Effect of faecal calprotectin testing on referrals for children with chronic gastrointestinal symptoms in primary care: study protocol for a cluster randomised controlled trial

General practitioners' experiences with chronic abdominal symptoms and a faecal calprotectin guided referral strategy in children: A Dutch qualitative study

BACKGROUND

General practitioners (GPs) often struggle to distinguish functional gastrointestinal disorders (FGID) from organic disorders in children with chronic abdominal symptoms. A referral strategy guided by faecal calprotectin (FCal) testing may help.

OBJECTIVE

This study explores GPs' experiences with these children and the strategy.

METHODS

GPs were sampled purposively to data saturation. Ultimately, we conducted one focus group session and 13 semi-structured interviews with 17 Dutch GPs who had been involved in a randomised controlled trial evaluating an FCal-testing strategy. The online focus group and interviews were recorded, transcribed verbatim, and subject to thematic content analysis.

RESULTS

Four themes arose: diagnostic confidence, fear of missing something severe, reassurance and managing FGID in primary care. Although GPs typically felt confident during the diagnostic process, they did fear missing somatic or psychosocial conditions. They felt more diagnostically confident due to FCals clear indications, high diagnostic accuracy, and non-invasiveness. Reassurance was considered crucial in children with FGID, either by labelling symptoms, providing explanatory models, or offering medical interventions (e.g. FCal testing). When helping children with FGID proved too difficult, GPs referred to specialist care. Besides the integration of FCal during reassurance, the testing strategy did not help GPs manage children with FGID.

CONCLUSION

While the FCal-strategy improved diagnosis according to GPs, they found the primary challenge to be managing children with FGID. Nevertheless, they found the FCal-strategy beneficial, likely due to its integration into reassurance strategies. Further research focusing on enhancing communication and interventions for paediatric FGID in primary care is warranted.

Management of children with non-acute abdominal pain and diarrhea in Dutch primary care: a retrospective cohort study based on a routine primary care database (AHON)

OBJECTIVE

To describe the testing, prescription, referral, and follow-up management by general practitioners (GPs) for children presenting with non-acute abdominal pain and/or diarrhea in primary care.

DESIGN

Retrospective cohort study with one-year follow-up.

SETTING

Registry data from a Dutch primary care database (AHON) between 2015 and 2019.

SUBJECTS

Children aged 4-18 years old who presented by face-to-face consultation in primary care for non-acute abdominal pain and/or diarrhea (>7 days).

MAIN OUTCOME MEASURES

We recorded the proportions of children who received (1) diagnostic testing, medicine prescriptions, follow-up consultations, and referrals at their first visit and (2) repeat consultations and referrals by one-year of follow-up.

RESULTS

Among the 2200 children (median age, 10.5 years; interquartile range, 7.0-14.6) presenting to a GP with non-acute abdominal pain and/or diarrhea, most reported abdominal pain (78.7%). At the first visit, GPs performed diagnostic testing for 32.2%, provided a prescription to 34.5%, and referred 2.5% to secondary care. Twenty-five percent of the children had a follow-up consultation within four weeks and 20.8% had a repeat consultation between four weeks and one year. Thirteen percent of the children were referred to secondary care by one year. However, only 1% of all children had documentation of an organic diagnosis needing management in secondary care.

CONCLUSION

One-third of children received diagnostic testing or a medicine prescription. Few had a follow-up consultation and >10% was referred to pediatric care. Future research should explore the motivations of GPs why and which children receive diagnostic and medical interventions.

Promoting early testing and appropriate referral to reduce diagnostic delay for children with suspected inflammatory bowel disease, a narrative review

BACKGROUND AND OBJECTIVE

When a child with chronic gastrointestinal (GI) symptoms presents to a primary care physician or general paediatrician, the clinician is challenged with differentiating between functional or organic disease. When there is a high suspicion of inflammatory bowel disease (IBD), rapid referral to a paediatric gastroenterologist for assessment and treatment will help protect against the sequelae of a delayed diagnosis for a child. However, this must be balanced against the need for ensuring appropriate referrals and avoiding invasive diagnostic testing for those with non-organic aetiology. The objective of this narrative review was to present evidence on specific presenting symptoms, testing, and risk factors of paediatric IBD that may aid the identification of children requiring timely referral for specialist care, thereby reducing the chance of a delayed diagnosis.

METHODS

Literature databases (Medline, Embase) were searched using terms specific to the population studied, and topic specific terms relating to each section of the review. Year limits were set for 2010-2022. Included papers were limited to original research, with meta-analyses considered where of benefit.

KEY CONTENT AND FINDINGS

Children often present with non-specific GI symptoms that may be associated with a delayed diagnosis for those with subsequent IBD. Symptoms such as rectal bleeding or weight loss may indicate the need for rapid referral. However, non-specific symptoms necessitate testing strategies to differentiate between those with possible IBD and non-organic conditions. Definitive laboratory testing for IBD is not yet available. This review outlines those metrics that should be considered and monitored, then utilised to make a comprehensive referral to tertiary care for specialist paediatric gastroenterology review. Summaries are provided relating to presenting symptoms, extra-intestinal manifestations (EIMs), and alarm symptoms in order to highlight those reported most frequently. The diagnostic accuracy and importance of interpreting faecal calprotectin (FC) levels, in conjunction with additional measures, are also outlined.

CONCLUSIONS

Diagnostic testing to effectively identify children with IBD without the need for endoscopy is not yet available. Primary care physicians and general paediatricians must, therefore, rely on interpreting a combination of symptoms, laboratory parameters, and risk factors to assess the need for specialist referral and diagnosis.

Qualitative study evaluating the expectations and experiences of Dutch parents of children with chronic gastrointestinal symptoms visiting their general practitioner

OBJECTIVES

Chronic gastrointestinal symptoms are common among children and affect their daily activities and quality of life. The majority will be diagnosed with a functional gastrointestinal disorder. Effective reassurance and education are, therefore, key components of the physician's management. Qualitative studies have shown how parents and children experience specialist paediatric care, yet less is known about general practitioners (GPs), who manage most cases in the Netherlands and have a more personal and enduring relationship with their patients. Therefore, this study evaluates the expectations and experiences of parents of children visiting a GP for chronic gastrointestinal symptoms.

DESIGN

We conducted a qualitative interview study. Online interviews were audio and video recorded, transcribed verbatim and independently analysed by the first two authors. Data were collected and analysed concurrently until data saturation was reached. Using thematic analysis, we developed a conceptual framework reflecting respondent expectations and experiences. We performed a member check of the interview synopsis and the conceptual framework.

SETTING

Dutch primary care.

PARTICIPANTS

We purposively sampled participants from a randomised controlled trial evaluating the effectiveness of faecal calprotectin testing in children with chronic gastrointestinal complaints in primary care. Thirteen parents and two children participated.

RESULTS

Three key themes emerged: disease burden, GP-patient relationship and reassurance. Often, the experienced disease burden and the pre-existing GP-patient relationship influenced expectations (eg, for further investigations or a sympathetic ear), and when a GP fulfilled these expectations, a trusting GP-patient relationship ensued that facilitated reassurance. We found that individual needs influenced these themes and their interrelationships.

CONCLUSION

Insights provided by this framework could help GPs managing children with chronic gastrointestinal symptoms in daily practice and may therewith improve the consultation experience for parents. Further research should evaluate whether this framework also holds true for children.

TRIAL REGISTRATION NUMBER

NL7690.