IBD Care Research Articles

P044 Designing Interventions to Elevate the Quality of IBD Care: A Systematic Review of Quality Improvement Initiatives.

P044 Designing Interventions to Elevate the Quality of IBD Care: A Systematic Review of Quality Improvement Initiatives.

P072 The Pathway IBD Care in Rio de Janeiro From a Tertiary Referral Center Point of View.

P072 The Pathway IBD Care in Rio de Janeiro From a Tertiary Referral Center Point of View.

Transition to Adult IBD Care: A Pilot Multi-Site, Telehealth Hybrid Intervention.

Transition to adult IBD care continues to be a challenge. Efficacious models of improving transition to adult care in the United States are lacking. We present data from a pilot, prospective, non-randomized, intervention implemented at IBD centers in the Midwest and Southeast United States. Adolescents and young adults (AYAs; 16-20 years) with IBD and their parents completed a 4- to 5-month transition program (1 in-person group session; 4 individual telehealth sessions). Primary outcomes were feasibility (i.e., recruitment, retention, fidelity) and acceptability (i.e., program satisfaction). Secondary outcomes were changes in transition readiness, self-management skill acquisition, perceived readiness to transfer to adult care, and disease knowledge. The study exceeded goals for recruitment (target N = 20; actual: 36) and retention (target: 80%; actual: 86.11%). On average, it took participants 20.91 ± 3.15 weeks to complete our 4- to 5-month intervention and there were no deviations from the study protocol. Participant ratings for overall program satisfaction, perceived helpfulness, and program length and format were positive. Increases in transition readiness, t(30) = 8.30, d = 1.49, p < .001, self-management skill acquisition, t(30) = 3.93, d = 0.70, p < .001, and disease knowledge, t(30) = 8.20, d = 1.58, p < .001 were noted. AYA- and parent-perceived transfer readiness also improved (p's < .05; d's = 0.76-1.68). This article presents feasibility and acceptability data for a 4- to 5-month transition intervention. Improvements in AYA transition readiness, self-management skill acquisition, IBD knowledge, and AYA/parent perceived transfer readiness were also observed.

S3203 Patient Outcomes in IBD: Assessing the Effects of a CME Program and Quality Improvement Activity

INTRODUCTION: The management of IBD has improved with the availability of new therapies. These treatments can lead to immune suppression, resulting in increased risk of infection. Many of these infections are preventable with immunizations. Despite the effectiveness of vaccines in preventing these diseases, many patients with IBD are not receiving immunizations in accordance with recommendations of the ACG and ACIP. METHODS: This education teamed a panel of gastroenterologists with PCPs to address best practices in vaccinations, preventative care, and treating patients in coordinated, patient-centered care in IBD. The activity included a quality improvement component for learners (n = 25) to review their patient charts at baseline and post-education for: vaccination documentation/completion rates, rates of screening for comorbidities, and quality of life. Methods for this study included: • Live 90-min CME/CE panel discussion + enduring webcast. • Quality Improvement project with learners. • Quantitative and qualitative data collection and analysis. • Predictive modeling analysis. RESULTS: Increased knowledge: • 59% regarding pneumococcal vaccine schedules for patients with IBD. • 48% about ACG Clinical Guidelines for Preventive Care in IBD. • 56% identifying the impact of the IBD medical home on patients with IBD. Quality Improvement: Learners (n = 25) submitted data from a total of 250 patient charts. Improvements were noted in all areas surveyed for: influenza and pneumococcal vaccination, herpes zoster vaccination, mental health, melanoma and non-melanoma skin cancer, cervical cancer, bone health, and smoking cessation. PredictCME: All else being equal, a clinician’s IBD patient load and not any other education or demographic element predicts appropriate vaccine recommendation and understanding of the role of the IBD medical home. Clinicians who have fewer patients with IBD may be more likely to follow these guidelines to preventive health potentially due to their ability to pay more attention to these patients. CONCLUSION: Overall, learners are 7% more knowledgeable than non-learner controls. The high performance of controls is likely associated with a higher number of gastroenterologists in the control survey compared to the learner survey represented by subscribers that included gastroenterologists and primary care clinicians. While knowledgeable, controls lacked confidence in their abilities. Further education on implementing guidelines will improve confidence and adoption of appropriate guidelines.Figure 1.: Quality Improvement data: Clinicians improved their screening for vaccinations, mental health, cancer, and bone health while also improving upon counseling patients for smoking cessation.

