Cost-effectiveness of Telemedicine-directed Specialized vs Standard Care for Patients With Inflammatory Bowel Diseases in a Randomized Trial

Position statement of the Spanish Working Group on Crohn's Disease and Ulcerative Colitis on the use of Telemedicine in Inflammatory Bowel Disease

Inflammatory Bowel Disease (IBD) is a chronic digestive condition that requires continuous monitoring by healthcare professionals to determine appropriate therapy and manage short- and long-term complications. Telemedicine has become an essential approach for managing chronic conditions such as IBD, improving care accessibility and continuity, decreasing hospitalization rates, and optimizing patient follow-up. It enables rapid treatment adjustments and encourages patient self-management. Additionally, it reduces the burden on the healthcare system by decreasing unnecessary in-person visits and provides real-time support, thereby improving quality of life and clinical outcomes. The objective of this position statement by the Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU) is to establish recommendations for the use of telemedicine in its different modalities (teleconsulting, telemonitoring, mobile applications and telepharmacy) for patients with IBD and address the legal, ethical, and technical aspects necessary for its proper implementation.

Reducing outpatient visits for FIT-positive participants of colorectal cancer screening programs with home-based digital counselling

Digital counselling can alleviate the burden on healthcare systems and patients. While it has been evaluated as a supplement to standard care or a substitute for follow-up visits, its use for initial triaging and counselling remains unstudied. We developed a Digital Intake Tool (DIT) to facilitate the entire pre-colonoscopy counselling process for FIT-positive participants of a colorectal cancer screening program digitally, replacing the need for physicians. In this multicentre prospective non-inferiority study, we evaluated if the DIT could replace in-person counselling. DIT-counselling resulted in adequately prepared participants in 96.5%, compared to 97.6% after in-person counselling, demonstrating non-inferiority. Outpatient visits were significantly reduced, with only 3.4% requiring face-to-face consultations. Patient experiences were highly positive, without increased psychological distress or anxiety, and effective knowledge transfer. This approach benefits patients and healthcare systems, allowing patients to receive care at home, reducing travel and carbon emissions, while increasing outpatient capacity. ICTRP-registration: NL9315, March 8, 2021.

What do patients and informal caregivers value in IBD care? A narrative inquiry

BACKGROUND

Inflammatory Bowel Disease (IBD) is an increasingly prevalent chronic condition that impacts the lives of patients and their relatives, and burdens healthcare systems. Redesigning care processes is warranted, with digital technologies offering opportunities to increase efficiency and reduce workloads. However, successful innovations require meaningful involvement of patients and informal caregivers. In this study, we aimed to identify what IBD patients and their informal caregivers value in IBD care.

METHODS

A purposive sample of 18 IBD patients and 8 informal caregivers was drawn from an academic and a non-academic hospital in the Netherlands. Semi-structured interviews with a narrative approach focused on capturing real-life experiences and personal stories related to IBD care. Transcripts were analysed using inductive thematic analysis.

RESULTS

Patients and informal caregivers valued clear information and support regarding the disease, treatment, and daily management, along with active involvement in treatment planning. Regular contact with the same trusted healthcare professionals (HCPs), and effective treatment that alleviates symptoms and enables normal living, were deemed important. Patients appreciated a holistic, personalized approach. They welcomed remote care for follow-up and self-management, as long as the remote monitoring program was trustworthy and included easily accessible outpatient care if needed. Informal caregivers valued attentive HCPs who take patients seriously.

CONCLUSIONS

Key elements of IBD care valued by patients and informal caregivers include comprehensive support, active involvement, a person-centred approach, easy access to outpatient care, regular follow-ups with trusted HCPs, and remote care complementing outpatient services. Innovation teams should consider these elements when refining and developing innovations in IBD care.

Psychological interventions for treatment of inflammatory bowel disease

BACKGROUND

Persons with inflammatory bowel disease (IBD) have an increased risk of suffering from psychological problems. The association is assumed to be bi-directional. Psychological treatment is expected to improve quality of life (QoL), psychological issues and, possibly, disease activity. Many trials have tested various psychotherapy approaches, often in combination with educational modules or relaxation techniques, with inconsistent results.

OBJECTIVES

To assess the effects of psychological interventions on quality of life, emotional state and disease activity in persons of any age with IBD.

SEARCH METHODS

We searched Web of Science Core Collection, KCI-Korean Journal Database, Russian Science Citation Index, MEDLINE, Psyndex, PsycINFO, Embase, Cochrane Central Register of Controlled Trials, and LILACS from inception to May 2023. We also searched trial registries and major gastroenterological and selected other IBD-related conferences from 2019 until 2023.

SELECTION CRITERIA

Randomized controlled trials of psychological interventions in children or adults with IBD compared to no therapy, sham (i.e. simulated intervention), or other active treatment, with a minimum follow-up time of two months, were eligible for inclusion, irrespective of publication status and language of publication. Interventions included psychotherapy and other non-pharmacological interventions addressing cognitive or emotional processing, patient education, or relaxation techniques to improve individual health status.

DATA COLLECTION AND ANALYSIS

Two raters independently extracted data and assessed the study quality using the Risk of Bias 2 Tool. Pooled standardized mean differences (SMD) for continuous outcomes and relative risks (RR) for event data were calculated with 95% confidence intervals (CI), based on separate random-effects models by age group, type of therapy and type of control. An SMD of 0.2 was considered a minimally relevant difference. SMD ≥ 0.4 was considered a moderate effect. Group analyses were planned to examine differential effects by type of IBD, disease activity, psychological comorbidity, therapy subtype, and treatment intensity. Statistical heterogeneity was determined by calculating the I2 statistic. Publication bias was assessed by presenting a funnel plot and calculating the Eggers Test. GRADE Profiling was used to describe the certainty of the evidence for relevant results.

MAIN RESULTS

Sixty-eight studies were eligible. Of these, 48 had results reported in sufficient detail for inclusion in the meta-analyses (6111 adults, 294 children and adolescents). Two trials were excluded from the meta-analysis following sensitivity analysis and tests for asymmetry because of implausible results. Most studies used multimodular approaches. The risk of bias was moderate for most outcomes, and high for some. The most common problems in individual trials were the inability to blind participants and investigators and outcome measures susceptible to measurement bias. The main issues leading to downgrading of the certainty of the evidence were heterogeneity of results, low precision and high or moderate risk of bias in the included trials. Publication bias could not be shown for any of the inspected analyses. In adults, psychotherapy was slightly more effective than care-as-usual (CAU) in improving short-term QoL (SMD 0.23, 95% CI 0.12 to 0.34; I2 = 13%; 20 trials, 1572 participants; moderate-certainty), depression (SMD -0.27, 95% CI -0.39 to -0.16; I2 = 0%; 16 trials, 1232 participants; moderate-certainty), and anxiety (SMD -0.29, 95% CI -0.40 to -0.17; I2 = 1%; 15 studies, 1135 participants; moderate-certainty). The results for disease activity were not pooled due to high heterogeneity (I2 = 72%). Interventions which used patient education may also have small positive short-term effects on QoL (SMD 0.19, 95% CI 0.06 to 0.32; I2 = 11%; 12 trials, 1058 participants; moderate-certainty), depression (SMD -0.22, 95% CI -0.37 to -0.07; I2 = 11%; 7 studies, 765 participants; moderate-certainty) and anxiety (SMD -0.16, 95% CI -0.32 to 0.00; I2 = 10%; 6 studies, 668 participants; moderate-certainty). We did not find an effect of education on disease activity (SMD -0.09, 95% CI -0.28 to 0.10; I2 = 38%; 7 studies, 755 participants; low-certainty). Pooled results on the effects of relaxation techniques showed small effects on QoL (SMD 0.25, 95% CI 0.08 to 0.41; I2 = 30%; 12 studies, 916 participants; moderate-certainty), depression (SMD -0.18, 95% CI -0.35 to -0.02; I2 = 0%; 7 studies, 576 participants; moderate-certainty), and anxiety (SMD -0.26, 95% CI -0.43 to -0.09; I2 = 13%; 8 studies, 627 participants; moderate-certainty). Results for disease activity were not pooled due to high heterogeneity (I2 = 72%). In children and adolescents, multimodular psychotherapy increased quality of life (SMD 0.54, 95% CI 0.06 to 1.02; I2 = 19%; 3 studies, 91 participants; moderate-certainty). The results for anxiety were inconclusive (SMD -0.09; 95% CI 0.-64 to 0.46; 2 trials, 51 patients, very low-certainty). Pooled effects were not calculated for depressive symptoms. Disease activity was not assessed in any of the trials compared to CAU. In education, based on one study, there might be a positive effect of the intervention on quality of life (MD 7.1, 95% CI 2.18 to 12.02; 40 patients; low-certainty evidence) but possibly not on depression (MD -6, 95% CI -12.01 to 0.01; 41 patients; very low-certainty). Anxiety and disease activity were not assessed for this comparison. Regarding the effects of relaxation techniques on children and adolescents, all results were inconclusive (very low-certainty).

AUTHORS' CONCLUSIONS

Psychological interventions in adults are likely to improve the quality of life, depression and anxiety slightly. Psychotherapy is probably also effective for improving the quality of life in children and adolescents. The evidence suggests that psychological interventions may have little to no effect on disease activity. The interpretation of these results presents a challenge due to the clinical heterogeneity of the included trials, particularly concerning the type and various components of the common multimodular interventions. This complexity underscores the need for further research and exploration in this area.

Limitations in real-world telemonitoring applicability in gastroenterology and hepatology: a systematic review

Objective

Telemonitoring has the potential to improve healthcare delivery. While the field continues to develop, ensuring interventions are accessible across disease populations is essential for successful clinical translation. This systematic review of telemonitoring aims to understand the generalisability of study findings in the distinctly different patient cohorts of inflammatory bowel disease (IBD) and decompensated cirrhosis, focusing on differences in sociodemographic characteristics.

Design/method

Relevant studies were identified by searching Ovid MEDLINE, EMBASE and Cochrane databases from 2013 to January 2024. A narrative review was conducted.

Results

27 studies with 3806 patients were included. IBD-based studies predominated (n=23, 85%) with four (15%) studies in patients with decompensated cirrhosis. All studies were undertaken in high-income economies. While age and gender were documented in most studies, only 11% documented ethnicity, 33% documented socioeconomic status and 33% documented education status. Substance misuse with alcohol, smoking or other illicit drugs was documented in 7%. Multiple languages were available in 15% of studies. There was significant heterogeneity in endpoints used across studies investigating interventions in both patient cohorts.

Conclusions

This systematic review demonstrates the lack of reporting in critical demographic domains with significant heterogeneity in study design and endpoints across both disease processes. This potentially limits the use of telemonitoring outside of a trial setting. To improve real-world implementation and reduce the impact of health inequalities, it is critical that a consensus is reached for minimum reporting standards for telemedicine interventions.

