Effects of introduction of an inflammatory bowel disease nurse position on the quality of delivered care

Outcomes of a Comprehensive Specialist Inflammatory Bowel Disease Nursing Service

BACKGROUND

Inflammatory bowel disease (IBD) is best managed by a multidisciplinary team within a dedicated IBD service. IBD nurses play an important role within this team. We aimed to evaluate the contribution of our comprehensive outpatient IBD nursing service on patient outcomes, quality of care, and healthcare costs.

METHODS

We performed a retrospective review of all IBD nurse encounters with patients over a 12-month period from October 2020 to September 2021 at a tertiary IBD referral center. Each nurse encounter was classified with respect to its clinical context, activities, and outcomes. Descriptive statistics were used to characterize these encounters and an economic analysis was performed to estimate the cost savings to the hospital.

RESULTS

A total of 2537 nurse encounters occurred with 682 patients; 41% of encounters were nurse-initiated contacts with patients and 34% were patient-initiated contacts with the nurse helpline (26% via email, 8% via telephone). Most encounters involved clinical assessments (66%), providing education, counseling or updates (47%), and reviewing investigation results (38%). A gastroenterologist was consulted for advice in 35% of contacts. An estimated 29 emergency department visits, 1925 outpatient clinic visits, and 137 general practitioner visits were avoided. After deducting costs incurred, a net estimated annual saving of up to AUD $570 838 was achieved. Nurses commonly facilitated faster access to investigations (29%), education provision (28%), delivery of biologic services (25%), and medication changes (19%).

CONCLUSIONS

A comprehensive IBD nursing service is associated with improved patient outcomes and quality of care, and reduced healthcare costs. This study supports the expanding role of IBD nurses in a modern multidisciplinary IBD service and the need for greater funding and integration of IBD nurses into IBD services.

Freeing Time and Reducing Costs: The Value of a Specialized Nursing Service in IBD

This invited editorial provides commentary on the manuscript by Yu et al regarding outcomes of a dedicated IBD nursing service. We highlight financial, time, and care quality benefits identified by the authors and contextualize the results for journal readership.

A quality assessment of inflammatory bowel disease nursing care in Finland: a nationwide cross-sectional descriptive study

OBJECTIVES OF THE ARTICLE

Inflammatory bowel disease (IBD) nursing has been identified as a crucial component in the IBD service delivery. This article aims to provide a comprehensive overview of the state of IBD nursing care in Finland, and to identify areas that would benefit from further research.

MATERIALS AND METHODS

Tertiary IBD outpatient clinics nationwide were invited to participate in a cross-sectional descriptive study conducted using an electronic survey. The quality of IBD nursing services was assessed using the Nursing Care Quality in IBD (NCQ-IBD) evaluation tool.

RESULTS

Of the 34 identified clinics, 27 participated (79.4%) in the study. The NCQ-IBD tool classifies the clinics in four categories, where A indicates the highest level of quality, and D the lowest. In this study, 26 clinics (96.3%) were classified at level C, and one clinic (3.7%) at level D. Nursing responsibilities in IBD management and informing the patients were at a high level of quality, whereas nursing research in IBD was at a low level. An IBD database (i.e. clinical IBD registry) was in use only in 10 clinics. Although training in the clinical aspects of IBD was readily available, there was a lack of training plans for IBD, and clinics seldom held an annual review of the IBD nursing activities and outcomes. There were very few clinics using structured indices and questionnaires, and only 16 clinics (59.3%) applied a written IBD protocol.

CONCLUSION

In the Finnish IBD nursing service, as measured with the NCQ-IBD tool, several areas for future improvement were identified.

Development and Validation of an E-Learning Educational Program for Acquiring Basic Knowledge in Inflammatory Bowel Disease Nursing

Introduction

This study focuses on developing and validating an e-learning educational program for nurturing inflammatory bowel disease (IBD) nursing specialists.

Methods

The program was developed using the attention, relevance, confidence, and satisfaction models within the instructional design framework. The program validation encompassed four steps: (1) nurses took a basic IBD knowledge test (pretest), (2) participants scoring <80% were encouraged to undergo web-based training, (3) a follow-up test (posttest) gauged post-training improvement, and (4) participant satisfaction with e-learning was assessed.

Results

The analysis included 63 participants. The average score in the pretest was 81.3%, 40 participants exceeded the pretest passing score, which is 80% (average: 88.3%), and 23 participants failed (average: 69.1%). Of those who failed, 19 participants showed improvement after undergoing web-based training, with their posttest scores exceeding the passing threshold (average: 97.4%). The comparison results between the passing and failing groups revealed no correlation between the baseline characteristics of the participants. The participants were highly satisfied with the e-learning program.

