Home Biofeedback for the Treatment of Dyssynergic Defecation: Does It Improve Quality of Life and Is It Cost-Effective?

OBJECTIVES: Biofeedback therapy, whether administered at home or in office settings, is effective for dyssynergic defecation (DD). Whether home biofeedback improves quality of life (QOL) and is cost-effective when compared with office biofeedback is unknown. METHODS: QOL was assessed in 8 domains (SF-36) at baseline and after treatment (3 months), alongside economic evaluation during a randomized controlled trial (RCT) comparing home and office biofeedback in patients with DD (Rome III). Costs related to both biofeedback programs were estimated from the hospital financial records, study questionnaires, and electronic medical records. A conversion algorithm (Brazier) was used to calculate the patient's quality-adjusted life years (QALYs) from SF-36 responses. Cost-effectiveness was expressed as incremental costs per QALY between the treatment arms. RESULTS: One hundred patients (96 female patients, 50 in each treatment arm) with DD participated. Six of the 8 QOL domains improved (P < 0.05) in office biofeedback, whereas 4 of the 8 domains improved (P < 0.05) in home biofeedback; home biofeedback was noninferior to office biofeedback. The median cost per patient was significantly lower (P < 0.01) for home biofeedback ($1,112.39; interquartile range (IQR), $826-$1,430) than for office biofeedback ($1,943; IQR, $1,622-$2,369), resulting in a cost difference of $830.11 The median QALY gained during the trial was 0.03 for office biofeedback and 0.07 for home biofeedback (P = NS). The incremental cost-effectiveness ratio was $20,752.75 in favor of home biofeedback. DISCUSSION: Biofeedback therapy significantly improves QOL in patients with DD regardless of home or office setting. Home biofeedback is a cost-effective treatment option for DD compared with office biofeedback, and it offers the potential of treating many more patients in the community.

Pill Properties that Cause Dysphagia and Treatment Failure.

BACKGROUND: Pills (tablets and capsules) are widely used to administer prescription drugs or to take supplements such as vitamins. Unfortunately, little is known about how much effort it takes Americans to swallow these various pills. More specifically, it is not known to what extent hard-to-swallow pills might affect treatment outcomes (eg, interfering with adherence to prescribed medications or causing clinical complications). It is also unclear which properties (eg, size, shape, or surface texture) Americans prefer or reject for their pills. To learn more about these issues, we interviewed a small group of individuals. METHODS: We invited individuals in waiting rooms of our tertiary health care center to participate in structured interviews about their pill-taking habits and any problems they have swallowing pills. We inquired which pill properties they believed caused swallowing problems. Participants scored capsules and pills of representative size, shape, and texture for swallowing effort and reported their personal preferences. RESULTS: Of 100 successive individuals, 99 participants completed the interview (65% women, mean age = 41 years, range = 23-77 years). Eighty-three percent took pills daily (mean 4 pills/d; 56% of those pills were prescribed by providers). Fifty-four percent of participants replied yes to the question, "Did you ever have to swallow a solid medication that was too difficult?" Four percent recounted serious complications: 1% pill esophagitis, 1% pill impaction, and 2% stopped treatments (antibiotic and prenatal supplement) because they could not swallow the prescribed pills. Half of all participants routinely resorted to special techniques (eg, plenty of liquids or repeated or forceful swallows). Sixty-one percent of those having difficulties cited specific pill properties: 27% blamed size (20% of problems were caused by pills that were too large whereas 7% complained about pills that were too small to sense); 12% faulted rough surface texture; others cited sharp edges, odd shapes, or bad taste/smell. Extra-large pills were widely loathed, with 4 out of 5 participants preferring to take 3 or more medium-sized pills instead of a single jumbo pill. CONCLUSIONS: Our survey results suggest that 4 out of 5 adult Americans take several pills daily, and do so without undue effort. It also suggests that half of today's Americans encounter pills that are hard to swallow. Up to 4% of our participants gave up on treatments because they could not swallow the prescribed pills. Up to 7% categorically rejected taking pills that are hard to swallow. Specific material properties are widely blamed for making pills hard to swallow; extra-large capsules and tablets are universally feared, whereas medium-sized pills with a smooth coating are widely preferred. Our findings suggest that health care providers could minimize treatment failures and complications by prescribing and dispensing pills that are easy to swallow. Industry and regulatory bodies may facilitate this by making swallowability an essential criterion in the design and licensing of oral medications. Such policies could lessen the burden of pill taking for Americans and improve the adherence with prescribed treatments.

Clinical outcome of single plastic stent treatment of benign iatrogenic biliary strictures: is the outcome predetermined?

