Care For Inflammatory Bowel Disease Patients Research Articles

Telemonitoring for patients with inflammatory bowel disease amid the COVID-19 pandemic—A cost-effectiveness analysis

Background and aimCOVID-19 pandemic burdens the healthcare systems, causes healthcare avoidance, and might worsen the outcomes of inflammatory bowel disease (IBD) management. We aimed to estimate the impact of pandemic-related avoidance on outpatient IBD management, and the cost-effectiveness of adding telemonitoring during pandemic from the perspective of Hong Kong public healthcare provider.MethodsThe study was performed by a decision-analytic model to estimate the quality-adjusted life-years (QALYs) and cost of care for IBD patients before and during the pandemic, and to compare the cost and QALYs of adding telemonitoring to standard care (SC-TM) versus standard care alone (SC) for IBD patients during the pandemic. The sources of model inputs included publications (retrieved from literature search) and public data. Sensitivity analyses were conducted to examine the robustness of base-case results.ResultsStandard care with pandemic-related avoidance (versus without avoidance) lost 0.0026 QALYs at higher cost (by USD43). The 10,000 Monte Carlo simulations found standard care with pandemic-related avoidance lost QALYs and incurred higher cost in 100% and 96.82% of the time, respectively. Compared with the SC group, the SC-TM group saved 0.0248 QALYs and reduced cost by USD799. Monte Carlo simulations showed the SC-TM group gained higher QALYs at lower cost in 100% of 10,000 simulations.ConclusionsStandard care for IBD patients during pandemic with healthcare avoidance appears to worsen treatment outcomes at higher cost and lowered QALYs. The addition of telemonitoring to standard care seems to gain higher QALYs and reduce cost, and is therefore a potential cost-effective strategy for IBD management during the pandemic.

Secondary Indicators for an Evaluation and Guidance System for Quality of Care in Inflammatory Bowel Disease Centers: A Critical Review of the Inflammatory Bowel Disease Quality of Care Center.

The number of patients with inflammatory bowel disease (IBD) has increased remarkably in recent years. However, the level of health care for IBD patients varies greatly among regions of China. Standardization of health care for IBD patients is essential to improve quality of care (QoC). The mission of the IBD Quality Care Evaluation Center (IBDQCC) is to establish indicators for QoC. Since 2017, the IBDQCC has developed structure, process, and outcome indicators with the steering committee of IBD specialists and methodologists; 28 core and 13 secondary IBD QoC indicators were selected using a Delphi method. Applications for certification of IBD quality care units were made voluntarily and preliminarily screened through the IBDQCC committee. Regional units had to meet all core indicators, and units of excellence were required to meet all core indicators together with an additional 50% of secondary indicators. As of 2019 and 2020, 69 IBD units (all from tertiary referral hospitals) have been certified as regional IBD units in China. The certification of excellence of the IBD units is currently undergoing auditing. The awareness of and appreciation for QoC in IBD is increasing in China, especially through the quality control evaluation program initiated by the IBDQCC, with a higher number of IBD units applying for the next round of certification. Although secondary indicators seem to play relatively minor roles in QoC, they suggest additional requirements for high-level centers.

Endoscopic colorectal cancer surveillance in inflammatory bowel disease: Considerations that we must not forget.

Inflammatory bowel disease (IBD), encompassing Crohn's disease and ulcerative colitis, is a chronic immune-mediated inflammatory disease that primarily affects the gastrointestinal tract and is characterized by periods of activity and remission. The inflammatory activity of the disease involving the colon and rectum increases the risk of colorectal cancer (CRC) over the years. Although prevention strategies are evolving, regular surveillance for early detection of neoplasia as a secondary prevention strategy is paramount in the care of IBD patients. In this review article, we discuss the current evidence of the risks of developing CRC and evaluate the best available strategies for screening and surveillance, as well as future opportunities for cancer prevention.

