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Hiramoto B, Flanagan R, Muftah M, Shah ED, Chan WW. Centrally Distributed Adiposity as a Modifiable Risk Factor for Fecal Incontinence: U.S. Population-Based Analysis. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00389-6. [PMID: 38657883 DOI: 10.1016/j.cgh.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 02/14/2024] [Accepted: 04/02/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND AND AIMS Fecal incontinence (FI) is highly prevalent with substantial impacts on quality of life and healthcare utilization. The impact of obesity on FI remains unclear, with differing conclusions using BMI as risk factor. We aimed to determine the association between obesity and FI, and whether this relationship is dependent on the distribution of adiposity (waist circumference-to-height ratio, WHtR). METHODS This was a population-based analysis of the National Health and Nutrition Examination Survey, including participants who responded to the bowel health survey in 2005-2010. FI was defined by the accidental bowel leakage of solid stool, liquid, or mucus at least once in the past month. Stepwise multivariable logistic regression models were constructed to assess risk factors for FI. RESULTS A total of 7,606 participants were included, with an overall FI prevalence of 9.2%. When stratified by quartiles of body measurements, FI was increasingly prevalent from 1st to 4th quartile for both WHtR (range: 5.3%-12.5%) and BMI (range: 7.1%-10.5%). WHtR was associated with FI and was a stronger predictor than BMI in all quartiles of body measurement. On multivariable analysis, WHtR remained a significant predictor of FI comparing the 4th to the 1st quartile of body measurements (OR:1.77, CI:1.11-2.80, p=0.017), whereas BMI was not. A WHtR cutoff of >0.592 optimized the Youden index in prediction of FI in the overall sample. CONCLUSION WHtR was independently associated with increased odds of FI in this nationally representative sample of US adults, whereas BMI was not consistently correlated. This suggests bowel continence may depend more on how body mass is distributed.
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Affiliation(s)
- Brent Hiramoto
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Ryan Flanagan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Mayssan Muftah
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Eric D Shah
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, United States
| | - Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
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Shah ED, Curley MA, Patel A, Lo WK, Chan WW. Heartburn Relief Is the Major Unmet Need for Drug Development in Gastroesophageal Reflux Disease: Threshold Value Analysis. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00202-7. [PMID: 38367746 DOI: 10.1016/j.cgh.2024.01.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 01/29/2024] [Accepted: 01/31/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND AND AIMS Heartburn symptoms contribute to healthcare-seeking among patients with gastroesophageal reflux disease (GERD). Despite clinical guidance, management is often dictated by insurance restrictions. Several potassium-competitive acid blockers (PCABs) are under development as a new class of therapy. We performed economic analyses to align GERD drug development with the needs of gastroenterologists, insurers and patients in a value-based environment. METHODS A decision-analytic model was constructed to compare vonoprazan 20 mg daily (an example of a PCAB), common over-the-counter or prescription proton pump inhibitor regimens, and no treatment over a 1-year time horizon. Clinical responses were evaluated based on the proportions of heartburn-free days in a recent phase 3 multicenter trial. Healthcare utilization for persistent reflux symptoms was derived from national observational studies compared with healthy control subjects. Costs and quality-adjusted life years were reported. RESULTS Without insurance coverage for appropriate therapy, patients spend $4443 and insurers spend $3784 on average per year for inadequately treated GERD symptoms. Our model estimates that PCABs could save at least $3000 in annual costs to patients and insurers, could generate quality-adjusted life year gains (+0.06 per year), and could be cost-saving to insurers as a covered option at a price up to $8.57 per pill, if these drugs are able to demonstrate similar effectiveness to proton pump inhibitors in future trials evaluating heartburn relief and erosive esophagitis healing to regulators. Threshold prices reflect pricing after all pharmacy benefits manager rebates and discounts. DISCUSSION We demonstrate that aiming GERD-related drug development toward heartburn relief appears critical to align cost-effective incentives for industry and insurers with those of patients and gastroenterologists.
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Affiliation(s)
- Eric D Shah
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan.
| | - Michael A Curley
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Amit Patel
- Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina; Division of Gastroenterology, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Wai-Kit Lo
- Division of Gastroenterology, Durham Veterans Affairs Medical Center, Durham, North Carolina; Division of Gastroenterology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Walter W Chan
- Division of Gastroenterology, Durham Veterans Affairs Medical Center, Durham, North Carolina; Division of Gastroenterology, Brigham and Women's Hospital, Boston, Massachusetts
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Shah ED, Ahuja NK, Brenner DM, Chan WW, Curley MA, Nee J, Iturrino-Moreda J, Staller K, Saini SD, Chey WD. Optimizing the Management Algorithm for Adults With Functional Constipation Failing a Fiber/Laxative Trial in General Gastroenterology: Cost-Effectiveness and Cost-Minimization Analysis. Am J Gastroenterol 2024; 119:342-352. [PMID: 37734345 PMCID: PMC10872778 DOI: 10.14309/ajg.0000000000002515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 09/05/2023] [Indexed: 09/23/2023]
Abstract
INTRODUCTION Anorectal function testing is traditionally relegated to subspecialty centers. Yet, it is an office-based procedure that appears capable of triaging care for the many patients with Rome IV functional constipation that fail empiric over-the-counter therapy in general gastroenterology, as an alternative to empirical prescription drugs. We aimed to evaluate cost-effectiveness of routine anorectal function testing in this specific population. METHODS We performed a cost-effectiveness analysis from the patient perspective and a cost-minimization analysis from the insurer perspective to compare 3 strategies: (i) empiric prescription drugs followed by pelvic floor physical therapy (PFPT) for drug failure, (ii) empiric PFPT followed by prescription drugs for PFPT failure, or (iii) care directed by up-front anorectal function testing. Model inputs were derived from systematic reviews of prospective clinical trials, national cost data sets, and observational cohort studies of the impact of chronic constipation on health outcomes, healthcare costs, and work productivity. RESULTS The most cost-effective strategy was upfront anorectal function testing to triage patients to appropriate therapy, in which the subset of patients without anal hypocontractility on anorectal manometry and with a balloon expulsion time of at least 6.5 seconds would be referred to PFPT. In sensitivity analysis, empiric PFPT was more cost effective than empiric prescription drugs except for situations in which the primary goal of treatment was to increase bowel movement frequency. If adopted, gastroenterologists would refer ∼17 patients per year to PFPT, supporting feasibility. DISCUSSION Anorectal function testing seems to be an emergent technology to optimize cost-effective outcomes, overcoming testing costs by phenotyping care.
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Affiliation(s)
| | - Nitin K. Ahuja
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, PA, USA
| | - Darren M. Brenner
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - Walter W. Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston, MA, USA
| | - Michael A. Curley
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Judy Nee
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Kyle Staller
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, MI, USA
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Shah ED. Concise Commentary: Red Mucosa Is Not Enough-Another Approach to Treating Dyspeptic Symptoms. Dig Dis Sci 2024; 69:320-321. [PMID: 38091177 PMCID: PMC10923084 DOI: 10.1007/s10620-023-08171-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/25/2023] [Indexed: 02/02/2024]
Affiliation(s)
- Eric D Shah
- Division of Gastroenterology and Hepatology, University of Michigan, 1500 E Medical Center Drive, 3912 Taubman Center SPC 5362, Ann Arbor, MI, 48109, USA.
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Schrum CJ, Dickinson MM, Shah ED, Speicher MR, Strohbehn K. Utilization of Rectal Examinations Before Magnetic Resonance Defecography Studies. Urogynecology (Phila) 2024; 30:153-160. [PMID: 37737745 DOI: 10.1097/spv.0000000000001404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
IMPORTANCE More information is needed to guide referring subspecialists on the appropriate patient evaluation before magnetic resonance defecography (MRD). OBJECTIVES This study aimed to evaluate how often health care providers perform digital rectal examination (DRE) before ordering MRD to investigate causes of bowel and pelvic floor complaints. STUDY DESIGN We conducted a retrospective cohort review, including MRD performed on female patients at an integrated health care system from 2016 through 2020. The primary outcome was the presence or absence of documented rectal examination in the year before defecography by the referring provider or 6 months prior by a primary care physician or pelvic floor physical therapist. We hypothesized that the overall rate of rectal examination would be high and unaffected by the referring provider's subspecialty. RESULTS Three hundred-four defecography tests were performed, with 209 patients (68.8%) referred by gastroenterology providers and 95 (31.2%) from other specialties. Gastroenterologists performed DRE in 32.8% of patients, in contrast to 84.4% of patients referred by other specialties ( P < 0.001). When comparing subspecialties that most commonly refer patients for MRD (gastroenterology, colorectal surgery and urogynecology), there was a statistically significant difference between gastroenterologists and colorectal surgeons ( P < 0.001) as well as urogynecologists ( P < 0.001) but no difference in the rate of rectal examination between colorectal surgeons and urogynecologists ( P = 1.00). CONCLUSIONS At our single integrated health system, the rate of DRE before MRD testing varied significantly by specialty. Our findings highlight the need for better understanding of DRE utility in the algorithms for evaluation of bowel and pelvic floor disorders.
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Affiliation(s)
- Colby J Schrum
- From the Department of Obstetrics and Gynecology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | | | - Eric D Shah
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Mark R Speicher
- American Association of Colleges of Osteopathic Medicine, Bethesda, MD
| | - Kris Strohbehn
- From the Department of Obstetrics and Gynecology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Shah ED, Law R. Valuing innovative endoscopic techniques: Hemostatic powder for the treatment of gastrointestinal tumor bleeding. Gastrointest Endosc 2024:S0016-5107(24)00007-5. [PMID: 38184119 DOI: 10.1016/j.gie.2023.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/18/2023] [Accepted: 12/25/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND AND AIMS Access to new endoscopic treatment modalities often depends on price. To resolve this gap and therefore help to ensure that care delivery can occur on a clinical basis, we aimed to establish the value to insurers of novel hemostatic powder to treat gastrointestinal tumor bleeding. METHODS A decision-analytic model developed to assess the impact of endoscopic intervention on the risk of 30-day readmission for gastrointestinal bleeding from an insurer perspective, was adapted to assess gastrointestinal tumor bleeding with hemostatic powder or standard endoscopic therapy. Costs were derived from Medicare populations. Outcomes were derived from a recent multicenter randomized clinical trial. RESULTS $651 to $1,613 to treat upper gastrointestinal tumor bleeding and $531 to $1,014 to treat lower gastrointestinal tumor bleeding based on risk reduction in 30-day hospital re-admission for re-bleeding. These valuations should represent medical device and incremental facility costs in addition to incremental physician and staff time. CONCLUSIONS Coverage for novel endoscopic hemostatic powder therapy appears cost-saving to insurers.
