Health Services Research & Development

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2006 HSR&D National Meeting Abstract


1011 — Effectiveness of a Model Physician-Patient Relationship in Veterans with Irritable Bowel Syndrome

Author List:
Spiegel BM (West Los Angeles VA Medical Center)
Naliboff B (West Los Angeles VA Medical Center)
Mayer E (UCLA School of Medicine)
Bolus R (UCLA School of Medicine)
Gralnek IM (Ramban Medical Center)
Shekelle P (West Los Angeles VA Medical Center)

Objectives:
Irritable bowel syndrome (IBS) is one of four multisymptom conditions that comprise the Gulf War Syndrome. Practice guidelines emphasize that the physician-patient relationship is the fundamental cornerstone of treatment in IBS, and that an effective relationship may improve health related quality of life (HRQOL) more than any available therapy. However, the components of this relationship have neither been operationally defined nor tested, and data suggest that the relationship is often sub-optimal. We performed a randomized controlled trial to compare the effect of a multifactorial intervention aimed at improving the physician-patient relationship in IBS versus usual care.

Methods:
We randomized patients with Rome II-positive IBS evaluated in the West Los Angeles VA GI Clinic to receive either a multi-factorial intervention or usual care. The intervention included 4 components: (1) point-of-care questionnaire designed to rapidly capture patients’ agenda, concerns, and HRQOL; (2) physician prompt card outlining key components of effective communication in IBS; (3) multi-media patient educational kit, including informational pamphlets, dietary card, website listings, and a self-empowerment video; and (4) patient home educational mailings. There were no specific diagnostic or treatment suggestions. The primary outcome was 3-month change scores on the IBS-QOL – a validated, disease-targeted HRQOL instrument. Secondary outcomes included global symptom relief (percentage scoring >4 on 6-point Likert scale) and satisfaction with care (7-point scale).

Results:
63 patients were enrolled (32 control; mean age=52; 33% women). There were no significant baseline differences between groups. The mean 3-month IBS-QOL change scores were +2.4 and +12.2 for the control and intervention groups, respectively (diff=9.8, 95% CI=5.2, 12.4; p=0.03; effect size [ES]=0.61). The percentage with global symptom relief was 15% and 56% in the control and intervention groups, respectively (p=0.001). Satisfaction was higher in the intervention group (p=0.016).

Implications:
These data indicate that a standardized physician-patient relationship improves global outcomes in veterans with IBS over and above routine care.

Impacts:
The impact on HRQOL observed in this study (ES=0.61) exceeds the HRQOL impact of the most effective pharmaceutical agents in IBS (ES range=0.2-0.5), suggesting that medical therapy alone is sub-optimal if not delivered in the context of a supportive physician-patient interaction.