Development of a real-time patient-reported outcome measure for symptom assessment in patients with functional dyspepsia using the experience sampling method

Patient-Reported Outcomes in Disorders of Gut-Brain Interaction

Disorders of gut-brain interaction are characterized by chronic gastrointestinal symptoms in the absence of abnormal endoscopic or radiologic findings or objective biomarkers that can be identified during routine clinical evaluation. The assessment of the symptom pattern and severity, therefore, is the key modality to evaluate the presence, impact, and evolution of these conditions, for both clinical and regulatory purposes. Patient-reported outcomes are structured symptom assessment questionnaires designed to evaluate symptom patterns, quantify severity of symptoms, and evaluate response to treatment at follow-up. This review provides an overview of currently available patient-reported outcomes for evaluating the main disorders of gut-brain interaction, specifically, functional dyspepsia; irritable bowel syndrome; and chronic constipation. It summarizes their content, level of validation for clinical practice and for research, and the regulatory approach to these conditions. Expected future developments and need for further research on patient-reported outcomes for these and other disorders of gut-brain interaction are highlighted.

Patient-reported outcome measures in functional dyspepsia: a systematic review and COSMIN analysis

BACKGROUND

Functional dyspepsia (FD) as a type of disorders of brain-gut interaction (DBGI), patient self-reporting of its symptoms becomes an important component of clinical outcome assessment. We performed a systematic review using Consensus Based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines to identify the best available patient-reported outcome measure (PROM) of FD.

METHODS

The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We searched four databases with no date limit, looking for previously confirmed PROMs for evaluating FD symptoms. An overall rating was then assigned based upon COSMIN guidelines, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess the level of evidence for psychometric properties of included PROMs.

RESULTS

Thirty articles covering outcome indicators of 24 patient reports were included. The Leuven Postprandial Distress Scale (LPDS) showed adequate content validity and moderate quality evidence of adequate internal consistency to generate an A recommendation.

CONCLUSION

LPDS is currently the most recommended PROM for patient self-reported FD symptoms. However, it fails to assess two important areas of cross-cultural validity/ measurement invariance and measurement error. Future research can be continuously improved on this basis.

Moment-to-moment relationships between pain, fatigue, and distress as a function of GI symptoms in fibromyalgia

OBJECTIVE

There is emerging evidence that people with both fibromyalgia and functional gastrointestinal (GI) disorders report more severe psychological symptoms than people with only fibromyalgia or a functional GI disorder. We use Ecological Momentary Assessment (EMA) to examine whether, for people with fibromyalgia, accompanying GI symptoms result in stronger bidirectional relationships between distress and bodily pain or fatigue.

METHODS

Participants were 67 women with fibromyalgia from a study by Okifuji et al. (2011; 13), in which EMA data on pain, fatigue, and distress was collected over 30 days. Thirty-three participants reported GI symptoms at baseline, and 34 participants reported no GI symptoms but at least one other bodily symptom. Using multilevel linear regressions with interaction terms, we compared the two groups on the strength of reciprocal within-day and day-to-day relationships between pain, fatigue, and distress.

RESULTS

GI symptom status did not moderate relationships between distress and pain. However, participants with GI symptoms uniquely reported more distress following increased fatigue within days (b = 0.120, 95%CI: 0.041,0.198), and sharper distress escalations across days (b = 0.078 95%CI: 0.007, 0.149).

CONCLUSION

We do not find evidence of stronger bidirectional within-day and day-to-day relationships between distress and bodily symptoms in this patient group. We do, however, find evidence of heightened fatigue-related distress and escalating distress. These cyclical processes can become a focus for cognitive behavioural therapy, patient education, and physical (exercise/sleep) therapy aimed at addressing fatigue.

