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The Potential of Integrated Nurse-Led Models to Improve Care for People With Functional Gastrointestinal Disorders

A Systematic Review

Linedale, Ecushla C. PhD; Mikocka-Walus, Antonina PhD; Gibson, Peter R. MD; Andrews, Jane M. PhD

Author Information
doi: 10.1097/SGA.0000000000000379

Abstract

Functional gastrointestinal disorders (FGIDs) are common (Chang, Lu, & Chen, 2010; Mountifield & Andrews, 2010), chronic, and complex, with biopsychosocial triggers, shifting symptoms over time (Halder et al., 2007), and the frequent presence of other unexplained, somatic complaints (Spiegel, Kanwal, Naliboff, & Mayer, 2005). The most common FGIDs are irritable bowel syndrome (IBS), which affects approximately 10% of the population globally (Hulisz, 2004; Talley, 2008a), and functional dyspepsia (FD), with a prevalence of 15% worldwide (El-Serag & Talley, 2004; Talley, 2008a). Symptoms of FGID significantly impair daily life and lead to high healthcare use and costs (Ålander, Svärdsudd, & Agréus, 2008; Kodner & Spreeuwenberg, 2002; Levy et al., 2001; Longstreth et al., 2003; Talley, Gabriel, Harmsen, Zinsmeister, & Evans, 1995), overuse of investigations (Linedale, Chur-Hansen, Mikocka-Walus, Gibson, & Andrews, 2016), and high levels of absenteeism and presenteeism (Talley, 2008b). Although FGIDs are common and significantly impact both the patient and the community, they are poorly handled in the healthcare system, creating frustration among patients and doctors alike (Knott, Holtmann, Turnbull, & Andrews, 2009).

Background

Recent developments of reliable, accepted diagnostic criteria (Lacy et al., 2016; Stanghellini et al., 2016) and effective evidence-based management options for FGIDs (Enck, Junne, Klosterhalfen, Zipfel, & Martens, 2010; Peters, Muir, & Gibson, 2015) do not appear to have been incorporated into current routine practice. Many primary healthcare providers lack confidence and continue to seek specialist input (Linedale, Mikocka-Walus, Gibson, & Andrews, 2016; Mitchell & Drossman, 1987; Shivaji & Ford, 2014), with capacity restraints resulting in extraordinarily long wait-lists. The delay in diagnosis and implementation of effective management options represents a lost opportunity to resolve symptoms, improve quality of life, improve workplace productivity, and reduce unnecessary societal expenditure on repeat consultation, unnecessary investigations, and ineffective treatments (Mearin & Lacy, 2012).

Given the chronic nature of FGIDs and the clear interplay of biological, psychological, and social factors in triggering symptoms (Drossman, 2016), an integrated model of care (IMoC) is needed. Integrated models of care have been successfully established in other chronic illnesses such as diabetes (Diabetes Australia, 2014) and asthma (Department of Health, Western Australia, 2012), yet have received little attention in FGIDs.

A model of care is a multidimensional concept that defines the way in which healthcare services are delivered (NSW Agency for Clinical Innovation, 2013). There are several elements of effective care of patients with FGID that could be addressed in an IMoC. The provision of a clear diagnosis and patient acceptance of this diagnosis are critical to the successful management of patients with FGIDs. Research has shown that both patient acceptance of functional diagnoses and diagnostic communication from the physician are poor (Collins et al., 2009; Ilnyckyj, Graff, Blanchard, & Bernstein, 2003; Linedale, Chur-Hansen, et al., 2016). Thus, a model of care incorporating the first point of patient contact with the medical system is likely to greatly improve patient outcomes and reduce costs. Other important elements of such a model include diagnostic criteria and the coordinated use of newer treatments with proven efficacy for global symptom relief, including cognitive–behavioral therapy, gut-directed hypnotherapy, and the low FODMAP diet (Enck et al., 2010; Peters et al., 2015).

Although there are many recommendations as to how FGID should be diagnosed and managed (American College of Gastroenterology Task Force on Irritable Bowel, 2009; Astegiano et al., 2008; National Institute for Health and Clinical Excellence [NICE], 2016), few designs have been tested to date. To inform the development of an IMoC for FGIDs, we undertook a systematic review of existing models that have been tested for FGIDs.

Methods

Types of Studies

The protocol for this quantitative systematic review was registered at PROSPERO International prospective register of systematic reviews January 15, 2016 (PROSPERO 2016:CRD42016033146) and the search conducted in January 2016. No new publications were identified in January–December 2016.

Inclusion Criteria

Primary studies concerning the diagnosis and management of FGIDs, IBS, or FD (diagnosed in primary, secondary, or tertiary care) were included. Studies of any quantitative research design published 1995–2016 and reporting patient-related outcomes (i.e., quality of life, symptom severity) in an adult population were included. Both full-text articles and abstracts were included.

Exclusion Criteria

Studies regarding patients with organic disease, or functional abdominal pain, were excluded, as were reviews, opinion pieces, dissertations, or secondary analyses. Qualitative studies, and those reporting cost or healthcare use alone, were excluded, as were studies trialing a treatment.

Search Methodology

Sources

Databases searched were PubMed, MEDLINE, EMBASE, Web of Science, Cochrane, CINAHL, PsycInfo, and the ISCRTN registry. Reference lists of all included studies were also searched, experts in the field were contacted to identify additional references, and authors contacted for further information as required.

