[Clinical practice guideline on the management of patients with gastroesophageal reflux disease (GERD)]

Mapping of the Gastrointestinal Short Form Questionnaire (GSF-Q) into EQ-5D-3L and SF-6D in patients with gastroesophageal reflux disease

BACKGROUND

The short, self-administered Gastroesophageal Reflux Disease (GERD) Symptom Frequency Questionnaire (GSFQ) is a specific Quality of Life (QoL) instrument which measures the impact of GERD symptoms on QoL. This study aims to map the specific scores in GSFQ into two generic instruments: SF-6D and EQ-5D-3 L, in order to obtain utility estimates derived from the GERD condition.

METHOD

A national representative sample of GERD patients was selected, stratified by gender, age (< 45, ≥45 years) and GERD severity (0-I, II-IV Savary-Miller score) for validation purposes. Age, gender, BMI, GERD diagnose, GERD severity, associated comorbidities and risk factors were recorded. GSFQ, SF-6D, EQ-5D-3 L, and the HRQoL Visual Analogue Scale (VAS) were answered by patients. Several mapping methods were estimated, regression using dummy variables, and linear, quadratic and cubic regression using optimal factor scores. The use of a GERD aggregated summary severity derived from the GSFQ was dimed the best predictor. Overall Mean Absolute Error (MAE), overall Mean Absolute Percentage Error (MAPE) were used as goodness-of-fit (GOF) indexes to compare models.

RESULTS

A total of 3405 patients were recruited by 490 clinicians. Mean age was 49 (±14.4) years and 49.8% were women. Reported comorbidities were clustered in 6 antecedents and 15 concomitant pathologies. Aggregation of levels for the frequency of symptoms items was found more suitable for estimation. Regression weights were found to follow a monotonous progressive pattern. Overall MAE ranged from 0.092 to 0.094 for SF-6D utility prediction and from 0.008 to 0.08 for EQ-5D-3 L, while MAPE values ranged from 27.9 to 29% for SF-6D and from 36.8 to 38.4% for EQ-5D-3 L. Cubic regression GOF demonstrated a better fit.

CONCLUSIONS

It is possible to translate specific GSFQ scores assessing GERD condition into generic SF-6D and EQ-5D-3 L utility values. Although regression using dummy variables is a suitable mapping procedure, other alternative mapping methods convey better fit, in particular cubic regression.

Is the reflux disease questionnaire useful for identifying GERD according to the Montreal definition?

Background

Scales for aiding physicians diagnose gastro-oesophageal reflux disease (GERD) have not been evaluated in terms of their ability to discriminate between troublesome symptoms (TS) and non-troublesome symptoms (NTS). Our objective is to evaluate the ability of the Reflux Disease Questionnaire (RDQ) to identify GERD according to referral of TS, in patients without previous proton pump inhibitor (PPI) treatment and in patients on PPI treatment.

Methods

Patients consulting physicians because of heartburn or acid regurgitation were recruited at 926 primary-care centres in Spain. They were asked to complete several questionnaires including the RDQ, and to define which of their symptoms were troublesome. Information on drug treatment was collected by the physician. We performed a receiver operating characteristic (ROC) curve analysis to ascertain the RDQ's optimum cut-point for identifying TS.

Results

4574 patients were included, 1887 without PPI and 2596 on PPI treatment. Among those without PPI treatment, 1722 reported TS. The area under the curve (AUC) was 0.79 for the RDQ, and the optimum RDQ cut-point for identifying TS was 3.18 (sensitivity, 63.2%; specificity, 80.2%). A total of 2367 patients on PPI treatment reported TS, and the optimum RDQ cut-off value was 3.06 (sensitivity, 65.4%; specificity, 71.8%).

Conclusions

An RDQ score higher than 3 shows good sensitivity and specificity for differentiating TS from NTS among patients without PPI or on PPI treatment. The RDQ is useful in primary care for diagnosis of GERD based on the Montreal definition.

Gastroesophageal reflux in critically ill children: a review

Gastroesophageal reflux (GER) is very common in children due to immaturity of the antireflux barrier. In critically ill patients there is also a high incidence due to a partial or complete loss of pressure of the lower esophageal sphincter though other factors, such as the use of nasogastric tubes, treatment with adrenergic agonists, bronchodilators, or opiates and mechanical ventilation, can further increase the risk of GER. Vomiting and regurgitation are the most common manifestations in infants and are considered pathological when they have repercussions on the nutritional status. In critically ill children, damage to the esophageal mucosa predisposes to digestive tract hemorrhage and nosocomial pneumonia secondary to repeated microaspiration. GER is mainly alkaline in children, as is also the case in critically ill pediatric patients. pH-metry combined with multichannel intraluminal impedance is therefore the technique of choice for diagnosis. The proton pump inhibitors are the drugs of choice for the treatment of GER because they have a greater effect, longer duration of action, and a good safety profile.