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Affiliation(s)
- Eric D Shah
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Ryan Law
- Division of Gastroenterology, Mayo Clinic, Rochester, MN
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7
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Shah ED, Yadlapati R, Chan WW. Optimizing the Management Algorithm for Esophageal Dysphagia After Index Endoscopy: Cost-Effectiveness and Cost-Minimization Analysis. Am J Gastroenterol 2024; 119:97-106. [PMID: 37883488 PMCID: PMC10841887 DOI: 10.14309/ajg.0000000000002521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/22/2023] [Indexed: 10/28/2023]
Abstract
INTRODUCTION Guidelines advise esophageal motility testing for dysphagia when structural disorders are ruled out, but cost concerns impede adoption. We evaluated cost-effective positioning of esophageal motility testing in the algorithm to evaluate esophageal dysphagia. METHODS We developed a decision analytic model comparing 3 strategies: (i) esophageal manometry, (ii) screening impedance planimetry followed by esophageal manometry if needed, or (iii) nonalgorithmic usual care. Diagnostic test accuracy was adapted to expected rates of esophageal motility disorders in general gastroenterology populations. We modeled routine testing for all patients with nonstructural/mechanical dysphagia compared with selective testing with strong suspicion for achalasia. Cost outcomes were defined on national commercial and Medicare datasets stratified on age and sex. Health outcomes were modeled on populations with achalasia. The time horizon was 1 year. RESULTS Motility testing was preferred over nonalgorithmic usual care due to cost savings rather than health gains. To commercial insurers, routine esophageal manometry for nonstructural/mechanical dysphagia would be cost-saving below a reimbursed cost of $2,415. Screening impedance planimetry would be cost saving below a reimbursed cost of $1,130. The limit for reimbursed costs would be lower for patients older than 65 years to achieve cost savings mainly due to insurance. Sex did not significantly influence cost-effectiveness. Patients and insurers preferred routine screening impedance planimetry before manometry when the index of suspicion for achalasia was below 6%. DISCUSSION Aligning with practice guidelines, routine esophageal motility testing seems cost saving to patients and insurers compared with nonalgorithmic usual care to evaluate nonstructural/mechanical dysphagia. Choice of testing should be guided by index of suspicion.
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Srinivasan V, Shah ED. Mini-review: Tailored per-oral endoscopic myotomy for type III achalasia. Neurogastroenterol Motil 2023; 35:e14700. [PMID: 37897117 PMCID: PMC10851349 DOI: 10.1111/nmo.14700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/09/2023] [Accepted: 10/13/2023] [Indexed: 10/29/2023]
Abstract
This mini-review summarizes the most recent literature regarding per-oral endoscopic myotomy for type III achalasia, emphasizing the poorly understood science of tailoring myotomy length during this procedure. In addition, special attention will be placed on the current subjective and objective biomarkers, such as the Eckardt score, used to evaluate treatment outcomes in this population to better contextualize the existing data on patient outcomes, as proposed by Low et al in the current issue of the Journal. Understanding the current treatment landscape for type III achalasia and identifying the key areas of research deficiencies will guide future investigation and management of this disease.
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Affiliation(s)
- Vamshek Srinivasan
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Eric D Shah
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
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Shah ED. Commentary on "The Impact of Vertical Integration on Physician Behavior and Healthcare Delivery: Evidence from Gastroenterology Practices". Manage Sci 2023; 69:7180-7181. [PMID: 38223784 PMCID: PMC10786344 DOI: 10.1287/mnsc.2023.01831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
This paper was accepted by Stefan Scholtes, healthcare management. Conflict of Interest Statement: E. D. Shah has consulted or served on advisory boards for Ardelyx, GI Supply, Mahana, Mylan, Neuraxis, Salix, Sanofi, and Takeda. Funding: E. D. Shah is funded by the National Institute of Diabetes and Digestive and Kidney Diseases [Grant NIH 1K23DK134752].
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Affiliation(s)
- Eric D Shah
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan 48109
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Shah ED, Wechsler EV. Reply. Clin Gastroenterol Hepatol 2023:S1542-3565(23)00915-1. [PMID: 37949333 DOI: 10.1016/j.cgh.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/02/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Eric D Shah
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Emily V Wechsler
- Department of Internal Medicine, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
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Wechsler EV, Shah ED. Reply. Clin Gastroenterol Hepatol 2023; 21:3195-3196. [PMID: 37001711 DOI: 10.1016/j.cgh.2023.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 03/16/2023] [Indexed: 04/27/2023]
Affiliation(s)
- Emily V Wechsler
- Geisel School of Medicine, Hanover, New Hampshire, Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire
| | - Eric D Shah
- Geisel School of Medicine, Hanover, New Hampshire, Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire
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Mehta N, Slatkin NE, Israel RJ, Stambler N, Shah ED. Impact of Patient Subgroups on the Efficacy and Safety of Methylnaltrexone for Opioid-Induced Constipation in Patients with Advanced Illness. J Pain Res 2023; 16:3529-3543. [PMID: 37881233 PMCID: PMC10595216 DOI: 10.2147/jpr.s416307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 09/25/2023] [Indexed: 10/27/2023] Open
Abstract
Purpose We evaluated the impact of baseline patient characteristics on safety and efficacy of methylnaltrexone, a peripherally acting µ-opioid receptor antagonist, in patients with advanced illness with opioid-induced constipation (OIC). Patients and Methods This analysis pooled data from 2 randomized, double-blind, placebo-controlled studies (study 302: NCT00402038; study 4000: NCT00672477) in patients with advanced illness, including cancer, and OIC. Patients were randomized to receive subcutaneous methylnaltrexone (study 302: 0.15 mg/kg; study 4000: 8 or 12 mg based on weight) or placebo every other day for 2 weeks. The proportions of patients achieving rescue-free laxation within 4 or 24 hours after the first dose of study drug were assessed in patient subgroups stratified by baseline age, Eastern Cooperative Oncology Group (ECOG) performance status, cancer status, laxative type, and opioid requirement. Treatment-emergent adverse events (TEAEs) were evaluated. Results Overall, 363 patients were included in this analysis (methylnaltrexone, 178; placebo, 185). Mean (SD) age was 66.3 (13.7) years and 48.5% were men overall. A significantly greater proportion of patients receiving methylnaltrexone versus placebo achieved rescue-free laxation within 4 hours (111/178 [62.4%] vs 31/185 [16.8%]; P<0.0001) and 24 hours (135/178 [75.8%] vs 81/185 [43.8%]; P<0.0001) of the first dose. These trends were consistent across all subgroups. Most patients experienced ≥1 TEAE in the overall population (methylnaltrexone, 82.1%; placebo, 76.2%), which remained consistent when stratified by baseline characteristics. More than half of TEAEs were gastrointestinal in nature. Abdominal pain was more common in patients receiving methylnaltrexone than placebo across baseline characteristic subgroups. Conclusion Methylnaltrexone treatment was superior to placebo in achieving rescue-free laxation within 4 and 24 hours after the first dose, irrespective of patients' cancer status, baseline ECOG performance status, or baseline opioid or laxative use. The methylnaltrexone safety profile remained consistent across baseline characteristic subgroups.
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Affiliation(s)
- Neel Mehta
- Department of Anesthesiology, Weill Cornell School of Medicine, New York, NY, USA
| | - Neal E Slatkin
- School of Medicine, University of California Riverside, Riverside, CA, USA
- Medical Affairs, Salix Pharmaceuticals, Bridgewater, NJ, USA
| | - Robert J Israel
- Clinical and Medical Affairs, Bausch Health US LLC, Bridgewater, NJ, USA
| | - Nancy Stambler
- Clinical Research, Progenics Pharmaceuticals, a Subsidiary of Lantheus Holdings Inc, North Billerica, MA, USA
| | - Eric D Shah
- Division of Gastroenterology and Hepatology, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
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Rao SSC, Ahuja NK, Bharucha AE, Brenner DM, Chey WD, Deutsch JK, Kunkel DC, Moshiree B, Neshatian L, Reveille RM, Sayuk GS, Shapiro JM, Shah ED, Staller K, Wexner SD, Baker JR. Optimizing the Utility of Anorectal Manometry for Diagnosis and Therapy: A Roundtable Review and Recommendations. Clin Gastroenterol Hepatol 2023; 21:2727-2739.e1. [PMID: 37302444 PMCID: PMC10542660 DOI: 10.1016/j.cgh.2023.05.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 04/13/2023] [Accepted: 05/25/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND & AIMS Anorectal manometry (ARM) is a comprehensive diagnostic tool for evaluating patients with constipation, fecal incontinence, or anorectal pain; however, it is not widely utilized for reasons that remain unclear. The aim of this roundtable discussion was to critically examine the current clinical practices of ARM and biofeedback therapy by physicians and surgeons in both academic and community settings. METHODS Leaders in medical and surgical gastroenterology and physical therapy with interest in anorectal disorders were surveyed regarding practice patterns and utilization of these technologies. Subsequently, a roundtable was held to discuss survey results, explore current diagnostic and therapeutic challenges with these technologies, review the literature, and generate consensus-based recommendations. RESULTS ARM identifies key pathophysiological abnormalities such as dyssynergic defecation, anal sphincter weakness, or rectal sensory dysfunction, and is a critical component of biofeedback therapy, an evidence-based treatment for patients with dyssynergic defecation and fecal incontinence. Additionally, ARM has the potential to enhance health-related quality of life and reduce healthcare costs. However, it has significant barriers that include a lack of education and training of healthcare providers regarding the utility and availability of ARM and biofeedback procedures, as well as challenges with condition-specific testing protocols and interpretation. Additional barriers include understanding when to perform, where to refer, and how to use these technologies, and confusion over billing practices. CONCLUSIONS Overcoming these challenges with appropriate education, training, collaborative research, and evidence-based guidelines for ARM testing and biofeedback therapy could significantly enhance patient care of anorectal disorders.
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Affiliation(s)
- Satish S C Rao
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Georgia, Augusta University, Augusta, Georgia.
| | - Nitin K Ahuja
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Darren M Brenner
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - William D Chey
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Jill K Deutsch
- Section of Digestive Diseases, Department of Internal Medicine, Yale New Haven Hospital, Yale School of Medicine, New Haven, Connecticut
| | - David C Kunkel
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Baharak Moshiree
- Division of Gastroenterology and Hepatology, Atrium Health, Wake Forest Medical University, Charlotte, North Carolina
| | - Leila Neshatian
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, California
| | - Robert M Reveille
- Division of Gastroenterology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Gregory S Sayuk
- Division of Gastroenterology, Washington University School of Medicine, Veterans Affairs Medical Center, St. Louis, Missouri
| | | | - Eric D Shah
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Kyle Staller
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida
| | - Jason R Baker
- Department of Gastroenterology and Hepatology, Atrium Health, University of North Carolina, Charlotte, North Carolina
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Shah ED, Curley MA, Ostler TL, Martinez-Camblor P, Chey WD. Clinical History Does Not Reliably Predict Clinical Outcomes With Pelvic Floor Physical Therapy to Treat Chronic Constipation. Clin Gastroenterol Hepatol 2023; 21:2960-2964.e1. [PMID: 36257509 DOI: 10.1016/j.cgh.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/15/2022] [Accepted: 10/03/2022] [Indexed: 02/07/2023]
Abstract
Chronic constipation affects 10%-20% of the population and impacts quality-of-life similarly to rheumatoid arthritis or congestive heart failure.1 We recently showed in a prospective clinical trial that up-front, community-based pelvic floor physical therapy is effective to treat chronic constipation for patients seeking general gastroenterology care after failing a brief trial of osmotic laxative or soluble fiber supplementation2 and can be guided by anorectal function testing.3,4 In this post hoc analysis, we aimed to evaluate whether factors on clinical history including specific symptoms, work-productivity impairment, health-related quality-of-life impairment, and psychological factors are useful to inform patient selection on the expected likelihood of clinical response without using anorectal function tests.