Best Practice Guidance for Adult Infusion Centres during the COVID-19 Pandemic: Report from the COVID-19 International Organization for the Study of IBD [IOIBD] Task Force.

Infusion centres are a central part in the management of patients with inflammatory bowel disease [IBD] and could be a source of transmission of SARS-COV-2. Here we aimed to develop global guidance for best practices of infusion centres for IBD patients and to determine the impact of the COVID-19 pandemic on these centres. Under the auspices of the International Organization for the Study of Inflammatory Bowel Disease [IOIBD], a task force [TF] was formed, an online survey was developed to query infusion centre protocols during COVID-19, and recommendations were made, based on TF experience and opinion. Recommendations focus mainly on patients screening, infusion centres re-organization, personnel protection, and protocol modifications such as shortening infusion duration or replacing it with subcutaneous alternatives. Implementing these recommendations will hopefully reduce exposure of both IBD patients and care givers to SARS-COV-2 and improve the function and safety of infusion centres during the COVID-19 pandemic as well as potential future threats.

Predicting Response to Vedolizumab in Inflammatory Bowel Disease.

Vedolizumab is known to be safe, well-tolerated, and effective. However, as personalization becomes an increasingly important aspect of IBD care and in lieu of guidelines to inform clinicians on positioning of biologics, there is a need to reliably predict response to inform patient preferences and shared decision-making. Recent data from clinical trials and real-world evidence have elucidated predictors of clinical and endoscopic response while providing the framework to establish predictive models. Current models are able to predict that those patients with less severe disease, without prior biologic exposure and who demonstrate early response to VDZ have the highest rates of durable clinical and endoscopic response and remission. When incorporating these models into clinical practice, clinicians will be able to identify those patients who are likely to respond before drug initiation as well as early non-responders and response latency after initiation of vedolizumab. In a shift toward personalization of medicine in IBD, the ability of predictive models for vedolizumab to aid pre-biologic and early management will inform both clinician and patient. Ideally this will provide both a personalized and more cost-effective approach, though further studies in cost-analysis in this framework are needed. Though current models are comprehensive of existing data, future research on microbial and translational biomarkers will be additive and necessary to provide full personalization of treatment.

Clinical pharmacists are making a difference in IBD care

Clinical pharmacists are making a difference in IBD care

Inflammatory Bowel Disease Care in the COVID-19 Pandemic Era: The Humanitas, Milan, Experience.

The outbreak of the COVID-19 caused by coronavirus SARS-CoV2, is rapidly spreading worldwide. This is the first pandemic caused by a coronavirus in history. More than 150 000 confirmed cases worldwide are reported involving the SARS-CoV2, with more than 5000 COVID-19-related deaths on March 14, 2020. Fever, chills, cough, shortness of breath, generalised myalgia, malaise, drowsiness, diarrhoea, confusion, dyspnoea, and bilateral interstitial pneumonia are the common symptoms. No therapies are available, and the only way to contain the virus spread is to regularly and thoroughly clean one’s hands with an alcohol-based hand rub or wash them with soap and water, to maintain at least 1 m [3 feet] distance from anyone who is coughing or sneezing, to avoid touching eyes, nose, and mouth, and to stay home if one feels unwell. No data are available on the risk of COVID-19 and outcomes in inflammatory bowel disease [IBD] patients. Outbreak restrictions can impact on the IBD care. We aim to give a viewpoint on how operationally to manage IBD patients and ensure quality of care in the current pandemic era.

