Patient and clinician preferences for surgical and medical treatment options in ulcerative colitis

Ileal pouch-anal anastomosis and end ileostomy result in equivalent graft survival following liver transplantation for inflammatory bowel disease-primary sclerosing cholangitis

INTRODUCTION

Patients with inflammatory bowel disease and primary sclerosing cholangitis may require both liver transplantation and colectomy. There are concerns about increased rates of hepatic artery thrombosis, biliary strictures, and hepatic graft loss in patients with ileal pouch-anal anastomosis compared to those with end ileostomy. We hypothesized that graft survival was not negatively affected by ileal pouch-anal anastomosis compared to end ileostomy.

MATERIALS AND METHODS

A tertiary center's database was searched for patients meeting the criteria of liver transplantation because of primary sclerosing cholangitis and total proctocolectomy with ileal pouch-anal anastomosis or end ileostomy because of ulcerative colitis. Primary endpoints were hepatic graft survival and post-transplant complications.

RESULTS

Fifty-five patients met the inclusion criteria between January 1990 and December 2022. Of these, 46 (84%) underwent ileal pouch-anal anastomosis, and 9 (16%) underwent end ileostomy. The average age at total proctocolectomy (41.5 vs. 49.1 years; p = 0.12) and sex distribution (female: 26.1% vs. 22.2%; p = 0.99) were comparable. The rates of re-transplantation (21.7% vs. 22.2%; p = 0.99), hepatic artery thrombosis (10.8% vs. 0; p = 0.58), acute rejection (32.6% vs. 44.4%; p = 0.7), chronic rejection (4.3% vs. 11.1%; p = 0.42), recurrence of primary sclerosing cholangitis (23.9% vs. 22.2%; p = 0.99), and biliary strictures (19.6% vs. 33.3%; p = 0.36) were similar between the ileal pouch-anal anastomosis and end ileostomy groups, respectively. None of the end ileostomy patients developed parastomal varices. The log-rank tests for graft (p = 0.97), recipient (p = 0.3), and combined graft/recipient survival (p = 0.73) were similar.

CONCLUSION

Ileal pouch-anal anastomosis did not negatively affect graft, recipient, and combined graft/recipient survival, or the long-term complications, compared to end ileostomy.

Three-stage versus modified two-stage surgery for ulcerative colitis: a patient-centred treatment trade-off study

AIM

There is ongoing debate about whether ileal pouch-anal anastomosis needs temporary diversion at the time of construction. Stomas may reduce risk for anastomotic leak (AL) but are also associated with complications, emergency department visits and readmissions. This treatment trade-off study aims to measure patients' preferences by assessing the absolute risk of AL and pouch failure (PF) they are willing to accept to avoid a diverting ileostomy.

METHODS

Fifty-two patients with ulcerative colitis, with or without previous pouch surgery, from Mount Sinai Hospital, Toronto, participated in this study. Standardized interviews were conducted using the treatment trade-off threshold technique. An online anonymous survey was used to collect patient demographics. We measured the absolute increased risk in AL and PF that patients would accept to undergo modified two-stage surgery as opposed to traditional three-stage surgery.

RESULTS

Thirty-two patients (mean age 38.7 ± 15.3) with previous surgery and 20 patients (mean age 39.5 ± 11.9) with no previous surgery participated. Patients were willing to accept an absolute increased leak rate of 5% (interquartile range 4.5%-15%) to avoid a diverting ileostomy. Similarly, patients were willing to accept an absolute increased PF rate of 5% (interquartile range 2.5%-10%). Younger patients, aged 21-29, had lower tolerance for PF, accepting an absolute increase of only 2% versus 5% for patients older than 30 (P = 0.01).

CONCLUSION

Patients were willing to accept a 5% increased AL rate or PF rate to avoid a temporary diverting ileostomy. This should be taken into consideration when deciding between modified two- and three-stage pouch procedures.

Patient preferences in treatment options of ulcerative colitis: a discrete choice experiment

INTRODUCTION

Since the number of medical treatment options for Ulcerative Colitis (UC) has expanded over the last decades, patients and physicians face challenges regarding decisions about the medication options. We aimed to identify patients' preferences about their UC treatment options in the Netherlands. Furthermore, we assessed after how many failed treatment options, patients are willing to consider surgical treatment.

METHODS

We conducted a web-based, multicenter, discrete choice experiment (DCE) among adult UC patients. Patients were repeatedly asked to choose between two hypothetical medicinal treatment options. The choice tasks were based on administration route, administration location, chance of symptom reduction (on short and long term) and chances on infection and other adverse events. Data were analyzed by using Hierarchical Bayes estimation.

