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Determinants of Healthcare-Seeking Behaviour in IBS

From Alimentary Pharmacology & Therapeutics

R. E. Williams,* C. L. Black,� H.-Y. Kim,� E. B. Andrews,� A. W. Mangel,� J. J. Buda,� & S. F. Cook,*

Aliment Pharmacol Ther. 2006;23(11):1667-1675. �2006 Blackwell Publishing

Discussion
Our finding that 49% of IBS subjects in our sample had sought medical care for abdominal symptoms in the past year is higher than previous US population-based studies, which report consultation rates for IBS symptoms in the past 12 months of 14-25%.[1, 11, 19] However, our study likely represents a subset of IBS patients with more severe disease because the study design necessitated that all subjects fulfil a modified version of the Rome II criteria for a period of at least 2 years. We found that females were more likely than males to receive a diagnosis of IBS by a doctor despite the fact that males sought medical care for their abdominal symptoms more frequently than females. This finding has not been previously reported in the literature and is in contrast to a report by Borum,[20] who conducted a survey of internal medicine doctors and found that doctors perceive IBS as easier to diagnose in men than in women. Several researchers have reported that the Manning and Rome criteria are less sensitive in diagnosing IBS in men than in women,[21, 22] but our results show that doctors are less likely to diagnose IBS in men than in women even when the men have abdominal symptoms which fulfil criteria for IBS.

More than half (55%) of subjects that had sought health care in the past year reported that the purpose of their most recent doctor visit was to get treatment for symptoms because previous treatment was unsatisfactory. Patient dissatisfaction with IBS therapy is consistent with several recent literature reviews of IBS treatment, which found limited or no evidence for the efficacy of current IBS medications, with the possible exception of the newer serotenergic agents, which are currently only approved for use in a small subset of patients with IBS.[23-25]

While abdominal pain or discomfort was the most common reason for seeking care among the healthcare seekers in our study, the severity of abdominal pain was not significantly different between the healthcare seekers and those that did not seek health care for their IBS. Other studies have reported an association between the frequency and/or severity of abdominal pain and healthcare-seeking behaviour,[1, 5-11] but we likely did not find an association in our study because all subjects must have experienced some degree of abdominal pain in order to meet our criteria for IBS and must have experienced this symptom for at least 2 years in order to be included in the study.

While a few studies have reported symptoms other than abdominal pain such as bloating,[9, 10] mucus per rectum, urgency, incomplete evacuation[9] and diarrhoea[5, 9] to be associated with seeking health care for IBS, we evaluated numerous abdominal symptoms and found associations only with decreased bowel movements in females and abdominal cramping in males.

Although we found differences in males and females regarding specific factors motivating healthcare-seeking behaviour, our results in both sexes are consistent with the finding that the presence of medical conditions in addition to IBS is associated with seeking health care for IBS symptoms. Females suffering from dyspepsia and pelvic pain were more likely to seek health care for IBS than subjects without these comorbid conditions. In contrast to several other studies that did not report an association between age and healthcare-seeking behaviour,[1, 6, 9] we found that older females were more likely to seek medical care for IBS than younger females. This is probably because older subjects are more likely to suffer from comorbid conditions that we did not measure, such as hypertension or cancer, which put them in frequent contact with the medical system. Because we limited our original cohort to individuals between the ages of 18 and 65 years, we could not evaluate healthcare-seeking behaviour above our age limits. In men, having a working status of disabled is along a similar vain, as the disabling condition also likely causes the subject to have frequent medical visits.

Earlier studies of healthcare-seeking behaviour and IBS concluded that symptoms of psychological distress are unrelated to IBS, but influence which patients will seek medical care for the condition.[4, 5] Our results are contrary to this finding. In a previous analysis, we found that subjects that continued to have IBS over a 2-year period had more psychological impairment that subjects that did not continue to have IBS during the follow-up period.[26] However, among those subjects that continued to meet the IBS criteria there was no difference in mental health status between healthcare seekers and healthcare non-seekers. Other recent studies have also found no association between psychological morbidity and seeking health care for IBS.[6, 27]

While we did not find an association with mental illness, we did find that the extent to which the subjects' IBS affected their physical and social functioning, as reflected in the IBSQOL scores, was important in distinguishing between those subjects that sought medical care for their IBS symptoms and those that did not. Greater interference of gastrointestinal symptoms with work and activities[6] and reduced IBS-specific quality of life[12] have previously been identified as predictors of health care use among IBS subjects. In our study, quality of life issues had a greater impact on the healthcare-seeking behaviour of males than that of females.

