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Sanayei AM, Mo C, Ballou S, McHenry N, Rangan V, Singh P, Iturrino J, Lembo A, Nee J. Burden and Treatment of Chronic Upper GI Symptoms and Diagnoses: A Nationwide Study. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00084-3. [PMID: 38278192 DOI: 10.1016/j.cgh.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 12/17/2023] [Accepted: 01/08/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND & AIMS Chronic gastrointestinal (GI) symptoms are a common reason for seeking medical care. We aim to determine the rates of ambulatory care use and to characterize demographics, work-up, and treatment (pharmacologic and nonpharmacologic) for patients with chronic upper GI symptoms and conditions in the United States. METHODS Estimates of annual visits for the most common upper GI symptoms and diagnoses including gastroesophageal reflux disease, dyspepsia, nausea and vomiting, and gastroparesis were recorded from the 2007-2015 National Ambulatory Medical Care Surveys. Only chronic conditions, defined as >3 months, were included. We calculated the weighted proportion of ambulatory visits associated with pharmacologic, nonpharmacologic treatment (eg, diet, complementary and alternative medicine), or both. RESULTS A total of 116,184,475 weighted ambulatory visits were identified between the years of 2007 and 2015 for adults (average of 12,909,386 annual visits) with chronic upper GI symptoms and diagnoses. Gastroesophageal reflux disease was the most common reason for an ambulatory visit (n = 11,200,193), followed by dyspepsia (n = 1,232,598), nausea and vomiting (n = 714,834), and gastroparesis (n = 140,312). Pharmacologic treatment was more common than nonpharmacologic treatment (44.7% vs 28.5%). A total of 37.6% of patients were not receiving treatment at the time of the visit. These treatment patterns did not significantly change over the time of our study. Upper endoscopies were the most ordered test, representing 7.5% of all investigated upper GI symptoms. CONCLUSIONS Chronic upper GI symptoms and diagnoses account for a high number of annual health care visits, both in primary care and specialty care. Although there are several treatments, many of these patients are not on any treatments.
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Affiliation(s)
- Ava M Sanayei
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
| | - Chen Mo
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Sarah Ballou
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Nicole McHenry
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Vikram Rangan
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Prashant Singh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Johanna Iturrino
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Anthony Lembo
- Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
| | - Judy Nee
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Ballou S, Rangan V, Eidelberg A, Proctor S, McHenry N, Nee J, Iturrino J, Lembo A, Singh P. What Is Unspecified Functional Bowel Disorder? A Commonly Seen, Rarely Recognized, and Poorly Understood Diagnosis. Am J Gastroenterol 2023; 118:1402-1409. [PMID: 37053553 DOI: 10.14309/ajg.0000000000002281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 04/04/2023] [Indexed: 04/15/2023]
Abstract
INTRODUCTION Unspecified functional bowel disorder (FBD-U) is a Rome IV diagnosis of exclusion and occurs when patients report bowel symptoms but do not meet the criteria for other functional bowel disorders (FBD; irritable bowel syndrome [IBS], functional constipation [FC], functional diarrhea [FDr], or functional bloating). Previous research suggests that FBD-U is as/more common than IBS. METHODS One thousand five hundred one patients at a single-center tertiary care center completed an electronic survey. Study questionnaires included Rome IV Diagnostic Questionnaires, anxiety, depression, sleep, health care utilization, and bowel symptom severity measures. RESULTS Eight hundred thirteen patients met Rome IV criteria for a FBD and 194 patients (13.1%) met criteria for FBD-U, representing the second most common FBD after IBS. Severity of abdominal pain, constipation, and diarrhea were lower in FBD-U compared with other FBD, whereas health care utilization was similar among the groups. Scores on measures of anxiety, depression, and sleep disturbances were similar in FBD-U compared with FC and FDr but were less severe than IBS. Between 25% and 50% of patients with FBD-U did not meet Rome IV criteria for other FBD due to timing of onset of the target symptom (e.g., constipation for FC, diarrhea for FDr, and abdominal pain for IBS). DISCUSSION FBD-U, by Rome IV criteria, is highly prevalent in clinical settings. These patients are not represented in mechanistic studies or clinical trials for not having met Rome IV criteria for other FBD. Making future Rome criteria less stringent would minimize the number fulfilling criteria for FBD-U and maximize the true representation of FBD in clinical trials.