Endoscopic retrograde cholangiopancreatography (ERCP) is used for the management of benign iatrogenic biliary strictures after cholecystectomy and liver transplantation. Multiple stents can injure biliary circulation. If resolution of reversible ductal edema and/or ischemia is the mechanism for successful therapy then single stent placement for benign biliary stricture should work. Retrospectively reviewed ERCP records between November 1999 and 2012 provided 25 patients with repeat ERCPs performed at 10-week intervals or if symptoms of stent occlusion were present. If strictures did not improve between stent changes and if removal was not an option, hepaticojejunostomy was used. Strictures resolved in 72% of patients. Seven patients underwent hepaticojejunostomy. Three had ERCP-related complications. No stricture recurrence occurred during the follow-up period. Endoscopic single plastic stent treatment of benign biliary iatrogenic strictures has comparable success to multiple stenting. Many postsurgical strictures may have reversible ischemic/edematous component with stenting to maintain bile drainage.

Hereditary hemochromatosis: missed diagnosis or misdiagnosis?

BACKGROUND: Hereditary hemochromatosis is a disorder that can cause iron overload and organ damage. Hereditary hemochromatosis is characterized by mutations in the HFE gene. HFE C282Y homozygotes and compound heterozygotes (C282Y/H63D) are at risk of developing manifestations of hemochromatosis. Abnormal iron study results also occur in many liver and hematologic diseases. The aim of this study was to evaluate the accuracy of diagnosis of hereditary hemochromatosis. METHODS: Pertinent clinical and laboratory data, including HFE genotype, were tabulated from the electronic medical records of patients with the International Classification of Diseases 9th Revision code 275, "disorders of iron metabolism," who were seen at a tertiary referral center between January 2002 and May 2012. RESULTS: HFE genotyping was obtained in only 373 of 601 patients (62%); 200 were C282Y homozygotes or compound heterozygotes. Of the 173 patients with nonhereditary hemochromatosis genotypes, 53% were misdiagnosed with hereditary hemochromatosis and 38% underwent phlebotomy. In two thirds of these cases, the misdiagnosis was made by a nonspecialist. In the remaining 228 patients who were not genotyped, 80 were diagnosed with hereditary hemochromatosis and 64 were phlebotomized. Of patients misdiagnosed with hemochromatosis, 68% had known liver disease and 5% had a hematologic cause of abnormal iron study results. CONCLUSIONS: Abnormal iron study results in patients with nonhereditary hemochromatosis genotypes commonly lead to a misdiagnosis of hereditary hemochromatosis and inappropriate treatment with phlebotomy. This error often is seen in the setting of elevated iron study results secondary to chronic liver diseases. Furthermore, hereditary hemochromatosis is commonly diagnosed and treated without HFE genotyping. We suggest that phlebotomy centers require a documented HFE genotype before initiating phlebotomy.

Associations between reduced hospital length of stay and 30-day readmission rate and mortality: 14-year experience in 129 Veterans Affairs hospitals.

BACKGROUND: Reducing length of stay (LOS) has been a priority for hospitals and health care systems. However, there is concern that this reduction may result in increased hospital readmissions. OBJECTIVE: To determine trends in hospital LOS and 30-day readmission rates for all medical diagnoses combined and 5 specific common diagnoses in the Veterans Health Administration. DESIGN: Observational study from 1997 to 2010. SETTING: All 129 acute care Veterans Affairs hospitals in the United States. PATIENTS: 4,124,907 medical admissions with subsamples of 2 chronic diagnoses (heart failure and chronic obstructive pulmonary disease) and 3 acute diagnoses (acute myocardial infarction, community-acquired pneumonia, and gastrointestinal hemorrhage). MEASUREMENTS: Unadjusted LOS and 30-day readmission rates with multivariable regression analyses to adjust for patient demographic characteristics, comorbid conditions, and admitting hospitals. RESULTS: For all medical diagnoses combined, risk-adjusted mean hospital LOS decreased by 1.46 days from 5.44 to 3.98 days, or 2% annually (P < 0.001). Reductions in LOS were also observed for the 5 specific common diagnoses, with greatest reductions for acute myocardial infarction (2.85 days) and community-acquired pneumonia (2.22 days). Over the 14 years, risk-adjusted 30-day readmission rates for all medical diagnoses combined decreased from 16.5% to 13.8% (P < 0.001). Reductions in readmissions were also observed for the 5 specific common diagnoses, with greatest reductions for acute myocardial infarction (22.6% to 19.8%) and chronic obstructive pulmonary disease (17.9% to 14.6%). All-cause mortality 90 days after admission was reduced by 3% annually. Of note, hospitals with mean risk-adjusted LOS that was lower than expected had a higher readmission rate, suggesting a modest tradeoff between hospital LOS and readmission (6% increase for each day lower than expected). LIMITATIONS: This study is limited to the Veterans Health Administration system; non-Veterans Affairs admissions were not available. No measure of readmission preventability was used. CONCLUSION: Veterans Affairs hospitals demonstrated simultaneous improvements in hospital LOS and readmissions over 14 years, suggesting that as LOS improved, hospital readmission did not increase. This is important because hospital readmission is being used as a quality indicator and may result in payment incentives. Future work should explore these relationships to see whether a tipping point exists for LOS reduction and hospital readmission. PRIMARY FUNDING SOURCE: Office of Rural Health and the Health Services Research & Development Service, Veterans Health Administration, U.S. Department of Veterans Affairs.

