Crohn's Colitis Care (CCCare): bespoke cloud-based clinical management software for inflammatory bowel disease

Crohn's Colitis Care, a Disease-Specific Electronic Medical Record, Enhances Data Capture in Pediatric Inflammatory Bowel Disease Care

Background and Aim

Crohn's Colitis Care, a structured, disease-specific electronic medical record, is proven to promote more complete data capture in adult Inflammatory Bowel Disease care. This study aimed to determine whether similar effectiveness was seen in pediatrics.

Methods

Matched patient records from a hospital's standard electronic medical record (pre-Crohn's Colitis Care) and those in Crohn's Colitis Care were retrospectively reviewed (12 months each). The presence of disease-specific data items per platform were compared (21 core, 5 age-specific). Data are presented as percentage recorded (recorded items/total eligible for age). Descriptive and statistical analytics were used.

Results

Paired records were reviewed for 114 children, of whom 78 (68%) had Crohn's disease and 69 (61%) were male. Median age at diagnosis was 13.5 years (IQR12.0-15.5), with mean disease duration 3.6 years (±2.4). Crohn's Colitis Care was more likely to capture 9 items: general wellbeing, stool urgency and frequency, disease duration, comorbidities, pubertal stage, sexual activity, alcohol and drug usage (each p < 0.05). The standard platform was more likely to capture 4 items: liquid stools, phenotype, disease indices, and vaccinations (each p < 0.05). Crohn's Colitis Care achieved more eligible data items recorded per patient (75.3% ±11.5 vs. 67.7% ± 8.9; p < 0.001). Item completion rate in both platforms inversely correlated with patient age (p < 0.05).

Conclusions

Consistent with findings in adult care, Crohn's Colitis Care achieved more complete disease-data capture in pediatrics compared to a standard platform. Given that not all items were better recorded in the structured platform, work to understand and address barriers is needed to optimize complete data capture for care and research.

Proposal and exploration of a novel score to quantify patient-perceived burden of inflammatory bowel disease under routine care

BACKGROUND

The burden of inflammatory bowel disease (IBD) is often reported on from a system or cost viewpoint. We created and explored a novel patient-perceived burden of disease (PPBoD) score in a large Australasian cohort.

AIM

To create and explore a novel patient-perceived burden of disease (PPBoD) score in a large Australasian cohort, and correlate PPBoD scores with demographics, disease and treatment factors.

METHODS

The Crohn Colitis Care Registry was interrogated in October 2023. Data from adults with IBD with an outpatient care encounter in the last 14 months among 17 centres were included. A novel PPBoD score was designed for ulcerative colitis (UC), Crohn disease (CD) and IBD-unclassified (IBDU). Correlations between PPBoD scores and demographics, disease and treatment factors were examined.

RESULTS

Of those with adequate data, 46.7% (2653/5685) had no PPBoD, 34.6% (1969/5685) had mild, 11.3% (641/5685) had moderate and 7.4% (422/5685) had significant PPBoD. New Zealanders were more likely to have higher PPBoD compared to Australians (P = 0.047). Greater PPBoD was seen in patients with CD and IBDU compared to patients with UC (P < 0.001) and females were more likely to have significant PPBoD (8.7%) than males (6.1%) (P < 0.001). People with no or mild PPBoD were more likely to be on advanced therapies (55.7% and 59.5% respectively) than those with significant PPBoD (46.3%) (P < 0.001). The proportion of people on advanced therapies in Australia was higher than in New Zealand (61.2% vs 38.5% respectively, P < 0.001). Steroid usage was significantly higher in people with greater PPBoD (significant BoD 7.1% vs no BoD 1.1%; P < 0.001).

CONCLUSION

Most of this real-world care cohort had no or mild PPBoD. Data suggest that higher PPBoD levels may be resolved by appropriate therapeutic escalations.

Development of software for collecting cleft-specific data in Malaysia

BACKGROUND

The World Health Organization (WHO) has recommended the development of a cleft-specific database for collecting and analyzing data on patients with cleft from birth to adulthood. However, such a database currently does not exist in Malaysia. The objective of this study was to develop a cleft lip and/or palate (CL/P) database software for Malaysia to streamline data collection and support comprehensive research to enhance outcomes of care.