RESULTS

A total of 172 UC patients participated in the DCE. More than half were anti-TNF experienced (52.9%). The chance of symptom reduction after one year (relative importance (RI) 27.7 (95% CI 26.0-29.4)) was most important in choosing between medicinal treatments, followed by the chance of infection (RI 22.3 (21.4 - 23.3)) and chance of symptom reduction after eight weeks (RI 19.5 (18.3 - 20.6)). Considering surgical treatment, nineteen patients (14.3%) would not even consider surgery after failing eight treatment options without any new available therapies left. Nine patients would consider surgery before trying any treatment options.

CONCLUSION

We found that symptom reduction after one year was the most important attribute in choosing between treatments in UC patients. These outcomes can help understand the trade-offs and preferences of UC patients.

What are the unmet needs and most relevant treatment outcomes according to patients with inflammatory bowel disease? A qualitative patient preference study

BACKGROUND AND AIMS

As more therapeutic options with their own characteristics become available for inflammatory bowel disease (IBD), drug development and individual treatment decision-making needs to be tailored towards patients' preferences and needs. This study aimed to understand patient preferences among IBD patients, and their most important treatment outcomes and unmet needs.

METHODS

This qualitative study consisted of 1) a scoping literature review, 2) two focus group discussions (FGDs) with IBD patients (n=11) using the nominal group technique, and 3) two expert panel discussions.

RESULTS

IBD patients discussed a multitude of unmet needs regarding their symptoms, side-effects, psychological and social issues for which they would welcome improved outcomes. Particularly, IBD patients elaborated on the uncertainties and fears they experienced regarding the possible need for surgery or an ostomy, the effectiveness and onset of action of their medication, and its long-term effects. Furthermore, participants extensively discussed the mental impact of IBD and their need for more psychological guidance, support, and improved information and communication with healthcare workers regarding their disease and emotional well-being. The following five characteristics were identified during the attribute grading as most important: prevent surgery, long-term clinical remission, improved quality of life (QoL), occurrence of urgency, and improved labor rate.

CONCLUSIONS

This study suggests that IBD drug development and treatment decision-making needs to improve IBD symptoms and adverse events that significantly impact IBD patients' QoL. Furthermore, this study underscores patients need for a shared decision-making process where their desired treatment outcomes and uncertainties are explicitly discussed and considered.

Acute Severe Colitis: The Need for Joint Management between Gastroenterologists and Surgeons

The management of hospitalized patients with acute, severe ulcerative colitis involves close coordination among a multidisciplinary team. For patients not improving on intravenous corticosteroids, surgical consultation should be sought. The remaining hospital course requires frequent communications between the gastroenterologist managing the medical aspects of care, and the colorectal surgeon involved in planning for potential surgery, to optimize patient outcomes. This comanagement includes joint decision-making around the timing of surgery, minimizing medications associated with postoperative morbidity, addressing nutritional and psychosocial aspects of the patient's condition, and planning for a coordinated postoperative course. In this review, we highlight these aspects of care and the need for coordination and communication between gastroenterologists and surgeons in the management of acute severe colitis.

AGA Technical Review on the Management of Moderate to Severe Ulcerative Colitis

A subset of patients with ulcerative colitis (UC) present with, or progress to, moderate to severe disease activity. These patients are at high risk for colectomy, hospitalization, corticosteroid dependence, and serious infections. The risk of life-threatening complications and emergency colectomy is particularly high among those patients hospitalized with acute severe ulcerative colitis. Optimal management of outpatients or inpatients with moderate to severe UC often requires the use of immunomodulator and/or biologic therapies, including thiopurines, methotrexate, cyclosporine, tacrolimus, TNF-α antagonists, vedolizumab, tofacitnib, or ustekinumab, either as monotherapy or in combination (with immunomodulators), to mitigate these risks. Decisions about optimal drug therapy in moderate to severe UC are complex, with limited guidance on comparative efficacy and safety of different treatments, leading to considerable practice variability. Therefore, the American Gastroenterological Association prioritized development of clinical guidelines on this topic. To inform the clinical guidelines, this technical review was completed in accordance with the Grading of Recommendations Assessment, Development and Evaluation framework. Focused questions in adult outpatients with moderate to severe UC included: (1) overall and comparative efficacy of different medications for induction and maintenance of remission in patients with or without prior exposure to TNF-α antagonists, (2) comparative efficacy and safety of biologic monotherapy vs combination therapy with immunomodulators, (3) comparative efficacy of top-down (upfront use of biologics and/or immunomodulator therapy) vs step-up therapy (acceleration to biologic and/or immunomodulator therapy only after failure of 5-aminosalicylates, and (4) role of continuing vs stopping 5-aminosalicylates in patients being treated with immunomodulator and/or biologic therapy for moderate to severe UC. Focused questions in adults hospitalized with acute severe ulcerative colitis included: (5) overall and comparative efficacy of pharmacologic interventions for inpatients refractory to corticosteroids, in reducing risk of colectomy, (6) optimal dosing regimens for intravenous corticosteroids and infliximab in these patients, and (7) role of adjunctive antibiotics in the absence of confirmed infections.

