Randomized patients in IBS research had different disease characteristics compared to eligible and recruited patients

Commentary: core descriptor sets using consensus methods support 'table one' consistency

BACKGROUND

Inconsistent reporting of patient characteristics in clinical research hampers reproducibility and limits analysis opportunities. This paper proposes condition-specific 'Core Descriptor Sets' comprising key factors like demographics, disease severity, comorbidities, and prognosis to standardize Table 1 reporting.

METHODS

Development entails stakeholder involvement, systematic identification of descriptors, value rating, and consensus-building using multiple Delphi rounds. Final agreement comes at an expert meeting.

CONCLUSION

Benefits include easier cross-study comparison, for example, through individual patient meta-analysis, facilitated by comparison of consistently reported individual data rather than group-level analysis. This may also support routine data analyses, subgroup and risk identification, and reduced research waste. Core Descriptor Sets describe cohorts thoroughly while minimizing research burden. They are intended to enable improved clinical characterization, personalization, reproducibility, data sharing, and knowledge building.

Are study populations in trials of antidepressants and psychotherapy comparable? A retrospective case study of two parallel running trials for multi- organ functional somatic disorder

This study retrospectively compares two previous parallel running, randomized, controlled trials of pharmacotherapy (imipramine) and psychotherapy (acceptance and commitment therapy) for multi-organ functional somatic disorder (FSD). Differences in demographics, psychiatric comorbidity, illness severity, and illness duration associated with eligibility for the two trials and patients' willingness to participate are explored using linear or binary regression models. 418 patients with multi-organ FSD was included. We found that 377 (95%) were eligible for psychotherapy and 257 patients (61%) for pharmacotherapy. Patients eligible for pharmacotherapy were less severely impaired, less often received disability pension, reported shorter illness duration and experienced less psychological distress than patients eligible for psychotherapy. Whilst exclusion criteria for both trials differed markedly, it was not possible to clearly identify patient or illness characteristics associated with patients' willingness to participate. The study showed that trial-specific exclusion criteria led to the selection of less complex and less severely impaired patients in the pharmacological trial in this sample of multi-organ FSD. Our findings have important implications for the interpretation and comparability of RCT results of different treatments in multi-organ FSD and may point to some common flaws in study design and interpretation of pharmacological vs. psychotherapeutic intervention trials in psychiatry.

Interpretability of the European Heart Failure Self-care Behaviour scale

OBJECTIVE

The European Heart Failure Self-care Behaviour scale (EHFScBs) is a valid patient-reported questionnaire to measure self-care behavior of heart failure (HF) patients. We assessed the interpretability of the EHFScBs.

METHODS

We used data of 1,023 HF patients. Interpretability refers to the clinical meaning of the score and its changes over time. We operationalized interpretability by evaluating distributions of EHFScBs scores across relevant HF subgroups by eyeballing, by testing the risk on hospitalizations and mortality of a plausible threshold, and by determining a clinically relevant minimal important change (MIC). The scale score ranged from 0 to 100, with a higher score meaning better self-care. A threshold of ≥70 was defined as adequate and <70 as inadequate self-care.

RESULTS

The EHFScBs scores were similarly normally distributed among the subgroups with a mean between 57.8 (SD 19.4) and 72.0 (SD 18.0). The 464 HF patients with adequate self-care had significantly less all-cause hospitalizations than the 559 patients with inadequate self-care.

CONCLUSION

The degree of self-care showed to be independent of relevant HF subgroups. A single threshold of 70 accurately discriminated between patients with adequate and inadequate self-care.

PRACTICE IMPLICATIONS

The threshold of 70 can be used in designing studies and informing health policy makers.

Analysis of recruitment in a pragmatic observational study on C-reactive protein point-of-care testing in primary care

INTRODUCTION

Failure to recruit all eligible study patients can lead to biased results. Little is known on selective patient recruitment in studies on implementation of diagnostic devices.

OBJECTIVES

The aim of this observational study was to measure recruitment of patients in an implementation study in primary care on use of point-of-care (POC) C-reactive protein (CRP) and to evaluate recruitment bias and its impact on the study endpoint.

METHODS

In a cross-sectional observational study on POC CRP implementation and related antibiotics prescribing, we compared included patients with all eligible patients to assess the representativeness of the included subjects. Eligible patients were adults presenting with acute cough in primary care between March and September 2012. The frequency of POC CRP testing and the proportion of prescribed antibiotics were compared between recruited and non-recruited patients. As measure of bias, odds ratios (ORs) with accompanying 95% confidence intervals (CIs) for the association between CRP level (<20 mg/l or not) and antibiotic prescribing were computed.