PROSPERO registration number

CRD42024497369.

The Costs of Home Monitoring by Telemedicine vs Standard Care for Inflammatory Bowel Diseases-A Danish Register-Based, 5-Year Follow-up Study

BACKGROUND AND AIMS

There are few studies on the cost-effectiveness of telemedicine for inflammatory bowel diseases. We assessed the long-term cost-effectiveness of a telemedicine solution compared to standard care (sCare), as well as its efficacy according to patient-reported outcomes (PROs).

METHODS

Between 2015 and 2020, we conducted a retrospective, register-based study among patients with ulcerative colitis and Crohn's disease. Direct and indirect healthcare costs over a 5-year period were obtained from Danish registers and compared to a control group. Costs were estimated on a yearly basis from 1 year before, until 5 years after, inclusion in the trial. Patients were divided into 2 groups: those not receiving biologics (Cohort 1) and those receiving biologics (Cohort 2).

RESULTS

We recruited 574 patients with inflammatory bowel diseases. In Cohort 1 (61.5%), average total direct costs and total earnings per patient per year were €14 043 and €307 793, respectively, in telemedicine compared to €16 226 and €252 166, respectively, in sCare. In Cohort 2 (38.5%), average total direct costs and total earnings were €73 916 and €215 833, respectively, in telemedicine compared to €41 748 and €203 667, respectively, in sCare. PROs showed improved quality of life, which was higher in Cohort 1 than in Cohort 2. Disease activity among patients with Crohn's disease increased after Years 3 and 4 in Cohorts 1 and 2, respectively.

CONCLUSION

Telemedicine is cost-effective for patients not receiving biologics. However, treatment with biologics is more expensive for patients enrolled in telemedicine. Careful attention to PROs in telemedicine improves quality of life and could prolong the time to relapse.

The IBD Clinic of Tomorrow: Holistic, Patient-Centric, and Value-based Care

There is increasing recognition of the associated bi-directional impact of inflammatory bowel disease (IBD) on patient well-being and the potential benefit of multidisciplinary teams to address these unique needs. At certain IBD centers, there has been an evolution towards patient-centric, holistic care to enhance well-being and improve health-related outcomes. Multiple models, incorporating various disciplines, care modalities, digital tools and care delivery, and resource support have arisen in IBD. Although most IBD centers of excellence are now incorporating such multidisciplinary care models, many practices still practice IBD-limited specialty care, limiting evaluations and interventions to the IBD itself and its direct consequences (eg, extraintestinal manifestations). In this piece, we seek to review the evolution of IBD care towards a patient-centric, holistic model (termed 360 IBD Care) including the role and impact of digital health tools, monitoring, and delivery in IBD, and a shift towards value-based care models with discussion of payor priorities in IBD. We also suggest potential opportunities for IBD practitioners to incorporate elements of holistic care on a local scale. Together, we hope such care models will enhance not only IBD-specific health outcomes, but also improve the general well-being of our patients with IBD today and tomorrow.

Sustainable practice in gastroenterology: travel-related CO2 emissions for gastroenterology clinic appointments in Canada

Background

Telemedicine is increasingly common in gastroenterology and may represent an opportunity for improving sustainability in medical care. The purpose of this study was to determine the carbon emissions related to travel for in-person gastroenterology clinic appointments.

Methods

We conducted a cross-sectional analysis evaluating carbon emissions associated with travel to gastroenterology appointments over a 2-week period. We determined the average number of appointments per day and used patient's postal codes to estimate travel distances. We estimated carbon emissions based on these travel distances and completed sensitivity analyses to model methods for emissions reductions.

Results

We assessed 975 clinic appointments, of which 71 were excluded (eg, insufficient data, non-physician appointments), leaving 904 included appointments of which 75% were follow-up (678) and the remainder were new consultations (226). Sixteen different gastroenterologists had an average of 22.7 patients per clinic. The mean return distance travelled per appointment was 57.3 km which translates to 14.9 kg CO2 per patient visit. An average day at our clinic was equal to burning 146.6 L of gasoline or the annual carbon capture of 15.5 trees. By changing follow-up appointments or those with a travel distance over 100 km to telehealth, emissions were reduced by 77%.

Conclusions

We demonstrate that a relatively modest change in the number of in-person visits can save thousands of litres of gasoline emissions annually from each practicing clinician. While we cannot avoid emissions related to travel for procedure-based appointments, the use of telemedicine is one potential strategy to reduce healthcare-related emissions.

The Cost of Inflammatory Bowel Disease Care: How to Make it Sustainable

The rising global prevalence of inflammatory bowel diseases (IBDs), such as Crohn's disease and ulcerative colitis, underscores the need to examine current and future IBD care costs. Direct health care expenses, including ambulatory visits, hospitalizations, and medications, are substantial, averaging $9,000 to $12,000 per person annually in high-income regions. However, these estimates do not fully account for factors such as disease severity, accessibility, and variability in health care infrastructure among regions. Indirect costs, predominantly stemming from loss in productivity due to absenteeism, presenteeism, and other intangible costs, further contribute to the financial burden of IBD. Despite efforts to quantify indirect costs, many aspects remain poorly understood, leading to an underestimation of their actual impact. Challenges to achieving cost sustainability include disparities in access, treatment affordability, and the absence of standardized cost-effective care guidelines. Strategies for making IBD care sustainable include early implementation of biologic therapies, focusing on cost-effectiveness in settings with limited resources, and promoting the uptake of biosimilars to reduce direct costs. Multidisciplinary care teams leveraging technology and patient-reported outcomes also hold promise in reducing both direct and indirect costs associated with IBD. Addressing the increasing financial burden of IBD requires a comprehensive approach that tackles disparities, enhances access to cost-effective therapeutics, and promotes collaborative efforts across health care systems. Embracing innovative strategies can pave the way for personalized, cost-effective care accessible to all individuals with IBD, ensuring better outcomes and sustainability.

Metrics for Evaluating Telemedicine in Randomized Controlled Trials: Scoping Review

BACKGROUND

Telemedicine involves medical, diagnostic, and treatment-related services using telecommunication technology. Not only does telemedicine contribute to improved patient quality of life and satisfaction by reducing travel time and allowing patients to be seen in their usual environment, but it also has the potential to improve disease management by making it easier for patients to see a doctor. Recently, owing to IT developments, research on telemedicine has been increasing; however, its usefulness and limitations in randomized controlled trials remain unclear because of the multifaceted effects of telemedicine. Furthermore, the specific metrics that can be used as cross-disciplinary indicators when comparing telemedicine and face-to-face care also remain undefined.

OBJECTIVE

This review aimed to provide an overview of the general and cross-disciplinarity metrics used to compare telemedicine with in-person care in randomized controlled trials. In addition, we identified previously unevaluated indicators and suggested those that should be prioritized in future clinical trials.

METHODS

MEDLINE and Embase databases were searched for publications that met the inclusion criteria according to PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews). Original, English-language articles on randomized controlled trials comparing some forms of telemedicine with face-to-face care from January 2019 to March 2024 were included, and the basic information and general metrics used in these studies were summarized.

RESULTS

Of the 2275 articles initially identified, 79 were included in the final analysis. The commonly used metrics that can be used across medical specialties were divided into the following 3 categories: (1) patient-centeredness (67/79, 85%), including patient satisfaction, workload, and quality of life; (2) patient outcomes (57/79, 72%), including general clinical parameters such as death, admission, and adverse events; and (3) cost-effectiveness (40/79, 51%), including cost assessment and quality-adjusted life year. Notably, only 25 (32%) of 79 studies evaluated all the 3 categories. Other metrics, such as staff convenience, system usability, and environmental impact, were extracted as indicators in different directions from the three categories above, although few previous reports have evaluated them (staff convenience: 8/79, 10%; system usability: 3/79, 4%; and environmental impact: 2/79, 3%).

CONCLUSIONS

A significant variation was observed in the metrics used across previous studies. Notably, general indicators should be used to enhance the understandability of the results for people in other areas, even if disease-specific indicators are used. In addition, indicators should be established to include all three commonly used categories of measures to ensure a comprehensive evaluation: patient-centeredness, patient outcomes, and cost-effectiveness. Staff convenience, system usability, and environmental impact are important indicators that should be used in future trials. Moreover, standardization of the evaluation metrics is desired for future clinical trials and studies.

TRIAL REGISTRATION

Open Science Forum Registries YH5S7; https://doi.org/10.17605/OSF.IO/YH5S7.

Optimizing 5-aminosalicylate for moderate ulcerative colitis: expert recommendations from the Asia-Pacific, Middle East, and Africa Inflammatory Bowel Disease Coalition

The lack of clear definition and classification for "moderate ulcerative colitis (UC)" creates ambiguity regarding the suitability of step-up versus top-down treatment approaches. In this paper, experts address crucial gaps in assessing and managing moderate UC. The Asia-Pacific, Middle East, and Africa Inflammatory Bowel Disease Coalition comprised 24 experts who convened to share, discuss and vote electronically on management recommendations for moderate UC. Experts emphasized that the goal of treating UC is to attain clinical, biomarker, and endoscopic remission using cost-effective strategies such as 5-aminosalicylates (5-ASAs), well-tolerated therapy that can be optimized to improve outcomes. Experts agreed that 5-ASA therapy could be optimized by maximizing dosage (4 g/day for induction of remission), combining oral and topical administration, extending treatment duration beyond 8 weeks, and enhancing patient adherence through personalized counselling and reduced pill burden. Treatment escalation should ideally be reserved for patients with predictors of aggressive disease or those who do not respond to 5-ASA optimization. Premature treatment escalation to advanced therapies (including biologics and oral small molecules) may have long-term health and financial consequences. This paper provides consensus-based expert recommendations and a treatment algorithm, based on current evidence and practices, to assist decision-making in real-world settings.

Telemonitoring of Active Inflammatory Bowel Disease Using the App TECCU: Short-Term Results of a Multicenter Trial of GETECCU

BACKGROUND

Telemonitoring for inflammatory bowel disease (IBD) has not consistently demonstrated superiority over standard care; however, noninferiority may be an acceptable outcome if remote care proves to be more efficient.

OBJECTIVE

This study aims to compare the remission time and quality of life of patients with active IBD managed through standard care versus the TECCU (Telemonitoring of Crohn Disease and Ulcerative Colitis) app.