An Exploration of How Individuals with an Ostomy Communicatively Manage Uncertainty

Individuals with an ostomy (a surgical diversion of part of the digestive tract through the abdomen) face a variety of uncertainties, due to the chronic and anatomy-altering nature of living with an ostomy, as well as the perceived stigma attached to having one. However, little is known about how these individuals negotiate uncertainty, and more specifically, how they manage the information they receive and disclose in the uncertainty management process. Thus, through 21 semi-structured interviews of individuals with an ostomy and the use of Uncertainty Management Theory as a theoretical framework, the current study found individuals with an ostomy attempted to negotiate uncertainty by managing information received and disclosed and by adapting to chronic uncertainty. This investigation recommends practical applications for medical professionals, supportive others, patients with an ostomy, as well as future surgical candidates to help manage uncertainty.

Development and evaluation of a patient decision aid for patients considering ongoing medical or surgical treatment options for ulcerative colitis using a mixed-methods approach: protocol for DISCUSS study

INTRODUCTION

Approximately 20%-30% of patients with ulcerative colitis (UC) require surgery, the majority of these being elective due to chronic symptoms refractory to medical treatment. The decision for surgery is difficult and dependent on patient preferences. Current resources for patients considering surgery have been found not to meet minimum international standards. The overall aim of the 'DISCUSS' study is to develop and evaluate a new patient decision aid (PtDA) for patients considering surgery for UC created in line with international minimum standards.

METHODS AND ANALYSIS

This is a prospective mixed-methods study of adults (18+ years) who are considering surgical intervention for UC across two regional centres in Yorkshire, UK. This study is in three stages. In stage 1 we will develop the PtDA and its content via systematic reviews and a patient questionnaire. In stage 2 we will assess the face validity of the PtDA using mixed-methods on key stakeholders using both semistructured interviews and questionnaires, following which the PtDA will be refined. In stage 3 we will assess the acceptability of using the PtDA in clinical practice. This will use a mixed-methods approach on clinicians and patients who are considering undergoing elective surgery. Questionnaires including the Preparation for Decision-Making Scale, a measure of anxiety and decisional conflict will be analysed at two timepoints using paired sample t-tests and CIs. Interviews with patients and clinicians will be analysed using thematic analysis.

ETHICS AND DISSEMINATION

Research ethics approval from North East-Tyne & Wear South Research Ethics Committee (Ref: 19/NE/0073) and Health Research Authority approval (Ref: 257044) have been granted. Results will be published in open access peer-reviewed journals, presented in conferences and distributed through the Crohn's and Colitis UK charity. External endorsement will be sought from the International Patient Decision Aid Standards Collaboration inventory of PtDAs.

PROSPERO REGISTRATION NUMBER

CRD42018115513, CRD42019126186, CRD42019125193.

Ulcerative Colitis: Shifting Sands

Ulcerative colitis (UC) is a chronic inflammatory bowel disease associated with considerable disease burden. We review some current misconceptions about UC in adults with the aim of optimizing care for patients. Although UC and Crohn's disease (CD) are considered discrete diseases, distinctions between them are not always clear-cut and phenotypes may change over time. Patient management should take into account disease manifestations, disease severity and extent, and response to prior treatments. Although disease extent often defines severity, distal UC is not always less disabling than extensive disease as patients can progress to more extensive disease. In addition, severe proctitis can give rise to severe and debilitating symptoms, with a substantial impact on health-related quality of life. UC carries an increased risk of colorectal cancer (CRC) compared with CD; however, more recent data indicate a similar risk of CRC in CD with colonic involvement as with UC. Corticosteroids are widely used to induce remission in UC, and prolonged use of steroids in patients with UC is common, but corticosteroid-free maintenance of remission is an important therapeutic goal. Although biologic therapies provide a valuable treatment option in UC, they are not clinically effective in all patients and are also associated with secondary loss of response.