METHODS

The development of the database software involves several key stages, including determining the requirements, designing the software interface, implementing the system, conducting thorough testing, and completing comprehensive documentation. The database software was mainly developed internally within the research institution. The team involved in developing the clinical database includes cleft clinicians, software developers, software designers, members of the Cleft Lip and Palate Association Malaysia (CLAPAM), and experts in database development.

RESULTS

An online and offline database software has been developed to store information on patients with CL/P in Malaysia. It is designed to be user-friendly, accommodating multiple specialties and capable of storing photographs, radiology, and three-dimensional files. Various methods have been implemented to ensure data security. Additionally, documentation including video tutorials, consent forms, and hard copy versions has been developed to complement the database.

CONCLUSION

A specialized cleft-specific database software has been successfully developed for use in Malaysia to improve data management and support CL/P patient care.

Stomal calprotectin as a biomarker for assessing Crohn disease activity in patients with stomas

BACKGROUND

Faecal calprotectin is a reliable biomarker for lower gastrointestinal inflammation. However, there are limited data on the utility of calprotectin from stoma effluent.

AIM

The aim of this study was to determine the performance of stomal calprotectin in identifying Crohn disease activity in those with a stoma.

METHODS

Patients with Crohn disease and an ileostomy or colostomy were identified from three sites in Australia using a clinical management software. Disease activity was classified based on the presence of inflammation on imaging and/or endoscopy within 3 months of the sample. The primary outcome was the median stomal calprotectin in people with active versus inactive Crohn disease. Other clinical indices, such as C-reactive protein and Harvey Bradshaw Index, were evaluated as a surrogate biomarker for disease activity.

RESULTS

Thirty stomal calprotectin results were identified for 23 patients with paired investigations. Of 30 cases, six had active disease. The median stomal calprotectin in active versus inactive disease were 17 μg/g (interquartile range (IQR) 5-211) and 61 μg/g (IQR 19-105, P = 0.38) respectively. Accordingly, stomal calprotectin demonstrated poor sensitivity for active disease (33% at cut-off of 50 μg/g). C-reactive protein was higher for active disease (25, IQR 5-199) compared with inactive disease (5, IQR 2-17, P = 0.06), but there was no difference in the Harvey Bradshaw Index (9 (IQR 7-11) vs 5 (3-7), P = 0.10).

CONCLUSION

Stomal calprotectin did not reliably distinguish between active and inactive Crohn disease. C-reactive protein is a more reliable biomarker for disease activity in the setting of ileostomy/colostomy. Further prospective studies are needed to identify more robust biomarkers for detecting inflammation in stoma patients.

Pediatric to Adult Transition in Inflammatory Bowel Disease: Consensus Guidelines for Australia and New Zealand

BACKGROUND

The incidence of pediatric inflammatory bowel disease (IBD) is rising, and there is an increasing need to support adolescents when they transition to adult care. Evidence supports the use of a structured transition process but there is great variation across Australasia. The study aim was to develop evidence and expert opinion-based consensus statements to guide transitional care services in IBD.

METHODS

A modified UCLA-RAND methodology was employed to develop consensus statements. An IBD expert steering committee was formed and a systematic literature review was conducted to guide the drafting of consensus statements. A multidisciplinary group was formed comprising 16 participants (clinicians, nurses, surgeons, psychologists), who anonymously voted on the appropriateness and necessity of the consensus statements using Likert scales (1 = lowest, 9 = highest) with a median ≥7 required for inclusion. Patient support groups, including direct input from young people with IBD, informed the final recommendations.

RESULTS

Fourteen consensus statements were devised with key recommendations including use of a structured transition program and transition coordinator, mental health and transition readiness assessment, key adolescent discussion topics, allied health involvement, age for transition, and recommendations for clinical communication and handover, with individualized patient considerations. Each statement reached median ≥8 for appropriateness, and ≥7 for necessity, in the first voting round, and the results were discussed in an online meeting to refine statements.

CONCLUSIONS

A multidisciplinary group devised consensus statements to optimize pediatric to adult transitional care for adolescents with IBD. These guidelines should support improved and standardized delivery of IBD transitional care within Australasia.

