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Practicing clinicians are increasingly required to be aware of the health economics of treatments they prescribe. Several papers in this edition of Frontline Gastroenterology, from authors around the world, reflect on this important emerging aspect of care. We are pleased to bring the journal content to the wider audience, as we continue to believe that the content is a reflection of exemplars of practice that can improve healthcare provision for the patients we treat as gastroenterologists and hepatologists. This global ambition is mirrored in our submissions from around the world, as well through the reach of our increasingly popular Twitter debates. The online reach of these debates is huge in addition to the opportunity to interact directly with internationally renowned leaders in the field. Do get involved - #FGDebate and follow @FrontGastro_BMJ.
Practical clinical tips for severe and common hepatology conditions
As ever, Frontline Gastroenterology is very pleased two publish two clinically influential hepatology manuscripts. Although relatively uncommon, refractory pruritus secondary to cholestasis is a very difficult condition for patient and physician, and the condition can sometimes precipitate the need to consider liver transplantation. The team from Leeds describe a rapid and complete therapy for this patient group when molecular adsorbents recirculation system (MARS) therapy is unavailable or has failed.
By contrast, in terms of prevalence, cardiovascular disease is one of the commonest causes of morbidity and mortality in patients with cirrhosis. Due to their association with hepatotoxicity, statins have often been under-prescribed in this patient group. This is especially relevant given the increased incidence of cirrhosis secondary to non-alcoholic fatty liver disease. Wright and colleagues from Harvard medical school have reviewed the recent studies of outcome in liver patients taking statins, as well as looking specifically at the emerging data on mechanisms and efficacy in ameliorating portal pressure and hepatocellular carcinoma development.1
The real life health economics of diagnosing and treating irritable bowel syndrome
With a well-recognised high prevalence, functional disorders represent a major part of the gastroenterologist's workload. The costs associated with this patient group become relevant in the model of healthcare funding advocated throughout the world, and Soubieres et al2 have defined this in a paper in this edition. As care providers and funders move towards better clinical coding, and with Rome IV about to report in 2016 with new diagnostic criteria for functional disorders, this analysis is especially timely as a benchmark of what we can improve in our own practices. This is an important analysis given the relative paucity of such publications outside the USA funding model. What emerges is the relative expense of treating pain and constipation symptoms, compared to diarrhoea. Also, it is clear that there is often a hesitation from secondary care clinicians in making a positive diagnosis, a message that will likely be addressed by Rome IV, hopefully giving clinically relevant guidance for the general gastroenterologist.
Endoscopy: from bowel preparation to post-procedure recovery
We are delighted to publish two endoscopy papers in this edition. The first is a randomised phase 2 clinical trial from Ormarsson and colleagues in Rejkyavik, Iceland.3 They have shown that fish oil suppositories are inferior to a standard docusate and sorbitol enema in terms of endoscopist satisfaction with the quality of view at flexible sigmoidoscopy. Although a negative result, it is studies like this that in the long run lead to optimized care for patients inasmuch as the suppositories may prove effective as a therapy for rectal evacuation as symptom relief (in a field where we have had no new agents for two decades) or as preparation for colorectal surgeons prior to bedside haemorrhoid procedures.
The brilliant singer-activist Pete Seeger said “Education is when you read the fine print; experience is what you get when you don't”. Serious harm resulting from conscious sedation is unacceptable and although we consent our patients carefully pre-procedure it is based on a poverty of data explaining at risk factors for needing to reverse sedation. Procedures on in-patients and the elderly, especially if there is an elevated ASA grade are especially prognostically risky, and ERCPs are especially so too. In addition, the paper raises an argument in the potential debate regarding use of propofol in these high risk patients. Learning from the experience of Zakeri et al4 reviewing over 73,000 procedures is the basis for improved experience, to paraphrase Pete Seeger.
Inflammatory bowel disease: are there service cost-savings to be had?
Our pedigree in publishing frontline IBD research remains high. In addition to papers on managing acute sever colitis as well as optimising trial design, we have two papers looking at health economics. Dharmasiri et al5 demonstrate a reduction of over £10k (€15k) per patient per year by using a strategy of allopurinol added to low dose azathioprine in an effort to preserve efficacy of the former, compared to switching to biologics. With regard to biologics Russell and a group of UK experts review the potential financial savings to be had with careful monitoring of efficacy of these agents.
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