The Burden of GERD on Health-related Quality of Life
This systematic review of the literature identified 19 studies that presented data on the impact of disruptive symptoms of heartburn and/or regurgitation on HRQL (Table 1). Nine studies were conducted in the community and 10 in the primary or secondary care setting. In total, the studies included 55 834 individuals with reflux symptoms. The reported mean age of participants in each study ranged from 43 years to 64 years, and 5–68% of them were women. Data were provided on the comparative burden of frequent reflux symptoms in eight studies and of severe reflux symptoms in 13 studies. Six studies included data on the comparative impact of nocturnal reflux symptoms: two reported the definition used for 'nocturnal symptoms', describing these as symptoms occurring when lying down to sleep at night, when awakening at night because of symptoms, or when waking up in the morning with symptoms; the other four studies did not state how nocturnal symptoms were defined. The characteristics of the 19 included studies and main results are summarised as online supporting information (online Table 1).
The most commonly used instrument was the Short Form Health Survey (SF-8, SF-12 or SF-36), a generic HRQL instrument that was used in 12 of the 19 studies; five provided comparative data on the impact of frequent symptoms, seven on that of severe symptoms and four on that of nocturnal symptoms. The second most commonly utilised instrument was the Work Productivity and Impairment questionnaire (WPAI), the generic version of which was used in four studies and disease-specific versions in three studies; two of these studies provided comparative data on the impact of frequent symptoms, four on that of severe symptoms and three on that of nocturnal symptoms. The Psychological and General Well Being index (PGWB), a generic HRQL instrument, was used in four studies, and all provided data on the impact of severe symptoms. Three studies used the disease-specific Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD); one provided data on the impact of frequent symptoms, three on that of severe symptoms and one on that of nocturnal symptoms. The EuroQol five-dimensional HRQL questionnaire (EQ-5D) and the Medical Outcomes Study Sleep disturbance scale (MOS Sleep), both of which are generic instruments, were used in two studies each, all of which provided data on the impact of severe symptoms. The Quality of Life Questionnaire in Gastroesophageal Reflux (RefluxQual), which is disease-specific, and the Epworth Sleepiness Scale (ESS) and the Pittsburgh Sleep Quality Index (PSQI), which are generic, were used in one study each; all three studies provided data on the impact of nocturnal symptoms, and one also assessed the impact of frequent symptoms.
Six studies used versions of the WPAI to assess the impact of disruptive GERD on work productivity, and five of these reported data separately for absenteeism and presenteeism. Overall, the mean number of hours absent from work per week was 2.4-times higher in the groups with disruptive GERD than in those with nondisruptive GERD [2.8 h (range: 0.3–7.0 h) vs. 1.2 h (range: 0.1–2.6 h); Figure 2]. Similarly, the overall mean reduction in productivity while at work was 1.5-times higher in the groups with disruptive GERD than in those with nondisruptive GERD [21.8% (range: 11.8–32.0%) vs. 15.0% (range: 5.1–24.9%); Figure 3].
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Figure 2.
Effect of reflux symptom frequency and severity, and of nocturnal reflux symptoms, on absenteeism in studies that reported the hours per week absent from work because of symptoms, using the Work Productivity and Impairment questionnaire (WPAI).[6, 8, 11, 20, 21] For Dubois et al., the number of hours absent per week was estimated by multiplying percentage reduction by a 40-h work week. [11]NR, not reported; NS, not statistically significant.
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Figure 3.
Effect of reflux symptom frequency and severity, and of nocturnal reflux symptoms, on presenteeism in studies that reported the percentage of reduced productivity while at work because of symptoms, using the Work Productivity and Impairment questionnaire (WPAI).[6, 8, 11, 20, 21]NR, not reported; NS, not statistically significant.
The groups with more frequent symptoms had a greater mean number of hours absent from work [2.8 h (range: 1.7–4.0 h) vs. 1.7 h (range: 0.6–2.6 h)] and a greater mean reduction in productivity while at work [21.9% (range: 12.2–28.3%) vs. 16.7% (range: 5.2–22.4%)] than those with less frequent symptoms (all P < 0.05; Figures 2 and 3). Similarly, the groups with more severe reflux symptoms had a greater mean number of hours absent from work [4.8 h (range: 2.5–7.0 h) vs. 0.6 h (range: 0.4–0.7 h)] and a greater mean reduction in productivity while at work [24.1% (range: 16.2–32.0%) vs. 10.6% (range: 5.3–16.0%)] than those with less severe symptoms (P < 0.001[21] and not reported[6]; Figures 2 and 3). One study reported only on the proportion of participants with reduced work productivity, which was lower in patients with mild symptoms than in those with severe symptoms (12% vs. 48%; P < 0.01).
