Overall, health-related quality of life (HRQOL) evaluations reflect the burden of illness from the patient’s point of view. The patient has basic needs, such as physiological requirements, security, social relationships, self-confidence and self-actualization. If these are fulfilled, well-being is promoted. If these needs are not satisfied, anxiety, tension and stress are created.24 This means that all patients will have to be treated individually to meet their needs, which may include specific treatment, explanations and understanding. For the patient, his/her symptoms are generally the major concern, regardless of whether or not the condition is medically serious. Disease severity correlates strongly with health-related quality of life (HRQOL) which rapidly improves with effective GORD treatment.16,94
Gastro-oesophageal reflux disease is a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications.1 Experience of heartburn at least twice weekly is thought to be sufficient to result in impaired quality of life.95 In GORD patients, sleep disturbance caused by GORD symptoms is remarkably prevalent and can lead to daytime tiredness, which disrupts daily functioning and productivity.1,9,26-28 GORD patients generally report decreased quality of life scores, reduced productivity and decreased well-being.1,5,9,28 Daily life becomes more adversely affected as the frequency and severity of GORD symptoms increase.29,30 In many of these patients, reported quality of life is lower than in patients who have untreated angina pectoris, chronic heart failure, hypertension or diabetes.5,31 Among the GORD subtypes, Kulig et al in a large multinational cohort study (n
= 6215) reported no relevant differences in symptoms and quality of life between patients with Barrett’s oesophagus, erosive GORD and non-erosive GORD at the study baseline. This further indicates that endoscopy results are of no relevance to their quality of life.31
Patients who suffer from GORD symptoms may be concerned about the possibility that more serious problems, such as heart disease or cancer, are the cause of their symptoms.1,91 GORD
55
can cause chest pain that closely mimics ischemic cardiac pain.1 Peptic ulcer disease, gastric or oesophageal malignancy, gall bladder disease, caustic oesophagitis and eosinophilic infection are other differentials of GORD. GORD is the final diagnosis in 50% of patients with non-cardiac chest pain, 78% of those with chronic hoarseness, and 10% of those presenting with chronic cough.96 Nevertheless, once cardiac causes have been excluded, patients are often left untreated. These patients carry a burden of increased health care use and functional impairment until they are correctly diagnosed and treated.97 A careful assessment to determine the correct causes of symptoms and communicate with the patient about GORD and its treatment are valuable in reassuring the patient.
The quality of life results provide a basis for a holistic view of the patient and supplement the traditional outcomes. They may also document the full range of treatment benefits and possible side-effects and can predict the treatment outcome. The purpose of focusing on health-related quality of life is to go beyond the presence and severity of symptoms of disease or side-effects of treatment and examine how patients perceive and experience these manifestations in their daily lives.
In a study by Van Rensburg et al in South Africa, most patients (62%) described their symptoms as being severe during the period.9 As a result of their symptoms, important reflux related aspects of life, such as problems with food and drink (3.5), emotional distress (3.6), impaired vitality (3.7), sleep disturbance (3.8) and impaired physical/social functioning (4.3) were experienced in the five dimensions of the quality of life in reflux and dyspepsia (QOLRAD) tool at baseline on a scale of 1 to 7, where 1 represents the “most severe impact on daily functioning” and 7 “no impact”. Reported visit to a doctor because of emotional problem during the past five years was 26%.9
El – Dika et al in Canada studied uninvestigated outpatients with mean age of 50 years (range 20 – 80years) with a clinical diagnosis of moderate to severe GORD.98 Unemployed persons
56
were 69%, females 53% and the mean number of months since diagnosis was 86 (range 1 to 504, i.e up to 42 years). The reported mean QOLRAD scores for the domains at baseline was:
vitality 4.3, emotional distress 4.5, sleep disturbance 4.5, food/drink problems 3.8 and physical/social function 5.5. The greatest impact was on food/drink problems (3.8) and vitality (4.3) domains. The mean change score after 4 weeks of PPI treatment (Esomeprazole) was 2.1 for vitality, emotional distress 2.0, sleep disturbance 2.1, food/drink problems 2.5 and physical/social function 1.3. The result indicated that GORD causes important reductions in HRQOL.98 Innocenti et al reported that the greater the improvement on the vitality domain of QOLRAD questionnaire during PPI therapy the more likely the patient was to be satisfied with the treatment.99
The reported baseline mean QOLRAD by Engels et al in Sweden among gastroenterology outpatient clinic participants with mean age of 49.1 ± 13.5 years showed that symptoms impacted strongly on vitality (3.9), followed by food/drink problems (4.1), sleep disturbance (4.5), emotional distress (4.7) and physical/social functioning (5.2).100
Kulig et al in a prospective, multi-centre, open cohort study; the Progression of Gastro-esophageal Reflux Disease (ProGERD), reported an increase of mean QOLRAD score on a 7-point Likert scale from 4.6 at baseline to 6.2 at 2 weeks using esomeprazole in adult participants (≥ 18 years).31 This represented a highly relevant clinical improvement.
In a survey conducted by the National Heartburn Alliance in the USA, more than 70% of the respondents reported reduced enjoyment of food and that eating out was a problem because of their GORD symptoms.101 In addition, majority reported that heartburn affected their sleep and caused problems with concentration at work, with over 30% stating that social activities were curbed by heartburn.101
57 2.4.2 Physical findings
There are few if any signs of GORD.1,2,5 A small proportion of patients with severe and extra-oesophageal GORD will have an inflamed pharynx or larynx, or dental erosions from the effects of acid regurgitation on these structures. However, the majority of patients will have no signs.