Reduced Unplanned Care and Disease Activity and Increased Quality of Life After Patient Enrollment in an Inflammatory Bowel Disease Medical Home

Defining the Roles of Inflammatory Bowel Disease Clinical Pharmacists in the United States: A Systematic Review and National RAND/UCLA Consensus

BACKGROUND

Given the complexity of inflammatory bowel disease (IBD) care, utilization of multidisciplinary teams is recommended to optimize outcomes. There is a growing recognition that clinical pharmacists should be an integral part of this care model. We sought to define the roles of IBD clinical pharmacists in the United States.

METHODS

A national multidisciplinary expert panel of 12 gastroenterologists and clinical pharmacists practicing in IBD clinics was assembled. We used the RAND/University of California, Los Angeles appropriateness method, with a total of 281 statements generated based on a systematic literature review and expert opinion. Each statement was anonymously rated as appropriate, uncertain, or inappropriate in 2 rounds of voting.

RESULTS

The number of publications evaluating the clinical pharmacists' roles in IBD is limited, primarily focusing on thiopurine initiation and monitoring, medication adherence, and switching to biosimilars. Medication education; medication initiation and monitoring; therapeutic drug monitoring; biosimilar management; health maintenance review; and transitions of care were deemed by the panel to be appropriate roles for IBD clinical pharmacists. In considering real-world settings, IBD clinical pharmacists should practice clinically under a predefined scope and primarily focus on complex treatments (eg, immunomodulators, biologics, and small molecules). Clinical pharmacists should also be included in practice settings with IBD specialized physicians. Additionally, clinical pharmacists caring for patients with IBD should be residency trained and board certified.

CONCLUSIONS

This consensus defines IBD clinical pharmacists' roles and provides a framework for embedded clinical pharmacists in IBD care.

Clinical Education: Psychosocial Assessment and Treatment Planning for Patients with Inflammatory Bowel Disease

Psychosocial factors play an important role in the disease course and illness experience of patients with inflammatory bowel disease (IBD). Consultation with a health psychologist is an important component of care for many IBD patients and provides an opportunity to identify areas of psychosocial concern, recognize coping deficits and strengths, and facilitate treatment recommendations. Psychosocial assessment in IBD requires a nuanced approach that goes beyond general mental health screening and considers the disease-specific concerns that impact patients. In this paper, we outline strategies for an IBD-focused psychological evaluation, including specific guidance for assessing disease-specific concerns of anxiety, depression, post-traumatic stress, sleep, pain, body image disturbance, food-related quality of life, and psychological resilience.

AGA Clinical Practice Update on Pain Management in Inflammatory Bowel Disease: Commentary

DESCRIPTION

Pain is a common symptom among patients with inflammatory bowel disease (IBD). Although pain typically occurs during episodes of inflammation, it is also commonly experienced when intestinal inflammation is quiescent. Many gastroenterologists are at a loss how to approach pain symptoms when they occur in the absence of gut inflammation. We provide guidance in this area as to the evaluation, diagnosis, and treatment of pain among patients with IBD.

METHODS

This CPU was commissioned and approved by the AGA Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPUC and external peer review through standard procedures of Gastroenterology. This expert commentary incorporates important as well as recently published studies in this field, and it reflects the experiences of the authors. Formal ratings regarding the quality of evidence or strength of the presented considerations were not included because systematic reviews were not performed.

Economics of Emergency Department Visits by Patients With Inflammatory Bowel Disease: A Real-World Analysis

Background

Inflammatory bowel disease (IBD) is associated with significant psychosocial, economic, and physical burden on patients. IBD care in the United States results in significant healthcare expenditure with recurring emergency department (ED) care and hospital admissions. Despite advances in therapy and improved access to specialty care, there is still room for improvement in cost-efficient care. Specialty medical homes and interdisciplinary care models have emerged as ways to improve medical care, patient outcomes, and quality of life, as well as improve the impact of healthcare costs. There is limited real-world data on cost in the United States, with many articles citing cost estimates from models.

Methods

We analyzed real-world data from our tertiary care center with a focus on recurrent ED visits by IBD patients. Descriptive statistics were used for a cost analysis of multiple ED visits by IBD patients. Patients with ≥4 visits to the ED in a 6-month period were described as SuperUsers and were included in a separate analysis. The cost of hospitalization was also included.

Results

Total cost associated with all ED visits from SuperUsers were $72 999.57 with an average of $6636.32 per patient. When the patients were admitted, the total cost of ED visits and hospitalizations was $721 461.52, with an average of $65 587.41 per patient.

Conclusions

ED utilization by IBD patients with or without hospitalization is expensive and is typically driven by a cohort of SuperUsers. More work needs to be done to improve cost-effectiveness in IBD care, including reducing the frequency of ED visits.

Value-Based Integrated Care: A Systematic Literature Review

BACKGROUND

Healthcare services worldwide are transforming themselves into value-based organizations. Integrated care is an important aspect of value-based healthcare (VBHC), but practical evidence-based recommendations for the successful implementation of integrated care within a VBHC context are lacking. This systematic review aims to identify how value-based integrated care (VBIC) is defined in literature, and to summarize the literature regarding the effects of VBIC, and the facilitators and barriers for its implementation.

METHODS

Embase, Medline ALL, Web of Science Core Collection, and Cochrane Central Register of Controlled Trails databases were searched from inception until January 2022. Empirical studies that implemented and evaluated an integrated care intervention within a VBHC context were included. Non-empirical studies were included if they described either a definition of VBIC or facilitators and barriers for its implementation. Theoretical articles and articles without an available full text were excluded. All included articles were analysed qualitatively. The Rainbow Model of Integrated Care (RMIC) was used to analyse the VBIC interventions. The quality of the articles was assessed using the Mixed Methods Appraisal Tool (MMAT).

RESULTS

After screening 1328 titles/abstract and 485 full-text articles, 24 articles were included. No articles were excluded based on quality. One article provided a definition of VBIC. Eleven studies reported-mostly positive- effects of VBIC, on clinical outcomes, patient-reported outcomes, and healthcare utilization. Nineteen studies reported facilitators and barriers for the implementation of VBIC; factors related to reimbursement and information technology (IT) infrastructure were reported most frequently.

CONCLUSION

The concept of VBIC is not well defined. The effect of VBIC seems promising, but the exact interpretation of effect evaluations is challenged by the precedence of multicomponent interventions, multiple testing and generalizability issues. For successful implementation of VBIC, it is imperative that healthcare organizations consider investing in adequate IT infrastructure and new reimbursement models. Systematic Review Registration: PROSPERO (CRD42021259025).

Risk factors for recurrent emergency care utilization for flares in inflammatory bowel disease

OBJECTIVES

Patients with inflammatory bowel disease (IBD) need frequent emergency care due to flares of their disease. However, understanding which patients are most vulnerable to repeat emergency care due to recurrent flares of their disease remains poor.

METHODS

This was a retrospective cohort study of Kaiser Permanente Northern California health plan members aged ≥18 years between 2009 and 2018. Our primary outcome was occurrence of repeat emergency department (ED) visits with a primary diagnosis code of IBD in the 6 months following their index ED visit. Baseline characteristics and clinical service use patterns were extracted. We used multivariable negative binomial regression analysis to measure the incident risk of a recurrent ED visit within 6 months.