LOCAL IBD-EXPERTS DISSATISFACTION WITH BIOLOGIC MEDICATION AUTHORIZATION DENIALS - A SURVEY OF SPECIFIC CLINICAL SCENARIOS

Abstract BACKGROUND Treatment with biologic medications for patients with inflammatory bowel disease (IBD) requires authorization by insurers. Insurance authorization denials are often a major obstacle in many clinical scenarios to use biologics, including specific denials of escalated dosing regimens directed by appropriate clinical indications. The objective of this study is to assess IBD-focused gastroenterologists’ (GIs) views and experiences on specific clinical scenarios resulting in biologic authorization denials. METHODS The survey was distributed by email to adult and pediatric IBD-focused GIs with 24 specific clinical scenarios, assessing experience and opinions on each authorization denial scenario. Survey data was recorded using REDCap software. RESULTS The survey was completed by 22 GIs including 17 adult GIs (81%), 4 pediatric GIs (19%), and one undisclosed provider. 70% or greater of participants disagreed with denials for (1) infliximab (IFX) dose-escalation, (2) Remicade in place of biosimilar, (3) facility-based IFX induction, (4) vedolizumab (VDZ) dose-escalation, (5) facility-based VDZ induction, (6) first-line ustekinumab (UST) therapy, (7) UST dose-escalation or re-induction, (8) UST maintenance after induction approval, (9) tofacitinib after mechanistic biologic failures, (10) VDZ or UST first-line in elderly or co-morbid patients, (11) facility-based biologic infusion for patients with prior acute infusion reactions. Variable experience was reported across the clinical scenarios ranging from 18.2% to 100%. In addition, variable experience was reported with the scenarios on whether specific denials were increasing in the past year, ranging from 16.7% to 90%. CONCLUSION This data portrays the collective experience of authorization denials as obstacles to using biologic medications, including escalated dosing, in multiple specific clinical scenarios. Many of these denial scenarios contradict treatment strategies that are utilized for optimal care of complex IBD patients. The data indicates many authorization denials reflect significant discrepancies between GIs and insurers on the clinical appropriateness of multiple different biologic treatment strategies. Broader survey data could better elucidate further experience with biologic treatment strategies that are being denied IBD patients, the nature of the obstacles created by insurers, and guide collaboration between physicians and insurers on best practices in the treatment of complex IBD patients.

The Impact of the COVID-19 Pandemic on IBD Care in Alberta: Patient and Provider Perspectives.

ObjectiveThe COVID-19 pandemic necessitated changes in the delivery of ambulatory care for patients with inflammatory bowel disease (IBD), including transitioning many visits to virtual formats and delaying non-urgent assessments. We aimed to evaluate the impact of the COVID-19 pandemic on IBD patient care from health care providers’ (HCP) and patients’ perspectives.MethodsWe administered a 42-question HCP survey and a 44-question patient survey, which evaluated HCP and patient experience and satisfaction with care delivery and delays in access to IBD care during the first wave of the COVID-19 pandemic.ResultsSurveys were completed by 19.2% (24/125) HCPs and 25.8% (408/1581) patients. Overall, 82.7% of patients with IBD maintained their care without disruption. The majority of patients were satisfied with a transition to virtual care. All HCPs were willing to use virtual care in the future; however, 60% (14/24) of HCPs reported that virtual care was not equivalent to in-person visits. Patients reported concerns around access to health resources, the uncertainty of IBD-specific care, and fear and stress due to employment uncertainty and safety. Providers also reported concerns about patient safety, patient education, adequate remuneration and challenges with providing care for new patients on virtual platforms.ConclusionWhile some delays in health care delivery occurred during the first wave of the pandemic, both patients and HCPs were satisfied with a transition to new models of care delivery. These models may remain in place post-pandemic and allow for flexibility in care delivery that is acceptable to both patients and HCPs.

Inflammatory bowel disease and immune-mediated inflammatory diseases: looking at the less frequent associations.

