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Zhen J, Simoneau M, Sharma P, Germain P, Watier-Levesque P, Othman A, Marshall JK, Afif W, Narula N. Acceptability, feasibility, and impact of the MyGut digital health platform in the monitoring and management of inflammatory bowel disease. J Can Assoc Gastroenterol 2024; 7:423-430. [PMID: 39679104 PMCID: PMC11638002 DOI: 10.1093/jcag/gwae029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2024] Open
Abstract
Background Digital health monitoring may help facilitate self-management strategies when caring for patients with inflammatory bowel disease (IBD). Aims This study investigated the feasibility of implementing the MyGut health application when caring for patients with IBD and evaluated whether its use improved health outcomes. Methods We conducted a prospective trial in 2 Canadian hospitals from 2020 to 2023. Patients with IBD were recruited from gastroenterology clinics, and the MyGut application was installed onto their mobile devices. Metrics such as acceptability, satisfaction, feasibility, quality-of-life scores (measured through the short IBD questionnaire [SIBDQ]), and resource utilization were collected throughout the 1-year follow-up period. Results Of the 84 patients enrolled, 58 patients (69%) continued to use the app until the study completion. At recruitment, all 84 patients (100%) were willing to use the MyGut application after a brief tutorial. There was a significant improvement in the SIBDQ scores after 1 year of MyGut use (mean = 56.0, SD 8.85 vs 52.0, SD 9.84) (P = .012). However, only 42.9% (21/49) of the patients were willing to continue using the application after 1 year, a significant decrease compared with the 71.4% (35/49) who were willing to continue after 2 months (P = .001). No differences were observed in the number of emergency room visits/hospitalizations (P = .78) before and after 1 year of MyGut use. Conclusions This study demonstrates that patients are willing to use digital health monitoring platforms and this may lead to improved quality of life. However, sustained efforts must be made to optimize its long-term feasibility.
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Affiliation(s)
- Jamie Zhen
- Department of Medicine, University of Ottawa, Ottawa, ON K1H 8L6, Canada
| | - Maude Simoneau
- Faculty of Medicine, McGill University, Montreal, QC H3G 2M1, Canada
| | - Pooja Sharma
- Institute for Management and Innovation, University of Toronto, Toronto, ON L5L 1C6, Canada
| | - Pascale Germain
- Research Institute of the McGill University Health Centre, Montreal, QC H3H 2R9, Canada
| | | | - Abdulrahman Othman
- Research Institute of the McGill University Health Centre, Montreal, QC H3H 2R9, Canada
| | - John K Marshall
- Department of Medicine (Division of Gastroenterology), McMaster University, Hamilton, ON L8S 4K1, Canada
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - Waqqas Afif
- Department of Gastroenterology, McGill University, Montreal, QC H3G 2M1, Canada
| | - Neeraj Narula
- Department of Medicine (Division of Gastroenterology), McMaster University, Hamilton, ON L8S 4K1, Canada
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON L8S 4K1, Canada
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2
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Israel A, Sharif K, Zada G, Friedenberg A, Vinker S, Lahat A. Comparative Analysis of Inflammatory Bowel Disease Management: Hospital-based Versus Community-based Care. J Clin Gastroenterol 2024:00004836-990000000-00364. [PMID: 39453694 DOI: 10.1097/mcg.0000000000002088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Accepted: 09/22/2024] [Indexed: 10/26/2024]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) encompasses chronic gastrointestinal disorders characterized by recurrent inflammation. Achieving mucosal healing and preventing disease progression are primary treatment goals. OBJECTIVES This study aimed to compare disease characteristics, medication utilization, procedures performed, and hospitalizations between IBD patients treated in hospital and community settings using the Leumit Health Service database. DESIGN A retrospective cohort study was conducted using data from the Leumit Health Service, comprising 3020 patients diagnosed with IBD from January 2010 to December 2019. METHODS Patients were divided based on primary care setting: hospital-based or community-based. Data included demographic characteristics, disease type, medication usage, procedures, and outcomes. Statistical analyses assessed differences between groups. RESULTS Hospital-treated patients were significantly younger (49.4±18.4 vs. 40.4±18.7, P<0.001 ), had higher rates of Crohn's disease (45.9% vs. 71.4%, P<0.001), exhibited higher inflammatory markers (calprotectin 768±2182 vs. 1305±2526, P<0.001), lower albumin (4.23±0.27 vs. 4.12±0.32, P<0.001), hemoglobin levels (13.4±1.6 vs. 12.9±1.6, P<0.001), and lower BMI (26.2±5.3 vs. 24.6±5.6, P<0.001) compared with community-treated patients. Hospital-treated patients had more endoscopic procedures, higher medication utilization rates, shorter treatment durations, and increased hospitalization occurrence (12.1% vs. 23.6%, P<0.001), length (0.67±3.34 vs. 1.45±5.88, P<0.001), and colectomies (4.73% vs. 15.8%, P<0.001). CONCLUSIONS Disparities exist in IBD management between hospital and community settings, influenced by disease severity and treatment approaches. Hospital-based care is associated with more aggressive disease and intensive interventions, while community-based care may reflect milder disease and conservative management. Integrating specialized care models and personalized approaches across settings can optimize patient outcomes and health care delivery for IBD management. Further research is needed to understand these disparities' underlying mechanisms and develop comprehensive care strategies.
