Are clinical outcomes in IBD improved by multidisciplinary clinics?

Abstract

Chronic inflammatory bowel disease (IBD), consisting of Crohn’s disease (CD) and ulcerative colitis (UC), has an incidence of 5 cases per 100,000 population. Despite recent progress in therapy, IBD follows a course of relapses and remissions, with 25%–50% of patients relapsing annually.1 Many patients face multiple problems with these diseases, such as a constant need for information about therapy, medications, nutrition, psychosocial issues, and possible surgical solutions, requiring a multidisciplinary approach.2 In some large centers this has resulted in the formation of multidisciplinary clinics, consisting of some or all of the following experts: gastroenterologists, nurse-educators, psychologists, dietitians, pharmacologists, and colorectal surgeons. The patients can see these experts either in 1 clinic visit or after referral to 1 or more of these disciplines. In addition, patients seen in specialist IBD clinics were provided better care than in nonspecialist clinics.3 Education of IBD patients is crucial for several reasons. At first diagnosis the patient needs to understand that IBD is chronic, needing regular follow-up and requiring compliance with medications administered for treatment as well as to prevent relapses. The nurse or nurse practitioner is an essential part of a multidisciplinary team to supply the patient with this education. Waters et al4 have shown that educated IBD patients display better compliance and visit emergency room less frequently than patient who did not receive formal education. However, formal education did not improve quality of life. Education will also instruct patients when to call about complications of IBD, such as when abscesses, intestinal obstructions, and fistulas appear and whenever the patient does not respond to therapy. Many IBD patients take multiple medications. A pharmacist can assist the patient with questions about drug interactions and their adverse effects. This function is especially important, e.g., at the start of immunosuppressive therapy when the nurse educator and/or the pharmacist can assist the patient with setting up schematic monitoring for adverse effects. The chronic nature of IBD can have a profound effect on the quality of life. Some patients require additional support with coping through counseling. IBD can also affect sexual relationships. Up to 50% of patients with CD in stable heterosexual relationships did not have regular sexual intercourse.5 Depression and anxiety are more common in IBD patients than in controls.6 In fact, recently the Luebeck semistructured Interview for Psychosocial Screening was developed as a rating tool for psychosocial stress in IBD patients.7 Recognition and treatment of depression will help with medical compliance and lifestyle modification. These psychosocial aspects of IBD can be easily dealt with by a psychologist on a multidisciplinary team. Many IBD patients, especially patients with small bowel CD or short gut syndrome, are malnourished and require dietary supplementation and advice.8 Improved caloric intake, calcium and vitamin D supplementation to prevent bone loss, and the avoidance of dairy products if lactoseintolerant require the input of a dietitian. Frequently, consultation with colorectal surgeons is required, not only for a surgical resection of diseased gut, but especially the surgical and medical management of complicated fistulizing CD requires a team effort by both a gastroenterologist and a colorectal surgeon. In summary, the management of patients with chronic IBD frequently requires a multidisciplinary approach. This holistic approach to the patient with IBD will dramatically improve quality of life and the patient–physician relationship. It is expected that these interventions will result in decreased healthcare use, improved knowledge, psychosocial parameters, outcomes, and adherence to medical regimens.