P0531 - Diagnosis and Management Utilization Amongst Veterans With IBS by IBS-Subtype and Provider Specialty

Sunday, October 22, 2023

3:30 PM – 7:00 PM PT

Location: Exhibit Hall

Has Audio

Presenting Author(s)

Jordyn N. Becker, BS

University of Nevada, Reno School of Medicine
Reno, NV

Jordyn N. Becker, BS¹, Pierce L. Claassen, BS², Celeste K. L.. Cravalho, BS¹, Garett Cecchini, BS¹, Paulene Cay, BS¹, Amneet Rai, PharmD³, Mark S. Riddle, MD, DrPH³
¹University of Nevada, Reno School of Medicine, Reno, NV; ²Washington State University, Elson S. Floyd College of Medicine, Spokane, WA; ³VA Sierra Nevada Health Care System, Reno, NV

Introduction: Irritable bowel syndrome (IBS) is a complex disorder of the gut-brain interaction, which affects 11% of people worldwide. Little is known about the current clinical management of Veterans with IBS within the Veterans Affairs (VA) health system, so we worked to retrospectively analyze the prior diagnostic workup and treatment of Veterans with IBS in multiple care settings in a large VA network.

Methods: A retrospective single center chart review study was conducted to identify practice patterns of IBS management in Veterans and areas to focus quality improvement initiatives. Subjects were included if they had at least two visits at the VA Sierra Nevada Health Care System with an IBS diagnostic code separated by at least six months. Subjects were excluded if they were previously diagnosed with IBS, had protected medical records, or had diagnostic codes of other gastrointestinal disease. IBS-subtype, provider specialty, and utilization of the guidelines from the American College of Gastroenterology were evaluated.

Results: The eligible cohort included 136 veterans, separated by subtype: IBS-diarrhea (48.9%), IBS-other (24.1%), IBS-mixed (18.0%), and IBS-constipation (9.0%). GI providers were more likely to recommend fiber and low FODMAP than primary care/non-GI providers (63.0% vs 28.6%, p< 0.0001 and 21.9% vs 6.4%, p=0.0141 respectively). Regarding IBS-D specific treatments, both GI and primary care/non-GI providers frequently followed recommendations related to alosetron use and avoidance of bile acid sequestrants, but they both had low practice utilization for rifaximin and mixed opioid agonist/antagonists. Lastly, GI providers were more likely to order a colonoscopy against recommendations than primary care/non-GI providers (26.0% vs 6.35%, p=0.0025).

Discussion: Differences in practice were noted in our study. GI trended more towards recommending soluble fiber among all IBS patients. In IBS-D, GI had better guideline-based practices for testing for celiac disease, fecal calprotectin and CRP. Additionally, GI specialists were more likely than PC to order a colonoscopy against recommendations. Additional cross-specialty studies may be justified to better understand diagnostic and management practices within the VA.

Table 1. Diagnosis and management utilization among eligible cohort study subjects by IBS-subtype.
	IBS-C			IBS-D			IBS-M			IBS-Other
Guideline Followed	GI N=11	PC N=3	p-value	GI N=32	PC N=28	p-value	GI N=10	Non-GI N=12	p-value	GI N=20	Non-GI N=20	p-value
IBS Generic
Colonoscopy	9 (82%)	3 (100%)	1.00	24 (75%)	26 (93%)	0.088	7 (70%)	12 (100%)	0.078	14 (70%)	18 (90%)	32 (80%)
Enteric Pathogen Stool Testing	10 (91%)	3 (100%)	1.00	21 (66%)	24 (86%)	0.084	6 (60%)	9 (75%)	0.35	17 (85%)	20 (100%)	37 (93%)
Food Allergy Testing	11 (100%)	3 (100%)	N/A	32 (100%)	28 (100%)	N/A	9 (90%)	12 (100%)	0.45	20 (100%)	20 (100%)	40 (100%)
Fiber	6 (55%)	0 (0%)	0.21	21 (66%)	7 (25%)	0.002	8 (80%)	4 (33%)	0.043	11 (55%)	7 (35%)	18 (45%)
TCA	1 (9%)	2 (67%)	.09	10 (31%)	9 (32%)	1.00	2 (20%)	4 (33%)	0.65	2 (10%)	6 (30%)	0.24
TCA Contraindication				9 (28%)	7 (25%)	1.00	2 (20%)	4 (33%)	0.65
Antispasmodics	9 (82%)	0 (0%)	0.027	20 (63%)	20 (71%)	0.59	8 (80%)	7 (58%)	0.38	19 (95%)	14 (70%)	33 (83%)
Peppermint oil	0 (0%)	0 (0%)	N/A	0 (0%)	1 (4%)	0.47	0 (0%)	0 (0%)	N/A	0 (0%)	0 (0%)	0 (0%)
Probiotics	8 (73%)	3 (100%)	1.00	8 (25%)	22 (79%)	< 0.001	3 (30%)	8 (66%)	0.20	7 (35%)	12 (60%)	19 (48%)
Low FODMAP diet	1 (9%)	0 (0%)	1.00	9 (28%)	3 (11%)	0.12	3 (30%)	1 (8%)	0.29	3 (15%)	0 (0%)	3 (8%)
IBS-C Specific
Guanylate cyclase activators	6 (55%)	0 (0%)	0.21
Chloride channel activators	2 (18%)	0 (0%)	1.00
Tegaserod	5 (45%)	0 (0%)	0.18
Tegaserod N/A	3 (27%)	3 (100%)	N/A
Polyethylene glycol	6 (55%)	3 (100%)	0.26
IBS-D Specific
CeD Testing				14 (44%)	3 (11%)	0.004	3 (30%)	3 (25%)	1.00
Fecal Calprotectin				7 (22%)	2 (7%)	0.15	0 (0%)	2 (17%)	0.48
CRP				5 (16%)	2 (4%)	0.43	1 (10%)	1 (8%)	1.00
Rifaximin				5 (16%)	0 (0%)	0.055	1 (10%)	1 (8%)	1.00
Opioids				0 (0%)	0 (0%)	N/A	0 (0%)	1 (8%)	1.00
Alosetron				31 (97%)	28 (100%)	1.00	9 (90%)	12 (100%)	0.45
Bile acid sequestrants				29 (91%)	27 (96%)	0.24	10 (100%)	11 (92%)	1.00

Legend: F: female, M: male, FODMAP: fermentable oligosaccharides, disaccharides, monosaccharides, and polyols, CeD: celiac disease, CRP: c-reactive protein, TCA: tricyclic antidepressant, GI: gastroenterology, PC: primary care.

Disclosures:

Jordyn Becker indicated no relevant financial relationships.

Pierce Claassen indicated no relevant financial relationships.

Celeste Cravalho indicated no relevant financial relationships.

Garett Cecchini indicated no relevant financial relationships.

Paulene Cay indicated no relevant financial relationships.

Amneet Rai indicated no relevant financial relationships.

Mark Riddle: Pfizer, Inc. – Employee.

Jordyn N. Becker, BS¹, Pierce L. Claassen, BS², Celeste K. L.. Cravalho, BS¹, Garett Cecchini, BS¹, Paulene Cay, BS¹, Amneet Rai, PharmD³, Mark S. Riddle, MD, DrPH³. P0531 - Diagnosis and Management Utilization Amongst Veterans With IBS by IBS-Subtype and Provider Specialty, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.