Hemorrhoidal Disease among doctors from Grade-A Tertiary Hospitals in Big Cities of China: results from web-based doctors as patients survey

doi:10.21203/rs.3.rs-2238816/v1

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Hemorrhoidal Disease among doctors from Grade-A Tertiary Hospitals in Big Cities of China: results from web-based doctors as patients survey

https://doi.org/10.21203/rs.3.rs-2238816/v1

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Background Doctors are at high risk of developing hemorrhoidal disease (HD), but it’s still not clear that how much doctors aware of this problem. OASIS (dOctors AS patIentS) study was conducted to understand the prevalence, awareness, diagnosis and treatment of HD among doctors in big cities of China.

Methods From August to October in 2020, an online survey was conducted through questionnaire among doctors from grade-A tertiary hospitals in 29 provinces across China.

Results A total of 1227 questionnaires were collected. The prevalence of HD was 56.8%, with a significant difference between internists and surgeons (P=0.01). 15.6% doctors with HD did not know well about the chronic nature of HD. 91.5% of doctors adopted general treatment, and 83.0% doctors considered that “oral medications are used only after ineffective topical medications”. Among the oral medications, the Micronized Purified Flavonoid Fraction (MPFF) performed best on the scores of the three most valuable aspects, but only 17% doctors had received treatment with MPFF.

Conclusions Doctors are at higher risk of developing HD, and HD is highly prevalent among Chinese doctors, but the awareness of that is not enough. There is a gap between the HD clinical practice and guideline recommendations even in doctors, such as late initiation of oral drug therapy and inadequate oral drug therapy. Therefore, awareness and standardized treatment of HD should be strengthened among Chinese doctors, and what’s more, ordinary people.

Doctors

hemorrhoidal disease

MPFF

Oral medication

survey

Hemorrhoidal disease (HD) is the most common anorectal diseases^[1] generally characterized by bleeding, swelling, prolapse, pain, itching and anal discomfort, which not only seriously affect the quality of patients’ life, but also may require urgent hospitalization and blood transfusion due to massive hemorrhage^[2]. There are many risk factors for HD, including age, gender, dietary and bowel habits, etc.^[3–6]. Among them, occupation is also one of the important factors^[7]. Doctors are at higher risk of developing HD due to high stress at work, inadequate sleep, long standing and sitting working position. However, there is no systematic study on the prevalence of HD among doctors in China. In order to understand the prevalence, diagnosis and treatment of HD among doctors, we investigated doctors from different departments of grade-A tertiary hospitals nationwide.

1.1 Subjects and Survey Design

There is a web-based survey conducted by a third-party platform in China(http://www.medlive.cn/), which has about 1,340,000 registered doctors (License is required for register). The survey enrolled representative population of Chinese doctors, and we designed sample quotas based on the principle of stratified probability sampling according to the registered doctors. Participants were recruited from August to October 2020. Email and SMS push were used, and doctors click on the link in email or SMS to participate in the online survey. To avoid multiple responses by a single person, each IP address is set to answer only once. The online questionnaire has two main parts: Screening questionnaire and Main questionnaire:

The screening questionnaire was designed to include doctors with Attending or above level based in Grade-A tertiary (highest level) hospitals from big cities (the 3rd-tier or above, according to 2019 Ranking of Cities’ Business Attractiveness) of China, and used to investigate the HD prevalence and comorbidities. The main questionnaire can only be answered by those who passed screening questionnaire. The main questionnaire is in order to further investigate on personal information and diagnosis, disease status and understanding, treatment options and preferences for oral medications of HD.

1.2 Ethics

Before starting the survey, participants were asked to consent to sharing some medical and health information about themselves. If they did not consent, the survey was stopped. Participant’s data were used in a general and anonymized manner for the purpose of this study only. The data were not provided to any third parties. This is an investigation of clinical outcomes without any intervention, neither Ethics Committee approval nor clinical trial registration was required.

1.3 Statistical Approach

The significant data is exported by using Excel, and is statistical analyzed by using SPSS 21.0. Chi-square test is used to test the significance in each dimension of categorical variables (multiple choice questions), and F test is used in continuous variables (numeric entry questions). In the test of significance, both chi-square test and F-test specify that at the 95% confidence level, differences between variables and dimensional groups are considered significant in statistics when the P-value is < 0.05. In addition, in case of skipping some questions due to logical relationship or a respondent’s omission, if the overall data is not affected, such data are included in the calculation, and the sample size is separately marked.

