Brennan M. Spiegel

University of North Carolina at Chapel Hill, North Carolina, United States

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Publications (250)2517.15 Total impact

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    ABSTRACT: Objectives: To develop a model that identifies patients at high risk for missing scheduled appointments ("no-shows" and cancellations) and to project the impact of predictive overbooking in a gastrointestinal endoscopy clinic-an exemplar resource-intensive environment with a high no-show rate. Study design: We retrospectively developed an algorithm that uses electronic health record (EHR) data to identify patients who do not show up to their appointments. Next, we prospectively validated the algorithm at a Veterans Administration healthcare network clinic. Methods: We constructed a multivariable logistic regression model that assigned a no-show risk score optimized by receiver operating characteristic curve analysis. Based on these scores, we created a calendar of projected open slots to offer to patients and compared the daily performance of predictive overbooking with fixed overbooking and typical "1 patient, 1 slot" scheduling. Results: Data from 1392 patients identified several predictors of no-show, including previous absenteeism, comorbid disease burden, and current diagnoses of mood and substance use disorders. The model correctly classified most patients during the development (area under the curve [AUC] = 0.80) and validation phases (AUC = 0.75). Prospective testing in 1197 patients found that predictive overbooking averaged 0.51 unused appointments per day versus 6.18 for typical booking (difference = -5.67; 95% CI, -6.48 to -4.87; P < .0001). Predictive overbooking could have increased service utilization from 62% to 97% of capacity, with only rare clinic overflows. Conclusions: Information from EHRs can accurately predict whether patients will no-show. This method can be used to overbook appointments, thereby maximizing service utilization while staying within clinic capacity.
    No preview · Article · Dec 2015 · The American journal of managed care
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    ABSTRACT: Opioids cause gastrointestinal (GI) symptoms such as nausea, vomiting, pain, and (in 40 percent) constipation that diminish patients' quality of life. Outside traditional surveys, little is known about the opioid-induced constipation (OIC) patient experience and its impact on pain management. The purpose of this study was to use data from social media platforms to qualitatively examine patient beliefs about OIC and other prominent GI side effects, their impact on effective pain management and doctor-patient interaction. The authors collected Tweets from March 25 to July 31, 2014, and e-forum posts from health-related social networking sites regardless of timestamp. The authors identified specific keywords related to opioids and GI side effects to locate relevant content in the dataset, which was then manually coded using ATLAS.ti software. The authors examined 2,519,868 Tweets and more than 1.8 billion e-forum posts, of which, 88,586 Tweets and 9,767 posts satisfied the search criteria. Three thousand three individuals experienced opioidinduced GI side effects, mostly related to phenanthrenes (n = 1,589), and 1,274 (42.4 percent) individuals described constipation. Over-the-counter medications and nonevidence-based natural approaches were most commonly used to alleviate constipation. Many individuals questioned, rotated, reduced, or stopped their opioid treatments as a result of their GI side effects. Investigation of social media reveals a struggle to balance pain management with opioid-induced GI side effects, especially constipation. Individuals are often unprepared to treat OIC, to modify opioid regiments without medical advice, and to resort to using natural remedies and treatments lacking scientific evidence of effectiveness. These results identify opportunities to improve physician-patient communication and explore effective treatment alternatives.
    No preview · Article · Nov 2015 · Journal of opioid management
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    ABSTRACT: Objectives: Prior reports have linked patient transmission of carbapenem-resistant Enterobacteriaceae (CRE, or "superbug") to endoscopes used during endoscopic retrograde cholangiopancreatography (ERCP). We performed a decision analysis to measure the cost-effectiveness of four competing strategies for CRE risk management. Methods: We used decision analysis to calculate the cost-effectiveness of four approaches to reduce the risk of CRE transmission among patients presenting to the hospital for symptomatic common bile duct stones. The strategies included the following: (1) perform ERCP followed by US Food and Drug Administration (FDA)-recommended endoscope reprocessing procedures; (2) perform ERCP followed by "endoscope culture and hold"; (3) perform ERCP followed by ethylene oxide (EtO) sterilization of the endoscope; and (4) stop performing ERCP in lieu of laparoscopic cholecystectomy (LC) with common bile duct