Assessment of Stakeholder Perceptions and Cost of Implementing a Telemedicine Specialty Program at Correctional Facilities in North Carolina

Background Delivering in-person health care to the more than 1.2 million incarcerated adults can be expensive, logistically challenging, fragmented, and pose security risks. The purpose of this study was to evaluate the implementation of a specialty care telemedicine program in statewide prisons in North Carolina during the COVID-19 pandemic. Methods We evaluated the first 6 months of implementation of a new telemedicine program to deliver specialty care to adults incarcerated in 55 North Carolina prison facilities. We measured patient and practitioner perceptions and the impact on the cost of care. Results A total of 3232 telemedicine visits were completed across 55 prisons within the first 6 months of the program. Most patients reported that the ability to use telemedicine contributed to their overall personal well-being and safety. Many practitioners found that working with the on-site nursing staff to conduct physical exams and to make collective decisions were key drivers to the success of telemedicine. A direct relationship was found between the telemedicine experience and patients' preference for future visits such that as satisfaction increased, the desire to use telemedicine increased. Telemedicine reduced total costs of care by $416,020 (net: -$95,480) within the first 6 months, and $1,195,377 estimated in the first 12 months postimplementation (95% confidence interval: $1,100,166-$1,290,587). Conclusions Implementing specialty care telemedicine in prison facilities enhanced patient and practitioner experiences and reduced costs within the prison system. The implementation of telemedicine in prison systems can increase access to care and reduce public safety risks by eliminating unnecessary off-site medical center visits.

Plecanatide Improves Symptoms of Irritable Bowel Syndrome with Constipation: Results of an Integrated Efficacy and Safety Analysis of Two Phase 3 Trials

Purpose

Patients with irritable bowel syndrome with constipation (IBS-C) experience abdominal pain with altered bowel movements. Plecanatide is indicated as IBS-C treatment in adults. This integrated analysis further characterizes plecanatide efficacy and safety in IBS-C.

Patients and Methods

Data pooled from 2 identically designed phase 3 trials included adults with IBS-C randomized to plecanatide 3 mg or 6 mg, or placebo once daily for 12 weeks. A daily diary recorded stool frequency/symptoms, with abdominal pain, bloating, cramping, discomfort, fullness, and straining intensity individually rated. Overall response (primary endpoint) was defined as ≥30% improvement from baseline in average worst abdominal pain severity and increase of ≥1 complete spontaneous bowel movement, during same week (composite), for ≥6 of 12 weeks. Secondary endpoints included sustained response (overall response, plus meeting weekly composite criteria during ≥2 of last 4 treatment weeks) and changes from baseline in individual symptoms. Safety assessments included adverse event monitoring.

Results

Overall, 2176 patients (74.0% female; mean [SD] age, 43.5 [14.1] years) were included in efficacy analyses (plecanatide 3 mg [n = 724], 6 mg [n = 723], placebo [n = 729]). A significantly greater percentage of patients achieved overall response with plecanatide 3 mg (25.6%) and 6 mg (26.7%) versus placebo (16.0%; both P < 0.001 vs placebo). A significantly greater percentage of patients were sustained responders with plecanatide 3 mg (24.3%) and 6 mg (25.6%) versus placebo (15.6%; both P < 0.001 vs placebo). Significant improvements from baseline in abdominal discomfort, abdominal fullness, abdominal pain, bloating, and cramping occurred as early as Week 1 (Week 2 for abdominal pain) with plecanatide and were maintained through Week 12 versus placebo. Diarrhea, the most common adverse event, occurred in 4.3% (3 mg), 4.0% (6 mg) and 1.0% (placebo) of patients, leading to study discontinuation in 1.2%, 1.4%, and 0 patients, respectively.

Conclusion

Plecanatide is safe and effective for treating global and individual IBS-C symptoms.

Implementing Collaborative Care Management of Behavioral Health for Patients with Inflammatory Bowel Disease

Background

Individuals with inflammatory bowel disease (IBD) are up to twice as likely to suffer from anxiety and/or depression. Collaborative care management (CoCM) is an evidence-based approach to treating behavioral health disorders that have proven effective for a range of conditions in primary care and some specialty settings. This model involves a team-based approach, with care delivered by a care manager (case reviews and behavioral therapy), psychiatrist (case reviews and psychopharmacological recommendations), and medical provider (ongoing care including psychopharmacological prescriptions). We assessed the feasibility and effectiveness of CoCM in reducing anxiety and depressive symptoms in patients with IBD.