Search Strategy

The search strategy covered three main concepts: FGIDs, models, and care, as indicated in Table 1.

TABLE 1. - Search Strategy Used
Concepts Synonyms Search Terms
Functional gastrointestinal disorders FGIDs
Functional gastrointestinal disorders
Functional bowel disease
IBS
Irritable bowel syndrome
Irritable colon
Functional dyspepsia
Epigastric pain syndrome
Postprandial distress syndrome
Nonulcer dyspepsia
Pseudo-ulcer syndrome
Pyloroduodenal irritability
Nervous dyspepsia
FGIDs “Colonic Diseases, Functional” [Mesh] OR Functional Gastrointestinal Disorder* [all] OR FGID [all] OR FGIDs [all] OR
Functional bowel disorder* [all] OR Functional bowel disease* [all] OR “Irritable bowel syndrome” [all] OR
IBS [all] OR
Irritable colon [all] OR
Functional dyspepsia [all] OR
Epigastric pain syndrome [all] OR
Postprandial distress syndrome [all] OR
Non-ulcer dyspepsia [all] OR
Pseudo-ulcer syndrome [all] OR
Pyloro-duodenal irritability [all] OR dyspepsia/psychology [mh] OR
Colonic diseases, functional [mh] functional colonic disease* [all]
Models Integrated
Multidisciplinary
Team-based
Models
Interdisciplinary
Holistic
Wholistic
Nurse-led
Student-led
Approach
Self-management
Biopsychosocial approach
Integrat* [all] OR
Mutlidisciplin* [all] OR
Team [all] OR
Model [all] OR Models [all] OR
Interdisciplin* [all] OR
Holistic [all] OR
Wholistic [all] OR
Nurse-led [all] OR
Student-led [all] OR
Approach* [all] OR
Manag* [all] OR Self manage* [all] OR
Biopsychosocial approach [all]
Care Healthcare
Primary care
Outpatient services
Interventions
Patient care
Health care [all] OR Healthcare [all] OR
Primary care [all] OR
Outpatient service* [all] OR
Nurse-led intervention* [all] OR Student-led intervention* [all] OR
Patient care [all] OR Usual care [all] OR Standard care [all]
Note. FGID = functional gastrointestinal disorder; IBS, inflammatory bowel syndrome.

Study Selection

A systematic review was conducted according to the five steps outlined by Khan, Kunz, Kleijnen, and Antes (2003). The framing question was as follows: “What models of care have been evaluated for functional gastrointestinal disorders?” In the first phase, titles and abstracts of the search results were screened by the primary researcher (E.L.) to assess suitability for inclusion. Studies whose suitability was uncertain were also screened by the second reviewer (A.M.W.) and consensus reached on inclusion. Where uncertainty regarding inclusion or disagreement occurred, a third researcher (J.M.A.) was consulted and a joint decision regarding selection was reached. In the second phase, full papers deemed suitable from the initial search were screened by both reviewers (E.L., A.M.W.) and checked against a predesigned relevance checking proforma based on the inclusion/exclusion criteria.

Data Extraction

Data including author, year of publication, country of origin, design, model of care, sample size and characteristics, disease type (e.g., FGID, IBS, FD), outcomes measured, and results were extracted by the primary researcher (E.L.), using a customized extraction table. Extracted data were checked against the original articles by the second reviewer (A.M.W.).

Data Synthesis

Because of the limited number of available studies, and heterogeneity in study design and outcomes measured, we provided a narrative synthesis of the findings regarding full models of care (including both diagnosis and management). Studies pertaining to components of a model (such as diagnosis, patient education, or management) are summarized in Figure 1 but not synthesized.

FIGURE 1.
FIGURE 1.:
PRISMA flow diagram. FGID = functional gastrointestinal disorder; IMoC = integrated model of care.

Assessment of Quality and Risk of Bias

Quality assessment of the seven included studies was conducted (see Supplemental Digital Content 1, available at: http://links.lww.com/GNJ/A47) using the Quality Assessment Tool for Quantitative Studies (Effective Public Health Practice Project [EPHP], 2007) as recommended by the Cochrane group (“The Cochrane Collaboration, 2011”). This scale allows all quantitative study designs to be assessed with one tool. Studies were assessed in the following domains: selection bias, study design, confounders, blinding, data collection methods, withdrawal and dropouts, intervention integrity, and analyses and scored according to the rules (EPHP, 2007). An overall global rating was given on the basis of the number of weak domain ratings (strong = no weak ratings; moderate = 1 weak rating; weak = 2 or more weak ratings). Studies were appraised independently by E.L. and A.M.W., and an overall rating reached by consensus. All studies regardless of quality rating were included in this review because of the scarcity of research found.

Results

Search Results

Of the 95 full-text articles identified, 57 were excluded (Figure 1) for reasons such as nonprimary research (n = 14), treatment trial (n = 10), duplicate abstract, protocol, or secondary analysis of the full-text article already included (n = 15), not pertaining to FGID (n = 4), or IMoC (n = 6), assessed outcomes not in inclusion criteria (n = 7), and data unpublished (n = 1). Of the 38 unique primary research studies that pertained to diagnosis or management of FGIDs (Figure 1), only six were deemed suitable for inclusion as a full IMoC, including both diagnostic and management components. A summary of the studies that considered only one of these components of care (i.e., diagnosis or management) is presented in Supplemental Digital Content 2 (available at: http://links.lww.com/GNJ/A48). An overview of these studies is included, as the examined components may be relevant to inform the development of a full IMoC for FGIDs (Figure 2). A review of individual components is outside the scope of this review.