The survey covered 342 grade A hospitals, with the geographical coverage of 29 provinces (autonomous regions and municipalities) in China. The doctors included are those with attending and above professional titles in internal medicine and surgery, including general medicine, cardiology, respiratory medicine, gastroenterology, neurology, medical oncology, endocrinology, infectious disease, nephrology, general surgery, orthopedics, urology, obstetrics and gynecology, hepatobiliary surgery, breast surgery, neurosurgery and vascular surgery, etc.. A total of 23,630 doctors were sent the questionnaire by email and SMS, and the number of clicks was 4,077 (the click-through rate was 4077/23,630 ≈ 17.3%), of which 2,850 people did not meet the inclusion criteria (2,651 people due to unwillingness to participate, 72 people due to city level, 112 people due to hospital level and 15 people due to professional title). And finally, 1227 people passed the screening, with a pass rate of 1227/4077 ≈ 30.1%.

After passing the screening questionnaire, 331 doctors successfully completed the main questionnaire. Among them, 212 doctors with HD completed all the contents in the main questionnaire, and 119 doctors without HD only completed the general information contents in the main questionnaire.

2.1.1 HD Prevalence and Comorbidities

Among the 1,227 doctors, a total of 697 doctors suffered from HD, with a prevalence of 56.8%. There were 621 internists and 606 surgeons in this survey, with a HD prevalence of 60.4% (375/621) and 53.1% (322/606) respectively, and the difference between internists and surgeons was statistically significant (P = 0.01). Among the doctors with HD, 39.7%(277/697) had cervical or lumbar spine disease, 32.3%(225/697) had sleep disorder, 26.1%(182/697) had chronic venous disease (CVD), 22.5%(157/697) had chronic gastritis or gastric ulcers, 18.4%(128/697) had hypertension and 10.3% (72/697) had urinary calculus.

2.1.2 General Information of the Doctors with and without HD

Among the 212 doctors with HD, the course of HD ranged from 1 to 35 years, with an average of 8.9 years. Among them, 59.4%(126/212) were male and 40.6%(86/212) were female. The age ranged from 29 to 70 years old, with an average age of 43.6 years. 76.9%(163/212) were from internal medicine. Among the 119 doctors without HD, 63.0% (75/119)were male and 37.0%(44/119) were female. The age ranged from 31 to 63 years old, with an average age of 44.5 years. And the majority of them were internal medicine, accounted for 85.7%(102/119).

Compared with doctors without HD, doctors with HD had significant longer defecation time (defecated more than 10 minutes/time, 20.8%(44/212) VS 9.2%(11/119), p = 0.006). Besides, doctors with HD have more pregnancy times (Previous pregnancy 2 or more, 30.2%(64/212) VS 25.2%(30/119)), smoking(10.4%(22/212) VS 8.4%(10/119)), and wrinkled, lumpy or nut-like defecation shape (32.1%(68/212) VS 18.5%(22/119)), but the differences are non-significant. (Table 1).

Table 1

Clinical characteristics of the doctors with and without HD
Items	Doctors with HD n = 212	Doctors without HD n = 119	P value
Age (Years)	43.6	44.5	0.321
Gender (male, n, %)	126, 59.4	69, 63	0.521
BMI	23.7	23.7	0.998
Sitting time > 10h per week (%)	78.8	79.0	0.662
Exercise time <0.5h per week (%)	17.9	13.4	0.740
Proportion of “sitting” working state (%)	54.9	55.0	0.975
Previous pregnancy (2 or more, %)	30.2	25.2	0.820
Smoking (%)	10.4	8.4	0.560
Number of defection (times)	1.1	1.3	0.395
Defecation time (>10 min, %)	20.8	9.2	0.006
Defecation shape (wrinkled, lumpy or nuts-like, %)	32.1	18.5	0.144

2.2 Conditions of HD

Among the 212 doctors with HD, 51.9%(110/212) had clinical grade I HD, 48.1%(102/212) were grade II and above (referred to the Goligher grading criteria⁷) (Fig. 1). Doctors with severe HD were relatively older (mean age of doctors with grade I, II, III&IV was 42.6 years, 43.8 years and 47.3 years respectively, P = 0.014). Besides, the higher HD graded, the more doctors have long sitting time (73.6%(81/110), 82.4%(61/74), 89.3%(25/28) of doctors with grade I, II, III&IV had sitting time > 10 hours per week respectively) and short exercise time(13.6%(15/110), 21.6%(16/74), 25%(7/28) of doctors with grade I, II, III&IV had exercise time<0.5 hour per week, respectively), although the difference was not statistically significant. What’s more, the higher HD graded, the more proportion of females suffered (the proportion of females with grade I, II, III&IV was 24.5% (27/110), 56.8% (42/74) and 60.7% (17/28) respectively, P = 0.000). (Table 2).

