Cluster-Randomized Comparative Effectiveness Trial of Physician-Directed Clinical Decision Support Versus Patient-Directed Education to Promote Appropriate Use of Opioids for Chronic Pain

We compared the effectiveness of physician-directed clinical decision support (CDS) administered via electronic health record versus patient-directed education to promote the appropriate use of opioids by conducting a cluster-randomized trial involving 82 primary care physicians and 951 of their patients with chronic pain. Primary outcomes were satisfaction with patient-physician communication consumer assessment of health care providers and system clinician and group survey (CG-CAHPS) and pain interference patient-reported outcomes measurement information system. Secondary outcomes included physical function (patient-reported outcomes measurement information system), depression (PHQ-9), high-risk opioid prescribing (>90 morphine milligram equivalents per day [≥90 mg morphine equivalent/day]), and co-prescription of opioids and benzodiazepines. We used multi-level regression to compare longitudinal difference-in-difference scores between arms. The odds of achieving the maximum CG-CAHPS score were 2.65 times higher in the patient education versus the CDS arm (P = .044; 95% confidence interval [CI] 1.03-6.80). However, baseline CG-CAHPS scores were dissimilar between arms, making these results challenging to interpret definitively. No difference in pain interference was found between groups (Coef = -0.64, 95% CI -2.66 to 1.38). The patient education arm experienced higher odds of Rx ≥ 90 milligrams morphine equivalent/day (odds ratio = 1.63; P = .010; 95% CI 1.13, 2.36). There were no differences between groups in physical function, depression, or co-prescription of opioids and benzodiazepines. These results suggest that patient-directed education may have the potential to improve satisfaction with patient-physician communication, whereas physician-directed CDS via electronic health records may have greater potential to reduce high-risk opioid dosing. More evidence is needed to ascertain the relative cost-effectiveness between strategies. PERSPECTIVE: This article presents the results of a comparative-effectiveness study of 2 broadly used communication strategies to catalyze dialog between patients and primary care physicians around chronic pain. The results add to the decision-making literature and offer insights about the relative benefits of physician-directed versus patient-directed interventions to promote the appropriate use of opioids.

Gastrointestinal symptom severity in irritable bowel syndrome, inflammatory bowel disease and the general population

BACKGROUND

Irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD) patients report similar gastrointestinal (GI) symptoms, yet comparisons of symptom severity between groups and with the general population (GP) are lacking.

METHODS

We compared Patient-Reported Outcomes Measurement Information System (PROMIS^® ) GI symptom scales measuring gastro-esophageal reflux (GER), disrupted swallowing, diarrhea, bowel incontinence, nausea/vomiting, constipation, belly pain, and gas/bloating in: (i) USA GP sample, (ii) IBS patients, and (iii) IBD patients from tertiary care and community populations. Symptom severity scores were based on T-score metric with mean 50±10 (standard deviation) relative to the GP.

KEY RESULTS

Of 1643 patients enrolled, there were 253 IBS patients (68% F, mean age 45±15 years), 213 IBD patients (46% F, mean age 41±14 years), and 1177 GP subjects (57% F, mean age 46±16 years). IBS patients reported greater severity of GER, disrupted swallowing, nausea/vomiting, belly pain, gas/bloating, and constipation symptoms than their IBD counterparts (all P<.05). Compared to the GP, IBD patients had worse belly pain, gas/bloating, diarrhea, and bowel incontinence, but less severe GER and disrupted swallowing (all P<.05), and IBS patients had more severe nausea/vomiting, belly pain, gas/bloating, and constipation (all P<.05). Women had more severe belly pain and gas/bloating than men, whereas men had more severe bowel incontinence (all P<.05).

CONCLUSION & INFERENCES

IBS and IBD are associated with more severe GI symptoms compared to the GP excluding esophageal symptoms. Unlike IBD, IBS is not characterized by observable GI inflammation but patients report more severe upper and lower GI symptoms.

Responsiveness to Change and Minimally Important Differences of the Patient-Reported Outcomes Measurement Information System Gastrointestinal Symptoms Scales

BACKGROUND

The NIH-sponsored Patient-Reported Outcomes Measurement Information System (PROMIS) Gastrointestinal (GI) Symptoms scales were developed to assess patients' GI symptoms in clinical settings.

AIMS

To assess responsiveness to change and provide minimally important difference (MID) estimates for the PROMIS GI Symptoms scales.

METHODS

A sample of 256 GI outpatients self-administered the eight PROMIS GI Symptoms scales (gastroesophageal reflux, disrupted swallowing, diarrhea, bowel incontinence/soilage, nausea and vomiting, constipation, belly pain, and gas/bloating/flatulence) at two visits. Patient self-reported and physician-reported assessments of the subjects' overall GI condition were employed as change anchors. In addition, we prospectively assessed change at both visits using a GI-symptom anchor, the Gastrointestinal Symptom Rating Scale (GSRS). Responsiveness to change was assessed using F-statistics. The minimally changed group was those somewhat better or somewhat worse on the retrospective anchors and changing by one category on the modified GSRS (e.g., from slight to mild discomfort to moderate to moderately severe discomfort).

RESULTS

Responsiveness to change was statistically significant for 6 of 8 PROMIS scales using the self-report GI anchor, 3 of 8 scales using the physician-reported anchor, and 5 of 5 scales using the corresponding GSRS scales as anchors. The MID estimates for scales for improvement and worsening were about 0.5-0.6 SD using the GSRS anchor and generally larger in magnitude than the change for the "about the same" group.

CONCLUSIONS

The responsiveness and MID estimates provided here for the PROMIS GI Symptoms scales can aid in scale score interpretation in clinical trials and observational studies.

PRISM, a Patient-Reported Outcome Instrument, Accurately Measures Symptom Change in Refractory Gastroesophageal Reflux Disease

BACKGROUND

Most patients with gastroesophageal reflux disease (GERD) experience relief following treatment with proton pump inhibitors (PPIs) (Vakil et al. in Am J Gastroenterol 101:1900-1920, 2006; Everhart and Ruhl in Gastroenterology 136:376-386, 2009). As many as 17-44% of patients, however, exhibit only partial response to therapy. Most extant GERD patient-reported outcome (PRO) instruments fail to meet development best practices as described by the FDA (Talley and Wiklund in Qual Life Res 14:21-33, 2005; Van Pinxteren et al. in Cochrane Database Syst Rev 18:CD002095, 2004; El-Serag et al. in Aliment Pharmacol Ther 32:720-737, 2010).

AIM

To develop and validate a PRO instrument for clinical trials involving patients with GERD who are PPI partial responders.

METHODS

We prepared a systematic literature review, held patient focus groups, convened an expert panel, and conducted cognitive interviews to establish content validity. Eligible participants took PPI therapy for at least 8 weeks, had undergone an upper endoscopy, and scored at least 8 points on the GerdQ [6]. Qualitative data guided development of 26 draft items. Items were reviewed by expert panels and debriefed with patients. The resulting 21-item instrument underwent psychometric evaluation during a Phase IIB trial.

RESULTS

During the trial, confirmatory factor analysis (n = 220) resulted in a four-factor model displaying the highest goodness of fit. All domains had a high inter-item correlation (Cronbach's α > 0.8). Test-retest reliability and convergent validity were strong, with highly significant (p < 0.01) correlations between average weekly PRISM scores and severity anchors and significant (p < 0.05) correlations with anchor subscales. Cumulative distribution functions revealed significant differences between responders and non-responders.

CONCLUSIONS

Analysis in a clinical trial setting demonstrated strong psychometric properties suggesting validity of PRISM. Developed in line with FDA guidance on PROs, PRISM represents an important new outcome measure for patients with GERD with a partial response to PPI therapy.

Impact of National Institutes of Health Gastrointestinal PROMIS Measures in Clinical Practice: Results of a Multicenter Controlled Trial

OBJECTIVES

The National Institutes of Health (NIH) created the Patient Reported Outcomes Measurement Information System (PROMIS) to allow efficient, online measurement of patient-reported outcomes (PROs), but it remains untested whether PROMIS improves outcomes. Here, we aimed to compare the impact of gastrointestinal (GI) PROMIS measures vs. usual care on patient outcomes.

METHODS

We performed a pragmatic clinical trial with an off-on study design alternating weekly between intervention (GI PROMIS) and control arms at one Veterans Affairs and three university-affiliated specialty clinics. Adults with GI symptoms were eligible. Intervention patients completed GI PROMIS symptom questionnaires on an e-portal 1 week before their visit; PROs were available for review by patients and their providers before and during the clinic visit. Usual care patients were managed according to customary practices. Our primary outcome was patient satisfaction as determined by the Consumer Assessment of Healthcare Providers and Systems questionnaire. Secondary outcomes included provider interpersonal skills (Doctors' Interpersonal Skills Questionnaire (DISQ)) and shared decision-making (9-item Shared Decision Making Questionnaire (SDM-Q-9)).