RESULTS

Of all 1473 eligible patients 348 (24%) were recruited. In recruited patients, POC CRP tests were conducted and antibiotics prescribed more frequently as compared to non-recruited patients (81% versus 6% and 44% versus 29%, respectively). The ORs were 18.2 (95%CI: 9.6-34.3), 30.5 (95%CI: 13.2-70.3) and 3.8 (95%CI: 0.9-14.8) respectively in all eligible patients, the recruited and the non-recruited patients.

CONCLUSION

Selective recruitment resulted in an overestimation of POC CRP test use and antibiotic prescribing.

Calculating Total Health Service Utilisation and Costs from Routinely Collected Electronic Health Records Using the Example of Patients with Irritable Bowel Syndrome Before and After Their First Gastroenterology Appointment

INTRODUCTION

Health economic models are increasingly important in funding decisions but most are based on data, which may therefore not represent the general population. We sought to establish the potential of real-world data available within the Clinical Practice Research Datalink (CPRD) and linked Hospital Episode Statistics (HES) to determine comprehensive healthcare utilisation and costs as input variables for economic modelling.

METHODS

A cohort of patients with irritable bowel syndrome (IBS) who first saw a gastroenterologist in 2008 or 2009, and with 3 years of data before and after their appointment, was created in the CPRD. Primary care, outpatient, inpatient, prescription and colonoscopy data were extracted from the linked CPRD and HES. The appropriate cost to the NHS was attached to each event. Total and stratified annual healthcare utilisation rates and costs were calculated before and after the gastroenterology appointment with distribution parameters. Absolute differences were calculated with 95% confidence intervals.

RESULTS

Total annual healthcare costs over 3 years increase by £935 (95% CI £928-941) following a gastroenterology appointment for IBS. We derived utilisation and cost data with parameter distributions stratified by demographics and time. Women, older patients, smokers and patients with greater comorbidity utilised more healthcare resources, which generated higher costs.

CONCLUSIONS

These linked datasets provide comprehensive primary and secondary care data for large numbers of patients, which allows stratification of outcomes. It is possible to derive input parameters appropriate for economic models and their distributions directly from the population of interest.

Systematic review of randomized controlled trials: fiber supplements for abdominal pain-related functional gastrointestinal disorders in childhood

BACKGROUND

A lack of safe and reliable treatments for abdominal pain-related functional gastrointestinal disorders (FGIDs) has prompted interest in new therapies.

AIM

To systematically evaluate the effect of dietary fibers for treating abdominal pain-related FGIDs in children.

METHODS

In December 2011, MEDLINE, EMBASE and the Cochrane Library were searched for randomized controlled trials (RCTs) evaluating fiber supplementation in children with FGIDs.

RESULTS

Only 3 RCTs were identified, which enrolled a total of 167 children and adolescents (5–17 years old) with recurrent abdominal pain. Only 1 study used the Rome III criteria. Patients were supplemented with different dietary fiber types for 4–6 weeks. The use of dietary fibers did not influence the proportion of responders to treatment, and improvement did not occur in reported clinically relevant outcomes such as no pain or a significant decrease in pain intensity (risk ratio 1.17, 95% confidence interval 0.75–1.81).

CONCLUSION

There is no evidence that supplementation with fiber as a dietary manipulation may be useful for treating children with FGIDs. However, one should not overlook the fact that the main limitation for recommendation of the routine fiber use in clinical practice derives from the weak quality and paucity of available studies.

The reach of depression screening preceding treatment: are there patterns of patients' self-selection?

This study evaluated the reach of depression screening followed by treatment programs for subsyndromal depression and explored demographic and clinical characteristics of patients who were reached versus those who were not. A two-item Patient Health Questionnaire-Depression was sent to 4196 type 2 diabetic patients. Positively screened patients were interviewed to assess the severity of depression, and those with subclinical symptoms were invited to treatment groups. The reach of screening procedure was evaluated by the total response rate, proportion of positive depression screenings, and proportion of eligible patients entering treatment programs. Predictors of responsiveness to screening and of participation in treatment were determined using logistic regression. Of the 34% of patients who returned the questionnaire (n = 1442), 40% reported depressive symptoms and a need for professional help (n = 581). Age (OR = 1.06, 95% CI = 1.05-1.08), BMI (OR = 1.02, 95% CI = 1.00-1.04), HbA1C (OR = .92, 95% CI = .86-.99), and LDL-cholesterol (OR = .90, 95% CI = .81-1.00) correlated with response to screening. Willingness to accept treatment was predicted by professional status (OR = 3.24, 95% CI = 1.53-6.87), education (OR = 1.21, 95% CI = 1.05-1.38), and BMI (OR = .91, 95% CI = .85-.98). Older patients with better diabetes control were more likely to be reached by postal screening for depressive symptoms. Professionally inactive, better-educated persons and those with lower BMI were more likely to participate in the intervention for subsyndromal depression.

