Crohn's and Colitis Canada's 2021 Impact of COVID-19 and Inflammatory Bowel Disease in Canada: Health Care Delivery During the Pandemic and the Future Model of Inflammatory Bowel Disease Care

Unmet Healthcare Needs Among People with Inflammatory Bowel Disease: A Canadian Cross-Sectional Population-Representative Study

PURPOSE

Despite current standards of care, many people with inflammatory bowel disease (IBD) experience significant disease complications and gaps in care. To better understand and address unmet healthcare needs, we need population-level evidence on perceived unmet healthcare needs in people with IBD. Our objective was to compare self-reported unmet healthcare needs among individuals with and without IBD and determine whether accessing medical care attenuates such need.

METHODS

We used the 2014 Canadian Community Health Survey, a population-representative cross-sectional survey with a multi-stage cluster randomized design. We compared perceived unmet healthcare needs among individuals with and without IBD using multilevel logistic regression, clustering by respondents' health regions and accounting for sociodemographic variables and non-IBD chronic conditions. In a second model, we additionally controlled for access to medical care (family physician, specialists, and psychologists).

RESULTS

Eighteen percent of people with IBD (n = 114/632) reported an unmet healthcare need within the preceding 12 months, compared with 11% (n = 5446/53,333) of those without IBD (SMD: 0.18). Those with IBD were more likely to have an unmet healthcare need (adjusted OR: 1.84, 95% CI 1.19-1.85). Additionally adjusting for respondent-reported recent access to medical care slightly attenuated the association between IBD and unmet healthcare needs (adjusted OR: 1.38, 95% CI 1.10-1.72).

CONCLUSION

We provide a population-level perspective on unmet healthcare needs, demonstrating the extent and prominence of gaps in the healthcare provided to individuals living with IBD. Our findings underscore the need for improved access to multidisciplinary healthcare teams, and enhanced patient-physician dialog surrounding perceived healthcare needs.

Discrepancies in perceptions of well-being: comparing parental and pediatric PROMIS-patient-reported outcomes in Crohn's disease

BACKGROUND

This study aims to evaluate and compare the perspectives of pediatric Crohn's disease (CD) patients and their parents/caregivers concerning global physical, emotional, and social health as well as health-related quality of life (HRQQL), using both the Patient-Reported Outcomes Measurement Information System (PROMIS) and the IMPACT III questionnaire.

METHODS

In a cross-sectional study, 31 dyads of pediatric CD patients (aged 8-17 years) and their parents/caregivers were recruited from an outpatient Pediatric Gastroenterology Center. Participants completed PROMIS (Global Health, Depressive Symptoms, Anxiety, Meaning and Purpose Pain Interference Life Satisfaction, Peer Relationships, Physical Activity and Fatigue) and IMPACT III measures. Comparative analyses using t-tests and multivariate analyses assessed the impact of demographic factors on score differences. Cohen's Kappa analysis evaluated the alignment between parent and child perceptions of disease status.

RESULTS

The sample comprised 58% females with a mean age of 15.2 (± 2) years and a mean disease duration of 2.7 (± 2.7) years. Most patients were in disease remission (83.9%) and perceived their disease as better or unchanged in the past 6 months. Concerning PROMIS scores, parents reported significantly lower global health scores (p < 0.001) and higher meaning and purpose scores (p = 0.029) compared to their children. Parental education and professional status significantly influenced PROMIS score differences. Specifically, mothers with specialized professions showed smaller differences in PROMIS depression and pain interference, although greater differences in PROMIS meaning and purpose, as compared to their respective children's scores. Fathers with specialized professions demonstrated greater differences in PROMIS anxiety scores but smaller differences in PROMIS life satisfaction scores. A significant misalignment between parent and child subjective perceptions of disease status was observed (p = 0.004), suggesting that parents may overestimate symptom severity or underestimate improvements compared to their children's experiences.

CONCLUSION

This study highlights the importance of integrating patient and parental perspectives in the clinical management of pediatric CD. The observed discrepancies in disease-related perceptions, influenced by parental educational and professional background, underscore the need for comprehensive assessments to ensure accurate, patient-centered care. For broader generalization, further research should explore these dynamics in newly diagnosed and hospitalized patients.

Informing Modern Models of Care: A Randomized, Sequential Trial of In-Person, Telehealth, and Telephone Appointments for Patients with Inflammatory Bowel Disease

BACKGROUND

A significant shift toward virtual care has occurred for many patients with inflammatory bowel disease (IBD). To date, there are no prospective studies assessing patients visits across different styles of appointments.

METHODS

We randomized IBD patients' appointments to in-person, video-assisted virtual, or telephone and subsequent appointments to the alternate style of visit in a single-center study in Victoria, Canada. Participants completed surveys after each appointment. Demographic data were collected and average scores were analyzed for potential associations.