RESULTS

There were 217 and 154 patients in the GI PROMIS and control arms, respectively. Patient satisfaction was similar between groups (P>0.05). Intervention patients had similar assessments of their providers' interpersonal skills (DISQ 89.4±11.7 vs. 89.8±16.0, P=0.79) and shared decision-making (SDM-Q-9 79.3±12.4 vs. 79.0±22.0, P=0.85) vs.

CONCLUSIONS

This is the first controlled trial examining the impact of NIH PROMIS in clinical practice. One-time use of GI PROMIS did not improve patient satisfaction or assessment of provider interpersonal skills and shared decision-making. Future studies examining how to optimize PROs in clinical practice are encouraged before widespread adoption.

Computer versus physician identification of gastrointestinal alarm features

OBJECTIVE

It is important for clinicians to inquire about "alarm features" as it may identify those at risk for organic disease and who require additional diagnostic workup. We developed a computer algorithm called Automated Evaluation of Gastrointestinal Symptoms (AEGIS) that systematically collects patient gastrointestinal (GI) symptoms and alarm features, and then "translates" the information into a history of present illness (HPI). Our study's objective was to compare the number of alarms documented by physicians during usual care vs. that collected by AEGIS.

METHODS

We performed a cross-sectional study with a paired sample design among patients visiting adult GI clinics. Participants first received usual care by their physicians and then completed AEGIS. Each individual thus contributed both a physician-documented and computer-generated HPI. Blinded physician reviewers enumerated the positive alarm features (hematochezia, melena, hematemesis, unintentional weight loss, decreased appetite, and fevers) mentioned in each HPI. We compared the number of documented alarms within patient using the Wilcoxon signed-rank test.

RESULTS

Seventy-five patients had both physician and AEGIS HPIs. AEGIS identified more patients with positive alarm features compared to physicians (53% vs. 27%; p<.001). AEGIS also documented more positive alarms (median 1, interquartile range [IQR] 0-2) vs. physicians (median 0, IQR 0-1; p<.001). Moreover, clinicians documented only 30% of the positive alarms self-reported by patients through AEGIS.

CONCLUSIONS

Physicians documented less than one-third of red flags reported by patients through a computer algorithm. These data indicate that physicians may under report alarm features and that computerized "checklists" could complement standard HPIs to bolster clinical care.

Computer-generated vs. physician-documented history of present illness (HPI): results of a blinded comparison

OBJECTIVES

Healthcare delivery now mandates shorter visits with higher documentation requirements, undermining the patient-provider interaction. To improve clinic visit efficiency, we developed a patient-provider portal that systematically collects patient symptoms using a computer algorithm called Automated Evaluation of Gastrointestinal Symptoms (AEGIS). AEGIS also automatically "translates" the patient report into a full narrative history of present illness (HPI). We aimed to compare the quality of computer-generated vs. physician-documented HPIs.

METHODS

We performed a cross-sectional study with a paired sample design among individuals visiting outpatient adult gastrointestinal (GI) clinics for evaluation of active GI symptoms. Participants first underwent usual care and then subsequently completed AEGIS. Each individual thereby had both a physician-documented and a computer-generated HPI. Forty-eight blinded physicians assessed HPI quality across six domains using 5-point scales: (i) overall impression, (ii) thoroughness, (iii) usefulness, (iv) organization, (v) succinctness, and (vi) comprehensibility. We compared HPI scores within patient using a repeated measures model.

RESULTS

Seventy-five patients had both computer-generated and physician-documented HPIs. The mean overall impression score for computer-generated HPIs was higher than physician HPIs (3.68 vs. 2.80; P<0.001), even after adjusting for physician and visit type, location, mode of transcription, and demographics. Computer-generated HPIs were also judged more complete (3.70 vs. 2.73; P<0.001), more useful (3.82 vs. 3.04; P<0.001), better organized (3.66 vs. 2.80; P<0.001), more succinct (3.55 vs. 3.17; P<0.001), and more comprehensible (3.66 vs. 2.97; P<0.001).

CONCLUSIONS

Computer-generated HPIs were of higher overall quality, better organized, and more succinct, comprehensible, complete, and useful compared with HPIs written by physicians during usual care in GI clinics.

Construct validity of the Patient-Reported Outcomes Measurement Information System gastrointestinal symptom scales in systemic sclerosis

OBJECTIVE

Gastrointestinal (GI) involvement is common in patients with systemic sclerosis (SSc; scleroderma). The Patient-Reported Outcomes Measurement Information System (PROMIS) GI symptom item bank captures upper and lower GI symptoms (reflux, disrupted swallowing, nausea/vomiting, belly pain, gas/bloating/flatulence, diarrhea, constipation, and fecal incontinence). The objective of this study was to evaluate the construct validity of the PROMIS GI bank in SSc.

METHODS

A total of 167 patients with SSc were administered the PROMIS GI bank and the University of California, Los Angeles, Scleroderma Clinical Trials Consortium Gastrointestinal Scale (GIT 2.0) instrument. GIT 2.0 is a multi-item instrument that measures SSc-associated GI symptoms. Product-moment correlations and a multitrait-multimethod analysis of the PROMIS GI scales with the GIT 2.0 symptom scales were used to evaluate convergent and discriminant validity.

RESULTS

Patients with SSc GI involvement had PROMIS GI scale scores 0.2-0.7 SD worse than the US general population. Correlations among scales measuring the same domains for the PROMIS GI and GIT 2.0 measures were large, ranging from 0.61 to 0.87 (average r = 0.77). The average correlation between different symptom scales was 0.22, supporting discriminant validity.

CONCLUSION

This study provides support for the construct validity of the PROMIS GI scales in SSc. Future research is needed to assess the responsiveness to change of these scales in patients with SSc.

Development of the NIH Patient-Reported Outcomes Measurement Information System (PROMIS) gastrointestinal symptom scales

OBJECTIVES

The National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS(®)) is a standardized set of patient-reported outcomes (PROs) that cover physical, mental, and social health. The aim of this study was to develop the NIH PROMIS gastrointestinal (GI) symptom measures.

METHODS

We first conducted a systematic literature review to develop a broad conceptual model of GI symptoms. We complemented the review with 12 focus groups including 102 GI patients. We developed PROMIS items based on the literature and input from the focus groups followed by cognitive debriefing in 28 patients. We administered the items to diverse GI patients (irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), systemic sclerosis (SSc), and other common GI disorders) and a census-based US general population (GP) control sample. We created scales based on confirmatory factor analyses and item response theory modeling, and evaluated the scales for reliability and validity.

RESULTS

A total of 102 items were developed and administered to 865 patients with GI conditions and 1,177 GP participants. Factor analyses provided support for eight scales: gastroesophageal reflux (13 items), disrupted swallowing (7 items), diarrhea (5 items), bowel incontinence/soilage (4 items), nausea and vomiting (4 items), constipation (9 items), belly pain (6 items), and gas/bloat/flatulence (12 items). The scales correlated significantly with both generic and disease-targeted legacy instruments, and demonstrate evidence of reliability.

CONCLUSIONS

Using the NIH PROMIS framework, we developed eight GI symptom scales that can now be used for clinical care and research across the full range of GI disorders.

GERD symptoms in the general population: prevalence and severity versus care-seeking patients

BACKGROUND

Prior estimates suggest that up to 40% of the US general population (GP) report symptoms of gastroesophageal reflux disease (GERD). However, symptoms in the GP versus patients seeking care for gastrointestinal (GI) complaints have not been compared. We estimated the prevalence and severity of GERD symptoms in the GP versus GI patients, and identified predictors of GERD severity. We hypothesized that similar to functional GI disorders, psychosocial factors would predict symptom severity in GERD as much, or perhaps more, than care-seeking behavior alone.

METHODS

We compared the prevalence of heartburn and regurgitation between a sample from the US GP and patients seeking GI specialty care. We compared GERD severity between groups using the NIH PROMIS(®) GERD scale. We then performed multivariable regression to identify predictors of GERD severity.

RESULTS

There was no difference in the prevalence of heartburn between the GP and patient groups (59 vs. 59%), but regurgitation was more common in patients versus GP (46 vs. 39%; p = 0.004). In multivariable regression, having high visceral anxiety (p < 0.001) and being divorced or separated (p = 0.006) were associated with higher GERD severity.