Incidence of Inflammatory Bowel Disease in Canterbury, New Zealand, 2018-2023

BACKGROUND

New diagnoses of inflammatory bowel diseases (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), can highlight health system burden and potentially give clues to disease aetiology. This population-based study aimed to measure the annual incidence of IBD over six years (2018-2023) in the Canterbury region of New Zealand.

METHODS

The medical records from public and private gastroenterology clinics were examined for new patients with a confirmed diagnosis of IBD from 1 January 2018 to 31 December 2023. Demographic and disease information (including the Montreal phenotype) was gathered in a secure database. Information was collected prospectively from 2021 to 2023 and retrospectively from 2018 to 2020.

RESULTS

The incidence of IBD in 2023 was 30.1 per 100,000 person-years (95% CI 25.9-34.7), CD: 14.8 (95% CI 11.9-18.1), and UC: 14.5 (95% CI 11.7-17.7). The average age was 35.0 years (SD 17.2) and New Zealand European was the predominant ethnicity (83.4%), with smaller proportions of Māori (7.7%) and Pacific Islanders (1.7%). Between 2018 and 2023, the annual incidence of IBD was 32.4 per 100,000 person-years. The proportion of CD diagnosed each year decreased, and in 2023, the proportion of CD was equivalent (49%) to the proportion with UC.

CONCLUSIONS

The incidence of IBD in Canterbury remains high, and the rates appeared stable over the six years 2018-2023, consistent with the stabilizing incidence stage of the 4-stage epidemiological model of IBD. Māori and Pacific Island ethnicities contributed a small number of cases of IBD, but the rates of IBD in these groups were higher than in previous studies.

Review article: Measuring disease severity in inflammatory bowel disease - Beyond treat to target

BACKGROUND

Inflammatory bowel disease (IBD) follows a heterogenous disease course and predicting a patient's prognosis is challenging. There is a wide burden of illness in IBD and existing tools measure disease activity at a snapshot in time. Comprehensive assessment of IBD severity should incorporate disease activity, prognosis, and the impacts of disease on a patient. This review investigates the concept of disease severity in adults with IBD to highlight key components contributing to this.

METHODS

To perform this narrative review, a Medline search was conducted for full-text articles available at 1st March 2024 using search terms which encompassed disease activity assessment, disease severity, prognosis, natural history of Crohn's disease (CD) and ulcerative colitis (UC), and the burden of IBD.

RESULTS

Current methods of disease assessment in IBD have evolved from a focus on the burden of symptoms to one that includes inflammatory targets, genetic, serological, and proteomic profiles, and assessments of quality-of-life (QoL), disability, and psychosocial health. Longitudinal studies of IBD suggest that the burden of illness is driven by disease phenotype, clinical markers of complicated disease course (previous intestinal resection, corticosteroid use, perianal disease in CD, recent hospitalisations in UC), gut inflammation, and the impact of IBD on the patient.

CONCLUSIONS

Disease severity in IBD can be difficult to conceptualise due to the multitude of factors that contribute to IBD outcomes. Measurement of IBD severity may better encapsulate the full burden of illness rather than gut inflammation alone at a single timepoint and may be associated with longitudinal outcomes.

Development and investigation of a non-invasive disease severity index for inflammatory bowel disease

INTRODUCTION

The disease severity index (DSI) encapsulates the inflammatory bowel disease (IBD) burden but requires endoscopic investigations. This study developed a non-invasive DSI using faecal calprotectin (DSI-fCal) and faecal myeloperoxidase (DSI-fMPO) instead of colonoscopy.

METHODS

Adults with IBD were recruited prospectively. Baseline biomarker concentrations were used to develop DSI-fCal and DSI-fMPO, and these were correlated with the original DSI, IBD-symptoms, endoscopic activity, and quality-of-life (QoL). Area under the receiver-operating-characteristics curves (AUROC) assessed DSI-fCal/DSI-fMPO as predictors of clinical and biochemical remission at six months (symptom remission and fCal <150 μg/g, respectively), and a complicated IBD-course at 24 months (disease relapse needing escalation of biologicals/immunomodulators/recurrent corticosteroids, IBD-hospitalisations/surgeries). Multivariable logistic regression assessed the utility of DSI-fCal/DSI-fMPO in predicting a complicated IBD-course at 24 months.

