Randomized, controlled trial of home telemanagement in patients with ulcerative colitis (UC HAT)

Telemonitoring of Crohn's Disease and Ulcerative Colitis (TECCU): Cost-Effectiveness Analysis

BACKGROUND

Although electronic health interventions are considered safe and efficient, evidence regarding the cost-effectiveness of telemonitoring in inflammatory bowel disease is lacking.

OBJECTIVE

We aimed to evaluate the cost-effectiveness and cost-utility of the Telemonitorización de la Enfermedad de Crohn y Colitis Ulcerosa (Telemonitoring of Crohn's Disease and Ulcerative Colitis [TECCU]) Web platform (G_TECCU intervention group) for telemonitoring complex inflammatory bowel disease, compared with standard care (G_control) and nurse-assisted telephone care (G_NT intervention group).

METHODS

We analyzed cost-effectiveness from a societal perspective by comparing the 3 follow-up methods used in a previous 24-week randomized controlled trial, conducted at a tertiary university hospital in Spain. Patients with inflammatory bowel disease who initiated immunosuppressants or biologic agents, or both, to control inflammatory activity were recruited consecutively. Data on the effects on disease activity (using clinical indexes) and quality-adjusted life-years (using the EuroQol 5 dimensions questionnaire) were collected. We calculated the costs of health care, equipment, and patients' productivity and social activity impairment. We compared the mean costs per patient, utilities, and bootstrapped differences.

RESULTS

We included 63 patients (21 patients per group). TECCU saved €1005 (US $1100) per additional patient in remission compared with G_control (95% CI €-13,518 to 3137; US $-14,798 to 3434), with a 79.96% probability of being more effective at lower costs. Compared with G_NT, TECCU saved €2250 (US $2463) per additional patient in remission (95% CI €-15,363 to 11,086; US $-16,817 to 12,135), and G_NT saved €538 (US $589) compared with G_control (95% CI €-6475 to 5303; US $-7088 to 5805). G_TECCU and G_NT showed an 84% and 67% probability, respectively, of producing a cost saving per additional quality-adjusted life-year (QALY) compared with G_control, considering those simulations that involved negative incremental QALYs as well.

CONCLUSIONS

There is a high probability that the TECCU Web platform is more cost-effective than standard and telephone care in the short term. Further research considering larger cohorts and longer time horizons is required.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02943538; https://clinicaltrials.gov/ct2/show/NCT02943538 (http://www. webcitation.org/746CRRtDN).

Digital Health Apps in the Clinical Care of Inflammatory Bowel Disease: Scoping Review

BACKGROUND

Digital health is poised to transform health care and redefine personalized health. As Internet and mobile phone usage increases, as technology develops new ways to collect data, and as clinical guidelines change, all areas of medicine face new challenges and opportunities. Inflammatory bowel disease (IBD) is one of many chronic diseases that may benefit from these advances in digital health. This review intends to lay a foundation for clinicians and technologists to understand future directions and opportunities together.

OBJECTIVE

This review covers mobile health apps that have been used in IBD, how they have fit into a clinical care framework, and the challenges that clinicians and technologists face in approaching future opportunities.

METHODS

We searched PubMed, Scopus, and ClinicalTrials.gov to identify mobile apps that have been studied and were published in the literature from January 1, 2010, to April 19, 2019. The search terms were ("mobile health" OR "eHealth" OR "digital health" OR "smart phone" OR "mobile app" OR "mobile applications" OR "mHealth" OR "smartphones") AND ("IBD" OR "Inflammatory bowel disease" OR "Crohn's Disease" (CD) OR "Ulcerative Colitis" (UC) OR "UC" OR "CD"), followed by further analysis of citations from the results. We searched the Apple iTunes app store to identify a limited selection of commercial apps to include for discussion.

RESULTS

A total of 68 articles met the inclusion criteria. A total of 11 digital health apps were identified in the literature and 4 commercial apps were selected to be described in this review. While most apps have some educational component, the majority of apps focus on eliciting patient-reported outcomes related to disease activity, and a few are for treatment management. Significant benefits have been seen in trials relating to education, quality of life, quality of care, treatment adherence, and medication management. No studies have reported a negative impact on any of the above. There are mixed results in terms of effects on office visits and follow-up.

CONCLUSIONS

While studies have shown that digital health can fit into, complement, and improve the standard clinical care of patients with IBD, there is a need for further validation and improvement, from both a clinical and patient perspective. Exploring new research methods, like microrandomized trials, may allow for more implementation of technology and rapid advancement of knowledge. New technologies that can objectively and seamlessly capture remote data, as well as complement the clinical shift from symptom-based to inflammation-based care, will help the clinical and health technology communities to understand the full potential of digital health in the care of IBD and other chronic illnesses.

Videoconference clinics improve efficiency of inflammatory bowel disease care in a remote and rural setting

INTRODUCTION

Patients with inflammatory bowel disease (IBD) require long-term secondary care with periodic specialist follow-up. This can be especially challenging for patients living in remote areas. One possible solution is the implementation of videoconference (VC) clinics as a distance-management tool. Here we assessed the use of VC clinics for IBD in terms of patient safety and economic benefit for patients with IBD living in rural areas in the Scottish Highlands and Islands.

METHODS

Eighty-eight patients participating in the IBD specialist nurses VC clinic administered via Raigmore Hospital, Inverness, Scotland, UK, between January 2016 and June 2017 were included in this study. A total of 229 appointments were assessed.

RESULTS

We found the use of a VC clinic to be safe and effective as only 0.9% of appointments required urgent medical assessment and 92% of the VC clinic appointments resulted in further VC clinic follow-up. A total travelling distance of 72,245.3 km and a total travelling time of 71,688 minutes were saved in this patient cohort. It was shown that an average of US$36.61 of potential travelling cost could be saved per appointment.

DISCUSSION

VC clinics represent a patient-centred participatory model of care for IBD patients living in remote areas with enormous time- and cost-saving potential while being safe and effective. Further investigations into patient satisfaction and the combination with other telemedicine tools such as telephone conferencing and mobile phone applications are needed to evaluate the full potential of the concept.

Big data in IBD: a look into the future

Big data methodologies, made possible with the increasing generation and availability of digital data and enhanced analytical capabilities, have produced new insights to improve outcomes in many disciplines. Application of big data in the health-care sector is in its early stages, although the potential for leveraging underutilized data to gain a better understanding of disease and improve quality of care is enormous. Owing to the intrinsic characteristics of inflammatory bowel disease (IBD) and the management dilemmas that it imposes, the implementation of big data research strategies not only can complement current research efforts but also could represent the only way to disentangle the complexity of the disease. In this Review, we explore important potential applications of big data in IBD research, including predictive models of disease course and response to therapy, characterization of disease heterogeneity, drug safety and development, precision medicine and cost-effectiveness of care. We also discuss the strengths and limitations of potential data sources that big data analytics could draw from in the field of IBD, including electronic health records, clinical trial data, e-health applications and genomic, transcriptomic, proteomic, metabolomic and microbiomic data.

Examination of the relationship between disease activity and patient-reported outcome measures in an inflammatory bowel disease cohort

BACKGROUND

The extent to which disease activity impacts patient-reported outcomes (PRO) is unclear.

AIMS

To examine the relationship between disease activity and PRO.

METHODS

Adult inflammatory bowel disease (IBD) patients attending a tertiary clinic from May to June 2015 were included. Assessment of disease activity (Simple Clinical Colitis Activity Index (SCCAI), Harvey Bradshaw Index (HBI)), IBD knowledge (CCKNOW), medication adherence (MMAS8), psychological distress (Hospital Anxiety and Depression Scale (HADS)), work productivity (WPAI) and quality of life (IBDQ) was performed to investigate any correlations between disease activity and PRO.

RESULTS

A total of 81 participants was included: 49% female, 57% Crohn disease (CD), 38% ulcerative colitis (UC) and 5% IBD-unclassified, with a median age of 34 years. At least mild levels of depression were present in 21 of 81 (26%) of patients; 37 of 81 (46%) expressed some level of anxiety. A moderate-to-strong correlation was found between disease activity and depression in UC (r = 0.84, P = 0.002) but not in CD (r = 0.53, P = 0.29). Disease activity correlated with: overall work impairment due to health (r = 0.85, P = 0.001), health-related impairment while working (r = 0.76, P = 0.02) and percentage of activity impaired due to health (r = 0.83, P = 0.002) in UC only.

CONCLUSIONS

Disease activity significantly affects mood and work productivity in patients with UC. Monitoring patients' ability to function and work, rather than minimising disease activity alone, should become a routine part of IBD care.

A Randomized Controlled Trial of TELEmedicine for Patients with Inflammatory Bowel Disease (TELE-IBD)

INTRODUCTION

Telemedicine has shown promise in inflammatory bowel disease (IBD). The objective of this study was to compare disease activity and quality of life (QoL) in a 1-year randomized trial of IBD patients receiving telemedicine vs. standard care.

METHODS

Patients with worsening symptoms in the prior 2 years were eligible for randomization to telemedicine (monitoring via texts EOW or weekly) or standard care. The primary outcomes were the differences in change in disease activity and QoL between the groups; change in healthcare utilization among groups was a secondary aim.