RESULTS

We found 2111 patients who met eligibility criteria, of whom 56.7% were female and 39.7% were non-White. During the 6-month observation period, 19.3% (n = 408) returned to the ED for a second IBD flare. In adjusted analyses, we found older age (incident risk ratio [IRR] 0.44, 95% confidence interval [CI] 0.31-0.62 for age 60+ compared to 18-30), higher neighborhood household income (IRR 0.80, 95% CI 0.65-0.98 for income ≥$85,000), and diagnosis of alcohol use disorder were associated with a lower risk of repeat ED utilization (IRR 0.62, 95% CI 0.41-0.93), while presence of mood disorder (IRR 1.26, 95% CI 1.03-1.58), history of opiate prescription (IRR 1.38, 95% CI 1.10-1.73), and corticosteroid prescription (IRR 1.57, 95% CI 1.27-1.95) were associated with increased risk of repeat ED utilization. Prompt outpatient follow-up was not associated with a lower odds of recurrent ED utilization (IRR 0.93, 95% CI 0.75-1.15).

CONCLUSIONS

Our study identified multiple patient characteristics associated with higher recurrent short-term use of the ED for IBD care. Although we did not find prompt outpatient follow-up after initial ED visit to be protective, targeted interventions directed at high-risk individuals based on mood disorders, opiate use, or steroid use may help to optimize care and health care utilization.

Personalized Treatment for Crohn's Disease: Current Approaches and Future Directions

Crohn's disease is a complex, relapsing and remitting inflammatory disorder of the gastrointestinal tract with a variable disease course. While the treatment options for Crohn's disease have dramatically increased over the past two decades, predicting individual patient response to treatment remains a challenge. As a result, patients often cycle through multiple different therapies before finding an effective treatment which can lead to disease complications, increased costs, and decreased quality of life. Recently, there has been increased emphasis on personalized medicine in Crohn's disease to identify individual patients who require early advanced therapy to prevent complications of their disease. In this review, we summarize our current approach to management of Crohn's disease by identifying risk factors for severe or disabling disease and tailoring individual treatments to patient-specific goals. Lastly, we outline our knowledge gaps in implementing personalized Crohn's disease treatment and describe the future directions in precision medicine.

Depression in Women With Inflammatory Bowel Disease: A Multifaceted Approach for a Multidimensional Problem

The prevalence of depression is higher in patients with inflammatory bowel disease (IBD) than in the general population. Women are more significantly affected by depression among those with IBD and in the general population. This review presents evidence on sex-based differences in depression pathogenesis and the effect of depression on various factors associated with IBD that affect women's lives, including sexual dysfunction, body image dissatisfaction, fertility, and overall quality of life. We also discuss sex-specific effects on IBD treatment, disease activity, and health care costs. Interestingly, women with IBD tend to seek and are more receptive to depression-related information. Given the underdiagnosis and undertreated nature of depression in individuals with IBD, effective screening and an optimal integrative treatment approach with relevant sex-specific needs are discussed. Evidence regarding the efficacy of psychotherapy, antidepressant pharmacotherapy, and IBD-specific therapy for depression is discussed. This review summarizes evidence of the effect of depression on both personal and professional aspects of the daily lives of women with IBD, which extends beyond negative moods. It applies this information to screening and integrative treatment, resulting in a holistic approach to this multidimensional problem. We also discuss how depression affects males with IBD differently from females. Finally, we discuss the need for gender-based studies on depression in individuals with IBD.

Novel symptom clusters predict disease impact and healthcare utilisation in inflammatory bowel disease: Prospective longitudinal follow-up study

BACKGROUND

Predicting adverse disease outcomes and high-volume users of healthcare amongst patients with inflammatory bowel disease (IBD) is difficult.

AIMS

The aim of this study is to use latent class analysis to create novel clusters of patients and to assess whether these predict outcomes during 6.5 years of longitudinal follow-up.

METHODS

Baseline demographic features, disease activity indices, anxiety, depression, and somatoform symptom-reporting scores were recorded for 692 adults. Faecal calprotectin (FC) was analysed at baseline in 348 (50.3%) patients (<250 mcg/g defined biochemical remission). Using baseline gastrointestinal and psychological symptoms, latent class analysis identified specific patient clusters. Rates of glucocorticosteroid prescription or flare, escalation, hospitalisation, or intestinal resection were compared between clusters using multivariate Cox regression.

RESULTS

A three-cluster model was the optimum solution; 132 (19.1%) patients had below-average gastrointestinal and psychological symptoms (cluster 1), 352 (50.9%) had average levels of gastrointestinal and psychological symptoms (cluster 2), and 208 (30.1%) had the highest levels of both gastrointestinal and psychological symptoms (cluster 3). Compared with cluster 1, cluster 3 had significantly increased risk of flare or glucocorticosteroid prescription (hazard ratio (HR): 2.13; 95% confidence interval (CI): 1.46-3.10), escalation (HR: 1.92; 95% CI: 1.34-2.76), a composite of escalation, hospitalisation, or intestinal resection (HR: 2.05; 95% CI: 1.45-2.88), or any of the endpoints of interest (HR: 2.06; 95% CI: 1.45-2.93). Healthcare utilisation was highest in cluster 3.

CONCLUSIONS

Novel model-based clusters identify patients with IBD at higher risk of adverse disease outcomes who are high-volume users of healthcare.

Characterizing Regionalization of Inflammatory Bowel Disease Hospitalizations and Operations in Washington State

BACKGROUND

Hospitalizations for inflammatory bowel disease (IBD) are a major contributor of healthcare utilization. We assessed IBD hospitalizations and surgical operations in Washington State to characterize regionalization patterns.

METHODS

We identified a cohort of hospitalizations for Crohn's disease (CD) or ulcerative colitis (UC) from 2008 to 2019 using Washington State's Comprehensive Hospital Abstract Reporting System (CHARS). Hospitalizations were characterized by emergent or elective acuity and whether an operation or endoscopic procedure was performed. Facility volume and distance travelled by patients were used to determine regionalization.

RESULTS

There were 20,494 IBD-related hospitalizations at 95 hospitals: 13,585 (66.3%) with CD and 6,909 (33.7%) with UC. Emergencies accounted for 78.2% of all IBD-related hospitalizations and did not differ between CD (78.3%) and UC (77.9%) (p = 0.54). Surgery was performed during 10.3% and endoscopy during 30.6% of emergent hospitalizations. 72.0% of emergent hospitalizations occurred at 22 facilities, while 71.1% of elective hospitalizations were concentrated at 9 facilities. Operations were performed during 78.5% of elective hospitalizations, and five hospitals performed 69% of all elective surgery. Laparoscopic surgery increased in both emergent (17% to 52%, p < 0.001) and elective operations (18% to 42%, p < 0.001) from 2008 to 2019.

CONCLUSIONS

In Washington State, most IBD hospitalizations were emergent, which were decentralized and typically non-operative. By contrast, most elective admissions involved surgery and were centralized at a few high-volume centers. Further understanding the drivers behind IBD hospitalizations may help optimize emergent medical and elective surgical care at a state level.

Polysubstance use in inflammatory bowel disease is associated with increased risk of emergency department visits: a longitudinal study

Background

Polysubstance use (PSU), the simultaneous use of 2 or more substances of abuse, is common in inflammatory bowel disease (IBD). Preliminary studies suggest it may be associated with poor outcomes. This prospective study evaluated the impact of PSU on disease activity and healthcare resource utilization in IBD.

Methods

This study was conducted in a tertiary IBD center between October 29, 2015, and December 31, 2019. Participants were assessed over 2 time points (index and follow-up outpatient appointments) separated by a minimum of 6 months. Demographics, endoscopic disease activity, and surveys assessing symptoms, healthcare resource utilization and substance use (tobacco, alcohol, marijuana, cocaine, methamphetamine, heroin, opioid, or benzodiazepine) were abstracted. We identified PSU during the index appointment and computed descriptive statistics and contingency table analyses, and multivariate logistic regression models at follow up to evaluate outcomes.

