David A. Leiman, MD, MSHP

Modern efforts to monitor and improve quality in health care can trace their roots to the early 20th century. At that time, hospitals initiated mechanisms to ensure standard practices for privileging clinicians, reporting medical records and clinical data, and establishing supervised diagnostic facilities. Years later, Avedis Donabedian published “Evaluating the Quality of Medical Care,” which outlined how health care should be measured across three areas – structure, process, and outcome – and became a foundational rubric for assessing quality in medicine.

Over the ensuing decades, with the rise of professional society guidelines and increasing government involvement in the reimbursement of health care, establishing benchmarks and tracking clinical performance has become increasingly important. The passage of the Affordable Care Act subsequently established a formal, legislative mandate for assessing clinical quality tied to reimbursement. Although the context, consequences, and details for reporting have evolved, quality tracking is now firmly entrenched across clinical practice, including gastroenterology. One such mechanism for this is the Merit-Based Incentive Payment System (MIPS), which is a quality payment program (QPP) administered by the Centers for Medicare & Medicaid Services. Today, both government and private payers are assessing measurements and improvements of quality to satisfy the Quintuple Aim of achieving better health outcomes, seeking efficient cost of care, improving patient experience, improving provider experience, and enhancing equity through the reduction health inequalities.

As we transition from a fee-based to a value-based care model, several important developments relevant to the practicing gastroenterologist are likely to occur as the broader landscape of quality reporting will continue shifting. This article will outline a vision of the future in quality measurement for gastroenterology.

Gastroenterologists have relatively few specialty-specific measures on which to report. The widespread use of the adenoma detection rate for screening colonoscopy does represent a success in quality improvement because it is easily calculated, is reproducible, and has been consistently associated with clinical outcomes. But the overall measure set is limited to screening colonoscopy and the management of viral hepatitis, meaning large areas of our practice are not included in this set. Developing new metrics related to broader areas of practice will be necessary to address this current shortcoming and increase the impact of quality programs to clinicians. Indeed, a recent environmental scan performed by the Core Quality Measures Collaborative, a public-private coalition of leaders working to facilitate measure alignment, proposed future areas for development, including gastroesophageal reflux disease, nonalcoholic fatty liver disease, and medication management.

The American Gastroenterological Association, through its defined process of guideline-to-measure development, has responded by creating metrics for the management of acute pancreatitis, Lynch syndrome testing, and eradicating Helicobacter pylori in the context of gastric intestinal metaplasia; additionally, previously defined measures exist for Barrett’s esophagus and inflammatory bowel disease. Therefore, gastroenterologists can expect to report on an expanding collection of measures in the future.

However, recognizing that not all measures may be equally applicable across populations and acknowledging the importance of risk adjustment, incorporating at least an assessment for risk stratification in their future development is vital. Specifically, social risk factors will need to be accounted for during development in ways that might include risk adjustment or stratification by groups. Increasing data demonstrate that clinician performance can vary by population served and that social determinants of health (SDoH) should be incorporated into an assessment of outcomes. Risk stratification may allow clinicians or practices to report outcomes by group without jeopardy of incurring performance-based penalties. However, the ultimate goal should be reducing inequities and closing care gaps rather than inadvertently lowering the bar for clinicians who primarily treat disenfranchised populations. Eventually, any new measures aiming to be included in a QPP require formal validity testing, which can delay their inclusion in such a set. Yet including stratification in their development will provide a more robust and accurate assessment of quality of care delivered according to one’s catchment and help serve to minimize the effects of SDoH.

Another way that quality measurement may account for a more comprehensive assessment of care delivered is by bundling similarly provided services, even those across multiple specialties. Such a future model is the MIPS Value Pathways, currently under development by CMS. While the exact make-up and reporting structure remains to be determined, a group of related metrics – for example, for colonic health – would likely be grouped together. This model might include an evaluation of a practice’s performance in screening colonoscopy, Lynch testing practices, and inflammatory bowel disease management, which could also be relevant to surgeons, pathologists, and oncologists. This paradigm could serve to increase quality alignment across specialties and reinforce a commitment toward improving care delivery and fulfill a value-based mandate.

Within this framework, though, a shared challenge across specialties exists for the capture and reporting of clinical data. The financial and time costs for quality reporting are well documented, therefore any future vision of quality must address means to ease this reporting burden. Accounting for this would be especially impactful to independent as well as small- to moderate-sized practices, which must provide their own resources for collecting and reporting, with the QPP payment adjustments often insufficient to replace lost revenue or expenses. Some administrative relief has been provided by CMS during the current COVID-19 pandemic, but this focused on allowing select clinicians to avoid reporting rather than addressing the fundamental challenges presented by extracting and documenting quality measures. Moving forward, an increasing emphasis will likely be on the use of artificial intelligence (AI), such as natural language processing, combined with discrete code extraction for tracking performance. While AI has the advantage of a more hands-free approach, such a system would itself require monitoring for performance to avoid unintended consequences.

Ultimately, providing high-quality care and improving patient outcomes are universal goals, though demonstrating this aspiration by reporting on quality metrics can be challenging. Quality measurement, though, is now firmly integrated into the fabric of clinical medicine. In the future, more facets of practice will be measured, patient-level factors and cross specialty reporting will increasingly be emphasized, and administrative burdens will be reduced.

Dr. Leiman is assistant professor of medicine at Duke University, Durham, N.C., cochair of the Core Quality Measure Collaborative Gastroenterology Workgroup, and chair of the AGA’s Quality Committee. Dr. Freedman is medical director, SE Territory, Aetna/CVS Health and cochair of the Core Quality Measure Collaborative Gastroenterology Workgroup. Dr. Anjou is a practicing clinical gastroenterologist at Connecticut GI, Torrington, and recent member of the AGA Quality Committee. The authors reported no conflicts related to this article.

Modern efforts to monitor and improve quality in health care can trace their roots to the early 20th century. At that time, hospitals initiated mechanisms to ensure standard practices for privileging clinicians, reporting medical records and clinical data, and establishing supervised diagnostic facilities. Years later, Avedis Donabedian published “Evaluating the Quality of Medical Care,” which outlined how health care should be measured across three areas – structure, process, and outcome – and became a foundational rubric for assessing quality in medicine.

Over the ensuing decades, with the rise of professional society guidelines and increasing government involvement in the reimbursement of health care, establishing benchmarks and tracking clinical performance has become increasingly important. The passage of the Affordable Care Act subsequently established a formal, legislative mandate for assessing clinical quality tied to reimbursement. Although the context, consequences, and details for reporting have evolved, quality tracking is now firmly entrenched across clinical practice, including gastroenterology. One such mechanism for this is the Merit-Based Incentive Payment System (MIPS), which is a quality payment program (QPP) administered by the Centers for Medicare & Medicaid Services. Today, both government and private payers are assessing measurements and improvements of quality to satisfy the Quintuple Aim of achieving better health outcomes, seeking efficient cost of care, improving patient experience, improving provider experience, and enhancing equity through the reduction health inequalities.

As we transition from a fee-based to a value-based care model, several important developments relevant to the practicing gastroenterologist are likely to occur as the broader landscape of quality reporting will continue shifting. This article will outline a vision of the future in quality measurement for gastroenterology.

Gastroenterologists have relatively few specialty-specific measures on which to report. The widespread use of the adenoma detection rate for screening colonoscopy does represent a success in quality improvement because it is easily calculated, is reproducible, and has been consistently associated with clinical outcomes. But the overall measure set is limited to screening colonoscopy and the management of viral hepatitis, meaning large areas of our practice are not included in this set. Developing new metrics related to broader areas of practice will be necessary to address this current shortcoming and increase the impact of quality programs to clinicians. Indeed, a recent environmental scan performed by the Core Quality Measures Collaborative, a public-private coalition of leaders working to facilitate measure alignment, proposed future areas for development, including gastroesophageal reflux disease, nonalcoholic fatty liver disease, and medication management.

