The New Gastroenterologist

Evolving endpoints and treat-to-target strategies in inflammatory bowel disease (IBD) incorporate a need for more frequent assessments of the disease, including objective measures of inflammation.^1,2 Intestinal ultrasound (IUS) is a noninvasive, well-tolerated,³ repeatable, point-of-care (POC) test that is highly sensitive and specific in detection of bowel inflammation, transmural healing,^4,5 and response to therapy in both Crohn’s disease (CD) and ulcerative colitis (UC).^6-8These unique features allow IUS to be an optimal tool for the current era of disease modification and tight disease control in IBD. As IUS is taking hold in the United States, there is a great need to teach the next generation of gastroenterologists about its value, how to incorporate it into clinical practice, and how to become appropriately trained and maintain competency.

Why incorporate IUS in the United States now?

Jordan Porter-Woodruff/University of Chicago

As IBD management has evolved, so has the appreciation for the value of bedside IUS as a tool that addresses very real needs for the field. Unlike other parts of the world in which ultrasound skills are part of the training curriculum, this has not been the case in internal medicine and gastroenterology training in the United States. In addition, there have been no specific billing codes or clear renumeration processes outlined for IUS,⁹ nor have there been any local training opportunities. Because of these challenges, it was not until recently that several leaders in IBD in the United States championed the potential of this technology and incorporated it into IBD management. Subsequently, a number of gastroenterologists have been trained and are now leading the effort to disseminate this tool throughout the United States. A consequence of these efforts resulted in support from the Helmsley Charitable Trust (Helmsley) and the creation of the Intestinal Ultrasound Group of the United States and Canada to address the gaps unique to North America as well as to strengthen the quality of IUS research through collaborations across the continent.

What is IUS, and when is it performed?

IUS is a sonographic exam performed by a gastroenterology-trained professional who scans the abdominal wall (and perineum when the rectum and perineal disease is evaluated), using both a convex low-frequency probe and linear high-frequency probe to evaluate the small intestine, colon, and rectum. The bowel is composed of five layers with alternating hyperechoic and hypoechoic layers: the mucosal-lumen interface (not a true part of the bowel wall), deep mucosa, submucosa, muscularis propria, and serosa. (Figure)

Dr. Noa Krugliak Cleveland

The most sensitive parameter for assessment of IBD activity is bowel wall thickness (≤ 3 mm in the small bowel and colon and ≤ 4 mm in the rectum are considered normal in adults).^8,10 The second key parameter is the assessment of vascularization, in which presence of hyperemia suggests active disease.¹¹ There are a number of indices to quantify hyperemia, with the most widely used being the Limberg score.¹² Additional parameters include assessment of loss of the delineation of the bowel wall layers (loss of stratification signifies active inflammation), increased thickness of the submucosa,¹³ increased mesenteric fatty proliferation (with increased inflammation, mesenteric fat proliferation will appear as a hyperechoic area surrounding the bowel), lymphadenopathy, bowel strictures, and extramural complications such as fistulae and abscess. Shear wave elastography may be an effective way to differentiate severe fibrotic strictures, but this is an area that requires more investigation.¹⁴

IUS has been shown to be an excellent tool in not only assessing disease activity and disease complication (with higher sensitivity than the Harvey-Bradshaw Index, serum C-reactive protein),¹⁵ but, unique to IUS, can provide early prediction of response in moderate to severe active UC.^6,7 This has also been shown with transperineal ultrasound in patients with UC, with the ability to predict response to therapy as early as 1 week from induction therapy.¹⁶ Furthermore, it can be used to assess transmural healing, which has been shown to be associated with improved outcomes in Crohn’s patient, such as lower rates of hospitalizations, surgery, medication escalation, and need for corticosteroids.¹⁷ IUS is associated with great patient satisfaction and greater understanding of disease-related symptoms when the patient sees the inflammation of the bowel. (Table)

How can you get trained in IUS?

Training in IUS varies across the globe, from incorporation of IUS into the standard training curriculum to available training programs that can be followed and attended outside of medical training. In the United States, interested gastroenterologists can now be trained by becoming a member of the International Bowel Ultrasound Group (IBUS Group) and applying to the workshops now available. The IBUS Group has developed an IUS-specific training curriculum over the last 16 years, which is comprised of three modules: a 2-day hands-on workshop (Module 1) with final examination of theoretical competency, a preceptorship at an “expert center” with an experienced sonographer for a total of 4 weeks to complete 40 supervised IUS examinations (Module 2), and didactics and a final examination (Module 3). Also with support from Helmsley, the first Module 1 to be offered in the United States was hosted at Mount Sinai Medical Center in New York in 2022, the second was hosted at the University of Chicago in March 2023, and the third is planned to take place at Cedars-Sinai Medical Center in Los Angeles in March 2024.¹⁸ With the growing interest and demand for IUS training in the United States, U.S. experts are working to develop new training options that will be less time consuming, scalable, and still provide appropriate training and competency assessment.

University of Chicago

How do you integrate IUS into your practice?

The keys to integrating IUS are a section chief or practice manager’s support of a trainee or faculty member for both funding of equipment and protected time for training and building of the program, as well as a permissive environment and collegial relationship with radiology. An ultrasound machine and additional transducers may range in price from $50,000-$120,000. Funding may be a limiting step for many, however. A detailed business plan is imperative to the success and investment of funds in an IUS program. With current billing practices in place that include ”limited abdominal ultrasound” (76705) and “Doppler ultrasound of the abdomen” (93975),¹⁹ reimbursement should include a technical fee, professional fee, and if in a hospital-based clinic, a facility fee. IUS pro-fee combined with technical fee is reimbursed at approximately 0.80 relative value units. When possible, the facility fee is included for approximately $800 per IUS visit. For billing and compliance with HIPAA, all billed IUS images must be stored in a durable and accessible format. It is recommended that the images and cine loops be digitally stored to the same or similar platform used by radiologists at the same institution. This requires early communication with the local information technology department for the connection of an ultrasound machine to the storage platform and/or electronic health record. Reporting results should be standardized with unique or otherwise available IUS templates, which also satisfy all billing components.⁹ The flow for incorporation of IUS into practice can be at the same time patients are seen during their visit, or alternatively, in a dedicated IUS clinic in which patients are referred by other providers and scheduled back to back.

Conclusions

In summary, the confluence of treat-to-target strategies in IBD, new treatment options in IBD, and successful efforts to translate IUS training and billing practices to the United States portends a great future for the field and for our patients.

Dr. Cleveland and Dr. Rubin, of the University of Chicago’s Inflammatory Bowel Disease Center, are speakers for Samsung/Boston Imaging.

References

1. Turner D et al. Gastroenterology. Apr 2021;160(5):1570-83. doi: 10.1053/j.gastro.2020.12.031

2. Hart AL and Rubin DT. Gastroenterology. Apr 2022;162(5):1367-9. doi: 10.1053/j.gastro.2022.02.013

3. Rajagopalan A et al. JGH Open. Apr 2020;4(2):267-72. doi: 10.1002/jgh3.12268

4. Calabrese E et al. Clin Gastroenterol Hepatol. Apr 2022;20(4):e711-22. doi: 10.1016/j.cgh.2021.03.030

5. Ripolles T et al. Inflamm Bowel Dis. Oct 2016;22(10):2465-73. doi10.1097/MIB.0000000000000882

6. Maaser C et al. Gut. Sep 2020;69(9):1629-36. doi: 10.1136/gutjnl-2019-319451

7. Ilvemark J et al. J Crohns Colitis. Nov 23 2022;16(11):1725-34. doi: 10.1093/ecco-jcc/jjac083

8. Sagami S et al. Aliment Pharmacol Ther. Jun 2020;51(12):1373-83. doi: 10.1111/apt.15767

9. Dolinger MT et al. Guide to Intestinal Ultrasound Credentialing, Documentation, and Billing for Gastroenterologists in the United States. Am J Gastroenterol. 2023.

10. Maconi G et al. Ultraschall Med. Jun 2018;39(3):304-17. doi: 10.1055/s-0043-125329

11. Sasaki T et al. Scand J Gastroenterol. Mar 2014;49(3):295-301. doi: 10.3109/00365521.2013.871744

12. Limberg B. Z Gastroenterol. Jun 1999;37(6):495-508.

13. Miyoshi J et al. J Gastroenterol. Feb 2022;57(2):82-9. doi: 10.1007/s00535-021-01847-3

14. Chen YJ et al. Inflamm Bowel Dis. Sep 15 2018;24(10):2183-90. doi: 10.1093/ibd/izy115

15. Kucharzik T et al. Apr 2017;15(4):535-42e2. doi: 10.1016/j.cgh.2016.10.040

16. Sagami S et al. Aliment Pharmacol Ther. May 2022;55(10):1320-9. doi: 10.1111/apt.16817

17. Vaughan R et al. Aliment Pharmacol Ther. Jul 2022;56(1):84-94. doi: 10.1111/apt.16892

18. International Bowel Ultrasound Group. https://ibus-group.org/

19. American Medical Association. CPT (Current Procedural Terminology). https://www.ama-assn.org/amaone/cpt-current-procedural-terminology




 

Evolving endpoints and treat-to-target strategies in inflammatory bowel disease (IBD) incorporate a need for more frequent assessments of the disease, including objective measures of inflammation.^1,2 Intestinal ultrasound (IUS) is a noninvasive, well-tolerated,³ repeatable, point-of-care (POC) test that is highly sensitive and specific in detection of bowel inflammation, transmural healing,^4,5 and response to therapy in both Crohn’s disease (CD) and ulcerative colitis (UC).^6-8These unique features allow IUS to be an optimal tool for the current era of disease modification and tight disease control in IBD. As IUS is taking hold in the United States, there is a great need to teach the next generation of gastroenterologists about its value, how to incorporate it into clinical practice, and how to become appropriately trained and maintain competency.

Why incorporate IUS in the United States now?

Jordan Porter-Woodruff/University of Chicago

As IBD management has evolved, so has the appreciation for the value of bedside IUS as a tool that addresses very real needs for the field. Unlike other parts of the world in which ultrasound skills are part of the training curriculum, this has not been the case in internal medicine and gastroenterology training in the United States. In addition, there have been no specific billing codes or clear renumeration processes outlined for IUS,⁹ nor have there been any local training opportunities. Because of these challenges, it was not until recently that several leaders in IBD in the United States championed the potential of this technology and incorporated it into IBD management. Subsequently, a number of gastroenterologists have been trained and are now leading the effort to disseminate this tool throughout the United States. A consequence of these efforts resulted in support from the Helmsley Charitable Trust (Helmsley) and the creation of the Intestinal Ultrasound Group of the United States and Canada to address the gaps unique to North America as well as to strengthen the quality of IUS research through collaborations across the continent.

What is IUS, and when is it performed?

IUS is a sonographic exam performed by a gastroenterology-trained professional who scans the abdominal wall (and perineum when the rectum and perineal disease is evaluated), using both a convex low-frequency probe and linear high-frequency probe to evaluate the small intestine, colon, and rectum. The bowel is composed of five layers with alternating hyperechoic and hypoechoic layers: the mucosal-lumen interface (not a true part of the bowel wall), deep mucosa, submucosa, muscularis propria, and serosa. (Figure)

Dr. Noa Krugliak Cleveland

The most sensitive parameter for assessment of IBD activity is bowel wall thickness (≤ 3 mm in the small bowel and colon and ≤ 4 mm in the rectum are considered normal in adults).^8,10 The second key parameter is the assessment of vascularization, in which presence of hyperemia suggests active disease.¹¹ There are a number of indices to quantify hyperemia, with the most widely used being the Limberg score.¹² Additional parameters include assessment of loss of the delineation of the bowel wall layers (loss of stratification signifies active inflammation), increased thickness of the submucosa,¹³ increased mesenteric fatty proliferation (with increased inflammation, mesenteric fat proliferation will appear as a hyperechoic area surrounding the bowel), lymphadenopathy, bowel strictures, and extramural complications such as fistulae and abscess. Shear wave elastography may be an effective way to differentiate severe fibrotic strictures, but this is an area that requires more investigation.¹⁴

IUS has been shown to be an excellent tool in not only assessing disease activity and disease complication (with higher sensitivity than the Harvey-Bradshaw Index, serum C-reactive protein),¹⁵ but, unique to IUS, can provide early prediction of response in moderate to severe active UC.^6,7 This has also been shown with transperineal ultrasound in patients with UC, with the ability to predict response to therapy as early as 1 week from induction therapy.¹⁶ Furthermore, it can be used to assess transmural healing, which has been shown to be associated with improved outcomes in Crohn’s patient, such as lower rates of hospitalizations, surgery, medication escalation, and need for corticosteroids.¹⁷ IUS is associated with great patient satisfaction and greater understanding of disease-related symptoms when the patient sees the inflammation of the bowel. (Table)

How can you get trained in IUS?

Training in IUS varies across the globe, from incorporation of IUS into the standard training curriculum to available training programs that can be followed and attended outside of medical training. In the United States, interested gastroenterologists can now be trained by becoming a member of the International Bowel Ultrasound Group (IBUS Group) and applying to the workshops now available. The IBUS Group has developed an IUS-specific training curriculum over the last 16 years, which is comprised of three modules: a 2-day hands-on workshop (Module 1) with final examination of theoretical competency, a preceptorship at an “expert center” with an experienced sonographer for a total of 4 weeks to complete 40 supervised IUS examinations (Module 2), and didactics and a final examination (Module 3). Also with support from Helmsley, the first Module 1 to be offered in the United States was hosted at Mount Sinai Medical Center in New York in 2022, the second was hosted at the University of Chicago in March 2023, and the third is planned to take place at Cedars-Sinai Medical Center in Los Angeles in March 2024.¹⁸ With the growing interest and demand for IUS training in the United States, U.S. experts are working to develop new training options that will be less time consuming, scalable, and still provide appropriate training and competency assessment.

University of Chicago

How do you integrate IUS into your practice?

The keys to integrating IUS are a section chief or practice manager’s support of a trainee or faculty member for both funding of equipment and protected time for training and building of the program, as well as a permissive environment and collegial relationship with radiology. An ultrasound machine and additional transducers may range in price from $50,000-$120,000. Funding may be a limiting step for many, however. A detailed business plan is imperative to the success and investment of funds in an IUS program. With current billing practices in place that include ”limited abdominal ultrasound” (76705) and “Doppler ultrasound of the abdomen” (93975),¹⁹ reimbursement should include a technical fee, professional fee, and if in a hospital-based clinic, a facility fee. IUS pro-fee combined with technical fee is reimbursed at approximately 0.80 relative value units. When possible, the facility fee is included for approximately $800 per IUS visit. For billing and compliance with HIPAA, all billed IUS images must be stored in a durable and accessible format. It is recommended that the images and cine loops be digitally stored to the same or similar platform used by radiologists at the same institution. This requires early communication with the local information technology department for the connection of an ultrasound machine to the storage platform and/or electronic health record. Reporting results should be standardized with unique or otherwise available IUS templates, which also satisfy all billing components.⁹ The flow for incorporation of IUS into practice can be at the same time patients are seen during their visit, or alternatively, in a dedicated IUS clinic in which patients are referred by other providers and scheduled back to back.

Conclusions

In summary, the confluence of treat-to-target strategies in IBD, new treatment options in IBD, and successful efforts to translate IUS training and billing practices to the United States portends a great future for the field and for our patients.

Dr. Cleveland and Dr. Rubin, of the University of Chicago’s Inflammatory Bowel Disease Center, are speakers for Samsung/Boston Imaging.

References

1. Turner D et al. Gastroenterology. Apr 2021;160(5):1570-83. doi: 10.1053/j.gastro.2020.12.031

2. Hart AL and Rubin DT. Gastroenterology. Apr 2022;162(5):1367-9. doi: 10.1053/j.gastro.2022.02.013

3. Rajagopalan A et al. JGH Open. Apr 2020;4(2):267-72. doi: 10.1002/jgh3.12268

4. Calabrese E et al. Clin Gastroenterol Hepatol. Apr 2022;20(4):e711-22. doi: 10.1016/j.cgh.2021.03.030

5. Ripolles T et al. Inflamm Bowel Dis. Oct 2016;22(10):2465-73. doi10.1097/MIB.0000000000000882

6. Maaser C et al. Gut. Sep 2020;69(9):1629-36. doi: 10.1136/gutjnl-2019-319451

7. Ilvemark J et al. J Crohns Colitis. Nov 23 2022;16(11):1725-34. doi: 10.1093/ecco-jcc/jjac083

8. Sagami S et al. Aliment Pharmacol Ther. Jun 2020;51(12):1373-83. doi: 10.1111/apt.15767

9. Dolinger MT et al. Guide to Intestinal Ultrasound Credentialing, Documentation, and Billing for Gastroenterologists in the United States. Am J Gastroenterol. 2023.

10. Maconi G et al. Ultraschall Med. Jun 2018;39(3):304-17. doi: 10.1055/s-0043-125329

11. Sasaki T et al. Scand J Gastroenterol. Mar 2014;49(3):295-301. doi: 10.3109/00365521.2013.871744

12. Limberg B. Z Gastroenterol. Jun 1999;37(6):495-508.

13. Miyoshi J et al. J Gastroenterol. Feb 2022;57(2):82-9. doi: 10.1007/s00535-021-01847-3

14. Chen YJ et al. Inflamm Bowel Dis. Sep 15 2018;24(10):2183-90. doi: 10.1093/ibd/izy115

15. Kucharzik T et al. Apr 2017;15(4):535-42e2. doi: 10.1016/j.cgh.2016.10.040

16. Sagami S et al. Aliment Pharmacol Ther. May 2022;55(10):1320-9. doi: 10.1111/apt.16817

17. Vaughan R et al. Aliment Pharmacol Ther. Jul 2022;56(1):84-94. doi: 10.1111/apt.16892

18. International Bowel Ultrasound Group. https://ibus-group.org/

19. American Medical Association. CPT (Current Procedural Terminology). https://www.ama-assn.org/amaone/cpt-current-procedural-terminology




 

Evolving endpoints and treat-to-target strategies in inflammatory bowel disease (IBD) incorporate a need for more frequent assessments of the disease, including objective measures of inflammation.^1,2 Intestinal ultrasound (IUS) is a noninvasive, well-tolerated,³ repeatable, point-of-care (POC) test that is highly sensitive and specific in detection of bowel inflammation, transmural healing,^4,5 and response to therapy in both Crohn’s disease (CD) and ulcerative colitis (UC).^6-8These unique features allow IUS to be an optimal tool for the current era of disease modification and tight disease control in IBD. As IUS is taking hold in the United States, there is a great need to teach the next generation of gastroenterologists about its value, how to incorporate it into clinical practice, and how to become appropriately trained and maintain competency.

Why incorporate IUS in the United States now?

Jordan Porter-Woodruff/University of Chicago

As IBD management has evolved, so has the appreciation for the value of bedside IUS as a tool that addresses very real needs for the field. Unlike other parts of the world in which ultrasound skills are part of the training curriculum, this has not been the case in internal medicine and gastroenterology training in the United States. In addition, there have been no specific billing codes or clear renumeration processes outlined for IUS,⁹ nor have there been any local training opportunities. Because of these challenges, it was not until recently that several leaders in IBD in the United States championed the potential of this technology and incorporated it into IBD management. Subsequently, a number of gastroenterologists have been trained and are now leading the effort to disseminate this tool throughout the United States. A consequence of these efforts resulted in support from the Helmsley Charitable Trust (Helmsley) and the creation of the Intestinal Ultrasound Group of the United States and Canada to address the gaps unique to North America as well as to strengthen the quality of IUS research through collaborations across the continent.

What is IUS, and when is it performed?

IUS is a sonographic exam performed by a gastroenterology-trained professional who scans the abdominal wall (and perineum when the rectum and perineal disease is evaluated), using both a convex low-frequency probe and linear high-frequency probe to evaluate the small intestine, colon, and rectum. The bowel is composed of five layers with alternating hyperechoic and hypoechoic layers: the mucosal-lumen interface (not a true part of the bowel wall), deep mucosa, submucosa, muscularis propria, and serosa. (Figure)

Dr. Noa Krugliak Cleveland

The most sensitive parameter for assessment of IBD activity is bowel wall thickness (≤ 3 mm in the small bowel and colon and ≤ 4 mm in the rectum are considered normal in adults).^8,10 The second key parameter is the assessment of vascularization, in which presence of hyperemia suggests active disease.¹¹ There are a number of indices to quantify hyperemia, with the most widely used being the Limberg score.¹² Additional parameters include assessment of loss of the delineation of the bowel wall layers (loss of stratification signifies active inflammation), increased thickness of the submucosa,¹³ increased mesenteric fatty proliferation (with increased inflammation, mesenteric fat proliferation will appear as a hyperechoic area surrounding the bowel), lymphadenopathy, bowel strictures, and extramural complications such as fistulae and abscess. Shear wave elastography may be an effective way to differentiate severe fibrotic strictures, but this is an area that requires more investigation.¹⁴

IUS has been shown to be an excellent tool in not only assessing disease activity and disease complication (with higher sensitivity than the Harvey-Bradshaw Index, serum C-reactive protein),¹⁵ but, unique to IUS, can provide early prediction of response in moderate to severe active UC.^6,7 This has also been shown with transperineal ultrasound in patients with UC, with the ability to predict response to therapy as early as 1 week from induction therapy.¹⁶ Furthermore, it can be used to assess transmural healing, which has been shown to be associated with improved outcomes in Crohn’s patient, such as lower rates of hospitalizations, surgery, medication escalation, and need for corticosteroids.¹⁷ IUS is associated with great patient satisfaction and greater understanding of disease-related symptoms when the patient sees the inflammation of the bowel. (Table)

How can you get trained in IUS?

Training in IUS varies across the globe, from incorporation of IUS into the standard training curriculum to available training programs that can be followed and attended outside of medical training. In the United States, interested gastroenterologists can now be trained by becoming a member of the International Bowel Ultrasound Group (IBUS Group) and applying to the workshops now available. The IBUS Group has developed an IUS-specific training curriculum over the last 16 years, which is comprised of three modules: a 2-day hands-on workshop (Module 1) with final examination of theoretical competency, a preceptorship at an “expert center” with an experienced sonographer for a total of 4 weeks to complete 40 supervised IUS examinations (Module 2), and didactics and a final examination (Module 3). Also with support from Helmsley, the first Module 1 to be offered in the United States was hosted at Mount Sinai Medical Center in New York in 2022, the second was hosted at the University of Chicago in March 2023, and the third is planned to take place at Cedars-Sinai Medical Center in Los Angeles in March 2024.¹⁸ With the growing interest and demand for IUS training in the United States, U.S. experts are working to develop new training options that will be less time consuming, scalable, and still provide appropriate training and competency assessment.

University of Chicago

How do you integrate IUS into your practice?

The keys to integrating IUS are a section chief or practice manager’s support of a trainee or faculty member for both funding of equipment and protected time for training and building of the program, as well as a permissive environment and collegial relationship with radiology. An ultrasound machine and additional transducers may range in price from $50,000-$120,000. Funding may be a limiting step for many, however. A detailed business plan is imperative to the success and investment of funds in an IUS program. With current billing practices in place that include ”limited abdominal ultrasound” (76705) and “Doppler ultrasound of the abdomen” (93975),¹⁹ reimbursement should include a technical fee, professional fee, and if in a hospital-based clinic, a facility fee. IUS pro-fee combined with technical fee is reimbursed at approximately 0.80 relative value units. When possible, the facility fee is included for approximately $800 per IUS visit. For billing and compliance with HIPAA, all billed IUS images must be stored in a durable and accessible format. It is recommended that the images and cine loops be digitally stored to the same or similar platform used by radiologists at the same institution. This requires early communication with the local information technology department for the connection of an ultrasound machine to the storage platform and/or electronic health record. Reporting results should be standardized with unique or otherwise available IUS templates, which also satisfy all billing components.⁹ The flow for incorporation of IUS into practice can be at the same time patients are seen during their visit, or alternatively, in a dedicated IUS clinic in which patients are referred by other providers and scheduled back to back.

Conclusions

In summary, the confluence of treat-to-target strategies in IBD, new treatment options in IBD, and successful efforts to translate IUS training and billing practices to the United States portends a great future for the field and for our patients.

Dr. Cleveland and Dr. Rubin, of the University of Chicago’s Inflammatory Bowel Disease Center, are speakers for Samsung/Boston Imaging.

References

1. Turner D et al. Gastroenterology. Apr 2021;160(5):1570-83. doi: 10.1053/j.gastro.2020.12.031

2. Hart AL and Rubin DT. Gastroenterology. Apr 2022;162(5):1367-9. doi: 10.1053/j.gastro.2022.02.013

3. Rajagopalan A et al. JGH Open. Apr 2020;4(2):267-72. doi: 10.1002/jgh3.12268

4. Calabrese E et al. Clin Gastroenterol Hepatol. Apr 2022;20(4):e711-22. doi: 10.1016/j.cgh.2021.03.030

5. Ripolles T et al. Inflamm Bowel Dis. Oct 2016;22(10):2465-73. doi10.1097/MIB.0000000000000882

6. Maaser C et al. Gut. Sep 2020;69(9):1629-36. doi: 10.1136/gutjnl-2019-319451

7. Ilvemark J et al. J Crohns Colitis. Nov 23 2022;16(11):1725-34. doi: 10.1093/ecco-jcc/jjac083

8. Sagami S et al. Aliment Pharmacol Ther. Jun 2020;51(12):1373-83. doi: 10.1111/apt.15767

9. Dolinger MT et al. Guide to Intestinal Ultrasound Credentialing, Documentation, and Billing for Gastroenterologists in the United States. Am J Gastroenterol. 2023.

