A26 DECONSTRUCTING DISTRESS: STAKEHOLDER ENGAGEMENT FOR EVIDENCE-BASED, PATIENT-CENTERED INTERVENTIONS FOR THE MANAGEMENT OF IBD-ASSOCIATED PSYCHOLOGICAL DISTRESS

Background

The growing prevalence of Inflammatory Bowel Disease (IBD) along with increasing complexity of providing high-quality, patient-centered care within a resource-constrained healthcare environment presents a major challenge. IBD-related psychological distress (IBD-PD) is the emotional impact of IBD and is associated with mental health disorders, increased disease severity, and premature mortality. With estimates of nearly 90% of IBD patients experiencing PD, the inability to provide high-quality, person-centered care for IBD-PD that is proportionate to clinical need is a significant care gap in the Canadian healthcare system.

Aims

To generate stakeholder-derived data to inform the design and development of stepped-intensity, cognitive behavioral therapy-based interventions for IBD-PD using evidence-based, patient–centered interventions and implementation strategies.

Methods

Virtual semi-structured interviews were conducted from September to October 2021. The interview guide was developed iteratively by researchers, IBD care providers, and patient research partners and guided by the COM-B Model of Behaviour and the Theoretical Domains Framework. Questions assessed perceptions, experiences, barriers, and facilitators to accessing IBD-PD care. Adults diagnosed with IBD were recruited from academic centers across Canada. Interviews were co-facilitated by a researcher and patient research partner, audio recorded, and transcribed. Using thematic analysis, codes were generated to identify themes using an inductive approach.

Results

As of October 2021, six interviews have been completed, with data collection ongoing. The mean participant age was 34.3 years (range 21–55 years) with 100% of respondents being female. The majority of participants worked full time (4/6, 67%) and all had completed at least high school. Diagnoses of Crohn’s Disease (3/6, 50%) and ulcerative colitis (3/6, 50%) were evenly distributed. Thematic analyses identified five major themes: 1) Lack of holistic care and acknowledgement of IBD-PD; 2) System-level and financial barriers to psychological support; 3) Lack of psychological support from providers with an understanding of IBD; 4) Preference for individualized virtual-based support; 5) Heavy reliance on informal support structures (caregivers) due to lack of access to formal psychological support.

Conclusions

As part of human-centered design, stakeholder engagement is key to understanding behavioral, social, attitudinal, and environmental barriers and facilitators for accessing IBD-PD care. Interviews are ongoing and specific intervention functions will be defined and incorporated into patient-centered implementation strategies.

Funding Agencies

None

A96 RAPID IMPLEMENTATION OF AN EVIDENCE-BASED, VIRTUAL COVID-19 VACCINE EDUCATION CLINIC AT NOVA SCOTIA COLLABORATIVE INFLAMMATORY DISEASE CLINIC (NSCIBD)

Background

Rapid adaptation of clinical management as well as policy decisions in relation to implementation of COVID-19 vaccination programs for persons living with IBD has been required throughout the pandemic.

Aims

To meet the need for public health-mandated COVID-19 vaccine education for patients living with IBD in Nova Scotia a novel, evidence-based, virtual COVID-19 vaccine educational intervention was developed, implemented, and evaluated.

Methods

An observational, cross sectional, implementation-effectiveness study was conducted at the NSCIBD program between April and July, 2021. The educational intervention consisted of a standardized evidence-based letter describing risks and benefits of COVID-19 vaccine emailed to patients in advance of a virtual clinic appointment. Virtual appointments were offered to all patients contacting the NSCIBD program with questions or concerns about vaccination. During these virtual visits standardized, evidence-based information was provided by a gastroenterologist (n=2) or IBD nurse practitioners (n=2) and patients were provided with an opportunity to address specific disease and treatment related concerns. Following the session, a link to an anonymous questionnaire was distributed via email to evaluate key implementation metrics including satisfaction, appropriateness, usefulness, perceived impact on knowledge and vaccine hesitancy, and recommendations for improvement. Data analysis was descriptive. Group means were expressed as proportions for categorical variables and means for numerical variables.