The American Gastroenterological Association, through its defined process of guideline-to-measure development, has responded by creating metrics for the management of acute pancreatitis, Lynch syndrome testing, and eradicating Helicobacter pylori in the context of gastric intestinal metaplasia; additionally, previously defined measures exist for Barrett’s esophagus and inflammatory bowel disease. Therefore, gastroenterologists can expect to report on an expanding collection of measures in the future.

However, recognizing that not all measures may be equally applicable across populations and acknowledging the importance of risk adjustment, incorporating at least an assessment for risk stratification in their future development is vital. Specifically, social risk factors will need to be accounted for during development in ways that might include risk adjustment or stratification by groups. Increasing data demonstrate that clinician performance can vary by population served and that social determinants of health (SDoH) should be incorporated into an assessment of outcomes. Risk stratification may allow clinicians or practices to report outcomes by group without jeopardy of incurring performance-based penalties. However, the ultimate goal should be reducing inequities and closing care gaps rather than inadvertently lowering the bar for clinicians who primarily treat disenfranchised populations. Eventually, any new measures aiming to be included in a QPP require formal validity testing, which can delay their inclusion in such a set. Yet including stratification in their development will provide a more robust and accurate assessment of quality of care delivered according to one’s catchment and help serve to minimize the effects of SDoH.

Another way that quality measurement may account for a more comprehensive assessment of care delivered is by bundling similarly provided services, even those across multiple specialties. Such a future model is the MIPS Value Pathways, currently under development by CMS. While the exact make-up and reporting structure remains to be determined, a group of related metrics – for example, for colonic health – would likely be grouped together. This model might include an evaluation of a practice’s performance in screening colonoscopy, Lynch testing practices, and inflammatory bowel disease management, which could also be relevant to surgeons, pathologists, and oncologists. This paradigm could serve to increase quality alignment across specialties and reinforce a commitment toward improving care delivery and fulfill a value-based mandate.

Within this framework, though, a shared challenge across specialties exists for the capture and reporting of clinical data. The financial and time costs for quality reporting are well documented, therefore any future vision of quality must address means to ease this reporting burden. Accounting for this would be especially impactful to independent as well as small- to moderate-sized practices, which must provide their own resources for collecting and reporting, with the QPP payment adjustments often insufficient to replace lost revenue or expenses. Some administrative relief has been provided by CMS during the current COVID-19 pandemic, but this focused on allowing select clinicians to avoid reporting rather than addressing the fundamental challenges presented by extracting and documenting quality measures. Moving forward, an increasing emphasis will likely be on the use of artificial intelligence (AI), such as natural language processing, combined with discrete code extraction for tracking performance. While AI has the advantage of a more hands-free approach, such a system would itself require monitoring for performance to avoid unintended consequences.

Ultimately, providing high-quality care and improving patient outcomes are universal goals, though demonstrating this aspiration by reporting on quality metrics can be challenging. Quality measurement, though, is now firmly integrated into the fabric of clinical medicine. In the future, more facets of practice will be measured, patient-level factors and cross specialty reporting will increasingly be emphasized, and administrative burdens will be reduced.

Dr. Leiman is assistant professor of medicine at Duke University, Durham, N.C., cochair of the Core Quality Measure Collaborative Gastroenterology Workgroup, and chair of the AGA’s Quality Committee. Dr. Freedman is medical director, SE Territory, Aetna/CVS Health and cochair of the Core Quality Measure Collaborative Gastroenterology Workgroup. Dr. Anjou is a practicing clinical gastroenterologist at Connecticut GI, Torrington, and recent member of the AGA Quality Committee. The authors reported no conflicts related to this article.

Modern efforts to monitor and improve quality in health care can trace their roots to the early 20th century. At that time, hospitals initiated mechanisms to ensure standard practices for privileging clinicians, reporting medical records and clinical data, and establishing supervised diagnostic facilities. Years later, Avedis Donabedian published “Evaluating the Quality of Medical Care,” which outlined how health care should be measured across three areas – structure, process, and outcome – and became a foundational rubric for assessing quality in medicine.

Over the ensuing decades, with the rise of professional society guidelines and increasing government involvement in the reimbursement of health care, establishing benchmarks and tracking clinical performance has become increasingly important. The passage of the Affordable Care Act subsequently established a formal, legislative mandate for assessing clinical quality tied to reimbursement. Although the context, consequences, and details for reporting have evolved, quality tracking is now firmly entrenched across clinical practice, including gastroenterology. One such mechanism for this is the Merit-Based Incentive Payment System (MIPS), which is a quality payment program (QPP) administered by the Centers for Medicare & Medicaid Services. Today, both government and private payers are assessing measurements and improvements of quality to satisfy the Quintuple Aim of achieving better health outcomes, seeking efficient cost of care, improving patient experience, improving provider experience, and enhancing equity through the reduction health inequalities.

As we transition from a fee-based to a value-based care model, several important developments relevant to the practicing gastroenterologist are likely to occur as the broader landscape of quality reporting will continue shifting. This article will outline a vision of the future in quality measurement for gastroenterology.

Gastroenterologists have relatively few specialty-specific measures on which to report. The widespread use of the adenoma detection rate for screening colonoscopy does represent a success in quality improvement because it is easily calculated, is reproducible, and has been consistently associated with clinical outcomes. But the overall measure set is limited to screening colonoscopy and the management of viral hepatitis, meaning large areas of our practice are not included in this set. Developing new metrics related to broader areas of practice will be necessary to address this current shortcoming and increase the impact of quality programs to clinicians. Indeed, a recent environmental scan performed by the Core Quality Measures Collaborative, a public-private coalition of leaders working to facilitate measure alignment, proposed future areas for development, including gastroesophageal reflux disease, nonalcoholic fatty liver disease, and medication management.

The American Gastroenterological Association, through its defined process of guideline-to-measure development, has responded by creating metrics for the management of acute pancreatitis, Lynch syndrome testing, and eradicating Helicobacter pylori in the context of gastric intestinal metaplasia; additionally, previously defined measures exist for Barrett’s esophagus and inflammatory bowel disease. Therefore, gastroenterologists can expect to report on an expanding collection of measures in the future.

However, recognizing that not all measures may be equally applicable across populations and acknowledging the importance of risk adjustment, incorporating at least an assessment for risk stratification in their future development is vital. Specifically, social risk factors will need to be accounted for during development in ways that might include risk adjustment or stratification by groups. Increasing data demonstrate that clinician performance can vary by population served and that social determinants of health (SDoH) should be incorporated into an assessment of outcomes. Risk stratification may allow clinicians or practices to report outcomes by group without jeopardy of incurring performance-based penalties. However, the ultimate goal should be reducing inequities and closing care gaps rather than inadvertently lowering the bar for clinicians who primarily treat disenfranchised populations. Eventually, any new measures aiming to be included in a QPP require formal validity testing, which can delay their inclusion in such a set. Yet including stratification in their development will provide a more robust and accurate assessment of quality of care delivered according to one’s catchment and help serve to minimize the effects of SDoH.

Another way that quality measurement may account for a more comprehensive assessment of care delivered is by bundling similarly provided services, even those across multiple specialties. Such a future model is the MIPS Value Pathways, currently under development by CMS. While the exact make-up and reporting structure remains to be determined, a group of related metrics – for example, for colonic health – would likely be grouped together. This model might include an evaluation of a practice’s performance in screening colonoscopy, Lynch testing practices, and inflammatory bowel disease management, which could also be relevant to surgeons, pathologists, and oncologists. This paradigm could serve to increase quality alignment across specialties and reinforce a commitment toward improving care delivery and fulfill a value-based mandate.

Within this framework, though, a shared challenge across specialties exists for the capture and reporting of clinical data. The financial and time costs for quality reporting are well documented, therefore any future vision of quality must address means to ease this reporting burden. Accounting for this would be especially impactful to independent as well as small- to moderate-sized practices, which must provide their own resources for collecting and reporting, with the QPP payment adjustments often insufficient to replace lost revenue or expenses. Some administrative relief has been provided by CMS during the current COVID-19 pandemic, but this focused on allowing select clinicians to avoid reporting rather than addressing the fundamental challenges presented by extracting and documenting quality measures. Moving forward, an increasing emphasis will likely be on the use of artificial intelligence (AI), such as natural language processing, combined with discrete code extraction for tracking performance. While AI has the advantage of a more hands-free approach, such a system would itself require monitoring for performance to avoid unintended consequences.