FIGURE 2.
FIGURE 2.:
Graphical summary of all studies pertaining to model of care. FGID = functional gastrointestinal disorder.

Nature of Studies

Included studies were all low in quality (Table 2). Two studies were only published in abstract form, and full data were unable to be analyzed (Buresi et al., 2014; Novak et al., 2014). One described subjective changes in patient outcomes without reference to baseline or statistical analysis (Dill & Dill, 1995). One study was a randomized controlled trial (Bengtsson, Ulander, Borgdal, & Ohlsson, 2010), three observational (Dill & Dill, 1995; Ilnyckyj et al., 2003; Moore, Gagan, & Perry, 2014), and two nonrandomized controlled designs (Buresi et al., 2014; Novak et al., 2014). Four studies evaluated IBS IMoCs in Sweden (Bengtsson et al., 2010), the United States (U.S.) (Dill & Dill, 1995), Canada (Ilnyckyj et al., 2003), and New Zealand (Moore et al., 2014), and two studies, only in abstract form, evaluated IMoCs for FD in Canada (Buresi et al., 2014; Novak et al., 2014). No studies presented an IMoC for FGIDs in general. Because of the small number, studies regarding IBS and FD are not discussed separately. Five articles assessed some form of a nurse-led care model (Bengtsson et al., 2010; Buresi et al., 2014; Dill & Dill, 1995; Moore et al., 2014; Novak et al., 2014), and one evaluated the performance of a structured gastroenterologist consultation (Ilnyckyj et al., 2003).