Patients with inflammatory bowel disease (IBD) often have other immune-mediated inflammatory diseases (IMIDs), and the prevalence of any IMID is higher in IBD patients than in the general population. IBD and other IMIDs involve alterations in innate and adaptive immune responses. Their co-occurrence depends on shared immune and inflammatory processes, pathogenic mechanisms, and genetic and environmental risk factors, including drugs, especially tumor necrosis factor inhibitors. The more common IMIDs associated with IBD have been widely described, so this review focuses on the less frequent associations. The IMIDs discussed here are skin disorders (psoriasis, atopic dermatitis, vitiligo, epidermolysis bullosa acquisita, cutaneous polyarteritis nodosa, and hidradenitis suppurativa), hepato-pancreatic diseases (autoimmune hepatitis, granulomatous hepatitis, and autoimmune pancreatitis), endocrine diseases (autoimmune thyroid diseases, and type 1 diabetes mellitus), multiple sclerosis, and respiratory diseases (asthma, bronchiectasis, and interstitial pneumonia). The early detection of IMIDs in IBD patients is important to prevent their deleterious clinical course and limit their psychological impact. Care for IBD patients with IMIDs should be multispecialist, with a single therapeutic strategy instead of treating each disease separately.

A consensus statement on health‐care transition for childhood‐onset inflammatory bowel disease patients

Inflammatory bowel disease (IBD) is a chronic relapsing inflammatory disorder of the intestine. The incidence of IBD is increasing worldwide, including Japan, and in approximately 25% of all affected patients it is diagnosed before 18 years of age. For the health maintenance of such patients, planned transition to adult care systems is essential. Previous Japanese surveys have revealed gaps between adult and pediatric gastroenterologists with regard to their knowledge and perception of health-care transition for patients with childhood-onset IBD. In 2021-2022, several Web workshops to discuss issues related to the transitional care of IBD patients were held by the Ministry of Health, Labour and Welfare of Japan as part of their program for research on intractable diseases. Clinicians experienced in IBD treatment for pediatric and adult patients participated. As a result, this panel of adult and pediatric gastroenterologists developed five consensus statements on the issue of "transfer from pediatric to adult care" and nine statements on the issue of "addressing transitional care (transition program)." To address current gaps in health-care transition for childhood-onset IBD patients, a programmed approach to transition, and better partnerships between pediatric and adult gastroenterologists are indicated. It is hoped that this consensus statement will provide a basis for the development of appropriate guidelines for clinical practice.

Therapeutic Drug Monitoring of Biologics for Patients with Inflammatory Bowel Diseases: How, When, and for Whom?

During the past decade, we have entered an era of biologics for the treatment of Crohn’s disease and ulcerative colitis. The therapeutic goal of inflammatory bowel disease (IBD) management has evolved from symptom control and clinical remission to mucosal healing or even deep remission. Histological remission for ulcerative colitis and transmural healing of Crohn’s disease are potential future goals. With the adoption of the treat-to-target concept, and given the need for tight control of IBD activity, therapeutic drug monitoring (TDM) is an important element of precision medicine. TDM involves the measurement of serum biologics and anti-drug antibodies levels, to confirm whether the right drug with the right dosage was prescribed to reach the right serum levels. TDM may help clinicians adjust biologics based on objective biomarkers instead of using empirical dosage escalation or making symptom-based therapeutic adjustments. Well-established reactive TDM algorithms have been proposed, and emerging evidence supports the clinical application of a proactive TDM strategy to enhance the duration of effective biologics and improve clinical outcomes. Recently, the proactive TDM strategy was shown to avoid the secondary loss of response to biologics, and improve long-term clinical outcomes in IBD patients. This review summarizes data from trials, and practice guidelines, on the clinical application of proactive and reactive TDM strategies for the daily care of biologic-treated IBD patients.

Improving the care of inflammatory bowel disease (IBD) patients: perspectives and strategies for IBD center management.