Results

A total of 298 patients participated in a virtual patient education session of which 265 provided a valid email address and invited to participate in the on-line survey. The response rate was 49% (131/265). Before the session, 48.9% (64/131) expressed vaccine hesitancy. Twenty-six percent (35/131) expressed concerns relating to risks versus benefits of COVID-19 vaccines. Ninety-one percent (119/131) of respondents found the education program helpful. The proportion of those willing to get vaccinated rose from 61% (pre) to 86.3% (post). Only 1.5% (2/131) indicated they would not get vaccinated. Seventy-seven percent (101/131) found the written and virtually administered educational content to be satisfactory. Eighty-eight percent (115/131) of respondents were willing to participate in similar types of virtual education offerings in the future.

Conclusions

Implementation of an evidence-based, multidisciplinary, virtual COVID-19 vaccination education intervention was perceived to be feasible, acceptable, and effective by IBD patients. Further research on innovative, evidence-based, multidisciplinary educational interventions and the impact of these interventions on IBD clinical outcomes are needed.

Funding Agencies

None

A77 IMPLEMENTATION OF GUT LINK-IBS; RESULTS OF A SEMI-STRUCTURED INTERVIEW OF PRIMARY CARE PROVIDERS

Background

The Division of Digestive Care and Endoscopy in Halifax, Nova Scotia has had longstanding challenges with GI referral volume outstripping divisional capacity resulting in limited access to specialist care. Many referrals for functional bowel disorders (FBD) are returned to referring providers. Although this helps rationalize limited system resources, it often impairs access to appropriate and necessary GI care. The co-development and implementation of clinical care pathways across gastroenterology and primary care may help to improve access to high-quality GI care.

Aims

The project aimed to engage primary healthcare providers (PHCPs) to identify environmental and behavioral barriers and facilitators for managing undifferentiated lower GI disorders in primary care. Data generated from stakeholder engagement will be used to develop, implement, and evaluate strategies for referral and management of FBD. A real-world, functional clinical care pathway that supports the implementation of evidence-based practices in the diagnosis and management of functional GI conditions within primary care will enhance care and timely access to specialist.

Methods

This is a qualitative study using semi-structured interviews of PHCPs working in Nova Scotia. Interview questions were developed and guided by the evidence-based implementation science frameworks. Physicians were recruited through existing primary care networks. Participants were offered a Zoom™virtual semi-structured interview. A brief intake questionnaire was administered to collect baseline demographics. Interviews were recorded and transcribed for data analysis. Data were categorized into coding schemes and themes were created using an inductive coding approach.

Results

As of October 2021, 9 interviews have been conducted. Average participant age was 44 years, with the majority identifying practice in a group or collaborative care setting (n=7, 78%). Five worked in urban practice settings and the remainder in rural areas. Preliminary major themes included:

1. A lack of satisfaction with access to gastrointestinal care, with most physicians noting it to be worse than access to other specialist services.

2. Management of FBDs were felt to be within the scope of primary care practice

3. Access to diagnostic tests like fecal calprotectin with appropriate education on its use as a diagnostic tool would be useful.

4. PHCP’s suggested care pathways be easy to use, require minimal time, and ideally be implemented within their pre-existing EMR or in paper form.

Conclusions

PHCPs acknowledge a significant burden of undifferentiated lower GI complaints in their practice and poor access to gastroenterology services. All participants were open to helping develop and use a clinical care pathway for the investigation and management of undifferentiated lower GI symptoms. Data collection and analysis are ongoing.

