Quality of life in inflammatory bowel disease and other chronic diseases

Health-related quality of life in inflammatory bowel disease: a comparison of patients receiving nurse-led versus conventional follow-up care

BACKGROUND

Inflammatory bowel disease (IBD), consisting of Crohn's disease (CD) and ulcerative colitis (UC), is a chronic disorder with a considerable negative impact on health-related quality of life (HRQoL). During the past decade, IBD nurse specialists have been increasingly involved in follow-up care of IBD outpatients, in a consultative and coordinating role, closely cooperating with gastroenterologists. Whether patients' HRQoL differs between nurses' follow-up care (NF) and conventional follow-up care (CF) has not been widely researched and the aim of this study was to compare two different follow-up regimes with respect to patients' HRQoL.

METHODS

This cross-sectional, multicenter study involved seven centers; five organized as CF, two as NF.

RESULTS

A total of 304 patients aged 18-80 years, 174 females and 130 males, were included, of whom 140 received care under the NF model and 164 under the CF model. Participants in the NF group had a statistically significant higher median total score on the Inflammatory Bowel Disease Questionnaire (IBDQ) (p-value < .001). This pattern could also be seen in the sub-scores of the different IBDQ domains. Despite a trend of higher IBDQ score in all domains in the NF model, the overall result in our study did not reach the limit of 16 points, defined as clinically significant. A higher proportion of NF patients had IBDQ scores defined as remission, as well as a statistically significant higher frequency of outpatient check-ups during a two-year follow-up period.

CONCLUSIONS

Nurse-led models are not inferior to conventional models with regards to patient reported HRQoL except in the social domain where the model showed to be clinically significant better. Further studies are needed to advance efforts to implement these models and increase access to IBD care.

Pain in IBD Patients: Very Frequent and Frequently Insufficiently Taken into Account

Background

Pain is a common symptom related to inflammatory bowel disease (IBD). In addition to abdominal pain, pain can also be an extraintestinal manifestation of IBD. Pain treatment is challenging and a substantial part of IBD patients are treated with opioids. Therefore, a better knowledge on pain symptoms is crucial for a better therapeutic approach to this clinical problem.

Methods

Patients of the Swiss IBD Cohort Study (SIBDCS) (n = 2152) received a questionnaire regarding pain intensity, pain localization and impact of pain on daily life and social activities. Furthermore, the questionnaire investigated the use of pain-specific medication.

Results

A vast majority of patients (71%) experienced pain during the disease course. For a substantial part of patients (49% in UC and 55% in CD) pain is a longstanding problem (>5 years). Pain in UC was of shorter duration compared to CD (p < 0.01). Abdominal pain (59.5%) and back pain (38.3%) were the main pain localizations. 67% of patients took pain medication; 24% received no pain treatment. The general quality of life was significantly lower in patients suffering of pain compared to those without pain (38 vs. 77; (-100 very bad; 100 very good) p<0.0001).

Conclusions

Prevalence of pain is high in patients of the SIBDCS. It is a longstanding problem for the majority of the patients affected. Pain was found to be undertreated in the SIBDCS and was significantly associated with health-related quality of life. Thus, an increased awareness is mandatory to address this frequent complication in the course of IBD.

Patient perception of chronic illness care in a large inflammatory bowel disease cohort

BACKGROUND

Improvements in care for inflammatory bowel diseases could use the Chronic Care Model, an evidence-based approach that has improved patient outcomes and reduced costs in other illnesses. Specific aims include (1) to explore patient perception of chronic illness care in a large inflammatory bowel disease cohort and (2) to determine whether demographic factors, medication adherence, quality of life, disease type, and activity were associated with perception of chronic illness care.

METHODS

We randomly selected 1000 participants from the Crohn's and Colitis Foundation of America Partners Internet cohort to receive the validated Patient Assessment of Chronic Illness Care (PACIC) instrument, which measures patient experience with specific aspects of care congruent with the Chronic Care Model on a scale of 1 to 5, with 5 being highest perception of care. We used descriptive and bivariate statistics to assess relationships.