The impact of reflux symptoms on the mean number of hours absent from work was found to be similar in individuals with frequent nocturnal symptoms and those with only occasional or no nocturnal symptoms [0.9 h (range: 0.1–1.1 h) vs. 0.6 h (range: 0.3–1.4 h); P > 0.05 for both studies]; the impact of frequent nocturnal symptoms on presenteeism was significant in one study (11.8% vs. 5.1%; P < 0.05),[11] but not in the other (26.6% vs. 24.9%; P > 0.05) (Figures 2 and 3). In the study that reported only on the proportion of participants with reduced work productivity, this was found to be higher in the group of individuals with nocturnal symptoms than in those with daytime symptoms only (70% vs. 31%; P < 0.01).
Overall, sleep quality scores were 1.5-times (range 1.2–1.9) lower in groups with disruptive GERD than in those with nondisruptive GERD in the three studies that provided such scores: greater overall symptom severity was associated with significant decreases in sleep quality in the two studies that used the MOS Sleep (score, mild: 64.1 and 70.3; severe: 48.2 and 36.4; all P < 0.05; online Table 1); and nocturnal reflux symptoms in addition to daytime symptoms were found to decrease sleep quality in a study that used the PSQI (score, daytime symptoms only: 8.2; daytime plus nocturnal symptoms: 6.7; P < 0.05; online Table 1).
Individuals with nocturnal symptoms had a lower HRQL than those with daytime symptoms in the study that used the QOLRAD to assess the impact of nocturnal reflux symptoms (actual values not reported). Similarly, in the study using the RefluxQual, the presence of nocturnal symptoms significantly impaired HRQL, as reflected in the lower scores in each of the seven dimensions of the instrument compared with the presence of daytime symptoms alone (all P < 0.001; actual values not reported).
Twelve studies used versions of the Short Form Health Survey to report on the impact of disruptive GERD on physical health (online Table 1). The groups with more frequent or severe reflux symptoms had lower scores than those with less frequent or severe symptoms. Five studies provided physical component summary scores (online Figure 1). Overall, the mean summary score was 1.1-times lower in the groups with disruptive GERD than in those with nondisruptive GERD [42.8 (range: 38.9–46.5) vs. 46.4 (range: 41.5–49.1); all P < 0.05]. In the four studies that evaluated the burden of nocturnal reflux symptoms, groups with frequent nocturnal symptoms had lower physical component summary scores than those with no or only occasional nocturnal symptoms. Nocturnal reflux symptoms in addition to daytime symptoms were found to increase sleepiness during the day in a study that used the ESS (ESS score, symptoms <2 nights/week vs. ≥2 nights/week: 8.2 vs. 7.6; P < 0.05).
Twelve studies used versions of the Short Form Health Survey to report on the impact of disruptive GERD on mental health (online Table 1). The groups with more frequent or severe reflux symptoms had lower mental component summary scores than those with less frequent or severe symptoms. Five studies provided mental component summary scores (online Figure 2). Overall, the mean summary score was 1.1-times lower in the groups with disruptive GERD than in those with nondisruptive GERD [45.0 (range: 41.6–49.5) vs. 47.9 (range: 44.4–51.5); P < 0.05 in four studies and >0.05 in one study]. Groups with frequent nocturnal symptoms had lower mental component summary scores than those with no or only occasional nocturnal symptoms in two of the four studies that evaluated the burden of nocturnal reflux symptoms[5, 11]; however, in the other two studies, mental health was similarly impaired in all individuals with reflux symptoms, irrespective of their frequency.
Overall, mean PGWB scores for psychological and general well-being were 1.3-times lower in groups with disruptive GERD than in those with nondisruptive GERD [66.9 (range: 50.1–77.8) vs. 84.6 (63.0–99.1); P < 0.05 for all comparator groups; Figure 4]. Increasing symptom frequency led to significant decreases in well-being in the study using the RefluxQual, as reflected by reducing scores in each of the seven dimensions of the instrument (all P < 0.001; actual values not reported). Similarly, well-being decreased with increasing symptom frequency in the study that used the EQ-5D (coefficient for heartburn: −0.63; for regurgitation: −0.63; both P < 0.001) and in a study that used the QOLRAD (Spearman's rho: 0.39–0.46). Greater symptom severity was also associated with significant decreases in well-being in a study that used the EQ-5D (mild: 0.78, moderate: 0.67, severe 0.50; P < 0.001) and in the three studies that used the QOLRAD (online Table 1).
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Figure 4.
Effect of reflux symptom severity on psychological and general well-being in studies using the Psychological and General Well Being index (PGWB).[3, 15, 18, 19]HRQL, health-related quality of life.