METHODS

A 2-arm, randomized, multicenter trial with a noninferiority design was conducted across 24 hospitals in Spain. The study included adult patients with IBD who were starting immunosuppressive or biological therapy. Participants were randomized into 2 groups: the telemonitoring group (G_TECCU) and the standard care group (G_Control). The follow-up schedule for the telemonitoring group (G_TECCU) was based on contacts via the TECCU app, while the control group (G_Control) adhered to standard clinical practice, which included in-person visits and telephone calls. In both groups, treatment adjustments were made based on the progression of disease activity and medication adherence, assessed using specific indices and biological markers at each check-up. The primary outcome was the duration of remission after 12 weeks, while secondary outcomes included quality of life, medication adherence, adverse events, and patient satisfaction.

RESULTS

Of the 169 patients enrolled, 158 were randomized and 150 were analyzed per protocol: telemonitoring (n=71) and control (n=79). After 12 weeks, the time in clinical remission was not inferior in the telemonitoring group (mean 4.20, SD 3.73 weeks) compared with the control group (mean 4.32, SD 3.28 weeks), with a mean difference between arms of -0.12 weeks (95% CI -1.25 to 1.01; noninferiority P=.02). The mean reduction in C-reactive protein values was -15.40 mg/L (SD 90.15 mg/L; P=.19) in the G_TECCU group and -13.16 mg/L (SD 54.61 mg/L; P=.05) in the G_Control group, with no significant differences between the 2 arms (P=.73). Similarly, the mean improvement in fecal calprotectin levels was 832.3 mg/L (SD 1825.0 mg/L; P=.003) in the G_TECCU group and 1073.5 mg/L (SD 3105.7 mg/L; P=.03) in the G_Control group; however, the differences were not statistically significant (P=.96). Quality of life improved in both groups, with a mean increase in the 9-item Inflammatory Bowel Disease Questionnaire score of 13.44 points (SD 19.1 points; P<.001) in the G_TECCU group and 18.23 points (SD 22.9 points; P=.001) in the G_Control group. Additionally, the proportion of patients who adhered to their medication significantly increased from 35% (25/71) to 68% (48/71) in the G_TECCU group (P=.001) and from 46% (36/79) to 73% (58/79) in the G_Control group (P=.001). The satisfaction rate remained stable at around 90%, although noninferiority was not demonstrated for the secondary outcomes.

CONCLUSIONS

Telemonitoring patients with active IBD is not inferior to standard care for achieving and maintaining short-term remission. The TECCU app may serve as a viable alternative follow-up tool, pending confirmation of improved health outcomes and cost-effectiveness over the long-term.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06031038; https://clinicaltrials.gov/ct2/show/NCT06031038.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/resprot.9639.

Telemedicine Compared to Office-Based Care of Patients With Cardiac Symptoms: Treatment and Outcomes

Background

An increasing proportion of visits are now delivered via a virtual platform. Virtual visits are limited by the lack of important components of cardiovascular assessment such as physician examination and electrocardiogram.

Objectives

The purpose of this study was to evaluate the quality of care delivered by virtual visits compared to office-based visits among adults who sought care for three common cardiac-related symptoms: dyspnea, dizziness, or palpitations.

Methods

Retrospective cohort study of 992,526 outpatient visits between January 1, 2017, and December 31, 2021, within an integrated health system, including 356,159 visits for dyspnea, 412,913 for dizziness, and 223,454 for palpitations. We compared the differences in patient characteristics associated with telemedicine visits versus in-office visits, evaluated the referral rates for noninvasive cardiac testing, and examined the association between virtual visits and 30-day clinical outcomes.

Results

Among 992,526 visits, 71.5% were office visits, 25.8% telephone visits, and 2.7% video visits. Median age was 59 (IQR: 43-72) years, and 63.1% were women. Patient characteristics associated with increased likelihood of virtual visits included younger age, female sex, being non-Hispanic Black, and being from lower-income households. No association was observed between visit types and 30-day cardiovascular hospitalization for patients with dizziness or palpitations. However, for patients with dyspnea, evaluation via virtual visits was associated with a higher risk of 30-day hospitalization for heart failure (aOR: 1.25; 95% CI: 1.16-1.36 for telephone visits; aOR: 1.45; 95% CI: 1.17-1.80 for video visits). Compared to office-based visits, patients with dyspnea were less likely to be referred for echocardiogram with telephone (aOR: 0.73; 95% CI: 0.72-0.75) or video visits (aOR: 0.92; 95% CI: 0.87-0.98).

Conclusions

Virtual visits may be appropriate for some clinical concerns but not all. Optimal alignment of clinical conditions with appropriate care modalities is an important component of a successful telemedicine strategy.

Framework of IBD Care Delivery Across Ages

IBD care has gone through a real transformation over the last century, moving from the mere unidirectional interaction between the physician and the patient to a stronger framework with multiple stakeholders who interconnect and strengthen each other. The patient has evolved from a passive subject to the central pole in the care pathway. Key elements of the future framework include patient self-care and empowerment, and remote monitoring [eHealth]. This care will be delivered by a multidisciplinary team acknowledging the pivotal role of the IBD nurse, and emphasising and measuring the quality of its work. The big challenge for the future is to establish a financially viable model to make this evolution durable in the long term, and this by using the principles of value-based health care.

Improving Hospital Efficiency and Cost Management: A Systematic Review and Meta-Analysis

Internationally, improving hospital efficiency and reducing costs in the healthcare sector is a goal that requires major effort and successful collaboration. Most hospitals have a dedicated department responsible for quality control, and this is where many of the challenges to efficiency and cost reductions arise. The purpose of this study is to review the literature on the successful improvement of hospital efficiency and cost reduction with no negative impact on the quality of patient care. For this study, we conducted a systematic review and meta-analysis. We screened the available data from 2014 to 2024 in various respected databases, including the Cumulated Index to Nursing and Allied Health Literature (CINAHL) (via EBSCO), the Cochrane Library (via Wiley), PubMed, Google Scholar, and Scopus. The selected articles (n = 7) met the criteria set by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, ensuring their quality and relevance. The study designs that were included are randomized clinical trials, systematic literature reviews, and prospective and retrospective cohort studies. The selected studies represent a wide range of programs and approaches that were adopted to address the issue of hospital efficiency and cost reduction, for example, the Plan-Do-Study-Act problem-solving model and a telemedicine program. These approaches achieved a 25%-50% reduction in costs, allowing for the reallocation of resources and, ultimately, an improvement in the quality of care (QoC). Regarding hospital efficiency, hospitals were encouraged to explore systems to support patient care that did not simply involve new equipment and would help reduce the supply shortage.  The findings of our study provide valuable insights that can act as a foundation for policymakers tasked with improving hospital efficiency and cost-effectiveness. On the one hand, this findings emphasize the importance of focusing on the provision of quality service, encouraging collaboration, and creating tailored solutions. On the other hand, this focus will help hospitals achieve systems that ensure efficiency, promote sustainable outcomes, and improve cost management in healthcare.

The effectiveness of continuity of care in patients with inflammatory bowel disease: a systematic review

AIM

To investigate the effectiveness of continuity of care in patients with inflammatory bowel disease.

BACKGROUND

The prevalence of inflammatory bowel disease(IBD) is increasing by years, especially in China. Moreover, IBD is prolonged and difficult to heal, which seriously impairs the quality of life of patients. Some studies have identified that continuity of care could contribute to the improvement of the quality of life, but the results remains inconclusive in patients with IBD.

METHODS

PRISMA guidelines was the outline of this study. Review Manager Software (version 5.3) was used to carry out the data analysis. Outcome assessments included quality of life (QoL), remission rates, number of outpatient clinic visits, and medication adherence.

RESULTS

Ultimately, 12 studies involving 2415 patients were brought into this meta-analysis. The results indicated there was no significant difference for continuity of care to improve the QoL in intervention group (SMD = 0.02, 95% CI: -0.08, 0.12). Besides, the remission rates of disease had no difference with those patients in the two groups (OR = 1.07, 95% CI: 0.72, 1.60). However, continued care could contribute to the number of outpatient clinic visits (MD = -0.84, 95% CI: -1.19, -0.49) and patients' adherence to medication significantly (OR = 2.40, 95% CI: 1.16, 4.95).

CONCLUSIONS

IBD patients could benefited from continuity of care with reducing their number of clinic visits and improving medication adherence. Nonetheless, there was no evidence of continuity of care contribute to QoL and remission of disease for these patients.

Telemedicine in inflammatory bowel disease from its origin to the post pandemic golden age: A narrative review

Inflammatory bowel disease (IBD), a chronic intestinal inflammatory disorder encompassing ulcerative colitis and Crohn's disease can be disabling and often requires lifelong treatment and follow-up. Digital health technologies and distance-management tools are less costly alternatives for IBD management and clinical monitoring. This review discusses how telephone/videoconference appointments enable treatment optimization from an early disease stage, provide complementary value-based patient care and educational resources, and allow consistent follow-up with a high standard of care. Replacing/supplementing traditional clinical consultations with telemedicine reduces healthcare utilization costs and the need for in-person consultations. The COVID-19 pandemic has accelerated the evolution of telemedicine in IBD, with several studies conducted since 2020 reporting high levels of patient satisfaction. Home-based injectable formulations coupled with telemedicine may become permanently embedded in healthcare systems in the post-pandemic period. While telemedicine consultations are well-accepted by many patients with IBD, they do not suit all patients or are not preferred (e.g., by elderly who do not have the means or ability to understand the associated technology). Ultimately, use of telemedicine should be decided by the patient and careful consideration is required to ensure that the patient is willing and capable of a successful remote visit.

Summary of the best evidence on self-management support schemes for patients with inflammatory bowel disease based on mobile health systems

Objective

Self-management support services can improve patients' self-management ability. This study summarized the best evidence on a self-management support scheme for patients with inflammatory bowel disease based on a mobile health system to accurately describe the current status of the field and provide recommendations for healthcare workers.

Methods

Two researchers retrieved studies from computer decision support systems, guideline websites, official association websites, and databases from the establishment of the database until October 2023. The quality of the included studies was independently evaluated by two authors using the Appraisal of Guidelines for Research and Evaluation Instrument II and the 2016 version of the corresponding evaluation standards of the Australian Joanna Briggs Institute Evidence-based Health Care Center. The classification of evidence and recommendation level adopted the 2014 version of the Australian Joanna Briggs Institute evidence pregrading and recommending level system.

Results

Fifteen studies were included, comprising one guideline, two expert consensuses, four systematic reviews, four quasi-experimental studies, and four qualitative studies. The overall quality of the included studies was moderate to high. Thirty-six pieces of best evidence were compiled for seven elements, namely, mobile health system type and functional support; mobile health system application preparation; health information recording, uploading, and presentation; zoning management of diseases and early warning of the active period; support related to health education; healthcare support team formation and services; and virtual communities.

