Neurogastroenterology & Motility Neurogastroenterol Motil (2014) 26, 1368–1385 doi: 10.1111/nmo.12402 REVIEW ARTICLE A four-country comparison of healthcare systems, implementation of diagnostic criteria, and treatment availability for functional gastrointestinal disorders A report of the Rome Foundation Working Team on cross-cultural, multinational research M. SCHMULSON,* E. CORAZZIARI,† U. C. GHOSHAL,‡ S.-J. MYUNG,§ C. D. GERSON,¶ E. M. M. QUIGLEY,** K.-A. GWEE†† & A. D. SPERBER‡‡ *Laboratorio de Hıgado, Pancreas y Motilidad (HIPAM)-Department of Experimental Medicine, Faculty of Medicine-Universidad Nacional Autonoma de Mexico (UNAM). Hospital General de Mexico, Mexico City, Mexico †Gastroenterologia A, Department of Internal Medicine and Medical Specialties, University La Sapienza, Rome, Italy ‡Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Science, Lucknow, India §Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea ¶Division of Gastroenterology, Mount Sinai School of Medicine, New York, NY, USA **Division of Gastroenterology and Hepatology, Houston Methodist Hospital and Weill Cornell Medical College, Houston, TX, USA ††Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore ‡‡Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel Key Messages • This report identified seven key issues related to healthcare provision that may impact how patients with FGIDs are investigated, diagnosed and managed. • Variations in healthcare provision around the world in patients with FGIDs have not been reviewed. • We compared four countries that are geographically and culturally diverse, and exhibit differences in the healthcare coverage provided to their population: Italy, South Korea, India and Mexico. • Since there is a paucity of publications relating to the issues covered in this report, some of the findings are based on the authors’ personal perspectives, press reports and other published sources. • Future directions for conducting cross-cultural and multinational research in FGIDs are provided. Address for Correspondence Abstract Dr. Max Schmulson, Laboratorio de Hıgado, Pancreas y Background Variations in healthcare provision Motilidad (HIPAM)-Departamento de Medicina Experimental, Facultad de Medicina-Universidad Nacional Autonoma de around the world may impact how patients with Mexico (UNAM), Hospital General de Mexico, Dr. Balmis functional gastrointestinal disorder (FGIDs) are inves- #148, Col. Doctores C.P, Mexico D.F. 06726, Mexico. tigated, diagnosed, and treated. However, these dif- Tel: 52-5556232673; fax: 52-5556232669; ferences have not been reviewed. Purposes The e-mail: [email protected] Multinational Working Team of the Rome Founda- Received: 2 April 2014 Accepted for publication: 22 June 2014 tion, established to make recommendations on the 1368 © 2014 John Wiley & Sons Ltd Volume 26, Number 10, October 2014 Comparison of healthcare systems and FGIDs conduct of multinational, cross-cultural research in INTRODUCTION FGIDs, identified seven key issues that are analyzed The structure of healthcare services may impact the herein: (i) coverage afforded by different healthcare way that patients with functional gastrointestinal systems/providers; (ii) level of the healthcare system disorders (FGIDs) are evaluated, diagnosed, and treated. where patients with FGIDs are treated; (iii) extent/ Currently there is no information available on differ- types of diagnostic procedures typically undertaken to ences in these services around the globe. The World diagnose FGIDs; (iv) physicians’ familiarity with and Health Organization has ranked the performance of its implementation of the Rome diagnostic criteria in 191 world members based on several indicators includ- clinical practice; (v) range of medications approved ing: (i) improving health status and reduced health for FGIDs and approval process for new agents; (vi) inequalities, (ii) level of responsiveness to the popula- costs involved in treating FGIDs; and (vii) prevalence tion’s expectations, (iii) inequalities in responsiveness and role of complementary/alternative medicine and fairness in financial contributions.1 Based on these (CAM) for FGIDs. Because it was not feasible to indicators, they concluded that countries with a survey all countries around the world, we compared a history of civil conflict or a high prevalence of HIV selected number of countries based on their geo- and AIDS are less efficient in providing healthcare to graphical and ethno-cultural diversity. Thus, we their populations, and performance increases with included Italy and South Korea as representative of higher health expenditure per capita.2 However, coun- nations with broad-based coverage