Symptom and health-related quality-of-life measures for use in selected gastrointestinal disease studies: a review and synthesis of the literature

Identification of upper GI diseases during screening gastroscopy using a deep convolutional neural network algorithm

BACKGROUND AND AIMS

The clinical application of GI endoscopy for the diagnosis of multiple diseases using artificial intelligence (AI) has been limited by its high false-positive rates. There is an unmet need to develop a GI endoscopy AI-assisted diagnosis system (GEADS) to improve diagnostic accuracy and clinical utility.

METHODS

In this retrospective, multicenter study, a convolutional neural network was trained to assess upper GI diseases based on 26,228 endoscopic images from Dazhou Central Hospital that were randomly assigned (3:1:1) to a training dataset, validation dataset, and test dataset, respectively. To validate the model, 6 external independent datasets comprising 51,372 images of upper GI diseases were collected. In addition, 1 prospective dataset comprising 27,975 images was collected. The performance of GEADS was compared with endoscopists with 2 professional degrees of expertise: expert and novice. Eight endoscopists were in the expert group with >5 years of experience, whereas 3 endoscopists were in the novice group with 1 to 5 years of experience.

RESULTS

The GEADS model achieved an accuracy of .918 (95% confidence interval [CI], .914-.922), with an F1 score of .884 (95% CI, .879-.889), recall of .873 (95% CI, .868-.878), and precision of .890 (95% CI, .885-.895) in the internal validation dataset. In the external validation datasets and 1 prospective validation dataset, the diagnostic accuracy of the GEADS ranged from .841 (95% CI, .834-.848) to .949 (95% CI, .935-.963). With the help of the GEADS, the diagnosing accuracies of novice and expert endoscopists were significantly improved (P < .001).

CONCLUSIONS

The AI system can assist endoscopists in improving the accuracy of diagnosing upper GI diseases.

Diabetic Enteropathy: From Molecule to Mechanism-Based Treatment

The incidence of the micro- and macrovascular complications of diabetes is rising, mirroring the increase in the worldwide prevalence. Arguably, the most common microvascular complication is neuropathy, leading to deleterious changes in both the structure and function of neurons. Amongst the various neuropathies with the highest symptom burden are those associated with alterations in the enteric nervous system, referred to as diabetic enteropathy. The primary aim of this review is to provide a contemporaneous summary of pathophysiology of diabetic enteropathy thereby allowing a "molecule to mechanism" approach to treatment, which will include 4 distinct aspects. Firstly, the aim is to provide an overview of the diabetes-induced structural remodelling, biochemical dysfunction, immune-mediated alterations, and inflammatory properties of the enteric nervous system and associated structures. Secondly, the aim is to provide a synopsis of the clinical relevance of diabetic enteropathy. Thirdly, the aim is to discuss the various patient-reported outcome measures and the objective modalities for evaluating dysmotility, and finally, the aim is to outline the clinical management and different treatment options that are available. Given the burden of disease that diabetic enteropathy causes, earlier recognition is needed allowing prompt investigation and intervention, which may lead to improvements in quality of life for sufferers.

High Rates of Smoking Especially in Female Crohn's Disease Patients and Low Use of Supportive Measures to Achieve Smoking Cessation--Data from the Swiss IBD Cohort Study

BACKGROUND AND AIMS

Smoking is a crucial environmental factor in inflammatory bowel disease [IBD]. However, knowledge on patient characteristics associated with smoking, time trends of smoking rates, gender differences and supportive measures to cease smoking provided by physicians is scarce. We aimed to address these questions in Swiss IBD patients.

METHODS

Prospectively obtained data from patients participating in the Swiss IBD Cohort Study was analysed and compared with the general Swiss population [GSP] matched by age, sex and year.

RESULTS

Among a total of 1770 IBD patients analysed [49.1% male], 29% are current smokers. More than twice as many patients with Crohn's disease [CD] are active smokers compared with ulcerative colitis [UC] [UC, 39.6% vs CD 15.3%, p < 0.001]. In striking contrast to the GSP, significantly more women than men with CD smoke [42.8% vs 35.8%, p = 0.025], with also an overall significantly increased smoking rate compared with the GSP in women but not men. The vast majority of smoking IBD patients [90.5%] claim to never have received any support to achieve smoking cessation, significantly more in UC compared with CD. We identify a significantly negative association of smoking and primary sclerosing cholangitis, indicative of a protective effect. Psychological distress in CD is significantly higher in smokers compared with non-smokers, but does not differ in UC.

CONCLUSIONS

Despite well-established detrimental effects, smoking rates in CD are alarmingly high with persistent and stagnating elevations compared with the GSP, especially in female patients. Importantly, there appears to be an unacceptable underuse of supportive measures to achieve smoking cessation.

Psychometric development of the Gastrointestinal Symptom Rating Questionnaire (GSRQ) demonstrated good validity

OBJECTIVES

To develop and validate a gastrointestinal (GI) symptom rating questionnaire for patients with luminal GI symptoms including where no diagnosis has been made.

STUDY DESIGN AND SETTING

We developed and validated the Gastrointestinal Symptom Rating Questionnaire (GSRQ) in three stages: (1) item generation to identify the relevant items for scale inclusion; (2) development and piloting on patients with a known GI disorder; and (3) testing in a sample of trial patients. We examined the underlying dimensions of the scale, internal consistency, validity, reproducibility, and responsiveness.

RESULTS

We identified four interpretable factors on the GSRQ. The GSRQ had good internal consistency (corrected item-subscale correlations between 0.4 and 0.8) and Cronbach's alpha greater than 0.7 for each subscale. Construct validity was demonstrated by modest but significant correlations with the Short Form 36 and the EQ5D index value. We demonstrated good reproducibility with intraclass correlations for test-retest scores between 0.71 and 0.77, and significant responsiveness ratios for all subscales in patients who had improved, and in two of the subscales in patients who had deteriorated.