RESULTS

Nine hundred and forty-five participants completed the PACIC (576 Crohn's disease, 339 ulcerative colitis, and 30 indeterminate or other; 74% female, mean age 45 [SD = 15.1], mean PACIC 2.4 [SD = 0.93]). Recent gastroenterologist visit, hospitalization, surgery, and current pouch/ostomy were all associated with significantly higher PACIC (P < 0.05). PACIC correlated positively with quality of life (Pearson's correlation = 0.12, P = 0.003) but not medication adherence or disease activity.

CONCLUSIONS

Reports of chronic illness care in this inflammatory bowel disease cohort are in the same range as other illnesses. PACIC is positively associated with quality of life, so efforts to align care with the Chronic Care Model may benefit this population. Subjects who had more subspecialty interactions reported an increased perception of care, indicating the important role of direct patient contact.

Development of a social morbidity score in patients with chronic ulcerative colitis as a potential guide to treatment

AIM

Present quality of life instruments for inflammatory bowel disease do not evaluate many social aspects of patients' lives that are potentially important in clinical decision making. We have developed a new Social Impact of Chronic Conditions - Inflammatory Bowel Disease (SICC-IBD) questionnaire to assess these areas.

METHOD

A 34-item questionnaire was piloted to determine quality of life relating to education, personal relationships, employment, independence and finance. It was compared with the Short Form 36-Item version 2 (SF-36v2) and the Inflammatory Bowel Disease Questionnaire (IBDQ) in 150 patients with chronic ulcerative colitis on an endoscopic surveillance register who had never had surgery.

RESULTS

Reliability and validity testing enabled the questionnaire to be shortened to only eight items. There was a high level of reliability (Cronbach's α=0.72). The questionnaire correlated well with the social functioning domain of the SF-36 (rs=0.56) and was able to distinguish clinical severity of disease.

CONCLUSION

The SICC-IBD is a new tool for assessment of patients with ulcerative colitis, which has identified new aspects of social disability for further study and for potential use as an additional tool in therapy decisions.

Impact of pain on health-related quality of life in patients with inflammatory bowel disease

AIM: To evaluate intensity, localization and cofactors of pain in Crohn’s disease and ulcerative colitis patients in connection with health-related quality of life (HRQOL) and disease activity.

METHODS: We reviewed and analyzed the responses of 334 patients to a specifically designed questionnaire based on the short inflammatory bowel disease questionnaire (SIBDQ) and the German pain questionnaire. Pain intensity, HRQOL, Crohn’s disease activity index (CDAI) and colitis activity index (CAI) were correlated and verified on a visual analog scale (VAS).

RESULTS: 87.9% of patients reported pain. Females and males reported comparable pain intensities and HRQOL. Surgery reduced pain in both genders (P = 0.023), whereas HRQOL only improved in females. Interestingly, patients on analgesics reported more pain (P = 0.003) and lower HRQOL (P = 0.039) than patients not on analgesics. A significant correlation was found in UC patients between pain intensity and HRQOL (P = 0.023) and CAI (P = 0.027), and in CD patients between HRQOL and CDAI (P = 0.0001), but not between pain intensity and CDAI (P = 0.35). No correlation was found between patients with low CDAI scores and pain intensity.

CONCLUSION: Most IBD patients suffer from pain and have decreased HRQOL. Our study reinforces the need for effective individualized pain therapy in IBD patients.

Home telemanagement for patients with ulcerative colitis (UC HAT)

Effective therapies exist to treat ulcerative colitis (UC); nonadherence, inadequate monitoring, and side-effects result in suboptimal outcomes. Novel methods for monitoring are needed. Our objectives were to assess acceptance of home automated telemanagement in ulcerative colitis (UC HAT). The UC HAT system consists of a laptop connected to a scale, a decision support server, and a web-based clinician portal. The UC HAT system facilitates self-care in UC patients by monitoring patient symptoms, side-effects, and adherence, and helping patients in following their individualized treatment plans. Ten adult patients with UC were trained to use UC HAT. Attitudinal surveys and qualitative interviews were performed. The results showed that all patients reported that use of the computer was not complicated. 90% reported that the symptom diary and side-effect questions were not difficult. All patients reported that the training was adequate and 70% reported that testing took little time. Seventy percent would feel safer using the system, and 90% would agree to use UC HAT in the future. Patients felt UC HAT would keep the patient and provider up to date on changes in symptoms. Self-testing appeared to make patients accountable for managing the disease. It was discussed that improved monitoring is needed for UC. Patients with UC can be easily trained to use HAT, and patient acceptance of the UC HAT system is high. Home automated telemanagement has potential to improve clinical outcomes and patient satisfaction in UC.