Conclusions

Our study evaluated the quality of the included studies and summarized a self-management support scheme for patients with inflammatory bowel disease based on a mobile health system. The main scheme was divided into 7 parts and 36 items, which can be used as a reference for healthcare workers so that they can provide more comprehensive and scientific self-management support services for patients with inflammatory bowel disease through mobile health systems.

Management of Inflammatory Bowel Disease Using E-health Technologies: A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

Technological advances have provided innovative, adaptive, and responsive models of care for inflammatory bowel diseases [IBD]. We conducted a systematic review to compare e-health interventions with standard care in management of IBD.

METHODS

We searched electronic databases for randomised, controlled trials [RCT] comparing e-health interventions with standard care for patients with IBD. Effect measures were standardised mean difference [SMD], odds ratio [OR], or rate ratio [RR], calculated using the inverse variance or Mantel-Haenszel statistical method and random-effects models. Version 2 of the Cochrane tool was used to assess the risk of bias. The certainty of evidence was appraised with the GRADE framework.

RESULTS

Fourteen RCTs [n = 3111; 1754 e-health and 1357 controls] were identified. The difference in disease activity scores (SMD 0.09, 95% confidence interval [CI]: -0.09-0.28) and clinical remission (odds ratio [OR] 1.12, 95% CI: 0.78-1.61) between e-health interventions and standard care were not statistically significant. Higher quality of life [QoL] [SMD 0.20, 95% CI: 0.05-0.35) and IBD knowledge [SMD 0.23, 95% CI: 0.10-0.36] scores were noted in the e-health group, and self-efficacy levels [SMD -0.09, 95% CI: -0.22-0.05] were comparable. E-health patients had fewer office [RR 0.85, 95% CI: 0.78-0.93] and emergency [RR 0.70, 95% CI: 0.51- 0.95] visits, with no statistically significant difference in endoscopic procedures, total health care encounters, corticosteroid use, and IBD related hospitalisation or surgery. The trials were judged to be at high risk of bias or to have some concerns for disease remission. The certainty of evidence was moderate or low.

CONCLUSION

E-health technologies may have a role in value-based care in IBD.

The 2023 Impact of Inflammatory Bowel Disease in Canada: Access to and Models of Care

Rising compounding prevalence of inflammatory bowel disease (IBD) (Kaplan GG, Windsor JW. The four epidemiological stages in the global evolution of inflammatory bowel disease. Nat Rev Gastroenterol Hepatol. 2021;18:56-66.) and pandemic-exacerbated health system resource limitations have resulted in significant variability in access to high-quality, evidence-based, person-centered specialty care for Canadians living with IBD. Individuals with IBD have identified long wait times, gaps in biopsychosocial care, treatment and travel expenses, and geographic and provider variation in IBD specialty care and knowledge as some of the key barriers to access. Care delivered within integrated models of care (IMC) has shown promise related to impact on disease-related outcomes and quality of life. However, access to these models is limited within the Canadian healthcare systems and much remains to be learned about the most appropriate IMC team composition and roles. Although eHealth technologies have been leveraged to overcome some access challenges since COVID-19, more research is needed to understand how best to integrate eHealth modalities (i.e., video or telephone visits) into routine IBD care. Many individuals with IBD are satisfied with these eHealth modalities. However, not all disease assessment and monitoring can be achieved through virtual modalities. The need for access to person-centered, objective disease monitoring strategies, inclusive of point of care intestinal ultrasound, is more pressing than ever given pandemic-exacerbated restrictions in access to endoscopy and cross-sectional imaging. Supporting learning healthcare systems for IBD and research relating to the strategic use of innovative and integrative implementation strategies for evidence-based IBD care interventions are greatly needed. Data derived from this research will be essential to appropriately allocating scarce resources aimed at improving person-centred access to cost-effective IBD care.

Remote care through telehealth for people with inflammatory bowel disease

BACKGROUND

People with inflammatory bowel disease (IBD) require intensive follow-up with frequent consultations after diagnosis. IBD telehealth management includes consulting by phone, instant messenger, video, text message, or web-based services. Telehealth can be beneficial for people with IBD, but may have its own set of challenges. It is important to systematically review the evidence on the types of remote or telehealth approaches that can be deployed in IBD. This is particularly relevant following the coronavirus disease 2019 (COVID-19) pandemic, which led to increased self- and remote-management.

OBJECTIVES

To identify the communication technologies used to achieve remote healthcare for people with inflammatory bowel disease and to assess their effectiveness.

SEARCH METHODS

On 13 January 2022, we searched CENTRAL, Embase, MEDLINE, three other databases, and three trials registries with no limitations on language, date, document type, or publication status.

SELECTION CRITERIA

All published, unpublished, and ongoing randomised controlled trials (RCTs) that evaluated telehealth interventions targeted at people with IBD versus any other type of intervention or no intervention. We did not include studies based on digital patient information resources or education resources, unless they formed part of a wider package including an element of telehealth. We excluded studies where remote monitoring of blood or faecal tests was the only form of monitoring.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from the included studies and assessed their risk of bias. We analysed studies on adult and paediatric populations separately. We expressed the effects of dichotomous outcomes as risk ratios (RRs) and the effects of continuous outcomes as mean differences (MDs) or standardised mean differences (SMDs), each with their 95% confidence intervals (CIs). We assessed the certainty of the evidence using GRADE methodology.

MAIN RESULTS

We included 19 RCTs with a total of 3489 randomised participants, aged eight to 95 years. Three studies examined only people with ulcerative colitis (UC), two studies examined only people with Crohn's disease (CD), and the remaining studies examined a mix of IBD patients. Studies considered a range of disease activity states. The length of the interventions ranged from six months to two years. The telehealth interventions were web-based and telephone-based. Web-based monitoring versus usual care Twelve studies compared web-based disease monitoring to usual care. Three studies, all in adults, provided data on disease activity. Web-based disease monitoring (n = 254) is probably equivalent to usual care (n = 174) in reducing disease activity in people with IBD (SMD 0.09, 95% CI -0.11 to 0.29). The certainty of the evidence is moderate. Five studies on adults provided dichotomous data that we could use for a meta-analysis on flare-ups. Web-based disease monitoring (n = 207/496) is probably equivalent to usual care (n = 150/372) for the occurrence of flare-ups or relapses in adults with IBD (RR 1.09, 95% CI 0.93 to 1.27). The certainty of the evidence is moderate. One study provided continuous data. Web-based disease monitoring (n = 465) is probably equivalent to usual care (n = 444) for the occurrence of flare-ups or relapses in adults with CD (MD 0.00 events, 95% CI -0.06 to 0.06). The certainty of the evidence is moderate. One study provided dichotomous data on flare-ups in a paediatric population. Web-based disease monitoring (n = 28/84) may be equivalent to usual care (n = 29/86) for the occurrence of flare-ups or relapses in children with IBD (RR 0.99, 95% CI 0.65 to 1.51). The certainty of the evidence is low. Four studies, all in adults, provided data on quality of life. Web-based disease monitoring (n = 594) is probably equivalent to usual care (n = 505) for quality of life in adults with IBD (SMD 0.08, 95% CI -0.04 to 0.20). The certainty of the evidence is moderate. Based on continuous data from one study in adults, we found that web-based disease monitoring probably leads to slightly higher medication adherence compared to usual care (MD 0.24 points, 95% CI 0.01 to 0.47). The results are of moderate certainty. Based on continuous data from one paediatric study, we found no difference between web-based disease monitoring and usual care in terms of their effect on medication adherence (MD 0.00, 95% CI -0.63 to 0.63), although the evidence is very uncertain. When we meta-analysed dichotomous data from two studies on adults, we found no difference between web-based disease monitoring and usual care in terms of their effect on medication adherence (RR 0.87, 95% CI 0.62 to 1.21), although the evidence is very uncertain. We were unable to draw any conclusions on the effects of web-based disease monitoring compared to usual care on healthcare access, participant engagement, attendance rate, interactions with healthcare professionals, and cost- or time-effectiveness. The certainty of the evidence is very low.

AUTHORS' CONCLUSIONS

The evidence in this review suggests that web-based disease monitoring is probably no different to standard care in adults when considering disease activity, occurrence of flare-ups or relapse, and quality of life. There may be no difference in these outcomes in children, but the evidence is limited. Web-based monitoring probably increases medication adherence slightly compared to usual care. We are uncertain about the effects of web-based monitoring versus usual care on our other secondary outcomes, and about the effects of the other telehealth interventions included in our review, because the evidence is limited. Further studies comparing web-based disease monitoring to standard care for the clinical outcomes reported in adults are unlikely to change our conclusions, unless they have longer follow-up or investigate under-reported outcomes or populations. Studies with a clearer definition of web-based monitoring would enhance applicability, enable practical dissemination and replication, and enable alignment with areas identified as important by stakeholders and people affected by IBD.

Patient education interventions for the management of inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease (IBD) is a life-long condition for which currently there is no cure. Patient educational interventions deliver structured information to their recipients. Evidence suggests patient education can have positive effects in other chronic diseases.

OBJECTIVES

To identify the different types of educational interventions, how they are delivered, and to determine their effectiveness and safety in people with IBD.

SEARCH METHODS

On 27 November 2022, we searched CENTRAL, Embase, MEDLINE, ClinicalTrials.gov, and WHO ICTRP with no limitations to language, date, document type, or publication status. Any type of formal or informal educational intervention, lasting for any time, that had content focused directly on knowledge about IBD or skills needed for direct management of IBD or its symptoms was included. Delivery methods included face-to-face or remote educational sessions, workshops, guided study via the use of printed or online materials, the use of mobile applications, or any other method that delivers information to patients.

SELECTION CRITERIA

All published, unpublished and ongoing randomised control trials (RCTs) that compare educational interventions targeted at people with IBD to any other type of intervention or no intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted data extraction and risk of bias assessment of the included studies. We analysed data using Review Manager Web. We expressed dichotomous and continuous outcomes as risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs). We assessed the certainty of the evidence using GRADE methodology.