TABLE 2. - Summary of Studies Included in the Systematic Review Including a Quality Assessment Using Quality Assessment Tool for Quantitative Studies
Reference/Country Study Design and Sample Details of Service Provided Comparators/Outcomes Measured Results/Limitations Quality Assessment
Bengtsson et al., 2010/Sweden Design: RCT (two-arm)
Sample: Women aged 18–65 years, referred 2003–2005 with preliminary diagnosis of IBS
Sample size:
Invited n = 50
Responded n = 39
Intervention n = 19
Control n = 20
Alternative diagnosis: 19/39 (49%)
Setting: Tertiary care
Model: Nurse-led clinic
Delivery mode: Patient consult
Timing: Prior to GE review
Further details: Nurse takes patient history, blood tests, and formulates care plan of patients diagnosed with IBS prior to GE review
Comparators: Treatment as usual (GE consult); patients in both groups received medical consult with GE, investigations, dietician visit as required
Primary outcomes: Gastrointestinal symptoms (GSRS) and psychological well-being and distress (PGWB)
Secondary outcomes: Patient acceptance of model, healthcare usage during intervention
Results: Symptom severity and well-being unchanged at follow-up
Nurse diagnosis was not acceptable as a stand-alone strategy
Intervention group used fewer GE visits than control (p value not assessed).
Limitations: Preliminary diagnoses were incomplete/inaccurate and nurse model unable to be adequately tested
Weak
Buresi et al., 2014/Canada Design: Cohort analytical
Sample: Adult patients with uninvestigated dyspepsia without alarm symptoms
Sample size: Not stated
Alternative diagnosis: Not stated
Setting: Tertiary care
Model: Nurse navigator clinic
Delivery mode: Multidisciplinary group session (nurse, dietician, mental health therapist)
Timing: Instead of GE review
Further details: Nurse performs celiac screen, urea breath test, trial of PPIs, and facilitates multidisciplinary group session by the nurse, dietician, and mental health therapist (and EGD for nonresponders)
Comparators:
1. Current therapy (test/treat or PPI) + GE consult and EGD in nonresponders
2. Prompt upper endoscopy and GE review
3. Prompt thin scope endoscopy and GE review
Outcomes: Cost, QALYs gained, and incremental costs per QALYs gained
Results: Nurse-navigator is the most effective strategy, thin scope endoscopy is the cheapest but less effective than the nurse-led strategy
Limitations: Abstract only: Full data unavailable
Weak—Abstract only
Dill & Dill, 1995/United States Design: Audit survey (n = 42)
Sample: Convenience sample of adult patients referred to the tertiary referral center diagnosed with IBS (1997–1998).
Sample size:
Invited n = 100
Responded n = 42
Setting: One solo, private gastroenterology practice
Model: GE consult/investigations/diagnosis, followed by nurse-led IBS school for ongoing management
Delivery mode: Individual consult
Timing: 1× 3-hr class
Further details:
First visit = GE-review with minimal tests, patient told possibility of IBS
Comparators: N/A
Outcomes: Subjective patient-reported changes in symptoms, symptom control, work productivity, healthcare utilization, satisfaction with the program
Results: Patients reported subjective improvement in symptoms, job, and social functioning, had fewer doctor visits, and were satisfied with the program.
Cost reduction: 38%
Weak
Alternative diagnosis: Study reports only on those patients diagnosed with IBS; no data on prevalence of other diagnoses Second visit = GE-flexible sigmoidoscopy performed and IBS diagnosis (where indicated), enrolled into nurse GI clinic with concurrent GE review; nurse clinic-pathophysiology plus educational material, review of medications, lifestyle, stressors, and dietary advice (elimination) + fiber supplements (psyllium)
Third visit: Nurse clinic. Evaluation of symptoms, continuing education, food challenge, consideration of psychosocial issues
Limitations: Observational study, not a trial. Results not statistically analyzed. Baseline and follow-up data not presented; only subjective patient-reported improvement since participation.
42% responders, no information on nonresponders
Ilnyckyj et al., 2003/Canada Design: Observational, 2-year longitudinal follow-up
Sample: Adult patients, referred to the GE, meeting Rome I criteria for IBS with symptom duration of 1 year or more (1996–1997) (n = 70)
Setting: Tertiary care
Model: Standardized diagnosis and management
Delivery mode: Individual consult
Timing: Initial consult—at least 30-min; follow-up at 6 weeks—at least 15 min
Further details:
1. Provide positive diagnosis (history, physical examination, testing as needed)
2. Patient education (including material) and reassurance
3. Standard initial and follow-up times and duration
Comparators: Baseline
Primary outcomes: Healthcare utilization
Secondary outcomes: Psychological functioning, pain, and patient morbidity
Results: Healthcare usage returned to baseline levels following consultation; no change in psychological distress or general functioning at 1 year
Limitations: No comparator, measures at 1 year may have overlooked changes in the short-term; GE consults were not standardized in investigative approach or treatment provided; needs repeating according to the current clinical approach
Weak
Moore et al., 2014/New Zealand Design: Observational, 3-month follow-up
Sample: Adult patients previously diagnosed with IBS fulfilling Rome II criteria, attending the IBS clinic
Setting: Secondary care
Model: Private IBS service conducted by a nurse practitioner
Delivery mode: Individual consult
Timing: Initial consult, plus follow-up 2 weeks later
Further details: Protocol-driven assessment
1. Abdominal and rectal physical examination
Comparators: N/A
Primary outcomes: Symptom severity, patient satisfaction, quality of life, and coping skills
Results: Improved symptoms, satisfaction with healthcare, and quality of life. No change in coping strategies
Limitations: No control group
Weak
Sample size:
Invited n = 55
Responded n = 45
Alternative diagnosis: 24/55 (43%)
2. Blood tests (CBE, iron studies, C-reactive protein, thyroid function, liver function, celiac antibodies, kidney function)
3. Stool tests (fecal microscopy and culture, fecal calprotectin)
Follow-up consult: Review results, discuss management strategy (education, lifestyle management, onward referrals)
Novak et al., 2014/Canada Design: Prospective, nonrandomly controlled study; 6-month follow-up
Sample: Adult patients with uninvestigated dyspepsia without alarm symptoms, from one primary care area (n = 359)
Sample size:
Invited n = not stated
Intervention n = 247 (107/247 endoscopy)
Control n = 112
Alternative diagnosis: 6/107 in the endoscopy group. Data not provided for the nonendoscopy group
Setting: Tertiary care
Model: Nurse-led, triage, multidisciplinary group management, followed by physician consult
Delivery mode: Group session plus individual consult
Timing: 1-hr group session, followed by brief physician consult
Further details:
1. Nurse triage of alarm vs. nonalarm patients
2. Nonalarm patients participated in session (dietician, nurse, pharmacist)
3. Followed by brief physician consult immediately after group consult
Comparators: Treatment as usual in patients referred from another primary care area (mainly wait-list control)
Outcomes: Symptom severity, patient satisfaction, satisfaction with the group format
Results: Symptom severity improved in the intervention group at 6-month follow-up. In total, 99% of patients reported benefit and support and 84% liked the group format.
Limitations: Abstract only: Full data unavailable for analysis. Details of intervention brief
Weak—Abstract only
Note. CBE – complete blood examination; EGD – esophagogastroduodenoscopy; GE – gastroenterologist; GI – gastrointestinal; GSRS – Gastrointestinal Symptom Rating Scale; IBS, inflammatory bowel syndrome; PGWB – Psychological General Well-Being Index; PPI – proton pump inhibitor; QALY – quality adjusted life year; RCT – randomized controlled trial.

Summary of Full Models of Care

Nurse-Led Models

Five studies evaluated a nurse-led model (Bengtsson et al., 2010; Buresi et al., 2014; Dill & Dill, 1995; Moore et al., 2014; Novak et al., 2014). These models differed in the setting, role, and timing of nurse management. Roles included the provision of active triage and patient education prior to a consult with a gastroenterologist (Bengtsson et al., 2010; Novak et al., 2014), ongoing holistic management postdiagnosis (Dill & Dill, 1995), screening and treatment trials prior to gastroenterologist consultation (Buresi et al., 2014), and independent nurse diagnosis and management (Moore et al., 2014). Full description of the models and findings are presented in Table 2.