RESULTS

348 participants were enrolled (117 control group, 115 TELE-IBD EOW, and 116 TELE-IBD weekly). 259 (74.4%) completed the study. Age was 38.9 ± 12.3 years, 56.6% were women, 91.9% were Caucasian, 67.9% had Crohn's disease (CD) and 42.5% had active disease at baseline. In CD, all groups experienced a decrease in disease activity (control -5.2 ± 5.0 to 3.7 ± 3.6, TELE-IBD EOW 4.7 ± 4.1 to 4.2 ± 3.9, and TELE-IBD weekly 4.2 ± 4.2 to 3.2 ± 3.4, p < 0.0001 for each of the groups) In UC, only controls had a significant decrease in disease activity (control 2.9 ± 3.1 to 1.4 ± 1.4, p = 0.01, TELE-IBD EOW 2.7 ± 3.1 to 1.7 ± 1.9, p = 0.35, and TELE-IBD Weekly 2.5 ± 2.5 to 2.0 ± 1.8, p = 0.31). QoL increased in all groups; the increase was significant only in TELE-IBD EOW (control 168.1 ± 34.0 to 179.3 ± 28.2, p = 0.06, TELE-IBD EOW 172.3 ± 33.1 to 181.5 ± 28.2, p = 0.03, and TELE-IBD Weekly 172.3 ± 34.5 to 179.2 ± 32.8, p = 0.10). Unadjusted and adjusted changes in disease activity and QoL were not significantly different among groups. Healthcare utilization increased in all groups. TELE-IBD weekly were less likely to have IBD-related hospitalizations and more likely to have non-invasive diagnostic tests and electronic encounters compared to controls; both TELE-IBD groups had decreased non-IBD related hospitalizations and increased telephone calls compared to controls.

DISCUSSION

Disease activity and QoL, although improved in all participants, were not improved further through use of the TELE-IBD system. TELE-IBD participants experienced a decrease in hospitalizations with an associated increase in non-invasive diagnostic tests, telephone calls and electronic encounters. Research is needed to determine if TELE-IBD can be improved through patient engagement and whether it can decrease healthcare utilization by replacing standard care.

'Quality of Care' Standards in Inflammatory Bowel Disease: A Systematic Review

BACKGROUND

Inflammatory bowel disease [IBD] includes chronic, disabling and progressive conditions that need a complex approach and management. Although several attempts have been made to standardize the care of IBD patients, no clear definitions of a global 'standard of care' are currently available.

METHODS

We performed a systematic review of the available literature, searching for all relevant data concerning three main domains of standards of quality of care in IBD patients: structure, process and outcomes. From the literature search, 2394 abstracts were retrieved, and 62 relevant papers were included in the final review.

RESULTS

Standards of quality of care in IBD include several aspects that can be summarized in three identified domains: structure, process and outcomes. The suggested structure of an IBD Unit includes a multi-disciplinary approach, effective referral processes, improved access using helplines, and departmental guidelines/pathways with identification of measurable quality indicators. Coordinated care models which incorporate a multi-disciplinary approach, structured clinical pathways or processes for the diagnosis, monitoring and treatment of IBD, fast-track recovery from IBD surgery, designated IBD clinics, virtual clinics and telemanagement are currently considered the main standards for process, although supporting data are limited. Several consensus statements on outcomes and quality indicators have been reported, focusing on outcomes in symptoms, function and quality of life restoration, survival and disease control, in addition to effective healthcare utilization.

CONCLUSIONS

The results of this systematic review can provide the basis for general recommendations for standards of quality of care in IBD.

Adherence to therapy of patients with inflammatory bowel diseases

Inflammatory bowel diseases are autoimmune systemic forms of pathology. The concept of continuous life-long drug intake is a cornerstone in their therapy. The review presents the factors that reduce patients adherence to treatment and ways to improve it. They include informing the patient about the disease and treatment, selection of individual therapy regimen, consolidation of achievements, provision of social support and interaction with other specialists.

A Web-Based Telemanagement System for Patients With Complex Inflammatory Bowel Disease: Protocol for a Randomized Controlled Clinical Trial

BACKGROUND

Telemedicine has been successfully used to provide inflammatory bowel disease (IBD) patients with health care services remotely via the implementation of information and communications technology, which uses safe and feasible apps that have been well accepted by patients in remission. However, the design of telemedicine apps in this setting involves difficulties that hinder the adherence of patients to the follow-up plans and the efficacy of these systems to improve disease activity and quality of life.

OBJECTIVE

This study aimed to evaluate the development of a Web platform, Telemonitoring of Crohn Disease and Ulcerative Colitis (TECCU), for remote monitoring of patients with complex IBD and the design of a clinical trial involving IBD patients who received standard care (G_Control), nurse-assisted telephone care (G_NT), or care based on distance monitoring (G_TECCU).

METHODS

We describe the development of a remote monitoring system and the difficulties encountered in designing the platform. A 3-arm randomized controlled trial was designed to evaluate the effectiveness of this Web platform in disease management compared with G_NT and G_Control.

RESULTS

According to the schedules established for the medical treatment initiated (corticosteroids, immunosuppressants, or biological agents), a total of 63 patients (21 patients from each group) answered periodic questionnaires regarding disease activity, quality of life, therapeutic adherence, adverse effects, satisfaction, work productivity, and social activities. Blood and stool analyses (fecal calprotectin) were performed periodically. On the basis of the results of these tests in G_TECCU, alerts were generated in a Web platform with adapted action plans, including changes in medication and frequency of follow-up. The main issues found were the development of an easy-to-use Web platform, the selection of validated clinical scores and objective biomarkers for remote monitoring, and the design of a clinical trial to compare the 3 main follow-up methods evaluated to date in IBD.

CONCLUSIONS

The development of a Web-based remote management program for safe and adequate control of IBD proved challenging. The results of this clinical trial will advance knowledge regarding the effectiveness of TECCU Web platform for improvement of disease activity, quality of life, and use of health care resources in complex IBD patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02943538; https://clinicaltrials.gov/ct2/show/NCT02943538 (Archived by WebCite at http://www.webcitation.org/6y4DQdmt8).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/9639.

Age Modifies the Association Between Depressive Symptoms and Adherence to Self-Testing With Telemedicine in Patients With Inflammatory Bowel Disease

BACKGROUND

Depression is common in patients with inflammatory bowel disease (IBD) and is known to be associated with poor adherence in the usual care setting. In the last decade, there has been an increase in the use of information technology (IT) for the delivery of IBD care, but the association between depressive symptoms (DS) and adherence to self-testing in this context is not known. We aimed to investigate this association among IBD patients managed via a text messaging-based telemedicine system.

METHODS

This was a prospective study of participants in the 2 intervention arms of the Telemedicine for Patients with IBD (TELE-IBD) trial. Depressive symptoms were measured at baseline, and then participants received periodic text messages to initiate IBD-specific self-testing. Treatment plans were similarly conveyed, and adherence to self-testing was evaluated at the end of 1 year. Regression analyses were performed, and age-stratified models were constructed to evaluate for effect modification.

RESULTS

Of the 193 study participants, 48% had DS at baseline. Overall, there was no significant association between DS and adherence to self-testing. However, upon stratification by age, adherence increased with depressive symptoms in those that were 40 years and younger (P = 0.02), but there was no association between depressive symptoms and adherence in the older group (P = 0.53).

CONCLUSIONS

Younger IBD patients with DS have high adherence when managed in a text messaging-based telemedicine program. Telemedicine interventions have the potential to improve health outcomes in this demographic-a group that is often thought to be difficult to manage due to nonadherence.

A Web-Based Telemanagement System for Improving Disease Activity and Quality of Life in Patients With Complex Inflammatory Bowel Disease: Pilot Randomized Controlled Trial

BACKGROUND

The reported efficacy of telemedicine in patients with inflammatory bowel disease (IBD) is inconsistent among studies, and data for complex IBD are lacking.

OBJECTIVE

We aimed to evaluate the impact of remote monitoring using a Web system-Telemonitorización de la Enfermedad de Crohn y Colitis Ulcerosa or Telemonitoring of Crohn's Disease and Ulcerative Colitis (TECCU)-as compared to standard care and telephone care on health outcomes and health care in patients with complex IBD.

METHODS

We performed a 3-arm randomized controlled trial. Adult patients with IBD who received immunosuppressants and biological agents were recruited from the IBD Unit of a tertiary university hospital. The patients were randomized into groups to receive remote monitoring (G_TECCU), nurse-assisted telephone care (G_NT), or standard care with in-person visits (G_control). All patients completed the study visits at baseline and at 12 and 24 weeks in addition to each type of intervention. The primary outcome was the percentage of patients in remission at 24 weeks. Secondary health outcomes were quality of life, medication adherence, adverse effects, satisfaction, and social activities. Data on the number of outpatient visits and telephone calls, emergency visits, hospitalizations, IBD-related surgeries, and corticosteroid courses were also collected.

RESULTS

A total of 63 patients were selected (21 patients in each group). During the study, 90.5% (19/21) of patients in G_control, 95.2% (20/21) in G_NT, and 85.7% (18/21) in G_TECCU were compliant to the intervention. After 24 weeks, the percentage of patients in remission was higher in G_TECCU (17/21, 81%) than in G_NT (14/21, 66.7%) and G_control (15/21, 71.4%). A higher improvement in disease activity was observed in G_TECCU than in G_control in terms of the Harvey-Bradshaw/Mayo (odds ratio=0.12, 95% CI=0.003-2.162, P=.19) and Harvey-Bradshaw/Walmsley (odds ratio=0.11, 95% CI=0.004-1.55, P=.13) indexes. Improvement in disease activity was associated with a larger reduction in fecal calprotectin values in G_TECCU compared to G_control (estimated intervention effect: odds ratio=-0.90; 95% CI=-1.96 to 0.16, P=.11). All completers adhered to treatment in G_TECCU. In addition, the quality of life, social activities, and satisfaction improved in all 3 groups. Although the number of outpatient visits and telephone calls was lower in G_TECCU than in G_NT and G_control, the safety profile was similar in all 3 groups.