CONCLUSIONS

More than half of a GP sample reports heartburn-higher than previous series and no different from GI patients. Although regurgitation was more prevalent in patients versus the GP, there was no difference in GERD severity between groups after adjusting for other factors; care seeking in GERD appears related to factors beyond symptoms, including visceral anxiety.

Development of an online library of patient-reported outcome measures in gastroenterology: the GI-PRO database

OBJECTIVES

Because gastrointestinal (GI) illnesses can cause physical, emotional, and social distress, patient-reported outcomes (PROs) are used to guide clinical decision making, conduct research, and seek drug approval. It is important to develop a mechanism for identifying, categorizing, and evaluating the over 100 GI PROs that exist. Here we describe a new, National Institutes of Health (NIH)-supported, online PRO clearinghouse-the GI-PRO database.

METHODS

Using a protocol developed by the NIH Patient-Reported Outcome Measurement Information System (PROMIS(®)), we performed a systematic review to identify English-language GI PROs. We abstracted PRO items and developed an online searchable item database. We categorized symptoms into content "bins" to evaluate a framework for GI symptom reporting. Finally, we assigned a score for the methodological quality of each PRO represented in the published literature (0-20 range; higher indicates better).

RESULTS

We reviewed 15,697 titles (κ>0.6 for title and abstract selection), from which we identified 126 PROs. Review of the PROs revealed eight GI symptom "bins": (i) abdominal pain, (ii) bloat/gas, (iii) diarrhea, (iv) constipation, (v) bowel incontinence/soilage, (vi) heartburn/reflux, (vii) swallowing, and (viii) nausea/vomiting. In addition to these symptoms, the PROs covered four psychosocial domains: (i) behaviors, (ii) cognitions, (iii) emotions, and (iv) psychosocial impact. The quality scores were generally low (mean 8.88 ± 4.19; 0 (min)-20 (max). In addition, 51% did not include patient input in developing the PRO, and 41% provided no information on score interpretation.

CONCLUSIONS

GI PROs cover a wide range of biopsychosocial symptoms. Although plentiful, GI PROs are limited by low methodological quality. Our online PRO library (www.researchcore.org/gipro/) can help in selecting PROs for clinical and research purposes.

Increased risk for irritable bowel syndrome after acute diverticulitis

BACKGROUND & AIMS

Individuals with diverticulosis frequently also have irritable bowel syndrome (IBS), but there are no longitudinal data to associate acute diverticulitis with subsequent IBS, functional bowel disorders, or related emotional distress. In patients with postinfectious IBS, gastrointestinal disorders cause long-term symptoms, so we investigated whether diverticulitis might lead to IBS. We compared the incidence of IBS and functional bowel and related affective disorders among patients with diverticulitis.

METHODS

We performed a retrospective study of patients followed up for an average of 6.3 years at a Veteran's Administration medical center. Patients with diverticulitis were identified based on International Classification of Diseases, 9th revision codes, selected for the analysis based on chart review (cases, n = 1102), and matched with patients without diverticulosis (controls, n = 1102). We excluded patients with prior IBS, functional bowel, or mood disorders. We then identified patients who were diagnosed with IBS or functional bowel disorders after the diverticulitis attack, and controls who developed these disorders during the study period. We also collected information on mood disorders, analyzed survival times, and calculated adjusted hazard ratios.

RESULTS

Cases were 4.7-fold more likely to be diagnosed later with IBS (95% confidence interval [CI], 1.6-14.0; P = .006), 2.4-fold more likely to be diagnosed later with a functional bowel disorder (95% CI, 1.6-3.6; P < .001), and 2.2-fold more likely to develop a mood disorder (CI, 1.4-3.5; P < .001) than controls.

CONCLUSIONS

Patients with diverticulitis could be at risk for later development of IBS and functional bowel disorders. We propose calling this disorder postdiverticulitis IBS. Diverticulitis appears to predispose patients to long-term gastrointestinal and emotional symptoms after resolution of inflammation; in this way, postdiverticulitis IBS is similar to postinfectious IBS.

Randomised clinical trial: symptoms of the irritable bowel syndrome are improved by a psycho-education group intervention

BACKGROUND

Evidence supports the effectiveness of cognitive behavioural approaches in improving the symptoms of the irritable bowel syndrome (IBS). Duration, cost and resistance of many patients towards a psychological therapy have limited their acceptance.

AIM

To evaluate the effectiveness of a psycho-educational intervention on IBS symptoms.

METHODS

Sixty-nine IBS patients (72% female) were randomised to an intervention or a wait-list control group. The IBS class consisted of education on a biological mind body disease model emphasising self-efficacy and practical relaxation techniques.

RESULTS

Patients in the intervention showed significant improvement on GI symptom severity, visceral sensitivity, depression and QoL postintervention and most of these gains were maintained at 3-month follow-up (Hedge's g = -0.46-0.77). Moderated mediation analyses indicated change in anxiety, visceral sensitivity, QoL and catastrophising due to the intervention had moderate mediation effects (Hedge's g = -0.38 to -0.60) on improvements in GI symptom severity for patients entering the trial with low to average QoL. Also, change in GI symptom severity due to the intervention had moderate mediation effects on improvements in QoL especially in patients with low to average levels of QoL at baseline. Moderated mediation analyses indicated mediation was less effective for patients entering the intervention with high QoL.

CONCLUSIONS

A brief psycho-educational group intervention is efficacious in changing cognitions and fears about the symptoms of the irritable bowel syndrome, and these changes are associated with clinically meaningful improvement in symptoms and quality of life. The intervention seems particularly tailored to patients with low to moderate quality of life baseline levels.

Gastrointestinal and psychological mediators of health-related quality of life in IBS and IBD: a structural equation modeling analysis

OBJECTIVES

Inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS) are chronic gastrointestinal (GI) syndromes in which both GI and psychological symptoms have been shown to negatively impact health-related quality of life (HRQOL). The objective of this study was to use structural equation modeling (SEM) to characterize the interrelationships among HRQOL, GI, and psychological symptoms to improve our understanding of the illness processes in both conditions.

METHODS

Study participants included 564 Rome positive IBS patients and 126 IBD patients diagnosed via endoscopic and/or tissue confirmation. All patients completed questionnaires to assess bowel symptoms, psychological symptoms (SCL-90R), and HRQOL (SF-36). SEM with its two components of confirmatory analyses and structural modeling were applied to determine the relationships between GI and psychological symptoms and HRQOL within the IBS and IBD groups.

RESULTS

For both IBD and IBS, psychological distress was found to have a stronger direct effect on HRQOL (-0.51 and -0.48 for IBS and IBD, respectively) than GI symptoms (-0.25 and -0.28). The impact of GI symptoms on psychological distress was stronger in IBD compared with IBS (0.43 vs. 0.22; P<0.05). The indirect effect of GI symptoms on HRQOL operating through psychological distress was significantly higher in IBD than IBS (-0.21 vs. -0.11; P<0.05).

CONCLUSIONS

Psychological distress is less dependent on GI symptom severity in IBS compared with IBD even though the degree that psychological distress impacts HRQOL is similar. The findings emphasize the importance of addressing psychological symptoms in both syndromes.

Influence of signalment on developing cranial cruciate rupture in dogs in the UK

OBJECTIVES

To investigate risk factors associated with cranial cruciate ligament rupture in dogs.

METHODS

Retrospective case-control study: medical records of a first-opinion veterinary practice were searched for dogs diagnosed with cranial cruciate ligament rupture (1995 to 2007). For each case, six unaffected dogs were randomly selected from all dogs presenting that day for comparison. Multi-variable binary logistic regression was performed to assess the association of variables on likelihood of cruciate rupture.

RESULTS

Frequency of cranial cruciate ligament rupture was 1·19% [95% confidence interval (CI) 1·02 to 1.36%]. West Highland white terriers (n=17), Yorkshire terriers (n=14) and Rottweilers (n=11) were at significantly increased risk of cranial cruciate ligament rupture (P≤0·002). Rottweilers were at five times greater risk compared with other pure breeds (OR 5·12, 95% CI 2·281 to 11·494, P<0·001), obesity quadrupled the risk of cranial cruciate ligament rupture (OR 3·756, 95% CI 1·659 to 8·502, P=0·001) and females were twice as likely to suffer cranial cruciate ligament failure compared to males (OR 2·054, 95% CI 1·467 to 2·877, P<0·001). Dogs less than two years old were statistically less likely to sustain cranial cruciate ligament rupture than dogs older than eight years (OR 0·246, 95% CI 0·127 to 0·477, P<0·001). There was no significant difference in median weights (in kilograms) of neutered dogs, compared to their entire counterparts in either the case group (P=0·994) or in the control group (P=0·630). There was also no significant difference in body condition (-underweight/normal weight/overweight/obese) of neutered versus entire dogs among the cases (P=0·243), or the controls (P=0·211).