Use of health care resources and cost of care for adults with constipation

BACKGROUND & AIMS

Constipation is a multisymptom disorder that frequently compromises quality of life and leads patients to seek medical advice. To evaluate the clinical and fiscal effects of constipation, we assessed health care resource use by patients with constipation enrolled in a large state Medicaid program.

METHODS

We identified 105,130 patients older than age 18 who saw a physician at least once for constipation and were enrolled in the California Medicaid program (Medi-Cal). We then studied health care resource use and costs (reimbursed by Medi-Cal) in 76,854 patients without supplementary insurance. The 15-month analysis period encompassed 3 months before and 12 months after the first visit. The prevalence of comorbid conditions was assessed in the sample of 105,130 patients.

RESULTS

During the study period, 106,555 physician visits were for constipation; the total associated cost was $3,016,017 ($39/patient). The total cost for gastrointestinal procedures and laboratory testing was $14,052,503 ($183/patient). There were 41,723 over-the-counter and 1665 prescription drug purchases; the total cost was $388,780 ($5/patient). Approximately 0.6% of patients (n = 479) were admitted to the hospital for constipation; the total cost was $1,433,708 ($2993/admission). The total direct health care costs for patients with constipation in the Medi-Cal system for the 15-month period was $18,891,008 ($246/patient). Within 12 months of the first physician visit for constipation, 5657 of 105,130 patients had hemorrhoids and 2288 had intestinal impaction or obstruction.

CONCLUSIONS

Adults seeking treatment for constipation account for significant health care resource use and often have comorbid conditions. The clinical and fiscal burden of constipation in US adults cannot be disregarded or trivialized.

Interaction between Mycobacterium avium subsp. paratuberculosis and environmental protozoa

Background

Interactions between Mycobacterium avium subsp. paratuberculosis (Map) and free-living protozoa in water are likely to occur in nature. The potential impact of ingestion of Map by two naturally occurring Acanthamoeba spp. on this pathogen's survival and chlorine resistance was investigated.

Results

Between 4.6 and 9.1% of spiked populations of three Map strains (NCTC 8578, B2 and ATCC 19698), which had been added at a multiplicity of infection of 10:1, were ingested by Acanthamoeba castellanii CCAP 1501/1B and A. polyphaga CCAP 1501/3B during co-culture for 3 h at 25°C. Map cells were observed to be present within the vacuoles of the amoebae by acid-fast staining. During extended co-culture of Map NCTC 8578 at 25°C for 24 d with both A. castellanii and A. polyphaga Map numbers did not change significantly during the first 7 days of incubation, however a 1–1.5 log₁₀ increase in Map numbers was observed between days 7 and 24 within both Acanthamoeba spp. Ingested Map cells were shown to be more resistant to chlorine inactivation than free Map. Exposure to 2 μg/ml chlorine for 30 min resulted in a log₁₀ reduction of 0.94 in ingested Map but a log₁₀ reduction of 1.73 in free Map (p < 0.001).

Conclusion

This study demonstrated that ingestion of Map by and survival and multiplication of Map within Acanthamoeba spp. is possible, and that Map cells ingested by amoebae are more resistant to inactivation by chlorine than free Map cells. These findings have implications with respect to the efficacy of chlorination applied to Map infected surface waters.

Impact of chronic conditions on quality of life in patients with inflammatory bowel disease

BACKGROUND

Although studies suggest that inflammatory bowel disease (IBD) has a significant impact on an individual's health-related quality of life, the added weight of other health conditions and comorbidities has not been investigated. The purpose of this study was to expand on prior research by taking into account the impact of other chronic health conditions on the health-related quality of life of individuals with IBD, and to develop a model to help clinicians understand the relative impact of various predictors of their patients' physical and mental health-related quality of life.

METHODS

615 patients from the gastroenterology outpatient practice of a large, urban university hospital received a self-administered survey including questions about their health conditions, the severity of their bowel symptoms, and their health-related quality of life (measured using the SF-36 instrument).