Patient and physician preferences for ulcerative colitis treatments in the United States

Purpose: This study aimed to elicit patient and physician preferences for ulcerative colitis (UC) treatments in the United States (US).

Patients and methods: The following UC treatment attributes included in the discrete-choice experiment (DCE) were identified during qualitative interviews with both patients and physicians: time to symptom improvement, chance of long-term symptom control, risks of serious infection and malignancy, mode and frequency of administration, and need for steroids. The DCE survey instruments were developed and administered to patients and physicians. A random-parameters logit model was used to estimate preference weights and conditional relative importance for these attributes.

Results: A total of 200 patients with moderate to severe UC (status determined using self-reported medication history) and 200 gastroenterologists completed the survey. Patients’ average age was 42 years; most (59%) were female. Patients considered symptom control 2.5 times as important as time to symptom improvement and 5-year risk of malignancy almost as important as long-term symptom control (relative importance, 0.79 vs 0.96 for long-term symptom control); they preferred oral to subcutaneous or intravenous administration (relative importance, 0.47 vs 0.11 and 0.18, respectively). For physicians, symptom control was the most important attribute and was five times as important as the risk of malignancy.

Conclusion: Both patients and physicians considered long-term symptom control the most important attribute relative to others; however, risk of malignancy was of almost-equal importance to patients but not physicians. Differences between patients’ and physicians’ preferences highlight the need for improved communication about the relevant benefits and risks of different UC treatments to improve therapeutic decision-making.

Eliciting stakeholder preferences for patient-centered research

BACKGROUND

Rather than identifying exposures and outcomes for research solely based on interests of medical professionals, there is a need for research that answers questions that are important to patients, so that they may make treatment decisions based on evidence that reflect their individual preferences.

OBJECTIVE

To identify exposures and outcomes of interest that could be studied with electronic health record data from inpatient care.

DESIGN SETTING PARTICIPANTS

Mixed-methods analysis of semi-structured interviews administered in 2017 to 76 patients and 26 physicians who receive or provide care at Beth Israel Deaconess Medical Center in Boston, MA.

MEASUREMENTS

After conducting detailed semi-structured interviews about topics of interest that can be studied using electronic health records of inpatient care, we used an inductive approach to identify themes about the health care experience.

RESULTS

Participants reported concerns about adverse effects of medication changes, drug interactions, and surgery and other invasive procedures. The outcomes of greatest concern to them were in-hospital deaths and hospital-acquired infections. Participants commented on the importance of clear communication and information transfers, the hospital environment, accurate skills and knowledge, and upholding patient dignity and respect.

CONCLUSION

Engaging patients and physicians in the research development process provided insight to the exposures and outcomes they consider important. Our questions about exposures and outcomes of interest were restricted to topics that could be studied with electronic health record data from inpatient care, but using a similar approach to elicit feedback about the health care experience could be used to glean insight for other areas of future research.

Factors that Influence Treatment and Non-treatment Decision Making Among Individuals with Inflammatory Bowel Disease: An Integrative Review

Inflammatory bowel disease (IBD) is a chronic illness with periods of varying disease activity called flares and remissions. Since IBD impacts quality of life, patients make IBD disease management decisions every day. Previous research indicates limited insight about factors that influence decisions regarding disease management and the types of decisions IBD patients make. The purpose of this integrative review is to identify types of treatment and non-treatment decisions and the factors that influence decision making regarding disease management among individuals with IBD. An integrative literature review was performed based on the Whittemore and Knafl framework. PubMed, Web of Science, and PsychINFO were searched for relevant articles, from 2010-2016, using the key terms: decision making, patient preferences, self-management, self-care, nutrition, diet, stress, symptom, Colitis, Crohns, and IBD. Twenty-eight articles met the inclusion criteria. From these, research showed two types of decisions: treatment decisions related to medication and surgery, and non-treatment decisions focused on diet modification. Five themes that influence decisions were identified: experiencing symptoms, provider recommendations, convenience attributes, psychosocial factors, and informational needs. Most of the studies found a positive relationship between an increased number of symptoms and a patient's willingness to engage in treatment decisions. Although support from providers is highly influential for treatment decisions, most studies reported that provider recommendations did not align with patient preferences. Future work is needed to understand factors that influence decisions among recently diagnosed patients, to focus on non-treatment-related decisions, and to clarify the role of psychosocial factors in promoting disease decision making among IBD patients. This integrative review identified that, for patients, experiencing symptoms is the most important factor that influences treatment and non-treatment decisions.

