IBD Care Research Articles

Framework of IBD Care Delivery Across Ages.

IBD care has gone through a real transformation over the last century, moving from the mere unidirectional interaction between the physician and the patient to a stronger framework with multiple stakeholders who interconnect and strengthen each other. The patient has evolved from a passive subject to the central pole in the care pathway. Key elements of the future framework include patient self-care and empowerment, and remote monitoring [eHealth]. This care will be delivered by a multidisciplinary team acknowledging the pivotal role of the IBD nurse, and emphasising and measuring the quality of its work. The big challenge for the future is to establish a financially viable model to make this evolution durable in the long term, and this by using the principles of value-based health care.

Review article: Novel therapies in inflammatory bowel disease - An update for clinicians.

Several new treatments including small molecules and biologics have been approved for the treatment of inflammatory bowel diseases in recent years. Clinicians and patients now have a wide variety of therapeutic options to choose from and these novel therapies provide several advantages including oral administration, lower immunogenicity, better selectivity and arguably better safety profiles. An increase in treatment options has increased the complexity of decision-making. Both patients and clinicians have had to become rapidly familiar with efficacy of new medications balanced against a range of pre-initiation requirements, dosing schedules and adverse event profiles. To provide a simple guide to practising clinicians on recently approved and emerging therapies and address key challenges around treatment strategies such as optimal sequencing and timing of treatment. We comprehensively searched the published literature and major conference abstracts to identify phase III placebo-controlled and active comparator trials for Crohn's disease and ulcerative colitis. Data for recently approved therapies including selective Janus kinase inhibitors, sphingosine-1 receptor modulators and p19 interleukin (IL)-23 inhibitors have demonstrated improved patient outcomes in both Crohn's disease and ulcerative colitis. Further comparative head-to-head studies have improved our understanding of when and how to optimally use newer therapies, specifically for IL-23 inhibitors. Data for emerging treatment options and novel treatment strategies such as early effective treatment, combinations of treatments and implications for sequencing are continuing to transform IBD care continually. Recently approved novel therapies have expanded the range of medical options available to treat IBD. However, further data from long-term extension studies, real-world studies and head-to-head trials are warranted to better inform the long-term safety and optimal sequencing of treatments for patients living with IBD.

Role of Intestinal Ultrasound for IBD Care: A Practical Approach.

Intestinal ultrasound (IUS) has recently become the imaging technique of choice for patients with different types of intestinal inflammation. IUS has a high sensitivity, specificity, positive predictive value, and negative predictive value when diagnosing Crohn's disease or ulcerative colitis. Further, it is now the preferred imaging modality for routine IBD reevaluations because of its non-invasiveness, cost-effectiveness, availability (at least in Europe), and reproducibility in all age groups. However, the clinical success of IUS requires IUS training for doctors and technicians who perform IUS with a standardised description of ultrasound findings of the terminal ileum and entire colon. Complications such as abscess formation, fistulae, and stenosis can be detected by either conventional IUS or contrast-enhanced ultrasound (CEUS). Lately, several disease activity scores have been proposed for Crohn's disease, postoperative Crohn's disease, and ulcerative colitis both in adults (including elderly) and in children. IUS was successfully used in randomised clinical trials in order to measure the treatment response. Therefore, IUS now plays a central role in clinical decision making.

Exploring the foundations of a digital health information service for patients with inflammatory bowel disease: a mixed method study in Gravitate-Health

BackgroundProviding relevant digital health information of high quality may promote treatment adherence and self-management for patients with inflammatory bowel disease. The development of digital health services is optimised by considering end users’ needs.AimTo identify key aspects required for digital promotion of inflammatory bowel disease patients’ self-management by exploring their health information needs and the preferences of both patients and healthcare professionals in relation to the digital provision of inflammatory bowel disease health services.MethodsData from an audit of 1,481 electronic health record summaries from an inflammatory bowel disease help line, 17 semi-structured interviews with inflammatory bowel disease patients and 2 focus group interviews with 11 healthcare professionals were analysed.ResultsPatients primarily contacted the hospital due to concerns about symptoms, examinations and tests, and medicines. Their concerns appeared to vary according to diagnosis, gender, age and disease duration. The interviews identified two overarching themes: (1) the available health information and patients’ health information needs, and (2) whishes, thoughts and preferences for a digital solution in IBD care with relevant and individualised information.ConclusionsThe findings delineate key aspects for developing a suitable digital health information service. Patients seek information from healthcare professionals about treatment; however, in a digital solution, they want access to relevant and practical information about the disease, treatment and self-management. Both patients and healthcare professionals saw opportunities for increasing health data availability to patients. However, healthcare professionals expressed concerns about adapting, maintaining and ensuring the relevance of patient health information without increasing their workload and, thus, reducing quality of care.