Methods

Patients with psychological distress identified by clinical impression and/or the results of the Patient Health Questionaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) were referred to the CoCM program. Data from our 9-month CoCM pilot were collected to assess depression and anxiety response and remission rates. We obtained provider surveys to assess provider acceptability with delivering care in this model.

Results

Though the SARS-CoV2 COVID-19 pandemic interrupted screening, 39 patients enrolled and 19 active participants completed the program. Overall, 47.4% had either a response or remission in depression, while 36.8% had response or remission in anxiety. The gastroenterologists highly agreed that the program was a beneficial resource for their patients and felt comfortable implementing the recommendations.

Discussion

CoCM is a potentially feasible and well accepted care delivery model for treatment of depression and anxiety in patients with IBD in a specialty gastroenterology clinic setting.

Implementation and Evaluation of a Telemedicine Program for Specialty Care in North Carolina Correctional Facilities

This cross-sectional study evaluates the implementation of a telemedicine program in North Carolina prisons based on responses from individuals who were incarcerated, health care practitioners, and telepresenters.

Backslide or forward progress? Virtual care at U.S. healthcare systems beyond the COVID-19 pandemic

The COVID-19 pandemic forced most U.S. healthcare systems to quickly pivot to virtual care. However, since peaking in late April, care has largely shifted back to in-person. Health systems are now challenged to further develop and integrate useful, usable, and sustainable virtual care tools into their broader care model in ways that benefit their organizations and the communities they serve.

An integrated electronic health record-based workflow to improve management of colonoscopy-generated pathology results

Purpose

Managing and communicating colonoscopy-generated pathology results and appropriate follow-up recommendations can be challenging. To improve this process, we developed and implemented a standardized electronic health record-based intervention with built-in decision support.

Methods

Fourteen attending endoscopists performed enough colonoscopies to qualify for the study. For each, we randomly sampled and abstracted data from 35 colonoscopies that met prespecified inclusion criteria during both the pre-intervention and also post-intervention periods. Follow-up recommendations were compared to guidelines. We used the Wilcoxon Signed Rank Test to assess the change in the proportion of cases with guideline-concordant results, the proportion with a documented follow-up result letter, and the median time to letter completion. A brief survey assessed endoscopists’ satisfaction with the intervention.

Results

In total, 1,947 colonoscopies were extracted, of which 968 met inclusion criteria. The proportion of follow-up recommendations that were guideline concordant increased from a median of 82.9% pre-intervention to 85.7% post-intervention (P=0.72). The proportion of observations with a documented follow-up result letter increased from a median of 88.9% pre-intervention to 97.1% post-intervention (P=0.07). The number of calendar days between the date of the colonoscopy and the date the letter was sent decreased from a median of 7.7 days pre-intervention to 6.8 days post-intervention (P=0.79). Eighty-six percentage of endoscopists were either “very satisfied” or “satisfied” with the overall process.

Conclusion

The intervention was not associated with a statistically significant increase in guideline-concordant recommendations or efficiency measures, perhaps due to high baseline performance. The intervention was well received by endoscopists and captured data necessary for important downstream processes.

Efficacy, safety, and tolerability of plecanatide in patients with irritable bowel syndrome with constipation: results of two phase 3 randomized clinical trials

OBJECTIVES

Two identical, phase 3, randomized, double-blind, placebo-controlled trials evaluated the efficacy and safety of plecanatide in patients with irritable bowel syndrome with constipation (IBS-C).

METHODS

Adults meeting Rome III criteria for IBS-C were randomized (1:1:1) to placebo or plecanatide (3 or 6 mg) for 12 weeks. The primary efficacy end point was the percentage of overall responders (patients reporting ≥30% reduction from baseline in worst abdominal pain plus an increase of ≥1 complete spontaneous bowel movement (CSBM)/week from baseline in the same week for ≥6 of 12 treatment weeks). Safety was assessed by adverse events (AEs).