Table 2

Characteristics of doctors with different clinical grades
Items	Clinical grading of HD
	Grade I n = 110	Grade II n = 74	Grade III & Ⅳ n = 28
Age (Years)	42.6	43.8	47.3	0.014
Gender (male, %)	75.5	43.2	39.3	0.000
BMI	24.2	23.0	23.8	0.011
Sitting time > 10h per week (%)	73.6	82.4	89.3	0.598
Exercise time <0.5h per week (%)	13.6	21.6	25.0	0.569
Proportion of “sitting” working state (%)	56.7	52.7	53.6	0.442
Previous pregnancy (2 or more, %)	29.6	28.6	35.3	0.607
Smoking (%)	88.2	89.2	96.4	0.437
Number of defection (times per day)	1.2	0.9	1.0	0.584
Defecation time (>10 min each time, %)	17.3	24.4	25	0.509
Defecation shape ( wrinkled, lumpy or nuts-like%)	55.4	62.2	60.7	0.255

Among the 212 doctors with HD, the most bothersome symptoms were “pain” (65.1%(138/212)) ,followed by “bleeding” (63.7%(135/212))(Fig. 2). They stated that the impact of HD on their quality of life was moderate, with an average score of 4.1 (1 to 10, 1 indicating little impact, 10 indicating extremely large impact; the higher the score is, the more life is impaired). About 31% doctors stated that they were bothered with the disease more than 20% of the time per month, about 6 days per month. The higher the grade of HD is, the more impact on life. The average scores for grade I, II, III&IV is 3.4, 4.6, 5.5 respectively (p = 0.000). 18.2%(20/110), 41.9%(31/74) and 46.4%(13/28) doctors were troubled more than 20% of the time each month for grade I, II, III&IV respectively (p = 0.001). (Table 3)

Table 3

Impact of HD on doctors by different clinical grading
Bothered time per month	Clinical grading of HD			P value
	Grade I	Grade II	Grade III and above
< 20%	81.8%	58.1%	53.6%		0.001
20%-40%	16.4%	33.8%	35.7%
40%-60%	1.8%	6.8%	3.6%
> 80%	0.0%	1.4%	7.1%

2.3 Diagnosis and Treatment of HD

As for acknowledge of HD, 15.6%(33/212) doctors with HD stated that they did not know “HD is one of the venous diseases, and are often complicated with CVD (commonly known as varicose veins)”. The difference in this aspect between doctors with different professional titles is statistically significant (the proportions among attending doctors, chief doctors and associate chief doctors were 26.4% (14/53), 14.4% (15/104) and 7.3% (4/55) respectively, P = 0.021).

When it comes to diagnosis, 50.5% (107/212) doctors with HD were self-diagnosed, 39.6% (84/212)were professional diagnosed by general or anorectal specialists, 9.0% (19/212) by physical examination and 0.9% (2/212) by other diagnostic methods. All doctors with HD had received treatment, of which the most was general treatment (91.5% (194/212)), mainly lifestyle and bowel habits change. Followed by topical medication (70.8% (150/212)) and oral medication (48.2% (102/212)) (Fig. 3). For the treatment efficacy, 25.0% (53/212) of the doctors considered that the treatment was effective and the disease was not recurrent, while 71.1% (151/212) considered although the treatment was effective, HD can be recurrent, and 3.3% (7/212) considered that the treatment was ineffective.