RESULTS

Forty-one patients were randomized to appointments, and 86 post-appointment surveys were completed, 30 in-person, 29 telephone, and 27 telehealth. The average age was 46.5 ± 18 years and 59% were female. The overall patient score (out of ten) by appointment type was 9.1 ± 1.0 for in-person, 7.8 ± 2.1 for telephone, and 8.0 ± 2.6 for telehealth without a statistically significant difference. While there was only a near statistically significant preference for in-person appointments compared with telehealth p = 0.055, it was statistically significant when comparing with phone appointments p = 0.014. The highest rated factors for preference of an in-person appointment were optimal communication and interaction with care provider (86%). For patients who preferred telehealth or telephone appointments, the highest rated factors were time and cost savings (71%, 43% and 58%, 33%, respectively). In-person appointments were associated with a significantly higher cost (p < 0.01), and longer time commitment.

CONCLUSIONS

Despite the increased cost and time commitment, in-person appointments were highly rated particularly in comparison to phone appointments. Based on this research, providers can be better informed on factors contributing to patients' preferred appointment style.

The impact of the COVID-19 pandemic on HIV treatment gap lengths and viremia among people living with HIV British Columbia, Canada, during the COVID-19 pandemic: Are we ready for the next pandemic?

The SARS-CoV-2 (COVID-19) pandemic has impacted the care of people living with HIV (PLWH). This study aims to characterize the impact of the pandemic on the length of HIV treatment gap lengths and viral loads among people living with HIV (PLWH) in British Columbia (BC), Canada, with a focus on Downtown Eastside (DTES), which is one of the most impoverished neighbourhoods in Canada. We analyzed data from the HIV/AIDS Drug Treatment Program from January 2019 to February 2022. The study had three phases: Pre-COVID, Early-COVID, and Late-COVID. We compared results for individuals residing in DTES, those not residing in DTES, and those with no fixed address. Treatment gap lengths and viral loads were analyzed using a zero-inflated negative binomial model and a two-part model, respectively, adjusting for demographic factors. Among the 8982 individuals, 93% were non-DTES residents, 6% were DTES residents, and 1% had no fixed address during each phase. DTES residents were more likely to be female, with Indigenous Ancestry, and have a history of injection drug use. Initially, the mean number of viral load measurements decreased for all PLWH during the Early-COVID, then remained constant. Treatment gap lengths increased for all three groups during Early-COVID. However, by Late-COVID, those with no fixed address approached pre-COVID levels, while the other two groups did not reach Early-COVID levels. Viral loads improved across each phase from Pre- to Early- to Late-COVID among people residing and not residing in DTES, while those with no fixed address experienced consistently worsening levels. Despite pandemic disruptions, both DTES and non-DTES areas enhanced HIV control, whereas individuals with no fixed address encountered challenges. This study offers insights into healthcare system preparedness for delivering HIV care during future pandemics, emphasizing community-driven interventions with a particular consideration of housing stability.

The Impact of the COVID-19 Pandemic on Patients with Ulcerative Colitis: Results from a Global Ulcerative Colitis Narrative Patient Survey

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic created challenges related to disease management of patients with ulcerative colitis (UC).

METHODS

The UC Narrative COVID-19 survey was conducted from August to December 2021 among adults with UC from the United States, Canada, Japan, France, and Finland. Patients were questioned on disease management, health care access and experience, and preferences for interactions with their doctor. Data were analyzed descriptively.

RESULTS

In total, 584 patients qualified for and completed the survey. Compared with 2019, 25% experienced more flares during the pandemic (from early 2020). Most patients (88%) taking prescription medication were very/somewhat satisfied with their current treatment plan; 53% were hesitant to make changes during the pandemic. Factors that patients agreed helped control UC symptoms during the pandemic included fewer social outings (37%), working from home (29%), and less busy schedules (28%). Greater anxiety/stress (43%) and hesitancy to visit a hospital/office (34%) made the control of UC symptoms more difficult. Compared with 2019, more patients relied on certain alternative support systems during the pandemic. Patients who used in-person and virtual appointments were equally very satisfied/satisfied with the quality of care (both 81%). In-person appointments were preferred by 68% of patients when meeting a new doctor, 55% when experiencing a flare, and 52% for regular check-ups; 41% preferred virtual appointments for UC prescription refills.

CONCLUSION

During the pandemic, most patients were satisfied with their current UC treatment plan and access to care; more patients relied on certain alternative UC management support systems, and many were impacted by anxiety/stress.

