Chronic Pain and Mood Disorders Are Not Barriers to Symptom Improvement Under Collaborative Co-managed Care (C3).

We analyzed a cohort of outpatients seen at the GI Motility Center at Dartmouth-Hitchcock Medical Center and being managed using our innovative C 3 model.[ 2 ] Our study followed the TRIPOD checklist for multivariable prediction models.[ 3 ] The Institutional Review Board at Dartmouth-Hitchcock determined that this study was exempt from review, prior to initiation of our study. Individuals were identified based on completion of a baseline and at least one follow-up electronic clinic intake form in our electronic health record system (EMR). We included individuals at least 18 years and no more than 80 years old. Patient age at treatment initiation was extracted from our EMR. The remainder of possible predictors of response as well as patient-reported outcomes were obtained from the electronic clinic intake questionnaires, including the presence of individual COPCs and mood disorders, prior management strategies utilized, and scores on several previously validated disease assessment tools. Clinical response was measured by whether a patient achieved adequate relief of gastrointestinal symptoms as a valid and reliable end point for clinical practice. Health-related quality of life (HRQOL) was measured using the CDC HRQOL-4 instrument assessing patients’ number of healthy days in the past 30 days. Data analysis was performed using R package icenREG. We used the Turnbull estimator[ 4 ] to generate survival curves under interval censorship and unadjusted and derived adjusted hazard ratios (HRs) from the Finkelstein proportional hazard models, which summarizes adjusted and unadjusted differences by groups.[ 5 ] Outcomes were censored after the last date of follow-up. Of note, the HRs therefore represent probability of non-response, and a lower HR <1.0 suggests a higher likelihood of response.

We identified 94 patients seen at the GI Motility Center who met eligibility criteria and were included in the overall cohort. Baseline characteristics are reported in Table 1 . The mean age was 47, 40% had at least one COPC, and 46% had at least one diagnosed mood disorder. 67% had tried at least one management strategy prior to referral to our center. Sixty-two patients (65.9%) reported adequate relief at any follow-up point. Quality of life data were available for 91 patients (96.8%), with 44 of them reporting improvement (48.3%). Patients with chronic constipation on initial survey had statistically significantly more frequent achievement of relief of symptoms, with hazard ratio (HR) of non-response of 0.25 (p-value: 0.0124, 95% Confidence Interval: 0.08-0.74), where low HR represents a higher likelihood of response. No other variables examined reached statistical significance as predictors of response. The presence of comorbid chronic pain conditions or mood disorders were also associated, though not significantly, with relief of symptoms and increased quality of life ( Table 2 , Figure 1 ). When adjusted for the performance on all baseline symptom questionnaires, COPC had a HR of 0.50 (p-value: 0.634) but a wide 95% confidence interval (0.03 to 8.5) for non-achievement of symptom relief. The unadjusted HR (0.55) had a narrower confidence interval (0.23 to 1.32). The unadjusted HR for non-achievement of symptom relief for mood disorders was 0.64 (0.2775; 0.28 to 1.44), while the adjusted increased to 0.99 with a p-value of 0.999 and non-informative confidence interval. Results were similar for improvement in quality of life.

In our cohort of patients managed under the novel C 3 model, patients with comorbidities associated with increased disease severity and healthcare utilization (COPCs, mood disorders) were able to achieve relief of symptoms and improvement in quality of life at an at least similar, and possibly increased, rate to compared to that of patients without these comorbidities. That no significant difference was found between these patients and their counterparts suggests that our care model effectively manages these patients. In fact, though limited by our small sample size, our hazard ratios of non-response of 0.50 to 0.70 strongly suggest that patients with these comorbidities had better outcomes than their peers. The C 3 model anchors on setting up-front expectations with patients, referring providers, and across the team; including all members of the care team on a cohesive team; and, centering care around the patient with their local primary care provider at the helm with gastroenterology positioned as a consultant. As mood disorders and COPCs are so common, the C 3 model is a general gastroenterology care model that emphasizes the importance of patient-physician communication, specialist-referring provider communication, and team communication in contemporary healthcare.[ 6 ] In a recent publication, we detail concrete steps to replicate this care model in gastroenterology practices.[ 2 ] Interestingly, our findings were independent of focus on specific disease mechanisms. And, our model did not anchor on delivering or having access to complex multidisciplinary care. For example, while symptom severity was moderate or severe in many patients, fewer than 5% of patients in our cohort accessed allied health resources, and treatments prescribed to patients were myriad. In other words, no specific treatment modality can explain our findings, but rather our findings more likely relate to use of the Rome framework to deliver a positive diagnosis in general gastroenterology within the context of the C 3 healthcare delivery model as a whole. We previously reported that the use of the C 3 model reduced the number of visits at our clinic from 3.1 visits to complete necessary care, compared to 5.8 visits at other Centers in the Gastroenterology Division, allowing us to shorten wait times for visits to 3 to 6 weeks rather than 6 to 12 months.(2) Additionally, we were able to triple the number of motility tests performed at our center, greatly increasing the amount of tertiary-care center level care administered while empowering patients’ local GIs to continue primary management. This model therefore improves access to expert consultation and favors delivery of health versus healthcare. Thus, we demonstrate that healthcare delivery and operations management play a critical role in healthcare and that attention is needed in this area to attain further critical breakthroughs that improve health across the spectrum of GI diseases.

Many patients referred to gastroenterologists have chronic overlapping pain conditions (COPCs) and mood disorders that portend greater disease severity and healthcare utilization.[ 1 ] As a result, GI practices often choose to silo care for affected patients into “motility centers”, clinics anchored on frequent follow-up visits and complex care plans. Unfortunately, this arrangement is not broadly scalable, posing access and equity challenges. We developed an innovative healthcare delivery model in which motility center gastroenterologists serve as consultants for patients across diseases who maintain their referring provider as their care home, representing collaborative, co-managed care (C 3 ). Our center frames treatment goals and expectations, develops longitudinal step-wise care plans, and maximizes patient engagement in care with local teams. We care for patients with esophageal reflux and dysmotility, eosinophilic esophagitis, pelvic floor, and general GI disorders such as disorders of gut-brain interaction. We aimed to determine whether comorbid chronic pain and mood disorders mediate patient outcomes in our C 3 model independent of specific treatment paradigms.