Four of the five nurse-led studies measured symptom severity and patient satisfaction. Symptomatic improvement was seen in all (Bengtsson et al., 2010; Dill & Dill, 1995; Moore et al., 2014; Novak et al., 2014). One study reported subjective improvement following the intervention (no baseline comparator) (Dill & Dill, 1995), two compared with baseline at 3- (Moore et al., 2014) and 6-month follow-up (Novak et al., 2014), and one compared with the control group (Bengtsson et al., 2010). Patient satisfaction was high (Dill & Dill, 1995; Novak et al., 2014) or improved compared with baseline (Moore et al., 2014), with the exception of the model reported by Bengtsson et al. (2010), where the nurse's role was to implement a care plan prior to consultation with a gastroenterologist. Two studies evaluated healthcare utilization and showed reduced gastroenterologist visits compared with treatment as usual controls (Bengtsson et al., 2010) and reduced doctor visits following the intervention (Dill & Dill, 1995). Psychosocial health was measured in various forms in four studies, with overall improvement found in all (Buresi et al., 2014; Dill & Dill, 1995; Moore et al., 2014) except that reported by Bengtsson et al. (2010). Studies that assessed quality of life (Buresi et al., 2014; Moore et al., 2014) and psychosocial functioning (Dill & Dill, 1995) showed improvement, but Moore et al. (2014) found no simultaneous improvement in coping strategies. The cost of a nurse-led model was assessed in two studies and found to be significantly reduced compared with current treatments (Buresi et al., 2014; Dill & Dill, 1995).

Structured Gastroenterologist Care

Only one observational cohort study investigated the value of a structured gastroenterologist consultation (Ilnyckyj et al., 2003). The consultation included establishing a positive diagnosis, investigations as indicated, education and reassurance, and psychological referrals as appropriate. Ambulatory gastroenterology visits returned to and remained at baseline levels for 2 years postconsultation. However, other ambulatory and psychiatric healthcare utilization remained unchanged. In addition, quality of life and pain remained unchanged at 1-year follow-up, although a reduction in pain was seen at the 2-year mark.

Discussion

This systematic review demonstrates that despite FGIDs being highly prevalent, there is a paucity of data examining IMoC for FGIDs. This represents a lost opportunity for effective and efficient provision of care to this large patient group, which can be ill-afforded considering the need for cost constraint and optimal outcomes in healthcare systems worldwide. Although a number of studies relate to the management of FGIDs, there is minimal research into IMoC that incorporate both diagnosis and management. This review considers IBS and FD together, as they often co-occur and thus are best treated as one clinical group. Many patients with IBS will subsequently have FD, and vice versa. In general, our healthcare systems function more efficiently when related conditions affecting one large patient group receive a similar (but not rigidly identical) approach. The current approaches to the diagnosis and management for IBS and FD are very similar; namely, exclude alarms, offer reassurance, explanation, and recommend lifestyle changes, and psychological and/or dietary therapies and medication when needed.

Functional gastrointestinal disorders are a significant and growing public health problem (Talley, 2008b), with up to 40% of the population affected within their lifetime (Chang, Locke, et al., 2010), and referrals representing up to 50% of gastroenterology workload (Mitchell & Drossman, 1987; Shivaji & Ford, 2014). There is a high economic cost of FGIDs, with an estimated annual cost of US $41 billion for IBS alone, in the United Kingdom, Japan, Australia, Sweden, Germany, France, and Canada in 2000 (Fullerton, 1998). These costs are driven by persistent and/or unmanaged symptoms, unnecessary investigations, repeated healthcare visits, and workplace impairment (Fortea & Prior, 2013; Talley, 2008a) and represent a significant opportunity for improved healthcare service delivery.

Dill and Dill (1995) describe the first nurse-led IBS model and its effectiveness in a single private practice in U.S. in 1995. This study provides preliminary evidence to suggest the economic and clinical benefit of a nurse-led IMoC. Surprisingly, further assessment of this model did not occur for another 25 years. However, recent studies show benefits of integrated nurse-led models on symptoms, psychosocial well-being, and quality of life (Buresi et al., 2014; Dill & Dill, 1995; Moore et al., 2014; Novak et al., 2014). In addition, nurse-led clinics were more cost-effective and may enable a larger volume of patients to be seen in specialist care. The use of a nurse to screen referrals and implement treatment trials in patients with no alarm features was effective, both independently of gastroenterology consultation (Moore et al., 2014) and in conjunction with specialist review (Buresi et al., 2014; Dill & Dill, 1995; Novak et al., 2014). The only ineffective nurse-led model was dependent upon an accurate primary care diagnosis (which was found to be lacking), giving further credence to the importance of including diagnosis in a model of care. Traditional gastroenterological care was assessed in only one study and was not effective in reducing symptoms or improving quality of life. However, this study was not controlled and the approach to diagnosis and management was not standardized.

Although these studies differed in the clinicians used and the role they played, several common features were apparent. All models included a standardized diagnostic pathway, provided patient education and reassurance, and focused on enabling the patient to self-manage their condition. The nurse-led models also provided continuing review, support, and co-ordination of care.

The overall quality of included studies was low, with most having design, sampling, or reporting limitations. All studies used convenience samples of referred patients, and most study designs were observational or nonrandomized controlled designs. In addition, all studies assessed either FD or IBS, not a model of care for all FGIDs, and the long-term effect of these models was not assessed. Despite the low quality of evidence, these studies do provide preliminary evidence for the potential effectiveness of nurse-led IMoCs in FGIDs and further larger scale, high-quality trials are warranted.