A245 IMPROVING KNOWLEDGE TRANSFER OF PREVENTATIVE CARE IN INFLAMMATORY BOWEL DISEASE USING ELECTRONIC LEARNING

Abstract Background Inflammatory bowel disease (IBD) is a complex chronic disease and it is imperative that gastroenterologists are familiar with the unique needs of the IBD patient. An important part of management involves education surrounding the general health maintenance needs of this patient population, especially those on immunomodulator and biologic therapy or those being considered for such treatment. A recent study showed that Canadian GI trainees are uncomfortable managing preventative care in IBD including vaccinations and bone protection. Using educational videos for trainees to improve core knowledge of these concepts remains unclear. Aims Assess educational efficacy of a core training module on trainee confidence and knowledge on preventative care in IBD. Methods This study assessed a preventative care in IBD video used as an educational tool in the University of Toronto GI trainee program as part of the annual GI in-training objective structured clinical examination (OSCE). Prior to the OSCE, a randomly selected cohort of trainees were provided the preventative care video. The remaining trainees prepared for the OSCE as standard. At the OSCE, one station asked all trainees to address preventative care in IBD with a standardized patient. Following the OSCE, a standardized evaluation of trainee confidence and degree of knowledge on vaccination, cancer screening, bone health, and mental health in IBD patients was performed. These evaluations and OSCE score were then compared between both cohorts. Data was analyzed using a t-test and p&amp;lt;0.05 was considered significant. Results A total of 10 subjects took part in the study. 5 subjects were exposed to the video prior to the OSCE and 5 were not exposed. Overall total score for trainees who had seen the video prior to the OSCE had a mean score of 85.3% (38.4/45) compared to those who had not seen the video prior had a mean score of 65.3% (29.4/45) with a p = 0.03. Global score in those exposed to the video was 70% (3.5/5) compared to 48% (2.4/5) in the unexposed group with a p= 0.006. Upon assessment of individuals topics, there was a trend in improved knowledge of vaccination and mental health screening in those exposed vs. unexposed to the educational video (52.6% vs. 32.6%, and 80% vs. 20%, respectively). No significant difference was identified between groups with respect to cancer screening and bone health. Conclusions Our study shows evidence that use of educational videos was efficacious with respect to GI trainee confidence and knowledge surrounding key concepts in preventative care of IBD patients. This exposure allows for improved patient education and management and lead to better-quality patient care. Overall, this study identifies a knowledge gap in trainee education and highlights the need for development of training tools to improve overall management of this complex and dynamic disease. Funding Agencies CAGVideo was a CAG accredited educational material, and supported by an educational grant from the Canadian Association of Gastroenterology and Abbvie Canada

A65 VARIATION IN THE CARE OF CHILDREN WITH INFLAMMATORY BOWEL DISEASE: A CANGIEC POPULATION-BASED STUDY

Abstract Background Inflammatory bowel disease (IBD) is rising rapidly in Canadian children. These children require consistent high-quality specialized care to prevent long-term complications. Aims Evaluate variation in health services utilization and surgery rates across pediatric IBD centres in Ontario. Methods Incident cases of IBD &amp;lt;16y (1999–2010), identified from health administrative data using a validated algorithm, were assigned to pediatric IBD centres based on location of IBD hospitalization, endoscopy and outpatient care. Children receiving IBD-specific care outside pediatric centres were also grouped. Frailty models, median hazard ratios (MHR), and Kendall’s t described variation in IBD-related ED visits, hospitalizations, and surgery 6–60 months after diagnosis, adjusting for age, sex, rural/urban household, and income. Mean diagnostic lag (time from first health system contact for an IBD symptom to final IBD diagnosis) and proportion of children with IBD care by gastroenterologists (GIs) at each centre were evaluated as centre-level predictors of variation. Results Of 2584 IBD cases, 73.4% were treated in a pediatric IBD centre. Between-centre differences accounted for 0.18% (MHR 1.06) and 0.41% (MHR 1.09) of variation in hospitalizations and ED visits, respectively. Children treated at centres where a higher proportion of children were cared for by GIs were more likely to be hospitalized (HR 2.09, 95% CI 1.26–3.45). Children treated at centres with a longer mean diagnostic lag were also more likely to be hospitalized (HR 1.01, 95% CI 1.003–1.02). ED visits were not associated with the proportion of children cared for by gastroenterologists or diagnostic lag. Among 1529 CD cases, 14.1% required intestinal resection; 1.79% of variation in the risk of surgery resulted from between-centre differences (MHR 1.20). Surgery was less common among patients at centres where more children were cared for by GIs (HR 0.24, 95% CI 0.07–0.84) and with a longer mean diagnostic lag (HR 0.98, 95% CI 0.97–0.99). After adjusting for these, between-centre differences accounted for 0.005% (MHR 1.01) of variation in care. Minimal variation was observed among the 11.0% of 872 UC cases requiring colectomy, with 0.37% of variation due to between-centre differences (MOR 1.09). Colectomy risk was not associated with GI care or diagnostic lag. Conclusions Variation in ED visits, hospitalizations, and surgery among children with IBD is small; however, centre-level differences in GI specialist care use and time to diagnosis were associated with hospitalization and surgery. It is essential to understand between-centre differences to reduce variation and ensure high-quality care. Funding Agencies CCC

