Do physicians follow evidence-based guidelines in the diagnostic work-up of IBS?

The Time-Dependent Association Between Irritable Bowel Syndrome and All-Cause and Cause-Specific Mortality: A Prospective Cohort Study Within the UK Biobank

INTRODUCTION

Irritable bowel syndrome (IBS) is one of the most common functional gastrointestinal disorders, but few studies have evaluated mortality risks among individuals with IBS. We explored the association between IBS and all-cause and cause-specific mortality in the UK Biobank.

METHODS

We included 502,369 participants from the UK Biobank with mortality data through 2022. IBS was defined using baseline self-report and linkage to primary care or hospital admission data. We estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause and cause-specific mortality using multivariable Cox proportional hazards regression models within partitioned follow-up time categories (0-5, >5-10, and >10 years).

RESULTS

A total of 25,697 participants (5.1%) had a history of IBS at baseline. After a median follow-up of 13.7 years, a total of 44,499 deaths occurred. Having an IBS diagnosis was strongly associated with lower risks of all-cause (HR = 0.70, 95% CI = 0.62-0.78) and all-cancer (HR = 0.69, 95% CI = 0.60-0.79) mortality in the first 5 years of follow-up. These associations were attenuated over follow-up, but even after 10 years of follow-up, associations remained inverse (all-cause: HR = 0.89, 95% CI = 0.84-0.96; all-cancer: HR = 0.87, 95% CI = 0.78-0.97) after full adjustment. Individuals with IBS had decreased risk of mortality from breast, prostate, and colorectal cancers in some of the follow-up time categories.

DISCUSSION

We found that earlier during follow-up, having diagnosed IBS was associated with lower mortality risk, and the association attenuated over time. Additional studies to understand whether specific factors, such as lifestyle and healthcare access, explain the inverse association between IBS and mortality are needed.

Diagnostic strategy of irritable bowel syndrome: a low- and middle-income country perspective

Irritable bowel syndrome (IBS) is a highly prevalent gastrointestinal disorder associated with substantial impairment which considerably burdens healthcare systems worldwide. Research on IBS has largely been conducted in high-income countries posing barriers to the application of diagnostic strategies in low- and middle-income countries (LMICs) due to differences in disease characteristics, healthcare resources, and socioeconomic factors. This review discusses the diagnostic issues associated with LMICs. We present a concise overview of the relevant approaches and propose a diagnostic strategy based on the latest evidence. A positive diagnostic strategy that relies on appropriate symptom-based criteria is crucial within the diagnostic framework. A combination of complete blood count, fecal occult blood test, and complete stool test may reliably identify individuals with suspected IBS who are more likely to have organic diseases, thus justifying the necessity for a colonoscopy. Eventually, we developed a diagnostic algorithm based on a limited setting perspective that summarizes the available evidence and may be applied in LMICs.

Mortality Risk in Irritable Bowel Syndrome: Results From a Nationwide Prospective Cohort Study

INTRODUCTION

Mortality concern is a frequent driver of care seeking in patients with irritable bowel syndrome (IBS). Data on mortality in IBS are scarce, and population-based studies have been limited in size. We examined mortality in IBS.

METHODS

A nationwide, matched, population-based cohort study was conducted in Sweden. We identified 45,524 patients undergoing a colorectal biopsy at any of Sweden's 28 pathology departments and with a diagnosis of IBS from 2002 to 2016 according to the National Patient Register, a nationwide registry of inpatient and outpatient specialty care. We compared the mortality risk between these individuals with IBS and age- and sex-matched reference individuals (n = 217,316) from the general population and siblings (n = 53,228). In separate analyses, we examined the role of mucosal appearance for mortality in IBS. Finally, we examined mortality in 41,427 patients with IBS not undergoing a colorectal biopsy. Cox regression estimated hazard ratios (HRs) for death.