MAIN RESULTS

We included 14 studies with a total of 2708 randomised participants, aged 11 to 75 years. Two studies examined populations who all had ulcerative colitis (UC); the remaining studies examined a mix of IBD patients (UC and Crohn's disease). Studies considered a range of disease activity states. The length of the interventions ranged from 30 minutes to 12 months. Education was provided in the form of in-person workshops/lectures, and remotely via printed materials or multimedia, smartphones and internet learning. Thirteen studies compared patient education interventions plus standard care against standard care alone. The interventions included seminars, information booklets, text messages, e-learning, a multi professional group-based programme, guidebooks, a staff-delivered programme based on an illustrated book, a standardised programme followed by group session, lectures alternating with group therapy, educational sessions based on an IBD guidebook, internet blog access and text messages, a structured education programme, and interactive videos. Risk of bias findings were concerning in all judgement areas across all studies. No single study was free of unclear or high of bias judgements. Reporting of most outcomes in a homogeneous fashion was limited, with quality of life at study end reported most commonly in six of the 14 studies which allowed for meta-analysis, with all other outcomes reported in a more heterogeneous manner that limited wider analysis. Two studies provided data on disease activity. There was no clear difference in disease activity when patient education (n = 277) combined with standard care was compared to standard care (n = 202). Patient education combined with standard care is probably equivalent to standard care in reducing disease activity in patients with IBD (standardised mean difference (SMD) -0.03, 95% CI -0.25 to 0.20), moderate-certainty evidence. Two studies provided continuous data on flare-up/relapse. There was no clear difference for flare-ups or relapse when patient education (n = 515) combined with standard care was compared to standard care (n = 507), as a continuous outcome. Patient education combined with standard care is probably equivalent to standard care in reducing flare-ups or relapse in patients with IBD (MD -0.00, 95% CI -0.06 to 0.05; moderate-certainty evidence). Three studies provided dichotomous data on flare-up/relapse. The evidence is very uncertain on whether patient education combined with standard care (n = 157) is different to standard care (n = 150) in reducing flare-ups or relapse in patients with IBD (RR 0.94, 95% CI 0.41 to 2.18; very low-certainty evidence). Six studies provided data on quality of life. There was no clear difference in quality of life when patient education combined with standard care (n = 721) was compared to standard care (n = 643). Patient education combined with standard care is probably equivalent to standard care in improving quality of life in patients with IBD (SMD 0.08, 95% CI -0.03 to 0.18; moderate-certainty evidence). The included studies did not report major differences on healthcare access. Medication adherence, patient knowledge and change in quality of life showed conflicting results that varied between no major differences and differences in favour of the educational interventions. Only five studies reported on adverse events. Four reported zero total adverse events and one reported one case of breast cancer and two cases of surgery in their interventions groups, and zero adverse events in their control group. Two studies compared delivery methods of patient education, specifically: web-based patient education interventions versus colour-printed books or text messages; and one study compared frequency of patient education, specifically: weekly educational text messages versus once every other week educational text messages. These did not show major differences for disease activity and quality of life. Other outcomes were not reported.

AUTHORS' CONCLUSIONS

The ways in which patient educational support surrounding IBD may impact on disease outcomes is complex. There is evidence that education added to standard care is probably of no benefit to disease activity or quality of life when compared with standard care, and may be of no benefit for occurrence of relapse when compared with standard care. However, as there was a paucity of specific information regarding the components of education or standard care, the utility of these findings is questionable. Further research on the impact of education on our primary outcomes of disease activity, flare-ups/relapse and quality of life is probably not indicated. However, further research is necessary, which should focus on reporting details of the educational interventions and study outcomes that educational interventions could be directly targeted to address, such as healthcare access and medication adherence. These should be informed by direct engagement with stakeholders and people affected by Crohn's and colitis.

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.

Follow-Up of Celiac Disease in Adults: "When, What, Who, and Where"

For patients with celiac disease (CeD), a lifelong gluten-free diet is not a voluntary lifestyle choice-it is a necessity. The key end points in clinical follow-up are symptom resolution, the normalization of weight, prevention of overweight, seroconversion, and negation or minimization of increased long-term morbidity. For the latter, a surrogate endpoint is mucosal healing, which means the normalization of histology to Marsh 0-1. Ideally, celiac follow-up care includes a multidisciplinary approach, effective referral processes, improved access that leverages technological advances, and following guidelines with the identification of measurable quality indicators, ideally informed by evidence-based research. Face-to-face CeD care and telemedicine are considered the standards for this process, although published data are insufficient. Guidelines and statements on diagnosis are readily available. However, data are lacking on optimal clinic visit intervals and outcomes and quality indicators such as improvement of symptoms, function and quality of life, survival and disease control, and how to most effectively use healthcare resources. The results of future research should provide the basis for general recommendations for evidence-based standards of quality of care in CeD.

Agreement between patients and physicians on scores of inflammatory bowel disease activity and burden assessed on a telemonitoring platform

BACKGROUND AND AIMS

Telemonitoring is increasingly used in the management of IBD patients. We investigated the agreement between patients and physicians on scores of disease activity and burden.

METHODS

Consecutive outpatients at one IBD clinic were recruited between February and December 2021. Enrolled patients completed a questionnaire for disease activity (Harvey-Bradshaw Index [HBI] for Crohn's disease or Simple Clinical Colitis Activity Index [SCCAI] for ulcerative colitis) and a test of disease burden (Pictorial Representation of Illness and Self Measure [PRISM]). They did the tests within 5 days of an outpatient visit, working independently on IBD Tool, a new web-based telemonitoring application. Concomitantly, the senior and junior physicians who examined them completed the same tests. The agreement was tested for every pair of scores.

RESULTS

Five hundred and sixty patients (289 Crohn's disease; 271 ulcerative colitis) completed disease questionnaires on IBD Tool (in total, 742 times). By Spearman's correlation, the agreement was substantial both for HBI (rho 0.685-0.837) and SCCAI (rho 0.694-0.888) for comparisons between patients, junior and senior physicians. The agreement was moderate-to-substantial for PRISM (rho 0.406-0.725) for the same comparisons. The correlation between disease activity (HBI/SCCAI) and PRISM scores was substantial for senior (rho 0.757-0.788) or junior (rho 0.746-0.753) physicians and moderate for patients (rho 0.458-0.486). The median PRISM score difference was 2.3-1.6 points lower between patients and senior-junior physicians.

CONCLUSION

Agreement between IBD patients and physicians was substantial for disease activity and moderate for disease impact. The inclusion of disease burden scoring in telemonitoring platforms provides important information for the management of IBD patients.Study highlightsWhat IS known•Continuous response to treatments and patient-reported outcomes became an essential goal for IBD patient management.•The use of tele-monitoring and eHealth technologies allows for regular disease assessments and for managing more efficiently IBD patients; disease questionnaires and tests are key to support eHealth tools.What is new here•Agreement between IBD patients and physicians was substantial for disease activity and moderate for disease burden, while agreement among junior and senior physicians was substantial for both.•PRISM performs as well for ulcerative colitis as for Crohn's patients.•The inclusion of disease burden tests might add to eHealth platforms valuable information, complemental to disease activity questionnaires.

Are we ready for telemonitoring inflammatory bowel disease? A review of advances, enablers, and barriers

This review summarizes the evidence about telemonitoring in patients with inflammatory bowel disease (IBD). To give an overview of the advances performed, as well as the enablers and barriers which favoured/hindered telemonitoring implementation. We performed a literature search in PubMed, EMBASE, MEDLINE, Cochrane Database, Web of Science and Conference Proceedings. Titles and abstracts published up to September 2022 were screened for a set of inclusion criteria: telemonitoring intervention, IBD as the main disease, and a primary study performed. Ninety-seven reports were selected for full review. Finally, 20 were included for data extraction and critical appraisal. Most studies used telemonitoring combined with tele-education, and programs evolved from home telemanagement systems towards web portals through mHealth applications. Web systems demonstrated patients’ acceptance, improvement in quality of life, disease activity and knowledge, with a good cost-effectiveness profile in the short-term. Initially, telemonitoring was almost restricted to ulcerative colitis, but new patient reported outcome measures, home-based tests and mobile devices favoured its expansion to different patients´ categories. However, technological and knowledge advances led to legal, ethical, economical and logistic issues. Standardization of remote healthcare is necessary, to improve the interoperability of systems as well as to address liability concerns and users´ preferences. Telemonitoring IBD is well accepted and improves clinical outcomes at a lower cost in the short-term. Funders, policymakers, providers, and patients need to align their interests to overcome the emerging barriers for its full implementation.

Telenutrition for the management of inflammatory bowel disease: Benefits, limits, and future perspectives

Patients with inflammatory bowel disease (IBD) require lifelong and personalized care by a multidisciplinary healthcare team. However, the traditional medical model is not ideal for patients who require continuous close monitoring and whose symptoms may dramatically worsen between regularly scheduled visits. Additionally, close dietary follow-up and monitoring of IBD in a traditional setting are challenging because of the disease complexity, high pressure on outpatient clinics with a small number of IBD specialist dietitians, and rising incidence. Given the significant burden of IBD, there is a need to develop effective dietary management strategies. The coronavirus disease 2019 pandemic caused an unprecedented shift from in-person care to delivering health care via technological remote devices. Traditional nutrition therapy and consultation can be provided by telenutrition through remote electronic communication applications that could greatly benefit patient care. Telenutrition might be useful, safe, and cost-effective compared with standard care. It is likely that virtual care for chronic diseases including IBD will continue in some form into the future. This review article summarizes the evidence about telenutrition applications in the management of IBD patients, and we gave an overview of the acceptance and impact of these interventions on health outcomes.

Best Practices for the Provision of Virtual Care: A Systematic Review of Current Guidelines

Background: Telemedicine has emerged as a feasible adjunct to in-person care in multiple clinical contexts, and its role has expanded in the context of the COVID-19 pandemic. However, there exists a general paucity of information surrounding best practice recommendations for conducting specialty or disease-specific virtual care. The purpose of this study was to systematically review existing best practice guidelines for conducting telemedicine encounters. Methods: A systematic review of MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) of existing guidelines for the provision of virtual care was performed. Data were synthesized using the Synthesis Without Meta-Analysis (SWiM) guideline, and the Appraisal of Guidelines for Research & Evaluation Instrument (AGREE II) tool was used to evaluate the quality of evidence. Results: A total of 60 guidelines for virtual care encounters were included; 52% of these were published in the context of the COVID-19 pandemic. The majority (95%) of provider guidelines specified a type of virtual encounter to which their guidelines applied. Of included guidelines, 65% provided guidance regarding confidentiality/security, 58% discussed technology/setup, and 56% commented on patient consent. Thirty-one guidelines also provided guidance to patients or caregivers. Overall guideline quality was poor. Discussion: General best practices for successful telemedicine encounters include ensuring confidentiality and consent, preparation before a visit, and clear patient communication. Future studies should aim to objectively assess the efficacy of existing clinician practices and guidelines on patient attitudes and outcomes to further optimize the provision of virtual care for specific patient populations.

Evaluation of the Effectiveness of Telemedicine Visits in a Pediatric Gastroenterology Service in the Context of COVID-19

BACKGROUND

During the first months of COVID-19, the Gastroenterology, Hepatology and Nutrition service of the Hospital Sant Joan de Déu in Barcelona, a leading pediatric center in Spain, introduced a new model of non-face-to-face care.

OBJECTIVE

To evaluate the impact of telephone consultations compared to those conducted face-to-face on healthcare utilization.

