Observational Study Open Access
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Nov 14, 2017; 23(42): 7635-7643
Published online Nov 14, 2017. doi: 10.3748/wjg.v23.i42.7635
Predictors of healthcare-seeking behavior among Chinese patients with irritable bowel syndrome
Wen-Juan Fan, Dong Xu, Min Chang, Li-Ming Zhu, Gui-Jun Fei, Xiao-Qing Li, Xiu-Cai Fang
Wen-Juan Fan, Dong Xu, Min Chang, Li-Ming Zhu, Gui-Jun Fei, Xiao-Qing Li, Xiu-Cai Fang, Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
Dong Xu, Department of Gastroenterology, The First Affiliated Hospital of Fujian Medical University, Fuzhou 350005, Fujian Province, China
ORCID number: Wen-Juan Fan (0000-0002-2927-9266); Dong Xu (0000-0002-6690-7049); Min Chang (0000-0003-3963-6455); Li-Ming Zhu (0000-0002-8710-8780); Gui-Jun Fei (0000-0001-6517-9695); Xiao-Qing Li (0000-0003-1334-1544); Xiu-Cai Fang (0000-0002-5600-8779).
Author contributions: Fan WJ collected the data and wrote the manuscript; Xu D and Chang M collected the data; Zhu LM, Fei GJ and Li XQ consulted with the patients; Fang XC designed the study, consulted with the patients and critically revised the manuscript; all authors had final approval of the article.
Supported by the Program of International S&T Cooperation, No. 2014DFA31850; Project of the National Key Technologies R&D Program in the 11th Five Year Plan period, No. 2007BAI04B01; and National High-tech R&D Program (“863” Program, 2010AA023007), China.
Institutional review board statement: The observational study was approved by the Ethics Committee of Peking Union Medical College Hospital.
Informed consent statement: Parts of study participants provided informed written consent prior to study enrollment and other patients orally consented to participate the study after informed.
Conflict-of-interest statement: The authors of the manuscript have no conflicts of interest to disclose.
Data sharing statement: We have submitted an article “Analysis of symptomatic characteristics of patients with irritable bowel syndrome in China” with the same database to Chinese Journal of General Practitioners, which has been published on 2017, 16(9): 668-671.
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/
Correspondence to: Xiu-Cai Fang, MD, Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, #1, Shuaifuyuan, Dongcheng District, Beijing 100730, China. fangxiucai2@aliyun.com
Telephone: +86-10-69156892 Fax: +86-10-69151963
Received: August 2, 2017
Peer-review started: August 4, 2017
First decision: August 30, 2017
Revised: September 13, 2017
Accepted: October 18, 2017
Article in press: October 19, 2017
Published online: November 14, 2017

Abstract
AIM

To analyze predictors of healthcare-seeking behavior among Chinese patients with irritable bowel syndrome (IBS) and their satisfaction with medical care.

METHODS

Participating patients met IBS Rome III criteria (excluding those with organic diseases) and were enrolled in an IBS database in a tertiary university hospital. Participants completed IBS questionnaires in face-to-face interviews. The questionnaires covered intestinal and extra-intestinal symptoms, medical consultations, colonoscopy, medications, and self-reported response to medications during the whole disease course and in the past year. Univariate associations and multivariate logistic regression were used to identify predictors for frequent healthcare-seeking behavior (≥ 3 times/year), frequent colonoscopies (≥ 2 times/year), long-term medications, and poor satisfaction with medical care.

RESULTS

In total, 516 patients (293 males, 223 females) were included. Participants’ average age was 43.2 ± 11.8 years. Before study enrollment, 55.2% had received medical consultations for IBS symptoms. Ordinary abdominal pain/discomfort (non-defecation) was an independent predictor for healthcare-seeking behavior (OR = 2.07, 95%CI: 1.31-3.27). Frequent colonoscopies were reported by 14.7% of patients (3.1 ± 1.4 times per year). Sensation of incomplete evacuation was an independent predictor for frequent colonoscopies (OR = 2.76, 95%CI: 1.35-5.67). During the whole disease course, 89% of patients took medications for IBS symptoms, and 14.7% reported they were satisfied with medical care. Patients with anxiety were more likely to report dissatisfaction with medical care (OR = 2.08, 95%CI: 1.20-3.59). In the past year, patients with severe (OR = 1.74, 95%CI: 1.06-2.82) and persistent (OR = 1.66, 95%CI: 1.01-2.72) IBS symptoms sought medical care more frequently.