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

Abstract 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 &amp; 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

Quality of Care Standards in Inflammatory Bowel Diseases: a European Crohn's and Colitis Organisation [ECCO] Position Paper.

The management of inflammatory bowel disease [IBD] is complex, and requires tight control of disease activity, close monitoring to avoid treatment side effects, health care professionals with expertise in IBD, and an interdisciplinary, holistic approach. Despite various efforts to standardise structures, processes, and outcomes,1-8 and due to the high variability at the local, national, and international levels, there are still no clear definitions or outcome measures available to establish quality of care standards for IBD patients which are applicable in all contexts and all countries. For this reason, the European Crohn's and Colitis Organisation [ECCO] supported the construction of a list of criteria summarising current standards of care in IBD. The list comprises 111 quality standard points grouped into three main domains [structure n = 31, process n = 42, outcomes n = 38] and is based on scientific evidence, interdisciplinary expert consensus, and patient-oriented perspectives. The list of proposed criteria is intended to represent the position of ECCO regarding the optimum quality of care that should be available to patients. Since health care systems and regulations vary considerably between countries, this list may require adaptation at local and national levels. It is recognised that not all these criteria that have been identified as optimal will be available in every unit. However, ECCO will continue its efforts to develop and coordinate projects and initiatives that will help to guarantee optimal quality of care for all IBD patients.

P043 FOCUSING ON THE FUTURE: REDUCING BARRIERS AND IMPROVING ACCESS TO IBD SPECIALTY CARE ACROSS CANADA

Abstract Background Inflammatory Bowel Disease (IBD) is a chronic immune-mediated disease which affects nearly two million North Americans, with Canada demonstrating the highest age-adjusted incidence and prevalence rates globally. Resulting from compounding prevalence rates, the IBD clinical burden continues to grow. With high demand and limited resources, timely access to specialty healthcare services continues to be a difficulty faced by both patients and healthcare providers. Despite this pervasive issue, there has been no published research to date elucidating the patient perspective using qualitative approaches to compare and contrast the patient experience across Canada. Aims The aim of the study was to elicit a qualitative stream of data to better understand phenomena related to access to healthcare for individuals 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 &amp; Colitis Canada. To ensure geographic diversity and representation, patients were recruited from both 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 seven provinces across Canada. All focus groups were audio recorded, transcribed verbatim, and coded for themes. Themes were distilled through qualitative thematic analysis using Atlas.ti software to ascertain congruence or discordance of patient experiences in relation to IBD care access. 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 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 can be better understood and improved on both a provincial and national scale.

P261 Systematic review with meta-analysis: The impact of concomitant immune-mediated diseases on the disease course of inflammatory bowel disease