Using a Patient Hotel: Perceptions of the Quality of Care by Patients Undergoing Analysis for Gastrointestinal Motility Disorders in the Netherlands

There is growing demand to improve healthcare services for patients. Patient hotel models can be applied to allow shorter inpatient stays, however, whether this improves patient satisfaction and quality of care is unknown. All consecutive patients referred for analysis of gastrointestinal (GI) motility disorders at Maastricht UMC, the Netherlands, who stayed overnight in the patient hotel (June 2017-July 2018), were asked to complete a questionnaire on patient satisfaction and quality of care. On a 4-point Likert scale, most patients reported they were largely to absolutely satisfied with the quality of care, regarding coordination, information, courtesy of nurses and staff, and privacy. Cost savings between 48,433 and 74,613 euros for 1 year were achieved, amounting to 613-944 euros per patient. Positive patient satisfaction and perception of quality of care with the patient hotel model were achieved. We show that moving overnight stays from inpatient to an outpatient hotel provides substantial financial savings for hospitals, healthcare providers, and insurance companies.

The Interplay Between Stress and Fullness in Patients With Functional Dyspepsia and Healthy Controls: An Exploratory Experience Sampling Method Study

OBJECTIVE

Fullness is a cardinal symptom in functional dyspepsia (FD). The use of real-time symptom assessment might provide more insight into factors, such as daily stress, that can influence fullness. Therefore, this study aimed to use the experience sampling method (a real-time, repeated-measurement method making use of repeated questionnaires available at random moments for a limited amount of time) to assess the association between stress and fullness in patients with FD and healthy controls (HCs).

METHODS

Thirty-five patients with FD (25 female, mean age = 44.7 years) and 34 HCs (24 female, mean age = 44.1 years) completed the experience sampling method (a maximum of 10 random moments per day) for 7 consecutive days. Stress and fullness were rated on an 11-point Numeric Rating Scale. Data between patients with FD and HCs were statistically compared using a Student samples t test and linear mixed-effects models with repeated measures (level 1) nested within participants (level 2).

RESULTS

Average fullness scores were 2.23 (standard error = 0.37) points higher in patients with FD compared with HCs (p < .001). Average stress scores were 1.37 (standard error = 0.30) points higher in patients with FD compared with HCs (p = .002).In FD, fullness scores increased with 0.14 for every 1-point increase in concurrent stress scores (p = .010). Fullness scores at t = 0 increased with 0.12 for every 1-point increase in stress scores at t = -1 (p = .019). T = 0 stress scores were not associated with change in t = -1 fullness scores. No associations between concurrent symptom scores were found for HCs.

CONCLUSIONS

Concurrent and preceding stress scores are positively associated with fullness scores in patients with FD, but not in HCs. These findings indicate that increased levels of stress may precede feelings of fullness in patients with FD.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT04204421.

Clinical Effect of Acupuncture Combined with Traditional Chinese Medicine Application on the Treatment of Functional Dyspepsia in Children and the Influence on Serum 5-HT and NO Levels

Objective

To explore the clinical effect of acupuncture combined with traditional Chinese medicine (TCM) application on the treatment of functional dyspepsia (FD) in children and the influence on serum 5-HT and NO levels.

Methods

94 FD children admitted to the pediatric department of our hospital from March 2019 to March 2020 were selected as the research object and divided into the study group (n = 45) and reference group (n = 49) by the number table method. The routine Western medicine therapy was given to the reference group and the combination therapy of acupuncture and TCM application was given to the study group to analyze the effect of different therapies on FD children by detecting their serum 5-hydroxytryptamine (5-HT) and nitric oxide (NO) levels and electrogastrogram (EGG) before and after treatment.

Results

The sex ratio, mean age, mean duration of disease, mean weight, mean BMI value, and residence of children in the two groups were not significantly different (P > 0.05); after treatment, the study group obtained significantly lower symptom scores and shorter disappearance time of clinical symptoms when comparing with the reference group (P < 0.001); the total clinical effective rate of the study group was significantly higher than that of the reference group (P < 0.05); the treated serum 5-HT and NO levels of children in both groups were significantly lower than those before treatment (P < 0.05), and in the between-group comparison, those of the study group were significantly lower (P < 0.05); and the treated AP, FP, and normal slow wave ratio of gastric antrum and body were significantly higher in the study group than in the reference group (P < 0.05).

Conclusion

The combination therapy of acupuncture and TCM application is a reliable method for improving the clinical symptoms in FD children. This strategy greatly reduces the levels of serum factors in child patients and shortens the corresponding treatment time. Further research will be conducive to establishing a better solution for such patients.

