The Uniformed Services Constipation Action Plan Is Superior to Standard of Care for the Management of Functional Constipation in a Pediatric Subspecialty Clinic for Military Beneficiaries

Purpose/Objectives: In 2019, functional constipation (FC) not only totaled 1207 visits at the Walter Reed Children's Center but also cost nearly $50,000 in purchased care for children in the National Capital Region.
After recognizing this disease burden, the author team developed the Uniformed Services Constipation Action Plan (USCAP) to assist in the stepwise home management of FC (Figure 1).

The aim of our study was to assess clinical outcomes, Healthcare-related Quality of Life (HRQoL) [by assessing for improving/higher Total Scale Scores (TSS)] and self-efficacy for home management of FC by comparing USCAP to standard of care (control) in our gastroenterology clinic.

Design/Methods: Military beneficiaries aged 4 years and older who met the ROME IV criteria for FC were block randomized to receive either the USCAP or control. All subjects were offered a defecation posture modification device (DPMD, ie potty stool) at no cost.

Clinical outcomes measured included pharmacotherapy plan adherence and whether Pediatric Bristol Stool Form Scale [PBSFS] 3 or 4 was achieved.
HRQoL was measured using the PedsQL™ Gastrointestinal Symptoms Module [PedsGIQL] (5-point Likert scale: 0- Never, 1- Almost Never, 2-Sometimes, 3-Often, 4-Almost Always).
Self-efficacy was measured using the Health Confidence Score [HCS] (4-point Likert scale:3-strongly agree, 2-agree, 1-neutral, 0-disagree).
Surveys were obtained at intake and 4 months later.

Results: 125 subjects have been enrolled (mean age 10.4 ± 5.5 years, 47% male).

70 subjects have completed the 4 month study (70%, N=49 reported using the DPMD) (Table1). 69% (N=48) of completed subjects received USCAP. 71% (n=34) USCAP participants reported using the DPMD. 57% (n=27) USCAP participants reported adherence to pharmacotherapy for the 4-month study period compared to 23% (n=5) controls, P =0.01.

75% (n=36) of the completed USCAP participants exhibited improvement in PBSFS compared to 32% (n=7) controls, P = 0.001. 47% (n=15) of encopretic USCAP participants resolved their incontinence compared to 56% (n=9) of controls.

The USCAP participants reported improved HRQoL with higher TSS (mean TSS= 76.3±29.4) and greater improvements in TSS (mean Δ= 14.1) compared to control (mean TSS= 65.1±33.9; mean Δ=1.8), P = 0.02.

USCAP participants demonstrated higher confidence scores at the time of diagnosis following education compared to control. This higher USCAP confidence was sustained (mean HCS 2.8±0.5) compared to control (mean HCS 2.2±0.9) through the end of the study, P = 0.01.

Conclusion/Discussion: The findings of our study demonstrate the benefit of incorporating the USCAP to the management plan for FC in children. Implementation of the USCAP was associated with increased adherence to prescribed pharmacotherapy, improved PBSFS, higher HRQoL, and increased confidence. The USCAP is a simple, inexpensive tool that has the potential to improve global outcomes for FC in children and should be recommended as standard clinical practice within each military treatment facility.