Ultimately, providing high-quality care and improving patient outcomes are universal goals, though demonstrating this aspiration by reporting on quality metrics can be challenging. Quality measurement, though, is now firmly integrated into the fabric of clinical medicine. In the future, more facets of practice will be measured, patient-level factors and cross specialty reporting will increasingly be emphasized, and administrative burdens will be reduced.

Dr. Leiman is assistant professor of medicine at Duke University, Durham, N.C., cochair of the Core Quality Measure Collaborative Gastroenterology Workgroup, and chair of the AGA’s Quality Committee. Dr. Freedman is medical director, SE Territory, Aetna/CVS Health and cochair of the Core Quality Measure Collaborative Gastroenterology Workgroup. Dr. Anjou is a practicing clinical gastroenterologist at Connecticut GI, Torrington, and recent member of the AGA Quality Committee. The authors reported no conflicts related to this article.

In July 2021, the Centers for Medicare & Medicaid Services released the Medicare Physician Fee Schedule (PFS) and Hospital Outpatient Prospective Payment System (OPPS)/Ambulatory Surgery Center (ASC) proposed rules for calendar year (CY) 2022. While the OPPS/ASC proposed rule was largely positive for gastroenterology, the PFS proposed rule was more of a mixed bag for practices.

No more colonoscopy coinsurance “loophole”: After nearly a decade of advocacy, the Removing Barriers to Colorectal Cancer Screening Act was finally signed into law this year and will take effect Jan. 1, 2023. The legislation phases out Medicare beneficiary cost-sharing obligations when a polyp or lesion is found and biopsied or removed as part of a screening colonoscopy or flexible sigmoidoscopy. The American Gastroenterological Association is pleased this will finally eliminate a surprise bill for patients and remove a barrier to colorectal cancer screening.

The phase out timeline is as follows:

• 80% payment for services furnished during CY 2022 (coinsurance, 20%).
• 85% payment for services furnished during CY 2023 through CY 2026 (coinsurance, 15%).
• 90% payment for services furnished during CY 2027 through CY 2029 (coinsurance, 10%).
• 100% payment for services furnished from CY 2030 onward (coinsurance, 0%).

Providers must continue to report HCPCS modifier “PT” in the hospital outpatient and ASC during the transition period to indicate that a planned colorectal cancer screening service converted to a diagnostic service.

Proposed 2022 PFS conversion factor could fall 3.75% unless Congress acts: The proposed 2022 PFS conversion factor is $33.58. The decrease reflects the expiration of the 3.75% payment increase provided by the Consolidated Appropriations Act. This congressional intervention averted a significant cut in Medicare physician payment that would have resulted in an almost 10% cut to GI services. The GI societies are working with Congress to avert cuts to physician payments next year as practices continue to recover from the pandemic.

GI procedure payments to increase 3% for hospital outpatient and ASCs: A 2.3% increase has been proposed for the conversion factors, resulting in $84.46 for hospitals and $50.04 for ASCs meeting quality reporting requirements. However, GI endoscopy procedure payments are expected to increase on average 3% in CY 2022.

Colon capsule endoscopy and POEM get new codes and payments: CMS accepted new CPT codes for colon capsule endoscopy (CCE) and peroral endoscopic myotomy (POEM) beginning Jan. 1, 2022.

CMS’s proposed CCE value of 2.41 physician work relative value units (wRVUs) reflects the recommendation of the American Medical Association RVS Update Committee (RUC), which is based on data from physicians who perform the procedure. The proposed national-level physician payments are $116.52 for the professional component and $664.21 for the technical component.

However, CMS did not accept the RUC’s recommendation of 15.50 wRVUs for POEM and, instead, proposed that POEM is similar in work to hemodialysis access CPT code 36819, which has a wRVU of 13.29 and a payment of $792.82. The RUC’s valuation of 15.50 wRVUs was based on data from nearly 120 physicians who perform POEM, and we are disappointed CMS chose to reject the robust survey data. The GI societies will defend the 15.50 wRVU in our comments.

The proposed facility fee for POEM is $3,160.76 in the hospital outpatient setting and $1,848.32 in the ASC. CMS’s proposed facility fee for colon capsule endoscopy is $814.44 in the hospital outpatient setting.

CMS moves physicians to MVPs and plans to phase out MIPS: CMS proposes to revise and phase out the Merit-Based Incentive Payment System (MIPS) and move physicians towards the MIPS Value Pathways (MVPs) system beginning in the 2023 performance year (PY). No GI MVPs were proposed for PY 2023. The GI societies are working with CMS as they develop MVPs to ensure any gastroenterology-related MVPs do not harm gastroenterologists.

CMS is statutorily required to weigh the MIPS Cost and Quality performance categories equally beginning with PY 2022. The proposed PY 2022 MIPS performance categories are:

• Quality: 30%.
• Cost: 30%.
• Promoting Interoperability: 25% (no change from 2021).
• Improvement Activities: 15% (no change from 2021).

CMS is also required by law beginning in 2022 to set the MIPS performance threshold to either the mean or median of the final scores for all MIPS eligible clinicians for a prior period. CMS proposes to use the mean final score from MIPS 2017 performance year/MIPS 2019 payment year, which would result in a performance threshold of 75 points and an additional performance threshold set at 89 points for exceptional performance.

CMS keeps all AGA-stewarded measures in MIPS 2022 program year: CMS has proposed to keep all AGA-stewarded measures in the MIPS program for the 2022 program year and accepted the substantive changes for the one-time screening for hepatitis C virus measure we received last year from the Physician Consortium for Performance Improvement. CMS proposed removal of the claims reporting option of American Society for Gastrointestinal Endoscopy–stewarded measure for photodocumentation of cecal intubation because it is topped-out; however, the registry version is still available in MIPS.

OQR Program includes colonoscopy measure for disparities reporting: CMS has identified six priority measures included in the Hospital Outpatient Quality Reporting (OQR) Program as candidate measures for disparities reporting stratified by dual eligibility, one of which is the Facility 7-Day Risk-Standardized Hospital Visit Rate After Outpatient Colonoscopy (OP-32).

The GI societies will jointly comment on issues in the 2022 PFS and OPPS/ASC proposed rules impacting gastroenterologists. We may also organize members to take action by submitting letters during the comment period, so watch your inbox for invitations to participate. We need your help to influence change.

Shivan Mehta, MD, MBA, is with the division of gastroenterology and hepatology at the University of Pennsylvania, Philadelphia, and is an AGA adviser to the American Medical Association RVS Update Committee. David A. Leiman, MD, MSHP, is with the division of gastroenterology at Duke University, Durham, N.C., and is the chair of the AGA Quality Committee. Neither have conflicts to declare.

In July 2021, the Centers for Medicare & Medicaid Services released the Medicare Physician Fee Schedule (PFS) and Hospital Outpatient Prospective Payment System (OPPS)/Ambulatory Surgery Center (ASC) proposed rules for calendar year (CY) 2022. While the OPPS/ASC proposed rule was largely positive for gastroenterology, the PFS proposed rule was more of a mixed bag for practices.

No more colonoscopy coinsurance “loophole”: After nearly a decade of advocacy, the Removing Barriers to Colorectal Cancer Screening Act was finally signed into law this year and will take effect Jan. 1, 2023. The legislation phases out Medicare beneficiary cost-sharing obligations when a polyp or lesion is found and biopsied or removed as part of a screening colonoscopy or flexible sigmoidoscopy. The American Gastroenterological Association is pleased this will finally eliminate a surprise bill for patients and remove a barrier to colorectal cancer screening.

The phase out timeline is as follows:

• 80% payment for services furnished during CY 2022 (coinsurance, 20%).
• 85% payment for services furnished during CY 2023 through CY 2026 (coinsurance, 15%).
• 90% payment for services furnished during CY 2027 through CY 2029 (coinsurance, 10%).
• 100% payment for services furnished from CY 2030 onward (coinsurance, 0%).