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Affiliation(s)
- Sarah Ballou
- Division of Gastroenterology and Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Vikram Rangan
- Division of Gastroenterology and Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Andrew Eidelberg
- Division of Gastroenterology and Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Samantha Proctor
- Division of Gastroenterology and Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Nicole McHenry
- Division of Gastroenterology and Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Judy Nee
- Division of Gastroenterology and Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Johanna Iturrino
- Division of Gastroenterology and Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Anthony Lembo
- Cleveland Clinic, Digestive Disease and Surgery Institute, Cleveland, Ohio, USA
| | - Prashant Singh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Ahmed A, McHenry N, Gulati S, Shah I, Sheth SG. Racial and Ethnic Disparities in Opioid Prescriptions for Patients with Abdominal Pain: Analysis of the National Ambulatory Medical Care Survey. J Clin Med 2023; 12:5030. [PMID: 37568432 PMCID: PMC10419480 DOI: 10.3390/jcm12155030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/21/2023] [Accepted: 07/27/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Disparities in pain control have been extensively studied in the hospital setting, but less is known regarding the racial/ethnic disparities in opioid prescriptions for patients with abdominal pain in ambulatory clinics. METHODS We examined opioid prescriptions during visits by patients presenting with abdominal pain between the years of 2006 and 2015, respectively, in the National Ambulatory Medical Care Survey database. Data weights for national-level estimates were applied. RESULTS We identified 4006 outpatient visits, equivalent to 114 million weighted visits. Rates of opioid use was highest among non-Hispanic White patients (12%), and then non-Hispanic Black patients (11%), and was the lowest in Hispanic patients (6%). Hispanic patients had lower odds of receiving opioid prescriptions compared to non-Hispanic White patients (OR = 0.49; 95% CI, 0.31-0.77, p = 0.002) and all non-Hispanic patients (OR 0.48; 95% CI 0.30-0.75; p = 0.002). No significant differences were noted in non-opioid analgesia prescriptions (p = 0.507). A higher frequency of anti-depressants/anti-psychotic prescriptions and alcohol use was recorded amongst the non-Hispanic patients (p = 0.027 and p = 0.001, respectively). CONCLUSIONS Rates of opioid prescriptions for abdominal pain patients were substantially lower for the Hispanic patients compared with the non-Hispanic patients, despite having a decreased rate of high-risk features, such as alcohol use and depression. The root cause of this disparity needs further research to ensure equitable access to pain management.
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Affiliation(s)
- Awais Ahmed
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Rabb 423, Boston, MA 02215, USA; (A.A.); (N.M.)
| | - Nicole McHenry
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Rabb 423, Boston, MA 02215, USA; (A.A.); (N.M.)
| | - Shivani Gulati
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Rabb 423, Boston, MA 02215, USA; (A.A.); (N.M.)
| | - Ishani Shah
- Department of Internal Medicine, Division of Gastroenterology, University of Utah Hospital, 50 N Medical Drive, Salt Lake City, UT 84132, USA
| | - Sunil G. Sheth
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Rabb 423, Boston, MA 02215, USA; (A.A.); (N.M.)
