Optimizing the Management Algorithm for Adults With Functional Constipation Failing a Fiber/Laxative Trial in General Gastroenterology: Cost-Effectiveness and Cost-Minimization Analysis.

INTRODUCTION: Anorectal function testing is traditionally relegated to subspecialty centers. Yet, it is an office-based procedure that appears capable of triaging care for the many patients with Rome IV functional constipation that fail empiric over-the-counter therapy in general gastroenterology, as an alternative to empirical prescription drugs. We aimed to evaluate cost-effectiveness of routine anorectal function testing in this specific population. METHODS: We performed a cost-effectiveness analysis from the patient perspective and a cost-minimization analysis from the insurer perspective to compare 3 strategies: (i) empiric prescription drugs followed by pelvic floor physical therapy (PFPT) for drug failure, (ii) empiric PFPT followed by prescription drugs for PFPT failure, or (iii) care directed by up-front anorectal function testing. Model inputs were derived from systematic reviews of prospective clinical trials, national cost data sets, and observational cohort studies of the impact of chronic constipation on health outcomes, healthcare costs, and work productivity. RESULTS: The most cost-effective strategy was upfront anorectal function testing to triage patients to appropriate therapy, in which the subset of patients without anal hypocontractility on anorectal manometry and with a balloon expulsion time of at least 6.5 seconds would be referred to PFPT. In sensitivity analysis, empiric PFPT was more cost effective than empiric prescription drugs except for situations in which the primary goal of treatment was to increase bowel movement frequency. If adopted, gastroenterologists would refer ∼17 patients per year to PFPT, supporting feasibility. DISCUSSION: Anorectal function testing seems to be an emergent technology to optimize cost-effective outcomes, overcoming testing costs by phenotyping care.

Demographic and Dietary Associations of Chronic Diarrhea in a Representative Sample of Adults in the United States.

OBJECTIVES: No studies to date estimate the prevalence of chronic diarrhea in the United States using the Bristol stool form scale (BSFS). This study aims to report the prevalence and associated factors of chronic diarrhea using BSFS scores in a nationally representative sample of US adults. METHODS: We identified 5,246 adult participants (age ≥20 years) who completed the bowel health questionnaire in the National Health and Nutrition Examination Survey 2009-2010 data set. Chronic diarrhea was defined as type 6 or 7 rating on the BSFS (mushy or liquid consistency) as the "usual or the most common stool type." Co-variables included age, race, education, poverty income ratio, body mass index, number of medications, feeling depressed, physical activity, and dietary intake. Prevalence estimates and prevalence odds ratios (PORs) were analyzed in adjusted multivariable models using appropriate sampling weights. RESULTS: We found a prevalence of chronic diarrhea of 6.6% (95% confidence interval (CI) 5.8, 7.4) in the nationally representative data set. High daily carbohydrate intake (POR 1.56, 95% CI 1.02, 2.40), obesity (POR 2.04, 95% CI 1.44, 2.89), feeling depressed (POR 1.84, 95% CI 1.21, 2.80), older age (POR 1.02, 95% CI 1.01, 1.02), and female sex (POR 1.68, 95% CI 1.28, 2.21) were positively correlated with chronic diarrhea. Non-Hispanic White race (POR 0.49, 95% CI 0.29, 0.81) and higher education (POR 0.60, 95% CI 0.43, 0.83) were negatively correlated with chronic diarrhea. CONCLUSIONS: In a nationally representative sample of the US adults, the prevalence of chronic diarrhea was 6.6%. We identified demographic, lifestyle, and dietary factors associated with chronic diarrhea.