CONCLUSIONS

This pilot clinical trial suggests that the TECCU Web-based system is a safe strategy for improving health outcomes in patients with complex IBD and reducing the use of health care resources.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02943538; https://clinicaltrials.gov/ct2/show/NCT02943538 (Archived by WebCite at http://www.webcitation.org/746CRRtDN).

Design considerations for an eHealth decision support tool in inflammatory bowel disease self-management

BACKGROUND

Electronic health (eHealth) decision support tools have the potential to: facilitate inflammatory bowel disease (IBD) self-management, reduce health care utilisation and alleviate the pressure on overburdened outpatient clinics. The purpose of this study was to explore the perspectives of key stakeholders on the potential use of a decision support tool for IBD patients.

METHODS

A qualitative study using focus group methodology was conducted at a tertiary IBD centre in Melbourne, Australia in February 2015. Key stakeholders, including physicians, nurses and patients, were included in the study. Two independent reviewers undertook inductive coding and generated themes.

RESULTS

In total, 31 participants were included in the study (including 16 males; 11 physicians; 6 nurses). An eHealth decision support tool was thought to be beneficial to facilitate IBD self-management. Four themes emerged: (i) Framework for the decision support tool - the tool should be an adjunct to current models of care and facilitate shared decision-making and patient engagement; (ii) Target population - stable patients with mild to moderate disease; (iii) Functionalities of the intervention - a web-based platform encompassing patient-reported outcomes, objective markers of disease and clinical algorithms based on international guidelines; and (iv) Design and Implementation - patients should be involved in the design.

CONCLUSIONS

eHealth interventions are thought to be an important strategy to facilitate self-management for patients with IBD. A multi-stage iterative approach should be adopted in the design and implementation process of eHealth interventions. Patient perspectives need to be sought prior to and throughout the development of an eHealth decision support tools for IBD.

Consensus recommendations for patient-centered therapy in mild-to-moderate ulcerative colitis: the i Support Therapy-Access to Rapid Treatment (iSTART) approach

Symptomatic ulcerative colitis (UC) can be a chronic, disabling condition. Flares in disease activity are associated with many of the negative impacts of mild-to-moderate UC. Rapid resolution of flares can provide benefits to patients and healthcare systems. i Support Therapy–Access to Rapid Treatment (iSTART) introduces patient-centered care for mild-to-moderate UC. iSTART provides patients with the ability to self-assess symptomology and self-start a short course of second-line treatment when necessary. An international panel of experts produced consensus statements and recommendations. These were informed by evidence from systematic reviews on the epidemiology, mesalazine (5-ASA) treatment, and patient use criteria for second-line therapy in UC. Optimized 5-ASA is the first-line treatment in all clinical guidelines, but may not be sufficient to induce remission in all patients. Corticosteroids should be prescribed as second-line therapy when needed, with budesonide MMX^® being a preferred steroid option. Active involvement of suitable patients in management of UC flares has the potential to improve therapy, with patients able to show good accuracy for flare self-assessment using validated tools. There is a place in the UC treatment pathway for an approach such as iSTART, which has the potential to provide patient, clinical and economic benefits.

Disparity in Crohn's disease activity between home and clinics is associated with unscheduled hospital visits due to disease flares

BACKGROUND/AIMS

E-health technologies have been implemented for the management of Crohn's disease (CD). We aimed to identify differences between patient activities at home and at routine clinic visits using a web-based self-reporting CD symptom diary (CDSD) and to determine the impact of this disparity on clinical outcomes.

METHODS

Patients with CD from three tertiary hospitals were invited to assess their symptoms at least once a week using CDSD. We identified patients who showed disparities in disease activity (high activity at home but normal at the next hospital visit) and evaluated clinical outcomes of these patients such as unscheduled visits due to flares using Kaplan-Meier analyses.

RESULTS

One hundred and forty-three patients recorded their symptoms weekly for at least 3 consecutive months and were included. Forty-eight patients (33.6%) showed disparate disease activities between at home and at the next outpatient clinic visit. The cumulative risk of unscheduled visits was significantly higher in this disparity group than in the concordant group (p = 0.001). Disparity in activity (p = 0.003), and anti-tumor necrosis factor use (p = 0.002) were independent risk factors of unscheduled visits due to disease flares.

CONCLUSION

Disparity in disease activity is considerable in CD patients and is related to the risk of unscheduled hospital visit.

Current Landscape of Telemedicine Practice in Inflammatory Bowel Disease

Inflammatory bowel disease (IBD), comprised of Crohn's disease and ulcerative colitis, affects 1.6 million people in the United States. Although effective medical treatments exist to treat the disease, outcomes are still suboptimal. The reasons for poor outcomes vary but include nonadherence to therapy, inadequate monitoring of patients, limited access to IBD specialty care, concurrent psychiatric disease, limited patient knowledge of the disease and treatments, and patient provider discordance. Telemedicine is a candidate intervention that can be used to improve patient outcomes through more frequent monitoring, patient self-management, delivery of education (patient and provider), and to increase access to multidisciplinary IBD care. Telemedicine includes remote monitoring, telehealth, teleconsultation, and teleconferencing. Telemedicine systems have been used in patients with IBD with widespread patient acceptance of the technology. However, early clinical trials demonstrated high attrition rates among intervention patients. In general, use of telemedicine systems have been associated with improved quality of life, improved patient knowledge, and decreased utilization of health care resources. Early studies evaluating telehealth visits report high patient satisfaction, decreased indirect costs to patients, and no decrease in quality of care delivered. Due to widespread access to computers and smart phones among patients, telemedicine will continue to expand in the care of patients with IBD. To optimize use and effectiveness of telemedicine, barriers for use including concerns over increased liability, need for informed consent, licensure restrictions to providing interstate telehealth visits, and cybersecurity need to be addressed.

What's app? Electronic health technology in inflammatory bowel disease

Electronic health (eHealth) data collection is increasingly used in many chronic illnesses, to track pattern of disease. eHealth systems have the potential to revolutionize care. Inflammatory bowel disease (IBD) is a paradigm for such an approach: this is a chronic disease that usually affects young and technologically literate patient population, who are motivated to be involved in their own care. A range of eHealth technologies are available for IBD. This review considers the strengths and weaknesses of 7 platforms that focus on patient-provider interaction. These have been developed in Denmark, United States, the Netherlands, and the United Kingdom, demonstrating an international interest in this form of technology and interaction. Not only do these technologies aim to improve care but they also have the potential to collect large amounts of information. Information includes demographics and patient reported outcomes (symptoms, quality of life), quality of care (steroid use, among other metrics) and outcomes such as hospitalization. These data could inform quality improvement programmes to improve their focus. eHealth technology is also open to machine learning to analyze large data sets, through which personalized algorithms may be developed.

Quality of care in inflammatory bowel diseases: What is the best way to better outcomes?

Inflammatory bowel disease (IBD) is a lifelong, progressive disease that has disabling impacts on patient's lives. Given the complex nature of the diagnosis of IBD and its management there is consequently a large economic burden seen across all health care systems. Quality indicators (QI) have been created to assess the different façades of disease management including structure, process and outcome components. Their development serves to provide a means to target and measure quality of care (QoC). Multiple different QI sets have been published in IBD, but all serve the same purpose of trying to achieve a standard of care that can be attained on a national and international level, since there is still a major variation in clinical practice. There have been many recent innovative developments that aim to improve QoC in IBD including telemedicine, home biomarker assessment and rapid access clinics. These are some of the novel advancements that have been shown to have great potential at improving QoC, while offloading some of the burden that IBD can have vis-a-vis emergency room visits and hospital admissions. The aim of the current review is to summarize and discuss available QI sets and recent developments in IBD care including telemedicine, and to give insight into how the utilization of these tools could benefit the QoC of IBD patients. Additionally, a treating-to-target structure as well as evidence surrounding aggressive management directed at tighter disease control will be presented.

Telemedicine and Mobile Health Technology Are Effective in the Management of Digestive Diseases: A Systematic Review

BACKGROUND

Mobile applications and interactive websites are an increasingly used method of telemedicine, but their use lacks evidence in digestive diseases.

AIM

This study aims to explore digestive disease studies that use telemedicine to effectively manage disease activity, help monitor symptoms, improve compliance to the treatment protocol, increase patient satisfaction, and enhance the patient-to-provider communication.

METHODS

EBSCO, PubMed, and Web of Science databases were searched using Medical Subject Headings and other keywords to identify studies that utilized telemedicine in patients with digestive disease. The PRISMA guidelines were used to identify 20 research articles that had data aligning with 4 common overlapping themes including, patient compliance (n = 13), patient satisfaction (n = 11), disease activity (n = 15), and quality of life (n = 13). The studies focused on digestive diseases including inflammatory bowel disease (n = 7), ulcerative colitis (n = 4), Crohn's Disease (n = 1), irritable bowel syndrome (n = 6), and colorectal cancer (n = 2).

RESULTS

From the studies included in this systematic review, patient compliance and patient satisfaction ranged between 25.7-100% and 74-100%, respectively. Disease activity, measured by symptom severity scales and physiological biomarkers, showed improvements following telemedicine interventions in several, but not all, studies. Similar to disease activity, general and disease-specific quality of life showed improvements following telemedicine interventions in as little as 12 weeks in some studies.