10. Maconi G et al. Ultraschall Med. Jun 2018;39(3):304-17. doi: 10.1055/s-0043-125329

11. Sasaki T et al. Scand J Gastroenterol. Mar 2014;49(3):295-301. doi: 10.3109/00365521.2013.871744

12. Limberg B. Z Gastroenterol. Jun 1999;37(6):495-508.

13. Miyoshi J et al. J Gastroenterol. Feb 2022;57(2):82-9. doi: 10.1007/s00535-021-01847-3

14. Chen YJ et al. Inflamm Bowel Dis. Sep 15 2018;24(10):2183-90. doi: 10.1093/ibd/izy115

15. Kucharzik T et al. Apr 2017;15(4):535-42e2. doi: 10.1016/j.cgh.2016.10.040

16. Sagami S et al. Aliment Pharmacol Ther. May 2022;55(10):1320-9. doi: 10.1111/apt.16817

17. Vaughan R et al. Aliment Pharmacol Ther. Jul 2022;56(1):84-94. doi: 10.1111/apt.16892

18. International Bowel Ultrasound Group. https://ibus-group.org/

19. American Medical Association. CPT (Current Procedural Terminology). https://www.ama-assn.org/amaone/cpt-current-procedural-terminology




 

Recruiting medical trainees is a major yearly step for all teaching hospitals in health care. The concept of interviewing residents and fellows virtually is not completely new and has been used in the past.¹ With the coronavirus disease-19 (COVID-19) epidemic, the Association of American Medical Colleges (AAMC) recommended in May 2020 that all interviews be conducted virtually to ensure safety and prevent spread of the disease.^2,3 Over the past few years, and with the gradual loosening of some restrictions, some programs have adopted a hybrid interview model for their recruitment plan, while others continue to use the virtual model exclusively.

In this paper, we share our personal experience with recruiting gastroenterology and hepatology fellows virtually, from the standpoint of the program director (Dr. Clark) and the associate program director (Dr. Dakhoul) of the fellowship program at the University of Florida in Gainesville. We have conducted our fellowship interviews for the academic year 2022-2023 completely virtually over multiple half-day sessions and fully matched all four positions. At the time of the interviews, we extended a general invitation to all candidates for an in-person visit for the purpose of touring the facilities and our community. Out of the 37 applicants interviewed, 2 made an in-person visit later.

After we concluded the interview season, we conducted a brief, anonymous survey to assess the overall experience of the interviewees with their virtual interviews. (See end of this article.) The survey contained a combination of single-choice questions and open-ended questions. The response rate was 35%. Most responders (92.3%) thought that they had a great understanding of the program from the information provided to them, and 84.6% were quite satisfied with their virtual interview experience. Regarding the likelihood of accepting the interview if it were offered in person, only one person answered that he/she would not have accepted the invitation. A total of 31% of participants might have changed the ranking of the program if they’d had an in-person interview instead.

When asked to choose between an invitation for an in-person vs. a virtual interview, the majority (77%) chose the virtual option. The stated pros of being interviewed virtually included convenience (not having to find coverage, etc.), time and cost savings, and a less stressful experience. Cons were focused mostly on not being able to see the hospital or the geographical area in person, as well as limited exposure to the facility and work environment for subjective assessment of “fitting” into the program. Additional comments included mostly positive feedback about the whole experience specific to the program. Finally, 77% of respondents recommended that the program should continue to conduct its interviews virtually.

It seems that the general feedback from our survey was positive. Certainly, limitations exist, including but not limited to the response rate, the geographic locations of the invited candidates, the design of the interview day, and familiarity with the fellowship program and the surrounding area. Several studies have been published on the topic with variable results across centers and among specialties, but most of them reported an encouraging overall experience.^4-9

Furthermore, the number of candidates who applied to our program has been steadily on the rise since the virtual platform was introduced. This has been the case nationwide and in other specialties as well.¹¹ Applicants invited for an interview rarely decline or cancel the invitation due to the convenience of the virtual setting.⁶ These factors can affect the choice of candidates and subsequently the results of the match, especially for smaller programs. These observations create a new dilemma of whether fellowship programs need to consider increasing the number of their interviewees to ascertain a full match. Although the number of gastroenterology fellowship positions is steadily increasing with new program openings every year, it might not match the speed of the up-trending number of applicants. This certainly creates concern for fairness and equity in the selection process in this very competitive subspecialty.

As most gastroenterology programs continue to recruit their fellows virtually, it is important to keep in mind a few key elements to enhance the virtual experience. These include: a) familiarity of the interviewers and interviewees with video conference software to avoid technical problems, b) inclusion of up-to-date information about the program on the institutional website as well as videos or live-stream tours to show the physical aspect of the training sites (mainly the endoscopy areas) as alternatives to in-person tours,¹² and c) timing of the interview, taking into consideration the different time zones of the invited applicants. Despite optimizing the virtual experience, some interviewees might still choose to visit in person. While this decision is solely voluntary and remains optional (at least in our program), it does allow program directors to indirectly evaluate candidates with a strong interest in the program.

In conclusion, there is no clear-cut answer to whether conducting interviews virtually is the best way to continue to recruit gastroenterology and hepatology fellows beyond the pandemic. While our perspective might be somewhat biased by the positive experience we had in the past few years recruiting our fellows virtually, this should be an individualized decision for every program. It is highly dependent on the location and size of each fellowship program, faculty engagement in the interview process, and the historical matching rates of the program. On a positive note, the individualized approach by each fellowship program should highlight the best features of the program and have a positive impact on recruitment at the local level. We have to bear in mind that a nonstandardized approach to fellow recruitment may have disadvantages to both programs and applicants with fewer resources to successfully compete and may introduce another element of uncertainty to an already stressful process for applicants and programs alike. As we continue to understand the implications of using the virtual platform and to reflect on the previous match results through the performance and satisfaction of the fellows recruited virtually, this option does not seem to have completely replaced in-person meetings. Further follow-up to evaluate the impact of virtual interviews should be done by surveying program directors nationally on the impact of match results before and after implementation of virtual interviews.
 

Survey

A. Do you think you had a good understanding of the UF GI Fellowship program from the information provided to you during your virtual interview?

1. I was provided with all the information I needed to know, and I had a great understanding of the program

2. I was provided with some information, and I had a fair understanding of the program

3. I was not provided with enough information, and I don’t think I understand the program well



B. How likely were you to accept this interview if this had been an in-person interview?

1. I would have still accepted the invitation regardless

2. I would have thought about possibly not accepting the invitation

3. I wouldn’t have accepted the invitation



C. Do you think an in-person interview would have changed your program ranking?

1. Yes

2. Maybe, I am not sure

3. No



D. If you had a choice between conducting this interview virtually vs. in-person, which one would you have chosen?

1. Virtual

2. In-person



E. Overall, how satisfied were you with your virtual GI Fellowship interview experience at UF?

1. Quite satisfied

2. Somewhat satisfied

3. Not at all satisfied



F. If you chose “somewhat satisfied” or “not at all satisfied” in the previous question, please tell us why, and what are the things that we could have done better:G. Do you think the UF GI Fellowship program should continue to conduct its interviews virtually (regardless of COVID)?

1. Yes

2. No



H. Please list some of the pros and cons of being interviewed virtually, in your opinion:
 

I. Additional comments:
 

Dr. Dakhoul, Ms. Rhoden, and Dr. Clark are with the division of gastroenterology and hepatology, University of Florida, Gainesville. They have no disclosures or conflicts.

References

1. Shah SK et al. Randomized evaluation of a web based interview process for urology resident selection. J Urol. Apr 2012;187(4):1380-4.

2. AAMC Interview Guidance for the 2022-2023 Residency Cycle. May 16, 2022.

3. Bernstein SA et al. Graduate medical education virtual interviews and recruitment in the era of COVID-19. J Grad Med Educ. Oct 2020;12(5):557-60.

4. Gupta S et al. Is the changing landscape of fellowship recruitment during COVID-19 here to stay? J Pediatr Surg. Oct 2022;57(10):445-50.

5. Vining CC et al. Virtual surgical fellowship recruitment during COVID-19 and its implications for resident/fellow recruitment in the future. Ann Surg Oncol. 2020 Dec;27(Suppl 3):911-15.

6. Simmons RP et al. Virtual Recruitment: Experiences and Perspectives of Internal Medicine Program Directors. Am J Med. Feb 2022;135(2):258-63.e251.

7. Daram SR et al. Interview from anywhere: Feasibility and utility of web-based videoconference interviews in the gastroenterology fellowship selection process. Am J Gastroenterol. Feb 2014;109(2):155-9.

8. Ponterio JM et al. The virtual interview format for fellowship recruitment in obstetrics and gynecology: A nationwide survey of program directors. Med Educ Online. Dec 2022;27(1):2054304.

9. DiGiusto M et al. Impact of the COVID-19 pandemic on the 2020 pediatric anesthesiology fellowship application cycle: A survey of program directors. Paediatr Anaesth. Mar 2022;32(3):471-8.

10. Hamade N et al. Virtual Gastroenterology Fellowship Recruitment During COVID-19 and Its Implications for the Future. Dig Dis Sci. Jun 2022;67(6):2019-28.

11. AAMC: ERAS Statistics. Historical Specialty Specific Data.

12. Advani R et al. An Overview of the GI Fellowship Interview: Part II-Tips for Selection Committees and Interviewers. Dig Dis Sci. May 2022;67(5):1712-17.

Recruiting medical trainees is a major yearly step for all teaching hospitals in health care. The concept of interviewing residents and fellows virtually is not completely new and has been used in the past.¹ With the coronavirus disease-19 (COVID-19) epidemic, the Association of American Medical Colleges (AAMC) recommended in May 2020 that all interviews be conducted virtually to ensure safety and prevent spread of the disease.^2,3 Over the past few years, and with the gradual loosening of some restrictions, some programs have adopted a hybrid interview model for their recruitment plan, while others continue to use the virtual model exclusively.

In this paper, we share our personal experience with recruiting gastroenterology and hepatology fellows virtually, from the standpoint of the program director (Dr. Clark) and the associate program director (Dr. Dakhoul) of the fellowship program at the University of Florida in Gainesville. We have conducted our fellowship interviews for the academic year 2022-2023 completely virtually over multiple half-day sessions and fully matched all four positions. At the time of the interviews, we extended a general invitation to all candidates for an in-person visit for the purpose of touring the facilities and our community. Out of the 37 applicants interviewed, 2 made an in-person visit later.

After we concluded the interview season, we conducted a brief, anonymous survey to assess the overall experience of the interviewees with their virtual interviews. (See end of this article.) The survey contained a combination of single-choice questions and open-ended questions. The response rate was 35%. Most responders (92.3%) thought that they had a great understanding of the program from the information provided to them, and 84.6% were quite satisfied with their virtual interview experience. Regarding the likelihood of accepting the interview if it were offered in person, only one person answered that he/she would not have accepted the invitation. A total of 31% of participants might have changed the ranking of the program if they’d had an in-person interview instead.

When asked to choose between an invitation for an in-person vs. a virtual interview, the majority (77%) chose the virtual option. The stated pros of being interviewed virtually included convenience (not having to find coverage, etc.), time and cost savings, and a less stressful experience. Cons were focused mostly on not being able to see the hospital or the geographical area in person, as well as limited exposure to the facility and work environment for subjective assessment of “fitting” into the program. Additional comments included mostly positive feedback about the whole experience specific to the program. Finally, 77% of respondents recommended that the program should continue to conduct its interviews virtually.

It seems that the general feedback from our survey was positive. Certainly, limitations exist, including but not limited to the response rate, the geographic locations of the invited candidates, the design of the interview day, and familiarity with the fellowship program and the surrounding area. Several studies have been published on the topic with variable results across centers and among specialties, but most of them reported an encouraging overall experience.^4-9

Furthermore, the number of candidates who applied to our program has been steadily on the rise since the virtual platform was introduced. This has been the case nationwide and in other specialties as well.¹¹ Applicants invited for an interview rarely decline or cancel the invitation due to the convenience of the virtual setting.⁶ These factors can affect the choice of candidates and subsequently the results of the match, especially for smaller programs. These observations create a new dilemma of whether fellowship programs need to consider increasing the number of their interviewees to ascertain a full match. Although the number of gastroenterology fellowship positions is steadily increasing with new program openings every year, it might not match the speed of the up-trending number of applicants. This certainly creates concern for fairness and equity in the selection process in this very competitive subspecialty.

As most gastroenterology programs continue to recruit their fellows virtually, it is important to keep in mind a few key elements to enhance the virtual experience. These include: a) familiarity of the interviewers and interviewees with video conference software to avoid technical problems, b) inclusion of up-to-date information about the program on the institutional website as well as videos or live-stream tours to show the physical aspect of the training sites (mainly the endoscopy areas) as alternatives to in-person tours,¹² and c) timing of the interview, taking into consideration the different time zones of the invited applicants. Despite optimizing the virtual experience, some interviewees might still choose to visit in person. While this decision is solely voluntary and remains optional (at least in our program), it does allow program directors to indirectly evaluate candidates with a strong interest in the program.

In conclusion, there is no clear-cut answer to whether conducting interviews virtually is the best way to continue to recruit gastroenterology and hepatology fellows beyond the pandemic. While our perspective might be somewhat biased by the positive experience we had in the past few years recruiting our fellows virtually, this should be an individualized decision for every program. It is highly dependent on the location and size of each fellowship program, faculty engagement in the interview process, and the historical matching rates of the program. On a positive note, the individualized approach by each fellowship program should highlight the best features of the program and have a positive impact on recruitment at the local level. We have to bear in mind that a nonstandardized approach to fellow recruitment may have disadvantages to both programs and applicants with fewer resources to successfully compete and may introduce another element of uncertainty to an already stressful process for applicants and programs alike. As we continue to understand the implications of using the virtual platform and to reflect on the previous match results through the performance and satisfaction of the fellows recruited virtually, this option does not seem to have completely replaced in-person meetings. Further follow-up to evaluate the impact of virtual interviews should be done by surveying program directors nationally on the impact of match results before and after implementation of virtual interviews.
 

Survey

A. Do you think you had a good understanding of the UF GI Fellowship program from the information provided to you during your virtual interview?

1. I was provided with all the information I needed to know, and I had a great understanding of the program

2. I was provided with some information, and I had a fair understanding of the program

3. I was not provided with enough information, and I don’t think I understand the program well



B. How likely were you to accept this interview if this had been an in-person interview?

1. I would have still accepted the invitation regardless

2. I would have thought about possibly not accepting the invitation

3. I wouldn’t have accepted the invitation



C. Do you think an in-person interview would have changed your program ranking?

1. Yes

2. Maybe, I am not sure

3. No



D. If you had a choice between conducting this interview virtually vs. in-person, which one would you have chosen?

1. Virtual

2. In-person



E. Overall, how satisfied were you with your virtual GI Fellowship interview experience at UF?

1. Quite satisfied

2. Somewhat satisfied

3. Not at all satisfied



F. If you chose “somewhat satisfied” or “not at all satisfied” in the previous question, please tell us why, and what are the things that we could have done better:G. Do you think the UF GI Fellowship program should continue to conduct its interviews virtually (regardless of COVID)?

1. Yes

2. No



H. Please list some of the pros and cons of being interviewed virtually, in your opinion:
 

I. Additional comments:
 

Dr. Dakhoul, Ms. Rhoden, and Dr. Clark are with the division of gastroenterology and hepatology, University of Florida, Gainesville. They have no disclosures or conflicts.

References

1. Shah SK et al. Randomized evaluation of a web based interview process for urology resident selection. J Urol. Apr 2012;187(4):1380-4.

2. AAMC Interview Guidance for the 2022-2023 Residency Cycle. May 16, 2022.

3. Bernstein SA et al. Graduate medical education virtual interviews and recruitment in the era of COVID-19. J Grad Med Educ. Oct 2020;12(5):557-60.

4. Gupta S et al. Is the changing landscape of fellowship recruitment during COVID-19 here to stay? J Pediatr Surg. Oct 2022;57(10):445-50.

5. Vining CC et al. Virtual surgical fellowship recruitment during COVID-19 and its implications for resident/fellow recruitment in the future. Ann Surg Oncol. 2020 Dec;27(Suppl 3):911-15.

6. Simmons RP et al. Virtual Recruitment: Experiences and Perspectives of Internal Medicine Program Directors. Am J Med. Feb 2022;135(2):258-63.e251.

7. Daram SR et al. Interview from anywhere: Feasibility and utility of web-based videoconference interviews in the gastroenterology fellowship selection process. Am J Gastroenterol. Feb 2014;109(2):155-9.

8. Ponterio JM et al. The virtual interview format for fellowship recruitment in obstetrics and gynecology: A nationwide survey of program directors. Med Educ Online. Dec 2022;27(1):2054304.

9. DiGiusto M et al. Impact of the COVID-19 pandemic on the 2020 pediatric anesthesiology fellowship application cycle: A survey of program directors. Paediatr Anaesth. Mar 2022;32(3):471-8.

10. Hamade N et al. Virtual Gastroenterology Fellowship Recruitment During COVID-19 and Its Implications for the Future. Dig Dis Sci. Jun 2022;67(6):2019-28.

11. AAMC: ERAS Statistics. Historical Specialty Specific Data.

12. Advani R et al. An Overview of the GI Fellowship Interview: Part II-Tips for Selection Committees and Interviewers. Dig Dis Sci. May 2022;67(5):1712-17.

Recruiting medical trainees is a major yearly step for all teaching hospitals in health care. The concept of interviewing residents and fellows virtually is not completely new and has been used in the past.¹ With the coronavirus disease-19 (COVID-19) epidemic, the Association of American Medical Colleges (AAMC) recommended in May 2020 that all interviews be conducted virtually to ensure safety and prevent spread of the disease.^2,3 Over the past few years, and with the gradual loosening of some restrictions, some programs have adopted a hybrid interview model for their recruitment plan, while others continue to use the virtual model exclusively.

In this paper, we share our personal experience with recruiting gastroenterology and hepatology fellows virtually, from the standpoint of the program director (Dr. Clark) and the associate program director (Dr. Dakhoul) of the fellowship program at the University of Florida in Gainesville. We have conducted our fellowship interviews for the academic year 2022-2023 completely virtually over multiple half-day sessions and fully matched all four positions. At the time of the interviews, we extended a general invitation to all candidates for an in-person visit for the purpose of touring the facilities and our community. Out of the 37 applicants interviewed, 2 made an in-person visit later.

After we concluded the interview season, we conducted a brief, anonymous survey to assess the overall experience of the interviewees with their virtual interviews. (See end of this article.) The survey contained a combination of single-choice questions and open-ended questions. The response rate was 35%. Most responders (92.3%) thought that they had a great understanding of the program from the information provided to them, and 84.6% were quite satisfied with their virtual interview experience. Regarding the likelihood of accepting the interview if it were offered in person, only one person answered that he/she would not have accepted the invitation. A total of 31% of participants might have changed the ranking of the program if they’d had an in-person interview instead.

When asked to choose between an invitation for an in-person vs. a virtual interview, the majority (77%) chose the virtual option. The stated pros of being interviewed virtually included convenience (not having to find coverage, etc.), time and cost savings, and a less stressful experience. Cons were focused mostly on not being able to see the hospital or the geographical area in person, as well as limited exposure to the facility and work environment for subjective assessment of “fitting” into the program. Additional comments included mostly positive feedback about the whole experience specific to the program. Finally, 77% of respondents recommended that the program should continue to conduct its interviews virtually.

It seems that the general feedback from our survey was positive. Certainly, limitations exist, including but not limited to the response rate, the geographic locations of the invited candidates, the design of the interview day, and familiarity with the fellowship program and the surrounding area. Several studies have been published on the topic with variable results across centers and among specialties, but most of them reported an encouraging overall experience.^4-9

Furthermore, the number of candidates who applied to our program has been steadily on the rise since the virtual platform was introduced. This has been the case nationwide and in other specialties as well.¹¹ Applicants invited for an interview rarely decline or cancel the invitation due to the convenience of the virtual setting.⁶ These factors can affect the choice of candidates and subsequently the results of the match, especially for smaller programs. These observations create a new dilemma of whether fellowship programs need to consider increasing the number of their interviewees to ascertain a full match. Although the number of gastroenterology fellowship positions is steadily increasing with new program openings every year, it might not match the speed of the up-trending number of applicants. This certainly creates concern for fairness and equity in the selection process in this very competitive subspecialty.

As most gastroenterology programs continue to recruit their fellows virtually, it is important to keep in mind a few key elements to enhance the virtual experience. These include: a) familiarity of the interviewers and interviewees with video conference software to avoid technical problems, b) inclusion of up-to-date information about the program on the institutional website as well as videos or live-stream tours to show the physical aspect of the training sites (mainly the endoscopy areas) as alternatives to in-person tours,¹² and c) timing of the interview, taking into consideration the different time zones of the invited applicants. Despite optimizing the virtual experience, some interviewees might still choose to visit in person. While this decision is solely voluntary and remains optional (at least in our program), it does allow program directors to indirectly evaluate candidates with a strong interest in the program.

In conclusion, there is no clear-cut answer to whether conducting interviews virtually is the best way to continue to recruit gastroenterology and hepatology fellows beyond the pandemic. While our perspective might be somewhat biased by the positive experience we had in the past few years recruiting our fellows virtually, this should be an individualized decision for every program. It is highly dependent on the location and size of each fellowship program, faculty engagement in the interview process, and the historical matching rates of the program. On a positive note, the individualized approach by each fellowship program should highlight the best features of the program and have a positive impact on recruitment at the local level. We have to bear in mind that a nonstandardized approach to fellow recruitment may have disadvantages to both programs and applicants with fewer resources to successfully compete and may introduce another element of uncertainty to an already stressful process for applicants and programs alike. As we continue to understand the implications of using the virtual platform and to reflect on the previous match results through the performance and satisfaction of the fellows recruited virtually, this option does not seem to have completely replaced in-person meetings. Further follow-up to evaluate the impact of virtual interviews should be done by surveying program directors nationally on the impact of match results before and after implementation of virtual interviews.
 

Survey

A. Do you think you had a good understanding of the UF GI Fellowship program from the information provided to you during your virtual interview?

1. I was provided with all the information I needed to know, and I had a great understanding of the program

2. I was provided with some information, and I had a fair understanding of the program

3. I was not provided with enough information, and I don’t think I understand the program well



B. How likely were you to accept this interview if this had been an in-person interview?

1. I would have still accepted the invitation regardless

2. I would have thought about possibly not accepting the invitation

3. I wouldn’t have accepted the invitation



C. Do you think an in-person interview would have changed your program ranking?

1. Yes

2. Maybe, I am not sure

3. No



D. If you had a choice between conducting this interview virtually vs. in-person, which one would you have chosen?

1. Virtual

2. In-person



E. Overall, how satisfied were you with your virtual GI Fellowship interview experience at UF?

1. Quite satisfied

2. Somewhat satisfied

3. Not at all satisfied



F. If you chose “somewhat satisfied” or “not at all satisfied” in the previous question, please tell us why, and what are the things that we could have done better:G. Do you think the UF GI Fellowship program should continue to conduct its interviews virtually (regardless of COVID)?

1. Yes

2. No



H. Please list some of the pros and cons of being interviewed virtually, in your opinion:
 

I. Additional comments:
 

Dr. Dakhoul, Ms. Rhoden, and Dr. Clark are with the division of gastroenterology and hepatology, University of Florida, Gainesville. They have no disclosures or conflicts.

References

1. Shah SK et al. Randomized evaluation of a web based interview process for urology resident selection. J Urol. Apr 2012;187(4):1380-4.

2. AAMC Interview Guidance for the 2022-2023 Residency Cycle. May 16, 2022.

3. Bernstein SA et al. Graduate medical education virtual interviews and recruitment in the era of COVID-19. J Grad Med Educ. Oct 2020;12(5):557-60.

4. Gupta S et al. Is the changing landscape of fellowship recruitment during COVID-19 here to stay? J Pediatr Surg. Oct 2022;57(10):445-50.

5. Vining CC et al. Virtual surgical fellowship recruitment during COVID-19 and its implications for resident/fellow recruitment in the future. Ann Surg Oncol. 2020 Dec;27(Suppl 3):911-15.

6. Simmons RP et al. Virtual Recruitment: Experiences and Perspectives of Internal Medicine Program Directors. Am J Med. Feb 2022;135(2):258-63.e251.

7. Daram SR et al. Interview from anywhere: Feasibility and utility of web-based videoconference interviews in the gastroenterology fellowship selection process. Am J Gastroenterol. Feb 2014;109(2):155-9.

8. Ponterio JM et al. The virtual interview format for fellowship recruitment in obstetrics and gynecology: A nationwide survey of program directors. Med Educ Online. Dec 2022;27(1):2054304.

9. DiGiusto M et al. Impact of the COVID-19 pandemic on the 2020 pediatric anesthesiology fellowship application cycle: A survey of program directors. Paediatr Anaesth. Mar 2022;32(3):471-8.

