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Persons with gastroesophageal reflux disease (GERD) frequently search online for information about causes and treatment options. The GerdQ self-assessment questionnaire can be used for diagnosis of GERD and follow-up of symptoms.
To assess whether it is feasible (1) to study the prevalence and impact of GERD in persons visiting a GERD information website, and (2) to identify partial responsiveness to proton pump inhibitor (PPI) therapy using the GerdQ.
All visitors (aged 18–79 years) to a GERD information website between November 2008 and May 2011 were invited to complete the GerdQ online. The GerdQ questionnaire consists of 6 questions (score per question: 0–3). In respondents who did not use PPIs, we used the questionnaire to identify those with GERD (total score ≥8) and assess the influence of these symptoms on their daily life, divided into low (total score <3 on impact questions) and high impact (total score ≥3 on impact questions). In PPI users, we used the GerdQ to quantify partial responsiveness by any report of heartburn, regurgitation, sleep disturbance, or over-the-counter medication use for more than 1 day in the preceding week. We subsequently asked GerdQ respondents scoring ≥8 to complete the disease-specific Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaire.
A total of 131,286 visitors completed the GerdQ, of whom 80.23% (n = 105,329) did not use a PPI. Of these, we identified 67,379 respondents (63.97%) to have GERD (n = 32,935; 48.88% high impact). We invited 14,028 non-PPI users to complete the QOLRAD questionnaire, of whom 1231 (8.78%) completed the questionnaire. Mean total QOLRAD scores were 5.14 (SEM 0.04) for those with high-impact GERD and 5.77 (SEM 0.04) for those with low-impact GERD (
The GerdQ identified GERD in many website respondents and measured partial responsiveness in the majority of PPI users. Both non-PPI users with GERD and PPI users with partial responsiveness were associated with a decreased health-related quality of life. We have shown the feasibility of GERD patient identification online.
The Internet has gained major influence in the information supply for both physicians and patients in the last decades and has generated new opportunities to study health care and diseases [
GERD is a chronic relapsing and remitting disorder with heartburn and regurgitation as cardinal symptoms. It is associated with a decreased health-related quality of life [
The majority of persons with GERD symptoms are underreported in the literature, because prior studies regarding GERD were mainly conducted in primary care [
The aims of the current study were to assess whether it is feasible to study the prevalence and impact of GERD in persons visiting a GERD information website and to identify partial responsiveness to PPI therapy using the GerdQ self-assessment questionnaire. Symptom scores were compared with a validated health-related quality-of-life instrument. We hypothesized that the prevalence of GERD in our Internet population would be high and that a higher GerdQ score would reflect a lower health-related quality of life.
The website www.maagzuur.nl contains information regarding GERD symptoms, possible causes, lifestyle advice, and treatment and diagnostic options. In May 2008, the Dutch translation of the GerdQ self-assessment questionnaire was launched on this website and could be completed by all website visitors (see
The GerdQ is a short and validated self-assessment questionnaire that assesses presence of GERD and determines the influence of symptoms on a patient’s daily life [
The first two questions (1 and 2) are positive predictors of GERD, where a higher symptom frequency is indicated by a higher score. Questions 3 and 4 address dyspeptic symptoms that decrease the probability of having GERD—that is, they are negative predictors of GERD. The two final questions (5 and 6) assess the impact of symptoms on a person’s daily life and are also positive predictors of GERD. The score on every question ranges from 0 to 3 for the four positive predictors of GERD (0 days is a score of 0; 1 day scores 1; 2–3 days scores 2, and 4–7 days scores 3, or in reversed order for the two negative predictors of GERD). In people who do not use a PPI, a GerdQ score of ≥8 indicates a high probability of having GERD. A cut-off of ≥3 on the GERD-impact questions 5 and 6 indicates a high impact of symptoms on a person’s daily life. We defined partial responsiveness in PPI users as more than 1 day of having heartburn (question 1), regurgitation (question 2), sleep disturbance (question 5), or over-the-counter acid suppressive medication use (question 6), all during the preceding week. We also analyzed partial responsiveness using a more stringent definition of persistence of heartburn, regurgitation, sleep disturbances, or over-the-counter medication use for at least 4 days during the preceding week. The questionnaire was shown to respondents together with a figure of a human torso with the breastbone and center of the upper stomach being marked.
