Is Irritable Bowel Syndrome a Diagnosis of Exclusion? A Survey of Primary Care Providers, Gastroenterologists, and IBS Experts

Abstract

OBJECTIVES-Guidelines emphasize that irritable bowel syndrome (IBS) is not a diagnosis of exclusion and encourage clinicians to make a positive diagnosis using the Rome criteria alone. Yet many clinicians are concerned about overlooking alternative diagnoses. We measured beliefs about whether IBS is a diagnosis of exclusion, and measured testing proclivity between IBS experts and community providers.METHODS-We developed a survey to measure decision-making in two standardized patients with Rome III-positive IBS, including IBS with diarrhea (D-IBS) and IBS with constipation (C-IBS). The survey elicited provider knowledge and beliefs about IBS, including testing proclivity and beliefs regarding IBS as a diagnosis of exclusion. We surveyed nurse practitioners, primary care physicians, community gastroenterologists, and IBS experts.RESULTS-Experts were less likely than nonexperts to endorse IBS as a diagnosis of exclusion (8 vs. 72%; P < 0.0001). In the D-IBS vignette, experts were more likely to make a positive diagnosis of IBS (67 vs. 38%; P < 0.001), to perform fewer tests (2.0 vs. 4.1; P < 0.01), and to expend less money on testing (US$297 vs. $658; P < 0.01). Providers who believed IBS is a diagnosis of exclusion ordered 1.6 more tests and consumed $364 more than others (P < 0.0001). Experts only rated celiac CONFLICT OF INTERESTGuarantor of the article: Brennan M.R. Spiegel, MD, MSHS. Specific author contributions: Study design, study implementation, data collection, data analysis, data interpretation, paper preparation, and paper approval: Brennan Spiegel; study design, study implementation, data collection, and paper review: Mary Farid; study design, data interpretation, and paper review: Eric Esrailian; study implementation and data collection: Jennifer Talley; study design, data interpretation, paper preparation, and paper approval: Lin Chang. Potential competing interests: Spiegel and Chang have served as advisors to Prometheus Laboratories, and have received grant support from Takeda Sucampo Pharmaceuticals, Rose Pharmaceuticals, and Prometheus Laboratories. NIH Public Access Author ManuscriptAm J Gastroenterol. Author manuscript; available in PMC 2010 October 4. CONCLUSIONS-Most community providers believe IBS is a diagnosis of exclusion; this belief is associated with increased resource use. Experts comply more closely with guidelines to diagnose IBS with minimal testing. This disconnect suggests that better implementation of guidelines is warranted to minimize variation and improve cost-effectiveness of care.

High Prevalence of Idiopathic Bile Acid Diarrhea Among Patients With Diarrhea-Predominant Irritable Bowel Syndrome Based on Rome III Criteria

“…As a result, non-experts demonstrated an increased utilization of resources, particularly in those presenting with D-IBS. 28 This highlights that, despite decades of expert opinion, clinicians remain concerned about the possibility of a missed organic pathology in patients meeting criteria for IBS. This is reinforced by the fact that celiac disease may account for up to 4% of IBS cases, 7 which subsequently led to a paradigm shift in international guidelines.…”

“…Such uncertainties are already apparent in clinical practice where healthcare professionals vary greatly in their beliefs as to whether IBS is a diagnosis of exclusion. 28 A survey conducted in the USA amongst primary care physicians, community -IB" internationally recognized panel of IBS key opinion leaders, revealed that non-experts were far more likely to endorse IBS as a diagnosis of exclusion (72% vs. 8%). As a result, non-experts demonstrated an increased utilization of resources, particularly in those presenting with D-IBS.…”

Enhancing Diagnostic Performance of Symptom-Based Criteria for Irritable Bowel Syndrome by Additional History and Limited Diagnostic Evaluation

“…Most investigators have used a normal colonoscopy as confirmation of a diagnosis of IBS; 12 that is, physicians still regard IBS as a diagnosis of exclusion, which is perhaps justified by the modest performance of the different symptom-based criteria for IBS proposed over the last four decades. 11,13 Indeed, the current level of diagnostic confidence, based exclusively on these criteria, has not reduced the performance of testing such as colonoscopy and biopsies in some settings, 14 despite the desirability to enhance high-value care.…”

Eluxadoline: a promising therapy that raises many questions

“…The direct and indirect costs of IBS in the US exceed $30 billion per year and the condition is associated with approximately 3.6 million annual physician visits (9,10). The diagnosis of IBS, particularly in primary care, is widely viewed as a diagnosis of exclusion established by negative testing for organic gastrointestinal or systemic diseases, consequently leading to dramatically higher health care costs related to diagnostic testing (11,12).…”