RESULTS

Overall, 2189 individuals were randomized across the two studies and 1879 completed the studies. Demographic and baseline characteristics were similar across treatment groups and between studies. The percentage of overall responders in Study 1 was 30.2% and 29.5% for plecanatide 3 and 6 mg, respectively, vs. 17.8% placebo (P < 0.001 for each dose vs. placebo), and in Study 2 was 21.5% (P = 0.009) and 24.0% (P < 0.001) for plecanatide 3 and 6 mg, respectively, compared to 14.2% for placebo. The percentage of sustained efficacy responders (overall responders plus weekly responders for ≥2 of last 4 weeks of the 12-week treatment period) was significantly greater for both doses of plecanatide vs. placebo across both studies. All secondary end points (stool frequency/consistency, straining, abdominal symptoms) showed statistically significant improvements compared with placebo. The most common AE was diarrhea (3 mg, 4.3%; 6 mg, 4.0%; placebo, 1.0%). Discontinuation due to diarrhea was infrequent (3 mg, 1.2%; 6 mg, 1.4%; placebo, 0).

CONCLUSIONS

Plecanatide significantly improved both abdominal pain and constipation symptoms of IBS-C with minimal associated side effects and high levels of tolerability.

Quality Measurement in Gastroenterology: Confessions of a Realist

Clinicians are required to report their performance on an ever-increasing number of quality measures. However, it is difficult to measure health care quality and it is unclear whether broadly applying accountability measures effectively improves care. This article considers these challenges and includes recommendations that may help gastroenterologists respond to demands for increased quality measurement.

WITHDRAWN: Quality Measurement in Gastroenterology: Confessions of a Realist

The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.cgh.2015.07.033. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

Development and pilot testing of an integrated, web-based self-management program for irritable bowel syndrome (IBS)

BACKGROUND

Although essential, many medical practices are unable to adequately support irritable bowel syndrome (IBS) patient self-management. Web-based programs can help overcome these barriers.

METHODS

We developed, assessed, and refined an integrated IBS self-management program (IBS Self-care). We then conducted a 12-week pilot test to assess program utilization, evaluate its association with patients' self-efficacy and quality of life, and collect qualitative feedback to improve the program.

KEY RESULTS

40 subjects with generally mild IBS were recruited via the Internet to participate in a 12-week pilot study. Subjects found the website easy to use (93%) and personally relevant (95%), and 90% would recommend it to a friend. Self-rated IBS knowledge increased from an average of 47.1 on a 100-point VAS scale (SD 22.1) at baseline to 77.4 (SD: 12.4) at week 12 (p < 0.0001). There were no significant changes in patient self-efficacy (Patient Activation Measure) or quality of life (IBS -Quality of Life Scale).

CONCLUSIONS & INFERENCES

The IBS Self-Care program was well received by users who after 12 weeks reported improved knowledge about IBS, but no significant changes in self-efficacy or quality of life. If applied to the right population, this low cost solution can overcome some of the deficiencies of medical care and empower individuals to better manage their own IBS.

Impact of the 2008-2009 economic recession on screening colonoscopy utilization among the insured

BACKGROUND & AIMS

Economic factors might affect the use of recommended preventative services. We sought to determine whether the recent severe economic recession was associated with diminished screening colonoscopy rates among an insured population and to assess the relationship between out-of-pocket (OOP) costs and screening colonoscopy use.

METHODS

Administrative data from 106 health plans (IMS LifeLink Health Plan Claims Database) were analyzed to determine monthly rates of screening colonoscopies performed on beneficiaries ages 50 to 64 years between January 2005 and November 2007 (prerecession), as well as from December 2007 through June 2009 (recession). Segmented regression models were used to evaluate changes in screening colonoscopy rates, as well as the relationship between screening and OOP costs before and during the recession.

RESULTS

Compared with prerecession trends, during the recession screening colonoscopy rates decreased by 68.9 colonoscopies/1 million individuals per month (95% confidence interval, -84.6 to -53.1; P < .001). Application of study estimates to the entire US population indicated that during the recession, commercially insured patients aged 50 to 64 years underwent approximately 500,000 fewer screening colonoscopies. Compared with those with low OOP costs, those with high OOP procedure costs had lower rates of screening before and during the recession, and had a greater reduction in screening rates during the recession (P = .035).