Funding Agencies

None

A109 LINKING PRIMARY AND SPECIALTY CARE FOR THE MANAGEMENT OF DIGESTIVE HEALTH CONDITIONS: AN EVALUATION OF GUT LINK IMPLEMENTATION

Background

Severe restrictions on in-person encounters and endoscopic procedures for digestive care have occurred as a result of the COVID-19 pandemic. This has exacerbated pre-existing barriers in access to gastroenterology (GI) care across Nova Scotia (NS) for patients and primary healthcare providers (PHCPs). In response, a provincial PHCP-GI consultative service (GUT LINK) was implemented at a single tertiary care center with the goal of supporting PHCPs in the management of non-urgent GI referral conditions.

Aims

To implement and evaluate the acceptability, feasibility, appropriateness, and early effectiveness of the GUT LINK PHCP-GI consultation service.

Methods

This is an ongoing prospective observational cohort study. All referrals received through the EMR-based referral and triage management system between May and November 2020 that were deemed to be amenable to management within primary care with specialist support were returned to the PHCP with the suggestion to arrange a GUT LINK telephone consultation. GUT LINK appointments were scheduled through an administrative support telephone line with the PHCP and a GI specialist. A post-consultation e-questionnaire was distributed to PHCPs who consented to participate. Feasibility (number of and indication for referrals, PHCP participation rates), acceptability and appropriateness (satisfaction, future use, likelihood to recommend) metrics and outcomes (case resolution, re-referrals, proportion requiring endoscopic investigations) were recorded. Patient charts were reviewed to determine whether the patient ultimately required GI speciality care. Analyses were descriptive and expressed as frequencies, means (+/-SD), medians (+/-SE), and proportions (%).

Results

A total of 45 GUT LINK consultations were completed between May and November 2020. Of these, 20% required GI specialist care and 80% have remained within primary care, with a median follow-up of 101 (+/-9.1) days. The indications for GUT LINK consultation included lower GI symptoms (64%), abnormal imaging or investigations (17%), and upper GI symptoms (19%).

To date, 21 PHCP agreed to be contacted for the post-consultation survey and 10 have been completed. All PHCPs reported that GUT LINK consultation was easy to access, while 90% found the advice helpful and 80% reported that that it resolved the issue. Following the GUT LINK appointment, 80% felt they would not need to refer their patient to GI.

Conclusions

The implementation of GUT LINK was acceptable, feasible, and improved access to specialist support for management of undifferentiated GI symptoms. Future research will focus on comprehensive stakeholder engagement in order to design, implement, and evaluate GUT LINK PHCP care pathways.

Funding Agencies

CAG

A175 BEHAVIORAL INTERVENTIONS TO ADDRESS INFLAMMATORY BOWEL DISEASE-RELATED DISTRESS AND QUALITY OF LIFE: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background

Inflammatory bowel disease-associated psychological distress (IBD-PD) (inclusive of anxiety, depression, and high levels of stress) is prevalent amongst persons living with IBD. IBD-PD impairs quality of life (QoL) and worsens disease outcomes. Research relating to the efficacy of behavioral interventions for IBD-PD has been limited.

Aims

This systematic review and meta-analysis was conducted to evaluate the efficacy of cognitive behavioral therapy (CBT)-based interventions for the management of IBD-PD and QoL in persons living with IBD.

Methods

Pre-defined criteria were used to identify randomized controlled studies reporting on the efficacy of CBT-based interventions for IBD-PD and QoL in adults living with IBD. Electronic databases including CINAHL, Cochrane Library, Embase, MEDLINE, PsycArticles, PsycInfo, Pubmed, and Web of Science were searched from inception to May 30, 2020. Studies published in English or French were included. Risk of bias was assessed using the Cochrane risk-of-bias tool by two independent reviewers (CH and MRF). Data was extracted and summarized qualitatively. A random-effects model was used to generate pooled estimates.