RESULTS

314 completed surveys were returned, resulting in a response rate of 51.1%. Two regression analyses were conducted to identify the role of patient demographic variables and other chronic conditions on the 2 primary outcomes of interest: the SF-36 Physical Component and Mental Component Summary scores. Statistically significant predictors of physical quality of life included IBD disease severity, arthritis, heart disease, age, anemia, back/shoulder pain, and hypertension; statistically significant predictors of mental health-related quality of life were IBD disease severity, depression/anxiety, age, and headaches.

CONCLUSIONS

IBD disease severity is the most important predictor of both physical and mental health-related quality of life in patients with this condition despite the presence of other chronic conditions.

Occurrence of Mycobacterium avium subsp. paratuberculosis in untreated water in Northern Ireland

Mycobacterium avium subsp. paratuberculosis is the known cause of Johne's disease of both domestic and wild ruminants and has been implicated as a possible cause of Crohn's disease in humans. The organism is shed in the feces of infected animals and can survive for protracted periods in the environment and hence could be present in catchment areas receiving agricultural runoff. A limited survey was undertaken in Northern Ireland to test for M. avium subsp. paratuberculosis in untreated water entering nine water treatment works (WTWs) over a 1-year period. Three detection methods were employed, viz., immunomagnetic separation-PCR and culture on Herrold's egg yolk medium (HEYM) and BACTEC 12B medium, the latter both supplemented with mycobactins. Of the 192 untreated water samples tested, 15 (8%) tested M. avium subsp. paratuberculosis positive by one or more of the three detection methods. M. avium subsp. paratuberculosis was successfully isolated from eight untreated water samples, three by BACTEC culture and five by culture on HEYM. Although the highest incidence of M. avium subsp. paratuberculosis was found in spring, overall, there was no statistically significant difference between the seasons. No significant correlation was found between numbers of coliforms or fecal coliforms and the presence of M. avium subsp. paratuberculosis. In general, a higher incidence of M. avium subsp. paratuberculosis was found in untreated water entering those WTWs that had a high mean water pH value over the sampling period. This work indicates the need to determine the efficacy of water treatment processes to either kill or remove M. avium subsp. paratuberculosis from untreated water and the possible risks posed by contact with recreational water sources.

Health related quality of life in Crohn's proctocolitis does not differ from a general population when in remission

OBJECTIVE

All treatment in Crohn's disease, although palliative, aims at restoring full health. The objective of this study was to compare health-related quality of life and psychosocial conditions in patients with Crohn's proctocolitis with a general population.

PATIENTS AND METHODS

One hundred and twenty-seven patients with Crohn's proctocolitis (median age 44 years, 44.1% men) were compared with 266 controls (median age 45 years, 50.7% men). A questionnaire consisting of the Short Form-36 (SF-36), the Psychological General Well-Being Index (PGWB) and a visual analogue scale (VAS) evaluating general health as well as questions regarding psychosocial conditions was used. Disease activity was evaluated by Best's modification of the classical Crohn's Disease Activity Index.

RESULTS

Patients in remission had a health related quality of life similar to controls according to the SF-36 apart from general health where scores were lower (P < 0.01). Patients with active disease scored lower in all aspects of the SF-36 (P < 0.001 or P < 0.0001) as well as the PGWB (P < 0.0001). In a model for multiple regression including age, gender, concomitant small bowel disease, permanent stoma, previous colonic surgery, disease activity, duration, and aggressiveness, disease activity was the only variable negatively predicting all 8 domains of the SF-36 in the patient group (P < 0.001). The mean annual sick-leave for patients and controls were 33.9 and 9.5 days (P < 0.0001), respectively. Sixty-eight percent of the patients and 78.4% of the controls (P = 0.04) were married or cohabited, 67.7% and 78.0% (P = 0.04), respectively, had children.

CONCLUSION

The health related quality of life for patients with Crohn's proctocolitis in remission does not differ from the general population. The disease has, however, a negative impact on parenthood, family life and professional performance.