Among females in our study, healthcare seeking was related to worry that their abdominal symptoms were related to cancer or other serious illness. Gick and Thompson[28] found that healthcare seeking among IBS subjects was associated with concern about the meaning of IBS symptoms but not anxiety trait in general. This is consistent with our finding that healthcare seekers were more likely than non-seekers to have anxiety regarding their IBS symptoms but not psychological dysfunction otherwise. Other studies have reported concern about the serious nature of their symptoms[10] and anxiety about abdominal pain[29] to be more prevalent in healthcare seekers than non-seekers, but these studies also report greater levels of psychological distress among healthcare seekers. The latter study included patients with all functional gastrointestinal disorders, not solely IBS.

In conclusion, we found that healthcare-seeking behaviour among IBS subjects were determined by the presence of comorbid medical conditions and the extent to which their IBS symptoms affected their physical and mental well-being rather than by the nature of their physical symptoms or any underlying psychological morbidity.

http://www.medscape.com/viewarticle/532484_1

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Making a Positive Diagnosis of IBS
From Medscape General Medicine�

MedGenMed Gastroenterology
IBS -- Review and What's New
Posted 07/26/2006

Amy Foxx-Orenstein, DO, FACG, FACP

IBS is not associated with any definitive biochemical, structural, or serologic abnormalities that define its presence. The hallmark feature of IBS is abdominal pain or discomfort associated with altered bowel habits, and, often, the abdominal pain prompts patients to seek medical care. Because the symptoms of IBS are common to a number of other GI conditions, IBS was long considered a "diagnosis of exclusion," leading to excessive testing of patients with characteristic symptoms. Fortunately, advances in research have led to the development of symptom-based approaches, aimed at standardizing IBS patient subgroups, and the development of consensus guidelines advocating a positive diagnosis of IBS based primarily on the pattern and nature of symptoms, without the need for excessive laboratory testing.[2,15]

In 1978, Manning and colleagues[16-18] proposed diagnostic criteria for IBS that were found to be reasonably sensitive and specific. More recently, an international group of experts in functional GI motility disorders convened to develop symptom-based criteria, known as the Rome criteria (Rome I,[19] Rome II,[15] and Rome III[20,21]), to better define and provide tools by which a positive diagnosis of these disorders could be made. The Rome I criteria for IBS were shown to be sensitive and specific.[22,23] The Rome II criteria, published in 1999,[15] were intended to simplify the more complex Rome I criteria by better defining the nonconsecutive, multisymptom nature of this disorder. Clinical studies validating the Rome II criteria are beginning to emerge.[24] Consensus has not yet been reached regarding which of the Rome criteria are more sensitive for identifying IBS patients in clinical practice[22,24,25] and which of the 2 more accurately estimates the prevalence of IBS.[17,26,27] A recent US population-based follow-up study found that the Rome II criteria were limited in capturing the fluctuating nature of IBS. Over a 2-year period, patients experienced symptoms episodically, including abdominal pain; the absence of pain at time of follow-up excluded many patients from meeting IBS criteria.[28] Overall, the Rome I and II criteria are considered useful for standardizing enrollment of patients into clinical trials. However, many clinicians believe that these criteria are too restrictive for use in clinical practice. The American College of Gastroenterology (ACG) Functional GI Disorders Task Force suggests using a broader definition of IBS: abdominal discomfort associated with altered bowel habits.[2] The Rome III working team met in the fall of 2004; updated criteria were published in April 2006. The principle difference between Rome III guidelines as compared with the Rome II criteria lies in the less restrictive timeframe for symptoms. Whereas the Rome II criteria require symptoms to be present for at least 12 weeks (not necessarily consecutive) in the past 12 months, the Rome III criteria require symptoms to originate for 6 months prior to diagnosis, and be currently active (ie, patient meets criteria) for 3 months. The categorization of IBS patients into the constipation, diarrhea, or mixed subtypes has also been revised (based on stool consistency).[20] It is hoped that the less restrictive symptom timeframe requirements of the Rome III guidelines will make them more clinically practical than the previous iterations.