CONCLUSION

Telemedicine and mobile health technology may be effective in managing disease activity and improving quality of life in digestive diseases. Future studies should explore both gastrointestinal and gastroesophageal diseases using these types of interventions.

The complexity of evaluating and increasing adherence in inflammatory bowel disease

Inflammatory bowel diseases (IBDs), due to their chronic and progressive nature, require lifelong treatment to relief and/or prevent inflammation and symptoms, obtaining mucosal healing at best. Therefore, adherence to treatment is an essential topic to address when treating patients with IBD. Nonetheless, adherence remains a common and complex issue in IBD care. Patient characteristics such as young age, male sex and employment has previously been verified as possible predictors of non-adherence. Additionally, evaluating adherence in itself is a challenge since both accurate and easy-to-use screening tools as well as golden standards are lacking.

Systematic review: advice lines for patients with inflammatory bowel disease

OBJECTIVE

Advice lines for patients with inflammatory bowel diseases (IBD) have been introduced internationally. However, only a few publications have described the advice line service and evaluated the efficiency of it with many results presented as conference posters. A systematic synthesis of evidence is needed and the aim of this article was to systematically review the evidence of IBD advice lines.

MATERIALS AND METHODS

A broad systematic literature search was performed to identify relevant studies addressing the effect of advice lines. The process of selection of the retrieved studies was undertaken in two phases. In phase one, all abstracts were review by two independent reviewers. In phase two, the full text of all included studies were independently reviewed by two reviewers. The included studies underwent quality assessment and data synthesis.

RESULTS

Ten published studies and 10 congress abstracts were included in the review. The studies were heterogeneous both in scientific quality and in the focus of the study. No rigorous evidence was found to support that advice lines improve disease activity in IBD and correspondingly no studies reported worsening in disease activity. Advice lines were found to be health economically beneficial with clear indications of the positive impact of advice lines from the patient perspective.

CONCLUSION

The levels of evidence of the effect of advice lines in IBD are low. However, the use of advice lines was found to be safe, and cost-effective. Where investigated, patients with IBD overwhelmingly welcome an advice line with high levels of patient satisfaction reported.

Patient Education in Inflammatory Bowel Disease: A Patient-Centred, Mixed Methodology Study

BACKGROUND

Consensus guidelines from the European Crohns and Colitis Organisation conclude that optimizing quality of care in inflammatory bowel disease [IBD] involves information and education. However, there is no standardized patient education programme in IBD and education varies from centre to centre.

AIM

To assess patients' education needs in IBD to facilitate design of a patient education programme.

METHODS

We created focus groups of 12 patients with IBD and used qualitative analysis to generate hypotheses. We then developed a quantitative questionnaire which was disseminated to 327 IBD patients attending three different centres. Five patients declined to participate and thus 322 patients (159 [49%] male, 180 [58%] Crohn's disease, median age 38 years and disease duration 7 years) were included.

RESULTS

Patients were most keen to receive education on medications, 'what to expect in future', living with IBD and diet. They wanted to receive this information from specialist doctors or nurses and believed it could improve their quality of life. Though the internet was the preferred source of general information [i.e. planning holidays], it was the least preferred source of IBD education. While there was a trend for females to prefer peer education, family history of IBD was the only statistically significant factor associated with information preferences.

CONCLUSION

This is a patient-centred, mixed methodology study on patient education in IBD. Patients' preferences for education include components such as what to expect and diet and patients seem to distrust the internet as an IBD information source. International validation would be valuable to create a consensus education programme.

Efficacy of Home Telemonitoring versus Conventional Follow-up: A Randomized Controlled Trial among Teenagers with Inflammatory Bowel Disease

BACKGROUND AND AIMS

Conventional follow-up of teenagers with inflammatory bowel diseases [IBD] is done during scheduled outpatient visits regardless of how well the patient feels. We designed a telemonitoring strategy for early recognition of flares and compared its efficacy with conventional follow-up.

METHODS

We used a multicentre randomized trial in patients aged 10-19 years with IBD in clinical remission at baseline. Participants assigned to telemonitoring received automated alerts to complete a symptom score and send a stool sample for measurement of calprotectin. This resulted in an individual prediction for flare with associated treatment advice and test interval. In conventional follow-up the health check interval was left to the physician's discretion. The primary endpoint was cumulative incidence of disease flares. Secondary endpoints were percentage of participants with a positive change in quality-of-life and cost-effectiveness of the intervention.

RESULTS

We included 170 participants [84 telemonitoring; 86 conventional follow-up]. At 52 weeks the mean number of face-to-face visits was significantly lower in the telemonitoring group compared to conventional follow-up [3.6 vs 4.3, p < 0.001]. The incidence of flares [33 vs 34%, p = 0.93] and the proportion of participants reporting positive change in quality-of-life [54 vs 44%, p = 0.27] were similar. Mean annual cost-saving was €89 and increased to €360 in those compliant to the protocol.

CONCLUSIONS

Telemonitoring is as safe as conventional follow-up, and reduces outpatient visits and societal costs. The positive impact on quality-of-life was similar in the two groups. This strategy is attractive for teenagers and families, and health professionals may be interested in using it to keep teenagers who are well out of hospital and ease pressure on overstretched outpatient services.

TRIAL REGISTRATION

NTR3759 [Netherlands Trial Registry].

E-health in inflammatory bowel diseases: More challenges than opportunities?

Patients with inflammatory bowel disease need close monitoring for an optimal disease management. For this, e-health technologies are promising tools. But the current evidence for the implementation of e-health in inflammatory bowel disease is weak. For this a critical evaluation of the existing evidence is presented. Furthermore some essential conditions need to be full-filled. We need a robust digital infrastructure that is workable for the patient and the healthcare provider. Important legal issues need to be solved to protect the patient. And the e-health technologies will have to proof their durability, feasibility and acceptance for the patient on the long term.

Psychological Considerations and Interventions in Inflammatory Bowel Disease Patient Care

The presence of psychological comorbidities, specifically anxiety and depression, is well documented in inflammatory bowel disease (IBD). The drivers of these conditions typically reflect 4 areas of concern: disease impact, treatment concerns, intimacy, and stigma. Various demographic and disease characteristics increase risk for psychological distress. However, the risk for anxiety and depression is consistent throughout IBD course and is independent of disease activity. Early intervention before psychological distress becomes uncontrolled is ideal, but mental health often is unaddressed during patient visits. Understanding available psychological treatments and establishing referral resources is an important part of the evolution of IBD patient care.

Psychological Considerations and Interventions in Inflammatory Bowel Disease Patient Care

The presence of psychological comorbidities, specifically anxiety and depression, is well documented in inflammatory bowel disease (IBD). The drivers of these conditions typically reflect 4 areas of concern: disease impact, treatment concerns, intimacy, and stigma. Various demographic and disease characteristics increase risk for psychological distress. However, the risk for anxiety and depression is consistent throughout IBD course and is independent of disease activity. Early intervention before psychological distress becomes uncontrolled is ideal, but mental health often is unaddressed during patient visits. Understanding available psychological treatments and establishing referral resources is an important part of the evolution of IBD patient care.

Medication adherence in inflammatory bowel disease

Inflammatory bowel disease (IBD) is a chronic idiopathic inflammatory condition with intestinal and extraintestinal manifestations. Medications are the cornerstone of treatment of IBD. However, patients often adhere to medication poorly. Adherence to medications is defined as the process by which patients take their medications as prescribed. Treatment non-adherence is a common problem among chronic diseases, averaging 50% in developed countries and is even poorer in developing countries. In this review, we will examine the adherence data in IBD which vary greatly depending on the study population, route of administration, and methods of adherence measurement used. We will also discuss the adverse clinical outcomes related to non-adherence to medical treatment including increased disease activity, flares, loss of response to anti-tumor necrosis factor therapy, and so forth. There are many methods to measure medication adherence namely direct and indirect methods, each with their advantages and drawbacks. Finally, we will explore different intervention strategies to improve adherence to medications.

Delivering High Value Inflammatory Bowel Disease Care Through Telemedicine Visits

BACKGROUND

Patients with inflammatory bowel disease (IBD) require regular follow-up to manage their care, which requires significant amount of time and out-of-pocket costs. Telemedicine in the form of video virtual visits could serve as an alternative to in-office visits. The aim of this project was to understand if telemedicine can provide high value care (defined as quality/cost) to outpatients with IBD.

METHODS

Patients who participated in the IBD telemedicine clinic in the second half of 2015 were included. Patient-reported survey data before and after the virtual visit were collected. A retrospective review was performed on the study cohort for quality outcome measures a year before and after starting the telemedicine clinic. Outcomes were analyzed using simple descriptive statistics. Differences in quality outcomes were compared using odds ratios.

RESULTS

Forty-eight patients were included in the analysis. Most patients travel more than 25 miles each way, take half a day off, and on average incur an additional out-of-pocket cost of $62 for an in-office visit. Most patients (98%) agreed that there was enough time spent with their physician, 91% agreed that they felt like the physician understood their disease state, and 78% reported that they clearly understood the follow-up plan after the visit. Analysis of quality outcome measures did not show any drop in the overall quality of care, after initiating the telemedicine program.

CONCLUSIONS

Telemedicine offers a low cost and convenient alternative for patients with IBD without compromising quality of care.