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Affiliation(s)
- Ariel Israel
- Leumit Research Institute and Department of Family Medicine, Leumit Health Services
- Faculty of Medicine, Tel-Aviv University
| | - Kassem Sharif
- Department of Gastroenterology, Chaim Sheba Medical Center, affiliated with Tel Aviv University, Faculty of Medicine, Tel Aviv
| | - Galit Zada
- Department of Gastroenterology, Chaim Sheba Medical Center, affiliated with Tel Aviv University, Faculty of Medicine, Tel Aviv
| | - Amir Friedenberg
- Leumit Research Institute and Department of Family Medicine, Leumit Health Services
- Faculty of Medicine, Tel-Aviv University
| | - Shlomo Vinker
- Leumit Research Institute and Department of Family Medicine, Leumit Health Services
- Faculty of Medicine, Tel-Aviv University
| | - Adi Lahat
- Department of Gastroenterology, Chaim Sheba Medical Center, affiliated with Tel Aviv University, Faculty of Medicine, Tel Aviv
- Department of Gastroenterology, Samson Assuta Ashdod Medical Center, affiliated with Faculty of Medicine, Ben Gurion University of the Negev, Be'er Sheva, Israel
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3
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Jauregui W, Abarca YA, Ahmadi Y, Menon VB, Zumárraga DA, Rojas Gomez MC, Basri A, Madala RS, Girgis P, Nazir Z. Shared Pathophysiology of Inflammatory Bowel Disease and Psoriasis: Unraveling the Connection. Cureus 2024; 16:e68569. [PMID: 39364475 PMCID: PMC11449469 DOI: 10.7759/cureus.68569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2024] [Indexed: 10/05/2024] Open
Abstract
Psoriasis (PS) and inflammatory bowel disease (IBD) are immune-mediated chronic conditions that share pathophysiological processes, including immune system dysfunction, microbiome dysbiosis, and inflammatory pathways. These pathways result in increased turnover of epithelial cells and compromised barrier function. The assessment of the literature suggests that immunopathogenic mechanisms, such as tumor necrosis factor (TNF)-α signaling and IL-23/IL-17 axis dysregulation, are shared by PS and IBD. Clinical characteristics and diagnostic approaches overlap significantly, and advances in biomarker identification benefit both conditions. Current treatments, namely biologics that target TNF-α, IL-17, and IL-23, show promising results in decreasing inflammation and controlling symptoms. Precision medicine approaches are prioritized in prospective therapeutic procedures to tailor pharmaceuticals based on specific biomarkers, perhaps improving outcomes and minimizing side effects. This study thoroughly examines and evaluates the body of research on PS and IBD. Several papers were examined to compile data on clinical features, diagnosis, therapies, pathophysiology, epidemiology, and potential future therapeutic developments. The selection of articles was based on three methodological qualities: relevance and addition to the knowledge of IBD and PS. The retrieved data were combined to provide a coherent summary of the state of the knowledge and to spot new trends. The overview of the latest studies demonstrates that both PS and IBD share pathophysiological foundations and therapeutic approaches. With a spotlight on particular biomarkers, advances in precision medicine provide a promising path toward enhancing therapeutic effectiveness and minimizing side effects.