Results
Overview of Included Studies
This systematic review of the literature identified 19 studies that presented data on the impact of disruptive symptoms of heartburn and/or regurgitation on HRQL (Table 1). Nine studies were conducted in the community and 10 in the primary or secondary care setting. In total, the studies included 55 834 individuals with reflux symptoms. The reported mean age of participants in each study ranged from 43 years to 64 years, and 5–68% of them were women. Data were provided on the comparative burden of frequent reflux symptoms in eight studies and of severe reflux symptoms in 13 studies. Six studies included data on the comparative impact of nocturnal reflux symptoms: two reported the definition used for 'nocturnal symptoms', describing these as symptoms occurring when lying down to sleep at night, when awakening at night because of symptoms, or when waking up in the morning with symptoms; the other four studies did not state how nocturnal symptoms were defined. The characteristics of the 19 included studies and main results are summarised as online supporting information (online Table 1).
The most commonly used instrument was the Short Form Health Survey (SF-8, SF-12 or SF-36), a generic HRQL instrument that was used in 12 of the 19 studies; five provided comparative data on the impact of frequent symptoms, seven on that of severe symptoms and four on that of nocturnal symptoms. The second most commonly utilised instrument was the Work Productivity and Impairment questionnaire (WPAI), the generic version of which was used in four studies and disease-specific versions in three studies; two of these studies provided comparative data on the impact of frequent symptoms, four on that of severe symptoms and three on that of nocturnal symptoms. The Psychological and General Well Being index (PGWB), a generic HRQL instrument, was used in four studies, and all provided data on the impact of severe symptoms. Three studies used the disease-specific Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD); one provided data on the impact of frequent symptoms, three on that of severe symptoms and one on that of nocturnal symptoms. The EuroQol five-dimensional HRQL questionnaire (EQ-5D) and the Medical Outcomes Study Sleep disturbance scale (MOS Sleep), both of which are generic instruments, were used in two studies each, all of which provided data on the impact of severe symptoms. The Quality of Life Questionnaire in Gastroesophageal Reflux (RefluxQual), which is disease-specific, and the Epworth Sleepiness Scale (ESS) and the Pittsburgh Sleep Quality Index (PSQI), which are generic, were used in one study each; all three studies provided data on the impact of nocturnal symptoms, and one also assessed the impact of frequent symptoms.
Impact on Work Productivity
Six studies used versions of the WPAI to assess the impact of disruptive GERD on work productivity, and five of these reported data separately for absenteeism and presenteeism. Overall, the mean number of hours absent from work per week was 2.4-times higher in the groups with disruptive GERD than in those with nondisruptive GERD [2.8 h (range: 0.3–7.0 h) vs. 1.2 h (range: 0.1–2.6 h); Figure 2]. Similarly, the overall mean reduction in productivity while at work was 1.5-times higher in the groups with disruptive GERD than in those with nondisruptive GERD [21.8% (range: 11.8–32.0%) vs. 15.0% (range: 5.1–24.9%); Figure 3].
(Enlarge Image)
Figure 2.
Effect of reflux symptom frequency and severity, and of nocturnal reflux symptoms, on absenteeism in studies that reported the hours per week absent from work because of symptoms, using the Work Productivity and Impairment questionnaire (WPAI).[6, 8, 11, 20, 21] For Dubois et al., the number of hours absent per week was estimated by multiplying percentage reduction by a 40-h work week. [11]NR, not reported; NS, not statistically significant.
(Enlarge Image)
Figure 3.
Effect of reflux symptom frequency and severity, and of nocturnal reflux symptoms, on presenteeism in studies that reported the percentage of reduced productivity while at work because of symptoms, using the Work Productivity and Impairment questionnaire (WPAI).[6, 8, 11, 20, 21]NR, not reported; NS, not statistically significant.
The groups with more frequent symptoms had a greater mean number of hours absent from work [2.8 h (range: 1.7–4.0 h) vs. 1.7 h (range: 0.6–2.6 h)] and a greater mean reduction in productivity while at work [21.9% (range: 12.2–28.3%) vs. 16.7% (range: 5.2–22.4%)] than those with less frequent symptoms (all P < 0.05; Figures 2 and 3). Similarly, the groups with more severe reflux symptoms had a greater mean number of hours absent from work [4.8 h (range: 2.5–7.0 h) vs. 0.6 h (range: 0.4–0.7 h)] and a greater mean reduction in productivity while at work [24.1% (range: 16.2–32.0%) vs. 10.6% (range: 5.3–16.0%)] than those with less severe symptoms (P < 0.001[21] and not reported[6]; Figures 2 and 3). One study reported only on the proportion of participants with reduced work productivity, which was lower in patients with mild symptoms than in those with severe symptoms (12% vs. 48%; P < 0.01).