Telemedicine for management of inflammatory bowel disease (myIBDcoach): a pragmatic, multicentre, randomised controlled trial

BACKGROUND

Tight and personalised control of inflammatory bowel disease in a traditional setting is challenging because of the disease complexity, high pressure on outpatient clinics, and rising incidence. We compared the effects of self-management with a telemedicine system, which was developed for all subtypes of inflammatory bowel disease, on health-care utilisation and patient-reported quality of care versus standard care.

METHODS

We did this pragmatic, randomised trial in two academic and two non-academic hospitals in the Netherlands. Outpatients aged 18-75 years with inflammatory bowel disease and without an ileoanal or ileorectal pouch anastomosis, who had internet access and Dutch proficiency, were randomly assigned (1:1) to care via a telemedicine system (myIBDcoach) that monitors and registers disease activity or standard care and followed up for 12 months. Randomisation was done with a computer-generated sequence and used the minimisation method. Participants, health-care providers, and staff who assessed outcome measures were not masked to treatment allocation. Primary outcomes were the number of outpatient visits and patient-reported quality of care (assessed by visual analogue scale score 0-10). Safety endpoints were the numbers of flares, corticosteroid courses, hospital admissions, emergency visits, and surgeries. Analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT02173002.

FINDINGS

Between Sept 9, 2014, and May 18, 2015, 909 patients were randomly assigned to telemedicine (n=465) or standard care (n=444). At 12 months, the mean number of outpatient visits to the gastroenterologist or nurse was significantly lower in the telemedicine group (1·55 [SD 1·50]) than in the standard care group (2·34 [1·64]; difference -0·79 [95% CI -0·98 to -0·59]; p<0·0001), as was the mean number of hospital admissions (0·05 [0·28] vs 0·10 [0·43]; difference -0·05 [-0·10 to 0·00]; p=0·046). At 12 months, both groups reported high mean patient-reported quality of care scores (8·16 [1·37] in the telemedicine group vs 8·27 [1·28] in the standard care group; difference 0·10 [-0·13 to 0·32]; p=0·411). The mean numbers of flares, corticosteroid courses, emergency visits, and surgeries did not differ between groups.

INTERPRETATION

Telemedicine was safe and reduced outpatient visits and hospital admissions compared with standard care. This self-management tool might be useful for reorganising care of inflammatory bowel disease towards personalised and value-based health care.

FUNDING

Maastricht University Medical Centre and Ferring.

Patient Education in a 14-month Randomised Trial Fails to Improve Adherence in Ulcerative Colitis: Influence of Demographic and Clinical Parameters on Non-adherence

BACKGROUND AND AIM

Recent observational studies document that non-adherence to mesalamine therapy during remission is frequent. We aimed to investigate patient impact of patient education using objective assessments of adherence.

METHODS

A 14-month randomised, prospective clinical trial of adherence to mesalamine was conducted in 248 patients with ulcerative colitis [UC], Colitis Activity Index [CAI] ≤ 9, receiving standard care [n = 122] versus a standardised patient education programme [n = 126]. Primary endpoint was adherence at all visits (5-aminosalicylic acid [5-ASA] urine levels). Secondary endpoints included quality of life (inflammatory bowel disease questionnaise [IBDQ]), disease activity, partial adherence, and self-assessment of adherence.

RESULTS

Patient allocation was well balanced. Baseline non-adherence was high in quiescent/mildly active UC [52.4%] without difference between the groups (52.4% of patients in the education group versus 52.5% in the standard care group [p = 0.99]). No difference between the intervention group and standard care was seen in IBDQ, partial adherence, self-assessment of adherence, or therapy satisfaction at all visits. We suggest a model in which individual risks for non-adherence are driven by patients with young age, short disease duration, and low education levels.

CONCLUSIONS

Non-adherence is frequent in a population with quiescent/mildly active UC. Although more than 25% of the population was not in remission at the various time points, no relationship between disease activity and adherence was seen over the 14-month observation period. Physicians should maximise their efforts to motivate high-risk patients for adherence. Future trials should use objective exposure assessments to examine the impact of continuous education and consultations on the background of individual risks to develop non-adherence.

Telemedicine in the treatment of patients with inflammatory bowel disease

Inflammatory bowel disease (IBD) is a chronic and relapsing disorder with significant medical, social and financial impacts. IBD patients require continuous follow-up, and healthcare resource use in this context increases over time. In the last decade, telemedicine has influenced the treatment of chronic diseases like IBD via the application of information and communication technologies to provide healthcare services remotely. Telemedicine and its various applications (telemanagement, teleconsulting and tele-education) enable closer follow-up and provide education resources that promote patient empowerment, encouraging treatment optimisation over the entire course of the disease. We describe the impact of using telemedicine on IBD health outcomes and discuss the limitations of implementing these systems in the real-life management of IBD patients.

Transforming Gastroenterology Care With Telemedicine

Health care is changing rapidly, so we must change with the times to develop more efficient, practical, cost-effective, and, importantly, high-quality methods to care for patients. We teach medical students that optimal patient care requires face-to-face interaction to collect information on the patient's history and perform the physical examination. However, management of many patients-especially those with chronic diseases-does not always require physical examination. Telemedicine offers an opportunity to take advantage of technology while leveraging the progressive push toward efficiency and value but also requires the belief that excellent patient care is not always provided in person. Telemedicine can include a variety of aspects of patient care adapted to be performed remotely, such as telemonitoring, tele-education, teleconsultation, and telecare. All of these have been evaluated in gastroenterology practice and have demonstrated feasibility and patient preference but have produced mixed results regarding patient outcomes. By combining telemedicine tools and new care models, we can redesign chronic disease management to include fewer in-person visits when patients are well yet increase access for patients who need to be seen. This change could lead to higher-value care by improving the experience of care, decreasing costs, and improving the health of the population. Barriers include reimbursement, licensing, and fear of litigation. However, if we hope to meet the needs of patients within our changing health care system, telemedicine should be incorporated into our strategy.

Development and Feasibility Study of a Telemedicine Tool for All Patients with IBD: MyIBDcoach

BACKGROUND

Tight control of disease activity, medication side effects, and adherence are crucial to prevent disease complications and improve quality of life in patients with inflammatory bowel disease (IBD). The chronic nature and increasing incidence of IBD demand health care innovations to guarantee future high-quality care. Previous research proved that integrated care by telemedicine can improve outcomes of chronic diseases. Currently available IBD telemedicine tools focus on specific patient subgroups. Therefore, we aimed to (1) develop a telemedicine system suitable for all patients with IBD in everyday practice and (2) to test this system's feasibility.

METHODS

With a structured iterative process between patients, dietitians, IBD nurse-specialists, and gastroenterologists, myIBDcoach was developed. During 3 months, myIBDcoach's feasibility was tested by 30 consecutive outpatients with IBD of 3 hospitals. Thereafter, patients and health care providers completed a questionnaire covering satisfaction, accessibility, and experiences with myIBDcoach.

RESULTS

MyIBDcoach enables continuous home-monitoring of patients with IBD and optimizes disease knowledge and communication between patients and health care providers. Besides disease activity, medication adherence, and side effects, myIBDcoach monitors malnutrition, smoking, quality of life, fatigue, life-events, work participation, stress, and anxiety and depression and provides e-learnings for patient empowerment. Patients graded the system with a mean of 7.8 of 10, and 93% would recommend myIBDcoach to other patients.

CONCLUSIONS

We developed myIBDcoach, which enables integrated care for all patients with IBD, regardless of disease severity or medication use. The feasibility study showed high satisfaction and compliance of patients and health care providers. To study myIBDcoach's efficacy, a multicenter randomized controlled trial has been initiated.

Medication non-adherence in adult patients affected by inflammatory bowel disease: a critical review and update of the determining factors, consequences and possible interventions

Achieving adherence to medications can be a serious challenge for patients affected by inflammatory bowel disease (IBD). Medical treatment is fundamental for inducing and maintaining remission, preventing flares and reducing the risk of colorectal cancer. Non-adherence may affect patients' quality of life resulting in unfavourable treatment outcomes, more hospitalizations and higher healthcare-related costs. Recognising and improving adherence is therefore a primary aim for the treatment of IBD. Areas covered: We critically discuss the current knowledge on medication non-adherence in adult patients affected by IBD, also mentioning a few issues concerning the paediatric and adolescent populations. In particular, we reviewed the literature focusing on the definition and detection of non-adherence, on its extent and on the possible non-modifiable and modifiable factors involved (patient-centred, therapy-related, disease-related and physician-related). Furthermore, we analysed the interventional studies performed so far. The literature review was conducted through PubMed addressing medication non-adherence in IBD, using the keywords 'adherence' and related terms and 'IBD, ulcerative colitis or Crohn's disease'. Expert commentary: Adherence to therapy for IBD is a complex yet fundamental issue that cannot be solved by addressing a single aspect only. Future studies should focus on patient-tailored and multidimensional interventions.

The impact of value-based healthcare for inflammatory bowel diseases on healthcare utilization: a pilot study

BACKGROUND AND OBJECTIVES

Value-based healthcare (VBHC) is considered to be the solution that will improve quality and decrease costs in healthcare. Many hospitals are implementing programs on the basis of this strategy, but rigorous scientific reports are still lacking. In this pilot study, we present the first-year outcomes of a VBHC program for inflammatory bowel disease (IBD) management that focuses on highly coordinated care, task differentiation of providers, and continuous home monitoring.