CONCLUSION

The GSRQ could be a useful tool to monitor quality of life in various luminal GI conditions and where a formal diagnosis has not been made.

Combination of symptoms, syndrome and disease: Treatment of refractory diabetic gastroparesis

AIM: To assess effect of combination of symptoms, syndrome and disease on treatment of diabetic gastroparesis with severe nausea and vomiting.

METHODS: Professor Tong Xiaolin’s clinical electronic medical records of patients who were treated between January 1, 2006 and October 1, 2012 were used as a database. Patients who met the inclusion criteria were enrolled. General information (name, sex and age), symptoms and blood glucose levels were obtained from the clinic electronic medical record, which was supplemented by a telephone interview. The patient-rated Gastroparesis Cardinal Symptom Index (GCSI) was used to evaluate the severity of the symptoms of gastroparesis. The effects of the treatment were assessed by the change in the severity of the symptoms of gastroparesis and the change in blood glucose between the baseline levels and the post-treatment levels at 1, 2, 4, 8 and 12 wk.

RESULTS: Forty-five patients had a mean GCSI nausea and vomiting severity score of 4.21 ± 0.67 and a total GCSI score of 2.77 ± 0.63 before treatment. There was a significant improvement in the nausea and vomiting score at every return visit compared with the baseline score (1 wk: 3.02 ± 1.04 vs 4.18 ± 0.71, P < 0.001; 2 wk: 2.32 ± 1.25 vs 4.16 ± 0.73, P < 0.001; 4 wk: 2.12 ± 1.26 vs 4.12 ± 0.73, P < 0.001; 8 wk: 1.79 ± 1.09 vs 4.24 ± 0.77, P < 0.001; 12 wk: 0.69 ± 0.92 vs 4.25 ± 0.70, P < 0.001). Twenty-five of the 45 patients had complete resolution of vomiting during the observation period (mean time to resolution was 37.9 ± 27.3 d). The postprandial fullness and early satiety subscale, bloating subscale and total GCSI scores were also improved. Finally, the blood glucose levels improved after treatment, although the change was not significant.

CONCLUSION: Use of the combination of symptoms, syndrome and disease to treat diabetic gastroparesis with refractory nausea and vomiting may be a new treatment option.

Methods for clinical evaluation of diabetic gastroparesis

An effective clinical assessment method is necessary for the development of new drugs. Currently, main methods for clinical evaluation of diabetic gastroparesis (DGP) include evaluation of gastric emptying, patients' subjective evaluation of disease severity and the change in pathogenic factors. However, there are many problems that need to address; the methods for the evaluation of gastric emptying have not been widely used, there is no uniform standard for the patients' subjective evaluation, and the pathogenic factors for DGP are not completely clear. In this article we will review the methods for clinical evaluation of DGP, with the emphasis on the above problems.

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

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Translation and validation of the Nepean Dyspepsia Index for functional dyspepsia in China

AIM: To assess the reliability and validity of the translated version of Nepean Dyspepsia Index (NDI) in Chinese patients with documented functional dyspepsia (FD).

METHODS: The translation process included forward translation, back translation, pretest and cross-cultural adaptation. Reliability and validity of the translated version were examined by asking 300 subjects to complete the Chinese version of the NDI. The mean age of subjects was 39.24 years and 68.7% of the subjects were women. Internal consistency analysis with Cronbach’s α was performed to test the reliability. Correlation analysis was used to assess the content validity. Factor analysis and structural equation models were used to assess the construct validity.

RESULTS: The Cronbach’s α coefficients ranged 0.833-0.960, well above the acceptable level of 0.70. Correlation analysis showed that each item had a strong correlation with the corresponding domain, but a weak correlation with other domains. Confirmatory factor analysis indicated that the comparative fit index was 0.94, higher than the acceptable level of 0.90.

CONCLUSION: The Chinese version of the NDI is a reliable and valid scale for measuring health-related quality of life and disease severity in Chinese patients with FD.

Impact of PPIs on patient focused symptomatology in GERD

About half of patients with gastroesophageal reflux disease (GERD) have a normal endoscopy, so symptom assessment is the only appropriate outcome measure for these persons. Symptom assessment is also of great importance in persons with erosive esophagitis. There is currently no fully validated questionnaire to compare symptom response to treatment of patients with GERD. The aim of this review is to consider ReQuest^™ assessment tool to evaluate esophageal, supra-esophageal, and infra-esophageal symptoms, as well as any modification of the patient’s quality of life. The ReQuest^™ may be combined with the Los Angeles classification of esophagitis (LA A–D), to include the normal endoscopic finding in normal endoscopy reflux disease. The ReQuest^™ score declines rapidly towards normal with patient treatment with a proton pump inhibitor. A proportion of patients need more than the usual 8 weeks of therapy. For example, in GERD patients with Los Angeles B–D, the ReQuest^™ score falls more with pantoprazole 40 mg than with esomoprazole 40 mg after 12 weeks of therapy. Now that the simplified ReQuest in Practice^™ is available, this validated brief questionnaire has potential as an instrument for use in GERD patients seen in everyday clinical practice.

Systematic review: health-related quality of life (HRQOL) questionnaires in gastro-oesophageal reflux disease

BACKGROUND

Although gastro-oesophageal reflux disease (GERD) has a well-established pathophysiology, the impact of GERD symptoms on the patients' quality of life can be profound. Therefore, health-related quality of life (HRQOL) questionnaires have become standard instruments to evaluate the effect of treatment in clinical trials.