The impact of ileal pouch-anal anastomosis on graft survival following liver transplantation for primary sclerosing cholangitis

BACKGROUND

Liver transplantation is the only life-extending intervention for primary sclerosing cholangitis (PSC). Given the co-existence with colitis, patients may also require colectomy; a factor potentially conferring improved post-transplant outcomes.

AIM

To determine the impact of restorative surgery via ileal pouch-anal anastomosis (IPAA) vs retaining an end ileostomy on liver-related outcomes post-transplantation.

METHODS

Graft survival was evaluated across a prospectively accrued transplant database, stratified according to colectomy status and type.

RESULTS

Between 1990 and 2016, 240 individuals with PSC/colitis underwent transplantation (cumulative 1870 patient-years until first graft loss or last follow-up date), of whom 75 also required colectomy. A heightened incidence of graft loss was observed for the IPAA group vs those retaining an end ileostomy (2.8 vs 0.4 per 100 patient-years, log-rank P = 0.005), whereas rates between IPAA vs no colectomy groups were not significantly different (2.8 vs 1.7, P = 0.1). In addition, the ileostomy group experienced significantly lower graft loss rates vs. patients retaining an intact colon (P = 0.044). The risks conferred by IPAA persisted when taking into account timing of colectomy as related to liver transplantation via time-dependent Cox regression analysis. Hepatic artery thrombosis and biliary strictures were the principal aetiologies of graft loss overall. Incidence rates for both were not significantly different between IPAA and no colectomy groups (P = 0.092 and P = 0.358); however, end ileostomy appeared protective (P = 0.007 and 0.031, respectively).

CONCLUSION

In PSC, liver transplantation, colectomy + IPAA is associated with similar incidence rates of hepatic artery thrombosis, recurrent biliary strictures and re-transplantation compared with no colectomy. Colectomy + end ileostomy confers more favourable graft outcomes.

Health State Utility Values for Ileostomies and Colostomies: a Systematic Review and Meta-Analysis

BACKGROUND

Ileostomies and colostomies may affect the quality of life of patients after colorectal surgery; however, the impact has been difficult to quantify using questionnaire-based measures. Utilities reflect patient preferences for health states and provide an alternate method of quality of life assessment. We aimed to systematically review the literature on utilities for ileostomy and colostomy health states.

METHODS

We searched MEDLINE, EMBASE, and EBM Reviews (to August 16, 2017) to identify studies reporting utilities for colostomies or ileostomies using direct or indirect, preference-based elicitation tools. We categorized utilities based on elicitation group (patients with stoma, patients without stoma, healthcare providers, general population) and tool. We pooled utilities using random effects models to determine mean utilities for each elicitation group and tool.

RESULTS

We identified ten studies reporting colostomy utilities and three studies reporting ileostomy utilities. Utilities were most commonly obtained using direct elicitation measures administered to individuals with an understanding of the health state. Patients with stomas and providers gave high utility ratings for the colostomy state (range 0.88-0.92 and 0.86-0.92, respectively, using direct elicitation tools). Ileostomy utilities obtained from patients following surgery and from providers also demonstrated high values placed on the ileostomy health state (range 0.88-1.0).

CONCLUSIONS

Following stoma surgery, values placed on quality of life are similar to those obtained from patients with conditions such as asthma and allergies or individuals of similar age without chronic conditions. This confirms the findings of questionnaire-based studies, which report minimal long-term decrements to overall quality of life among stomates.

Exploration of Predictive Biomarkers of Early Infliximab Response in Acute Severe Colitis: A Prospective Pilot Study

BACKGROUND

The outcomes of acute severe ulcerative colitis [ASUC] appear to be dependent on early intervention with the first and/or further infliximab [IFX] doses, although parameters to guide decision-making remain uncertain.

AIM

To assess whether serum/faecal IFX levels and inflammatory biomarkers early after IFX dose can predict ASUC outcomes.

METHODS

This prospective pilot study consecutively recruited inpatients with steroid-refractory ASUC, who then received 1-3 IFX rescue doses [5 mg/kg per dose] at the discretion of the treating clinician. Serum IFX, C-reactive protein [CRP], albumin and faecal calprotectin [FC] concentrations were measured daily as an inpatient, and then 7, 14, 28 and 42 days post-first IFX. Faecal IFX was measured 1 day post-IFX. The primary end point was clinical remission (partial Mayo [PM] = 0) and CRP ≤3 mg/l at 6 weeks. Secondary end points were 12-week clinical remission or colectomy during follow-up.