Remote Between Visit Monitoring in Inflammatory Bowel Disease Care: A Qualitative Study of CAPTURE-IBD Participants and Care Team Members.

We recently showed that CAPTURE-inflammatory bowel disease (IBD)-a care coordination intervention comprised of routine remote monitoring of patient-reported outcomes (PRO) and a care coordinator-triggered care pathway-was more effective at reducing symptom burden for patients with IBD compared to usual care. We aimed to understand how patients and care team providers experienced the intervention and evaluate purported mechanisms of action to plan for future implementation. In this study, 205 patients were randomized to CAPTURE-IBD (n = 100) or usual care(n = 105). We conducted semi-structured interviews with 16 of the 100 participants in the CAPTURE-IBD arm and 5 care team providers to achieve thematic saturation. We used qualitative rapid analysis to generate a broad understanding of experiences, perceived impact, the coordinator role, and suggested improvements. Findings highlight that the intervention was acceptable and user-friendly, despite concerns regarding increased nursing workload. Both participants and care team providers perceived the intervention as valuable in supporting symptom monitoring, psychosocial care, and between-visit action plans to improve IBD care and health outcomes. However, few participants leveraged the care coordinator as intended. Finally, participants reported that the intervention could be better tailored to capture day-to-day symptom changes and to meet the needs of patients with specific comorbid conditions (eg, ostomies). Remote PRO monitoring is acceptable and may be valuable in improving care management, promoting tight control, and supporting whole health in IBD. Future efforts should focus on testing and implementing refined versions of CAPTURE-IBD tailored to different clinical settings.

A new framework for nurses working in paediatric IBD care

The RCN Gastrointestinal Forum introduces their new IBD framework for adult and paeediatric care settings and discusses the latest UKHSA hepatitis C report

White Paper: American Gastroenterological Association Position Statement: The Future of IBD Care in the United States–Removing Barriers and Embracing Opportunities

Despite incredible growth in systems of care and rapidly expanding therapeutic options for people with inflammatory bowel disease, there are significant barriers that prevent patients from benefiting from these advances. These barriers include restrictions in the form of prior authorization, step therapy, and prescription drug coverage. Furthermore, inadequate use of multidisciplinary care and inflammatory bowel disease specialists limits patient access to high-quality care, particularly for medically vulnerable populations. However, there are opportunities to improve access to high-quality, patient-centered care. This position statement outlines the policy and advocacy goals that the American Gastroenterological Association will prioritize for collaborative efforts with patients, providers, and payors.

Artificial Intelligence and IBD: Where are We Now and Where Will We Be in the Future?

Artificial intelligence (AI) is quickly demonstrating the ability to address problems and challenges in the care of IBD. This review with commentary will highlight today's advancements in AI applications for IBD in image analysis, understanding text, and replicating clinical knowledge and experience. Advancements in machine learning methods, availability of high-performance computing, and increasing digitization of medical data are providing opportunities for AI to assist in IBD care. Multiple groups have demonstrated the ability of AI to replicate expert endoscopic scoring in IBD, with expansion into automated capsule endoscopy, enterography, and histologic interpretations. Further, AI image analysis is being used to develop new endoscopic scoring with more granularity and detail than is possible using conventional methods. Advancements in natural language processing are proving to reduce laborious tasks required in the care of IBD, including documentation, information searches, and chart review. Finally, large language models and chatbots that can understand language and generate human-like replies are beginning to exhibit clinical intelligence that will revolutionize how we deliver IBD care. Today, AI is being deployed to replicate expert judgement in specific tasks where disagreement, subjectivity, and bias are common. However, the near future will herald contributions of AI doing what we cannot, including new detailed measures of IBD, enhanced analysis of images, and perhaps even fully automating care. As we speculate on future technologic capabilities that may improve how we care for IBD, this review will also consider how we will implement and fairly use AI in practice.