AIM

To evaluate the reliability, validity and responsiveness of available GERD-specific HRQOL.

METHODS

A systematic literature search using the Medical Subject Headings terms: 'Gastro-oesophageal reflux', 'Heartburn' and 'Oesophagitis' with 'quality of life' and 'questionnaires' was preformed to identify the available HRQOL questionnaires. To analyse the psychometric properties of the respective tools, the actual guidelines for the use of patient-reported outcomes in clinical trials were applied.

RESULTS

We identified five GERD-specific HRQOL questionnaires but none of them fulfilled all quality criteria; either they did not meet the actual standards for psychometric properties (HBQOL, GERD-HRQL, Jasani et al.Aust Fam Physician 1999; 28: 515), or were impracticable to use in clinical trials. The generic and hybrid instruments lack specificity and sensitivity and were not designed for treatment evaluation in GERD patients.

CONCLUSION

There is need for a new evaluative tool in the assessment of HRQOL during GERD therapy.

Flexible coping psychotherapy for functional dyspeptic patients: a randomized, controlled trial

OBJECTIVE

This study tested the efficacy of a new psychotherapy, flexible coping psychotherapy (FCP), specifically designed for enhancing coping flexibility of patients with functional dyspepsia (FD). The design of this psychotherapy is based on the general cognitive-behavioral model and previous findings on FD.

METHODS

We adopted a randomized, controlled design to examine the differences between the target (FCP) and control (supportive psychotherapy [SPP]) conditions. Coping flexibility and outcome measures reported by 75 Chinese FD patients (18-65 years; 35% men) were assessed before and 12 months after treatment.

RESULTS

Results revealed that participants who received the FCP reported an increase in coping flexibility as well as reductions in self-rated dyspeptic symptom severity (SDSS), gastroenterologist-rated dyspeptic symptom severity, and anxiety levels (p values <.01). Participants who received the SPP reported reductions in SDSS and anxiety levels (p values <.0001). Although both groups reported a decrease in SDSS, only the SDSS level of the FCP group was comparable to that of a healthy community sample (p = .28).

CONCLUSIONS

These findings suggest that FCP is a potentially effective intervention for treating FD symptoms. Its effectiveness may be attributable to the specific components of FCP rather than common psychotherapeutic factors such as emotional support and empathy per se.

Translation and validation of the Chinese version of the Gastrointestinal Quality of Life Index in patients with gastric tumor

OBJECTIVE

Patients with gastric tumor are known to have deterioration in quality of life (QOL) following surgery. However, there is no valid disease-specific self-report QOL measure for clinical practice and research designated for Chinese in Hong Kong. The current study aimed at translating and validating a Chinese version of the Gastrointestinal Quality of Life Index (C-GIQLI) for use in patients with gastric tumors after gastrectomy.

METHODS

A translation of the English version of the instrument was performed. The psychometric properties of the C-GIQLI were investigated using internal consistency analysis, correlational analysis, and confirmatory factor analysis in 140 Chinese patients who had undergone surgery for gastric tumor.

RESULTS

The C-GIQLI demonstrated good test-retest reliability, internal consistency, and a factor structure consistent with the measurement model of the European version of the instrument.

CONCLUSION

The C-GIQLI is recommended as a valid and reliable self-report measure of QOL in patients with gastric tumor after gastrectomy.

Quality of life in patients with functional dyspepsia: Short- and long-term effect of Helicobacter pylori eradication with pantoprazole, amoxicillin, and clarithromycin or cisapride therapy: A prospective, parallel-group study

BACKGROUND

Quality of life (QOL) is impaired in functional dyspepsia (FD). Little is known about the effects of different therapies on the QOL profile in patients with this condition.

OBJECTIVES

The aims of this study were to measure baseline QOL in patients with FD and to assess changes in QOL over time associated with Helicobacter pylori eradication and prokinetic treatment. The primary and secondary end points were the improvement in QOL 6 weeks and 1 year after successful eradication of the infection or prokinetic therapy.

METHODS

This 1-year, single-center, prospective, open-label, controlled, parallel-group trial was conducted at the Department of Gastroenterology, Ferencvdros Health Centre, Budapest, Hungary. The Functional Digestive Disorder Quality of Life (FDDQoL) Questionnaire (MAPI Research Institute, Lyon, France) was translated and validated previously in Hungarian. Male and female subjects aged 20 to 60 years were enrolled and classified as H pylori positive (HP+), H pylori negative (HP-) with FD, or healthy (control group). The HP+ patients received pantoprazole 40 mg BID + amoxicillin 1000 mg BID + clarithromycin 500 mg BID for 7 days, followed by on-demand ranitidine (150-300 mg/d) for 1 year. The HP- patients received the prokinetic cisapride 10 mg TID for 1 month, followed by on-demand cisapride (10-20 mg/d) for 1 year. The FDDQoL questionnaire was completed by all 3 groups on enrollment, at 6 weeks, and 1 year.