RESULTS

Of 24 ASUC patients with a median follow-up of 28 months [range 13-44], 10 [42%] achieved remission at 6 weeks, 12 [50%] achieved 12-week remission, six [25%] had colectomy. In total, 97% received either two or three IFX doses. Post-first dose, receiver-operator curve-derived cutoffs of the area-under-curve [AUC, Days 4-7] concentrations for serum IFX, FC and PM scores each predicted the primary end point with 100% sensitivity, and predicted future colectomy with 89-94% sensitivity. In multivariate analyses, faecal IFX >1 µg/g (odds ratio [OR] 0.04 [0.2, 0.9]), PM AUCd1-3 < 20 (OR 20.2 [1.01, 404], each P < 0.05), FC AUCd1-3 < 10000 µg/ml [OR 13.6 [0.6, 294], trend only, p = 0.09) were each associated with clinical and CRP remission [6 weeks].

CONCLUSIONS

In ASUC, post-first dose IFX, early assessment of serum/faecal IFX, calprotectin and PM scores can accurately predict future remission and colectomy, and thus potentially aid in decision-making, i.e. accelerated IFX dosing or surgical planning if/when needed.

Patient Decision-Making About Emergency and Planned Stoma Surgery for IBD: A Qualitative Exploration of Patient and Clinician Perspectives

BACKGROUND

Many inflammatory bowel disease (IBD) patients worry about stoma-forming surgery (SFS), sometimes enduring poor bowel-related quality of life to avoid it. Anticipation of SFS and whether expectations match experience is underreported. This qualitative study explored influences on patients' SFS decision-making and compared preoperative concerns with postoperative outcomes.

METHODS

We purposively recruited participants with IBD from UK hospital outpatient and community sources, and IBD clinicians from public hospitals. Four focus groups, 29 semistructured patient participant interviews, and 18 clinician interviews were audio recorded, transcribed, and analysed thematically. Participants had a current temporary, recently-reversed, or permanent stoma, or were stoma naive.

RESULTS

Four themes emerged: Preoperative concerns and expectations, Patient decision-making, Surgery and recovery, and Long-term outcomes. Participants and clinicians agreed about most preoperative concerns, that outcomes were often better than expected, and support from others with a stoma is beneficial. Patient decision-making involves multiple factors, including disease status. Some clinicians avoid discussing SFS, and the phrase 'last resort' can bias patient perceptions; others recommend early discussion, increasing dialogue when medical management becomes ineffective. The postoperative period is particularly challenging for patients. Stoma acceptance is influenced by personal perceptions and pre- and postoperative clinical and social support.

CONCLUSION

Patients need balanced information on all treatment options, including surgery, from an early stage. Early multidisciplinary team dialogue about SFS, and contact with others living well with a stoma, could enable informed decision-making. Life with a stoma is often better than anticipated, improving quality of life and control. Ongoing specialist nursing support aids recovery and adjustment.

The Informational Needs and Preferences of Patients Considering Surgery for Ulcerative Colitis: Results of a Qualitative Study

BACKGROUND

Patients considering surgery for ulcerative colitis (UC) face a difficult decision as surgery may or may not improve quality of life. National Institute for Health and Care Excellence guidelines for UC emphasize the importance of providing quality preoperative information to patients but note no quality studies for the desired content of this information. Our aim was to explore patient information preferences prior to undergoing surgery for ulcerative colitis.

METHODS

Semistructured interviews with patients who underwent an operation and patients who considered but declined an operation were conducted. Interviews explored informational preferences, with emphasis on preoperative information given, preoperative information desired but not received, and retrospective informational desires. Interviews were transcribed and coded using an inductive thematic analysis using NVivo software. Data saturation was assessed after 12 interviews, with interviews continuing until saturation was achieved. Ethical approval was gained prior to interviews commencing (16/NW/0639).

RESULTS

A total of 16 interviews were conducted before data saturation was achieved (male n = 7, female n = 9). Eight patients declined surgery, and 8 opted for subtotal colectomy with permanent end ileostomy (n = 5) or ileoanal pouch (n = 3). A total of 4 themes and 14 subthemes were identified. Three dominant subthemes of informational shortcomings emerged: "long-term effects of surgery," "practicalities of daily living," and "long-term support." Peer support was desired by patients but was infrequently supported by health care professionals.

CONCLUSIONS

Current preoperative information does not address patient informational needs. Surgical consultations should be adapted to suit patient preferences. Clinical practice may need to be altered to ensure that patients are better supported following surgery.

Surgery versus Antibiotics for Uncomplicated Appendicitis: Which Would a Medical Student Want?