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Anderson K, Shah I, Yakah W, Cartelle AL, Zuberi SA, McHenry N, Horton L, Ahmed A, Freedman SD, Kothari DJ, Sheth SG. Prospective evaluation of an emergency department protocol to prevent hospitalization in mild acute pancreatitis: Outcomes and predictors of discharge. Pancreatology 2023; 23:299-305. [PMID: 36870814 DOI: 10.1016/j.pan.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/27/2023] [Accepted: 02/21/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND While acute pancreatitis (AP) contributes significantly to hospitalizations and costs, most cases are mild with minimal complications. In 2016, we piloted an observation pathway in the emergency department (ED) for mild AP and showed reduced admissions and length of stay (LOS) without increased readmissions or mortality. After 5 years of implementation, we evaluated outcomes of the ED pathway and identified predictors of successful discharge. METHODS We reviewed a prospectively enrolled cohort of patients with mild AP presenting to a tertiary care center ED between 10/2016 and 9/2021, evaluating LOS, charges, imaging, and 30-day readmission, and assessed predictors of successful ED discharge. Patients were divided into two main groups: successfully discharged via the ED pathway ("ED cohort") and admitted to the hospital ("admission cohort"), with subgroups to compare outcomes, and multivariate analysis to determine predictors of discharge. RESULTS Of 619 AP patients, 419 had mild AP (109 ED cohort, 310 admission cohort). The ED cohort was younger (age 49.3 vs 56.3,p < 0.001), had lower Charlson Comorbidity Index (CCI) (1.30 vs 2.43, p < 0.001), shorter LOS (12.3 h vs 116 h, p < 0.001), lower charges (mean $6768 vs $19886, p < 0.001) and less imaging, without differences in 30-day readmissions. Increasing age (OR: 0.97; p < 0.001), increasing CCI (OR: 0.75; p < 0.001) and biliary AP (OR: 0.10; p < 0.001) were associated with decreased ED discharge, while idiopathic AP had increased ED discharge (OR: 7.8; p < 0.001). CONCLUSIONS After appropriate triage, patients with mild AP (age <50, CCI <2, idiopathic AP) can safely discharge from the ED with improved outcomes and cost savings.
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Affiliation(s)
- Kelsey Anderson
- Department of Internal Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Ishani Shah
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - William Yakah
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Anabel Liyen Cartelle
- Department of Internal Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Shaharyar A Zuberi
- Department of Internal Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Nicole McHenry
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Laura Horton
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Awais Ahmed
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Steven D Freedman
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Darshan J Kothari
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Duke University Medical Center, Durham, NC, USA
| | - Sunil G Sheth
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA.
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Yu V, McHenry N, Proctor S, Wolf J, Nee J. Gastroenterologist Primer: Endometriosis for Gastroenterologists. Dig Dis Sci 2023; 68:2482-2492. [PMID: 36653576 DOI: 10.1007/s10620-022-07674-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 08/14/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND AND AIM A comprehensive understanding of endometriosis and its common gastrointestinal presentations are critical for gastroenterologists to ensure appropriate and timely screening and diagnosis. Endometriosis is a common inflammatory disease that frequently presents with gastrointestinal symptoms overlapping with irritable bowel syndrome (IBS) and other gastrointestinal disorders. Many endometriosis patients first present to a gastroenterologist or generalist, which may prolong the time to diagnosis and appropriate care. METHOD AND RESULTS This review describes the current literature on endometriosis presentation, overlap with gastrointestinal conditions, and standard diagnostic and treatment options for gastroenterologists to consider. For appropriate and swift treatment, gastroenterologists must consider an endometriosis diagnosis in females of menstruating age presenting with pain, bloating, altered stools, and non-gastrointestinal symptoms and refer patients for further evaluation.