CONCLUSIONS

During the recession of December 2007 to June 2009, insured individuals reduced their use of screening colonoscopy compared with the 2 years before the recession began. OOP costs were related inversely to screening use, especially during the recession. Policies to reduce cost sharing could increase adherence to recommended preventive services such as colonoscopy examinations.

Health care reform: 2012 update

The recent landmark health care reform legislation seeks to expand health insurance coverage, change incentives, and improve the quality and flow of information. This article reviews the elements of health care reform most relevant to clinical gastroenterology, discusses the ongoing challenges that health care reform legislation faces, and considers the potential implications for clinical practice.

Development and validation of the irritable bowel syndrome satisfaction with care scale

BACKGROUND & AIMS

Satisfaction with care is an important measure of quality, from the patients' perspective, and could also affect outcomes. However, there is no standard measure of patient satisfaction for irritable bowel syndrome (IBS) care; a multi-item, condition-specific instrument is needed.

METHODS

Using standard qualitative methods, we conducted focus groups to identify items that patients associated with satisfaction in their care for IBS. These and additional items identified by experts were placed into a preliminary questionnaire, which was refined through pilot testing and cognitive debriefing by additional patients, as well as standard statistical methods. The resulting instrument and several external validation measures were administered to 300 adult US patients with IBS. Factor analysis was performed to identify clinically relevant subscales and then psychometric properties were assessed.

RESULTS

We developed an IBS satisfaction with care scale (IBS-SAT) that has 38 items from 5 clinically relevant subscales (connection with provider, education, benefits of visit, office attributes, and access to care). This IBS-SAT had a high level of internal consistency (Crohnbach's α = .96). Convergent validity was established by correlations between the IBS-SAT and a single, global satisfaction with care question (r = 0.68; P < .001), and a generic, multi-item satisfaction scale (physician satisfaction questionnaire-18) (r = 0.75, P < .001). Discriminant validity (among known groups) was established across groups that were stratified based on IBS-quality of life (r = 0.34; P < .0001), IBS severity (functional bowel disorders severity index) (r = -0.21; P < .001), and number of unmet expectations (r = -0.38; P < .0001).

CONCLUSIONS

The IBS-SAT is a validated measure of patient satisfaction with IBS care. As a new, condition-specific instrument, it is likely to be a useful tool for quality measurement, health services research, and clinical trials.

Increasing frequency of opioid prescriptions for chronic abdominal pain in US outpatient clinics

BACKGROUND & AIMS

Opioids are sometimes used to treat chronic abdominal pain. However, opioid analgesics have not been proven to be an effective treatment for chronic abdominal pain and have been associated with drug misuse, constipation, and worsening abdominal pain. We sought to estimate the national prescribing trends and factors associated with opioid prescribing for chronic abdominal pain.

METHODS

Chronic abdominal pain-related visits by adults to US outpatient clinics were identified using reason-for-visit codes from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey (1997-2008). Data were weighted to produce national estimates of opioid prescriptions over time. Logistic regression analyses, adjusted for complex survey design, were performed to identify factors associated with opioid use.

RESULTS

The number of outpatient visits for chronic abdominal pain consistently decreased over time from 14.8 million visits (95% confidence interval [CI], 11.6-18.0 visits) in 1997 through 1999 to 12.2 million visits (95% CI, 9.0-15.6 visits) or 1863 visits per 100,000 population in 2006 through 2008 (P for trend = 0.04). Conversely, the adjusted prevalence of visits for which an opioid was prescribed increased from 5.9% (95% CI, 3.5%-8.3%) in 1997 through 1999 to 12.2% (95% CI, 7.5%-17.0%) in 2006 through 2008 (P = 0.03 for trend). Opioid prescriptions were most common among patients aged 25 to 40 years old (odds ratio [OR] 4.6; 95% CI, 1.2-18.4). Opioid prescriptions were less common among uninsured (OR 0.1; 95% CI, 0.04-0.40) and African American (OR 0.3; 95% CI, 0.1-0.9) patients.

CONCLUSIONS

From 1997 to 2008 opioid prescriptions for chronic abdominal pain more than doubled. Further studies are needed to better understand the reasons for and consequences of this trend.

Psychosocial factors are more important than disease activity in determining gastrointestinal symptoms and health status in adults at a celiac disease referral center

BACKGROUND

The relative effects of clinical and psychosocial variables on outcome in celiac disease (CD) has not previously been reported. In adult patients with (CD), we studied the relationships among demographics, psychosocial factors, and disease activity with health-related quality of life (HRQOL), health care utilization, and symptoms.