The incidence and prevalence rates of inflammatory bowel disease (IBD) have been increasing in East Asian countries over the past few decades. Accordingly, the general understanding and awareness of IBD among healthcare professionals has increased considerably in this region. This increase is ultimately associated with the evolving focus of IBD clinicians devoted to comprehensive patient care, especially in establishing IBD clinics/centers capable of providing multidisciplinary counseling. Comprehensive IBD care at IBD clinics/centers usually includes surgical and medication decision-making, transition from pediatric to adult clinics, care of extraintestinal manifestations, care of infectious diseases in patients undergoing immunomodulatory or biologic therapies, and nutritional, psychosocial, socioeconomic, and pharmacological care. Team members comprise specialists from various departments related to IBD and can be divided into core and ad hoc members. Usually, the scope of work in IBD clinics/centers involves patient care, patient outreach, and system management. Considering the environmental changes in IBD treatment, it is necessary to perform comprehensive IBD patient care in the form of a program based on competencies, rather than simply following the organization of previous IBD centers. The present review summarizes recent trends in IBD patient care and offers perspectives regarding IBD center management.

Subjective Needs and Thoughts for the Treatment of Patients with Inflammatory Bowel Disease: Applying Q Methodology.

Inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis, is a chronic inflammatory disorder of the gastrointestinal tract that requires lifetime management. Many studies have attempted to establish questionnaires and/or parameters to assess the quality of care for IBD patients. However, no study to date has investigated patients using the Q-methodology, which is subjective and has been studied systematically, to identify and categorize their opinions and subjective thinking about their disease and treatment. We have therefore aimed here to conduct a preliminary study of the Q-methodology to investigate the subjective thinking of IBD patients in Korea. Q-methodology, a method of analyzing the subjectivity of questionnaire items, was examined in this study. Inputs from 50 IBD patients were classified into 34 normalized statements using a 9-point scale with a normal distribution. The collected data were analyzed using the QUANL PC program. Using the Q-methodology, IBD patients were classified into type I, II, III, and IV treatment needs: medical staff-dependent, relationship-oriented, information-driven, and social awareness, respectively. The subjective needs of IBD patients and their thoughts about the treatment can be classified into four types. Our findings suggest that we can establish a systematic strategy for personalized care according to patient type.

Telehealth model of care for outpatient inflammatory bowel disease care in the setting of the COVID-19 pandemic.

BackgroundAdvances in inflammatory bowel disease (IBD) monitoring, greater number of available treatments and a shift towards tight disease control, IBD care has become more dynamic with regular follow ups.AimsWe assessed the impacts of the COVID‐19 pandemic on outpatient IBD patient care at a tertiary centre in Melbourne. More specifically, we assessed patient satisfaction with a telehealth model of care, failure to attend rates at IBD clinics and work absenteeism prior to and during the pandemic.MethodsWe conducted a retrospective, qualitative analysis to assess our aims through an online survey. We invited patients who attended an IBD outpatient clinic from April to June 2020 to participate. This study was conducted at a single, tertiary referral hospital in Melbourne. The key data points that we analysed were patient satisfaction with a telehealth model of care and the effect of telehealth clinics on work absenteeism.ResultsOne hundred and nineteen (88.1%) patients were ‘satisfied’ or ‘very satisfied’ with the care received in the telehealth clinic. Eighty‐four (60.4%) patients reported needing to take time off work to attend a face‐to‐face appointment, compared to 29 (20.9%) patients who needed to take time off work to attend telehealth appointments (P < 0.001). Clinic non‐attendance rates were similar prior to and during the pandemic with rates of 11.4% and 10.4% respectively (P = 0.840).ConclusionsPatients report high levels of satisfaction with a telehealth model of care during the COVID‐19 pandemic, with clinic attendance rates not being affected. Telehealth appointments significantly reduced work absenteeism when compared to traditional face‐to‐face clinics.