Conclusion

The program was effective as an educational program for acquiring basic knowledge to foster IBD nursing professionals. The learning design was adapted to the participants' lifestyles and tailored to the readiness of the nurse, ensuring a satisfactory e-learning user experience for the nurses.

Crossing barriers: the burden of inflammatory bowel disease across Western Europe

An estimated 2.5-3 million individuals (0.4%) in Europe are affected by inflammatory bowel disease (IBD). Whilst incidence rates for IBD are stabilising across Europe, the prevalence is rising and subsequently resulting in a significant cost to the healthcare system of an estimated 4.6-5.6 billion euros per year. Hospitalisation and surgical resection rates are generally on a downward trend, which is contrary to the rising cost of novel medication. This signifies a large part of healthcare cost and burden. Despite publicly funded healthcare systems in most European countries, there is still wide variation in how patients receive and/or pay for biologic medication. This review will provide an overview and discuss the different healthcare systems within Western Europe and the barriers that affect overall management of a changing IBD landscape, including differences to hospitalisation and surgical rates, access to medication and clinical trial participation and recruitment. This review will also discuss the importance of standardising IBD management to attain high-quality care for all patients with IBD.

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.

Content of Telephone Consultations of Patients With Inflammatory Bowel Disease: A Single-Center Descriptive Study

This study aimed to analyze the specific contents of telephone consultations of patients with inflammatory bowel disease. A medical record survey was conducted at a clinic in Japan for 1 year. Telephone consultation sheets recorded by nurses for calls with the patients or their relatives were reviewed. Content analysis was used to summarize the telephone consultation content. Consultations were categorized into 8 categories. Coding was conducted by 2 independent researchers. Concordance rates were evaluated using kappa coefficients. We analyzed 476 sheets. A total of 229 participants consulted the clinic at least once. The mean number of consultations per person was 2.1. Of these patients, 96 (40.9%) had ulcerative colitis. The kappa coefficient was 0.89. The most frequent consultation was "Consultation on worsening health: Inflammatory bowel disease is likely to have worsened" (42.0%). The second most frequent response was "Consultation or progress report on a worsening health condition: The disease is unlikely to have worsened" (19.8%). For consultations related to worsening the disease, it would be useful to assess symptoms over the phone using a disease activity index to ascertain the degree of worsening and to develop a screening tool for determining whether patients can continue remote support or require face-to-face consultation.

The cost of inflammatory bowel disease in high-income settings: a Lancet Gastroenterology & Hepatology Commission

The cost of caring for patients with inflammatory bowel disease (IBD) continues to increase worldwide. The cause is not only a steady increase in the prevalence of Crohn's disease and ulcerative colitis in both developed and newly industrialised countries, but also the chronic nature of the diseases, the need for long-term, often expensive treatments, the use of more intensive disease monitoring strategies, and the effect of the diseases on economic productivity. This Commission draws together a wide range of expertise to discuss the current costs of IBD care, the drivers of increasing costs, and how to deliver affordable care for IBD in the future. The key conclusions are that (1) increases in health-care costs must be evaluated against improved disease management and reductions in indirect costs, and (2) that overarching systems for data interoperability, registries, and big data approaches must be established for continuous assessment of effectiveness, costs, and the cost-effectiveness of care. International collaborations should be sought out to evaluate novel models of care (eg, 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 policy makers.

Medical consultation in ulcerative colitis: Key elements for improvement

Ulcerative colitis (UC) is a chronic inflammatory disease with a high impact. In order to improve patient outcomes, the clinician-patient relationship in daily practice is critical. Clinical guidelines provide a framework for UC diagnosis and treatment. However, standard procedures and the medical content focused upon medical consultations in UC patients has not yet been defined. Moreover, UC is a complex disease, given that patient characteristics and patient needs have been proven to vary during clinical consultation since establishing the diagnosis and upon the course of the disease. In this article, we have discussed the key elements and specific objectives to consider in medical consultation, such as diagnosis, first visits, follow-up visits, active disease patients, patients on topical therapies, new treatment initiation, refractory patients, extra-intestinal manifestations, as well as challenging situations. The key elements have been mentioned to comprise effective communication techniques, motivational interviewing (MI), as well as information and educational aspects, or organizational issues. The key elements to be implemented in daily practice were reported to comprise several general principles like duly prepared consultations, in addition to honesty and empathy with patients, as well as effective communication techniques, MI, information and educational points, or organizational issues. The role of other healthcare professionals such as specialized nurses, psychologists, or the use of checklists was also discussed and commented on.

