The Survey Of Digestive Health Across Europe - UEG
The Survey of DigestiveHealth Across EuropeHighlighting changing trends and healthcareinequalities in GI and liver disease
2The Survey of Digestive Health Across EuropeHighlighting changing trends and healthcare inequalities in GI and liver diseaseContentsGastrointestinal (GI) disorders04Inflammatory bowel disease (IBD)06Oesophageal and gastric cancer08Colorectal cancer10Liver disease12Hepatitis B and C virus infections14GI diseases in children16Screening18Training20Looking to the future221. Roberts SE, Samuel DG, Williams JG, et al. Survey ofDigestive Health across Europe. Part one: The burdenof gastrointestinal diseases and the organisation anddelivery of gastroenterology services across Europe.Report for United European Gastroenterology. August2014.All data and statistics contained within this booklet have been takenfrom the Survey of Digestive Health Across Europe original reports whichwere developed by Swansea University on behalf of UEG2. Anderson P, Dalziel K, Davies E et al. Survey of DigestiveHealth across Europe. Part two: The economic impact andburden of gastrointestinal diseases across Europe. Reportfor United European Gastroenterology. August 2014.
3The Survey of Digestive Health Across EuropeHighlighting changing trends and healthcare inequalities in GI and liver diseaseThe Survey of Digestive Health Across EuropeHighlighting changing trends and healthcareinequalities in GI and liver diseaseGastrointestinal (GI) and liver disorders are responsible for aroundone million deaths each year across Europe across all ages, andare associated with substantial morbidity and healthcare costs. Theincidence and prevalence of many GI disorders are highest amongstthe very young and the elderly, and as the European population ages,the disease burden will inevitably increase. Unfortunately, despite theirsubstantial prevalence and global impact, many digestive diseases arestill poorly understood and attract relatively little attention from either apolicy or funding perspective.United European Gastroenterology(UEG) is committed to raising politicaland public awareness of GI disordersthroughout the continent, informingpolicy makers, and encouragingresearch. To support this effort, accurateand up-to-date information is neededon the true burden of digestive diseasesand the current organisation anddelivery of care.The Survey of Digestive Health AcrossEurope1,2 – a hugely ambitious panEuropean project – was commissionedby UEG in 2013, with the aim ofsystematically reviewing all theavailable evidence on the clinical andpublic health burden of GI disordersand the delivery of gastroenterologyservices. Data was analysed from 28European Union (EU) member states,Norway, Switzerland, Liechtenstein andRussia.The Survey revealed changing trendsin many prevalent GI and liver diseasesand worrying inequalities in theprovision of healthcare services acrossthe continent. Notable increases in theincidence of most major GI disorderswere identified, and clear differences inoutcomes for patients between Easternand Western nations were highlighted.This booklet has been developedto summarise some of the Survey’skey findings.
4The Survey of Digestive Health Across EuropeHighlighting changing trends and healthcare inequalities in GI and liver diseaseGastrointestinal (GI) disordersThe GI disorders, dyspepsia, gastro-oesophagealreflux disease (GORD), peptic ulcers, Helicobacterpylori (H.pylori) infection, oesophagitis, irritablebowel syndrome (IBS) and pancreatitis are commonand costly conditions, yet they are often underreported and their true burden is difficult toquantify.Current data suggest that the incidence andprevalence of these GI disorders, which includes themost common functional disorders, are generallyincreasing, with the highest rates reported ineastern European countries and in less affluentparts of western Europe. Many of these conditions,if inadequately treated, can lead to potentiallylife-threatening complications. Mortality ratesare highest in eastern and north eastern Europeand lowest in north west Scandinavia and theMediterranean islands.Very