BACKGROUND

Recent data suggest that treatment of acute, uncomplicated appendicitis (AUA) with antibiotics is as effective as surgery. A 2015 study indicated that more than 50% of patients would choose antibiotic therapy. Medical students represent a unique population of potential patients with greater medical knowledge than the general public and possibly less bias than practicing physicians. Therefore, we aimed to evaluate what the MEDICAL STUDENT'S treatment choice for AUA would be and what factors influence these decisions.

METHODS

We conducted a survey of current medical students at a single institution. Survey data included demographics, interest in surgery or a procedure-related specialty, knowledge of and experience with surgery and antibiotics, and concerns about treatments. A summary of the literature regarding the efficacy and safety of antibiotics and surgery was presented. Each participant was asked which treatment he or she would choose if affected by AUA.

RESULTS

A series of 255 medical students completed the survey (mean age 24.8 ± 2.4 y; 51.5% female). The largest number of respondents (41.2%) were second-year students, and more than half (54.2%) reported an interest in a procedure-related specialty. Nearly all (93%) reported prior antibiotic use (19% reporting adverse effects), and 50% had prior surgery (20% reporting adverse events). When asked to identify concerns about each treatment choice, "surgical complications" was selected most frequently (82%) for surgery, and "adverse events and side effects" was selected most frequently for antibiotics (57%). When asked how they would treat their own AUA, 66.3% selected surgery, 24.3% selected antibiotics, and 9.4% were unsure. Race, gender, specialty of interest, year of training, and history of adverse effects related to antibiotics or surgery were not significantly related to treatment choice (all p > 0.1).

CONCLUSION

When informed of the benefits and risks of surgery and antibiotics to treat AUA, medical students in our study were more likely to choose surgery.

Insights into variations in preferred selection criteria for acute stroke endovascular therapy

Background

Endovascular thrombectomy (ET) is safe, effective, and cost-effective for large artery occlusion ischemic stroke, even if under different selection criteria.

Purpose

To study the preferences for ET selection criteria by surveying clinicians and consumers, where number needed to treat to achieve functional independence is the only factor being considered.

Methods

A survey providing visual representation of the proportion of patients treated and expected functional outcomes, based on the selection criteria in each of the recent randomized trials of ET, was distributed nationwide in Australia and New Zealand to clinicians and consumers. The preferred selection criteria were identified by the frequency of first choice and using decision-analysis techniques to assess consensus by treating respondents as a panel of experts and aggregating their preferences on selection criteria.

Results

104 clinicians and 107 consumer respondents (43/107 (40%) stroke survivors) took part in the study. Selection criteria of EXTEND-IA were ranked as the most preferred by the consensus process analysis and were the first choice of 64 individual clinicians (61.5%; 95% CI 52% to 71%). ESCAPE trial selection criteria were ranked as the most preferred option and chosen by 42 individual consumers (39%; 95% CI 29% to 48%). Most clinicians based their choice on the ratio of patients benefiting from ET, while consumers considered the absolute number of patients benefiting.

Conclusions

Consumers favor maximization of the absolute number achieving good outcome in comparison with clinicians. This finding suggests that less restrictive criteria may be favored in clinical practice.

A Systematic Review of Internet Decision-Making Resources for Patients Considering Surgery for Ulcerative Colitis

BACKGROUND

Guidance from the Royal College of Surgeons advocates patient use of on-line resources to assist in decision making. Our aim was to assess the quality of on-line resources to facilitate decision making for patients considering surgery for ulcerative colitis (UC).

METHODS

We undertook a systematic review based on PRISMA guidelines. This was registered on the PROSPERO database (CRD42016047177). We searched Google and repositories using several lay search terms for patient information discussing surgery for UC, published in English. Quality of content on websites was assessed using the validated DISCERN instrument and by minimum standards for decision aids (IPDASi v4.0 checklist). Decision aids were also assessed by the IPDAS checklist. Readability of written content was ascertained using the Flesch-Kincaid score.

RESULTS

Our searches identified 175 websites and one decision aid-119 results were excluded at initial screen and 32 were excluded at full text assessment, leaving 25 sources for review. The mean Flesch-Kincaid score for websites was 44.9 (±9.73, range 28.1-61.4), suggesting material was difficult to read. No websites compared surgery to medical management or traded off patient preferences. The median IPDAS score was 5/12 (range 1-7). The median global score based on the DISCERN rating was 1/5 (range 1-5), identifying most websites as poor quality. The decision aid scored 9/12 on the IPDAS checklist, not meeting minimum standards.

