BACKGROUND/RATIONALE:
Colorectal cancer (CRC) is the third most commonly diagnosed cancer and the third leading cause of cancer deaths among Veterans. Multiple screening modalities are available and have been shown to decrease the incidence and mortality from CRC, but the Veterans Health Administration's (VHA) capacity to provide this screening is strained. The VHA has addressed this challenge by hiring additional staff and outsourcing endoscopic care to non-VHA providers, at great expense to the organization. A complementary and more cost-effective approach to increasing the supply of staff is to optimize the efficiency of existing resources to absorb additional demand.

Because of its importance to providing quality and timely care to Veterans, improving health care efficiency and productivity is a major initiative in the VHA strategic plan. A number of methodologies have been used to improve efficiency in health care delivery including six sigma and lean. Discrete event simulation (DES) is an operations research methodology that is not routinely used in VHA system redesign efforts but can be applied to improve patient flow and efficiency of clinic operations. DES has been well established and validated as a business intelligence tool in the manufacturing sector and has been shown to be effective in a number of healthcare contexts. However, while there have been numerous publications on the creation of DES models in healthcare, there has been a dearth of literature on their implementation and use.

OBJECTIVE(S):
The proposed research aims to bridge this limitation and develop generalizable knowledge regarding how DES can be used most effectively to improve efficiency in GI endoscopy and how to facilitate broader implementation of this approach within the VHA to improve capacity for CRC screening.

METHODS:
The conceptual framework for complex innovations proposed by Helfrich, Weiner et al. will guide the development and testing of the simulation-guided intervention. This intervention will be developed and assessed using a mixed-methods approach that combines elements of health systems engineering and implementation science. The proposed project has three aims: 1) Utilize DES modeling to evaluate opportunities for increased efficiency of the Durham VA GI Endoscopy Unit; 2) Conduct a formative evaluation to understand the barriers and facilitators to implementing simulation-guided systems redesign with the VHA; and 3) Pilot the use of simulation modeling to guide systems redesign activities in the endoscopy unit at the Durham VA Medical Center.

FINDINGS/RESULTS:
Not yet available.

IMPACT:
The proposed career development program will result in a simulation-based intervention to expand the colorectal cancer screening capacity of the VHA through improved endoscopy unit efficiency and will enable additional independent research, guided by implementation theory, on the dissemination of simulation-guided systems redesign more broadly within the VHA. This research program aligns with the strategic goals of HSR&D and can strengthen the important link between clinical care, healthcare systems engineering and systems redesign.

PUBLICATIONS:

