Inflammatory Bowel Disease Care Research Articles

P860 The Costs of Inflammatory Bowel Diseases in High-Income Settings

Abstract Background Crohn’s disease (CD) and ulcerative colitis (UC), together known as inflammatory bowel diseases (IBD), affect approximately seven million people globally. The continuous rise in IBD prevalence and the aging of populations will inevitably lead to an increasing use of health care resources. In parallel with these trends, continuing innovations in IBD therapeutics, diagnostics, and preventatives are creating more options for IBD patients seeking to reduce their disease burden. These trends pose an imminent burden on health care systems and require that we identify modifiable cost drivers in IBD care and develop strategies for delivering equitable and affordable care for all patients. Methods This Lancet Gastroenterology & Hepatology Commission, consisting of a diverse faculty of health care professionals with expertise in the field of IBD and health economists, was formed to deliver an extensive summary of the literature and discuss key topics on the costs and cost-effectiveness of treating IBD in the present, and how this is likely to look in the future. Furthermore, it offers suggestions for how to deliver affordable IBD care in the coming years. The report’s focus was on high-income countries in Europe, North America, Australia and New Zealand, and Asia. Results The Commission drew together a wide range of expertise to discuss the current costs of IBD care, the drivers of increasing costs, as well as how to deliver affordable care for IBD in the future. The key conclusions are that (i) increases in health care costs must be evaluated against improved disease control and reductions in indirect costs, and (ii) that overarching systems for data interoperability, registries, and big data approaches must be established for continuous assessment of effectiveness, costs, and cost-effectiveness of care. International collaborations should be sought in order to evaluate novel models of care (such as value-based health care, including integrated health care and participatory health care models), as well as to improve the education and training of clinicians, patients, and policymakers. Measures to reduce the costs of IBD care are summarised in Table 1. Conclusion Increases in health care costs must be evaluated against improved disease control and reductions in indirect costs. Evaluations should be systematically aligned between countries and regions. Detailed analysis of the current epidemiology and the likely effects of changing IBD management on disease course and socioeconomic outcomes is essential; and will become even more imperative in the era of precision medicine, where complex biotechnologies will require expensive analyses, highly skilled personnel, and drug development for what may sometimes be relatively small patient groups.

P432 Patient satisfaction and patient costs associated with telephone clinic appointments in Inflammatory Bowel Disease (IBD) following the pandemic

Abstract Background Prior to the COVID-19 pandemic, conventional management of outpatient care in IBD predominantly revolved around face-to-face clinic appointments. In the changing landscape of care provision during the pandemic, appointments were conducted almost exclusively through telephone consultation. An electronic questionnaire was developed to assess patient satisfaction and patient costs. Methods A pilot was carried out with 15 patients to identify any technical issues with e-mail delivery of the questionnaire and gauge face validity of the questionnaire content. 1400 patients registered with the TrueColours-IBD remote digital monitoring system were sent the questionnaire link via e-mail in May 2021. No demographic data were collected by design, in order to avoid the perception of bias and ensure freedom of expression through anonymity. Results 506 responses were received including 21 duplicates which were excluded, totalling 485 valid responses. 408/485 patients reported having a telephone appointment with the IBD service since March 2020, 484/485 reported having had a face-to-face appointment in the past. 348/408 (86%) were either ‘very satisfied’ or ‘somewhat satisfied’ with their most recent telephone consultation, while 22 (6%) were either ‘very dissatisfied’ or ‘somewhat dissatisfied’. 247/408 (61%) were also either ‘very satisfied’ or ‘somewhat satisfied’ with the ease of accessing further care if required, compared to 33/408 (8%) who were either ‘very dissatisfied’ or ‘somewhat dissatisfied’. Given the choice, 195/408 (48%) patients preferred to receive a telephone appointment in the future; 147/408 (36%) would opt for face-to-face and 66/408 (16%) stated no preference, all with the option of changing that choice if needed. Telephone appointments were associated with a mean total patient time off-work or leisure of 23 minutes (S.D. 51, n=408) compared to 190 minutes (S.D. 96, n=484) for face-to-face appointments. The average cost of time off work or leisure associated with telephone appointments was £5.55 (S.D. = £15.74, n=408), compared to £43.42 (S.D. = £31.27, n=484) for face-to-face appointments (Table 1). Costs of transport add further to face-to-face appointment costs. Greater proportions of patients had a companion for their face-to-face appointment and required childcare compared to telephone consultations (Table 2), which again increases the difference in costs. Conclusion Almost half of surveyed patients stated a preference for telephone appointments, although a third still preferred traditional follow-up. An evolution of care pathways is supported by patient preference and the statistically significant time and cost savings to patients receiving telephone appointments.