CLINICAL SIGNIFICANCE

Cranial cruciate ligament rupture is more likely in Rottweilers and in female dogs, older dogs and obese dogs. Following multi-variable analysis, it was established that neutering was not associated with increased risk of cranial cruciate ligament rupture.

Understanding gastrointestinal distress: a framework for clinical practice

We describe a framework to help clinicians think about health-related quality of life in their gastrointestinal (GI) patients. We introduce "GI distress" as a clinically relevant concept and explain how it may result from physical symptoms, cognitions, and emotions. The GI distress framework suggests that providers should divide GI physical symptoms into four categories: pain, gas/bloat, altered defecation, and foregut symptoms. We describe how these physical symptoms can be amplified by maladaptive cognitions, including external locus of control, catastrophizing, and anticipation anxiety. We suggest determining the level of embarrassment from GI symptoms and asking about stigmatization. GI patients may also harbor emotional distress from their illness and may exhibit visceral anxiety marked by hypervigilance, fear, and avoidance of GI sensations. Look for signs of devitalization, indicated by inappropriate fatigue. When appropriate, screen for suicidal ideations. Finally, we provide a list of high-yield questions to screen for these maladaptive cognitions and emotions, and explain how the GI distress framework can be used in clinical practice.

A randomized trial of 2 prescription strategies for opioid treatment of chronic nonmalignant pain

The use of opioid medications for treating chronic noncancer pain is growing; however, there is a lack of good evidence regarding their long-term effectiveness, association with substance abuse, and proper prescribing guidelines. The current study directly compares for the first time in a randomized trial the effectiveness of a conservative, hold the line (Stable Dose) prescribing strategy for opioid medications with a more liberal dose escalation (Escalating Dose) approach. This 2-arm, parallel, randomized pragmatic clinical trial followed 135 patients referred to a specialty pain clinic at a Veterans Affairs Hospital for 12 months (94% male and 74% with musculoskeletal pain). Primary outcomes included monthly or quarterly evaluations of pain severity, pain relief from medications, pain-related functional disability, and opioid misuse behaviors. All subjects received identical pain treatment except for the application of treatment group specific strategies for opioid prescriptions. No group differences were found for primary outcomes of usual pain or functional disability although the Escalating Dose group did show a small but significantly larger increase in self-rated pain relief from medications. About 27% of patients were discharged over the course of the study due to opioid misuse/noncompliance, but there were no group differences in rate of opioid misuse.

PERSPECTIVE

The results of this study demonstrate that even in carefully selected patients there is a significant risk of problematic opioid misuse. Although in general there were no statistically significant differences in the primary outcomes between groups, the escalating dose strategy did lead to small improvements in self-reported acute relief from medications without an increase in opioid misuse, compared to the stable dose strategy.

Measuring symptoms in the irritable bowel syndrome: development of a framework for clinical trials

BACKGROUND

There is uncertainty about how to measure patient-reported outcomes (PROs) in IBS. The Food and Drug Administration (FDA) emphasizes that PROs must be couched in a conceptual framework, yet existing IBS PROs were not based on such a framework.

AIM

To perform qualitative analyses to inform a new conceptual framework for IBS symptoms.

METHODS

Following FDA guidance, we searched the literature for extant IBS questionnaires. We then performed interviews in IBS patients to learn about the illness experience in their own words. We cultivated vocabulary to inform a conceptual framework depicted with domains, sub-domains, and item categories, per FDA guidance.

RESULTS

We identified 13 questionnaires with items encompassing 18 symptoms. We recruited 123 IBS patients for cognitive interviews. Major themes included: pain and discomfort are different - asking about discomfort is nonspecific and should be avoided in future PROs; bowel urgency is multifaceted - PROs should measure bowel immediacy, controllability, and predictability; and PROs should divide bloating into how it feels vs. how it looks. Symptom experience may be determined by 35-item categories within five domains: (i) pain; (ii) gas/bloat; (iii) diarrhoea; (iv) constipation; and (v) extraintestinal symptoms.

CONCLUSIONS

We applied FDA guidance to develop a framework that can serve as the foundation for developing a PRO for IBS clinical trials.

Characterizing abdominal pain in IBS: guidance for study inclusion criteria, outcome measurement and clinical practice

BACKGROUND

Although irritable bowel syndrome (IBS) is a multisymptom disorder, abdominal pain drives illness severity more than other symptoms. Despite consensus that IBS trials should measure pain to define study entry and determine efficacy, the optimal method of measuring pain remains uncertain.

AIM

To determine whether combining information from multiple pain dimensions may capture the IBS illness experience more effectively than the approach of measuring 'pain predominance' or pain intensity alone.

METHODS

Irritable bowel syndrome patients rated dimensions of pain, including intensity, frequency, constancy, predominance, predictability, duration, speed of onset and relationship to bowel movements. We evaluated the impact of each dimension on illness severity using multivariable regression techniques.

RESULTS

Among the pain dimensions, intensity, frequency, constancy and predictability were strongly and independently associated with illness severity; the other dimensions had weaker associations. The clinical definition of 'pain predominance', in which patients define pain as their most bothersome symptom, was insufficient to categorize patients by illness severity.

CONCLUSIONS

Irritable bowel disease pain is multifaceted; some pain dimensions drive illness more than others. IBS trials should measure various pain dimensions, including intensity, constancy, frequency and predictability; this may improve upon the customary use of measuring pain as a unidimensional symptom in IBS.

Dialysis practices that distinguish facilities with below- versus above-expected mortality

BACKGROUND AND OBJECTIVES

Mortality rates vary widely among dialysis facilities even after adjustment with standardized mortality ratios (SMRs). This variation may occur because top-performing facilities use practices not shared by others, because the SMR fails to capture key patient characteristics, or both. Practices were identified that distinguish top- from bottom-performing facilities by SMR.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A cross-sectional survey was performed of staff across three organizations. Staff members rated the perceived quality of their units' patient-, provider-, and facility-level practices using a six-point Likert scale. Facilities were divided into those with above- versus below-expected mortality on the basis of SMRs from U.S. Renal Data Service facility reports. Mean Likert scores were computed for each practice using t tests. Practices that were statistically significant (P ≤ 0.05) and achieved at least a medium effect size of ≥0.4 were reported. Significant predictors were entered into a linear regression model.

RESULTS

Dialysis facilities with below-expected mortality reported that patients in their unit were more activated and engaged, physician communication and interpersonal relationships were stronger, dieticians were more resourceful and knowledgeable, and overall coordination and staff management were superior versus facilities with above-expected mortality. Staff ratings of these practices explained 31% of the variance in SMRs.

CONCLUSIONS

Patient-, provider-, and facility-level practices partly explain SMR variation among facilities. Improving SMRs may require processes that reflect a coordinated, multidisciplinary environment (i.e., no one group, practice, or characteristic will drive facility-level SMRs). Understanding and improving SMRs will require a holistic view of the facility.

Dialysis practices that distinguish top- versus bottom-performing facilities by hemoglobin outcomes

BACKGROUND

Because there is wide variation in outcomes across dialysis facilities, it is possible that top-performing units use practices not shared by others. The Identifying Best Practices in Dialysis (IBPiD) Study seeks to identify practices that distinguish top- from bottom-performing facilities by key outcomes, including achievement of recommended hemoglobin targets.

STUDY DESIGN

Observational study with cross-sectional study ascertainment of predictors and outcomes.

PREDICTORS

Facility dialysis practices ascertained using practice surveys of dialysis staff who indicated their level of agreement that each practice occurs in their facility (1-6 on a Likert scale).

SETTING & PARTICIPANTS

423 personnel in 90 dialysis facilities from 1 for-profit and 2 not-for-profit dialysis organizations.

OUTCOMES

Percentage of patients per month per facility with hemoglobin levels of 11-12 g/dL. We divided facilities by median into top- versus bottom-performing groups and compared mean scores for each practice using t tests. We report practices that were statistically significant and achieved at least a medium effect size (ES) >or=0.4.

RESULTS

17 of 155 tested predictors were significant. Achievement of hemoglobin level targets was related most strongly to the use of chairside computers (ES, 0.8 [95% CI, 0.4-1.4]), extent/quality of educational videos (ES, 0.6 [95% CI, 0.2-1.1]), frequency of calling per diem staff if short staffed (ES, 0.6 [95% CI, 0.21-1.1]), policy that nurses pass written competency examinations before hire (ES, 0.6 [95% CI, 0.2-1.0]), and technician cannulation mastery (ES, 0.6 [95% CI, 0.2-1.1]).