RESULTS

During follow-up, there were 3,290 deaths in individuals with IBS (9.4/1,000 person-years) compared with 13,255 deaths in reference individuals (7.9/1,000 person-years), resulting in an HR of 1.10 (95% confidence interval [CI] = 1.05-1.14). After adjustment for confounders, IBS was not linked to mortality (HR = 0.96; 95% CI = 0.92-1.00). The risk estimates were neutral when patients with IBS were compared with their siblings. The underlying mucosal appearance on biopsy had only a marginal impact on mortality, and patients with IBS not undergoing a colorectal biopsy were at no increased risk of death (HR = 1.02; 95% CI = 0.99-1.06).

DISCUSSION

IBS does not seem to confer an increased risk of death.

Referrals to a tertiary hospital: A window into clinical management issues in functional gastrointestinal disorders

BACKGROUND AND AIM

To investigate the quality of and reasons for referrals of patients with likely functional gastrointestinal disorders (FGID) and explore patients' experience of clinical management.

METHODS

A cross sectional, mixed-methods study was undertaken. Referrals (July 2013-2015) to one gastroenterology outpatient department triaged as "likely FGID", the referred patients and their referring primary healthcare providers were examined.

RESULTS

A total of 69% of patients reported not yet receiving an initial diagnosis, 52% reported persistent/distressing symptoms or reduced quality of life, 24% feared missed or worsening pathology, and 35% were seeking repeat specialist consultation. Most patients were dissatisfied (40%) or only partially satisfied (36%) with current management. Dissatisfaction was significantly related to the lack of provision of a diagnosis and effective treatment options (P < 0.001). Referral quality was poor and with the reason for referral clearly communicated in only 25%. Common referral reasons included repeat presentations (n = 32), diagnostic uncertainty (n = 19), to ensure nothing is missed (n = 19), patient request (n = 17), no response to treatment (n = 16), and to allay patient fears (n = 14). A total of 28/60 primary healthcare providers were confident that their patient had a FGID, yet sought confirmation (n = 16), second opinion (n = 8), or advice (n = 4).

CONCLUSION

Current management of FGID in usual care is suboptimal, as evidenced by the tertiary referral load, patient dissatisfaction, and the lack of provision of diagnoses and effective treatment options. Some clinicians lack confidence in effectively identifying and managing these conditions. Resources and supports to equip and assist clinicians to identify and manage FGID successfully may enhance patient care.

Uncertain Diagnostic Language Affects Further Studies, Endoscopies, and Repeat Consultations for Patients With Functional Gastrointestinal Disorders

BACKGROUND & AIMS

Although guidelines state that functional gastrointestinal disorders (FGIDs) can be diagnosed with minimal investigation, consultations and investigations still have high costs. We investigated whether these are due to specific behaviors of specialist clinicians by examining differences in clinician approaches to organic gastrointestinal diseases vs FGIDs.

METHODS

We performed a retrospective review of 207 outpatient department letters written from the gastroenterology unit at a tertiary hospital after patient consultations from 2008 through 2011. We collected data from diagnostic letters and case notes relating to patients with organic (n = 108) or functional GI disorders (n = 119). We analyzed the content of each letter by using content analysis and reviewed case files to determine which investigations were subsequently performed. Our primary outcome was the type of diagnostic language used and other aspects of the clinical approach.

RESULTS

We found gastroenterologists to use 2 distinct types of language, clear vs qualified, which was consistent with their level of certainty (or lack thereof), for example, "the patient is diagnosed with…." vs "it is possible that this patient might have….". Qualified diagnostic language was used in a significantly higher proportion of letters about patients with FGIDs (63%) than organic gastrointestinal diseases (13%) (P < .001). In addition, a higher proportion of patients with FGIDs underwent endoscopic evaluation than patients with organic gastrointestinal diseases (79% vs 63%; P < .05).

CONCLUSIONS

In an analysis of diagnoses of patients with FGIDs vs organic disorders, we found that gastroenterologists used more qualified (uncertain) language in diagnosing patients with FGIDs. This may contribute to patient discard of diagnoses and lead to additional, unwarranted endoscopic investigations.

Perceived risk as a barrier to appropriate diagnosis of irritable bowel syndrome

AIM: To evaluate perceived risk, diagnostic testing, and acceptance of a diagnosis of irritable bowel syndrome (IBS) among the Korean laypersons.

