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Management of chronic constipation in a community hospital
AJG – September, Suppl., 2001
Abstracts
Purpose: This analysis estimates the likelihood of identifying irritable bowel syndrome (IBS) patients with administrative encounter data and a survey using the Rome I symptom criteria in a sample of patients having had a flexibible sigmoidoscopy for any reason. Methods: A survey including the ROME I symptom criteria for IBS was sent to 6,500 enrollees in a large managed care organization (MCO) who had received a flexible sigmoidoscopy during the year 2000. Patients were identified as IBS-positive or negative based on Rome I criteria. Encounter data for the prior two-year period were examined. Patients without practitioner visits or hospitalizations were eliminated. Patients were classified as having definite IBS (at least one administrative code for IBS); possible IBS (at least one administrative code for related GI conditions such as abdominal pain, constipation, diarrhea, dyspepsia, and reflux); or no IBS. Results: Survey responses were received from 2,613 patients (40.2% response rate), of whom 2,594 had at least one practitioner visit or hospitalization. 619 patients (23.9%) were IBS positive and 117 (4.5%) had at least one claim for IBS. Among IBS positive respondents, 70 had a definite IBS code (sensitivity ⫽ 11.3%), while 191 (30.9%) had codes indicating possible IBS. Among IBS negative respondents, 47 of 1,975 had codes indicating definite IBS and 335 (17.0%) had codes indicating possible IBS (specificity ⫽ 97.6%). Even among IBS positive respondents considered high utilizers (10⫹ visits/hospitalizations (n ⫽ 458)), only 58 (12.7%) had a code indicating definite IBS, while 159 (34.7%) had a code indicating possible IBS. IBS Diagnosis Based on Encounter Data IBS Diagnosis Based on Rome I
Definite IBS (N ⴝ 117)
Possible IBS (N ⴝ 526)
No IBS (N ⴝ 1,951)
Positive (N ⫽ 619) Negative (N ⫽ 1,975)
70 (11.3%) 47 (2.4%)
191 (30.9%) 335 (17.0%)
358 (57.8%) 1,593 (80.6%)
Conclusions: Among a sample of MCO patients having undergone flexible sigmoidoscopy for any reason, administrative encounter data identified a small proportion of those with IBS, even among high utilizers of health care services. Even when other GI conditions that could be related to IBS are included, fewer than half of patients who meet ROME I criteria for IBS would have been identified using administrative data. These findings suggest that IBS is either substantially under-recognized and/or that appropriate diagnostic codes are often not applied to IBS patients. This research was supported by a Research Grant from Novartis.
870 Management of chronic constipation in a community hospital Holger Kranich, Affan Quadri, Geetha Ganesan, Affi Aboud and Thomas Puetz*. 1Gastroenterology, University Of WI Milwaukee Campus SSMC, Milwaukee, WI, United States. Purpose: Patients with chronic constipation make frequent visits to Emergency department (ED) and Primary care providers (PCPs). This may be due to the lack of proper long term care plans. Aims: To look at the diagnostic work-up and treatment offered to patients with chronic constipation who make frequent visits to the ED or PCPs. Methods: All patients with chronic constipation making 3 or more visits to ED or PCPs, in a Community Hospital were identified. A structured questionnaire was used to record the demographics, coexisting conditions/ medications affecting constipation, diagnostic work-up and treatment offered to these patients for each visit. In addition any long term care plan and patient’s compliance was also recorded. Results: Forty-three patients had 210 visits to ED or PCPs between 1995 and 1999 for chronic constipation. There were 26 females and 17 males with mean age of 61. Most common presentation was abdominal pain. The diagnostic evaluation included Abdominal X-rays 89(84%), Out patient Colonoscopy/Flexible sigmoidoscopy in an open access system 16(15%) and SITZMARKS study 1 (0.9%). Medications used, which may contribute to constipation, were Calcium Channel blockers, Antipsychotics, Antide-
S273
pressants, and Narcotic pain medications. Most of the patients were continued on these medications. Prophylactic treatment offered was Osmotic laxatives 20%, Stool softeners 14%, Stimulant laxatives 12%, Fiber 10%, Enemas/Laxative suppositories 9 %, and Golyte/Miralax 2%. Thirty-three percent of the patients were not given any prophylactic treatment. Only 11.4 % patients were compliant to the treatment given on previous visits. Conclusions: Patients with chronic constipation make frequent visits to Emergency departments and Primary Care Providers. Better characterization of patients with proper diagnostic work-up, long term care plans and improvement of noncompliance to treatment would be needed to over come this problem.