P851 Impact of an integrated model of care for inflammatory bowel disease on direct healthcare costs: A population-based matched cohort study from Saskatchewan, Canada

Abstract Background Integrated models of care (IMC) for IBD lead to reduced hospitalizations, surgeries, comorbidities, and overall improved outcomes. There are limited studies assessing the impact of IMC on direct healthcare costs. We aimed to estimate the impact of exposure to an IMC on direct healthcare costs among individuals diagnosed with IBD. Methods We conducted a quasi-experimental difference-in-difference (DID) cost analysis using administrative health data from Saskatchewan, Canada. We included individuals ≥18 years old meeting a validated administrative IBD case definition between January 2009 and March 2015. IBD cases were classified as exposed or non-exposed to the Saskatchewan IMC and required to have three years of healthcare coverage after baseline (i.e., first visit with an IMC [exposed] or a non-IMC [non-exposed] gastroenterologist). The direct healthcare costs were derived from the administrative databases, adjusted to 2014/15 Canadian dollars, and categorized into hospitalizations, physician visits, and medication claim costs (i.e., immunomodulators [IMM], biologics [BIOL], aminosalicylates[5-ASA]). Propensity scores (PS) were calculated based on healthcare utilization and comorbidities in the 12 months before baseline. Cases (exposed) were matched 1:5 controls (non-exposed) based on PS and disease duration. DID estimators were determined for each cost category using mixed linear regression models including age, sex, disease type, and area of residence as covariables. Results In total, 2905 IBD cases were included in the study, 597 exposed and 2308 non-exposed individuals (Figure); the majority were females (52%), lived in urban areas (74%), and had Crohn’s Disease (61%). The mean age was 44.6 years (SD=15.5) and the average disease duration at baseline was 5.7 years (SD=5). In comparison to the non-exposed group, the costs of physician visits (IBD-related [DID= $-139, 95%CI -209 to -68], IBD-specific [DID=$-155, 95%CI -212 to -97], and specialty visits [DID=$-135, 95%CI -201 to -69]); and IMM dispensations (DID=$-18, 95%CI -35 to -2) were lower in the exposed group. Conversely, we identified higher total healthcare costs (DID=$1707, 95%CI 369 to 3044); IBD-related medication (DID=$2341, 95%CI 1484 to 3197) and BIOL (DID= $2467, 95%CI 1605 to 3328) dispensations costs in the exposed group. There were no other statistically significant differences between the groups. Conclusion We identified lower physician visit and IMM costs in the exposed group than in the non-exposed one. Total healthcare costs were higher among the exposed group, largely driven by higher BIOL costs. These results highlight the potential cost impact of IMC for IBD and the need for cost-effectiveness studies of IMC to further assess value of this care model.

DOP55 The increasing burden of direct and indirect costs of IBD

Abstract Background The cost of care for inflammatory bowel disease (IBD) has nearly doubled over the last two decades. With an increasing number of patients and evolving treatment paradigms utilizing costly but efficacious biologic agents earlier and more often, the cost burden is only expected to worsen. Furthermore, IBD carries significant indirect costs to lost productivity of patients and their caregivers and out-of-pocket healthcare expenses borne directly by patients. Methods This talk will explore the current landscape and drivers of IBD direct costs and indirect costs as well as discuss challenges in assessing and comparing such data across countries Results Direct costs of IBD management have shifted substantially in recent years, primarily due to the emergence and penetrance of biologic therapy into clinical practice. Despite the increased use of biologic agents in IBD treatment, the expenditure on hospitalization and surgery has had a relatively small impact on reductions in cost, and the mean per capita costs spent on biologics in recent years is higher than what was saved on hospitalization per capita. In fact, direct health care costs associated with IBD treatment have dramatically increased over the last decade. New biologics and small molecules are also expected to be approved in the coming years, which is only likely to further increase the economic burden of IBD. These drivers of increasing costs may be offset by the recent loss of patent exclusivity for infliximab and adalimumab in much of the Western world, which has allowed for increased competition in the form of biosimilar agents and a reduction in prices. The greatest burden of indirect costs in this population relates to absenteeism and presenteeism among working individuals and premature retirement. However, costs related to reduced professional development and personal achievement due to illness—as well as caregiver costs—are largely unknown. Conclusion IBD is an expensive chronic disease with payments only expected to rise. Treating CD remains more expensive than treating UC and biologics escalate treatment costs and these are not offset by possible reductions of hospitalization and other costs. Direct costs differ substantially between countries and health care systems. Indirect cost constitute a significant burden on society

P815 Diet, nutrition, and the multidisciplinary approach in adults with Inflammatory Bowel Disease

