Klaus Bielefeldt

Goal: The study was designed to assess drug costs for constipation therapy and to relate costs to markers of functional status. Background: Secretagogues have been introduced as new agents for the treatment of constipation. Previously published modeling studies suggested that improved productivity lowers the indirect disease burden and balances the higher drug costs. Study: Data were abstracted from the publicly available Medical Expenditure Panel Survey to identify adults with a functional gastrointestinal disorder who received a prescription for laxatives or secretagogues covering >2 days. Demographic data, recorded health care utilization and cost, and markers of functional status were extracted for the years from 2005 to 2017 to determine differences between participants treated with secretagogues or laxatives. Results: The cohort of 2006 persons was female predominant [67.8%; age: 56.9 (55.8-57.9) years] and spent $92.89 (75.68-110.10) for medications treating constipation. The use of secretagogues (10.3% of the cohort) was the best independent predictor of constipation treatment costs. Using quality of life measures, perceived limitations in activities or work, and absenteeism, there was no difference between participants receiving laxatives and those taking secretagogues. Conclusion: Using survey data designed to be representative of the United States population, the study identified secretagogues as a key cost factor in drug treatment of constipation. The results do not support models suggesting improved role functioning offsets these higher direct expenditures. While prospective comparative studies are needed to more definitively correlate costs with direct or indirect benefits of different agents, limiting the use of more expensive medications to otherwise refractory cases may help to reign in the spiraling health care costs in this country.

Background Despite national campaigns and other efforts to improve colorectal cancer (CRC) screening, participation rates remain below targets set by expert panels. We hypothesized that availability and practice patterns of healthcare providers may contribute to this gap. Method Using data of the Medical Expenditure Panel Survey for the years between 2000 and 2016, we extracted demographic, socioeconomic, and health-related data as well as reported experiences about barriers to care, correlating results with answers about recent participation in colorectal cancer screening. As CRC screening guidelines recommend initiation of testing at age 50, we focused on adults 50 years or older. Results We included responses of 163,564 participants for the period studied. There was a significant increase in CRC screening rates over time. Comorbidity burden, poverty, race, and ethnicity independently predicted participation in screening. Lack of insurance coverage and cost of care played an important role as reported barrier. Convenient access to care, represented by availability of appointments beyond typical business hours, and frequency of provider interactions, correlated with higher rates of screening. Conclusion Our data show a positive effect of educational efforts and healthcare reform with coverage of screening. Easy and more frequent access to individual providers predicted a higher likelihood of completed screening tests. This finding could translate into more widespread implementation of screening programs, as the increasingly common virtual care delivery offers a new and convenient option to patients.

Introduction Despite expanding treatment options, patients with functional gastrointestinal disorders (FGID) frequently express concerns about problems with access to care. We hypothesized that health insurance coverage contributes to the perceived problems with care delivery. Methods Using the Medical Expenditure Panel Survey, we examined a cohort of participants defined by the diagnosis code for FGID plus the recorded prescription for laxative therapy. Demographic data, healthcare utilization and cost, insurance coverage, comorbid conditions, and information about provider characteristics were extracted for the years 2005–2015. Age- and sex-matched controls were identified for each year included. Barriers to care were based on responses to questions about inability to receive timely care or medication. Logistic regression was used to identify independent predictors of perceived barriers. Results The cohort was female predominant (67.8%; mean age: 58.8 ± 0.33 years) with 15.4% reporting problems with access to care. Limited insurance coverage was most commonly cited by respondents. Consistent with this result, uninsured persons were significantly more likely to report barriers to care, while the type of insurance for those covered did not independently predict access problems. In addition, comorbidity burden and provider-specific factors, such as available contact options or insufficient explanations, correlated with perceived barriers to care delivery. Conclusion While the study design cannot establish causal links, persons with FGID commonly report access problems, which correlate with lack of health insurance and comorbidities. Providers can influence this perception by offering more flexible office hours and incorporating patient expectations related to treatment explanations and shared decision-making.

Introduction Cohort studies from referral centers suggest an increasing burden of functional gastric disorders, with frequent emergency room (ER) visits, hospitalizations, or absenteeism. We hypothesized that recruitment from tertiary care sites skews results and thus investigated the burden of these illnesses, using the population-based data of the Medical Expenditure Panel Survey (MEPS). Methods Using MEPS data for the years 2000–2015, demographic, economic, healthcare-related, and quality-of-life indicators were extracted for adults reporting the diagnosis of functional gastric diseases to assess trends and to compare results with data from all adults surveyed. Results Between 2000 and 2015, 2.7 ± 0.2% of the adults surveyed reported a functional gastric illness. Within the period studied, 28.8 ± 2.8% and 17.9 ± 1.6% of this cohort reported ER visits or hospitalizations, respectively. Only a fraction of these persons attributed the ER visits (22.6 ± 0.9%) or admissions (10.9 ± 0.8%) to the functional gastric disorder. Rates remained stable rates during the period studied. Female sex, measures of physical function, comorbidities, and an income below the poverty line were predictors of healthcare utilization. While utilization was stable over time, annual costs increased by 113.9 ± 16.6% during the study period, outpacing the inflation rate of 37.6%. Conclusions Persons with functional gastric disorders have significant healthcare needs and face increasing costs of care, largely due to coexisting illnesses. While it is important to recognize this impact, the need for emergency care or hospitalizations remained stable and lower than reported for patients seen in tertiary referral centers, providing reassuring information for patients and providers.

The observed mortality < 5 years after the index colonoscopy lowered the overall impact of screening, which should prompt health care providers to perform a more thorough assessment of the potential reduced benefit for individual veterans when incorporating cancer risk, comorbidity burden, and age-based criteria.

Collaboration between health care professionals and the pharmaceutical industry often drives medical progress and, thus, benefits patients. Clinical trials reflect this reality, as industry sources support about half of the investigations focused on drugs or devices, raising concerns about potential conflicts of interest (COIs).¹ Systematic reviews suggest an apparent bias of published studies that were more likely to report positive findings when the authors received support from industry.^2,3 While journal editors responded to these findings by mandating disclosures of potential COIs,^4-6 the possible extent of industry sponsorship came to light in the course of investigations by the Department of Justice, which led to a settlement between the United States and 5 companies owing to concerns about violations of federal anti-kickback regulations, as physicians had received consulting fees for using joint implants produced by these companies.⁷

A specialty outreach program relied on telemedicine to reach patients with gastrointestinal and liver diseases in a large service area.

Gastroparesis is defined as a combination of chronic dyspeptic symptoms and delayed emptying of a solid test meal. It remains a difficult-to-treat disorder with a significant impact on quality of life. Although gastroparesis is defined by delayed emptying, several important studies did not find a correlation between this biomarker and symptom severity or treatment success. Thus, some of the more recent trials explored strategies that ranged from antiemetics to antidepressants. Although dietary management showed benefit, most of the other interventions were barely superior to placebo or were not superior at all. Placebo responses were often quite high and this complicates the assessment of active agents. While it complicates the design and interpretation of clinical trials, high response rates for active and sham interventions indicate that we can achieve symptom relief in many patients and thus give them some reassurance. If indeed most therapies are only marginally better than placebo, the differences in adverse effects should be weighed more strongly, a point that is especially important in view of the controversy surrounding metoclopramide. Mechanistic studies introduced the network of macrophages as another potentially important player in the development of gastroparesis. Results are too preliminary and are largely based on preclinical data but show up- and downregulation of cellular elements controlling gastric function. Thus, future developments may teach us how they interfere with some of these mechanisms in clinical settings, potentially making gastroparesis a reversible process.