10. Hamade N et al. Virtual Gastroenterology Fellowship Recruitment During COVID-19 and Its Implications for the Future. Dig Dis Sci. Jun 2022;67(6):2019-28.

11. AAMC: ERAS Statistics. Historical Specialty Specific Data.

12. Advani R et al. An Overview of the GI Fellowship Interview: Part II-Tips for Selection Committees and Interviewers. Dig Dis Sci. May 2022;67(5):1712-17.

Dear friends,

Since the last issue of The New Gastroenterologist, the GI Fellowship Match has occurred and CONGRATULATIONS to the Class of 2026! You’ve all been on an arduous journey to get here, and it’s really time to slow down and soak up as much as you can. For those who did not match, do not give up, because you are still the future of GI!

This issue of TNG is particularly special to me, because it marks my first official selection of articles as I embark on my own TNG journey, and the theme is the future of GI. In the “In Focus” article this quarter, Dr. Eugenia N. Uche-Anya and Dr. Tyler M. Berzin review the vast and emerging advances of artificial intelligence (AI) in colonoscopy, its role in augmenting patient care, obstacles in incorporating AI into current practice, and the future of AI in gastroenterology and hepatology. One important aspect of developing our future in these technologies includes getting involved with industry. Dr. Raman Muthusamy gives practical tips on developing and navigating relationships with industry, with highlights on understanding intellectual property and conflicts of interest.

Continuing our trek into the future of GI, telemedicine came into the fold with the COVID-19 pandemic, and it is clearly here to stay. Dr. Russ R. Arjal repositions telemedicine as a way to increase access to care and optimize practice revenue, with the aim of improving patient outcomes in the future.

Last, to ground this issue clinically, Dr. Jason Kwon and Dr. Paul T. Kroner review the gastrointestinal, hepatic, and pancreaticobiliary adverse manifestations and management of immune checkpoint inhibitors, especially now that immunotherapies have revolutionized the treatment of cancer. As gastroenterologists, we are and will be seeing more and more of these adverse events.

If you are interested in contributing or have ideas for future TNG topics, please contact me ([email protected]). You may also contact Jillian Schweitzer ([email protected]), managing editor of TNG.

Until next time, I leave you with a historical fun fact: Philipp Bozzini is credited with having developed the first endoscope in 1805, called the Lichtleiter (German for “light conductor”), using a candle as its light source. Adolf Kussmaul, however, developed the first rigid gastroscope in 1868, recruiting a sword-swallower in his first demonstration.


Yours truly,

Judy A. Trieu, MD, MPH
Editor-in-Chief
Advanced Endoscopy Fellow
Division of Gastroenterology & Hepatology
University of North Carolina at Chapel Hill

Dear friends,

Since the last issue of The New Gastroenterologist, the GI Fellowship Match has occurred and CONGRATULATIONS to the Class of 2026! You’ve all been on an arduous journey to get here, and it’s really time to slow down and soak up as much as you can. For those who did not match, do not give up, because you are still the future of GI!

This issue of TNG is particularly special to me, because it marks my first official selection of articles as I embark on my own TNG journey, and the theme is the future of GI. In the “In Focus” article this quarter, Dr. Eugenia N. Uche-Anya and Dr. Tyler M. Berzin review the vast and emerging advances of artificial intelligence (AI) in colonoscopy, its role in augmenting patient care, obstacles in incorporating AI into current practice, and the future of AI in gastroenterology and hepatology. One important aspect of developing our future in these technologies includes getting involved with industry. Dr. Raman Muthusamy gives practical tips on developing and navigating relationships with industry, with highlights on understanding intellectual property and conflicts of interest.

Continuing our trek into the future of GI, telemedicine came into the fold with the COVID-19 pandemic, and it is clearly here to stay. Dr. Russ R. Arjal repositions telemedicine as a way to increase access to care and optimize practice revenue, with the aim of improving patient outcomes in the future.

Last, to ground this issue clinically, Dr. Jason Kwon and Dr. Paul T. Kroner review the gastrointestinal, hepatic, and pancreaticobiliary adverse manifestations and management of immune checkpoint inhibitors, especially now that immunotherapies have revolutionized the treatment of cancer. As gastroenterologists, we are and will be seeing more and more of these adverse events.

If you are interested in contributing or have ideas for future TNG topics, please contact me ([email protected]). You may also contact Jillian Schweitzer ([email protected]), managing editor of TNG.

Until next time, I leave you with a historical fun fact: Philipp Bozzini is credited with having developed the first endoscope in 1805, called the Lichtleiter (German for “light conductor”), using a candle as its light source. Adolf Kussmaul, however, developed the first rigid gastroscope in 1868, recruiting a sword-swallower in his first demonstration.


Yours truly,

Judy A. Trieu, MD, MPH
Editor-in-Chief
Advanced Endoscopy Fellow
Division of Gastroenterology & Hepatology
University of North Carolina at Chapel Hill

Dear friends,

Since the last issue of The New Gastroenterologist, the GI Fellowship Match has occurred and CONGRATULATIONS to the Class of 2026! You’ve all been on an arduous journey to get here, and it’s really time to slow down and soak up as much as you can. For those who did not match, do not give up, because you are still the future of GI!

This issue of TNG is particularly special to me, because it marks my first official selection of articles as I embark on my own TNG journey, and the theme is the future of GI. In the “In Focus” article this quarter, Dr. Eugenia N. Uche-Anya and Dr. Tyler M. Berzin review the vast and emerging advances of artificial intelligence (AI) in colonoscopy, its role in augmenting patient care, obstacles in incorporating AI into current practice, and the future of AI in gastroenterology and hepatology. One important aspect of developing our future in these technologies includes getting involved with industry. Dr. Raman Muthusamy gives practical tips on developing and navigating relationships with industry, with highlights on understanding intellectual property and conflicts of interest.

Continuing our trek into the future of GI, telemedicine came into the fold with the COVID-19 pandemic, and it is clearly here to stay. Dr. Russ R. Arjal repositions telemedicine as a way to increase access to care and optimize practice revenue, with the aim of improving patient outcomes in the future.

Last, to ground this issue clinically, Dr. Jason Kwon and Dr. Paul T. Kroner review the gastrointestinal, hepatic, and pancreaticobiliary adverse manifestations and management of immune checkpoint inhibitors, especially now that immunotherapies have revolutionized the treatment of cancer. As gastroenterologists, we are and will be seeing more and more of these adverse events.

If you are interested in contributing or have ideas for future TNG topics, please contact me ([email protected]). You may also contact Jillian Schweitzer ([email protected]), managing editor of TNG.

Until next time, I leave you with a historical fun fact: Philipp Bozzini is credited with having developed the first endoscope in 1805, called the Lichtleiter (German for “light conductor”), using a candle as its light source. Adolf Kussmaul, however, developed the first rigid gastroscope in 1868, recruiting a sword-swallower in his first demonstration.


Yours truly,

Judy A. Trieu, MD, MPH
Editor-in-Chief
Advanced Endoscopy Fellow
Division of Gastroenterology & Hepatology
University of North Carolina at Chapel Hill

Introduction

The professional activity of physicians has traditionally consisted of patient care, teaching/education, and research in varying proportions. These aims, especially education and research, have traditionally been achieved in academic health settings. However, involvement with industry can afford all physicians an opportunity to increase patient referrals, gain exposure to colleagues through a variety of educational opportunities, and participate in meaningful research projects they could not initiate independently. This article will discuss a variety of ways that gastroenterologists can engage with industry to achieve a mutually beneficial relationship.

How to initiate relationships with industry

Here are several ways to initiate a collaboration with industry. A few of the most common ways are to become a site investigator of a multicenter device or pharmaceutical trial, participate as a member of a speaker’s bureau, or obtain training on a new technology and subsequently incorporate it into your clinical practice. To find out what trials are enrolling and looking for additional sites or new studies that are being planned, I would suggest contacting the company’s local representative and have them put you in touch the appropriate personnel in the clinical trials division. For individuals who become involved in trials, this can be a great way to improve your understanding of how to design and conduct clinical trials as well as gain exposure to colleagues with similar clinical and research interests. Some of my closest long-term collaborators and friends have been individuals who I initially met as part of industry trials at investigator meetings. Another approach is to participate in a speaker’s bureau, which can be an excellent way to improve one’s presentation skills as well as gain knowledge with respect to a specific disease state. It is also a great way to network, meet colleagues, and develop a local and regional reputation as a content expert on a specific topic. Methods to find out about such opportunities include touring the exhibit halls during educational meetings and reading scientific journals to identify new products that are launching. I have found these sorts of opportunities can significantly increase topic-based referrals. Finally, obtaining training on a new diagnostic or therapeutic technology (usually through an industry-sponsored course) can allow individuals an opportunity to offer a unique or distinctive service to their community. In addition, as further clinical expertise is gained, the relationship can be expanded to offer local, regional, or even national training courses to colleagues via either on-site or virtual courses. Similarly, opportunities to speak about or demonstrate the technology/technique at educational courses may also follow.

Navigating and expanding the relationship

Once an individual establishes a relationship with a company or has established a reputation as a key opinion leader, additional opportunities for engagement may become available. These include serving as a consultant, becoming a member of an advisory board, participating or directing educational courses for trainees/practitioners, or serving as the principal investigator of a future clinical trial. Serving as a consultant can be quite rewarding as it can highlight clinical needs, identify where product improvement can be achieved, and focus where research and development funds should be directed. Serving on the advisory board can afford an even higher level of influence where corporate strategy can be influenced. Such input is particularly impactful with smaller companies looking to enter a new field or expand a limited market share. There are also a variety of educational opportunities offered by industry including local, regional, and national courses that focus on utilizing a new technology or education concerning a specific disease state. These courses can be held locally at the physician’s clinical site or off site to attract the desired target audience. Finally, being involved in research studies, especially early-stage projects, can be critical as many small companies have limited capital, and it is essential for them to design studies with appropriate endpoints that will ideally achieve both regulatory approval as well as payor coverage. Of note, in addition to relationships directly involving industry, the American Gastroenterological Association Center for GI Innovation and Technology (CGIT) also offers the opportunity to be part of key opinion leader meetings arranged and organized by the AGA. This may allow for some individuals to participate who may be restricted from direct relationships with industry partners. The industry services offered by the CGIT also include clinical trial design and registry management services.

Entrepreneurship/intellectual property

A less commonly explored opportunity with industry involves the development of one’s own intellectual property. Some of the most impactful technologies in my advanced endoscopy clinical practice have been developed from the ideas of gastroenterology colleagues that have been successfully commercialized. These include radiofrequency ablation technology to treat Barrett’s esophagus and the development of lumen-apposing stents. There are several options for physicians with an idea for an innovation. These can include working with a university technology transfer department if they are in an academic setting, creation of their own company, or collaborating with industry to develop the device through a licensing/royalty agreement. The AGA CGIT offers extensive resources to physicians with new ideas on how to secure their intellectual property as well as to evaluate the feasibility of the aforementioned options to choose which may be most appropriate for them.

Important caveats

It is important that physicians with industry relations be aware of their local institutional policies. Some institutions may prohibit such activities while others may limit the types of relationships or the amount of income that can be received. It is the physician’s responsibility to be aware of their institution’s guidelines prior to formalizing industry agreements. If intellectual property is involved, it is essential to know the specific rules regarding physician remuneration, especially pertaining to royalty or equity agreements. Furthermore, with regard to presentations and publications, it is required to acknowledge industry relations and potential conflicts of interest. Failure to do so may adversely affect an individual’s reputation as well as lead to additional consequences such as the potential for retraction of publications or restrictions regarding future educational speaking opportunities. In addition, key opinion leaders often consult for several companies that may be in competition with each other. Therefore, it is essential that there is no disclosure of confidential proprietary information among companies. Finally, the financial incentives resulting from industry collaboration should never influence physician judgment when interpreting or speaking about data regarding product efficacy or safety.

Conclusions

In summary, there are numerous opportunities for physicians to collaborate with industry. These relationships can be very rewarding and can serve to expedite the introduction of new diagnostic or treatment modalities and provide the opportunity to network and interact with colleagues as well as to participate in important research that improves clinical practice. The nature of these relationships should always be transparent, and it is the physician’s responsibility to ensure that the types of relationships that are engaged in are permitted by their employer. Over the course of my career, I have participated in nearly all forms of these relationships and have seen that participation lead to important publications, changes in corporate strategy, the fostering of acquisitions, and the rapid development and utilization of new endoscopic technologies. It is my personal belief than industry relationships can improve professional satisfaction, enhance one’s brand, and most importantly, expedite clinical innovation to improve patient care.

Dr. Muthusamy is professor of clinical medicine at the University of California, Los Angeles, and medical director of endoscopy, UCLA Health System. He disclosed ties with Medtronic, Boston Scientific, Motus GI, Endogastric Solutions, and Capsovision.

Introduction

The professional activity of physicians has traditionally consisted of patient care, teaching/education, and research in varying proportions. These aims, especially education and research, have traditionally been achieved in academic health settings. However, involvement with industry can afford all physicians an opportunity to increase patient referrals, gain exposure to colleagues through a variety of educational opportunities, and participate in meaningful research projects they could not initiate independently. This article will discuss a variety of ways that gastroenterologists can engage with industry to achieve a mutually beneficial relationship.

How to initiate relationships with industry

Here are several ways to initiate a collaboration with industry. A few of the most common ways are to become a site investigator of a multicenter device or pharmaceutical trial, participate as a member of a speaker’s bureau, or obtain training on a new technology and subsequently incorporate it into your clinical practice. To find out what trials are enrolling and looking for additional sites or new studies that are being planned, I would suggest contacting the company’s local representative and have them put you in touch the appropriate personnel in the clinical trials division. For individuals who become involved in trials, this can be a great way to improve your understanding of how to design and conduct clinical trials as well as gain exposure to colleagues with similar clinical and research interests. Some of my closest long-term collaborators and friends have been individuals who I initially met as part of industry trials at investigator meetings. Another approach is to participate in a speaker’s bureau, which can be an excellent way to improve one’s presentation skills as well as gain knowledge with respect to a specific disease state. It is also a great way to network, meet colleagues, and develop a local and regional reputation as a content expert on a specific topic. Methods to find out about such opportunities include touring the exhibit halls during educational meetings and reading scientific journals to identify new products that are launching. I have found these sorts of opportunities can significantly increase topic-based referrals. Finally, obtaining training on a new diagnostic or therapeutic technology (usually through an industry-sponsored course) can allow individuals an opportunity to offer a unique or distinctive service to their community. In addition, as further clinical expertise is gained, the relationship can be expanded to offer local, regional, or even national training courses to colleagues via either on-site or virtual courses. Similarly, opportunities to speak about or demonstrate the technology/technique at educational courses may also follow.

Navigating and expanding the relationship

Once an individual establishes a relationship with a company or has established a reputation as a key opinion leader, additional opportunities for engagement may become available. These include serving as a consultant, becoming a member of an advisory board, participating or directing educational courses for trainees/practitioners, or serving as the principal investigator of a future clinical trial. Serving as a consultant can be quite rewarding as it can highlight clinical needs, identify where product improvement can be achieved, and focus where research and development funds should be directed. Serving on the advisory board can afford an even higher level of influence where corporate strategy can be influenced. Such input is particularly impactful with smaller companies looking to enter a new field or expand a limited market share. There are also a variety of educational opportunities offered by industry including local, regional, and national courses that focus on utilizing a new technology or education concerning a specific disease state. These courses can be held locally at the physician’s clinical site or off site to attract the desired target audience. Finally, being involved in research studies, especially early-stage projects, can be critical as many small companies have limited capital, and it is essential for them to design studies with appropriate endpoints that will ideally achieve both regulatory approval as well as payor coverage. Of note, in addition to relationships directly involving industry, the American Gastroenterological Association Center for GI Innovation and Technology (CGIT) also offers the opportunity to be part of key opinion leader meetings arranged and organized by the AGA. This may allow for some individuals to participate who may be restricted from direct relationships with industry partners. The industry services offered by the CGIT also include clinical trial design and registry management services.

Entrepreneurship/intellectual property

A less commonly explored opportunity with industry involves the development of one’s own intellectual property. Some of the most impactful technologies in my advanced endoscopy clinical practice have been developed from the ideas of gastroenterology colleagues that have been successfully commercialized. These include radiofrequency ablation technology to treat Barrett’s esophagus and the development of lumen-apposing stents. There are several options for physicians with an idea for an innovation. These can include working with a university technology transfer department if they are in an academic setting, creation of their own company, or collaborating with industry to develop the device through a licensing/royalty agreement. The AGA CGIT offers extensive resources to physicians with new ideas on how to secure their intellectual property as well as to evaluate the feasibility of the aforementioned options to choose which may be most appropriate for them.

Important caveats

It is important that physicians with industry relations be aware of their local institutional policies. Some institutions may prohibit such activities while others may limit the types of relationships or the amount of income that can be received. It is the physician’s responsibility to be aware of their institution’s guidelines prior to formalizing industry agreements. If intellectual property is involved, it is essential to know the specific rules regarding physician remuneration, especially pertaining to royalty or equity agreements. Furthermore, with regard to presentations and publications, it is required to acknowledge industry relations and potential conflicts of interest. Failure to do so may adversely affect an individual’s reputation as well as lead to additional consequences such as the potential for retraction of publications or restrictions regarding future educational speaking opportunities. In addition, key opinion leaders often consult for several companies that may be in competition with each other. Therefore, it is essential that there is no disclosure of confidential proprietary information among companies. Finally, the financial incentives resulting from industry collaboration should never influence physician judgment when interpreting or speaking about data regarding product efficacy or safety.

Conclusions

In summary, there are numerous opportunities for physicians to collaborate with industry. These relationships can be very rewarding and can serve to expedite the introduction of new diagnostic or treatment modalities and provide the opportunity to network and interact with colleagues as well as to participate in important research that improves clinical practice. The nature of these relationships should always be transparent, and it is the physician’s responsibility to ensure that the types of relationships that are engaged in are permitted by their employer. Over the course of my career, I have participated in nearly all forms of these relationships and have seen that participation lead to important publications, changes in corporate strategy, the fostering of acquisitions, and the rapid development and utilization of new endoscopic technologies. It is my personal belief than industry relationships can improve professional satisfaction, enhance one’s brand, and most importantly, expedite clinical innovation to improve patient care.

Dr. Muthusamy is professor of clinical medicine at the University of California, Los Angeles, and medical director of endoscopy, UCLA Health System. He disclosed ties with Medtronic, Boston Scientific, Motus GI, Endogastric Solutions, and Capsovision.

Introduction

The professional activity of physicians has traditionally consisted of patient care, teaching/education, and research in varying proportions. These aims, especially education and research, have traditionally been achieved in academic health settings. However, involvement with industry can afford all physicians an opportunity to increase patient referrals, gain exposure to colleagues through a variety of educational opportunities, and participate in meaningful research projects they could not initiate independently. This article will discuss a variety of ways that gastroenterologists can engage with industry to achieve a mutually beneficial relationship.

How to initiate relationships with industry

Here are several ways to initiate a collaboration with industry. A few of the most common ways are to become a site investigator of a multicenter device or pharmaceutical trial, participate as a member of a speaker’s bureau, or obtain training on a new technology and subsequently incorporate it into your clinical practice. To find out what trials are enrolling and looking for additional sites or new studies that are being planned, I would suggest contacting the company’s local representative and have them put you in touch the appropriate personnel in the clinical trials division. For individuals who become involved in trials, this can be a great way to improve your understanding of how to design and conduct clinical trials as well as gain exposure to colleagues with similar clinical and research interests. Some of my closest long-term collaborators and friends have been individuals who I initially met as part of industry trials at investigator meetings. Another approach is to participate in a speaker’s bureau, which can be an excellent way to improve one’s presentation skills as well as gain knowledge with respect to a specific disease state. It is also a great way to network, meet colleagues, and develop a local and regional reputation as a content expert on a specific topic. Methods to find out about such opportunities include touring the exhibit halls during educational meetings and reading scientific journals to identify new products that are launching. I have found these sorts of opportunities can significantly increase topic-based referrals. Finally, obtaining training on a new diagnostic or therapeutic technology (usually through an industry-sponsored course) can allow individuals an opportunity to offer a unique or distinctive service to their community. In addition, as further clinical expertise is gained, the relationship can be expanded to offer local, regional, or even national training courses to colleagues via either on-site or virtual courses. Similarly, opportunities to speak about or demonstrate the technology/technique at educational courses may also follow.

Navigating and expanding the relationship

Once an individual establishes a relationship with a company or has established a reputation as a key opinion leader, additional opportunities for engagement may become available. These include serving as a consultant, becoming a member of an advisory board, participating or directing educational courses for trainees/practitioners, or serving as the principal investigator of a future clinical trial. Serving as a consultant can be quite rewarding as it can highlight clinical needs, identify where product improvement can be achieved, and focus where research and development funds should be directed. Serving on the advisory board can afford an even higher level of influence where corporate strategy can be influenced. Such input is particularly impactful with smaller companies looking to enter a new field or expand a limited market share. There are also a variety of educational opportunities offered by industry including local, regional, and national courses that focus on utilizing a new technology or education concerning a specific disease state. These courses can be held locally at the physician’s clinical site or off site to attract the desired target audience. Finally, being involved in research studies, especially early-stage projects, can be critical as many small companies have limited capital, and it is essential for them to design studies with appropriate endpoints that will ideally achieve both regulatory approval as well as payor coverage. Of note, in addition to relationships directly involving industry, the American Gastroenterological Association Center for GI Innovation and Technology (CGIT) also offers the opportunity to be part of key opinion leader meetings arranged and organized by the AGA. This may allow for some individuals to participate who may be restricted from direct relationships with industry partners. The industry services offered by the CGIT also include clinical trial design and registry management services.

Entrepreneurship/intellectual property

A less commonly explored opportunity with industry involves the development of one’s own intellectual property. Some of the most impactful technologies in my advanced endoscopy clinical practice have been developed from the ideas of gastroenterology colleagues that have been successfully commercialized. These include radiofrequency ablation technology to treat Barrett’s esophagus and the development of lumen-apposing stents. There are several options for physicians with an idea for an innovation. These can include working with a university technology transfer department if they are in an academic setting, creation of their own company, or collaborating with industry to develop the device through a licensing/royalty agreement. The AGA CGIT offers extensive resources to physicians with new ideas on how to secure their intellectual property as well as to evaluate the feasibility of the aforementioned options to choose which may be most appropriate for them.

Important caveats

It is important that physicians with industry relations be aware of their local institutional policies. Some institutions may prohibit such activities while others may limit the types of relationships or the amount of income that can be received. It is the physician’s responsibility to be aware of their institution’s guidelines prior to formalizing industry agreements. If intellectual property is involved, it is essential to know the specific rules regarding physician remuneration, especially pertaining to royalty or equity agreements. Furthermore, with regard to presentations and publications, it is required to acknowledge industry relations and potential conflicts of interest. Failure to do so may adversely affect an individual’s reputation as well as lead to additional consequences such as the potential for retraction of publications or restrictions regarding future educational speaking opportunities. In addition, key opinion leaders often consult for several companies that may be in competition with each other. Therefore, it is essential that there is no disclosure of confidential proprietary information among companies. Finally, the financial incentives resulting from industry collaboration should never influence physician judgment when interpreting or speaking about data regarding product efficacy or safety.

Conclusions

In summary, there are numerous opportunities for physicians to collaborate with industry. These relationships can be very rewarding and can serve to expedite the introduction of new diagnostic or treatment modalities and provide the opportunity to network and interact with colleagues as well as to participate in important research that improves clinical practice. The nature of these relationships should always be transparent, and it is the physician’s responsibility to ensure that the types of relationships that are engaged in are permitted by their employer. Over the course of my career, I have participated in nearly all forms of these relationships and have seen that participation lead to important publications, changes in corporate strategy, the fostering of acquisitions, and the rapid development and utilization of new endoscopic technologies. It is my personal belief than industry relationships can improve professional satisfaction, enhance one’s brand, and most importantly, expedite clinical innovation to improve patient care.

Dr. Muthusamy is professor of clinical medicine at the University of California, Los Angeles, and medical director of endoscopy, UCLA Health System. He disclosed ties with Medtronic, Boston Scientific, Motus GI, Endogastric Solutions, and Capsovision.

Considerable advances in artificial intelligence (AI) and machine-learning (ML) methodologies have led to the emergence of promising tools in the field of gastrointestinal endoscopy. Computer vision is an application of AI/ML that has been successfully applied for the computer-aided detection (CADe) and computer-aided diagnosis (CADx) of colon polyps and numerous other conditions encountered during GI endoscopy. Outside of computer vision, a wide variety of other AI applications have been applied to gastroenterology, ranging from natural language processing (NLP) to optimize clinical documentation and endoscopy quality reporting to ML techniques that predict disease severity/treatment response and augment clinical decision-making. This article focuses on opportunities for AI applications in colonoscopy, reviews the existing data, describes the challenges limiting widespread adoption, and explores future directions.