Results

162 consecutively enrolled IBD patients were included. Seventy-five patients (46%) were polysubstance users at the index appointment. The most common cohorts were utilizing tobacco and alcohol (n=40) or tobacco and opioids (n=13). On bivariate and multivariate analyses, PSU during the index visit was positively associated with emergency department (ED) visits (odds ratio [OR] 2.51, 95% confidence interval [CI] 1.24-5.07; P=0.01) and negatively associated with extraintestinal manifestations (OR 0.37, 95%CI 0.18-0.74; P=0.005). Age, sex, disease activity, disease subtype and IBD-related symptoms were not associated with PSU.

Conclusions

IBD patients exhibiting PSU had increased risk of future ED visits. This study highlights the risks of PSU and reinforces the importance of appropriate substance use screening.

Impact of Care in an Interdisciplinary Inflammatory Bowel Disease Specialty Clinic on Outcomes in Patients Insured with Medicaid

BACKGROUND

Inflammatory bowel disease (IBD) patients are known to benefit from care delivered in a specialized, interdisciplinary setting. We aimed to evaluate the impact of this model on health outcomes, quality metrics, and health care resource utilization (HRU) in IBD patients insured with Medicaid.

MATERIALS AND METHODS

In July 2017, IBD patients at our tertiary hospital were transitioned from a fellows' general gastroenterology (GI) clinic to a fellows' interdisciplinary IBD clinic. IBD patients were included if they were insured with Medicaid, had at least 1 visit in the general GI clinic between July 1, 2016 and June 30, 2017, and at least 1 visit between July 1, 2017 and June 30, 2018 in the IBD clinic. Characteristics related to patients' IBD course, overall health care maintenance, and HRU were compared.

RESULTS

A total of 170 patients (51% male, mean age 39 y) were included. After the transition to the IBD clinic, use of corticosteroids (37% vs. 25%; P =0.004) and combination therapy were significantly lower (55% vs. 38%; P =0.0004), although use of high-dose biologics numerically increased (58.5% vs. 67%; P =0.05). Posttransition, patients showed significantly lower levels of mean C-reactive protein ( P =0.04). After the transition, patients attended significantly fewer outpatient GI visits ( P =0.0008) but were more often seen by other health care specialists ( P =0.0003), and experienced a numeric decrease in HRU with fewer emergency department visits, hospitalizations, and surgeries.

CONCLUSIONS

Care in an interdisciplinary, IBD specialty setting is associated with significantly decreased corticosteroid use, decreased C-reactive protein levels, and improved access to ancillary services in Medicaid patients.

A Comprehensive Self-Management Intervention for Inflammatory Bowel Disease (CSM-IBD): Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

Despite pharmacological treatment, individuals with inflammatory bowel disease (IBD) experience a variety of symptoms, including abdominal pain, fatigue, anxiety, and depression. Few nonmedical self-management interventions are available for people with IBD. A validated comprehensive self-management (CSM) intervention is effective for patients with irritable bowel syndrome who can have symptoms similar to those of individuals with IBD. We created a modified CSM intervention tailored to individuals with IBD (CSM-IBD). The CSM-IBD is an 8-session program delivered over 8-12 weeks with check-ins with a registered nurse.

OBJECTIVE

The primary objective of this pilot study is to determine the feasibility and acceptability of study procedures and the CSM-IBD intervention and to evaluate preliminary efficacy on quality of life and daily symptoms for a future randomized controlled trial. Additionally, we will examine the association of socioecological, clinical, and biological factors with symptoms at baseline and response to intervention.

METHODS

We are conducting a pilot randomized controlled trial of the CSM-IBD intervention. Participants aged 18-75 years who are experiencing at least 2 symptoms are eligible for inclusion. We plan to enroll 54 participants who will be randomized (2:1) into the CSM-IBD program or usual care. Patients in the CSM-IBD program will have 8 intervention sessions. Primary study outcomes include the feasibility of recruitment, randomization, and data or sample collection, as well as the acceptability of study procedures and interventions. Preliminary efficacy outcome variables include quality of life and symptoms. Outcomes data will be assessed at baseline, immediately post intervention, and 3 months post intervention. Participants in the usual care group will have access to the intervention after study participation.

RESULTS

This project is funded by the National Institutes of Nursing Research and reviewed by the University of Washington's institutional review board. Recruitment began in February 2023. As of April 2023, we have enrolled 4 participants. We expect the study to be completed by March 2025.

CONCLUSIONS

This pilot study will evaluate the feasibility and efficacy of a self-management intervention (a web-based program with weekly check-ins with a registered nurse) that aims to improve symptom management in individuals with IBD. In the long term, we aim to validate a self-management intervention to improve patient quality of life, reduce direct and indirect costs related to IBD, and be culturally appropriate and accessible, particularly in rural and underserved communities.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05651542; https://clinicaltrials.gov/ct2/show/NCT05651542.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/46307.

The cost of inflammatory bowel disease in high-income settings: a Lancet Gastroenterology & Hepatology Commission

The cost of caring for patients with inflammatory bowel disease (IBD) continues to increase worldwide. The cause is not only a steady increase in the prevalence of Crohn's disease and ulcerative colitis in both developed and newly industrialised countries, but also the chronic nature of the diseases, the need for long-term, often expensive treatments, the use of more intensive disease monitoring strategies, and the effect of the diseases on economic productivity. This Commission draws together a wide range of expertise to discuss the current costs of IBD care, the drivers of increasing costs, and how to deliver affordable care for IBD in the future. The key conclusions are that (1) increases in health-care costs must be evaluated against improved disease management and reductions in indirect costs, and (2) that overarching systems for data interoperability, registries, and big data approaches must be established for continuous assessment of effectiveness, costs, and the cost-effectiveness of care. International collaborations should be sought out to evaluate novel models of care (eg, value-based health care, including integrated health care, and participatory health-care models), as well as to improve the education and training of clinicians, patients, and policy makers.

Understanding clinician connections to inform efforts to promote high-quality inflammatory bowel disease care

BACKGROUND

Highly connected individuals disseminate information effectively within their social network. To apply this concept to inflammatory bowel disease (IBD) care and lay the foundation for network interventions to disseminate high-quality treatment, we assessed the need for improving the IBD practices of highly connected clinicians. We aimed to examine whether highly connected clinicians who treat IBD patients were more likely to provide high-quality treatment than less connected clinicians.

METHODS

We used network analysis to examine connections among clinicians who shared patients with IBD in the Veterans Health Administration between 2015-2018. We created a network comprised of clinicians connected by shared patients. We quantified clinician connections using degree centrality (number of clinicians with whom a clinician shares patients), closeness centrality (reach via shared contacts to other clinicians), and betweenness centrality (degree to which a clinician connects clinicians not otherwise connected). Using weighted linear regression, we examined associations between each measure of connection and two IBD quality indicators: low prolonged steroids use, and high steroid-sparing therapy use.

RESULTS

We identified 62,971 patients with IBD and linked them to 1,655 gastroenterologists and 7,852 primary care providers. Clinicians with more connections (degree) were more likely to exhibit high-quality treatment (less prolonged steroids beta -0.0268, 95%CI -0.0427, -0.0110, more steroid-sparing therapy beta 0.0967, 95%CI 0.0128, 0.1805). Clinicians who connect otherwise unconnected clinicians (betweenness) displayed more prolonged steroids use (beta 0.0003, 95%CI 0.0001, 0.0006). The presence of variation is more relevant than its magnitude.

CONCLUSIONS

Clinicians with a high number of connections provided more high-quality IBD treatments than less connected clinicians, and may be well-positioned for interventions to disseminate high-quality IBD care. However, clinicians who connect clinicians who are otherwise unconnected are more likely to display low-quality IBD treatment. Efforts to improve their quality are needed prior to leveraging their position to disseminate high-quality care.

A Missing Piece of the Puzzle: Patient and Provider Perspectives on Pain Management Needs and Opioid Prescribing in Inflammatory Bowel Disease Care

Background

Recent data have shown high rates of opioid misuse among inflammatory bowel disease (IBD) patients. We conducted a qualitative study to explore IBD patient and provider perceptions and experiences with pain management and opioid prescribing.