The lack of research (and interest) in models of care for FGIDs to date is most likely influenced by a poor understanding of the mechanism for pathogenesis in FGIDs, lack of diagnostic tests, and uniformly effective management options, as well as differences between and changes within healthcare systems worldwide (Agréus & Borgquist, 2002; Levy et al., 2001). However, with recent advances in the development of positive diagnostic criteria and effective global symptom management strategies, it is now possible to develop a model of care that can be implemented in virtually any developed country.

This review specifically targeted only those studies pertaining to an integrated approach to the diagnosis and management of FGIDs. The process of diagnosis is a critical component to the model of care. Many clinicians consider a functional diagnosis but are reluctant to communicate this to the patient (Mearin & Lacy, 2012) or to document it (Harkness, Grant, O'Brien, Chew-Graham, & Thompson, 2013), and many patients are reluctant to accept a functional diagnosis (Collins et al., 2009). However, a timely, clear, accurate diagnosis is critical in FGIDs, as it provides reassurance, alleviates patients' concerns, and helps move the patient from a diagnostic search to an effective management strategy (Collins et al., 2009; Linedale et al., 2016).

Recommendations

Despite the shortcomings in our understanding, we do have a useful biopsychosocial model (implicating psychological state, increased motor reactivity, visceral hypersensitivity, changes in mucosal immune/inflammatory function, and altered enteric nervous system) (Drossman, 2006), diagnostic guidelines (NICE, 2016), and effective dietary/psychological treatment options (De Giorgio, Volta, & Gibson, 2016; Peters et al., 2015). Although guidelines recommend a biopsychosocial approach to the diagnosis and management of FGIDs, little direction is given on how (Gastroenterological Society of Australia [GESA], 2003; Lacy et al., 2016; NICE, 2016; Quigley et al., 2016). The Rome IV criteria recommend a tiered approach to the management of FGIDs according to symptom severity (Lacy et al., 2016). Current recommendations from NICE are that FGIDs are diagnosed in primary care based on characteristic symptoms without alarms, with the judicious use of investigations (Dalrymple & Bullock, 2008). Referrals for psychological interventions are recommended if no symptom improvement after 12 months' treatment with lifestyle modification and symptom-based pharmacotherapy. The development of a standard IMoC that incorporates both diagnostic and evidence-based management pathways is the next step forward in improving patient care for FGIDs. Key components of such a model include the provision of a timely, clear diagnosis, patient education, empowerment, care co-ordination, multidisciplinary teams, and individual care plans (Carter, Chalouhi, McKenna, & Richardson, 2011).

Future Directions

This review highlights the paucity of research into the development and assessment of IMoCs for FGIDs. However, the preliminary evidence indicates a role for nurse-led models of care in FGIDs. Future studies should be large, randomized controlled trials, comparing standard gastroenterological care with integrated models, with both patient outcomes and cost evaluated. Detailed descriptions of the content of both the diagnostic and management arms of the model of care are also needed to evaluate whether components of IMoC are evidence-based and effective. Furthermore, evidence of the standardization of the IMoC within the trial is necessary to ensure accuracy of the findings.

Conclusion

There is minimal research to date trialing models of care that incorporate a standardized approach to diagnosis as well as evidence-based management. Furthermore, no studies have assessed FGIDs in general but there are those restricted to either FD or IBS. Existing research on full models of care is of low quality, with most pertaining to nurse models of care. However, these preliminary data suggest that models of care incorporating protocol-driven assessment and diagnosis, in conjunction with ongoing holistic care, are economically viable, can be delivered by nurses, and may facilitate timely diagnosis and management and improve patient outcomes.