In the United States, colonoscopy is the standard for colon cancer screening and prevention; however, precancerous polyps can be missed for various reasons, ranging from subtle surface appearance of the polyp or location behind a colonic fold to operator-dependent reasons such as inadequate mucosal inspection. Though clinical practice guidelines have set adenoma detection rate (ADR) thresholds at 20% for women and 30% for men, studies have shown a 4- to 10-fold variation in ADR among physicians in clinical practice settings^,1 with an estimated adenoma miss rate (AMR) of 25% and a false-negative colonoscopy rate of 12%.² Variability in adenoma detection affects the risk of interval colorectal cancer post colonoscopy.^3,4

AI provides an opportunity for mitigating this risk. Advances in deep learning and computer vision have led to the development of CADe systems that automatically detect polyps in real time during colonoscopy, resulting in reduced adenoma miss rates (Table 1). In addition to polyp detection, deep-learning technologies are also being used in CADx systems for polyp diagnosis and characterization of malignancy risk. This could aid therapeutic decision-making: Unnecessary resection or histopathologic analysis could be obviated for benign hyperplastic polyps. On the other end of the polyp spectrum, an AI tool that could predict the presence or absence of submucosal invasion could be a powerful tool when evaluating early colon cancers for consideration of endoscopic submucosal dissection vs. surgery. Examples of CADe polyp detection and CADx polyp characterization are shown in Figure 1.

Other potential computer vision applications that may improve colonoscopy quality include tools that help measure adequacy of mucosal exposure, segmental inspection time, and a variety of other parameters associated with polyp detection performance. These are promising areas for future research. Beyond improving colonoscopy technique, natural language processing tools already are being used to optimize clinical documentation as well as extract information from colonoscopy and pathology reports that can facilitate reporting of colonoscopy quality metrics such as ADR, cecal intubation rate, withdrawal time, and bowel preparation adequacy. AI-powered analytics may help unlock large-scale reporting of colonoscopy quality metrics on a health-systems level⁵ or population-level,⁶ helping to ensure optimal performance and identifying avenues for colonoscopy quality improvement.

In comparison, the data landscape for CADx is nascent and currently limited to several retrospective studies dating back to 2009 and a few prospective studies that have shown promising results.^10,11 There is an expectation that integrated CADx also may support the adoption of “resect and discard” or “diagnose and leave” strategies for low-risk polyps. About two-thirds of polyps identified on average-risk screening colonoscopies are diminutive polyps (less than 5 mm in size), which rarely have advanced histologic features (about 0.5%) and are sometimes non-neoplastic (30%). Malignancy risk is even lower in the distal colon.¹² As routine histopathologic assessment of such polyps is mostly of limited clinical utility and comes with added pathology costs, CADx technologies may offer a more cost-effective approach where polyps that are characterized in real-time as low-risk adenomas or non-neoplastic are “resected and discarded” or “left in” respectively. In 2011, prior to the development of current AI tools, the American Society for Gastrointestinal Endoscopy set performance thresholds for technologies supporting real-time endoscopic assessment of the histology of diminutive colorectal polyps. The ASGE recommended 90% histopathologic concordance for “resect and discard” tools and 90% negative predictive value for adenomatous histology for “diagnose and leave,” tools.¹³ Narrow-band imaging (NBI), for example, has been shown to meet these benchmarks^14,15 with a modeling study suggesting that implementing “resect and discard” strategies with such tools could result in annual savings of $33 million without adversely affecting efficacy, although practical adoption has been limited.¹⁶ More recent work has directly explored the feasibility of leveraging CADx to support “leave-in-situ” and “resect-and-discard” strategies.¹⁷

Similarly, while CADe use in colonoscopy is associated with additional up-front costs, a modeling study suggests that its associated gains in ADR (as detailed in Table 1) make it a cost-saving strategy for colorectal cancer prevention in the long term.¹⁸ There is still uncertainty on whether the incremental CADe-associated gains in adenoma detection will necessarily translate to significant reductions in interval colorectal cancer risk, particularly for endoscopists who are already high-performing polyp detectors. A recent study suggests that, although higher ADRs were associated with lower rates of interval colorectal cancer, the gains in interval colorectal cancer risk reduction appeared to level off with ADRs above 35%-40% (this finding may be limited by statistical power).¹⁹ Further, most of the data from CADe trials suggest that gains in adenoma detection are not driven by increased detection of advanced lesions with high malignancy risk but by small polyps with long latency periods of about 5-10 years, which may not significantly alter interval cancer risk. It remains to be determined whether adoption of CADe will have an impact on hard outcomes, most importantly interval colorectal cancer risk, or merely result in increased resource utilization without moving the needle on colorectal cancer prevention. To answer this question, the OperA study – a large-scale randomized clinical trial of 200,000 patients across 18 centers from 13 countries – was launched in 2022. It will investigate the effect of colonoscopy with CADe on a number of critical measures, including long-term interval colon cancer risk.²⁰

Despite commercial availability of regulatory-approved CADe systems and data supporting use for adenoma detection in colonoscopy, mainstream adoption in clinical practice has been sluggish. Physician survey studies have shown that, although there is considerable interest in integrating CADe into clinical practice, there are concerns about access, cost and reimbursement, integration into clinical work-flow, increased procedural times, over-reliance on AI, and algorithmic bias leading to errors.^21,22 In addition, without mandatory requirements for ADR reporting or clinical practice guideline recommendations for CADe use, these systems may not be perceived as valuable or ready for prime time even though the evidence suggests otherwise.^23,24 For CADe systems to see widespread adoption in clinical practice, it is important that future research studies rigorously investigate and characterize these potential barriers to better inform strategies to address AI hesitancy and implementation challenges. Such efforts can provide an integration framework for future AI applications in gastroenterology beyond colonoscopy, such as CADe of esophageal and gastric premalignant lesions in upper endoscopy, CADx for pancreatic cysts and liver lesions on imaging, NLP tools to optimizing efficient clinical documentation and reporting, and many others.

Dr. Uche-Anya is in the division of gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston. Dr. Berzin is with the Center for Advanced Endoscopy, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston. Dr. Berzin is a consultant for Wision AI, Medtronic, Magentiq Eye, RSIP Vision, and Docbot.

Corresponding Author: Eugenia Uche-Anya [email protected] Twitter: @UcheAnyaMD @tberzin

References

1. Corley DA et al. Can we improve adenoma detection rates? A systematic review of intervention studies. Gastrointest Endosc. Sep 2011;74(3):656-65. doi: 10.1016/j.gie.2011.04.017.

2. Zhao S et al. Magnitude, risk factors, and factors associated with adenoma miss rate of tandem colonoscopy: A systematic review and meta-analysis. Gastroenterology. 05 2019;156(6):1661-74.e11. doi: 10.1053/j.gastro.2019.01.260.

3. Kaminski MF et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med. May 13 2010;362(19):1795-803. doi: 10.1056/NEJMoa0907667.

4. Corley DA et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med. Apr 03 2014;370(14):1298-306. doi: 10.1056/NEJMoa1309086.

5. Laique SN et al. Application of optical character recognition with natural language processing for large-scale quality metric data extraction in colonoscopy reports. Gastrointest Endosc. 03 2021;93(3):750-7. doi: 10.1016/j.gie.2020.08.038.

6. Tinmouth J et al. Validation of a natural language processing algorithm to identify adenomas and measure adenoma detection rates across a health system: a population-level study. Gastrointest Endosc. Jul 14 2022. doi: 10.1016/j.gie.2022.07.009.

7. Glissen Brown JR et al. Deep learning computer-aided polyp detection reduces adenoma miss rate: A United States multi-center randomized tandem colonoscopy study (CADeT-CS Trial). Clin Gastroenterol Hepatol. 07 2022;20(7):1499-1507.e4. doi: 10.1016/j.cgh.2021.09.009.

8. Wallace MB et al. Impact of artificial intelligence on miss rate of colorectal neoplasia. Gastroenterology. 07 2022;163(1):295-304.e5. doi: 10.1053/j.gastro.2022.03.007.

9. Hassan C et al. Performance of artificial intelligence in colonoscopy for adenoma and polyp detection: a systematic review and meta-analysis. Gastrointest Endosc. 01 2021;93(1):77-85.e6. doi: 10.1016/j.gie.2020.06.059.

10. Glissen Brown JR and Berzin TM. Adoption of new technologies: Artificial intelligence. Gastrointest Endosc Clin N Am. Oct 2021;31(4):743-58. doi: 10.1016/j.giec.2021.05.010.

11. Larsen SLV and Mori Y. Artificial intelligence in colonoscopy: A review on the current status. DEN open. Apr 2022;2(1):e109. doi: 10.1002/deo2.109.

12. Gupta N et al. Prevalence of advanced histological features in diminutive and small colon polyps. Gastrointest Endosc. May 2012;75(5):1022-30. doi: 10.1016/j.gie.2012.01.020.

13. Rex DK et al. The American Society for Gastrointestinal Endoscopy PIVI (Preservation and Incorporation of Valuable Endoscopic Innovations) on real-time endoscopic assessment of the histology of diminutive colorectal polyps. Gastrointest Endosc. Mar 2011;73(3):419-22. doi: 10.1016/j.gie.2011.01.023.

14. Abu Dayyeh BK et al. ASGE Technology Committee systematic review and meta-analysis assessing the ASGE PIVI thresholds for adopting real-time endoscopic assessment of the histology of diminutive colorectal polyps. Gastrointest Endosc. Mar 2015;81(3):502.e1-16. doi: 10.1016/j.gie.2014.12.022.

15. Mori Y et al. Real-time use of artificial intelligence in identification of diminutive polyps during colonoscopy: A prospective study. Ann Intern Med. Sep 18 2018;169(6):357-66. doi: 10.7326/M18-0249.

16. Hassan C et al.. A resect and discard strategy would improve cost-effectiveness of colorectal cancer screening. Clin Gastroenterol Hepatol. Oct 2010;8(10):865-9, 869.e1-3. doi: 10.1016/j.cgh.2010.05.018.

17. Hassan C et al. Artificial intelligence allows leaving-in-situ colorectal polyps. Clin Gastroenterol Hepatol. Nov 2022;20(11):2505-13.e4. doi: 10.1016/j.cgh.2022.04.045.

18. Areia M et al. Cost-effectiveness of artificial intelligence for screening colonoscopy: a modelling study. Lancet Digit Health. 06 2022;4(6):e436-44. doi: 10.1016/S2589-7500(22)00042-5.

19. Schottinger JE et al. Association of physician adenoma detection rates with postcolonoscopy colorectal cancer. JAMA. 2022 Jun 7;327(21):2114-22. doi: 10.1001/jama.2022.6644.

20. Oslo Uo. Optimising colorectal cancer prevention through personalised treatment with artificial intelligence. 2022.

21. Wadhwa V et al. Physician sentiment toward artificial intelligence (AI) in colonoscopic practice: a survey of US gastroenterologists. Endosc Int Open. Oct 2020;8(10):E1379-84. doi: 10.1055/a-1223-1926.

22. Kader R et al. Survey on the perceptions of UK gastroenterologists and endoscopists to artificial intelligence. Frontline Gastroenterol. 2022;13(5):423-9. doi: 10.1136/flgastro-2021-101994.

23. Rex DKet al. Artificial intelligence improves detection at colonoscopy: Why aren’t we all already using it? Gastroenterology. 07 2022;163(1):35-7. doi: 10.1053/j.gastro.2022.04.042.

24. Ahmad OF et al. Establishing key research questions for the implementation of artificial intelligence in colonoscopy: A modified Delphi method. Endoscopy. 09 2021;53(9):893-901. doi: 10.1055/a-1306-7590

Considerable advances in artificial intelligence (AI) and machine-learning (ML) methodologies have led to the emergence of promising tools in the field of gastrointestinal endoscopy. Computer vision is an application of AI/ML that has been successfully applied for the computer-aided detection (CADe) and computer-aided diagnosis (CADx) of colon polyps and numerous other conditions encountered during GI endoscopy. Outside of computer vision, a wide variety of other AI applications have been applied to gastroenterology, ranging from natural language processing (NLP) to optimize clinical documentation and endoscopy quality reporting to ML techniques that predict disease severity/treatment response and augment clinical decision-making. This article focuses on opportunities for AI applications in colonoscopy, reviews the existing data, describes the challenges limiting widespread adoption, and explores future directions.

In the United States, colonoscopy is the standard for colon cancer screening and prevention; however, precancerous polyps can be missed for various reasons, ranging from subtle surface appearance of the polyp or location behind a colonic fold to operator-dependent reasons such as inadequate mucosal inspection. Though clinical practice guidelines have set adenoma detection rate (ADR) thresholds at 20% for women and 30% for men, studies have shown a 4- to 10-fold variation in ADR among physicians in clinical practice settings^,1 with an estimated adenoma miss rate (AMR) of 25% and a false-negative colonoscopy rate of 12%.² Variability in adenoma detection affects the risk of interval colorectal cancer post colonoscopy.^3,4

AI provides an opportunity for mitigating this risk. Advances in deep learning and computer vision have led to the development of CADe systems that automatically detect polyps in real time during colonoscopy, resulting in reduced adenoma miss rates (Table 1). In addition to polyp detection, deep-learning technologies are also being used in CADx systems for polyp diagnosis and characterization of malignancy risk. This could aid therapeutic decision-making: Unnecessary resection or histopathologic analysis could be obviated for benign hyperplastic polyps. On the other end of the polyp spectrum, an AI tool that could predict the presence or absence of submucosal invasion could be a powerful tool when evaluating early colon cancers for consideration of endoscopic submucosal dissection vs. surgery. Examples of CADe polyp detection and CADx polyp characterization are shown in Figure 1.

Other potential computer vision applications that may improve colonoscopy quality include tools that help measure adequacy of mucosal exposure, segmental inspection time, and a variety of other parameters associated with polyp detection performance. These are promising areas for future research. Beyond improving colonoscopy technique, natural language processing tools already are being used to optimize clinical documentation as well as extract information from colonoscopy and pathology reports that can facilitate reporting of colonoscopy quality metrics such as ADR, cecal intubation rate, withdrawal time, and bowel preparation adequacy. AI-powered analytics may help unlock large-scale reporting of colonoscopy quality metrics on a health-systems level⁵ or population-level,⁶ helping to ensure optimal performance and identifying avenues for colonoscopy quality improvement.

In comparison, the data landscape for CADx is nascent and currently limited to several retrospective studies dating back to 2009 and a few prospective studies that have shown promising results.^10,11 There is an expectation that integrated CADx also may support the adoption of “resect and discard” or “diagnose and leave” strategies for low-risk polyps. About two-thirds of polyps identified on average-risk screening colonoscopies are diminutive polyps (less than 5 mm in size), which rarely have advanced histologic features (about 0.5%) and are sometimes non-neoplastic (30%). Malignancy risk is even lower in the distal colon.¹² As routine histopathologic assessment of such polyps is mostly of limited clinical utility and comes with added pathology costs, CADx technologies may offer a more cost-effective approach where polyps that are characterized in real-time as low-risk adenomas or non-neoplastic are “resected and discarded” or “left in” respectively. In 2011, prior to the development of current AI tools, the American Society for Gastrointestinal Endoscopy set performance thresholds for technologies supporting real-time endoscopic assessment of the histology of diminutive colorectal polyps. The ASGE recommended 90% histopathologic concordance for “resect and discard” tools and 90% negative predictive value for adenomatous histology for “diagnose and leave,” tools.¹³ Narrow-band imaging (NBI), for example, has been shown to meet these benchmarks^14,15 with a modeling study suggesting that implementing “resect and discard” strategies with such tools could result in annual savings of $33 million without adversely affecting efficacy, although practical adoption has been limited.¹⁶ More recent work has directly explored the feasibility of leveraging CADx to support “leave-in-situ” and “resect-and-discard” strategies.¹⁷

Similarly, while CADe use in colonoscopy is associated with additional up-front costs, a modeling study suggests that its associated gains in ADR (as detailed in Table 1) make it a cost-saving strategy for colorectal cancer prevention in the long term.¹⁸ There is still uncertainty on whether the incremental CADe-associated gains in adenoma detection will necessarily translate to significant reductions in interval colorectal cancer risk, particularly for endoscopists who are already high-performing polyp detectors. A recent study suggests that, although higher ADRs were associated with lower rates of interval colorectal cancer, the gains in interval colorectal cancer risk reduction appeared to level off with ADRs above 35%-40% (this finding may be limited by statistical power).¹⁹ Further, most of the data from CADe trials suggest that gains in adenoma detection are not driven by increased detection of advanced lesions with high malignancy risk but by small polyps with long latency periods of about 5-10 years, which may not significantly alter interval cancer risk. It remains to be determined whether adoption of CADe will have an impact on hard outcomes, most importantly interval colorectal cancer risk, or merely result in increased resource utilization without moving the needle on colorectal cancer prevention. To answer this question, the OperA study – a large-scale randomized clinical trial of 200,000 patients across 18 centers from 13 countries – was launched in 2022. It will investigate the effect of colonoscopy with CADe on a number of critical measures, including long-term interval colon cancer risk.²⁰

Despite commercial availability of regulatory-approved CADe systems and data supporting use for adenoma detection in colonoscopy, mainstream adoption in clinical practice has been sluggish. Physician survey studies have shown that, although there is considerable interest in integrating CADe into clinical practice, there are concerns about access, cost and reimbursement, integration into clinical work-flow, increased procedural times, over-reliance on AI, and algorithmic bias leading to errors.^21,22 In addition, without mandatory requirements for ADR reporting or clinical practice guideline recommendations for CADe use, these systems may not be perceived as valuable or ready for prime time even though the evidence suggests otherwise.^23,24 For CADe systems to see widespread adoption in clinical practice, it is important that future research studies rigorously investigate and characterize these potential barriers to better inform strategies to address AI hesitancy and implementation challenges. Such efforts can provide an integration framework for future AI applications in gastroenterology beyond colonoscopy, such as CADe of esophageal and gastric premalignant lesions in upper endoscopy, CADx for pancreatic cysts and liver lesions on imaging, NLP tools to optimizing efficient clinical documentation and reporting, and many others.

Dr. Uche-Anya is in the division of gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston. Dr. Berzin is with the Center for Advanced Endoscopy, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston. Dr. Berzin is a consultant for Wision AI, Medtronic, Magentiq Eye, RSIP Vision, and Docbot.

Corresponding Author: Eugenia Uche-Anya [email protected] Twitter: @UcheAnyaMD @tberzin

References

1. Corley DA et al. Can we improve adenoma detection rates? A systematic review of intervention studies. Gastrointest Endosc. Sep 2011;74(3):656-65. doi: 10.1016/j.gie.2011.04.017.

2. Zhao S et al. Magnitude, risk factors, and factors associated with adenoma miss rate of tandem colonoscopy: A systematic review and meta-analysis. Gastroenterology. 05 2019;156(6):1661-74.e11. doi: 10.1053/j.gastro.2019.01.260.

3. Kaminski MF et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med. May 13 2010;362(19):1795-803. doi: 10.1056/NEJMoa0907667.

4. Corley DA et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med. Apr 03 2014;370(14):1298-306. doi: 10.1056/NEJMoa1309086.

5. Laique SN et al. Application of optical character recognition with natural language processing for large-scale quality metric data extraction in colonoscopy reports. Gastrointest Endosc. 03 2021;93(3):750-7. doi: 10.1016/j.gie.2020.08.038.

6. Tinmouth J et al. Validation of a natural language processing algorithm to identify adenomas and measure adenoma detection rates across a health system: a population-level study. Gastrointest Endosc. Jul 14 2022. doi: 10.1016/j.gie.2022.07.009.

7. Glissen Brown JR et al. Deep learning computer-aided polyp detection reduces adenoma miss rate: A United States multi-center randomized tandem colonoscopy study (CADeT-CS Trial). Clin Gastroenterol Hepatol. 07 2022;20(7):1499-1507.e4. doi: 10.1016/j.cgh.2021.09.009.

8. Wallace MB et al. Impact of artificial intelligence on miss rate of colorectal neoplasia. Gastroenterology. 07 2022;163(1):295-304.e5. doi: 10.1053/j.gastro.2022.03.007.

9. Hassan C et al. Performance of artificial intelligence in colonoscopy for adenoma and polyp detection: a systematic review and meta-analysis. Gastrointest Endosc. 01 2021;93(1):77-85.e6. doi: 10.1016/j.gie.2020.06.059.

10. Glissen Brown JR and Berzin TM. Adoption of new technologies: Artificial intelligence. Gastrointest Endosc Clin N Am. Oct 2021;31(4):743-58. doi: 10.1016/j.giec.2021.05.010.

11. Larsen SLV and Mori Y. Artificial intelligence in colonoscopy: A review on the current status. DEN open. Apr 2022;2(1):e109. doi: 10.1002/deo2.109.

12. Gupta N et al. Prevalence of advanced histological features in diminutive and small colon polyps. Gastrointest Endosc. May 2012;75(5):1022-30. doi: 10.1016/j.gie.2012.01.020.

13. Rex DK et al. The American Society for Gastrointestinal Endoscopy PIVI (Preservation and Incorporation of Valuable Endoscopic Innovations) on real-time endoscopic assessment of the histology of diminutive colorectal polyps. Gastrointest Endosc. Mar 2011;73(3):419-22. doi: 10.1016/j.gie.2011.01.023.

14. Abu Dayyeh BK et al. ASGE Technology Committee systematic review and meta-analysis assessing the ASGE PIVI thresholds for adopting real-time endoscopic assessment of the histology of diminutive colorectal polyps. Gastrointest Endosc. Mar 2015;81(3):502.e1-16. doi: 10.1016/j.gie.2014.12.022.

15. Mori Y et al. Real-time use of artificial intelligence in identification of diminutive polyps during colonoscopy: A prospective study. Ann Intern Med. Sep 18 2018;169(6):357-66. doi: 10.7326/M18-0249.

16. Hassan C et al.. A resect and discard strategy would improve cost-effectiveness of colorectal cancer screening. Clin Gastroenterol Hepatol. Oct 2010;8(10):865-9, 869.e1-3. doi: 10.1016/j.cgh.2010.05.018.

17. Hassan C et al. Artificial intelligence allows leaving-in-situ colorectal polyps. Clin Gastroenterol Hepatol. Nov 2022;20(11):2505-13.e4. doi: 10.1016/j.cgh.2022.04.045.

18. Areia M et al. Cost-effectiveness of artificial intelligence for screening colonoscopy: a modelling study. Lancet Digit Health. 06 2022;4(6):e436-44. doi: 10.1016/S2589-7500(22)00042-5.

19. Schottinger JE et al. Association of physician adenoma detection rates with postcolonoscopy colorectal cancer. JAMA. 2022 Jun 7;327(21):2114-22. doi: 10.1001/jama.2022.6644.

20. Oslo Uo. Optimising colorectal cancer prevention through personalised treatment with artificial intelligence. 2022.

21. Wadhwa V et al. Physician sentiment toward artificial intelligence (AI) in colonoscopic practice: a survey of US gastroenterologists. Endosc Int Open. Oct 2020;8(10):E1379-84. doi: 10.1055/a-1223-1926.

22. Kader R et al. Survey on the perceptions of UK gastroenterologists and endoscopists to artificial intelligence. Frontline Gastroenterol. 2022;13(5):423-9. doi: 10.1136/flgastro-2021-101994.

23. Rex DKet al. Artificial intelligence improves detection at colonoscopy: Why aren’t we all already using it? Gastroenterology. 07 2022;163(1):35-7. doi: 10.1053/j.gastro.2022.04.042.

24. Ahmad OF et al. Establishing key research questions for the implementation of artificial intelligence in colonoscopy: A modified Delphi method. Endoscopy. 09 2021;53(9):893-901. doi: 10.1055/a-1306-7590

Considerable advances in artificial intelligence (AI) and machine-learning (ML) methodologies have led to the emergence of promising tools in the field of gastrointestinal endoscopy. Computer vision is an application of AI/ML that has been successfully applied for the computer-aided detection (CADe) and computer-aided diagnosis (CADx) of colon polyps and numerous other conditions encountered during GI endoscopy. Outside of computer vision, a wide variety of other AI applications have been applied to gastroenterology, ranging from natural language processing (NLP) to optimize clinical documentation and endoscopy quality reporting to ML techniques that predict disease severity/treatment response and augment clinical decision-making. This article focuses on opportunities for AI applications in colonoscopy, reviews the existing data, describes the challenges limiting widespread adoption, and explores future directions.

In the United States, colonoscopy is the standard for colon cancer screening and prevention; however, precancerous polyps can be missed for various reasons, ranging from subtle surface appearance of the polyp or location behind a colonic fold to operator-dependent reasons such as inadequate mucosal inspection. Though clinical practice guidelines have set adenoma detection rate (ADR) thresholds at 20% for women and 30% for men, studies have shown a 4- to 10-fold variation in ADR among physicians in clinical practice settings^,1 with an estimated adenoma miss rate (AMR) of 25% and a false-negative colonoscopy rate of 12%.² Variability in adenoma detection affects the risk of interval colorectal cancer post colonoscopy.^3,4

AI provides an opportunity for mitigating this risk. Advances in deep learning and computer vision have led to the development of CADe systems that automatically detect polyps in real time during colonoscopy, resulting in reduced adenoma miss rates (Table 1). In addition to polyp detection, deep-learning technologies are also being used in CADx systems for polyp diagnosis and characterization of malignancy risk. This could aid therapeutic decision-making: Unnecessary resection or histopathologic analysis could be obviated for benign hyperplastic polyps. On the other end of the polyp spectrum, an AI tool that could predict the presence or absence of submucosal invasion could be a powerful tool when evaluating early colon cancers for consideration of endoscopic submucosal dissection vs. surgery. Examples of CADe polyp detection and CADx polyp characterization are shown in Figure 1.