Health-related quality of life in inflammatory bowel disease: a comparison of patients receiving nurse-led versus conventional follow-up care

BACKGROUND

Inflammatory bowel disease (IBD), consisting of Crohn's disease (CD) and ulcerative colitis (UC), is a chronic disorder with a considerable negative impact on health-related quality of life (HRQoL). During the past decade, IBD nurse specialists have been increasingly involved in follow-up care of IBD outpatients, in a consultative and coordinating role, closely cooperating with gastroenterologists. Whether patients' HRQoL differs between nurses' follow-up care (NF) and conventional follow-up care (CF) has not been widely researched and the aim of this study was to compare two different follow-up regimes with respect to patients' HRQoL.

METHODS

This cross-sectional, multicenter study involved seven centers; five organized as CF, two as NF.

RESULTS

A total of 304 patients aged 18-80 years, 174 females and 130 males, were included, of whom 140 received care under the NF model and 164 under the CF model. Participants in the NF group had a statistically significant higher median total score on the Inflammatory Bowel Disease Questionnaire (IBDQ) (p-value < .001). This pattern could also be seen in the sub-scores of the different IBDQ domains. Despite a trend of higher IBDQ score in all domains in the NF model, the overall result in our study did not reach the limit of 16 points, defined as clinically significant. A higher proportion of NF patients had IBDQ scores defined as remission, as well as a statistically significant higher frequency of outpatient check-ups during a two-year follow-up period.

CONCLUSIONS

Nurse-led models are not inferior to conventional models with regards to patient reported HRQoL except in the social domain where the model showed to be clinically significant better. Further studies are needed to advance efforts to implement these models and increase access to IBD care.

Core indicators of an evaluation and guidance system for quality of care in inflammatory bowel disease centers: A critical review

The mission of the IBD Quality Care Evaluation Center (IBDQCC) is to establish indicators of quality of care (QoC), certify IBD units to generate a network of IBD quality care, and eventually improve the national level of IBD healthcare. The final list of 28 core and 13 secondary IBD QoC indicators suitable for the healthcare system in China were selected using a Delphi consensus methodology. Units that met all core indicators were qualified as "regional"; units that met all core indicators together with more than 50% of the secondary indicators received a rating of "excellence." Using the selected QoC core indicators for certifying IBD units, a network of IBD quality care units covering the majority of IBD patients in China was established.

Funding

This work was financially supported by Cultivation Funding for Clinical Scientific Research Innovation, Renji Hospital, School of Medicine, Shanghai Jiaotong University (RJPY-LX-004), National Natural Science Foundation of China (No. 81,770,545), Shanghai Science and Technology Innovation Initiative (21SQBS02302), and Cultivated Funding for Clinical Research Innovation, Renji Hospital, School of Medicine, Shanghai Jiaotong University (RJPY-LX-004).

The effect of a nurse-led advice line and virtual clinic on inflammatory bowel disease service delivery: an Australian study

BACKGROUND

This retrospective cohort study investigated the economic impact of implementing a nurse-led inflammatory bowel disease (IBD) advice-line and virtual clinic on the Australian healthcare system. The advice line is a telephone and email service managed by IBD specialist nurses. The virtual clinic is a planned, formal communication between the gastroenterologist and the specialist IBD nurse the result of which is communicated to the patient electronically.

METHODS

Advice line telephone calls and virtual clinic consultations registered between 1 June 2015 and 1 June 2016 were reviewed and analyzed in terms of outcome: avoidance of general practitioner (GP) consultation, IBD outpatient consultation, emergency department (ED) presentation, or hospital admission. Cost-benefit analysis was conducted to estimate financial savings.

RESULTS

During the study period, 220 calls were received through the advice line and 1017 virtual clinic consultations occurred. The advice line resulted in the avoidance of 53 GP visits, 159 IBD outpatient department visits, six ED presentations, and one hospital admission. The virtual clinic resulted in the avoidance of four GP visits, 954 IBD outpatient department visits, and 58 ED presentations. This led to an estimated annual cost saving of AUD 169 376.80, with the annual costs incurred estimated to be $58 713. Thus, the annual net benefit of implementing the advice line and the virtual clinic was estimated to be $110 663.80.