Providers must continue to report HCPCS modifier “PT” in the hospital outpatient and ASC during the transition period to indicate that a planned colorectal cancer screening service converted to a diagnostic service.

Proposed 2022 PFS conversion factor could fall 3.75% unless Congress acts: The proposed 2022 PFS conversion factor is $33.58. The decrease reflects the expiration of the 3.75% payment increase provided by the Consolidated Appropriations Act. This congressional intervention averted a significant cut in Medicare physician payment that would have resulted in an almost 10% cut to GI services. The GI societies are working with Congress to avert cuts to physician payments next year as practices continue to recover from the pandemic.

GI procedure payments to increase 3% for hospital outpatient and ASCs: A 2.3% increase has been proposed for the conversion factors, resulting in $84.46 for hospitals and $50.04 for ASCs meeting quality reporting requirements. However, GI endoscopy procedure payments are expected to increase on average 3% in CY 2022.

Colon capsule endoscopy and POEM get new codes and payments: CMS accepted new CPT codes for colon capsule endoscopy (CCE) and peroral endoscopic myotomy (POEM) beginning Jan. 1, 2022.

CMS’s proposed CCE value of 2.41 physician work relative value units (wRVUs) reflects the recommendation of the American Medical Association RVS Update Committee (RUC), which is based on data from physicians who perform the procedure. The proposed national-level physician payments are $116.52 for the professional component and $664.21 for the technical component.

However, CMS did not accept the RUC’s recommendation of 15.50 wRVUs for POEM and, instead, proposed that POEM is similar in work to hemodialysis access CPT code 36819, which has a wRVU of 13.29 and a payment of $792.82. The RUC’s valuation of 15.50 wRVUs was based on data from nearly 120 physicians who perform POEM, and we are disappointed CMS chose to reject the robust survey data. The GI societies will defend the 15.50 wRVU in our comments.

The proposed facility fee for POEM is $3,160.76 in the hospital outpatient setting and $1,848.32 in the ASC. CMS’s proposed facility fee for colon capsule endoscopy is $814.44 in the hospital outpatient setting.

CMS moves physicians to MVPs and plans to phase out MIPS: CMS proposes to revise and phase out the Merit-Based Incentive Payment System (MIPS) and move physicians towards the MIPS Value Pathways (MVPs) system beginning in the 2023 performance year (PY). No GI MVPs were proposed for PY 2023. The GI societies are working with CMS as they develop MVPs to ensure any gastroenterology-related MVPs do not harm gastroenterologists.

CMS is statutorily required to weigh the MIPS Cost and Quality performance categories equally beginning with PY 2022. The proposed PY 2022 MIPS performance categories are:

• Quality: 30%.
• Cost: 30%.
• Promoting Interoperability: 25% (no change from 2021).
• Improvement Activities: 15% (no change from 2021).

CMS is also required by law beginning in 2022 to set the MIPS performance threshold to either the mean or median of the final scores for all MIPS eligible clinicians for a prior period. CMS proposes to use the mean final score from MIPS 2017 performance year/MIPS 2019 payment year, which would result in a performance threshold of 75 points and an additional performance threshold set at 89 points for exceptional performance.

CMS keeps all AGA-stewarded measures in MIPS 2022 program year: CMS has proposed to keep all AGA-stewarded measures in the MIPS program for the 2022 program year and accepted the substantive changes for the one-time screening for hepatitis C virus measure we received last year from the Physician Consortium for Performance Improvement. CMS proposed removal of the claims reporting option of American Society for Gastrointestinal Endoscopy–stewarded measure for photodocumentation of cecal intubation because it is topped-out; however, the registry version is still available in MIPS.

OQR Program includes colonoscopy measure for disparities reporting: CMS has identified six priority measures included in the Hospital Outpatient Quality Reporting (OQR) Program as candidate measures for disparities reporting stratified by dual eligibility, one of which is the Facility 7-Day Risk-Standardized Hospital Visit Rate After Outpatient Colonoscopy (OP-32).

The GI societies will jointly comment on issues in the 2022 PFS and OPPS/ASC proposed rules impacting gastroenterologists. We may also organize members to take action by submitting letters during the comment period, so watch your inbox for invitations to participate. We need your help to influence change.

Shivan Mehta, MD, MBA, is with the division of gastroenterology and hepatology at the University of Pennsylvania, Philadelphia, and is an AGA adviser to the American Medical Association RVS Update Committee. David A. Leiman, MD, MSHP, is with the division of gastroenterology at Duke University, Durham, N.C., and is the chair of the AGA Quality Committee. Neither have conflicts to declare.

In July 2021, the Centers for Medicare & Medicaid Services released the Medicare Physician Fee Schedule (PFS) and Hospital Outpatient Prospective Payment System (OPPS)/Ambulatory Surgery Center (ASC) proposed rules for calendar year (CY) 2022. While the OPPS/ASC proposed rule was largely positive for gastroenterology, the PFS proposed rule was more of a mixed bag for practices.

No more colonoscopy coinsurance “loophole”: After nearly a decade of advocacy, the Removing Barriers to Colorectal Cancer Screening Act was finally signed into law this year and will take effect Jan. 1, 2023. The legislation phases out Medicare beneficiary cost-sharing obligations when a polyp or lesion is found and biopsied or removed as part of a screening colonoscopy or flexible sigmoidoscopy. The American Gastroenterological Association is pleased this will finally eliminate a surprise bill for patients and remove a barrier to colorectal cancer screening.

The phase out timeline is as follows:

• 80% payment for services furnished during CY 2022 (coinsurance, 20%).
• 85% payment for services furnished during CY 2023 through CY 2026 (coinsurance, 15%).
• 90% payment for services furnished during CY 2027 through CY 2029 (coinsurance, 10%).
• 100% payment for services furnished from CY 2030 onward (coinsurance, 0%).

Providers must continue to report HCPCS modifier “PT” in the hospital outpatient and ASC during the transition period to indicate that a planned colorectal cancer screening service converted to a diagnostic service.

Proposed 2022 PFS conversion factor could fall 3.75% unless Congress acts: The proposed 2022 PFS conversion factor is $33.58. The decrease reflects the expiration of the 3.75% payment increase provided by the Consolidated Appropriations Act. This congressional intervention averted a significant cut in Medicare physician payment that would have resulted in an almost 10% cut to GI services. The GI societies are working with Congress to avert cuts to physician payments next year as practices continue to recover from the pandemic.

GI procedure payments to increase 3% for hospital outpatient and ASCs: A 2.3% increase has been proposed for the conversion factors, resulting in $84.46 for hospitals and $50.04 for ASCs meeting quality reporting requirements. However, GI endoscopy procedure payments are expected to increase on average 3% in CY 2022.

Colon capsule endoscopy and POEM get new codes and payments: CMS accepted new CPT codes for colon capsule endoscopy (CCE) and peroral endoscopic myotomy (POEM) beginning Jan. 1, 2022.

CMS’s proposed CCE value of 2.41 physician work relative value units (wRVUs) reflects the recommendation of the American Medical Association RVS Update Committee (RUC), which is based on data from physicians who perform the procedure. The proposed national-level physician payments are $116.52 for the professional component and $664.21 for the technical component.

However, CMS did not accept the RUC’s recommendation of 15.50 wRVUs for POEM and, instead, proposed that POEM is similar in work to hemodialysis access CPT code 36819, which has a wRVU of 13.29 and a payment of $792.82. The RUC’s valuation of 15.50 wRVUs was based on data from nearly 120 physicians who perform POEM, and we are disappointed CMS chose to reject the robust survey data. The GI societies will defend the 15.50 wRVU in our comments.

The proposed facility fee for POEM is $3,160.76 in the hospital outpatient setting and $1,848.32 in the ASC. CMS’s proposed facility fee for colon capsule endoscopy is $814.44 in the hospital outpatient setting.