CONCLUSION

Chinese patients with IBS present high rates of frequent healthcare-seeking behavior, colonoscopies, and medications, and low satisfaction with medical care. Intestinal symptoms are major predictors for healthcare-seeking behavior.

Key Words: Irritable bowel syndrome, Colonoscopy, Healthcare seeking, Treatment, Outcomes

Core tip: The prevalence of irritable bowel syndrome (IBS) in the general Chinese population is about 6.5%. Many patients are dissatisfied with the efficacy of traditional IBS treatments. Data about healthcare-seeking behavior among these patients in China are lacking. We analyzed a database of patients with IBS from Peking Union Medical College Hospital to identify predictors for healthcare-seeking behavior and satisfaction with medical care among this population. We found high rates of frequent healthcare-seeking behavior, colonoscopies, and medications, and low satisfaction with medical care. Intestinal symptoms were major predictors for healthcare-seeking behavior. Anxiety influenced satisfaction with medical care.



INTRODUCTION

Irritable bowel syndrome (IBS) is a common functional bowel disorder with a global prevalence of 11%[1]. A meta-analysis found the pooled prevalence of IBS in a Chinese community was 6.5%[2]. Rome III criteria indicate IBS is characterized by persistent or recurrent abdominal pain or discomfort associated with altered bowel habits, and patients with IBS report lower quality of life[3]. In the United States, IBS is associated with an annual economic burden of more than 20 billion dollars (direct and indirect healthcare costs)[4]. Data from Korea in 2008 showed the annual average National Health Insurance costs for IBS per person were USD64.1, the cost for outpatient care was USD43.7, and that for inpatient care was USD1087.9[5]. A Chinese study focused on medical costs showed that IBS accounted for 3.3% of the total healthcare budget for the entire Chinese nation[6]. Data from Western countries indicated intestinal symptoms (including increasing pain severity and duration) were independently associated with seeking healthcare for IBS[7], and frequent consulters were more likely to have coexisting anxiety or depression[8]. In France, 71.9% of patients consulted their general physicians, 45.9% consulted gastroenterologists, and 8% had been hospitalized for IBS[9]. An epidemiological study in China demonstrated that 22.4%[10] of patients with IBS symptoms sought healthcare, but there were no detailed data revealing the predictors for healthcare-seeking behavior among patients with IBS in China.

The pathogenesis of IBS is unclear, and its diagnosis depends on Rome diagnostic criteria. However, in France, 67% of patients who met Rome II criteria underwent additional investigations to determine etiologies[9]. The therapeutic goals of IBS are to alleviate intestinal symptoms, reduce episodes, and improve quality of life. Nevertheless, many patients with IBS are dissatisfied with the efficacy of traditional treatment options and undergo frequent consultations, referrals, multiple medications, and even unnecessary abdominal or pelvic surgeries[11]. The present study aimed to provide evidence for IBS management strategies through a database analysis of patients with IBS from Peking Union Medical College Hospital (PUMCH).

MATERIALS AND METHODS
Participants

Participants were consecutive patients with IBS enrolled in a gastroenterology clinic at PUMCH (a tertiary university hospital) from June 2009 to February 2016. Eligible patients were aged 18-65 years. All patients met Rome III diagnostic and subtype criteria[12], including recurrent abdominal pain or discomfort at least 3 d/mo in the last 3 mo associated with two or more of these features: (1) improvement with defecation; (2) onset associated with a change in the frequency of stools; and (3) onset associated with a change in the form of stools. Criteria were fulfilled in the last 3 mo with symptom onset at least 6 months before diagnosis. Patients with organic gastrointestinal diseases and metabolic diseases were excluded based on the results of routine tests for blood, urine, stool; liver, kidney, and thyroid function; measurements of carcinoembryonic antigen, erythrocyte sedimentation rate and C-reactive protein; and abdominal ultrasound and colonoscopy in the past year. Eligible patients needed to be able to complete the questionnaires. After being informed about the study, some participating patients provided informed written consent and others provided oral consent to participate before study enrollment. This study was approved by the PUMCH Ethics Committee (S-234).