CONCLUSION

Specialized-IBD-nurse-led advice line and virtual clinic improves IBD patients' access to services and reduces healthcare costs. This highlights the importance of a proactive multidisciplinary approach in optimizing the care of patients with IBD.

Patients' perspectives on medication for inflammatory bowel disease: a mixed-method systematic review

Inflammatory bowel disease (IBD) is a lifelong chronic disease that frequently requires long-term medical treatment to maintain remission. Patient perspectives on IBD medication are important to understand as nonadherence to IBD medication is common. We aim to synthesize the evidence about patients' perspectives on medication for IBD. A mixed-method systematic review was conducted on Scopus, EMBASE, Web of Science, and CINAHL. The convergent integrated approach to synthesis and integration of qualitative and quantitative findings was used for data analysis. Twenty-five articles from 20 countries were included in this review (20 quantitative, 3 qualitative, and 2 mixed-method studies). Patients have identified a lack of knowledge in the areas of efficacy, side effects, and characteristics of medications as key elements. Some negative views on IBD medication may also be present (e.g. the high number of pills and potential side effects). Lack of knowledge about medication for IBD was identified as a common issue for patients. Health services delivery for IBD should take into consideration these patients' perspectives. A focus on improving patient education in these areas could help empower patients and alleviate doubts resulting in better disease management and improved healthcare outcomes.

Clinical communication in inflammatory bowel disease: a systematic review of the study of clinician-patient dialogue to inform research and practice

OBJECTIVES

This systematic review aims to investigate what is currently known about the characteristics of interactions between patients with inflammatory bowel disease (IBD) and their clinicians and its effect on patient outcomes.

DATA SOURCES

Scopus, PubMed, Embase, Communication Abstracts, Health & Society, Linguistics and Language Behaviour Abstracts and PsycINFO were systematically searched from inception to June 2021.

STUDY ELIGIBILITY CRITERIA

Peer-reviewed journal articles and book chapters in English investigating the characteristics of naturally occurring interactions between clinicians that manage IBD and patients with IBD during recorded consultations were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

Risk of bias was assessed using a specifically developed quality assessment tool, grounded in linguistic theory and the Mixed Methods Appraisal Tool. A narrative synthesis guided by the linguistic concept of metafunction was performed to synthesise the findings.

RESULTS

Of the 2883 abstracts reviewed five formed the basis of the review. Interactions between IBD nurses and patients have been mostly characterised in terms of information provision regarding prescribed medications without consideration of the interpersonal aspect. Discussing online medical information with nurses has been shown to improve patient satisfaction. Analyses of gastroenterologist-patient interactions have concentrated on the clinical relationship which has been shown to be disease-centred. Shared decision making in ulcerative colitis has been shown to be compromised due to lack of transparency regarding treatment goals.

LIMITATIONS

This review did not include articles in languages other than English. Cumulative evidence could not be produced due to the small number of included studies and the diversity of contexts, theories and data types.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

There is a paucity of systematic research on naturally occurring clinical communication in IBD and its effect on outcomes. Further research needs to be done to address this knowledge gap.

PROSPERO REGISTRATION NUMBER

CRD42020169657.

Adherence improvement in patients with ulcerative colitis: a multidisciplinary consensus document

OBJECTIVES

1)To analyze evidence about poor adherence / non-adherence including their prevalences, associated factors, and interventions in ulcerative colitis (UC) patients; 2)To provide a framework to improve poor adherence / non-adherence.

METHODS

A qualitative approach was applied. A literature review was performed using Medline. Primary searches were performed with Mesh and free texts to identify articles that analyzed prevalence, causes, associated factors, and interventions designed to improve poor adherence/ non-adherence in UC patients. The studies' quality was evaluated using the Oxford scale. The results were presented and discussed in a nominal group meeting, comprising a multidisciplinary committee of six gastroenterologists, one psychologist, one nurse, and one patient. Several overarching principles and recommendations were generated. A consensus procedure was implemented via a Delphi process during which each committee member produced a score ranging from 0 = totally disagree to 10 = totally agree. Agreement was considered if at least 70% of the participants voted ≥7.

RESULTS

The literature review included 75 articles. Non-adherence rates ranged from 7%-72%. We found a great variability in the methods employed to assess adherence, associated factors, and interventions designed to improve adherence. Overall, eight overarching principles and six recommendations were generated, all of them achieving the pre-established agreement level, including, among others, the identification, classification, and management of non-adherence.