METHODOLOGY

Two main indicators of effectiveness are used: the degree of resolution (percentage of first telemedicine visits that did not generate any new visits in the following 4 and 12 months) and the average number of subsequent visits. A distinction was made between visits for general pathologies (less complex) and those for pathologies treated in monographic consultations (chronic or complex pathologies). Effectiveness at 4 and 12 months was also compared.

RESULTS

After 4 months from the first visit, the degree of resolution is lower in the first telemedicine visits than in face-to-face visits for both general pathologies and those of monographic agendas for chronic and complex pathologies. After twelve months, the first general telemedicine visits are less resolute than face-to-face visits, while the resolution rate is the same for chronic and complex pathology visits. Each telemedicine visit generates on average more visits than face-to-face visits. In the short term, 133.4% more in the case of general visits and 51.4% more in the case of chronic and complex visits. In the long term, general telemedicine visits generate 57.31% more visits, while no statistically significant difference is observed between chronic and complex face-to-face and telemedicine visits.

CONCLUSION

The results of this study show that the resolution capacity of the non-face-to-face model in pediatric care in the pandemic context is generally lower and generates more successive visits than the face-to-face model. This lower performance of the telemedicine model should be counterbalanced with its advantages.

The profile of the key pro-inflammatory cytokines in the serum of patients with CD and their association with the disease severity and activity

BACKGROUND

The epidemiology of Crohn's disease (CD) has changed over the past decades, demonstrating a trend toward increased prevalence in developing countries, while in developed countries, its incidence has stabilized. The study aimed to examine the profile of the key pro-inflammatory cytokines in the serum of patients with CD and establish their association with the severity and activity of the disease.

METHODS

A total of 61 patients (29 women (47.5%), 32 men (52.5%) aged from 18 to 40 years (mean age (30.42 ± 2.51) years) with the verified diagnosis of CD in the active phase were examined. The control group consisted of 30 healthy people of corresponding age.

RESULTS

CD is characterized by a reliable increase of pro-inflammatory cytokines in blood compared to healthy people: tumor necrosis factor-α (TNF-α) - by 4.45 times (137.46 ± 9.72 vs. 30.88 ± 2.08 pg/ml in healthy people, p < 0,001), interleukin-1α (IL-1α) - by 5.08 times (51.55 ± 4.36 vs. 10.14 ± 0.93 pg/ml, p < 0.001), interleukin-6 (IL-6) - by 2.16 times (20.03 ± 1.81 vs. 9.27 ± 0.52 pg/ml, p < 0.001), interleukin-8 (IL-8) - by 2.04 times (25.74 ± 2.05 vs. 12.62 ± 1.16 pg/ml, p < 0.001), and interferon-γ (IFN-γ) - by 5.30 times (208.63 ± 14.29 vs. 39.35 ± 2.40 pg/ml, p < 0.001). The authors have established direct correlations between the Crohn's disease activity index and blood content of TNF-α (r = 0.84, p < 0.013), INF-γ (r = 0.61, p < 0.028); between TNF-α and INF-γ content (r = 0.67, p < 0.023), IL-1α (r = 0.49, p < 0.042), IL-6 (r = 0.40, p < 0.045), and IL-8 (r = 0.51, p < 0.033); INF-γ and IL-1α (r = 0.53, p < 0.040), IL-6 (r = 0.37, p < 0.039), IL-8 (r = 0.44, p < 0.040).

CONCLUSIONS

Patients with CD were found to have multiple cytokines (TNF-α, IL-1α, IL-6, IL-8, and IFN-γ,). The content of cytokines correlated positively with the CD activity index.

Mobile Apps for the Management of Gastrointestinal Diseases: Systematic Search and Evaluation Within App Stores

Background

Gastrointestinal diseases are associated with substantial cost in health care. In times of the COVID-19 pandemic and further digitalization of gastrointestinal tract health care, mobile health apps could complement routine health care. Many gastrointestinal health care apps are already available in the app stores, but the quality, data protection, and reliability often remain unclear.

Objective

This systematic review aimed to evaluate the quality characteristics as well as the privacy and security measures of mobile health apps for the management of gastrointestinal diseases.

Methods

A web crawler systematically searched for mobile health apps with a focus on gastrointestinal diseases. The identified mobile health apps were evaluated using the Mobile Application Rating Scale (MARS). Furthermore, app characteristics, data protection, and security measures were collected. Classic user star rating was correlated with overall mobile health app quality.

Results

The overall quality of the mobile health apps (N=109) was moderate (mean 2.90, SD 0.52; on a scale ranging from 1 to 5). The quality of the subscales ranged from low (mean 1.89, SD 0.66) to good (mean 4.08, SD 0.57). The security of data transfer was ensured only by 11 (10.1%) mobile health apps. None of the mobile health apps had an evidence base. The user star rating did not correlate with the MARS overall score or with the individual subdimensions of the MARS (all P>.05).

Conclusions

Mobile health apps might have a positive impact on diagnosis, therapy, and patient guidance in gastroenterology in the future. We conclude that, to date, data security and proof of efficacy are not yet given in currently available mobile health apps.

Comparison of Quality Performance Measures for Patients Receiving In-Person vs Telemedicine Primary Care in a Large Integrated Health System

IMPORTANCE

Despite its rapid adoption during the COVID-19 pandemic, it is unknown how telemedicine augmentation of in-person office visits has affected quality of patient care.

OBJECTIVE

To examine whether quality of care among patients exposed to telemedicine differs from patients with only in-person office-based care.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective cohort study, standardized quality measures were compared between patients with office-only (in-person) visits vs telemedicine visits from March 1, 2020, to November 30, 2021, across more than 200 outpatient care sites in Pennsylvania and Maryland.

EXPOSURES

Patients completing telemedicine (video) visits.

MAIN OUTCOMES AND MEASURES

χ2 tests determined statistically significant differences in Health Care Effectiveness Data and Information Set (HEDIS) quality performance measures between office-only and telemedicine-exposed groups. Multivariable logistic regression controlled for sociodemographic factors and comorbidities.

RESULTS

The study included 526 874 patients (409 732 office-only; 117 142 telemedicine exposed) with a comparable distribution of sex (196 285 [49.7%] and 74 878 [63.9%] women), predominance of non-Hispanic (348 127 [85.0%] and 105 408 [90.0%]) and White individuals (334 215 [81.6%] and 100 586 [85.9%]), aged 18 to 65 years (239 938 [58.6%] and 91 100 [77.8%]), with low overall health risk scores (373 176 [91.1%] and 100 076 [85.4%]) and commercial (227 259 [55.5%] and 81 552 [69.6%]) or Medicare or Medicaid (176 671 [43.1%] and 52 513 [44.8%]) insurance. For medication-based measures, patients with office-only visits had better performance, but only 3 of 5 measures had significant differences: patients with cardiovascular disease (CVD) receiving antiplatelets (absolute percentage difference [APD], 6.71%; 95% CI, 5.45%-7.98%; P < .001), patients with CVD receiving statins (APD, 1.79%; 95% CI, 0.88%-2.71%; P = .001), and avoiding antibiotics for patients with upper respiratory infections (APD, 2.05%; 95% CI, 1.17%-2.96%; P < .001); there were insignificant differences for patients with heart failure receiving β-blockers and those with diabetes receiving statins. For all 4 testing-based measures, patients with telemedicine exposure had significantly better performance differences: patients with CVD with lipid panels (APD, 7.04%; 95% CI, 5.95%-8.10%; P < .001), patients with diabetes with hemoglobin A1c testing (APD, 5.14%; 95% CI, 4.25%-6.01%; P < .001), patients with diabetes with nephropathy testing (APD, 9.28%; 95% CI, 8.22%-10.32%; P < .001), and blood pressure control (APD, 3.55%; 95% CI, 3.25%-3.85%; P < .001); this was also true for all 7 counseling-based measures: cervical cancer screening (APD, 12.33%; 95% CI, 11.80%-12.85%; P < .001), breast cancer screening (APD, 16.90%; 95% CI, 16.07%-17.71%; P < .001), colon cancer screening (APD, 8.20%; 95% CI, 7.65%-8.75%; P < .001), tobacco counseling and intervention (APD, 12.67%; 95% CI, 11.84%-13.50%; P < .001), influenza vaccination (APD, 9.76%; 95% CI, 9.47%-10.05%; P < .001), pneumococcal vaccination (APD, 5.41%; 95% CI, 4.85%-6.00%; P < .001), and depression screening (APD, 4.85%; 95% CI, 4.66%-5.04%; P < .001).

CONCLUSIONS AND RELEVANCE

In this cohort study of patients with telemedicine exposure, there was a largely favorable association with quality of primary care. This supports telemedicine's value potential for augmenting care capacity, especially in chronic disease management and preventive care. This study also identifies a need for understanding relationships between the optimal blend of telemedicine and in-office care.

Satisfaction With Telehealth Among Patients With Irritable Bowel Syndrome During COVID-19: Cross-Sectional Survey Findings

INTRODUCTION

Coronavirus disease 2019 rapidly shifted health care toward telehealth. We assessed satisfaction with and preferences for telehealth among patients with irritable bowel syndrome (IBS).

METHODS

We conducted a cross-sectional survey in an integrated healthcare system in Southern California with members aged 18-90 years with an International Classification of Diseases 9 and 10 codes for IBS from office-based encounters between June 1, 2018, and June 1, 2020. Eligible patients were emailed a survey assessing telehealth satisfaction overall and by patient-related factors, IBS characteristics, health and technologic literacy, utilization, and coronavirus disease 2019 perceptions. We identified perceived telehealth benefits and challenges. Multivariable logistic regression identified predictors of telehealth dissatisfaction.

RESULTS

Of 44,789 surveys sent, 5,832 (13.0%) patients responded and 1,632 (3.6%) had Rome IV IBS. Among 1,314 (22.5%) patients with IBS and prior telehealth use (mean age 52.6 years [17.4]; 84.9% female; and 59.4% non-Hispanic White, 29.0% Hispanic, and 5.6% non-Hispanic Black), 898 (68.3%) were satisfied, 130 (9.9%) were dissatisfied, and 286 (21.8%) felt neutral. In addition, 78.6% would use telehealth again. Independent predictors of telehealth dissatisfaction include social media use of once a week or less (adjusted odds ratio [OR] = 2.1; 1.3-3.5), duration of IBS for &lt;1 year (adjusted OR = 8.2; 1.9-35.8), and willingness to travel 60 plus minutes for face-to-face visits (adjusted OR = 2.6; 1.4-3.7). Patients' main concern with telehealth was a lack of physical examination.

DISCUSSION

Most of the patients with IBS are satisfied with telehealth. Shorter duration of IBS diagnosis, comfort with technology, and increased willingness to travel were associated with telehealth dissatisfaction. These predictors may help identify a target population for a focused IBS-telehealth program.