RESULTS

In total, 171 patients were included (Crohn's disease=99, female=90, median age=46y (IQR 36-59)). DSI-fCal and DSI-fMPO correlated with the original DSI (r>0.9, p<0.001), endoscopic indices (r=0.45-0.49, p<0.001), IBD-symptoms (r=0.53-0.58, p<0.001) and QoL (r=-0.57-0.58, p<0.001). Baseline DSI-fCal (AUROC=0.79, 95% CI 0.65-0.92) and DSI-fMPO (AUROC=0.80, 95% CI 0.67-0.93) were associated with 6-month clinical and biochemical remission. DSI-fCal (AUROC=0.83, 95% CI 0.77-0.89) and DSI-fMPO (AUROC=0.80, 95% CI 0.73-0.87) performed similarly in predicting a complicated IBD-course to the original DSI (pdifference>0.05). The non-invasive DSI was independently associated with a complicated IBD-course on multivariable analyses (DSI-fCal28, aOR=6.04, 95% CI 2.42-15.08; DSI-fMPO25, aOR=7.84, 95% CI 2.96-20.73).

CONCLUSIONS

The DSI-fCal and DSI-fMPO perform similarly in prognosticating the longitudinal disease course as the original DSI, whilst avoiding a need for an endoscopic assessment.

Co-design and Consultation Ensure Consumer Needs Are Met: Building an eHealth Platform for Children with Inflammatory Bowel Disease

BACKGROUND

Crohn's Colitis Care is an adult inflammatory bowel disease eHealth system. Crohn's Colitis Care required additional pediatric functionality to enable life-long records and mitigate transition inadequacies.

AIM

This study describes and evaluates a consensus method developed to ensure consumer needs were met.

METHODS

Pediatric-specific functionality and associated resources considered important for inclusion were developed by a clinician consensus group. This group was divided into thematic subgroups and underwent two voting rounds. The content validity index was used to determine items reaching consensus. Children with inflammatory bowel disease and their parents were later shown a descriptive list of non-clinical inclusion topics proposed by the consensus group, and asked to vote on whether topic-related functionality and resources should be included.

RESULTS

The consensus process consulted 189 people in total (38 clinicians, 32 children with inflammatory bowel disease and 119 parents). There was agreement across all groups to incorporate functionality and resources pertaining to quality of life, mental health, self-management, and transition readiness; however, divergence was seen for general inflammatory bowel disease facts, your inflammatory bowel disease history, and satisfaction. Cost saw the greatest disparity, being less supported by consumers compared to clinicians. Over 75% of consumers agreed it would be okay for appointments to take longer for survey completion, and > 90% thought Crohn's Colitis Care should allow consumers to ask their treating team questions.

CONCLUSIONS

Widespread consumer co-design and consultation were important in unveiling differing perspectives to ensure Crohn's Colitis Care was built to support both consumer and clinician perspectives. Consumers collaborate to create a list of functionality and resources to be included in software (left), influencing the final product build (right).

Development of the Escalation of Therapy or Intervention (ETI) Calculator for Patients with Ulcerative Colitis Using ePROMs

BACKGROUND AND AIMS

Digital collection of patient-reported outcome measures [PROMs] is largely unexplored as a basis for follow-up for patients with ulcerative colitis [UC]. Our aim was to develop a model to predict the likelihood of escalation of therapy or intervention at an outpatient appointment that may be used to rationalize follow-up.

METHODS

TrueColours-IBD is a web-based, real-time, remote monitoring software that allows longitudinal collection of ePROMs. Data for prediction modelling were derived from a Development Cohort, guided by the TRIPOD statement. Logistic regression modelling used ten candidate items to predict escalation of therapy or intervention. An Escalation of Therapy or Intervention [ETI] calculator was developed, and applied in a Validation Cohort at the same centre.

RESULTS

The Development Cohort [n = 66] was recruited in 2016 and followed for 6 months [208 appointments]. From ten items, four significant predictors of ETI were identified: SCCAI, IBD Control-8, faecal calprotectin, and platelets. For practicality, a model with only SCCAI and IBD Control-8, both entered remotely by the patient, without the need for faecal calprotectin or blood tests was selected. Between 2018 and 2020, a Validation Cohort of 538 patients [1188 appointments] was examined. A 5% threshold on the ETI calculator correctly identified 343/388 [88%] escalations and 274/484 [57%] non-escalations.

