- Email: [email protected]
S1831 Health Care Costs Associated with Fecal Incontinence
6 years duration, reported adequate relief of symptoms following an education/medical management intervention and 71% reported continued success at 12-month follow-up. These patients had an average of > 3 physician visits, specifically for FI, just in the previous 6 months. In addition to higher symptom severity and lower QOL measures, depression also predicted failure from run-in. Assessing patients with FI for depression may aid in developing an effective treatment plan that may include psychotherapy. [Supported by grants RO1 DK57048, R24 DK67674, and MO1 RR00046].
S1832
Background: Epidemiological studies of fecal incontinence (FI) show a consistent association with self-reported diarrhea and an inconsistent association with self-reported constipation. However, subjects differ in what they mean by diarrhea and constipation. Aim: Determine whether usual stool consistency and stool frequency are associated with FI in a national population based sample. Methods: Subjects in the NHANES survey for 2005-2006 were asked to rate their usual or most common stool type using the 7 descriptions from the Bristol Stool Scale (Gut 1994;35:1455). We pooled ratings 1 and 2 (hard and lumpy), ratings 3-5 (normal consistencies), and ratings 6 and 7 (mushy and watery). Subjects were also asked how often they usually have bowel movements, and responses were merged into 3 ranges: <3/week, 3-21/week, and >21/week. FI was defined as any involuntary loss of mucus, liquid, or solid stool during the last 30 days. NHANES over-samples minorities and the elderly for increased precision; it provides weights for each subject's data to obtain estimates for the national population. Subjects were 2079 males and 2229 females aged 20 or older. Prevalences (in percent) for the national population are estimated and their 95% confidence intervals (CI) are given. Results: See table. For both females and males, having stools that are typically loose or watery or stools that are more frequent than 21/week was associated with a 3-4 fold increase in the rate of FI. Neither typically hard/lumpy stools nor infrequent stools were associated with significant increases in FI for males or females. Conclusions: Having typically loose/watery stools and/or stools more than 3 times per day is significantly associated with the presence of FI and may be a target for preventing or treating FI. [Supported by grants from the National Institute of Child Health and Human Development and the NIH Office of Research on Women's Health (U01 HD41249, U10 HD41250, U10 HD41261, U10 HD41267, U10 HD54136, U10 HD54214, U10 HD54215, and U10 HD54241)]
S1830 Twelve Month Follow-Up for Patients with Pelvic Floor Dyssynergia-Type Constipation (PFD) Reporting Adequate Relief After a 4-Week Education and Medical Management Run-in Intervention Steve Heymen, Yolanda V. Scarlett, William E. Whitehead Introduction: 18 out of 117 patients (15%) with PFD reported adequate relief from a 4week run-in phase (including education and medical management) of an RCT that compared Biofeedback to two credible alternative treatments (DCR 2007;50:428). Aim: To assess longterm effects of a conservative intervention for patients with chronic constipation due to PFD. Method: Education included a review of pelvic floor muscle physiology and manometry results, toileting schedules, use of diary data, and instructions to defecate without excessive force. Medical management included dietary advice and stool softeners, as needed, to modify stool consistency. All patients were encouraged to contact the therapist at least every 4 days for modification of instructions, if unsuccessful. All run-in responders were invited to return for 3-month and 12-month follow-up evaluations that included repeat anorectal manometry, diary data collection, and repeat psychometric evaluation. Results: 78% of run-in responders continued to report adequate relief of symptoms at 3-month follow-up. 72% of patients reported continued success at 12-month follow-up. Subjects lost to follow-up (n=2) were counted as treatment failures. Patients who failed the run-in intervention reported worse constipation symptoms (p < 0.01), higher depression (p < 0.05), and lower general, and disease specific quality of life measures (p < 0.05) at baseline, than run-in responders. None of the responders reported a history of physical abuse, compared to 26% of patients who failed run-in (p < 0.05). There were no differences between responders or non-responders in: age, race, symptom duration, sexual abuse history, pelvic floor physiology, colonic transit time, or number of physician visits for 6 months prior to the study. The only variable associated with continued success at 12-month follow-up was the number of days/week with unassisted bowel movements (6 vs. 1 per week, respectively). Discussion: Fifteen percent of patients with chronic constipation of greater than 15 years duration reported adequate relief of symptoms following an education/medical management intervention and 72% reported continued success at 12-month follow-up. These patients reported an average of more than 5 physician visits, specifically for constipation, just in the previous 6 months. In addition to higher symptom severity and lower QOL measures being associated with treatment failure during run-in, depression also predicted failure from run-in. Assessing patients with constipation for depression may aid in developing an effective treatment plan that may include psychotherapy. [Supported by grants RO1 DK57048, R24 DK67674, MO1 RR00046]