Methods

We conducted a focus group with IBD patients and semistructured interviews with IBD-focused physicians and nurses. We used an inductive approach for analysis and the constant comparison method to develop and refine codes and identify prominent themes. We analyzed interview and focus group data concurrently to triangulate themes.

Results

Nine patients and 10 providers participated. We grouped themes into 3 categories: (1) current practices to manage pain; (2) perceived pain management challenges; and (3) suggestions to optimize pain management. In the first category (current practices), both patients and providers reported building long-term patient-provider relationships and the importance of exploring nonpharmacologic pain management strategies. Patients reported proactively trying remedies infrequently recommended by IBD providers. In the second category (pain management challenges), patients and providers reported concerns about opioid use and having limited options to treat pain safely. Patients discussed chronic pain and having few solutions to manage it. In the third category, providers shared suggestions for improvement such as increasing use of nonpharmacologic pain management strategies and enhancing care coordination.

Conclusions

Despite some common themes between the 2 groups, we identified some pain management needs (eg, addressing chronic pain) that matter to patients but were seldom discussed by IBD providers. Addressing these areas of potential disconnect is essential to optimize pain management safety in IBD care.

People Living with Inflammatory Bowel Disease Want Multidisciplinary Healthcare: A Qualitative Content Analysis

This study reports on the preferences of people with inflammatory bowel disease (IBD) for their healthcare. Overall, 477 people with IBD responded to an open-ended survey question within a larger study. We qualitatively content-analysed these responses with open coding using NVivo. Respondents expressed a desire for (1) better communication, (2) multidisciplinary care, (3) better treatment, services and specialist care, (4) whole person care, (5) health promotion, (6) proactive healthcare, (7) fewer administrative issues and (8) improved hospital experience. Patients with IBD want patient-centred, multidisciplinary care. Healthcare professionals should facilitate patients' access to proactive care.

Association of inflammatory bowel disease with suicidal ideation, suicide attempts, and suicide: A systematic review and meta-analysis

OBJECTIVE

Inflammatory bowel disease (IBD) is associated with psychiatric comorbidities. However, the association between IBD and suicidal ideation or suicide attempts has not been well established. This study aimed to perform a systematic review and meta-analysis to elucidate the relationship between IBD and suicidal ideation, suicide attempts, and suicide.

METHODS

We systematically searched five electronic databases - PubMed, Embase, CENTRAL, Web of Science, and PsycINFO - from their inception to January 28, 2022. Quality assessment, data synthesis, subgroup analyses, sensitivity analyses, and publication bias assessment were performed on the included studies.

RESULTS

We identified 28 studies with 1,047,755 patients with IBD. The pooled prevalence of suicidal ideation in patients with IBD was 17.3% (95% CI, 9.5%-25.2%). Patients with IBD were associated with an increased risk of suicide attempts (relative risk [RR], 1.39; 95% CI, 1.08-1.79) and suicide deaths (RR, 1.25; 95% CI, 1.09-1.43) than the controls without IBD. Patients with Crohn's disease subtypes, female IBD, pediatric-onset IBD, young adult IBD, and short-duration IBD had a particularly high risk for suicide.

CONCLUSION

Patients with IBD had a high prevalence of suicidal ideation and a significantly higher likelihood of suicide attempts and suicide. Caring for patients with IBD, including their mental health needs, may require concerted efforts among gastroenterologists and other healthcare providers.

Interventions to Decrease Unplanned Healthcare Utilization and Improve Quality of Care in Adults With Inflammatory Bowel Disease: A Systematic Review

BACKGROUND & AIMS

Inflammatory bowel disease (IBD) care and outcomes exhibit substantial variability, suggesting quality gaps. We aimed to identify interventions to narrow these gaps.

METHODS

We performed a systematic review of Medline, Embase, and Web of Science through May 2021 to find manuscripts and abstracts reporting quality improvement (QI) interventions in IBD. We included studies with interventions that addressed acute care utilization, vaccination, or Crohn's and Colitis Foundation quality indicators for care processes, including pre-therapy testing, tobacco cessation, colorectal cancer surveillance, Clostridium difficile infection screening in flares, sigmoidoscopy in patients hospitalized with ulcerative colitis, and use of steroid-sparing therapy. The primary objective was to identify successful QI interventions. Risk of bias assessment was conducted using the Joanna Briggs Institute critical appraisal checklist.

RESULTS

Twenty-three manuscripts and 23 meeting abstracts met inclusion criteria. Influenza and pneumococcal vaccination were the most studied indicators (24 references), followed by emergency room and/or hospital utilization, tobacco cessation, and pre-therapy testing (17, 11, and 10 references, respectively). Electronic medical record-based interventions were the most frequent, whereas other initiatives used strategies that included changes to care structure or delivery, vaccination protocols, or physician and patient education. Successful interventions matched the complexity of the metric to the intervention including making changes to care structure or delivery, empowered non-physician staff, and used electronic medical record changes to prompt clinicians.

CONCLUSIONS

The quality of IBD care can be improved with diverse interventions that range from simple to complex. However, these interventions are not universally successful. Clinicians should emulate successful interventions and design new initiatives to narrow gaps in care quality.

The Pediatric Inflammatory Bowel Disease Medical Home: A Proposed Model

Care for patients with inflammatory bowel disease (IBD) can be complex and costly. Care delivery models to address these challenges and improve care quality are essential. The patient-centered medical home (PCMH), which was developed in the primary care setting, has recently been applied successfully to the adult IBD population. Following the tenets of the PCMH, this specialty medical home (SMH) emphasizes team-based care that is accessible, comprehensive, patient/family-centered, coordinated, compassionate, and continuous and has demonstrated improved patient outcomes. Children and young adults with IBD have equally complex care needs, with additional challenges not faced by the adult population such as growth, physical and psychosocial development, and transition of care from pediatric to adult providers. Thus, we advocate that the components of the PCMH are equally-if not more-important in caring for the pediatric patient population. In this article, we review what is known about the application of the PCMH model in adult IBD care, describe care delivery within the Center for Pediatric and Adolescent IBD at Nationwide Children's Hospital as an example of a pediatric IBD medical home, and propose a research agenda to further the development and dissemination of comprehensive care delivery for children and adolescents with IBD.

Resilience-based Integrated IBD Care Is Associated With Reductions in Health Care Use and Opioids

BACKGROUND & AIMS

Integrated inflammatory bowel disease (IBD) care is effective but not routinely implemented. Validated methods that simultaneously address mind and body targets such as resilience may improve access and outcomes. We describe the development and implementation of the GRITT method and its impact on resilience, health care utilization (HCU), and opioid use in IBD.

METHODS

Consecutive patients from an academic IBD center were evaluated for low resilience on the basis of provider referral. Low resilience patients were invited to participate in the GRITT program. Primary outcome was % reduction in HCU. Secondary outcomes were change in resilience and corticosteroid and opioid use. Patients were allocated into 2 groups for analysis: GRITT participants (GP) and non-participants (NP). Clinical data and HCU in the year before enrollment were collected at baseline and 12 months. One-way repeated measures multivariate analysis of covariance evaluated group × time interactions for the primary outcome. Effect size was calculated for changes in resilience over time.

RESULTS

Of 456 screened IBD patients 394 were eligible, 184 GP and 210 NP. GP had greater reduction in HCU than NP: 71% reduction in emergency department visits, 94% reduction in unplanned hospitalizations. There was 49% reduction in opioid use and 73% reduction in corticosteroid use in GP. Resilience increased by 27.3 points (59%), yielding a large effect size (d = 2.4).