CONCLUSIONS

Poor adherence / non-adherence are common in UC patients, being a relevant clinical concern. Health professionals should address this issue and actively involve the patients in implementing effective and individualized interventions to improve adherence.

Quality of care in inflammatory bowel disease: actual health service experiences fall short of the standards

BACKGROUND

Quality of care in inflammatory bowel disease (IBD) has received much attention internationally; however, the available surveys focus on health professionals rather than patients.

AIMS

To assess the experiences of healthcare for people living with IBD against established Australian IBD Standards.

METHODS

An online cross-sectional survey was conducted with Australians ≥16 years old recruited via Crohn's & Colitis Australia membership, public and private clinics and the Royal Flying Doctor Service. Participants completed a questionnaire incorporating items addressing the Australian IBD Standards 2016, the Picker Patient Experience Questionnaire, IBD Control Survey and the Manitoba Index.

RESULTS

Complete data were provided by 731 respondents (71.5% female, median age 46 years, ranging from 16 to 84 years). While the majority (74.8%) were satisfied with their IBD healthcare, the care reported did not meet the Australian IBD Standards. Overall, 32.4% had access to IBD nurses, 30.9% to a dietician and 12% to a psychologist in their treating team. Participants managed by public IBD clinics were most likely to have access to an IBD nurse (83.7%), helpline (80.7%) and research trials (37%). One third of respondents reported waiting >14 days to see a specialist when their IBD flared. Participants received enough information, mostly from medical specialists (88.8%) and IBD nurses (79.4%). However, 51% wanted to be more involved in their healthcare.

CONCLUSIONS

These data show discordance between expectations of patients and national standards with current levels of service provision, which fail to deliver equitable and comprehensive IBD care.

The lived experiences of people with inflammatory bowel diseases: A phenomenological hermeneutic study

AIM

The aim of this research was to provide an in-depth study about the life experiences of patients with inflammatory bowel diseases.

METHODS

The phenomenological (hermeneutic) method was used to analyse data. The data were collected between March 25 and July 1, 2019. A homogeneous group of 25 patients were included as participants by purposeful sampling methods. Interviews were conducted in the hospital patient-education room.

RESULTS

The results of this study emphasize the importance of understanding the fears, worries, difficulties and life experiences of patients with inflammatory bowel diseases. Three main themes were identified: a flare phase of the disease, a remission period and coping behaviours. Study findings included the experiences of social isolation; inability to perform daily activities of living and to work; stress in the flare phase of the disease; concerns about the future in the remission phase and physical and spiritual strategies used for coping.

CONCLUSION

Coping with the physical symptoms and emotional difficulties of inflammatory bowel diseases can prevent patients from living a normal life. The results of this article highlight the importance of understanding the fear, anxiety, difficulties and life experiences of these patients.

SUMMARY STATEMENT

What is already known about the topic? Some research on inflammatory bowel disease exists, but patient experiences differ. IBD patients may not be able to maintain a normal life due to the effects of the disease. What does this paper add? It enables nurses to know and understand the life experiences of IBD patients. The implications of this paper: Knowing and understanding the experiences of IBD patients, nurses can provide personalized care and support tailored to each patient's needs and concerns.

Inflammatory Bowel Disease Nurse-Practical Messages

Background and Objectives: Patients affected by inflammatory bowel diseases (IBDs) are complex patients with various problems from a clinical and psychological point of view. This complexity must be addressed by a multidisciplinary team, and an inflammatory bowel disease nurse can be the ideal professional figure to create a link between doctor and patient. The objective of this comprehensive review is to describe the figure of inflammatory bowel disease nurses and the various benefits that their introduction into a multidisciplinary team can bring, as well as a focus on how to become an inflammatory bowel disease nurse. Materials and Methods: A search on the PubMed database was performed by associating the terms "IBD" or "inflammatory bowel disease" with the Boolean term AND to the various issues addressed: "life impact", "communication", "fistulas", "ostomy", "diet", "incontinence", "sexuality", "parenthood", "fatigue", "pain management", and "follow up appointments". Regarding the analysis of the benefits that the IBD nurse brings, the terms "IBD", "inflammatory bowel diseases", "Crohn's disease", and "ulcerative colitis" were used, associating them with the terms "benefit", "costs", "team", and "patients". Finally, regarding the focus on how to become an IBD nurse, an IBD nurse was interviewed. Results: An IBD nurse is a valuable nursing figure within the multidisciplinary team that takes care of patients with IBD because this nurse performs important functions from both a clinical assistance point of view (management of fistulas, ostomies, infusion of biological drugs) and an information and therapeutic education point of view (communication with patients, direct contact with patients by telephone or email). Furthermore, this nurse performs the "filter" function between doctor and patient, saving time for doctors that will be used for more outpatient visits. Conclusions: The introduction of an inflammatory bowel disease nurse is therefore recommended for multidisciplinary organizations dealing with the clinical course of patients suffering from IBD.