REFERENCES

Agréus L., Borgquist L. (2002). The cost of gastro-oesophageal reflux disease, dyspepsia and peptic ulcer disease in Sweden. Pharmacoeconomics, 20(5), 347–355.
Ålander T., Svärdsudd K., Agréus L. (2008). Functional gastrointestinal disorder is associated with increased non-gastrointestinal healthcare consumption in the general population. International Journal of Clinical Practice, 62(2), 234–240.
American College of Gastroenterology Task Force on Irritable Bowel Syndrome; Brandt L. J., Chey W. D., Foxx-Orenstein A. E., Schiller L. R., Schoenfeld P. S., Quigley E. M. (2009). An evidence-based position statement on the management of irritable bowel syndrome. The American Journal of Gastroenterology, 104(Suppl. 1), S1–S35. doi:10.1038/ajg.2008.122
Astegiano M., Pellicano R., Sguazzini C., Berrutti M., Simondi D., Reggiani S., Rizzetto M. (2008). 2008 Clinical approach to irritable bowel syndrome. Minerva Gastroenterologica e Dietologica, 54(3), 251–257.
Bengtsson M., Ulander K., Borgdal E. B., Ohlsson B. (2010). A holistic approach for planning care of patients with irritable bowel syndrome. Gastroenterology Nursing, 33(2), 98–108. doi:10.1097/SGA.0b013e3181d60026
Buresi M. C., Andrews C. N., Novak K. L., Swain M. G., Johnston C., Kathol B., Heitman S. J. (2014). A cost–utility analysis of novel and current strategies for the management of uninvestigated dyspepsia. Gastroenterology, 146(5), S558–S559.
Carter K., Chalouhi E., McKenna S., Richardson B. (2011). What it takes to make integrated care work. Health International, 11, 48–55.
Chang F. Y., Lu C. L., Chen T. S. (2010). The current prevalence of irritable bowel syndrome in Asia. Journal of Neurogastroenterology and Motility, 16(4), 389–400. doi:10.5056/jnm.2010.16.4.389
Chang J. Y., Locke G. R., McNally M. A., Halder S. L., Schleck C. D., Zinsmeister A. R., Talley N. J. (2010). Impact of functional gastrointestinal disorders on survival in the community. American Journal of Gastroenterology, 105(4), 822–832.
    Collins J., Farrall E., Turnbull D. A., Hetzel D. J., Holtmann G., Andrews J. M. (2009). Do we know what patients want? The doctor–patient communication gap in functional gastrointestinal disorders. Clinical Gastroenterology and Hepatology, 7(11), 1252–1254, 1254.e1–e2. doi:10.1016/j.cgh.2009.06.025
    Dalrymple J., Bullock I. (2008). Diagnosis and management of irritable bowel syndrome in adults in primary care: Summary of NICE guidance. BMJ, 336(7643), 556–558. doi:10.1136/bmj.39484.712616.AD
    De Giorgio R., Volta U., Gibson P. R. (2016). Sensitivity to wheat, gluten and FODMAPs in IBS: Facts or fiction? Gut, 65(1), 169. doi:10.1136/gutjnl-2015-309757
    Department of Health, Western Australia. (2012). Asthma model of care. Retrieved from https://ww2.health.wa.gov.au/∼/media/Files/Corporate/general%20documents/Health%20Networks/Respiratory/Asthma-Model-of-Care.pdf
    Diabetes Australia. (2014). General practice management of type 2 diabetes. Melbourne, Victoria, Australia: Diabetes Australia. Retrieved from https://static.diabetesaustralia.com.au/s/fileassets/diabetes-australia/5ed214a6-4cff-490f-a283-bc8279fe3b2f.pdf
    Dill B., Dill J. E. (1995). The RN's role in the office treatment of irritable bowel syndrome. Gastroenterology Nursing, 18(3), 100–103.
    Drossman D. A. (2006). The functional gastrointestinal disorders and the Rome III process. Gastroenterology, 130(5), 1377–1390. doi:10.1053/j.gastro.2006.03.008
    Drossman D. A. (2016). Functional gastrointestinal disorders: History, pathophysiology, clinical features, and Rome IV. Gastroenterology. doi:10.1053/j.gastro.2016.02.032
    Effective Public Health Practice Project (EPHP). (2007). Quality assessment tool for quantitative studies. Retrieved from http://www.ephpp.ca/tools.html
    El-Serag H. B., Talley N. J. (2004). The prevalence and clinical course of functional dyspepsia. Alimentary Pharmacology & Therapeutics, 19(6), 643–654. doi:10.1111/j.1365-2036.2004.01897.x
    Enck P., Junne F., Klosterhalfen S., Zipfel S., Martens U. (2010). Therapy options in irritable bowel syndrome. European Journal of Gastroenterology & Hepatology, 22(12), 1402–1411. doi:10.1097/MEG.0b013e3283405a17
    Fortea J., Prior M. (2013). Irritable bowel syndrome with constipation: A European-focused systematic literature review of disease burden. Journal of Medical Economics, 16(3), 329–341.
    Fullerton S. (1998). Functional digestive disorders (FDD) in the year 2000—Economic impact. European Journal of Surgery, 164(S12), 62–64. doi:10.1080/11024159850191463
    Gastroenterological Society of Australia (GESA). (2003). Irritable bowel syndrome IBS. Retrieved from http://www.gesa.org.au/files/editor_upload/File/Professional/IBS_2nd_Edition.pdf
    Halder S. L., Locke G. R., Schleck C. D., Zinsmeister A. R., Melton L. J. 3rd, Talley N. J. (2007). Natural history of functional gastrointestinal disorders: A 12-year longitudinal population-based study. Gastroenterology, 133(3), 799.e791–807.e791. doi:10.1053/j.gastro.2007.06.010
    Harkness E. F., Grant L., O'Brien S. J., Chew-Graham C. A., Thompson D. G. (2013). Using read codes to identify patients with irritable bowel syndrome in general practice: A database study. BMC Family Practice, 14, 183. doi:10.1186/1471-2296-14-183
    Hulisz D. (2004). the burden of illness of irritable bowel syndrome: Current challenges and hope for the future. Journal of Managed Care Pharmacy, 10(4), 10.
