Focus April 11
18/3/11
15:40
Page 27
Irritable Bowel Syndrome | Hot Topic
Managing Irritable Bowel Syndrome in the Community: The financial burden and the way forward Marianne Williams, BSc Hons, RD, Specialist Allergy & IBS Dietitian
Introduction Irritable Bowel Syndrome (IBS) is a chronic and debilitating functional gastrointestinal disorder. Recent research has suggested that at least ten per cent of the United Kingdom population suffer from IBS1 with annually 2.34 million people seeking advice from a general practitioner.2, 3 This constitutes a significant healthcare cost and highlights the enormity of IBS as a UK health issue. This article will discuss the costs of managing IBS in the community, along with diagnosis and dietetic treatment, and present solutions to improve the management of this patient group.
Cost implications As long ago as 1997, Wells et al estimated that the treatment of IBS cost the UK NHS £45.6 million annually4 including inpatient, outpatient care, diagnostic and therapeutic procedures, laboratory tests and rehabilitation. This was a tremendous cost at around 0.1 per cent of the total NHS spend for what was then still seen as a fairly obscure disease. In 2006, Maxion-Bergemann et al 5 reviewed the costs of IBS in the UK and US and used data which compared IBS costs to those of matched controls. They showed that costs incurred by IBS patients for outpatient appointment, GP visits and costs for medications were significantly higher. Seventy-five per cent of IBS patients in the UK used a prescription drug to treat their IBS, with many medications being prescribed for over 100 days. Although both the 2008 NICE report on IBS6 and the 2010 NHS Economic Report: Value of calprotectin in screening out irritable bowel syndrome,7 clearly suggested diet as a first line treatment for IBS, local GPs report that they are inadequately trained in the use of IBS diagnostic criteria and have little knowledge of the new dietary approaches now available for this condition. However, one in 12 GP consultations are based around gastrointestinal problems with 46 per cent being diagnosed as having IBS. This equates to a full-time GP seeing eight patients per week with IBS as their main complaint.8 Presently, GPs often refer for costly specialist consultations and/or prescribe a number
of drugs.2 Education of GPs by dietitians would seem essential. Indeed, Bellini states that: “If GPs have an adequate understanding of IBS they will be better able to diagnose and manage the syndrome and expenditures for possibly useless tests and treatments can be avoided.”2 What became apparent when reviewing the data on costs was that referrals into secondary care formed a significant financial burden with research papers suggesting that between 20 per cent8 and 31 per cent2 of IBS patients will undergo invasive secondary care investigations. In 2010, at a Clinical Engagement Event, held at Guys & St Thomas’s NHS Foundation Trust (GSTT) in London, it was noted that IBS outpatient referral to secondary care cost is in the region of £250 per person and that: “90 per cent of patients referred by primary care to gastroenterology would end up having some sort of endoscopic procedure.” 9 This must raise financial cause for concern and possibly highlight an urgent need for primary care IBS diagnosis and treatment education. The national tariffs for referrals, investigations and suggested treatments are listed in Table One. It is clear to see from this table that replacing visits and investigations into secondary care with dietetic treatment could significantly reduce the total cost burden of IBS, although I would question the use of a Band 5 dietitian: the responsibility and level of academic knowledge required to run a dietetic-led IBS clinic would realistically demand a specialist or advanced dietitian at band 6 or 7.
