How Can We Better Manage Functional Gastrointestinal Disease

Background
GPs appear to have difficulty diagnosing and managing patients with functional gastrointestinal disorders (FGID) such as irritable bowel syndrome, as judged by the large numbers of gastroenterology referrals. Current practice does not match the recommendations of a positive symptom‐based diagnosis with minimal testing (in the absence of red flags) and primary care management (Drossman, 2006; Hulisz, 2004).

Aim
To explore the driving factors behind gastroenterology referrals for patients with likely FGIDs.

Methods
Referrals triaged as a likely FGID were identified from the ‘routine waitlist’ of the Gastroenterology Department of an Australian public hospital between July 2013 and April 2015. Patients were invited to undertake a routine panel of blood/stool tests and complete a structured, alarm‐based questionnaire to exclude organic disease. Participants’ referring GPs were invited to complete a referral questionnaire. Patient symptoms were classified according to the Rome III criteria for FGIDs. Where abnormal test results and/or alarms were found, notes were reviewed by a gastroenterologist (GE) and a prompt GE appointment offered, where judged appropriate.

Results
Of the 295 pts invited, 102 completed the questionnaire and 61 of their GPs completed the survey. The majority of referrals did not specify a reason for referral (74/102). When asked the main reason for referral 21 GPs simply relisted the symptoms without providing a rationale for the referral, and 4 declined to answer. Other common reasons given included persistent symptoms (n = 12), request for endoscopic procedure (n = 8) and inability to diagnose (n = 6). The most frequent reasons for referral selected from a structured list were: repeat presentations (n = 32), diagnostic uncertainty (n = 19), to ensure nothing is missed (n = 19), patient request (n = 17), no response to treatment (n = 16) and to allay patient fears (n = 14). Twenty eight GPs were confident of a FGID diagnosis, 5 were confident of an organic diagnosis (although 3 were unable to suggest what this was) and 27 unsure/not confident in a FGID diagnosis. Of the 87 patients (54 female, mean 41y) who have completed the screening process 32 were found to warrant GE review. Alarms were significantly under‐reported in all of these cases with 24/32 referrals failing to mention alarms (alarms present in 21) and 3 stating no alarms (alarms present in all).

Conclusion
A lack of confidence in diagnosing and managing FGIDs in primary care appears to be driving gastroenterology referrals for patients with suspected FGIDs. GP referrals were inadequate for the safe triage of patients to waiting lists, with over a third of patients triaged as non‐urgent with suspected FGIDs subsequently found to warrant earlier GE review. Resources to assist GPs in diagnosing and managing FGIDs in primary care and improved referral quality may both help to ensure effective patient care and efficient use of healthcare resources.