The impact of reflux symptoms on the mean number of hours absent from work was found to be similar in individuals with frequent nocturnal symptoms and those with only occasional or no nocturnal symptoms [0.9 h (range: 0.1–1.1 h) vs. 0.6 h (range: 0.3–1.4 h); P > 0.05 for both studies]; the impact of frequent nocturnal symptoms on presenteeism was significant in one study (11.8% vs. 5.1%; P < 0.05),[11] but not in the other (26.6% vs. 24.9%; P > 0.05) (Figures 2 and 3). In the study that reported only on the proportion of participants with reduced work productivity, this was found to be higher in the group of individuals with nocturnal symptoms than in those with daytime symptoms only (70% vs. 31%; P < 0.01).
Impact on Sleep
Overall, sleep quality scores were 1.5-times (range 1.2–1.9) lower in groups with disruptive GERD than in those with nondisruptive GERD in the three studies that provided such scores: greater overall symptom severity was associated with significant decreases in sleep quality in the two studies that used the MOS Sleep (score, mild: 64.1 and 70.3; severe: 48.2 and 36.4; all P < 0.05; online Table 1); and nocturnal reflux symptoms in addition to daytime symptoms were found to decrease sleep quality in a study that used the PSQI (score, daytime symptoms only: 8.2; daytime plus nocturnal symptoms: 6.7; P < 0.05; online Table 1).
Individuals with nocturnal symptoms had a lower HRQL than those with daytime symptoms in the study that used the QOLRAD to assess the impact of nocturnal reflux symptoms (actual values not reported). Similarly, in the study using the RefluxQual, the presence of nocturnal symptoms significantly impaired HRQL, as reflected in the lower scores in each of the seven dimensions of the instrument compared with the presence of daytime symptoms alone (all P < 0.001; actual values not reported).
Impact on Physical Health
Twelve studies used versions of the Short Form Health Survey to report on the impact of disruptive GERD on physical health (online Table 1). The groups with more frequent or severe reflux symptoms had lower scores than those with less frequent or severe symptoms. Five studies provided physical component summary scores (online Figure 1). Overall, the mean summary score was 1.1-times lower in the groups with disruptive GERD than in those with nondisruptive GERD [42.8 (range: 38.9–46.5) vs. 46.4 (range: 41.5–49.1); all P < 0.05]. In the four studies that evaluated the burden of nocturnal reflux symptoms, groups with frequent nocturnal symptoms had lower physical component summary scores than those with no or only occasional nocturnal symptoms. Nocturnal reflux symptoms in addition to daytime symptoms were found to increase sleepiness during the day in a study that used the ESS (ESS score, symptoms <2 nights/week vs. ≥2 nights/week: 8.2 vs. 7.6; P < 0.05).
Impact on Mental Health
Twelve studies used versions of the Short Form Health Survey to report on the impact of disruptive GERD on mental health (online Table 1). The groups with more frequent or severe reflux symptoms had lower mental component summary scores than those with less frequent or severe symptoms. Five studies provided mental component summary scores (online Figure 2). Overall, the mean summary score was 1.1-times lower in the groups with disruptive GERD than in those with nondisruptive GERD [45.0 (range: 41.6–49.5) vs. 47.9 (range: 44.4–51.5); P < 0.05 in four studies and >0.05 in one study]. Groups with frequent nocturnal symptoms had lower mental component summary scores than those with no or only occasional nocturnal symptoms in two of the four studies that evaluated the burden of nocturnal reflux symptoms[5, 11]; however, in the other two studies, mental health was similarly impaired in all individuals with reflux symptoms, irrespective of their frequency.
Impact on Overall Well-being
Overall, mean PGWB scores for psychological and general well-being were 1.3-times lower in groups with disruptive GERD than in those with nondisruptive GERD [66.9 (range: 50.1–77.8) vs. 84.6 (63.0–99.1); P < 0.05 for all comparator groups; Figure 4]. Increasing symptom frequency led to significant decreases in well-being in the study using the RefluxQual, as reflected by reducing scores in each of the seven dimensions of the instrument (all P < 0.001; actual values not reported). Similarly, well-being decreased with increasing symptom frequency in the study that used the EQ-5D (coefficient for heartburn: −0.63; for regurgitation: −0.63; both P < 0.001) and in a study that used the QOLRAD (Spearman's rho: 0.39–0.46). Greater symptom severity was also associated with significant decreases in well-being in a study that used the EQ-5D (mild: 0.78, moderate: 0.67, severe 0.50; P < 0.001) and in the three studies that used the QOLRAD (online Table 1).
(Enlarge Image)
Figure 4.
Effect of reflux symptom severity on psychological and general well-being in studies using the Psychological and General Well Being index (PGWB).[3, 15, 18, 19]HRQL, health-related quality of life.
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