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Prevalence and Severity Versus Care-Seeking Patients Dig Dis Sci DOI 10.1007/s10620-014-3181-8 ORIGINAL ARTICLE GERD Symptoms in the General Population: Prevalence and Severity Versus Care-Seeking Patients Erica Cohen • Roger Bolus • Dinesh Khanna • Ron D. Hays • Lin Chang • Gil Y. Melmed • Puja Khanna • Brennan Spiegel Received: 24 December 2013 / Accepted: 20 April 2014 Ó Springer Science+Business Media New York (Outside the USA) 2014 Abstract scale. We then performed multivariable regression to Background Prior estimates suggest that up to 40 % of identify predictors of GERD severity. the US general population (GP) report symptoms of gas- Results There was no difference in the prevalence of troesophageal reflux disease (GERD). However, symptoms heartburn between the GP and patient groups (59 vs. in the GP versus patients seeking care for gastrointestinal 59 %), but regurgitation was more common in patients (GI) complaints have not been compared. We estimated the versus GP (46 vs. 39 %; p = 0.004). In multivariable prevalence and severity of GERD symptoms in the GP regression, having high visceral anxiety (p \ 0.001) and versus GI patients, and identified predictors of GERD being divorced or separated (p = 0.006) were associated severity. We hypothesized that similar to functional GI with higher GERD severity. disorders, psychosocial factors would predict symptom Conclusions More than half of a GP sample reports severity in GERD as much, or perhaps more, than care- heartburn—higher than previous series and no different seeking behavior alone. from GI patients. Although regurgitation was more pre- Methods We compared the prevalence of heartburn and valent in patients versus the GP, there was no difference in regurgitation between a sample from the US GP and GERD severity between groups after adjusting for other patients seeking GI specialty care. We compared GERD factors; care seeking in GERD appears related to factors severity between groups using the NIH PROMISÒ GERD beyond symptoms, including visceral anxiety. Keywords Gastroesophageal reflux disease Á Disclaimer The opinions and assertions contained herein are the sole Patient-reported outcomes Á Symptoms views of the authors and are not to be construed as official or as reflecting the views of the Department of Veteran Affairs. E. Cohen Á B. Spiegel (&) D. Khanna Á P. Khanna Department of Gastroenterology, VA Greater Los Angeles Division of Rheumatology, University of Michigan, Ann Arbor, Healthcare System, 11301 Wilshire Blvd, Bldg 115, MI, USA Room 215, Los Angeles, CA 90073, USA e-mail: [email protected] R. D. Hays Division of General Internal Medicine and Health Services E. Cohen Á G. Y. Melmed Research, David Geffen School of Medicine at UCLA, Department of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA West Hollywood, CA, USA R. D. Hays R. Bolus Á L. Chang Á B. Spiegel Department of Health Services, UCLA School of Public Health, Division of Digestive Diseases, David Geffen School Los Angeles, CA, USA of Medicine at UCLA, Los Angeles, CA, USA L. Chang R. Bolus Á B. Spiegel Center for Neurobiology of Stress, David Geffen School UCLA/VA Center for Outcomes Research and Education, of Medicine at UCLA, Los Angeles, CA, USA Los Angeles, CA, USA 123 Dig Dis Sci Abbreviations symptom severity and hypothesized that similar to func- GI Gastrointestinal tional GI disorders (FGIDs), psychosocial factors would PRO Patient-reported outcome predict symptom severity in GERD as much, or perhaps HRQOL Health-related quality of life more, than care-seeking behavior alone. PROMIS Patient-Reported Outcome Measurement Information System Methods Study Overview Introduction To study the prevalence and severity of GERD symptoms Gastroesophageal reflux disease (GERD) is associated with in the GP and those seeking care for GI disorders, we impaired health-related quality of life and substantial conducted a cross-sectional online survey using items resource utilization [1, 2]. The prevalence of reflux developed for the NIH Patient-Reported Outcome Mea- symptoms is steadily rising throughout the industrialized surement Information System (PROMISÒ; www.nihPRO world [3]. An estimated 20–40 % of Western adult popu- MIS.org)[16, 17]. PROMIS is a federally supported NIH lations report chronic heartburn or regurgitation symptoms Roadmap Initiative that developed patient-reported out- [4–7], although fewer meet formal diagnostic criteria for come (PRO) measures across the breadth and depth of GERD [8]. Over nine million primary care visits are disease, including GI disorders. The PROMIS GI item attributed to GERD annually; it remains the most common banks cover 8 broad symptom categories, one of which is gastroenterology-related outpatient diagnosis [9]. GERD is GERD [17, 18]. The PROMIS GERD items measure