Abstract Background Patients with Inflammatory Bowel Disease (IBD) may associate dietary triggers with symptoms and even relapse of the disease, yet this is rarely acknowledged and included in treatment plans. Patients often self-impose dietary restrictions and manipulate their diet which can have significant health complications including nutrient deficiencies and malnutrition1. This often leads to a worse disease state, poorer clinical outcomes, and a reduced quality of life for these patients2. Methods A self-administered survey was digitally created with Crohn’s and Colitis UK (CCUK) and advertised through the CCUK website and their social media accounts. Patients with IBD aged ≥18 years were identified through convenience sampling. Those who were three months peri-operative or had a stoma were excluded from the study as their nutritional needs and experiences were likely to be more complex. Statistical Package for Social Sciences (version 27) was used for statistical analysis. A P-value of <0.05 was considered statistically significant. Results 267 participants completed the survey, 77.5% were female, 30% of participants were aged 36-45 years and 53.9% had Crohn’s disease. 44.9% of participants had been diagnosed with IBD for >10 years. 90% of participants believed that food impacted on their disease at least some of the time. 77% reported that dietary therapy may be useful in managing their disease (P-value < 0.001). Table 1 highlights where patients with IBD source dietary information. 93% of patients report a ‘trial and error’ approach to dietary manipulation to reduce their symptoms. Access to formal dietetic advice is extremely limited and reported by only 13% of participants. The majority of participants (78.7%) reported that a multidisciplinary approach was ‘very important’ in IBD care despite 68.2% reporting no access to a multidisciplinary team (P-value = 0.006). Table 1. Sources of IBD dietary information Conclusion Diet plays an important role in the disease course for patients with IBD; however, our respondents reported poor dietary support from healthcare professionals. This may lead to unsupervised dietary restrictions based on poor sources of information that can cause or worsen nutrient deficiencies and lead to adverse health outcomes. Patients with IBD should have access to high quality dietary advice to help manage the disease.

P028 Transitioning patients from intravenous to subcutaneous infliximab and vedolizumab for inflammatory bowel disease – what is the opportunity cost of improving access to health care?

Abstract Background Biologic drugs are highly effective for inflammatory bowel disease (IBD) management but are key drivers of costs of care especially when administered intravenously (IV). Availability of subcutaneous (SC) formulations has increased convenience for patients and improved access to care but at the cost of revenue to health services. The aim of this study was to evaluate the economic impact of transitioning a tertiary centre IBD cohort from IV to SC biologic administration and assess the implications for key stakeholders. Methods A retrospective analysis of all patients that received IV infliximab or vedolizumab in the outpatient infusion centre of a tertiary, IBD centre between July 2019 and June 2021 was undertaken. Data were extracted from electronic medical records, pharmacy dispensing systems and the hospital business intelligence unit. An economic analysis and theoretical financial/capacity impact analysis of a transition to a SC model was estimated under two theoretical scenarios, using a random 10% and 30% of the patient cohort. Results Transitioning our IBD cohort from IV to SC administration would result in a loss of $2,732,123.75, comprised of $1,463,003.75 in Weighted Inlier Equivalent Separation (WIES) and $1,269,120 in drug procurement revenue. However, it would ease capacity in the infusion centre by up to 5256 hours. Conclusion Transitioning patients to SC administration results in improved access to infusion centres and substantial savings to state governments; however, switching results in a loss of IV-biologic generated WIES to health services. Alternative funding models are required to achieve sustainability in IBD care and reduce reliance on IV biologic generated income.

P367 Significant impact on health care utilization upon implementation of an electronic IBD care management program.

Abstract Background The management of Inflammatory Bowel Diseases (IBD) remains to be a significant challenge because of its unpredictable clinical course and high associated costs. Recently, we implemented an electronic IBD care management program, provided by DEARhealth BV, which offers care-pathways that configurate according to individual IBD risk profiles, called THINK. High-risk (HR) IBD patients (current biochemical disease activity) will receive more intense monitoring and provider interactions compared to Low-risk (LR) (>3 years in remission) and Intermediate-risk (IR) (other patients) individuals (figure 1). In this project, before implementation of THINK, we aimed to assess whether 1. Current healthcare utilisation (HCU) (consultations, lab tests, calprotectin) differs between risk groups and 2, what the effect of implementing THINK would be on HCU (focused on consultations and laboratory tests) in a retrospective-analysed population. Methods 161 consecutive IBD patients in hospital A, categorized in either the HR or IR group, were studied prospectively during 1 year before implementation of THINK. HCU was captured using an electronical medical record (EMR) and included consultations, blood tests and calprotectin. Furthermore, HCU in the years 2018-2019 in the IBD population of hospital B was studied (extraction of EMR). This historical data was compared to the THINK care path (see figure 1) when optimal implemented. The analysis focused on the activities present in de THINK care pathway (consultations and laboratory tests) to uncover the potential of the electronic IBD care management program. Results Baseline characteristics for hospital A cohort (N=161) are summed in Table 1. We followed 102 patients (60 Crohn) in the IR group and 59 patients in the HR group (29 Crohn). As expected, significant more HCU was present in the HR group (table 2). In hospital B, the utilization impact assessment was performed in the IBD cohort of 543 Crohn and 495 colitis patients. A difference in clinic consults was observed of -52,7% (HR), -53.5% (IR) and -29,3% (LR). The difference in laboratory tests utilization was found -54,0% (HR), -27.8% (IR) and -3,1% (LR). Conclusion Our initial experiences with a novel IBD management program demonstrated the feasibility of accurate remote disease activity monitoring and significant impact on utilization patterns due to the risk-based care pathway configurations. However, the analysis shows the ideal fictive situation when using standardized care pathways which cannot fully be considered the real-time situation. In this analysis no unexpected events are included. Future research should investigate the realization of these predictions.

