Opportunities to optimise care and choice in joint replacement surgery using a digitally delivered, holistic PreHab pathway.

PURPOSE: To describe the implementation and evaluation of a hospital-initiated, community-based, digital prehabilitation program (My PreHab Program: MPP) for adults referred for elective joint replacement. METHODS: MPP was implemented July 2022 and comprises a personalised digital health screen that guides the provision of self-management resources. Adults (>18 years) referred and accepted, or already waitlisted, for total knee/hip replacement surgery were eligible. Individuals requiring category 1 (urgent) or emergency surgery and those without a mobile phone were excluded. Implementation and intervention outcome measures (program adoption, equity of reach, fidelity, acceptability, appropriateness, feasibility, engagement, preliminary surgical outcomes) were explored via study-specific measures and hospital records. RESULTS: Of those invited (N = 689), 77.8% participated. Participants and non-participants were similar in key demographic variables except regional invitees were more likely to participate than metropolitan (88.0% vs 75.4%, p = .002) and non-participants tended to be older (median age = 69.0 vs 64.0, p = .005). Participants reported on average four modifiable risk factors: most commonly chronic pain (79.1%), obesity (57.3%), and frailty (40.9%). Most participants (80.4%) reviewed all resources provided and reported action/intention to address issues identified (90.9%). Participants perceived MPP as acceptable (3.2/5), appropriate (3.3/5), and feasible (3.4/5). Early trends for participants progressing to surgery (n = 33) show a reduced length of stay (MPP = 4.3, baseline = 5.3 days). CONCLUSION: MPP demonstrated high adoption, fidelity, and participant engagement. It is acceptable, appropriate and feasible and has the potential to be scaled-up digitally at low-cost. Modifiable risk factors were prevalent and early indications suggest this preoperative intervention may benefit both patients and the healthcare system.

Development of a feasible and acceptable digital prehabilitation pathway to improve elective surgical outcomes.

Objectives: To codesign and assess the feasibility, acceptability, and appropriateness of a hospital-initiated, community delivered approach to health optimization (prehab) prior to planned surgery. Design: Participatory codesign combined with a prospective, observational cohort study (April-July 2022). Setting: A large metropolitan tertiary referral service with 2 participating hospitals. Participants: All people referred for orthopaedic assessment for joint replacement surgery (hip or knee) triaged as category 2 or 3. Exclusions: category 1; no mobile number. Response rate 80%. Intervention: My PreHab Program is a digitally enabled pathway that screens participants for modifiable risk factors for post-operative complications and provides tailored information to enable health optimization prior to surgery with the help of their regular doctor. Outcome measures: Acceptability, feasibility, appropriateness, and engagement with the program. Results: 36/45 (80%) registered for the program (ages 45-85 yrs.), completed the health-screening survey and had ≥1 modifiable risk factor. Eighteen responded to the consumer experience questionnaire: 11 had already seen or scheduled an appointment with their General Practitioner and 5 planned to. 10 had commenced prehab and, 7 planned to. Half indicated they were likely (n = 7) or very likely (n = 2) to recommend My PreHab Program to others. The My PreHab Program scored an average 3.4 (SD 0.78) for acceptability, 3.5 (SD 0.62) for appropriateness, and 3.6 (SD 0.61) for feasibility, out of a score of 5. Conclusions: This digitally delivered intervention is acceptable, appropriate, and feasible to support a hospital-initiated, community-based prehab program.

The Potential of Integrated Nurse-Led Models to Improve Care for People With Functional Gastrointestinal Disorders: A Systematic Review.

Functional gastrointestinal disorders such as irritable bowel syndrome and functional dyspepsia are extremely common, debilitating, and costly. Although diagnostic guidelines and effective management options exist, management is suboptimal, with long waiting lists, delayed diagnosis, and poor patient outcomes. The aim of this systematic review was to explore and evaluate evidence for existing models of care for functional gastrointestinal disorders. Thirty-eight studies pertaining to the diagnosis or management of functional gastrointestinal disorders were found; however, only 6 investigated a full model of care. Five studies assessed a nurse-led model and 1 a structured gastroenterologist consultation. Nurse-led models were cheaper to current treatments and resulted in symptomatic improvement, high patient satisfaction, reduced healthcare usage, and improved psychosocial functioning and quality of life, whereas standard gastroenterological care did not alleviate pain or improve quality of life. There is minimal research trialing integrated models of care for the diagnosis and management of functional gastrointestinal disorders. This represents a lost opportunity for timely and effective healthcare provision to a large patient group. Although low in quality, preliminary data suggest that integrated nurse-led models of care are economically viable and may facilitate timely diagnosis and management and improve patient outcomes. Furthermore, studies to robustly evaluate the efficacy, safety, and acceptability of such models are needed.

Faecal calprotectin testing for identifying patients with organic gastrointestinal disease: systematic review and meta-analysis.