A277 SYNOPTIC REPORTING IN INFLAMMATORY BOWEL DISEASE

Abstract Background Inflammatory bowel disease is a chronic medical condition requiring regular clinical assessment and evaluation. Specialist involvement often occurs regularly to determine disease activity, progression, and consider therapeutic changes for disease control. The rapid advancement of scientific evidence and addition of novel medications have combined to make IBD care increasingly complex. Moreover, evolving standards of care have led to an increased burden of documentation. Synoptic reporting is a novel documentation method that standardizes the input of clinical data and generates comprehensive reports based on that data. It has yet to be widely accepted throughout medicine, but is commonly used in surgery and diagnostics. Advancements within IBD have amplified the need for meticulous reporting of patients' previous therapies and preventative health care: areas synoptic reporting excels in. Aims We analyzed for the presence of disease-related, treatment-based, and preventative health elements in consultation reports across standard of care and synoptic reporting methods. Methods We identified consecutive IBD consultations from Jan 1 2023 onwards for participating gastroenterologists, up to 10 reports for most clinicians, if available. Each report was labeled synoptic or standard reporting. Manual review was used to determine whether each element was present and coded in binary fashion, except for female reproductive health, which was absent, present, or N/A. For analysis, data was partitioned based on whether synoptic reporting was used, with the percentage of reports including each element being calculated based on this data. Comparisons for inclusion were then completed between the groups. Results We identified a total of 62 consultations with 19 utilizing synoptic reporting. Reporting methods fared similarly for age, sex, year of diagnosis, and summary of course. Synoptic reporting performed significantly better in reporting vaccinations, marijuana use, as well as B12, vitamin D, and ferritin levels. Differences exceeding 20% were found in the reporting of EIMs, CRC screening, and female reproductive health, though these were not at a level of statistical significance in this preliminary study. Conclusions We found through our analysis that synoptic reporting is a simple tool that creates reports with a greater inclusion of elements important for disease management and health maintenance. Relaying this information back to patients' practitioners can theoretically improve outcomes through better preventative care, active monitoring, and awareness of patients’ disease history by future consultants. Future research will focus on expanding the study population as well as gaining further insight into the utility of synoptic reporting in improving clinical communication and disease management. Funding Agencies None

COST-DRIVERS OF HEALTHCARE EXPENDITURES IN INFLAMMATORY BOWEL DISEASE

Abstract INTRODUCTION Inflammatory bowel diseases (IBD) are gastrointestinal (GI) conditions associated with significant costs. Effective management of IBD should focus on improving patient symptoms and outcomes while containing healthcare costs. To develop high-value treatment strategies and influence policy on high-value care, we must first have a better understanding of the primary drivers of cost in this population. METHODS We conducted a real-world descriptive cohort study using data from IBM Watson, which is a nationwide insurance claims database covering millions of commercially insured individuals across the US. We identified adult patients aged 18 to 65 years with encounters associated with a diagnosis of IBD in the primary or secondary position from January 2019 to January 2020 based on ICD-10-CM codes for Crohn's disease (555.x) and ulcerative colitis (556.x). Analysis of IBD prevalence, costs, and service utilization was based on ICD, CPT, and NDC codes related to IBD conditions and services. All other codes without an associated GI diagnosis in the primary or secondary position were attributed to all-cause costs. Measures of cost and utilization were calculated as a per member per year (PMPY). RESULTS 105,496 patients with IBD were identified (Table 1). The mean PMPY total costs were $40,842 of which $31,051 (76%) were directly related to GI-related costs. Mean PMPY total costs in this population ranged from $1,178 to $144,945, with 15% of members experiencing costs > $76,346 PMPY. The main drives of GI-related costs can be divided into the following three categories: Inpatient costs ($8,206 [26%]), outpatient medical service costs ($11,306 [36%]), and drug costs ($11,539 [37%]) (Table 2). Per member utilization includes: 0.22 inpatient admissions, 0.10 surgeries, 1.02 GI visits, 2.87 non-gastroenterologist GI visit (which could include a visit to a primary medical doctor, rheumatologist, dietician, etc), 4.57 GI-testing, 0.48 GI imaging, 0.61 GI endoscopy, and 1.07 biologic medication prescriptions. CONCLUSIONS IBD care carries a significant financial burden on the US healthcare system. Unplanned emergency service and medication utilization continue to make up the majority of costs of IBD care and need to be the focus of value-based interventions. While appropriate high-cost pharmaceutical utilization should not be reduced, innovative strategies leveraging more cost-effective medication delivery may provide an important opportunity to curb costs. Furthermore, the high rate of non-gastroenterologist GI visits suggests that there is a potential for optimizing care pathways, by incorporating multidisciplinary care including, PCPs, mid-level providers, and other ancillary services into the IBD care model.

COMPARING REAL-WORLD OUTCOMES, MEASURED AS 12 AND 24-MONTH IBD-RELATED SURGERIES, BETWEEN INFLIXIMAB DOSE OPTIMIZED PATIENTS USING THERAPEUTIC DRUG MONITORING (TDM) VS AN UNOPTIMIZED CONTROL GROUP, IN A LARGE US COMMUNITY-BASED GASTROENTEROLOGY PRACTICES

