Digital health tools, artificial intelligence, and a move to truly integrated care will shape the future of the practice of gastroenterology, William D. Chey, MD, FACG, said in his J. Edward Berk Distinguished Lecture at the American College of Gastroenterology (ACG) Scientific Meeting on October 26.

Dr Chey is the Nostrant Professor of Gastroenterology & Nutrition Sciences and director of the GI Physiology Laboratory at the University of Michigan.

“I understand as a clinician all the challenges we face in the clinic every day,” Dr Chey said. He used as an example of those challenges—and the evolution of gastroenterology— the treatment of patients with irritable bowel syndrome (IBS).

“We all understand that this is a team sport. IBS involves a multidisciplinary team, including dieticians and perhaps GI psychotherapists. But this is not where we started. It began with the gastroenterologist talking to the patient and choosing a medication based on the predominant complaint.”

Referring to a slide illustrating numerous therapeutic interventions, Dr Chey said, “The good news is we have a lot of options; the bad news is that none of them work all that well. We may see some significant therapeutic gains over placebo but by no means is any of these a silver bullet for IBS.”

He noted that patients with IBS “will tell  you that the two biggest triggers involve what they eat, and when they’re stressed.” Now, there is an evidence base confirms that diet and stress are in fact significant in the management of IBS.

The Low FODMAP diet is the most evidence-based dietary intervention, Dr Chey said, showing effectiveness in reducing abdominal pain, bloating, and distention. Although most of the studies to date have shown a high risk of bias, “In general, the data tends to move in the right direction.”

He referenced a study of patients in 69 general practices across Europe who were randomized to the antispasmodic otilonium or the low FODMAP diet, which was administrated via a smartphone app. “The low FODMAP diet was more effective consistently over 6 months,” he said.

The elimination phase is just the beginning, Dr Chey said. “Consider this a test of 2 to 6 weeks.  If the patient doesn’t respond within a few weeks, discontinue this diet and move on. But if there is response, then the second phase involves reintroduction of foods; the third phase is when you can customize and liberalize the diet.” He added that more than 80% of patients are able to liberalize the low FODMAP diet.

Both the Mediterranean diet and guidelines from the UK’s National Institute for Health and Care Excellence (NICE) also show effectiveness in IBS.

Behavioral therapies also have evidence supporting their effectiveness in treating patients with IBS, Dr Chey said. “Psychological therapists, at any level of GI symptoms, should be equal partners in the care team.” The key to success is the patient’s own insight into how their mental and emotional health affect their symptoms, and their willingness to engage with a therapist.

A meta-analysis of 41 randomized controlled trials of behavioral therapies for IBS showed that the most efficacious was minimal contact cognitive behavioral therapy (CBT); face-to-face CBT and gut-directed hypnosis also showed effectiveness.

The role of minimal contact CBT will be very important in efforts to deliver integrated care, he explained, “because there are just 400 GI therapists in the US to serve 17,000 gastroenterologists.” Using minimal contact CBT will enable those therapists to efficiently serve far more patients than would be possible with only face-to-face therapy.

Utilizing behavioral therapy is an essential element of integrated care (IC), which Dr Chey described as the blend of behavioral health with general and specialty medical services. Integrated care “puts the patient at the center and addresses full range of physical, emotional, mental, social, spiritual, and environmental influences that affect health.”

Evolution to integrated care, Dr Chey said, is “the real pie-in-the-sky type of care, where we want to go.” Rather than patients seeing separate providers independently for all aspects of treatment, IC is “team-based, collaborative care.” However, it has been mostly available only in large academic centers.

There is now evidence to support the efficacy of IC, as well, Dr Chey said. A study published last year showed that of 188 patients with functional gastrointestinal disorders were randomized to traditional care or IC, he explained; 57% of patients receiving traditional care had a global response, compared to 84% in the IC group. Among those with IBS, the cost of a successful outcome was also lower in the IC group compared to the traditional care cohort.

“If IC is so great, why aren’t we doing it?” Dr Chey asked. “Well, first of all, almost all of the literature on this subject has been published only in the last 10 years, so that limited the evidence. There are also access barriers to sufficient dieticians and behavioral therapists, especially those with a special understanding of GI issues. And even though the cost of IC is lower over time, there are high up-front costs.”

One way to minimize those costs is to make more use of digital health tools, Dr Chey said. Using digital programs and technology “can enhance efficiency of health care delivery and make care more personalized and precise.” Novel technological solutions are being developed at a record pace, he noted.

Dr Chey explained that mobile apps have been developed for tracking symptoms, diet, stool, and more. Technology is being used to deliver at-home care from cognitive behavioral therapy to gut-directed hypnosis and guidance for following a low   FODMAP diet. At-home diagnostics are available for blood, stool, and breath testing. And virtual integrated care platforms can deliver those integrated care services that are the ultimate goal.

“This is the best-funded space in health care right now. Between $500 million and $1 billion is being invested per week in the digital health space,” Dr Chey said. “We should all be paying attention to what’s happening here.”

--Rebecca Mashaw

Chey, WD. The end of the beginning: megatrends in gastroenterology. The J Edward Berk Distinguished Lecture. Presented at the American College of Gastroenterology Scientific Meeting. October 26, 2021.