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Affiliation(s)
- Walter Jauregui
- General Medicine, Universidad Nacional Autónoma de Honduras, Tegucigalpa, HND
| | - Yozahandy A Abarca
- Internal Medicine, Escuela de Medicina y Ciencias de la Salud, Tecnológico de Monterrey, Mexico City, MEX
| | - Yasmin Ahmadi
- School of Medicine, Royal College of Surgeons in Ireland - Medical University of Bahrain, Muharraq, BHR
| | - Vaishnavi B Menon
- Internal Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | | | | | - Aleeza Basri
- Internal Medicine, Liaquat University of Medical and Health Sciences, Hyderabad, PAK
| | | | - Peter Girgis
- Internal Medicine, Ross University School of Medicine, Bridgetown, BRB
| | - Zahra Nazir
- Internal Medicine, Combined Military Hospital, Quetta, PAK
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4
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Hans AK. Close postdischarge follow-up reduces readmission in patients with inflammatory bowel disease. Proc AMIA Symp 2024; 37:525-526. [PMID: 38910818 PMCID: PMC11188805 DOI: 10.1080/08998280.2024.2349986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Accepted: 04/23/2024] [Indexed: 06/25/2024] Open
Affiliation(s)
- Amneet K. Hans
- Baylor Scott & White Center for Inflammatory Bowel Diseases, Dallas, Texas, USA
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5
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Boyd T, Araka EB, Kochar B, Ananthakrishnan AN. Differences in Management and Outcomes of Older and Younger Adults with Acute Severe Ulcerative Colitis. J Crohns Colitis 2024; 18:570-577. [PMID: 37897720 PMCID: PMC11037104 DOI: 10.1093/ecco-jcc/jjad183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Indexed: 10/30/2023]
Abstract
BACKGROUND Older adults with ulcerative colitis [UC] have greater morbidity than younger adults. The goal of this study was to investigate differences in the management and outcomes of older and younger patients hospitalised with severe UC. METHODS We conducted a retrospective cohort study of patients hospitalised for acute severe ulcerative colitis requiring intravenous steroids. We compared outcomes of adults aged ≥65 years with outcomes of younger patients. Primary study outcomes included frequency and timing of medical and surgical rescue therapy during the hospitalisation, postoperative complications, frailty, and mortality outcomes up to 1 year following the hospitalisation. RESULTS Our cohort included 63 older adults [≥65 years] and 137 younger adults [14-64 years]. Despite similar disease severity at hospitalisation, older adults were half as likely to receive medical rescue therapy (odds ratio 0.45, 95% confidence interval [CI] 0.22-0.91). This difference was more striking among the frailest older adults. Older patients were similarly likely to undergo surgery but were more likely to undergo urgent or emergent procedures [50%] compared with younger patients [13%] [p <0.004]. The fraction of older adults at high risk for frailty increased from 33% pre-hospitalisation to 42% post-hospitalisation. Nearly one-third [27.8%] of older adults died within 1 year of hospitalisation, with half the deaths among older adults being attributable to UC or complications of UC. CONCLUSIONS In comparison with younger patients, older adults had lower frequency use of medical rescue therapy, higher rates of emergency surgery, and increased mortality within 1 year. Further research is needed to optimise care pathways in this population.
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Affiliation(s)
- Taylor Boyd
- Harvard Medical School, Harvard University, Boston, MA, USA
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Bharati Kochar
- Harvard Medical School, Harvard University, Boston, MA, USA
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Ashwin N Ananthakrishnan
- Harvard Medical School, Harvard University, Boston, MA, USA
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
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6
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Tran P, Tjahja M, Wang Y, Seth N, Reyes R, Bussell C, Edwards A, Johnson CM. Close outpatient follow-up associated with reduced readmission rates in patients with inflammatory bowel disease. Proc AMIA Symp 2024; 37:517-524. [PMID: 38910831 PMCID: PMC11188799 DOI: 10.1080/08998280.2024.2335095] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 03/18/2024] [Indexed: 06/25/2024] Open
Abstract
Background Few studies have shown the effects of prompt outpatient follow-up in relation to reducing readmission rates in patients hospitalized with inflammatory bowel disease (IBD). Our study evaluated whether postdischarge follow-up was associated with fewer IBD-related readmissions. Methods This single-center retrospective study included 477 patients with Crohn's disease (CD) or ulcerative colitis (UC) who were readmitted to our tertiary care hospital from January 1, 2016, to June 1, 2022. Rehospitalization admissions were defined as admissions that occurred within 90 days after discharge date. We used a chi-square or Fisher's exact test to test for bivariate comparisons to determine if there was an association in patients readmitted for IBD and primary care or gastroenterology follow-up at 1, 2, 3, and 4 weeks versus no follow-up. Results In UC patients, there were 118 admissions from 2016 to 2022; 36/118 (31%) and 41/118 (34.7%) of the patients were readmitted at 30 days and 90 days, respectively. In the CD group, there were 101 (36.73%) readmissions among 277 patients, with 174 nonreadmissions (63.27%). Conclusions Gastroenterology follow-up within 1 month was associated with reduced rates of admission in both groups (P < 0.05). This study highlights the importance of close gastroenterology follow-up for IBD-related hospitalizations.