exploration (CBDE). Our outcome was incremental cost per quality-adjusted life year (QALY) gained. Results: In the base-case scenario, ERCP with FDA-recommended endoscope reprocessing was the most cost-effective strategy. Both the ERCP with culture and hold ($4,228,170/QALY) and ERCP with EtO sterilization ($50,572,348/QALY) strategies had unacceptable incremental costs per QALY gained. LC with CBDE was dominated, being both more costly and marginally less effective vs. the alternatives. In sensitivity analysis, ERCP with culture and hold became the most cost-effective approach when the pretest probability of CRE exceeded 24%. Conclusions: In institutions with a low CRE prevalence, ERCP with FDA-recommended reprocessing is the most cost-effective approach for mitigating CRE transmission risk. Only in settings with an extremely high CRE prevalence did ERCP with culture and hold become cost-effective.Am J Gastroenterol advance online publication, 3 November 2015; doi:10.1038/ajg.2015.358.
    No preview · Article · Nov 2015 · The American Journal of Gastroenterology
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    ABSTRACT: Background: Postoperative ileus (POI) can worsen outcomes, increase cost, and prolong hospitalization. We previously found that a disposable, non-invasive acoustic gastrointestinal surveillance (AGIS) biosensor distinguishes healthy controls from patients recovering from abdominal surgery. Here, we tested whether AGIS can prospectively predict which patients will develop POI in a multicenter study. Study design: AGIS is a disposable device embedded with a microphone that adheres to the abdominal wall and connects to a computer that measures acoustic intestinal rate (IR), defined as motility events/minute. We applied AGIS for 60 min before and continuously after abdominal surgery. Clinicians blinded to AGIS recordings clinically separated patients into those with vs. without POI. We used receiver operating characteristic curve analysis to calculate sensitivity, specificity, and negative predictive value (NPV) of AGIS to predict POI. Results: There were 28 subjects; nine developed POI. Median IR was 3.01/min and 4.46/min between POI and non-POI groups, respectively (P = 0.03). AGIS predicted POI onset with a sensitivity, specificity, and NPV of 63, 72, and 81 %, respectively. Conclusion: Non-invasive, abdominal, acoustic monitoring prospectively predicts POI. Surgeons may use AGIS to rule out POI with over 80 % certainty; this offers added confidence to advance feeding earlier in those for whom it is safe.
    No preview · Article · Sep 2015 · Journal of Gastrointestinal Surgery
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    ABSTRACT: Elimination diets have been used for many years to treat irritable bowel syndrome (IBS). These approaches had fallen out of favor until a recent resurgence, which was based on new randomized controlled trial (RCT) data that suggested it might be effective. The evidence for the efficacy of dietary therapies has not been evaluated systematically. We have therefore conducted a systematic review to examine this issue. MEDLINE, EMBASE, and the Cochrane Controlled Trials Register were searched up to December 2013. Trials recruiting adults with IBS, which compared any form of dietary restriction or addition of an offending food group in patients already on a restricted diet vs. placebo, control therapy, or "usual management", were eligible. Dichotomous symptom data were pooled to obtain a relative risk of remaining symptomatic after therapy as well as the number needed to treat with a 95% confidence interval. We identified 17 RCTs involving 1,568 IBS patients that assessed elimination diets. Only three RCTs involving 230 patients met our eligibility criteria, all of which evaluated different approaches, and thus a meta-analysis could not be conducted. More evidence is needed before generally recommending elimination diets for IBS patients.
    Full-text · Article · Aug 2015 · Clinical and Translational Gastroenterology
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    ABSTRACT: It is important for clinicians to inquire about "alarm features" as it may identify those at risk for organic disease and who require additional diagnostic workup. We developed a computer algorithm called Automated Evaluation of Gastrointestinal Symptoms (AEGIS) that systematically collects patient gastrointestinal (GI) symptoms and alarm features, and then "translates" the information into a history of present illness (HPI). Our study's objective was to compare the number of alarms documented by physicians during usual care vs. that collected by AEGIS. We performed a cross-sectional study with a paired sample design among patients visiting adult GI clinics. Participants first received usual care by their physicians and then completed AEGIS. Each individual thus contributed both a physician-documented and computer-generated HPI. Blinded physician reviewers enumerated the positive alarm features (hematochezia, melena, hematemesis, unintentional weight loss, decreased appetite, and fevers) mentioned in each HPI. We compared the number of