CONCLUSIONS

Mind-body care that focuses on building resilience in the context of IBD care may be a novel approach to reduce unplanned HCU and opioid use, but large, multicenter, randomized controlled trials are needed.

Simplified Machine Learning Models Can Accurately Identify High-Need High-Cost Patients With Inflammatory Bowel Disease

INTRODUCTION

Hospitalization is the primary driver of inflammatory bowel disease (IBD)-related healthcare costs and morbidity. Traditional prediction models have poor performance at identifying patients at highest risk of unplanned healthcare utilization. Identification of patients who are high-need and high-cost (HNHC) could reduce unplanned healthcare utilization and healthcare costs.

METHODS

We conducted a retrospective cohort study in adult patients hospitalized with IBD using the Nationwide Readmissions Database (model derivation in the 2013 Nationwide Readmission Database and validation in the 2017 Nationwide Readmission Database). We built 2 tree-based algorithms (decision tree classifier and decision tree using gradient boosting framework [XGBoost]) and compared traditional logistic regression to identify patients at risk for becoming HNHC (patients in the highest decile of total days spent in hospital in a calendar year).

RESULTS

Of 47,402 adult patients hospitalized with IBD, we identified 4,717 HNHC patients. The decision tree classifier model (length of stay, Charlson Comorbidity Index, procedure, Frailty Risk Score, and age) had a mean area under the receiver operating characteristic curve (AUC) of 0.78 ± 0.01 in the derivation data set and 0.78 ± 0.02 in the validation data set. XGBoost (length of stay, procedure, chronic pain, drug abuse, and diabetic complication) had a mean AUC of 0.79 ± 0.01 and 0.75 ± 0.02 in the derivation and validation data sets, respectively, compared with AUC 0.55 ± 0.01 and 0.56 ± 0.01 with traditional logistic regression (peptic ulcer disease, paresthesia, admission for osteomyelitis, renal failure, and lymphoma) in derivation and validation data sets, respectively.

DISCUSSION

In hospitalized patients with IBD, simplified tree-based machine learning algorithms using administrative claims data can accurately predict patients at risk of progressing to HNHC.

Relative Contribution of Disease Activity and Psychological Health to Prognosis of Inflammatory Bowel Disease During 6.5 Years of Longitudinal Follow-Up

BACKGROUND & AIMS

Symptoms of common mental disorders, such as anxiety or depression, are common in inflammatory bowel disease (IBD) and may affect prognosis. However, unlike clinical or biochemical markers of disease activity, psychological health is not a recommended therapeutic target. We assessed relative contribution of poor psychological health and clinical or biochemical activity to prognosis.

METHODS

Demographic features, IBD subtype, treatments, and anxiety and depression scores were recorded at baseline for 760 adults, with clinical activity determined using validated scoring systems. Fecal calprotectin was analyzed in 379 (49.9%) patients (≥250 μg/g used to define biochemical activity). Glucocorticosteroid prescription or flare, escalation, hospitalization, intestinal resection, or death were assessed during 6.5 years of follow-up. Occurrence was compared using multivariate Cox regression across 4 patient groups according to presence of disease remission or activity, with or without symptoms of a common mental disorder, at baseline.

RESULTS

In total, 718 (94.5%) participants provided data. Compared with clinical remission without symptoms of a common mental disorder at baseline, need for glucocorticosteroid prescription or flare (hazard ratio [HR], 2.36; 95% confidence interval [CI], 1.58-3.54), escalation (HR, 1.65; 95% CI, 1.14--2.40), and death (HR, 4.99; 95% CI, 1.80-13.88) were significantly higher in those with clinical activity and symptoms of a common mental disorder. Rates in those with clinical remission and symptoms of a common mental disorder at baseline or those with clinical activity without symptoms of a common mental disorder were not significantly higher. Similarly, with biochemical activity and symptoms of a common mental disorder, rates of glucocorticosteroid prescription or flare (HR, 2.48; 95% CI, 1.38-4.46), escalation (HR, 2.97; 95% CI, 1.74-5.06), hospitalization (HR, 3.10; 95% CI, 1.43-6.68), and death (HR, 6.26; 95% CI, 2.23-17.56) were significantly higher.

CONCLUSIONS

Psychological factors are important determinants of poor prognostic outcomes in IBD and should be considered as a therapeutic target.

A Care Coordination Intervention Improves Symptoms But Not Charges in High-Risk Patients With Inflammatory Bowel Disease

BACKGROUND

Inflammatory bowel disease (IBD) is associated with substantial symptom burden, variability in clinical outcomes, and high direct costs. We sought to determine if a care coordination-based strategy was effective at improving patient symptom burden and reducing healthcare costs for patients with IBD in the top quintile of predicted healthcare utilization and costs.

METHODS

We performed a randomized controlled trial to evaluate the efficacy of a patient-tailored multicomponent care coordination intervention composed of proactive symptom monitoring and care coordinator-triggered algorithms. Enrolled patients with IBD were randomized to usual care or to our care coordination intervention over a 9-month period (April 2019 to January 2020). Primary outcomes included change in patient symptom scores throughout the intervention and IBD-related charges at 12 months.

RESULTS

Eligible IBD patients in the top quintile for predicted healthcare utilization and expenditures were identified. A total of 205 patients were enrolled and randomized to our intervention (n = 100) or to usual care (n = 105). Patients in the care coordinator arm demonstrated an improvement in symptoms scores compared with usual care (coefficient, -0.68, 95% confidence interval, -1.18 to -0.18; P = .008) without a significant difference in median annual IBD-related healthcare charges ($10,094 vs $9080; P = .322).

CONCLUSIONS

In this first randomized controlled trial of a patient-tailored care coordination intervention, composed of proactive symptom monitoring and care coordinator-triggered algorithms, we observed an improvement in patient symptom scores but not in healthcare charges. Care coordination programs may represent an effective value-based approach to improve symptoms scores without added direct costs in a subgroup of high-risk patients with IBD. (ClinicalTrials.gov, Number: NCT04796571).

How Should Pain, Fatigue, and Emotional Wellness Be Incorporated Into Treatment Goals for Optimal Management of Inflammatory Bowel Disease?

Early diagnosis and the optimal control of inflammation, with a continuous cycle of assessment, treatment, monitoring, and adjustment of therapy, is best practice for the management of inflammatory bowel disease. However, patients express frustration with ongoing challenging symptoms, often discordant with inflammation, including abdominal pain, fatigue, depression, anxiety, and emotional wellness; these are often not optimally addressed by inflammatory bowel disease clinicians due to lack of time or resources. This review will highlight the burden of these symptoms and issues, suggest ways of assessing these in clinical practice, highlight the importance of acknowledging and validating the symptoms and issues with patients, reassuring them that they are being heard, and discuss different possible models of service delivery for psychosocial support, from fully integrated gastropsychology models to referral pathways that optimize community support. We suggest the importance of the treat-to-target concept, where the target is not only control of inflammation but also emotional wellness.

Specialized Emergency Department Assessment and Multidisciplinary Intervention After Discharge Improve Management of Patients With Inflammatory Bowel Diseases

GOAL

The aim was to assess proactive specialized inflammatory bowel diseases (IBD) emergency department (ED) consultation and multidisciplinary IBD team (IBD-MDT) intervention on IBD-related patient outcomes after discharge.

BACKGROUND

Despite advances in patient care, IBD-related ED visits have increased and substantially contribute to the IBD burden.

METHODS

Consecutive patients with IBD (below 50 y) who visited the ED during November 2017 to April 2018 (intervention group) were compared with patients with IBD that visited the same ED during 2014 to 2017 (standard-care group). The primary outcomes were hospitalization and ED revisits at 30, 90, and 180 days.