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Affiliation(s)
- Eric D Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
| | - Michael A Curley
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Tracy L Ostler
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Pablo Martinez-Camblor
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - William D Chey
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan
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15
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Wechsler EV, Shah ED. Reply. Clin Gastroenterol Hepatol 2023; 21:2985-2986. [PMID: 36914144 DOI: 10.1016/j.cgh.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 03/01/2023] [Indexed: 03/16/2023]
Affiliation(s)
- Emily V Wechsler
- Geisel School of Medicine, Hanover, New Hampshire; Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire
| | - Eric D Shah
- Geisel School of Medicine, Hanover, New Hampshire; Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire
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16
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Wechsler EV, Chan W, Shah ED. Reply. Clin Gastroenterol Hepatol 2023; 21:2987-2988. [PMID: 36967103 DOI: 10.1016/j.cgh.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 03/09/2023] [Indexed: 04/26/2023]
Affiliation(s)
- Emily V Wechsler
- Geisel School of Medicine, Hanover, New Hampshire; Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire
| | - Walter Chan
- Division of Gastroenterology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Eric D Shah
- Geisel School of Medicine, Hanover, New Hampshire; Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire
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17
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Shah ED, Chan WW, Jodorkovsky D, Lee Lynch K, Patel A, Patel D, Yadlapati R. Optimizing the Management Algorithm for Heartburn in General Gastroenterology: Cost-Effectiveness and Cost-Minimization Analysis. Clin Gastroenterol Hepatol 2023:S1542-3565(23)00676-6. [PMID: 37683879 PMCID: PMC10918040 DOI: 10.1016/j.cgh.2023.08.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 08/08/2023] [Accepted: 08/16/2023] [Indexed: 09/10/2023]
Abstract
BACKGROUND AND AIMS Heartburn is the most common symptom seen in gastroenterology practice. We aimed to optimize cost-effective evaluation and management of heartburn. METHODS We developed a decision analytic model from insurer and patient perspectives comparing 4 strategies for patients failing empiric proton pump inhibitors (PPIs): (1) PPI optimization without testing, (2) endoscopy with PPI optimization for all patients, (3) endoscopy with PPI discontinuation when erosive findings are absent, and (4) endoscopy/ambulatory reflux monitoring with PPI discontinuation as appropriate for phenotypic management. Health outcomes were respectively defined on systematic reviews of clinical trials. Cost outcomes were defined on Centers for Medicare and Medicaid Services databases and commercial multipliers for direct healthcare costs, and national observational studies evaluating healthcare utilization. The time horizon was 1 year. All testing was performed off PPI. RESULTS PPI optimization without testing cost $3784/y to insurers and $3128 to patients due to lower work productivity and suboptimal symptom relief. Endoscopy with PPI optimization lowered insurer costs by $1020/y and added 11 healthy days/y by identifying erosive reflux disease. Endoscopy with PPI discontinuation added 11 additional healthy days/y by identifying patients without erosive reflux disease that did not need PPI. By optimizing phenotype-guided treatment, endoscopy/ambulatory reflux monitoring with a trial of PPI discontinuation was the most effective of all strategies (gaining 22 healthy days/y) and saved $2183 to insurers and $2396 to patients. CONCLUSIONS Among patients with heartburn, endoscopy with ambulatory reflux monitoring (off PPI) optimizes cost-effective management by matching treatment to phenotype. When erosive findings are absent, trialing PPI discontinuation is more cost-effective than optimizing PPI.
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Affiliation(s)
- Eric D Shah
- Division of Gastroenterology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan.
| | - Walter W Chan
- Division of Gastroenterology, Department of Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Daniela Jodorkovsky
- Division of Gastroenterology, Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kristle Lee Lynch
- Division of Gastroenterology, Department of Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amit Patel
- Division of Gastroenterology, Department of Internal Medicine, Duke University School of Medicine and Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Dhyanesh Patel
- Division of Gastroenterology, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rena Yadlapati
- Division of Gastroenterology, Department of Internal Medicine, University of California San Diego, San Diego, California
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18
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Shah ED. Concise Commentary: Welcome to Club MED-How the Proposed Diagnostic Entity "Mixed Esophageal Disease" Can Resolve Diagnosis Overload. Dig Dis Sci 2023; 68:3555-3556. [PMID: 37490151 PMCID: PMC10583819 DOI: 10.1007/s10620-023-08041-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2023] [Indexed: 07/26/2023]
Affiliation(s)
- Eric D Shah
- Division of Gastroenterology and Hepatology, University of Michigan, 1500 E Medical Center Drive, 3912 Taubman Center SPC 5362, Ann Arbor, MI, 48105, USA.
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Muratore A, Shah ED, Chan WW. Cost-Benefit Analysis of Hydrogen Breath Test-Directed Rifaximin for Treatment of Diarrhea-Predominant Irritable Bowel Syndrome. Clin Gastroenterol Hepatol 2023; 21:2695-2696.e1. [PMID: 36152896 DOI: 10.1016/j.cgh.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 09/02/2022] [Accepted: 09/12/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Alicia Muratore
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Business School, Boston, Massachusetts
| | - Eric D Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Health, Lebanon, New Hampshire
| | - Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
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Wechsler EV, Martinez-Camblor P, Curley MA, Shah ED. Chronic Pain and Mood Disorders Are Not Barriers to Symptom Improvement Under Collaborative Co-managed Care (C 3). Dig Dis Sci 2023; 68:3569-3572. [PMID: 37540390 DOI: 10.1007/s10620-023-08055-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 07/21/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVES Patients with comorbid chronic pain and mood disorders have more severe gastrointestinal disease and higher healthcare expenses than their peers. We sought to determine whether management under our innovative Collaborative Co-Managed Care (C3) general gastroenterology care model improved outcomes. METHODS Patient questionnaires completed by outpatients at our GI Motility Center were analyzed alongside demographic information to determine predictors of response to treatment based on adequate relief of gastrointestinal symptoms and improvement in quality of life. RESULTS These comorbidities did not significantly impair response and may be associated with improved response under our model. CONCLUSIONS The C3 general gastroenterology care model anchors on setting expectations and team-based communication and improves outcomes of, and access to, care.
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Affiliation(s)
- Emily V Wechsler
- Geisel School of Medicine, Hanover, NH, USA
- Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, NH, USA
| | | | - Michael A Curley
- Geisel School of Medicine, Hanover, NH, USA
- Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, NH, USA
| | - Eric D Shah
- Geisel School of Medicine, Hanover, NH, USA.
- Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, NH, USA.
- University of Michigan, 1500 E Medical Center Drive, 3912 Taubman Center SPC 5362, Ann Arbor, MI, 48109, USA.
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21
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Shah ED, Curley MA, Ostler TL, Greeley ARB, Martinez-Camblor P, Chey WD. Empiric Pelvic Rehabilitation Delivered by Pelvic Floor Physical Therapists as an Up-Front Treatment for Chronic Constipation. Clin Gastroenterol Hepatol 2023; 21:2415-2417. [PMID: 35934289 DOI: 10.1016/j.cgh.2022.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 06/30/2022] [Accepted: 07/15/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Eric D Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
| | - Michael A Curley
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Tracy L Ostler
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Pablo Martinez-Camblor
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - William D Chey
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan
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22
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Wechsler EV, Ahuja NK, Brenner D, Chan W, Chang L, Chey WD, Lembo AJ, Moshiree B, Nee J, Shah SC, Staller K, Shah ED. Up-Front Endoscopy Maximizes Cost-Effectiveness and Cost-Satisfaction in Uninvestigated Dyspepsia. Clin Gastroenterol Hepatol 2023; 21:2378-2388.e28. [PMID: 36646234 PMCID: PMC10542651 DOI: 10.1016/j.cgh.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 12/01/2022] [Accepted: 01/05/2023] [Indexed: 01/18/2023]
Abstract
BACKGROUND & AIMS Practice guidelines promote a routine noninvasive, non-endoscopic initial approach to investigating dyspepsia without alarm features in young patients, yet many patients undergo prompt upper endoscopy. We aimed to assess tradeoffs among costs, patient satisfaction, and clinical outcomes to inform discrepancy between guidelines and practice. METHODS We constructed a decision-analytic model and performed cost-effectiveness/cost-satisfaction analysis over a 1-year time horizon on patients with uninvestigated dyspepsia without alarm features referred to gastroenterology. A RAND/UCLA expert panel informed model design. Four competing diagnostic/management strategies were evaluated: prompt endoscopy, testing for Helicobacter pylori and eradicating if present (test-and-treat), testing for H pylori and performing endoscopy if present (test-and-scope), and empiric acid suppression. Outcomes were derived from systematic reviews of clinical trials. Costs were informed by prospective observational cohort studies and national commercial/federal cost databases. Health gains were represented using quality-adjusted life years. RESULTS From the patient perspective, costs and outcomes were similar for all strategies (maximum out-of-pocket difference of $30 and <0.01 quality-adjusted life years gained/year regardless of strategy). Prompt endoscopy maximized cost-satisfaction and health system reimbursement. Test-and-scope maximized cost-effectiveness from insurer and patient perspectives. Results remained robust on multiple one-way sensitivity analyses on model inputs and across most willingness-to-pay thresholds. CONCLUSIONS Noninvasive management strategies appear to result in inferior cost-effectiveness and patient satisfaction outcomes compared with strategies promoting up-front endoscopy. Therefore, additional studies are needed to evaluate the drivers of patient satisfaction to facilitate inclusion in value-based healthcare transformation efforts.
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Affiliation(s)
- Emily V Wechsler
- Geisel School of Medicine, Hanover, New Hampshire; Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire
| | - Nitin K Ahuja
- Division of Gastroenterology, Penn Medicine, Philadelphia, Pennsylvania
| | - Darren Brenner
- Division of Gastroenterology, Northwestern Medicine, Chicago, Illinois
| | - Walter Chan
- Division of Gastroenterology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lin Chang
- Division of Gastroenterology, University of California Los Angeles, Los Angeles, California
| | - William D Chey
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan
| | - Anthony J Lembo
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Baha Moshiree
- Division of Gastroenterology, Atrium Health, Charlotte, North Carolina
| | - Judy Nee
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Shailja C Shah
- Division of Gastroenterology, University of California San Diego, San Diego, California
| | - Kyle Staller
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Eric D Shah
- Geisel School of Medicine, Hanover, New Hampshire; Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire; Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan.
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23
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Affiliation(s)
- Eric D Shah
- Dartmouth-Hitchcock Health, Lebanon, New Hampshire, USA
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24
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Chang L, Chey WD, Imdad A, Almario CV, Bharucha AE, Diem S, Greer KB, Hanson B, Harris LA, Ko C, Murad MH, Patel A, Shah ED, Lembo AJ, Sultan S. American Gastroenterological Association-American College of Gastroenterology Clinical Practice Guideline: Pharmacological Management of Chronic Idiopathic Constipation. Am J Gastroenterol 2023; 118:936-954. [PMID: 37204227 PMCID: PMC10544839 DOI: 10.14309/ajg.0000000000002227] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/27/2023] [Indexed: 05/20/2023]
Abstract
INTRODUCTION Chronic idiopathic constipation (CIC) is a common disorder associated with significant impairment in quality of life. This clinical practice guideline, jointly developed by the American Gastroenterological Association and the American College of Gastroenterology, aims to inform clinicians and patients by providing evidence-based practice recommendations for the pharmacological treatment of CIC in adults. METHODS The American Gastroenterological Association and the American College of Gastroenterology formed a multidisciplinary guideline panel that conducted systematic reviews of the following agents: fiber, osmotic laxatives (polyethylene glycol, magnesium oxide, lactulose), stimulant laxatives (bisacodyl, sodium picosulfate, senna), secretagogues (lubiprostone, linaclotide, plecanatide), and serotonin type 4 agonist (prucalopride). The panel prioritized clinical questions and outcomes and used the Grading of Recommendations Assessment, Development, and Evaluation framework to assess the certainty of evidence for each intervention. The Evidence to Decision framework was used to develop clinical recommendations based on the balance between the desirable and undesirable effects, patient values, costs, and health equity considerations. RESULTS The panel agreed on 10 recommendations for the pharmacological management of CIC in adults. Based on available evidence, the panel made strong recommendations for the use of polyethylene glycol, sodium picosulfate, linaclotide, plecanatide, and prucalopride for CIC in adults. Conditional recommendations were made for the use of fiber, lactulose, senna, magnesium oxide, and lubiprostone. DISCUSSION This document provides a comprehensive outline of the various over-the-counter and prescription pharmacological agents available for the treatment of CIC. The guidelines are meant to provide a framework for approaching the management of CIC; clinical providers should engage in shared decision making based on patient preferences as well as medication cost and availability. Limitations and gaps in the evidence are highlighted to help guide future research opportunities and enhance the care of patients with chronic constipation.