little information exists on the economicburden of these disorders across Europe, however,direct costs associated with frequent physicianvisits and medical treatments and high rates ofcomplications and hospitalisation, and indirect costsdue to substantial levels of personal disability, workabsenteeism and loss of productivity are all likely tocontribute to their sizable socioeconomic burden.With a rising prevalence and high rates of morbidityand mortality in less affluent parts of Europe,these common and costly conditions exert a sizablesocioeconomic burden across the continent.SWIBSscotlandNORWAYA review of 8countries showedvariations inincidence from 4.2%(Netherlands) to9.7% (France)DYS5%DENMARKDENMARKIBS4.2%Highest rates of acutepancreatitis reported fromPoland, Finland, Spainand ScotlandPancreatitisIncrease in ageing Europeanpopulations will result inincreased incidenceof GI ALYITALYSPAINSPAIN
5The Survey of Digestive Health Across EuropeHighlighting changing trends and healthcare inequalities in GI and liver diseaseHighest in easternand north eastern EuropeDYS5%Mortality from(non-malignant)GI diseasesFINLANDLowest in northwest Scandinavia and theMediterranean IslandsFINLANDWEDENReducedproductivityReduced productivity in daily lifeof 26% across EuropeHas a higher prevalenceESTONIAof more than 60% in easternEurope including Hungaryand Poland and partsofLATVIAsouthern EuropeDYS15%DYS15%cost USTRIAGORDRUSSIALinked to an increased risk ofduodenal ulcers, gastric ulcersand malignanciescost ofabsenteeismPOLANDHighest hospital admissionrates reported from studiesin northern regions of EuropeHP60%SLOVAKIAHUNGARYHUNGARYHighest rates of more15% for Hungary,Italy and PolandROMANIAthanDyspepsiaLowest rates of less than5% for Denmark, Finlandand SwitzerlandReduction in productivityestimated to cost employers 3 billionPeptic UlcerMortality (per 100,000population) highest ineastern Europe and lowestin southern Europecost of absenteeism fromwork estimated at 1 billionGermanhealthcarecostsHigh incidence in Germany resultsin estimated healthcare costs of 4.8 billion
6The Survey of Digestive Health Across EuropeHighlighting changing trends and healthcare inequalities in GI and liver diseaseInflammatory bowel disease (IBD)The inflammatory bowel diseases, Crohn’sdisease and ulcerative colitis, are common,chronic inflammatory conditions that primarilyaffect young people in adolescence and earlyadulthood. The incidence and prevalence ofIBD have increased in the last few decadesthroughout Europe, with significant geographicvariations reported. The highest incidence ratesare observed in Scandinavia and the UnitedKingdom, while the lowest rates are seen insouthern and eastern Europe.Dramatic sustained increase in incidence in manywestern countriesRecent increase in incidence in eastern Europeputting pressure on healthcare systemsHeavy financial burden to westernhealthcare systems
7The Survey of Digestive Health Across EuropeHighlighting changing trends and healthcare inequalities in GI and liver diseasemore common in northernand western regions ofEurope, especially forCrohn’s diseaseMany people with IBD have frequent relapses orcontinuous active disease that often results incomplications requiring hospitalisation and/or surgery.Treatment strategies vary widely across Europe, whichis likely to affect cost and clinical outcomes. The longterm impact of IBD in terms of direct and indirect costsand the burden on the individual is huge. Direct costsassociated with IBD have increased significantly over thepast decade, primarily as a result of the increased use ofbiological therapies.The Survey reported that the impact of IBD on the socialand psychological development of paediatric patients isoften overlooked and should be explored further.a north: south and aneast: west gradient in theincidence of both Crohn’sdisease and ulcerative colitis.Availability of drugs,investigations and treatmentstrategies vary significantlyacross EuropeWorrying increases in the incidence and prevalence ofIBD, inconsistent treatment practices, and high rates ofcomplications contribute to a poor outlook for youngpeople with IBD in Europe.