LIMITATIONS

This is a cross-sectional study that can address only associations, not causations. Future research should measure the longitudinal predictive value of these practices.

CONCLUSIONS

High-performing facilities report more effective education programs, better staff management, higher staff competency, and higher use of chairside computers, a potential marker of information technology proficiency. This suggests that hemoglobin level management is enhanced by processes reflecting a coordinated multidisciplinary environment.

Psychometric evaluation of patient-reported outcomes in irritable bowel syndrome randomized controlled trials: a Rome Foundation report

BACKGROUND & AIMS

There is debate about how best to measure patient-reported outcomes (PROs) in irritable bowel syndrome (IBS). We pooled data to measure the psychometric properties of IBS end points, including binary responses (eg, "adequate relief") and 50% improvement in symptom severity.

METHODS

We pooled data from 12 IBS drug trials involving 10,066 participants. We tested the properties of binary response and 50% improvement end points, including the impact of baseline severity on performance, and measured construct validity using clinical anchors.

RESULTS

There were 9044 evaluable subjects (age, 44 years; 85% female; 58% IBS constipation-prominent [IBS-C]; 31% IBS diarrhea-prominent [IBS-D]). Using the binary end point, the proportion responding in the mild, moderate, and severe groups was 42%, 40%, and 38%, respectively (P = .0008). There was no effect of baseline severity on binary response (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.99-1.0; P = .07). The proportions reaching 50% improvement in pain were 45%, 41%, and 41%, respectively; there was a small, yet significant, impact of baseline severity (OR, 1.04; 95% CI, 1.03-1.05; P < .0001) that did not meet clinical relevance criteria. Both end points revealed strong construct validity and detected "minimally clinically important differences" in symptoms. Both provided better discriminant spread in IBS-D than IBS-C.

CONCLUSIONS

Both the traditional binary and 50% improvement end points are equivalent in their psychometric properties. Neither is impacted by baseline severity, and both demonstrate excellent construct validity. They are optimized for the IBS-D population but also appear valid in IBS-C.

Developing valid and reliable health utilities in irritable bowel syndrome: results from the IBS PROOF Cohort

OBJECTIVES

A "utility" is a measure of health-related quality of life (HRQOL) that ranges between 0 (death) and 1 (perfect health). Disease-targeted utilities are mandatory to conduct cost-utility analyses. Given the economic and healthcare burden of irritable bowel syndrome (IBS), cost-utility analyses will play an important role in guiding health economic decision-making. To inform future cost-utility analyses in IBS, we measured and validated the IBS utilities.

METHODS

We analyzed data from Rome III IBS patients in the Patient Reported Observed Outcomes and Function (PROOF) Cohort-a longitudinal multi-center IBS registry. At entry, the patients completed a multi-attribute utility instrument (EuroQOL), bowel symptom items, IBS severity measurements (IBS Severity Scale (IBSSS), Functional Bowel Disease Severity Index (FBDSI)), HRQOL indexes (IBS quality-of-life instrument (IBS-QOL), Center for disease control-4 (CDC-4)), and the Worker Productivity Activity Index for IBS (WPAI). We repeated assessments at 3 months.

RESULTS

There were 257 patients (79% women; age=43+/-15 years) at baseline and 85 at 3 months. The mean utilities in patients with severe vs. non-severe IBS were 0.70 and 0.80, respectively (P<0.001). There were no differences in utilities among IBS with constipation (IBS-C), IBS with diarrhea (IBS-D), and mixed IBS (IBS-M) subgroups. EuroQOL utilities correlated with FBDSI (r=0.31; P<0.01), IBSSS (r=0.36; P<0.01), IBS-QOL (r=0.36; P<0.01), CDC-4 (r=0.44; P<0.01), WPAI presenteeism (r=0.16; P<0.01), abdominal pain (r=0.43; P<0.01), and distension (r=0.18; P=0.01). The utilities in patients reporting "considerable relief" of symptoms at 3 months vs. those without considerable relief were 0.78 and 0.73, respectively (P=0.02).

CONCLUSIONS

EuroQOL utilities are valid and reliable in IBS. The utility of severe IBS (0.7) is similar to Class III congestive heart failure and rheumatoid arthritis. These validated utilities can be employed in future IBS cost-utility analyses.

Health-related quality of life predicts mortality in patients with advanced chronic liver disease

BACKGROUND & AIMS

It is well-established that cirrhosis negatively impacts health-related quality of life (HRQOL). However, it is less clear how to use this information in everyday clinical practice. If HRQOL predicted survival in cirrhosis, then measuring HRQOL would have important clinical implications. We sought to measure the association between HRQOL and survival in patients with cirrhosis and investigated whether the relationship between HRQOL and survival is independent of Model for End-Stage Liver Disease (MELD).

METHODS

We measured HRQOL in 156 patients with cirrhosis awaiting liver transplantation by using the Short Form Liver Disease Quality of Life instrument. We followed patients prospectively and used Cox proportional hazard models to measure the independent effect of baseline HRQOL on survival, adjusting for MELD and other covariates.

RESULTS

During a mean 9-month follow-up, 26 (17%) patients died, and 30 (20%) received liver transplants. In unadjusted analysis, higher baseline HRQOL predicted lower mortality (hazard ratio, 0.96; 95% confidence interval, 0.94-0.99). Specifically, for each 1-point increase in HRQOL, there was a 4% decrease in mortality. These results did not change after adjusting for MELD scores, patient demographics, or psychosocial characteristics; the MELD score accounted for 1% of the variation in HRQOL scores (P = .18). Survival was most strongly predicted by activities of daily living, health distress, sleep disturbance, and perceived disease stigma.

CONCLUSIONS

Higher HRQOL predicts lower mortality in patients with cirrhosis. This relationship is independent of MELD; MELD does not capture liver-specific HRQOL. Beyond its use as a secondary outcome in clinical trials, HRQOL could be used to predict survival of patients with advanced liver disease.

Is there "cherry picking" in the ESRD Program? Perceptions from a Dialysis Provider Survey

BACKGROUND AND OBJECTIVES

Changes in ESRD reimbursement policy, including proposed bundled payment, have raised concern that dialysis facilities may use "cherry picking" practices to attract a healthier, better insured, or more adherent patient population.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

As part of a national survey to measure beliefs about drivers of quality in dialysis, respondents were asked about their perceptions of cherry picking, including the frequency and effect of various cherry picking strategies on dialysis outcomes. We surveyed a random sample of 250 nurse members of the American Nephrology Nurses Association, 250 nephrologist members of the American Medical Association, 50 key opinion leaders, and 2000 physician members of the Renal Physicians Association. We tested hypothesized predictors of perception, including provider group, region, age, experience, and the main practice facility features.

RESULTS

Three-quarters of respondents reported that cherry picking occurred "sometimes" or "frequently." There were no differences in perceptions by provider or facility characteristics, insurance status, or health status. In multivariable regression, perceived cherry picking was 2.8- and 3.5-fold higher in the northeast and Midwest, respectively, versus the west. Among various cherry picking strategies, having a "low threshold to 'fire' chronic no-shows/late arrivers," and having a "low threshold to 'fire' for noncompliance with diet and meds" had the largest perceived association with outcomes.

CONCLUSIONS

Under current reimbursement practices, dialysis caregivers perceive that cherry picking is common and important. An improved understanding of cherry picking practices, if evident, may help to protect vulnerable patients if reimbursement practices were to change.

Assessing school effectiveness

The Collegiate Learning Assessment (CLA) program measures value added in colleges and universities, by testing the ability of freshmen and seniors to think logically and write clearly. The program is popular enough that it has attracted critics. In this paper, we outline the methods used by the CLA to determine value added. We summarize the criticisms, which revolve around the question of which students take the CLA tests. Typically, samples are not random, so that selection bias is a concern, as is confounding. We respond by showing that criticisms of CLA procedures are not supported by the data.

Prospective validation of the short form liver disease quality of life instrument

BACKGROUND

Despite the realization that health-related quality of life (HRQOL) is an important outcome in patients with liver disease, there is scarcity of disease-targeted HRQOL measures that have undergone prospective evaluation.

AIM

To validate prospectively the short form of liver disease quality of life instrument (the SF-LDQOL) in patients with advanced liver disease.

METHODS

The SF-LDQOL includes 36 disease-targeted items representing nine domains: symptoms of liver disease, effects of liver disease, memory/concentration, sleep, hopelessness, distress, loneliness, stigma of liver disease and sexual problems. We administered the SF-LDQOL to 156 advanced liver disease patients at baseline and at 6-month follow-up. We estimated internal consistency reliability for multi-item scales, item discrimination across scale and evaluated construct validity by estimating the associations of SF-LDQOL scores with SF-36 scores, symptom severity and disability days. To evaluate the SF-LDQOL's responsiveness, we compared HRQOL changes for patients who received with those who did not receive liver transplantation (LT).

