1. Assessment Module Layout
Questions
Correct Answers
Incorrect Answers
Critique/Rationale
Link to Didactic Content for Additional Study
Link to Additional Study Materials
What is the ACC doing and what is the ACG doing related to assessment?
Revisit Initial Questions & Answer Correctly
Other Enduring Materials (CME)
Digitally Captured Live Presentations
Post to a Discussion Forum
Materials Outside of AGA Including TheGut.org
Other
Critique/Rationale
Link to Additional Study Materials
Application to Practice
Evaluation

2. Question answered correctly A 52 year old Caucasian male is referred to you for heartburn. He has a 20 yr history of heartburn with intermittent symptoms while on once a day PPI therapy. He denies dysphagia, nausea or vomiting. His physical examination is notable for a BMI of 40, but his physical examination and laboratory studies are otherwise unremarkable. EGD shows the following in the distal esophagus: Endoscopic biopsies are likely to show: A: Normal gastric epithelium. B: Intestinal metaplasia. C: Erosive esophagitis. D: Squamous cell carcinoma. E: Adenocarcinoma.

3. Critique/Rationale:
Barrett’s esophagus is found in approximately 6 to 12% of patients undergoing endoscopy for symptoms of GERD and in 1% or less of unselected patient populations undergoing endoscopy. The prevalence of long-segment Barrett’s esophagus (3 cm or more of interstitial metaplasia) is approximately 5%, whereas that of short-segment Barrett’s esophagus (less than 3 cm of interstitial metaplasia) is approximately 6 to 12% in patients undergoing endoscopy in a variety of settings. Autopsy data suggest that the majority of cases of Barrett’s esophagus go undetected in the general population. This may be due to the observation that esophageal sensitivity to acid perfusion is impaired in these patients. Furthermore, only approximately 5% of patients with esophageal adenocarcinoma have an antecedent diagnosis of Barrett’s esophagus.

4. Correct Answers will Link to Additional Study Materials
AGA Institute Cases Online A Woman with Worsening GERD and Barrett’s Esophagus TheGut.org
High Stakes and High Risk: Improving the Odds in Barrett's Esophagus, Colorectal Cancer and NSAID-Induced Complications PubMed The development and validation of an endoscopic grading system for Barrett's esophagus:
the Prague C & M criteria Practice guidelines
ASGE: Role of Endoscopy in The Management of Barrett's Esophagus
SSAT: Patient Care Guidelines
Management of Barrett's Esophagus

5. Additional Links for Reference and Study
AGA Institute
Position Statement and Technical Review Role of the Gastroenterologist in the Management of Esophageal Carcinoma
GI Core Curriculum Training in Acid-Peptic Disease
(chapter 1, third edition, May 2007)
Future Trends Committee
Endoscopic advances (October 2006)

6. Question answered incorrectly A 52 year old Caucasian male is referred to you for heartburn. He has a 20 yr history of heartburn with intermittent symptoms while on once a day PPI therapy. He denies dysphagia, nausea or vomiting. His physical examination is notable for a BMI of 40, but his physical examination and laboratory studies are otherwise remarkable. EGD shows the following in the distal esophagus: Endoscopic biopsies are likely to show: A: Normal gastric epithelium. B: Intestinal metaplasia. C: Erosive esophagitis. D: Squamous cell carcinoma. E: Adenocarcinoma.

7. Incorrect Answers will Link to Didactic Content for Additional Study
Barrett’s esophagus is a complication of gastroesophageal reflux disease. Endoscopically, this lesion is recognized by displacement of the squamocolumnar junction proximal to the gastroesophageal junction. Histologically, it is characterized by metaplastic transformation of the esophageal squamous epithelium to a specialized columnar intestinal metaplastic epithelium with acid mucin-containing goblet cells
Return to question for retest:

8. Revisit Initial Question & Answer Correctly
Question A 52 year old Caucasian male is referred to you for heartburn. He has a 20 yr history of heartburn with intermittent symptoms while on once a day PPI therapy. He denies dysphagia, nausea or vomiting. His physical examination is notable for a BMI of 40, but his physical examination and laboratory studies are otherwise unremarkable. EGD shows the following in the distal esophagus: Endoscopic biopsies are likely to show: A: Normal gastric epithelium. B: Intestinal metaplasia. C: Erosive esophagitis. D: Squamous cell carcinoma. E: Adenocarcinoma.