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Affiliation(s)
- Phi Tran
- Department of Internal Medicine, Baylor Scott and White Medical Center, Temple, Texas, USA
| | - Matthew Tjahja
- Department of Internal Medicine, Baylor Scott and White Medical Center, Temple, Texas, USA
| | - Yilun Wang
- Texas A&M School of Medicine, College Station, Bryan, Texas, USA
| | - Nikhil Seth
- Department of Internal Medicine, Baylor Scott and White Medical Center, Temple, Texas, USA
| | - Rylyn Reyes
- Division of Gastroenterology, Baylor Scott and White Medical Center, Temple, Texas, USA
| | - Charles Bussell
- Division of Gastroenterology, Baylor Scott and White Medical Center, Temple, Texas, USA
| | - Audrene Edwards
- Baylor Scott and White Research Institute, Dallas, Texas, USA
| | - Christopher M. Johnson
- Department of Internal Medicine, Baylor Scott and White Medical Center, Temple, Texas, USA
- Division of Gastroenterology, Baylor Scott and White Medical Center, Temple, Texas, USA
- Baylor College of Medicine, Temple, Texas, USA
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7
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Miyatani Y, Micic D. Revisiting the Risk of Hospital Readmission in Severe Ulcerative Colitis. Inflamm Bowel Dis 2024; 30:688-689. [PMID: 37682866 DOI: 10.1093/ibd/izad212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Indexed: 09/10/2023]
Affiliation(s)
- Yusuke Miyatani
- Inflammatory Bowel Disease Center, Section of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, University of Chicago Medicine, University of Chicago, Chicago, IL, USA
| | - Dejan Micic
- Inflammatory Bowel Disease Center, Section of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, University of Chicago Medicine, University of Chicago, Chicago, IL, USA
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8
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Malter L, Hong SJ, Lopatin S, Murphy M, Hudesman D, Kane S, Rubin DT. Increasing Exposure to Inflammatory Bowel Diseases Education in Gastroenterology Fellowship: The Pilot IBD 101 Experience. Inflamm Bowel Dis 2024:izad311. [PMID: 38217539 DOI: 10.1093/ibd/izad311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) management has become increasingly complex, and education varies across fellowship programs. IBD 101 was designed to introduce first-year gastroenterology (GI) fellows to IBD care and training. METHODS In 2019, a cohort of fellows participated in a 1-day course with small group learning and group observed structured clinical examinations. Pre- and postcourse surveys were administered to evaluate the course. To assess the long-term impact, surveys were emailed in May 2022 to all third-year fellows from previously participating programs. The primary outcome was comfort managing IBD scenarios and information regarding each fellow's exposure to IBD education. RESULTS Fifty-five fellows from 32 programs participated. A total of 49 (89%) of 55 completed pre- and postcourse surveys. All fellows agreed that the course content was appropriate. In the postcourse survey, all fellows reported increased comfort managing IBD patients. Ninety-six percent of attendees stated that they would strongly recommend this course. Thirty-six fellows completed surveys in 2022, 21 (58%) attendees and 15 (42%) nonattendees. Attendees reported equivalent or higher levels of comfort compared with nonattendees. Higher global competence was noted among attendees (odds ratio, 5.21; 95% confidence interval, 0.91-29.9; P = .06) after adjusting for presence of a local IBD specialist, number of IBD patients seen monthly (≤5 vs >5), and rotation through an IBD service. CONCLUSIONS IBD 101, an introductory course for first-year GI trainees, was associated with increased comfort managing IBD with a durable benefit independent of individual access to IBD education. Continuation of this program will further enhance the IBD education of future GI fellows.