RESULTS

The internal consistency reliability coefficients were > or = 0.70 for seven of nine scales in baseline and for all scales in follow-up administration. The SF-LDQOL correlated highly with SF-36 scores, symptom severity, disability days and global health. Patients undergoing LT reported improved HRQOL compared with patients without LT and the responsiveness indices were excellent.

CONCLUSIONS

This study provides support for the reliability and validity of the SF-LDQOL in patients with advanced chronic liver disease. This instrument may be useful in everyday clinical practice and in future clinical trials.

Identifying best practices in dialysis care: results of cognitive interviews and a national survey of dialysis providers

BACKGROUND AND OBJECTIVES

Because there is wide variation in case-mix adjusted outcomes across dialysis facilities, it is possible that top-performing facilities use practices not shared by others. We sought to catalogue "best practices" that may account for interfacility variations in outcomes.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This multidisciplinary study identified candidate best practices in dialysis through a staged process, including systematic review, cognitive interviews, and a national "virtual focus group" of dialysis providers. The resulting candidate practices were rank-ordered by perceived importance as determined by mean RAND Appropriateness Scores from a national survey of nephrologists, nurses, and opinion leaders.

RESULTS

A total of 155 candidate best practices were identified. Among these, respondents believed dialysis outcomes are most strongly related to 1) characteristics of multidisciplinary care conferences, 2) technician proficiency in protecting vascular access, 3) training of nurses to provide education in fluid management, vascular access, and nutrition, 4) use of random and blinded audits of staff performance, and 5) communication and teamwork among staff. In contrast, there was wide disagreement about the importance of facility-based health maintenance practices, optimal staffing ratios, frequency of dialysis-based physician visits, and optimal frequency of multidisciplinary care.

CONCLUSIONS

This study provides a "conceptual map" of candidate dialysis best practices and highlights areas of general agreement and disagreement. These findings can help the dialysis community think critically about what may define "best practice" and provide targets for future research in quality improvement.

Adrenocortical hormone abnormalities in men with chronic prostatitis/chronic pelvic pain syndrome

OBJECTIVES

To identify adrenocortical hormone abnormalities as indicators of endocrine dysfunction in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).

METHODS

We simultaneously measured the serum concentrations of 12 steroids in patients with CP/CPPS and controls, using isotope dilution liquid chromatography, followed by atmospheric pressure photospray ionization and tandem mass spectrometry.

RESULTS

We evaluated 27 patients with CP/CPPS and 29 age-matched asymptomatic healthy controls. In the mineralocorticoid pathway, progesterone was significantly greater, and the corticosterone and aldosterone concentrations were significantly lower, in the patients with CP/CPPS than in the controls. In the glucocorticoid pathway, 11-deoxycortisol was significantly lower and the cortisol concentrations were not different between the patients and controls. In the sex steroid pathway, the androstenedione and testosterone concentrations were significantly greater in those with CP/CPPS than in the controls. The estradiol, dehydroepiandrosterone, and dehydroepiandrosterone sulfate concentrations were not different between the patients and controls. The National Institutes of Health-Chronic Prostatitis Symptom Index total and pain domain scores correlated positively with the 17-hydroxyprogesterone and aldosterone (P <0.001) and negatively with the cortisol (P <0.001) concentrations.

CONCLUSIONS

Our results suggest reduced activity of CYP21A2 (P450c21), the enzyme that converts progesterone to corticosterone and 17-hydroxyprogesterone to 11-deoxycortisol. Furthermore, these results provide insights into the biologic basis of CP/CPPS. Follow-up studies should explore the possibility that patients with CP/CPPS meet the diagnostic criteria for nonclassic congenital adrenal hyperplasia and whether the hormonal findings improve or worsen in parallel with symptom severity.

The Collegiate Learning Assessment: facts and fantasies

The Collegiate Learning Assessment (CLA) is a computer administered, open-ended (as opposed to multiple-choice) test of analytic reasoning, critical thinking, problem solving, and written communication skills. Because the CLA has been endorsed by several national higher education commissions, it has come under intense scrutiny by faculty members, college administrators, testing experts, legislators, and others. This article describes the CLA's measures and what they do and do not assess, how dependably they measure what they claim to measure, and how CLA scores differ from those on other direct and indirect measures of college student learning. For instance, analyses are conducted at the school rather than the student level and results are adjusted for input to assess whether the progress students are making at their school is better or worse than what would be expected given the progress of "similarly situated" students (in terms of incoming ability) at other colleges.

Development and validation of a disease-targeted quality of life instrument in chronic hepatitis B: the hepatitis B quality of life instrument, version 1.0

Despite the increasing realization that health-related quality of life (HRQOL) is an important outcome in chronic HBV infection, there are no validated, disease-targeted instruments currently available. We sought to develop and validate the first disease-targeted HRQOL instrument in noncirrhotic HBV: the Hepatitis B Quality of Life instrument, version 1.0 (HBQOL v1.0). We established content validity for the HBQOL v1.0 by conducting a systematic literature review, an expert focus group, and cognitive interviews with HBV patients. We administered the resultant questionnaire to 138 HBV patients. We used factor analysis to test hypotheses regarding HRQOL domains and measured construct validity by comparing HBQOL v1.0 scores across several anchors, including viral response to treatment, SF-36 scores, and global health. Finally, we measured test-retest and internal consistency reliability. Content validation revealed that HBV affects multiple aspects of psychological, social, and physical health. The resultant questionnaire summarized this HRQOL impact with 31 items across six subscales: psychological well-being, anticipation anxiety, vitality, disease stigma, vulnerability, and transmissibility. Internal consistency and test-retest reliability were excellent. The HBQOL v1.0 discriminated between viral responders versus nonresponders and correlated highly with SF-36 scores and global health.

CONCLUSION

Patients with chronic HBV infection attribute a wide range of negative psychological, social, and physical symptoms to their condition, even in the absence of cirrhosis or cancer. The HBQOL v1.0 is a valid and reliable measure that captures this HRQOL decrement. This instrument may be useful in everyday clinical practice and in future clinical trials.

Psychometric properties of the Early Trauma Inventory-Self Report

Childhood trauma is an important public health problem, but there are limitations in our ability to measure childhood abuse. The purpose of this study was to develop a self-report instrument for the assessment of childhood trauma that is valid but simple to administer. A total of 288 subjects with and without trauma and psychiatric disorders were assessed with the Early Trauma Inventory-Self Report (ETI-SR), an instrument for the assessment of physical, emotional, and sexual abuse, as well as general traumas, which measures frequency, onset, emotional impact, and other variables. Validity and consistency of the ETI-SR using different methods of scoring was assessed. The ETI-SR was found to have good validity and internal consistency. No method was found to be superior to the simple method of counting the number of items endorsed as having ever occurred in terms of validity. Some items were found to be redundant or not necessary for the accurate measurement of trauma severity within specific domains. Subsequent analyses with a shortened checklist of items showed acceptable validity and internal consistency. These findings suggest that the ETI-SR is a valid measure of early trauma, and suggest future directions for a shortened version of the ETI-SR that could be more easily incorporated into clinical research studies and practice settings.

The central role of gastrointestinal-specific anxiety in irritable bowel syndrome: further validation of the visceral sensitivity index

OBJECTIVES

The Visceral Sensitivity Index (VSI) was developed as the first instrument to assess gastrointestinal-specific anxiety, the cognitive, affective, and behavioral response to fear of gastrointestinal sensations, symptoms, and the context in which these visceral sensations and symptoms occur. The purpose of the current study was to a) replicate the previously reported psychometric properties of the VSI, b) assess the known-groups and concurrent validity of the instrument, and c) test conceptual hypotheses regarding gastrointestinal-specific anxiety in comparison to other general measures of psychological distress as a crucial mechanism (mediator/moderator) underlying irritable bowel syndrome diagnosis and its symptoms.

METHODS

Two undergraduate student samples (n > 500) were administered the VSI along with measures assessing presence of lower gastrointestinal symptoms, nongastrointestinal pain, health-service utilization, anxiety, depression, vitality, neuroticism, and anxiety sensitivity. Path analyses tested the hypothesis that gastrointestinal-specific anxiety mediates the relationship between affective variables and irritable bowel syndrome diagnosis and symptoms. A 'known-groups' validity approach elucidated the relevance of gastrointestinal-specific anxiety across a spectrum of irritable bowel syndrome patients.