N05 Highlighting the critical contributions of Inflammatory Bowel Disease nurses in Canada: Perspectives from nurses, gastroenterologists, individuals living with IBD, and caregivers.

Abstract Background Multidisciplinary teams are essential in managing Inflammatory Bowel Disease (IBD). IBD nurses play a critical role in improving patient outcomes and providing cost-effective quality of care. In Canada, access to IBD nurses remain inconsistent. There are more than 270,000 people living with IBD in Canada and fewer than 90 IBD nurses to care for them. This study was conducted to capture the value of IBD nurses, to identify gaps in resources, and to generate strategies for building IBD nurse capacity and enhancing the contributions of IBD nurses in Canada. Methods A convergent mixed-methods design was utilized to gather input from 4 stakeholder groups: IBD nurses, gastroenterologists, individuals living with IBD, and caregivers. Data collection was done through completing a review of the literature, stakeholder surveys, and one-on-one online semi-structured interviews with all stakeholders. Descriptive statistics were used for the quantitative analysis. Semi-structured interviews were audio recorded and transcribed verbatim then thematically analyzed. Results The IBD nurse’s role in clinical care was recognized as a value-add across all stakeholder groups. Having access to a specialized IBD nurse was recognized as a service that elevates the quality and continuity of patient care. As the interface between patients and other healthcare providers, there was recognition amongst stakeholders that IBD nurses are ideally positioned to educate patients about IBD management, general health promotion in the context of chronic disease and may support other aspects of care such as psychosocial, nutrition, and other extraintestinal manifestations or to help guide patients toward appropriate care channels. Many IBD nurses view advocacy as a logical extension of their official responsibilities, helping IBD patients to make treatment decisions and assisting them with disease challenges that affect their quality of life. Conclusion IBD nurses represent an underused resource in Canadian IBD care. Canada currently falls short of the recommended 2.5 full-time IBD nurse equivalents per 250,000 population. Achieving this objective will require a commitment to train IBD nurses and additional funding for their education and employment. The government can work with nursing institutions to set benchmarks, establish training programs, and create opportunities for IBD nurses in Canada. Introducing more IBD nurses into the system and using them to their full capacity makes sense from both a clinical and economic standpoint. It lifts the burden on gastroenterologists and primary care physicians, reduces costs to health systems while improving the overall quality of care for IBD patients.

P883 Parental and perinatal risk factors associated with onset of Inflammatory Bowel Disease: A systematic literature review and meta-analysis

Abstract Background Several risk factors have been associated with the onset of Inflammatory Bowel Disease (IBD), including pre and early life exposures occurring during gestation and up to the end of an infant’s first year of life. Perinatal factors linked to the subsequent development of IBD include parental and environmental exposures. It is postulated that exposure to such factors impacts immune system development leading to alterations in immune responses and increased susceptibility to disease. Limited evidence evaluates this association systematically whilst focusing specifically on the perinatal period. The purpose of this review was to systematically determine whether parental and perinatal factors are associated with IBD onset. Methods We searched the following electronic databases: Ovid MEDLINE, Web of Science, and the Cochrane Library. Searches were conducted from 01/01/2002 until 26/01/2022. Keywords and search terms related to ‘perinatal’ and ‘inflammatory bowel disease’ were applied. Case control studies, RCTs and cohort studies evaluating the association between parental and perinatal factors and IBD were included. Study protocol details have been published on the International Prospective Register of Systematic Reviews (PROSPERO). Available from: http://https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022290798Databases Results Our initial search identified 14,989 potentially relevant articles to include (see Figure 1). After title and abstract screening there were 119 articles that met the eligibility criteria. After full-text review and further assessment of these 119 articles, 18 articles were deemed suitable for study synthesis based on the eligibility criteria. Across the 18 articles, a range of parental and perinatal factors were included: family history IBD (n=8), breastfeeding (n=7), disease during pregnancy (n=4), maternal age (n=4), birth delivery method (n=4), antibiotic exposure (n=3), pre-term birth (n=3), birth weight (n=2), environmental exposures in infancy (e.g. pet exposure, rural dwelling) (n=2), diet (n=1), vaccination (n=1) and maternal smoking (n=1). Conclusion This review provides a detailed summary of parental and perinatal factors associated with the onset of IBD. The evidence generated will influence the development of diagnostic risk assessment tools and detailed patient pathway paradigms to address current shortcomings within the delivery of IBD care, providing opportunities to improve efficiency and reduce healthcare costs. The findings will inform on key targets for primary prevention strategies at this early life stage and provide valuable insight on IBD onset to academics, clinicians, patients and policy makers.