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Affiliation(s)
- Lin Chang
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - William D. Chey
- Division of Gastroenterology & Hepatology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Aamer Imdad
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Christopher V. Almario
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Adil E. Bharucha
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Susan Diem
- Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA
- University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Katarina B. Greer
- Cleveland VA Healthcare System, Cleveland, Ohio, USA
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Brian Hanson
- Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Lucinda A. Harris
- Division of Gastroenterology & Hepatology, Mayo Clinic, Phoenix, Arizona, USA
| | - Cynthia Ko
- Division of Gastroenterology & Hepatology, University of Washington, Washington, DC, USA
| | | | - Amit Patel
- Division of Gastroenterology, Duke University School of Medicine and the Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Eric D. Shah
- Division of Gastroenterology & Hepatology, Michigan Medicine, Ann Arbor, Michigan, USA
- Division of Gastroenterology & Hepatology, Department of Medicine, DartMouth Health, Lebanon, New Hampshire, USA
| | - Anthony J. Lembo
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Disease and Surgery Institute; Cleveland Clinic, Cleveland, Ohio, USA
| | - Shahnaz Sultan
- Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA
- University of Minnesota, Minneapolis, Minnesota, USA
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25
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Chang L, Chey WD, Imdad A, Almario CV, Bharucha AE, Diem S, Greer KB, Hanson B, Harris LA, Ko C, Murad MH, Patel A, Shah ED, Lembo AJ, Sultan S. American Gastroenterological Association-American College of Gastroenterology Clinical Practice Guideline: Pharmacological Management of Chronic Idiopathic Constipation. Gastroenterology 2023; 164:1086-1106. [PMID: 37211380 PMCID: PMC10542656 DOI: 10.1053/j.gastro.2023.03.214] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/27/2023] [Indexed: 05/23/2023]
Abstract
INTRODUCTION Chronic idiopathic constipation (CIC) is a common disorder associated with significant impairment in quality of life. This clinical practice guideline, jointly developed by the American Gastroenterological Association and the American College of Gastroenterology, aims to inform clinicians and patients by providing evidence-based practice recommendations for the pharmacological treatment of CIC in adults. METHODS The American Gastroenterological Association and the American College of Gastroenterology formed a multidisciplinary guideline panel that conducted systematic reviews of the following agents: fiber, osmotic laxatives (polyethylene glycol, magnesium oxide, lactulose), stimulant laxatives (bisacodyl, sodium picosulfate, senna), secretagogues (lubiprostone, linaclotide, plecanatide), and serotonin type 4 agonist (prucalopride). The panel prioritized clinical questions and outcomes and used the Grading of Recommendations Assessment, Development, and Evaluation framework to assess the certainty of evidence for each intervention. The Evidence to Decision framework was used to develop clinical recommendations based on the balance between the desirable and undesirable effects, patient values, costs, and health equity considerations. RESULTS The panel agreed on 10 recommendations for the pharmacological management of CIC in adults. Based on available evidence, the panel made strong recommendations for the use of polyethylene glycol, sodium picosulfate, linaclotide, plecanatide, and prucalopride for CIC in adults. Conditional recommendations were made for the use of fiber, lactulose, senna, magnesium oxide, and lubiprostone. DISCUSSION This document provides a comprehensive outline of the various over-the-counter and prescription pharmacological agents available for the treatment of CIC. The guidelines are meant to provide a framework for approaching the management of CIC; clinical providers should engage in shared decision making based on patient preferences as well as medication cost and availability. Limitations and gaps in the evidence are highlighted to help guide future research opportunities and enhance the care of patients with chronic constipation.
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Affiliation(s)
- Lin Chang
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California.
| | - William D Chey
- Division of Gastroenterology & Hepatology, Michigan Medicine, Ann Arbor, Michigan
| | - Aamer Imdad
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, SUNY Upstate Medical University, Syracuse, New York
| | - Christopher V Almario
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Susan Diem
- Minneapolis VA Healthcare System, Minneapolis, Minnesota; University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - Katarina B Greer
- Cleveland VA Healthcare System, Cleveland, Ohio; Case Western Reserve University, Cleveland, Ohio
| | - Brian Hanson
- Minneapolis VA Healthcare System, Minneapolis, Minnesota; Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Lucinda A Harris
- Division of Gastroenterology & Hepatology, Mayo Clinic, Phoenix, Arizona
| | - Cynthia Ko
- Division of Gastroenterology & Hepatology, University of Washington, Washington, DC
| | | | - Amit Patel
- Division of Gastroenterology, Duke University School of Medicine and the Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Eric D Shah
- Division of Gastroenterology & Hepatology, Michigan Medicine, Ann Arbor, Michigan; Division of Gastroenterology & Hepatology, Department of Medicine, DartMouth Health, Lebanon, New Hampshire
| | - Anthony J Lembo
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Disease and Surgery Institute; Cleveland Clinic, Cleveland, Ohio
| | - Shahnaz Sultan
- Minneapolis VA Healthcare System, Minneapolis, Minnesota; University of Minnesota, Minneapolis, Minnesota
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Busam JA, Shah ED. The Rise of Private Equity in Gastroenterology Practices. Gastroenterol Hepatol (N Y) 2023; 19:264-271. [PMID: 37799457 PMCID: PMC10548246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Private equity (PE) investment in gastroenterology practices has significantly increased over the past several years. Because PE firms are prevented legally from owning a medical practice in many states, they usually form a management services organization to oversee all nonclinical aspects of the practice, leaving all clinical functions to the physician owners. Gastroenterology practices have become attractive investments to PE firms because of the willingness of gastroenterologists to join a PE-backed practice and the potential to earn profits through consolidating the market. Research has started to examine the effects of PE-backed practices on patients and on the gastroenterology specialty specifically. Questions remain regarding the benefits for physicians. This article examines PE investment in gastroenterology practices and how this may impact the specialty in the future.
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Affiliation(s)
- Jonathan A. Busam
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Eric D. Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
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Shah ED, Pelletier EA, Greeley C, Sieglinger EE, Sanchez JD, Northam KA, Perrone JA, Curley MA, Navas CM, Ostler TL, Burnett Greeley AR, Martinez-Camblor P, Baker JR, Chey WD. Utility of Anorectal Testing to Predict Outcomes With Pelvic Floor Physical Therapy in Chronic Constipation: Pragmatic Trial. Clin Gastroenterol Hepatol 2023; 21:1070-1081. [PMID: 35640864 DOI: 10.1016/j.cgh.2022.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/30/2022] [Accepted: 05/05/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We performed a clinical trial that aimed to inform the clinical utility of anorectal manometry (ARM) and balloon expulsion time (BET) as up-front tests to predict outcomes with community-based pelvic floor physical therapy as the next best step to address chronic constipation after failing an empiric trial of soluble fiber supplementation or osmotic laxatives. METHODS We enrolled 60 treatment-naïve patients with Rome IV functional constipation failing 2 weeks of soluble fiber supplementation or osmotic laxatives. All patients underwent ARM/BET (London protocol) followed by community-based pelvic floor physical therapy. Outcomes were assessed at baseline and 12 weeks. The primary end point was clinical response (Patient Assessment of Constipation-Symptoms instrument). RESULTS Fifty-three patients completed pelvic rehabilitation and the post-treatment questionnaire. Contemporary frameworks define dyssynergia on balloon expulsion time and dyssynergic patterns (ARM), but these parameters did not inform clinical outcomes (area under the curve [AUC], <0.6). Squeeze pressure (>192.5 mm Hg on at least 1 of 3 attempts; sensitivity, 47.6%; specificity, 83.9%) and limited squeeze duration (inability to sustain 50% of squeeze pressure for >20 seconds; sensitivity, 71.4%; specificity, 58.1%) were the strongest predictors of clinical outcomes. Combining BET with squeeze duration (BET greater than 6.5 seconds and limited squeeze duration) improved predictive accuracy (AUC, 0.75; 95% CI, 0.59-0.90). BET poorly predicted outcomes as a single test (AUC, 0.54; 95% CI, 0.38-0.69). CONCLUSIONS Using ARM to evaluate squeeze profiles, rather than dyssynergia, appears useful to screen patients with chronic constipation for up-front pelvic floor physical therapy based on likelihood of response. BET appears noninformative as a single screening test (ClinicalTrials.gov: NCT04159350).
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Affiliation(s)
- Eric D Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
| | - Elizabeth A Pelletier
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Carol Greeley
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Emily E Sieglinger
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jamie D Sanchez
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Kayla A Northam
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jessica A Perrone
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Michael A Curley
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Christopher M Navas
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Tracy L Ostler
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Pablo Martinez-Camblor
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jason R Baker
- Division of Gastroenterology, Atrium Health, Charlotte, North Carolina
| | - William D Chey
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan
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Shah ED, Pelletier EA, Greeley C, Sieglinger EE, Sanchez JD, Northam KA, Perrone JA, Curley MA, Navas CM, Ostler TL, Burnett Greeley AR, Martinez-Camblor P, Baker JR, Harris A, Siegel CA, Chey WD. An Office-Based, Point-of-Care Test Predicts Treatment Outcomes With Community-Based Pelvic Floor Physical Therapy in Patients With Chronic Constipation. Clin Gastroenterol Hepatol 2023; 21:1082-1090. [PMID: 35341952 DOI: 10.1016/j.cgh.2022.03.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/02/2022] [Accepted: 03/12/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Rectal evacuation disorders are common among constipated patients. We aimed to evaluate the accuracy of an investigational point-of-care test (rectal expulsion device [RED]) to predict outcomes with community-based pelvic floor physical therapy. METHODS We enrolled patients meeting Rome IV criteria for functional constipation failing fiber/laxatives for more than 2 weeks. RED was inserted and self-inflated, and then time-to-expel was measured in a left lateral position. All patients underwent empiric community-based pelvic floor physical therapy in routine care with outcomes measured at 12 weeks. The primary end point was global clinical response (Patient Assessment of Constipation Symptoms score reduction, >0.75 vs baseline). Secondary end points included improvement in health-related quality-of-life (Patient Assessment of Constipation Quality of Life score reduction, >1.0) and complete spontaneous bowel movement frequency (Food and Drug Administration complete spontaneous bowel movement responder definition). RESULTS Thirty-nine patients enrolled in a feasibility phase to develop the use-case protocol. Sixty patients enrolled in a blinded validation phase; 52 patients (mean, 46.9 y; 94.2% women) were included in the intention-to-treat analysis. In the left lateral position, RED predicted global clinical response (generalized area under the curve [gAUC], 0.67; 95% CI, 0.58-0.76]), health-related quality-of-life response (gAUC, 0.67; 95% CI, 0.58-0.77; P < .001), and complete spontaneous bowel movement response (gAUC, 0.63; 95% CI, 0.57-0.71; P < .001). As a screening test, a normal RED effectively rules out evacuation disorders (expected clinical response, 8.9%; P = .042). Abnormal RED in the left lateral position (defined as expulsion within 5 seconds or >120 seconds) predicted 48.9% clinical response to physical therapy. A seated maneuver enhanced the likelihood of clinical response (71.1% response with seated RED retained >13 seconds) but likely is unnecessary in most settings. CONCLUSIONS RED offers an opportunity to disrupt the paradigm by offering a personalized approach to managing chronic constipation in the community (Clinicaltrials.gov: NCT04159350).