Methods

IBS symptom questionnaires were administered by well-trained investigators in face-to-face interviews. Information collected included demographic data, IBS disease course, frequency and severity of IBS symptoms, defecation-related symptoms, extra-intestinal symptoms, examination results in the past year, and psychological and sleeping status and management. Symptom score for IBS with diarrhea (IBS-D) was calculated according to Zhu et al[3], with a total possible score of 15 that reflected the frequency and severity of abdominal pain/discomfort, frequency of bowel movements during symptom onset, and improvement of abdominal pain/discomfort with defecation. We defined mild symptoms as a symptom score ≤ 8, moderate symptoms as 9-10, and severe symptoms as > 10, based on symptom score percentiles and the severity and frequency of abdominal pain, number of other symptoms, health-related quality of life, and healthcare use[13]. In this questionnaire, ordinary abdominal pain/discomfort referred to abdominal pain/discomfort during non-defecation, whereas persistent symptoms referred to having IBS symptom onset every day.

Patients with difficulty falling asleep, light sleep/dreaminess, sleeping time < 6 h, or early awakening in the past 3 mo were defined as having sleeping disorders. The Hamilton anxiety (HAMA) and Hamilton depression (HAMD) scales were used to evaluate patients’ psychological status by specially trained professionals through conversation and observation[14].

The validated simplified Chinese version of the IBS-Quality of Life (IBS-QOL) instrument was completed by patients and transformed to scores according to the instructions provided[3,15]. Healthcare-seeking conditions consisted of healthcare-seeking behavior throughout the whole disease course and the past year, medical costs, treatment efficacy evaluation, and satisfaction with medical care as reported by patients. Medical costs were converted and presented as USD, based on the average exchange rate during 2009-2015 from the National Bureau of Statistics of China (USD1 = CNY6.4195).

Statistical analysis

All analyses were performed using SPSS version 19.0 (IBM Corporation, Somers, NY, United States). Parametric data were presented as mean ± SD. Nonparametric data were presented as median (interquartile range). Comparisons among the two groups were made by Student’s t-tests for parametric data. The Mann–Whitney U test was used to compare nonparametric data between the two groups. Chi-square tests were used for categorical variables. Spearman’s test was performed to assess nonparametric correlations between two quantitative variables. Univariate associations were identified by χ2 tests. Variables that were significant in the chi-square tests were included in a multivariate logistic regression model to identify independent predictors for healthcare-seeking behavior among patients with IBS. P < 0.05 was considered statistically significant.

RESULTS
Demographic data

Data for 516 patients with IBS were included in the final analysis. Patients’ average age was 43.2 ± 11.8 years, and the sample included 56.8% males and 43.2% females. The median IBS disease course was 6.5 (8) years; 30.8% of patients had a disease course ≥ 10 years, and 12.0% ≥ 20 years.

IBS-D, IBS with constipation (IBS-C) and mixed IBS (IBS-M) accounted for 94.4%, 3.5%, and 2.1% of patients, respectively. We did not include patients with unsubtyped IBS. The average symptom score for IBS-D was 9.4 ± 1.6; 26.2% had mild symptoms, 51.7% moderate symptoms, and 22.1% severe symptoms. In addition, 58.1% of patients had coexisting sleeping disorders, with a median duration of 3.5 (9) years. A total of 362 patients (70.2%) completed HAMA and HAMD assessment. The average HAMA score was 16.2 ± 7.3 and the average HAMD score was 13.2 ± 6.1. We found that 62.1% of patients had coexisting anxiety, of which 49.6% were moderate to severe. In addition, 29% of patients had coexisting depression, with 14.2% being moderate to severe. The average IBS-QOL score was 71.7 ± 17.9, and there was no significant difference between males and females (73.0 ± 17.7 vs 71.0 ± 19.1, P = 0.22).

Healthcare-seeking behavior among patients with IBS

During the whole disease course, 285 patients (55.2%) had sought healthcare at least once for IBS symptoms (current consultation not included). These patients were defined as the consulter group. In the past year this figure increased to 79.3%, with an average number of visits of 4.5 ± 6.2. The majority of patients (79.3%) consulted with tertiary hospitals; primary/secondary care accounted for 20.7% of consultations. In addition, most patients (97.9%) consulted with gastroenterologists; 8.6% also consulted with other departments including general physicians (9.5%), traditional Chinese medicine practitioners (6.8%), and gynecologists (4.6%).