The validated disease-specific QOLRAD questionnaire was developed to monitor health-related quality of life in patients with heartburn and dyspepsia. It contains 25 questions clustered in five domains: emotional distress, sleep disturbance, food and drink problems, physical and social functioning, and vitality [
Questionnaires were stored online in a specially designed website content management system (TripTic bv, Eindhoven, The Netherlands). Data were analyzed using SPSS version 16.0 (IBM Corporation, Somers, NY, USA). We calculated total GerdQ score by summing scores for all of the GerdQ questions. The mean age of respondents with high-impact GERD and low-impact GERD were analyzed using the Student
The GerdQ self-assessment questionnaire was completed 153,415 times between November 2008 and May 2011. After removing duplicate entries (n = 16,447) and excluding respondents aged less than 18 years or 80 years and over (n = 5682), we entered 131,286 GerdQ questionnaires into our analysis (
Flow of participants through the study. PPI = proton pump inhibitor. GERD = gastroesophageal reflux disease. QOLRAD = Quality of Life in Reflux and Dyspepsia.
The mean age of the 105,329 respondents who did not use PPIs was 41.6 (SD 14) years, and 49.72% (n = 52,369) were male. A total of 37,950 respondents (36.03%) scored <8 on the GerdQ, indicating a low probability for GERD. The remainder (n = 67,379; 64.0%) scored ≥8, of whom half (n = 32,935; 48.88%) reported GERD with a high impact on the respondent’s daily life. Respondents with GERD were older than those without GERD, and the mean age was even higher in respondents with GERD with high impact (
Baseline characteristics of respondents with and without proton pump inhibitor (PPI) use.
Characteristic | No PPI use | PPI use | |||||
No GERDa
|
Low-impact |
High-impact |
Adequate |
Partial |
|||
Male, n (%) | 17,562 (46.28%) | 18,035 (52.36%)c | 16,772 (50.92%) | 1,539 (49.15%)d | 10,132 (44.39%) | ||
Age (years), mean (SD) | 39.2 (14) | 41.7 (14)c | 44.3 (14) | 49.9 (14)d | 48.3 (14) | ||
|
|||||||
18–30 | 12,937 (34.09%) | 9346 (27.13%)c | 6500 (19.74%) | 349 (11.15%)d | 2719 (11.91%) | ||
31–40 | 7953 (20.96%) | 7096 (20.60%) | 6721 (20.41%) | 437 (13.96%) | 3821 (16.74%) | ||
41–50 | 8157 (21.49%) | 8051 (23.37%) | 8252 (25.06%) | 717 (22.90%) | 5787 (25.35%) | ||
51–60 | 5833 (15.37%) | 6237 (18.11%) | 7217 (21.91%) | 861 (27.50%) | 5815 (25.48%) | ||
61–70 | 2575 (6.79%) | 3038 (8.82%) | 3527 (10.71%) | 603 (19.26%) | 3644 (15.96%) | ||
71–79 | 495 (1.30%) | 676 (1.96%) | 718 (2.18%) | 164 (5.24%) | 1040 (4.56%) |
a Gastroesophageal reflux disease.
b Partial response: heartburn, regurgitation, sleep disturbance, or over-the-counter medication use for >1 day during the preceding week.
c
d
Of respondents with low-impact GERD, 61.59% (n = 21,215) took over-the-counter medication less than once per week, compared with 8.64% (n = 2846) of respondents with high-impact GERD (
Frequency of over-the-counter medication use in respondents with and without proton pump inhibitor (PPI) use.