CONCLUSIONS

Available information for patients considering surgery for UC is generally low quality. The development of a new decision aid to support patients considering surgery for UC is recommended.

Assessing internet-based information used to aid patient decision-making about surgery for perianal Crohn's fistula

BACKGROUND

Decision-making in perianal Crohn's fistula (pCD) is preference sensitive. Patients use the internet to access healthcare information. The aim of this study was to assess the online information and patient decision aids relating to surgery for pCD.

METHODS

A search of Google™ and the Decision Aids Library Inventory (DALI) was performed using a predefined search strategy. Patient-focussed sources providing information about pCD surgery were included in the analysis. Written health information was assessed using the International Patient Decision Aids Standards (IPDAS) and DISCERN criteria. The readability of the source content was assessed using the Flesch-Kincaid score.

RESULTS

Of the 201 sources found, 187 were excluded, leaving 14 sources for analysis. Three sources were dedicated to pCD, and six sources mentioned pCD-specific outcomes. The most common surgical intervention reported was seton insertion (n = 13). The least common surgical intervention reported was proctectomy (n = 1). The mean IPDAS and DISCERN scores were 4.43 ± 1.65 out of 12 (range = 2-8) and 2.93 ± 0.73 out of 5 (range = 1-5), respectively. The mean reading ease was US college standard.

CONCLUSIONS

We found no patient decision aids relating to surgery for pCD. The online sources relating to surgery for pCD are few, and their quality is poor, as seen in the low IPDAS and DISCERN scores. Less than half of the sources mentioned pCD-specific outcomes, and three sources were solely dedicated to providing information on pCD. Healthcare professionals should look to create a patient tool to assist decision-making in pCD.

Colectomy rates in patients with ulcerative colitis following treatment with infliximab or ciclosporin: a systematic literature review

This review aimed to compile all available published data on colectomy rates following treatment using infliximab or ciclosporin in adult ulcerative colitis patients and to analyse colectomy rates, timing to colectomy and postcolectomy mortality for each treatment. We systematically reviewed the literature after 1990 reporting colectomy rates in ulcerative colitis patients treated with infliximab or ciclosporin, excluding articles on paediatric patients, patients with indeterminate colitis or Crohn's disease and bowel surgery not related to ulcerative colitis. We presented weighted mean colectomy rates and mortality rates. Cox's regression was used to assess time to colectomy adjusting for colitis severity, patient age and sex. We tabulated 78 studies reporting on ciclosporin and/or infliximab and colectomy rates or postcolectomy mortality rates. Not all studies reported data in a standardized manner. Infliximab had a significantly lower colectomy rate than ciclosporin at 36 months when analysing all studies, studies directly comparing infliximab and ciclosporin and studies using severe colitis patients, but not at 3, 12 or 24 months. Severity and age were key indicators in the likelihood of undergoing colectomy after treatment. Postcolectomy mortality rates were less than 1.5% for both drugs. This review indicates that long-term colectomy rates following infliximab are significantly lower than ciclosporin in the longer term, and that postcolectomy mortality following infliximab and ciclosporin is very low. However, many key data items were missing from research articles, reducing our ability to establish with more confidence the actual impact of these two drugs on colectomy rates and postcolectomy mortality rates.

Long-term outcomes of colectomy surgery among patients with ulcerative colitis

The objective of this study was to evaluate long-term health-related quality of life outcomes among patients who had a colectomy within the previous 10 years. A cross-sectional survey was administered to consecutive patients ≥18 years of age with ulcerative colitis who had a colectomy within the last 10 years from centers in Canada, Australia, and the United Kingdom. Data were extracted from medical chart reviews to confirm selected self-reported patient characteristics. Of 351 survey respondents, 49 % were male and the median age was 40 years (interquartile range 30-52). Respondents were diagnosed with UC a median of 9.2 (5.7-15.1) years prior to the survey and first surgery occurred a median of 3.7 (2.1-5.8) years ago. Although most respondents (84 %) reported improved quality of life compared to the status before surgery, 81 % experienced problems in at least one of the following areas: depression, work productivity, restrictions in diet, body image, and sexual function. According to HADS scores, 30 and 17 % of survey respondents experienced anxiety and depression, respectively. Among moderate to severe UC patients pre-colectomy, 27 % of men and 28 % of women reported that their sexual life was worse now than before surgery. The mean EQ-5D utility index score overall was 0.79 (95 % confidence interval 0.77-0.81). Quality of life after colectomy for UC is generally good, but there are persistent quality of life issues that impact multiple domains, including psychological and sexual functioning.