In the past year, 49.1% of patients had more than three consultations. Patients with anxiety and depression underwent more consultations than patients without [anxiety, 3.0 (3.5) vs 2.0 (2.8), P = 0.005; depression, 3.0 (4.0) vs 2.0 (2.9), P = 0.001]. The number of consultations for patients with IBS in the past year was positively correlated with symptom score (r = 0.271, P < 0.001) but negatively correlated with IBS-QOL score (r = -0.228, P < 0.001).

Colonoscopies: During the whole disease course, 41.9% of patients underwent colonoscopies (average 1.7 ± 1.3); 76 patients (14.7%) underwent at least two colonoscopies, with the maximum being 10 (over 6 years). In the past year, 64.9% of patients underwent colonoscopies (average 1.1 ± 0.3); 19 patients (3.7%) had colonoscopies at least twice (maximum of three).

Medications and efficacy: In total, 89% of patients with IBS had taken medications during the whole disease course, with 54.7% reporting intermittent use and 16.9% long-term use. Consulters were more likely to take medications than non-consulters (93.7% vs 83.1%, P < 0.001). In the past year, the rate of medication was 88.8% and 14.8% of patients took more than three kinds of medications. Common medications used by patients with IBS-D were probiotics, traditional Chinese medicines, pinaverium bromide, loperamide, and traditional antispasmodics. Probiotics were most commonly used (52.2%), followed by traditional Chinese medicine (41.3%) (Table 1). Patient-reported medication response rates in the past year were over 50%. Although the overall response rate for pinaverium bromide was 73.1% and probiotics was 61.2%, “somewhat response” for the two medications was reported by 52.4% and 55.9%, respectively (Figure 1). Common medications used by those with IBS-C included traditional Chinese medicine, enemas, and prokinetics.

Table 1 Irritable bowel syndrome with diarrhea patients reported medication use (n = 487) n (%).
MedicationsThe whole disease courseThe past year
Probiotics240 (49.3)254 (52.2)
Traditional Chinese Medicine195 (40.0)201 (41.3)
Pinaverium bromide49 (10.1)82 (16.8)
Loperamide19 (3.9)21 (4.3)
Traditional antispasmodic11 (2.3)10 (2.1)
Figure 1
Figure 1 Patients with irritable bowel syndrome with diarrhea reported effective rate in the past year. Number on top of the column referred to number of patients who used that kind of drug. TCM: Traditional Chinese medicine; PB: Pinaverium bromide.
Medical costs and overall satisfaction with medical care

Total direct medical costs estimated per patient per year for the whole disease course and for the past year were USD691.8 ± 1067.2 and USD762.7 ± 1146.0, respectively, with a maximum amount of USD7788.8. Degree of satisfaction with medical care was reported as complete satisfaction for 11.4% of patients, satisfaction for 31.8%, and dissatisfaction for 56.8%. Non-consulters reported a higher overall satisfaction rate (including complete satisfaction and satisfaction) than consulters (58.9% vs 30.5%, P < 0.001).

Variables influencing healthcare-seeking behavior and satisfaction

Univariate analysis: We investigated predictors for consultation, frequent consultations (≥ 3 times/year), frequent colonoscopies (≥ 2 times/year), long-term medications, multiple medications (≥ 3 kinds), and dissatisfaction with medical care in the whole disease course and the past year. Consulters were more likely to present with ordinary abdominal pain/discomfort, persistent symptoms, anxiety, and depression in the whole disease course. In the past year, consulters were more likely to have loose stools (Bristol Stool Form Scale type 6) and weight loss (Table 2). In addition, among frequent consulters over the whole disease course, the percentages of females, severe symptoms, weight loss, and coexisting functional dyspepsia (FD) were higher than among patients with < 3 consultations/year. In the past year, variables influencing healthcare-seeking behavior included severe symptoms, ordinary abdominal pain/discomfort, persistent symptoms, weight loss, and FD (Table 3). During the whole disease course, more females than males reported frequent colonoscopies (52.6% vs 38.6%, P = 0.047), sensation of incomplete evacuation (84.2% vs 65%, P = 0.003), and coexisting pain in other parts of the body (50% vs 33.6%, P = 0.018).