Patient-Reported Outcome Measure for Real-time Symptom Assessment in Women With Endometriosis: Focus Group Study

BACKGROUND

Symptoms related to endometriosis have a significant impact on the quality of life, and symptoms often recur. The experience sampling method (ESM), a digital questioning method characterized by randomly repeated momentary assessments, has several advantages over traditionally used measurements, including the ability to assess the temporal relationship between variables such as physical, mental, and social factors.

OBJECTIVE

The aim of this study is to develop an ESM tool for patients with endometriosis to accurately measure symptoms and their course over time, allowing for personalized treatment and adequate monitoring of treatment efficacy in individual patients.

METHODS

On the basis of international guidelines, items from validated questionnaires were selected through a literature review and during focus groups and multidisciplinary expert meetings. Data analysis was conducted using ATLAS.ti (ATLAS.ti Scientific Software Development GmbH). The feasibility and usability of the newly developed momentary assessment tool were tested for 28 consecutive days in 5 patients with endometriosis-related pain symptoms.

RESULTS

Momentary assessment items contained questions concerning endometriosis symptoms, general somatic symptoms, psychological symptoms, contextual information, and the use of food and medication. A morning questionnaire on sleep and sexuality was included. In a pilot study, the patients considered the tool easy to use but time consuming. The average compliance rate of momentary assessments was 37.8% (106/280), with the highest completion rate during the first week (39/70, 56%). Therefore, it is advisable to use the ESM for a maximum of 7 days.

CONCLUSIONS

A new digital tool for endometriosis symptom assessment was developed using the ESM, which may help overcome the limitations of current retrospective questionnaires. After validation and testing, future studies will be planned to evaluate the use of this tool in a clinical setting in order to propose a personalized treatment plan for women with endometriosis.

Digital Instruments for Reporting of Gastrointestinal Symptoms in Clinical Trials: Comparison of End-of-Day Diaries Versus the Experience Sampling Method

Background

Questionnaires are necessary tools for assessing symptoms of disorders of the brain-gut interaction in clinical trials. We previously reported on the excellent adherence to a smartphone app used as symptom diary in a randomized clinical trial on irritable bowel syndrome (IBS). Other sampling methods, such as the experience sampling method (ESM), are better equipped to measure symptom variability over time and provide useful information regarding possible symptom triggers, and they are free of ecological and recall bias. The high frequency of measurements, however, could limit the feasibility of ESM in clinical trials.

Objective

This study aimed to compare the adherence rates of a smartphone-based end-of-day diary and ESM for symptom assessment in IBS and functional dyspepsia (FD).

Methods

Data from 4 separate studies were included. Patients with IBS participated in a randomized controlled trial, which involved a smartphone end-of-day diary for a 2+8-week (pretreatment + treatment) period, and an observational study in which patients completed ESM assessments using a smartphone app for 1 week. Patients with FD participated in a randomized controlled trial, which involved a smartphone end-of-day diary for a 2+12-week (pretreatment + treatment) period, and an observational study in which patients completed ESM assessments using a smartphone app for 1 week. Adherence rates were compared between these 2 symptom sampling methods.

Results

In total, 25 patients with IBS and 15 patients with FD were included. Overall adherence rates for the end-of-day diaries were significantly higher than those for ESM (IBS: 92.7% vs 69.8%, FD: 90.1% vs 61.4%, respectively).

Conclusions

This study demonstrates excellent adherence rates for smartphone app–based end-of-day diaries as used in 2 separate clinical trials. Overall adherence rates for ESM were significantly lower, rendering it more suitable for intermittent sampling periods rather than continuous sampling during longer clinical trials.

Patient preferences of healthcare delivery in irritable bowel syndrome: a focus group study

Background

Irritable bowel syndrome (IBS) is a highly prevalent disorder with significant negative impact on quality of life of patients that results in high healthcare use and costs. Improving healthcare outcomes for IBS patients is warranted, however the exact needs of IBS patients with regard to therapy and control of symptoms are unknown.

Methods

Focus group interviews, using a two-stage model, were performed with twenty-three IBS patients meeting Rome III criteria and one mother of a patient, from four different regions from the Netherlands.