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Affiliation(s)
- Lisa Malter
- Division of Gastroenterology, Department of Medicine, NYU Langone Health, New York, NY, USA
| | - Simon J Hong
- Division of Gastroenterology, Department of Medicine, NYU Langone Health, New York, NY, USA
| | - Sarah Lopatin
- Division of Gastroenterology, Department of Medicine, NYU Langone Health, New York, NY, USA
| | - Megan Murphy
- Division of Gastroenterology, Department of Medicine, NYU Langone Health, New York, NY, USA
| | - David Hudesman
- Division of Gastroenterology, Department of Medicine, NYU Langone Health, New York, NY, USA
| | - Sunanda Kane
- Division of Gastroenterology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
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9
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Ledder O, Harel S, Lujan R, Friss C, Orlanski-Meyer E, Yogev D, Loewenberg Weisband Y, Greenfeld S, Kariv R, Lederman N, Matz E, Schwartz D, Focht G, Dotan I, Turner D. Residence in Peripheral Regions and Low Socioeconomic Status Are Associated With Worse Outcomes of Inflammatory Bowel Diseases: A Nationwide Study From the epi-IIRN. Inflamm Bowel Dis 2024; 30:1-8. [PMID: 36917191 DOI: 10.1093/ibd/izad034] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Indexed: 03/16/2023]
Abstract
BACKGROUND Timely access to quality medical care impacts patient outcomes in inflammatory bowel disease (IBD). In a nationwide study from the epidemiology group of the Israeli IBD research nucleus we aimed to assess the impact of residence and socioeconomic status (SES) on disease outcomes. METHODS We utilized data from the 4 health maintenance organizations in Israel, representing 98% of the population. Regions were defined as central, northern and southern; SES was graded from lowest to highest (from 1 to 4) as per Israel Central Bureau of Statistics. The primary outcome was steroid dependency, with secondary outcomes of surgeries and biologic therapy use. RESULTS A total of 28 216 IBD patients were included: 15 818 (56%) Crohn's disease (CD) and 12 398 (44%) ulcerative colitis; 74%, 12% and 14% resided in central, southern, and northern Israel, respectively (SES 1: 21%, SES 4: 12%). Lower SES was associated with steroid dependency (20% in SES 1 vs 12% in SES 4 in CD; P < .001; and 18% vs 12% in ulcerative colitis; P < .001), and higher surgery rates (12% vs 7%; P < .001, and 1.4% vs 0.7%; P = .115, respectively). There were higher steroid dependency and CD surgery rates in peripheral vs central regions. In multivariable models, both SES and peripheral region were independently associated with poorer outcomes. CONCLUSIONS We found that lower SES and peripheral residence were associated with deleterious outcomes in IBD. This should be considered by policymakers and should encourage strategies for improving outcomes in populations at risk.
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Affiliation(s)
- Oren Ledder
- Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sasha Harel
- Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Rona Lujan
- Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Chagit Friss
- Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Esther Orlanski-Meyer
- Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Dotan Yogev
- Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, Jerusalem, Israel
| | | | | | | | | | - Eran Matz
- Leumit Health Services, Tel Aviv, Israel
| | - Doron Schwartz
- Department of Gastroenterology and Hepatology, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Gili Focht
- Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Iris Dotan
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dan Turner
- Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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10
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Stovall SL, Soriano CR, Kaplan JA, La Selva D, Lord J, Moonka R, Zisman TL, Simianu VV. Characterizing Regionalization of Inflammatory Bowel Disease Hospitalizations and Operations in Washington State. J Gastrointest Surg 2023; 27:2493-2505. [PMID: 37532905 DOI: 10.1007/s11605-023-05731-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 05/30/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Hospitalizations for inflammatory bowel disease (IBD) are a major contributor of healthcare utilization. We assessed IBD hospitalizations and surgical operations in Washington State to characterize regionalization patterns. METHODS We identified a cohort of hospitalizations for Crohn's disease (CD) or ulcerative colitis (UC) from 2008 to 2019 using Washington State's Comprehensive Hospital Abstract Reporting System (CHARS). Hospitalizations were characterized by emergent or elective acuity and whether an operation or endoscopic procedure was performed. Facility volume and distance travelled by patients were used to determine regionalization. RESULTS There were 20,494 IBD-related hospitalizations at 95 hospitals: 13,585 (66.3%) with CD and 6,909 (33.7%) with UC. Emergencies accounted for 78.2% of all IBD-related hospitalizations and did not differ between CD (78.3%) and UC (77.9%) (p = 0.54). Surgery was performed during 10.3% and endoscopy during 30.6% of emergent hospitalizations. 72.0% of emergent hospitalizations occurred at 22 facilities, while 71.1% of elective hospitalizations were concentrated at 9 facilities. Operations were performed during 78.5% of elective hospitalizations, and five hospitals performed 69% of all elective surgery. Laparoscopic surgery increased in both emergent (17% to 52%, p < 0.001) and elective operations (18% to 42%, p < 0.001) from 2008 to 2019. CONCLUSIONS In Washington State, most IBD hospitalizations were emergent, which were decentralized and typically non-operative. By contrast, most elective admissions involved surgery and were centralized at a few high-volume centers. Further understanding the drivers behind IBD hospitalizations may help optimize emergent medical and elective surgical care at a state level.
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Affiliation(s)
- Stephanie L Stovall
- Department of Surgery, Virginia Mason Franciscan Health, 1100 9th Ave, C6-GS, Seattle, WA, 98101, USA
| | - Celine R Soriano
- Department of Surgery, Virginia Mason Franciscan Health, 1100 9th Ave, C6-GS, Seattle, WA, 98101, USA
| | - Jennifer A Kaplan
- Department of Surgery, Virginia Mason Franciscan Health, 1100 9th Ave, C6-GS, Seattle, WA, 98101, USA
| | - Danielle La Selva
- Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - James Lord
- Benaroya Research Institute, Seattle, WA, USA
- Department of Gastroenterology, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Ravi Moonka
- Department of Surgery, Virginia Mason Franciscan Health, 1100 9th Ave, C6-GS, Seattle, WA, 98101, USA
| | - Timothy L Zisman
- Department of Gastroenterology, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Vlad V Simianu
- Department of Surgery, Virginia Mason Franciscan Health, 1100 9th Ave, C6-GS, Seattle, WA, 98101, USA.