871 Evidence-based analysis of the benefit of esomeprazole in the treatment of erosive esophagitis (EE) Jeffrey G Levine*, Clara Hwang, Albert Roach and David J Bjorkman. 1 AstraZeneca LP, Wayne, PA, United States; 2AstraZeneca LP, Wayne, PA, United States; 3AstraZeneca LP, Wayne, PA, United States; and 4 University of Utah School of Medicine, Salt Lake City, UT, United States. Purpose: Number needed to treat (NNT) provides a meaningful measure of the magnitude of difference between 2 therapies and allows a basis for cost comparisons. Using evidence-based medicine concepts, we determined the relative efficacy of esomeprazole versus omeprazole for preventing treatment failures (unhealed EE) during acute treatment. Methods: We calculated the NNT to prevent 1 patient with endoscopically documented EE from having unhealed EE after 8 weeks of treatment for esomeprazole 40 mg (n ⫽ 2446) relative to omeprazole 20 mg (n ⫽ 2431) using pooled healing rate data from 3 large trials that had essentially the same study protocols. The primary endpoint, endoscopic healing at week 8, was analyzed using a log rank test, and 8-week healing rates were estimated by life table methods. The relative risk reduction (RRR) and absolute risk reduction (ARR) for treatment failure (no healing) were first determined. The NNT was then calculated as 1/ARR. Results: Pooled response rates and NNTs for esomeprazole versus omeprazole are shown in the table. In the pooled analysis, esomeprazole showed a significantly higher 8-week healing rate than omeprazole (p ⬍ 0.001). The analysis indicates that 14 patients would need to be treated for 8 weeks with esomeprazole 40 mg instead of omeprazole 20 mg to prevent 1 treatment failure. Conclusions: Esomeprazole is more effective than omeprazole for healing EE, with an NNT of 14. This NNT can be used as a basis for comparing relative efficacy and costs of esomeprazole and other PPIs across clinical trials. Eso 40 mg (n ⴝ 2446) % Healed (95% CI) 93.4% (92.4%–94.5%)
Ome 20 mg (n ⴝ 2431) % Healed (95% CI)
RRR
ARR
NNT
86.2% (84.8%–87.7%)
52.2% (43.5%–60.7%)
7.2% (5.5%–8.9%)
14 (11–18)
872 Cost effectiveness of misoprostol vs. omeprazole in the prevention of NSAID associated gastrointestinal symptoms in high risk patients Loughney TM, Jai EM, Goo E, Dydek GJ, Beaudoin D, Hammond S, Egan JE, Yoshinobu BH. Tripler Army Medical Center, Honolulu, HI. Purpose: The objective of this study was to compare the efficacy and total utilization of resources in a cost-effectiveness analysis of misoprostol versus omeprazole in the prevention of NSAID-associated symptoms in high-risk patients.
Abstracts
Purpose: This analysis estimates the likelihood of identifying irritable bowel syndrome (IBS) patients with administrative encounter data and a survey using the Rome I symptom criteria in a sample of patients having had a flexibible sigmoidoscopy for any reason. Methods: A survey including the ROME I symptom criteria for IBS was sent to 6,500 enrollees in a large managed care organization (MCO) who had received a flexible sigmoidoscopy during the year 2000. Patients were identified as IBS-positive or negative based on Rome I criteria. Encounter data for the prior two-year period were examined. Patients without practitioner visits or hospitalizations were eliminated. Patients were classified as having definite IBS (at least one administrative code for IBS); possible IBS (at least one administrative code for related GI conditions such as abdominal pain, constipation, diarrhea, dyspepsia, and reflux); or no IBS. Results: Survey responses were received from 2,613 patients (40.2% response rate), of whom 2,594 had at least one practitioner visit or hospitalization. 619 patients (23.9%) were IBS positive and 117 (4.5%) had at least one claim for IBS. Among IBS positive respondents, 70 had a definite IBS code (sensitivity ⫽ 11.3%), while 191 (30.9%) had codes indicating possible IBS. Among IBS negative respondents, 47 of 1,975 had codes indicating definite IBS and 335 (17.0%) had codes indicating possible IBS (specificity ⫽ 97.6%). Even among IBS positive respondents considered high utilizers (10⫹ visits/hospitalizations (n ⫽ 458)), only 58 (12.7%) had a code indicating definite IBS, while 159 (34.7%) had a code indicating possible IBS. IBS Diagnosis Based on Encounter Data IBS Diagnosis Based on Rome I
Definite IBS (N ⴝ 117)
Possible IBS (N ⴝ 526)
No IBS (N ⴝ 1,951)
Positive (N ⫽ 619) Negative (N ⫽ 1,975)
70 (11.3%) 47 (2.4%)
191 (30.9%) 335 (17.0%)
358 (57.8%) 1,593 (80.6%)
Conclusions: Among a sample of MCO patients having undergone flexible sigmoidoscopy for any reason, administrative encounter data identified a small proportion of those with IBS, even among high utilizers of health care services. Even when other GI conditions that could be related to IBS are included, fewer than half of patients who meet ROME I criteria for IBS would have been identified using administrative data. These findings suggest that IBS is either substantially under-recognized and/or that appropriate diagnostic codes are often not applied to IBS patients. This research was supported by a Research Grant from Novartis.