Abstract BACKGROUND Anti-TNFs such as infliximab (IFX) continue to be the standard of care to treat moderate-to-severe IBD. Remission and reducing detrimental outcomes are achievable goals when therapeutic drug monitoring (TDM) is implemented to assist with IFX therapy optimization. TDM aids in achieving & maintaining adequate drug exposure to avoid loss of response by offering actionable information to guide treatment adjustments. The value of TDM has been described in numerous studies which show that optimization of anti-TNFs correlates with improved clinical outcomes & the use of TDM is recommended by IBD guidelines and expert consensus. A potential evidence gap is the lack of real-world outcomes data when Anser®, a TDM test, is implemented in a community setting. OBJECTIVE Describe & compare the real-world outcomes, measured as IBD-related surgeries, in IFX dose optimized patients using Anser® TDM as part of ongoing IBD care as compared to a no TDM control group in a community-based practice setting. METHODS De-identified patient charts from a US-based community gastroenterology practice were analyzed for all patients (ages 8 to 89) treated with IFX from 2016 to 2022. Matching records to Prometheus Laboratories test results were then tokenized. Two cohorts were structured, Anser TDM as part of ongoing IBD care & no TDM. Groups were matched by propensity score, baseline disease, demographics, and comorbidities for comparison. Real-world outcomes were accessible via Lynx.MD online database. Analysis was conducted, stratifying patients as all IFX patients or anti-TNF naïve patients (TNF-N), to compare the percentage of IBD-related surgeries for 12 or 24-month outcomes. IBD surgeries were recorded in patient charts as colectomies, surgeries for fistula, bowel perforations, drainage of abscesses, adhesiolysis and other surgical bowel procedures. Statistical analysis was completed by Lynx.MD. RESULTS The size of Anser TDM (n= 235 to 337) and no TDM (n= 223 to 321) cohorts varied depending on the analysis criteria. Crohn’s disease was majority (2/3) and median age ranged from 36 to 39. For all IFX patients the 12-month outcomes of any IBD surgery was 1.2% for Anser TDM vs 6.5% for no TDM (5.4%, P=0.001). For TNF-N patients, the rate was 1% and 6.8%, respectively (5.7%, P=0.001). The results for 24-month outcomes for all IFX patients were 4.1% for Anser TDM vs 9.8% for no TDM (4.1%, p=0.016), and 4.3% vs 9% respectively for TNF-N (4.8%, P=0.06). CONCLUSIONS Real-world outcomes data for 12 and 24-months demonstrate that the Anser IFX TDM group had significantly lower rates of IBD surgeries for all patients, including for 12-month outcomes in TNF-N. This finding provides the first analysis, on Anser® TDM used to optimize patient’s IFX dosing, in comparison to a matched cohort of no TDM patients within the same community gastroenterology clinic setting.

P889 Facilitating equitable IBD care trust-wide: a need for treatment targets in IBD?

Abstract Background Timely biological therapy in IBD is associated with reduced disease progression, especially in CD (Berg et al 2019). However, there are no clear UK standards detailing the timescale in which IBD care should be delivered. We evaluated the time between initial consideration of therapy and first dose in a district general hospital and tertiary referral centre in Barts Health NHS Trust. Methods Details of patients receiving biologics for IBD at Newham (NUH) and Royal London Hospital (RLH) (between 2018 – 2022) were obtained from infusion clinics; electronic records were reviewed for 50 recent referrals. The following information was collected: demographics, phenotype, drug, first documentation of consideration of biologic, completion of funding application, onset of therapy. Results Demographics: NUH: Age (median(IQR)) = 43.5(30.3 – 50.56) Gender (F:M) = 26:24, CD:UC = 34:16, Biologic: infliximab:vedolizumab:ustekinumab:adalimumab: 29:5:11:5, First biologic: n=34 RLH: Age (median(IQR)) = 31.6 (24.6 – 41.1) Gender (F:M) = 27:23 CD:UC = 23:27, Biologic: infliximab:vedolizumab:ustekinumab:adalimumab: 34:12:3:1, First biologic: n=25 There was substantially longer time between initial consideration of therapy and first dose delivered at NUH 94.5 days (44 – 174) compared with RLH 35.5 days (23.75 –69) (p<0.01). However, time from completion of funding application to first dose did not differ significantly between sites (43.5 days (30.3 – 50.6) vs 31.6 (24.6 – 41.1), p=0.42). In patients receiving first biologic, there was a trend towards a longer time since diagnosis at NUH (3.2 years (1.0 – 9.1) vs 1.7 years (0.5 – 4.3), p=0.08). Conclusion Patients treated in a tertiary referral centre started biologics sooner after consideration, and earlier in disease course. This does not appear due to availability of infusion services, but due to time to complete initial investigations and finalise escalation. This may reflect differences in service set-up; in particular, NUH manages IBD care with a single IBD nurse, and fewer options for fast-track clinic follow up. A clear UK IBD standards framework identifying recommended time frames for establishing biologics is indicated, to ensure equity in care across tertiary and DGH settings.