[Study of the clinical profile and management of patients with gastroesophageal reflux disease in primary care in Spain]

OBJECTIVE

To assess the clinical profile and management of patients with gastroesophageal reflux disease (GERD) in primary care.

METHODS

A multinational, multicenter study was performed comprising a 4-month retrospective phase for the screening, selection and assessment of patients who had consulted for any GERD-related cause (index visit), and a cross-sectional phase in which clinical data were recorded and the following questionnaires were administered: the Reflux Disease Questionnaire and the Gastroesophageal Reflux Disease Impact Scale (GIS).

RESULTS

Among the 24 participating Spanish centers, 2.7% of the patients (95% CI: 2.6-2.9) had consulted at least once because of GERD. Approximately 50% of the patients showed frequent (2 or more days a week) or moderate to severe symptoms of heartburn, acid regurgitation or chest pain. Although the patients received effective pharmacological treatment at the index visit, clinically relevant GERD symptoms persisted in 16% after a median follow-up of 5 months. These symptoms were associated with a strong disease impact as evaluated with the GIS.

CONCLUSION

GERD represents a substantial burden for primary care physicians. Although effective drugs are used for the treatment of this condition, clinically relevant symptoms persist in a substantial proportion of patients.

Management of gastroesophageal reflux disease in primary care settings in Spain: SYMPATHY I study

OBJECTIVE

Our study was designed to assess the symptom loads, treatment strategies, and impact on daily life of patients with gastroesophageal reflux disease (GERD) symptoms who consulted primary care (PC) health care providers in Spain.

METHODS

This was a multicenter, observational, cross-sectional study in a sample of 5735 consecutive patients visiting PC clinics with GERD symptoms. Participating primary care physicians (PCPs) collected clinical data by using a questionnaire, and completed a survey on their perceptions of diagnostic and therapeutic approaches to GERD. Patients self-completed the GERD Impact Scale during the study visit.

RESULTS

In the week before visiting the PC clinic, typical GERD symptoms were present in a majority of patients (89.6% heartburn and 81.6% regurgitation), but extraesophageal symptoms were also frequent (55.6% reflux-related sleep disturbances, 45.7% noncardiac chest pain, 30.8% chronic cough, and 24.7% hoarseness), these being more prevalent in the patients diagnosed earlier. Although primary care physicians considered that 55.9% of the patients could be diagnosed on the basis of symptoms without further investigation, in their practice only one-third of new diagnoses of GERD and 71.1% of those already diagnosed were symptom-managed. Upon arrival at the clinic, patients with GERD symptoms were taking the following medications: 28.1% (47.8% in the case of those already diagnosed) proton pump inhibitors (PPIs), 16.6% antacids, 6.1% H2 antagonists, and 4.5% prokinetics. Most patients (90.2%) were treated with PPIs after the study visit. The evaluation of agreement between physicians and patients on the severity of GERD resulted in a kappa index of 0.19.

CONCLUSION

There is a high occurrence of typical and extraesophageal symptoms in patients in Spain complaining of GERD symptoms in PC settings. Two-thirds of new GERD patients were referred for further investigation. PPIs were the treatment prescribed in almost all cases. The degree of agreement between physicians and patients about the severity of the symptoms was limited.

[Cultural adaptation to Spanish and validation of the Gastrointestinal Short Form Questionnaire]

OBJECTIVE

To describe the process followed for the cultural and psychometric adaptation (validation) to Spanish of the Gastrointestinal Short Form Questionnaire (GSFQ), used to measure the interference of symptoms of gastroesophageal reflux disease GERD and to report the psychometric properties of this instrument.

MATERIAL AND METHODS

The adaptation process was supervised by a five-member expert panel. After forward and backward translations in duplicate, a Spanish version was obtained, which was administered to two samples; a five-patient pilot sample to check comprehension and face validity, and a 4,000-patient sample to check structural validity (factor analysis and reliability), construct validity, and discriminative validity.