P761 Negative Body Image in Inflammatory Bowel Disease persists despite Modern IBD care

Abstract Background Body image dissatisfaction (BID) is prevalent in patients with Inflammatory Bowel Disease (IBD). Historically female sex, previous IBD surgery, impaired QoL have been associated with negative body image. The introduction of biologic therapies and modern IBD care in Australia in 2007 has improved disease control and endoscopic outcomes, but it is unclear if body image has improved in parallel with this. We aimed to determine whether body image and QoL have improved amongst IBD patients with modern IBD car Methods Tertiary IBD service patients were offered inclusion in the study in 2006 by postal survey (pre-biologic era), and in 2021 by electronic survey (biologic era). Surveys included demographics and history of IBD surgery. In the pre-biologic era (PBE) body image dissatisfaction (BID) and QoL were assessed using a patient reported yes/no question, followed by an open question about how IBD or treatment has changed the way they view their body’s appearance. In the biologic era (BE) the validated modified Body Image Scale and Short Inflammatory Bowel Disease Questionnaire were used. Results The BE included 135 patients, 59% female, mean age 45.9. The PBE included 215 patients, 66% female and mean age 35.5. PBE had 40% reporting IBD surgery vs 36% in BE (P=0.489). BID was observed in 67% vs 39% of the PBE and BE respectively (p<0.01). In the PBE free text responses elicited themes of dissatisfaction with medication or steroid-related appearance changes (41%), bloating (30%), weight gain (28%), weight loss (12%), and specific appearance changes. The link between body image and QoL was mentioned by 33% of patients, with 8% specifically mentioning its impact on their mental health. Females were affected to a greater extent in both PBE (75% vs 52% p<0.01), and BE (50.5% versus 22% p<0.01). In the PBE patients with surgical intervention for IBD had higher rates of BID than those without surgery (81% vs 58%, p<0.01). This association between surgery and BID was not observed in the BE (47% vs 34.9%, p=0.168). In the PBE those with BID were significantly more likely to report impaired QoL(97% vs 71%, p<0.01). This association persisted with time with BE patients with BID also having higher rates of QoL impairment (85% vs 45% p<0.01). Conclusion Whilst the rate of BID has decreased with modern IBD treatment; it remains highly prevalent and is associated with impaired QoL. Whilst females remain disproportionately affected, the historically observed association between IBD surgery and impaired body image was not demonstrated in the BE. This may reflect improved surgical techniques and biologic down staging prior to surgery. However, body image remains an important Patient Reported Outcome in IBD and warrants further attention.

P670 “What Matters To You?” – How do patient views compare with a patient experience framework and UK national standards of care?

Abstract Background There is increasing focus on the organisation of services for people with IBD. Patient experience of care is an important consideration in service delivery. The United Kingdom NHS Long Term Plan indicates the importance of support that is more differentiated for individuals, with more personalised care when needed, which starts with the question ‘What matters to you?”. This is particularly important for people with inflammatory bowel disease (IBD). Methods The aim was to identify ‘What matters to you?’ for people attending a single UK teaching centre IBD service and to relate it to patient experience and national standards of care. Invitations to take part in the AWARE-IBD quality improvement programme were sent to 4082 patients receiving IBD care at a single UK teaching centre in 2 rounds (October 2021 and May 2022). Invitation letters included an anonymous open-ended questionnaire asking patients “what matters to you?”. Responses were extracted as qualitative data and coded using two frameworks: Patient experience domains (Bull et al) (Communication, Patient-centred Care, Quality, Integration, Involvement, Accessibility, Environment and Facilities, Discomfort) and national IBD UK Standards. Frequencies for each coding strategy were calculated to determine the most important patient experience domains and IBD UK standards. Results Responses were received from 408 and 205 patients from each recruitment round (n=613). Figure 1 displays frequencies for each patient experience domain. Accessibility (47.5% and 53.2% respectively), Communication (19.6% and 12.7%) and Patient-Centred Care (15.7% and 11.2%) were expressed most frequently. Sub-themes included access to and contact with IBD nurse specialists, timely and accessible appointments and regular contact with a specialist IBD health care professional (HCP). Responses were coded to IBD UK standards, where possible (Table 1). Responses most frequently coded to statements relating to shared decision making, having a personalised care plan, access to an IBD nurse specialist including helpline and regular clinical review. 77 responses could not be coded to an IBD UK standard. Conclusion Access to the IBD service when needed matters most to patients with good communication of information and personalised, patient-centred care. Service organisation should therefore reflect these facets of patient experience and defined standards. Patient views that are not currently represented in published standards should be considered in future iterations. This study also highlights personalised written care plans and improved access to the IBD Nurse Advice line.