The Rome III criteria, in conjunction with careful history-taking (medical, family, and medication) and thorough physical examination, can be applied as part of the stepwise, symptom-based approach to diagnosing IBS (Figure). The presence of alarm features (eg, rectal bleeding, history of colon cancer or inflammatory bowel disease) potentially indicative of organic disease necessitates further evaluation.[2]

Until recently, the role of diagnostic testing in diagnosing IBS was a topic of continuing debate. Recent evidence indicates that when a patient meets the Rome criteria, and has no features suggestive of organic disease, the pretest probability of making an accurate diagnosis of IBS based primarily on symptoms is high. In a systematic review conducted by Cash and colleagues,[32] the pretest probability of inflammatory bowel disease, colorectal cancer, or infectious diarrhea was found to be less than 1% in patients meeting symptom-based criteria for IBS. Extensive diagnostic testing rarely identifies organic GI disease in these patients. However, one exception is celiac disease: the pretest probability of celiac disease in patients meeting symptom-based criteria for IBS was 10 times higher than that in the general population.[32] Recently, testing for celiac disease in patients with suspected IBS with diarrhea (IBS-D) has been shown to be most financially feasible in areas in which the prevalence of celiac disease is at least 8%.[33] These findings were supported by the evidence-based recommendation made by the ACG Functional GI Disorders Task Force, whereby they concluded that there is insufficient evidence to recommend the routine performance of diagnostic testing in patients who meet symptom-based criteria for IBS (eg, Manning, Rome I, Rome II) -- therefore, supporting a symptom-based approach to making a positive diagnosis of IBS.[2]

The extent to which this guidance is implemented into clinical practice is based on clinical judgment and experience of the physicians. Most physicians agree that standard laboratory testing, such as complete cell blood count, chemistry panel, and erythrocyte sedimentation rate, should be performed in patients with symptoms of IBS. However, if these studies have been performed recently, after symptoms emerged, there is no need to repeat them. For a patient with IBS symptoms and no comorbid conditions, test results should all be within normal limits. Colonoscopy is generally not required in the absence of features indicative of organic disease (eg, family history of colon cancer), although it should be performed in individuals older than 50 years of age.[1] However, as mentioned previously, if the patient (regardless of age) underwent colonoscopy after the development of symptoms, a repeat test is not warranted. In addition to routine laboratory testing, thyroid function studies, ova and parasite examination, urinalysis, and breath tests for lactose intolerance may be considered. Globally, however, the value of diagnostic testing in IBS has not been established in patients who meet symptom-based criteria for IBS and who do not have symptoms indicative of organic disease; additional diagnostic testing does not increase the probability of detecting organic disease and does not alter the diagnosis of IBS once it is made.[32, 34-36]

A symptom-based diagnosis of IBS is durable. In a longitudinal study in which 75 patients were reevaluated 10 to 13 years after an initial IBS diagnosis, all patients still met the diagnostic criteria for IBS (Manning, Rome I, Rome II) and few had received an alternative diagnosis during that period.[37] In other studies with follow-up periods ranging from 3 to 5 years, development of organic disease occurred in less than 7% of patients initially given a diagnosis of IBS using the symptom-based approach.[38]

Historically IBS was considered a diagnosis by exclusion and was viewed as a purely psychosomatic condition. Within the past 2 decades, however, symptom-based diagnostic criteria have been established that allow physicians to positively and confidently diagnose IBS.

Amy Foxx-Orenstein, DO, FACG, FACP, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.

Medscape General Medicine. 2006;8(3) �2006 Medscape

http://www.medscape.com/viewarticle/532089_2

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Heather is the Administrator of the IBS Message Boards. She is the author of Eating for IBS and The First Year: IBS, and the CEO of Heather's Tummy Care. Join her IBS Newsletter. Meet Heather on Facebook!

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