Perspectives on gastroesophageal reflux disease in primary care: the REFLEX study of patient-physician agreement

Knowledge and practice of family medicine and internal medicine residents toward the management of gastroesophageal reflux disease in Riyadh, Saudi Arabia

Background

Accurate diagnosis and management of gastroesophageal reflux disease (GERD) remain a challenge in the primary care setting. The objective was to assess GERD management's knowledge and practice and its association with the family and internal medicine residents.

Methods

A cross-sectional study between January 2019 and September 2020 among the family and internal medicine residents in Riyadh, Saudi Arabia. Residents answered a self-administrated questionnaire about knowledge and practices of GERD management.

Results

A total of 596 residents were included in the current study. The average age was 26.8 ± 2.1 years, and 54.5% of the residents were males. The median knowledge score was 62.5%. The majority (89.8%) of the residents were using acid suppression drugs empirically, mainly proton-pump inhibitors (75.8%), for <8-week durations (69.7%) being taken before meals (84.7%). Frequent diagnostic testing for GERD included urea breath test (50.7%), 24-hour pH-metry/24-hour pH probe (47.3%), and upper endoscopy with biopsy (40.7%). Frequent causes for referral included gastrointestinal bleeding (82.6%), weight loss/appetite loss (82.2%), and failure of therapy (78.7%). Better knowledge was associated with older age, family medicine training, better referral practices, frequent reporting of atypical symptoms, and reading recent guidelines.

Conclusions

We are reporting a moderate knowledge level among a group of family and internal medicine residents trained in Riyadh hospitals. Practices were generally good with some areas that need improvement, especially diagnostic testing. There is an urgent need for educational programs that target family and internal medicine residents, such as education courses that include lectures and clinical discussions with the senior staff. Also, we suggest health care organizations in Saudi Arabia establish well-structured Saudi National GERD Guidelines.

Reflux Symptoms - Functional and Structural Diseases: The Approach from the General Practitioner

A primary care management strategy of gastroesophageal reflux disease (GERD) should pay attention to the epidemiology, prevalence, and distribution of reflux-like symptoms in the community and to the special characteristics of patients presenting for the first time with reflux symptoms in primary care. General practitioners (GPs) encounter daily challenges to make cost-effective differential diagnostic and therapeutic decisions, avoiding needless and costly investigation or referral. They should provide long-term effective control of symptoms and esophageal healing in a personalized, symptom-based, patient-centered, and evidence-based manner. GPs should use a practical system of triage in order to distinguish the high majority of patients with self-limiting conditions from the minority with alarm symptoms with potentially severe disorder. They should also discriminate between troublesome and nontroublesome reflux symptoms. Most GERD is uncomplicated and can be treated using management algorithms that make the best use of resources. Some strategies such as "step-down," "intermittent," or "on-demand" therapy can cost-effectively improve the long-term management and quality of life of patients with recurrent GERD. The accurate interpretation of "step-down" therapeutic strategy and a careful interpretation of proton pump inhibitor refractoriness are also essential.

Acceptable outcomes after fundoplication-different views are held by patients, GPs, and surgeons

Antireflux surgery aims to improve quality of life. However, whether patients and clinicians agree on what this means, and what is an acceptable outcome following fundoplication, is unknown. This study used clinical scenarios pertinent to laparoscopic fundoplication for gastroesophageal reflux to define acceptable outcomes from the perspective of patients, surgeons, and general practitioners (GPs). Patients who had previously undergone a laparoscopic fundoplication, general practitioners, and esophagogastric surgeons were invited to rank 11 clinical scenarios of outcomes following laparoscopic fundoplication for acceptability. Clinicopathological and practice variables were collated for patients and clinicians, respectively. GPs and esophagogastric surgeons additionally were asked to estimate postfundoplication outcome probabilities. Descriptive and multivariate statistical analyses were undertaken to examine for associations with acceptability. Reponses were received from 331 patients (36.4% response rate), 93 GPs (13.4% response), and 60 surgeons (36.4% response). Bloating and inability to belch was less acceptable and dysphagia requiring intervention more acceptable to patients compared to clinicians. On regression analysis, female patients found bloating to be less acceptable (OR: 0.51 [95%CI: 0.29-0.91]; P = 0.022), but dysphagia more acceptable (OR: 1.93 [95%CI: 1.17-3.21]; P = 0.011). Postfundoplication estimation of reflux resolution was higher and that of bloating was lower for GPs compared to esophagogastric surgeons. Patients and clinicians have different appreciations of an acceptable outcome following antireflux surgery. Female patients are more concerned about wind-related side effects than male patients. The opposite holds true for dysphagia. Surgeons and GPs differ in their estimation of event probability for patient recovery following antireflux surgery, and this might explain their differing considerations of acceptable outcomes.