P766 Practical application of evidence-based dietary therapy into inflammatory bowel disease care shows high patient satisfaction, compliance, and efficacy. The Delectable Program

Abstract Background Diet is an accepted therapy for Inflammatory Bowel Disease (IBD). Controlled trials have demonstrated that exclusive enteral nutrition (EEN) and the Crohn’s Disease Exclusion Diet (CDED) induce remission in Crohn’s disease. Low sulphur and plant-based diets are being investigated in ulcerative colitis (UC). Reducing ultra-processed, additive-containing food intake is emerging as important, given its role in initiating and perpetuating disease. IBD patients believe in the value of the diet, but there is no evidence for diet tolerability and benefit outside of clinical trials. The DELECTABLE program, a dietitian-led telehealth service, aims to evaluate structured, evidence-based dietary therapy as part of routine clinical care. Here we present satisfaction, compliance and efficacy results. Methods In this open-label, prospective, observational program, Crohn’s disease and pouchitis patients were offered the CDED or a wholefood additive-free diet, UC patients were offered a low-sulphur plant-based diet or wholefood diet, and patients with microscopic colitis were offered the wholefood diet. The primary outcome was diet satisfaction (modified DSAT-28; possible range: 28 to 140). Dietitian-rated compliance, patient-rated compliance, disease activity score (CDAI, partial Mayo score), CRP, and faecal calprotectin were secondary outcomes. Baseline to week 12 differences were assessed using the Mann-Whitney-U-test or Wilcoxon-sign-test for continuous variables and McNemar’s test for categorical variables. Results Of 165 patients referred, 79 enrolled in the program. Fifty-seven (72%) enrolled patients have completed 12 weeks of diet therapy. Across all diet arms combined, diet satisfaction score increased from week 1 (89.3) to week 12 (93.7; P<0.001). Dietitian and patient-rated compliance were 4/6 and 3/5, respectively, at week 1 and did not change at week 12. CDAI was reduced on all diet arms combined (60.0 to 41.5, P=0.003) and on the CDED (128.9 to 46.6, P=0.004), with a trend for reduced CDAI on the wholefood diet. There was a trend towards reduced CRP across all diet arms and on the wholefood diet (49.5 to 25.3, P=0.363). The proportion of patients in remission, based on CDAI, increased when all diet arms were combined and on the CDED and wholefood diet (P<0.001). Faecal calprotectin was numerically reduced on the CDED (95.0 ug/g to 53.5 ug/g) and UC diet (184.0 ug/g to 159.0 ug/g), but these results did not reach statistical significance. Conclusion Half of the referred patients are interested in pursuing a supervised, long-term diet program. Implementation of well-balanced, effective diet therapies is feasible and well-accepted by patients, with a promising impact on disease activity.

SPATIAL CONCORDANCE OF LEFT AND RIGHT COLON FINDINGS IN PEDIATRIC PATIENTS WITH ULCERATIVE COLITIS AFTER TREAMTENT

Abstract OBJECTIVES Achieving endoscopic remission has become the preferred clinical endpoint in the care of inflammatory bowel disease (IBD) patients. This requires repeat colonoscopy in patients with ulcerative colitis (UC) after initiation of therapy. Recent adult data suggests findings in the left colon on flexible sigmoidoscopy can be highly predictive of the findings if a full colonoscopy was performed; however, pediatric data is lacking for this association. The primary aim our study to assess the accuracy of findings on the left colon with the right colon for repeat endoscopy in pediatric patients with UC. METHODS This was a retrospective chart review of pediatric patients with UC seen at a single, academic center between 2010-2021. Patient demographics, clinical disease activity, laboratory values and endoscopic findings were collected. The Mayo Endoscopy Score (MES) was used to assess the findings in the right and left colon by a single reader (JM). Histologic findings were assessed using the Geobes index by a pathology resident (AKA) and over-read by an attending pathologist (SS). Weighted kappa correlation was used to assess concordance between left and right colon endoscopic and histologic findings. Receiver operator curve (ROC) analysis was used to assess the accuracy of left-sided findings predicting right-sided findings. RESULTS We analyzed repeat endoscopies from 57 patients, of which 31 (54.4%) were male, mean age at UC diagnosis was 13.5 ± 4.1 years, 53 (93%) were Caucasian. Most common medication was oral mesalamine (67.2%) and most common distribution was pancolitis (53.4%). Mean time between index and repeat colonoscopy was 11.3 months. On repeat colonoscopy, endoscopic findings on the left colon moderately correlated with findings on the right colon [(κ = 0.53 (0.30-0.75)], similarly histologic findings for the left and right colon had a moderate correlation [(κ = 0.41 (0.17-0.64)]. Area under the ROC (AUC) was 0.89 for endoscopic remission anywhere in the colon and 0.98 for complete endoscopic healing anywhere in the colon. Longer interval between the index and follow-up colonoscopy did not affect odds of concordance. CONCLUSIONS We found that endoscopic and histologic severity correlated between the right and left colon for repeat assessment after initiation of biologic therapy. Left sided findings were highly accurate for endoscopic remission and complete endoscopic healing anywhere in the colon. This data suggest a flexible sigmoidoscopy could be feasible in lieu of full colonoscopy when assessing for endoscopic remission in pediatric patients with UC, to reduce the burden to the family and healthcare system. Further, prospective studies with a central reading component for histology and endoscopy are needed to validate these findings.