P376 Improving stress and fatigue in a real-world setting among patients with Inflammatory Bowel Disease through a digital platform

Abstract Background Fatigue is one of the most prominent and disabling symptoms reported by adult patients with inflammatory bowel disease (IBD). Also, stress is perceived by these patients as one of the main causes of IBD flare-ups. Therapeutic guidelines call for effective disease assessment, early intervention, and personalized care using a treat-to-target approach which may be hard to achieve through standard care. Providing patients with effective self-management strategies and patient support programs (PSPs) via a digital platform to complement standard care, may be optimal for improving fatigue and reducing stress. The objective of this study was to perform a preliminary test of engagement and effectiveness of a newly developed 16-week PSP delivered via the digital platform Sidekick Health. Methods Participants were recruited via Finnish IBD patient association websites and social media (advertisements through Facebook and Instagram). Participants entered baseline characteristics upon program signup. Platform engagement was automatically tracked, and participants reported stress, energy levels (fatigue), and quality of sleep through the platform. Results An intention to treat (ITT) sample included 205 participants. Eighty people completed the required outcome measures during weeks 12-16 (completers). More women than men took part (61.5%) with the average age of 40.3 years (mean, SD=11.5) and average BMI of 27.9 (mean, SD=6.0). ITT analyses showed significant improvements in ratings of stress (t(204)=3.488; p&amp;lt;0.01, percentage change=-9.52%), and energy levels (t(204)=-2.381; p&amp;lt;0.05, percentage change=4.60%). No significant difference was observed in quality of sleep (t(204)=-1.368; p=0.173). For completers (n=80), significant improvements were observed for stress (t(79)=4.574; p&amp;lt;0.01, percentage change=-23.26%) and energy levels (t(79)=-2.440; p&amp;lt;0.05, percentage change=9.48%) but not for quality of sleep (t(79)=-1.319; p=0.191). Conclusion These results indicate that participation in the Sidekick Health PSP for IBD has significant positive effects on patient-reported stress and energy levels. These findings are promising and provide initial support for using this digital platform for supplementing standard care for IBD patients.

P424 Treatment persistence of first-line anti-TNF therapy in patients with inflammatory bowel diseases: results from a real-world study over 20 years

Abstract Background Anti-TNF therapy is still the most frequently used first-line biologic treatment in inflammatory bowel disease (IBD). This study aimed to determine length of treatment persistence and to describe reasons for discontinuation of first-line anti-TNF therapy used in the standard care of IBD patients. Methods A single-center, real-world, retrospective study including IBD patients (Crohn’s disease (CD), ulcerative colitis (UC), IBD unclassified (IBD-U)), who received an anti-TNF therapy in the last 20 years at the study center, was conducted. Length of first-line anti-TNF therapy, differences in treatment duration between infliximab (IFX) and adalimumab (ADA) and between CD and UC, reasons for discontinuation, side effects leading to cessation, treatment following first-line anti-TNF therapy, rates of surgery and death, and factors being associated with treatment failure were assessed. Results 586 patients were identified as having received first-line anti-TNF therapy at the study center. 48 patients were excluded due to shortness of available data. 538 patients (CD: 367, UC: 147, IBD-U: 24) with a median follow-up of 8.1 years were included in the analysis. Median (IQR) treatment persistence was 21.0 (6.0, 57.0) months in the total cohort. Treatment withdrawal arose frequently (40%) within the first year of therapy and treatment persistence was longer in CD compared to UC (CD: 27.0 (8.0, 71.0) months, UC: 11.0 (3.0, 34) months, p&amp;lt;0.001). Treatment failure (51%) and side effects (24%) were the most commonly noticed reasons for withdrawal from therapy. 14% withdrew from therapy due to remission. The diagnosis of UC, female sex, the absence of prior intestinal resections, lower hemoglobin and albumin levels at anti-TNF initiation predicted treatment failure. Patients with CD continued ADA treatment longer than IFX treatment (ADA: (40.5 (14.2, 80.5) months, IFX: 18.0 (4.8, 65.0) months, p&amp;lt;0.001). Within the follow-up period, 17% of UC patients underwent colectomy and 34% of CD patients had at least one intestinal resection after start of first-line anti-TNF therapy. 2% of all patients died due to various reasons. Conclusion Treatment persistence of first-line anti-TNF therapy is limited in IBD patients due to a large proportion of treatment failures and side effects.