Table 2 Factors with significant difference between consulted and non-consulted patients with irritable bowel syndrome n (%).
ConsultersNon-consultersOR (95%CI)
During the whole disease coursen = 285n = 231
Ordinary abdominal pain/discomfort174 (61.1)101 (43.7)2.02 (1.43-2.92)
Persistent symptoms104 (36.5)60 (26.0)1.64 (1.12-2.40)
Disease course ≥ 7 yr121 (42.5)77 (33.3)1.48 (1.03-2.12)
Co-existed with GERD157 (55.1)107 (46.3)1.42 (1.00-2.01)
Sleeping disorder179 (62.8)121 (52.4)1.54 (1.08-2.18)
Anxiety1128 (67.4)98 (57.0)1.56 (1.02-2.38)
Depression164 (33.7)41 (23.8)1.62 (1.02-2.58)
In the past yearn = 409n = 107
Mental labor199 (48.7)33 (30.8)2.13 (1.35-3.35)
Severe abdominal pain68 (16.6)27 (25.2)0.59 (0.36-0.98)
Loose stool312 (83.6)70 (72.9)1.70 (1.07-2.69)
Weight loss119 (29.1)17 (15.9)2.17 (1.24-3.81)
Table 3 Factors with significant difference between frequent and infrequent consulters in patients with irritable bowel syndrome n (%).
Frequent consultersInfrequent consultersOR (95%CI)
During the whole disease coursen = 136n = 149
Female76 (55.9)65 (43.6)0.55 (0.35-0.86)
Severe symptoms39 (28.7)24 (16.1)1.93 (1.08-3.45)
Weight loss45 (33.1)26 (17.4)2.34 (1.35-4.07)
Co-existed with FD94 (69.1)79 (53)1.98 (1.22-3.22)
In the past yearn = 201n = 208
Severe symptoms62 (30.8)24 (11.5)3.42 (2.03-5.75)
Ordinary abdominal pain/discomfort123 (61.2)97 (46.6)1.8 (1.22-2.67)
Persistent symptoms80 (39.8)48 (23.1)2.20 (1.44-3.38)
Weight loss71 (35.3)48 (23.1)1.82 (1.18-2.81)
Co-existed with FD131 (65.2)114 (54.8)1.54 (1.04-2.30)

Table 4 lists differences between patients with long-term medications and intermittent medications, multiple medications (≥ 3 kinds) and fewer than three kinds of medications. Patients with persistent symptoms, weight loss, and anxiety were more likely to take long-term and multiple medications.

Table 4 Factors with significant difference of medication behaviors in patients with irritable bowel syndrome in the past year n (%).
Long-term medication(n = 88)Intermittent medication (n = 370)OR (95%CI)Medications ≥ 3 kinds (n = 68)Medications < 3 kinds (n = 390)OR (95%CI)
Mental labor26 (29.5)169 (45.7)0.59 (0.30-0.82)
Severe symptoms33 (37.5)73 (19.7)2.44 (1.48-4.03)
Persistent symptoms45 (51.1)107 (28.9)2.57 (1.60-4.13)33 (48.5)119 (30.5)2.15 (1.27-3.62)
Weight loss40 (45.5)86 (23.2)2.75 (1.70-4.47)28 (41.2)98 (25.1)2.09 (1.22-3.56)
Anxiety146 (79.3)163 (61.3)2.42 (1.23-4.79)40 (78.4)169 (61.9)1.87 (1.11-3.15)
Depression124 (41.4)75 (28.2)1.80 (1.00-3.23)
Co-exist with FD49 (72.1)232 (59.5)1.76 (1.00-3.10)

Comparison of degree of satisfaction with medical care in the whole disease course and in the past year showed that IBS symptoms, weight loss, sleeping disorders, and psychological disorders influenced patient-reported satisfaction rates (Table 5).

Table 5 Factors with significant difference between irritable bowel syndrome patients with satisfaction and dissatisfaction to medical care n (%).
SatisfactionDissatisfactionOR (95%CI)
During the whole disease coursen = 293n = 223
Severe symptoms76 (25.9)38 (17.0)1.71 (1.10-2.64)
Ordinary abdominal pain/discomfort179 (61.1)96 (43.0)2.08 (1.46-2.96)
Persistent symptoms112 (38.2)52 (23.3)2.04 (1.38-3.01)
Mucous stool196 (66.9)129 (57.8)1.47 (1.03-2.11)
Weight loss90 (30.7)46 (20.6)1.71 (1.13-2.57)
Co-existed with GERD162 (55.3)102 (45.7)1.47 (1.03-2.08)
Co-existed with sleeping disorder189 (64.5)111 (49.8)1.83 (1.29-2.62)
Anxiety1145 (72.5)81 (50.0)2.64 (1.70-4.08)
Depression173 (36.5)32 (19.8)2.34 (1.44-3.78)
In the past yearn = 255n = 261
Severe symptoms69 (27.1)45 (17.2)1.69 (1.11-2.58)
Ordinary abdominal pain/discomfort155 (60.8)120 (46.0)1.66 (1.17-2.34)
Persistent symptoms98 (38.4)66 (25.3)1.73 (1.19-2.52)
Mucous stool172 (67.5)153 (58.6)1.46 (1.02-2.10)
Weight loss81 (31.8)55 (21.1)1.65 (1.11-2.45)
Anxiety1125 (72.7)101 (53.2)2.34 (1.51-3.64)
Depression161 (35.5)44 (23.2)1.82 (1.15-2.89)