Management of gastroesophageal reflux disease: Patient and physician communication challenges and shared decision making

Gastroesophageal reflux disease (GERD) is a common upper esophageal condition and typical symptoms can include heartburn and sensation of regurgitation while atypical symptoms include chronic cough, asthma, hoarseness, dyspepsia and nausea. Typically, diagnosis is presumptive given the presence of typical and atypical symptoms and is an indication for empiric therapy. Treatment management can include lifestyle modifications and/or medication therapy with proton pump inhibitor (PPI) class being the preferred and most effective. Complete symptom resolution is not always achieved and long-term PPI therapy can put patients at risk for serious side effects and needless expense. The brain-gut connection and hypervigilance plays an important role in symptom resolution and treatment success, especially in the case of non-PPI responders. Hypervigilance is a combination of increased esophageal sensory sensitivity in combination with exaggerated threat perception surrounding esophageal symptoms. Hypervigilance requires a different approach to GERD managements, where continued PPI therapy and surgery are usually not recommended. Rather, helping physicians and patients understand the brain-gut connection can guide and improve care. Education and reassurance should be the main pillars or treatment. However, it is important not to suggest the symptoms are due to anxiety alone, this often leads to patient dissatisfaction. Patient dissatisfaction with treatment reveals the need for a more patient-centered approach to GERD management and better communication between patients and providers. Shared decision making (SDM) with the incorporation of patient-reported outcomes (PRO) promotes patient adherence and satisfaction. SDM is a joint discussion between clinician and patient in which a mutually shared solution is explored for GERD symptoms. For SDM to work the physician needs to capture patients’ perceptions which may not be obtained in the standard interview. This can be done through the use of PROs which promote a dialogue with patients about their symptoms and treatment priorities in the context of the SDM patient encounter. SDM could potentially help in the management of patient expectations for GERD treatment, ultimately positively impacting their health-related quality of life.

The Economic Impact of Levothyroxine Dose Adjustments: the CONTROL HE Study

Background

In general, hypothyroidism can be adequately treated with a consistent daily dose of levothyroxine. However, the need for levothyroxine dose adjustments is frequent in clinical practice. The extent to which levothyroxine dose adjustments increase the utilization of healthcare resources has not previously been described in the clinical literature.

Objective

The primary objective of our study was to measure the effect of levothyroxine dose adjustments in terms of their utilization of healthcare resources including direct and indirect costs. A secondary goal was to identify any differences in patient characteristics that may be responsible for levothyroxine dose adjustments.

Methods

A retrospective medical chart review was conducted among patients of selected healthcare providers in the USA. Patients who were recently started on levothyroxine therapy (<6 months) were excluded to avoid situations that were more likely attributable to treatment initiation than inadequate therapeutic effect. Trained nurses extracted data from patient charts and electronic medical record systems for review. We analyzed the cost of resources consumed by the frequency of levothyroxine dose changes over 24 months: 0 dose changes (no dose adjustment group); one dose change, two dose changes, three or more dose changes (≥1 dose adjustment group).

Results

The study included 454 patients. Overall estimated resource utilization was higher per patient in the ≥1 dose adjustment group (US$5824) vs. the no dose adjustment group (US$3166) during the 24-month study period. When direct and indirect costs were combined, overall costs of care were greatest in patients requiring three or more dose adjustments (US$8220/patient). Patients in this cohort incurred 2.5-fold greater total costs compared with patients requiring no dose adjustments (US$8220 vs. US$3166). Among the 58 patients in the group requiring three or more dose adjustments, mean direct medical costs were significantly higher than in the patients requiring no dose adjustments (US$6387 vs. US$2182). Patients with at least one dose adjustment experienced a 40.3% increase in lost productivity vs. patients who had no dose adjustments (US$1381 vs. US$984). Loss of productivity was highest among patients with three or more levothyroxine dose adjustments. Among this cohort, there was an 86.4% increase in lost productivity vs. patients who had no levothyroxine dose adjustments (US$1833 vs. US$984).

Conclusions

Patients experiencing multiple levothyroxine dose adjustments were shown to consume more healthcare resources, resulting in higher costs than those who required no dose adjustments. Each care episode contributed to lost time and wages with total estimated lost productivity escalating with increasing levothyroxine dose adjustments over a 24-month period.