S1833 S1831
National Health and Nutrition Examination Survey (NHANES) of Fecal Incontinence: Characteristics of Incontinent Stools William E. Whitehead
Health Care Costs Associated with Fecal Incontinence Steve Heymen, Olafur S. Palsson, Michael Von Korff, Rona L. Levy, Marsha J. Turner, William E. Whitehead
Background: Fecal incontinence (FI) occurs in 7-9% of US adults. Its impact on quality of life ranges from minimal to severe and may include admission to a nursing home. This impact likely depends on the frequency and type of stool lost. Aims: Characterize the prevalence of FI according to the frequency and type of stool lost. Methods: Questions from the Fecal Incontinence Severity Index (Dis Colon Rectum 1999;42:1525), which asks about the frequency of accidental bowel leakage during the last month separately for mucus, liquid, and solid stool, were included in the NHANES survey in 2005 and 2006. FI was defined as any involuntary loss of mucus, liquid, or solid stool; this definition of FI does not include gas. NHANES over-samples minorities and the elderly for increased precision; it provides weights for each subject's data to obtain estimates for the national population. Subjects were 2079 males and 2229 females aged 20 or older. Prevalence estimates (percents) for the national population and 95% confidence intervals are reported. Results: See tables. The estimated prevalence of FI is 8.8% [CI 7.1, 10.4%] of adult women and 7.7% [CI 6.0, 9.4%] of adult men, which correspond to 8.4 million women and 6.9 million men in the USA. Of those with FI, loss of liquid stool is reported by 72% of women and 77% of men, and solid stool incontinence by 23% of women and 15% of men. Also, 67% of women and 69% of men with FI report the frequency of FI as 1-3 times per month. FI is a daily occurrence for 8.5% of women and 10.5% of men with FI. Conclusions: Most FI consists of liquid stool. In 2/3 of cases with FI, it occurs infrequently, but at least weekly FI is reported by an estimated 2.7% of women and 2.6% of men, corresponding to 2.6 million women and 2.4 million men in the USA. At least daily FI is reported by 0.9% of women and 0.7% of men, corresponding to 0.9 million women and 0.6 million men. Correlation with quality of life impact is needed. [Supported by NICHD and NIH Office of Research on Women's Health grants U01 HD41249, U10 HD41250, U10 HD41261, U10 HD41267, U10 HD54136, U10 HD54214, U10 HD54215, U10 HD54241]
Background: No U.S. data are available which distinguish health care costs for fecal incontinence (FI) from costs for urinary incontinence. Aims: Estimate GI-related and all cause health care expenditures and frequency of outpatient visits in patients with FI compared to patients without FI. Methods: A sample of 1031 patients (32% female, mean age 66.3 years) who made at least one health care visit in the last year was invited to participate (60.6% response rate). FI was assessed by asking, “In the last 3 months, how often have you accidentally leaked liquid or solid stool?” Health care costs in US$ and utilization (number of outpatient visits) were obtained from claims data files and averaged for the previous 5 years. Mean and 95% confidence intervals are reported. Results: FI was reported by 34.1% including 23.4% with FI up to 1/month and 10.7% with FI more than 1/month. Only 10 of 317 patients (3.2%) with self-reported FI had a clinical diagnosis of FI in the medical record for the last 5 years. Patients with FI were older (71.5 vs. 63.1 years respectively, p<0.001) but similar in sex (33% vs. 32% male) and race (90% vs. 87% Caucasian) to patients without FI. Health care costs and utilization were related to the presence and severity of FI; see table. For all patients with FI, annual total health care costs were $5877 ($3911-$4860), GI-related health care costs including FI-related visits were $284 ($242-$327), outpatient visits numbered 9.1 (8.6-9.7), and GI-related outpatient visits numbered 0.33 (0.29-0.38). All comparisons remained significant after adjusting for age. Conclusions: FI is prevalent in an HMO setting (34.1%) but rarely diagnosed. Total health care cost is 34% higher and GI-related cost is 89% higher in patients with FI. It is unknown how much of the excess health care costs are directly related to FI vs. being related to comorbid medical conditions. [Supported by Novartis Pharmaceuticals and NIH grants R24 DK31369 and RO1 DK57048]