Journal Articles

1. Horton A, Posner S, Sullivan B, Cornejo J, Davis A, Fields M, McIntosh T, Gellad Z, Shimpi R, Gyawali CP, Patel A. Esophageal contractile segment impedance from high-resolution impedance manometry correlates with mean nocturnal baseline impedance and acid exposure time from 24-hour pH-impedance monitoring. Diseases of the esophagus : official journal of the International Society for Diseases of the Esophagus. 2020 Dec 7; 33(12).
2. Horton A, Sullivan B, Charles K, McIntosh T, Davis A, Gellad Z, Shimpi R, Gyawali CP, Patel A. Esophageal Baseline Impedance From High-resolution Impedance Manometry Correlates With Mean Nocturnal Baseline Impedance From pH-impedance Monitoring. Journal of neurogastroenterology and motility. 2020 Sep 30; 26(4):455-462.
3. Sullivan BA, Qin X, Redding TS, Gellad ZF, Stone A, Weiss D, Madison AN, Sims KJ, Williams CD, Lieberman D, Hauser ER, Provenzale D. Genetic Colorectal Cancer and Adenoma Risk Variants Are Associated with Increasing Cumulative Adenoma Counts. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology. 2020 Nov 1; 29(11):2269-2276.
4. Jawitz NG, Gellad ZF, Lin L, Wood RK, Leiman DA. Patient, Physician, and Procedure Characteristics Are Independently Predictive of Polyp Detection Rates in Clinical Practice. Digestive diseases and sciences. 2021 Aug 1; 66(8):2570-2577.
5. Sullivan BA, Redding TS, Hauser ER, Gellad ZF, Qin X, Gupta S, Robertson DJ, Weiss DG, O MC, Madison AN, Sims KJ, Williams CD, Hong JC, Lieberman D, Provenzale D. High-Risk Adenomas at Screening Colonoscopy Remain Predictive of Future High-Risk Adenomas Despite an Intervening Negative Colonoscopy. The American journal of gastroenterology. 2020 Aug 1; 115(8):1275-1282.
6. Wosik J, Fudim M, Cameron B, Gellad ZF, Cho A, Phinney D, Curtis S, Roman M, Poon EG, Ferranti J, Katz JN, Tcheng J. Telehealth transformation: COVID-19 and the rise of virtual care. Journal of the American Medical Informatics Association : JAMIA. 2020 Jun 1; 27(6):957-962.
7. Leiman DA, Jawitz NG, Lin L, Wood RK, Gellad ZF. Terminal ileum intubation is not associated with colonoscopy quality measures. Journal of gastroenterology and hepatology. 2020 Sep 1; 35(9):1503-1508.
8. Musselwhite LW, Redding TS, Sims KJ, O'Leary MC, Hauser ER, Hyslop T, Gellad ZF, Sullivan BA, Lieberman D, Provenzale D. Advanced neoplasia in Veterans at screening colonoscopy using the National Cancer Institute Risk Assessment Tool. BMC cancer. 2019 Nov 12; 19(1):1097.
9. Spechler SJ, Hunter JG, Jones KM, Lee R, Smith BR, Mashimo H, Sanchez VM, Dunbar KB, Pham TH, Murthy UK, Kim T, Jackson CS, Wallen JM, von Rosenvinge EC, Pearl JP, Laine L, Kim AW, Kaz AM, Tatum RP, Gellad ZF, Lagoo-Deenadayalan S, Rubenstein JH, Ghaferi AA, Lo WK, Fernando RS, Chan BS, Paski SC, Provenzale D, Castell DO, Lieberman D, Souza RF, Chey WD, Warren SR, Davis-Karim A, Melton SD, Genta RM, Serpi T, Biswas K, Huang GD. Randomized Trial of Medical versus Surgical Treatment for Refractory Heartburn. The New England journal of medicine. 2019 Oct 17; 381(16):1513-1523.
10. Lieberman D, Sullivan BA, Hauser ER, Qin X, Musselwhite LW, O'Leary MC, Redding TS, Madison AN, Bullard AJ, Thomas R, Sims KJ, Williams CD, Hyslop T, Weiss D, Gupta S, Gellad ZF, Robertson DJ, Provenzale D. Baseline Colonoscopy Findings Associated With 10-Year Outcomes in a Screening Cohort Undergoing Colonoscopy Surveillance. Gastroenterology. 2020 Mar 1; 158(4):862-874.e8.
11. Zullig LL, Bhatia HL, Gellad ZF, Eatherly M, Henderson R, Bosworth HB. Adoption of direct-acting antiviral medications for hepatitis C: a retrospective observational study. BMC health services research. 2019 Jul 25; 19(1):521.