P202 Streamlining primary and secondary care pathways reduces the time-to-specialist IBD care: the emergence of FIT and the relative decline of calprotectin testing in primary care

Abstract Background Streamlining primary and secondary care pathways reduces the time-to-specialist IBD care. Prior to the COVID-19 pandemic, using an algorithm that screens endoscopy reports for probable IBD, we halved the time to IBD specialist review and treatment. Previous studies report that faecal immunochemical testing (FIT) could be used like calprotectin to test for suspected IBD. We sought to define the changing use of calprotectin and FIT prior to the diagnosis of IBD, and to determine whether their use influenced the time to secondary care treatment. Methods We conducted a retrospective observational cohort study of the time from endoscopic diagnosis of IBD to initiation of treatment. Demographics, stool testing, referral route, disease type, clinical review and treatment data were recorded from our electronic patient record. We sought factors associated with a delay in treatment defined as the upper quartile of time-to-treatment using logistic regression. Results Between 01/07/16 and 01/09/23 there were 805 new diagnoses of IBD (503 UC, 225 Crohn’s disease and 77 IBD-U). Monthly diagnosis rates were stable across the pandemic, except for March 2020 due to endoscopy unit closure. The median time from endoscopy to specialist review was 19.0 days (IQR7.0-44.0) and time to outpatient treatment 5.0 days (IQR 0.0-29.0 days). Overall, the use of pre-IBD diagnosis stool biomarkers has increased over time, but since 2020 there has been a progressive rise in FIT, and a decrease in calprotectin, testing (Fig 1). By 2023, people with a new diagnosis of IBD were more likely to have FIT than calprotectin testing. Whilst stool biomarker testing did not influence the time-to-IBD treatment, FIT testing was associated with a reduced delay from primary referral to endoscopy (OR 0.17 p=0.023). Factors associated with a delay in treatment were a diagnosis of Crohn’s disease versus UC/IBDU, having your index endoscopy undertake by a colorectal surgeon and being managed on a non-emergency pathway. IBD nurse contact prior to medical clinic review was associated with a significant reduction in delay to treatment (OR 0.55 p=0.003) Conclusion In the Southwest of the UK, pre-IBD diagnosis FIT, is now more common than pre-IBD diagnosis calprotectin testing. Factors linked to a delay in treatment were being diagnosed with Crohn’s disease versus UC/IBDU, having your index endoscopy undertaken by a colorectal surgeon and not specialist nurse or gastroenterologist and being managed on a non-emergency pathway. Further studies are needed to understand the influence of FIT versus calprotectin testing in the primary care diagnosis of IBD.

P335 Development and validation of a Belgian set of quality indicators for inflammatory bowel diseases

Abstract Background Quality indicators are standardized, evidence-based measures of health care quality, categorised as structure (to assess the care setting), process (to assess high-quality care actions by healthcare professionals) or outcome indicators (results of actions undertaken by healthcare professionals). Several quality indicator sets have been developed to standardise, measure and optimise IBD care. Our aim was to develop and validate a set to assess IBD care in Belgium and to select a subset of indicators with room for improvement that can be used to implement and improve care in clinical practice. Methods The importance of 221 quality indicators (49 structure, 135 process and 37 outcome) identified through literature was scored on a 10-point Likert scale in a two-round modified Delphi exercise by IBD experts. In a third round, the experts indicated and ranked their top 10 indicators with most room for improvement benefitting the patient in the Belgian healthcare system to agree on an improvement subset. In parallel, patient perspectives were collected through two linguistic patient focus groups, one in Flemish (6 participants) and one in French (4 participants). A final consensus meeting was organised to discuss 1) the patient perspectives gained through the focus groups, 2) the results of two Delphi scoring rounds and 3) the results of the additional ranking round. Indicators scoring ≥7 by ≥80% of the participants during the second scoring round, or based on agreement during the consensus meeting, were included in the final set. Results Thirty-two experts (11 IBD nurses and 21 clinicians including 2 paediatricians) participated in all three voting rounds, of which 19 also participated in the consensus meeting (6 IBD nurses and 13 IBD clinicians including 2 IBD paediatricians). In total, 199 quality indicators were agreed upon to assess IBD care in Belgium (41 structure, 123 process and 35 outcome). Eighteen (3 structure, 14 process and 1 outcome; Table) were retained in the improvement subset, related to patient characteristics, endoscopy guidelines, infection prevention, steroid use, the IBD care team, services provided in the IBD clinic, the documentation of patient characteristics, the care pathway and the monitoring of disease activity. The decision to include the latter five themes was driven by the importance to patients, which was evident from the patient focus groups. Conclusion An evidence and consensus based set of quality indicators was developed and validated - including an improvement subset - allowing Belgian IBD centres to evaluate quality of provided care, set up quality improvement projects and potentially launch a benchmarking study.

