Chronic Disease Management Programme

Dáil Éireann Debate, Tuesday - 16 April 2013

Tuesday, 16 April 2013

Questions (1216, 1217, 1218, 1219, 1220, 1221, 1222)

Jerry Buttimer

Question:

1216. Deputy Jerry Buttimer asked the Minister for Health his views on the increase of coeliac disease amongst the population; if there is any specific breakdown of the increase of coeliac disease in terms of age group or geographical location; and if he will make a statement on the matter. [16668/13]

Jerry Buttimer

Question:

1217. Deputy Jerry Buttimer asked the Minister for Health if he or his officials' attention, or the Health Service Executive has been drawn to the UK National Institute for Health and Clinical Excellence Guidelines for the recognition and assessment of coeliac disease; if he will outline the national policy, if any, which currently exists for the recognition and assessment of coeliac disease here; and if he will make a statement on the matter. [16669/13]

Jerry Buttimer

Question:

1218. Deputy Jerry Buttimer asked the Minister for Health the level of information, if any, that exists on the number of persons with undiagnosed coeliac disease who are misdiagnosed as having other conditions; the clinical and cost implications of same; and if he will make a statement on the matter. [16670/13]

Jerry Buttimer

Question:

1219. Deputy Jerry Buttimer asked the Minister for Health his policy and the relevant agencies, on the most appropriate treatment for those with coeliac disease; the level of support for those on the general medical service scheme for access to this treatment; and if he will make a statement on the matter. [16671/13]

Jerry Buttimer

Question:

1220. Deputy Jerry Buttimer asked the Minister for Health the commitment of his Department, and the relevant agencies, to encourage targeted screening for coeliac disease; the various elements which would be required to introduce such a screening programme; and if he will make a statement on the matter. [16672/13]

Jerry Buttimer

Question:

1221. Deputy Jerry Buttimer asked the Minister for Health his policy and the Health Service Executive on what they deem to be a reasonable time from initial screening for coeliac disease to positivity; and if he will make a statement on the matter. [16673/13]

Jerry Buttimer

Question:

1222. Deputy Jerry Buttimer asked the Minister for Health the commitment of the Health Service Executive to ensure access to dietetics for those newly diagnosed with coeliac disease; if he will seek details on the current take-up levels of the provision of this service through the HSE; and if he will make a statement on the matter. [16674/13]

Written answers

Minister for Health

I propose to take Questions Nos. 1216 to 1222, inclusive, together.

Coeliac disease is a common digestive condition where a person is intolerant (has an adverse reaction) to the protein gluten which is found in wheat, barley and rye. If someone with coeliac disease is exposed to gluten, they may experience a wide range of symptoms and adverse effects, including diarrhoea, bloating, abdominal pain, weight loss and malnutrition. The cause or causes of coeliac disease are unknown, but it is thought to be associated with a combination of genetic and environmental factors.

Prevalence

During the 1980s, before advances in testing for coeliac disease were made, the condition was mistakenly thought to be rare.

Coeliac disease is now recognised to be a common condition that is thought to affect approximately 1 in every 100 people. Women are two to three times more likely to develop coeliac disease than men. Cases of coeliac disease have been diagnosed in people of all ages.

In some cases, coeliac disease does not cause any noticeable symptoms, or it causes very mild symptoms. As a result, it is thought that at least 50% or possibly as many as 90% of cases are either undiagnosed or misdiagnosed as other digestive conditions, such as irritable bowel syndrome (IBS). The Department of Health does not have information about the clinical and cost implications of undiagnosed cases. Data on the prevalence of coeliac disease in Ireland are not routinely available since it is not a condition covered either by statutory notification nor at present included in any disease registers.

Information on discharges from publicly-funded acute hospitals is collected via the Hospital Inpatient Enquiry (HIPE) system which records diagnoses and procedures for each in-patient and day case. Patients with a principal diagnosis of coeliac disease can be identified and the following Table displays the results for the period 2007 to 2011 by HSE region of residence and age group. The data shows an increase in discharges with this diagnosis over the period, particularly in the 0-14 age group. In the absence of prevalence data it is not possible to identify whether this increase indicates an increase in the disease or a change in diagnostic practice. It must be emphasised that the data refer only to hospitalised cases and that if a person is admitted more than once during the year for a specific condition each admission is counted separately in HIPE. For these reasons, the figures cannot be interpreted as an estimate of the prevalence of coeliac disease within the community.