Table One: National Tariffs for Referrals, Procedures and Treatments Resource/Treatment10 GP visit
£36.00
Nurse visit
£11.00
Specialist visit
£188.81
IBS medication*
£17.22
Dietitian (hourly rate)**
£24.29
Psychological intervention (hourly rate)
£41.55
Procedure10 Colonoscopy
£544.45
Sigmoidoscopy
£365.59
Treatments
3
Dietitian with 3 1-hour sessions** £73.00 Resource/Treatments10 Tricyclic antidepressants annually
£21.13
Serotonin reuptake inhibitors annually
£25.73
Psychological therapy with 7 sessions @ £41.55
£291
* Based soley on the use of Mebeverine (antispasmodic) ** Based on referral to band 5 dietitian at the time of reference publication
CN Focus Vol.3 No.1 April 2011 | 27
Focus April 11
18/3/11
15:40
Page 28
Hot Topic | Irritable Bowel Syndrome Table Two: Evidence-based Dietetic Treatments for IBS1, 6, 12, 13
clearly suggested that, in the absence of ‘red flags’, dietary and lifestyle advice should form a first line treatment in IBS for two months before further investigations are considered by the GP.7 In September 2010, the British Dietetic Association (BDA) Gastroenterology Specialist Group produced a Professional Guideline, ‘UK Evidencebased practice guidelines for the dietetic management of irritable bowel syndrome (IBS) in adults’.1 This BDA document set out the dietetic care pathway with three approaches to dietary management:
Food Related Treatment of IBS
Professional Responsibility
Supporting Documents
Establishing healthy eating patterns
dietitian
NICE 2008 IBS Guidelines; BDA 2010 professional guideline for IBS
Lactose intolerance
dietitian
BDA 2010 professional guideline for IBS
Milk protein allergy
dietitian
BDA 2010 professional guideline for IBS: DRACMA Guidelines
Fructose malabsorption
dietitian
BDA 2010 professional guideline for IBS; Gibson et al. 2010
Fermentable carbohydrate intolerance
dietitian
BDA 2010 professional guideline for IBS; Gibson et al. 2010
Probiotic use
dietitian
NICE 2008 IBS Guidelines; BDA 2010 professional guideline for IBS
Elimination or empirical diet
dietitian
NICE 2008 IBS Guidelines; BDA 2010 professional guideline for IBS
1. Diet & lifestyle 2. Dairy foods: a. Lactose intolerance OR b. Milk protein allergy 3. Assess dietary fibre and avoid wheat bran
Insufficient fibre
dietitian
BDA 2010 professional guideline for IBS
SECOND LINE:
Figure 1: Model Structure for Diagnostic Pathway of Patients Presenting with Lower Gastrointestinal Symptoms
6. Elimination OR empirical diet See Table Two for evidence-based dietetic treatments for IBS.
Suspected IBS with no red flags and below age of 45 Biomarker test for inflammation at initial GP visit e.g. calprotectin -ve biomarker results
colonoscopy/sigmoidoscopy
Management of IBS with diet and lifestyle for 2 months
-ve results GP to use medication and further tests
+ve results no longer need to return to GP
still -ve then for secondary care endoscopy Adapted from: 2010 document CEP09041 NHS Purchasing & Supply Agency: Centre for Evidence-based Purchasing Economic Report.
Diagnosis of IBS 6
Both the NICE guidance 2008 and/or Rome III criteria 200611 are used to help diagnose IBS. NICE 2008: Diagnosis of Irritable Bowel Syndrome In Adults6 Patient should have the following symptoms for at least six months: Abdominal pain or discomfort; Bloating; Change in bowel habit. Positive diagnostic criteria for IBS: Abdominal pain/discomfort; a) relieved by defaecation OR; b) associated with altered bowel frequency or stool form. AND at least two of the following: altered stool passage (straining, urgency, incomplete evacuation); abdominal bloating, distention, tension or hardness; symptoms made worse by eating; passage of mucus. Other features may also be present: lethargy, nausea, backache, bladder symptoms. Coeliac disease should also be ruled out and the presence of ‘red flags’ indicates necessity for secondary care referral, e.g. blood in stools, unintentional weight loss, sudden change in
28 | CN Focus Vol.3 No.1 April 2011
4. Fibre – Linseed supplementation in constipation dominant IBS 5. Fermentable carbohydrates (FODMAPs) 6. Probiotics
THIRD LINE:
Presenting symptoms & GP assessment
+ve biomarker results
FIRST LINE:
symptoms, family history of ovarian or bowel cancer, unexplained anaemia, abdominal/rectal masses, inflammatory markers for IBD. New biomarker tests such as faecal calprotectin are becoming available to distinguish IBS from IBD. These tests cost less than £35 each and can potentially save patients going for costly endoscopy. In my clinics, patients often present with bloating, wind, abdominal pain, nausea and either constipation or diarrhoea. Diarrhoea predominant patients often suffer with urgency which can severely affect their quality of life.
