Multidisciplinary Care of Functional Gastrointestinal Disorders

Abstract

Functional gastrointestinal disorders are highly prevalent. They constitute the most common presentation for gastroenterology specialist consultation and are among the most common conditions seen by general practitioners. These disorders include irritable bowel syndrome, functional dyspepsia and constipation. Their treatment is associated with substantial costs to the healthcare system, while other costs include impaired workforce productivity. Functional gastrointestinal disorders are typically characterised by an absence of “organic” pathology. Psychological and dietary factors are thought to play some part. Despite the efficacy of psychologically-based, behavioural and dietary therapies they are rarely incorporated into specialist care, and rarely form first line therapy. The typical model of specialist care involves a gastroenterologist working in isolation; the outcome of such a model of care has not been adequately evaluated. This thesis involves a collection of studies which evaluate the outcome of gastroenterologist-only care for functional gastrointestinal disorders, other models of care, and a multi-disciplinary model of care. I have demonstrated that symptom outcomes twelve months after care in a gastroenterologist-only clinic is poor. The majority of patients were dissatisfied with care, continued to have symptoms, and were often absent from work due to symptoms. This is the first study to have evaluated the outcomes of a gastroenterologist-only clinic. In a systematic review of the literature I have evaluated the models of care which have been evaluated for functional gastrointestinal disorders. This is the first published evaluation of models of care for functional gut disorders and suggested the benefit of allied clinicians incorporated into the care of functional gastrointestinal disorders. To evaluate if a multi-disciplinary model of care is superior to a gastroenterologist-only clinic model I critically reviewed the literature regarding trial design. I then designed a comprehensive, pragmatic, randomised trial that evaluated symptoms, quality of life, psychological wellbeing and cost. The MANTRA (multi-disciplinary treatment of functional gastrointestinal disorders) study is the first randomised study to evaluate the benefit of a multi-disciplinary model of care for functional gastrointestinal disorders. It demonstrated clinically-relevant, statistically significant, superiority of a multi-disciplinary clinic compared with a gastroenterologist-only standard care clinic, with regards to symptoms, quality of life, psychological wellbeing and cost. The studies in this thesis demonstrate that the current specialist-only model of care for these highly prevalent and costly conditions is inadequate. The thesis also provides a clear rationale and evidence base for a multi-disciplinary clinic model for the treatment of functional gastrointestinal disorders with respect to all important outcomes.