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Wang S, van Schooten FJ, Jin H, Jonkers D, Godschalk R. The Involvement of Intestinal Tryptophan Metabolism in Inflammatory Bowel Disease Identified by a Meta-Analysis of the Transcriptome and a Systematic Review of the Metabolome. Nutrients 2023; 15:2886. [PMID: 37447212 DOI: 10.3390/nu15132886] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/18/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
Evidence is emerging for the role of intestinal tryptophan metabolism in the development of inflammatory bowel disease (IBD). In order to identify the role of altered intestinal tryptophan metabolism in IBD pathogenesis, a meta-analysis of the transcriptome was performed to identify differentially expressed genes involved in the tryptophan metabolism pathways in intestinal biopsies of IBD as compared to non-IBD controls. Moreover, a systematic review of the metabolome was performed to identify the concurrent changes in tryptophan metabolites. Integration of the transcriptome and metabolome identified various alterations in intestinal tryptophan metabolism during active disease in IBD patients, including decreased intestinal tryptophan absorption, enhanced kynurenine pathway, increased interstitial serotonin availability, changed indole pathway, and activated aryl hydrocarbon receptor signaling. Therefore, a network of intestinal tryptophan metabolism pathways in IBD could be established, helping to assess the potential of genes and metabolites involved in these pathways as diagnostic markers and targets for IBD management.
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Affiliation(s)
- Shan Wang
- Department of Pharmacology and Toxicology, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, 6200 MD Maastricht, The Netherlands
| | - Frederik-Jan van Schooten
- Department of Pharmacology and Toxicology, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, 6200 MD Maastricht, The Netherlands
| | - Han Jin
- Department of Pathology, School for Cardiovascular Diseases (CARIM), Maastricht University Medical Center+ (MUMC+), 6200 MD Maastricht, The Netherlands
| | - Daisy Jonkers
- Department of Internal Medicine, Division Gastroenterology-Hepatology, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, 6200 MD Maastricht, The Netherlands
| | - Roger Godschalk
- Department of Pharmacology and Toxicology, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, 6200 MD Maastricht, The Netherlands
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12
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Li Fraine S, Malhamé I, Cafaro T, Simard C, MacNamara E, Martel M, Barkun A, Wyse JM. A Simple Admission Order-set Improves Adherence to Canadian Guidelines for Hospitalized Patients With Severe Ulcerative Colitis. J Can Assoc Gastroenterol 2023. [DOI: 10.1093/jcag/gwac032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Abstract
Background
Individuals hospitalized with severe ulcerative colitis represent a complex group of patients. Variation exists in the quality of care of admitted patients with inflammatory bowel disease. We hypothesized that implementation of a standardized admission order set could result in improved adherence to current best practice guidelines (Toronto Consensus Statements) for the management of this patient population.
Methods
A retrospective cohort study of patients admitted with severe ulcerative colitis to a Montreal tertiary center was conducted. Two cohorts were defined based on pre- and post-implementation of a standardized order set. Adherence to 11 quality indicators was assessed before and after implementation of the intervention. These included: Clostridioides difficile and stool cultures testing, ordering an abdominal X-ray and CRP, organizing a flexible sigmoidoscopy, documenting latent tuberculosis, initiating thromboprophylaxis, use of intravenous steroids, prescribing infliximab if refractory to steroids, limiting narcotics, and surgical consultation if refractory to medical therapy.
Results
Adherence to 6 of the 11 quality indicators was improved in the post-intervention cohort. Significant increases were noted in adherence to C difficile testing (75.5% versus 91.9%, P < 0.05), CRP testing (71.4% versus 94.6%, P < 0.01), testing for latent tuberculosis (38.1% versus 84.6%, P < 0.01), thromboprophylaxis (28.6% versus 94.6%, P < 0.01), adequate corticosteroids prescription (72.9% versus 94.6%, P < 0.01), and limitation of narcotics prescribed (68.8% versus 38.9%, P < 0.01).
Conclusions
Implementation of a standardized order set, focused on pre-defined quality indicators for hospitalized patients with severe UC, was associated with meaningful improvements to most quality indicators defined by the Toronto Consensus Statements.