Abstract Background Several studies have shown an association between inflammatory bowel diseases [IBD] and immune-mediated diseases [IMIDs], but data on the impact of co-occurring IMIDs on IBD course are inconsistent. The aim of this study was to investigate the impact of co-occurring IMIDs on IBD phenotype and disease course. Methods PubMed and EMBASE were searched from database inception through December 2018 and updated in October 2019 for studies reporting prevalences or odds, risks or hazard ratios of IBD-related disease outcomes in patients with and without co-existing IMIDs. Meta-analyses were performed to estimate summary prevalences and risks of the outcomes which included disease extension, IBD-related surgery and hospitalisation, malignancy, mortality and need of medication (biologic therapy, steroids and immunomodulators). IMIDs were stratified into primary sclerosing cholangitis [PSC] and ‘IMIDs other than PSC’. Results A total of 93 studies comprising 14,307 IBD patients with IMIDs and 3,409,914 IBD patients without IMIDs were included in the study. Summary risks and prevalences with 95% confidence intervals for each outcome are presented in figures 1 and 2, respectively. The following results are all significant (p &amp;lt; 0.05). Compared with patients without co-occurring IMIDs, patients with ulcerative colitis [UC] and co-occurring IMIDs other than PSC more frequently received immunomodulators and steroids, and patients with Crohn’s disease [CD] and concomitant IMIDs other than PSC more often received biologic therapy. UC patients with co-existing IMIDs other than PSC more often underwent IBD-related surgery, while patients with CD and PSC received fewer surgeries. In addition, UC patients with co-occurring PSC were at increased risk for having extensive colitis, pancolitis, and malignancies. Patients with UC and PSC had a higher mortality rate, but no difference was found among patients with IMIDs other than PSC. PSC did not influence hospitalisation rates among IBD patients. Conclusion This meta-analysis found that IBD patients with co-existing IMIDs have a different disease course than patients without concomitant IMIDs. This study emphasises the importance of multidisciplinary care of IBD and that physicians caring for IBD patients need to be aware of IMIDs as a prognostic factor.

N27 What people want! Exploring inflammatory bowel disease patients’ perspectives on healthcare professionals addressing sexual well-being

Abstract Background Inflammatory bowel disease (IBD) affects every aspect of one’s life, yet no routine assessment for the impact on sexuality is made. Our aim was to explore patients’ perspective on healthcare professionals (HCPs) addressing sexuality/sexual well-being concerns. Methods This was a qualitative narrative study. Inclusion criteria were any sexual orientation and with known IBD for longer than 18 months. Data were collected via semi structured interviews and anonymous narrative accounts submitted via Google Forms. Thematic analysis was used to analyse the data. Results Fourteen adults, 4 male and 10 female, took part. Eleven participants were from the UK, one from the USA of America and one for South Africa. The following main themes and subthemes were identified: I cannot imagine talking about my sex life (a difficult topic; there is not enough time), Those who talked about sex, talked badly (nobody volunteered information; badly handled conversations), Still living whilst unwell (sex is an important part of my life; sex issues break down relationships, medicalised body), IBD ruined my sex life (feeling unattractive; feelings of shame and embarrassment), I feel unheard (HCPs don’t open the discussion; sex not taken seriously), I’m a person, not my IBD (holistic approach to care; time, space and ways to talk about sex). The findings reflect the importance of sexual well-being to those living with IBD, the experiences of such conversations, barriers to conversations with HCPs on sexual well-being, and suggestions on how HCPs should address their unmet needs. The importance of discussing intimacy and sexuality was emphasised, as participants felt their sexual well-being was considerably affected by IBD. The majority reported that HCPs did not initiate discussions on sexual well-being, nor did they understand the impact of IBD on sexual well-being, with a distinct accent on the perceived lack of a holistic approach to their care. Therefore, participants made suggestions for practice, such as provision of information related to sexual well-being in the form of leaflets, additionally to HCPs raising the issue. Conclusion Our findings indicate that communicating on sexuality/sexual well-being is a problematic area of IBD care. HCPs must be cognisant of the sexual well-being concerns and needs of those living with IBD, who want this topic discussed routinely, as part of a holistic approach to their clinical care.

P611 Provision of care for pregnant women with IBD in the UK - the current landscape