RESULTS

A total of 101 HP+ patients, 98 HP- patients, and 123 healthy controls were included in the study (185 women, 137 men; mean age, 39.0 ears). The mean (SD) baseline QOL scores were significantly lower in the HP+ group (53.3 [9.6]; 95% CI, 54.4-58.2) and the HP- groups (50.0 [9.8]; 95% CI, 58.0-62.0) compared with that in healthy controls (76.2 [8.7]; 95% CI, 74.6-77.8) (both, P < 0.001). Analysis of the short-term domain scores found that the HP+ group had significantly decreased scores in 6 of 8 domains: daily activities (P = 0.005), anxiety level (P = 0.02), diet (P = 0.008), sleep (P < 0.001), discomfort (P = 0.004), and disease control (P = 0.02); the HP- group had significantly decreased scores in 5 of 8 domains: daily activities (P < 0.001), diet (P = 0.004), sleep (P = 0.005), discomfort (P < 0.001), and disease control (P = 0.02). Eradication of the infection was successful in 77/101 (76.2%) of the patients on intent-to-treat analysis and 77/94 (81.9%) on per-protocol analysis. Eradication was associated with an increase in mean (SD) QOL score to 70.8 (10.7) at 6 weeks (95% CI, 63.3-73.2; P < 0.001 vs baseline) and to 75.3 (9.3) at 1 year (95% CI, 73.2-77.5; P= 0.05 vs 6 weeks). In the HP- group, the QOL score increased to 73.3 (9.7) (95% CI, 71.3-75.4; P < 0.001 vs baseline) at 6 weeks of cisapride treatment and to 76.5 (8.5) at 1 year (95% CI, 74.5-78.4; P = 0.06 vs 6 weeks). Most of the impaired domain scores improved significantly after both treatments. The short-term effect size was 1.48 in HP+ and 1.35 in HP- patients. Adverse events (AEs) occurred in 22 (21.8%) patients in the HP+ group (nausea, 8 [7.9%] patients; diarrhea, 5 [5.0%]; loss of appetite, 5 [5.0%]; stomatitis, 5 [5.0%]; abdominal pain, 4 [4.0%]; bloating, 4 [4.0%]; headache, 4 [4.0%]; vomiting, 4 [4.0%]; constipation, 3 [3.0%]; and vaginitis, 3 [3.0%]). In HP- cases, AEs occurred in 9 (9.2%) patients (abdominal cramps, 7 [7.1%]; diarrhea, 4 [4.1%]; and nausea, 3 [3.1%]).

CONCLUSION

In this study in patients with FD and healthy controls, eradication of H pylori infection in infected patients and cisapride treatment in uninfected patients reversed low QOL scores during the 1-year follow-up period.

The infant gastroesophageal reflux questionnaire revised: development and validation as an evaluative instrument

BACKGROUND & AIMS

Gastroesophageal reflux disease (GERD) is frequently experienced by infants, and disease-specific measures are needed to evaluate treatment benefits. We revised the Infant Gastroesophageal Reflux Questionnaire (I-GERQ) on the basis of information from parents of infants with GERD and physicians and subjected it to a psychometric evaluation.

METHODS

A 3-week, multi-country observational study of 185 caregivers of infants younger than 18 months with GERD and 93 caregivers of control infants was conducted. Caregivers completed the I-GERQ-R weekly and recorded symptoms in a Daily Diary. Caregivers and physicians rated global disease severity and change in overall GERD symptoms.

RESULTS

Slightly more than half of infants were male with a mean age of 6.7 months, and most infants had been diagnosed with GERD for a little more than 2 months (mean, 66.7 days). Internal consistency reliability for the I-GERQ-R ranged from 0.86 to 0.87, and test-retest reliability was 0.85. Construct validity was demonstrated by significant differences between cases and controls on all item scores (all P<.01) and the total score (P<.0001), correlations with relevant Daily Diary symptoms, and both physician-rated (P<.05) and caregiver-rated disease severity (P<.05). Mean baseline to 3-week I-GERQ-R change scores for those infants whose caregivers reported improvement was -5.7 compared with -0.3 for those whose caregivers reported worse/same (P<.001). Physician ratings of change resulted in similar findings, with mean changes of -5.7 for those rated improved and -0.1 for those rated as worse/same (P<.0001).

CONCLUSION

This study demonstrated the I-GERQ-R is a reliable, valid, and clinically responsive measure of infant GERD symptoms.

Patient reported outcomes in gastroesophageal reflux disease: an overview of available measures

Gastroesophageal reflux disease (GERD) is a common, chronic disorder. The main symptom of GERD is heartburn, although a diverse range of symptoms can be associated with the disease including acid regurgitation and epigastric pain. GERD is also a risk factor for Barrett's oesophagus and esophageal adenocarcinoma. The impact of GERD symptoms on patients' lives can be profound and is unrelated to the presence or absence of esophagitis. The impact of GERD can be measured by assessing the patient perspective using Patient Reported Outcomes (PROs). There are two categories of questionnaires that can be used to measure the effect of GERD on health-related quality of life (HRQoL), namely generic and disease or treatment specific. The use of PRO instruments has become more accepted in the assessment of disease treatment. Well-designed instruments that assess physical, psychological and emotional factors can provide clinicians with the data that will promote effective management decisions for the treatment of GERD. The most frequently used instruments in GERD are reviewed here, in terms of their psychometric properties.

Validation of a Quality-of-Life Instrument for Laryngopharyngeal Reflux

OBJECTIVES

To establish the reliability, validity, and responsiveness of a new, disease-specific assessment tool, the LPR-HRQL, which assesses patient-reported outcomes (PRO) with regard to health-related quality of life (HRQL) of patients with laryngopharyngeal reflux (LPR).

DESIGN

A prospective, open-label, repeated-measures study.

SETTING

Six centers in 4 states in the eastern United States.

PATIENTS

Patients with LPR.

INTERVENTIONS

Open-label treatment with 20 mg of omeprazole twice daily. Clinical and PRO HRQL data were collected. Several PRO instruments were administered to patients at each of several time points; these instruments included the Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36), a general HRQL tool; the Voice Handicap Index (VHI), a symptom-specific tool for assessing voice problems; and the QOLRAD instrument (Quality of Life in Reflux and Dyspepsia), used to assess the impact of gastroesophageal reflux disease.