METHODS

IBD patients treated within the VBHC program were identified in an administrative claims database from a commercial insurer allowing comparisons to matched controls. Only patients for whom data were available the year before and after starting the program were included. Healthcare utilization including visits, hospitalizations, laboratory and imaging tests, and medications were compared between groups.

RESULTS

In total, 60 IBD patients treated at the VBHC Center were identified and were matched to 177 controls. Significantly fewer upper endoscopies were performed (-10%, P=0.012), and numerically fewer surgeries (-25%, P=0.49), hospitalizations (-28%, 0=0.71), emergency department visits (-37%, P=0.44), and imaging studies (-25 to -86%) were observed. In addition, 65% fewer patients (P=0.16) used steroids long term. IBD-related costs were 16% ($771) lower than expected (P=0.24).

CONCLUSION

These are the first results of a successfully implemented VBHC program for IBD. Encouraging trends toward fewer emergency department visits, hospitalizations, and long-term corticosteroid use were observed. These results will need to be confirmed in a larger sample with more follow-up.

Self-managed eHealth Disease Monitoring in Children and Adolescents with Inflammatory Bowel Disease: A Randomized Controlled Trial

BACKGROUND

To evaluate the impact of eHealth on disease activity, the need for hospital contacts, and medical adherence in children and adolescents with inflammatory bowel disease (IBD). Furthermore, to assess eHealth's influence on school attendance and quality of life (QoL).

METHODS

Patients with IBD, 10 to 17 years attending a public university hospital, were prospectively randomized to a 2-year open label case-controlled eHealth intervention. The eHealth-group used the web-application young.constant-care.com (YCC) on a monthly basis and in case of flare-ups, and were seen at one annual preplanned outpatient visit. The control-group continued standard visits every third month. Every 3 months, both groups had blood and fecal calprotectin tested and the following were assessed: escalation in medication, disease activity, hospital contacts, medical adherence, school absence, and QoL.

RESULTS

Fifty-three patients in nonbiological treatment were included (27 eHealth/26 control). We found no differences between the groups regarding escalation in treatment and disease activity (symptoms, fecal calprotectin, and blood). The number of total outpatient visits (mean: eHealth 3.26, SEM 0.51; control 7.31, SEM 0.69; P < 0.0001) and IBD-related school absence (mean days: eHealth 1.6, SEM 0.5; control 16.5, SEM 4.4; P < 0.002) was significantly lower in the eHealth-group. No differences in medical adherence and QoL were found. Adherence to YCC was 81% (384 of the 475 expected entries). None of the patients or parents felt unsafe using the eHealth system.

CONCLUSIONS

The use of eHealth in children and adolescents with IBD is feasible, does not lead to impaired disease control, and can be managed by the patients without risk of increased disease activity.

Development and Validation of an Inflammatory Bowel Diseases Monitoring Index for Use With Mobile Health Technologies

BACKGROUND & AIMS

Mobile health technologies are advancing rapidly as smartphone use increases. Patients with inflammatory bowel disease (IBD) might be managed remotely through smartphone applications, but no tools are yet available. We tested the ability of an IBD monitoring tool, which can be used with mobile technologies, to assess disease activity in patients with Crohn's disease (CD) or ulcerative colitis (UC).

METHODS

We performed a prospective observational study to develop and validate a mobile health index for CD and UC, which monitors IBD disease activity using patient-reported outcomes. We collected data from disease-specific questionnaires completed by 110 patients with CD and 109 with UC who visited the University of California, Los Angeles, Center for IBD from May 2013 through January 2014. Patient-reported outcomes were compared with clinical disease activity index scores to identify factors associated with disease activity. Index scores were validated in 301 patients with CD and 265 with UC who visited 3 tertiary IBD referral centers (in California or Europe) from April 2014 through March 2015.

RESULTS

We assessed activity of CD based on liquid stool frequency, abdominal pain, patient well-being, and patient-assessed disease control, and activity of UC based on stool frequency, abdominal pain, rectal bleeding, and patient-assessed disease control. The indices identified clinical disease activity with area under the receiver operating characteristic curve values of 0.90 in patients with CD and 0.91 in patients with UC. They identified endoscopic activity with area under the receiver operating characteristic values of 0.63 in patients with CD and 0.82 in patients with UC. Both scoring systems responded to changes in disease activity (P < .003). The intraclass correlation coefficient for test-retest reliability was 0.94 for CD and for UC.

CONCLUSIONS

We developed and validated a scoring system to monitor disease activity in patients with CD and UC that can be used with mobile technologies. The indices identified clinical disease activity with area under the receiver operating characteristic curve values of 0.9 or higher in patients with CD or UC, and endoscopic activity in patients with UC but not CD.

Machine learning approaches to personalize early prediction of asthma exacerbations

Patient telemonitoring results in an aggregation of significant amounts of information about patient disease trajectory. However, the potential use of this information for early prediction of exacerbations in adult asthma patients has not been systematically evaluated. The aim of this study was to explore the utility of telemonitoring data for building machine learning algorithms that predict asthma exacerbations before they occur. The study dataset comprised daily self-monitoring reports consisting of 7001 records submitted by adult asthma patients during home telemonitoring. Predictive modeling included preparation of stratified training datasets, predictive feature selection, and evaluation of resulting classifiers. Using a 7-day window, a naive Bayesian classifier, adaptive Bayesian network, and support vector machines were able to predict asthma exacerbation occurring on day 8, with sensitivity of 0.80, 1.00, and 0.84; specificity of 0.77, 1.00, and 0.80; and accuracy of 0.77, 1.00, and 0.80, respectively. Our study demonstrated that machine learning techniques have significant potential in developing personalized decision support for chronic disease telemonitoring systems. Future studies may benefit from a comprehensive predictive framework that combines telemonitoring data with other factors affecting the likelihood of developing acute exacerbation. Approaches implemented for advanced asthma exacerbation prediction may be extended to prediction of exacerbations in patients with other chronic health conditions.

EHealth Technologies in Inflammatory Bowel Disease: A Systematic Review

BACKGROUND AND AIMS

Electronic-health technologies (eHealth) such as Web-based interventions, virtual clinics, smart-phone applications, and telemedicine are being used to manage patients with inflammatory bowel disease (IBD). We aimed to: (1) Evaluate the impact of eHealth technologies on conventional clinical indices and patient-reported outcome measures (PROs) in IBD; (2) assess the effectiveness, cost-effectiveness and feasibility of using eHealth technologies to facilitate the self-management of individuals with IBD, and; (3) provide recommendations for their design and optimal use for patient care.

METHODS

Relevant publications were identified via a literature search, and 17 publications were selected based on predefined quality parameters.

RESULTS

Six randomized controlled trials and nine observational studies utilizing eHealth technologies in IBD were identified. Compared with standard outpatient-led care, eHealth technologies have led to improvements in: Relapse duration [(n = 1) 18 days vs 77 days, p < 0.001]; disease activity (n = 2); short-term medication adherence (n = 3); quality of life (n = 4); IBD knowledge (n = 2); healthcare costs (n = 4); the number of acute visits to the outpatient clinic due to IBD symptoms (n = 1), and; facilitating the remote management of up to 20% of an IBD cohort (n = 2). Methodological shortcomings of eHealth studies include heterogeneity of outcome measures, lack of clinician/patient input, lack of validation against conventional clinical indices and PROs, and limited cost-benefit analyses.

CONCLUSIONS

EHealth technologies have the potential for promoting self-management and reducing the impact of the growing burden of IBD on health care resource utilization. A theoretical framework should be applied to the development, implementation, and evaluation of eHealth interventions.

Use of Complementary and Alternative Medicine for Inflammatory Bowel Disease Is Associated with Worse Adherence to Conventional Therapy: The COMPLIANT Study

BACKGROUND

Complementary and alternative medicine (CAM) use is highly prevalent among inflammatory bowel disease (IBD patients). We assessed whether its use, both for IBD and for general health, influenced adherence to conventional medications.

METHODS

We enrolled 392 IBD subjects in a prospective cohort study and categorized them as CAM nonusers (38%) and those who used CAM for general health (CAM-GEN, 41%) and for IBD (CAM-IBD, 21%). Their self-reported adherence was measured using the 4-item Morisky Adherence Scale during a median follow-up period of 6.8 months.

RESULTS

CAM-IBD users were less likely to be adherent to medical therapy than CAM nonusers and CAM-GEN users (70% vs. 84% and 81%, respectively, P < 0.05). Nearly all subjects who were nonadherent reported that it was unintentional (97%), and this did not vary use of CAM. After adjusting for confounders, the adjusted odds ratio for adherence among CAM-IBD relative to CAM nonuser was 0.47 (95% CI, 0.22-0.96). CAM-GEN demonstrated similar adherence to CAM nonusers (adjusted odds ratio, 0.85; 95% CI, 0.44-1.66). CAM-IBD was also less likely than CAM nonusers and CAM-GEN to have improvement in their adherence scores during follow-up (14% vs. 33% and 34%, respectively, P < 0.01). The adjusted odds ratio for improved adherence in CAM-IBD compared with CAM nonusers and CAM-GEN were 0.32 (95% CI, 0.15-0.69) and 0.34 (95% CI, 0.16-0.72), respectively.

CONCLUSIONS

CAM-IBD, but not CAM-GEN, was associated with lower adherence to IBD medical therapy. A third of CAM nonusers and CAM-GEN improved adherence during the observation period, suggesting a Hawthorne effect.