METHODS

Among 101 adults newly referred to a tertiary care center with biopsy-proven CD we assessed: (a) demographic factors and diet status; (b) disease measures (Marsh score, tissue transglutaminase antibody (tTG) level, weight change and additional blood studies); and (c) Psychosocial status (psychological distress, life stress, abuse history, and coping). Multivariate analyses were performed to predict HRQOL, daily function, self-reported health, number of physician visits, and GI symptoms (pain and diarrhea).

RESULTS

Impaired HRQOL and daily function was associated with psychological distress and poorer coping. Self-report of poorer health was associated with poorer coping, longer symptom duration, lower education, and greater weight loss. More physician visits were associated with poorer coping, abnormal tTG levels, and milder Marsh classification. Greater pain scores were seen in those with higher psychological distress and greater weight loss. Finally, diarrhea was associated with greater psychological distress and poorer coping.

CONCLUSIONS

In patients presenting to a CD referral center, psychosocial factors more strongly affect health status and GI symptoms than disease measures.

Systematic review: self-management support interventions for irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome is an extremely common and costly condition. Because there is no cure, patients must be supported to manage their own condition.

AIM

To assess systematically the interventions used to support irritable bowel syndrome patient self-management.

METHODS

A search of PubMed, EMBASE, CINAHL and PsycINFO was performed to identify all studies that involved self-management support interventions for irritable bowel syndrome. Studies that compared the self-management-related intervention to a control group were included.

RESULTS

Eleven studies that involved a total of 1657 patients were included. For nearly all studies, the intervention was associated with statistically significant benefits. However, across studies there was significant heterogeneity in terms of sample size, diagnostic criteria, study setting, study design, primary outcome, statistical analyses and study quality. Therefore, individual study results could not be statistically combined.

CONCLUSIONS

Many self-management support interventions appear benefit patients with irritable bowel syndrome. However, studies were limited by methodological flaws. Furthermore, feasibility in 'real world' clinical practice is uncertain. Thus, practical self-management interventions that can be applied across various clinical settings should be developed, and then tested in well-designed clinical trials.

Effect of weekend hospital admission on gastrointestinal hemorrhage outcomes

OBJECTIVE

To determine whether outcomes for patients admitted with UGIH differ depending on weekend versus weekday admission, and whether any such differences are mediated by discrepancies in the use and timing of endoscopy.

METHODS

This was a cross-sectional comparison of mortality, resource use, and the utilization and timing of esophagogastroduodenoscopy (EGD) among patients admitted with upper gastrointestinal hemorrhage (UGIH) on weekends to those admitted on a weekday. Hospitals in 31 states from the Nationwide Inpatient Sample between 1998 and 2003 were included. This resulted in 75,636 patients admitted during the week and 23,339 admitted on a weekend with UGIH. Multivariable analyses were conducted to evaluate the effect of weekend admission on UGIH outcomes.

RESULTS

Compared to patients admitted on a weekday, for those admitted on a weekend: in-hospital mortality was higher (unadjusted mortality 3.76 vs. 3.33%; P = 0.003; adjusted HR = 1.09, 95% CI = 1.00-1.18); adjusted length of stay was 1.7% longer (P = 0.0098); and adjusted in-hospital charges were 3.3% higher (P = 0.0038). Although these patients were less likely to undergo endoscopy (adjusted OR = 0.94; P = 0.004) and waited longer for this procedure (adjusted HR = 0.87; P < 0.001), these discrepancies did not fully explain their inferior outcomes.

CONCLUSIONS

Weekend admission for UGIH is associated with an increased risk of death, slightly longer lengths of stay, and marginally higher in-patient charges. Discrepancies in the use and timing of endoscopy do not account for these differences.

The development and validation of a new coeliac disease quality of life survey (CD-QOL)

BACKGROUND

Previous studies on coeliac disease (CD)-related quality of life (QOL) have been limited by their use of a 'generic' rather than coeliac disease-specific assessment instruments.

AIM

To develop and psychometrically validate a new coeliac disease-specific instrument, the CD-QOL.