CMS moves physicians to MVPs and plans to phase out MIPS: CMS proposes to revise and phase out the Merit-Based Incentive Payment System (MIPS) and move physicians towards the MIPS Value Pathways (MVPs) system beginning in the 2023 performance year (PY). No GI MVPs were proposed for PY 2023. The GI societies are working with CMS as they develop MVPs to ensure any gastroenterology-related MVPs do not harm gastroenterologists.

CMS is statutorily required to weigh the MIPS Cost and Quality performance categories equally beginning with PY 2022. The proposed PY 2022 MIPS performance categories are:

• Quality: 30%.
• Cost: 30%.
• Promoting Interoperability: 25% (no change from 2021).
• Improvement Activities: 15% (no change from 2021).

CMS is also required by law beginning in 2022 to set the MIPS performance threshold to either the mean or median of the final scores for all MIPS eligible clinicians for a prior period. CMS proposes to use the mean final score from MIPS 2017 performance year/MIPS 2019 payment year, which would result in a performance threshold of 75 points and an additional performance threshold set at 89 points for exceptional performance.

CMS keeps all AGA-stewarded measures in MIPS 2022 program year: CMS has proposed to keep all AGA-stewarded measures in the MIPS program for the 2022 program year and accepted the substantive changes for the one-time screening for hepatitis C virus measure we received last year from the Physician Consortium for Performance Improvement. CMS proposed removal of the claims reporting option of American Society for Gastrointestinal Endoscopy–stewarded measure for photodocumentation of cecal intubation because it is topped-out; however, the registry version is still available in MIPS.

OQR Program includes colonoscopy measure for disparities reporting: CMS has identified six priority measures included in the Hospital Outpatient Quality Reporting (OQR) Program as candidate measures for disparities reporting stratified by dual eligibility, one of which is the Facility 7-Day Risk-Standardized Hospital Visit Rate After Outpatient Colonoscopy (OP-32).

The GI societies will jointly comment on issues in the 2022 PFS and OPPS/ASC proposed rules impacting gastroenterologists. We may also organize members to take action by submitting letters during the comment period, so watch your inbox for invitations to participate. We need your help to influence change.

Shivan Mehta, MD, MBA, is with the division of gastroenterology and hepatology at the University of Pennsylvania, Philadelphia, and is an AGA adviser to the American Medical Association RVS Update Committee. David A. Leiman, MD, MSHP, is with the division of gastroenterology at Duke University, Durham, N.C., and is the chair of the AGA Quality Committee. Neither have conflicts to declare.

The transition from gastroenterology fellowship to independent practice can be daunting. There may be concerns about procedural competency and increased levels of responsibility. Recent trainees have to manage their newly busy clinical schedules while trying to integrate evidence from a rapidly evolving landscape of medical literature into daily practice. Many recent graduates also are expected to participate in financial decisions or contribute to assessments about resource allocation regarding new technologies. These are challenges faced by those in both community and academic positions but may be more keenly felt in the first years of practice regardless of setting.

Without the benefit of experience, incorporating pertinent evidence from both within and outside of the field of gastroenterology as well as identifying disruptive technologies can be particularly difficult. There is scant guidance in this area, either during fellowship or from the existing literature¹. Yet these are skills that, when properly developed, can be lifelong assets and, as a result, an evaluation of this process is warranted. Herein, we identify recent developments relevant to gastroenterologists to illustrate a conceptual framework for judging novel information.

A practical concern for the new gastroenterologist is learning to efficiently evaluate the merits of the latest research and then implement this knowledge in the clinic. Maintaining active society membership often includes access to scholarly journals. For example, AGA members receive Gastroenterology, Clinical Gastroenterology and Hepatology, and Cellular and Molecular Gastroenterology and Hepatology as part of their member benefits and have the opportunity to receive alerts when new content is published. Social media outlets such as Twitter and Facebook also simplify the process for readers to identify high-impact studies² (see social media urls at the end of the story). In addition to reading, however, a critical review of these studies can prevent premature enthusiasm for modifying practice. The evolving evidence base for understanding proton pump inhibitor (PPI) risks is illustrative. Several studies attracted widespread media attention describing serious associated side effects, ranging from MI³ to dementia⁴ and stroke⁵. These studies were provocative but a decision to withhold PPIs from patients based on these concerns alone could lead to unintended consequences with poor outcomes. Ultimately, subsequent studies published only months later challenged these associations.^6-8 Instead, thoughtful disclosure to patients of known risks and appropriate indications for PPI therapy based on resources such as the AGA Best Practice Advice⁹ is prudent. Reading more may be necessary but is insufficient; finding a forum to discuss novel research topics, such as in a monthly journal club¹⁰ or group practice meeting, can lead to stimulating discussion about how to apply pertinent research to change practice. The AGA Community is an excellent venue for this kind of interaction.

In many situations, keeping informed of updates about the risks and safety of medications prescribed by nongastroenterologists, particularly as they relate to GI conditions, can be even more difficult. A prime example of this is the rapidly expanding literature on indications and risks of direct oral anticoagulants. Rotating on the inpatient consultation service, with the chance to interact with multiple non-GI providers, affords an excellent opportunity to stay up to date. With the increased prevalence of atrial fibrillation as well as the potential expanded indications for direct oral anticoagulants based on recent randomized, controlled trials^11,12, practicing gastroenterologists will be comanaging increasing numbers of patients hospitalized with gastrointestinal bleeding (GIB). Our understanding of the availability and indication for targeted reversal agents, such as idarucizumab, as well as nonspecific reversal agents, such as prothrombin complex concentrates, for those with life-threatening GIB is critical to optimal management of these patients. Multidisciplinary collaborations, such as with cardiogastroenterology clinics¹³, can be leveraged for optimal management of direct oral anticoagulants in the periendoscopy period.

Traditional outpatient consultative approaches are sometimes necessary but frequent reference to consensus societal guidelines on endoscopy in patients on antithrombotics¹⁴ should be made, particularly if they are printed and readily available in the ambulatory clinic and endoscopy suites. When information may be too new or sparse to utilize a national guideline, employing local data or experience to create a hospital-specific algorithm can ensure the delivery of high-quality, collaborative patient care.

Much like reviewing the literature, evaluating new technologies poses its own challenges. Changes in clinical practice may be slow, as in the adoption of noninvasive methods for Barrett’s esophagus screening.¹⁵ But in an age when news of advances and updates in management spreads at tremendous speed through the use of social media, the ability to pivot or assimilate new discoveries and techniques will become increasingly relevant and important. A professional society’s endorsement can provide a framework for a decision, but other principles at play include sensible, critical analyses of the outcomes and costs as well as a balance of organizational and societal perspectives.¹⁶ The use of impedance planimetry is one such example. This is a relatively new technology, but it has received increasing interest recently.¹⁷ The first questions when considering adopting this type of device likely will be about its supporting evidence and the risk for causing harm. The pace of publications regarding its use for measuring esophageal distensibility has accelerated¹⁸. But good data does not necessarily translate into extensive uptake. Other important factors also are practical, e.g., whether a technology committee’s approval is needed and what is the learning curve, available technical support, need for capital purchases, reimbursement, etc. Functional luminal imaging probe (FLIP^®) technology was developed to assess compliance in primary esophageal disorders and now has been applied to several other areas including anorectal disease, bariatric surgery, and therapeutic endoscopy^19,20. Although seemingly a niche market, there is potential widespread application and an opportunity for collaborations that might not have been evident at first blush. Ultimately, any evaluation of new technology is to a certain extent speculation. Is the technology mature or novel? If it is the latter, this may provide a marketing advantage and facilitate a relationship that could lead to academic partnerships.

Embracing new devices and modifications to existing practice paradigms happens on a spectrum²¹. We are reminded of the maxim, “never be the first or last to adopt change.” One must be on the lookout for revolutionary or game-changing advances but be cautious to avoid irresponsible enthusiasm. Whether it is incorporating evidence from a recent study into everyday practice or judging the potential of new equipment, a balance must be achieved between detailed evaluation of the literature and understanding the practical consequences and feasibility of implementing change. Although these may be competing interests, achieving this is a pivotal step in success for the new gastroenterologist.