Dietetic treatments The 2008 NICE guidance on IBS6 suggested diet and lifestyle as a first line treatment for IBS. It suggested that if diet was considered a major factor in the symptoms then the patient should be referred to a registered dietitian for ‘single food avoidance and exclusion diets’. In January 2010 the NHS Centre for EvidenceBased Purchasing produced an ‘Economic Analysis Model Structure’7 in relation to IBS diagnosis which
Practicalities of managing IBS in the community Most IBS patients are managed in primary care14 and the 2008, NICE guidance on IBS6 stated that dietetic input should include three one hour sessions per patient to ensure adequate patient education.3 The BDA IBS Guidance recommends that IBS diets can require 45-60 minutes of face-to-face contact time. However, many community dietitians have insufficient time allocation, often with 30 minutes for an initial appointment and only 15 minutes for a review. Community dietitians require specialist training in the fermentable carbohydrate diet (FODMAP diet)15 and training in allergies and intolerances. The dietitian must know when a particular diet is appropriate for each individual patient. They also need access to specialist resources. A lack of clinic time along with a lack of specialist dietetic training can lead to insufficient education of the patient, potentially resulting in dissatisfied patients and poor outcomes from dietary intervention. Consequently patients continue to visit their GP and request medication or further costly investigation.16
So what’s the solution? Solution A: A Dietetic-led IBS Clinic in Primary Care Funding an IBS clinic within primary care is a potential ‘win-win’ situation: a dietitian with the necessary competencies can run a clinic seeing patients who have no ‘red flags’ and negative biomarker results, for dietary intervention as a first line treatment. A proportion of the money saved by preventing unnecessary referrals into secondary
Focus April 11
18/3/11
15:40
Page 29
Irritable Bowel Syndrome | Hot Topic care, repeat visits to GPs and a reduction in prescriptions can then be used to help fund this new service. This should form the core message of any funding application. See Figure 1. The service would fit comfortably into the organisational structure of a community dietetics department as there is, as yet, generally no community gastroenterology specialist dietitian. It would seem that secondary care may also be supportive of such a development, with a local Consultant Gastroenterologist commenting: “With the exception of difficult refractory cases, IBS could be dealt with very adequately in the dietetic primary care sector.” He continued: “The referral to secondary care dietitians is neither realistic, due to sheer volume, or appropriate, as they are non-acute patients.”17 Funding a community dietetic led IBS clinic within primary care appears to be a novel but logical approach.
Solution B: A Community Gastroenterology Dietitian This approach utilises all the core competencies needed for a dietitian to run an IBS dietetic-led clinic but extends the use of these competencies to make potentially more savings for the NHS. Dietetic gastroenterology has traditionally been the remit of secondary care dietitians and, indeed, their skills and expertise are invaluable within the acute sector. However, there are conditions which have little
need for dietetic secondary care input and simply compound the waiting times and resources of secondary care dietetics departments: a) IBS; b) coeliac disease and; c) allergy and intolerance. The dietetic treatment of all of these conditions could happily be addressed predominantly within primary care with a clear pathway for referral into secondary care when appropriate.16 A local Consultant Gastroenterologist felt that: “Coeliac referral for annual reviews into secondary care is unnecessary and these patients could be dealt with in primary care with annual blood tests and dietary check ups from a community-based dietitian.” 1 7 Patients diagnosed with coeliac disease in primary care, with a positive blood test, could also be sent directly to a community gastroenterology dietitian.
Conclusion IBS, although not life threatening, poses a significant financial burden on the NHS through its notable use of resources. Taking into account the impressive success rate of some forms of dietary treatment for IBS,13, 15 a dietetic-led primary care IBS clinic or a specialist community gastroenterology dietitian could potentially prevent a significant proportion of patients from being referred into secondary care, reduce repeat visits to GPs and should also significantly reduce prescriptions given to these
patients in both primary and secondary care. The July 2010, the White Paper ‘Equity and excellence: Liberating the NHS’19 emphasised the need for the NHS to save money, while making it easier for professionals to innovate and improve outcomes. GP consortia are being encouraged to use resources to “achieve the best and most cost efficient outcomes for patients” and redesign patient pathways and local services “based on effective dialogue and partnership with hospitalbased specialists”. In this area of the UK (South Somerset), there is support from both hospital-based specialists and local GPs for the development of a specialist dietetic primary care facility for this condition, whether in the form of a specialist IBS service or a more encompassing community dietetic gastroenterology service.17 Ultimately, in this environment of financial prudence, it would seem wise and efficient to move several costly conditions under one innovative umbrella of ‘primary care dietetic gastroenterology’. The treatments and skills are available. The support from both secondary and primary care in South Somerset is in place. The potential cost savings are substantial. There appears to be no conflict or reproduction of services. All that remains is implementation.