870 Management of chronic constipation in a community hospital Holger Kranich, Affan Quadri, Geetha Ganesan, Affi Aboud and Thomas Puetz*. 1Gastroenterology, University Of WI Milwaukee Campus SSMC, Milwaukee, WI, United States. Purpose: Patients with chronic constipation make frequent visits to Emergency department (ED) and Primary care providers (PCPs). This may be due to the lack of proper long term care plans. Aims: To look at the diagnostic work-up and treatment offered to patients with chronic constipation who make frequent visits to the ED or PCPs. Methods: All patients with chronic constipation making 3 or more visits to ED or PCPs, in a Community Hospital were identified. A structured questionnaire was used to record the demographics, coexisting conditions/ medications affecting constipation, diagnostic work-up and treatment offered to these patients for each visit. In addition any long term care plan and patient’s compliance was also recorded. Results: Forty-three patients had 210 visits to ED or PCPs between 1995 and 1999 for chronic constipation. There were 26 females and 17 males with mean age of 61. Most common presentation was abdominal pain. The diagnostic evaluation included Abdominal X-rays 89(84%), Out patient Colonoscopy/Flexible sigmoidoscopy in an open access system 16(15%) and SITZMARKS study 1 (0.9%). Medications used, which may contribute to constipation, were Calcium Channel blockers, Antipsychotics, Antide-
S273
pressants, and Narcotic pain medications. Most of the patients were continued on these medications. Prophylactic treatment offered was Osmotic laxatives 20%, Stool softeners 14%, Stimulant laxatives 12%, Fiber 10%, Enemas/Laxative suppositories 9 %, and Golyte/Miralax 2%. Thirty-three percent of the patients were not given any prophylactic treatment. Only 11.4 % patients were compliant to the treatment given on previous visits. Conclusions: Patients with chronic constipation make frequent visits to Emergency departments and Primary Care Providers. Better characterization of patients with proper diagnostic work-up, long term care plans and improvement of noncompliance to treatment would be needed to over come this problem.
871 Evidence-based analysis of the benefit of esomeprazole in the treatment of erosive esophagitis (EE) Jeffrey G Levine*, Clara Hwang, Albert Roach and David J Bjorkman. 1 AstraZeneca LP, Wayne, PA, United States; 2AstraZeneca LP, Wayne, PA, United States; 3AstraZeneca LP, Wayne, PA, United States; and 4 University of Utah School of Medicine, Salt Lake City, UT, United States. Purpose: Number needed to treat (NNT) provides a meaningful measure of the magnitude of difference between 2 therapies and allows a basis for cost comparisons. Using evidence-based medicine concepts, we determined the relative efficacy of esomeprazole versus omeprazole for preventing treatment failures (unhealed EE) during acute treatment. Methods: We calculated the NNT to prevent 1 patient with endoscopically documented EE from having unhealed EE after 8 weeks of treatment for esomeprazole 40 mg (n ⫽ 2446) relative to omeprazole 20 mg (n ⫽ 2431) using pooled healing rate data from 3 large trials that had essentially the same study protocols. The primary endpoint, endoscopic healing at week 8, was analyzed using a log rank test, and 8-week healing rates were estimated by life table methods. The relative risk reduction (RRR) and absolute risk reduction (ARR) for treatment failure (no healing) were first determined. The NNT was then calculated as 1/ARR. Results: Pooled response rates and NNTs for esomeprazole versus omeprazole are shown in the table. In the pooled analysis, esomeprazole showed a significantly higher 8-week healing rate than omeprazole (p ⬍ 0.001). The analysis indicates that 14 patients would need to be treated for 8 weeks with esomeprazole 40 mg instead of omeprazole 20 mg to prevent 1 treatment failure. Conclusions: Esomeprazole is more effective than omeprazole for healing EE, with an NNT of 14. This NNT can be used as a basis for comparing relative efficacy and costs of esomeprazole and other PPIs across clinical trials. Eso 40 mg (n ⴝ 2446) % Healed (95% CI) 93.4% (92.4%–94.5%)
Ome 20 mg (n ⴝ 2431) % Healed (95% CI)
RRR
ARR
NNT
86.2% (84.8%–87.7%)
52.2% (43.5%–60.7%)
7.2% (5.5%–8.9%)
14 (11–18)
872 Cost effectiveness of misoprostol vs. omeprazole in the prevention of NSAID associated gastrointestinal symptoms in high risk patients Loughney TM, Jai EM, Goo E, Dydek GJ, Beaudoin D, Hammond S, Egan JE, Yoshinobu BH. Tripler Army Medical Center, Honolulu, HI. Purpose: The objective of this study was to compare the efficacy and total utilization of resources in a cost-effectiveness analysis of misoprostol versus omeprazole in the prevention of NSAID-associated symptoms in high-risk patients.