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 2023 Impact of Inflammatory Bowel Disease in Canada: COVID-19 and IBD

The COVID-19 pandemic had a monumental impact on the inflammatory bowel disease (IBD) community. At the beginning of the pandemic, knowledge on the effect of SARS-CoV-2 on IBD was lacking, especially in those with medication-suppressed immune systems. Throughout the pandemic, scientific literature exponentially expanded, resulting in clinical guidance and vaccine recommendations for individuals with IBD. Crohn's and Colitis Canada established the COVID-19 and IBD Taskforce to process and communicate rapidly transforming knowledge into guidance for individuals with IBD and their caregivers, healthcare providers, and policy makers. Recommendations at the onset of the pandemic were based on conjecture from experience of prior viruses, with a precautionary principle in mind. We now know that the risk of acquiring COVID-19 in those with IBD is the same as the general population. As with healthy populations, advanced age and comorbidities increase the risk for severe COVID-19. Individuals with IBD who are actively flaring and/or who require high doses of prednisone are susceptible to severe COVID-19 outcomes. Consequently, sustaining maintenance therapies (e.g., biologics) is recommended. A three-dose mRNA COVID-19 vaccine regimen in those with IBD produces a robust antibody response with a similar adverse event profile as the general population. Breakthrough infections following vaccine have been observed, particularly as the virus continues to evolve, which supports receiving a bivalent vaccine booster. Limited data exist on the impact of IBD and its therapies on long-term outcomes following COVID-19. Ongoing research is necessary to address new concerns manifesting in those with IBD throughout the evolving pandemic.

The Experiences of Older Adults Living With Inflammatory Bowel Disease: A Scoping Review

The prevalence of inflammatory bowel disease is rising in persons older than 65 years. Although there is extensive literature on inflammatory bowel disease in older adults from a disease-related outcome, epidemiological, and treatment perspective, the older adult perspective on inflammatory bowel disease-related care needs and experiences is not well represented. This scoping review examines the existing literature regarding the care experiences of older adults living with inflammatory bowel disease. A systematic search was conducted using 3 concepts: older adults, inflammatory bowel disease, and patient experience. Seven publications met the inclusion criteria. Reported data include study design and methods, sample characteristics, and findings relevant to the research question. Two themes were identified: preferences for interactions with healthcare personnel and peer support networks, and barriers to accessing care for inflammatory bowel disease needs. An overarching concept across all studies was the need and request for individualized, patient-centered care where patient preferences are considered. This review highlights the need for more research on the older adult age group to guide evidence-informed practice that meets their individual inflammatory bowel disease care needs.

Declining Corticosteroid Use for Inflammatory Bowel Disease Across Alberta: A Population-Based Cohort Study

BACKGROUND AND AIMS

Corticosteroid-free remission is a primary treatment goal in IBD which may be achieved with greater use of anti-TNF therapy. We defined temporal trends of corticosteroid use, anti-TNF use, hospitalization and surgery in a prevalent IBD cohort within the province of Alberta, Canada.

METHODS

Health administrative data were used to identify medication dispensing, hospitalizations and surgery in individuals with IBD from 2010 to 2015. Temporal trends were calculated using log-binomial regression for medications and log-linear models for hospitalizations and surgery rates. Analyses were stratified based on geographic location.

RESULTS

Of 28890 individuals with IBD, 50.3% had Crohn's disease. One in six individuals (15.45%) were dispensed a corticosteroid. Corticosteroid use decreased in both metropolitan areas (AAPC -20.08%, 95% CI: -21.78 to -18.04) and non-metropolitan areas (AAPC -18.14%, 95% CI: -20.78 to -18.04) with a similar pattern for corticosteroid dependence. Corticosteroid dependence was more prevalent in UC vs. CD (P < 0.05), and in the pediatric IBD cohort (13.45) compared to the adult (8.89) and elderly (7.54) cohorts (per 100 prevalent population, P < 0.001). The proportion of individuals dispensed an anti-TNF increased over the study period (AAPC 12.58%, 95% CI: 11.56 to 13.61). Significantly more non-metropolitan versus metropolitan residing individuals were hospitalized for any reason, for an IBD-related, or IBD-specific indication (all P < 0.001) though the proportion requiring IBD surgery was similar between groups.

CONCLUSIONS

An increase in anti-TNF use corresponded to a decline in corticosteroid use and dependence in those with IBD. Inequities in IBD care still exist based on location and age.

The future of telemedicine and wearable technology in IBD

PURPOSE OF REVIEW

Telemedicine has quickly become an essential part of modern healthcare, particularly in the management of chronic conditions like inflammatory bowel disease. The purpose of this review is to describe the current use of telehealth, mobile applications and wearable devices in inflammatory bowel disease and potential future applications.

RECENT FINDINGS

Telemedicine was increasingly used during the Coronavirus Disease 2019 pandemic. Virtual consultations allowed clinical care to continue despite pandemic-related restrictions without compromising the quality of care for patients with inflammatory bowel disease (IBD). It also benefits patients who would not have access to care due to financial or geographical barriers. Mobile applications allow patients with IBD to record disease activity among other metrics, allowing for earlier healthcare provider intervention. Wearable devices are increasingly being explored to monitor physiological indicators of disease activity and flare.

SUMMARY

Telehealth and remote patient monitoring has been successfully integrated into the care of IBD patients. The advantages of these modalities include better access to specialist care and remote noninvasive disease monitoring. Careful consideration must be given to patient privacy, data protection and equitable access. These modalities have enormous potential to improve patient care through accurate consistent data collection and even the prediction of disease activity.