8The Survey of Digestive Health Across EuropeHighlighting changing trends and healthcare inequalities in GI and liver diseaseOesophageal and gastric cancerOesophageal and gastric canceraccount for around 6% of all cancersin men and 3% of all cancers inwomen. Oesophageal cancer typicallyaffects people aged between 60 and80 years, with the most important riskfactors being severe, longstandinggastro-oesophageal reflux disease(GORD), smoking and heavy alcoholconsumption. There were 34,534 newcases of oesophageal cancer recordedin the EU in 2012, with an incidencerate of 6.9 per 100,000 population.The incidence is highest in northeastern European countries.Gastrointestinal cancer incidence.incidence of 684,000 casesacross 27 EU member statesin 2012Highest incidencenorth east Europethe most common cancer inmen and the second mostcommon in womenHighest reported incidencefrom north eastern EuropeLowest incidenceScandinaviaLowest reported incidencefrom Scandinavia andnorth west Europeancountriesaccounted for 30% of allnew cancers among menand 25% among women
9The Survey of Digestive Health Across EuropeHighlighting changing trends and healthcare inequalities in GI and liver diseaseHighest incidenceamongst men in easternEurope, lowest in western andsouthern regionsPancreaticcancerMortality highest in parts of UK,Scandinavia, Eastern Europeand the NetherlandsukirelandNetherlandsHighest incidence in theUK, Netherlands and IrelandExpected to continuefalling throughout ncerIncrease in populationmortality for oesophagealcancer predicted to increaseover the next 10 yearsPotentially levellingor increasing in the longerterm for parts ofwestern EuropeUsually highest incentral and western EuropeOne and fiveyear survivalAppears to be lowestin eastern EuropeGastric cancer also mainly affects olderpeople, with 80% of cases diagnosedbetween the ages of 60 and 80 years.The main risk factor for gastric cancer islongstanding H. pylori infection. More than80,000 new cases of gastric cancer werereported in the EU in 2012, with an incidencerate of 20.6 per 100,000 population. There isa strong east/west gradient in the incidenceof gastric cancer, which reflects the higherprevalence of H. pylori infection in easternEurope and parts of southern Europe.Projections for mortality due to oesophagealand gastric cancer indicate continuingreductions across the continent.These potentially preventable cancerscontinue to exert a heavy toll on our elderlypopulation in Europe, but mortality ratesare falling across the continent, with furtherreductions predicted.
10The Survey of Digestive Health Across EuropeHighlighting changing trends and healthcare inequalities in GI and liver diseaseColorectal cancerColorectal cancer (CRC) is the mostcommon GI cancer in Europe, with342,137 new cases recorded in theEU in 2012. The incidence of CRC ishigher in men than in women. Themain risk factors for CRC includea family history of the condition,the hereditary conditions, Lynchsyndrome or familial adenomatouspolyposis, and long-term IBD. Otherrisk factors include diabetes, dietslow in fibre and high in saturatedfats, a sedentary lifestyle, exposure toradiation, heavy alcohol consumptionand tobacco smoking.The prognosis for CRC is relativelygood compared with other GImalignancies and there is relativelylittle variation in reported survivalacross most European countries.Population-based mortality for CRChas been falling for several decadesin most western, northern andcentral European countries. However,mortality is continuing to increasein many eastern European countries– particularly in men – and in someparts of southern Europe.Colorectalcancer isthe mostcommontype of GIcancer inEuropeincidence rate of 68 per100,000 population342,137 new cases (14.3%of all cancers) recorded inthe EU in 2012accounts for about half of all GImalignancies in EuropeIncidence higher amongst men(79 per 100,000) than women (54)Annual cost of treatment in theUK alone totals over 480 million
11The Survey of Digestive Health Across EuropeHighlighting changing trends and healthcare inequalities in GI and liver diseaseHighest incidence amongst womenreported in north western EuropePopulation based mortalityfalling in almost all western,northern and centralEuropean countriesIncreasing in many easternEuropean countries,particularly for menIncreasing in some southernEuropean countries includingGreece, Portugal and SpainHighest incidence amongstmen appears to be in parts ofeastern EuropeCRC screening programmes arewell established in most Europeancountries, however, participationrates vary widely, and their impacton mortality has not yet been fullyestablished.Predicted to continuefalling for up to a decadeacross northern andwestern Europe then leveloff or increasePredicted to increase orremain static in easternEurope over next decadeOur most common GI cancer is nowassociated with a relatively goodprognosis and improved survivalrates in most European countries.However, mortality is increasing inmany parts of Eastern Europe.
