Observational Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jun 28, 2019; 25(24): 3079-3090
Published online Jun 28, 2019. doi: 10.3748/wjg.v25.i24.3079
Evaluation of clinical outcomes in an interdisciplinary abdominal pain clinic: A retrospective, exploratory review
Amanda D Deacy, Craig A Friesen, Vincent S Staggs, Jennifer V Schurman
Amanda D Deacy, Craig A Friesen, Jennifer V Schurman, Division of Gastroenterology, Children’s Mercy Kansas City; UMKC School of Medicine, Kansas City, MO 64108, United States
Amanda D Deacy, Jennifer V Schurman, Division of Developmental and Behavioral Sciences, Children’s Mercy Kansas City; UMKC School of Medicine, Kansas City, MO 64108, United States
Vincent S Staggs, Biostatistics and Epidemiology, Health Services and Outcomes Research, Children’s Mercy Kansas City; UMKC School of Medicine, Kansas City, MO 64108, United States
Author contributions: Deacy AD, Friesen CA, and Schurman JV contributed to study conception and design; Deacy AD and Staggs VS contributed to data acquisition, data analysis and interpretation, and writing of article; Deacy AD, Friesen CA, Staggs VS, and Schurman JV contributed to editing, reviewing and final approval of article.
Institutional review board statement: This study was reviewed and approved by the Children's Mercy Hospital Pediatric Institutional Review Board.
Informed consent statement: Waivers of permission/assent and consent were deemed appropriate for this study.
Conflict-of-interest statement: None to declare.
STROBE statement: The authors have read the STROBE statement – checklist of items, and the manuscript was prepared and revised according to the STROBE Statement – checklist of items.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Amanda D Deacy, PhD, Associate Professor, Psychologist, Division of Developmental and Behavioral Sciences, Children’s Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States. addeacy@cmh.edu
Telephone: +1-816-302-3042 Fax: +1-816-234-1553
Received: March 30, 2019
Peer-review started: April 1, 2019
First decision: May 9, 2019
Revised: May 21, 2019
Accepted: May 31, 2019
Article in press: June 2, 2019
Published online: June 28, 2019
ARTICLE HIGHLIGHTS
Research background

Abdominal pain characteristic of pediatric functional gastrointestinal disorders (FGIDs) is known to be associated with a high degree of psychosocial comorbidity and to persist into adulthood without intervention. Likewise, it is well accepted that a host of biological, psychological, and social factors contribute and interact in complicated and varying ways to produce the various FGID phenotypes. Historically, treatment for pediatric FGIDs has been conducted such that, following a “negative” medical evaluation and/or unsuccessful medical treatment, referrals to mental health providers are made and relevant treatments undertaken. One alternative to this model is the delivery of co-located medical and psychological care in the context of an interdisciplinary treatment team. Although the benefits of integrated care are well documented in pediatrics, interdisciplinary care remains the exception, rather than the standard, in the care of pediatric FGID patients. The current study aims to address this current gap in the existing literature.

Research motivation

In an effort to measure and improve upon clinical change in both medical and psychosocial outcomes in pediatrics FGIDs, we employed naturalistic data collection as part of standard of care in an interdisciplinary specialty clinic. In so doing, we collected a rich and diverse data set that allowed us to evaluate patients’ clinical resolution, as well as identify factors that complicate symptom improvement. This is significant in that it adds to the small, existing literature on the efficacy of interdisciplinary treatment for pediatric FGIDs in an outpatient tertiary care setting. Furthermore, identification of psychosocial factors that delay or prevent symptom improvement sets the stage for early, proactive intervention.

Research objectives

The primary research objectives included: evaluation of outcomes with interdisciplinary treatment in pediatric patients with pain-related FGIDs, and identification of patient characteristics that predicted clinical outcomes.

Research methods

Study participants were 392 children, ages 8-18 (M = 13.8; SD = 2.7), seen between August 1, 2013 and June 15, 2016 in an interdisciplinary APC housed within the Gastroenterology Division of a medium-sized children’s hospital in the United States. To be eligible for the study, patients had to be 8 years of age or older and have had abdominal pain for ≥ 8 wk at the time of initial evaluation. Medical and psychosocial data collected naturalistically as part of standard of care were retrospectively reviewed and analyzed. Logistic regression was used to model odds of reporting vs. never reporting improvement, as well as to differentiate rapid from slower improvers. Collecting data in this way allows for early identification of patient factors that can complicate the treatment course of pediatric FGIDs, thereby allowing for proactive intervention. Second, data collection at each and every visit allows provider teams to be clinically nimble and adapt to changes in patients’ presentations more quickly than would be possible without this information. Finally, repeated data collection at naturalistic time points during provides ample statistical power for modeling complex clinical questions whose answers reflect the real-world waxing and waning of symptoms and associated circumstances, thereby decreasing the chance of missing naturally occurring symptomatic variability.

Research results

Nearly 70% of patients followed during the study period achieved clinical resolution on at least one of the employed outcome indices. Among those who achieved resolution during follow up, close to half did so within roughly 2 mo after initial evaluation and initiation of interdisciplinary treatment. Patient age, sleep, ease of relaxation, and depression all significantly predicted the likelihood of resolution, with older age, poor sleep, difficulty relaxing, and the presence of depression predicting worse outcomes. Poor sleep also was found to significantly predict the rapidity of clinical resolution such that it delayed clinical resolution of symptoms beyond the first follow up visit. The identification of the relationships between patient age, sleep, ease of relaxation, and depression and FGID symptom improvement is a critical first step in crafting the most effective biopsychosocial interventions for this complex set of diagnoses.

Research conclusions

As anticipated, a great majority of patients treated in the context of an interdisciplinary model of care for chronic abdominal pain demonstrated improvement. In addition, unique psychosocial characteristics were able to be identified that uniquely predicted the presence and pace of positive outcomes. Based on our findings, clinical outcomes among youth with pediatric FGIDs are likely facilitated by intensive targeting of older children and teens to bolster their clinical outcomes, consistent attention paid to sleep quality and quantity during clinic visits, offering of training in specific relaxation training methods, and repeated screening and referral for pediatric and adolescent depression. Furthermore, these findings highlight the need for continued inquiry into the benefit and necessity of concurrent medical and psychosocial screening and intervention as standard of care for all for children affected by FGIDs.

Research perspectives

Use of naturalistically collected data in the context of an observational study provides rich and unique clinical and research opportunities. Data collected as standard of care in a busy clinic provides opportunities for individualized, in-the-moment intervention with patients as they present, as well as the ability of researchers to identify patterns among groups of patients. In the case of the current study, we were able to identify behavioral factors that, if addressed, have the potential to increase the likelihood of clinical symptom resolution among youth with FGIDs. Future investigations would benefit from the use of controlled research designs wherein researchers compared standard medical care to interdisciplinary care.