Electronic supplementary material

The online version of this article (doi:10.1007/s40261-016-0462-3) contains supplementary material, which is available to authorized users.

Comorbidities, Concomitant Medications, and Diet as Factors Affecting Levothyroxine Therapy: Results of the CONTROL Surveillance Project

Background

The CONTROL Surveillance Project was a comprehensive patient-based survey conducted among hypothyroid patients undergoing treatment. The primary objective of the study was to specifically quantify the prevalence of factors adversely affecting levothyroxine therapy.

Methods

Participants were selected from a large proprietary database. Those eligible for the study completed a 21-question survey.

Results

Of the eligible hypothyroid patients, 925 (92.5 %) were being treated with levothyroxine monotherapy. The mean age was 60.4 years; 755 (81.6 %) were female and 168 (18.2 %) were male. Almost half of those receiving levothyroxine (435, 47.0 %) had at least one comorbid condition that could adversely affect its absorption: gastroesophageal reflux disease (33.8 % of patients), irritable bowel syndrome (9.7 %), lactose intolerance (7.8 %), or a history of gastric bypass surgery or bowel resection (3.0 %). Other factors reported by many patients that could adversely affect levothyroxine absorption included use of prescription medications (20.6 %) and over-the-counter medications (34.3 %) used to treat comorbid gastrointestinal (GI) conditions; use of dietary supplements (51.8 %, primarily calcium and iron); and intake of foods/beverages high in fiber, iodine, or soy (68.0 %). Of the 13.4 % who reported difficulty controlling their hypothyroid symptoms, significantly more patients with comorbid GI conditions reported such difficulty (7.8 versus 5.6 %, P < 0.01). Frequent changes in levothyroxine dosing (two or more dose changes in the past year) were reported by 8.0 % of survey participants. Those with GI comorbidities were nearly twice as likely to have such changes (5.0 versus 3.0 %, P < 0.01).

Conclusion

Better initial workup of patients, including identification of relevant GI comorbidities and allergies, may help in the early detection of factors that may affect the performance of levothyroxine.

The Intestinal Gas Questionnaire: development of a new instrument for measuring gas-related symptoms and their impact on daily life

BACKGROUND

Although gas-related symptoms (GRS) are common and intrusive, there are no questionnaires to quantitate this problem. This study aimed to develop an instrument to rectify this gap in our knowledge.

METHODS

Concepts were initially identified from the literature and interviews with gastroenterologists. Exploratory one-to-one interviews and focus groups with irritable bowel syndrome (IBS) patients (n = 28) and non-IBS subjects (n = 27) with GRS were conducted in UK, France, and Spain leading to a conceptual framework for the questionnaire. Last, iterative rounds of cognitive debriefing were performed with IBS (n = 16) and non-IBS subjects (n = 14).

KEY RESULTS

From the first three steps, nine GRS (bloating, distension, flatulence, odorous flatulence, difficult gas evacuation, stomach rumbling, belching, bad breath, and abdominal movement) were identified although abdominal movement was subsequently excluded. Twelve quality of life domains affected by these symptoms were identified as: Clothing, emotional, physical appearance, diet, daily living, work, social life, physical activity, relationships, sex life, sleep, and cognitive function. A 24-h recall for symptoms and a 7-day recall for impact assessment were supported by the qualitative findings. Cognitive debriefing confirmed the understanding of the instrument. Across the three languages, the instrument was conceptually and linguistically consistent.

CONCLUSIONS & INFERENCES

The International Gas Questionnaire is a 2-part instrument, developed rigorously and simultaneously in three languages assessing seven symptoms (17 items) and their impact on 12 domains (26 items) in IBS and general population. It is now undergoing psychometric validation and should provide a unique tool for epidemiological surveys and clinical trials for developing new treatments for these symptoms.

Esophageal mucosal breaks in gastroesophageal reflux disease partially responsive to proton pump inhibitor therapy

OBJECTIVES

Approximately 20-30% of patients with gastroesophageal reflux disease (GERD) do not experience complete symptom resolution during proton pump inhibitor (PPI) therapy. The aim of this study was to determine the prevalence of esophageal mucosal breaks among patients who have a partial response to PPI therapy.