Other potential computer vision applications that may improve colonoscopy quality include tools that help measure adequacy of mucosal exposure, segmental inspection time, and a variety of other parameters associated with polyp detection performance. These are promising areas for future research. Beyond improving colonoscopy technique, natural language processing tools already are being used to optimize clinical documentation as well as extract information from colonoscopy and pathology reports that can facilitate reporting of colonoscopy quality metrics such as ADR, cecal intubation rate, withdrawal time, and bowel preparation adequacy. AI-powered analytics may help unlock large-scale reporting of colonoscopy quality metrics on a health-systems level⁵ or population-level,⁶ helping to ensure optimal performance and identifying avenues for colonoscopy quality improvement.

In comparison, the data landscape for CADx is nascent and currently limited to several retrospective studies dating back to 2009 and a few prospective studies that have shown promising results.^10,11 There is an expectation that integrated CADx also may support the adoption of “resect and discard” or “diagnose and leave” strategies for low-risk polyps. About two-thirds of polyps identified on average-risk screening colonoscopies are diminutive polyps (less than 5 mm in size), which rarely have advanced histologic features (about 0.5%) and are sometimes non-neoplastic (30%). Malignancy risk is even lower in the distal colon.¹² As routine histopathologic assessment of such polyps is mostly of limited clinical utility and comes with added pathology costs, CADx technologies may offer a more cost-effective approach where polyps that are characterized in real-time as low-risk adenomas or non-neoplastic are “resected and discarded” or “left in” respectively. In 2011, prior to the development of current AI tools, the American Society for Gastrointestinal Endoscopy set performance thresholds for technologies supporting real-time endoscopic assessment of the histology of diminutive colorectal polyps. The ASGE recommended 90% histopathologic concordance for “resect and discard” tools and 90% negative predictive value for adenomatous histology for “diagnose and leave,” tools.¹³ Narrow-band imaging (NBI), for example, has been shown to meet these benchmarks^14,15 with a modeling study suggesting that implementing “resect and discard” strategies with such tools could result in annual savings of $33 million without adversely affecting efficacy, although practical adoption has been limited.¹⁶ More recent work has directly explored the feasibility of leveraging CADx to support “leave-in-situ” and “resect-and-discard” strategies.¹⁷

Similarly, while CADe use in colonoscopy is associated with additional up-front costs, a modeling study suggests that its associated gains in ADR (as detailed in Table 1) make it a cost-saving strategy for colorectal cancer prevention in the long term.¹⁸ There is still uncertainty on whether the incremental CADe-associated gains in adenoma detection will necessarily translate to significant reductions in interval colorectal cancer risk, particularly for endoscopists who are already high-performing polyp detectors. A recent study suggests that, although higher ADRs were associated with lower rates of interval colorectal cancer, the gains in interval colorectal cancer risk reduction appeared to level off with ADRs above 35%-40% (this finding may be limited by statistical power).¹⁹ Further, most of the data from CADe trials suggest that gains in adenoma detection are not driven by increased detection of advanced lesions with high malignancy risk but by small polyps with long latency periods of about 5-10 years, which may not significantly alter interval cancer risk. It remains to be determined whether adoption of CADe will have an impact on hard outcomes, most importantly interval colorectal cancer risk, or merely result in increased resource utilization without moving the needle on colorectal cancer prevention. To answer this question, the OperA study – a large-scale randomized clinical trial of 200,000 patients across 18 centers from 13 countries – was launched in 2022. It will investigate the effect of colonoscopy with CADe on a number of critical measures, including long-term interval colon cancer risk.²⁰

Despite commercial availability of regulatory-approved CADe systems and data supporting use for adenoma detection in colonoscopy, mainstream adoption in clinical practice has been sluggish. Physician survey studies have shown that, although there is considerable interest in integrating CADe into clinical practice, there are concerns about access, cost and reimbursement, integration into clinical work-flow, increased procedural times, over-reliance on AI, and algorithmic bias leading to errors.^21,22 In addition, without mandatory requirements for ADR reporting or clinical practice guideline recommendations for CADe use, these systems may not be perceived as valuable or ready for prime time even though the evidence suggests otherwise.^23,24 For CADe systems to see widespread adoption in clinical practice, it is important that future research studies rigorously investigate and characterize these potential barriers to better inform strategies to address AI hesitancy and implementation challenges. Such efforts can provide an integration framework for future AI applications in gastroenterology beyond colonoscopy, such as CADe of esophageal and gastric premalignant lesions in upper endoscopy, CADx for pancreatic cysts and liver lesions on imaging, NLP tools to optimizing efficient clinical documentation and reporting, and many others.

Dr. Uche-Anya is in the division of gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston. Dr. Berzin is with the Center for Advanced Endoscopy, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston. Dr. Berzin is a consultant for Wision AI, Medtronic, Magentiq Eye, RSIP Vision, and Docbot.

Corresponding Author: Eugenia Uche-Anya [email protected] Twitter: @UcheAnyaMD @tberzin

References

1. Corley DA et al. Can we improve adenoma detection rates? A systematic review of intervention studies. Gastrointest Endosc. Sep 2011;74(3):656-65. doi: 10.1016/j.gie.2011.04.017.

2. Zhao S et al. Magnitude, risk factors, and factors associated with adenoma miss rate of tandem colonoscopy: A systematic review and meta-analysis. Gastroenterology. 05 2019;156(6):1661-74.e11. doi: 10.1053/j.gastro.2019.01.260.

3. Kaminski MF et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med. May 13 2010;362(19):1795-803. doi: 10.1056/NEJMoa0907667.

4. Corley DA et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med. Apr 03 2014;370(14):1298-306. doi: 10.1056/NEJMoa1309086.

5. Laique SN et al. Application of optical character recognition with natural language processing for large-scale quality metric data extraction in colonoscopy reports. Gastrointest Endosc. 03 2021;93(3):750-7. doi: 10.1016/j.gie.2020.08.038.

6. Tinmouth J et al. Validation of a natural language processing algorithm to identify adenomas and measure adenoma detection rates across a health system: a population-level study. Gastrointest Endosc. Jul 14 2022. doi: 10.1016/j.gie.2022.07.009.

7. Glissen Brown JR et al. Deep learning computer-aided polyp detection reduces adenoma miss rate: A United States multi-center randomized tandem colonoscopy study (CADeT-CS Trial). Clin Gastroenterol Hepatol. 07 2022;20(7):1499-1507.e4. doi: 10.1016/j.cgh.2021.09.009.

8. Wallace MB et al. Impact of artificial intelligence on miss rate of colorectal neoplasia. Gastroenterology. 07 2022;163(1):295-304.e5. doi: 10.1053/j.gastro.2022.03.007.

9. Hassan C et al. Performance of artificial intelligence in colonoscopy for adenoma and polyp detection: a systematic review and meta-analysis. Gastrointest Endosc. 01 2021;93(1):77-85.e6. doi: 10.1016/j.gie.2020.06.059.

10. Glissen Brown JR and Berzin TM. Adoption of new technologies: Artificial intelligence. Gastrointest Endosc Clin N Am. Oct 2021;31(4):743-58. doi: 10.1016/j.giec.2021.05.010.

11. Larsen SLV and Mori Y. Artificial intelligence in colonoscopy: A review on the current status. DEN open. Apr 2022;2(1):e109. doi: 10.1002/deo2.109.

12. Gupta N et al. Prevalence of advanced histological features in diminutive and small colon polyps. Gastrointest Endosc. May 2012;75(5):1022-30. doi: 10.1016/j.gie.2012.01.020.

13. Rex DK et al. The American Society for Gastrointestinal Endoscopy PIVI (Preservation and Incorporation of Valuable Endoscopic Innovations) on real-time endoscopic assessment of the histology of diminutive colorectal polyps. Gastrointest Endosc. Mar 2011;73(3):419-22. doi: 10.1016/j.gie.2011.01.023.

14. Abu Dayyeh BK et al. ASGE Technology Committee systematic review and meta-analysis assessing the ASGE PIVI thresholds for adopting real-time endoscopic assessment of the histology of diminutive colorectal polyps. Gastrointest Endosc. Mar 2015;81(3):502.e1-16. doi: 10.1016/j.gie.2014.12.022.

15. Mori Y et al. Real-time use of artificial intelligence in identification of diminutive polyps during colonoscopy: A prospective study. Ann Intern Med. Sep 18 2018;169(6):357-66. doi: 10.7326/M18-0249.

16. Hassan C et al.. A resect and discard strategy would improve cost-effectiveness of colorectal cancer screening. Clin Gastroenterol Hepatol. Oct 2010;8(10):865-9, 869.e1-3. doi: 10.1016/j.cgh.2010.05.018.

17. Hassan C et al. Artificial intelligence allows leaving-in-situ colorectal polyps. Clin Gastroenterol Hepatol. Nov 2022;20(11):2505-13.e4. doi: 10.1016/j.cgh.2022.04.045.

18. Areia M et al. Cost-effectiveness of artificial intelligence for screening colonoscopy: a modelling study. Lancet Digit Health. 06 2022;4(6):e436-44. doi: 10.1016/S2589-7500(22)00042-5.

19. Schottinger JE et al. Association of physician adenoma detection rates with postcolonoscopy colorectal cancer. JAMA. 2022 Jun 7;327(21):2114-22. doi: 10.1001/jama.2022.6644.

20. Oslo Uo. Optimising colorectal cancer prevention through personalised treatment with artificial intelligence. 2022.

21. Wadhwa V et al. Physician sentiment toward artificial intelligence (AI) in colonoscopic practice: a survey of US gastroenterologists. Endosc Int Open. Oct 2020;8(10):E1379-84. doi: 10.1055/a-1223-1926.

22. Kader R et al. Survey on the perceptions of UK gastroenterologists and endoscopists to artificial intelligence. Frontline Gastroenterol. 2022;13(5):423-9. doi: 10.1136/flgastro-2021-101994.

23. Rex DKet al. Artificial intelligence improves detection at colonoscopy: Why aren’t we all already using it? Gastroenterology. 07 2022;163(1):35-7. doi: 10.1053/j.gastro.2022.04.042.

24. Ahmad OF et al. Establishing key research questions for the implementation of artificial intelligence in colonoscopy: A modified Delphi method. Endoscopy. 09 2021;53(9):893-901. doi: 10.1055/a-1306-7590

Gastroenterology

October 2022

Cryer B et al. Bridging the Racial, Ethnic, and Gender Gap in Gastroenterology. Gastroenterology. 2022 Oct;163(4):800-5. doi: 10.1053/j.gastro.2022.08.037. PMID: 36137708.



Bajaj JS and Nagy LE. Natural History of Alcohol-Associated Liver Disease: Understanding the Changing Landscape of Pathophysiology and Patient Care. Gastroenterology. 2022 Oct;163(4):840-51. doi: 10.1053/j.gastro.2022.05.031. Epub 2022 May 19. PMID: 35598629; PMCID: PMC9509416.



November 2022

Grunvald E et al; AGA Clinical Guidelines Committee. AGA Clinical Practice Guideline on Pharmacological Interventions for Adults With Obesity. Gastroenterology. 2022 Nov;163(5):1198-225. doi: 10.1053/j.gastro.2022.08.045. Epub 2022 Oct 20. PMID: 36273831.



December 2022

Blackett JW et al. Comparison of Anorectal Manometry, Rectal Balloon Expulsion Test, and Defecography for Diagnosing Defecatory Disorders. Gastroenterology. 2022 Dec;163(6):1582-92.e2. doi: 10.1053/j.gastro.2022.08.034. Epub 2022 Aug 19. PMID: 35995074; PMCID: PMC9691522.



de Voogd F et al. Intestinal Ultrasound Is Accurate to Determine Endoscopic Response and Remission in Patients With Moderate to Severe Ulcerative Colitis: A Longitudinal Prospective Cohort Study. Gastroenterology. 2022 Dec;163(6):1569-81. doi: 10.1053/j.gastro.2022.08.038. Epub 2022 Aug 24. PMID: 36030056.
 

Clinical Gastroenterology and Hepatology

October 2022

Bhavsar-Burke I et al. How to Promote Professional Identity Development and Support Fellows-In-Training Through Teaching, Coaching, Mentorship, and Sponsorship. Clin Gastroenterol Hepatol. 2022 Oct;20(10):2166-9. doi: 10.1016/j.cgh.2022.05.043. Epub 2022 Aug 7. PMID: 35948073.



van Megen F et al. A Low FODMAP Diet Reduces Symptoms in Treated Celiac Patients With Ongoing Symptoms – A Randomized Controlled Trial. Clin Gastroenterol Hepatol. 2022 Oct;20(10):2258-66.e3. doi: 10.1016/j.cgh.2022.01.011. Epub 2022 Jan 17. PMID: 35051648.



November 2022

Sharzehi K et al. AGA Clinical Practice Update on Management of Subepithelial Lesions Encountered During Routine Endoscopy: Expert Review. Clin Gastroenterol Hepatol. 2022 Nov;20(11):2435-43.e4. doi: 10.1016/j.cgh.2022.05.054. Epub 2022 Jul 13. PMID: 35842117.



December 2022

Kardashian A et al. Food Insecurity is Associated With Mortality Among U.S. Adults With Nonalcoholic Fatty Liver Disease and Advanced Fibrosis. Clin Gastroenterol Hepatol. 2022 Dec;20(12):2790-9.e4. doi: 10.1016/j.cgh.2021.11.029. Epub 2021 Dec 16. PMID: 34958747.



Schuitenmaker JM et al. Sleep Positional Therapy for Nocturnal Gastroesophageal Reflux: A Double-Blind, Randomized, Sham-Controlled Trial. Clin Gastroenterol Hepatol. 2022 Dec;20(12):2753-62.e2. doi: 10.1016/j.cgh.2022.02.058. Epub 2022 Mar 14. PMID: 35301135.
 

Techniques and Innovations in Gastrointestinal Endoscopy

Azizian JM et al. Yield of Post-Acute Diverticulitis Colonoscopy for Ruling Out Colorectal Cancer. Tech Innov Gastrointest Endosc. 2022;24(3):254-61. doi: 10.1016/j.tige.2022.04.001. Epub 2022 Apr 18. PMID: 36540108; PMCID: PMC9762736.
 

Gastro Hep Advances

Kim RW et al. Timely Albumin Improves Survival in Patients With Cirrhosis on Diuretic Therapy Who Develop Acute Kidney Injury: Real-World Evidence in the United States. Gastro Hep Advances. 2023;2(2):252-60. doi: 10.1016/j.gastha.2022.10.008.

Gastroenterology

October 2022

Cryer B et al. Bridging the Racial, Ethnic, and Gender Gap in Gastroenterology. Gastroenterology. 2022 Oct;163(4):800-5. doi: 10.1053/j.gastro.2022.08.037. PMID: 36137708.



Bajaj JS and Nagy LE. Natural History of Alcohol-Associated Liver Disease: Understanding the Changing Landscape of Pathophysiology and Patient Care. Gastroenterology. 2022 Oct;163(4):840-51. doi: 10.1053/j.gastro.2022.05.031. Epub 2022 May 19. PMID: 35598629; PMCID: PMC9509416.



November 2022

Grunvald E et al; AGA Clinical Guidelines Committee. AGA Clinical Practice Guideline on Pharmacological Interventions for Adults With Obesity. Gastroenterology. 2022 Nov;163(5):1198-225. doi: 10.1053/j.gastro.2022.08.045. Epub 2022 Oct 20. PMID: 36273831.



December 2022

Blackett JW et al. Comparison of Anorectal Manometry, Rectal Balloon Expulsion Test, and Defecography for Diagnosing Defecatory Disorders. Gastroenterology. 2022 Dec;163(6):1582-92.e2. doi: 10.1053/j.gastro.2022.08.034. Epub 2022 Aug 19. PMID: 35995074; PMCID: PMC9691522.



de Voogd F et al. Intestinal Ultrasound Is Accurate to Determine Endoscopic Response and Remission in Patients With Moderate to Severe Ulcerative Colitis: A Longitudinal Prospective Cohort Study. Gastroenterology. 2022 Dec;163(6):1569-81. doi: 10.1053/j.gastro.2022.08.038. Epub 2022 Aug 24. PMID: 36030056.
 

Clinical Gastroenterology and Hepatology

October 2022

Bhavsar-Burke I et al. How to Promote Professional Identity Development and Support Fellows-In-Training Through Teaching, Coaching, Mentorship, and Sponsorship. Clin Gastroenterol Hepatol. 2022 Oct;20(10):2166-9. doi: 10.1016/j.cgh.2022.05.043. Epub 2022 Aug 7. PMID: 35948073.



van Megen F et al. A Low FODMAP Diet Reduces Symptoms in Treated Celiac Patients With Ongoing Symptoms – A Randomized Controlled Trial. Clin Gastroenterol Hepatol. 2022 Oct;20(10):2258-66.e3. doi: 10.1016/j.cgh.2022.01.011. Epub 2022 Jan 17. PMID: 35051648.



November 2022

Sharzehi K et al. AGA Clinical Practice Update on Management of Subepithelial Lesions Encountered During Routine Endoscopy: Expert Review. Clin Gastroenterol Hepatol. 2022 Nov;20(11):2435-43.e4. doi: 10.1016/j.cgh.2022.05.054. Epub 2022 Jul 13. PMID: 35842117.



December 2022

Kardashian A et al. Food Insecurity is Associated With Mortality Among U.S. Adults With Nonalcoholic Fatty Liver Disease and Advanced Fibrosis. Clin Gastroenterol Hepatol. 2022 Dec;20(12):2790-9.e4. doi: 10.1016/j.cgh.2021.11.029. Epub 2021 Dec 16. PMID: 34958747.



Schuitenmaker JM et al. Sleep Positional Therapy for Nocturnal Gastroesophageal Reflux: A Double-Blind, Randomized, Sham-Controlled Trial. Clin Gastroenterol Hepatol. 2022 Dec;20(12):2753-62.e2. doi: 10.1016/j.cgh.2022.02.058. Epub 2022 Mar 14. PMID: 35301135.
 

Techniques and Innovations in Gastrointestinal Endoscopy

Azizian JM et al. Yield of Post-Acute Diverticulitis Colonoscopy for Ruling Out Colorectal Cancer. Tech Innov Gastrointest Endosc. 2022;24(3):254-61. doi: 10.1016/j.tige.2022.04.001. Epub 2022 Apr 18. PMID: 36540108; PMCID: PMC9762736.
 

Gastro Hep Advances

Kim RW et al. Timely Albumin Improves Survival in Patients With Cirrhosis on Diuretic Therapy Who Develop Acute Kidney Injury: Real-World Evidence in the United States. Gastro Hep Advances. 2023;2(2):252-60. doi: 10.1016/j.gastha.2022.10.008.

Gastroenterology

October 2022

Cryer B et al. Bridging the Racial, Ethnic, and Gender Gap in Gastroenterology. Gastroenterology. 2022 Oct;163(4):800-5. doi: 10.1053/j.gastro.2022.08.037. PMID: 36137708.



Bajaj JS and Nagy LE. Natural History of Alcohol-Associated Liver Disease: Understanding the Changing Landscape of Pathophysiology and Patient Care. Gastroenterology. 2022 Oct;163(4):840-51. doi: 10.1053/j.gastro.2022.05.031. Epub 2022 May 19. PMID: 35598629; PMCID: PMC9509416.



November 2022

Grunvald E et al; AGA Clinical Guidelines Committee. AGA Clinical Practice Guideline on Pharmacological Interventions for Adults With Obesity. Gastroenterology. 2022 Nov;163(5):1198-225. doi: 10.1053/j.gastro.2022.08.045. Epub 2022 Oct 20. PMID: 36273831.



December 2022

Blackett JW et al. Comparison of Anorectal Manometry, Rectal Balloon Expulsion Test, and Defecography for Diagnosing Defecatory Disorders. Gastroenterology. 2022 Dec;163(6):1582-92.e2. doi: 10.1053/j.gastro.2022.08.034. Epub 2022 Aug 19. PMID: 35995074; PMCID: PMC9691522.



de Voogd F et al. Intestinal Ultrasound Is Accurate to Determine Endoscopic Response and Remission in Patients With Moderate to Severe Ulcerative Colitis: A Longitudinal Prospective Cohort Study. Gastroenterology. 2022 Dec;163(6):1569-81. doi: 10.1053/j.gastro.2022.08.038. Epub 2022 Aug 24. PMID: 36030056.
 

Clinical Gastroenterology and Hepatology

October 2022

Bhavsar-Burke I et al. How to Promote Professional Identity Development and Support Fellows-In-Training Through Teaching, Coaching, Mentorship, and Sponsorship. Clin Gastroenterol Hepatol. 2022 Oct;20(10):2166-9. doi: 10.1016/j.cgh.2022.05.043. Epub 2022 Aug 7. PMID: 35948073.



van Megen F et al. A Low FODMAP Diet Reduces Symptoms in Treated Celiac Patients With Ongoing Symptoms – A Randomized Controlled Trial. Clin Gastroenterol Hepatol. 2022 Oct;20(10):2258-66.e3. doi: 10.1016/j.cgh.2022.01.011. Epub 2022 Jan 17. PMID: 35051648.



November 2022

Sharzehi K et al. AGA Clinical Practice Update on Management of Subepithelial Lesions Encountered During Routine Endoscopy: Expert Review. Clin Gastroenterol Hepatol. 2022 Nov;20(11):2435-43.e4. doi: 10.1016/j.cgh.2022.05.054. Epub 2022 Jul 13. PMID: 35842117.



December 2022

Kardashian A et al. Food Insecurity is Associated With Mortality Among U.S. Adults With Nonalcoholic Fatty Liver Disease and Advanced Fibrosis. Clin Gastroenterol Hepatol. 2022 Dec;20(12):2790-9.e4. doi: 10.1016/j.cgh.2021.11.029. Epub 2021 Dec 16. PMID: 34958747.



Schuitenmaker JM et al. Sleep Positional Therapy for Nocturnal Gastroesophageal Reflux: A Double-Blind, Randomized, Sham-Controlled Trial. Clin Gastroenterol Hepatol. 2022 Dec;20(12):2753-62.e2. doi: 10.1016/j.cgh.2022.02.058. Epub 2022 Mar 14. PMID: 35301135.
 

Techniques and Innovations in Gastrointestinal Endoscopy

Azizian JM et al. Yield of Post-Acute Diverticulitis Colonoscopy for Ruling Out Colorectal Cancer. Tech Innov Gastrointest Endosc. 2022;24(3):254-61. doi: 10.1016/j.tige.2022.04.001. Epub 2022 Apr 18. PMID: 36540108; PMCID: PMC9762736.
 

Gastro Hep Advances

Kim RW et al. Timely Albumin Improves Survival in Patients With Cirrhosis on Diuretic Therapy Who Develop Acute Kidney Injury: Real-World Evidence in the United States. Gastro Hep Advances. 2023;2(2):252-60. doi: 10.1016/j.gastha.2022.10.008.

Introduction

The field of cancer immunotherapy has exploded in recent years, with new therapies showing promising results for effective treatment of various cancer types. Immune checkpoint inhibitors (ICI) work by blocking checkpoint proteins that prevent breakdown of tumor cells by T-lymphocytes. Checkpoint proteins exist to prevent autoimmunity and destruction of healthy cells, but may allow tumor cells to grow unchallenged. Three checkpoint proteins – cytotoxic T-lymphocyte protein–4 (CTLA-4), programmed cell-death protein–1 (PD-1), and programmed cell-death protein ligand–1 (PDL-1) – are therapeutic targets for current ICIs.¹

ICIs are used to treat various cancer types (e.g., lung, renal-cell, and Hodgkin’s lymphoma). Immune-related adverse events (irAE) are frequently seen with ICI use, ranging from 15% to 90%, and can occur at any point during, or even after, treatment.²Although ICIs are known to cause multisystem adverse reactions, this review will discuss the spectrum of these reactions in the gastrointestinal and hepatopancreaticobiliary realms.

Immune checkpoint inhibitor–related gastrointestinal adverse reactions

GI adverse reactions are the second most common irAE, occurring in about 35%-50% of all reported irAEs.³ Anti-CTLA-4 medications have the highest association with GI irAE. The most common GI symptoms are diarrhea, abdominal pain, urgency, and nausea/vomiting. GI involvement can occur along the entirety of the GI tract – from the oral cavity to the colorectum. These are usually seen within 6-8 weeks of starting treatment, but can occur as early as 1 week after initiation or as late as 12 months after the last dose.² Although colitis is the most common area of luminal inflammation, aphthous ulcers, esophagitis, gastritis, and enteritis can be seen. Anti-CTLA-4 antibodies have the highest associated rate of diarrhea (33%-50%) and colitis (7%-22%) of all ICIs.⁴ Computed tomography (CT) may show colonic wall thickening or fat stranding, indicating inflammation. Endoscopically, the colon can appear grossly normal or demonstrate erythema, erosions, ulcerations, and/or loss of vascular pattern.⁵ Inflammation can be patchy or continuous. Typical histology shows increased lamina propria cellularity, neutrophilic infiltration (intraepithelial or crypt abscesses), and increased crypt apoptosis.⁶

The liver, pancreas, gallbladder, and biliary tract can also be affected by irAE. The liver is most commonly involved (i.e. 5% of irAE), manifesting as asymptomatic liver chemistry elevation, particularly aminotransferases. This can progress to acute symptomatic hepatitis with jaundice, fever, or malaise, and rarely to fulminant hepatitis. ICI-associated hepatitis appears histologically similar to autoimmune hepatitis, with pan-lobular hepatitis and infiltrating CD8+ T lymphocytes seen on liver biopsy.⁷ Less commonly, pancreatic toxicity can occur (<2% of irAE), seen with anti-CTLA-4 therapy.⁸ While this typically results in asymptomatic lipase or amylase elevations (2.7%), acute pancreatitis (AP) can occur(1.9%). ICI-associated AP presents with classic symptoms and imaging changes, but can also manifest with exocrine or endocrine pancreatic insufficiency. An increase in rates of acute acalculous cholecystitis has been reported in patients receiving ICIs compared to patients receiving non-ICI chemotherapy.⁹ There are also rare reports of ICI-associated secondary sclerosing cholangitis.
 