RESULTS

Factor analyses of the LPR-HRQL scales confirmed single dimensions for each. All LPR-HRQL items contributed to internal consistency of scales and had substantial variability permitting useful information. Substantial evidence of convergent and divergent validity with SF-36, VHI, and QOLRAD items was observed. Test-retest validity was adequate for the time interval tested. Changes in domain scores of the LPR-HRQL at 4 and 6 months documented its responsiveness.

CONCLUSIONS

The LPR-HRQL displays reliability, validity, and responsiveness, has face validity, and is simple and not burdensome to administer, score, and analyze. Accordingly, it may be used to assist physicians and patients in understanding the HRQL burden of LPR and the impact of therapy.

Development and psychometric evaluation of the patient assessment of upper gastrointestinal symptom severity index (PAGI-SYM) in patients with upper gastrointestinal disorders

OBJECTIVE

Describe the development and evaluation of a new self-report instrument, the patient assessment of upper gastrointestinal disorders-symptom severity index (PAGI-SYM) in subjects with gastroesophageal reflux disease (GERD), dyspepsia, or gastroparesis.

METHODS

Recruited subjects with GERD (n=810), dyspepsia (n = 767), or gastroparesis (n = 169) from the US, France, Germany, Italy, the Netherlands, and Poland. Subjects completed the PAGI-SYM, SF-36, a disease-specific HRQL measure (PAGI-QOL), and disability day questions. Two-week reproducibility was evaluated in 277 stable subjects. We evaluated construct validity by correlating subscale scores with SF-36, PAGI-QOL, disability days, and global symptom severity scores.

RESULTS

The final 20-item PAGI-SYM has six subscales: heartburn/regurgitation, fullness/early satiety, nausea/vomiting, bloating, upper abdominal pain, and lower abdominal pain. Internal consistency reliability was good (alpha = 0.79-0.91); test-retest reliability was acceptable (Intraclass correlation coefficients alpha=0.60-0.82). PAGI-SYM subscale scores correlated significantly with SF-36 scores (all p < 0.0001), PAGI-QOL scores (all p < 0.0001), disability days (p < 0.0001), and global symptom severity (p < 0.0001). Mean PAGI-SYM scores varied significantly in groups defined by disability days (all p < 0.0001), where greater symptom severity was associated with more disability days.

CONCLUSIONS

Results suggest the PAGI-SYM, a brief symptom severity instrument, has good reliability and evidence supporting construct validity in subjects with GERD, dyspepsia, or gastroparesis.

Cross-cultural development and validation of a patient self-administered questionnaire to assess quality of life in upper gastrointestinal disorders: The PAGI-QOL�

OBJECTIVE

Summarize the Patient Assessment of Upper GastroIntestinal Disorders-Quality of Life (PAGI-QOL) development and provide results on its reliability and validity from the international psychometric validation in dyspepsia, GastroEsophageal Reflux Disease (GERD), and gastroparesis.

METHODS

Subjects completed the pilot PAGI-QOL at baseline and 8 weeks; and a subsample also at 2 weeks. Other assessments were: Patient Assessment of Upper Gastrointestinal Disorders-Symptom Severity Index, SF-36, number of disability days.

RESULTS

1736 patients completed the PAGI-QOL at baseline. The questionnaire was reduced, producing a 30-item final version covering five domains: Daily Activities, Clothing, Diet and Food Habits, Relationship (REL), and Psychological Well-Being and Distress. Internal consistency was excellent (Cronbach's alpha range: 0.83-0.96). Test-retest reproducibility was good: intraclass correlations coefficients were over 0.70 except for the REL scale (0.61). Concurrent validity between the PAGI-QOL total score and all SF-36 subscale scores was good with moderate (0.52) to strong (0.72) correlations. PAGI-QOL scores showed excellent discriminant properties: patients who had spent some days in bed, had missed some days at work, and were kept from usual activities had much lower PAGI-QOL scores than those who did not (p < 0.0001).

CONCLUSION

The PAGI-QOL is a valid and reliable instrument assessing quality of life in patients with dyspepsia, GERD, or gastroparesis.

Responsiveness and interpretation of a quality of life questionnaire specific to upper gastrointestinal disorders

BACKGROUND AND AIMS

The Patient Assessment of Upper Gastrointestinal Disorders-Quality of Life (PAGI-QOL) has been developed and validated to assess quality of life in gastroesophageal reflux disease, dyspepsia, and gastroparesis. The aim of this work was to assess responsiveness of the PAGI-QOL to clinical changes and provide guidance for the interpretation of score changes.

METHODS

The analysis was based on 2 observational multicenter, longitudinal, 8-week observation studies, one in the United States and one in 5 European countries. The Overall Treatment Effect scale completed by patients and clinicians at 8 weeks was used to define groups of improved, worsened, and stable patients. Responsiveness was assessed by describing the change in PAGI-QOL scores for each of these groups, comparing these changes over time, and calculating effect sizes and standardized response means. These data were used to define the minimal clinically important difference.

RESULTS

A total of 1736 patients with upper gastrointestinal disorders were analyzed. High sensitivity to change over time was demonstrated, with effect sizes and standardized response means in improved patients for the PAGI-QOL total score ranging from 0.79-1.41. A change of 0.4 for the PAGI-QOL total score might be considered as the minimal clinically important difference when comparing pretreatment and post-treatment PAGI-QOL total scores.

CONCLUSIONS

The PAGI-QOL questionnaire is a responsive and clinically relevant instrument for assessing quality of life in patients with upper gastrointestinal disorders.