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Affiliation(s)
- Eric D Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
| | - Elizabeth A Pelletier
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Carol Greeley
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Emily E Sieglinger
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jamie D Sanchez
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Kayla A Northam
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jessica A Perrone
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Michael A Curley
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Christopher M Navas
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Tracy L Ostler
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Pablo Martinez-Camblor
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jason R Baker
- Division of Gastroenterology, Atrium Health, Charlotte, North Carolina
| | | | - Corey A Siegel
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - William D Chey
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan
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Shah ED. Concise Commentary: Testing the Reliability and Accuracy of the Fecobionics Device. Dig Dis Sci 2023; 68:2508-2509. [PMID: 36879179 DOI: 10.1007/s10620-023-07891-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2023] [Indexed: 03/08/2023]
Affiliation(s)
- Eric D Shah
- Division of Gastroenterology and Hepatology, Center for Gastrointestinal Motility, Esophageal, and Swallowing Disorders, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, 03766, USA.
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Chey WD, Baker JR, Watts L, Harris A, Shah ED. Development of a Simple, Point-of-Care Device to Test Anorectal Function in Patients with Constipation: Randomized Clinical Trial. Clin Gastroenterol Hepatol 2023; 21:832-834. [PMID: 34864156 PMCID: PMC9160215 DOI: 10.1016/j.cgh.2021.11.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/24/2021] [Accepted: 11/26/2021] [Indexed: 02/07/2023]
Abstract
Functional constipation (FC) is one of the most frequently encountered gastrointestinal conditions in practice.1 Practice guidelines universally recommend that patients with typical constipation symptoms and no alarm features be treated empirically with dietary/lifestyle interventions and laxative therapy.2,3 Unfortunately, by the time a patient reaches a gastroenterologist, these treatments frequently have already been tried. Anorectal function testing (anorectal manometry [ARM] and balloon expulsion test [BET]) is the next best step in management guidelines in this all-too-common scenario, because treatment can then be targeted toward pelvic floor dysfunction or colon transit abnormalities. Unfortunately, more than 95% of patients continue to take only over-the-counter laxatives and receive empirical dietary advice, whereas fewer than 2% undergo physiologic evaluation to ascertain the cause of their symptoms.4 Indeed, more than 90% of patients desire more effective treatment options. These observations call into question the wisdom of a management strategy that fails to recognize the intrinsic diversity of the constipation universe and reinforces the misguided "one size fits all" empirical treatment strategy.
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Affiliation(s)
- William D Chey
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan
| | - Jason R Baker
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan
| | - Lydia Watts
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan
| | | | - Eric D Shah
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan; Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
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Shah ED, Chamberlain BH, Rhiner M, Slatkin NE, Stambler N, Israel RJ. Subcutaneous Methylnaltrexone as Treatment for Opioid-Induced Constipation in Patients with Advanced Cancer and Noncancer Illnesses: A Post Hoc Analysis of Two Clinical Trials. J Pain Res 2023; 16:395-406. [PMID: 36798078 PMCID: PMC9926929 DOI: 10.2147/jpr.s366460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 01/22/2023] [Indexed: 02/11/2023] Open
Abstract
Purpose To evaluate the efficacy and safety of subcutaneous (SC) methylnaltrexone for opioid-induced constipation (OIC) in patients with and without active cancer. Patients and Methods We analyzed two randomized, double-blind, placebo-controlled, Phase 3/4 trials (NCT00402038, NCT00672477). Patients received SC methylnaltrexone (study 302, 0.15 mg/kg; study 4000, 8 mg or 12 mg based on body weight) or placebo every other day for 2 weeks. Patients were stratified by cancer status. Primary efficacy endpoints included proportion of patients achieving rescue-free laxation (RFL); secondary endpoints included time to RFL, pain intensity scores, and safety/tolerability. Trial results were evaluated separately. Results The safety population (patients receiving ≥1 study drug dose) included 364 patients (study 302, n=134; study 4000, n=230). Study 302 had 78 patients with active cancer (methylnaltrexone, n=37; placebo, n=41) and 56 without cancer (methylnaltrexone, n=26; placebo, n=30); study 4000 had 152 patients with active cancer (methylnaltrexone, n=79; placebo, n=73) and 78 without cancer (methylnaltrexone, n=37; placebo, n=41). A significantly greater proportion of patients treated with methylnaltrexone achieved a laxation response within 4 hours after at least 2 of the first 4 doses versus placebo, dosed by body weight (cancer, 54.1% [methylnaltrexone] vs 7.3% [placebo], P<0.0001; noncancer, 48.0% vs 10.0%; P<0.005) or given as a weight-adjusted fixed dose (cancer, 59.5% vs 6.8%; noncancer, 70.3% vs 14.6%; P<0.0001 each). With fixed-dose methylnaltrexone, average time to RFL for patients with and without cancer was <1 hour of the first dose; with methylnaltrexone dosed by body weight, the first RFL occurred in <4 and <7 hours of treatment in patients with and without cancer, respectively. No significant differences were found in pain scores. SC methylnaltrexone was well tolerated at all doses in all patient cohorts. Conclusion SC methylnaltrexone was efficacious in inducing rapid RFL and safe among patients with and without active cancer suffering from OIC.
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Affiliation(s)
- Eric D Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA,Correspondence: Eric D Shah, Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03766, USA, Tel +1 603-650-5261, Email
| | | | - Michelle Rhiner
- Department of Family Medicine, Loma Linda University Health, Loma Linda, CA, USA
| | - Neil E Slatkin
- School of Medicine, University of California Riverside, Riverside, CA, USA,Medical Affairs, Salix Pharmaceuticals, Bridgewater, NJ, USA
| | - Nancy Stambler
- Clinical Research, Progenics Pharmaceuticals, Inc., A Subsidiary of Lantheus Holdings, Inc, New York, NY, USA
| | - Robert J Israel
- Clinical and Medical Affairs, Bausch Health US, LLC, Bridgewater, NJ, USA
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Pathipati MP, Shah ED, Kuo B, Staller KD. Digital health for functional gastrointestinal disorders. Neurogastroenterol Motil 2023; 35:e14296. [PMID: 34796577 PMCID: PMC9117568 DOI: 10.1111/nmo.14296] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 10/27/2021] [Accepted: 11/01/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Functional gastrointestinal disorders are a common but challenging set of conditions to treat. Gastroenterology practices often struggle to meet the needs of patients with functional disorders given the need for careful monitoring, frequent communication, and management of stressors that occur outside of the clinical setting. In recent years, applications in digital health have created a new set of tools that can improve the care of these patients, including through improved symptom tracking, physiologic monitoring, direct provision of care, and patient support. PURPOSE The purpose of this review is to evaluate how digital applications are being used to manage functional gastrointestinal disorders today, with several examples of relevant technologies and organizations. It also the shortcomings of current treatment strategies and how they can be overcome.
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Affiliation(s)
- Mythili P. Pathipati
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Eric D. Shah
- Division of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Braden Kuo
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Kyle D. Staller
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Busam JA, Shah ED. Editorial: what is needed to achieve success in developing diagnostic technologies for patients with gastrointestinal motility disorders - past and present. Aliment Pharmacol Ther 2022; 56:1615-1616. [PMID: 36352746 DOI: 10.1111/apt.17225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jonathan A Busam
- Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire, USA
| | - Eric D Shah
- Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire, USA
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Shah ED, Barry LA, Connolly ML, Del Giudice KA, Dillehay RT, Greeley C, McBride S, Northam KA, Pelletier EA, Perrone JA, Rothstein RI, Sanchez JD, Siegel CA, Sieglinger EE, Tetreault PN, Weiss JD, Wilson TLA, Curley MA. Collaborative Co-Managed Care (C 3): A Sustainable Gastrointestinal Motility Practice Model. Clin Gastroenterol Hepatol 2022; 20:1907-1911. [PMID: 35640865 DOI: 10.1016/j.cgh.2022.05.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Eric D Shah
- Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire.
| | - Lauren A Barry
- Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire
| | - Mariah L Connolly
- Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire
| | - Kathy A Del Giudice
- Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire
| | - Richard T Dillehay
- Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire
| | - Carol Greeley
- Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire
| | - Shari McBride
- Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire
| | - Kayla A Northam
- Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire
| | - Elizabeth A Pelletier
- Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire
| | - Jessica A Perrone
- Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire
| | - Richard I Rothstein
- Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire
| | - Jamie D Sanchez
- Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire
| | - Corey A Siegel
- Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire
| | - Emily E Sieglinger
- Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire
| | - Patrick N Tetreault
- Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire
| | - Joseph D Weiss
- Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire
| | - Tammy-Lynn A Wilson
- Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire
| | - Michael A Curley
- Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire
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Shah ED, Wechsler EV. Editorial: work and activity impairment are important considerations to optimise treatment plans for irritable bowel syndrome. Aliment Pharmacol Ther 2022; 56:892-893. [PMID: 35934848 DOI: 10.1111/apt.17143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Eric D Shah
- Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire, USA
| | - Emily V Wechsler
- Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire, USA
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Shah ED. Zinc Deficiency and Intestinal Permeability in the Context of Rational Diagnostic and Drug Development for Diarrhea-Predominant Irritable Bowel Syndrome. Dig Dis Sci 2022; 67:3477-3478. [PMID: 35018534 DOI: 10.1007/s10620-021-07369-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2021] [Indexed: 12/09/2022]
Affiliation(s)
- Eric D Shah
- Division of Gastroenterology and Hepatology, Center for Gastrointestinal Motility, Esophageal, and Swallowing Disorders, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, 03766, USA.
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Shah ED. Delta Variant: Expanding the Indication for Eluxadoline to Bile Acid Diarrhea. Dig Dis Sci 2022; 67:3481-3482. [PMID: 35122590 DOI: 10.1007/s10620-022-07386-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/03/2022] [Indexed: 12/09/2022]
Affiliation(s)
- Eric D Shah
- Center for Gastrointestinal Motility, Esophageal, and Swallowing Disorders, Division of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, 03766, USA.
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Shah ED, Amann ST, Hobley J, Islam S, Taunk R, Wilson L. 2021 National Survey on Prior Authorization Burden and Its Impact on Gastroenterology Practice. Am J Gastroenterol 2022; 117:802-805. [PMID: 35296630 PMCID: PMC9060934 DOI: 10.14309/ajg.0000000000001728] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 03/08/2022] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Prior authorizations (PAs) are intended to control prescription drug expenditures. METHODS One hundred fifty-six physician and advanced practice provider members of the American College of Gastroenterology completed a national survey to assess PA burden and impact. RESULTS One-half of PA requests relate to prescription refills. Greater than 50% of the respondents choose inferior treatments at least weekly because of perceived PA burden for preferred agents. One-half of the respondents reported a patient who experienced serious adverse events due to PA-related care delays. DISCUSSION PA is an administrative burden that exhausts practice resources and may have a negative impact on patient care.