AGA journals' social media accounts

http://twitter.com/aga_gastro

http://twitter.com/aga_cgh

http://twitter.com/aga_cmgh

https://www.facebook.com/gastrojournal/

https://www.facebook.com/cghjournal/

https://www.facebook.com/cmghjournal/

References

1. Arora V et al. Closing the gap between internal medicine training and practice: Recommendations from recent graduates. Am J Med. 2005 Jun;118(6):685-7.

2. Gray DM et al. Making social media work for your practice. Clin Gastroenterol Hepatol. 2017 Nov;15:1651-4.

3. Shah NH et al. Proton pump inhibitor usage and the risk of myocardial infarction in the general population. PLoS One. 2015 Jun 10;10:e0124653.

4. Gomm W et al. Association of proton pump inhibitors with risk of dementia: A pharmacoepidemiological claims data analysis. JAMA Neurol. 2016 Apr;73(4):410-6.

5. Wang YF et al. Proton-pump inhibitor use and the risk of first-time ischemic stroke in the general population: A nationwide population-based study. Am J Gastroenterol. 2017 Jul;112:1084-93.

6. Nguyen LH et al. No significant association between proton pump inhibitor use and risk of stroke after adjustment for lifestyle factors and indication. Gastroenterology. 2018 Apr; 154(5):1290-7.

7. Lochhead P et al. Association between proton pump inhibitor use and cognitive function in women. Gastroenterology. 2017 Oct;153(4):971-9.

8. Landi SN et al. No increase in risk of acute myocardial infarction in privately insured adults prescribed proton pump inhibitors vs histamine-2 receptor antagonists (2002-2014). Gastroenterology 2018 Mar;154(4):861-73.

9. Freedberg DE et al. The risks and benefits of long-term use of proton pump inhibitors: Expert review and best practice advise from the American Gastroenterological Association. Gastroenterology. 2017 Mar;152:706-15.

10. Judd S et al. Approach to presenting a clinical journal club. Gastroenterology. 2014 Jun;146(7):1591-3.

11. Weitz JI et al. Rivaroxaban or aspirin for extended treatment of venous thromboembolism. N Engl J Med. 2017 Mar 30;376:1211-22.

12. Eikelboom JW et al. Rivaroxaban with or without aspirin in stable cardiovascular disease. N Engl J Med. 2017 Oct. 5;377:1319-30.

13. Abraham NS. Novel oral anticoagulants and gastrointestinal bleeding: a case for cardiogastroenterology. Clin Gastroenterol Hepatol. 2013;11(4):324-8.

14. Acosta RD et al. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc. 2016;83:3-16.

15. Sami SS et al. Screening for Barrett’s esophagus and esophageal adenocarcinoma: rationale, recent progress, challenges and future directions. Clin Gastroenterol Hepatol. 2015 Apr;13:623-34.

16. Laupacis A et al. How attractive does a new technology need to be to warrant adoption and utilization? Tentative guidelines for using clinical and economic evaluations. CMAJ. 1992 Feb 15;146:473-81.

17. Hirano I et al. Functional lumen imaging probe for the management of esophageal disorders: Expert review from the clinical practice updates committee of the AGA Institute. Clin Gastroenterol Hepatol. 2017 Mar;15:325-34.

18. Kwiatek MA et al. Esophagogastric junction distensibility assessed with an endoscopic functional luminal imaging probe (EndoFLIP). Gastrointest Endosc. 2010 Aug;72:272-82.

19. Leroi AM et al. The diagnostic value of the functional lumen imaging probe versus high-resolution anorectal manometry in patients with fecal incontinence. Neurogastroenterol Motil. 2018 Jan 18; doi: 10.1111/nmo.13291.

20. Reynolds JL et al. Intraoperative assessment of the effects of laparoscopic sleeve gastrectomy on the distensibility of the lower esophageal sphincter using impedance planimetry. Surg Endosc. 2016 Nov;30:4904-9.

21. Aisenberg J. Optical biopsy for colorectal polyps: moving along the S-shaped curve. Gastrointest Endosc. 2014 Mar;79:399-401.

Dr. Leiman, assistant professor of medicine, division of gastroenterology, Duke University, Durham, N.C.; Dr. Sengupta, assistant professor of medicine, section of gastroenterology, hepatology, and nutrition, University of Chicago Medical Center.

The transition from gastroenterology fellowship to independent practice can be daunting. There may be concerns about procedural competency and increased levels of responsibility. Recent trainees have to manage their newly busy clinical schedules while trying to integrate evidence from a rapidly evolving landscape of medical literature into daily practice. Many recent graduates also are expected to participate in financial decisions or contribute to assessments about resource allocation regarding new technologies. These are challenges faced by those in both community and academic positions but may be more keenly felt in the first years of practice regardless of setting.

Without the benefit of experience, incorporating pertinent evidence from both within and outside of the field of gastroenterology as well as identifying disruptive technologies can be particularly difficult. There is scant guidance in this area, either during fellowship or from the existing literature¹. Yet these are skills that, when properly developed, can be lifelong assets and, as a result, an evaluation of this process is warranted. Herein, we identify recent developments relevant to gastroenterologists to illustrate a conceptual framework for judging novel information.

A practical concern for the new gastroenterologist is learning to efficiently evaluate the merits of the latest research and then implement this knowledge in the clinic. Maintaining active society membership often includes access to scholarly journals. For example, AGA members receive Gastroenterology, Clinical Gastroenterology and Hepatology, and Cellular and Molecular Gastroenterology and Hepatology as part of their member benefits and have the opportunity to receive alerts when new content is published. Social media outlets such as Twitter and Facebook also simplify the process for readers to identify high-impact studies² (see social media urls at the end of the story). In addition to reading, however, a critical review of these studies can prevent premature enthusiasm for modifying practice. The evolving evidence base for understanding proton pump inhibitor (PPI) risks is illustrative. Several studies attracted widespread media attention describing serious associated side effects, ranging from MI³ to dementia⁴ and stroke⁵. These studies were provocative but a decision to withhold PPIs from patients based on these concerns alone could lead to unintended consequences with poor outcomes. Ultimately, subsequent studies published only months later challenged these associations.^6-8 Instead, thoughtful disclosure to patients of known risks and appropriate indications for PPI therapy based on resources such as the AGA Best Practice Advice⁹ is prudent. Reading more may be necessary but is insufficient; finding a forum to discuss novel research topics, such as in a monthly journal club¹⁰ or group practice meeting, can lead to stimulating discussion about how to apply pertinent research to change practice. The AGA Community is an excellent venue for this kind of interaction.

In many situations, keeping informed of updates about the risks and safety of medications prescribed by nongastroenterologists, particularly as they relate to GI conditions, can be even more difficult. A prime example of this is the rapidly expanding literature on indications and risks of direct oral anticoagulants. Rotating on the inpatient consultation service, with the chance to interact with multiple non-GI providers, affords an excellent opportunity to stay up to date. With the increased prevalence of atrial fibrillation as well as the potential expanded indications for direct oral anticoagulants based on recent randomized, controlled trials^11,12, practicing gastroenterologists will be comanaging increasing numbers of patients hospitalized with gastrointestinal bleeding (GIB). Our understanding of the availability and indication for targeted reversal agents, such as idarucizumab, as well as nonspecific reversal agents, such as prothrombin complex concentrates, for those with life-threatening GIB is critical to optimal management of these patients. Multidisciplinary collaborations, such as with cardiogastroenterology clinics¹³, can be leveraged for optimal management of direct oral anticoagulants in the periendoscopy period.

Traditional outpatient consultative approaches are sometimes necessary but frequent reference to consensus societal guidelines on endoscopy in patients on antithrombotics¹⁴ should be made, particularly if they are printed and readily available in the ambulatory clinic and endoscopy suites. When information may be too new or sparse to utilize a national guideline, employing local data or experience to create a hospital-specific algorithm can ensure the delivery of high-quality, collaborative patient care.