9. Critique/Rationale:
Barrett’s esophagus is found in approximately 6 to 12% of patients undergoing endoscopy for symptoms of GERD and in 1% or less of unselected patient populations undergoing endoscopy. The prevalence of long-segment Barrett’s esophagus (3 cm or more of interstitial metaplasia) is approximately 5%, whereas that of short-segment Barrett’s esophagus (less than 3 cm of interstitial metaplasia) is approximately 6 to 12% in patients undergoing endoscopy in a variety of settings. Autopsy data suggest that the majority of cases of Barrett’s esophagus go undetected in the general population. This may be due to the observation that esophageal sensitivity to acid perfusion is impaired in these patients. Furthermore, only approximately 5% of patients with esophageal adenocarcinoma have an antecedent diagnosis of Barrett’s esophagus.

10. Correct Answers will Link to Additional Study Materials
AGA Institute Cases Online A Woman with Worsening GERD and Barrett’s Esophagus TheGut.org
High Stakes and High Risk: Improving the Odds in Barrett's Esophagus, Colorectal Cancer and NSAID-Induced Complications PubMed The development and validation of an endoscopic grading system for Barrett's esophagus:
the Prague C & M criteria Practice guidelines
ASGE: Role of Endoscopy in The Management of Barrett's Esophagus
SSAT: Patient Care Guidelines
Management of Barrett's Esophagus

11. Additional Links for Reference and Study
AGA Institute
Position Statement and Technical Review Role of the Gastroenterologist in the Management of Esophageal Carcinoma
GI Core Curriculum Training in Acid-Peptic Disease
(chapter 1, third edition, May 2007)
Future Trends Committee
Endoscopic advances (October 2006)

12. Application to Practice (didactic)
The epidemiology of Barrett's esophagus is incompletely described. Published studies indicate it is more prevalent in older, white males, a pattern that mirrors that of esophageal adenocarcinoma (EAC). Emerging data suggests that Barrett's may be as prevalent in Hispanics as whites, and that rates among women and other minority groups are increasing. In patients with esophageal reflux disease, those with Barrett's are more likely to report the onset of GERD at an early age, have increased duration of symptoms, increased severity of nocturnal symptoms and more GERD-related complications such as esophagitis, ulceration, stricture and bleeding. The increased risk of Barrett's in this type of patient may be great, with some studies citing a 6.4 fold increase in those with symptoms greater than 10 years. Thus, symptoms of Barrett's are indistinguishable from symptoms of GERD without Barrett's complications. Further, many with Barrett's have no symptoms at all. Other factors have also emerged as potentially related to the development of EAC, including tobacco use, diet low in fruits and vegetables, and increased body mass index (BMI). Interestingly, evidence suggests that use of aspirin/NSAIDs may be associated with decreased risks of EAC.

13. AGA CME Café (2005): Barrett's Esophagus and Adenocarcinoma

14. AGA Institute Discussion Forum

15. AGA Institute Discussion Forum
“How frequently do you screen your at risk patients?
Every two or three years?”

16. Practice Improvement Modules (PIMs)
Option for members to build their own PIMs around Barrett’s Esophagus:
How does your practice track patients with interstitial metaplasia, interstitial metaplasia with low-grade and high-grade metaplasia?
What performance measures will you use to prospectively track how you manage these patients? Etc.
[PIMs satisfy specific point requirements for MOC and are eligible for CME credit]

17. Assess learner’s experience
Helpful, not helpful in making clinical decisions with your patients?
How would you rank the utility of these educational materials on this topic?
Are there any revisions you would you make to this educational material?
[Offer the member an opportunity to post their thoughts to an AGA Institute discussion forum]

18. Back office functions: Log responses & route them
To the member’s personal learning portfolio (populates CME credit and points toward MOC)
To an activity database that aggregates member feedback
Continuous needs assessment data
Continuous member assessment of activity effectiveness (dynamic ranking of materials when members search)
Determine when educational activities need revision, content accuracy or teaching effectiveness may have eroded

19. Benefits
Real time assessment and modification of the questions and critiques
Updates quicker based on learner responses and changes in the science
Granular: substantive learning can be done in minute increments
Ubiquitously available from a desktop PC or PDA
Paperless production will control costs

20. The Next Question
Four modules, thematically related, in sequence, and by design.
The plan:
“Think big, start small, scale fast.”
The concept:
“Aesthetic rigor: elegance, economy and formal coherence.”

21. National Medical Society
Mission of a
National Medical Society
Support Research Enterprise (Basic Science & Clinical)
Encourage Curiosity
Member Personal Learning Portfolio
Information Disseminated
Build a Professional Community
Patient Care is Delivered

22. Instructional Designer
Now Hiring!
Instructional Designer
Contact:
Charles Willis
(301)

23. Thanks to: JB McGee, MD Geoff Braden, MD Jay Kuemmerle, MD
Ashley Lombard
Carrie Smith
Kwesi Agyeman