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Affiliation(s)
- Steven Li Fraine
- Division of Gastroenterology, McGill University Health Centre , Montreal, Quebec , Canada
- Division of Gastroenterology, Jewish General Hospital, McGill University , Montreal, Quebec , Canada
| | - Isabelle Malhamé
- Division of General Internal Medicine, McGill University Health Centre , Montreal, Quebec , Canada
| | - Teresa Cafaro
- Division of General Internal Medicine, Jewish General Hospital, McGill University , Montreal, Quebec , Canada
| | - Camille Simard
- Division of General Internal Medicine, Jewish General Hospital, McGill University , Montreal, Quebec , Canada
| | - Elizabeth MacNamara
- Department of Medical Biochemistry, Jewish General Hospital, McGill University , Montreal, Quebec , Canada
| | - Myriam Martel
- Division of Gastroenterology, McGill University Health Centre , Montreal, Quebec , Canada
| | - Alan Barkun
- Division of Gastroenterology, McGill University Health Centre , Montreal, Quebec , Canada
| | - Jonathan M Wyse
- Division of Gastroenterology, Jewish General Hospital, McGill University , Montreal, Quebec , Canada
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13
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Caplan A, McConnell R, Velayos F, Mahadevan U, Lewin S. Delayed Initiation of Rescue Therapy Associated with Increased Length of Stay in Acute Severe Ulcerative Colitis. Dig Dis Sci 2022; 67:5455-5461. [PMID: 35389167 PMCID: PMC9652198 DOI: 10.1007/s10620-022-07490-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 03/16/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Reducing hospitalization length of stay (LOS) for acute severe ulcerative colitis (ASUC) will reduce healthcare costs, mitigate hospitalization-associated risks (e.g., venous thromboembolism), and improve quality of life. METHODS A chart review was performed of all adult ASUC-related hospitalizations at University of California, San Francisco, from July 1, 2014, to December 31, 2017. Univariate and multivariate analyses were performed to identify factors associated with LOS < 7 days versus ≥ 7 days. A subgroup analysis was performed excluding patients who underwent colectomy during hospitalization. RESULTS A total of 95 ASUC-related hospitalizations were identified. The initial univariable analysis identified the following factors associated with LOS ≥ 7 days (P < 0.05): higher maximum heart rate in the first 24 h, higher C-reactive protein, being biologic therapy naïve, and a later hospital day of biologic therapy initiation. On mixed model multivariable analysis, later hospital day of biologic initiation was associated with increased LOS ≥ 7 days (OR 3.1 95% CI 1.2-7.56, p = 0.012). CONCLUSIONS We identified multiple predictors for longer hospital LOS, including factors related to disease severity (non-modifiable) and treatment (potentially modifiable). Importantly, this study identified biologic naïve treatment status and delayed inpatient biologic therapy initiation as predictors of longer LOS (≥ 7 days) in patients who did not ultimately require colectomy during their hospital stay. Potentially modifiable strategies to reduce LOS may include early communication and patient education about biologic therapy in both the inpatient and outpatient setting.
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Affiliation(s)
- Alyssa Caplan
- Division of Gastroenterology, University of California, 513 Parnassus Avenue S-357, San Francisco, CA, 94143, USA
| | | | | | - Uma Mahadevan
- Division of Gastroenterology, University of California, 513 Parnassus Avenue S-357, San Francisco, CA, 94143, USA
| | - Sara Lewin
- Division of Gastroenterology, University of California, 513 Parnassus Avenue S-357, San Francisco, CA, 94143, USA.
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Miles M, Peña-Sánchez JN, Heisler C, Cui Y, Mathias H, Stewart M, Jones JL. Models of Care for Inflammatory Bowel Disease: A National Cross-sectional Survey to Characterize the Landscape of Inflammatory Bowel Disease Care in Canada. CROHN'S & COLITIS 360 2022; 4:otac046. [PMID: 36778510 PMCID: PMC9802273 DOI: 10.1093/crocol/otac046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Indexed: 12/03/2022] Open
Abstract
Background Collaborative care models improve inflammatory bowel disease (IBD) patient outcomes, yet little is known about the capacity or available resources to deliver such model of care in Canada. We aimed to describe the structure and process characteristics of clinical care delivery models for IBD across Canada, including the number of collaborative care centers. Methods A cross-sectional study was conducted between November 2017 and October 2018 through an online survey. This survey was distributed to gastroenterologists at community and academic centers across Canada who provide care for IBD patients. Comparisons between collaborative and non-collaborative centers were analyzed using chi-squares or t-tests. Descriptive statistics of respondent demographics were also generated. Results Seventy-two gastroenterologists from 62 unique IBD centers completed the survey. A total of 7 unique collaborative centers and 55 unique non-collaborative centers were identified. There were significant differences between collaborative and non-collaborative centers in some aspects of access to IBD care, patient assessment and referral process, and patent education and empowerment. Notably, very few centers had processes for implementing and evaluating evidence-based clinical pathways, and auditing quality indicators. Conclusions Our findings identify areas for improving the quality of IBD care in Canada. Expanding the number of and access to collaborative care centers in Canada is needed, in addition to increased focus on patient education, communication, and implementation of evidence-based care pathways.