RESULTS

Good concurrent, divergent and discriminant validity was demonstrated. Logistic regression revealed that gastrointestinal-specific anxiety is the key explanatory variable of irritable bowel syndrome diagnostic status. Path analysis demonstrated that gastrointestinal-specific anxiety mediates the relationship between general psychological distress measures and gastrointestinal symptom severity. The VSI was related to gastrointestinal, but not nongastrointestinal, symptom severity.

CONCLUSIONS

Overall, the VSI demonstrated excellent psychometric properties providing further support for its use in mechanistic studies of the role of anxiety in irritable bowel syndrome presentation.

The addiction behaviors checklist: validation of a new clinician-based measure of inappropriate opioid use in chronic pain

This study introduces the Addiction Behaviors Checklist (ABC), which is a brief (20-item) instrument designed to track behaviors characteristic of addiction related to prescription opioid medications in chronic pain populations. Items are focused on observable behaviors noted both during and between clinic visits. One hundred thirty-six consecutive veterans in a multidisciplinary Veterans Affairs Chronic Pain Clinic who were receiving long-term opioid medication treatment were included in this study. This study represents one of the first to follow a sample of chronic pain patients on opioid therapy over time, using a structured assessment tool to evaluate and track behaviors suggestive of addiction. Interrater reliability and concurrent validity data are presented, as well as a cut-off score for use in determining inappropriate medication use. The psychometric findings support the ABC as a viable assessment tool that can increase a provider's confidence in determinations of appropriate vs. inappropriate opioid use.

Is a negative colonoscopy associated with reassurance or improved health-related quality of life in irritable bowel syndrome?

BACKGROUND

Although colonoscopy is rarely of clinical use in irritable bowel syndrome (IBS), it is, nonetheless, frequently performed in IBS. Proponents contend that a normal colonoscopy provides reassurance and improves health-related quality of life (HRQOL). However, no previous data have measured these effects. We sought to measure the association of a normal colonoscopy with reassurance and HRQOL in patients with IBS aged <50 years.

METHODS

We retrospectively evaluated 458 patients with IBS, aged 18 to 49 years. Subjects completed a symptom questionnaire, the Symptom Checklist 90 (SCL-90) psychometric checklist, and the Short Form 36 (SF-36) Health Survey. The main outcomes were HRQOL as measured by the mental component score (MCS) and the physical component score (PCS) of the SF-36 and reassurance as operationalized by a negative response to the question: "Do you think there is something seriously wrong with your body?" The independent variable was presence or absence of a previous normal colonoscopy. We performed regression analysis to control for potential confounders, including timing of colonoscopy.

RESULTS

The unadjusted mean SF-36 PCS was 42 +/- 10 (0-100 scale: 0, worst) in patients with recent colonoscopy (<12 months), 45 +/- 11 in patients with distant colonoscopy (>12 months), and 45 +/- 10 in patients without colonoscopy (p = 0.78). The mean SF-36 MCS in the 3 groups were 42 +/- 13, 44 +/- 11, and 43 +/- 11 (p = 0.57). Colonoscopy did not impact the proportion reassured (69.3%, 67.2%, 66.6%; p = 0.85). There were no significant differences between groups for any outcomes when adjusting for potential confounders.

CONCLUSIONS

We found no independent association between a negative colonoscopy and reassurance or improved HRQOL in IBS patients aged <50 years. These results suggest that the role of colonoscopy in IBS may be limited but require confirmation in prospective trials.

Characterization of the alternating bowel habit subtype in patients with irritable bowel syndrome

BACKGROUND

Due to a wide range of symptom patterns, patients with irritable bowel syndrome (IBS) are often subgrouped by bowel habit. However, the IBS subgroup with alternating bowel habits (IBS-A) has been poorly characterized.

OBJECTIVES

(i) To determine a set of bowel habit symptom criteria, which most specifically identifies IBS patients with an alternating bowel habit, (ii) to describe IBS-A bowel symptom patterns, and (iii) to compare clinical characteristics among IBS-A, constipation-predominant (IBS-C), and diarrhea-predominant IBS (IBS-D).

METHODS

One thousand one hundred and two Rome I positive IBS patients were analyzed. Three sets of potential criteria for IBS-A were developed and compared by multirater Kappa test. Gastrointestinal, psychological, extraintestinal symptoms, and health-related quality of life were compared in IBS-A, IBS-C, and IBS-D using chi(2) test and analysis of variance (ANOVA).

RESULTS

Stool consistency was determined to be the most specific criteria for alternating bowel habits. IBS-A patients reported rapid fluctuations in bowel habits with short symptom flares and remissions. There was a greater prevalence of psychological and extraintestinal symptoms in the IBS-A subgroup compared to IBS-C and IBS-D. No differences were seen between bowel habit subtypes in health-related quality of life.

CONCLUSIONS

IBS-A patients have rapidly fluctuating symptoms and increased psychological comorbidity, which should be taken into account for clinical practice and clinical trials.

Impact of irritable bowel syndrome on patients' lives: development and psychometric documentation of a disease-specific measure for use in clinical trials

OBJECTIVE

To develop a disease-specific questionnaire to capture the impact of irritable bowel syndrome (IBS) and its treatment on patients' lives, the Irritable Bowel Syndrome Impact Scale (IBS-IS).

PATIENTS AND METHODS

One hundred and fifty-five IBS patients participated (126 (81%) female; age (mean+/-SD) 45.5+/-12.4 years). We developed the initial 39 items from the literature, available IBS-specific instruments and input from physicians, nurses and patients. We deleted IBS-IS items with a high ceiling effect, items that measured a different construct and items showing a high correlation (r>0.90) with another item and with Rasch analysis, leaving 26 items. We then applied exploratory factor analysis to examine domain groupings. Subjects completed the IBS-IS instrument, the Gastrointestinal Symptom Rating Scale for IBS (GSRS-IBS), Short Form-36 (SF-36), Visceral Sensitivity Index (VSI), and Hospital Anxiety and Depression (HAD) scale. Internal consistency, construct validity and discriminate validity were assessed.

RESULTS

The 26 items represented five domains: fatigue, impact on daily activities, sleep disturbance, emotional distress and eating habits. The internal consistency reliability for the domains was 0.87 to 0.96. Most associations between similar constructs in the IBS-IS, GSRS-IBS, SF-36, VSI, and HAD were >0.40. Each IBS-IS domain score decreased with increasing IBS symptom severity (P<0.05), and the patients scored >5 score units lower than a US general population scored on all eight SF-36 dimensions.

CONCLUSION

The IBS-IS is a short, user-friendly instrument with excellent psychometric properties that has potential usefulness for clinical trials.

Clinical determinants of health-related quality of life in patients with irritable bowel syndrome

BACKGROUND

Current guidelines recommend routine assessment of health-related quality of life (HRQOL) in patients with irritable bowel syndrome (IBS). However, physicians rarely have the time to measure HRQOL with the appropriate methodological rigor, and data suggest that HRQOL in patients with IBS is often estimated using inaccurate clinical gestalt. The identification of predictive factors could allow physicians to better assess HRQOL without using misleading clinical clues. We, therefore, sought to identify determinants of HRQOL in patients with IBS.

METHODS

We examined 770 patients, 18 years or older, with IBS at a university-based referral center. Subjects completed a symptom questionnaire, the Symptoms Checklist-90 items psychometric checklist, and the 36-Item Short-Form Health Survey. The main outcome was HRQOL as measured by the mental and physical component scores of the 36-Item Short-Form Health Survey. We first developed a list of hypothesis-driven HRQOL predictors, and then performed multivariate regression analysis to measure the independent association of each predictor with HRQOL.

RESULTS

Seven factors (r(2) = 0.39) independently predicted physical HRQOL: (1) more than 5 physician visits per year, (2) tiring easily, (3) low in energy, (4) severe symptoms, (5) predominantly painful symptoms, (6) the feeling that there is "something seriously wrong with body," and (7) symptom flares for longer than 24 hours. Eight factors (r(2) = 0.36) independently predicted mental HRQOL: (1) feeling tense, (2) feeling nervous, (3) feeling hopeless, (4) difficulty sleeping, (5) tiring easily, (6) low sexual interest, (7) IBS symptom interference with sexual function, and (8) low energy.

CONCLUSIONS

Health-related quality of life in patients with IBS is primarily related to extraintestinal symptoms rather than traditionally elicited gastrointestinal symptoms. These findings suggest that rather than focusing on physiological epiphenomena (stool characteristics and subtype of IBS) and potentially misleading clinical factors (age and disease duration), physicians might be better served to gauge global symptom severity, address anxiety, and eliminate factors contributing to chronic stress in patients with IBS.

