially reviewed, of which, 324 were included in the analysis. There were 216 African American patients, 75 white patients and 33 patients of another or undocumented ethnicity. Of the 216 African American patients, 39 (18%) had a documented de-escalation discussion. Of the 75 white patients, 22 (29%) had documentation of an attempt to de-escalate therapy. There was a statistically significant difference in the frequency of documented attempts at PPI de-escalation in African-American patients compared to white patients (p = 0.048). Conclusion: It is recommended that in patients with uncomplicated GERD who have obtained symptomatic relief with PPIs, there should be an attempt to de-escalate therapy. This study suggests that gastroenterologists inconsistently attempt de-escalation of PPI treatment in those maintained on chronic therapy. Additionally, there was a difference in de-escalation attempts based upon patients' ethnicity. Increased efforts should be made to decrease chronic PPI therapy in all patients in which it is warranted. Efforts should be made to eliminate racial disparity in GERD management.
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