the associated with increased reports of restricted activity and frequency, severity, impact, and bother of cardinal GERD missed work, imposing a financial burden for both symptoms, including heartburn and regurgitation, using a healthcare systems and employers alike [10]. seven-day recall period. The scales correlate significantly Although previous research evaluated GERD epidemi- with both generic (e.g., Euro-QOL, SF12) and disease- ology in the general population (GP) [11] and patient targeted legacy instruments (e.g., Gastrointestinal Symp- population [12], respectively, no study has compared the tom Rating Scale [GSRS]) and demonstrate evidence of prevalence or severity of GERD symptoms between these reliability [18]. In addition to NIH PROMIS items, we groups. Because care-seekers are a subset of the larger collected demographic and clinical information about each population, we might expect that patients have more fre- subject and administered the PROMIS Global Health quent, severe, or bothersome symptoms than people in the items, the Visceral Sensitivity Index (VSI) [19, 20], SF- GP. However, little is known about the differences between 12Ò health survey, and the GI Symptoms Rating Scale groups or what drives care-seeking behavior in the first (GSRS) [21]. place—not only for GERD symptoms, but for other chronic gastrointestinal (GI) symptoms as well. Selection of Patients Previous research has explored aspects of care seeking and resource utilization in GERD. For example, a French We recruited a diverse group of participants from outpa- study compared patients with weekly versus less frequent tient clinical practices and national cohorts seeking care at symptoms and found that patients with weekly GERD university, community, and Veteran Affairs institutions. perceived their symptoms to be more severe and had We invited patients seeking care at these outpatient clinics greater healthcare utilization [13]. Even subjects with for an active GI symptom of any kind, including, but not infrequent GERD often experienced substantial impact on limited to, GERD symptoms. Our sample included patients their daily activities and sought medical advice, suggesting with inflammatory bowel disease (IBD) seeking care at that factors beyond symptom frequency may drive the Cedars-Sinai Medical Center, a tertiary center in Los GERD illness experience [13]. However, less is known Angeles; patients with GI symptoms from systemic scle- about the role of psychosocial factors and care seeking in rosis seeking care at a specialty clinic at the University of GERD. Although psychosocial factors are associated with Michigan; patients with FGIDs seeking care at a specialty healthcare seeking in irritable bowel syndrome (IBS) [14] clinic at the University of California Los Angeles; and and dyspepsia [15], their role in GERD remains unclear. patients with diverse GI conditions seeking care at a gen- In this study, we sought to describe the prevalence and eral GI clinic at the West Los Angeles Veterans Admin- severity of GERD symptoms in a representative US GP istration Medical Center. In addition, we partnered with the sample versus a broad range of patients seeking GI sub- International Foundation for Functional Gastrointestinal specialty care. Furthermore, we identified predictors of Disorders (IFFGD) to survey a cohort of patients with 123 Dig Dis Sci Fig. 1 NIH PROMISÒ GERD How often did you have regurgitation—that is, food or liquid coming back up into your Scale throat or mouth without vomiting? Never One Day 2-6 days Once a day More than once a day What was the most food or liquid you had come back up into your mouth at one time? None Enough to fill a little of my mouth Enough to fill some of my mouth Enough to fill most of my mouth So much that it filled my entire mouth After eating a meal, how often did food or liquid come back into your throat or mouth without vomiting? Never Rarely Sometimes Often Always How often did you re-swallow food that came back into your throat? Never Rarely Sometimes Often Always How often did you feel like you were going to burp, but food or liquid came up instead? Never One day 2-6 days Once a day More than once a day How often did you feel lie there was too much saliva in your mouth? Never Rarely Sometimes Often Always diverse FGIDs enrolled in IFFGD mailing lists. All patients Selection of Controls were invited to complete the confidential online survey instrument, administered by Survey Monkey software In addition to GI patient recruitment, CintÒ (www.cint. (www.surveymonkey.com). Patients without Internet com), a survey research firm, recruited a sample of indi- access could request paper surveys sent to their home, or viduals representative of the GP in terms of gender, eth- completed in clinic, as needed. Patients
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