CONCLUSIONS

A calculator based on digital, patient-entered data on symptoms and quality of life can predict whether a patient with UC requires escalation of therapy or intervention at an outpatient appointment. This may be used to streamline outpatient appointments for patients with UC.

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.

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.

Integration of mental health and quality of life screening tools in an inflammatory bowel disease-specific electronic medical record (Crohn Colitis Care): process and early outcomes

Psychological problems are prevalent in people with inflammatory bowel diseases but are not routinely addressed. To improve recognition, three psychological screening tools were integrated into clinical management software (Crohn Colitis Care). In the first 6 months, completion rates varied between participating sites, and approximately 23-34% of respondents scored in moderate or higher ranges for psychological distress. Evaluation of the clinical utility of the module to improve patient outcomes is recommended.

A Study of Cloud-Based Remote Clinical Care Technology

This paper uses cloud computing to build and design remote clinical care technology, and the study refines the evaluation approach for the elements and builds an evaluation prototype for the strategy, uses service design theory to improve the design of the service part of the assistive system, summarizes the list of requirements based on system design and service design, and designs a service design prototype. Through design practice, the detailed design of the software interaction interface and the auxiliary product of the care assistance system based on the prototype are investigated. Based on the user perspective, the strategy of meeting user expectations and improving user information literacy is proposed; based on the social network perspective, the strategy of establishing a long-term mechanism for smart medical operation and improving the information interaction network environment is proposed; and based on the system service perspective, the strategy of optimizing the system function design and innovating the service model is proposed. Compared with the traditional written patient handover, the application of MNIS under cloud computing can significantly shorten the handover time of surgical patients, improve the standardized rate of surgical safety verification execution and the qualified rate of nursing documents, while the rate of standardized application of prophylactic antibiotics is also significantly higher than that of the control group. The questionnaire survey of nursing staff in the operating room showed that clinical nursing staff was generally satisfied with the clinical application of MNIS under cloud computing, with an average satisfaction score of 64.5 to 11.3, and an average score of 3.58 to 0.54 for each item. Among them, pre-application training of MNIS, departmental support for MNIS, and its ease of verification in surgical patients were the three main factors favoring the clinical application of MNIS in the operating room with cloud computing, while barriers to wireless network connectivity, inconvenient PDA input, and small screen size were the three main drawbacks affecting its application. The determined clinical evaluation index system of MNIS in the operating room is innovative, which not only includes clinical care indicators but also covers general hardware and software indicators, which can effectively reflect the practical application capability of mobile terminal clinical and user experience feelings, and the evaluation index system is comprehensive.

Assessing effectiveness and patient perceptions of a novel electronic medical record for the management of inflammatory bowel disease

Background and Aim

There is an increasing prevalence of chronic disease worldwide, resulting in multiple management challenges. Inflammatory bowel disease (IBD) is an exemplar chronic disease requiring coordinated longitudinal care. We propose that Crohn's Colitis Care (CCCare), a novel IBD-specific, structured electronic medical record is effective at improving data capture and is acceptable to patients.

Methods

A comparison was made between IBD-data completeness in usual records and CCCare. CCCare's acceptability to patients was assessed in two independent IBD patient cohorts and included:• Overall ratings of acceptability.• Factors associated with pre-exposure acceptability ratings.• Whether exposure and security concerns influenced acceptability ratings.• Direct patient feedback through CCCare's patient portal.

Results

In all cases reviewed, there was data gain using structured CCCare fields compared with IBD documentation in usual medical records. The overall acceptability in the combined cohort (n = 310) was very high. More than three-quarters of patients rated acceptability as >7 of 10. Self-reported information technology (IT) literacy positively associated with acceptability. Exposure had a small positive affect on acceptability, whereas security concerns had little impact on acceptability. Patient portal feedback revealed that most patients are very likely to recommend CCCare to others (8.56 ± 2.2 [out of 10]).

Conclusion

CCCare is effective in supporting more complete IBD-specific data capture compared with usual medical records. It is highly acceptable to patients, especially those with reasonable IT literacy. Patient concerns about privacy and security of electronic medical records (EMRs) did not significantly affect acceptability.