Multivariate analysis: We entered the above influencing factors into a multivariate logistic regression model, and found ordinary (not pre-defecation) abdominal pain/discomfort was an independent predictor for consultation in the whole disease course. Severe symptoms and persistent symptoms were independent predictors for frequent consultations in the past year. In the whole disease course, frequent colonoscopies were associated with sensation of incomplete evacuation. In the past year, long-term medications were associated with persistent symptoms and weight loss. In the whole disease course, coexisting anxiety was the strongest independent predictor for dissatisfaction with medical care (Table 6).

Table 6 Multivariate analysis of factors associated with healthcare seeking behaviors and satisfaction to medical care in patients with irritable bowel syndrome.
Adjusted OR (95%CI)
Consultation in the whole disease course
Ordinary abdominal pain/discomfort2.07 (1.31-3.27)
Consultation in the past year
Mental labor2.19 (1.35-3.55)
Weight loss2.17 (1.22-3.89)
Frequent consultations in the whole disease course
Severe symptoms1.88 (1.12-3.15)
Weight loss1.94 (1.09-3.47)
Frequent consultations in the past year
Severe symptoms1.74 (1.06-2.82)
Persistent symptoms1.66 (1.01-2.72)
Frequent colonoscopies in the whole disease course
Sensation of incomplete evacuation2.76 (1.35-5.67)
Co-existed pain in other parts of the body1.92 (1.07-3.45)
Long-term medication in the past year
Persistent symptoms2.02 (1.07-3.81)
Weight loss2.58 (1.38-4.82)
Dissatisfaction with medical care in the whole disease course
Ordinary abdominal pain/discomfort1.99 (1.24-3.18)
Weight loss1.73 (1.01-2.95)
Anxiety2.08 (1.20-3.59)
DISCUSSION

In the present study, we analyzed clinical medical care data for patients with IBS from a tertiary hospital, and found that IBS-D was most common in China. Most patients consulted with gastroenterologists in tertiary hospitals, and there was a high rate of colonoscopies. In patients with IBS-D, the most commonly used medications were probiotics. Conventional treatments were reported as partially effective, and patient-reported satisfaction rates were low. Ordinary abdominal pain/discomfort, severe and persistent symptoms, weight loss, and anxiety were independent predictors for healthcare-seeking behavior and satisfaction with medical care.

In our study, patients with IBS showed a long disease course, with 30% of patients having IBS for more than 10 years, which highlighted the importance of accurate diagnosis and effective management[16]. Most of our participants had IBS-D, with 5.5% having IBS-C/IBS-M; these rates are much lower than domestic epidemiological data[10]. This might be attributed to the fact that we enrolled patients with typical IBS symptoms, and suggests patients with IBS-D might be more likely to seek healthcare. In the whole disease course, the consultation rate for IBS symptoms (55.2%) was similar to that in Taiwan (47%)[17] and the United States (46%)[18], but was lower than in Australia (73%)[18]. Chinese patients with IBS mostly consulted with tertiary hospitals (78.9%) and gastroenterologists (97.9%), which differs from Western countries[9,19] and may be related to a lack of well-established referral systems. A small number of patients consulted with other departments because of coexisting headache and urogenital symptoms[20].