Results

Eight studies (922 participants) met criteria for inclusion in this review. The studies evaluated outcomes of quality of life and IBD-PD using the IBD Questionnaire (IBDQ), United Kingdom IBDQ, Short IBSQ, 36-Item Short Form Survey (SF-36), Short Health Scale, Perceived Stress Questionnaire (PSQ), Perceived Stress Scale (PSS-10), Hospital anxiety depression scale (HADS) and the Depression, Anxiety and Stress Scale-21 Items (DASS-21). Of the 8 studies, 2 were low, 2 high, and 4 at intermediate risk of bias. Interventions, duration, and outcome assessments differed across studies and observed attrition rates were high. The pooled odds ratio for the short-term impact of CBT on IBDQ (n=3) was 0.30 (95% CI 0.17- 0.44) favoring CBT. Perceived stress (PSQ and PSS-10) were only reported in 3 studies as secondary outcomes. Overall, CBT had no observed benefit for perceived stress. Measurement of anxiety and depression was inconsistent across studies. The impact of CBT on anxiety and depression varied with studies revealing both neutral and positive results.

Conclusions

In patients IBD-PD, CBT-based interventions were observed to lead to short-term improvements in disease-related QoL. The impact of CBT on IBD-PD remains unclear due to limitations in study quality and heterogeneity in study design. Further studies are needed to evaluate the efficacy of CBT-based interventions for IBD-PD and to define the role of behavioral interventions delivered within the context of collaborative, biopsychosocial models of care. Expert consensus on best practice for CBT-based interventions and IBD-PD evaluation are needed.

Funding Agencies

None

A116 ASSESSING THE EFFECTIVENESS OF THE NURSE NAVIGATOR ROLE IN AN IBD MEDICAL HOME: A RETROSPECTIVE COHORT STUDY

Background

Patients living with chronic illnesses require long-term and often repeated interactions with the healthcare system. Inflammatory Bowel Disease (IBD) is an incurable, chronic gastrointestinal disease which frequently flares and remits. The nurse navigator (NN) serves as the point of first contact for IBD connecting patients with their multidisciplinary care team in order facilitate and expedite assessment, treatment and navigation through the healthcare system with the goal of improving disease-related outcomes while reducing healthcare system burden.

Aims

The aim of this study was to assess the impact of implementation of an IBD NN role within a multidisciplinary IBD Medical home on access to care, disease related outcomes, patient satisfaction with care, and healthcare resource use.

Methods

This was a retrospective cohort study comparing an IBD patient population that had access to a 24/7 NN-led helpline to a reference population who did not have access to such a service. Data between August 2017 and October 2019 were extracted from patient charts. Distribution of number of flares and time to clinical assessment between the NN exposed cohort and a non-NN exposed cohort are planned using multivariate analysis. This is a preliminary description of the NN-exposed cohort only.

Results

Preliminary results identified a total of 643 patients in the NN-exposed cohort. The majority of our NN-exposed population were female (64.3%). The mean age was 46.42 ± 16.86 years. Sixty-five percent of patients had CD, 33% UC and 2% IBDU. Of the 729 calls extracted, care coordination (39%) was the most frequent indication for calls followed by flare (25%), and medication education (16%). Patients made the majority (52.8%) of calls compared to NN initiated calls (47.2%). The mean number of calls per patient was 2.64 ± 2.51 (range 1–18) during the study period. Time to clinic assessment post flare call was on average 10.22 ± 8.51 days.

Conclusions

These results are descriptive of the NN-exposed cohort. Data comparing outcomes amongst the NN-exposed cohort to the non-exposed cohort will be presented at CDDW.

Funding Agencies

None

A61 FOCUSING ON THE FUTURE: REDUCING BARRIERS AND IMPROVING ACCESS TO IBD SPECIALTY CARE ACROSS CANADA

Background

Canada has the highest global age-adjusted incidence and prevalence rates of Inflammatory Bowel Disease (IBD). Resulting from compounding prevalence and limited resources, timely access to specialty care is a challenge faced by patients and healthcare providers. Despite this issue, there has been no published research elucidating the patient perspective using qualitative approaches to compare and contrast the patient experience across Canada.