P592 Higher predictive power of epigenetic signatures for response to vedolizumab and ustekinumab in anti-TNF naïve patients with active Crohn’s disease

Abstract Background Despite the significant progress in IBD care with biological therapies, the current 'trial-and-error' method remains suboptimal. Previous results from our EPIC-CD study demonstrated that two distinct epigenetic panels of 25 and 68 DNA methylation markers, respectively, were associated with (non-)response to vedolizumab (VDZ) and ustekinumab (USTE) in active Crohn’s disease (CD)1. Data from clinical trials have demonstrated that response rates in patients naïve to biological treatment are higher. We therefore aimed to evaluate the performance of our models in bionaive and anti-TNF exposed subpopulations. Methods We prospectively measured peripheral blood DNA methylation profiles from 184 adult CD patients prior to treatment with VDZ or USTE in a discovery (n=126) and independent validation (n=58) cohort using the Illumina EPIC BeadChip array. Between 26 and 52 weeks, patients were categorized as responders or non-responders based on a combination of endoscopic response (≥50% reduction in SES-CD score), steroid-free clinical response (≥3-point drop in Harvey-Bradshaw Index (HBI) or HBI ≤4 AND no systemic steroids), and/or biochemical response (≥50% reduction in C-reactive protein (CRP) and fecal calprotectin or a CRP ≤5 g/mL and fecal calprotectin ≤250 µg/g). Epigenetic biomarker identification and classification analyses were conducted through stability selection gradient boosting on the discovery cohort. Subsequently, the performance of the identified epigenetic biomarkers was assessed independently on the validation cohort, with patients stratified by prior anti-TNF exposure. Results Out of the 58 patients in the validation cohort, 25 received treatment with VDZ, and 33 with USTE, with 52% (n=13) and 36% (n=12) respectively naïve to anti-TNF treatment. Baseline characteristics between anti-TNF naive and anti-TNF exposed patients showed no significant differences, despite a slight significant age difference in the vedolizumab group, where anti-TNF exposed patients were significantly younger (table 1). In the overall independent validation cohort, the prediction models demonstrated an AUC of 0.75 for both VDZ and USTE. However, after stratification by prior anti-TNF exposure, we observed increased performance of our models among anti-TNF naive patients for both VDZ (AUCnon-exposed=0.85 versus AUCexposed=0.66) and USTE (AUCnon-exposed=0.97 versus AUCexposed=0.63 (figure 1). Conclusion Our findings demonstrate that prior anti-TNF exposure leads to somewhat reduced predictive power of our epigenetic models for Vedolizumab and Ustekinumab response. The predictive models may therefore find its optimal application in bio-naive patients, although they remain significant in anti-TNF exposed patients.

P018 Inequalities in healthcare access, experience and outcomes in adults with Inflammatory Bowel Disease: A scoping review

Abstract Background Inflammatory Bowel Diseases (IBD) are long-term conditions requiring lifelong access to, and interactions with health services. Accumulating evidence of inequalities in health care access, experience and outcomes for individuals with IBD is apparent. However there is no existing review that systematically maps these inequalities.The purpose of this review was to map and describe the inequalities in healthcare access, experiences, and outcomes of care for adults with IBD, to identify research gaps and future research priorities in this area. Methods A scoping review was conducted to retrieve quantitative, qualitative, and mixed methods evidence from three electronic databases (EMBASE, Medline and CINAHL). English written articles published between 2000 and 2023 were systematically searched using a search strategy. The Joanna Briggs Institute protocol for scoping reviews was followed to perform data extraction and analysis. Results 1343 records were identified. 51 studies met the criteria for inclusion. Studies addressed ethnic disparities of healthcare (33/51), inequalities driven by socioeconomic differences (12/51), rurality (7/51), gender (3/51), age (2/51), culture (2/51), literacy (1/51) and sexuality (1/51). The interrelationship of disparities relating to outcome, access and experience is illustrated in Figure 1. Poorer health outcomes (42/51 studies) were described in those from Black, Asian, and Hispanic ethnic groups in relation to hospital admission, readmission, emergency room attendance, length of stay, IBD-related complications, post-operative complications, treatment delay and length of stay. Deprivation, insurance status in US populations, rural location and age also affected outcome. Access inequalities (24/51 studies) were described to services, therapies and surgery but also to educational opportunities. Poor experience of care (8/51 studies) included appointment issues, lack of cultural understanding and fragmented care. A lack of research was found in the LGBTQIA+ community (1/51). No research was found to investigate inequalities in IBD patients with learning disabilities or autism. Conclusion Inequality affecting a wide range of population characteristics affects outcomes, access and experience in IBD care. Services need to be organised and delivered in a way that addresses this. Further research, including qualitative methods, is particularly needed to understand health experiences of underserved patient populations with IBD. The lack of research amongst LGBTQIA+ individuals, and with learning disabilities, poses a risk of creating inequalities within inequalities.