Aescuven forte (Aescuven forte Tablets, Maizhiling) (34.4%(73/212)), MaYingLong (Diosmin Tablets) (32.1%(68/212)) and Alvenor (Micronised Purified Flavonoid Fraction, MPFF, Citrus Bioflavonoids Tablets) (17.0%(36/212)) were top 3 oral medications commonly used drugs. In terms of timing of using oral medications, most of the doctors with HD (83.0%(176/212)) considered that “oral medications are used only after ineffective topical medications”, followed by “oral medications can be used as premedication to control acute symptoms” (36.3%(77/212)) and “oral medications can be used as premedication to assist with rapid recovery” (26.4%(56/212)). (Fig. 4)

When choosing oral medications, doctors attached the most importance to “reduce recurrence” (55.7%(118/212)), “potently improve symptoms” (48.6%(103/212)) and “rapid onset” (48.1%(102/212)). Doctors also believed that oral medications can “ be better efficacy in combination with topical medications” (36.8%(78/212)), “directly act on the core of the disease by the mechanism of action” (36.8%(78/212)), “ be more safe as they extracted from natural plants” (28.8%(61/212)) and “be used as premedication to rapid control acute symptoms before surgery and accelerate postoperative recovery” (11.8%(25/212)).Doctors scored the above medical performance characteristics of Mayinglong, Aescuwen and MPFF, MPFF performed best in all three aspects, while Aescuwen with the lowest score. (Fig. 5)

HD is one of the most common anorectal diseases in China. The latest national-scale epidemiological survey shown that the prevalence of HD in China is 50.28%^[8]. The results obtained from the population survey in different regions of China are similar to the above conclusions^[2]. Further subgroup analysis reveals that besides dietary habits and bowel habits, occupation is also one important influencing factors for HD,[9] of which the work groups with stressful work, irregular life, inadequate sleep and need to be sedentary are at higher risk of developing HD^[10]. Internal hemorrhoids are generally graded based on Goligher’s classification: Grade I: nonprolapsing hemorrhoids; Grade II: prolapsing hemorrhoids on straining but reduce spontaneously; Grade III: prolapsing hemorrhoids requiring manual reduction; Grade IV: non-reducible prolapsing hemorrhoids^[11].

Sedentary working habits is of particular higher risk. On the one hand, long-term exposure to a fixed posture will affect blood circulation leading to pelvic blood stasis and venous congestion, greatly affecting the digestion, absorption, peristaltic function of the intestine, causing constipation and HD^[9]. On the other hand, sedentary state will lead to autonomic dysfunction and perineal dampness, resulting in inflammation which induce HD and other anorectal diseases^[7]. The occupational characteristics of doctors accord with the high risk factors of HD, such as stressful work, irregular life, inadequate sleep, strenuous activity, causing excessive increase of intra-abdominal pressure^{[7, 8]}, making them a high risk group for the disease. The prevalence of HD was about 56.8% among doctors from grade-A tertiary hospitals in this study, which was significantly higher than that in the general population. The internists having a significantly higher prevalence of than surgeons (60.4% vs.53.1%, p = 0.01). This may be related to the need for internists to stay in the "sitting" position for longer periods at work. As we can see in this investigation, the longer doctors sit, the higher HD graded. Pregnancy also puts pressure on the veins in the lower body, making female doctors suffer more incidence of higher grade HD (the proportion of females with grade III&IV is 60.7%).

In addition, HD and CVD has a common etiology and similar risk factors. Low-fiber diet leads to chronic constipation, which leads to increased intra-abdominal pressure. It was suggested that this pressure would easily be transmitted to the hemorrhoidal plexus as they have no valves. The valves of the lower limb veins would offer initial protection but would eventually become incompetent and expose the veins to elevated pressure^{[12, 13]}. The multinational CHORUS study^[14] has shown that there is a significant correlation between HD and CVD (P = 0.004). This is also consistent with the result of this study: 26.1% of the doctors with HD had concomitant CVD, which was higher than the prevalence of CVD among the general population in China (8.89%)^[15]. The population in this study was doctors with strong medical background, however, the awareness of HD was still disappointing. 15.6% of the doctors with HD state they don’t know that “HD are one of the venous diseases, and are often complicated with CVD”

Symptoms attributed to hemorrhoids include bleeding, pain, pruritus, fecal seepage, prolapse and mucus discharge^{[16, 17]}. Though the most common manifestation of hemorrhoids is painless rectal bleeding^{[18, 19]}, doctors said the most bothersome symptoms are pain and bleeding(65.1%,63.7% respectively). That’s might because doctors relatively seldom panic about bleeding owning to their profession, while pain will haunt them almost every minutes. When it comes to the treatments received, lots of patients have a tendency to use self-medication rather than to seek proper medical attention^[18], so as doctors. More than 50% doctors in this investigation with HD were self-diagnosed. From my point of view, bleeding or anal pain should not be diagnosed as hemorrhoids until the colon is adequately evaluated. Thus, as soon as the symptom occur, one should turn general or anorectal specialists for help.