Management

Evaluation and management of GI irAEs are guided by severity, based on the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) grading classification (Table 1).¹⁰

A thorough history of GI and systemic symptoms should be obtained and compared to baseline bowel habits. Patients with mild symptoms should undergo studies to assess alternate etiologies for their symptoms. Bacterial stool cultures and testing for C. difficile should be performed. Erythrocyte sedimentation rate, C-reactive protein, fecal lactoferrin, and calprotectin can help assess the degree of intestinal inflammation and can be used to risk-stratify or assess treatment response. CT scans can assess for colitis and associated complications, including abdominal abscess, toxic megacolon, and bowel perforation.

Patients unresponsive to initial treatment for grade I irAE, with hematochezia, or with at least grade 2 diarrhea, should undergo GI consultation and endoscopic evaluation. Flexible sigmoidoscopy is the test of choice, as 95% of patients will have left-sided colonic inflammation.¹¹ Patients with at least grade 3 diarrhea should be hospitalized for treatment. In cases of failed methylprednisolone and when infliximab is ineffective or contraindicated, vedolizumab is suggested, although evidence is limited.¹²

Patients responsive to systemic corticosteroids (complete resolution or improvement to grade 1) can continue a tapered regimen over 4-6 weeks. There is conflicting evidence on the effect that corticosteroids have on ICI-related antitumor response rates. While some studies report no change in antitumor response rates or survival, others report reduced overall survival.¹³ Regardless, given its unfavorable side-effect profile, steroids should be used only for short periods of time.

PD-1 and PD-L1 antibodies can be restarted after symptoms have resolved or improved to grade 1, having finished the corticosteroid taper. CTLA-4 antibodies should be discontinued permanently in the setting of grade 3 toxicity. All ICIs should be discontinued permanently in grade 4 toxicity.

Conclusions

Therapy with ICI is a rapidly expanding and changing field. Side effects of ICIs can affect nearly every organ system, and thus management should involve a multidisciplinary team of oncologists, pathologists, radiologists, pharmacists, and other specialists. Given that GI adverse effects are the second most commonly affected system, all gastroenterologists and hepatologists should be knowledgeable about the spectrum of GI adverse events, as well as with the respective clinical presentations, diagnostics, and management of these events.

Dr. Kwon is with the division of gastroenterology and hepatology, University of California Irvine, Orange. Dr. Kröner is with the division of advanced endoscopy, Riverside Health System, Newport News, Va. The authors certify that they have no financial arrangements (e.g., consultancies, stock ownership, equity interests, patent-licensing arrangements, research support, honoraria, etc.) with a company whose product figures prominently in this manuscript or with a company making a competing product. Funding: None.

References

1. Webster RM. The immune checkpoint inhibitors: where are we now? Nature Reviews: Drug Discovery. 2014;13(12):883.

2. Thompson JA et al. NCCN guidelines insights: Management of immunotherapy-related toxicities, version 1.2020: Featured updates to the NCCN guidelines. J Natl Compr Canc Netw. 2020;18(3):230-41.

3. Bertrand A et al. Immune related adverse events associated with anti-CTLA-4 antibodies: Systematic review and meta-analysis. BMC Med. 2015 Sep 4;13:211.

4. Gupta A et al. Systematic review: Colitis associated with anti‐CTLA‐4 therapy. Aliment Pharmacol Ther. 2015;42(4):406-17.

5. Verschuren EC et al. Clinical, endoscopic, and histologic characteristics of ipilimumab-associated colitis. Clin Gastroenterol Hepatol. 2016;14(6):836-42.

6. Foppen MHG et al. Immune checkpoint inhibition–related colitis: Symptoms, endoscopic features, histology and response to management. ESMO Open. 2018;3(1):e000278.

7. Sanjeevaiah A et al. Approach and management of checkpoint inhibitor–related immune hepatitis. J Gastrointest Oncol. 2018;9(1):220.

8. Abu-Sbeih H et al. Clinical characteristics and outcomes of immune checkpoint inhibitor–induced pancreatic injury. J Immunother Cancer. 2019 Feb 6;7(1):31.

9. Abu-Sbeih H et al. Case series of cancer patients who developed cholecystitis related to immune checkpoint inhibitor treatment. J Immunother Cancer. 2019 May 3;7(1):118.

10. Thompson JA et al. Management of immunotherapy-related toxicities, version 1.2019, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw. 2019;17(3):255-89.

11. Marthey L et al. Cancer immunotherapy with anti-CTLA-4 monoclonal antibodies induces an inflammatory bowel disease. J Crohns Colitis. 2016;10(4):395-401.

12. Abu-Sbeih H et al. Outcomes of vedolizumab therapy in patients with immune checkpoint inhibitor–induced colitis: A multicenter study. J Immunother Cancer. 2018 Dec 5;6(1):142.

13. Das S and Johnson DB. Immune-related adverse events and anti-tumor efficacy of immune checkpoint inhibitors. J Immunother Cancer. 2019 Nov 15;7(1):306.

14. Reddy HG et al. Immune checkpoint inhibitor–associated colitis and hepatitis. Clin Transl Gastroenterol. 2018 Sep 19;9(9):180.

15. Reynolds K et al. Diagnosis and management of hepatitis in patients on checkpoint blockade. Oncologist. 2018;23(9):991-7.

Introduction

The field of cancer immunotherapy has exploded in recent years, with new therapies showing promising results for effective treatment of various cancer types. Immune checkpoint inhibitors (ICI) work by blocking checkpoint proteins that prevent breakdown of tumor cells by T-lymphocytes. Checkpoint proteins exist to prevent autoimmunity and destruction of healthy cells, but may allow tumor cells to grow unchallenged. Three checkpoint proteins – cytotoxic T-lymphocyte protein–4 (CTLA-4), programmed cell-death protein–1 (PD-1), and programmed cell-death protein ligand–1 (PDL-1) – are therapeutic targets for current ICIs.¹

ICIs are used to treat various cancer types (e.g., lung, renal-cell, and Hodgkin’s lymphoma). Immune-related adverse events (irAE) are frequently seen with ICI use, ranging from 15% to 90%, and can occur at any point during, or even after, treatment.²Although ICIs are known to cause multisystem adverse reactions, this review will discuss the spectrum of these reactions in the gastrointestinal and hepatopancreaticobiliary realms.

Immune checkpoint inhibitor–related gastrointestinal adverse reactions

GI adverse reactions are the second most common irAE, occurring in about 35%-50% of all reported irAEs.³ Anti-CTLA-4 medications have the highest association with GI irAE. The most common GI symptoms are diarrhea, abdominal pain, urgency, and nausea/vomiting. GI involvement can occur along the entirety of the GI tract – from the oral cavity to the colorectum. These are usually seen within 6-8 weeks of starting treatment, but can occur as early as 1 week after initiation or as late as 12 months after the last dose.² Although colitis is the most common area of luminal inflammation, aphthous ulcers, esophagitis, gastritis, and enteritis can be seen. Anti-CTLA-4 antibodies have the highest associated rate of diarrhea (33%-50%) and colitis (7%-22%) of all ICIs.⁴ Computed tomography (CT) may show colonic wall thickening or fat stranding, indicating inflammation. Endoscopically, the colon can appear grossly normal or demonstrate erythema, erosions, ulcerations, and/or loss of vascular pattern.⁵ Inflammation can be patchy or continuous. Typical histology shows increased lamina propria cellularity, neutrophilic infiltration (intraepithelial or crypt abscesses), and increased crypt apoptosis.⁶

The liver, pancreas, gallbladder, and biliary tract can also be affected by irAE. The liver is most commonly involved (i.e. 5% of irAE), manifesting as asymptomatic liver chemistry elevation, particularly aminotransferases. This can progress to acute symptomatic hepatitis with jaundice, fever, or malaise, and rarely to fulminant hepatitis. ICI-associated hepatitis appears histologically similar to autoimmune hepatitis, with pan-lobular hepatitis and infiltrating CD8+ T lymphocytes seen on liver biopsy.⁷ Less commonly, pancreatic toxicity can occur (<2% of irAE), seen with anti-CTLA-4 therapy.⁸ While this typically results in asymptomatic lipase or amylase elevations (2.7%), acute pancreatitis (AP) can occur(1.9%). ICI-associated AP presents with classic symptoms and imaging changes, but can also manifest with exocrine or endocrine pancreatic insufficiency. An increase in rates of acute acalculous cholecystitis has been reported in patients receiving ICIs compared to patients receiving non-ICI chemotherapy.⁹ There are also rare reports of ICI-associated secondary sclerosing cholangitis.
 

Management

Evaluation and management of GI irAEs are guided by severity, based on the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) grading classification (Table 1).¹⁰

A thorough history of GI and systemic symptoms should be obtained and compared to baseline bowel habits. Patients with mild symptoms should undergo studies to assess alternate etiologies for their symptoms. Bacterial stool cultures and testing for C. difficile should be performed. Erythrocyte sedimentation rate, C-reactive protein, fecal lactoferrin, and calprotectin can help assess the degree of intestinal inflammation and can be used to risk-stratify or assess treatment response. CT scans can assess for colitis and associated complications, including abdominal abscess, toxic megacolon, and bowel perforation.

Patients unresponsive to initial treatment for grade I irAE, with hematochezia, or with at least grade 2 diarrhea, should undergo GI consultation and endoscopic evaluation. Flexible sigmoidoscopy is the test of choice, as 95% of patients will have left-sided colonic inflammation.¹¹ Patients with at least grade 3 diarrhea should be hospitalized for treatment. In cases of failed methylprednisolone and when infliximab is ineffective or contraindicated, vedolizumab is suggested, although evidence is limited.¹²

Patients responsive to systemic corticosteroids (complete resolution or improvement to grade 1) can continue a tapered regimen over 4-6 weeks. There is conflicting evidence on the effect that corticosteroids have on ICI-related antitumor response rates. While some studies report no change in antitumor response rates or survival, others report reduced overall survival.¹³ Regardless, given its unfavorable side-effect profile, steroids should be used only for short periods of time.

PD-1 and PD-L1 antibodies can be restarted after symptoms have resolved or improved to grade 1, having finished the corticosteroid taper. CTLA-4 antibodies should be discontinued permanently in the setting of grade 3 toxicity. All ICIs should be discontinued permanently in grade 4 toxicity.

Conclusions

Therapy with ICI is a rapidly expanding and changing field. Side effects of ICIs can affect nearly every organ system, and thus management should involve a multidisciplinary team of oncologists, pathologists, radiologists, pharmacists, and other specialists. Given that GI adverse effects are the second most commonly affected system, all gastroenterologists and hepatologists should be knowledgeable about the spectrum of GI adverse events, as well as with the respective clinical presentations, diagnostics, and management of these events.

Dr. Kwon is with the division of gastroenterology and hepatology, University of California Irvine, Orange. Dr. Kröner is with the division of advanced endoscopy, Riverside Health System, Newport News, Va. The authors certify that they have no financial arrangements (e.g., consultancies, stock ownership, equity interests, patent-licensing arrangements, research support, honoraria, etc.) with a company whose product figures prominently in this manuscript or with a company making a competing product. Funding: None.

References

1. Webster RM. The immune checkpoint inhibitors: where are we now? Nature Reviews: Drug Discovery. 2014;13(12):883.

2. Thompson JA et al. NCCN guidelines insights: Management of immunotherapy-related toxicities, version 1.2020: Featured updates to the NCCN guidelines. J Natl Compr Canc Netw. 2020;18(3):230-41.

3. Bertrand A et al. Immune related adverse events associated with anti-CTLA-4 antibodies: Systematic review and meta-analysis. BMC Med. 2015 Sep 4;13:211.

4. Gupta A et al. Systematic review: Colitis associated with anti‐CTLA‐4 therapy. Aliment Pharmacol Ther. 2015;42(4):406-17.

5. Verschuren EC et al. Clinical, endoscopic, and histologic characteristics of ipilimumab-associated colitis. Clin Gastroenterol Hepatol. 2016;14(6):836-42.

6. Foppen MHG et al. Immune checkpoint inhibition–related colitis: Symptoms, endoscopic features, histology and response to management. ESMO Open. 2018;3(1):e000278.

7. Sanjeevaiah A et al. Approach and management of checkpoint inhibitor–related immune hepatitis. J Gastrointest Oncol. 2018;9(1):220.

8. Abu-Sbeih H et al. Clinical characteristics and outcomes of immune checkpoint inhibitor–induced pancreatic injury. J Immunother Cancer. 2019 Feb 6;7(1):31.

9. Abu-Sbeih H et al. Case series of cancer patients who developed cholecystitis related to immune checkpoint inhibitor treatment. J Immunother Cancer. 2019 May 3;7(1):118.

10. Thompson JA et al. Management of immunotherapy-related toxicities, version 1.2019, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw. 2019;17(3):255-89.

11. Marthey L et al. Cancer immunotherapy with anti-CTLA-4 monoclonal antibodies induces an inflammatory bowel disease. J Crohns Colitis. 2016;10(4):395-401.

12. Abu-Sbeih H et al. Outcomes of vedolizumab therapy in patients with immune checkpoint inhibitor–induced colitis: A multicenter study. J Immunother Cancer. 2018 Dec 5;6(1):142.

13. Das S and Johnson DB. Immune-related adverse events and anti-tumor efficacy of immune checkpoint inhibitors. J Immunother Cancer. 2019 Nov 15;7(1):306.

14. Reddy HG et al. Immune checkpoint inhibitor–associated colitis and hepatitis. Clin Transl Gastroenterol. 2018 Sep 19;9(9):180.

15. Reynolds K et al. Diagnosis and management of hepatitis in patients on checkpoint blockade. Oncologist. 2018;23(9):991-7.

Introduction

The field of cancer immunotherapy has exploded in recent years, with new therapies showing promising results for effective treatment of various cancer types. Immune checkpoint inhibitors (ICI) work by blocking checkpoint proteins that prevent breakdown of tumor cells by T-lymphocytes. Checkpoint proteins exist to prevent autoimmunity and destruction of healthy cells, but may allow tumor cells to grow unchallenged. Three checkpoint proteins – cytotoxic T-lymphocyte protein–4 (CTLA-4), programmed cell-death protein–1 (PD-1), and programmed cell-death protein ligand–1 (PDL-1) – are therapeutic targets for current ICIs.¹

ICIs are used to treat various cancer types (e.g., lung, renal-cell, and Hodgkin’s lymphoma). Immune-related adverse events (irAE) are frequently seen with ICI use, ranging from 15% to 90%, and can occur at any point during, or even after, treatment.²Although ICIs are known to cause multisystem adverse reactions, this review will discuss the spectrum of these reactions in the gastrointestinal and hepatopancreaticobiliary realms.

Immune checkpoint inhibitor–related gastrointestinal adverse reactions

GI adverse reactions are the second most common irAE, occurring in about 35%-50% of all reported irAEs.³ Anti-CTLA-4 medications have the highest association with GI irAE. The most common GI symptoms are diarrhea, abdominal pain, urgency, and nausea/vomiting. GI involvement can occur along the entirety of the GI tract – from the oral cavity to the colorectum. These are usually seen within 6-8 weeks of starting treatment, but can occur as early as 1 week after initiation or as late as 12 months after the last dose.² Although colitis is the most common area of luminal inflammation, aphthous ulcers, esophagitis, gastritis, and enteritis can be seen. Anti-CTLA-4 antibodies have the highest associated rate of diarrhea (33%-50%) and colitis (7%-22%) of all ICIs.⁴ Computed tomography (CT) may show colonic wall thickening or fat stranding, indicating inflammation. Endoscopically, the colon can appear grossly normal or demonstrate erythema, erosions, ulcerations, and/or loss of vascular pattern.⁵ Inflammation can be patchy or continuous. Typical histology shows increased lamina propria cellularity, neutrophilic infiltration (intraepithelial or crypt abscesses), and increased crypt apoptosis.⁶

The liver, pancreas, gallbladder, and biliary tract can also be affected by irAE. The liver is most commonly involved (i.e. 5% of irAE), manifesting as asymptomatic liver chemistry elevation, particularly aminotransferases. This can progress to acute symptomatic hepatitis with jaundice, fever, or malaise, and rarely to fulminant hepatitis. ICI-associated hepatitis appears histologically similar to autoimmune hepatitis, with pan-lobular hepatitis and infiltrating CD8+ T lymphocytes seen on liver biopsy.⁷ Less commonly, pancreatic toxicity can occur (<2% of irAE), seen with anti-CTLA-4 therapy.⁸ While this typically results in asymptomatic lipase or amylase elevations (2.7%), acute pancreatitis (AP) can occur(1.9%). ICI-associated AP presents with classic symptoms and imaging changes, but can also manifest with exocrine or endocrine pancreatic insufficiency. An increase in rates of acute acalculous cholecystitis has been reported in patients receiving ICIs compared to patients receiving non-ICI chemotherapy.⁹ There are also rare reports of ICI-associated secondary sclerosing cholangitis.
 

Management

Evaluation and management of GI irAEs are guided by severity, based on the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) grading classification (Table 1).¹⁰

A thorough history of GI and systemic symptoms should be obtained and compared to baseline bowel habits. Patients with mild symptoms should undergo studies to assess alternate etiologies for their symptoms. Bacterial stool cultures and testing for C. difficile should be performed. Erythrocyte sedimentation rate, C-reactive protein, fecal lactoferrin, and calprotectin can help assess the degree of intestinal inflammation and can be used to risk-stratify or assess treatment response. CT scans can assess for colitis and associated complications, including abdominal abscess, toxic megacolon, and bowel perforation.

Patients unresponsive to initial treatment for grade I irAE, with hematochezia, or with at least grade 2 diarrhea, should undergo GI consultation and endoscopic evaluation. Flexible sigmoidoscopy is the test of choice, as 95% of patients will have left-sided colonic inflammation.¹¹ Patients with at least grade 3 diarrhea should be hospitalized for treatment. In cases of failed methylprednisolone and when infliximab is ineffective or contraindicated, vedolizumab is suggested, although evidence is limited.¹²

Patients responsive to systemic corticosteroids (complete resolution or improvement to grade 1) can continue a tapered regimen over 4-6 weeks. There is conflicting evidence on the effect that corticosteroids have on ICI-related antitumor response rates. While some studies report no change in antitumor response rates or survival, others report reduced overall survival.¹³ Regardless, given its unfavorable side-effect profile, steroids should be used only for short periods of time.

PD-1 and PD-L1 antibodies can be restarted after symptoms have resolved or improved to grade 1, having finished the corticosteroid taper. CTLA-4 antibodies should be discontinued permanently in the setting of grade 3 toxicity. All ICIs should be discontinued permanently in grade 4 toxicity.

Conclusions

Therapy with ICI is a rapidly expanding and changing field. Side effects of ICIs can affect nearly every organ system, and thus management should involve a multidisciplinary team of oncologists, pathologists, radiologists, pharmacists, and other specialists. Given that GI adverse effects are the second most commonly affected system, all gastroenterologists and hepatologists should be knowledgeable about the spectrum of GI adverse events, as well as with the respective clinical presentations, diagnostics, and management of these events.

Dr. Kwon is with the division of gastroenterology and hepatology, University of California Irvine, Orange. Dr. Kröner is with the division of advanced endoscopy, Riverside Health System, Newport News, Va. The authors certify that they have no financial arrangements (e.g., consultancies, stock ownership, equity interests, patent-licensing arrangements, research support, honoraria, etc.) with a company whose product figures prominently in this manuscript or with a company making a competing product. Funding: None.

References

1. Webster RM. The immune checkpoint inhibitors: where are we now? Nature Reviews: Drug Discovery. 2014;13(12):883.

2. Thompson JA et al. NCCN guidelines insights: Management of immunotherapy-related toxicities, version 1.2020: Featured updates to the NCCN guidelines. J Natl Compr Canc Netw. 2020;18(3):230-41.

3. Bertrand A et al. Immune related adverse events associated with anti-CTLA-4 antibodies: Systematic review and meta-analysis. BMC Med. 2015 Sep 4;13:211.

4. Gupta A et al. Systematic review: Colitis associated with anti‐CTLA‐4 therapy. Aliment Pharmacol Ther. 2015;42(4):406-17.

5. Verschuren EC et al. Clinical, endoscopic, and histologic characteristics of ipilimumab-associated colitis. Clin Gastroenterol Hepatol. 2016;14(6):836-42.

6. Foppen MHG et al. Immune checkpoint inhibition–related colitis: Symptoms, endoscopic features, histology and response to management. ESMO Open. 2018;3(1):e000278.

7. Sanjeevaiah A et al. Approach and management of checkpoint inhibitor–related immune hepatitis. J Gastrointest Oncol. 2018;9(1):220.

8. Abu-Sbeih H et al. Clinical characteristics and outcomes of immune checkpoint inhibitor–induced pancreatic injury. J Immunother Cancer. 2019 Feb 6;7(1):31.

9. Abu-Sbeih H et al. Case series of cancer patients who developed cholecystitis related to immune checkpoint inhibitor treatment. J Immunother Cancer. 2019 May 3;7(1):118.

10. Thompson JA et al. Management of immunotherapy-related toxicities, version 1.2019, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw. 2019;17(3):255-89.

11. Marthey L et al. Cancer immunotherapy with anti-CTLA-4 monoclonal antibodies induces an inflammatory bowel disease. J Crohns Colitis. 2016;10(4):395-401.

12. Abu-Sbeih H et al. Outcomes of vedolizumab therapy in patients with immune checkpoint inhibitor–induced colitis: A multicenter study. J Immunother Cancer. 2018 Dec 5;6(1):142.

13. Das S and Johnson DB. Immune-related adverse events and anti-tumor efficacy of immune checkpoint inhibitors. J Immunother Cancer. 2019 Nov 15;7(1):306.

14. Reddy HG et al. Immune checkpoint inhibitor–associated colitis and hepatitis. Clin Transl Gastroenterol. 2018 Sep 19;9(9):180.

15. Reynolds K et al. Diagnosis and management of hepatitis in patients on checkpoint blockade. Oncologist. 2018;23(9):991-7.

It was my dream from an early age to become a physician. Even as a child I was fascinated by medical procedures and interventions. As I pursued my medical degree, I became increasingly interested in a career where I could integrate patient care and the latest innovations in technology.

Training in gastroenterology has provided me an exciting mix of patient care and procedures, with medical devices and technologies that are constantly evolving. As I began my career, I joined Dayton Gastroenterology, a private practice affiliated with GI fellowship at Wright State University, Fairborn, Ohio, because the practice provided an opportunity to care for patients, train GI fellows, and provide employment opportunities to the community I serve.

After spending so many years to become an expert in medicine and then training in gastroenterology, it might have seemed daunting to go back to school to get an education in another field. But we all know the medical environment is constantly changing – in the last decade dramatically so, in technology as well as in how groups are organizing themselves in response to health care consolidation and other external forces. Developing expertise in both medicine and business can prepare physicians to be better advocates and leaders as health care continues to change.
 

The importance of understanding the business of health care

Consolidation in health care has increasingly impacted private practices, with more primary care and specialty physicians being employed by hospitals. In some areas of the country, this has affected the flow of patient referrals to independent GI practices, and these practices must now adapt to continue serving their communities. This is being amplified by the increasing demands for patient services coupled with staffing issues and reimbursement cuts.

These challenges have resulted in some smaller practices joining local hospitals systems. Others have come together to form larger groups or managed services organizations (MSO), and some have partnered with private equity firms to compete in response to these market forces.

During our training and education in medical school, we aren’t taught how to run a successful practice. We aren’t taught how to bring together different industry partners, collaborators, and payers or how to build patient-centric practice models. But sometimes the best method of learning is by doing, and my experiences during the merger of Dayton Gastroenterology with One GI, a physician-focused MSO with practices in six states, was invaluable.

That merger process taught me a lot about how companies are valued, the nuances in determining deal flow, networking, human capital, and everything else involved in how a transaction takes place. I developed a greater understanding about how to develop and build successful large practices, with improved employee satisfaction, company culture, and great patient experience.
 

Developing a positive practice culture

It was during the process of partnering with One GI and during the pandemic that I decided to pursue my desire to get a formal business education, and I’m glad I did. The executive MBA program at the Kellogg School of Management at Northwestern University allowed me to gain an in-depth understanding of various aspects of business, finance, accounting, marketing, leadership, governance, organizational transformation, negotiations, and so much more, all while continuing to work full time as a gastroenterologist in private practice.

