LOS ANGELES — An educational tool kit designed to improve patient-physician interactions during visits for irritable bowel syndrome had a greater impact on global symptom relief than did any medication ever studied for the enigmatic disorder.
Dr. Brennan M. Spiegel and associates at the University of California, Los Angeles, tested the tool kit in a randomized study of 73 patients with irritable bowel syndrome (IBS) symptoms who attended the gastrointestinal disease catchment clinic for the VA Greater Los Angeles Health Care System.
Follow-up surveys 3 months later found that patients assigned to the physician-patient intervention group were far more likely than were those who received standard care to say they had achieved relief of their global symptoms (20 of 36 patients, or 56%, compared with 5 of 34 patients, or 15%.)
The intervention effect size of 0.75 “exceeds the largest effect size demonstrated in pharmaceutical studies for IBS,” Dr. Spiegel said at the annual Digestive Disease Week.
For example, studies of alosetron using similar outcome measures had effect sizes between 0.2 and 0.5, he said.
“This does not mean by any means that these agents are not effective. It does suggest that medical therapy alone may be suboptimal if it is not delivered in the context of a supportive and informative physician-patient interaction,” he said.
The multifactorial intervention consisted of a five-part tool kit that included:
▸ A waiting room questionnaire to document the patient's primary concerns, fears, and opinions about what might be causing IBS symptoms.
▸ A laminated flash card for the physician that includes key components of an effective discussion of IBS, including reminders to ask about psychosocial elements of the disease, descriptions of IBS in lay language, and the fact that IBS is not a life-threatening disease.
▸ A worksheet and diagram of the brain and gut that the physician could use to depict a simple explanation of the complex neural circuitry linking the two.
▸ A multimedia patient educational kit, including a self-empowerment video, an explanation of the brain-gut axis in lay language, information about support groups, a dietary card, and educational materials about IBS from the National Institutes of Health.
▸ A letter, sent 1 month following the office visit, asking the patient, “How are you doing?” and providing information about how to contact the physician if symptoms had not improved. This correspondence also included more educational information about IBS.
Physicians were free to use or ignore the patient's questionnaire, the flash card, and worksheet during the office visit; however, most found that it actually “streamlined” the visit, Dr. Spiegel said.
Similarly, patients could read or dispose of the educational materials provided. Some told investigators that they found the worksheet very important, while others primarily relied on the diet cards they found in the take-home educational kit.
Whatever elements did the trick, the intervention clearly had an impact on patients, with significant differences seen in global IBS symptoms, satisfaction, and perceptions of physicians' interpersonal skills.
Ironically, the same physicians saw IBS patients assigned to the intervention group or to usual care.
When independent observers assessed physicians' notes from the visits, they found “very large differences” between the intervention and standard care groups in terms of observations concerning patients' quality of life and extraintestinal symptoms such as anxiety or depression. None of the physician notes documenting visits with control group patients mentioned patients' fears and concerns or disease education efforts, while these elements appeared in their notes regarding 23% and 54% of intervention patient visits, respectively.
Dr. Spiegel prefaced the report on his findings by acknowledging the deep frustration many physicians feel in dealing with patients with IBS, since the disease is common and expensive, symptom expression is heterogeneous, the disease model is incomplete, and highly effective treatment options are scarce.
This frustration can spill over into office visits that leave neither party satisfied.
“Unfortunately, data from our group and others demonstrate that there is a disconnect, oftentimes, between physicians and patients,” he said. “Patients often feel uninformed after they have left the office and physicians often do a poor job of predicting patients' severity when patients and physicians fill out the same questionnaire.”
The low-cost intervention, which will now be further tested, may help to bridge gaps in communication, fostering the physician/patient relationship as a cornerstone of treatment of IBS, Dr. Spiegel said.