METHODS: We designed a conceptual framework to evaluate the health-seeking behavior of subjects based on a knowledge, attitude, and practice model. We developed a vignette-based questionnaire about IBS based on a literature review and focused group interviews. The vignette described a 40-year-old woman who meets the Rome III criteria for IBS without red-flag signs. It was followed by questions about demographic characteristics, health behaviors, IBS symptoms, risk perception, perceived need for diagnostic tests, and acceptance of a positive diagnosis of IBS. We planned a nationwide survey targeting laypersons without IBS and between the ages of 20 and 69 years. Survey participants were selected by quota sampling stratified by gender, age, and nationwide location. A multivariate logistic model was constructed based on literature reviews, univariate analysis, and a stepwise selection method to investigate correlations between the perceived risk, need for diagnostic tests, and acceptance of a positive diagnosis.

RESULTS: Of 2354 eligible households, 1000 subjects completed the survey and 983 subjects were analyzed, excluding those who met symptom criteria for IBS. After reading the IBS vignette, the majority of subjects (86.8%) responded that the patient was at increased risk of severe disease. The most frequent concern was colon cancer (59.8%), followed by surgical condition (51.5%). Most subjects responded the patient needs diagnostic tests (97.2%). Colonoscopy was the most commonly required test (79.5%). Less than half of the respondents requested a stool examination (45.0%), blood test (40.7%), abdominal ultrasound (36.0%), or computed tomography (20.2%). The subjects who felt increased risk were more likely to see a need for colonoscopy [adjusted odds ratio (aOR) = 2.10, 95%CI: 1.38-3.18]. When asked about the positive diagnosis, the most frequent response was that “the patient would not be reassured” (65.7%). The increased risk perception group was less likely to be reassured by a positive diagnosis of IBS, compared to the other respondents (aOR = 0.52, 95%CI: 0.34-0.78).

CONCLUSION: For IBS diagnosis, increased risk perception is a possible barrier to the appropriate use of diagnostic tests and to the patient’s acceptance of a positive diagnosis.

The role of primary care physicians in early diagnosis and treatment of chronic gastrointestinal diseases

Chronic gastrointestinal disorders are a source of substantial morbidity, mortality, and cost. They are common in general practice, and the primary care physician (PCP) has a central role in the early detection and management of these problems. The need to make cost-effective diagnostic and treatment decisions, avoid unnecessary investigation and referral, provide long-term effective control of symptoms, and minimize the risk of complications constitute the main challenges that PCPs face. The literature review shows that, although best practice standards are available, a considerable number of PCPs do not routinely follow them. Low rates of colorectal cancer screening, suboptimal testing and treatment of Helicobacter pylori infection, inappropriate use of proton pump inhibitors, and the fact that most PCPs are still approaching the irritable bowel disease as a diagnosis of exclusion represent the main gaps between evidence-based guidelines and clinical practice. This manuscript points out that updating of knowledge and skills of PCPs via continuing medical education is the only way for better adherence with standards and improving quality of care for patients with gastrointestinal diseases.

Diversity of endoscopy center operations and practice variation across California's safety-net hospital system: a statewide survey

Background

Little is known about endoscopic services provided or operational practice variation within California public hospital endoscopy centers.

Methods

A survey was distributed to all 18 California public hospitals with endoscopy centers to assess operational practices.

Results

Eight of 18 hospitals responded to the survey. Six of the eight responding hospitals used a closed access system for patient referrals. Mean wait time for an endoscopic procedure was 42.4 ± 37.7 days (N = 8) with a mean procedure no-show/cancellation rate of 14.5 ± 8.0% (N = 7). All responding public hospitals performed colonoscopy, esophagogastroduodenoscopy, PEG tube placement, and endoscopic retrograde cholangiopancreatography (ERCP) with two hospitals performing endoscopic ultrasound. There was significant practice variation in the documentation of endoscopic quality and performance measurements among the responding hospitals. Multiple methods were used to communicate pathology results to patients: GI clinic visit (6/8), primary physician (4/8), telephone (2/8) or letter (1/8).

Conclusion

Our study highlights the diversity and practice variations of endoscopy center operations at California public hospitals and serves as a catalyst for future collaborations among safety-net hospitals.