Hospitalisations with a Principal Diagnosis of Coeliac Disease by HSE Region of Residence and Age, 2007 - 2011

HSE Region of Residence	Age Group	2007	2008	2009	2010	2011
	0-14 Years	29	39	39	41	67
	15-44 Years	74	101	83	70	74
Dublin Mid-Leinster	45-64 Years	77	73	71	69	49
	65+ Years	34	41	28	40	38
	All Ages	214	254	221	220	228
	0-14 Years	22	26	22	17	37
	15-44 Years	38	43	53	49	50
Dublin North-East	45-64 Years	36	39	39	48	39
	65+ Years	15	17	13	16	21
	All Ages	111	125	127	130	147
	0-14 Years	27	28	24	41	58
	15-44 Years	89	69	57	93	71
South	45-64 Years	89	57	63	76	64
	65+ Years	40	37	50	47	19
	All Ages	245	191	194	257	212
	0-14 Years	30	23	26	30	44
	15-44 Years	46	49	86	76	88
West	45-64 Years	52	64	58	72	72
	65+ Years	24	26	30	38	31
	All Ages	152	162	200	216	235
	0-14 Years	108	116	111	129	206
	15-44 Years	247	262	279	288	283
Total	45-64 Years	254	233	231	265	224
	65+ Years	113	121	121	141	109
	All Ages	722	732	742	823	822

Notes:

Source: Hospital In-patient Enquiry (HIPE).

The data reported above refer to inpatients and daycases with a principal diagnosis of Coeliac Disease (ICD-10-AM K90.0). Approximately 16% of the discharges reported above were re-admissions to the same hospital following a previous admission.

Treatment

Coeliac disease is usually treated by simply excluding foods that contain gluten from the diet. This prevents damage to the lining of the intestines (gut) that is caused by gluten, and the associated symptoms, such as diarrhoea and stomach pain. Many basic food items do not contain gluten and a wide range of gluten free alternatives to foods containing wheat, barley and rye is available in supermarkets and pharmacies.

Patients with coeliac disease can receive help and advice from their General Practitioner about dietary management and should also be referred for dietetic advice to ensure that the diet is balanced and contains all the nutrients needed, including essential vitamins and minerals.

In relation to the level of support available on the General Medical service for patients with coeliac disease, eligibility for health services in Ireland is based primarily on residency and means. The Health Act 1970 (as amended) provides for two categories of eligibility for all persons ordinarily resident in the country, i.e. full eligibility (medical card) and limited eligibility (all others). Full eligibility is determined mainly by reference to income limits and is granted to persons who, in the opinion of the Health Service Executive (HSE) are unable to provide general practitioner, medical and surgical services to persons and themselves and their dependants without undue hardship. There is a provision for discretion to grant a card in cases of "undue hardship" where the income guidelines are exceeded.

Persons with full eligibility (medical card holders) are entitled to a range of services including general practitioner services, prescribed drugs and medicines, all in-patient public hospital services in public wards including consultants services, all out-patient public hospital services including consultants services, dental, ophthalmic and aural services and appliances and maternity and infant care services. They are also entitled to prescribed drugs and medicines subject to a €1.50 charge per prescribed item (maximum charge of €19.50 per month). Other services such as allied health professional services may be available to medical card holders.

People with limited eligibility (non-medical card holders) are entitled, subject to certain charges, to all in-patient public hospital services in public wards including consultant services and out-patient pubic hospital services including consultants services. The current public hospital statutory in-patient charge is €75 per night, to a maximum of €750 in any twelve consecutive months. Attendance at accident and emergency departments is subject to a charge of €100 where the patient does not have a referral note from his/her doctor. This charge applies only to the first episode of care. Under the Drug Payment Schemes, no individual or family in this category pays more than €144 per calendar month towards the cost of approved prescribed medicines. The scheme significantly reduces the cost burden for families and individuals incurring ongoing expenditure on medicines.

In the current financial environment the Health Service Executive (HSE) faces a continuing challenge to deliver services in a way that will minimise any adverse impact on patients and continue to protect, as far as possible, the most vulnerable citizens. Unfortunately, as a result it has become necessary for the HSE to suspend certain products from its list of items reimbursable under the GMS and other community drug schemes. This includes gluten-free products.

Gluten-free products have become more widely available in supermarkets in recent years and tend to be significantly cheaper than products sold through community pharmacies. A Supplementary Welfare Allowance Adult Diet Supplement may be awarded by the Department of Social Protection to eligible persons. Persons wishing to apply for this allowance can do so by completing an application form which can be downloaded at the following link: http://www.welfare.ie/EN/Forms/Documents/swa9.pdf. Separate application forms are available for children. For persons who are not awarded a Diet Supplement, monies spent on gluten-free foods can be taken into account for tax purposes.

Screening

Screening for coeliac disease involves a two stage process:

blood tests to help identify people who may have coeliac disease

gut biopsy to confirm the diagnosis.

Routine screening for coeliac disease is not recommended unless a patient has symptoms associated with the condition or pre-existing risk factors.

In 2009, the UK National Institute for Health and Clinical Excellence (NICE) issued guidance about when testing for coeliac disease should be carried out. Information about the NICE guidance is available on the HSE website.

http://www.hse.ie/eng/services/flu/A-Z/C/Coeliac-disease/Diagnosing-coeliac-disease.html

The NICE guidance identifies the signs or symptoms for which testing for coeliac disease is strongly recommended for adults or children. The guidance also identifies a number of disease conditions in which testing for coeliac disease is or may be recommended.

In addition, I have arranged to have the Deputy's specific questions in relation to access to screening and access to dietetics referred to the HSE for attention and a more detailed response.