Much like reviewing the literature, evaluating new technologies poses its own challenges. Changes in clinical practice may be slow, as in the adoption of noninvasive methods for Barrett’s esophagus screening.¹⁵ But in an age when news of advances and updates in management spreads at tremendous speed through the use of social media, the ability to pivot or assimilate new discoveries and techniques will become increasingly relevant and important. A professional society’s endorsement can provide a framework for a decision, but other principles at play include sensible, critical analyses of the outcomes and costs as well as a balance of organizational and societal perspectives.¹⁶ The use of impedance planimetry is one such example. This is a relatively new technology, but it has received increasing interest recently.¹⁷ The first questions when considering adopting this type of device likely will be about its supporting evidence and the risk for causing harm. The pace of publications regarding its use for measuring esophageal distensibility has accelerated¹⁸. But good data does not necessarily translate into extensive uptake. Other important factors also are practical, e.g., whether a technology committee’s approval is needed and what is the learning curve, available technical support, need for capital purchases, reimbursement, etc. Functional luminal imaging probe (FLIP^®) technology was developed to assess compliance in primary esophageal disorders and now has been applied to several other areas including anorectal disease, bariatric surgery, and therapeutic endoscopy^19,20. Although seemingly a niche market, there is potential widespread application and an opportunity for collaborations that might not have been evident at first blush. Ultimately, any evaluation of new technology is to a certain extent speculation. Is the technology mature or novel? If it is the latter, this may provide a marketing advantage and facilitate a relationship that could lead to academic partnerships.

Embracing new devices and modifications to existing practice paradigms happens on a spectrum²¹. We are reminded of the maxim, “never be the first or last to adopt change.” One must be on the lookout for revolutionary or game-changing advances but be cautious to avoid irresponsible enthusiasm. Whether it is incorporating evidence from a recent study into everyday practice or judging the potential of new equipment, a balance must be achieved between detailed evaluation of the literature and understanding the practical consequences and feasibility of implementing change. Although these may be competing interests, achieving this is a pivotal step in success for the new gastroenterologist.

AGA journals' social media accounts

http://twitter.com/aga_gastro

http://twitter.com/aga_cgh

http://twitter.com/aga_cmgh

https://www.facebook.com/gastrojournal/

https://www.facebook.com/cghjournal/

https://www.facebook.com/cmghjournal/

References

1. Arora V et al. Closing the gap between internal medicine training and practice: Recommendations from recent graduates. Am J Med. 2005 Jun;118(6):685-7.

2. Gray DM et al. Making social media work for your practice. Clin Gastroenterol Hepatol. 2017 Nov;15:1651-4.

3. Shah NH et al. Proton pump inhibitor usage and the risk of myocardial infarction in the general population. PLoS One. 2015 Jun 10;10:e0124653.

4. Gomm W et al. Association of proton pump inhibitors with risk of dementia: A pharmacoepidemiological claims data analysis. JAMA Neurol. 2016 Apr;73(4):410-6.

5. Wang YF et al. Proton-pump inhibitor use and the risk of first-time ischemic stroke in the general population: A nationwide population-based study. Am J Gastroenterol. 2017 Jul;112:1084-93.

6. Nguyen LH et al. No significant association between proton pump inhibitor use and risk of stroke after adjustment for lifestyle factors and indication. Gastroenterology. 2018 Apr; 154(5):1290-7.

7. Lochhead P et al. Association between proton pump inhibitor use and cognitive function in women. Gastroenterology. 2017 Oct;153(4):971-9.

8. Landi SN et al. No increase in risk of acute myocardial infarction in privately insured adults prescribed proton pump inhibitors vs histamine-2 receptor antagonists (2002-2014). Gastroenterology 2018 Mar;154(4):861-73.

9. Freedberg DE et al. The risks and benefits of long-term use of proton pump inhibitors: Expert review and best practice advise from the American Gastroenterological Association. Gastroenterology. 2017 Mar;152:706-15.

10. Judd S et al. Approach to presenting a clinical journal club. Gastroenterology. 2014 Jun;146(7):1591-3.

11. Weitz JI et al. Rivaroxaban or aspirin for extended treatment of venous thromboembolism. N Engl J Med. 2017 Mar 30;376:1211-22.

12. Eikelboom JW et al. Rivaroxaban with or without aspirin in stable cardiovascular disease. N Engl J Med. 2017 Oct. 5;377:1319-30.

13. Abraham NS. Novel oral anticoagulants and gastrointestinal bleeding: a case for cardiogastroenterology. Clin Gastroenterol Hepatol. 2013;11(4):324-8.

14. Acosta RD et al. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc. 2016;83:3-16.

15. Sami SS et al. Screening for Barrett’s esophagus and esophageal adenocarcinoma: rationale, recent progress, challenges and future directions. Clin Gastroenterol Hepatol. 2015 Apr;13:623-34.

16. Laupacis A et al. How attractive does a new technology need to be to warrant adoption and utilization? Tentative guidelines for using clinical and economic evaluations. CMAJ. 1992 Feb 15;146:473-81.

17. Hirano I et al. Functional lumen imaging probe for the management of esophageal disorders: Expert review from the clinical practice updates committee of the AGA Institute. Clin Gastroenterol Hepatol. 2017 Mar;15:325-34.

18. Kwiatek MA et al. Esophagogastric junction distensibility assessed with an endoscopic functional luminal imaging probe (EndoFLIP). Gastrointest Endosc. 2010 Aug;72:272-82.

19. Leroi AM et al. The diagnostic value of the functional lumen imaging probe versus high-resolution anorectal manometry in patients with fecal incontinence. Neurogastroenterol Motil. 2018 Jan 18; doi: 10.1111/nmo.13291.

20. Reynolds JL et al. Intraoperative assessment of the effects of laparoscopic sleeve gastrectomy on the distensibility of the lower esophageal sphincter using impedance planimetry. Surg Endosc. 2016 Nov;30:4904-9.

21. Aisenberg J. Optical biopsy for colorectal polyps: moving along the S-shaped curve. Gastrointest Endosc. 2014 Mar;79:399-401.

Dr. Leiman, assistant professor of medicine, division of gastroenterology, Duke University, Durham, N.C.; Dr. Sengupta, assistant professor of medicine, section of gastroenterology, hepatology, and nutrition, University of Chicago Medical Center.

The transition from gastroenterology fellowship to independent practice can be daunting. There may be concerns about procedural competency and increased levels of responsibility. Recent trainees have to manage their newly busy clinical schedules while trying to integrate evidence from a rapidly evolving landscape of medical literature into daily practice. Many recent graduates also are expected to participate in financial decisions or contribute to assessments about resource allocation regarding new technologies. These are challenges faced by those in both community and academic positions but may be more keenly felt in the first years of practice regardless of setting.

Without the benefit of experience, incorporating pertinent evidence from both within and outside of the field of gastroenterology as well as identifying disruptive technologies can be particularly difficult. There is scant guidance in this area, either during fellowship or from the existing literature¹. Yet these are skills that, when properly developed, can be lifelong assets and, as a result, an evaluation of this process is warranted. Herein, we identify recent developments relevant to gastroenterologists to illustrate a conceptual framework for judging novel information.

A practical concern for the new gastroenterologist is learning to efficiently evaluate the merits of the latest research and then implement this knowledge in the clinic. Maintaining active society membership often includes access to scholarly journals. For example, AGA members receive Gastroenterology, Clinical Gastroenterology and Hepatology, and Cellular and Molecular Gastroenterology and Hepatology as part of their member benefits and have the opportunity to receive alerts when new content is published. Social media outlets such as Twitter and Facebook also simplify the process for readers to identify high-impact studies² (see social media urls at the end of the story). In addition to reading, however, a critical review of these studies can prevent premature enthusiasm for modifying practice. The evolving evidence base for understanding proton pump inhibitor (PPI) risks is illustrative. Several studies attracted widespread media attention describing serious associated side effects, ranging from MI³ to dementia⁴ and stroke⁵. These studies were provocative but a decision to withhold PPIs from patients based on these concerns alone could lead to unintended consequences with poor outcomes. Ultimately, subsequent studies published only months later challenged these associations.^6-8 Instead, thoughtful disclosure to patients of known risks and appropriate indications for PPI therapy based on resources such as the AGA Best Practice Advice⁹ is prudent. Reading more may be necessary but is insufficient; finding a forum to discuss novel research topics, such as in a monthly journal club¹⁰ or group practice meeting, can lead to stimulating discussion about how to apply pertinent research to change practice. The AGA Community is an excellent venue for this kind of interaction.