Disease burden of post-infectious irritable bowel syndrome in The Netherlands

Post-infectious irritable bowel syndrome (PI-IBS) has been established as a sequel of infectious intestinal disease (IID). The aim of this study was to estimate the burden of PI-IBS caused by the pathogens Campylobacter, Salmonella and Shigella, and to compare this with other outcomes associated with these pathogens. The attributable risk of PI-IBS due to bacterial pathogens was calculated and linked to national data on gastroenteritis incidence and measures for severity and duration of illness in order to estimate the burden of PI-IBS. One year post-infection, IBS developed in 9% of patients with bacterial IID. The burden of PI-IBS adds over 2300 disability adjusted life years to the total annual disease burden for the selected pathogens. PI-IBS is a frequent sequel of IID, resulting in a considerable disease burden compared to other outcomes. If this relationship is not considered, this will result in an underestimation of the disease burden of IID.

Soluble or insoluble fibre in irritable bowel syndrome in primary care? Randomised placebo controlled trial

OBJECTIVE

To determine the effectiveness of increasing the dietary content of soluble fibre (psyllium) or insoluble fibre (bran) in patients with irritable bowel syndrome.

DESIGN

Randomised controlled trial.

SETTING

General practice.

PARTICIPANTS

275 patients aged 18-65 years with irritable bowel syndrome.

INTERVENTIONS

12 weeks of treatment with 10 g psyllium (n=85), 10 g bran (n=97), or 10 g placebo (rice flour) (n=93).

MAIN OUTCOME MEASURES

The primary end point was adequate symptom relief during at least two weeks in the previous month, analysed after one, two, and three months of treatment to assess both short term and sustained effectiveness. Secondary end points included irritable bowel syndrome symptom severity score, severity of abdominal pain, and irritable bowel syndrome quality of life scale.

RESULTS

The proportion of responders was significantly greater in the psyllium group than in the placebo group during the first month (57% v 35%; relative risk 1.60, 95% confidence interval 1.13 to 2.26) and the second month of treatment (59% v 41%; 1.44, 1.02 to 2.06). Bran was more effective than placebo during the third month of treatment only (57% v 32%; 1.70, 1.12 to 2.57), but this was not statistically significant in the worst case analysis (1.45, 0.97 to 2.16). After three months of treatment, symptom severity in the psyllium group was reduced by 90 points, compared with 49 points in the placebo group (P=0.03) and 58 points in the bran group (P=0.61 versus placebo). No differences were found with respect to quality of life. Fifty four (64%) of the patients allocated to psyllium, 54 (56%) in the bran group, and 56 (60%) in the placebo group completed the three month treatment period. Early dropout was most common in the bran group; the main reason was that the symptoms of irritable bowel syndrome worsened.

CONCLUSIONS

Psyllium offers benefits in patients with irritable bowel syndrome in primary care.

TRIAL REGISTRATION

Clinical trials NCT00189033.

Soluble or insoluble fibre in irritable bowel syndrome in primary care? Randomised placebo controlled trial

OBJECTIVE

To determine the effectiveness of increasing the dietary content of soluble fibre (psyllium) or insoluble fibre (bran) in patients with irritable bowel syndrome.

DESIGN

Randomised controlled trial.

SETTING

General practice.

PARTICIPANTS

275 patients aged 18-65 years with irritable bowel syndrome.

INTERVENTIONS

12 weeks of treatment with 10 g psyllium (n=85), 10 g bran (n=97), or 10 g placebo (rice flour) (n=93).

MAIN OUTCOME MEASURES

The primary end point was adequate symptom relief during at least two weeks in the previous month, analysed after one, two, and three months of treatment to assess both short term and sustained effectiveness. Secondary end points included irritable bowel syndrome symptom severity score, severity of abdominal pain, and irritable bowel syndrome quality of life scale.

RESULTS

The proportion of responders was significantly greater in the psyllium group than in the placebo group during the first month (57% v 35%; relative risk 1.60, 95% confidence interval 1.13 to 2.26) and the second month of treatment (59% v 41%; 1.44, 1.02 to 2.06). Bran was more effective than placebo during the third month of treatment only (57% v 32%; 1.70, 1.12 to 2.57), but this was not statistically significant in the worst case analysis (1.45, 0.97 to 2.16). After three months of treatment, symptom severity in the psyllium group was reduced by 90 points, compared with 49 points in the placebo group (P=0.03) and 58 points in the bran group (P=0.61 versus placebo). No differences were found with respect to quality of life. Fifty four (64%) of the patients allocated to psyllium, 54 (56%) in the bran group, and 56 (60%) in the placebo group completed the three month treatment period. Early dropout was most common in the bran group; the main reason was that the symptoms of irritable bowel syndrome worsened.

CONCLUSIONS

Psyllium offers benefits in patients with irritable bowel syndrome in primary care.

TRIAL REGISTRATION

Clinical trials NCT00189033.