METHODS

Through a series of focus groups, we elicited items from patients that related to the specific nature of their disease and its impact on their basic needs. Through expert review, cognitive debriefing with patients and pilot testing, a scale was developed, refined and administered to 387 patients on a gluten-free diet from both community-based support groups and a tertiary care referral centre. Finally, a formal validation study was conducted to assess the psychometric properties of the CD-QOL.

RESULTS

The final CD-QOL has 20 items across four clinically relevant subscales (Limitations, Dysphoria, Health Concerns, and Inadequate Treatment). The CD-QOL has high internal consistency, reliability, and psychometric validation indicates both convergent and discriminate validity.

CONCLUSIONS

The CD-QOL is a reliable and valid measure of coeliac disease related QOL. As a new disease-specific instrument, it is likely to be a useful tool for evaluating patients with this disorder.

United States health care reform in 2009: a primer for gastroenterologists

The US health care system is characterized by staggering costs alongside limited access, uneven quality, and subpar health outcomes. Although federal policymakers have long acknowledged this health care crisis, there still has been no fundamental realignment in health care organization or delivery. With a new Presidential Administration and deep economic recession, profound changes now appear imminent. These changes are likely to impact gastroenterologists significantly, including who they treat, how they deliver care, and how they are compensated. This article considers the most likely reforms, including health insurance and the drive toward universal coverage; a shift to reimbursement models that reward quality over the entire episode of care; reorganization of health care delivery around more highly integrated practices, patient-centered medical homes, and accountable care organizations; and electronic health records, comparative effectiveness research, and reporting transparency as necessary tools for implementing systemic change. Finally, anticipating these changes, this article concludes with specific recommendations to enable gastroenterologists to adapt to new practice environments.

Direct-to-consumer and physician promotion of tegaserod correlated with physician visits, diagnoses, and prescriptions

BACKGROUND & AIMS

Direct-to-consumer advertisement (DTCA) and physician promotion of drugs can influence patient and physician behaviors. We sought to determine the relationship between promotion of tegaserod and the number of office visits for abdominal pain, constipation, and bloating; diagnoses of irritable bowel syndrome (IBS); and tegaserod prescriptions.

METHODS

We used an Integrated Promotional Services database to estimate tegaserod DTCA and promotion expenditures; the National Ambulatory/Hospital Medical Care Surveys (1997-2005) to estimate the number of ambulatory care visits for abdominal pain, constipation, and bloating and diagnoses of IBS; and IMS Health's National Prescription Audit Plus (Fairfield, CT) to estimate the number of prescriptions. We constructed segmented and multivariate regression models to analyze the data.

RESULTS

In the 3 months immediately following the start of tegaserod DTCA, there was a significant increase in physician visits (by 1 million; 95% confidence interval [CI], 0.5-1.6 million) and IBS diagnoses (by 397,025; 95% CI, 3909-790,141). Subsequently, the trend of visits and IBS diagnoses was reduced. In multivariate analyses that examined the overall relationship of promotion with visits, diagnoses, and prescriptions, only the relationship between physician promotion and tegaserod prescribing was significant; every $1 million spent on physician promotion resulted in an additional 4108 prescriptions (95% CI, 2526-5691).

CONCLUSIONS

The initial DTCA of tegaserod was associated with a significant, immediate increase in physician visits and IBS diagnoses. This trend reversed and, in multivariate models, neither DTCA nor physician promotion correlated with visits or diagnoses. Physician promotion (although not DTCA) correlated with tegaserod prescription volume.

Irritable bowel syndrome subtypes defined by Rome II and Rome III criteria are similar

BACKGROUND

The implications of the Rome III recommendations to change the irritable bowel syndrome (IBS) subtype criteria for stool pattern are unknown.

AIM

(1) Determine the level of agreement between Rome II and Rome III subtypes and (2) compare the behaviors of Rome II and Rome III subtypes over time.

METHODS

Female patients (n=148) with Rome II defined IBS were prospectively tracked over 5 consecutive 3-month periods. At baseline, bowel habit reports on questionnaires were used to subclassify patients into Rome II and Rome III subtypes. Over the subsequent 15 months, bowel habit reports on diary cards were used to subclassify patients based on previously derived surrogate criteria into Rome II and Rome III IBS subtypes.