Nursing-sensitive outcomes in adult inflammatory bowel disease: A systematic review

AIMS

To evaluate nursing activity through outcomes that are affected, provided, and/or influenced by nurses and defined as nursing-sensitive outcomes in adult IBD patients.

DESIGN

Systematic review without meta-analysis.

DATA SOURCES

PubMed, Embase, CINAHL, PsycINFO, and the Cochrane Library databases on August 2019.

REVIEW METHODS

Peer-reviewed articles published between 2000-2020 were reviewed. The outcome measures were contextualized and presented by OMERACT Filter 2.0.

RESULTS

Twenty-four studies were included. Eighteen nursing-sensitive outcomes were identified. These outcomes defined eight domains for health intervention, fitting into three core areas (resource use/economic impact, life impact, pathophysiological manifestations). Fifty-three measurement instruments were identified.

CONCLUSIONS

Through 53 measurement tools, with use of OMERACT framework, 18 nursing-sensitive outcomes in the main 3 core areas were identified, highlighting the multidimensional role of nursing. Further insights are to be carried out to define nursing outcomes included in IBD nursing intervention studies.

IMPACT

These results could serve as a cornerstone for further investigations and validation by a panel of experts to standardizing nursing activity in a multidisciplinary context.

Inflammatory Bowel Disease Nurses' Perspectives: Prioritizing Adolescent Transition Readiness Factors

PURPOSE

Despite the wealth of knowledge and expertise that Inflammatory Bowel Disease (IBD) nurses bring to the transition process, health literature lacks nurses' perspectives on transition readiness. The purpose of study was to ask IBD nurses to prioritize care transition readiness factors for adolescents living with IBD.

DESIGN AND METHODS

The cross-sectional exploratory survey was researcher-developed and distributed online to IBD nurses across Canada. The survey was divided into nine transition topic categories.

RESULTS

Fifty-six female registered nurses from six Canadian provinces participated in the study. Overall, nurses rated all items within each transition topic category to be very important in facilitating adolescent transition to adult healthcare. The highest individual mean scores and the highest prioritized categories were within the Knowing IBD and Healthcare Provider Relationships categories, emphasizing the importance for adolescents to understand their disease and feel comfortable communicating their needs and questions to healthcare providers.

CONCLUSIONS

The transition process needs to be individualized and comprehensive addressing a multitude of biopsychosocial factors in order to support IBD patients and families to achieve healthy adult self-care behaviours that can foster positive health outcomes.

PRACTICE IMPLICATIONS

Healthcare providers, adolescents, and parents must work collaboratively to achieve identified transition goals so that the transition process is a mutually satisfying experience. A comprehensive readiness assessment tool is suggested to assist in the transition process. Transition readiness assessment must start early, be ongoing, be age-appropriate, and be individualized to the patient needs.

Effects of introduction of an inflammatory bowel disease nurse position on healthcare use

OBJECTIVE

Inflammatory bowel diseases (IBDs) are chronic relapsing remitting diseases which potentially result in hospitalisation, requiring long-term outpatient follow-up, ideally by a dedicated, multidisciplinary team. In this team, the IBD nurse is the key point of access for education, advice and support.The aim of this study was to assess the impact of introduction of an IBD nurse position on healthcare use and costs in a tertiary IBD centre.

METHODS

An IBD nurse was instituted in September 2017 in our multidisciplinary IBD team. We compared differences in healthcare use 1 year before and 1 year after the introduction of an IBD nurse position for all the patients with a confirmed diagnosis of IBD attending the Robert Debre Hospital via two information sources: Programme de Médicalisation des Systèmes d'Information and Centre des Maladies Rares.

RESULTS

252 patients (78.5% of patients with IBD followed up in our centre) were included in the patient education programme. After the introduction of an IBD nurse position, fewer patients were hospitalised for a flare, with less hospital stays: 56 before vs 28 after (p=0.002). An estimated saving of €35 070 was achieved through the decrease of hospitalisations for flare.More patients were also hospitalised for diagnosis: 32 hospitalisations before vs 54 hospitalisations after (p=0.001). All other hospitalisation categories were comparable, and the same reasons for hospitalisation were found before and after.