Abstract Background inflammatory bowel disease (IBD) results in increased rates of negative pregnancy outcomes; particularly in poorly controlled disease. We aimed to describe the current landscape of provision of antenatal care for women with IBD in the UK. Methods This cross-sectional study collected data on service set-up, on principles of care pre, during, and after pregnancy and on perceived responsibilities of clinicians. An online survey was distributed to all gastroenterology units in the UK. Results Data were provided for 97 of 273 IBD units. Pre-pregnancy counselling was not available in 7%, offered routinely (39%), or on request (54%) but predominantly (91%) in an ad-hoc fashion rather than in a dedicated set-up. Ninety-two per cent of units provided a nominated gastroenterology consultant during pregnancy. In 86% of this was the patient’s usual consultant rather than a consultant with expertise in pregnancy (14%). Combined clinics with obstetricians and gastroenterologists were offered in 14% of units only, but more often in academic rather than district hospitals (24% vs. 7%; p = 0.043) Otherwise, communication with obstetrics was ‘as and when required’ in 51% of cases. Patients were reviewed either every trimester (55%), monthly (15%) or ‘only when required’ (30%). The majority of respondents thought gastroenterologists should be involved in decisions regarding routine vaccinations (70%), breastfeeding (80%), folic acid dosage (61%), and VTE prophylaxis (53%). Sixty-five per cent of participants thought that gastroenterologists should be involved in decision-making regarding the delivery method. Regarding IBD indications for elective caesarean section, 94% of participants recommended these for active peri-anal disease, 30% for previous but healed peri-anal disease, 56% for ileo-anal pouch and 20% for previous abdominal and/or pelvic surgery. Conclusion In a nationwide survey on the provision of antenatal IBD care we found considerable variation in all aspects of service provision, particularly the availability of expertise and specialist services. We have detected areas of poor care (review only when required, communication ad-hoc only, poor provision of dedicated pre-pregnancy counselling). A significant minority of IBD units also felt that they do not need to provide input into areas such as VTE prophylaxis, delivery method and folic acid dosing. IBD indications for caesarean section seem to be poorly understood by a sizable minority. A basic framework to inform service set-up, and better education on the available clinical guidance for clinicians, is required to ensure consistent identification and review of patients and high-quality care.

P201 Evaluating access to inflammatory bowel disease care across Canada: Proceedings from the 2017 IBD Access Summit

Abstract 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 speciality care in Canada has not been reviewed. This lack of understanding presents a barrier in evaluating and implementing changes in IBD speciality care. The aim of the project was to identify key barriers and facilitators for and to develop a national working strategy to address limitations in access to IBD speciality care. Methods The IBD Summit was held in Toronto, Ontario in November 2017, sponsored by SPOR-CIHR catalyst funding and in partnership with Crohn’s and 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 paediatric and adult gastroenterologists, patients, researchers, and policymakers. 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 centralised triage systems; increased comprehensive care support for patients and primary care physicians; and increased community supports for patients and providers. Conclusion 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 speciality 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.

P549 A virtual clinic enhances the quality use of anti-TNF dose intensification and rates of treatment success using a treat-to-target approach compared with standard outpatient care in Crohn’s disease

Abstract Background Virtual clinics (VC) represent a novel model-of-care which promote quality use of biologics and facilitate a treat-to-target (T2T) approach. We aimed to evaluate the clinical and process-driven outcomes of intensified anti-TNF therapy for secondary loss of response (SLoR) in a VC compared with standard outpatient care (SoC). Methods A retrospective multicenter, parallel observational cohort study of patients with Crohn’s disease (CD) who underwent anti-TNF dose intensification to address SLoR with up to 2-years of follow-up was undertaken. Objective assessments of disease activity and anti-TNF trough levels at SLoR then during subsequent 6-month semesters were compared longitudinally between VC and SoC groups. ‘Anti-TNF escalation success’ was the primary endpoint, defined as achieved when two consecutive 6-month semesters of objective assessment demonstrated inactive disease. Dose intensification was defined as ‘appropriate’ if there was both objective evidence of disease activity, plus anti-TNF trough levels at or below the lower limit of the therapeutic range prior to intensification. ‘Treatment escalation failure’ was defined by the occurrence of one or more of biologic switching, discontinuation or further intensification; recommencement of corticosteroids, or IBD-related surgery. Results 149 patients (69 VC vs. 80 SoC) underwent infliximab (n = 94) or adalimumab (n = 55) dose intensification with similar baseline patient, disease and treatment characteristics between cohorts. The median duration of follow-up post dose-intensification was 1.9 and 1.5 years for the SoC and VC cohorts respectively (p = 0.37). There were higher rates of appropriate dose intensification (82.6 vs. 40.0%, p &amp;lt; 0.01) across the VC cohort. Higher proportions of anti-TNF escalation success (60.9 v 35.0%, p &amp;lt; 0.01), biomarker remission (i.e., C-Reactive Protein (&amp;lt;5mg/l) and faecal calprotectin (&amp;lt;150 μg/ml) normalisation, log-rank tests, p = 0.06 and p &amp;lt; 0.01 respectively), tight disease monitoring (84.1 vs. 28.8%, p &amp;lt; 0.01) and de-escalation of intensified therapy (21.3 vs. 10.0%, p = 0.03) were also achieved by the VC cohort following dose-intensification. Conclusion This study favoured a VC-led model of care over standard outpatient-based IBD care in facilitating an effective T2T approach to CD management. A VC model of care improved quality use of intensified anti-TNF therapy through processes that promoted appropriate dose intensification and encouraged more frequent anti-TNF dose de-escalation. Moreover, tight semester-based monitoring using a T2T-based strategy facilitated by the VC was associated with improved treatment outcomes.