documented alarms within patient using the Wilcoxon signed-rank test. Seventy-five patients had both physician and AEGIS HPIs. AEGIS identified more patients with positive alarm features compared to physicians (53% vs. 27%; p<.001). AEGIS also documented more positive alarms (median 1, interquartile range [IQR] 0-2) vs. physicians (median 0, IQR 0-1; p<.001). Moreover, clinicians documented only 30% of the positive alarms self-reported by patients through AEGIS. Physicians documented less than one-third of red flags reported by patients through a computer algorithm. These data indicate that physicians may under report alarm features and that computerized "checklists" could complement standard HPIs to bolster clinical care. Copyright © 2015. Published by Elsevier Ireland Ltd.
    No preview · Article · Jul 2015 · International Journal of Medical Informatics
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    ABSTRACT: African Americans have the highest burden of colorectal cancer (CRC) in the United States of America (USA) yet lower CRC screening rates than whites. Although poor screening has prompted efforts to increase screening uptake, there is a persistent need to develop public health interventions in partnership with the African American community. The aim of this study was to conduct focus groups with African Americans to determine preferences for the content and mode of dissemination of culturally tailored CRC screening interventions. In June 2013, 45-75-year-old African Americans were recruited through online advertisements and from an urban Veterans Affairs system to create four focus groups. A semi-structured interview script employing open-ended elicitation was used, and transcripts were analyzed using ATLAS.ti software to code and group data into a concept network. A total of 38 participants (mean age = 54) were enrolled, and 59 ATLAS.ti codes were generated. Commonly reported barriers to screening included perceived invasiveness of colonoscopy, fear of pain, and financial concerns. Facilitators included poor diet/health and desire to prevent CRC. Common sources of health information included media and medical providers. CRC screening information was commonly obtained from medical personnel or media. Participants suggested dissemination of CRC screening education through commercials, billboards, influential African American public figures, Internet, and radio. Participants suggested future interventions include culturally specific information, including details about increased risk, accessing care, and dispelling of myths. Public health interventions to improve CRC screening among African Americans should employ media outlets, emphasize increased risk among African Americans, and address race-specific barriers. Specific recommendations are presented for developing future interventions.
    Full-text · Article · May 2015 · Journal of Cancer Education
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    Folasade P May · Christopher V Almario · Ninez Ponce · Brennan M R Spiegel
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    ABSTRACT: OBJECTIVES: Although screening for colorectal cancer (CRC) is recommended for all adults aged 50 to 75 years in the United States, there are racial and ethnic disparities in who receives screening. Individuals lacking appropriate CRC screening cite various reasons for nonadherence, including lack of provider recommendation for screening. The purpose of this study is to evaluate the association between patient race and lack of provider recommendation for CRC screening as the primary reason for screening nonadherence. METHODS: We conducted a cross-sectional observational study of individuals aged 50 to 75 years from the 2009 California Health Interview Survey who reported nonadherence to 2008 United States Preventive Service Task Force CRC screening guidelines. The outcome was self-report that the main reason for not undergoing CRC screening was lack of a physician recommendation ("non-recommendation") for screening. We performed logistic regression to determine significant predictors of non-recommendation, with particular attention to the role of race. RESULTS: The study cohort included 5,793 unscreened subjects. Of the subjects, 19.1% reported that lack of a provider recommendation was the main reason for CRC nonscreening. African Americans (adjusted odds ratio (adj. OR) 1.46, 95% confidence interval (CI) 1.03-2.05) and English-speaking Asians (adj. OR 1.65, 95% CI 1.24-2.20) were more likely than whites to report physician non-recommendation as the main reason for lack of screening. Asian non-English speakers, however, were less likely to report physician non-recommendation (adj. OR 0.31, 95% CI 0.11-0.91). CONCLUSION: Racial minorities are less likely than whites to receive a physician recommendation for CRC screening. Future research should evaluate why race appears to influence provider recommendations to pursue CRC screening; this is an important step to reduce disparities in CRC screening and lessen the burden of CRC in the United States.
    Full-text · Article · May 2015 · The American Journal of Gastroenterology