The impact of laryngopharyngeal reflux on patient-reported quality of life

OBJECTIVES/HYPOTHESIS

The objectives were to assess patient-reported outcomes, specifically, the health-related quality of life of patients with laryngopharyngeal reflux, and to compare those reported levels with the health-related quality of life of patients with gastroesophageal reflux disease and a general population.

STUDY DESIGN

Prospective study.

METHODS

As part of a prospective study to validate a health-related quality of life instrument for laryngopharyngeal reflux, patient-reported data were collected before the initiation of therapy. Use of the Short Form-36 (SF-36), a generic instrument, allowed the health-related quality of life of the patients with laryngopharyngeal reflux to be compared with benchmarks existing for patients with gastroesophageal reflux disease and a general U.S. population.

RESULTS

The 117 patients with laryngopharyngeal reflux often reported multiple symptoms, most frequently, chronic throat-clearing (85.5%), globus (82.1%), and hoarseness (80.3%). Their mean health-related quality of life was statistically significantly worse than that of a general U.S. population in seven of the eight SF-36 domains. The most dramatic differences between patients with laryngopharyngeal reflux and the general population were in social functioning and bodily pain (P <.001). Mean scores for patients with laryngopharyngeal reflux were significantly lower than those for patients with gastroesophageal reflux disease in social functioning (P <.001) and vitality (P =.0017). In five of the six remaining domains, patients with laryngopharyngeal reflux reported lower mean scores than did patients with gastroesophageal reflux disease, but those differences were not statistically significant.

CONCLUSION

The study's assessment of health-related quality of life suggests that laryngopharyngeal reflux has a significant negative impact on the lives of patients. Although its impact is similar in some respects to that of gastroesophageal reflux disease, laryngopharyngeal reflux has a more significant impact on patients' social functioning and vitality.

Patient assessment of treatment satisfaction: methods and practical issues

Measurement of treatment satisfaction in gastro-oesophageal reflux disease (GORD) is compromised by an insufficient conceptual foundation and poor assessment methods. The current state of the art in measuring treatment satisfaction is incomplete, and the existing measurement is insufficient. Here, the definition, conceptualisation, application, and methodological issues associated with measurement of treatment satisfaction in GORD are reviewed. Treatment satisfaction may be important for differentiating among GORD treatments, and for monitoring patient outcomes in clinical practice.

Systematic review: do we need a new gastro-oesophageal reflux disease questionnaire?

BACKGROUND

Gastro-oesophageal reflux disease (GERD) is highly prevalent in Western countries. Because the majority of patients do not present with endoscopic abnormalities, the assessment of the symptom severity and quality of life, and their response to treatment, has become increasingly important. Self-assessed symptom questionnaires are now key instruments in clinical trials.

AIM

To evaluate the validity of available GERD measurement tools.

METHODS

An ideal GERD symptom assessment instrument, suitable as a primary end-point for clinical trials, should possess the following characteristics: (i) be sensitive in patients with GERD; (ii) cover the frequency and intensity of typical and atypical GERD symptoms; (iii) be multidimensional (cover all symptom dimensions); (iv) have proven psychometric properties (validity, reliability and responsiveness); (v) be practical and economical; (vi) be self-assessed; (vii) use 'word pictures' which are easy to understand for patients; (viii) respond rapidly to changes (responsiveness over short time intervals); (ix) be used daily to assess changes during and after therapy; and (x) be valid in different languages for international use.

RESULTS

A literature review revealed five scales that met some of the above characteristics, but did not fulfil all criteria.

CONCLUSION

There is a need for a new evaluative tool for the assessment of GERD symptoms and their response to therapy.

Impact of functional gastrointestinal disorders on health-related quality of life: a population-based case-control study

BACKGROUND

The health-related quality of life is impaired in patients with functional gastrointestinal disorders seen in referral centres.

AIM

To determine whether the health-related quality of life is impaired in subjects with functional disorders in the community and whether any differences can be explained by psychological co-morbidity.

METHODS

In a population-based, nested, case-control study, subjects reporting symptoms of either dyspepsia or irritable bowel syndrome and healthy controls were interviewed and completed a battery of psychological measures plus a validated, generic, health-related quality of life measure (Medical Outcomes Study 36-item short form health survey, SF-36). The association between irritable bowel syndrome and dyspepsia and the physical and mental composite scores of SF-36 were assessed with and without adjustment for psychological state.

RESULTS

One hundred and twelve cases (30 dyspepsia, 39 irritable bowel syndrome, 32 dyspepsia and irritable bowel syndrome and 11 gastrointestinal symptoms but not dyspepsia or irritable bowel syndrome) and 110 controls were enrolled. In the unadjusted linear regression models, irritable bowel syndrome (but not dyspepsia) was negatively associated with the physical composite score (P < 0.05); in an adjusted model, the association between the physical health-related quality of life and irritable bowel syndrome was explained by the Symptom Checklist-90 somatization score alone. In unadjusted models, irritable bowel syndrome and dyspepsia were each negatively associated with the mental composite score (P < 0.05). The association between the mental health-related quality of life and dyspepsia remained after adjusting for psychological covariates, but the association between this and irritable bowel syndrome was not significant after adjustment.

CONCLUSIONS

In the community, health-related quality of life is impaired in subjects with irritable bowel syndrome and dyspepsia; however, much of this association can be explained by psychological factors.

The clinical characteristics and impact of laryngopharyngeal reflux disease on health-related quality of life

BACKGROUND AND OBJECTIVES

Although it is accepted that reflux of stomach acid causes gastroesophageal reflux disease (GERD), it is less well understood that it also contributes to the clinical signs and symptoms of laryngitis in the form of laryngopharyngeal reflux (LPR). Study objectives were to identify what is known about the impact of LPR on health-related quality of life (HRQL) compared with the impact of GERD on HRQL and to assess whether currently available HRQL instruments adequately measure this impact or if a new disease-specific instrument should be recommended.