12The Survey of Digestive Health Across EuropeHighlighting changing trends and healthcare inequalities in GI and liver diseaseLiver diseaseChronic liver disease has been estimated to affect almost30 million people in the EU, although difficulties obtainingdata from individual countries hinder the global evaluationof the burden of liver disease in Europe. Chronic liverdisease is caused by a range of conditions that resultin liver injury and dysfunction, including heavy alcoholconsumption, hepatitis B or C infections, exposure tocertain drugs and toxins, and metabolic syndromes relatedto being overweight and obesity.Chronic alcohol consumption is the primary cause ofchronic liver disease in Europe, although, in someregions, hepatitis B and C infections are also majorrisk factors. Alcohol consumption decreased during the1990s, but increased steadily during the last decade toreach hazardous levels in many European countries.Mortality from chronic liver disease is well documentedin Europe, with the highest rates reported in easternand north eastern countries. Liver disease caused byalcohol consumption is by far the most lethal form ofthe condition. The prognosis for people with late-stageliver disease remains dismal and has not improvedsubstantially over the last 50 years.Alcohol consumption has reached hazardous levels inmany European countries, contributing to the growingburden of liver disease. The prognosis for people withlate-stage liver disease remains dismal.Alcohol-related liver diseaseIncreases in hospitalised cases of alcoholic liverdisease over the last two decades are widespread122% Finland166% Scotland138% England and WalesAcross Europe alcohol is generally regardedas the leading cause of liver diseaseEurope has the highest levels of alcohol drinkersin the worldEach European consumes 12.5 litresof pure alcohol – more than doublethe world averageeastern European countries have experiencedincreased levels of consumption over recent yearswhere harmful drinking and alcohol abuse is higherthan other parts of EuropeAlcohol consumption is the third causeof disease and mortality across EuropeThere is concern that younger Europeans are drinkingheavily and more often
13The Survey of Digestive Health Across EuropeHighlighting changing trends and healthcare inequalities in GI and liver diseaseChronic liverdiseasefinlandhighest rates30 per 100,000highest rates of mortality of morethan 30 per 100,000 populationare mostly from some eastern ornorth eastern countrieslowest Rates8 per 100,000Lowest rates of less than 8 per100,000 mainly in Scandinavian orMediterranean iliaryCirrhosisSubstantial increase since mid1980s reported across parts ofEngland, Finland and EstoniaRecent increase of 63% in theNetherlandsLiver TransplantationTransplantation assessment andsurgery widely available acrosswestern EuropeMost of eastern Europe, withthe exception of Poland is underresourced and have limitedexpertise
14The Survey of Digestive Health Across EuropeHighlighting changing trends and healthcare inequalities in GI and liver diseaseHepatitis B and C virus infectionsromaniaScreening now commonpractice across EuropeitalygreeceHighest reported incidence ofhepatitis B in Romania and GreeceIn western Europe, hepatitis C has been reported to lead to.Hepatitis B is transmitted frominfected mothers to up to 90%of babies across Europe70% of all cases of40% of all cases ofchronic hepatitis,liver cirrhosis, and60% of all cases ofhepatocellular cancer
The Survey of Digestive Health Across EuropeHighlighting changing trends and healthcare inequalities in GI and liver diseaseHighest reportedincidence ofhepatitis C inparts of easternand southernEurope includingItaly and RomaniaThroughout Europe, 21% of thosewith the hepatitis C virus (HCV) hadbeen discriminated against in theworkplaceThe liver diseases, due to hepatitisB and C viruses, affect millionsof Europeans, with the highestprevalence found amongst thosewho inject drugs. Hepatitis Bis spread primarily throughunprotected sex and contaminatedneedles, although perinataltransmission remains an importantsource of infection across Europe.While most cases of hepatitis C arefound amongst intravenous drugusers, blood transfusions, othermedical procedures, unprotectedsex, tattooing equipment andtransmission from mother to babyare also important modes of virustransmission. Co-infection withboth viruses may occur.Surveillance systems for hepatitisB and C differ widely across Europeand although EU notification ratesof 3.5 cases per 100,000 (hepatitisB) and 7.8 cases per 100,000population (hepatitis C) have beenreported by the European Centrefor Disease Prevention and Control,these figures are likely to be anunderestimate of the true situation.15The highest rates of notification forhepatitis B are currently in northernEuropean countries such as Poland,Sweden, the UK, Latvia and Ireland.For hepatitis C, the highest ratesare in Scandinavia and other partsof northern or eastern Europe.Effective hepatitis virus surveillancesystems are now in place in mostEuropean countries and thesehave had a major impact onthe healthcare burden of theseconditions. Nevertheless, fromthe research highlighted in theSurvey, hepatitis B and C continueto exert a heavy personal burdenon affected individuals, withfrequent physician visits, poor workperformance and discrimination inthe workplace commonly reported.Effective hepatitis surveillancesystems have reduced thehealthcare burden of hepatitis Band C across Europe, but affectedindividuals continue to paya heavy price.