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Affiliation(s)
- Eric D. Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Health, Lebanon, New Hampshire, USA
| | | | - James Hobley
- GastroIntestinal Specialists, Shreveport, Louisiana, USA
| | | | - Raja Taunk
- Anne Arundel Gastroenterology Associates, Annapolis, Maryland, USA
| | - Louis Wilson
- Wichita Falls Gastroenterology Associates, Wichita Falls, Texas, USA
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Shah ED, Brenner DM, Chen VL. Baseline Predictors of Discontinuation of Prescription Drug Therapy for IBS-C: Cohort Analysis at an Integrated Healthcare System. Dig Dis Sci 2022; 67:1213-1221. [PMID: 33779879 PMCID: PMC8478965 DOI: 10.1007/s10620-021-06963-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 03/16/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Effective prescription drug treatment of constipation-predominant irritable bowel syndrome (IBS-C) requires patients to remain on daily therapy, yet predictive factors to optimize treatment selection are unknown. AIMS We assessed whether common comorbidities including chronic overlapping pain conditions (COPCs), mood disorders, or concurrent medications influence the risk of discontinuing IBS-C prescription drug therapy. METHODS We included all IBS-C patients who initiated treatment with the secretagogues linaclotide or lubiprostone across the Michigan Medicine healthcare system between 2012 and 2016. A Cox proportional hazards model was constructed to model time-to-treatment discontinuation as a valid, quantifiable measure of IBS medication persistence using hazards ratios (HR) with 95% confidence intervals (CI). RESULTS Our cohort included 225 patients on linaclotide and 492 on lubiprostone (mean age 48.3 years, 86.9% women, 46.6% with at least one COPC, 60.3% with at least one mood disorder) with an average follow-up of 2.1 years. Patients with at least one COPC (HR = 0.566; 95%CI = 0.371-0.863) and also women (HR = 0.535; 95%CI = 0.307-0.934) had a lower risk of discontinuing linaclotide, while COPCs predicted a trend toward increased discontinuation of lubiprostone (HR = 1.254; 95%CI = 0.997-1.576). Age, comorbid mood disorders, and baseline use of narcotics or benzodiazepines did not significantly mediate the risk of treatment discontinuation; our findings remained stable in univariate and multivariable analyses. CONCLUSIONS COPCs and sex appear to influence the likelihood of discontinuation of two commonly prescribed secretagogues, while mood disorders, narcotics, and benzodiazepines may not. Routine assessment for comorbid COPCs prior to initiating therapy may optimize IBS-C treatment selection and outcomes in practice.
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Affiliation(s)
- Eric D. Shah
- Center for Gastrointestinal Motility, Esophageal, and Swallowing Disorders, Division of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03766, USA,Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Darren M. Brenner
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Vincent L. Chen
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, MI, USA
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Yoon WJ, Shah ED, Lee TH, Jang S, Law R, Park DH. Endoscopic Ultrasound-Guided Versus Percutaneous Transhepatic Biliary Drainage in Patients With Malignant Biliary Obstruction: Which Is the Optimal Cost-Saving Strategy After Failed ERCP? Front Oncol 2022; 12:844083. [PMID: 35280826 PMCID: PMC8914424 DOI: 10.3389/fonc.2022.844083] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 02/04/2022] [Indexed: 01/29/2023] Open
Abstract
Background and Aim Although endoscopic ultrasound-guided biliary drainage (EUS-BD) after failed primary ERCP in malignant distal biliary obstruction has similar clinical outcomes compared to percutaneous transhepatic biliary drainage (PTBD), little is known about optimal cost-saving strategy after failed ERCP. We performed a cost analysis of EUS-BD and PTBD after failed ERCP in two countries with different health care systems in the East and West. Methods From an unpublished database nested in a randomized controlled trial, we compared the cost between EUS-BD and PTBD in Korea. The total cost was defined as the sum of the total biliary drainage costs plus the cost of hospital stay to manage adverse events. We also performed a cost-minimization analysis using a decision-analytic model of a US Medicare population. Results In Korea, the median total costs for the biliary intervention ($1,203.36 for EUS-BD vs. $1,517.83 for PTBD; P=.0015) and the median total costs for the entire treatment were significantly higher in PTBD ($4,175.53 for EUS-BD vs. $5,391.87 for PTBD; P=.0496) due to higher re-intervention rate in PTBD. In cost-minimization analysis of US Medicare population, EUS-BD would cost $9,497.03 and PTBD $13,878.44 from a Medicare insurance perspective (average cost-savings in choosing EUS-BD of $4,381.41 in the US). In sensitivity analysis, EUS-BD was favored over PTBD regardless of the expected re-intervention rate in EUS-BD and PTBD. Conclusions EUS-BD may have an impact on cost-savings due to better clinical outcomes profile compared to PTBD after failed ERCP, even in different medical insurance programs.
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Affiliation(s)
- Won Jae Yoon
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, South Korea
| | - Eric D. Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
| | - Tae Hoon Lee
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, South Korea
| | - Sunguk Jang
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, United States
| | - Ryan Law
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
| | - Do Hyun Park
- Digestive Diseases Research Center, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
- *Correspondence: Do Hyun Park,
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Shah ED, Salwen-Deremer JK, Gibson PR, Muir JG, Eswaran S, Chey WD. Comparing Costs and Outcomes of Treatments for Irritable Bowel Syndrome With Diarrhea: Cost-Benefit Analysis. Clin Gastroenterol Hepatol 2022; 20:136-144.e31. [PMID: 33010413 DOI: 10.1016/j.cgh.2020.09.043] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 08/28/2020] [Accepted: 09/21/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Irritable bowel syndrome (IBS) is one of the most expensive gastroenterological conditions and is an ideal target for developing a value-based care model. We assessed the comparative cost-benefit of treatments for IBS with diarrhea (IBS-D), the most common IBS subtype from insurer and patient perspectives. METHODS We constructed a decision analytic model assessing trade-offs among guideline-recommended and recently FDA-approved drugs, supplements, low FODMAP diet, cognitive behavioral therapy (CBT). Outcomes and costs were derived from systematic reviews of clinical trials and national databases. Health-gains were represented using quality-adjusted life years (QALY). RESULTS From an insurer perspective, on-label prescription drugs (rifaximin, eluxadoline, alosetron) were significantly more expensive than off-label treatments, low FODMAP, or CBT. Insurer treatment preferences were driven by average wholesale prescription drug prices and were not affected by health gains in sensitivity analysis within standard willingness-to-pay ranges up to $150,000/QALY-gained. From a patient perspective, prescription drug therapies and neuromodulators appeared preferable due to a reduction in lost wages due to IBS with effective therapy, and also considering out-of-pocket costs of low FODMAP food and out-of-pocket costs to attend CBT appointments. Comparative health outcomes exerted influence on treatment preferences from a patient perspective in cost-benefit analysis depending on a patients' willingness-to-pay threshold for additional health-gains, but health outcomes were less important than out-of-pocket costs at lower willingness-to-pay thresholds. CONCLUSIONS Costs are critical determinants of IBS treatment value to patients and insurers, but different costs drive patient and insurer treatment preferences. Divergent cost drivers appear to explain misalignment between patient and insurer IBS treatment preferences in practice.
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Affiliation(s)
- Eric D Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
| | - Jessica K Salwen-Deremer
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Department of Psychiatry, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Peter R Gibson
- Department of Gastroenterology, Central Clinical School, Monash University, Melbourne, Australia
| | - Jane G Muir
- Department of Gastroenterology, Central Clinical School, Monash University, Melbourne, Australia
| | - Shanti Eswaran
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan
| | - William D Chey
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan
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Shah ED, Chang L, Lembo A, Staller K, Curley MA, Chey WD. Price Is Right: Exploring Prescription Drug Coverage Barriers for Irritable Bowel Syndrome Using Threshold Pricing Analysis. Dig Dis Sci 2021; 66:4140-4148. [PMID: 33433804 DOI: 10.1007/s10620-020-06806-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 12/22/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Prescription drug costs exert profound effects on commercial insurance coverage and access to effective therapy. AIMS We aimed to assess threshold pricing to achieve budget neutrality of FDA-approved drugs treating irritable bowel syndrome from an insurance perspective, based on cost-savings resulting in decreased healthcare utilization through effective disease management. METHODS We constructed a decision-analytic model from an insurance perspective to assess the budget impact of IBS prescription drugs under usual insurance coverage levels in practice: (1) unrestricted drug access or (2) step therapy in a primary care population of middle-age, care-seeking IBS patients. Budget-neutral drug prices were then calculated which resulted in $0 budget impact to insurers with a short-term, one-year time horizon. RESULTS If used according to FDA labeling, IBS-D drugs cost between $4778 and $16,844 per year and IBS-C drugs cost between $4319 and $4955 per year. These drug costs often exceed insurance expenditures of $6999 for IBS-D and $3929 for IBS-C if left untreated. Therefore, for drugs to have $0 budget impact to insurers, their prices would need to be discounted 36.7-74.2% for IBS-D drugs and 59.3-82.5% for IBS-C. IBS drugs are already priced to support step therapy "failing one of several common, inexpensive IBS treatments with a responder rate > 30-40%," reflecting the subpopulation with more severe disease and greater healthcare costs. CONCLUSIONS Broader prescription drug coverage for patients failing common, inexpensive IBS treatments to which at least 30-40% of patients would typically respond appears warranted to enable gastroenterologists to offer personalized approaches targeting specific mechanisms of this heterogeneous disease.
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Affiliation(s)
- Eric D Shah
- Center for Gastrointestinal Motility, Esophageal, and Swallowing Disorders, Section of Gastroenterology and Hepatology, Geisel School of Medicine at Dartmouth College, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, 03766, USA.
| | - Lin Chang
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Anthony Lembo
- Digestive Disease Center, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Kyle Staller
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Michael A Curley
- Center for Gastrointestinal Motility, Esophageal, and Swallowing Disorders, Section of Gastroenterology and Hepatology, Geisel School of Medicine at Dartmouth College, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, 03766, USA
| | - William D Chey
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, MI, USA
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Ortengren AR, Ramkissoon RA, Chey WD, Baker JR, Staller K, Iturrino J, Shah ED. Anorectal manometry to diagnose dyssynergic defecation: Systematic review and meta-analysis of diagnostic test accuracy. Neurogastroenterol Motil 2021; 33:e14137. [PMID: 33772969 PMCID: PMC10091423 DOI: 10.1111/nmo.14137] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 02/23/2021] [Accepted: 03/09/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Chronic constipation is a common condition, and dyssynergic defecation underlies up to 40% of cases. Anorectal manometry is recommended to assess for dyssynergic defecation among chronically constipated patients but remains poorly standardized. We aimed to evaluate the diagnostic accuracy of anorectal manometry and determine optimal testing parameters. METHODS We performed a systematic review with meta-analysis of diagnostic test accuracy including cohort studies of chronically constipated patients and case-control studies of patients with dyssynergic defecation or healthy controls. Meta-analysis was performed to determine summary sensitivity, specificity, and area under the curve (AUC) with 95% confidence intervals (CI). KEY RESULTS A total of 15 studies comprising 2140 patients were included. Including all studies (estimating optimal diagnostic accuracy), the AUC was 0.78 [95% CI 0.72-0.82], summary sensitivity was 79% [61%-90%], and summary specificity was 64% [44%-79%] to diagnose dyssynergic defecation. In cohort studies only (estimating real-world diagnostic accuracy), the AUC was 0.72 [0.66-0.77], summary sensitivity was 86% [64%-95%], and summary specificity was 49% [30%-68%]. Employing three consecutive simulated defecation attempts improved sensitivity to 94%. A fourth simulated defecation maneuver with air insufflation may improve accuracy. Measuring anorectal pressures to identify complex dyssynergic patterns did not improve real-world diagnostic accuracy estimates over anal pressure measurement alone. Choice of manometry system did not impact diagnostic accuracy. CONCLUSIONS & INFERENCES Following the current iteration of the London consensus protocol (three simulated defecation attempts measuring anal relaxation), the role of anorectal manometry in evaluating dyssynergic defecation appears limited. Future iterations of this protocol may improve diagnostic accuracy.