RESULTS

The questionnaire showed a unique dimension that matched that of the original questionnaire. Reliability was high (alpha=0.83), and the correlation between even-odd items was good (r=0.69). The overall score correlated with generic health-related quality of life measures evaluated by the EQ-5D tariff (r=0.499) and VAS (r=-0.481). The scale discriminated between GERD severity levels (p<0.008) as measured by the Savary-Miller scale, except for the most severe level with respect to the levels immediately below. The questionnaire was able to detect differences between diverse concomitant diseases and antecedents. Sensitivity with respect to the GERD clinician criterion was 60.5% and specificity was 68.3%. Normative comparison scaling values are reported.

CONCLUSIONS

The results show acceptable psychometric properties. A new instrument to assess the interference of GERD symptoms is thus available to health professionals. This instrument takes the patient's perspective into account.

Optimising acid inhibition treatment

Acid inhibition is safe and useful in several clinical settings. Proton pump inhibitors are more effective than H2-receptor antagonists in virtually all cases. Proton pump inhibitors should be used in: the eradication of Helicobacter pylori; the treatment of non-H. pylori-related peptic ulcer healing; for the prevention and treatment of non-steroidal anti-inflammatory drug-induced upper digestive lesions; for bleeding peptic lesions; and, especially, in the short-term and long-term control of gastro-oesophageal reflux disease. The timing, the dosing and the specific drugs should be adapted to the particular patient, clinical situation and local factors. For instance, in a patient with active bleeding from a duodenal ulcer, intravenous constant infusion should be the preferred treatment. When seeking oral 'potent' acid inhibition (refractory gastro-oesophageal reflux disease, and perhaps Barrett's oesophagus), available data suggest that the pharmacological and clinical profiles of esomeprazole are slightly better.

Maintenance Therapy in Gastro-oesophageal Reflux Disease

Gastro-oesophageal reflux disease (GORD) is a chronic condition. Symptom control and the maintenance of healing of erosive oesophagitis, if present, are important topics. In patients responding to a proton pump inhibitor (PPI) and showing no treatment symptoms it is appropriate to consider long-term treatment strategies, whether continuous, intermittent or on demand. Maintenance PPI therapy is well tolerated for up to 10 years of continuous use. Furthermore, tachyphylaxis does not occur during long-term maintenance PPI therapy. Previous concerns about risks of long-term PPI therapy in Heliobacter pylori-negative or H. pylori-positive patients have not materialized, while no cases of intestinal metaplasia with dysplasia or adenocarcinoma were found. The choice between medical and surgical therapy should depend upon informed patient preference. The optimal candidate for antireflux surgery is a young patient, with typical GORD symptoms, with erosive oesophagitis, with previous complete symptom resolution on acid-suppression therapy and unable to undergo continuous therapy, or alternatively in patients with regurgitation predominating over heartburn as long as the surgical procedures are conducted by an expert surgical team. Endoscopic therapy for erosive GORD should currently be regarded as experimental. The endoscopic procedures are safe, although they remain untested in patients with severe erosive oesophagitis and/or significant hiatal hernia.

Repercusión de la enfermedad en pacientes con reflujo gastroesofágico. Evidencia de un estudio metodológico reciente en España

INTRODUCTION

The clinical and socioeconomic burden of gastroesophageal reflux disease (GERD) is considerable.

AIM

The aim of this study was to describe the impact of heartburn on patients' health-related quality of life (HRQL) in Spain, using validated generic and disease-specific instruments to measure patient-reported outcomes.

PATIENTS AND METHODS

Patients with symptoms of heartburn completed the Spanish versions of the Gastrointestinal Symptom Rating Scale (GSRS), the Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD), the Short Form-36 (SF-36) and the Hospital Anxiety and Depression (HAD) scale. The frequency and severity of heartburn in the previous 7 days were also recorded.

RESULTS

One hundred fifty-eight patients completed the assessments (mean age: 51 years, SD = 16; 58% female). Sixty-one percent of the patients had moderate symptoms and 73% had symptoms on three or more days in the previous week. Patients were most bothered by symptoms of reflux (mean GSRS score of 3.8 on a scale of 1 [not bothered] to 7 [very bothered]), abdominal pain (3.1) and indigestion (3.1). As a result of their symptoms, patients experienced problems with food and drink (mean QOLRAD score of 4.5 on a scale of 1 to 7, where 1 represents the most severe impact on daily functioning), impaired vitality (4.7) and emotional distress (4.8). This led to impaired overall HRQL across all domains (mean SF-36 score of this heartburn population compared with a general population in Spain). The HAD scale showed that 28% of patients were anxious and 13% were depressed.

CONCLUSION

There is consistent evidence that GERD substantially impairs all aspects of HRQL.