Aims

To elicit a qualitative data stream to better understand phenomena related to access to healthcare for Canadians living with IBD from a patient-centered perspective.

Methods

Patients diagnosed with IBD (≥18 years of age) were recruited from gastroenterology clinics and communities through IBD specialists and Crohn’s & Colitis Canada. To ensure geographic diversity and representation, patients were recruited from urban and rural regions. In order to acquire multiple access perspectives, patients were invited to bring a family member who was involved in their care to the focus groups. Co-facilitated by a researcher and a patient research partner, the focus groups were held in Nova Scotia, New Brunswick, Quebec, Ontario, Manitoba, Saskatchewan, and British Columbia. All focus groups were audio recorded, transcribed, and coded for themes. Themes were distilled through qualitative thematic analysis using Atlas.ti software to ascertain congruence or discordance of IBD specialty care access experiences.

Results

A total of 63 participants were recruited in fourteen focus groups across seven provinces. The majority of participants were female (41/63, 65%) and from urban/suburban regions (34/63, 54%). The mean age of participants was 48 years (SD=16 years, range=16 to 77 years). Preliminary analyses illustrated three patient-identified access barrier themes: 1) Lack of multidisciplinary care (psycho-social and nutrition support), 2) Diagnostic delay, and 3) Inability to effectively receive and provide communication with healthcare providers. In response, four solutions were proposed: 1) Integration of holistic care into the clinical practice, 2) Readily accessible psycho-social and nutritional support, 3) Increased patient advocacy, and 4) Continuity and liaison through provision of a healthcare navigator resource.

Conclusions

The complexity of specialty care access for IBD patients in Canada cannot be underestimated. It is vital to possess a robust understanding of healthcare system structures, processes, and the significant impact these factors have on patients and the care received. Through the use of patient-centered exploration of barriers and facilitators, access to IBD specialty care in Canada can be better understood and improved on both a provincial and national scale.

Funding Agencies

CIHRNova Scotia Health Authority Research Fund

A157 THE EFFECTIVENESS OF A STANDARDIZED BIOLOGIC CARE PATHWAY IN THE MANAGEMENT AND TREATMENT OF INFLAMMATORY BOWEL DISEASE

Background

Inflammatory Bowel Disease (IBD) is a class of chronic immune-mediated diseases. Biologics have revolutionized the treatment of IBD. Existing literature suggests significant variation exists in the use of biologic treatment among physicians, from provider-specific prescribing to completion of the pre-biologic workup. These differences may influence the effectiveness of achieving and maintaining long-term remission. Clinical care pathways may serve to standardize the use of biologics in the treatment of IBD leading to improvements in patient outcomes and consistency of care provided from different specialists.

Aims

To determine if the use of biologics to treat IBD managed within a standardized biologic care pathway (BCP) is safer and more effective compared to the current standard of care.

Methods

This was a retrospective, real-world cohort study of a prospectively implemented evidence-based BCP at the Nova Scotia Collaborative IBD (NSCIBD) program between 2015 and 2019. Patient inclusion criteria consisted of any adult with a diagnosis of IBD (including Crohn’s Disease, ulcerative colitis, IBD-Unclassified) aged 18 years or older who was managed within the NSCIBD program. Preliminary descriptive analyses of the data are presented. Data collection is ongoing and multivariate analyses will be presented in full at CDDW.