  • No preview · Article · Apr 2015 · Gastroenterology

  • No preview · Article · Apr 2015 · Gastroenterology

  • No preview · Article · Apr 2015 · Gastroenterology
  • Folasade P. May · Mark W. Reid · Samuel E. Cohen · Brennan Spiegel

    No preview · Article · Apr 2015 · Gastroenterology

  • No preview · Article · Apr 2015 · Gastroenterology

  • No preview · Article · Apr 2015 · Gastroenterology

  • No preview · Article · Apr 2015 · Gastroenterology
  • Carl Nordstrom · Mark W. Reid · Sundip S. Karsan · Brennan Spiegel

    No preview · Article · Apr 2015 · Gastroenterology
  • Christopher V Almario · Folasade P May · Ninez A Ponce · Brennan M R Spiegel
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    ABSTRACT: Guidelines recommend that persons with a high-risk family history of colorectal cancer (CRC) undergo colonoscopy examinations every 5 y, starting when they are 40 y old. We investigated factors associated with colonoscopy screening of individuals with a family history of CRC, focusing on race and ethnicity. In a retrospective study, we analyzed data from the 2009 California Health Interview Survey on persons 40-80 y old with a first-degree relative (mother, father, sibling or child) with CRC who had visited a physician within the past 5 y. Our study included an unweighted and population-weighted sample of 2539 and 870,214 individuals with a family history of CRC, respectively. We performed a survey-weighted logistic regression analyses to adjust for relevant demographic and socioeconomic variables and used estimates to calculate relative risks (RR) and 95% confidence intervals (CI) for colonoscopy examination within the past 5 y. In the weighted sample, 60.0% of subjects received a colonoscopy within the past 5 y. A physician recommendation for CRC screening increased the odds that an individual would undergo colonoscopy examination (RR, 1.89; 95% CI, 1.61-2.24). Latinos were 31% less likely to receive colonoscopies than Whites (95% CI, 7%-55%). Among individuals 40-49 y old, African Americans were 71% less likely to have had a colonoscopy than Whites (95% CI, 13%-96%). Based on an analysis of data from the California Health Interview Survey, less than two-thirds of individuals with a family history of CRC reported receiving guideline-recommended colonoscopy examinations within the past 5 y. We observed racial and ethnic disparities in colonoscopy screening of this high-risk group; Latinos and African Americans were less likely to have had a colonoscopy than Whites. Copyright © 2015 AGA Institute. Published by Elsevier Inc. All rights reserved.
    No preview · Article · Feb 2015 · Clinical Gastroenterology and Hepatology
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    ABSTRACT: Patient-reported outcomes (PROs) are gaining recognition as key measures for improving the quality of patient care in clinical care settings. Three factors have made the implementation of PROs in clinical care more feasible: increased use of modern measurement methods in PRO design and validation, rapid progression of technology (eg, touchscreen tablets, Internet accessibility, and electronic health records), and greater demand for measurement and monitoring of PROs by regulators, payers, accreditors, and professional organizations. As electronic PRO collection and reporting capabilities have improved, the challenges of collecting PRO data have changed. To update information on PRO adoption considerations in clinical care, highlighting electronic and technical advances with respect to measure selection, clinical workflow, data infrastructure, and outcomes reporting. Five practical case studies across diverse health care settings and patient populations are used to explore how implementation barriers were addressed to promote the successful integration of PRO collection into the clinical workflow. The case studies address selecting and reporting of relevant content, workflow integration, previsit screening, effective evaluation, and electronic health record integration. These case studies exemplify elements of well-designed electronic systems, including response automation, tailoring of item selection and reporting algorithms, flexibility of collection location, and integration with patient health care data elements. They also highlight emerging logistical barriers in this area, such as the need for specialized technological and methodological expertise, and design limitations of current electronic data capture systems.
    No preview · Article · Feb 2015 · Medical Care