RESULTS

The intervention group (45 patients, mean age 32.43±8.6 y, 57.8% male) and the standard-care group (237 patients) had comparable baseline characteristics, including age, sex, and IBD type, and similar rates of hospital admissions from the ED (46.7% vs. 38.8%, P=0.32). The intervention group more frequently underwent computed tomography (40% vs. 8%, P<0.001) and surgical interventions (13.3% vs. 0.8%, P<0.001) within the same hospital admission, compared with the standard-care group. In the intervention group, 24 patients were discharged from the ED, of whom 17 patients visited the IBD clinic (median 5 d postdischarge) and the majority were referred to ambulatory IBD-MDT services (dietitian: 46.7%, psychologist: 6.7%, advanced endoscopist: 8.9%, and proctology services: 6.7%). The intervention group had significantly fewer ED revisits than the standard-care group (30 d: 4.4% vs. 19.8%, P=0.013; 90 d: 4.4% vs. 35.9%, P<0.001; 180 d: 6.7% vs. 43%, P<0.001).

CONCLUSION

Proactive specialized ED assessments and IBD-MDT interventions after a hospital discharge were preferable; they significantly reduced the ED revisit rate for at least 6 months.

OUP accepted manuscript

Background

Canada has among the highest incidence and prevalence rates of inflammatory bowel disease (IBD) in the world. While access to IBD specialty care can have a direct impact on health-related outcomes, the complexity of accessing IBD specialty care within Canada is not well understood and presents a barrier to implementation and evaluation of IBD specialty care.

Aim

The IBD Summit was held in partnership with Crohn’s & Colitis Canada to identify barriers and facilitators of IBD specialty care by exploring the perceptions and experiences of key stakeholders of IBD care across Canada.

Results

A total of 20 key stakeholders attended, including gastroenterologists, patients, researchers and policymakers. Perceptions and experiences of stakeholders were transcribed, coded and thematically analyzed. Three key categories relating to access to IBD care arose: (1) inadequate system structure, (2) process inefficiencies and (3) using outcomes to guide system change. The IBD Summit identified similar perceptions and experiences among stakeholders and across provinces, highlighting common barriers and facilitators that transcended provincial and health care system boundaries.

Conclusions

Key suggestions identify the clinical importance of comprehensive integrated multidisciplinary care approaches with enhanced communication between patient and health care providers, greater information sharing among team members, streamlined referral and triage processes, and improved incorporation of best practice into clinical care. Stakeholders across Canada and in other countries may benefit from the suggestions presented herein, as well as the successful use of collaborative and inclusive methods of gathering the perceptions and experiences of key stakeholders from diverse backgrounds.

Quality of Care Program Reduces Unplanned Health Care Utilization in Patients With Inflammatory Bowel Disease

INTRODUCTION

There is significant variation in processes and outcomes of care for patients with inflammatory bowel disease (IBD), suggesting opportunities to improve quality of care. We aimed to determine whether a structured quality of care program can improve IBD outcomes, including the need for unplanned health care utilization.

METHODS

We used a structured approach to improve adult IBD care in 27 community-based gastroenterology practices and academic medical centers. Patient-reported outcomes (PRO) and health care utilization were collected at clinical visits. Outcomes were monitored monthly using statistical process control charts; improvement was defined by special cause (nonrandom) variation over time. Multivariable logistic regression was applied to patient-level data. Nineteen process changes were offered to improve unplanned health care utilization. Ten outcomes were assessed, including disease activity, remission status, urgent care need, recent emergency department use, hospitalizations, computed tomography scans, health confidence, corticosteroid or opioid use, and clinic phone calls.

RESULTS

We collected data prospectively from 20,382 discrete IBD visits. During the 15-month project period, improvement was noted across multiple measures, including need for urgent care, hospitalization, steroid use, and opioid utilization. Adjusted multivariable modeling showed significant improvements over time across multiple outcomes including urgent care need, health confidence, emergency department utilization, hospitalization, corticosteroid use, and opioid use. Attendance at monthly coached webinars was associated with improvement.

DISCUSSION

Outcomes of IBD care were improved using a structured quality improvement program that facilitates small process changes, sharing of best practices, and ongoing feedback. Spread of these interventions may facilitate broad improvement in IBD care when applied to a large population.

Health Economic Impact of a Multicenter Quality-of-Care Initiative for Reducing Unplanned Healthcare Utilization Among Patients With Inflammatory Bowel Disease

INTRODUCTION

A multicenter adult inflammatory bowel disease learning health system (IBD Qorus) implemented clinical care process changes for reducing unplanned emergency department visits and hospitalizations using a Breakthrough Series Collaborative approach.

METHODS

Using Markov decision models, we determined the health economic impact of participating in the Collaborative from the third-party payer perspective.

RESULTS

Across all 23 sites, participation in the Collaborative was associated with lower annual costs by an average of $2,528 ± $233 per patient when compared with the baseline period.

DISCUSSION

Implementing clinical care process changes using a Collaborative approach was associated with overall cost savings. Future work should examine which specific interventions are most effective and whether such cost savings are sustainable.

Approach to the Management of Recently Diagnosed Inflammatory Bowel Disease Patients: A User's Guide for Adult and Pediatric Gastroenterologists

Inflammatory bowel diseases (IBDs), including Crohn's disease and ulcerative colitis, are chronic, progressive, immune-mediated diseases of adults and children that have no cure. IBD can cause significant morbidity and lead to complications such as strictures, fistulas, infections, and cancer. In children, IBD can also result in growth impairment and pubertal delays. IBD is highly heterogenous, with severity ranging from mild to severe and symptoms ranging from mild to debilitating. Delay in IBD diagnosis, especially in Crohn's disease, is common and associated with adverse outcomes. Early diagnosis and prompt institution of treatment are the cornerstones for improving outcomes and maximizing health. Early diagnosis requires a low threshold of suspicion and red flags to guide early specialist referral at the primary provider level. Although the armamentarium of IBD medications is growing, many patients will not respond to treatment, and the selection of first-line therapy is critical. Risk stratification of disease severity, based on clinical, demographic, and serologic markers, can help guide selection of first-line therapy. Clinical decision support tools, genomics, and other biomarkers of response to therapy and risk of adverse events are the future of personalized medicine. After starting appropriate therapy, it is important to confirm remission using objective end points (treat to target) with continued control of inflammation with adjustment of therapy using surrogate biomarkers (tight control). Lastly, IBD therapy extends far beyond medications, and other aspects of the overall health and wellbeing of the patient are critical. These include preventive health, nutrition, and psychobehavioral support addressing patients' concerns around complementary therapy and medication adherence, prevention of disability, and ensuring open communication.

Golimumab improves work productivity in patients suffering from moderate to severe ulcerative colitis: results of a prospective study over 24 months

BACKGROUND

Ulcerative colitis (UC) is a chronic inflammatory bowel disease with recurrent episodes of debilitating symptoms negatively affecting work productivity and health-related quality of life (HRQoL). The use of biologics in UC treatment improves work and HRQoL but prospective long-term data concerning the treatment with TNFα inhibitor golimumab in UC patients are still rare. Therefore, our study aimed to evaluate the change in work productivity, capacity for daily activities and HRQoL in UC patients treated with golimumab in Germany.

METHODS

Using the Work Productivity and Activity Impairment questionnaire, the change in work productivity and in capacity for daily activities after 3 months and over the whole observational period of 24 months were assessed (both primary endpoints). Disease-specific and health-related quality of life (QoL) were analyzed with the Inflammatory Bowel Disease Questionnaire (IBDQ), the Short-Form 12 Health Survey Questionnaire (SF-12), and the Partial Mayo Score (secondary endpoints). Further, disease-related hospitalization rates were assessed.