The Rome III IBS diagnostic criteria emphasize improvement of abdominal pain/discomfort after defecation. However, our data showed more than half of participating patients presented with ordinary abdominal pain/discomfort (non-defecation). In addition, ordinary abdominal pain/discomfort was an independent predictor for healthcare seeking among patients with IBS. Previous published papers indicated the severity[7,16,21], frequency[21], and duration[7] of abdominal pain were predictors for seeking healthcare among patients with IBS. We demonstrated that the number of visits was positively correlated with intestinal symptom scores, and patients with severe symptoms and weight loss were more likely to frequently seek healthcare. In the past year, predictors for frequent consultations included persistent symptoms. Weight loss was one of the alarm features for patients with IBS[22] with a reported prevalence of 21%, which might be associated with FD (especially postprandial distress syndrome[23] and psychological disorders[24]). The reported prevalence of gastrointestinal malignancies in the population with unintentional weight loss was 6%-38%[25]. Patients with IBS were more worried about having serious diseases than healthy controls[26], and 21% of healthcare seekers reported “fear that abdominal symptoms relate to cancer or other illness” as the most important reason for seeking healthcare[27]. Usually, patients attributed their symptoms to organic etiologies such as intestinal infection or ulcers[28]. Fear of organic diseases prompted frequent consultations[29].

A previous study in Hong Kong[30] showed a higher degree of anxiety was an independent factor associated with healthcare-seeking behavior in IBS, but that study did not show the exact degree of anxiety and odds ratios. Despite intestinal symptoms, we found patients with anxiety and depression had more visits. During the whole disease course, anxiety and depression were more common among consulters than non-consulters. However, multifactor analysis indicated that anxiety and depression were not independent predictors for healthcare-seeking behavior.

Before study enrollment, 64.9% of patients underwent colonoscopies and 14.7% of patients had colonoscopies at least twice. In an American cohort study, the detection rate of structural lesions of the colon in non-IBS-C patients fulfilling Rome II criteria without alarm features was similar to healthy controls[31]. Akhtar et al. reviewed medical records of patients with IBS who underwent colonoscopies because of new gastrointestinal symptoms 15 years after diagnosis, and found that there was no difference in the prevalence of organic colonic lesions with non-IBS controls[32]. The newly established Rome IV criteria recommend appropriate diagnostic testing only if alarm symptoms are present[13]. The American College of Gastroenterology recommends colonoscopy should be performed in patients with IBS who have alarm features and in those aged over 50 years[22]. In China, the high colonoscopy rate may be associated with the increasing incidence of colorectal cancer[33] and the relatively low cost of examination. We demonstrated that the sensation of incomplete evacuation and pain in other parts of the body were independent predictors for frequent colonoscopies.

In total, 88% of patients had taken medications in the past year, and 14.8% had taken more than three kinds of medications. Probiotics were the most commonly used drugs. Despite multiple studies confirming the efficacy of probiotics in treating IBS[34,35], our results displayed a markedly low response rate and they are not the most commonly used drugs in Western countries. Most other investigated drugs were partially effective, which was similar to a study in the United States that showed only 19%, 18%, 15%, and 10% of patients with IBS reported medical therapy was completely effective in relieving constipation, diarrhea, abdominal pain, and bloating, respectively[11]. Psychological evaluations at enrollment showed a high prevalence of anxiety and depression, although few patients reported use of antidepressants or psychotherapy. Interestingly, 83.1% of non-consulters had taken medications, which might partially account for the low response rate. In the past year, patients with persistent symptoms and weight loss were more likely to take long-term medications.

IBS severely influenced patients’ quality of life and caused considerable financial burden. In Germany[36], total costs for IBS were €994.97 per patient per year, 37% of which was for medications; in the past year, one in 15 patients was hospitalized for IBS. In the present study, average direct costs were estimated at USD762.7 per patient in the past year. Even so, the patient-reported rate of complete satisfaction was 11.4%, which was close to United States data (14%)[11] and indicates dissatisfaction with current treatment is a global issue. In addition, 41.1% of non-consulters reported dissatisfaction with medical care, which suggests they were unsatisfied with over-the-counter drugs. Coexisting anxiety was the strongest predictor for poor satisfaction with medical care, followed by ordinary abdominal pain/discomfort. The latter suggests that the pathogenesis of ordinary abdominal pain/discomfort differs from pre-defecation abdominal pain/discomfort, and may need higher level treatment (e.g., centrally acting drugs).

There were some limitations in this study. First, we set strict inclusion criteria for patients with IBS, which excluded patients with light, atypical symptoms, and fewer examinations. In addition, some patients did not complete HAMA and HAMD evaluations. Patient-reported healthcare-seeking behavior was retrospective and we did not know whether their medications were prescription or over-the-counter medicines. Finally, our study was a single-center study and might not be representative of the overall situation in China.