16The Survey of Digestive Health Across EuropeHighlighting changing trends and healthcare inequalities in GI and liver diseaseGI diseases in childrenThe Survey of Digestive Health Across Europe evaluated a rangeof GI disorders that frequently affect children, including IBD,GORD, dyspepsia, H. pylori infection, coeliac disease and recurrentabdominal pain – all of which add to the burden of illness inEurope. The Survey reported that the incidence of many paediatricdisorders was increasing in many countries, yet the impact of theseconditions on the child’s social and psychological well-being is oftenoverlooked.Paediatric IBD is of particular concern, since up to 30% of cases ofIBD begin in childhood, and studies suggest its prevalence is on theincrease. Unfortunately, the Survey has emphasised the disparitybetween the quality of services provided to adults and that offered tochildren, and the lack of information on how children transition frompaediatric to adult care.Two welcome developments in the management of paediatric IBDare highlighted in the survey reports: joint publication by EuropeanCrohn’s and Colitis Organisation (ECCO) and the European Society forPaediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN)of the first paediatric specific guidelines for IBD patients and theinitiation of the EUROKIDS registry.The incidence of many childhood GI disorders is increasing in manycountries, yet the impact of these conditions on the child’s social andpsychological well-being is often overlooked.GORDincidence varies from2 – 10% of youngpeople across Europemost frequent ininfants between oneand four years withrisk factors includinglow birth weight andcow’s milk allergyHELICOBACTERPyloriHighest incidenceamongst youngpeople reportedfrom eastern Europealong with parts ofwestern Europe
17The Survey of Digestive Health Across EuropeHighlighting changing trends and healthcare inequalities in GI and liver diseasePaediatric inflammatory bowel disease, coeliac disease and oesophagitisare increasing in many European countriespaediatric-onsetIBD increaseHigh prevalenceof functionalGI disorders inchildrenfinlandnorwayswedenA recent review of the incidenceand prevalence of paediatriconset IBD reported a generaltrend for an overall increaseover the past few decadesHighest incidenceCrohn’s diseaseChildhoodonset IBDaccountsfor about20 to 30%of all casesof IBDfrancehungaryUp to one in four casesof IBD present and arediagnosed during childhood(under the age of 16 years)Highest reported incidence ofpaediatric Crohn’s disease hasrecently been from Sweden,Hungary and Norway with lowestincidence from PolandHighest incidencepaediatriculcerative colitisIn the last decade the highestincidence of paediatric ulcerativecolitis has been reported fromFrance, Finland and Hungary
18The Survey of Digestive Health Across EuropeHighlighting changing trends and healthcare inequalities in GI and liver diseaseScreeningVariation in screeningstrategies.FINLANDfrom voluntary guidelines (UK)multiple national guidelines(France and Germany)treatment pathways (Franceand Italy) and online oncologydatabases (Netherlands andFrance)ukPercentage of populationscreened for CRC varies from 2.6%in Malta to 54.2% in GermanY withdata lacking for much of EuropegermanymaltalithuaniaReported participation rates forcolorectal cancer (CRC) screeningprogrammes vary from 20%(Croatia) to 70% tiaROMANIAITALYDisparities in provision existsacross regions with 71.6% ofnorthern Italians having accessto CRC screening versus 7% ofItalians in the southhepatitis Screeningprogrammes.are widespread across Europewith only a few exceptions,notably Lithuania, Luxembourgand RomanianorthMALTAsouth
The Survey of Digestive Health Across EuropeHighlighting changing trends and healthcare inequalities in GI and liver diseaseCurrently no Europe-wideconsensus over screening forhigh-risk genetic groupsDemand for screening predictedto rise with ageing populationMuch of Europe will be illequipped to fund and resourcemore widespread screeningprogrammes and subsequentincreases in endoscopic andcancer services19Colorectal cancer (CRC) screening programmes are now well establishedin most European countries. The type of screening programme varies widelyfrom population-based faecal occult blood testing to the targeted use ofscreening using flexible sigmoidoscopy or colonoscopy. Participation inpopulation-wide CRC screening also varies widely across Europe.The Survey highlights the possibility that CRC screening programmes maypotentially disadvantage other patient groups that require regular endoscopyservices, pointing to significant variation in endoscopy services and capacityacross Europe.Screening for hepatitis B and C is also common practice across Europeanregions, since early detection is critical for successful treatment anderadication of the disease. Screening now plays a crucial role in thefundamental function of hepatitis services, with most countries adoptingroutine screening for blood-borne viruses during pregnancy and someintroducing additional screening programmes for high-risk groups.While these programmes may be heterogeneous, they have been creditedwith markedly reducing the burden of infectious hepatitis in Europe.CRC screening programmes are well established in most European countries,although the types of programme and participation rates vary widely.Hepatitis B and C screening programmes have markedly reduced the burdenof infectious hepatitis across Europe.