The Visceral Sensitivity Index: development and validation of a gastrointestinal symptom-specific anxiety scale

BACKGROUND

Anxiety related to gastrointestinal sensations, symptoms or the contexts in which these may occur is thought to play a significant role in the pathophysiology as well as in the health outcomes of patients with irritable bowel syndrome.

AIM

To develop a valid and reliable psychometric instrument that measures gastrointestinal symptom-specific anxiety.

METHODS

External and internal expert panels as well as a patient focus group evaluated a large pool of potential item stems gathered from the psychological and gastrointestinal literature. Potential scale items were then administered to 96 patients diagnosed with irritable bowel syndrome along with a set of validating questionnaires. Final item selection was based upon rigorous empirical criteria and the psychometric properties of the final scale were examined.

RESULTS

A final unidimensional 15-item scale, the Visceral Sensitivity Index, demonstrated excellent reliability as well as good content, convergent, divergent and predictive validity.

CONCLUSIONS

The findings suggest that the Visceral Sensitivity Index is a reliable, valid measure of gastrointestinal symptom-specific anxiety that may be useful for clinical assessment, treatment outcome studies, and mechanistic studies of the role of symptom-related anxiety in patients with irritable bowel syndrome.

The effect of life stress on symptoms of heartburn

OBJECTIVE

Psychosocial stressors have been associated with exacerbations of symptoms in functional and inflammatory disorders of the gastrointestinal tract. The present longitudinal study tests the general hypothesis that life stressors can exacerbate symptoms in patients with chronic heartburn.

METHODS

Sixty subjects with current heartburn symptoms were recruited by community advertisement and assessed for presence of stressful life events retrospectively over the preceding 6 months and prospectively for 4 months. Symptom severity by daily diary, quality of life, and psychological symptoms of anxiety, depression, and vital exhaustion were also measured.

RESULTS

The presence of a severe, sustained life stress during the previous 6 months significantly predicted increased heartburn symptoms during the following 4 months. In addition, symptoms showed a strong, independent correlation with vital exhaustion. Affective and subjective stress ratings were not strongly related to heartburn severity; however, anxiety showed the strongest relationship to impaired quality of life and depression to heartburn medication use.

CONCLUSIONS

As with other chronic conditions such as irritable bowel syndrome (IBS), heartburn severity appears to be most responsive to major life events and not an accumulation of more minor stressors or fluctuations in mood. In addition, vital exhaustion, which may in part result from sustained stress, may represent the psychophysiological symptom complex most closely associated with heartburn exacerbation. Potential mechanisms for these results include increased level and frequency of esophageal acid exposure, inhibition of gastric emptying of acid, or stress-induced hypersensitivity.

Is there a difference between abdominal pain and discomfort in moderate to severe IBS patients?

OBJECTIVES

The aims of this study were to: 1) determine the relative prevalence of self-reported pain-predominant and discomfort-predominant symptom patterns in irritable bowel syndrome (IBS) patients; and 2) test the hypotheses that pain-predominant patients report higher GI symptom severity, show higher psychological symptom severity, show worse quality of life, and demonstrate higher health care use.

METHODS

A total of 256 consecutive ROME I-positive IBS patients with moderate to severe symptoms were classified according to whether they rated their predominant IBS symptoms as pain (n = 52), or as nonpainful discomfort (n = 128) on the Irritable Bowel Syndrome Quality of Life questionnaire. The validity of this classification scheme was confirmed by interview in a subsample of 45 patients. IBS-specific symptom patterns, psychometric assessment, and health-related quality of life measures were obtained using validated survey instruments.

RESULTS

Contrary to the generally accepted notion that pain is the most predominant symptom in IBS, twice as many patients self-classified their symptoms as abdominal discomfort rather than abdominal pain. The classifications based on questionnaire data were shown to be valid in a subsample of subjects (n = 45) who underwent classification based on an independent, blinded, clinical interview (r = 0.77, p < 0.05). Pain and discomfort subgroups were similar in age, gender, predominant bowel habit, and overall GI symptom severity. In addition, the subgroups reported similar degrees of psychological distress, impaired quality of life, and increased patterns of health care use.

CONCLUSIONS

Subgroups of moderate to severe IBS patients do report their predominant GI symptoms in terms of pain or nonpainful discomfort, regardless of severity of their overall GI symptoms or psychological symptoms. These findings are most consistent with a cognitive labeling bias of visceral sensations as either pain or discomfort.

Do older internists use more hospital resources than younger internists for patients hospitalized with chest pain? A study of patients hospitalized in the coronary care and intermediate care units

OBJECTIVES

Recent concern about escalating healthcare expenditures has prompted healthcare payers and hospitals to identify physicians whose hospital resource consumption exceeds expected norms. The goals of this study were to determine whether analyses of practice patterns in this manner may a) systematically identify older physicians as big resource "spenders," and b) provide misleading information caused by the failure to adjust utilization data for severity of illness.

DESIGN

A prospective, observational study.

SETTING

The coronary care and intermediate care unit in an 1,100-bed community hospital.

PATIENTS

A total of 217 patients hospitalized for chest pain cared for by noncardiologists.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

On initial inspection, it appeared that the patients of older physicians had longer lengths of stay and greater charge expenditures than the patients of younger physicians. However, further evaluation demonstrated that older physicians cared for older (76 vs. 67 yrs old, p = .0001) and more severely ill patients (judged by risk of complications, risk of acute ischemic heart disease, and disease staging). Older physicians cared for more severely ill myocardial infarction patients than did younger physicians (Killip Classification 2.0 vs. 1.1, p less than .00003). After adjusting for severity of illness, there were fewer differences in hospital charges and consultant use between older and younger physicians, although the patients of older physicians remained hospitalized longer.

CONCLUSIONS

There is little difference in resource utilization between patients cared for by older and younger internists after controlling for severity of illness. This investigation highlights the potential hazards of ignoring severity of illness when judging physician efficiency in the coronary care unit.

The principle of parsimony: Glasgow Coma Scale score predicts mortality as well as the APACHE II score for stroke patients

Although the development and use of severity-of-illness measures has gained widespread enthusiasm, uncertainty remains as to the optimal measure for stroke patients. The Health Care Financing Administration recently derived a severity-of-illness measure based on the APACHE II system to explain differences in Medicare mortality rates among hospitals treating stroke patients. We hypothesized that the Glasgow Coma Scale score provides prognostic information of accuracy comparable to that of the APACHE II score for stroke patients, yet is simpler and cheaper to abstract from the medical record. We therefore studied 246 patients hospitalized with stroke, including 49 oversampled mortalities. The Glasgow Coma Scale score was as accurate as the APACHE II score in predicting stroke mortality both before (r = -0.50 and r = 0.50, respectively) and after (r = -0.40 and r = 0.38, respectively) the oversampled mortalities were excluded. The APACHE II score required abstraction of 16 variables from the medical record compared with three for the Glasgow Coma Scale score and required more than three times the time to abstract from the medical record. Therefore, in the interest of parsimonious data collection, the Glasgow Coma Scale may be a preferable severity-of-illness measure for patients with stroke.

Early "step-down" transfer of low-risk patients with chest pain. A controlled interventional trial

OBJECTIVE

To determine whether providing private practitioners with triage criteria for their low-risk chest pain patients would safely enhance bed utilization efficiency in coronary and intermediate care units.

DESIGN

Prospective, controlled, interventional trial using an alternate month study design.

SETTING

A large teaching community hospital.

PATIENTS

Cohort of 404 low-risk patients with chest pain for whom a diagnosis of myocardial infarction has been excluded and who have not sustained complications, required interventions, or developed unstable comorbidity.

INTERVENTIONS

During intervention months, private practitioners caring for low-risk patients in the coronary and intermediate care units were contacted 24 hours after admission. Physicians were informed that the transfer of low-risk patients to nonmonitored beds could probably be done safely, based on the results of a pilot study. The practitioner had the option of agreeing to or deferring patient transfer. During control months, physicians were not contacted in this way.

MEASUREMENTS AND MAIN RESULTS

Use of the triage criteria by private practitioners reduced lengths of stay in the intermediate and coronary care units by 36% and 53%, respectively. Bed availability increased by 744 intermediate and 372 coronary care unit bed-days per year. Charges decreased by $2.6 million per year and profits improved by $390,000 per year. There were not significant differences in complications between control and intervention patients and in no case (95% CI, 0% to 1.6%) did the triage criteria adversely affect quality of care.

CONCLUSIONS

The early transfer triage criteria may be a safe and efficacious decision aid for improving bed utilization in intermediate and coronary care units. In addition, this study shows the feasibility of and potential benefits from applying practice guidelines at a community hospital.