Diagnostic testing in extraesophageal GERD: another case of "furor medicus"?

Proton pump inhibitors (PPIs) work for most patients with gastroesophageal reflux disease (GERD). But when PPIs fail to work, or when there are atypical extra-esophageal symptoms, diagnostic and management decisions become much more difficult. Although atypical GERD is common, there are limited data about how best to approach these patients. The temptation is often to perform extensive diagnostic testing, sometimes to little avail. In this issue of The Journal, Francis et al. present a new study to help close the research gap in understanding the costs and benefits of testing in atypical GERD. The authors conclude that diagnostic testing is very expensive and real-life benefits are modest. This editorial reviews the findings, places them into clinical perspective, and concludes that diagnostic testing in atypical GERD may be another example of "furor medicus" - an old but descriptive term referring to the instinct of doctors to implore "don't just stand there, do something!" The data from Francis et al. suggest we might do the opposite in atypical GERD: "Don't just do something, stand there."

Irritable bowel syndrome: Physicians' awareness and patients' experience

AIM: To study if and how physicians use the irritable bowel syndrome (IBS) diagnostic criteria and to assess treatment strategies in IBS patients.

METHODS: A questionnaire was sent to 191 physicians regarding IBS criteria, diagnostic methods and treatment. Furthermore, 94 patients who were diagnosed with IBS underwent telephone interview.

RESULTS: A total of 80/191 (41.9%) physicians responded to the survey. Overall, 13 patients were diagnosed monthly with IBS by specialists in gastroenterology (SGs) and 2.5 patients by general practitioners (GPs). All the SGs knew of the criteria to diagnose IBS, as did 46/70 (65.7%) GPs. Seventy-nine percent used the patient’s history, 38% used a physical examination, and 38% exclusion of other diseases to diagnose IBS. Only 18/80 (22.5%) physicians used specific IBS criteria. Of the patients interviewed, 59/94 (62.8%) knew they had experienced IBS. Two out of five patients knew IBS and had seen a physician because of IBS symptoms. Half of those received a diagnosis of IBS. A total of 13% were satisfied with treatment. IBS affected daily activities in 43% of cases.

CONCLUSION: Half of the patients with IBS who consulted a physician received a diagnosis. Awareness and knowledge of diagnostic criteria for IBS differ between SGs and GPs.

Confidence-based learning CME: overcoming barriers in irritable bowel syndrome with constipation

INTRODUCTION

Performance of health care professionals depends on both medical knowledge and the certainty with which they possess it. Conventional continuing medical education interventions assess the correctness of learners' responses but do not determine the degree of confidence with which they hold incorrect information. This study describes the use of confidence-based learning (CBL) in an activity designed to enhance learners' knowledge, confidence in their knowledge, and clinical competence with regard to constipation-predominant IBS (IBS-C), a frequently underdiagnosed and misdiagnosed condition.

METHODS

The online CBL activity included multiple-choice questions in 2 modules: Burden of Care (BOC; 28 questions) and Patient Scenarios (PS; 9 case-based questions). After formative assessment, targeted feedback was provided, and the learner focused on material with demonstrated knowledge and/or confidence gaps. The process was repeated until 85% of questions were answered correctly and confidently (ie, mastery was attained).

RESULTS

Of 275 participants (24% internal medicine, 13% gastroenterology, 32% family medicine, and 31% other), 249 and 167 completed the BOC and PS modules, respectively. Among all participants, 61.8% and 98.2% achieved mastery in the BOC and PS modules, respectively. Baseline mastery levels between specialties were significantly different in the BOC module (p = 0.002); no significant differences were evident between specialties in final mastery levels. Approximately one-third of learners were confident and wrong in topics of epidemiology, defining IBS and constipation, and treatments in the first iteration. No significant difference was observed between specialties for the PS module in either the first or last iterations.

DISCUSSION

Learners achieved mastery in topics pertaining to IBS-C regardless of baseline knowledge or specialty. These data indicate that CME activities employing CBL can be used to address knowledge and confidence gaps.