The cost-effectiveness of digital health interventions: A systematic review of the literature

Background

Digital health interventions have significant potential to improve safety, efficacy, and quality of care, reducing waste in healthcare costs. Despite these premises, the evidence regarding cost and effectiveness of digital tools in health is scarce and limited.

Objectives

The aim of this systematic review is to summarize the evidence on the cost-effectiveness of digital health interventions and to assess whether the studies meet the established quality criteria.

Methods

We queried PubMed, Scopus and Web of Science databases for articles in English published from January 1, 2016 to December 31, 2020 that performed economic evaluations of digital health technologies. The methodological rigorousness of studies was assessed with the Consolidated Health Economic Evaluation Reporting Standards (CHEERS). The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2009 checklist.

Results

Search identified 1,476 results, 552 of which were selected for abstract and 35 were included in this review. The studies were heterogeneous by country (mostly conducted in upper and upper-middle income countries), type of eHealth intervention, method of implementation, and reporting perspectives. The qualitative analysis identified the economic and effectiveness evaluation of six different types of interventions: (1) seventeen studies on new video-monitoring service systems; (2) five studies on text messaging interventions; (3) five studies on web platforms and digital health portals; (4) two studies on telephone support; (5) three studies on new mobile phone-based systems and applications; and (6) three studies on digital technologies and innovations.

Conclusion

Findings on cost-effectiveness of digital interventions showed a growing body of evidence and suggested a generally favorable effect in terms of costs and health outcomes. However, due to the heterogeneity across study methods, the comparison between interventions still remains difficult. Further research based on a standardized approach is needed in order to methodically analyze incremental cost-effectiveness ratios, costs, and health benefits.

Current Applications of Telemedicine in Gastroenterology

Telemedicine generally refers to the use of technology to communicate with patients and provide health care from a distance. Advances in technology, specifically computers, cellphones, and other mobile devices, have facilitated healthcare providers' growing ability to virtually monitor and mentor patients. There has been a progressive expansion in the use of telemedicine in the field of gastroenterology (GI), which has been accelerated by the COVID-19 pandemic. In this review, we discuss telemedicine-its history, various forms, and limitations-and its current applications in GI. Specifically, we focus on telemedicine in GI practice in general and specific applications, including the management of inflammatory bowel disease, celiac disease, and colorectal cancer surveillance and its use as an aid in endoscopic procedures.

Patient Satisfaction and Perceived Quality of Care with Telemedicine in a Pediatric Gastroenterology Clinic

INTRODUCTION

The coronavirus disease 2019 pandemic necessitated a shift to telemedicine for many clinics. This study aimed to better understand patient perception regarding telemedicine visits in a pediatric subspecialty clinic and to describe differences in management provided virtually versus in-person.

MATERIALS AND METHODS

This survey study and chart review was conducted at the Doernbecher Children's Hospital gastroenterology outreach clinics from May to June, 2020. The main hospital is located in Portland, Oregon, with the outreach clinics located in Salem, Eugene, and Medford, Oregon. Families were surveyed within 2 weeks of their visit, with a 6-month follow up survey.

RESULTS

There were 111 respondents to the initial survey (34% response rate). The majority of patients had initial positive impressions of telemedicine, with 75% feeling that the quality of telemedicine visits were as good as or better than in-person visits. At 6 months, there were 80 respondents (34% response rate), and this positive impression persisted with 72% of families reporting no negatives from their telemedicine experience. New patients seen via telemedicine were prescribed medications more frequently than those seen in-person (73% versus 45%, p = 0.02).

DISCUSSION

Patients and families felt the benefits of telemedicine visits outweighed the limitations both initially and at 6-month follow up. Telemedicine offers an effective alternative for pediatric subspecialty care especially for select conditions and follow up visits. However, the more frequent prescriptions could reflect the adaptation of clinical practice with the telemedicine platform, and further studies are needed.

Telemonitoring for patients with inflammatory bowel disease amid the COVID-19 pandemic—A cost-effectiveness analysis

Background and aim

COVID-19 pandemic burdens the healthcare systems, causes healthcare avoidance, and might worsen the outcomes of inflammatory bowel disease (IBD) management. We aimed to estimate the impact of pandemic-related avoidance on outpatient IBD management, and the cost-effectiveness of adding telemonitoring during pandemic from the perspective of Hong Kong public healthcare provider.

Methods

The study was performed by a decision-analytic model to estimate the quality-adjusted life-years (QALYs) and cost of care for IBD patients before and during the pandemic, and to compare the cost and QALYs of adding telemonitoring to standard care (SC-TM) versus standard care alone (SC) for IBD patients during the pandemic. The sources of model inputs included publications (retrieved from literature search) and public data. Sensitivity analyses were conducted to examine the robustness of base-case results.

Results

Standard care with pandemic-related avoidance (versus without avoidance) lost 0.0026 QALYs at higher cost (by USD43). The 10,000 Monte Carlo simulations found standard care with pandemic-related avoidance lost QALYs and incurred higher cost in 100% and 96.82% of the time, respectively. Compared with the SC group, the SC-TM group saved 0.0248 QALYs and reduced cost by USD799. Monte Carlo simulations showed the SC-TM group gained higher QALYs at lower cost in 100% of 10,000 simulations.

Conclusions

Standard care for IBD patients during pandemic with healthcare avoidance appears to worsen treatment outcomes at higher cost and lowered QALYs. The addition of telemonitoring to standard care seems to gain higher QALYs and reduce cost, and is therefore a potential cost-effective strategy for IBD management during the pandemic.

Point-of-Care Testing and Home Testing: Pragmatic Considerations for Widespread Incorporation of Stool Tests, Serum Tests, and Intestinal Ultrasound

Breaking through the biologic therapy efficacy plateau for inflammatory bowel disease requires the strategic development of personalized biomarkers in the tight control model. After risk stratification early in the disease course, targeted serial monitoring consistently to assess clinical outcomes in response to therapy allows for quick therapeutic adjustments before bowel damage can occur. Point-of-care intestinal ultrasound performed by the treating gastroenterologist is an accurate cross- sectional biomarker that monitors intestinal inflammation in real-time, enhances patient care, and increases shared understanding to help achieve common treatment goals. Combining intestinal ultrasound during a clinic visit with existing serum and stool biomarkers in a home testing setup with electronic health monitoring allows for an optimized, patient-centered personalized treatment algorithm that may improve treatment outcomes. Here, we review the current state, pragmatic considerations, and future implications of point-of-care testing and home testing for noninvasive inflammatory bowel disease monitoring in the tight control model.

French experience with telemedicine in inflammatory bowel disease: a patients and physicians survey

BACKGROUND AND AIMS

The use of telemedicine dramatically increased during the COVID-19 pandemic. We collected patients and physicians experience on telemedicine in the field of inflammatory bowel disease (IBD).

METHODS

We conducted a nationwide survey between September 2020 and January 2021. A self-administered questionnaire was sent to participants through mailing lists of the national patients' association and IBD expert groups.

RESULTS

Overall, 300 patients and 110 gastroenterologists filled out the survey. On a 10 points scale of satisfaction with telemedicine, 60% of patients noted a score ≥8 and 52.7% of physicians ≥7. Patients and gastroenterologists felt that the duration of teleconsultations appeared to be shorter than in-person visits in 57.5 and 55.1% of cases, respectively. All participants agreed that telemedicine is appropriate in dedicated situations and not for flare-up consultations. For 55.1% of patients, quality of care was the same via telemedicine, whereas 51.4% of gastroenterologists believed they managed less well their patients. Lack of clinical examination being pointed out as the main limitation of telemedicine. Three-quarters of patients and gastroenterologists would agree to use telemedicine more often in the future.

CONCLUSION

Patients and gastroenterologists were satisfied with telemedicine and would be willing to use it in the future. However, telemedicine does not replace in-person visits and should be discussed on a case-by-case basis.

Comparable Quality Performance of Acute Low-Back Pain Care in Telemedicine and Office-Based Cohorts

Introduction: Back pain is among the most common presentations in primary care offices. National organizations have standardized the appropriate use of imaging for acute low-back pain (LBP). The objective of this study was to evaluate the use of imaging in LBP between telemedicine and in-person clinical encounters. Methods: This retrospective cohort compared secondary data from 20,624 telemedicine and office encounters in a large nonprofit health system from July 1, 2019, to June 30, 2021. The proportion of patients aged 18-50 years who did not receive imaging for acute LBP (X-ray, computed tomography, or magnetic resonance imaging) within 28 days of the provider encounter was measured according to Healthcare Effectiveness Data and Information Set specifications. Performance was compared across race, ethnicity, age, body mass index, overall risk score, and insurance type. Chi-squared tests determined significant differences between cohorts (p < 0.05). Results: Patients seen via telemedicine had significantly lower rates of imaging within 28 days of their physician encounter (office: 16.32%, telemedicine: 11.20%; difference: 5.12%; p < 0.01). This was consistent across racial, ethnic, and risk score subgroups. Discussion: For practices and health systems, telemedicine might be a higher value approach for initial evaluation of acute LBP in primary care. For policy makers, telemedicine can save on health care costs without negatively impacting quality performance measures. Conclusions: Telemedicine is unlikely to compromise quality of acute LBP care, supporting this virtual space as an alternative care venue. The most beneficial use of telemedicine might be triaging initial encounters of acute LBP in primary care. Stronger evidence could support its long-term potential for driving value through cost savings.

Telemedicine Is an Effective Tool to Monitor Disease Activity in IBD Patients in the COVID-19 Era: A Single Centre Experience Based on Objective Data

Background: The COVID-19 outbreak has led IBD clinics to adopt a remote monitoring approach in order to guarantee an adequate follow-up of patients with inflammatory bowel disease (IBD) and ensure the rules of social distancing. Aim: The aim of the study was to perform a survey on IBD patients who underwent remote monitoring in our tertiary referral center, to assess adherence, patients’ perceptions and satisfaction, and finally their opinions for future monitoring. Furthermore, we evaluated changes in disease activity and Quality of Life (QoL) using validated questionnaires. Methods: Consecutive patients with IBD scheduled for follow-up visits were switched to remote monitoring through e-mail from March 2020 to February 2021. Patients were asked to complete a questionnaire focusing on the following elements of the intervention: (1) self-assessment questions, (2) action plans, and (3) educational messages. Results: Four hundred and twenty four Caucasian patients completed the survey. 233 (55.1%) were male, 220 (52.0%) had Crohn’s Disease (CD). Median baseline Mayo Score and Harvey Bradshaw Index were 3 and 4, respectively. 9 (2.1%) patients were referred to the emergency department because of disease flares. 410 (96.9%) patients were satisfied with telemedicine, and 320 (76.5%) patients reported that they would maintain this approach also after COVID-19 pandemic. Overall, on univariate logistic regression analysis, none of the variables were related to patients’ satisfaction or to an improved QoL. The presence of ulcerative colitis was associated with the need for treatment change. Conclusions: Our results suggest that a telemedicine approach is well accepted by patients with IBD and could represent an effective tool in monitoring disease activity. Further controlled studies are warranted to properly assess if telemedicine can replace face-to-face consultations in IBD.