a
p<.002 vs No FI; b p<.05 vs FI 1/month
A-279
AGA Abstracts
AGA Abstracts
National Health and Nutrition Examination Survey (NHANES): Association of Usual Stool Consistency and Frequency with Fecal Incontinence William E. Whitehead
S1832
Background: Epidemiological studies of fecal incontinence (FI) show a consistent association with self-reported diarrhea and an inconsistent association with self-reported constipation. However, subjects differ in what they mean by diarrhea and constipation. Aim: Determine whether usual stool consistency and stool frequency are associated with FI in a national population based sample. Methods: Subjects in the NHANES survey for 2005-2006 were asked to rate their usual or most common stool type using the 7 descriptions from the Bristol Stool Scale (Gut 1994;35:1455). We pooled ratings 1 and 2 (hard and lumpy), ratings 3-5 (normal consistencies), and ratings 6 and 7 (mushy and watery). Subjects were also asked how often they usually have bowel movements, and responses were merged into 3 ranges: <3/week, 3-21/week, and >21/week. FI was defined as any involuntary loss of mucus, liquid, or solid stool during the last 30 days. NHANES over-samples minorities and the elderly for increased precision; it provides weights for each subject's data to obtain estimates for the national population. Subjects were 2079 males and 2229 females aged 20 or older. Prevalences (in percent) for the national population are estimated and their 95% confidence intervals (CI) are given. Results: See table. For both females and males, having stools that are typically loose or watery or stools that are more frequent than 21/week was associated with a 3-4 fold increase in the rate of FI. Neither typically hard/lumpy stools nor infrequent stools were associated with significant increases in FI for males or females. Conclusions: Having typically loose/watery stools and/or stools more than 3 times per day is significantly associated with the presence of FI and may be a target for preventing or treating FI. [Supported by grants from the National Institute of Child Health and Human Development and the NIH Office of Research on Women's Health (U01 HD41249, U10 HD41250, U10 HD41261, U10 HD41267, U10 HD54136, U10 HD54214, U10 HD54215, and U10 HD54241)]
S1830 Twelve Month Follow-Up for Patients with Pelvic Floor Dyssynergia-Type Constipation (PFD) Reporting Adequate Relief After a 4-Week Education and Medical Management Run-in Intervention Steve Heymen, Yolanda V. Scarlett, William E. Whitehead Introduction: 18 out of 117 patients (15%) with PFD reported adequate relief from a 4week run-in phase (including education and medical management) of an RCT that compared Biofeedback to two credible alternative treatments (DCR 2007;50:428). Aim: To assess longterm effects of a conservative intervention for patients with chronic constipation due to PFD. Method: Education included a review of pelvic floor muscle physiology and manometry results, toileting schedules, use of diary data, and instructions to defecate without excessive force. Medical management included dietary advice and stool softeners, as needed, to modify stool consistency. All patients were encouraged to contact the therapist at least every 4 days for modification of instructions, if unsuccessful. All run-in responders were invited to return for 3-month and 12-month follow-up evaluations that included repeat anorectal manometry, diary data collection, and repeat psychometric evaluation. Results: 78% of run-in responders continued to report adequate relief of symptoms at 3-month follow-up. 72% of patients reported continued success at 12-month follow-up. Subjects lost to follow-up (n=2) were counted as treatment failures. Patients who failed the run-in intervention reported worse constipation symptoms (p < 0.01), higher depression (p < 0.05), and lower general, and disease specific quality of life measures (p < 0.05) at baseline, than run-in responders. None of the responders reported a history of physical abuse, compared to 26% of patients who failed run-in (p < 0.05). There were no differences between responders or non-responders in: age, race, symptom duration, sexual abuse history, pelvic floor physiology, colonic transit time, or number of physician visits for 6 months prior to the study. The only variable associated with continued success at 12-month follow-up was the number of days/week with unassisted bowel movements (6 vs. 1 per week, respectively). Discussion: Fifteen percent of patients with chronic constipation of greater than 15 years duration reported adequate relief of symptoms following an education/medical management intervention and 72% reported continued success at 12-month follow-up. These patients reported an average of more than 5 physician visits, specifically for constipation, just in the previous 6 months. In addition to higher symptom severity and lower QOL measures being associated with treatment failure during run-in, depression also predicted failure from run-in. Assessing patients with constipation for depression may aid in developing an effective treatment plan that may include psychotherapy. [Supported by grants RO1 DK57048, R24 DK67674, MO1 RR00046]