Frequency |
No PPI use | PPI use | |||
No GERDa
|
Low-impact |
High-impact |
Adequate |
Partial |
|
<1 | 31,673 (83.46%) | 21,215 (61.59%) | 2846 (8.64%) | 2221 (70.94%) | 8352 (36.59%) |
1 | 4086 (10.77%) | 9128 (26.50%) | 3169 (9.62%) | 910 (29.06%) | 2195 (9.62%) |
2–3 | 1692 (4.46%) | 4101 (11.91%) | 13,427 (40.77%) | 0 (0%) | 4587 (20.10%) |
4–7 | 499 (1.31%) | 0 (0%) | 13,493 (40.97%) | 0 (0%) | 7692 (33.70%) |
a Gastroesophageal reflux disease.
b Partial response: heartburn, regurgitation, sleep disturbance, or over-the-counter medication use for >1 day during the preceding week.
In a subset of respondents we inquired about duration of symptoms. Of those with low-impact GERD, 45.6% (n = 554) reported symptom duration of 1 year or less, while 56.3% (n = 930) of those with high-impact GERD reported symptoms for more than 2 years (
Duration of symptoms in respondents with and without proton pump inhibitor (PPI) use.
Duration |
No PPI use | PPI use | ||
Low-impact |
High-impact |
Adequate |
Partial |
|
0–6 | 376 (30.95%) | 290 (17.55%)c | 34 (18.4%) | 190 (13.76%)d |
7–12 | 178 (14.65%) | 213 (12.89%) | 14 (7.6%) | 123 (8.91%) |
13–24 | 130 (10.70%) | 219 (13.26%) | 13 (7.0%) | 131 (9.49%) |
>24 | 531 (43.70%) | 930 (56.30%) | 124 (67.0%) | 937 (67.85%) |
a Gastroesophageal reflux disease.
b Partial response: heartburn, regurgitation, sleep disturbance, or over-the-counter medication use for >1 day during the preceding week.
c
d
A total of 14,028 respondents were eligible for (ie, GerdQ score ≥8) and invited to complete the QOLRAD questionnaire, of whom 1231 (8.78%) completed the questionnaire. The total mean QOLRAD score in respondents with GERD with low impact on daily life was 5.77 (SEM 0.04), compared with 5.14 (SEM 0.04) in those with high-impact GERD (
Quality of Life in Reflux and Dyspepsia (QOLRAD) scores by domain in respondents with gastroesophageal reflux disease (GERD) who did not use proton pump inhibitors (PPIs). Error bars indicate SEM. *
The mean age of PPI users was 48.5 (SD 14) years, and 44.96% (n = 11,671) were male. A total of 22,826 PPI users (87.94%) reported having heartburn or regurgitation, sleep disturbances due to GERD symptoms, or intake of over-the-counter acid suppressive medication for more than 1 day per week. We classified these PPI users as partial responders, and this subgroup was younger and had a higher proportion of women (
A total of 6238 PPI users were eligible for and invited to complete the QOLRAD questionnaire, of whom 599 (9.60%) completed the disease-specific quality-of-life questionnaire. The total mean QOLRAD score over all domains was 5.88 (SEM 0.14) in PPI users with adequate relief and 4.62 (SEM 0.05) in PPI users with partial response (
In both groups of PPI users, scores in the vitality and food/drink domains were lowest, with a consistently lower score in those with partial response. The total mean QOLRAD scores in the two subgroups of partial responders were 5.14 (SEM 0.09) for responders with symptoms persisting at most 3 days per week and 4.43 (SEM 0.06) for responders with symptoms persisting at least 4 days per week (
Quality of Life in Reflux and Dyspepsia (QOLRAD) scores by domain in proton pump inhibitor (PPI) users. Error bars indicate SEM. a
Quality of Life in Reflux and Dyspepsia (QOLRAD) scores by domain in proton pump inhibitor (PPI) users with subdivision of partial responders. *
We found that the prevalence of GERD in website visitors was high, as over 60% of responders without PPI use scored at or above the predefined cut-off on the GerdQ questionnaire. Of the respondents with GERD who did not use a PPI, 49% reported that their symptoms had a great influence on their daily life, in the form of sleep disturbances, and that they needed over-the-counter medications. This was associated with a decreased health-related quality of life. Almost 90% of PPI users reported persistent GERD symptoms for at least 1 day per week. Partial responders taking PPI therapy had a lower health-related quality of life than those who did not use PPIs and those with adequate symptom relief obtained from PPI therapy.