How Can We Do Transition Successfully from Pediatric to Adult Clinics in Inflammatory Bowel Disease?

With the increasing incidence of pediatric inflammatory bowel disease (IBD) in children and its impact throughout life, transition care has become an important issue. In Korea, no guidelines have been proposed to support the transition from the pediatric clinic to the adult IBD clinic. This paper reviews the current issues related to IBD patient care during the transition from pediatrics to adults to identify the barriers and critical elements for a successful transition. Thus far, a multi-disciplinary pediatric/adult clinic or alternate visits between pediatric and adult health care providers is the best model for pediatric to adult IBD clinics. Self-reliance and independence of patients with pediatric IBD are also essential for a successful transition. In addition, the timing of the transition from a pediatric clinic to an adult IBD clinic should not be determined because the issue is not the chronological age but rather the individual maturity.

Telemedicine and Integrated Multidisciplinary Care for Pediatric IBD Patients: A Review.

The global COVID-19 pandemic brought with it an unprecedented, widespread implementation of telemedicine services, requiring pediatric inflammatory bowel disease (IBD) providers to shift in-person clinic visits to a virtual platform. With the passing of the one-year anniversary of the global pandemic, telemedicine continues to be offered and utilized. Although it remains unclear as to the extent to which telemedicine services will be used in the future, it is critical to understand how integrated multidisciplinary treatment—the standard of care in pediatric IBD—is delivered through a virtual platform. This paper provides an overview of the existing literature examining integrated multidisciplinary care for pediatric IBD provided via telemedicine. The author also presents one integrated multidisciplinary IBD program’s response to the global pandemic and subsequent transition to telemedicine. Challenges around implementation and directions for future research in this area are also discussed.

Are patients with inflammatory bowel disease receiving adequate immunisation?

Abstract Background Inflammatory Bowel Disease (IBD) treatment may increase the risk of infections. Vaccines are part of the comprehensive IBD patient care. The aim of this study was to describe indications and adherence of immunizations in IBD and identify possible associated factors. Methods A cross-sectional, analytic study was conducted in patients from an IBD Program of a tertiary center in Chile, between April – June 2019. Patients were asked to answer a vaccine survey and information also was obtained from the National Immunization Registry. Descriptive and association statistic were used (χ2; p Results A total of 243 patients were included (148 ulcerative colitis (UC), 86 Crohn´s disease (CD) and 9 non-classifiable IBD). Only six patients (2%) of IBD patients received a complete immunization schedule. The highest vaccine rates were against influenza (67%), hepatitis B virus (40%), 13-valent pneumococcal (34%) and 23-polysaccharide pneumococcal (16%). The influenza vaccine rate has significantly increased, reaching 67% in 2019. The survey showed that 23% of patients have not been immunized with any vaccine, mainly due to lack of time, lack of medical prescription and high cost. Conclusion In this cohort, although vaccination rates are higher than previously reported, adherence to IBD immunization program would be improved, being considered since diagnosis by the multidisciplinary team.