Update on the management of constipation in the elderly: new treatment options.

Constipation disproportionately affects older adults, with a prevalences of 50% in community-dwelling elderly and 74% in nursing-home residents. Loss of mobility, medications, underlying diseases, impaired anorectal sensation, and ignoring calls to defecate are as important as dyssynergic defecation or irritable bowel syndrome in causing constipation. Detailed medical history on medications and co-morbid problems, and meticulous digital rectal examination may help identify causes of constipation. Likewise, blood tests and colonoscopy may identify organic causes such as colon cancer. Physiological tests such as colonic transit study with radio-opaque markers or wireless motility capsule, anorectal manometry, and balloon expulsion tests can identify disorders of colonic and anorectal function. However, in the elderly, there is usually more than one mechanism, requiring an individualized but multifactorial treatment approach. The management of constipation continues to evolve. Although osmotic laxatives such as polyethylene glycol remain mainstay, several new agents that target different mechanisms appear promising such as chloride-channel activator (lubiprostone), guanylate cyclase agonist (linaclotide), 5HT(4) agonist (prucalopride), and peripherally acting mu-opioid receptor antagonists (alvimopan and methylnaltrexone) for opioid-induced constipation. Biofeedback therapy is efficacious for treating dyssynergic defecation and fecal impaction with soiling. However, data on efficacy and safety of drugs in elderly are limited and urgently needed.

Do hospitalists affect clinical outcomes and efficiency for patients with acute upper gastrointestinal hemorrhage (UGIH)?

BACKGROUND: Care by hospitalists has been associated with improved/similar clinical outcomes and efficiency. However, less is known about their effect on conditions dependent upon specialists for procedures/treatment plans. Our objective was to compare care for upper gastrointestinal hemorrhage (UGIH) patients attended by academic hospitalists and nonhospitalists. METHODS: The study included 450 UGIH patients admitted to general medical services of 6 teaching hospitals. Outcomes included in-hospital mortality and complications (ie, recurrent bleeding, intensive care unit [ICU] transfer, decompensation, transfusion, reendoscopy, 30-day readmission). Efficiency was measured by hospital costs and length of stay (LOS). RESULTS: Of 450 patients, 40% (177) were cared for by hospitalists with no differences between groups by endoscopic diagnosis, performance of early esophagogastroduodenoscopy (EGD), Rockall risk score, or Charlson comorbidity index. Unadjusted clinical outcomes between hospitalists and nonhospitalists were similar except for 2 outcomes: patients cared for by hospitalists were more likely to receive a transfusion (74% vs. 63%; P = 0.02) or be readmitted within 30 days (7.3% vs. 3.3%; P = 0.05). However, differences in adverse outcomes between providers were not seen after multivariable adjustments. Median LOS was similar for hospitalists and nonhospitalists (4 days; P = 0.69), but patients cared for by hospitalists had higher median costs ($7,359 vs. $6,181; P < 0.01). In multivariable analyses, LOS was similar (5.2 vs. 4.7 days; P = 0.15) and costs remained higher for the hospitalist-led teams (P < 0.03). CONCLUSIONS: Despite having similar overall outcomes and LOS, costs were higher in UGIH patients attended by hospitalists. These results suggest that the academic hospitalist model may be tempered in patients requiring specialists for procedures or management.

Treating pelvic floor disorders of defecation: management or cure?

Pelvic floor disorders that affect defecation consist of structural disorders (eg, rectocele) and functional disorders (eg, dyssynergic defecation). Evaluation includes a thorough history and physical examination, a careful digital rectal examination, and physiologic tests such as anorectal manometry, colonic transit study, and balloon expulsion test. Defecography and dynamic MRI may facilitate detection of structural defects. Management consists of education and counseling regarding bowel function, diet, laxatives, and behavioral therapies. Recently, several randomized, clinical trials have shown that biofeedback therapy is effective in dyssynergic defecation. Dyssynergia may also coexist in structural disorders such as solitary rectal ulcer syndrome or rectocele. Hence, before proceeding with surgery, neuromuscular training or biofeedback should be considered. Several surgical approaches, including stapled transanal rectal resection, have been advocated, but well-controlled randomized studies are lacking and their efficacy is unproven.