20The Survey of Digestive Health Across EuropeHighlighting changing trends and healthcare inequalities in GI and liver diseaseTrainingHigh quality, standardised gastroenterology training iscritical to future service delivery in Europe, however,significant heterogeneity remains in the delivery of educationacross the continent. Major differences in terms of the lengthof gastroenterology training, training methodologies used,and levels of supervision were identified by the Survey, withunder-training reported in several key areas.gastroenterology training in Europe varies from4 – 9 years with a median of 5 – 6 yearsThere is an absence of evidence from European countrieson both the content and quality of postgraduate andundergraduate training in gastroenterology. The Surveyidentified a need to map different national curricula forpostgraduate and undergraduate education within theEuropean curriculum and to address the predicted futureneeds of the European population.Both the knowledge-based examination developed bythe European Board of Gastroenterology and Hepatology(EBGH) and the European training syllabus in paediatricgastroenterology developed by ESPGHAN are consideredimportant initiatives to improve standards of trainingand reduce variability of practice across Europe and arehighlighted in the Survey.throughout much of Europethe inflammatory bowel diseasenurse is increasingly important inmanaging patientsSignificant heterogeneity in the delivery of gastroenterologyeducation and training in key areas of GI medicine have beenidentified across the continent. This could potentially impactfuture service delivery in Europe.multi-disciplinary clinics are ad hoc in most Europeancountries occurring only in the larger hospitals
21The Survey of Digestive Health Across EuropeHighlighting changing trends and healthcare inequalities in GI and liver diseaseVariation in colorectalcancer screeningand outcomes isparalleled by variationin endoscopy servicesand capacity acrossEuropeA survey of10 Europeancountrieshighlighteda lack ofstandardisedtraining33% of traineesin their last yearfelt under trainedin endoscopicprocedures33%Currently few countries utilisea nurse endoscopy workforce23%23% in their last yearfelt under trained inhepatologyThe European Society of Gastroenterology andEndoscopy Nurses and Associates (ESGENA) has driven acollaboration between European countries to establisha harmonised training programme for endoscopy nurses
22The results of this survey have highlighted that there isgenerally poor reporting of the quality of life and economicimpact of gastrointestinal disorders from the majority ofEuropean countries. Future research is required that willstudy incidence, prognosis and the public health burden ofnumerous GI conditions across Europe.Specifically, research is needed to address the weak evidencebase relating to the prevalence and public health burden ofmost liver diseases, the optimal tool for predicting the needfor liver transplantation and the impact of minimal alcoholpricing levels.Interested and specialist European groups need to addressthe absence of published work on the benefits of transitionalclinics for inflammatory bowel disease and the psychologicalbenefit for paediatric patients with IBD.Accurate mapping of existing workforce data per head ofpopulation is a priority to ensure effective planning of futureservices and workforce training.The Survey of Digestive Health Across EuropeHighlighting changing trends and healthcare inequalities in GI and liver diseaseThe Survey of Digestive Health AcrossEurope highlights some areas of goodpractice as well as showing many areasthat require attention at both a nationaland European level. Our hope is that,ultimately, the Survey and the reportsgenerated will help to improve care andhealth outcomes and reduce inequalitiesacross the continent.Michael Farthing, UEG President
23The Survey of Digestive Health Across EuropeHighlighting changing trends and healthcare inequalities in GI and liver diseaseStarting the ConversationShare your thoughts and comments on the situationacross Europe and the priorities for improvingservice provision @my UEG #shapingGITo download the infographics or a summary of theSurvey visit www.ueg.eu/research/activitiesTogether we can advancegastroenterological careThe full report can be found at:ueg.sagepub.com/site/White Book/White Book.xhtml
This project was led by the UEG Future Trends Committee and undertaken by a group of researchers from Swansea University in Wales.
Digestive Health across Europe. Part one: The burden of gastrointestinal diseases and the organisation and delivery of gastroenterology services across Europe. Report for United European Gastroenterology. August 2014. 2. Anderson P, Dalziel K, Davies E et al. Survey of Digestive Health across Europe. Part two: The economic impact and
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