IMMATURE LOW-DENSITY NEUTROPHILS AS MEDIATORS OF PYODERMA GANGRENOSUM AND INFLAMMATORY BOWEL DISEASE PATHOGENESIS

Pyoderma gangrenosum (PG) is a debilitating skin condition characterized by deep, pus-filled, non-healing ulcers packed with neutrophils and is a common extraintestinal manifestation of inflammatory bowel disease (IBD). Strikingly, ∼40% of people with an initial presentation of PG go on to be also diagnosed with IBD, suggesting that both diseases have common factors driving their pathogenesis. The molecular and cellular mechanisms of PG and IBD co-development are currently unknown, hampering the development of effective treatment strategies for individuals affected by both diseases. Prior studies of individuals with PG demonstrate an enrichment of circulating immature low-density neutrophils (LDGs) that are sensitized to undergo NETosis, a specialized form of cell death. NETosis induces inflammation and, when dysregulated, can promote chronic cycles of inflammation. We hypothesize that LDGs mediate NETosis-driven inflammation in both PG and IBD, but the LDGs from individuals that develop both diseases are functionally distinct. In this translational study, blood samples are collected from healthy subjects or individuals with only PG, only Crohn’s disease, only ulcerative colitis, or individuals with both PG and IBD for the analysis of neutrophil populations, neutrophil function, as well as circulating markers of inflammation and NETosis. Preliminary data from 45 subjects demonstrate an enrichment of circulatory LDGs (CD45+ CD15+ CD66b+ CD10+ CD16+ cells from the low density fraction) in individuals with inflammatory disease as compared to healthy subjects (19.2% +/- 2.81%, n=41 vs. 9.9% +/- 2.9%, n=4; p=0.04). This is correlated with increased NETosis in vitro, however differences in the responsiveness of LDGs to priming signals, such as IL-1β, TNFα, and IL-6, are emerging between disease sub-groups. There is considerable variation in the levels of LDGs within disease sub-groups and analyses are underway to determine whether this variation correlates with subject reported disease activity, inflammatory markers (serum C-reactive protein), or circulating markers of NETosis (serum citrullinated histone 3). These preliminary findings point to the presence of a unique population of cells potentially contributing to inflammatory cross-talk between the skin and gut. Further analysis of these potentially disease driving cells may result in more effective care of IBD patients with extraintestinal manifestations, such as PG, through more mechanistically targeted therapeutic approaches, as well as potential biomarker discovery that predicts which PG patients are more likely to develop IBD leading to earlier intervention and better disease outcomes.

Targeted housestaff intervention reduces opioid use without worsening patient-reported pain scores and improves outcomes among patients with IBD: the "IBD pain ladder".

Opioid analgesic use is associated with increased mortality, higher readmission rates, and reduced quality of life among patients with inflammatory bowel disease (IBD). With the goal of reducing inpatient opioid use among patients with IBD admitted to our inpatient gastroenterology (GI) service, we designed and implemented a standardized, educational intervention providing analgesic decision support to internal medicine and emergency medicine housestaff at our institution. Pre-intervention data was collected from patients admitted during a 9-month period prior to intervention. Post-intervention patients were identified prospectively. The primary outcome was reduction in aggregate inpatient opioid use in oral morphine equivalents per patient. A total of 68 patients with 81 hospitalizations were analyzed. There was no statistically significant difference in baseline admission characteristics between the two groups. Our primary outcome was achieved with a statistically significant reduction in opioid use during hospitalization (43.4mg vs 7.7mg; p < 0.01). Secondary outcomes achieved included reduction in new opioid prescriptions upon discharge, reduced hospital length of stay, and reduced 90-day readmission rates. There was no significant difference between patients' pain scores between the two groups. We believe this intervention, aimed at housestaff education, provides a roadmap for pain management decision-making in this patient population. It is a readily reproducible strategy that can be widely applied to improve inpatient IBD patient care. Importantly, patient experience and pain scores were unchanged despite lower use of inpatient opioid analgesia, highlighting successful opioid-sparing analgesics in most inpatients with IBD.