We met for classes in-person each month over the course of four days. There were also live and recorded virtual sessions in between each monthly class. The program was rigorous, but worth it. Connecting with leaders from different industries and learning from exceptional professors alongside these professionals was an invaluable experience.

Two of the most vital things I learned were the importance of team building and development of a company culture that will sustain an organization over the long term. I learned management strategies to empower employees, governance best practices, and how to align the interests of internal and external stakeholders.

Anyone can buy a practice, and anyone can merge their practice into a larger entity, but it is critical to understand the components of a successful integration. Culture eats strategy for breakfast. You can have the best minds, develop the best processes, but if there is not a strong culture with the alignment of physicians, staff, and practice management, even the best strategies can easily fail.

What to look for in joining a practice

As physicians, we all want to be the best at what we do. It’s important to be intentional about what you value and how you would like to shape your career. When considering which practice you might join, there are several things to consider, such as the location, medical needs of the community, and services offered by the practice. Equally important is understanding how the practice is managed.

Does the practice promote growth opportunities for its physicians and staff? Are there governance structures and processes in place to empower and retain talented staff? What values does the practice portray? Is there a buy-in or buy-out when becoming a partner in the practice, and are there equity opportunities? These are just some of many questions early-career physicians should ask.
 

My MBA helped me become a better leader

A physician understands the needs of delivering exceptional medical care, the challenges involved, and the resources required. Increasing the depth and breadth of our knowledge is power. Good people make good organizations, but great people make great organizations. Those of us who are on the front lines are the best advocates for our patients and other frontline workers. We can become powerful advocates and leaders when we better understand how business trends and other external forces affect our ability to care for the patients in the future.

Pursuing a business education provides a strong foundation for physician leaders who have strong analytical intuition and focus on patient-centric practice models. If you are considering a career in private practice and are interested in practice management or growing a practice, an MBA or similar educational programs will provide an understanding of finance, accounting, and other business-related fields that can enable physicians to become agile and empathic leaders.
 

Dr. Appalaneni is a practicing gastroenterologist at Dayton Gastroenterology in Ohio. She is Executive Vice President of Clinical Innovation at One GI, a physician-led managed services organization. Dr. Appalaneni has no conflicts to declare.

It was my dream from an early age to become a physician. Even as a child I was fascinated by medical procedures and interventions. As I pursued my medical degree, I became increasingly interested in a career where I could integrate patient care and the latest innovations in technology.

Training in gastroenterology has provided me an exciting mix of patient care and procedures, with medical devices and technologies that are constantly evolving. As I began my career, I joined Dayton Gastroenterology, a private practice affiliated with GI fellowship at Wright State University, Fairborn, Ohio, because the practice provided an opportunity to care for patients, train GI fellows, and provide employment opportunities to the community I serve.

After spending so many years to become an expert in medicine and then training in gastroenterology, it might have seemed daunting to go back to school to get an education in another field. But we all know the medical environment is constantly changing – in the last decade dramatically so, in technology as well as in how groups are organizing themselves in response to health care consolidation and other external forces. Developing expertise in both medicine and business can prepare physicians to be better advocates and leaders as health care continues to change.
 

The importance of understanding the business of health care

Consolidation in health care has increasingly impacted private practices, with more primary care and specialty physicians being employed by hospitals. In some areas of the country, this has affected the flow of patient referrals to independent GI practices, and these practices must now adapt to continue serving their communities. This is being amplified by the increasing demands for patient services coupled with staffing issues and reimbursement cuts.

These challenges have resulted in some smaller practices joining local hospitals systems. Others have come together to form larger groups or managed services organizations (MSO), and some have partnered with private equity firms to compete in response to these market forces.

During our training and education in medical school, we aren’t taught how to run a successful practice. We aren’t taught how to bring together different industry partners, collaborators, and payers or how to build patient-centric practice models. But sometimes the best method of learning is by doing, and my experiences during the merger of Dayton Gastroenterology with One GI, a physician-focused MSO with practices in six states, was invaluable.

That merger process taught me a lot about how companies are valued, the nuances in determining deal flow, networking, human capital, and everything else involved in how a transaction takes place. I developed a greater understanding about how to develop and build successful large practices, with improved employee satisfaction, company culture, and great patient experience.
 

Developing a positive practice culture

It was during the process of partnering with One GI and during the pandemic that I decided to pursue my desire to get a formal business education, and I’m glad I did. The executive MBA program at the Kellogg School of Management at Northwestern University allowed me to gain an in-depth understanding of various aspects of business, finance, accounting, marketing, leadership, governance, organizational transformation, negotiations, and so much more, all while continuing to work full time as a gastroenterologist in private practice.

We met for classes in-person each month over the course of four days. There were also live and recorded virtual sessions in between each monthly class. The program was rigorous, but worth it. Connecting with leaders from different industries and learning from exceptional professors alongside these professionals was an invaluable experience.

Two of the most vital things I learned were the importance of team building and development of a company culture that will sustain an organization over the long term. I learned management strategies to empower employees, governance best practices, and how to align the interests of internal and external stakeholders.

Anyone can buy a practice, and anyone can merge their practice into a larger entity, but it is critical to understand the components of a successful integration. Culture eats strategy for breakfast. You can have the best minds, develop the best processes, but if there is not a strong culture with the alignment of physicians, staff, and practice management, even the best strategies can easily fail.

What to look for in joining a practice

As physicians, we all want to be the best at what we do. It’s important to be intentional about what you value and how you would like to shape your career. When considering which practice you might join, there are several things to consider, such as the location, medical needs of the community, and services offered by the practice. Equally important is understanding how the practice is managed.

Does the practice promote growth opportunities for its physicians and staff? Are there governance structures and processes in place to empower and retain talented staff? What values does the practice portray? Is there a buy-in or buy-out when becoming a partner in the practice, and are there equity opportunities? These are just some of many questions early-career physicians should ask.
 

My MBA helped me become a better leader

A physician understands the needs of delivering exceptional medical care, the challenges involved, and the resources required. Increasing the depth and breadth of our knowledge is power. Good people make good organizations, but great people make great organizations. Those of us who are on the front lines are the best advocates for our patients and other frontline workers. We can become powerful advocates and leaders when we better understand how business trends and other external forces affect our ability to care for the patients in the future.

Pursuing a business education provides a strong foundation for physician leaders who have strong analytical intuition and focus on patient-centric practice models. If you are considering a career in private practice and are interested in practice management or growing a practice, an MBA or similar educational programs will provide an understanding of finance, accounting, and other business-related fields that can enable physicians to become agile and empathic leaders.
 

Dr. Appalaneni is a practicing gastroenterologist at Dayton Gastroenterology in Ohio. She is Executive Vice President of Clinical Innovation at One GI, a physician-led managed services organization. Dr. Appalaneni has no conflicts to declare.

It was my dream from an early age to become a physician. Even as a child I was fascinated by medical procedures and interventions. As I pursued my medical degree, I became increasingly interested in a career where I could integrate patient care and the latest innovations in technology.

Training in gastroenterology has provided me an exciting mix of patient care and procedures, with medical devices and technologies that are constantly evolving. As I began my career, I joined Dayton Gastroenterology, a private practice affiliated with GI fellowship at Wright State University, Fairborn, Ohio, because the practice provided an opportunity to care for patients, train GI fellows, and provide employment opportunities to the community I serve.

After spending so many years to become an expert in medicine and then training in gastroenterology, it might have seemed daunting to go back to school to get an education in another field. But we all know the medical environment is constantly changing – in the last decade dramatically so, in technology as well as in how groups are organizing themselves in response to health care consolidation and other external forces. Developing expertise in both medicine and business can prepare physicians to be better advocates and leaders as health care continues to change.
 

The importance of understanding the business of health care

Consolidation in health care has increasingly impacted private practices, with more primary care and specialty physicians being employed by hospitals. In some areas of the country, this has affected the flow of patient referrals to independent GI practices, and these practices must now adapt to continue serving their communities. This is being amplified by the increasing demands for patient services coupled with staffing issues and reimbursement cuts.

These challenges have resulted in some smaller practices joining local hospitals systems. Others have come together to form larger groups or managed services organizations (MSO), and some have partnered with private equity firms to compete in response to these market forces.

During our training and education in medical school, we aren’t taught how to run a successful practice. We aren’t taught how to bring together different industry partners, collaborators, and payers or how to build patient-centric practice models. But sometimes the best method of learning is by doing, and my experiences during the merger of Dayton Gastroenterology with One GI, a physician-focused MSO with practices in six states, was invaluable.

That merger process taught me a lot about how companies are valued, the nuances in determining deal flow, networking, human capital, and everything else involved in how a transaction takes place. I developed a greater understanding about how to develop and build successful large practices, with improved employee satisfaction, company culture, and great patient experience.
 

Developing a positive practice culture

It was during the process of partnering with One GI and during the pandemic that I decided to pursue my desire to get a formal business education, and I’m glad I did. The executive MBA program at the Kellogg School of Management at Northwestern University allowed me to gain an in-depth understanding of various aspects of business, finance, accounting, marketing, leadership, governance, organizational transformation, negotiations, and so much more, all while continuing to work full time as a gastroenterologist in private practice.

We met for classes in-person each month over the course of four days. There were also live and recorded virtual sessions in between each monthly class. The program was rigorous, but worth it. Connecting with leaders from different industries and learning from exceptional professors alongside these professionals was an invaluable experience.

Two of the most vital things I learned were the importance of team building and development of a company culture that will sustain an organization over the long term. I learned management strategies to empower employees, governance best practices, and how to align the interests of internal and external stakeholders.

Anyone can buy a practice, and anyone can merge their practice into a larger entity, but it is critical to understand the components of a successful integration. Culture eats strategy for breakfast. You can have the best minds, develop the best processes, but if there is not a strong culture with the alignment of physicians, staff, and practice management, even the best strategies can easily fail.

What to look for in joining a practice

As physicians, we all want to be the best at what we do. It’s important to be intentional about what you value and how you would like to shape your career. When considering which practice you might join, there are several things to consider, such as the location, medical needs of the community, and services offered by the practice. Equally important is understanding how the practice is managed.

Does the practice promote growth opportunities for its physicians and staff? Are there governance structures and processes in place to empower and retain talented staff? What values does the practice portray? Is there a buy-in or buy-out when becoming a partner in the practice, and are there equity opportunities? These are just some of many questions early-career physicians should ask.
 

My MBA helped me become a better leader

A physician understands the needs of delivering exceptional medical care, the challenges involved, and the resources required. Increasing the depth and breadth of our knowledge is power. Good people make good organizations, but great people make great organizations. Those of us who are on the front lines are the best advocates for our patients and other frontline workers. We can become powerful advocates and leaders when we better understand how business trends and other external forces affect our ability to care for the patients in the future.

Pursuing a business education provides a strong foundation for physician leaders who have strong analytical intuition and focus on patient-centric practice models. If you are considering a career in private practice and are interested in practice management or growing a practice, an MBA or similar educational programs will provide an understanding of finance, accounting, and other business-related fields that can enable physicians to become agile and empathic leaders.
 

Dr. Appalaneni is a practicing gastroenterologist at Dayton Gastroenterology in Ohio. She is Executive Vice President of Clinical Innovation at One GI, a physician-led managed services organization. Dr. Appalaneni has no conflicts to declare.

AGA members advocate for GI during Alliance of Specialty Medicine fly-in

In December, six AGA members joined more than 100 specialty doctors organized by the Alliance of Specialty Medicine, a coalition that represents specialty physicians, to meet with House and Senate offices and discuss pressing policy priorities.

Members spoke on behalf of GI and stressed the need for Congress to act immediately on the upcoming Medicare cuts, and discussed step therapy protocols, prior authorization reform, and the role of artificial intelligence in the specialty.

Courtesy AGA

Our members represented GI well throughout the day’s meetings!

AGA PAC Board Member and Congressional Advocate Dr. Sadeea Abbasi spoke to House Leader Kevin McCarthy (R-CA) about challenges specialty doctors are facing and petitioned for Congress to mitigate the nearly 10 percent Medicare payment cuts before the end of the 117th Congress.

Additionally, AGA Government Affairs Committee Chair Dr. Rotonya Carr engaged with several members of Congress on issues impacting specialty care and discussed the future of AI in medicine with Rep. Mariannette Miller-Meeks (R-IA), who is an ophthalmologist.

Thank you to all our members who spoke on behalf of GI! We appreciate our AGA leaders who took time to participate!

• Sadeea Abbasi, MD, PhD
• Dawn B. Beaulieu, MD, AGAF
• Brent Burnette, MD
• Rotonya M. Carr, MD, FACP
• Peter S. Margolis, MD, AGAF
• Suzette Rivera MacMurray, MD

Learn how AGA is advocating for you. Visit gastro.org/advocacy.

AGA workshops champion women in GI

At AGA, we’re committed to supporting, empowering, and amplifying women in GI. As part of our ongoing efforts, we were thrilled to host nearly 250 women at four Women in GI regional workshops this fall. These workshops provided women across the country with opportunities to develop their personal and professional networks, participate in leadership development seminars, receive career mentoring, and engage in various wellness practices.

Following the conclusion of the regional workshops, we hosted the AGA Women’s Leadership Collaboration Conference at the AGA national office in Bethesda, Md.

Courtesy AGA

During the two-day conference, 22 delegates discussed workplace experiences, reported on their region’s workshop, and participated in strategy development exercises to further gender equity in GI, which included identifying tactics and ideas for action.

This unique event brought together delegates from each regional workshop, including 2023 Dr. Maria Leo-Lieber scholarship winners Alyssa Parian and Alexandra Livanos, who attended the Northeast workshop. It was a great time of collaboration and connection with the AGA #WomenInGI community!

Thank you to everyone who participated and made the events a success. We look forward to uplifting all women in GI and identifying ways to support the community in the coming year.

AGA thanks Johnson & Johnson Health Care Systems, Inc. for their support of this program.


 

Help move innovation forward at the 2023 AGA Tech Summit

Innovative technologies for endoscopy, advanced imaging, and bariatric care are a few of the topics that will headline the 2023 AGA Tech Summit, March 9-10, 2023, at the Grand Hyatt San Francisco. Registration is now open. Visit techsummit.gastro.org to secure your spot.

The Tech Summit is where GI innovators, clinicians, medical device companies, venture capitalists and regulatory agencies meet to foster the development and adoption of GI technologies. It is the perfect venue for:

• All innovators, entrepreneurs and clinicians who want to build their professional networks in the GI space.
• Early-stage GI companies who want to showcase their technologies and find new ideas for further innovations that will improve patient care.
• GI fellows who want an exclusive and immersive behind-the-scenes look into the MedTech world.

Learn more by visiting techsummit.gastro.org.

AGA members advocate for GI during Alliance of Specialty Medicine fly-in

In December, six AGA members joined more than 100 specialty doctors organized by the Alliance of Specialty Medicine, a coalition that represents specialty physicians, to meet with House and Senate offices and discuss pressing policy priorities.

Members spoke on behalf of GI and stressed the need for Congress to act immediately on the upcoming Medicare cuts, and discussed step therapy protocols, prior authorization reform, and the role of artificial intelligence in the specialty.

Courtesy AGA

Our members represented GI well throughout the day’s meetings!

AGA PAC Board Member and Congressional Advocate Dr. Sadeea Abbasi spoke to House Leader Kevin McCarthy (R-CA) about challenges specialty doctors are facing and petitioned for Congress to mitigate the nearly 10 percent Medicare payment cuts before the end of the 117th Congress.

Additionally, AGA Government Affairs Committee Chair Dr. Rotonya Carr engaged with several members of Congress on issues impacting specialty care and discussed the future of AI in medicine with Rep. Mariannette Miller-Meeks (R-IA), who is an ophthalmologist.

Thank you to all our members who spoke on behalf of GI! We appreciate our AGA leaders who took time to participate!

• Sadeea Abbasi, MD, PhD
• Dawn B. Beaulieu, MD, AGAF
• Brent Burnette, MD
• Rotonya M. Carr, MD, FACP
• Peter S. Margolis, MD, AGAF
• Suzette Rivera MacMurray, MD

Learn how AGA is advocating for you. Visit gastro.org/advocacy.

AGA workshops champion women in GI

At AGA, we’re committed to supporting, empowering, and amplifying women in GI. As part of our ongoing efforts, we were thrilled to host nearly 250 women at four Women in GI regional workshops this fall. These workshops provided women across the country with opportunities to develop their personal and professional networks, participate in leadership development seminars, receive career mentoring, and engage in various wellness practices.

Following the conclusion of the regional workshops, we hosted the AGA Women’s Leadership Collaboration Conference at the AGA national office in Bethesda, Md.

Courtesy AGA

During the two-day conference, 22 delegates discussed workplace experiences, reported on their region’s workshop, and participated in strategy development exercises to further gender equity in GI, which included identifying tactics and ideas for action.

This unique event brought together delegates from each regional workshop, including 2023 Dr. Maria Leo-Lieber scholarship winners Alyssa Parian and Alexandra Livanos, who attended the Northeast workshop. It was a great time of collaboration and connection with the AGA #WomenInGI community!

Thank you to everyone who participated and made the events a success. We look forward to uplifting all women in GI and identifying ways to support the community in the coming year.

AGA thanks Johnson & Johnson Health Care Systems, Inc. for their support of this program.


 

Help move innovation forward at the 2023 AGA Tech Summit

Innovative technologies for endoscopy, advanced imaging, and bariatric care are a few of the topics that will headline the 2023 AGA Tech Summit, March 9-10, 2023, at the Grand Hyatt San Francisco. Registration is now open. Visit techsummit.gastro.org to secure your spot.

The Tech Summit is where GI innovators, clinicians, medical device companies, venture capitalists and regulatory agencies meet to foster the development and adoption of GI technologies. It is the perfect venue for:

• All innovators, entrepreneurs and clinicians who want to build their professional networks in the GI space.
• Early-stage GI companies who want to showcase their technologies and find new ideas for further innovations that will improve patient care.
• GI fellows who want an exclusive and immersive behind-the-scenes look into the MedTech world.

Learn more by visiting techsummit.gastro.org.

AGA members advocate for GI during Alliance of Specialty Medicine fly-in

In December, six AGA members joined more than 100 specialty doctors organized by the Alliance of Specialty Medicine, a coalition that represents specialty physicians, to meet with House and Senate offices and discuss pressing policy priorities.

Members spoke on behalf of GI and stressed the need for Congress to act immediately on the upcoming Medicare cuts, and discussed step therapy protocols, prior authorization reform, and the role of artificial intelligence in the specialty.

Courtesy AGA

Our members represented GI well throughout the day’s meetings!

AGA PAC Board Member and Congressional Advocate Dr. Sadeea Abbasi spoke to House Leader Kevin McCarthy (R-CA) about challenges specialty doctors are facing and petitioned for Congress to mitigate the nearly 10 percent Medicare payment cuts before the end of the 117th Congress.

Additionally, AGA Government Affairs Committee Chair Dr. Rotonya Carr engaged with several members of Congress on issues impacting specialty care and discussed the future of AI in medicine with Rep. Mariannette Miller-Meeks (R-IA), who is an ophthalmologist.

Thank you to all our members who spoke on behalf of GI! We appreciate our AGA leaders who took time to participate!

• Sadeea Abbasi, MD, PhD
• Dawn B. Beaulieu, MD, AGAF
• Brent Burnette, MD
• Rotonya M. Carr, MD, FACP
• Peter S. Margolis, MD, AGAF
• Suzette Rivera MacMurray, MD

Learn how AGA is advocating for you. Visit gastro.org/advocacy.

AGA workshops champion women in GI

At AGA, we’re committed to supporting, empowering, and amplifying women in GI. As part of our ongoing efforts, we were thrilled to host nearly 250 women at four Women in GI regional workshops this fall. These workshops provided women across the country with opportunities to develop their personal and professional networks, participate in leadership development seminars, receive career mentoring, and engage in various wellness practices.

Following the conclusion of the regional workshops, we hosted the AGA Women’s Leadership Collaboration Conference at the AGA national office in Bethesda, Md.

Courtesy AGA

During the two-day conference, 22 delegates discussed workplace experiences, reported on their region’s workshop, and participated in strategy development exercises to further gender equity in GI, which included identifying tactics and ideas for action.

This unique event brought together delegates from each regional workshop, including 2023 Dr. Maria Leo-Lieber scholarship winners Alyssa Parian and Alexandra Livanos, who attended the Northeast workshop. It was a great time of collaboration and connection with the AGA #WomenInGI community!

Thank you to everyone who participated and made the events a success. We look forward to uplifting all women in GI and identifying ways to support the community in the coming year.

AGA thanks Johnson & Johnson Health Care Systems, Inc. for their support of this program.


 

Help move innovation forward at the 2023 AGA Tech Summit

Innovative technologies for endoscopy, advanced imaging, and bariatric care are a few of the topics that will headline the 2023 AGA Tech Summit, March 9-10, 2023, at the Grand Hyatt San Francisco. Registration is now open. Visit techsummit.gastro.org to secure your spot.

The Tech Summit is where GI innovators, clinicians, medical device companies, venture capitalists and regulatory agencies meet to foster the development and adoption of GI technologies. It is the perfect venue for:

• All innovators, entrepreneurs and clinicians who want to build their professional networks in the GI space.
• Early-stage GI companies who want to showcase their technologies and find new ideas for further innovations that will improve patient care.
• GI fellows who want an exclusive and immersive behind-the-scenes look into the MedTech world.

Learn more by visiting techsummit.gastro.org.

The first time I considered telehealth as a viable option for care delivery was in February 2020. I had just heard that one of my patients had been diagnosed with COVID-19 and admitted to Evergreen Health, a hospital our practice covered just outside of Seattle. The news was jarring. Suddenly, it became crystal clear that patient access to care and the economic survival of our business would require another approach. Seemingly overnight, we built a telehealth program and began seeing patients virtually from the comfort and safety of home.

We certainly weren’t alone. From January to March 2020, the Centers for Disease Control and Prevention showed a 154% increase in telehealth visits.¹ Even as the postpandemic era settles in, the use of telehealth today is 38 times greater than the pre-COVID baseline, creating a market valued at $250 billion per year.² What value might gastroenterologists gain from the use of telehealth going forward? Data are emerging that virtual care can reduce expensive and unnecessary emergency room visits, help effectively manage chronic disease, address disparities in care, and increase access to specialty care.³ For today’s overburdened GI practices, telehealth can improve patient access to care, alleviate the clinician shortage with work-from-home options for practitioners, and present innovative methods of increasing revenue streams – all while improving quality of care.
 

As GI demand outpaces supply, it’s time to consider alternative channels of care

The prevalence of gastrointestinal illness, the size of the market, and the growing difficulty in gaining access to care makes it natural to consider whether virtual care may benefit patients and GI practices alike. Approximately 70 million Americans, or 1 in 5, live with chronic GI symptoms.⁴ On an annual basis, more than 50 million primary care visits and 15 million ER visits in the United States have a primary diagnostic code for GI disease.⁵ Annual expenditures to address GI conditions, valued at $136 billion, outpace those of other high-cost conditions such as heart disease or mental health.⁶ And with the recent addition of 21 million patients between 45 and 49 years of age who now require colon cancer screening, plus the expected postpandemic increase in GI illness, those numbers are likely to grow.⁷

Compounding matters is a shortage of clinicians. Between early physician retirements and a limited number of GI fellowships, gastroenterology was recently identified by a Merritt Hawkins survey as the “most in-demand” specialty.⁸ Patients are already waiting months, and even up to a year in some parts of the country, to see a gastroenterologist. GI physicians, likewise, are running ragged trying to keep up and are burning out in the process.
 

The case for virtual GI care

Until the pandemic, many of us would not have seriously considered a significant role for virtual care in GI. When necessity demanded it, however, we used this channel effectively with both patients and providers reporting high rates of satisfaction with telehealth for GI clinic visits.⁹

In a recent published study with a sizable cohort of GI patients across a wide spectrum of conditions, only 17% required a physical exam following a telehealth visit. Over 50% said they were very likely or likely to continue using telehealth in the future. Interestingly, it was not only a young or tech-savvy population that ranked telehealth highly. In fact, Net Promoter Scores (a proven measure of customer experience) were consistently high for employed patients aged 60 or younger.¹⁰

Recent research also has demonstrated that telehealth visits meet quality standards and do so efficiently. A Mayo Clinic study demonstrated that telehealth visits in GI were delivered with a similar level of quality based on diagnostic concordance,¹¹ and a recent study by Tang et al. found that 98% of visits for routine GI issues were completed within 20 minutes.¹²

Finally, establishing a virtual channel allows a clinic to increase its staffing radius by using geographically dispersed GI providers, including appropriately licensed physicians or advanced practice providers who may reside in other states. The use of remote providers opens up the possibility for “time zone arbitrage” to allow for more flexible staffing that’s similar to urgent care with wraparound and weekend hours – all without adding office space or overhead.
 

Financial implications

Given the long tail of demand in GI, increasing capacity will increase revenue. Telehealth increases capacity by allowing for the efficient use of resources and expanding the reach of practices in engaging potential providers.