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    ABSTRACT: Although African Americans have the highest incidence and mortality from colorectal cancer (CRC), they are less likely than other racial groups to undergo CRC screening. Previous research has identified barriers to CRC screening among African Americans. However we lack a systematic review that synthesizes contributing factors and informs interventions to address persistent disparities. We conducted a systematic review to evaluate barriers to colonoscopic CRC screening in African Americans. We developed a conceptual model to summarize the patient-, provider-, and system-level barriers and suggest strategies to address these barriers. Nineteen studies met inclusion criteria. Patient barriers to colonoscopy included fear, poor knowledge of CRC risk, and low perceived benefit of colonoscopy. Provider-level factors included failure to recommend screening and knowledge deficits about guidelines and barriers to screening. System barriers included financial obstacles, lack of insurance and access to care, and intermittent primary care visits. There are modifiable barriers to colonoscopic CRC screening among African Americans. Future interventions should confront patient fear, patient and physician knowledge about barriers, and access to healthcare services. As the Affordable Care Act aims to improve uptake of preventive services, focused interventions to increase CRC screening in African Americans are essential and timely. Copyright © 2014. Published by Elsevier Inc.
    No preview · Article · Dec 2014 · Preventive Medicine
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    ABSTRACT: Objectives: Healthcare delivery now mandates shorter visits with higher documentation requirements, undermining the patient-provider interaction. To improve clinic visit efficiency, we developed a patient-provider portal that systematically collects patient symptoms using a computer algorithm called Automated Evaluation of Gastrointestinal Symptoms (AEGIS). AEGIS also automatically "translates" the patient report into a full narrative history of present illness (HPI). We aimed to compare the quality of computer-generated vs. physician-documented HPIs. Methods: We performed a cross-sectional study with a paired sample design among individuals visiting outpatient adult gastrointestinal (GI) clinics for evaluation of active GI symptoms. Participants first underwent usual care and then subsequently completed AEGIS. Each individual thereby had both a physician-documented and a computer-generated HPI. Forty-eight blinded physicians assessed HPI quality across six domains using 5-point scales: (i) overall impression, (ii) thoroughness, (iii) usefulness, (iv) organization, (v) succinctness, and (vi) comprehensibility. We compared HPI scores within patient using a repeated measures model. Results: Seventy-five patients had both computer-generated and physician-documented HPIs. The mean overall impression score for computer-generated HPIs was higher than physician HPIs (3.68 vs. 2.80; P<0.001), even after adjusting for physician and visit type, location, mode of transcription, and demographics. Computer-generated HPIs were also judged more complete (3.70 vs. 2.73; P<0.001), more useful (3.82 vs. 3.04; P<0.001), better organized (3.66 vs. 2.80; P<0.001), more succinct (3.55 vs. 3.17; P<0.001), and more comprehensible (3.66 vs. 2.97; P<0.001). Conclusions: Computer-generated HPIs were of higher overall quality, better organized, and more succinct, comprehensible, complete, and useful compared with HPIs written by physicians during usual care in GI clinics.
    Full-text · Article · Dec 2014 · The American Journal of Gastroenterology

Publication Stats

5k Citations
2,517.15 Total Impact Points


  • 2015
    • University of North Carolina at Chapel Hill
      North Carolina, United States
  • 2003-2015
    • University of California, Los Angeles
      • • Division of Digestive Diseases
      • • Department of Health Services
      Los Ángeles, California, United States
    • VA Greater Los Angeles Healthcare System
      Los Ángeles, California, United States
    • Vanderbilt University
      Нашвилл, Michigan, United States
  • 2002-2015
    • Cedars-Sinai Medical Center
      • Cedars Sinai Medical Center
      Los Ángeles, California, United States
  • 2012
    • Harvard Medical School
      Boston, Massachusetts, United States
  • 2007-2011
    • Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center
      Torrance, California, United States
  • 2009-2010
    • Stanford University
      • • Department of Medicine
      • • Stanford Health Policy (Center for Health Policy and Center for Primary Care and Outcomes Research)
      Palo Alto, California, United States
    • Columbia University
      New York, New York, United States
  • 2008
    • United BioSource Corporation
      Maryland, United States
  • 2004
    • University of Manitoba
      Winnipeg, Manitoba, Canada
  • 2001
    • University of Wisconsin - Milwaukee
      Milwaukee, Wisconsin, United States