12. Voils CI, King HA, Thorpe CT, Blalock DV, Kronish IM, Reeve BB, Boatright C, Gellad ZF. Content Validity and Reliability of a Self-Report Measure of Medication Nonadherence in Hepatitis C Treatment. Digestive diseases and sciences. 2019 Oct 1; 64(10):2784-2797.
13. Volk ML, Mellinger J, Bansal MB, Gellad ZF, McClellan M, Kanwal F. A Roadmap for Value-Based Payment Models Among Patients With Cirrhosis. Hepatology (Baltimore, Md.). 2019 Mar 1; 69(3):1300-1305.
14. Finn RT, Lloyd B, Patel YA, Allen JT, Cornejo J, Davis A, McIntosh T, Ferguson S, Sims K, Sudaj S, Taheri J, Burr NA, Provenzale D, Gellad ZF. Decreasing Endoscopy No-Shows Using a Lean Improvement Framework. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2019 Jun 1; 17(7):1224-1227.e3.
15. Ding X, Gellad ZF, Mather C, Barth P, Poon EG, Newman M, Goldstein BA. Designing risk prediction models for ambulatory no-shows across different specialties and clinics. Journal of the American Medical Informatics Association : JAMIA. 2018 Aug 1; 25(8):924-930.
16. Mull HJ, Gellad ZF, Gupta RT, Valle JA, Makarov DV, Silverman T, Branch-Elliman W. Factors Associated With Emergency Department Visits and Hospital Admissions After Invasive Outpatient Procedures in the Veterans Health Administration. JAMA surgery. 2018 Aug 1; 153(8):774-776.
17. Egberg MD, Gulati AS, Gellad ZF, Melmed GY, Kappelman MD. Improving Quality in the Care of Patients with Inflammatory Bowel Diseases. Inflammatory Bowel Diseases. 2018 Jul 12; 24(8):1660-1669.
18. Holman RR, Bethel MA, Mentz RJ, Thompson VP, Lokhnygina Y, Buse JB, Chan JC, Choi J, Gustavson SM, Iqbal N, Maggioni AP, Marso SP, Öhman P, Pagidipati NJ, Poulter N, Ramachandran A, Zinman B, Hernandez AF, EXSCEL Study Group. Effects of Once-Weekly Exenatide on Cardiovascular Outcomes in Type 2 Diabetes. The New England journal of medicine. 2017 Sep 28; 377(13):1228-1239.
19. Japinga M, Saunders R, Gellad ZF, McClellan M. The Evolving Payment Reform Landscape: New Opportunities for Gastroenterology Leadership. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2017 Sep 1; 15(9):1322-1325.
20. Gellad ZF. Cultivating Competencies for Value-Based Care. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2017 Jul 1; 15(7):969-971.
21. Finn RT, Boyd A, Lin L, Gellad ZF. Bolus Administration of Fentanyl and Midazolam for Colonoscopy Increases Endoscopy Unit Efficiency and Safety Compared With Titrated Sedation. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2017 Sep 1; 15(9):1419-1426.e2.
22. Day TE, Gellad ZF. The Value of Negative Results in Quality Improvement: A Simulation Perspective. American journal of medical quality : the official journal of the American College of Medical Quality. 2016 Jul 1; 31(4):376-8.
23. Gellad ZF, Day TE. What Is Value Stream Mapping, and How Can It Help My Practice? The American journal of gastroenterology. 2016 Apr 1; 111(4):447-8.
24. Saini SD, Adams MA, Brill JV, Gupta N, Naveed M, Rosenberg JA, Gellad ZF. Colorectal Cancer Screening Quality Measures: Beyond Colonoscopy. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2016 May 1; 14(5):644-7.
25. Partin MR, Gravely A, Gellad ZF, Nugent S, Burgess JF, Shaukat A, Nelson DB. Factors Associated With Missed and Cancelled Colonoscopy Appointments at Veterans Health Administration Facilities. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2016 Feb 1; 14(2):259-67.
26. Seidelman J, Zuo R, Udayakumar K, Gellad ZF. Caught on Capsule: Iron-deficiency Anemia Due to Hookworm Infection. The American journal of medicine. 2016 Feb 1; 129(2):167-9.
27. Mansouraty G, Gellad ZF. Website Review: Review of patient-oriented websites on hemorrhoids. Gastroenterology. 2015 Apr 25.
28. Gellad ZF, Voils CI, Lin L, Provenzale D. Physician perceptions on colonoscopy quality: results of a national survey of gastroenterologists. Gastroenterology research and practice. 2014 Mar 6; 2014:510494.