CONCLUSION

This study demonstrates that the IBD nurse position reduces hospital admissions. Instead of the traditional model, the IBD nurse provides accessible advice and allows patients to be outpatients.

Patient-initiated appointment systems for adults with chronic conditions in secondary care

BACKGROUND

Missed hospital outpatient appointments is a commonly reported problem in healthcare services around the world; for example, they cost the National Health Service (NHS) in the UK millions of pounds every year and can cause operation and scheduling difficulties worldwide. In 2002, the World Health Organization (WHO) published a report highlighting the need for a model of care that more readily meets the needs of people with chronic conditions. Patient-initiated appointment systems may be able to meet this need at the same time as improving the efficiency of hospital appointments.

OBJECTIVES

To assess the effects of patient-initiated appointment systems compared with consultant-led appointment systems for people with chronic or recurrent conditions managed in secondary care.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and six other databases. We contacted authors of identified studies and conducted backwards and forwards citation searching. We searched for current/ongoing research in two trial registers. Searches were run on 13 March 2019.

SELECTION CRITERIA

We included randomised trials, published and unpublished in any language that compared the use of patient-initiated appointment systems to consultant-led appointment systems for adults with chronic or recurrent conditions managed in secondary care if they reported one or more of the following outcomes: physical measures of health status or disease activity (including harms), quality of life, service utilisation or cost, adverse effects, patient or clinician satisfaction, or failures of the 'system'.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all references at title/abstract stage and full-text stage using prespecified inclusion criteria. We resolved disagreements though discussion. Two review authors independently completed data extraction for all included studies. We discussed and resolved discrepancies with a third review author. Where needed, we contacted authors of included papers to provide more information. Two review authors independently assessed the risk of bias using the Cochrane Effective Practice and Organisation of Care 'Risk of bias' tool, resolving any discrepancies with a third review author. Two review authors independently assessed the certainty of the evidence using GRADE.

MAIN RESULTS

The 17 included randomised trials (3854 participants; mean age 41 to 76 years; follow-up 12 to 72 months) covered six broad health conditions: cancer, rheumatoid arthritis, asthma, chronic obstructive pulmonary disease, psoriasis and inflammatory bowel disease. The certainty of the evidence using GRADE ratings was mainly low to very low. The results suggest that patient-initiated clinics may make little or no difference to anxiety (odds ratio (OR) 0.87, 95% confidence interval (CI) 0.68 to 1.12; 5 studies, 1019 participants; low-certainty evidence) or depression (OR 0.79 95% CI 0.51 to 1.23; 6 studies, 1835 participants; low-certainty evidence) compared to the consultant-led appointment system. The results also suggest that patient-initiated clinics may make little or no difference to quality of life (standardised mean difference (SMD) 0.12, 95% CI 0.00 to 0.25; 7 studies, 1486 participants; low-certainty evidence) compared to the consultant-led appointment system. Results for service utilisation (contacts) suggest there may be little or no difference in service utilisation in terms of contacts between the patient-initiated and consultant-led appointment groups; however, the effect is not certain as the rate ratio ranged from 0.68 to 3.83 across the studies (median rate ratio 1.11, interquartile (IQR) 0.93 to 1.37; 15 studies, 3348 participants; low-certainty evidence). It is uncertain if service utilisation (costs) are reduced in the patient-initiated compared to the consultant-led appointment groups (8 studies, 2235 participants; very low-certainty evidence). The results suggest that adverse events such as relapses in some conditions (inflammatory bowel disease and cancer) may have little or no reduction in the patient-initiated appointment group in comparison with the consultant-led appointment group (MD -0.20, 95% CI -0.54 to 0.14; 3 studies, 888 participants; low-certainty evidence). The results are unclear about any differences the intervention may make to patient satisfaction (SMD 0.05, 95% CI -0.41 to 0.52; 2 studies, 375 participants) because the certainty of the evidence is low, as each study used different questions to collect their data at different time points and across different health conditions. Some areas of risk of bias across all the included studies was consistently high (i.e. for blinding of participants and personnel and blinding of outcome assessment, other areas were largely of low risk of bias or were affected by poor reporting making the assessment unclear).

