Multidisciplinary approach bests specialist care for functional GI problems

Last Updated: 2020-08-03

By Marilynn Larkin

NEW YORK (Reuters Health) - For patients with irritable bowel syndrome and other functional gastrointestinal disorders, a multidisciplinary team approach was more effective and less costly than gastroenterologist-only care in an open-label, single-center trial.

"We believe our study is practice changing," Dr. Chamara Basnayake of the University of Melbourne told Reuters Health by email. "It has been well known that psychologically-based, behavioral and dietary therapies are effective for these disorders, yet they are not routinely provided, in an integrated fashion, as frontline care. Major gastrointestinal societies have recommended multidisciplinary care, yet no study had evaluated whether it was superior to a standard gastroenterologist-only approach."

As reported in The Lancet Gastroenterology and Hepatology, of 1,632 patients referred to the hospital's gastroenterology clinic, 188 were eligible for the study. Key exclusions included: non-English speaking, patient incapable of completing questionnaires, referral suggested, an organic gastrointestinal disorder, an active eating disorder, current opiate use, or clinic attendance in the past two years.

One hundred and twenty-three patients were assigned to multidisciplinary care and 65 to standard care. Overall, about 63% of participants were women and the median age at randomization was about 35.

Median follow-up from baseline to discharge was 226 days in the standard care group and 179 in the multidisciplinary group. Standard group patients had a median of two clinic visits; multidisciplinary group patients had a median of five visits, during which 62% saw allied clinicians.

The primary outcome was a score of 4 (slightly better) or 5 (much better) on a 5-point Likert scale assessing global symptom improvement.

Global symptom improvement was seen in 84% patients in the multidisciplinary group compared with 57% of those in the standard group (risk ratio 1.50); 83% of multidisciplinary patients versus 63% in the standard group reported adequate relief of symptoms in the past seven days.

Among those with irritable bowel syndrome(IBS), 66% of multidisciplinary group patients experienced a 50-point or higher reduction in IBS Severity Scoring System (IBS-SSS),compared with 38% of those receiving standard care.

A 50% reduction in the Nepean Dyspepsia Index was noted in 13 patients with functional dyspepsia (46%) in the multidisciplinary group compared with three (11%) in the standard care group.

After treatment, median Hospital and Anxiety and Depression Scale scores were lower in the multidisciplinary group (10 vs. 13) and the median Euro-Qol 5D-5L quality of life visual analogue scale was higher in multidisciplinary group (75 vs. 70).

RAND Short Form-36 scales did not differ between the groups at discharge. After treatment, the median Somatic Symptom Scale-8 score was lower in the multidisciplinary group (9 vs. 10).

Further, fewer patients in the multidisciplinary group (26%) were absent from work because of gut symptoms than in the standard-care group (37%).

Dr. Basnayake said, "It is likely the cost benefits of our approach will reach beyond the healthcare system, as patients were less likely to take time off from work, or see their GPs for other conditions."

"This approach is likely to have value for a range of disorders...and this broad potential deserves formal study," he added. "We are following up our patients 12 months after discharge from care and we hope to present these findings soon."

Dr. William Chey of the University of Michigan, author of a related editorial, commented in an email to Reuters Health, "Many of us have long believed that an integrated, multidisciplinary care model leads to better clinical outcomes compared to traditional care delivered by just a gastroenterologist."

"My center has been delivering integrated care with dietitians and behavioral therapists for more than 10 years. We can't imagine doing it any other way," he said.

"However, imagining something is better is not proof," he affirmed. "The paper...provides the long-awaited evidence which makes clear that integrated care should be the standard, not the exception."

"Of course," he added, "there will be a number of important practical hurdles which will stand in the way of widespread adoption of integrated care, not the least of which is the ability of smaller practices to access GI nutrition and behavioral health services and the ability of health care providers to received third party payment for these services."

"Telehealth may provide at least a partial solution to the access issues," he said. "Creation of virtual care networks may allow smaller practices to access services that would otherwise not be available to them."

SOURCE: https://bit.ly/3ka2Al9 and https://bit.ly/31edIVD The Lancet Gastroenterology and Hepatology, online July 14, 2020.