OBJECTIVES: To assess the clinical effectiveness of faecal calprotectin (FC) testing for distinguishing between organic gastrointestinal diseases (organic GID), such as inflammatory bowel disease (IBD), and functional gastrointestinal disorders (functional GIDs). STUDY DESIGN: Studies that assessed the accuracy of FC testing for differentiating between IBD or organic GID and functional GIDs were reviewed. Articles published in English during January 1998 - June 2018 that compared diagnostic FC testing in primary care and outpatient hospital settings with a reference test and employed the standard enzyme-linked immunosorbent FC assay method with a cut-off of 50 or 100 µg/g faeces were included. Study quality was assessed with QUADAS-2, an evidence-based quality assessment tool for diagnostic accuracy studies. DATA SOURCES: MEDLINE and EMBASE; reference lists of screened articles. DATA SYNTHESIS: Eighteen relevant studies were identified. For distinguishing patients with organic GID (including IBD) from those with functional GIDs (16 studies), the estimated sensitivity of FC testing was 81% (95% CI, 74-86%), the specificity 81% (95% CI, 71-88%); area under the curve (AUC) was 0.87. For distinguishing IBD from functional GIDs (ten studies), sensitivity was 88% (95% CI, 80-93%), specificity 72% (95% CI, 59-82%), and AUC 0.89. Assuming a population prevalence of organic GID of 1%, the positive predictive value was 4.2%, the negative predictive value 100%. The difference in sensitivity and specificity between FC testing cut-offs of 50 µg/g and 100 µg/g faeces was not statistically significant (P = 0.77). CONCLUSIONS: FC testing is clinically useful for distinguishing organic GID (including IBD) from functional GIDs, and its incorporation into clinical practice for evaluating patients with lower gastrointestinal symptoms could lead to fewer patients with functional GIDs undergoing colonoscopy, reducing costs for both patients and the health system. PROSPERO REGISTRATION: CRD4201810507.

Diagnosis and management of irritable bowel syndrome: a guide for the generalist.

Irritable bowel syndrome (IBS) and other functional gastrointestinal disorders (FGIDs) are so prevalent they cannot reasonably have their diagnoses and management based within specialty care. However, delayed diagnosis, lengthy wait times for specialist review, overinvestigation and lack of clear diagnostic communication are common. The intrusive symptoms of IBS and other FGIDs impair patient functioning and reduce quality of life, and come with significant costs to individual patients and the health care system, which could be reduced with timely diagnosis and effective management. IBS, in particular, is no longer a diagnosis of exclusion, and there are now effective dietary and psychological therapies that may be accessed without specialist referral. The faecal calprotectin test is widely available, yet not on the Medical Benefits Schedule, and a normal test result reliably discriminates between people with IBS and patients who warrant specialist referral.

Referrals to a tertiary hospital: A window into clinical management issues in functional gastrointestinal disorders.

BACKGROUND AND AIM: To investigate the quality of and reasons for referrals of patients with likely functional gastrointestinal disorders (FGID) and explore patients' experience of clinical management. METHODS: A cross sectional, mixed-methods study was undertaken. Referrals (July 2013-2015) to one gastroenterology outpatient department triaged as "likely FGID", the referred patients and their referring primary healthcare providers were examined. RESULTS: A total of 69% of patients reported not yet receiving an initial diagnosis, 52% reported persistent/distressing symptoms or reduced quality of life, 24% feared missed or worsening pathology, and 35% were seeking repeat specialist consultation. Most patients were dissatisfied (40%) or only partially satisfied (36%) with current management. Dissatisfaction was significantly related to the lack of provision of a diagnosis and effective treatment options (P < 0.001). Referral quality was poor and with the reason for referral clearly communicated in only 25%. Common referral reasons included repeat presentations (n = 32), diagnostic uncertainty (n = 19), to ensure nothing is missed (n = 19), patient request (n = 17), no response to treatment (n = 16), and to allay patient fears (n = 14). A total of 28/60 primary healthcare providers were confident that their patient had a FGID, yet sought confirmation (n = 16), second opinion (n = 8), or advice (n = 4). CONCLUSION: Current management of FGID in usual care is suboptimal, as evidenced by the tertiary referral load, patient dissatisfaction, and the lack of provision of diagnoses and effective treatment options. Some clinicians lack confidence in effectively identifying and managing these conditions. Resources and supports to equip and assist clinicians to identify and manage FGID successfully may enhance patient care.

Uncertain Diagnostic Language Affects Further Studies, Endoscopies, and Repeat Consultations for Patients With Functional Gastrointestinal Disorders.

BACKGROUND & AIMS: Although guidelines state that functional gastrointestinal disorders (FGIDs) can be diagnosed with minimal investigation, consultations and investigations still have high costs. We investigated whether these are due to specific behaviors of specialist clinicians by examining differences in clinician approaches to organic gastrointestinal diseases vs FGIDs. METHODS: We performed a retrospective review of 207 outpatient department letters written from the gastroenterology unit at a tertiary hospital after patient consultations from 2008 through 2011. We collected data from diagnostic letters and case notes relating to patients with organic (n = 108) or functional GI disorders (n = 119). We analyzed the content of each letter by using content analysis and reviewed case files to determine which investigations were subsequently performed. Our primary outcome was the type of diagnostic language used and other aspects of the clinical approach. RESULTS: We found gastroenterologists to use 2 distinct types of language, clear vs qualified, which was consistent with their level of certainty (or lack thereof), for example, "the patient is diagnosed with…." vs "it is possible that this patient might have….". Qualified diagnostic language was used in a significantly higher proportion of letters about patients with FGIDs (63%) than organic gastrointestinal diseases (13%) (P < .001). In addition, a higher proportion of patients with FGIDs underwent endoscopic evaluation than patients with organic gastrointestinal diseases (79% vs 63%; P < .05). CONCLUSIONS: In an analysis of diagnoses of patients with FGIDs vs organic disorders, we found that gastroenterologists used more qualified (uncertain) language in diagnosing patients with FGIDs. This may contribute to patient discard of diagnoses and lead to additional, unwarranted endoscopic investigations.