If the provisional diagnosis of HD has been made, basic treatment can be started. Such as sufficient water intake, healthy diet, physical activity and toilet training, etc.^{[9, 20]}. Although almost all doctors have received general treatment, the effect was unsatisfactory, and 71.7% stated that although effective, HD was recurrent. Only 48.2% doctors use oral treatment, but most of them only use oral medication after topical failure or when the disease is very severe.

Actually, the main goal of medical treatment is to control acute symptoms of hemorrhoids. Guidelines for the treatment of HD of China and abroad recommend oral veno-active drugs as the reference treatment which can be used in patients with all clinical grades and have effect in relieving symptoms such as pain, bleeding, etc., and preventing recurrence^{[2, 20, 21]}. The latest 2020 China HD guideline recommends that MPFF is the preferred venous-active drug for the treatment of patients with grade I-IV HD (level 1A recommendation). It also recommends MPFF as an adjunct to device and surgical therapy (level 1A recommendation), and MPFF or non-steroidal anti-inflammatory drugs as well as topical agents containing aluminum sulfate as an adjunct in patients with HD for the improvement of postoperative symptoms (level 1A recommendation)^[2]. Subgroup analysis results from the multinational CHORUS study have shown that the utilization rate of intravenous active drugs in patients with HD is as high as 95.7%, of which 86.2% of patients select MPFF among veno-active drugs^[14]. However, this study indicated that although MPFF was shown to be superior in satisfying doctor-valued benefits, the usage rate was only 17%, which is much lower than the utilization rate of MPFF among patients with HD abroad.

OASIS is a large-scale web-based survey to understand the prevalence, awareness, diagnosis and treatment of HD among doctors in big cities of China. It found that the prevalence of HD in Chinese doctor population was higher than that in the general population. However, the doctors are mostly diagnosed and treated based on personal knowledge, lacking standardized treatment procedure, thus affecting the treatment effect. We urgently need to strengthen the education on HD in order to early detect the high-risk factors for preventing the occurrence of HD, and instruct patients to see a doctor in time after the occurrence of symptoms of HD. There is a gap between the HD clinical practice and guideline recommendations, such as late initiation of oral drug therapy and inadequate oral drug therapy. This may be one of the reasons for unsatisfactory therapeutic effect and high recurrence rate. The treatment guideline education among doctors is needed to be strengthened and then further develop a standardized diagnosis and treatment plan suitable for HD patients.

Ethics approval and consent to participate:

This is an investigation of clinical outcomes without any intervention, neither Ethics Committee approval nor clinical trial registration was required. Before starting the survey, participants were asked to consent to sharing some medical and health information about themselves.

Consent for publication:

Not applicable.

Availability of data and materials:

Please contact author for data requests.

Competing interest:

We have no financial and non-financial conflicts of interest.

Competing interests:

The authors declared no conflicts of interest.

Funding:

This work was supported by the National High Level Hospital Clinical Research Funding [2022-PUMCH-C-005] and National High Level Hospital Clinical Research Funding [2022-PUMCH-B-00]. The funding agencies played no role in the design, collection, analysis or interpretation of data reported in this study.

Authors’ contributions：

Xiaoyuan Qiu wrote the main manuscript text and designed the survey. Yuxin Liu was responsible for research implementation. Weikun Shi collected and analyzed data. Guole Lin designed the survey, supervised the research and guided article writing. All authors read and approved the final manuscript.

Acknowledgements：

We are very grateful to the organizations and volunteers involved in this study. Additionally, we thank Prof. Guole Lin, who shared his expertise on colorectal and anal surgery.

Authors' information:

1Department of Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China 100730

Correspondence to: Guole Lin, M.D., Ph.D. Department of Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China 100730. Peking Union Medical College Hospital (Dongdan campus), No.1 Shuaifuyuan Wangfujing Dongcheng District, Beijing,China 100730. E-mail: [email protected]. Tel: 13801081483

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No competing interests reported.

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Hemorrhoidal Disease among doctors from Grade-A Tertiary Hospitals in Big Cities of China: results from web-based doctors as patients survey

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Abstract

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Background

1 Methods

2 Results

3 Discussions

4 Conclusion

Declarations

References

Additional Declarations

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