METHODS

The authors combined a systematic literature review with prospective patient evaluation via focus groups. The review, using MEDLINE, focused on clinical characteristics and HRQL measurement and impact. Focus groups involving a total of 30 patients with LPR provided input on clinical manifestations of the disease and its HRQL impact.

RESULTS

Information gleaned from the literature indicates that less than 40% of patients presenting with symptoms of laryngitis directly attributable to reflux also report experiencing the classic symptoms of heartburn and acid regurgitation associated with GERD. Reflux laryngitis is thus a distinct clinical entity from GERD and may have a unique impact on HRQL. Although multiple instruments are available to assess the impact of GERD on HRQL, no specific instruments are available for LPR. Focus group discussions identified voice problems, chronic cough, throat clearing, and swallowing difficulties to be key concerns of patients with LPR. These manifestations negatively impact HRQL as described by the focus group participants, notably in role functioning, physical well-being, and emotional well-being.

CONCLUSIONS

A disease-specific instrument to assess the impact of LPR on HRQL would contribute to clinical care and the evaluation of new therapies. This instrument would ideally be sensitive to the variety of LPR's symptomatic presentations.

Development and validation of a patient-assessed gastroparesis symptom severity measure: the Gastroparesis Cardinal Symptom Index

BACKGROUND

Patient-based symptom assessments are necessary to evaluate the effectiveness of medical treatments for gastroparesis.

AIM

To summarize the development and measurement qualities of the Gastroparesis Cardinal Symptom Index (GCSI), a new measure of gastroparesis-related symptoms.

METHODS

The GCSI was based on reviews of the medical literature, clinician interviews and patient focus groups. The measurement qualities (i.e. reliability, validity) of the GCSI were examined in 169 gastroparesis patients. Patients were recruited from seven clinical centres in the USA to participate in this observational study. Patients completed the GCSI, SF-36 Health Survey and disability day questions at a baseline visit and again after 8 weeks. Clinicians independently rated the severity of the patients' symptoms, and both clinicians and patients rated the change in gastroparesis-related symptoms over the 8-week study.

RESULTS

The GCSI consists of three sub-scales: post-prandial fullness/early satiety, nausea/vomiting and bloating. The internal consistency reliability was 0.84 and the test-re-test reliability was 0.76 for the GCSI total score. Significant relationships were observed between the clinician-assessed symptom severity and the GCSI total score, and significant associations were found between the GCSI scores and SF-36 physical and mental component summary scores and restricted activity and bed disability days. Patients with greater symptom severity, as rated by clinicians, reported greater symptom severity on the GCSI. The GCSI total scores were responsive to changes in overall gastroparesis symptoms as assessed by clinicians (P = 0.0002) and patients (P = 0.002).

CONCLUSION

The findings of this study indicate that the GCSI is a reliable and valid instrument for measuring the symptom severity in patients with gastroparesis.

Cognitive and motivational processes underlying coping flexibility: a dual-process model

Discriminative facility was proposed as a cognitive process and need for closure was proposed as a motivational process underlying coping flexibility. The dual-process model posits that need for closure influences discriminative facility, which in turn modifies coping flexibility and psychological adjustment. In Study 1, results of structural equation modeling provided support for the dual-process model. This model was further examined using experimental methods (Study 2) and a prospective design (Study 3). Consistent with the dual-process model, results from all 3 studies showed that participants who were more motivated to seek alternative coping strategies tended to encode stressful situations in a more differentiated way. These individuals used a greater variety of strategies to fit different situational demands and were better adjusted.

Heartburn in patients with gastro-oesophageal reflux disease in Germany and Sweden: a study on patients' burden of disease

BACKGROUND

Gastro-oesophageal reflux disease (GORD) is widespread in the general population and presents in most cases with heartburn as the main symptom. The severity of symptoms is not necessarily related to erosive damage to the oesophagus due to acid reflux, but the frequency and severity of symptoms have an impact on the health-related QOL (HR-QOL) of the patient.

OBJECTIVE

To characterise patients with GORD who consult a physician because of heartburn with respect to medical background and burden of disease in Germany and Sweden.

METHODS

A total of 1011 patients who had been experiencing symptoms of GORD, including heartburn, for at least 1 year were recruited by physicians, who collected data on the patients' previous diagnosis and treatment. The patients themselves were interviewed by telephone about their heartburn. The EuroQOL 5-dimensional HR-QOL questionnaire (EQ-5D) and the Gastrointestinal Symptom Rating Scale (GSRS) were used to measure patient-reported outcomes.

RESULTS

About half of the patients had been experiencing symptoms of GORD for >5 years. The majority (54%) perceived the severity of their heartburn as moderate. Thirty-eight percent of the patients had been examined by endoscopy during the last 12 months and 79% of these had macroscopic oesophagitis. Medical treatment for heartburn had been prescribed to 88% of the patients. The mean annual number of days with heartburn was assessed as 170 days per patient, with the majority of patients (64%) experiencing heartburn every week. HR-QOL was reduced in these patients as expressed by EQ-5D scores compared to scores for a general population. Patients with GORD had problems related to gastrointestinal symptoms as rated by GSRS scores. More severe heartburn was associated with a greater number of symptom days and reduced HR-QOL scores, whereas a relationship between the findings at endoscopy and the severity of symptoms or HR-QOL could not be found.

CONCLUSION

This study demonstrates that heartburn confers a significant burden on patients with GORD, related to the frequency and severity of symptoms and reflected in the reduction in HR-QOL as perceived by the patients.