Results

In total 249 patients were included in the cohort study (111 BCP patients, 138 non-BCP patients). The mean age was 49 years (range of 17–86 years). Sixty-nine percent (171/249) of patients were diagnosed with CD, 28% (70/249) with UC, and 3% (8/249) with IBD-U. The mean duration of disease was 13 years (range of 0–36 years). Use of combination therapy was similar between the cohorts with 64% of BCP patients (n=102) and 63% of non-BCP patients (n=123) on combination therapy. Thirty-eight percent of the BCP cohort required dosing interval changes vs. 29% in the non-BCP cohort (0.24 fold higher in BCP cohort). Seventy-one percent of the BCP patients were exposed to TDM vs. 41% of the non-BCP cohort (0.40-fold more TDM in pathway cohort). Although 34% of BCP patients and 38% of non-BCP cohort patients reached clinical remission (n=103 and 125, respectively), 38% of BCP patients and 21% of non-BCP patients achieved endoscopic remission (0.5-fold lower in the non-BCP cohort), (n=29 and 53, respectively).

Conclusions

Preliminary analyses suggest patients managed within a BCP have their biologic management guided more often by the results of TDM and objective biomarkers than those not managed within a BCP. Although clinical remission was observed to be similar between the cohorts, attainment of endoscopic remission was more likely amongst patients managed within the BCP. Additional multivariate analyses will be presented at CDDW with a larger cohort size.

Funding Agencies

None

A67 EVALUATING ACCESS TO IBD CARE ACROSS CANADA: PROCEEDINGS FROM THE 2017 IBD ACCESS SUBMMIT

Background

Inflammatory Bowel Disease (IBD) is a chronic, immune-mediated disease, with Canada demonstrating the highest incidence and prevalence rates in the world. Patients with IBD often require lifelong treatment and, therefore, lifelong interactions with the healthcare system. Access to care can have a direct impact on patient health-related outcomes. Although acknowledged as a problem, the complexity of accessing IBD specialty care in Canada has not been reviewed. This lack of understanding presents a barrier in evaluating and implementing changes in IBD specialty care.

Aims

To identify key barriers and facilitators for and to develop a national working strategy to address limitations in access to IBD specialty care by exploring the perceptions and experiences of key stakeholders (pediatric and adult gastroenterologists, IBD patients, researchers, and policy makers).

Methods

The IBD Summit was held in Toronto, Ontario in November 2017, sponsored by SPOR-CIHR catalyst funding and in partnership with Crohn’s & Colitis Canada. Perceptions and experiences of key stakeholders were gathered during two audio-recorded stakeholder dialogues held during the Summit. The audio recordings were transcribed and coded to compare and contrast between key stakeholders to determine potential differences in access to IBD care. Five final themes are highlighted in this report.

Results

A total of 21 key stakeholders attended, including pediatric and adult gastroenterologists, patients, researchers, and policy makers. Five key themes of importance relating to access to IBD care arose from The IBD Summit:(1) Integrated Models of Care, (2) IT Enhanced Care, (3) Health System Process, (4) Communication and Advocacy, and (5) Community Supports. The IBD Summit identified similar perceptions and experiences, highlighting common barriers and facilitators that transcend provincial borders. Shared perceptions included a need for common medical records and overall improved IT-enhanced care for managing IBD; improved centralized triage systems; increased comprehensive care support for patients and primary care physicians; and increased community supports for patients and providers.

Conclusions

Highlights from the IBD Summit present several clinically relevant and actionable suggestions for improved access to IBD speciality care across Canada. The suggestions provided by key stakeholders highlight the need for a system-level redesign in order to improve access to enhanced models of care. Improvements in access to IBD specialty care can only occur through partnerships between those working within the healthcare system and those within the community. Future research will involve pursuing deeper insight into the experience of patient and provider stakeholders as they navigate the healthcare system in order to access and provide care.

Funding Agencies

CIHRNova Scotia Health Authority Research Fund

FPMRS challenges on behalf of the Collaborative Research in Pelvic Surgery Consortium (CoRPS): managing complicated cases : Series 3: Challenging recurrent prolapse in a medically complicated patient

This case presents the work-up and management of a spina bifida patient with recurrent prolapse. Four international experts also provide their evaluation of and approach to this complex case. According to the literature, little is known regarding the approach to the management of this specific patient population.