    Ilnyckyj A., Graff L. A., Blanchard J. F., Bernstein C. N. (2003). Therapeutic value of a gastroenterology consultation in irritable bowel syndrome. Alimentary Pharmacology & Therapeutics, 17(7), 871–880.
    Khan K. S., Kunz R., Kleijnen J., Antes G. (2003). Five steps to conducting a systematic review. Journal of the Royal Society of Medicine, 96(3), 118.
    Knott V. E., Holtmann G., Turnbull D. A., Andrews J. M. (2009). M1253 patients' satisfaction with specialist gastroenterologist consultation for irritable bowel syndrome (IBS) and health care utilisation: Exploring the role of patient expectations. Gastroenterology, 136(5), A-382–A-383.
    Kodner D. L., Spreeuwenberg C. (2002). Integrated care: Meaning, logic, applications, and implications—A discussion paper. International Journal of Integrated Care, 2, e12.
    Lacy B. E., Mearin F., Chang L., Chey W. D., Lembo A. J., Simren M., Spiller R. (2016). Bowel disorders. Gastroenterology. doi:10.1053/j.gastro.2016.02.031
    Levy R. L., Korff M., Whitehead W. E., Stang P., Saunders K., Jhingran P., Feld A. D. (2001). Costs of care for irritable bowel syndrome patients in a health maintenance organization. The American Journal of Gastroenterology, 96(11), 3122–3129.
    Linedale E. C., Chur-Hansen A., Mikocka-Walus A., Gibson P. R., Andrews J. M. (2016). Uncertain diagnostic language affects further studies, endoscopies, and repeat consultations for patients with functional gastrointestinal disorders. Clinical Gastroenterology and Hepatology, 14(12), 1735.e1–1741.e1. doi:10.1016/j.cgh.2016.06.030
    Linedale E., Mikocka-Walus A., Gibson P., Andrews J. (2016). Referrals to a tertiary hospital: A window into the effectiveness of management of patients with functional gastrointestinal disorders in primary care. Manuscript submitted for publication.
    Longstreth G. F., Wilson A., Knight K., Wong J., Chiou C. F., Barghout V., Ofman J. J. (2003). Irritable bowel syndrome, health care use, and costs: A U.S. managed care perspective. The American Journal of Gastroenterology, 98(3), 600–607.
    Mearin F., Lacy B. E. (2012). Diagnostic criteria in IBS: Useful or not? (Report). Neurogastroenterology & Motility, 24, 791.
    Mitchell C. M., Drossman D. A. (1987). Survey of the AGA membership relating to patients with functional gastrointestinal disorders. Gastroenterology, 92(5, Pt. 1), 1282–1284.
    Moore J. S., Gagan M. J., Perry R. E. (2014). The benefits of a nurse-led service in the identification and management of symptoms of irritable bowel syndrome. Gastroenterology Nursing, 37(6), 416–423. doi:10.1097/sga.0000000000000073
    Mountifield R., Andrews J. A. (2010). Managing irritable bowel syndrome. Medicine Today, 11(2), 32–40.
    National Institute for Health and Clinical Excellence (NICE). (2016). Irritable bowel syndrome in adults: NICE quality standard [QS114]. London, England: Author.
    Novak K. L., Kathol B., Swain M. G., Johnston C., Kwan J., Bucholtz L., Andrews C. N. (2014). Sa1074 nurse-led, interactive group sessions for dyspepsia and GERD referrals: A prospective controlled study of the “nurse navigator” clinic. Gastroenterology, 146(5), S-192–S-193. doi:10.1016/S0016-5085(14)60678-8
    NSW Agency for Clinical Innovation. (2013). Understanding the process to develop a Model of Care: An ACI Framework. Retrieved from https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0009/181935/HS13-034_Framework-DevelopMoC_D7.pdf
    Peters S. L., Muir J. G., Gibson P. R. (2015). Review article: Gut-directed hypnotherapy in the management of irritable bowel syndrome and inflammatory bowel disease. Alimentary Pharmacology & Therapeutics, 41(11), 1104–1115.
    Quigley E. M., Fried M., Gwee K. A., Khalif I., Hungin A. P., Lindberg G., ... Review Team. (2016). World Gastroenterology Organisation global guidelines irritable bowel syndrome: A global perspective update September 2015. Journal of Clinical Gastroenterology, 50(9), 704–713. doi:10.1097/MCG.0000000000000653
    Shivaji U. N., Ford A. C. (2014). Prevalence of functional gastrointestinal disorders among consecutive new patient referrals to a gastroenterology clinic. Frontline Gastroenterology, 5(4), 266. doi:10.1136/flgastro-2013-100426
    Spiegel B. M., Kanwal F., Naliboff B., Mayer E. (2005). The impact of somatization on the use of gastrointestinal health-care resources in patients with irritable bowel syndrome. The American Journal of Gastroenterology, 100(10), 2262–2273.
    Stanghellini V., Chan F. K., Hasler W. L., Malagelada J. R., Suzuki H., Tack J., Talley N. J. (2016). Gastroduodenal disorders. Gastroenterology, 150(6), 1380–1392. doi:10.1053/j.gastro.2016.02.011
    Talley N. J. (2008a). Functional gastrointestinal disorders as a public health problem. Neurogastroenterology & Motility, 20(Suppl. 1), 121–129. doi:10.1111/j.1365-2982.2008.01097.x
    Talley N. J. (2008b). Functional gastrointestinal disorders as a public health problem. Neurogastroenterology & Motility, 20(Suppl. 1), 121–129. doi:10.1111/j.1365-2982.2008.01097.x
    Talley N. J., Gabriel S. E., Harmsen W. S., Zinsmeister A. R., Evans R. W. (1995). Medical costs in community subjects with irritable bowel syndrome. Gastroenterology, 109(6), 1736–1741.
    The Cochrane Collaboration. (2011, March). Cochrane handbook for systematic reviews of interventions. Version 5.1.0. Retrieved from www.handbook.cochrane.org

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