In many situations, keeping informed of updates about the risks and safety of medications prescribed by nongastroenterologists, particularly as they relate to GI conditions, can be even more difficult. A prime example of this is the rapidly expanding literature on indications and risks of direct oral anticoagulants. Rotating on the inpatient consultation service, with the chance to interact with multiple non-GI providers, affords an excellent opportunity to stay up to date. With the increased prevalence of atrial fibrillation as well as the potential expanded indications for direct oral anticoagulants based on recent randomized, controlled trials^11,12, practicing gastroenterologists will be comanaging increasing numbers of patients hospitalized with gastrointestinal bleeding (GIB). Our understanding of the availability and indication for targeted reversal agents, such as idarucizumab, as well as nonspecific reversal agents, such as prothrombin complex concentrates, for those with life-threatening GIB is critical to optimal management of these patients. Multidisciplinary collaborations, such as with cardiogastroenterology clinics¹³, can be leveraged for optimal management of direct oral anticoagulants in the periendoscopy period.

Traditional outpatient consultative approaches are sometimes necessary but frequent reference to consensus societal guidelines on endoscopy in patients on antithrombotics¹⁴ should be made, particularly if they are printed and readily available in the ambulatory clinic and endoscopy suites. When information may be too new or sparse to utilize a national guideline, employing local data or experience to create a hospital-specific algorithm can ensure the delivery of high-quality, collaborative patient care.

Much like reviewing the literature, evaluating new technologies poses its own challenges. Changes in clinical practice may be slow, as in the adoption of noninvasive methods for Barrett’s esophagus screening.¹⁵ But in an age when news of advances and updates in management spreads at tremendous speed through the use of social media, the ability to pivot or assimilate new discoveries and techniques will become increasingly relevant and important. A professional society’s endorsement can provide a framework for a decision, but other principles at play include sensible, critical analyses of the outcomes and costs as well as a balance of organizational and societal perspectives.¹⁶ The use of impedance planimetry is one such example. This is a relatively new technology, but it has received increasing interest recently.¹⁷ The first questions when considering adopting this type of device likely will be about its supporting evidence and the risk for causing harm. The pace of publications regarding its use for measuring esophageal distensibility has accelerated¹⁸. But good data does not necessarily translate into extensive uptake. Other important factors also are practical, e.g., whether a technology committee’s approval is needed and what is the learning curve, available technical support, need for capital purchases, reimbursement, etc. Functional luminal imaging probe (FLIP^®) technology was developed to assess compliance in primary esophageal disorders and now has been applied to several other areas including anorectal disease, bariatric surgery, and therapeutic endoscopy^19,20. Although seemingly a niche market, there is potential widespread application and an opportunity for collaborations that might not have been evident at first blush. Ultimately, any evaluation of new technology is to a certain extent speculation. Is the technology mature or novel? If it is the latter, this may provide a marketing advantage and facilitate a relationship that could lead to academic partnerships.

Embracing new devices and modifications to existing practice paradigms happens on a spectrum²¹. We are reminded of the maxim, “never be the first or last to adopt change.” One must be on the lookout for revolutionary or game-changing advances but be cautious to avoid irresponsible enthusiasm. Whether it is incorporating evidence from a recent study into everyday practice or judging the potential of new equipment, a balance must be achieved between detailed evaluation of the literature and understanding the practical consequences and feasibility of implementing change. Although these may be competing interests, achieving this is a pivotal step in success for the new gastroenterologist.

AGA journals' social media accounts

http://twitter.com/aga_gastro

http://twitter.com/aga_cgh

http://twitter.com/aga_cmgh

https://www.facebook.com/gastrojournal/

https://www.facebook.com/cghjournal/

https://www.facebook.com/cmghjournal/

References

1. Arora V et al. Closing the gap between internal medicine training and practice: Recommendations from recent graduates. Am J Med. 2005 Jun;118(6):685-7.

2. Gray DM et al. Making social media work for your practice. Clin Gastroenterol Hepatol. 2017 Nov;15:1651-4.

3. Shah NH et al. Proton pump inhibitor usage and the risk of myocardial infarction in the general population. PLoS One. 2015 Jun 10;10:e0124653.

4. Gomm W et al. Association of proton pump inhibitors with risk of dementia: A pharmacoepidemiological claims data analysis. JAMA Neurol. 2016 Apr;73(4):410-6.

5. Wang YF et al. Proton-pump inhibitor use and the risk of first-time ischemic stroke in the general population: A nationwide population-based study. Am J Gastroenterol. 2017 Jul;112:1084-93.

6. Nguyen LH et al. No significant association between proton pump inhibitor use and risk of stroke after adjustment for lifestyle factors and indication. Gastroenterology. 2018 Apr; 154(5):1290-7.

7. Lochhead P et al. Association between proton pump inhibitor use and cognitive function in women. Gastroenterology. 2017 Oct;153(4):971-9.

8. Landi SN et al. No increase in risk of acute myocardial infarction in privately insured adults prescribed proton pump inhibitors vs histamine-2 receptor antagonists (2002-2014). Gastroenterology 2018 Mar;154(4):861-73.

9. Freedberg DE et al. The risks and benefits of long-term use of proton pump inhibitors: Expert review and best practice advise from the American Gastroenterological Association. Gastroenterology. 2017 Mar;152:706-15.

10. Judd S et al. Approach to presenting a clinical journal club. Gastroenterology. 2014 Jun;146(7):1591-3.

11. Weitz JI et al. Rivaroxaban or aspirin for extended treatment of venous thromboembolism. N Engl J Med. 2017 Mar 30;376:1211-22.

12. Eikelboom JW et al. Rivaroxaban with or without aspirin in stable cardiovascular disease. N Engl J Med. 2017 Oct. 5;377:1319-30.

13. Abraham NS. Novel oral anticoagulants and gastrointestinal bleeding: a case for cardiogastroenterology. Clin Gastroenterol Hepatol. 2013;11(4):324-8.

14. Acosta RD et al. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc. 2016;83:3-16.

15. Sami SS et al. Screening for Barrett’s esophagus and esophageal adenocarcinoma: rationale, recent progress, challenges and future directions. Clin Gastroenterol Hepatol. 2015 Apr;13:623-34.

16. Laupacis A et al. How attractive does a new technology need to be to warrant adoption and utilization? Tentative guidelines for using clinical and economic evaluations. CMAJ. 1992 Feb 15;146:473-81.

17. Hirano I et al. Functional lumen imaging probe for the management of esophageal disorders: Expert review from the clinical practice updates committee of the AGA Institute. Clin Gastroenterol Hepatol. 2017 Mar;15:325-34.

18. Kwiatek MA et al. Esophagogastric junction distensibility assessed with an endoscopic functional luminal imaging probe (EndoFLIP). Gastrointest Endosc. 2010 Aug;72:272-82.

19. Leroi AM et al. The diagnostic value of the functional lumen imaging probe versus high-resolution anorectal manometry in patients with fecal incontinence. Neurogastroenterol Motil. 2018 Jan 18; doi: 10.1111/nmo.13291.

20. Reynolds JL et al. Intraoperative assessment of the effects of laparoscopic sleeve gastrectomy on the distensibility of the lower esophageal sphincter using impedance planimetry. Surg Endosc. 2016 Nov;30:4904-9.

21. Aisenberg J. Optical biopsy for colorectal polyps: moving along the S-shaped curve. Gastrointest Endosc. 2014 Mar;79:399-401.

Dr. Leiman, assistant professor of medicine, division of gastroenterology, Duke University, Durham, N.C.; Dr. Sengupta, assistant professor of medicine, section of gastroenterology, hepatology, and nutrition, University of Chicago Medical Center.