P126 Differential granulocyte populations as therapeutic targets in fistula

Abstract Background Despite the recent increase in therapeutic options in IBD care, treatment of perianal disease and in particular fistula remains highly challenging. Specific targeted medical therapy is not currently available, and a majority of patients fails to respond to surgical intervention. In contrast, cryptoglandular fistula show much higher response rates with closure in up to 80-90% of patients. Interestingly, the most present cell type in fistula, the granulocyte, is also the least studied due to their fragile nature. To fill this void, we evaluated granulocytes in perianal fistula and those present in the blood. Methods Curettage material of 18 fistula (Crohn n=15 and cryptoglandular n=5) was obtained and processed by mass cytometry. Two additional samples were obtained (1 Crohn, 1 cryptoglandular) together with matching blood samples and assessed by single cell RNASeq. Results As expected, granulocytes formed the majority of all cells in all fistula (mean 64%). Cryptoglandular fistula displayed significantly more granulocytes than Crohn’s related fistula. Single cell analysis showed 4 subsets: Subset 1 was the main subset in blood, and expressed high levels of LAMTOR4. Interestingly, although found both in blood and fistula, abundance was much higher in blood (80 vs 10%) and signaling cascades differed. In blood, activity was associated with degranulation, IL8 activity and migration. In fistula, a very strong IFNa/b signature was present. Subset 2 expressed high MMP9, and showed degranulating activity. Subsets 3 and 4 were almost exclusively found in the fistula tracts, and were defined by expression of PI3 and LRG1 respectively. Pathway analysis showed the PI3+ population to have strong cytokine signaling but little degranulating or migratory activity. Conversely, the LRG1+ population showed little cytokine activity, but stronger degranulating activity and integrin signaling. The two populations also expressed distinctive chemokine receptors, with PI3+ cells expressing high levels of CXCR4, while LRG1+ express CXC1 and CXCR2, suggesting differntial recruiment and potential modulation. In that light, it is interesting to note the proportion of PI3+ and LRG1+ cells differed between patients, with the majority of Crohn derived cells being PI3+ while the cryptoglandular fistula mainly contained LRG1+ cells. Conclusion Granulocytes form the main cellular component of fistula tracts in both Crohn and cryptoglandular fistula. Four different subsets of granulocytes could be identified, of which the two main subtypes in fistula tracts appear to differ significantly both in phenotype, activity and method of recruitment. This data may be a starting point for specific interventions in this highly abundant but often overlooked cell type.

P840 Structural evaluation of Inflammatory Bowel Disease Comprehensive Care Units in Brazil

Abstract Background In Brazil there is no methodology for evaluating health services recognized as Comprehensive Care Units (CCU), making it difficult to assess the quality of care provided for IBD patients. Aims: Map the distribution of this units and identify strengths and weaknesses, considering local and regional characteristics with a view to proposing a ranking system for Brazilian centers. Methods The study was carried out in three phases. First, GEDIIB developed 22 questions to characterize CCU in Brazil. The questionary was constructed based on GETECCU criteria. All GEDIIB members were invited to respond to the survey with the 11 questions considered most relevant. In the last phase, an analysis of the results obtained in the CCU was carried out, using the IBM SPSS Statistics v 29.0.1.0 software. Descriptive statistics were used to characterize the unit´s profile. The chi-square test was used to compare categorical variables Results There were 109 responses, 53 from public centers. Of these, 11 were excluded. Most units were concentrated in the Southeastern region 22 (52.4%) and only one (2.4%) in the Northern region of Brazil. Thirty-nine centers (92.9%) perform endoscopic procedures, but only 9 (21.4%) have access to enteroscopy and/or capsule endoscopy. Thirty-three centers (78.6%) offer infusion therapy locally, 26 (61.9%) maintain IBD patient records, 13 (31.0%) reported having an IBD nurse, 34 (81.0%) have specific evidence-based protocols and only 7 (16.7%) have a patient satisfaction methodology. In the private scenario there were 56 responses, of which 10 were excluded. There is also a concentration in the Southeastern and Southern regions. Thirty-nine centers (84.8%) have access to endoscopic procedures and 19 perform enteroscopy and/or capsule endoscopy. Infusion therapy is available in 24 centers (52.2%). Thirty-nine (84.8%) maintain a specific database of IBD patients, 17 (37%) have an IBD nurse, 36 (78.3%) have specific evidence-based protocols, and 22 (47.8%) apply a patient satisfaction methodology. Multidisciplinary teams (p< 0.002) and infusion centers (p< 0.01) predominate in public centers as compared to private ones. Telemedicine (p< 0.027), capsule endoscopy (p< 0.001), exclusive registration of patients with IBD (p< 0.015) and patient satisfaction methodologies (p< 0.002) are predominant in private centers as compared to public centers. Conclusion IBD CCU in Brazil were mainly located in the southeastern and southern regions of the country. Most centers have dedicated multidisciplinary teams and specialists involved in IBD treatment. There is still a current need to improve the proportion of nurses' involvement in IBD care in Brazil.