Results

Twenty-four participants were included of whom majority were female (n = 21), mean age was 43 years, and mean duration of IBS was 18 years. Five categories of patients’ perspectives were identified: clear communication, a multidisciplinary treatment team, centers of expertise, focus on scientific research and information about IBS that is widely available for patients.

Conclusions

Based on these findings we highlight the need for IBS care givers to take these key items into account in IBS care. These elements aid clinicians, but mostly patients, in coping and management of symptoms and subsequent healthcare outcomes, reducing overall healthcare use and costs.

Psychometric evaluation of an experience sampling method-based patient-reported outcome measure in functional dyspepsia

BACKGROUND

Due to important biases, conventional end-of-day and end-of-week assessment methods of gastrointestinal symptoms in functional dyspepsia (FD) are considered suboptimal. Real-time symptom assessment based on the experience sampling method (ESM) could be a more accurate measurement method. This study aimed to evaluate validity and reliability of an ESM-based patient-reported outcome measure (PROM) for symptom assessment in FD.

METHODS

Thirty-five patients with FD (25 female, mean age 44.7 years) completed the ESM-based PROM (a maximum of 10 random moments per day) and an end-of-day symptom diary for 7 consecutive days. On day 7, end-of-week questionnaires were completed including the Nepean Dyspepsia Index (NDI) and Patient Assessment of Gastrointestinal Symptom Severity Index (PAGI-SYM).

KEY RESULTS

Experience sampling method and corresponding end-of-day scores for gastrointestinal symptoms were significantly associated (ICCs range 0.770-0.917). However, end-of-day scores were significantly higher (Δ0.329-1.031) than mean ESM scores (p < 0.05). Comparing ESM with NDI and PAGI-SYM scores, correlations were weaker (Pearson's r range 0.467-0.846). Cronbach's α coefficient was good for upper gastrointestinal symptoms (α = 0.842). First half-week and second half-week scores showed very good consistency (ICCs range 0.913-0.975).

CONCLUSION AND INFERENCES

Good validity and reliability of a novel ESM-based PROM for assessing gastrointestinal symptoms in FD patients was demonstrated. Moreover, this novel PROM allows to evaluate individual symptom patterns and can evaluate interactions between symptoms and environmental/contextual factors. ESM has the potential to increase patients' disease insight, provide tools for self-management, and improve shared decision making. Hence, this novel tool may aid in the transition toward personalized health care for FD patients.

Symptom-network dynamics in irritable bowel syndrome with comorbid panic disorder using electronic momentary assessment: A randomized controlled trial of escitalopram vs. placebo

INTRODUCTION

Momentary ecological assessment indicated alleviated abdominal pain in escitalopram treatment of irritable bowel syndrome (IBS) with comorbid panic disorder. Hitherto, little is known about symptom formation, i.e., how psychological impact physical symptoms, and vice versa, and about the effect of SSRI-treatment on symptom formation.

OBJECTIVE

To investigate how psychological and somatic symptoms co-vary over time in IBS patients with comorbid panic disorder and how they are affected by escitalopram treatment.

METHODS

Experience sampling data from 14 IBS patients with panic disorder were obtained from a single-centre, double-blind, parallel-group, randomized controlled trial on escitalopram versus placebo. At baseline, after three and six months, multilevel time-lagged linear regression analysis was used to construct symptom networks. Network connections represented coefficients between various affect and gastrointestinal items.

RESULTS

Connectivity increased up to 3 months in both groups. Between 3 and 6 months, connectivity decreased for placebo and further increased in the escitalopram group. Additionally, a steep increase in node strength for negative affect nodes was observed in the escitalopram network and the opposite for positive affect nodes. Over time, group symptom networks became increasingly different from each other. Anxious-anxious and enthusiastic-relaxed became significantly different between groups at 6 months. The connection that changed significantly in all analyses was anxious-anxious.

CONCLUSIONS

Escitalopram treatment was associated with changes in the symptom networks in IBS patients with panic disorder. While mood and physical symptoms improve over time, mainly connectivity between mood nodes changed, possibly pointing towards a healthier emotion regulation resulting in alleviation of physical symptoms.