RESULTS

The level of agreement between Rome II and Rome III subtype assignments was quite high (86.5%; kappa 0.79). The behavior of Rome II and Rome III subtypes over time was also similar in terms of subtype prevalence, subtype stability, and the proportion of subjects who met criteria for alternating irritable bowel syndrome.

CONCLUSIONS

Rome II and Rome III IBS subtypes are in high agreement and behave similarly over time. Therefore, studies that used Rome II subtype criteria and studies that will use Rome III criteria will define comparable populations.

A meta-analysis of the placebo response in complementary and alternative medicine trials of irritable bowel syndrome

Among patients with irritable bowel syndrome (IBS) enrolled in clinical trials of conventional medical therapy, the placebo response rate is high. IBS patients also frequently use complementary and alternative medicine (CAM), which may act through an 'enhanced placebo effect'. The purpose of this study was to estimate the magnitude of the placebo response rate in CAM trials for IBS and to identify factors that influence this response. We performed a systematic review and meta-analysis of randomized, placebo-controlled clinical trials of CAM therapies for IBS identified from MEDLINE/EMBASE/PsychLIT databases from 1970 to 2006. Placebo and active treatment response rates for global symptom improvement were assessed. Nineteen studies met the inclusion criteria. The pooled estimate of the placebo response rate was 42.6% (95% confidence interval, 38.0-46.5%). Significant heterogeneity existed across trials (range 15.0-72.2%, P < 0.00001). Higher placebo response rates correlated with a longer duration of treatment (r = 0.455, P = 0.05) and a greater number of office visits (r = 0.633, P = 0.03). Among IBS patients in CAM trials, the placebo response rate is high. That this rate is similar in magnitude to that seen in conventional medicine trials suggests that the placebo response is independent of the type of therapy used and that it is not particularly 'enhanced' in CAM trials.

Increased colonic pain sensitivity in irritable bowel syndrome is the result of an increased tendency to report pain rather than increased neurosensory sensitivity

OBJECTIVE

The aim was to determine whether lower visceral pain thresholds in irritable bowel syndrome (IBS) primarily reflect physiological or psychological factors.

METHODS

Firstly, 121 IBS patients and 28 controls underwent balloon distensions in the descending colon using the ascending methods of limits (AML) to assess pain and urge thresholds. Secondly, sensory decision theory analysis was used to separate physiological from psychological components of perception: neurosensory sensitivity (p(A)) was measured by the ability to discriminate between 30 mm Hg vs 34 mm Hg distensions; psychological influences were measured by the report criterion-that is, the overall tendency to report pain, indexed by the median intensity rating for all distensions, independent of intensity. Psychological symptoms were assessed using the Brief Symptom Inventory (BSI).

RESULTS

IBS patients had lower AML pain thresholds (median: 28 mm Hg vs 40 mm Hg; p<0.001), but similar neurosensory sensitivity (median p(A): 0.5 vs 0.5; p = 0.69; 42.6% vs 42.9% were able to discriminate between the stimuli better than chance) and a greater tendency to report pain (median report criterion: 4.0 ("mild" pain) vs 5.2 ("weak" pain); p = 0.003). AML pain thresholds were not correlated with neurosensory sensitivity (r = -0.13; p = 0.14), but were strongly correlated with report criterion (r = 0.67; p<0.0001). Report criterion was inversely correlated with BSI somatisation (r = -0.26; p = 0.001) and BSI global score (r = -0.18; p = 0.035). Similar results were seen for the non-painful sensation of urgency.

CONCLUSION

Increased colonic sensitivity in IBS is strongly influenced by a psychological tendency to report pain and urge rather than increased neurosensory sensitivity.

A meta-analysis of the placebo response in complementary and alternative medicine trials of irritable bowel syndrome