METHODS

This was an analysis of data from a phase 2b clinical trial carried out to assess the efficacy and safety of a reflux inhibitor, lesogaberan (AZD3355), as an add-on to PPI therapy in this patient population (clinicaltrials.gov reference: NCT01005251). A total of 661 patients with persistent GERD symptoms who had received a minimum of 4 weeks of PPI therapy were included in the study. The prevalence of esophageal mucosal breaks was assessed according to (i) the most recent endoscopy results from within the previous 24 months, if available ("historical" endoscopies), and (ii) the results of endoscopies performed at study baseline ("baseline" endoscopies). Baseline endoscopies were not carried out in patients who had a historical endoscopy showing an absence of esophageal mucosal breaks.

RESULTS

Historical endoscopy results were available for 244 patients, of whom 48 (19.7%) had esophageal mucosal breaks. Baseline endoscopies were carried out in 465 patients, of whom 146 (31.4%) had esophageal mucosal breaks. Sensitivity analyses showed a prevalence of esophageal mucosal breaks of 20-30%. In both the historical and baseline endoscopies, most esophageal mucosal breaks were Los Angeles grades A or B.

CONCLUSIONS

In patients with GERD symptoms partially responsive to PPI therapy, mild-to-moderate severity esophageal mucosal breaks are common (prevalence 20-30%), and may contribute to symptom etiology.

Systematic review: symptom assessment using patient-reported outcomes in gastroesophageal reflux disease and dyspepsia

OBJECTIVE

The importance of symptom assessment using patient-reported outcomes (PROs) is becoming increasingly recognized in the management of upper gastrointestinal (GI) disease. The authors aimed to review systematically the methodological aspects of PRO instrument development and use in the GERD or dyspepsia literature, and to assess these instruments' properties in light of the Food and Drug Administration's (FDA) guidance.

MATERIAL AND METHODS

Systematic PubMed and Embase searches (using terms based on the FDA guidance) identified studies that reported methodological aspects in developing or using PRO instruments for GERD or dyspepsia symptom measurement.

RESULTS

Ten studies were identified (six systematically and four from citation lists). Studies reported the development or use of a relevant PRO instrument, with a focus on methodological aspects that the FDA guidance describes as important for patient understanding. Studies demonstrated heterogeneity of recall periods, symptoms and response options. Two studies demonstrated that a lack of consistent vocabulary may contribute to discrepancy in symptom reporting between investigators and patients. Two studies indicated that symptoms must be described in a manner that is relevant to patients. One study described the development of a PRO instrument separately in two languages, acknowledging linguistic and cultural differences between populations. One study demonstrated changes in symptom severity based on the recall period.

CONCLUSIONS

There is considerable heterogeneity in the methodology used to develop PRO instruments for upper GI disease. Adherence to best practices in PRO development and validation may improve the quality and utility of these measures, leading to improved communication in clinical practice.

Partial symptom-response to proton pump inhibitors in patients with non-erosive reflux disease or reflux oesophagitis - a post hoc analysis of 5796 patients

BACKGROUND

Although most patients with gastro-oesophageal reflux disease (GERD) benefit from proton pump inhibitor (PPI) therapy, some experience only partial symptom relief.

AIM

To determine the prevalence of partial heartburn response to PPIs and its impact on health-related quality of life.

METHODS

Four randomised, double-blind studies in adults with reflux disease compared esomeprazole 40 mg/day or 20 mg/day with omeprazole 20 mg/day, or esomeprazole 40 mg/day with pantoprazole 40 mg/day. Patients with heartburn on ≥4 days during the 1-week recall period at baseline were included. Partial response was defined as heartburn on ≥3 days during the last treatment week and reduced heartburn frequency after 4 weeks of treatment compared with baseline.

RESULTS

The analysis included 2645 patients with non-erosive reflux disease (mean age: 48.8 years; 54.4% women) and 3151 patients with reflux oesophagitis (mean age: 50.6 years; 37.1% women). At baseline, most patients reported heartburn on 5-7 days (non-erosive reflux disease: 82.2%; reflux oesophagitis: 86.8%). Partial heartburn response occurred in 19.9% of patients with non-erosive reflux disease and 14.0% with reflux oesophagitis. Defining partial response as heartburn on ≥2 days increased these rates to 26.2% and 19.3%, respectively; defining partial response as heartburn of moderate or severe intensity on ≥3 days decreased these rates to 6.4% and 5.3%, respectively. Nonresponse to PPIs was rare (non-erosive reflux disease: 2.4%; reflux oesophagitis: 1.4%).

CONCLUSION

Using our conservative definition, partial heartburn response to proton pump inhibitor therapy occurred in 14-20% of gastro-oesophageal reflux disease patients, more commonly in non-erosive reflux disease than in reflux oesophagitis.