Home Biofeedback for the Treatment of Dyssynergic Defecation: Does It Improve Quality of Life and Is It Cost-Effective?

OBJECTIVES: Biofeedback therapy, whether administered at home or in office settings, is effective for dyssynergic defecation (DD). Whether home biofeedback improves quality of life (QOL) and is cost-effective when compared with office biofeedback is unknown. METHODS: QOL was assessed in 8 domains (SF-36) at baseline and after treatment (3 months), alongside economic evaluation during a randomized controlled trial (RCT) comparing home and office biofeedback in patients with DD (Rome III). Costs related to both biofeedback programs were estimated from the hospital financial records, study questionnaires, and electronic medical records. A conversion algorithm (Brazier) was used to calculate the patient's quality-adjusted life years (QALYs) from SF-36 responses. Cost-effectiveness was expressed as incremental costs per QALY between the treatment arms. RESULTS: One hundred patients (96 female patients, 50 in each treatment arm) with DD participated. Six of the 8 QOL domains improved (P < 0.05) in office biofeedback, whereas 4 of the 8 domains improved (P < 0.05) in home biofeedback; home biofeedback was noninferior to office biofeedback. The median cost per patient was significantly lower (P < 0.01) for home biofeedback ($1,112.39; interquartile range (IQR), $826-$1,430) than for office biofeedback ($1,943; IQR, $1,622-$2,369), resulting in a cost difference of $830.11 The median QALY gained during the trial was 0.03 for office biofeedback and 0.07 for home biofeedback (P = NS). The incremental cost-effectiveness ratio was $20,752.75 in favor of home biofeedback. DISCUSSION: Biofeedback therapy significantly improves QOL in patients with DD regardless of home or office setting. Home biofeedback is a cost-effective treatment option for DD compared with office biofeedback, and it offers the potential of treating many more patients in the community.

Pill Properties that Cause Dysphagia and Treatment Failure.

BACKGROUND: Pills (tablets and capsules) are widely used to administer prescription drugs or to take supplements such as vitamins. Unfortunately, little is known about how much effort it takes Americans to swallow these various pills. More specifically, it is not known to what extent hard-to-swallow pills might affect treatment outcomes (eg, interfering with adherence to prescribed medications or causing clinical complications). It is also unclear which properties (eg, size, shape, or surface texture) Americans prefer or reject for their pills. To learn more about these issues, we interviewed a small group of individuals. METHODS: We invited individuals in waiting rooms of our tertiary health care center to participate in structured interviews about their pill-taking habits and any problems they have swallowing pills. We inquired which pill properties they believed caused swallowing problems. Participants scored capsules and pills of representative size, shape, and texture for swallowing effort and reported their personal preferences. RESULTS: Of 100 successive individuals, 99 participants completed the interview (65% women, mean age = 41 years, range = 23-77 years). Eighty-three percent took pills daily (mean 4 pills/d; 56% of those pills were prescribed by providers). Fifty-four percent of participants replied yes to the question, "Did you ever have to swallow a solid medication that was too difficult?" Four percent recounted serious complications: 1% pill esophagitis, 1% pill impaction, and 2% stopped treatments (antibiotic and prenatal supplement) because they could not swallow the prescribed pills. Half of all participants routinely resorted to special techniques (eg, plenty of liquids or repeated or forceful swallows). Sixty-one percent of those having difficulties cited specific pill properties: 27% blamed size (20% of problems were caused by pills that were too large whereas 7% complained about pills that were too small to sense); 12% faulted rough surface texture; others cited sharp edges, odd shapes, or bad taste/smell. Extra-large pills were widely loathed, with 4 out of 5 participants preferring to take 3 or more medium-sized pills instead of a single jumbo pill. CONCLUSIONS: Our survey results suggest that 4 out of 5 adult Americans take several pills daily, and do so without undue effort. It also suggests that half of today's Americans encounter pills that are hard to swallow. Up to 4% of our participants gave up on treatments because they could not swallow the prescribed pills. Up to 7% categorically rejected taking pills that are hard to swallow. Specific material properties are widely blamed for making pills hard to swallow; extra-large capsules and tablets are universally feared, whereas medium-sized pills with a smooth coating are widely preferred. Our findings suggest that health care providers could minimize treatment failures and complications by prescribing and dispensing pills that are easy to swallow. Industry and regulatory bodies may facilitate this by making swallowability an essential criterion in the design and licensing of oral medications. Such policies could lessen the burden of pill taking for Americans and improve the adherence with prescribed treatments.