Health-related quality of life and gastrointestinal disease

Society is changing rapidly, and new aspects need to be considered when evaluating treatment of disease. Health-related quality of life (HRQL) is a relatively new addition to the tools clinicians use to gain a better understanding of the impact of disease and its treatment. The questions 'What is it?', 'How it is measured?' and 'How can the information be used?' are now better understood than a few years ago. Generic instruments to capture HRQL enable a broad assessment of a range of aspects and can be used to make comparisons between different patient populations. Irrespective of the choice of instrument, they can classify the influence of different factors, such as gender, age, general health status and disease severity. Health-related quality of life assessments have been made in many areas of gastroenterology, such as reflux disease, inflammatory bowel disease and irritable bowel syndrome, to describe the burden of illness and the impact of treatment. Health-related quality of life as a prediction of treatment response is another interesting option. Its ability in the context of surgical intervention and outcomes is also emerging even though more work must be done in this area. Health-related quality of life evaluations, as an additional tool in the management of patients, are here to stay.

Advances in the management of Crohn's disease: economic and clinical potential of infliximab

New therapies for Crohn's disease are being developed based on improvements in our understanding of the disease's immune and inflammatory properties. One of these new therapies is infliximab, a monoclonal antibody directed against the proinflammatory cytokine tumor necrosis factor-alpha. Recent studies indicate that treatment of moderately to severely ill Crohn's disease patients with infliximab produces a rapid and profound reduction in the signs, symptoms, and severity of this disease. Beyond its clinical impact, Crohn's disease also carries significant economic consequences. Earlier reports on the costs of managing this disease estimated the average annual medical costs per patient at $9197, with the total annual cost of illness estimated to exceed $1.7 billion. Hospitalizations and surgeries represented 80% of these costs. Additional analyses have been conducted for this review to reflect more current treatment patterns. Assuming that proven increases in response and remission rates lead to diminished disease severity, infliximab can be expected to reduce the number of hospitalizations and surgeries in moderately to severely ill patients, with substantial cost savings. Moreover, improvement in disease status and quality of life may allow Crohn's disease patients to lead more productive lives.

Metabolic features of inflammatory bowel disease in a remission phase of the disease activity

OBJECTIVES

To evaluate the anthropometric and metabolic characteristics of patients with Crohn's disease (CD) and ulcerative colitis (UC), comparing both groups with healthy volunteers.

DESIGN

A cross-sectional study.

SETTING

The Department of Internal Medicine, Catholic University Hospital, Rome, Italy.

SUBJECTS

Thirty-four patients with biopsy-proven inflammatory bowel disease (18 CD; 16 UC) in clinical remission (SCDAI < 3 and Powell-Tuck index < 4) not receiving steroid therapy.

INTERVENTIONS

All patients had a clinical examination.

MAIN OUTCOME MEASURES

Blood indicators of inflammation and nutritional status. Body composition was assessed by both anthropometry and bioimpedance and metabolic variables were measured by indirect calorimetry over a 60-90 min period.

RESULTS

CD had a lower body weight than both controls (58.1 kg, range 41.5-71.0 vs. 66.4 kg, range 57.0-76.0; P < 0.001) and UC) 58.1 kg, range 41.5-71.0 vs. 69.6 kg, range 50.5-94.0; (P < 0.001). Fat-free mass (FFM) did not differ between the groups, whilst fat mass was significantly lower in CD than in UC (P < 0.05) and controls (P < 0.001). Normalizing the basal metabolic rate by FFM, a higher value was found in CD compared with UC (143 kJ kg-1) d-(-1), range 97.5-179 vs. 133 kJ kg-1 d-1, range 123-148; P < 0.05) and control subject 143 kj kg-1 d-1, range 97.5-179 vs. 134 kj kg-1 d-1, range 122-162; P < 0.05). The nonprotein respiratory quotient was significantly lower in CD compared to UC 0.80, range 0.73-0.84 vs. 0.84, range 0.79-0.91; P < 0.01) and controls (0.80, range 0.73-0.84 vs. 0.83, range 0.81-0.87; P < 0.001), with a consequently higher lipid oxidation rate in CD.

CONCLUSIONS

CD subjects showed a decreased fat mass and enhanced utilization of lipids compared with UC and controls. These data could be explained by the larger intestinal involvement and considered as a contribution to lipid tissue wasting in CD.