Irritable bowel syndrome: diagnostic approaches in clinical practice

BACKGROUND

Irritable bowel syndrome (IBS), a functional gastrointestinal disorder long considered a diagnosis of exclusion, has chronic symptoms that vary over time and overlap with those of non-IBS disorders. Traditional symptom-based criteria effectively identify IBS patients but are not easily applied in clinical practice, leaving >40% of patients to experience symptoms up to 5 years before diagnosis.

OBJECTIVE

To review the diagnostic evaluation of patients with suspected IBS, strengths and weaknesses of current methodologies, and newer diagnostic tools that can augment current symptom-based criteria.

METHODS

The peer-reviewed literature (PubMed) was searched for primary reports and reviews using the limiters of date (1999-2009) and English language and the search terms irritable bowel syndrome, diagnosis, gastrointestinal disease, symptom-based criteria, outcome, serology, and fecal markers. Abstracts from Digestive Disease Week 2008-2009 and reference lists of identified articles were reviewed.

RESULTS

A disconnect is apparent between practice guidelines and clinical practice. The American Gastroenterological Association and American College of Gastroenterology recommend diagnosing IBS in patients without alarm features of organic disease using symptom-based criteria (eg, Rome). However, physicians report confidence in a symptom-based diagnosis without further testing only up to 42% of the time; many order laboratory tests and perform sigmoidoscopies or colonoscopies despite good evidence showing no utility for this work-up in uncomplicated cases. In the absence of diagnostic criteria easily usable in a busy practice, newer diagnostic methods, such as stool-form examination, fecal inflammatory markers, and serum biomarkers, have been proposed as adjunctive tools to aid in an IBS diagnosis by increasing physicians' confidence and changing the diagnostic paradigm to one of inclusion rather than exclusion.

CONCLUSION

New adjunctive testing for IBS can augment traditional symptom-based criteria, improving the speed and safety with which a patient is diagnosed and avoiding unnecessary, sometimes invasive, testing that adds little to the diagnostic process in suspected IBS.

Importance of early diagnosis in patients with irritable bowel syndrome

Patients with irritable bowel syndrome (IBS) account for >$20 billion in direct and indirect costs annually, a large portion of which relates to making the diagnosis. The diagnosis of IBS is challenging because symptoms can vary between patients and overlap with those of other disorders. This review examines the current diagnostic approach in IBS and discusses new tools that may improve diagnostic confidence earlier in the process. The prevalence of organic disease among patients who meet symptom-based criteria for IBS (eg, Rome III) is generally low; therefore, in the absence of "alarm features," the probability for organic disease is very low. Increased public awareness of IBS symptoms and physician awareness of symptom-based criteria for IBS are needed to facilitate earlier diagnosis. Accumulating evidence suggests that fecal and/or serum biomarkers may be helpful in differentiating IBS from non-IBS disorders. These tools may help minimize unnecessary testing and diagnostic delays. As biomarkers are further studied and developed, they are likely to become an integral part of the diagnosis of IBS and reduce the potential for incorrect diagnosis and treatment delays.

The yield of colonoscopy in patients with non-constipated irritable bowel syndrome: results from a prospective, controlled US trial

OBJECTIVES

There are limited data on the yield of colonoscopy in patients with irritable bowel syndrome (IBS). This study compared the prevalence of structural colonic lesions in patients with suspected non-constipation-predominant IBS and healthy volunteers. We also determined the yield of rectosigmoid biopsies in patients with suspected IBS.

METHODS

This was a prospective, case-control study conducted at three US sites. Patients with suspected non-constipation-predominant IBS (Rome II) underwent colonoscopy with rectosigmoid biopsies. Healthy persons undergoing colonoscopy for colorectal cancer screening or polyp surveillance comprised the control group. Abnormalities identified at colonoscopy were compared between suspected IBS and control groups.

