The Inflammatory Bowel Disease Medical Home: From Patients to Populations

White Paper: American Gastroenterological Association Position Statement: The Future of IBD Care in the United States-Removing Barriers and Embracing Opportunities

Despite incredible growth in systems of care and rapidly expanding therapeutic options for people with inflammatory bowel disease, there are significant barriers that prevent patients from benefiting from these advances. These barriers include restrictions in the form of prior authorization, step therapy, and prescription drug coverage. Furthermore, inadequate use of multidisciplinary care and inflammatory bowel disease specialists limits patient access to high-quality care, particularly for medically vulnerable populations. However, there are opportunities to improve access to high-quality, patient-centered care. This position statement outlines the policy and advocacy goals that the American Gastroenterological Association will prioritize for collaborative efforts with patients, providers, and payors.

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

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

The Pediatric Inflammatory Bowel Disease Medical Home: A Proposed Model

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

Frequency of Opioid Prescription at Emergency Department Discharge in Patients with Inflammatory Bowel Disease: A Nationwide Analysis

BACKGROUND & AIMS

Patients with inflammatory bowel disease (IBD) frequently experience chronic pain. Patients will often seek out care in the emergency department (ED) where short-term opioid use may be associated with potential treatment-related complications. We aimed to assess the rate and factors associated with opioid prescription in IBD patients discharged from the ED.

METHODS

We conducted a cross-sectional analysis of data collected in the US National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2006-2017. We determined the proportion of adult patients (≥18 years) with IBD prescribed an opioid in ED or at ED discharge. Logistic regression was used to evaluate predictors of opioid prescription. Time-trend analysis was performed to evaluate temporal patterns in opioid use. All analyses were adjusted for complex survey design.

RESULTS

We identified ∼965,000 weighted discharges from the ED for patients with IBD. In total, 51.9% [95% CI: 42.2% -61.6%] of visits resulted in opioid administration in ED and 35.3% [95% CI: 26.5% -45.2%] of IBD-related ED discharges were associated with an opioid prescription. IBD patients with moderate/severe pain (adjusted odds ratio aOR 5.06 [95% CI: 1.72 -14.90], p < 0.01) were more likely to receive opioids whereas older age (aOR 0.73 per decade [95% CI: 0.55 -0.98], p = 0.04) were less likely. In temporal analysis, a trend towards decreasing opioid use in ED and opioid prescriptions at discharge was observed in 2015-2017.

CONCLUSIONS

More than one third of IBD patients are prescribed an opioid at discharge from ED, highlighting a potential gap in care for accessing effective pain management solutions in this population.

A Narrative Review of Factors Historically Influencing Telehealth Use across Six Medical Specialties in the United States

Prior to the COVID-19 pandemic, studies in the US have identified wide variations in telehealth use across medical specialties. This is an intriguing problem, because the US has historically lacked a standardized set of telehealth coverage and reimbursement policies, which has posed a barrier to telehealth use across all specialties. Although all medical specialties in the US have been affected by these macro (policy-level) barriers, some specialties have been able to integrate telehealth use into mainstream practice, while others are just gaining momentum with telehealth during COVID-19. Although the temporary removal of policy (coverage) restrictions during the pandemic has accelerated telehealth use, uncertainties remain regarding future telehealth sustainability. Since macro (policy-level) factors by themselves do not serve to explain the variation in telehealth use across specialties, it would be important to examine meso (organizational-level) and micro (individual-level) factors historically influencing telehealth use across specialties, to understand underlying reasons for variation and identify implications for widespread sustainability. This paper draws upon the existing literature to develop a conceptual framework on macro-meso-micro factors influencing telehealth use within a medical specialty. The framework is then used to guide a narrative review of the telehealth literature across six medical specialties, including three specialties with lower telehealth use (allergy-immunology, family medicine, gastroenterology) and three with higher telehealth use (psychiatry, cardiology, radiology) in the US, in order to synthesize themes and gain insights into barriers and facilitators to telehealth use. In doing so, this review addresses a gap in the literature and provides a foundation for future research. Importantly, it helps to identify implications for ensuring widespread sustainability of telehealth use in the post-pandemic future.

Improved Smoking Cessation Rates in a Pharmacist-Led Program Embedded in an Inflammatory Bowel Disease Specialty Medical Home

BACKGROUND

Cigarette smoking is associated with disease progression, poor outcomes, and increased biologic use in Crohn's Disease (CD). In this prospective study, we describe the structure and results of a pharmacist-driven smoking cessation program in an Inflammatory Bowel Disease (IBD) Specialty Medical Home.

METHODS

One pharmacist designed and implemented a collaborative drug therapy management (CDTM) program, which allowed the pharmacist to initiate and modify smoking cessation aids, monitor medication safety and efficacy, and provide behavioral counseling. Crohn's Disease patients who were current smokers and referred to the program were analyzed. Clinical and demographic data, disease activity, and smoking history were collected. The primary outcome was the proportion of patients in the enrolled group and the declined group who quit smoking at least once during the follow-up period. Secondary outcomes include demographic and clinical differences between enrolled and declined patients, and enrolled quitters and non-quitters.

RESULTS

Thirty-two patients were referred to the program and 19 participated. Over a median follow-up period of 305 [264-499] days, 42% (8/19) of enrolled patients quit smoking at least once. Fifteen percent (2/13) of declined patients quit smoking. Patients who continued to smoke had more instances of loss of response to a biologic, need to start a new biologic, or escalation of biologic therapy. The CDTM pharmacist was able to provide all necessary clinical services for smokers enrolled in the program.

CONCLUSIONS

A pharmacist-led smoking cessation program in a specialty medical home is feasible. It may result in successful quit attempts and may optimize IBD medication use.

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

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

Healthcare use, work loss and total costs in incident and prevalent Crohn's disease and ulcerative colitis: results from a nationwide study in Sweden

BACKGROUND

There are limited data on population-wide assessment of cost in Crohn's disease (CD) and ulcerative colitis (UC).

AIM

To estimate the societal cost of actively treated CD and UC in Sweden.

METHODS

We identified 10 117 prevalent CD and 19 762 prevalent UC patients, aged ≥18 years on 1 January 2014 and 4028 adult incident CD cases and 8659 adult incident UC cases (2010-2013) from Swedish Patient Register. Each case was matched to five population comparators. Healthcare costs were calculated from medications, outpatient visits, hospitalisations and surgery. Cost of productivity losses was derived from disability pension and sick leave.

RESULTS

The mean annual societal costs per working-age patient (18-64 years) with CD and UC were $22 813 (vs $7533 per comparator) and $14 136 (vs $7351 per comparator), respectively. In patients aged ≥65 years, the mean annual costs of CD and UC were $9726 and $8072 vs $3875 and $4016 per comparator, respectively. The majority of cost for both CD (56%) and UC (59%) patients originated from productivity losses. Higher societal cost of working-age CD patients as compared to UC patients was related to greater utilisation of anti-TNF (22.2% vs 7.4%) and increased annual disability pension (44 days vs 25 days). Among incident CD and UC patients, the mean total cost over the first year per patient was over three times higher than comparators.

CONCLUSION

In Sweden, the societal cost of incident and prevalent CD and UC patients was consistently two to three times higher than the general population.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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