Among patients with irritable bowel syndrome (IBS) enrolled in clinical trials of conventional medical therapy, the placebo response rate is high. IBS patients also frequently use complementary and alternative medicine (CAM), which may act through an 'enhanced placebo effect'. The purpose of this study was to estimate the magnitude of the placebo response rate in CAM trials for IBS and to identify factors that influence this response. We performed a systematic review and meta-analysis of randomized, placebo-controlled clinical trials of CAM therapies for IBS identified from MEDLINE/EMBASE/PsychLIT databases from 1970 to 2006. Placebo and active treatment response rates for global symptom improvement were assessed. Nineteen studies met the inclusion criteria. The pooled estimate of the placebo response rate was 42.6% (95% confidence interval, 38.0-46.5%). Significant heterogeneity existed across trials (range 15.0-72.2%, P < 0.00001). Higher placebo response rates correlated with a longer duration of treatment (r = 0.455, P = 0.05) and a greater number of office visits (r = 0.633, P = 0.03). Among IBS patients in CAM trials, the placebo response rate is high. That this rate is similar in magnitude to that seen in conventional medicine trials suggests that the placebo response is independent of the type of therapy used and that it is not particularly 'enhanced' in CAM trials.

Inflammatory bowel disease is not a risk factor for cardiovascular disease mortality: results from a systematic review and meta-analysis

OBJECTIVES

Inflammation in general, and C-reactive protein (CRP) in particular, are closely associated with atherosclerosis. Similarly, the risk of cardiovascular (CV) disease is increased in several systemic inflammatory diseases. The purpose of this study was to examine whether inflammatory bowel disease (IBD) increases CV mortality, an indirect surrogate for CV disease incidence.

METHODS

A systematic review of studies on CV mortality rates in patients with IBD published between 1965 and 2006 was performed. Studies were included for analysis if they reported data on CV-disease-specific standardized mortality ratios (SMRs) for Crohn's disease (CD) and/or ulcerative colitis (UC). A meta-analysis of SMRs from included studies was performed.

RESULTS

The review ultimately included 11 studies. Overall there were 4,532 patients with CD and 9,533 patients with UC. SMR point estimates ranged from 0.7 to 1.5 for patients with CD and 0.6-1.1 for patients with UC. There was not a statistically significant increase in CV SMR for either CD or UC in any study. However, two studies demonstrated a statistically significant decrease in CV SMR for UC. Finally, the meta-SMR for CD was 1.0 (95% CI 0.8-1.1) and the meta-SMR for UC was 0.9 (95% CI 0.8-1.0).

CONCLUSIONS

IBD is not associated with increased CV mortality. Although CV mortality is a suboptimal surrogate for CV disease incidence, this finding provides indirect evidence against an association between IBD and CV disease.

Clinical characteristics of familial versus sporadic Crohn's disease using the Vienna Classification

BACKGROUND

The etiology of Crohn's disease, an illness protean in its manifestations, may be better resolved through studies involving more homogenous subgroups of patients. Because a strong genetic influence exists, family history of inflammatory bowel disease may be a useful variable for patient classification if patients with familial and sporadic Crohn's disease are clinically different. Our study attempted to define any possible differences.

METHODS

The medical records of 552 patients were reviewed, and patients were classified according to guidelines of the Vienna Classification. Patients were then divided based on family history of inflammatory bowel disease, and the familial and sporadic groups were compared.

RESULTS

Overall, 422 (78.9%) patients were diagnosed before age 40 years (A1) and 114 (21.1%) at age 40 years or older (A2). There were 141 (26.3%) patients with disease involving the terminal ileum only (L1), 211 (39.4%) in the colon only (L2), 117 (21.9%) in the terminal ileum and colon (L3), and 66 (12.3%) in the upper gastrointestinal tract (L4). Disease behavior, as determined at the time of last visit or telephone contact, was nonstricturing, nonpenetrating (B1) in 149 (27.9%) patients, stricturing (B2) in 50 (9.3%) patients, and penetrating (B3) in 336 (62.8%) patients. Comparisons among the groups of 53 patients with first-degree relatives only, the 96 patients with either first-, second-, or third-degree relatives (familial CD group), and the 439 patients with sporadic disease demonstrated no differences in sex, age at diagnosis, or disease location. There was a difference in disease behavior between the familial and sporadic groups (p = 0.048) that failed to exist when nonstricturing, nonpenetrating cases were excluded. No such difference was observed between the first-degree relatives only group and the sporadic group (p > 0.10).

CONCLUSIONS

Using the Vienna Classification, familial and sporadic Crohn's disease differed only in disease behavior. However, this difference failed to exist after patients with nonstricturing, nonpenetrating disease were excluded. Therefore, familial and sporadic groups appear to be quite similar clinically, and family history does not appear to be a variable useful for disease subclassification.