USING A REAL TIME DASHBOARD TO SUPPORT POPULATION HEALTH IN INFLAMMATORY BOWEL DISEASE

Abstract The Phoenix Children’s Hospital (PCH) Inflammatory Bowel Disease (IBD) Clinic provides care for nearly 500 patients. As a group, PCH is part of the ImproveCareNow (ICN) network—a collaboration of over 100 centers worldwide to improve IBD care. Patient care has followed ICN guidelines including a weekly pre-visit planning (PVP) session. PVP is a time intensive process of manual chart review and data gathering for upcoming clinic patients. To improve this process and patient care, our group created a real-time IBD dashboard. OBJECTIVES: The aims of the dashboard were to identify and validate our patient population, improve efficiency by automating data gathering for PVP, and create a visual representation . Secondary aim, was to optimize processes including documentation, order entry and timely follow-up. METHODS: Data is sourced from the Allscripts electronic medical record (EMR). Data retrieval is contingent upon documentation. Our population of patients with IBD was identified based on a charted ICD-10 diagnosis of CD, UC or IC. PCH has a data warehouse of orders, results, Admission-Discharge-Transfer documentation, and flowsheets from the EMR and external data sources. Data is harvested and hosted using Microsoft Power BI for live review at weekly PVP. Once desired data points were hosted, focus was on process improvement (proper documentation, follow-up orders, and patient visits every 200 days). RESULTS: The dashboard hosts patients seen within the last 200 days, provider follow-up order placement, and physician global assessment (PGA) since January 2021. The percent of patients with follow-up orders placed was 61% in 2021. With dashboard enhancements and data visibility, this improved to 99% as of October 17, 2022. Physician global assessment (PGA) was recorded in 81% of encounters in 2021. Our most recent documentation rate is 92% on October 17, 2022. Our group had seen 82% of patients within the 200 days in 2021. Currently we have seen 89% of patients within 200 days as of October 17, 2022 (of these 91% of patients with active disease have been seen). We have instituted a work-flow process with schedulers to ensure patients are contacted and scheduled and not transitioned or moved. Figure 1 Historical Data from 1/2021-10/2021 Figure 2 Current Data as of 10/17/2022 CONCLUSIONS: With time, the IBD dashboard has proven to be a powerful tool in improving process measures. Our hope is these improvements will lend themselves to improved patient outcomes. With the ability to view data in real time in an automated fashion, staff hours have been saved and reallocated to other patient care needs. With continuous review of the data and introduction of accountability, we continue to see improvement. We now have the capacity to add additional metrics to the dashboard and our this can be viewed as a proof of concept for use in other specialties and chronic disease states.

IBD barriers across the continents: a continent-specific analysis - Australasia.

Australasia, encompassing Australia, New Zealand, and Papua New Guinea, has some of the highest prevalence's of inflammatory bowel disease (IBD) in the world. The way IBD medicine is practiced varies between and within these countries. There are numerous shared issues of IBD care between Australia and New Zealand, whereas Papua New Guinea has its' own unique set of circumstances. This review looks to explore some of the barriers to IBD care across the continent from the perspective of local IBD healthcare professionals. Barriers to IBD care that are explored include access to IBD multidisciplinary teams, provision of nutritional-based therapies, the prevalence and engagement of IBD-associated mental health disorders, access to medicine, access to endoscopy, rural barriers to care, Indigenous IBD care and paediatric issues. We look to highlight areas where improvements to IBD care across Australasia could be made as well as address research needs.

Barriers to optimizing inflammatory bowel disease care in the United States.

Significant progress in the management and modification of inflammatory bowel disease (IBD) has been made; however, significant barriers to the optimization of IBD care in the United States still exist. The majority of these barriers are constructed by insurance carriers and the integration of market pressures into healthcare decision-making. In this review, we highlight the barriers to IBD care optimization within the context of the US insurance system and review current and proposed solutions.

Barriers in inflammatory bowel disease care in Central and Eastern Europe: a region-specific analysis.

Inflammatory bowel diseases (IBD), including Crohn's disease and ulcerative colitis, are chronic immune-mediated diseases with a high incidence and prevalence in Europe. Since these are diseases with associated disability, they require complex management and the availability of high-quality healthcare resources. We focused on the analysis of IBD care in selected countries of Central and Eastern Europe (Croatia, the Czech Republic, Hungary, Moldova, Poland, Romania and Slovakia) targeting the availability and reimbursement of diagnostic and therapeutic modalities, the role of IBD centers and also education and research in IBD. As part of the analysis, we created a questionnaire of 73 statements organized in three topics: (1) diagnostics, follow-up and screening, (2) medications and (3) IBD centers. The questionnaire was filled out by co-authoring IBD experts from individual countries, and then the answers and comments on the questionnaire were analyzed. We identified that despite the financial burden, which still partially persists in the region, the availability of some of the cost-saving tools (calprotectin test, therapeutic drug monitoring) differs among countries, mainly due to variable reimbursement from country to country. In most participating countries, there also remains a lack of dedicated dietary and psychological counseling, which is often replaced by recommendations offered by gastroenterologists. However, there is adequate availability of most of the currently recommended diagnostic methods and therapies in each participating country, as well as the implementation of established IBD centers in the region.