Marianne is being supported by her community dietetic manager to set up a new Community Gastroenterology Service in the South Somerset area this Summer 2011. Initially the service will be two days per month and will take referrals from local South Somerset GPs for coeliac, allergy and IBS patients with a view long-term of making this a county-wide service. References: 1. British Dietetic Association Gastroenterology Specialist Group (2010) Professional Consensus Statement: Evidence-based practice guidelines for the dietetic management of irritable bowel syndrome (IBS) in adults. Birmingham. 2. Belllini M, et al (2005). The general practitioner’s approach to irritable bowel sydrome: From intention to practice. Journal of Digestive and Liver Disease; 37(12): 934-939. 3. National Institute for Health and Clinical Excellence (2008). Costing report. Implementing NICE guidance: NICE clinical guideline 61. London: NICE. 4. Wells NE, Hahn BA, Whorwell PJ (1997). Clinical economics review: irritable bowel syndrome. Aliment Pharmacol Ther.; 11 (6): 1019-1030. 5. Maxion-Bergemann S, et al (2006). Costs of irritable bowel syndrome in the UK and US. Pharmacoeconomics; 24(1): 21-37. 6. National Institute for Health and Clinical Excellence (2008). Quick Reference Guide: Irritable bowel syndrome in adults. Diagnosis and management of irritable bowel syndrome in primary care. NICE clinical guideline 61. London: NICE. 7. NHS Purchasing and Supply Agency (2010). Centre for Evidence-based Purchasing ‘Economic report. Value of calprotectin in screening out irritable bowel syndrome’: CEP09041: London. 8. Thompson WG, et al (2000). Irritable bowel syndrome in general practice: prevalence, characteristics and referral Gut; 46: 78-82. 9. Irving P peter.irving@kcl.ac.uk (2010) IBS Clinical Engagement Event [E-mail] Message to M Williams (marianne@wisediet.co.uk) Sent Friday 4th June 2010, 09:46. 10. NHS Purchasing and Supply Agency (2010). Centre for Evidence-based Purchasing Evidence review. Value of calprotectin in screening out irritable bowel syndrome: CEP09026: London. 11. Drossman DA (2006). The Functional Gastrointestinal disorders and the Rome III Process. Gastroenterology; 130:1377-1390. 12. Fiocchi A, et al (2010). World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cows’ Milk Allergy (DRACMA) Guidelines. World Allergy Organization Journal; April 2010. 13. Gibson PR, Shepherd SJ (2010). Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach. Journal of Gastroenterology and Hepatology; 25: 252-258. 14. Thompson WG, et al (2001). The management of irritable bowel syndrome: a European primary and secondary care collaboration. European Journal of Gastroenterology & Hepatology; 13(8): 933-939 15. Staudacher HM, et al (2010). Implementation of the low FODMAP diet in the UK: How easy is it and does it work? Gut; 59: A149. 16. Halpert AD, et al (2007). What patients know about irritable bowel syndrome (IBS) and what they would like to know. National survey on patient educational needs in IBS and development and validation of patient educational needs questionnaire (PEQ). American Journal of Gastroenterology; 102: 1972-1982. 17. Williams M (2010). Irritable Bowel Syndrome: Are dietetic secondary care referrals appropriate? Report commissioned by the Nutrition & Dietetics Department at Yeovil District Hospital, Somerset, UK. 18. National Institute for Health and Clinical Excellence (2010). Full Guideline: ‘Diagnosis and assessment of food allergy in children and young people in primary care and community settings’: London: NICE. 19. Department of Health (2010). NHS White Paper presented to parliament by the Secretary of State for Health by Command of Her Majesty. ‘Equity and excellence: Liberating the NHS’; The Stationery Office: Report No: Cm 7881; ISBN 9780101788120.
IBS & IBD Study Day – West Country ‘Novel diagnostics, treatments and probiotics’ Date: Thursday 19th May 2011, 12:30 – 5pm • Venue: Brigwater Exchange Centre, Somerset Just off M5 at Bridgwater, between Bristol and Taunton For Gastroenterologists, GPs, Dietitians, Practice Nurses, Gastroenterology Nurses This is a very rare opportunity to hear four of the top researchers in the field of IBS and IBD talk in the West Country. • Dr Peter Irving – Consultant Gastroenterologist from Guys & St Thomas’s NHS Foundation Trust • Dr Jeremy Tibble – Consultant Gastroenterologist from Brighton & Sussex University Hospitals NHS Trust • Heidi Staudacher – Research Dietitan at Kings College London • Dr Kevin Whelan – Lecturer in Nutritional Sciences and Research Dietitian Closing speech will be from Yvonne McKenzie, Chairman of the British Dietetic Association Gastroenterology Group on the new evidence based IBS practice guidelines and new IBS dietetic treatment pathways.
FREE parking, FREE lunch & FREE goodie bags – Sponsored by Yakult www.gastrolectures2011.org.uk – for more details on speakers & their talks, venue, booking forms, etc.
CN Focus Vol.3 No.1 April 2011 | 29