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Affiliation(s)
- Vanessa Yu
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA.
| | - Nicole McHenry
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Samantha Proctor
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Jacqueline Wolf
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Judy Nee
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
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McHenry N, Ahmed A, Shah I, Freedman SD, Nee J, Lembo A, Sheth SG. Racial and Ethnic Disparities in Opioid Prescriptions in Benign and Malignant Pancreatic Disease in the United States. Pancreas 2022; 51:1359-1364. [PMID: 37099779 DOI: 10.1097/mpa.0000000000002180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
OBJECTIVES Racial-ethnic disparities in pain management are common but not known among pancreatic disease patients. We sought to evaluate racial-ethnic disparities in opioid prescriptions for pancreatitis and pancreatic cancer patients. METHODS Data from the National Ambulatory Medical Care Survey were used to examine racial-ethnic and sex differences in opioid prescriptions for ambulatory visits by adult pancreatic disease patients. RESULTS We identified 207 pancreatitis and 196 pancreatic cancer patient visits, representing 9.8 million visits, but weights were repealed for analysis. No sex differences in opioid prescriptions were found among pancreatitis (P = 0.78) or pancreatic cancer patient visits (P = 0.57). Opioids were prescribed at 58% of Black, 37% of White, and 19% of Hispanic pancreatitis patient visits (P = 0.05). Opioid prescriptions were less common in Hispanic versus non-Hispanic pancreatitis patients (odds ratio, 0.35; 95% confidence interval, 0.14-0.91; P = 0.03). We found no racial-ethnic differences in opioid prescriptions among pancreatic cancer patient visits. CONCLUSIONS Racial-ethnic disparities in opioid prescriptions were observed in pancreatitis, but not pancreatic cancer patient visits, suggesting possible racial-ethnic bias in opioid prescription practices for patients with benign pancreatic disease. However, there is a lower threshold for opioid provision in the treatment of malignant, terminal disease.
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Affiliation(s)
| | | | | | | | - Judy Nee
- From the Digestive Disease Center
| | | | - Sunil G Sheth
- Pancreas Center, Beth IsraelDeaconess Medical Center, Boston, MA
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McHenry N, Shah I, Ahmed A, Freedman SD, Kothari DJ, Sheth SG. Racial Variations in Pain Management and Outcomes in Hospitalized Patients With Acute Pancreatitis. Pancreas 2022; 51:1248-1250. [PMID: 37078952 DOI: 10.1097/mpa.0000000000002160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
OBJECTIVES Acute pancreatitis (AP) is a common cause of hospitalization. Black AP patients have higher risk for alcoholic etiology and hospitalization than White patients. We evaluated outcomes and treatment disparities by race in hospitalized AP patients. METHODS We retrospectively analyzed Black and White AP patients admitted 2008-2018. Primary outcomes were length of stay, intensive care unit admission, 30-day readmissions, and mortality. Secondary outcomes included pain scores, opioid dosing, and complications. RESULTS We identified 630 White and 186 Black AP patients. Alcoholic AP (P < 0.001), tobacco use (P = 0.013), and alcohol withdrawal (P < 0.001) were more common among Blacks. There were no differences in length of stay (P = 0.113), intensive care unit stay (P = 0.316), 30-day readmissions (P = 0.797), inpatient (P = 0.718) or 1-year (P = 0.071) mortality, complications (P = 0.080), or initial (P = 0.851) and discharge pain scores (P = 0.116). Discharge opioids were prescribed more frequently for Whites (P = 0.001). CONCLUSIONS Hospitalized Black and White AP patients had similar treatment and outcomes. Standardized protocols used to manage care may eliminate racial biases. Disparities in discharge opioid prescriptions may be explained by higher alcohol and tobacco use by Black patients.
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Affiliation(s)
- Nicole McHenry
- From the Digestive Disease Center, Beth Israel Deaconess Medical Center
| | - Ishani Shah
- From the Digestive Disease Center, Beth Israel Deaconess Medical Center
| | - Awais Ahmed
- From the Digestive Disease Center, Beth Israel Deaconess Medical Center
| | | | - Darshan J Kothari
- Division of Gastroenterology and Hepatology, Duke University Medical Center, Durham, NC
| | - Sunil G Sheth
- Pancreas Center, Beth Israel Deaconess Medical Center, Boston, MA
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