In conclusion, Chinese patients with IBS were dominated by those with IBS-D. Patients most commonly consulted with tertiary hospitals and gastroenterologists, and there was a high rate of colonoscopies. Most conventional treatments were only partially effective and patients reported low satisfaction rates. Intestinal symptoms influenced healthcare-seeking behavior among patients with IBS from different levels, and coexisting anxiety was the strongest predictor for dissatisfaction with medical care.

ARTICLE HIGHLIGHTS
Research background

Irritable bowel syndrome (IBS) is a chronic recurrent functional bowel disorder which impairs patients’ quality of life. Patients with IBS report poor treatment response and satisfaction rates for traditional treatments and undergo frequent consultations and referrals. In China, data for predictors of healthcare-seeking behavior and satisfaction with medical care are lacking. Studies regarding predictors for healthcare-seeking behavior among patients with IBS may provide evidence for IBS management strategies in this region.

Research motivation

The present study comprehensively summarized the characteristics of healthcare-seeking behavior, medical costs, and satisfaction with care among Chinese patients with IBS. The authors also investigated predictors for frequent consultations, frequent colonoscopies, dissatisfaction with medical care, and long-term and multiple medications among Chinese patients with IBS. The authors’ study provides a basis for future studies on healthcare-seeking behavior among patients with IBS, and may provide management guidance for clinicians.

Research objectives

The main objectives of this study were to investigate the characteristics of healthcare-seeking behavior, medical costs, and satisfaction with care among Chinese patients with IBS, and determine predictors for frequent consultations, frequent colonoscopies, dissatisfaction with medical care, and long-term and multiple medications in this population.

Research methods

The authors enrolled patients with IBS who met Rome III diagnostic criteria and excluded organic diseases in a tertiary gastroenterology clinic from 2009 to 2016. Patients were administered IBS questionnaires in face-to-face interviews, which included intestinal and extra-intestinal symptoms, medical consultations and management. Data were collected and analyzed with SPSS version 19.0 software. Patients were divided into frequent consulters and infrequent consulters; frequent colonoscopies and infrequent colonoscopies; long-term medications and intermittent medications; medications ≥ 3 kinds and medications < 3 kinds; satisfaction with medical care and dissatisfaction with medical care. Univariate analysis was conducted with χ2 test to detect factors with significant differences between groups and the significant different factors above were entered into a multivariate logistic regression model to determine independent predictors for their healthcare-seeking behavior.

Research results

The authors found Chinese IBS patient present high rates of frequent healthcare- seeking behavior, colonoscopies, medications and low satisfaction with medical care. Abdominal pain/discomfort during non-defecation period (ordinary abdominal pain/discomfort) instead of pre-defecation abdominal pain/discomfort was the independent predictor for their healthcare-seeking behavior. Sensation of incomplete evacuation was the independent predictor for frequent colonoscopies. Patients with anxiety were more likely to report “dissatisfaction to medical care”. In the past year, patients with severe and persistent IBS symptoms sought medical care frequently. How to educate patients and obtain reasonable utilization of medical resources need to be solved.

Research conclusions

The results demonstrated that most patients with IBS were partially responsive to traditional treatment. Intestinal symptoms were major predictors for healthcare-seeking behavior, and patients with anxiety were more likely to be dissatisfied with medical care. The authors’ results provided guidance for Chinese IBS management. Doctors should pay attention to patients with specific symptoms such as ordinary abdominal pain/discomfort and anxiety.

Research perspectives

From the study, The authors learned that patients with IBS tended to undergo frequent consultations and investigations. Physicians should give patients sufficient explanations and pay attention to their psychological status. Future researches might emphasize the reasons of low effective rate of routine treatments and investigate the efficacy of psychological treatment through prospective studies.

ACKONWLEDGMENTS

The authors thank Shaomei Han from Department of Epidemiology and Statistics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and School of Basic Medicine, Peking Union Medical College for her statistical support.

Footnotes

Manuscript source: Unsolicited manuscript

Specialty type: Gastroenterology and hepatology

Country of origin: China

Peer-review report classification

Grade A (Excellent): 0

Grade B (Very good): B

Grade C (Good): C, C, C

Grade D (Fair): 0

Grade E (Poor): 0

P- Reviewer: Chiba T, Ducrotte P, Dumitrascu DL, Rodrigo L S- Editor: Gong ZM L- Editor: A E- Editor: Lu YJ

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