P757 Focusing on the future: Reducing barriers and improving access to inflammatory bowel disease specialty care across Canada

Abstract Background Inflammatory Bowel Disease (IBD) is a chronic immune-mediated disease which affects nearly two million North Americans, with Canada demonstrating the highest age-adjusted incidence and prevalence rates globally. Resulting from compounding prevalence and limited resources, timely access to IBD care continues to be a widespread issue for patients and healthcare providers. Despite this pervasive issue, there has been no published research to date elucidating the patient perspective using qualitative approaches to compare and contrast the patient experience across Canada. The aim of the study was to elicit a qualitative stream of data to better understand phenomena related to access to IBD care 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 &amp; Colitis Canada. To ensure geographic diversity and representation, patients were recruited from both urban and rural regions. In order to acquire multiple access perspectives, patients were invited to bring a family member involved in their care to the focus groups. Co-facilitated by a researcher and patient-research partner, all focus groups were audio recorded, transcribed verbatim, and coded for themes. Themes were distilled through qualitative thematic analysis using Atlas.ti software to ascertain congruence or discordance of patient experiences in relation to IBD care access. Results Sixty-three participants were recruited in 14 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). Thematic analyses identified four main barrier themes, each with multiple sub-themes: (1) structure/system issues (i.e. system stagnation), (2) processes (i.e. information management), (3) experiences (i.e. psychosocial support), and (4) patient as partner (i.e. autonomy, power dynamics). In response, four solution themes were proposed: (1) integration of holistic care into the clinical practice, (2) readily accessible psychosocial and nutritional support, (3) increased patient advocacy, and (4) continuity and liaison through provision of a healthcare navigator resource. Conclusion The complexity of IBD specialty care access 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 can be better understood and improved on both a national and international scale.

Are we choosing wisely for inflammatory bowel disease care? The IG-IBD choosing wisely campaign

BackgroundThe “Choosing Wisely” campaigns have the aim of promoting a better clinician-patient relationship. AimsThe Italian Group for the Study of Inflammatory Bowel Disease (IG-IBD) conducted a choosing wisely campaign for IBD. MethodsTen IG-IBD panellists conducted the campaign through a modified Delphi process. All IG-IBD members were asked to submit five statements starting with “Do not…” addressing any IBD-related procedure or treatment the necessity of which should be questioned. All recommendations were evaluated by the panellists who prioritised each item. The top ten recommendations were prioritised again by IG-IBD members, and the top five recommendations were identified. Results110 members (mean age 42 ± 12; 62 males) participated in the campaign. The top five recommendations were as follow: 1. Do not use corticosteroids for maintenance therapy, or without a clear indication; 2. Do not forget venous thromboembolism prophylaxis in hospitalised patients with active disease; 3. Do not treat perianal Crohn's disease with biologics without prior surgical evaluation; 4. Do not discontinue IBD-related medications during pregnancy unless specifically indicated; 5. Do not delay surgery. ConclusionThe IG-IBD promoted a campaign with a bottom-up approach, identifying five recommendations that could be useful for providing a better IBD care, especially among non-IBD experts.