Patient-Centered Outcomes of Medication Adherence Interventions: Systematic Review and Meta-Analysis

OBJECTIVE

Using meta-analytic procedures to synthesize changes in patient-centered outcomes after medication adherence interventions.

METHODS

Strategies to locate studies included online searches of 13 databases and 19 research registries, hand searches of 57 journals, and author and ancestry searches of all eligible studies. Search terms included patient compliance, medication adherence, and related terms. Searches were conducted for all studies published since 1960. Eligible published or unpublished primary studies tested medication adherence interventions and reported medication knowledge, quality of life, physical function, and symptom outcomes. Primary study attributes and outcome data were reliably coded. Overall standardized mean differences (SMDs) were analyzed using random-effects models. Dichotomous and continuous moderator analyses and funnel plots were used to explore risks of bias.

RESULTS

Thorough searching located 141 eligible reports. The reports included 176 eligible comparisons between treatment and control subjects across 23,318 subjects. Synthesis across all comparisons yielded statistically significant SMDs for medication knowledge (d = 0.449), quality of life (d = 0.127), physical function (d = 0.142), and symptoms (d = 0.182). The overall SMDs for studies focusing on subsamples of patients with specific illnesses were more modest but also statistically significant. Of specific symptoms analyzed (depression, anxiety, pain, energy/vitality, cardiovascular, and respiratory), only anxiety failed to show a significant improvement after medication adherence interventions. Most SMDs were significantly heterogeneous, and risk of bias analyses suggested links between study quality and SMDs.

CONCLUSIONS

Modest but significant improvements in patient-centered outcomes were observed after medication adherence interventions.

[Impact of the incorporation of a nurse in an inflammatory bowel disease unit]

INTRODUCTION

Multidisciplinary units are needed because of the growing complexity and volume of patients with inflammatory bowel disease (IBD).

OBJECTIVES

To evaluate the healthcare, economic and research impact of incorporating a nurse into the IBD unit of the Puerta de Hierro Majadahonda University Hospital.

METHODS

We prospectively recorded the activity carried out by the nurse of the IBD unit from March 2010 to December 2014.

RESULTS

During this period, healthcare demand progressively increased, with 1,558 patients being attended by our unit. The healthcare provided by the nurse included 5,293 electronic mails and 678 telephone calls. We estimated that this activity represented a saving of 3,504 in-person medical consultations and 852 accident and emergency department visits. Other activities consisted of monitoring treatments with biological and non-biological agents (8,371 laboratory tests), extraction of 342 blood samples, follow-up of 1047 diagnostic tests and consultations with other medical specialties, health education in self-administration of drugs in 114 patients, the performance of 158 granulocyte apheresis procedures, and participation in 25 research projects.

CONCLUSION

The incorporation of a specialised nurse in an IBD unit had major economic, healthcare and research benefits.

Mobile Phone Apps for Inflammatory Bowel Disease Self-Management: A Systematic Assessment of Content and Tools

Background

The rising incidence of inflammatory bowel disease (IBD) over the past decade has resulted in increased health care utilization and longer IBD outpatient waiting lists. Self-management is recognized as an important aspect of chronic disease management but its application to IBD has been limited. The age of IBD onset in a majority of patients is in their 20s to 30s. Mobile phone apps are a technology familiar to young adults and represent an opportunity to explore self-management as a new model of health care delivery for IBD.

Objective

The aim of this study was to explore the content and tools of existing IBD apps to identify functionalities that may facilitate patient self-management.

Methods

We systematically assessed apps targeted at IBD patients via searches of Google (Android devices) and Apple (iOS devices) app stores with pre-defined inclusion and exclusion criteria. Apps were assessed for specific functionalities; presence of professional medical involvement; consistency with international IBD guidelines based on “complete,” “partial,” or “absent” coverage of consensus statements derived from the European Crohn’s and Colitis Organisation, American College of Gastroenterology, and the Gastroenterology Society of Australia; comprehensiveness of data that could be entered; and average pricing.

Results

Of the 238 apps screened, 26 apps were assessed, including 10 available on Android platforms, 8 on iOS platforms, and 8 on both. Over half (14/26, 54%) of the apps had diary functionalities; over a third (10/26, 39%) provided health information about IBD. None of the apps offered decision support to facilitate the self-initiation of medical therapy. Five of 26 (19%) had professional medical involvement in their design. Apps demonstrated “complete” coverage of only 38% of the international consensus statements explored. The average price of the apps was AUD$1.37.

Conclusions

Apps may provide a useful adjunct to the management of IBD patients. However, a majority of current apps suffer from a lack of professional medical involvement and limited coverage of international consensus guidelines. Future studies and app design for IBD should include professional medical involvement, evidence-based guidelines, and functionalities with decision support that are specifically tailored to patient self-management.

Interventions to Improve Adherence in Patients with Immune-Mediated Inflammatory Disorders: A Systematic Review

BACKGROUND

In patients with immune-mediated inflammatory disorders, poor adherence to medication is associated with increased healthcare costs, decreased patient satisfaction, reduced quality of life and unfavorable treatment outcomes.

OBJECTIVE

To determine the impact of different interventions on medication adherence in patients with immune-mediated inflammatory disorders.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, EMBASE and Cochrane Library.

STUDY ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Included studies were clinical trials and observational studies in adult outpatients treated for psoriasis, Crohn's disease, ulcerative colitis, rheumatoid arthritis, spondyloarthritis, psoriatic arthritis or multiple sclerosis.

STUDY APPRAISAL AND SYNTHESIS METHODS

Intervention approaches were classified into four categories: educational, behavioral, cognitive behavioral, and multicomponent interventions. The risk of bias/study limitations of each study was assessed using the GRADE system.

RESULTS

Fifteen studies (14 clinical trials and one observational study) met eligibility criteria and enrolled a total of 1958 patients. Forty percent of the studies (6/15) was conducted in patients with inflammatory bowel disease, half (7/15) in rheumatoid arthritis patients, one in psoriasis patients and one in multiple sclerosis patients. Seven out of 15 interventions were classified as multicomponent, four as educational, two as behavioral and two as cognitive behavioral. Nine studies, of which five were multicomponent interventions, had no serious limitations according to GRADE criteria. Nine out of 15 interventions showed an improvement of adherence: three multicomponent interventions in inflammatory bowel disease; one intervention of each category in rheumatoid arthritis; one multicomponent in psoriasis and one multicomponent in multiple sclerosis.

CONCLUSION

The assessment of interventions designed for increasing medication adherence in IMID is rare in the literature and their methodological quality may be improved in upcoming studies. Nonetheless, multicomponent interventions showed the strongest evidence for promoting adherence in patients with IMID.

Interactive telemedicine: effects on professional practice and health care outcomes

BACKGROUND

Telemedicine (TM) is the use of telecommunication systems to deliver health care at a distance. It has the potential to improve patient health outcomes, access to health care and reduce healthcare costs. As TM applications continue to evolve it is important to understand the impact TM might have on patients, healthcare professionals and the organisation of care.

OBJECTIVES

To assess the effectiveness, acceptability and costs of interactive TM as an alternative to, or in addition to, usual care (i.e. face-to-face care, or telephone consultation).

SEARCH METHODS

We searched the Effective Practice and Organisation of Care (EPOC) Group's specialised register, CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers to June 2013, together with reference checking, citation searching, handsearching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We considered randomised controlled trials of interactive TM that involved direct patient-provider interaction and was delivered in addition to, or substituting for, usual care compared with usual care alone, to participants with any clinical condition. We excluded telephone only interventions and wholly automatic self-management TM interventions.

DATA COLLECTION AND ANALYSIS

For each condition, we pooled outcome data that were sufficiently homogenous using fixed effect meta-analysis. We reported risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and mean differences (MD) for continuous outcomes.

MAIN RESULTS

We included 93 eligible trials (N = 22,047 participants), which evaluated the effectiveness of interactive TM delivered in addition to (32% of studies), as an alternative to (57% of studies), or partly substituted for usual care (11%) as compared to usual care alone.The included studies recruited patients with the following clinical conditions: cardiovascular disease (36), diabetes (21), respiratory conditions (9), mental health or substance abuse conditions (7), conditions requiring a specialist consultation (6), co morbidities (3), urogenital conditions (3), neurological injuries and conditions (2), gastrointestinal conditions (2), neonatal conditions requiring specialist care (2), solid organ transplantation (1), and cancer (1).Telemedicine provided remote monitoring (55 studies), or real-time video-conferencing (38 studies), which was used either alone or in combination. The main TM function varied depending on clinical condition, but fell typically into one of the following six categories, with some overlap: i) monitoring of a chronic condition to detect early signs of deterioration and prompt treatment and advice, (41); ii) provision of treatment or rehabilitation (12), for example the delivery of cognitive behavioural therapy, or incontinence training; iii) education and advice for self-management (23), for example nurses delivering education to patients with diabetes or providing support to parents of very low birth weight infants or to patients with home parenteral nutrition; iv) specialist consultations for diagnosis and treatment decisions (8), v) real-time assessment of clinical status, for example post-operative assessment after minor operation or follow-up after solid organ transplantation (8) vi), screening, for angina (1).The type of data transmitted by the patient, the frequency of data transfer, (e.g. telephone, e-mail, SMS) and frequency of interactions between patient and healthcare provider varied across studies, as did the type of healthcare provider/s and healthcare system involved in delivering the intervention.We found no difference between groups for all-cause mortality for patients with heart failure (16 studies; N = 5239; RR:0.89, 95% CI 0.76 to 1.03, P = 0.12; I(2) = 44%) (moderate to high certainty of evidence) at a median of six months follow-up. Admissions to hospital (11 studies; N = 4529) ranged from a decrease of 64% to an increase of 60% at median eight months follow-up (moderate certainty of evidence). We found some evidence of improved quality of life (five studies; N = 482; MD:-4.39, 95% CI -7.94 to -0.83; P < 0.02; I(2) = 0%) (moderate certainty of evidence) for those allocated to TM as compared with usual care at a median three months follow-up. In studies recruiting participants with diabetes (16 studies; N = 2768) we found lower glycated haemoglobin (HbA1c %) levels in those allocated to TM than in controls (MD -0.31, 95% CI -0.37 to -0.24; P < 0.00001; I(2)= 42%, P = 0.04) (high certainty of evidence) at a median of nine months follow-up. We found some evidence for a decrease in LDL (four studies, N = 1692; MD -12.45, 95% CI -14.23 to -10.68; P < 0.00001; I(2 =) 0%) (moderate certainty of evidence), and blood pressure (four studies, N = 1770: MD: SBP:-4.33, 95% CI -5.30 to -3.35, P < 0.00001; I(2) = 17%; DBP: -2.75 95% CI -3.28 to -2.22, P < 0.00001; I(2) = 45% (moderate certainty evidence), in TM as compared with usual care.Seven studies that recruited participants with different mental health and substance abuse problems, reported no differences in the effect of therapy delivered over video-conferencing, as compared to face-to-face delivery. Findings from the other studies were inconsistent; there was some evidence that monitoring via TM improved blood pressure control in participants with hypertension, and a few studies reported improved symptom scores for those with a respiratory condition. Studies recruiting participants requiring mental health services and those requiring specialist consultation for a dermatological condition reported no differences between groups.