RESULTS

This prospective non-interventional study included 286 patients. Thereof, 212 patients were employed at baseline (modified intention to treat analysis set employed at baseline, mITTe). 61.3% of the mITTe patients had moderate and 17.0% had severe UC. Three months after initiation of golimumab therapy, total work productivity impairment (TWPI) score and activity impairment score improved significantly from baseline with a mean change of - 17.3% (p < 0.0001) and - 14.4% (p < 0.0001), respectively. Results persisted over 24 months (mean change TWPI score: - 24.5%, mean change activity impairment score: - 30.0%). Disease- and health-related QoL also improved significantly under golimumab treatment as indicated by increased IBDQ [mean change: 28.0 (SD: ± 36.1, month 3), 42.1 (SD: ± 39.5, month 24)] and SF-12 scores [PCS-12: 45.9 (SD: ± 8.5), MCS-12: 4.9 (SD: ± 10.6, month 3), PCS-12: 5.9 (SD: ± 9.0), MCS-12: 6.4 (SD: ± 11.1, month 24)]. Disease-related hospitalization rate decreased from 16.0% (BL) to 4.3% at month 24 and the mean number of missed working days due to UC decreased from 8.2 (SD: 17.6, BL) to 0.7 (SD: 2.1) after golimumab induction.

CONCLUSIONS

Golimumab leads to notable long-term improvements in work productivity, daily activity, HRQoL, and disease-related hospitalization rates in patients with moderate to severe UC.

TRIAL REGISTRATION

PEI (Paul-Ehrlich-Institute, Langen, Germany) Registration Nr: NIS#255 ( https://www.pei.de/SharedDocs/awb/nis-0201-0300/0255.html ).

Prevalence of symptoms of anxiety and depression in patients with inflammatory bowel disease: a systematic review and meta-analysis

BACKGROUND

Inflammatory bowel disease (IBD) is a lifelong condition with no cure. Patients with IBD might experience symptoms of common mental disorders such as anxiety and depression because of bidirectional communication via the gut-brain axis and chronicity of symptoms, and because of impaired quality of life and reduced social functioning. However, uncertainties remain about the magnitude of this problem. We aimed to assess prevalence of symptoms of anxiety or depression in adult patients with IBD.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE, Embase, Embase Classic, and PsycINFO for papers published from inception to Sept 30, 2020, reporting observational studies that recruited at least 100 adult patients with IBD and that reported prevalence of symptoms of anxiety or depression according to validated screening instruments. We excluded studies that only used a structured interview to assess for these symptoms and studies that did not provide extractable data. We extracted data from published study reports and calculated pooled prevalences of symptoms of anxiety and depression, odds ratios (OR), and 95% CIs.

FINDINGS

Of 5544 studies identified, 77 fulfilled the eligibility criteria, including 30 118 patients in total. Overall, pooled prevalence of anxiety symptoms was 32·1% (95% CI 28·3-36·0) in 58 studies (I²=96·9%) and pooled prevalence of depression symptoms was 25·2% (22·0-28·5) in 75 studies (I²=97·6%). In studies that reported prevalence of anxiety or depression in patients with Crohn's disease and ulcerative colitis within the same study population, patients with Crohn's disease had higher odds of anxiety symptoms (OR 1·2, 95% CI 1·1-1·4) and depression symptoms (1·2, 1·1-1·4) than patients with ulcerative colitis. Overall, women with IBD were more likely to have symptoms of anxiety than were men with IBD (pooled prevalence 33·8% [95% CI 26·5-41·5] for women vs 22·8% [18·7-27·2] for men; OR 1·7 [95% CI 1·2-2·3]). They were also more likely to have symptoms of depression than men were (pooled prevalence 21·2% [95% CI 15·4-27·6] for women vs 16·2% [12·6-20·3] for men; OR 1·3 [95% CI 1·0-1·8]). The prevalence of symptoms of anxiety (57·6% [95% CI 38·6-75·4]) or depression (38·9% [26·2-52·3]) was higher in patients with active IBD than in patients with inactive disease (38·1% [30·9-45·7] for anxiety symptoms and 24·2% [14·7-35·3] for depression symptoms; ORs 2·5 [95% CI 1·5-4·1] for anxiety and 3·1 [1·9-4·9] for depression).

INTERPRETATION

There is a high prevalence of symptoms of anxiety and depression in patients with IBD, with up to a third of patients affected by anxiety symptoms and a quarter affected by depression symptoms. Prevalence was also increased in patients with active disease: half of these patients met criteria for anxiety symptoms and a third met criteria for depression symptoms. Encouraging gastroenterologists to screen for and treat these disorders might improve outcomes for patients with IBD.

FUNDING

None.

The four epidemiological stages in the global evolution of inflammatory bowel disease

Inflammatory bowel disease (IBD) is a global disease; its evolution can be stratified into four epidemiological stages: Emergence, Acceleration in Incidence, Compounding Prevalence and Prevalence Equilibrium. In 2020, developing countries are in the Emergence stage, newly industrialized countries are in the Acceleration in Incidence stage, and Western regions are in the Compounding Prevalence stage. Western regions will eventually transition to the Prevalence Equilibrium stage, in which the accelerating prevalence levels off as the IBD population ages and possibly as a result of an unexpected rise in mortality during the COVID-19 pandemic. Mitigating the global burden of IBD will require concerted efforts in disease prevention and health-care delivery innovations that respond to changing demographics of the global IBD population. In this Perspective, we summarize the global epidemiology of IBD and use these data to stratify disease evolution into four epidemiological stages.

Establishing a medical home for patients with inflammatory bowel diseases: a qualitative study

The Patient-Centered Medical Home model has gained popularity in primary care to provide early effective care to patients with chronic conditions. Prior research on specialty medical homes has been cross-sectional and focused on patient outcomes. The objective of this longitudinal qualitative study was to identify best practices in establishing a specialty medical home in Inflammatory Bowel Diseases (IBD Home). The multimethod study included direct observations of multidisciplinary team meetings (30 hours over one year) and in-depth interviews with individual team members (N=11) and referring physicians (N=6) around their participation in the IBD home. All interviews were professionally transcribed verbatim. Two researchers coded transcripts for themes using NVivo software. Weekly team meetings (N=9±3) included behavioral health providers, nurse practitioners, nurses, dietitians, a clinical pharmacist, and clinical coordinators. Physicians referred patients with psychosocial comorbidities to the IBD home. Initially the team enrolled all referred patients. Later, they developed exclusion criteria and a patient complexity score to manage the volume. Some providers reported increase in their workload (social work, nutrition) while others’ workload was unaffected (gastroenterology, nursing). No physicians attended team meetings regularly. Regular in-person meetings helped to strengthen the team. Involving physicians as consultants on an ad hoc basis without regular meeting attendance empowered other team members to take ownership of the IBD Home.

Decreasing Colectomy Rate for Ulcerative Colitis in the United States Between 2007 and 2016: A Time Trend Analysis

BACKGROUND

Improved treatment approaches for ulcerative colitis (UC), including novel medications, might reduce the need for colectomy. We performed a retrospective cohort study of adult patients (age 18-64) with UC in the United States to examine time trends for colectomy and biologic use from 2007 to 2016.

METHODS

We estimated quarterly rates for colectomy and biologic use using the IQVIA Legacy PharMetrics Adjudicated Claims Database. We used interrupted time series methods with segmented regression to assess time trends with 95% confidence intervals (CIs) for biologic use and colectomy before and after the emergence of newly available biologic therapies in 2014.

RESULTS

Among 93,930 patients with UC, 2275 (2.4%) underwent colectomy from 2007 to 2016. Biologic use rates increased significantly from 2007 to 2016, from 131 per 1000 person-years in 2007 (95% CI, 121 to 140) to 589 per 1000 person-years in 2016 (95% CI, 575 to 604; P < 0.001). Colectomy rates decreased significantly between 2007 and 2016, from 7.8 per 1000 person-years (95% CI, 7.4 to 8.2) to 4.2 per 1000 person-years in 2016 (95% CI, 3.2 to 5.1; P < 0.001). An interruption in 2014 was associated with a positive trend deflection for biologic use (+72 treatments per 1000 person-years per year (95% CI, 61 to 83) and a negative trend deflection for colectomy (-0.76 per 1000 person-years per year; 95% CI, -1.47 to -0.05).