Risk factors for incomplete telehealth appointments among patients with inflammatory bowel disease.

The COVID-19 pandemic led to the urgent implementation of telehealth visits in inflammatory bowel disease (IBD) care; however, data assessing feasibility remain limited. We looked to determine the completion rate of telehealth appointments for adults with IBD, as well as to evaluate demographic, clinical, and social predictors of incomplete appointments. We conducted a retrospective analysis of all patients with IBD who had at least one scheduled telehealth visit at the NYU IBD Center between 1 March 2020 and 31 August 2021, with only the first scheduled telehealth appointment considered. Medical records were parsed for relevant covariables, and multivariable logistic regression was used to estimate the adjusted association between demographic factors and an incomplete telehealth appointment. From 1 March 2020 to 31 August 2021, there were 2508 patients with IBD who had at least one telehealth appointment, with 1088 (43%) having Crohn's disease (CD), 1037 (41%) having ulcerative colitis (UC), and 383 (15%) having indeterminate colitis. Of the initial telehealth visits, 519 (21%) were not completed, including 435 (20%) among patients <60 years as compared to 84 (23%) among patients ⩾60 years (p = 0.22). After adjustment, patients with CD had higher odds of an incomplete appointment as compared to patients with UC [adjusted odds ratio (adjOR): 1.37, 95% confidence interval (CI): 1.10-1.69], as did females (adjOR: 1.26, 95% CI: 1.04-1.54), and patients who had a non-first-degree relative listed as an emergency contact (adjOR: 1.69, 95% CI: 1.16-2.44). While age ⩾60 years was not associated with appointment completion status, we did find that age >80 years was an independent predictor of missed telehealth appointments (adjOR: 2.92, 95% CI: 1.12-7.63) when compared to individuals aged 60-70 years. Patients with CD, females, and those with less social support were at higher risk for missed telehealth appointments, as were adults >80 years. Engaging older adults via telehealth, particularly those aged 60-80 years, may therefore provide an additional venue to complement in-person care.

Characteristics and Treatment Outcomes of Transition among Patients with Inflammatory Bowel Disease.

This study aimed to assess disease characteristics and outcomes of transition in patient care among adolescent patients with inflammatory bowel disease (IBD). Data from patients younger than 18 years who were diagnosed with IBD (Crohn's disease, ulcerative colitis, or intestinal Behçet's disease) were investigated. We categorized the patients into two groups: transition IBD group (Group A, diagnosed in pediatric care followed by transfer to/attendance in adult IBD care) and non-transition group (Group B, diagnosed and followed up in pediatric care or adult IBD care without transfer). Data from a total of 242 patients [Group A (n=29, 12.0%), Group B (n=213, 88.0%)] were analyzed. A significantly higher number of patients was diagnosed at an earlier age in Group A than in Group B (p<0.001). Group A patients had more severe disease in terms of number of disease flare ups (p=0.011) and frequency of bowel-related complications (p<0.001). Multiple linear regression analysis showed that Group B patients had more medical non-compliance than Group A patients (β=2.31, p=0.018). After transition, IBD-related admission frequency, emergency admission frequency, disease flare frequency, and medical non-compliance were significantly improved. The transition IBD group had more severe disease. Medical non-compliance was lower in the transition IBD group. Clinical outcomes improved after transition.

Inflammatory bowel disease in Saudi Arabia: a review article

Inflammatory Bowel Disease (IBD) encompasses chronic intestinal disorders, like ulcerative colitis (UC) and Crohn&amp;apos;s disease, causing gastrointestinal (GI) tract inflammation. Saudi Arabia, particularly among pediatric populations, has seen an increasing prevalence of IBD. Clinical symptoms, including abdominal pain, diarrhea, weight loss, and rectal bleeding, significantly impact patients&amp;apos; lives, requiring lifelong medical care, especially for children. The study highlights the growing burden of IBD in Saudi Arabia due to insufficient epidemiological data and rising disease incidence. Early IBD diagnosis is crucial for successful management and improved outcomes. Effective treatments for mild to moderate UC, such as 5-aminosalicylic acid-based drugs like mesalazine and sulfasalazine, show promising results. However, patients may experience ongoing GI symptoms even after successful treatment, underscoring the need for comprehensive care. Frequent remissions and relapses pose a challenge, necessitating continuous monitoring and appropriate medical intervention. Untreated symptoms can negatively impact patients&amp;apos; well-being and increase healthcare expenditures. Hence, exploring better approaches for long-term symptom control and mucosal repair is essential. In severe cases, surgical interventions like total colectomy become necessary, but the focus should be on optimizing medical therapies to reduce the need for drastic measures. In conclusion, early detection, accurate diagnosis, and proper management of IBD in Saudi Arabia are vital. Collaborative efforts among healthcare professionals, researchers, and policymakers are required to gather comprehensive epidemiological data and develop targeted strategies for improving IBD care. Addressing these challenges and opportunities can enhance the quality of life for IBD patients in Saudi Arabia and potentially alleviate the burden on the healthcare system.