IMMATURE LOW-DENSITY NEUTROPHILS AS MEDIATORS OF PYODERMA GANGRENOSUM AND INFLAMMATORY BOWEL DISEASE PATHOGENESIS

Abstract Pyoderma gangrenosum (PG) is a debilitating skin condition characterized by deep, pus-filled, non-healing ulcers packed with neutrophils and is a common extraintestinal manifestation of inflammatory bowel disease (IBD). Strikingly, ~40% of people with an initial presentation of PG go on to be also diagnosed with IBD, suggesting that both diseases have common factors driving their pathogenesis. The molecular and cellular mechanisms of PG and IBD co-development are currently unknown, hampering the development of effective treatment strategies for individuals affected by both diseases. Prior studies of individuals with PG demonstrate an enrichment of circulating immature low-density neutrophils (LDGs) that are sensitized to undergo NETosis, a specialized form of cell death. NETosis induces inflammation and, when dysregulated, can promote chronic cycles of inflammation. We hypothesize that LDGs mediate NETosis-driven inflammation in both PG and IBD, but the LDGs from individuals that develop both diseases are functionally distinct. In this translational study, blood samples are collected from healthy subjects or individuals with only PG, only Crohn’s disease, only ulcerative colitis, or individuals with both PG and IBD for the analysis of neutrophil populations, neutrophil function, as well as circulating markers of inflammation and NETosis. Preliminary data from 45 subjects demonstrate an enrichment of circulatory LDGs (CD45+ CD15+ CD66b+ CD10+ CD16+ cells from the low density fraction) in individuals with inflammatory disease as compared to healthy subjects (19.2% +/- 2.81%, n=41 vs. 9.9% +/- 2.9%, n=4; p=0.04). This is correlated with increased NETosis in vitro, however differences in the responsiveness of LDGs to priming signals, such as IL-1β, TNFα, and IL-6, are emerging between disease sub-groups. There is considerable variation in the levels of LDGs within disease sub-groups and analyses are underway to determine whether this variation correlates with subject reported disease activity, inflammatory markers (serum C-reactive protein), or circulating markers of NETosis (serum citrullinated histone 3). These preliminary findings point to the presence of a unique population of cells potentially contributing to inflammatory cross-talk between the skin and gut. Further analysis of these potentially disease driving cells may result in more effective care of IBD patients with extraintestinal manifestations, such as PG, through more mechanistically targeted therapeutic approaches, as well as potential biomarker discovery that predicts which PG patients are more likely to develop IBD leading to earlier intervention and better disease outcomes.

S0816 Pediatric to Adult IBD Patient Care: A Comparison of Outcomes Between Transitional Clinic Care and Traditional Clinic Care

INTRODUCTION: Inflammatory bowel disease (IBD) is a chronic illness that impacts all age groups. For those diagnosed in childhood, transitioning from pediatric to adult IBD providers can be particularly difficult. We developed an IBD "transition clinic" (TC) at our center to help address these challenges. The aim of our study was to compare the health care utilization of patients who did and did not receive care in our IBD TC. METHODS: We performed a retrospective chart review of 18 to 26-year-old patients transitioning at our IBD center between 2017 and 2018. Data collected included demographic variables, IBD type and duration. IBD related health care resource utilization outcomes were also obtained. These include admissions and no-show rates since the start of TC or adult IBD clinic respectively and steroid use during the first two years since the start of these clinics. A chi-square test for categorical variables and student t-test for continuous variables was used for comparing the variables in both of the groups. All analysis was performed in SAS v9.4. RESULTS: We identified 50 IBD patients who were cared for in our TC and 65 who were not. While the patients seen in TC were significantly younger, each cohort had similar sex distribution, disease duration and disease type distribution (Table 1). TC patients demonstrated lower mean hospital admissions, and a trend toward fewer clinic no-shows (P = 0.05) (Table 1). CONCLUSION: We demonstrated that an IBD transition clinic can improve patient outcomes, as individuals receiving care in our TC were less likely to be admitted to the hospital. It is possible that other key outcomes (including disease activity, IBD complications and psychosocial variables) may also be impacted by this service. Thus, larger, objective studies evaluating these issues in TCs are still needed. Ultimately, identifying a more streamlined and structured, yet customizable, approach to the transition process in IBD is warranted.TABLE 1.: Demographic variables and health care utilization outcomes