CONCLUSIONS

Among commercially insured patients in the United States from 2007 to 2016, biologic use rates increased, colectomy rates decreased, and both trends were impacted by the interruption in 2014. These findings suggest that new biologic therapies may have contributed to decreased colectomy rates.

Patterns of Primary, Specialty, Urgent Care, and Emergency Department Care in Children With Inflammatory Bowel Diseases

OBJECTIVES

Pediatric patients with inflammatory bowel diseases (IBD) require treatment, monitoring, and health maintenance services. We described patterns of primary, specialty, emergency department (ED) and urgent care delivery, and explored patient- and system-related variables that impact ED/urgent care utilization.

METHODS

We conducted a cross sectional survey of parents of children with IBD at a large tertiary children's hospital.

RESULTS

One hundred sixty-one parents completed the survey (75% response). Mean patient age 13.9 years (51% boys); 80% Crohn disease, 16% ulcerative colitis, 4% IBD-unspecified. Mean disease duration 4 years (standard deviation [SD] 2.7). Thirty percent had at least 1 other chronic disease, 31% had a history of IBD-related surgery. Parents were predominantly Caucasian (94%), well-educated (61% bachelor's degree/higher), part of a 2-parent household (79%) living in a suburban setting (57%). Seventy-seven percent of patients had private insurance. In the past year, most children had 1 to 2 IBD-related office visits (54%) with their gastroenterology (GI) doctor and no IBD-related hospitalizations (79%). Eighty-eight percent (N = 141) had a primary care provider (PCP), and most (70%) saw their PCP 1 to 2 times. Even so, 86% (N = 139) received medical care from places other than their PCP or GI doctor; 27% in the ED and 45% at urgent care. Children of parents with less than a bachelor's degree, families that lived further from their GI doctor, and children who saw their PCP more often were more likely to utilize ED/urgent care.

CONCLUSIONS

ED/urgent care utilization in pediatric patients with IBD was greater than expected, potentially contributing to fragmented, costly care and worse outcomes.

The burden of cost in inflammatory bowel disease: a medical economic perspective

PURPOSE OF REVIEW

The cost of care for inflammatory bowel disease (IBD) has nearly doubled over the last two decades. With evolving treatment paradigms utilizing costly but efficacious biologic agents earlier and more often, the cost burden is only expected to worsen. The purpose of this review is to explore the current economic landscape and drivers of IBD healthcare costs along with potential mechanisms for improving value and cost-effectiveness of IBD care.

RECENT FINDINGS

The prevalence of IBD continues to rapidly expand with costs following suit. As compensation models change, the medical community is more incentivized than ever to develop cost reduction strategies including incorporation of high-value care measures, cooperative data aggregation, and technological solutions, with many of these interventions demonstrating promising results.

SUMMARY

IBD is an expensive chronic disease with payments only expected to rise. In light of this financial conundrum, new practice models, such as the IBD specialty medical home and remote telemedicine, are being tested with an emphasis on cost reduction. Many of these strategies are demonstrating improved patient outcomes while also curbing expenses. These early successes set the stage for continued cooperation, collaboration, and growth in value-based management of IBD.

The Cost of Use of the Emergency Department by Persons With Inflammatory Bowel Disease Living in a Canadian Health Region: A Retrospective Population-Based Study

BACKGROUND

We aimed to determine the costs of emergency department (ED) attendance by persons with inflammatory bowel disease (IBD) not admitted to hospital from the ED.

METHODS

This was a population-based administrative database study linking the University of Manitoba IBD Epidemiology Database with the Winnipeg Regional Health Authority (WRHA) ED Information Service database. We identified persons with IBD who presented to the ED and were not admitted between January 1, 2009 and March 31, 2012. We then applied costs in Canadian dollars for these visits including an average ED visit cost plus 26% for overhead (total = $508), an average estimated cost of laboratory investigations ($50), and costs for each of radiographic imaging, lower endoscopy and consultation with an internist/gastroenterologist or a surgeon. We tallied the costs of each unique ED presentation. We determined average costs for visits associated with specific consultations or investigations.

RESULTS

One thousand six hundred and eighty-two persons with IBD (4,853 individual visits) attended the ED and did not get hospitalized. The average cost per ED visit by a person with IBD who did not get hospitalized was $650. This resulted in a total expenditure of $3,152,227 on these persons for their ED attendance or $969,916 per year. The visits with the highest mean costs were those associated with an abdominal computerized tomography scan ($979), those associated with surgical consultation ($1019), and those associated with an internist/gastroenterologist consultation ($942).

CONCLUSION

Better strategies for management of acute issues for persons with IBD that can reduce the use of an ED are needed and can be considerably cost saving.

Managing Pain and Psychosocial Care in IBD: a Primer for the Practicing Gastroenterologist

PURPOSE OF REVIEW

This review focuses on the relationship between trauma and pain in inflammatory bowel disease (IBD), and offers effective treatment strategies.

RECENT FINDINGS

Recent evidence points to bidirectional pathways between psychiatric disorders and IBD. The impact of trauma and development of post-traumatic stress symptoms on IBD disease course is beginning to be appreciated including its relationship with pain. First-line treatments for both psychiatric and chronic pain disorders include behavioral interventions such as cognitive behavioral therapy, hypnosis, and mindfulness, and there is emerging evidence studying Acceptance and Commitment Therapy and telehealth interventions. Pharmacological treatments using neuromodulators can also be beneficial. An integrated care team, such as a subspecialty medical home model, can provide the best patient experience and address comprehensive care needs efficiently and effectively. Psychosocial factors impact IBD course and necessitate effective management. Despite the significant limitations of research, particularly lack of clinical trials examining behavioral and pharmacotherapy interventions in IBD, effective treatments exist and are best utilized in an integrated care setting.

Risk Factors for Medication Nonadherence to Self-Injectable Biologic Therapy in Adult Patients With Inflammatory Bowel Disease

BACKGROUND

In inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), nonadherence to biologic therapy increases risk of disease flare. The aim of this study was to identify risk factors for nonadherence.

METHODS

This was a single-center retrospective study evaluating patients with IBD treated at a tertiary care center and prescribed self-injectable biologic therapy using the center's specialty pharmacy. Adherence was defined using medication possession ratio (MPR). Nonadherence was defined as MPR <0.86.

RESULTS

Four hundred sixty patients (n = 393 with CD and n = 67 with UC) were evaluated with mean MPR (interquartile range) equaling 0.89 (0.48-1). Overall, 69% of patients were adherent (defined as MPR ≥0.86), 66% of patients with CD and 87% of patients with UC. In univariate analysis, several factors increased risk of nonadherence: CD diagnosis, insurance type, psychiatric history, smoking, prior biologic use, and narcotic use (P < 0.05). In multivariable analysis, Medicaid insurance (odds ratio [OR], 5.5; 95% confidence interval [CI], 1.85-15.6) and CD diagnosis (OR, 2.8; 95% CI, 1.3-6.0) increased risk of nonadherence. In CD, as the number of risk factors increased (narcotic use, psychiatric history, prior biologic use, and smoking), the probability of nonadherence increased. Adherence was 72% in patients with 0-1 risk factors, decreasing to 62%, 61%, and 42% in patients with 2, 3, and 4 risk factors, respectively (P < 0.05).

CONCLUSIONS

This study identified risk factors for nonadherence to biologic therapy. In patients with CD, the probability of nonadherence increased as the number of risk factors increased.