We used the validated self-assessment questionnaire GerdQ to assess the prevalence of GERD among website visitors. Research via the Internet has several advantages and generates new possibilities. As only a minority of patients with GERD visit a health care provider, we can use the Internet to study people who are normally out of the scope of traditional research methods [
We have shown that it is possible to detect patients with GERD symptoms through a dedicated website. This method can also be used for other conditions. We found that over 150,000 respondents completed the GerdQ questionnaire made accessible online on a health information website, emphasizing the need for disease information on the Internet. However, the skills of the general population to adequately seek health information on the Internet have been shown to be insufficient [
In our study, only 10% of invited respondents completed the QOLRAD questionnaire. We consider the low response rate on completing the QOLRAD questionnaire to be the main drawback of research via an open access questionnaire. Respondents lack face-to-face contact and miss any relationship with the researchers, reducing their willingness to complete a questionnaire without any expected personal gain. A previous study by McCambridge et al assessed the effect of length and relevance of questionnaires on completion rates [
We used the GerdQ self-assessment questionnaire to identify partial responsiveness in PPI users. This is a novel and very promising feature of the GerdQ. We found that almost 90% of all PPI users had heartburn or regurgitation, sleep problems, or over-the-counter acid suppressive medication use for more than 1 day per week. Of the PPI users, 62% reported persistent symptoms on at least 4 days during the preceding week. Respondents with symptoms persisting at least 4 days per week reported the lowest health-related quality of life in our survey.
A recently published systematic review found that reflux symptoms during PPI therapy persisted in 17%-45% of patients in primary care and the general population [
Our study has several strengths. We included over 130,000 participants in our study, which is the largest population studied for GERD so far [
Our study also has limitations. First, we have to take selection bias into account. Online health information seekers are probably younger and more educated than are people who search for health information offline [
The results of our study have some important implications for clinical practice. Many persons searching the Internet for information about reflux have GERD. This generates new opportunities for using the Internet to recognize and treat GERD. It is possible to detect people with GERD and to advise them at first to adjust their lifestyle and take an over-the-counter medication. If these measures are ineffective, these people can be advised to seek medical treatment. People can also regularly complete the GerdQ self-assessment questionnaire via the Internet to assess the effectiveness of their treatment. If they are dissatisfied, they can contact a health care practitioner.
Most PPI users searching the Internet report persistent symptoms or use over-the-counter medication in addition to PPI treatment. General practitioners and gastroenterologists assume that most patients with GERD are adequately treated [
We have shown that it is feasible to find patients through a dedicated website for GERD. This concept will also be applicable to other conditions and diseases.
The GerdQ self-assessment questionnaire was completed by over 130,000 website visitors. Two-thirds of respondents who did not use PPIs obtained a score suggestive of GERD. The prevalence of partial responsiveness to PPI therapy was high. Respondents reporting a high impact of GERD had a decreased disease-specific health-related quality of life. Identification of people with GERD through a GERD information website has been shown to be feasible.
The GerdQ self-assessment questionnaire.
gastroesophageal reflux disease
proton pump inhibitor
Quality of Life in Reflux and Dyspepsia
We thank TripTic bv, Eindhoven, for data storage and provision, and in particular Eefje op den Buysch for her assistance. We thank the editorial board (Jan-Willem Straathof MD PhD, and Hugo Boender MD) and we thank AstraZeneca BV, the Netherlands, for financial support of the website www.maagzuur.nl. The sponsor did not have any influence on the analysis, writing, and conclusions of the article.
MGHvO designed the study. MMT and MGHvO performed statistical analyses. All authors had full access to study data. MMT and MGHvO drafted the first and subsequent versions of the manuscript with input from JBMJ. All authors read and approved the final manuscript.
MGH van Oijen has received grant support from AstraZeneca and Janssen, and has served as a consultant for AstraZeneca and Pfizer. MM Tielemans and JBMJ Jansen have no conflicts of interest.