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Affiliation(s)
- Alexandra R. Ortengren
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Health, Lebanon, NH, USA
| | - Resham A. Ramkissoon
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Health, Lebanon, NH, USA
| | - William D. Chey
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, MI, USA
| | - Jason R. Baker
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, MI, USA
| | - Kyle Staller
- Division of Gastroenterology, Massachussetts General Hospital, Boston, MA, USA
| | - Johanna Iturrino
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Eric D. Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Health, Lebanon, NH, USA
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Shah ED. Gastro-Intestinal Symptoms and Autism Spectrum Disorder: A Potential Link [Response to Letter]. Clin Exp Gastroenterol 2021; 14:375-376. [PMID: 34548804 PMCID: PMC8448504 DOI: 10.2147/ceg.s337372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 09/02/2021] [Indexed: 11/23/2022] Open
Affiliation(s)
- Eric D Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Health, Lebanon, NH, USA
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Shah ED, Lacy BE, Chey WD, Chang L, Brenner DM. Tegaserod for Irritable Bowel Syndrome With Constipation in Women Younger Than 65 Years Without Cardiovascular Disease: Pooled Analyses of 4 Controlled Trials. Am J Gastroenterol 2021; 116:1601-1611. [PMID: 34047303 PMCID: PMC8315186 DOI: 10.14309/ajg.0000000000001313] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 04/12/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Tegaserod was the first US Food and Drug Administration-approved drug for irritable bowel syndrome with constipation (IBS-C) in women and was recently reapproved for use. Recognizing that clinical trials were performed almost 20 years ago, we performed an integrated analysis on patient-reported outcomes relevant to current practice including previously unpublished data. METHODS Data from 4 12-week, randomized, placebo-controlled trials evaluating tegaserod 6 mg b.i.d. in patients with IBS-C were pooled. We analyzed 2 groups: all women (overall population) and women younger than 65 years without a history of cardiovascular ischemic events (indicated population). The primary end point was subjective global assessment of IBS-C symptom relief. Responders rated themselves as "considerably" or "completely" relieved ≥50% of the time or at least "somewhat relieved" 100% of the time over the last 4 weeks. RESULTS The overall and indicated populations included 2,939 (tegaserod [n = 1,478]; placebo [n = 1,461]) and 2,752 (tegaserod [n = 1,386]; placebo [n = 1,366]) participants, respectively. The pooled odds ratios (95% confidence interval) for clinical response during the last 4 weeks in the overall and indicated populations with tegaserod were 1.37 (1.18, 1.59; P < 0.001) and 1.38 (1.18, 1.61; P < 0.001). In the overall and indicated populations, clinical response rates for tegaserod during the last 4 weeks were 43.3% and 44.1% versus 35.9% and 36.5% with placebo (P < 0.001). Adverse events were similar between groups. No significant cardiovascular events related to tegaserod were observed in patients with ≤1 cardiac risk factor. DISCUSSION Tegaserod 6 mg b.i.d. reduced IBS-C symptoms in overall and US Food and Drug Administration-indicated populations (women aged <65 years with no history of cardiovascular ischemic events).
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Affiliation(s)
- Eric D. Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Brian E. Lacy
- Division of Gastroenterology & Hepatology, Mayo Clinic, Jacksonville, Jacksonville, Florida, USA
| | - William D. Chey
- University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Lin Chang
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Darren M. Brenner
- Division of Gastroenterology and Hepatology Northwestern University—Feinberg School of Medicine, Chicago, Illinois, USA
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Elmunzer BJ, Spitzer RL, Foster LD, Merchant AA, Howard EF, Patel VA, West MK, Qayed E, Nustas R, Zakaria A, Piper MS, Taylor JR, Jaza L, Forbes N, Chau M, Lara LF, Papachristou GI, Volk ML, Hilson LG, Zhou S, Kushnir VM, Lenyo AM, McLeod CG, Amin S, Kuftinec GN, Yadav D, Fox C, Kolb JM, Pawa S, Pawa R, Canakis A, Huang C, Jamil LH, Aneese AM, Glamour BK, Smith ZL, Hanley KA, Wood J, Patel HK, Shah JN, Agarunov E, Sethi A, Fogel EL, McNulty G, Haseeb A, Trieu JA, Dixon RE, Yang JY, Mendelsohn RB, Calo D, Aroniadis OC, LaComb JF, Scheiman JM, Sauer BG, Dang DT, Piraka CR, Shah ED, Pohl H, Tierney WM, Mitchell S, Condon A, Lenhart A, Dua KS, Kanagala VS, Kamal A, Singh VK, Pinto-Sanchez MI, Hutchinson JM, Kwon RS, Korsnes SJ, Singh H, Solati Z, Willingham FF, Yachimski PS, Conwell DL, Mosier E, Azab M, Patel A, Buxbaum J, Wani S, Chak A, Hosmer AE, Keswani RN, DiMaio CJ, Bronze MS, Muthusamy R, Canto MI, Gjeorgjievski VM, Imam Z, Odish F, Edhi AI, Orosey M, Tiwari A, Patwardhan S, Brown NG, Patel AA, Ordiah CO, Sloan IP, Cruz L, Koza CL, Okafor U, Hollander T, Furey N, Reykhart O, Zbib NH, Damianos JA, Esteban J, Hajidiacos N, Saul M, Mays M, Anderson G, Wood K, Mathews L, Diakova G, Caisse M, Wakefield L, Nitchie H, Waljee AK, Tang W, Zhang Y, Zhu J, Deshpande AR, Rockey DC, Alford TB, Durkalski V. Digestive Manifestations in Patients Hospitalized With Coronavirus Disease 2019. Clin Gastroenterol Hepatol 2021; 19:1355-1365.e4. [PMID: 33010411 PMCID: PMC7527302 DOI: 10.1016/j.cgh.2020.09.041] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 09/21/2020] [Accepted: 09/22/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS The prevalence and significance of digestive manifestations in coronavirus disease 2019 (COVID-19) remain uncertain. We aimed to assess the prevalence, spectrum, severity, and significance of digestive manifestations in patients hospitalized with COVID-19. METHODS Consecutive patients hospitalized with COVID-19 were identified across a geographically diverse alliance of medical centers in North America. Data pertaining to baseline characteristics, symptomatology, laboratory assessment, imaging, and endoscopic findings from the time of symptom onset until discharge or death were abstracted manually from electronic health records to characterize the prevalence, spectrum, and severity of digestive manifestations. Regression analyses were performed to evaluate the association between digestive manifestations and severe outcomes related to COVID-19. RESULTS A total of 1992 patients across 36 centers met eligibility criteria and were included. Overall, 53% of patients experienced at least 1 gastrointestinal symptom at any time during their illness, most commonly diarrhea (34%), nausea (27%), vomiting (16%), and abdominal pain (11%). In 74% of cases, gastrointestinal symptoms were judged to be mild. In total, 35% of patients developed an abnormal alanine aminotransferase or total bilirubin level; these were increased to less than 5 times the upper limit of normal in 77% of cases. After adjusting for potential confounders, the presence of gastrointestinal symptoms at any time (odds ratio, 0.93; 95% CI, 0.76-1.15) or liver test abnormalities on admission (odds ratio, 1.31; 95% CI, 0.80-2.12) were not associated independently with mechanical ventilation or death. CONCLUSIONS Among patients hospitalized with COVID-19, gastrointestinal symptoms and liver test abnormalities were common, but the majority were mild and their presence was not associated with a more severe clinical course.
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Affiliation(s)
- B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Department of Medicine, Charleston, South Carolina.
| | - Rebecca L Spitzer
- Division of Gastroenterology and Hepatology, Department of Medicine, Charleston, South Carolina
| | - Lydia D Foster
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Ambreen A Merchant
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Eric F Howard
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Vaishali A Patel
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Mary K West
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Emad Qayed
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; Division of Digestive Diseases, Department of Medicine, Grady Memorial Hospital, Atlanta, Georgia
| | - Rosemary Nustas
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; Division of Digestive Diseases, Department of Medicine, Grady Memorial Hospital, Atlanta, Georgia
| | - Ali Zakaria
- Division of Gastroenterology, Department of Medicine, Ascension Providence Hospital/Michigan State University, College of Human Medicine, Southfield, Michigan
| | - Marc S Piper
- Division of Gastroenterology, Department of Medicine, Ascension Providence Hospital/Michigan State University, College of Human Medicine, Southfield, Michigan
| | - Jason R Taylor
- Division of Gastroenterology and Hepatology, Department of Medicine, Saint Louis University, St. Louis, Missouri
| | - Lujain Jaza
- Division of Gastroenterology and Hepatology, Department of Medicine, Saint Louis University, St. Louis, Missouri
| | - Nauzer Forbes
- Division of Gastroenterology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Millie Chau
- Division of Gastroenterology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Luis F Lara
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Georgios I Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Michael L Volk
- Division of Gastroenterology, Department of Medicine, Loma Linda University, Loma Linda, California
| | - Liam G Hilson
- Division of Gastroenterology, Department of Medicine, University of Southern California, Los Angeles, California
| | - Selena Zhou
- Division of Gastroenterology, Department of Medicine, University of Southern California, Los Angeles, California
| | - Vladimir M Kushnir
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Alexandria M Lenyo
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Caroline G McLeod
- Division of Gastroenterology and Hepatology, Department of Medicine, Charleston, South Carolina
| | - Sunil Amin
- Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Gabriela N Kuftinec
- Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Dhiraj Yadav
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Charlie Fox
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jennifer M Kolb
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Swati Pawa
- Division of Gastroenterology, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Rishi Pawa
- Division of Gastroenterology, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Andrew Canakis
- Section of Gastroenterology, Department of Medicine, Boston University Medical Center, Boston, Massachusetts
| | - Christopher Huang
- Section of Gastroenterology, Department of Medicine, Boston University Medical Center, Boston, Massachusetts
| | - Laith H Jamil
- Section of Gastroenterology and Hepatology, Department of Internal Medicine, Beaumont Health, Royal Oak, Michigan; Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Andrew M Aneese
- Section of Gastroenterology and Hepatology, Department of Internal Medicine, Beaumont Health, Royal Oak, Michigan
| | - Benita K Glamour
- Division of Gastroenterology, Department of Medicine, University Hospitals of Cleveland Medical Center, Cleveland, Ohio
| | - Zachary L Smith
- Division of Gastroenterology, Department of Medicine, University Hospitals of Cleveland Medical Center, Cleveland, Ohio
| | - Katherine A Hanley
- Division of Gastroenterology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jordan Wood
- Division of Gastroenterology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Harsh K Patel
- Department of Gastroenterology, Ochsner Health, New Orleans, Louisiana
| | - Janak N Shah
- Department of Gastroenterology, Ochsner Health, New Orleans, Louisiana
| | - Emil Agarunov
- Division of Gastroenterology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Amrita Sethi
- Division of Gastroenterology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Evan L Fogel
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Gail McNulty
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Abdul Haseeb
- Division of Gastroenterology and Nutrition, Department of Medicine, Loyola University Medical Center, Chicago, Illinois
| | - Judy A Trieu
- Division of Gastroenterology and Nutrition, Department of Medicine, Loyola University Medical Center, Chicago, Illinois
| | - Rebekah E Dixon
- The Dr. Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jeong Yun Yang
- The Dr. Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Robin B Mendelsohn
- Gastroenterology, Hepatology and Nutrition service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Delia Calo
- Gastroenterology, Hepatology and Nutrition service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Olga C Aroniadis
- Division of Gastroenterology, Department of Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
| | - Joseph F LaComb
- Division of Gastroenterology, Department of Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
| | - James M Scheiman
- Division of Gastroenterology, Department of Medicine, University of Virginia Medical School, Charlottesville, Virginia
| | - Bryan G Sauer
- Division of Gastroenterology, Department of Medicine, University of Virginia Medical School, Charlottesville, Virginia
| | - Duyen T Dang
