Issues in the diagnosis and management of functional gastrointestinal disorders: the development of a novel clinical pathway

Abstract

Functional gastrointestinal disorders (FGIDs) affect one in four people during their lifetime and are a growing public health concern. These disorders are characterised by distressing, chronic recurring symptoms that reduce quality of life, and negatively impact patients physically, psychologically, socially and economically. Although largely managed in primary care, referrals for specialist care represent up to 50% of ambulatory gastroenterology care. New developments in diagnostic criteria and effective management options are available but under-utilised. The aims of this study were to 1) determine current issues in the diagnosis and management of FGIDs in primary and tertiary care; 2) explore tested models of care for FGID; and 3) design and evaluate an algorithm-based approach to the diagnosis and management of FGIDs (ADAM-FGID). A cross sectional, mixed-methods study was undertaken based on referrals (July 2013-15) to one gastroenterology outpatient department triaged as ‘likely FGID’. Patient characteristics, concerns and satisfaction with care, and reasons for referral were explored. The clinical approach to FGID diagnosis and management in tertiary care was assessed via audits of specialist correspondence and endoscopic procedures. A systematic review of FGID models of care was performed and a novel algorithm-based approach to the diagnosis and management of FGIDs was developed and trialled. There was a clear paucity of research into models of care for FGID, with only 6 low-quality studies. Primary healthcare providers (PHCPs) referring to tertiary care lacked confidence in the diagnosis and management of FGIDs, and patients expressed dissatisfaction with the lack of provision of a diagnosis or effective management options. Within tertiary care, unclear diagnostic language was more prevalent in FGIDs than organic disorders (63% vs. 13%; p<.001), as were endoscopic investigations (79% vs. 63%; p<.05). Almost 80% of all patients diagnosed with FGID were found to have undergone upper gastrointestinal endoscopy (UGIE) or colonoscopy. Existing endoscopic appropriateness criteria were inadequate in their consideration of functional symptoms, and preliminary evidence showed locally developed alarm-based appropriateness criteria to have better negative predictive value. The ADAM-FGID was found to be both safe and effective. 39% of referrals required more urgent gastroenterological review than original triage category, with organic disease subsequently diagnosed in 31% of these. 82% of FGID diagnoses were stable during follow-up. Patient buy-in to the model was good, with 80% entering management and 61% reporting symptom improvement at 6 weeks. Moreover, 68% of patients, and all referring doctors found the approach to be at least moderately acceptable. Patients reported being reassured by the approach, and found the management options useful. Primary health care providers acknowledged the potential of this approach to reduce waiting times for endoscopic procedures and to provide reassurance to both patients and themselves. FGIDs are poorly handled in the public health system and little research into effective models of care has been conducted. This study identifies multiple issues and opportunities to improve patient care and strategies to achieve these improvements are presented. The clinical pathway for the diagnosis and management of FGIDs, which is not dependent upon specialist review, is safe, feasible and acceptable and has potential to capacity build by reducing specialist burden and expediting effective care.