The majority of telehealth visits are reimbursable. Since 1995, 40 states and the District of Columbia have enacted mandatory telehealth coverage laws, and 20 states require that telehealth visits be paid on par with in-person visits.¹³ With the pandemic Medicare waivers, parity was extended through government programs and is expected by many insiders to continue in some form going forward. By an overwhelming bipartisan majority, the House of Representatives recently passed the Advancing Telehealth Beyond COVID-19 Act, which would extend most temporary telemedicine policies through 2024. This legislation would affect only Medicare reimbursement, but changes in Medicare policy often influence the policies of commercial payers.¹⁴

While reimbursement for clinic visits is important, the larger financial implication for extending clinics virtually is in the endoscopy suite. Most revenue (70%-80%) in community GI practices is generated from endoscopic services and related ancillary streams. For an endoscopist, spending time in the clinic is effectively a loss leader. Adding capacity with a virtual clinic and geographically dispersed providers can open up GI physicians to spend more time in the endoscopy suite, thereby generating additional revenue.

Given the rapid consolidation of the GI space, income repair post private equity transaction is top of mind for both established physicians and young physicians entering the labor market. Having a virtual ancillary differentiates practices and may prove useful for recruitment. Increasing access by using remote providers during evenings and weekends may “unclog the pipes,” improve the patient and provider experience, and increase revenue.
 

Overcoming obstacles

Creating a telehealth platform – particularly one that crosses state lines – requires an understanding of a complex and evolving regulatory environment. Licensing is one example. When telehealth is used, it is considered to be rendered at the location of the patient. A provider typically has to be licensed in the state where the patient is located at the time of the clinical encounter. So, if providers cross jurisdictional boundaries to provide care, multiple state licenses may be required.

In addition, medical malpractice and cyber insurance for telemedicine providers are niche products. And as with the use of any technology, risks of a data breach or other unauthorized disclosure of protected health information make it vital to ensure data are fully encrypted, networks are secure, and all safeguards are followed according to the Health Information and Portability and Accountability Act (HIPAA).

Perhaps most challenging are payers, both commercial and governmental. The location of a distant site provider can affect network participation for some but not all payers. Understanding payer reimbursement policies is time-intensive, and building relationships within these organizations is crucial in today’s rapidly changing environment.
 

The ultimate aim: Better patient outcomes

Of course, the main goal is to take care of patients well and in a timely fashion. Better access will lead to an improved patient experience and a greater emphasis on the important cognitive aspects of GI care. Moreover, efficient use of physician time will also improve clinician satisfaction while increasing revenue and downstream value. Most importantly, increased access via a virtual channel may positively impact patient outcomes. For instance, data show that distance from an endoscopy center is negatively associated with the stage of colon cancer diagnosis.¹⁵ Providing a virtual channel to reach these distant patients will likely increase the opportunity for high-impact procedures like colonoscopy.

Change can be hard, but it will come

The old saying is that change comes slowly, then all at once. Access is a chronic pain point for GI practices that has now reached a critical level.

The GI market is enormous and rapidly evolving; it will continue to attract disruptive interest and several early-stage digital first GI companies have entered the ecosystem. There is a risk for disintermediation as well as opportunities for collaboration. The next few years will be interesting.

As we transition to a postpandemic environment, telehealth can continue to improve patient access and present new revenue streams for GI practices – all while improving quality of care. Seeing around the corner likely means expanding the reach of your clinic and offering multiple channels of care. There is likely a significant opportunity for those who choose to adapt.
 

Dr. Arjal is cofounder, chief medical officer, and president of Telebelly Health and is a board-certified gastroenterologist who previously served as vice president of Puget Sound Gastroenterology and a vice president of clinical affairs for GastroHealth. He currently serves on the American Gastroenterological Association (AGA) Practice Management and Economics Committee. He has no conflicts. He is on LinkedIn and Twitter (@RussArjalMD).

References

1. Koonin LM et al. Trends in the use of telehealth during the emergence of the COVID-19 pandemic – United States, January-March 2020. MMWR Morb Mortal Wkly Rep. 2020. Oct 30;69(43):1595-9.

2. “Telehealth: A quarter-trillion-dollar post-COVID-19 reality?” McKinsey & Company, July 9, 2021.

3. The telehealth era is just beginning, Robert Pearl and Brian Wayling, Harvard Business Review, May-June, 2022.

4. Peery et al. Burden and cost of gastrointestinal, liver, and pancreatic diseases in the United States: Update 2018. Gastroenterology. 2019. Jan;156(1):254-72.

5. See id.

6. See id.

7. Sieh, K. Post-COVID-19 functional gastrointestinal disorders: Prepare for a GI aftershock. J Gastroenterol Hepatol. 2022 March;37(3):413-4.

8. Newitt, P. Gastroenterology’s biggest threats. Becker’s, GI & Endoscopy, 2021 Oct 8, and Physician Compensation Report, 2022. Physicians Thrive (projecting a shortage of over 1,600 Gastroenterologists by 2025).

9. Dobrusin et al. Gastroenterologists and patients report high satisfaction rates with Telehealth services during the novel coronavirus 2019 pandemic. Clin Gastroenterol Hepatol. 2020;8(11):2393-7.

10. Dobrusin et al. Patients with gastrointestinal conditions consider telehealth equivalent to in-person care. Gastroenterology. 2022 Oct 4. doi: 10.1053/j.gastro.2022.09.035.

11. Demaerschalk et al. Assessment of clinician diagnostic concordance with video telemedicine in the integrated multispecialty practice at Mayo Clinic during the beginning of COVID-19 pandemic from March to June, 2020. JAMA Netw Open. 2022 Sep;5(9):e2229958.

12. Tang et al. A model for the pandemic and beyond: Telemedicine for all gastroenterology referrals reduces unnecessary clinic visits. J Telemed Telecare. 2022 Sep 28(8):577-82.

13. Dills A. Policy brief: Telehealth payment parity laws at the state level. Mercatus Center, George Mason University.

14. H.R.4040 – Advancing Telehealth Beyond COVID-19 Act of 2021. Congress.gov.

15. Brand et al. Association of distance, region, and insurance with advanced colon cancer at initial diagnosis. JAMA Netw Open. 2022 Sep 1;5(9):e2229954.

The first time I considered telehealth as a viable option for care delivery was in February 2020. I had just heard that one of my patients had been diagnosed with COVID-19 and admitted to Evergreen Health, a hospital our practice covered just outside of Seattle. The news was jarring. Suddenly, it became crystal clear that patient access to care and the economic survival of our business would require another approach. Seemingly overnight, we built a telehealth program and began seeing patients virtually from the comfort and safety of home.

We certainly weren’t alone. From January to March 2020, the Centers for Disease Control and Prevention showed a 154% increase in telehealth visits.¹ Even as the postpandemic era settles in, the use of telehealth today is 38 times greater than the pre-COVID baseline, creating a market valued at $250 billion per year.² What value might gastroenterologists gain from the use of telehealth going forward? Data are emerging that virtual care can reduce expensive and unnecessary emergency room visits, help effectively manage chronic disease, address disparities in care, and increase access to specialty care.³ For today’s overburdened GI practices, telehealth can improve patient access to care, alleviate the clinician shortage with work-from-home options for practitioners, and present innovative methods of increasing revenue streams – all while improving quality of care.
 

As GI demand outpaces supply, it’s time to consider alternative channels of care

The prevalence of gastrointestinal illness, the size of the market, and the growing difficulty in gaining access to care makes it natural to consider whether virtual care may benefit patients and GI practices alike. Approximately 70 million Americans, or 1 in 5, live with chronic GI symptoms.⁴ On an annual basis, more than 50 million primary care visits and 15 million ER visits in the United States have a primary diagnostic code for GI disease.⁵ Annual expenditures to address GI conditions, valued at $136 billion, outpace those of other high-cost conditions such as heart disease or mental health.⁶ And with the recent addition of 21 million patients between 45 and 49 years of age who now require colon cancer screening, plus the expected postpandemic increase in GI illness, those numbers are likely to grow.⁷

Compounding matters is a shortage of clinicians. Between early physician retirements and a limited number of GI fellowships, gastroenterology was recently identified by a Merritt Hawkins survey as the “most in-demand” specialty.⁸ Patients are already waiting months, and even up to a year in some parts of the country, to see a gastroenterologist. GI physicians, likewise, are running ragged trying to keep up and are burning out in the process.
 

The case for virtual GI care

Until the pandemic, many of us would not have seriously considered a significant role for virtual care in GI. When necessity demanded it, however, we used this channel effectively with both patients and providers reporting high rates of satisfaction with telehealth for GI clinic visits.⁹

In a recent published study with a sizable cohort of GI patients across a wide spectrum of conditions, only 17% required a physical exam following a telehealth visit. Over 50% said they were very likely or likely to continue using telehealth in the future. Interestingly, it was not only a young or tech-savvy population that ranked telehealth highly. In fact, Net Promoter Scores (a proven measure of customer experience) were consistently high for employed patients aged 60 or younger.¹⁰

Recent research also has demonstrated that telehealth visits meet quality standards and do so efficiently. A Mayo Clinic study demonstrated that telehealth visits in GI were delivered with a similar level of quality based on diagnostic concordance,¹¹ and a recent study by Tang et al. found that 98% of visits for routine GI issues were completed within 20 minutes.¹²

Finally, establishing a virtual channel allows a clinic to increase its staffing radius by using geographically dispersed GI providers, including appropriately licensed physicians or advanced practice providers who may reside in other states. The use of remote providers opens up the possibility for “time zone arbitrage” to allow for more flexible staffing that’s similar to urgent care with wraparound and weekend hours – all without adding office space or overhead.
 

Financial implications

Given the long tail of demand in GI, increasing capacity will increase revenue. Telehealth increases capacity by allowing for the efficient use of resources and expanding the reach of practices in engaging potential providers.

The majority of telehealth visits are reimbursable. Since 1995, 40 states and the District of Columbia have enacted mandatory telehealth coverage laws, and 20 states require that telehealth visits be paid on par with in-person visits.¹³ With the pandemic Medicare waivers, parity was extended through government programs and is expected by many insiders to continue in some form going forward. By an overwhelming bipartisan majority, the House of Representatives recently passed the Advancing Telehealth Beyond COVID-19 Act, which would extend most temporary telemedicine policies through 2024. This legislation would affect only Medicare reimbursement, but changes in Medicare policy often influence the policies of commercial payers.¹⁴

While reimbursement for clinic visits is important, the larger financial implication for extending clinics virtually is in the endoscopy suite. Most revenue (70%-80%) in community GI practices is generated from endoscopic services and related ancillary streams. For an endoscopist, spending time in the clinic is effectively a loss leader. Adding capacity with a virtual clinic and geographically dispersed providers can open up GI physicians to spend more time in the endoscopy suite, thereby generating additional revenue.

Given the rapid consolidation of the GI space, income repair post private equity transaction is top of mind for both established physicians and young physicians entering the labor market. Having a virtual ancillary differentiates practices and may prove useful for recruitment. Increasing access by using remote providers during evenings and weekends may “unclog the pipes,” improve the patient and provider experience, and increase revenue.
 

Overcoming obstacles

Creating a telehealth platform – particularly one that crosses state lines – requires an understanding of a complex and evolving regulatory environment. Licensing is one example. When telehealth is used, it is considered to be rendered at the location of the patient. A provider typically has to be licensed in the state where the patient is located at the time of the clinical encounter. So, if providers cross jurisdictional boundaries to provide care, multiple state licenses may be required.

In addition, medical malpractice and cyber insurance for telemedicine providers are niche products. And as with the use of any technology, risks of a data breach or other unauthorized disclosure of protected health information make it vital to ensure data are fully encrypted, networks are secure, and all safeguards are followed according to the Health Information and Portability and Accountability Act (HIPAA).

Perhaps most challenging are payers, both commercial and governmental. The location of a distant site provider can affect network participation for some but not all payers. Understanding payer reimbursement policies is time-intensive, and building relationships within these organizations is crucial in today’s rapidly changing environment.
 

The ultimate aim: Better patient outcomes

Of course, the main goal is to take care of patients well and in a timely fashion. Better access will lead to an improved patient experience and a greater emphasis on the important cognitive aspects of GI care. Moreover, efficient use of physician time will also improve clinician satisfaction while increasing revenue and downstream value. Most importantly, increased access via a virtual channel may positively impact patient outcomes. For instance, data show that distance from an endoscopy center is negatively associated with the stage of colon cancer diagnosis.¹⁵ Providing a virtual channel to reach these distant patients will likely increase the opportunity for high-impact procedures like colonoscopy.

Change can be hard, but it will come

The old saying is that change comes slowly, then all at once. Access is a chronic pain point for GI practices that has now reached a critical level.

The GI market is enormous and rapidly evolving; it will continue to attract disruptive interest and several early-stage digital first GI companies have entered the ecosystem. There is a risk for disintermediation as well as opportunities for collaboration. The next few years will be interesting.

As we transition to a postpandemic environment, telehealth can continue to improve patient access and present new revenue streams for GI practices – all while improving quality of care. Seeing around the corner likely means expanding the reach of your clinic and offering multiple channels of care. There is likely a significant opportunity for those who choose to adapt.
 

Dr. Arjal is cofounder, chief medical officer, and president of Telebelly Health and is a board-certified gastroenterologist who previously served as vice president of Puget Sound Gastroenterology and a vice president of clinical affairs for GastroHealth. He currently serves on the American Gastroenterological Association (AGA) Practice Management and Economics Committee. He has no conflicts. He is on LinkedIn and Twitter (@RussArjalMD).

References

1. Koonin LM et al. Trends in the use of telehealth during the emergence of the COVID-19 pandemic – United States, January-March 2020. MMWR Morb Mortal Wkly Rep. 2020. Oct 30;69(43):1595-9.

2. “Telehealth: A quarter-trillion-dollar post-COVID-19 reality?” McKinsey & Company, July 9, 2021.

3. The telehealth era is just beginning, Robert Pearl and Brian Wayling, Harvard Business Review, May-June, 2022.

4. Peery et al. Burden and cost of gastrointestinal, liver, and pancreatic diseases in the United States: Update 2018. Gastroenterology. 2019. Jan;156(1):254-72.

5. See id.

6. See id.

7. Sieh, K. Post-COVID-19 functional gastrointestinal disorders: Prepare for a GI aftershock. J Gastroenterol Hepatol. 2022 March;37(3):413-4.

8. Newitt, P. Gastroenterology’s biggest threats. Becker’s, GI & Endoscopy, 2021 Oct 8, and Physician Compensation Report, 2022. Physicians Thrive (projecting a shortage of over 1,600 Gastroenterologists by 2025).

9. Dobrusin et al. Gastroenterologists and patients report high satisfaction rates with Telehealth services during the novel coronavirus 2019 pandemic. Clin Gastroenterol Hepatol. 2020;8(11):2393-7.

10. Dobrusin et al. Patients with gastrointestinal conditions consider telehealth equivalent to in-person care. Gastroenterology. 2022 Oct 4. doi: 10.1053/j.gastro.2022.09.035.

11. Demaerschalk et al. Assessment of clinician diagnostic concordance with video telemedicine in the integrated multispecialty practice at Mayo Clinic during the beginning of COVID-19 pandemic from March to June, 2020. JAMA Netw Open. 2022 Sep;5(9):e2229958.

12. Tang et al. A model for the pandemic and beyond: Telemedicine for all gastroenterology referrals reduces unnecessary clinic visits. J Telemed Telecare. 2022 Sep 28(8):577-82.

13. Dills A. Policy brief: Telehealth payment parity laws at the state level. Mercatus Center, George Mason University.

14. H.R.4040 – Advancing Telehealth Beyond COVID-19 Act of 2021. Congress.gov.

15. Brand et al. Association of distance, region, and insurance with advanced colon cancer at initial diagnosis. JAMA Netw Open. 2022 Sep 1;5(9):e2229954.

The first time I considered telehealth as a viable option for care delivery was in February 2020. I had just heard that one of my patients had been diagnosed with COVID-19 and admitted to Evergreen Health, a hospital our practice covered just outside of Seattle. The news was jarring. Suddenly, it became crystal clear that patient access to care and the economic survival of our business would require another approach. Seemingly overnight, we built a telehealth program and began seeing patients virtually from the comfort and safety of home.

We certainly weren’t alone. From January to March 2020, the Centers for Disease Control and Prevention showed a 154% increase in telehealth visits.¹ Even as the postpandemic era settles in, the use of telehealth today is 38 times greater than the pre-COVID baseline, creating a market valued at $250 billion per year.² What value might gastroenterologists gain from the use of telehealth going forward? Data are emerging that virtual care can reduce expensive and unnecessary emergency room visits, help effectively manage chronic disease, address disparities in care, and increase access to specialty care.³ For today’s overburdened GI practices, telehealth can improve patient access to care, alleviate the clinician shortage with work-from-home options for practitioners, and present innovative methods of increasing revenue streams – all while improving quality of care.
 

As GI demand outpaces supply, it’s time to consider alternative channels of care

The prevalence of gastrointestinal illness, the size of the market, and the growing difficulty in gaining access to care makes it natural to consider whether virtual care may benefit patients and GI practices alike. Approximately 70 million Americans, or 1 in 5, live with chronic GI symptoms.⁴ On an annual basis, more than 50 million primary care visits and 15 million ER visits in the United States have a primary diagnostic code for GI disease.⁵ Annual expenditures to address GI conditions, valued at $136 billion, outpace those of other high-cost conditions such as heart disease or mental health.⁶ And with the recent addition of 21 million patients between 45 and 49 years of age who now require colon cancer screening, plus the expected postpandemic increase in GI illness, those numbers are likely to grow.⁷

Compounding matters is a shortage of clinicians. Between early physician retirements and a limited number of GI fellowships, gastroenterology was recently identified by a Merritt Hawkins survey as the “most in-demand” specialty.⁸ Patients are already waiting months, and even up to a year in some parts of the country, to see a gastroenterologist. GI physicians, likewise, are running ragged trying to keep up and are burning out in the process.
 

The case for virtual GI care

Until the pandemic, many of us would not have seriously considered a significant role for virtual care in GI. When necessity demanded it, however, we used this channel effectively with both patients and providers reporting high rates of satisfaction with telehealth for GI clinic visits.⁹

In a recent published study with a sizable cohort of GI patients across a wide spectrum of conditions, only 17% required a physical exam following a telehealth visit. Over 50% said they were very likely or likely to continue using telehealth in the future. Interestingly, it was not only a young or tech-savvy population that ranked telehealth highly. In fact, Net Promoter Scores (a proven measure of customer experience) were consistently high for employed patients aged 60 or younger.¹⁰

Recent research also has demonstrated that telehealth visits meet quality standards and do so efficiently. A Mayo Clinic study demonstrated that telehealth visits in GI were delivered with a similar level of quality based on diagnostic concordance,¹¹ and a recent study by Tang et al. found that 98% of visits for routine GI issues were completed within 20 minutes.¹²

Finally, establishing a virtual channel allows a clinic to increase its staffing radius by using geographically dispersed GI providers, including appropriately licensed physicians or advanced practice providers who may reside in other states. The use of remote providers opens up the possibility for “time zone arbitrage” to allow for more flexible staffing that’s similar to urgent care with wraparound and weekend hours – all without adding office space or overhead.
 

Financial implications

Given the long tail of demand in GI, increasing capacity will increase revenue. Telehealth increases capacity by allowing for the efficient use of resources and expanding the reach of practices in engaging potential providers.

The majority of telehealth visits are reimbursable. Since 1995, 40 states and the District of Columbia have enacted mandatory telehealth coverage laws, and 20 states require that telehealth visits be paid on par with in-person visits.¹³ With the pandemic Medicare waivers, parity was extended through government programs and is expected by many insiders to continue in some form going forward. By an overwhelming bipartisan majority, the House of Representatives recently passed the Advancing Telehealth Beyond COVID-19 Act, which would extend most temporary telemedicine policies through 2024. This legislation would affect only Medicare reimbursement, but changes in Medicare policy often influence the policies of commercial payers.¹⁴

While reimbursement for clinic visits is important, the larger financial implication for extending clinics virtually is in the endoscopy suite. Most revenue (70%-80%) in community GI practices is generated from endoscopic services and related ancillary streams. For an endoscopist, spending time in the clinic is effectively a loss leader. Adding capacity with a virtual clinic and geographically dispersed providers can open up GI physicians to spend more time in the endoscopy suite, thereby generating additional revenue.

Given the rapid consolidation of the GI space, income repair post private equity transaction is top of mind for both established physicians and young physicians entering the labor market. Having a virtual ancillary differentiates practices and may prove useful for recruitment. Increasing access by using remote providers during evenings and weekends may “unclog the pipes,” improve the patient and provider experience, and increase revenue.
 

Overcoming obstacles

Creating a telehealth platform – particularly one that crosses state lines – requires an understanding of a complex and evolving regulatory environment. Licensing is one example. When telehealth is used, it is considered to be rendered at the location of the patient. A provider typically has to be licensed in the state where the patient is located at the time of the clinical encounter. So, if providers cross jurisdictional boundaries to provide care, multiple state licenses may be required.

In addition, medical malpractice and cyber insurance for telemedicine providers are niche products. And as with the use of any technology, risks of a data breach or other unauthorized disclosure of protected health information make it vital to ensure data are fully encrypted, networks are secure, and all safeguards are followed according to the Health Information and Portability and Accountability Act (HIPAA).

Perhaps most challenging are payers, both commercial and governmental. The location of a distant site provider can affect network participation for some but not all payers. Understanding payer reimbursement policies is time-intensive, and building relationships within these organizations is crucial in today’s rapidly changing environment.
 

The ultimate aim: Better patient outcomes

Of course, the main goal is to take care of patients well and in a timely fashion. Better access will lead to an improved patient experience and a greater emphasis on the important cognitive aspects of GI care. Moreover, efficient use of physician time will also improve clinician satisfaction while increasing revenue and downstream value. Most importantly, increased access via a virtual channel may positively impact patient outcomes. For instance, data show that distance from an endoscopy center is negatively associated with the stage of colon cancer diagnosis.¹⁵ Providing a virtual channel to reach these distant patients will likely increase the opportunity for high-impact procedures like colonoscopy.

Change can be hard, but it will come

The old saying is that change comes slowly, then all at once. Access is a chronic pain point for GI practices that has now reached a critical level.

The GI market is enormous and rapidly evolving; it will continue to attract disruptive interest and several early-stage digital first GI companies have entered the ecosystem. There is a risk for disintermediation as well as opportunities for collaboration. The next few years will be interesting.

As we transition to a postpandemic environment, telehealth can continue to improve patient access and present new revenue streams for GI practices – all while improving quality of care. Seeing around the corner likely means expanding the reach of your clinic and offering multiple channels of care. There is likely a significant opportunity for those who choose to adapt.
 

Dr. Arjal is cofounder, chief medical officer, and president of Telebelly Health and is a board-certified gastroenterologist who previously served as vice president of Puget Sound Gastroenterology and a vice president of clinical affairs for GastroHealth. He currently serves on the American Gastroenterological Association (AGA) Practice Management and Economics Committee. He has no conflicts. He is on LinkedIn and Twitter (@RussArjalMD).

References

1. Koonin LM et al. Trends in the use of telehealth during the emergence of the COVID-19 pandemic – United States, January-March 2020. MMWR Morb Mortal Wkly Rep. 2020. Oct 30;69(43):1595-9.

2. “Telehealth: A quarter-trillion-dollar post-COVID-19 reality?” McKinsey & Company, July 9, 2021.

3. The telehealth era is just beginning, Robert Pearl and Brian Wayling, Harvard Business Review, May-June, 2022.

4. Peery et al. Burden and cost of gastrointestinal, liver, and pancreatic diseases in the United States: Update 2018. Gastroenterology. 2019. Jan;156(1):254-72.

5. See id.

6. See id.

7. Sieh, K. Post-COVID-19 functional gastrointestinal disorders: Prepare for a GI aftershock. J Gastroenterol Hepatol. 2022 March;37(3):413-4.

8. Newitt, P. Gastroenterology’s biggest threats. Becker’s, GI & Endoscopy, 2021 Oct 8, and Physician Compensation Report, 2022. Physicians Thrive (projecting a shortage of over 1,600 Gastroenterologists by 2025).

9. Dobrusin et al. Gastroenterologists and patients report high satisfaction rates with Telehealth services during the novel coronavirus 2019 pandemic. Clin Gastroenterol Hepatol. 2020;8(11):2393-7.

10. Dobrusin et al. Patients with gastrointestinal conditions consider telehealth equivalent to in-person care. Gastroenterology. 2022 Oct 4. doi: 10.1053/j.gastro.2022.09.035.

11. Demaerschalk et al. Assessment of clinician diagnostic concordance with video telemedicine in the integrated multispecialty practice at Mayo Clinic during the beginning of COVID-19 pandemic from March to June, 2020. JAMA Netw Open. 2022 Sep;5(9):e2229958.

12. Tang et al. A model for the pandemic and beyond: Telemedicine for all gastroenterology referrals reduces unnecessary clinic visits. J Telemed Telecare. 2022 Sep 28(8):577-82.

13. Dills A. Policy brief: Telehealth payment parity laws at the state level. Mercatus Center, George Mason University.

14. H.R.4040 – Advancing Telehealth Beyond COVID-19 Act of 2021. Congress.gov.

15. Brand et al. Association of distance, region, and insurance with advanced colon cancer at initial diagnosis. JAMA Netw Open. 2022 Sep 1;5(9):e2229954.