Journal Other

1. Gellad ZF. Issue Highlights. Clinical Gastroenterology and Hepatology. 2017 Aug 16; 15(10):1483-1484.
2. Partin MR, Shaukat A, Nelson DB, Gravely A, Nugent S, Gellad ZF, Burgess JF. Reply. Clinical Gastroenterology and Hepatology. 2016 Mar 1; 14(3):486.
3. Rubenstein JH, Lieberman D, Fennerty B, Gellad ZF. Measuring the quality of Barrett's esophagus management with measures that are high quality. [Editorial]. Gastroenterology. 2015 Nov 1; 149(6):1298-301.
4. Yang YX, Brill J, Krishnan P, Leontiadis G, American Gastroenterological Association Clinical Practice Guidelines Committee. American Gastroenterological Association Institute Guideline on the Role of Upper Gastrointestinal Biopsy to Evaluate Dyspepsia in the Adult Patient in the Absence of Visible Mucosal Lesions. Gastroenterology. 2015 Oct 1; 149(4):1082-7.
5. Gellad ZF. Quality Measures in Gastroenterology. [Editorial]. American Gastroenterological Association AGA Perspectives. 2015 Jul 12;(June/July):22-23.

Conference Presentations

1. Gellad ZF. A Randomized Trial of Medical and Surgical Treatments for Patients With GERD Symptoms That Are Refractory to Proton Pump Inhibitors. Paper presented at: VA Durham Cooperative Studies Program Epidemiology Center Research Day; 2016 Jun 20; Durham, NC.
2. Gellad ZF. Quality Metrics in GI: Embrace and Expand. Presented at: Digestive Disease Week Annual Conference; 2016 May 24; San Diego, CA.
3. Gellad ZF. Updates on the Current Measures Used to Define Quality in GI & Hepatology. Paper presented at: Digestive Disease Week Annual Conference; 2016 May 24; San Diego, CA.
4. Gellad ZF. How Gastroenterology Practices Large & Small are Adapting to the New Era of Quality Measurement. Presented at: Digestive Disease Week Combined Clinical Annual Symposia; 2016 May 23; San Diego, CA.
5. Liberman D, Abbott D, Hauser E, O MC, Williams C, McNeil RB, Sullivan B, Musselwhite L, Gellad ZF, Weiss D, Provenzale D. Clinical Risk Group at Baseline is Associated with 10 Year Outcomes in a Screening Cohort-Longitudinal Analysis of the CSP 380 Cohort. Paper presented at: Digestive Disease Week Annual Conference; 2016 May 21; San Diego, CA.
6. Sullivan B, Abbott D, Hauser E, O'Leary MC, Williams C, McNeil RB, Musselwhite L, Gellad ZF, Weiss D, Lieberman D, Provenzale D. Risk Factors Associated with the Development of Adenoma Multiplicity in a Screening Cohort. Poster session presented at: Digestive Disease Week Annual Conference; 2016 May 21; San Diego, CA.
7. Gellad ZF. Simulation-Guided Systems Redesign in GI Endoscopy. Paper presented at: Baylor College of Medicine Department of Medicine House Staff Research Annual Symposium; 2016 Feb 4; Waco, TX.
8. Gellad ZF. Demonstrating Value in HCV Care within the VA. Paper presented at: VA SCAN Hepatology Telehealth Network Annual Meeting; 2016 Jan 12; Fredericksburg, VA.
9. Hauser E, Musselwhite LW, McNeil RB, Abbott D, Thomas C, O MC, Andrews SM, Wagner L, Gellad ZF, Weiss DG, Lieberman DT, Provenzale D. Interactions of Family History with Baseline Risk Factors at 5-Year Follow-up in a Colorectal Cancer (CRC) Screening Study in US 19 Veterans. Poster session presented at: American Society of Human Genetics Annual Meeting; 2015 Oct 6; Baltimore, MD.
10. Partin MR, Gravel A, Gellad ZF, Nugent S, Burgess JF, Shaukat A, Nelson DB. Individual and Organizational Predictors of Cancelled and Missed Colonoscopy Appointments: An Observational Study. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 10; Philadelphia, PA.
11. Gellad ZF. Introduction to Patient Quality Reporting System (PQRS). Paper presented at: Digestive Disease Week Annual Conference; 2015 May 18; Washington, DC.
12. Gellad ZF. Making Dollars and Sense of Quality. Presented at: Digestive Disease Week Annual Conference; 2015 May 18; Washington, DC.
13. Gellad ZF. Quality Metrics in Gastroenterology: Past, Present, Future. Paper presented at: Digestive Disease Week Annual Conference; 2015 May 18; Washington, DC.
14. Gellad Z, Kanwal F. Development of Quality Metrics in Gastroenterology. Paper presented at: Digestive Disease Week Annual Conference; 2015 May 16; Washington, DC.
15. Gellad ZF, Chermak D, Brown E, Taheri J. Automating Endoscopy Unit Efficiency Metrics: Leveraging the Electronic Health Record for Process Improvement. Poster session presented at: Digestive Disease Week Annual Conference; 2015 May 16; Washington, DC.
16. Gellad ZF. Who’s on First: Healthcare Systems Engineering in GI Endoscopy. Paper presented at: Virginia Commonwealth University School of Medicine Quarterly Meeting; 2015 Apr 22; Charlottesville, VA.
17. Gellad ZF. Quality Versus Efficiency. Paper presented at: Johns Hopkins Medicine Division of Gastroenterology and Hepatology Annual Endoscopy Directors Meeting; 2015 Mar 28; Washington, DC.
18. Taheri J, Brown G, Gellad ZF, Patel S, Robles S. Nurse-Physician Ratio in an Internal Medicine Residency Clinic. Poster session presented at: Industrial and Systems Engineering Research Conference; 2015 Mar 3; Dubai, United Arab Emirates.
19. Gellad ZF. Simulation-Guided Systems Redesign in GI Endoscopy. Paper presented at: Duke University Clinical Research Institute Annual Clinical Medicine Series; 2015 Feb 24; Durham, NC.
20. Bhaskar A, Gellad ZF. Physician-Directed Bolus Sedation for Colonoscopy Improves Endoscopy Unit Efficiency. Poster session presented at: American College of Gastroenterology Annual Meeting; 2014 Oct 22; Philadelphia, PA.

DRA: Digestive Diseases, Health Systems
DRE: Treatment - Implementation, Technology Development and Assessment
Keywords: Outcomes - Patient
MeSH Terms: none