AUTHORS' CONCLUSIONS

Patient-initiated appointment systems may have little or no effect on patient anxiety, depression and quality of life compared to consultant-led appointment systems. Other aspects of disease status and experience also appear to show little or no difference between patient-initiated and consultant-led appointment systems. Patient-initiated appointment systems may have little or no effect on service utilisation in terms of service contact and there is uncertainty about costs compared to consultant-led appointment systems. Patient-initiated appointment systems may have little or no effect on adverse events such as relapse or patient satisfaction compared to consultant-led appointment systems.

Patient Understanding of "Flare" and "Remission" of Inflammatory Bowel Disease

Patients with inflammatory bowel disease have adopted medical jargon terms of "flare" and "remission," but what they mean by these terms is ill-defined and may have implications for nurse-patient communication and treatment expectancy. The aim of this study was to elicit patients' understanding of "flare" and "remission." Individuals with self-reported inflammatory bowel disease were recruited through social media. A web-based survey, with closed and open-ended questions, was administered. Conventional content analysis was used to evaluate respondents' perceptions of jargon terms. A word cloud was generated to augment analysis by visualization of word use frequency. A majority of the 34 respondents had a symptom-focused understanding and described these terms as alternating states. Various symptoms were understood to signify "flare," which was largely attributed to lifestyle factors. Corroborated by the word cloud, there was rare mention of inflammation or tissue damage. This study demonstrates that an understanding of "flare" and "remission" by patients with inflammatory bowel disease is largely symptom-based. The role of inflammation, medication failure, and targets of inflammatory bowel disease treatment beyond symptom control are not currently well known to patients with inflammatory bowel disease. To create a shared understanding of symptoms and treatment goals between the patient and the nurse, patient education on emerging expectations of inflammatory bowel disease care should be prioritized.

The impacts of an inflammatory bowel disease nurse specialist on the quality of care and costs in Finland

INTRODUCTION

A specialized inflammatory bowel disease (IBD) nurse is considered a valuable and cost-effective member of a multidisciplinary team, not all clinics responsible for IBD care employ such nurses. We evaluated IBD nurse resources, quality of care and cost effects on IBD patients care in a nationwide study in Finland.

METHODS

A healthcare professional electronic survey was conducted in order to assess the impact of an IBD nurse on the quality of care. To study the cost effects, we obtained nationwide comprehensive data covering years between 2008 and 2016 from major administrative healthcare districts of Finland. Patients with a diagnosis of IBD (ICD-code K50 or K51) were identified from the data and their personal contacts and hospitalization were analyzed. The results were compared between healthcare districts with an IBD nurse and healthcare districts without an IBD nurse.

RESULTS

Forty-nine physicians and 88 nurses responded to the survey. Of the physicians, 92% reported that an established IBD nurse had released physician's resources. The most important IBD nurse contributions listed were patient support and follow-up (79-81% of the respondents). Healthcare district, which had an established IBD nurse, produced more patient contacts. A larger proportion of the contacts was managed by the IBD nurse. Clinics with an IBD nurse reported less patient hospitalization (4-9% vs 11-19%, p < .001). Estimated annual cost savings while employing an IBD nurse may be significant.

CONCLUSION

The introduction of an IBD nurse led to better quality of care and potentially significant cost savings by reducing hospitalization rates and reallocating physician's time resources.

Systematic review: advice lines for patients with inflammatory bowel disease

OBJECTIVE

Advice lines for patients with inflammatory bowel diseases (IBD) have been introduced internationally. However, only a few publications have described the advice line service and evaluated the efficiency of it with many results presented as conference posters. A systematic synthesis of evidence is needed and the aim of this article was to systematically review the evidence of IBD advice lines.

MATERIALS AND METHODS

A broad systematic literature search was performed to identify relevant studies addressing the effect of advice lines. The process of selection of the retrieved studies was undertaken in two phases. In phase one, all abstracts were review by two independent reviewers. In phase two, the full text of all included studies were independently reviewed by two reviewers. The included studies underwent quality assessment and data synthesis.

RESULTS

Ten published studies and 10 congress abstracts were included in the review. The studies were heterogeneous both in scientific quality and in the focus of the study. No rigorous evidence was found to support that advice lines improve disease activity in IBD and correspondingly no studies reported worsening in disease activity. Advice lines were found to be health economically beneficial with clear indications of the positive impact of advice lines from the patient perspective.

CONCLUSION

The levels of evidence of the effect of advice lines in IBD are low. However, the use of advice lines was found to be safe, and cost-effective. Where investigated, patients with IBD overwhelmingly welcome an advice line with high levels of patient satisfaction reported.