S1833 S1831
National Health and Nutrition Examination Survey (NHANES) of Fecal Incontinence: Characteristics of Incontinent Stools William E. Whitehead
Health Care Costs Associated with Fecal Incontinence Steve Heymen, Olafur S. Palsson, Michael Von Korff, Rona L. Levy, Marsha J. Turner, William E. Whitehead
Background: Fecal incontinence (FI) occurs in 7-9% of US adults. Its impact on quality of life ranges from minimal to severe and may include admission to a nursing home. This impact likely depends on the frequency and type of stool lost. Aims: Characterize the prevalence of FI according to the frequency and type of stool lost. Methods: Questions from the Fecal Incontinence Severity Index (Dis Colon Rectum 1999;42:1525), which asks about the frequency of accidental bowel leakage during the last month separately for mucus, liquid, and solid stool, were included in the NHANES survey in 2005 and 2006. FI was defined as any involuntary loss of mucus, liquid, or solid stool; this definition of FI does not include gas. NHANES over-samples minorities and the elderly for increased precision; it provides weights for each subject's data to obtain estimates for the national population. Subjects were 2079 males and 2229 females aged 20 or older. Prevalence estimates (percents) for the national population and 95% confidence intervals are reported. Results: See tables. The estimated prevalence of FI is 8.8% [CI 7.1, 10.4%] of adult women and 7.7% [CI 6.0, 9.4%] of adult men, which correspond to 8.4 million women and 6.9 million men in the USA. Of those with FI, loss of liquid stool is reported by 72% of women and 77% of men, and solid stool incontinence by 23% of women and 15% of men. Also, 67% of women and 69% of men with FI report the frequency of FI as 1-3 times per month. FI is a daily occurrence for 8.5% of women and 10.5% of men with FI. Conclusions: Most FI consists of liquid stool. In 2/3 of cases with FI, it occurs infrequently, but at least weekly FI is reported by an estimated 2.7% of women and 2.6% of men, corresponding to 2.6 million women and 2.4 million men in the USA. At least daily FI is reported by 0.9% of women and 0.7% of men, corresponding to 0.9 million women and 0.6 million men. Correlation with quality of life impact is needed. [Supported by NICHD and NIH Office of Research on Women's Health grants U01 HD41249, U10 HD41250, U10 HD41261, U10 HD41267, U10 HD54136, U10 HD54214, U10 HD54215, U10 HD54241]
Background: No U.S. data are available which distinguish health care costs for fecal incontinence (FI) from costs for urinary incontinence. Aims: Estimate GI-related and all cause health care expenditures and frequency of outpatient visits in patients with FI compared to patients without FI. Methods: A sample of 1031 patients (32% female, mean age 66.3 years) who made at least one health care visit in the last year was invited to participate (60.6% response rate). FI was assessed by asking, “In the last 3 months, how often have you accidentally leaked liquid or solid stool?” Health care costs in US$ and utilization (number of outpatient visits) were obtained from claims data files and averaged for the previous 5 years. Mean and 95% confidence intervals are reported. Results: FI was reported by 34.1% including 23.4% with FI up to 1/month and 10.7% with FI more than 1/month. Only 10 of 317 patients (3.2%) with self-reported FI had a clinical diagnosis of FI in the medical record for the last 5 years. Patients with FI were older (71.5 vs. 63.1 years respectively, p<0.001) but similar in sex (33% vs. 32% male) and race (90% vs. 87% Caucasian) to patients without FI. Health care costs and utilization were related to the presence and severity of FI; see table. For all patients with FI, annual total health care costs were $5877 ($3911-$4860), GI-related health care costs including FI-related visits were $284 ($242-$327), outpatient visits numbered 9.1 (8.6-9.7), and GI-related outpatient visits numbered 0.33 (0.29-0.38). All comparisons remained significant after adjusting for age. Conclusions: FI is prevalent in an HMO setting (34.1%) but rarely diagnosed. Total health care cost is 34% higher and GI-related cost is 89% higher in patients with FI. It is unknown how much of the excess health care costs are directly related to FI vs. being related to comorbid medical conditions. [Supported by Novartis Pharmaceuticals and NIH grants R24 DK31369 and RO1 DK57048]
a
p<.002 vs No FI; b p<.05 vs FI 1/month
A-279
AGA Abstracts
AGA Abstracts
National Health and Nutrition Examination Survey (NHANES): Association of Usual Stool Consistency and Frequency with Fecal Incontinence William E. Whitehead