AUTHORS' CONCLUSIONS

The findings in our review indicate that the use of TM in the management of heart failure appears to lead to similar health outcomes as face-to-face or telephone delivery of care; there is evidence that TM can improve the control of blood glucose in those with diabetes. The cost to a health service, and acceptability by patients and healthcare professionals, is not clear due to limited data reported for these outcomes. The effectiveness of TM may depend on a number of different factors, including those related to the study population e.g. the severity of the condition and the disease trajectory of the participants, the function of the intervention e.g., if it is used for monitoring a chronic condition, or to provide access to diagnostic services, as well as the healthcare provider and healthcare system involved in delivering the intervention.

Interactive telemedicine: effects on professional practice and health care outcomes

BACKGROUND

Telemedicine (TM) is the use of telecommunication systems to deliver health care at a distance. It has the potential to improve patient health outcomes, access to health care and reduce healthcare costs. As TM applications continue to evolve it is important to understand the impact TM might have on patients, healthcare professionals and the organisation of care.

OBJECTIVES

To assess the effectiveness, acceptability and costs of interactive TM as an alternative to, or in addition to, usual care (i.e. face-to-face care, or telephone consultation).

SEARCH METHODS

We searched the Effective Practice and Organisation of Care (EPOC) Group's specialised register, CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers to June 2013, together with reference checking, citation searching, handsearching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We considered randomised controlled trials of interactive TM that involved direct patient-provider interaction and was delivered in addition to, or substituting for, usual care compared with usual care alone, to participants with any clinical condition. We excluded telephone only interventions and wholly automatic self-management TM interventions.

DATA COLLECTION AND ANALYSIS

For each condition, we pooled outcome data that were sufficiently homogenous using fixed effect meta-analysis. We reported risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and mean differences (MD) for continuous outcomes.

MAIN RESULTS

We included 93 eligible trials (N = 22,047 participants), which evaluated the effectiveness of interactive TM delivered in addition to (32% of studies), as an alternative to (57% of studies), or partly substituted for usual care (11%) as compared to usual care alone.The included studies recruited patients with the following clinical conditions: cardiovascular disease (36), diabetes (21), respiratory conditions (9), mental health or substance abuse conditions (7), conditions requiring a specialist consultation (6), co morbidities (3), urogenital conditions (3), neurological injuries and conditions (2), gastrointestinal conditions (2), neonatal conditions requiring specialist care (2), solid organ transplantation (1), and cancer (1).Telemedicine provided remote monitoring (55 studies), or real-time video-conferencing (38 studies), which was used either alone or in combination. The main TM function varied depending on clinical condition, but fell typically into one of the following six categories, with some overlap: i) monitoring of a chronic condition to detect early signs of deterioration and prompt treatment and advice, (41); ii) provision of treatment or rehabilitation (12), for example the delivery of cognitive behavioural therapy, or incontinence training; iii) education and advice for self-management (23), for example nurses delivering education to patients with diabetes or providing support to parents of very low birth weight infants or to patients with home parenteral nutrition; iv) specialist consultations for diagnosis and treatment decisions (8), v) real-time assessment of clinical status, for example post-operative assessment after minor operation or follow-up after solid organ transplantation (8) vi), screening, for angina (1).The type of data transmitted by the patient, the frequency of data transfer, (e.g. telephone, e-mail, SMS) and frequency of interactions between patient and healthcare provider varied across studies, as did the type of healthcare provider/s and healthcare system involved in delivering the intervention.We found no difference between groups for all-cause mortality for patients with heart failure (16 studies; N = 5239; RR:0.89, 95% CI 0.76 to 1.03, P = 0.12; I(2) = 44%) (moderate to high certainty of evidence) at a median of six months follow-up. Admissions to hospital (11 studies; N = 4529) ranged from a decrease of 64% to an increase of 60% at median eight months follow-up (moderate certainty of evidence). We found some evidence of improved quality of life (five studies; N = 482; MD:-4.39, 95% CI -7.94 to -0.83; P < 0.02; I(2) = 0%) (moderate certainty of evidence) for those allocated to TM as compared with usual care at a median three months follow-up. In studies recruiting participants with diabetes (16 studies; N = 2768) we found lower glycated haemoglobin (HbA1c %) levels in those allocated to TM than in controls (MD -0.31, 95% CI -0.37 to -0.24; P < 0.00001; I(2)= 42%, P = 0.04) (high certainty of evidence) at a median of nine months follow-up. We found some evidence for a decrease in LDL (four studies, N = 1692; MD -12.45, 95% CI -14.23 to -10.68; P < 0.00001; I(2 =) 0%) (moderate certainty of evidence), and blood pressure (four studies, N = 1770: MD: SBP:-4.33, 95% CI -5.30 to -3.35, P < 0.00001; I(2) = 17%; DBP: -2.75 95% CI -3.28 to -2.22, P < 0.00001; I(2) = 45% (moderate certainty evidence), in TM as compared with usual care.Seven studies that recruited participants with different mental health and substance abuse problems, reported no differences in the effect of therapy delivered over video-conferencing, as compared to face-to-face delivery. Findings from the other studies were inconsistent; there was some evidence that monitoring via TM improved blood pressure control in participants with hypertension, and a few studies reported improved symptom scores for those with a respiratory condition. Studies recruiting participants requiring mental health services and those requiring specialist consultation for a dermatological condition reported no differences between groups.

AUTHORS' CONCLUSIONS

The findings in our review indicate that the use of TM in the management of heart failure appears to lead to similar health outcomes as face-to-face or telephone delivery of care; there is evidence that TM can improve the control of blood glucose in those with diabetes. The cost to a health service, and acceptability by patients and healthcare professionals, is not clear due to limited data reported for these outcomes. The effectiveness of TM may depend on a number of different factors, including those related to the study population e.g. the severity of the condition and the disease trajectory of the participants, the function of the intervention e.g., if it is used for monitoring a chronic condition, or to provide access to diagnostic services, as well as the healthcare provider and healthcare system involved in delivering the intervention.

Structure and content components of self-management interventions that improve health-related quality of life in people with inflammatory bowel disease: a systematic review, meta-analysis and meta-regression

AIMS AND OBJECTIVES

The purpose of this review was to identify and categorise the components of the content and structure of effective self-management interventions for patients with inflammatory bowel disease.

BACKGROUND

Inflammatory bowel diseases are chronic gastrointestinal disorders impacting health-related quality of life. Although the efficacy of self-management interventions has been demonstrated in previous studies, the most effective components of the content and structure of these interventions remain unknown.

DESIGN

A systematic review, meta-analysis and meta-regression of randomised controlled trials was used.

METHODS

A systematic search of six electronic databases, including Pubmed, Embase, Cochrane central register of controlled trials, Web of Science, Cumulative Index of Nursing and Allied Health Literature and Chinese Biomedical Literature Database, was conducted. Content analysis was used to categorise the components of the content and structure of effective self-management interventions for inflammatory bowel disease. Clinically important and statistically significant beneficial effects on health-related quality of life were explored, by comparing the association between effect sizes and various components of self-management interventions such as the presence or absence of specific content and different delivery methods.

RESULTS

Fifteen randomised controlled trials were included in this review. Distance or remote self-management interventions demonstrated a larger effect size. However, there is no evidence for a positive effect associated with specific content component of self-management interventions in adult patients with inflammatory bowel disease in general.

CONCLUSIONS

The results showed that self-management interventions have positive effects on health-related quality of life in patients with inflammatory bowel disease, and distance or remote self-management programmes had better outcomes than other types of interventions.

RELEVANCE TO CLINICAL PRACTICE

This review provides useful information to clinician and researchers when determining components of effective self-management programmes for patients with inflammatory bowel disease. More high-quality randomised controlled trials are needed to test the results.