of healthcare in tries may give different weights to these indicators,3 as the population and India and Mexico as newly people in different cultural and social settings value industrialized countries where there may be limited individual healthcare goals in different ways. For provision of healthcare for substantial segments of example, some countries may assign greater impor- the population. In light of the paucity of formal tance to indicators of health distribution and less publications on these issues, we included additional importance to health level, so flexibility is sources from the medical literature as well as needed when weighing the importance of each health perspectives provided by local experts and the media. indicator.4 Finally, we provide future directions on healthcare Svoronos and Mate proposed that evaluations of issues that should be taken into account and imple- public health programs should not only assess mented when conducting cross-cultural and multi- whether an intervention works, but also why and national research in FGIDs. how it works. Thus, when implementing interven- Keywords available medications, CAM, cross-cul- tions which aim to improve healthcare delivery tural, multinational trials, diagnostic procedures, across varied populations, it is important to be expenditures, Functional gastrointestinal disorders, sensitive to contextual differences.5 For example, healthcare coverage, IBS, registration process. the availability of medicines may differ across differ- ent populations and may vary from the public to the Abbreviations: BM, Bowel movements; BRICS, Brazil, private sector within individual countries. Cameron Russia, India, China, and South Africa (Emerging et al. showed that medicines for chronic conditions economies); BSS, Bristol Stool Scale; CAM, Comple- (e.g., diabetes, hypertension) are less available than mentary and Alternative Medicine; COFEPRIS, Federal for acute ones (e.g., viral/parasitic infections) in low Commission for the Protection Against Sanitary Risks and middle-income countries, particularly in the (Mexico); EKG, Electrocardiogram; EMEA, European public sector.6 Medicines Agency; EU, European Union; FGIDs, Func- Functional gastrointestinal disorders, especially irri- tional Gastrointestinal Disorder; GERD, Gastro-esoph- table bowel syndrome (IBS) and functional constipa- ageal Reflux Disease; GI, Gastrointestinal; GPs, tion, are common chronic disorders7,8 that produce a General Practitioners; H , Histamine 2 receptors; IBS- 2 negative economic burden because of the cost of C, IBS with Constipation; IBS-D, IBS with Diarrhea; investigations, medical consultations and surgeries IBS, Irritable Bowel Syndrome; IBS-M, Mixed IBS; that are not medically indicated, absenteeism and loss IMSS, Mexican Institute of Social Security (Mexico); of work productivity, and impaired health-related KFDA, Korean Food & Drug Administration; MISTs, quality of life.9–11 FGIDs have not been investigated Mexico, Indonesia, South Korea, and Turkey (Emerging as public healthcare problems, especially, from a economies); NHI, National Health Care Insurance multinational, cross-cultural perspective.6 System (South Korea); NHS, National Health Service As part of a comprehensive global initiative (Italy); PPIs, Proton Pump Inhibitors; RIIIAQ, Rome III of the Rome Foundation, the Working Team on Adult Questionnaire; USD, United States Dollars. © 2014 John Wiley & Sons Ltd 1369 M. Schmulson et al. Neurogastroenterology and Motility Cross-Cultural, Multinational Research was created (iii) diagnostic procedures that are used and to what in June 2011 to foster multinational research in extent; (iv) knowledge and use of the Rome diagnos- FGIDs and make recommendations on the conduct of tic criteria among healthcare providers; (v) available this investigation. The Working Team was divided medications for FGIDs and the process for the into five sub-committees (reported elsewhere),12 one registration and approval of new pharmaceuticals; of which focused on Healthcare Systems and Infra- (vi) the economic burden on healthcare services from structure in Different Countries. Seven healthcare FGIDs; and (vii) use of complementary and alterna- issues that need to be considered when conducting tive medicine (CAM) for FGIDs (Fig. 1). multinational, cross-cultural research in FGIDs were As it would not be feasible to conduct a comparative selected by the members of this sub-committee based review of every country in the world, due to the lack of on their expertise, following face to face discussions global information, we decided to compare a selected that took place in May 2012 in San Diego, California group of geographically