RESULTS

In all, 466 suspected IBS patients and 451 controls were enrolled. Suspected IBS patients were significantly younger (P<0.0001) and more frequently female (P<0.0001) than controls. The most common lesions in suspected IBS patients were hemorrhoids (18.2%), polyps (14.6%), and diverticulosis (8.8%). Suspected IBS patients had a lower prevalence of adenomas (7.7% vs. 26.1%, P<0.0001) and diverticulosis (8.8% vs. 21.3%, P<0.0001) and higher prevalence of mucosal erythema or ulceration (4.9% vs. 1.8%, P<0.01) compared with controls. Logistic regression found the between-group differences in adenoma prevalence to be robust after correction for demographic factors. The overall prevalence of microscopic colitis in suspected IBS patients was 1.5% (7/466) and 2.3% (4/171) in those > or =45 years of age.

CONCLUSIONS

The prevalence of structural abnormalities of the colon is no higher in suspected non-constipation IBS patients than in healthy controls. Microscopic colitis can be identified in a small proportion of persons with IBS symptoms.

Is irritable bowel syndrome a diagnosis of exclusion?: a survey of primary care providers, gastroenterologists, and IBS experts

OBJECTIVES

Guidelines emphasize that irritable bowel syndrome (IBS) is not a diagnosis of exclusion and encourage clinicians to make a positive diagnosis using the Rome criteria alone. Yet many clinicians are concerned about overlooking alternative diagnoses. We measured beliefs about whether IBS is a diagnosis of exclusion, and measured testing proclivity between IBS experts and community providers.

METHODS

We developed a survey to measure decision-making in two standardized patients with Rome III-positive IBS, including IBS with diarrhea (D-IBS) and IBS with constipation (C-IBS). The survey elicited provider knowledge and beliefs about IBS, including testing proclivity and beliefs regarding IBS as a diagnosis of exclusion. We surveyed nurse practitioners, primary care physicians, community gastroenterologists, and IBS experts.

RESULTS

Experts were less likely than nonexperts to endorse IBS as a diagnosis of exclusion (8 vs. 72%; P<0.0001). In the D-IBS vignette, experts were more likely to make a positive diagnosis of IBS (67 vs. 38%; P<0.001), to perform fewer tests (2.0 vs. 4.1; P<0.01), and to expend less money on testing (US$297 vs. $658; P<0.01). Providers who believed IBS is a diagnosis of exclusion ordered 1.6 more tests and consumed $364 more than others (P<0.0001). Experts only rated celiac sprue screening and complete blood count as appropriate in D-IBS; nonexperts rated most tests as appropriate. Parallel results were found in the C-IBS vignette.

CONCLUSIONS

Most community providers believe IBS is a diagnosis of exclusion; this belief is associated with increased resource use. Experts comply more closely with guidelines to diagnose IBS with minimal testing. This disconnect suggests that better implementation of guidelines is warranted to minimize variation and improve cost-effectiveness of care.

Exploring the agreement between diagnostic criteria for IBS in primary care in Greece

Background

Irritable Bowel Syndrome (IBS) is frequently diagnosed in primary care. Its diagnosis is based on diagnostic criteria but their use is limited in primary care.

We aimed to assess the diagnostic agreement between the older (Manning's and Rome II) and the new (Rome III) criteria for the diagnosis of IBS in primary care in Greece.

Methods

Medical records of 5 Health Centers in rural Crete, Greece, were reviewed for a four-year period and patients with the diagnosis of IBS were invited to a structured interview. Kappa agreement of the Rome III criteria with the criteria of Manning and Rome II was estimated. One hundred and twenty three patients were eligible for interview and 67 (54.5%) participated. Forty-six (69%) fulfilled the Manning, 32(48%) the Rome II, and 16(24%) the Rome III criteria. Twenty-seven (40%) patients were identified as IBS according to the questionnaire for the identification of functional gastrointestinal diseases (FGIDs). The agreement of Rome III with Manning criteria was poor (kappa = 0.25). The agreement between the FGIDs questionnaire and the Manning, Rome II and Rome III criteria was: kappa = 0.30, 0.31 and 0.24 respectively. Moderate agreement was found between the Rome II and III criteria (kappa = 0.51).

Conclusion

Questionnaires and criteria deriving from expert's consensus meetings or tertiary hospitals are not easy to apply in rural primary care where symptoms are often underestimated by patients and complicated questions can be confusing.