- Division of Gastroenterology, Department of Medicine, Henry Ford Health System, Detroit, Michigan
| | - Cyrus R Piraka
- Division of Gastroenterology, Department of Medicine, Henry Ford Health System, Detroit, Michigan
| | - Eric D Shah
- Section of Gastroenterology and Hepatology, Department of Medicine, Dartmouth-Hitchcock Health, Lebanon, New Hampshire
| | - Heiko Pohl
- Section of Gastroenterology and Hepatology, Department of Medicine, Dartmouth-Hitchcock Health, Lebanon, New Hampshire; Section of Gastroenterology and Hepatology, Department of Medicine, VA Medical Center, White River Junction, Vermont
| | - William M Tierney
- Section of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Stephanie Mitchell
- Section of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Ashwinee Condon
- Division of Gastroenterology, Department of Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Adrienne Lenhart
- Division of Gastroenterology, Department of Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Kulwinder S Dua
- Division of Gastroenterology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Vikram S Kanagala
- Division of Gastroenterology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ayesha Kamal
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Vikesh K Singh
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Maria Ines Pinto-Sanchez
- Division of Gastroenterology, Department of Medicine, McMaster University Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Joy M Hutchinson
- Division of Gastroenterology, Department of Medicine, McMaster University Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Richard S Kwon
- Division of Gastroenterology and Hepatology, Department of Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Sheryl J Korsnes
- Division of Gastroenterology and Hepatology, Department of Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Harminder Singh
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Zahra Solati
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Field F Willingham
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Patrick S Yachimski
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Darwin L Conwell
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Evan Mosier
- Division of Gastroenterology, Department of Medicine, Loma Linda University, Loma Linda, California
| | - Mohamed Azab
- Division of Gastroenterology, Department of Medicine, Loma Linda University, Loma Linda, California
| | - Anish Patel
- Division of Gastroenterology, Department of Medicine, Loma Linda University, Loma Linda, California
| | - James Buxbaum
- Division of Gastroenterology, Department of Medicine, University of Southern California, Los Angeles, California
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Amitabh Chak
- Division of Gastroenterology, Department of Medicine, University Hospitals of Cleveland Medical Center, Cleveland, Ohio
| | - Amy E Hosmer
- Division of Gastroenterology, Department of Medicine, University Hospitals of Cleveland Medical Center, Cleveland, Ohio
| | - Rajesh N Keswani
- Division of Gastroenterology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Christopher J DiMaio
- The Dr. Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michael S Bronze
- Section of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Raman Muthusamy
- Division of Gastroenterology, Department of Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Marcia I Canto
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - V Mihajlo Gjeorgjievski
- Section of Gastroenterology and Hepatology, Department of Internal Medicine, Beaumont Health, Royal Oak, Michigan
| | - Zaid Imam
- Section of Gastroenterology and Hepatology, Department of Internal Medicine, Beaumont Health, Royal Oak, Michigan
| | - Fadi Odish
- Section of Gastroenterology and Hepatology, Department of Internal Medicine, Beaumont Health, Royal Oak, Michigan
| | - Ahmed I Edhi
- Section of Gastroenterology and Hepatology, Department of Internal Medicine, Beaumont Health, Royal Oak, Michigan
| | - Molly Orosey
- Section of Gastroenterology and Hepatology, Department of Internal Medicine, Beaumont Health, Royal Oak, Michigan
| | - Abhinav Tiwari
- Section of Gastroenterology and Hepatology, Department of Internal Medicine, Beaumont Health, Royal Oak, Michigan
| | - Soumil Patwardhan
- Section of Gastroenterology and Hepatology, Department of Internal Medicine, Beaumont Health, Royal Oak, Michigan
| | - Nicholas G Brown
- Division of Gastroenterology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Anish A Patel
- Division of Gastroenterology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Collins O Ordiah
- Division of Gastroenterology and Hepatology, Department of Medicine, Charleston, South Carolina
| | - Ian P Sloan
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Lilian Cruz
- Division of Gastroenterology, Department of Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
| | - Casey L Koza
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Uchechi Okafor
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Thomas Hollander
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Nancy Furey
- Division of Gastroenterology, Department of Medicine, University Hospitals of Cleveland Medical Center, Cleveland, Ohio
| | - Olga Reykhart
- Division of Gastroenterology, Department of Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
| | - Natalia H Zbib
- Section of Gastroenterology and Hepatology, Department of Medicine, Dartmouth-Hitchcock Health, Lebanon, New Hampshire
| | - John A Damianos
- Section of Gastroenterology and Hepatology, Department of Medicine, Dartmouth-Hitchcock Health, Lebanon, New Hampshire
| | - James Esteban
- Division of Gastroenterology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nick Hajidiacos
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Melissa Saul
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Melanie Mays
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Gulsum Anderson
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kelley Wood
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Laura Mathews
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Galina Diakova
- Division of Gastroenterology, Department of Medicine, University of Virginia Medical School, Charlottesville, Virginia
| | - Molly Caisse
- Section of Gastroenterology and Hepatology, Department of Medicine, Dartmouth-Hitchcock Health, Lebanon, New Hampshire
| | - Lauren Wakefield
- Division of Gastroenterology and Hepatology, Department of Medicine, Charleston, South Carolina
| | - Haley Nitchie
- Division of Gastroenterology and Hepatology, Department of Medicine, Charleston, South Carolina
| | - Akbar K Waljee
- Division of Gastroenterology and Hepatology, Department of Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Weijing Tang
- Department of Statistics, University of Michigan, Ann Arbor, Michigan
| | - Yueyang Zhang
- Department of Statistics, University of Michigan, Ann Arbor, Michigan
| | - Ji Zhu
- Department of Statistics, University of Michigan, Ann Arbor, Michigan
| | - Amar R Deshpande
- Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Don C Rockey
- Division of Gastroenterology and Hepatology, Department of Medicine, Charleston, South Carolina
| | - Teldon B Alford
- Division of Gastroenterology and Hepatology, Department of Medicine, Charleston, South Carolina
| | - Valerie Durkalski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina
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Moudgal R, Schultz AW, Shah ED. Systemic Disease Associations with Disorders of Gut-Brain Interaction and Gastrointestinal Transit: A Review. Clin Exp Gastroenterol 2021; 14:249-257. [PMID: 34135613 PMCID: PMC8197439 DOI: 10.2147/ceg.s283685] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 05/25/2021] [Indexed: 12/12/2022] Open
Abstract
Functional gastrointestinal disorders (FGID) are now classified within the Rome IV framework as disorders of gut-brain interaction (DGBI). Disorders of gastrointestinal transit (as defined by abnormalities on contemporary gastrointestinal motility testing) frequently are associated with symptoms that are also characteristic of DGBIs. In this narrative review, we outline a non-inclusive set of systemic diseases or risk factors that have been classically associated with DGBIs and disorders of gastrointestinal transit; these include diabetes mellitus, paraneoplastic syndromes, surgery, Parkinson's disease, systemic sclerosis, endocrinopathies, polypharmacy, and post-infectious syndromes.
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Affiliation(s)
- Rohitha Moudgal
- Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Andrew W Schultz
- Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Eric D Shah
- Section of Gastroenterology and Hepatology, Dartmouth-HitchcockHealth,One Medical Center Drive, Lebanon, NH, USA
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Affiliation(s)
- Eric D Shah
- Center for Gastrointestinal Motility, Esophageal, and Swallowing Disorders, Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, 03756, USA.
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Shah ED, Pourmorteza M, Elmunzer BJ, Ballou SK, Papachristou GI, Lara LF, Okafor U, Pfeil SA, Conwell DL, Krishna SG. Psychological Health Among Gastroenterologists During the COVID-19 Pandemic: A National Survey. Clin Gastroenterol Hepatol 2021; 19:836-838.e3. [PMID: 33278574 PMCID: PMC7955767 DOI: 10.1016/j.cgh.2020.11.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 11/20/2020] [Accepted: 11/25/2020] [Indexed: 02/07/2023]
Abstract
The COVID-19 pandemic poses unprecedented and unique challenges to gastroenterologists eager to maintain clinical practice, patients' health, and their own physical/mental well-being. We aimed to estimate the prevalence and critical determinants of psychological distress in gastroenterologists during the COVID-19 pandemic.
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Affiliation(s)
- Eric D. Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Health, Lebanon, New Hampshire
| | - Mohsen Pourmorteza
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio
| | - B. Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | - Sarah K. Ballou
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Georgios I. Papachristou
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio
| | - Luis F. Lara
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio
| | - Uche Okafor
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio
| | - Sheryl A. Pfeil
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio
| | - Darwin L. Conwell
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio
| | - Somashekar G. Krishna
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio,Reprint requests Address requests for reprints to: Somashekar G. Krishna, MD, MPH, Division of Gastroenterology, Hepatology & Nutrition, Ohio State Wexner Medical Center, 395 West Twelfth Avenue, Columbus, Ohio 43210
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Coburn ES, Siegel CA, Winter M, Shah ED. Hemophagocytic Lymphohistiocytosis Occurring in Inflammatory Bowel Disease: Systematic Review. Dig Dis Sci 2021; 66:843-854. [PMID: 32300936 DOI: 10.1007/s10620-020-06252-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 04/03/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a rare and aggressive syndrome of excessive cytokine requiring prompt recognition and aggressive therapy. AIMS We aimed to systematically characterize HLH in moderate-to-severe inflammatory bowel disease (IBD). METHODS We performed a systematic review of the literature (PubMED; EMBASE) and FDA Adverse Event Reporting System in accordance with the PRISMA statement. Use of biologics was used as a surrogate definition for disease severity (consistent with usual and contemporary clinical management), to enable identification of rare HLH cases with the highest fidelity. RESULTS 58 cases of HLH occurring in IBD patients are known (mean age: 26.0 years, 70% male, 83% with Crohn's disease, mean disease duration 7.0 years). 34.5% of patients were undergoing induction therapy at HLH diagnosis. All cases occurred on patients exposed to anti-TNF agents, but cases with anti-integrin or anti-IL-12/23 exposure were reported. 2/3 of cases did not report prior AZA/6MP exposure. Underlying opportunistic infection or lymphoma was found in > 80% of cases. Survival was 70% if promptly recognized and treated. Five patients restarted biologics after HLH resolved, and one patient developed recurrent HLH. CONCLUSIONS HLH is rare among IBD patients exposed to biologic therapy. Most cases had an identifiable infection or malignancy at the time of diagnosis as well as history of immunomodulator use. Risk factors may include younger age, male gender, presence of Crohn's disease, and induction phase of treatment. Our study is not intended to assess risk of HLH with specific IBD therapies.
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Affiliation(s)
- Elliot S Coburn
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, 03766, USA
| | - Corey A Siegel
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, 03766, USA
| | - Michael Winter
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, 03766, USA
| | - Eric D Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, 03766, USA.
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.
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