Trends in U.S. Health Care Spending on Inflammatory Bowel Diseases, 1996-2016

BACKGROUND

Inflammatory bowel diseases (IBD) are rising in prevalence and are associated with high health care costs. We estimated trends in U.S. health care spending in patients with IBD between 1996 and 2016.

METHODS

We used data on national health care spending developed by the Institute for Health Metrics and Evaluations for the Disease Expenditure Project. We estimated corresponding U.S. age-specific prevalence of IBD from the Global Burden of Diseases Study. From these 2 sources, we estimated prevalence-adjusted, temporal trends in U.S. health care spending in patients with IBD, stratified by age groups (<20 years, 20-44 years, 45-64 years, ≥65 years) and by type of care (ambulatory, inpatient, emergency department [ED], pharmaceutical prescriptions, and nursing care), using joinpoint regression, expressed as an annual percentage change (APC) with 95% confidence intervals.

RESULTS

Overall, annual U.S. health care spending on IBD increased from $6.4 billion (95% confidence interval, 5.7-7.4) in 1996 to $25.4 billion (95% confidence interval, 22.4-28.7) in 2016, corresponding to a per patient increase in annual spending from $5714 to $14,033. Substantial increases in per patient spending on IBD were observed in patients aged ≥45 years. Between 2011 and 2016, inpatient and ED care accounted for 55.8% of total spending and pharmaceuticals accounted for 19.9%, with variation across age groups (inpatient/ED vs pharmaceuticals: ages ≥65 years, 57.6% vs 11.2%; ages 45-64 years, 49.5% vs 26.9%; ages 20-44 years, 59.2% vs 23.6%).

CONCLUSIONS

Even after adjusting for rising prevalence, U.S. health care spending on IBD continues to progressively increase, primarily in middle-aged and older adults, with unplanned health care utilization accounting for the majority of costs.

Demographic Factors Associated With Successful Telehealth Visits in Inflammatory Bowel Disease Patients

BACKGROUND

This study evaluated synchronous audiovisual telehealth and audio-only visits for patients with inflammatory bowel disease (IBD) to determine frequency of successful telehealth visits and determine what factors increase the likelihood of completion.

METHODS

Data were collected from March to July 2020 in a tertiary care adult IBD clinic that was transitioned to a fully telehealth model. A protocol for telehealth was implemented. A retrospective analysis was performed using electronic medical record (EMR) data. All patients were scheduled for video telehealth. If this failed, providers attempted to conduct the visit as audio only.

RESULTS

Between March and July 2020, 2571 telehealth visits were scheduled for adult patients with IBD. Of these, 2498 (99%) were successfully completed by video or phone. Sixty percent were female, and the median age was 41 years. Eighty six percent of the population was white, 8% black, 2% other, and 4% were missing. Seventy-five percent had commercial insurance, 15% had Medicare, 5% had Medicaid, and 5% had other insurance. No significant factors were found for an attempted but completely failed visit. Using a multivariate logistic regression model, increasing age (odds ratio, 1.80; 95% CI, 1.55-2.08; P < 0.05), noncommercial insurance status (odds ratio, 1.89; 95% CI, 1.61-2.21; P < 0.05), and black race (odds ratio, 2.07; 95% CI, 1.38-3.08; P < 0.05) increased the likelihood of a video encounter failure.

CONCLUSIONS

There is a high success rate for telehealth within an IBD population with defined clinic protocols. Certain patient characteristics such as age, race, and health insurance type increase the risk of failure of a video visit.

Information and communication technologies in Patients with Immune-Mediated Inflammatory Diseases: Cross-Sectional Survey (Preprint)

Background

Information and communication technologies (ICTs) are changing the traditional health care model and redefining personalized health. ICTs offer effective communication and real-time monitoring of patients and provide additional data to support clinical decision-making, improve the quality of care, and contribute to the empowerment of patients. However, evidence on the use of ICTs and digital preferences of immune-mediated inflammatory disease (IMID) patients is scarce.

Objective

The aim of this study is to describe the degree of use of ICTs in patients with IMIDs (including rheumatic diseases, inflammatory bowel diseases, and psoriasis), identify their needs, and analyze their interest in the use of apps as tools for better management of their disease.

Methods

A questionnaire was created by a multidisciplinary team including pharmacists, rheumatologists, gastroenterologists, dermatologists, and nurses with experience in ICTs applied to the field of IMID. The survey included 27 questions organized into 3 blocks: (1) sociodemographic characteristics, (2) ICT use for health-related information, and (3) patient expectations about mobile health.

Results

A total of 472 questionnaires were analyzed. Overall, 52.9% (250/472) of patients were diagnosed with a rheumatologic disease, 39.4% (186/472) with inflammatory bowel disease, and 12.3% (58/472) with psoriasis. The state of health was considered good by 45.6% (215/472) of patients. Patients were interested in staying informed about health issues in 86.9% (410/427) of cases and sought health-related information mainly from the internet (334/472, 70.8%) and health care professionals (318/472, 67.4%). Overall, 13.6% (64/472) did not trust the health information they found in internet. Of the patients, 42.8% (202/472) had a health app, and 42.2% (199/472) had found it on their own. Patients would like a health app to help mainly to manage appointments (281/472, 59.5%), obtain information about their diseases and treatments (274/472, 58.1%), and get in contact with health professionals (250/472, 53.0%). Overall, 90.0% (425/472) of patients reported they would use an app to manage their IMID if their health professional recommended it, and 58.0% (274/472) would pay or probably be willing to pay for it.

Conclusions

IMID patients were very interested in finding health-related information via ICTs, especially using smartphones and apps recommended by health professionals. Appointment management, advice on disease and treatment management, and personalized communication with health professionals were the most desired app features identified. Health professionals should play an essential role in recommending and validating these tools to ensure they are of high quality.

Digital Health Technologies for Remote Monitoring and Management of Inflammatory Bowel Disease: A Systematic Review

INTRODUCTION

Digital health technologies may be useful tools in the management of chronic diseases. We performed a systematic review of digital health interventions in the management of patients with inflammatory bowel diseases (IBD) and evaluated its impact on (i) disease activity monitoring, (ii) treatment adherence, (iii) quality of life (QoL) measures, and/or (iv) health care utilization.

METHODS

Through a systematic review of multiple databases through August 31, 2020, we identified randomized controlled trials in patients with IBD comparing digital health technologies vs standard of care (SoC) for clinical management and monitoring and reporting impact on IBD disease activity, treatment adherence, QoL, and/or health care utilization or cost-effectiveness. We performed critical qualitative synthesis of the evidence supporting digital health interventions in patients with IBD and rated certainty of evidence using Grading of Recommendations Assessment, Development and Evaluation.

RESULTS

Overall, we included 14 randomized controlled trials (median, 98 patients; range 34-909 patients; follow-up <12 months) that compared web-based interventions, mobile applications, and different telemedicine platforms with SoC (clinic-based encounters). Although overall disease activity and risk of relapse were comparable between digital health technologies and SoC (very low certainty of evidence), digital health interventions were associated with lower rate of health care utilization and health care costs (low certainty of evidence). Digital health interventions did not significantly improve patients' QoL and treatment adherence compared with SoC (very low certainty of evidence). Trials may have intrinsic selection bias due to nature of digital interventions.

DISCUSSION

Digital health technologies may be effective in decreasing health care utilization and costs, though may not offer advantage in reducing risk of relapse, QoL, and improving treatment adherence in patients with IBD. These techniques may offer value-based care for population health management.

Racial and Socioeconomic Disparities in Utilization of Telehealth in Patients with Liver Disease During COVID-19

BACKGROUND AND AIMS

The coronavirus disease 2019 (COVID-19) pandemic resulted in a rapid expansion of telehealth services in hepatology. However, known racial and socioeconomic disparities in internet access potentially translate into barriers for the use of telehealth, particularly video technology. The specific aim of this study was to determine if disparities in race or socioeconomic status exist among patients utilizing telehealth visits during COVID-19.

METHODS

We performed a retrospective cohort study of all adult patients evaluated in hepatology clinics at Duke University Health System. Visit attempts from a pre-COVID baseline period (January 1, 2020 through February 29, 2020; n = 3328) were compared to COVID period (April 1, 2020 through May 30, 2020; n = 3771).

RESULTS

On multinomial regression modeling, increasing age was associated with higher odds of a phone or incomplete visit (canceled, no-show, or rescheduled after May 30,2020), and non-Hispanic Black race was associated with nearly twice the odds of completing a phone visit instead of video visit, compared to non-Hispanic White patients. Compared to private insurance, Medicaid and Medicare were associated with increased odds of completing a telephone visit, and Medicaid was associated with increased odds of incomplete visits. Being single or previously married (separated, divorced, widowed) was associated with increased odds of completing a phone compared to video visit compared to being married.

CONCLUSIONS

Though liver telehealth has expanded during the COVID-19 pandemic, disparities in overall use and suboptimal use (phone versus video) remain for vulnerable populations including those that are older, non-Hispanic Black, or have Medicare/Medicaid health insurance.

The Use of Telemedicine in Older Patients with Gastrointestinal Diseases

Purpose of Review

The COVID-19 pandemic helped us understand that telemedicine provides an alternative way to manage patients remotely, with an added benefit of saving time and travel costs. However, barriers may exist in an older population of patients such as inadequate technology availability and knowledge, and lack of internet connectivity. This systematic review and analysis of data at an academic medical center examines the current literature and investigates the efficacy of telemedicine for older adults requiring gastrointestinal care.

Recent Findings

In the systematic review, we included 22 manuscripts from an initial 120 that were identified based on inclusion and exclusion criteria. In this existing literature, telemedicine visits were equivalent or better than in-person visits based on many metrics, including patient satisfaction, time and money saved, and standard patient outcomes. At a rural academic medical center, there was a steady decrease in the failure rate of telemedicine visits from April 2020 to May 2022 in all age groups, including the 65 + age group, from 17% in April 2020 to 3% in May 2022.

Summary

Telemedicine offers a comparable alternative to in-person visits that is convenient, low-cost, and does not compromise quality of care for older patients obtaining GI care. The COVID-19 pandemic has accelerated progress and uptake of telemedicine, and the successful use by all ages including older patients opens the broader conversation about the continued use of telemedicine for care in various areas of medicine.