N02 Inflammatory bowel disease patients with impaired quality of life on biologic therapy benefit from the support of an IBD nurse specialist: Results of a randomized controlled trial in Germany (IBDBIO-ASSIST study) - The IBD nurses perspective

Abstract Background IBD nurses play an important role in the Multidisciplinary Team of managing patients with IBD. IBDBIO-ASSIST was a randomised controlled trial assessing the efficacy of care provided by an IBD nurse specialist in improving health-related quality of life (QoL) in IBD patients on biologic therapy in an outpatient setting in Germany. Methods In total, 1086 IBD patients on biologic therapy were randomly assigned to either a control group (CG) receiving usual IBD care or an intervention group (IG) receiving additional care from an IBD nurse. Two IBD nurses per site received an extra study specific IBD training before including patients. The primary outcome was disease-specific QoL (sIBDQ) assessed at months (M) 6, 12, and 18. In addition, IBD nurses provided a final assessment of various aspects of their work in the context of the study at M6 (T0) and M15 (T1), and patients were asked about their satisfaction level with the IBD nurses. Results The analysis of patients with impaired QoL at baseline (EQ-VAS < 75 [median]), showed an improvement in sIBDQ over 6 M that became significant at M12 and remained significant through M18 (baseline: IG 4.24; CG 4.31; M18: IG 5.02; CG 4.76; P= .017) (Table 1). Regarding the 5 aspects of fun, usefulness, successful discussions in consultations with patients, successful support of patients, and appreciation by patients, the nurses expressed positive assessments (“completely” and “rather”) at both measurement points, with values of more than 90% (Fig. 1). About 20% to 30% of the nurses reported being rather dissatisfied with two aspects of their jobs: time and space resources for discussions and recognition by physicians. 94% of patients in the IG felt that the additional care provided by the IBD nurses was highly beneficial. Conclusion IBD patients with impaired QoL derived a significant benefit from the additional care provided by an IBD nurse specialist, leading to meaningful improvements in sIBDQ over the long term. The survey results from the IBD nurses and patients in the IG revealed a very positive perception of the new form of care. It is noteworthy that an improvement in care provision was reported both by the nurses and the participating patients. Some physicians also experienced benefits from the intervention as they were relieved of certain time-consuming tasks by the IBD nurses. It should be noted that more than 20% of the IBD nurses did not feel sufficiently appreciated by physicians, and about 30% criticised the lack of time and space resources. When introducing the IBD nurse-led care concept into usual practice, these aspects should be considered.

N29 Patient evaluation of digital IBD care in patient initiated follow up pathway using MyIBD Care app and home calprotectin test

Abstract Background Remote patient monitoring via web applications has been reported to have benefits with improvement in patient-reported quality of life, medication adherence, and decreased heath care costs. Mobile applications can be used for symptom reporting and this along with home biomarker testing can facilitate patient initiated follow up. There remain uncertainties in the acceptance of digital technologies in routine follow up care among IBD patients. We aimed to survey the pilot users of MyIBD care app and CalproSmart home calprotectin monitoring in an IBD cohort Methods Patients participating in the patient initiated follow up (PIFU) cohort in IBD Home digital care pathway at a tertiary IBD referral centre were included in this pilot survey before full roll out of the programme. Patients were given detailed written and electronic information about the pathway before signing up. Predefined survey questions were administered using electronic in app methodology. The survey questions were ranked in Likert scale from strongly agree, agree, neither agree or disagree, disagree and strongly disagree. Data reported as proportion of responses to each category. Results 132 surveys were collected and analysed. Ninety three percent of responses understood the rationale for their inclusion to the digital pathway. Confidence in contacting the IBD team through digital pathway was reported in 89% of responses and 68% felt more in control of own condition. Eight six percent of patients understood the requirements for completing patient reported outcome measures and home calprotectin test while in the pathway and also felt confident in taking home calprotectin test. However only 44% felt closer to the clinical care team with the pathway. Conclusion Digital pathway incorporating a patient initiated follow up and self-monitoring is acceptable to IBD patients in stable remission with high satisfaction scores in all domains