The impact of treatment for gastro-oesophageal reflux disease on health-related quality of life: a literature review

Gastro-oesophageal reflux disease (GORD) is common in the general population and is diagnosed based on patient-reported symptoms and clinical tests. Although clinical tests are available, significant percentages of patients report symptoms of heartburn and reflux despite negative endoscopies, and 24-hour pH tests are not often used by primary-care physicians in diagnosis. Consequently, patient-reported symptoms and health-related QOL (HR-QOL) are important in assessing treatment outcome. HR-QOL is significantly impaired in patients with GORD, and HR-QOL is associated with symptom severity and changes in GORD-related symptoms. The objective of this literature review is to examine the impact of pharmacological treatment on HR-QOL in patients with GORD. Generic and disease-specific HR-QOL measures have been used in clinical trials to evaluate the impact of GORD on patient functioning and well-being. The Psychological General Well-Being (PGWB) Index and the 36-Item Short-Form Health Survey (SF-36) have been used in several clinical trials of treatment for GORD and have consistently shown that HR-QOL improves with successful therapy. These trials have been conducted primarily with two pharmacological agents, omeprazole and ranitidine. On the Heartburn-specific Quality of Life questionnaire, patients treated with ranitidine reported better HR-QOL after treatment compared with placebo therapy. In two clinical trials where omeprazole and ranitidine were compared, patients treated with omeprazole reported significantly better HR-QOL (based on the PGWB Index) than those treated with ranitidine; however, 2 other trials did not detect significant differences between the treatments. Results from clinical trials using disease-specific measures (Gastrointestinal Quality of Life Index [GIQLI] and Heartburn-specific Quality of Life questionnaire) demonstrate similar findings, supporting the association between treatment-related symptom resolution and improvements in HR-QOL. The GIQLI was used in a trial comparing pantoprazole and ranitidine, where results favoured pantoprazole therapy. Several studies have demonstrated that resolution of GORD symptoms is associated with improvement in HR-QOL. Although there is evidence that treatment for GORD does improve symptoms and HR-QOL outcomes, further research is needed to more completely understand the value of medical therapy for GORD.

Health-related quality of life among persons with irritable bowel syndrome: a systematic review

AIM

To perform a systematic review of the literature with three objectives: (1) to compare the health related quality of life (HRQoL) of patients with irritable bowel syndrome with that of healthy controls; (2) to compare the HRQoL of irritable bowel syndrome patients to those with other diseases; and (3) to examine therapy-associated changes in HRQoL of irritable bowel syndrome patients.

METHODS

Searches of all English and non-English articles from 1980 to 2001 were performed in Medline and Embase, and two investigators performed independent data abstraction.

RESULTS

Seventeen articles met our selection criteria. 13 studies addressed objective no. 1; 11 showed a significant reduction in HRQoL among irritable bowel syndrome patients. Of these, only one study was considered of high quality. Four studies addressed objective no. 2, none of which was considered to be high quality in addressing this objective. Four trials (three of high quality) addressed objective no. 3. One showed that symptomatic improvement with Leupron compared to placebo was accompanied an improvement only in the comparative health domain of the HRQoL. The second study reported significant positive changes in HRQoL after 12 weeks of cognitive behavioural therapy. The third report of two placebo-controlled studies indicated significant improvement with alosetron on most domains of Irritable Bowel Syndrome Quality of Life Questionnaire.

CONCLUSIONS

(i) There is reasonable evidence for a decrease in HRQoL in patients with moderate to severe irritable bowel syndrome; however, the data are conflicting regarding the impact of irritable bowel syndrome on HRQoL in population-based studies of nonconsulters. (ii) HRQoL in irritable bowel syndrome patients is impaired to a degree comparable to other chronic disorders such as GERD and depression. (iii) A therapeutic response in irritable bowel syndrome-related pain has a corresponding improvement in HRQoL. (iv) Limitations of the literature include focusing on moderate-severe irritable bowel syndrome in referral centres, and lack of appropriate controls

Validity of a Work Productivity and Activity Impairment questionnaire for patients with symptoms of gastro-esophageal reflux disease (WPAI-GERD)--results from a cross-sectional study

OBJECTIVES

To validate a Work Productivity and Activity Impairment questionnaire (WPAI-GERD) developed to measure lost productivity due to symptoms of gastro-esophageal reflux disease (GERD).

METHODS AND DATA

The WPAI-GERD was administered along with two quality-of-life questionnaires, Quality of Life in Reflux and Dyspepsia (QOLRAD) and Short Form 36 (SF-36), to a Swedish working population (N = 136) visiting a general practitioner for symptoms attributed to GERD. Correlation coefficients were calculated between each productivity variable derived from the WPAI-GERD and symptom severity, symptom frequency, quality of life dimensions, age, and gender. Statistical tests were carried out to determine the relationship between each productivity variable and the severity of heartburn.

RESULTS

High correlations (range: 0.30-0.75) were found between productivity and symptom severity as well as between productivity and quality-of-life dimensions related to work and daily activities. The results demonstrated the ability of the questionnaire to discriminate between different grades of heartburn severity. On average, patients with heartburn reported 2.5 hours absence from work, 23% reduced productivity while at work, and 30% reduced productivity while doing regular daily activities during the week preceding the consultation. The SF-36 scores implied that patients, especially those with moderate-to-severe heartburn, had a poor quality of life compared with a normal population.

CONCLUSION

The results indicate a high convergent and discriminant validity of the WPAI-GERD questionnaire and also show that patients consulting a physician because of symptoms attributed to GERD report substantial impairment in both productivity and health-related quality of life.

Health-related quality of life and gastrointestinal disease

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