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Affiliation(s)
- Matthew Miles
- Present address: South Health Campus, Alberta Health Services, Calgary, Alberta, Canada
| | - Juan Nicolás Peña-Sánchez
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Courtney Heisler
- Division of Digestive Care and Endoscopy, Nova Scotia Health, Halifax, Nova Scotia, Canada
| | - Yunsong Cui
- Atlantic PATH, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Holly Mathias
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Michael Stewart
- Division of Digestive Care and Endoscopy, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jennifer L Jones
- Address correspondence to: Jennifer L. Jones, MD, MSc, FRCPC, Division of Digestive Care and Endoscopy, Department of Medicine, Dalhousie University, Queen Elizabeth II Health Sciences Center, Suite 915 Victoria Building, 1276 South Park Street, Halifax, NS B3H 2Y9, Canada ()
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15
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Consultative vs Dedicated Inpatient Service for GI Training and Patient Care. Am J Gastroenterol 2022; 117:1728-1730. [PMID: 35973175 DOI: 10.14309/ajg.0000000000001895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 06/17/2022] [Indexed: 12/11/2022]
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Fudman DI, Perez-Reyes AE, Niccum BA, Melmed GY, Khalili H. Interventions to Decrease Unplanned Healthcare Utilization and Improve Quality of Care in Adults With Inflammatory Bowel Disease: A Systematic Review. Clin Gastroenterol Hepatol 2022; 20:1947-1970.e7. [PMID: 34481951 DOI: 10.1016/j.cgh.2021.08.048] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/25/2021] [Accepted: 08/30/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Inflammatory bowel disease (IBD) care and outcomes exhibit substantial variability, suggesting quality gaps. We aimed to identify interventions to narrow these gaps. METHODS We performed a systematic review of Medline, Embase, and Web of Science through May 2021 to find manuscripts and abstracts reporting quality improvement (QI) interventions in IBD. We included studies with interventions that addressed acute care utilization, vaccination, or Crohn's and Colitis Foundation quality indicators for care processes, including pre-therapy testing, tobacco cessation, colorectal cancer surveillance, Clostridium difficile infection screening in flares, sigmoidoscopy in patients hospitalized with ulcerative colitis, and use of steroid-sparing therapy. The primary objective was to identify successful QI interventions. Risk of bias assessment was conducted using the Joanna Briggs Institute critical appraisal checklist. RESULTS Twenty-three manuscripts and 23 meeting abstracts met inclusion criteria. Influenza and pneumococcal vaccination were the most studied indicators (24 references), followed by emergency room and/or hospital utilization, tobacco cessation, and pre-therapy testing (17, 11, and 10 references, respectively). Electronic medical record-based interventions were the most frequent, whereas other initiatives used strategies that included changes to care structure or delivery, vaccination protocols, or physician and patient education. Successful interventions matched the complexity of the metric to the intervention including making changes to care structure or delivery, empowered non-physician staff, and used electronic medical record changes to prompt clinicians. CONCLUSIONS The quality of IBD care can be improved with diverse interventions that range from simple to complex. However, these interventions are not universally successful. Clinicians should emulate successful interventions and design new initiatives to narrow gaps in care quality.
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Affiliation(s)
- David I Fudman
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Andrea Escala Perez-Reyes
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Blake A Niccum
- Department of Medicine, Massachusetts General Hospital, Harvard University, Boston, Massachusetts
| | - Gil Y Melmed
- Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, New York, New York
| | - Hamed Khalili
- Division of Gastroenterology, Massachusetts General Hospital, Harvard University, Boston, Massachusetts
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17
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Barnes EL. Treating IBD? Don't Forget that Mental Health Matters. Dig Dis Sci 2022; 67:4321-4323. [PMID: 35503485 PMCID: PMC10559126 DOI: 10.1007/s10620-022-07510-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/29/2022] [Indexed: 12/09/2022]
Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, Campus Box #7080, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA.
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, Chapel Hill, NC, USA.
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Kandasamy C, Shah I, Yakah W, Ahmed A, Tintara S, Sorrento C, Freedman SD, Kothari DJ, Sheth SG. The Impact of an Inpatient Pancreatitis Service and Educational Intervention Program on the Outcome of Acute Pancreatitis. Am J Med 2022; 135:350-359.e2. [PMID: 34717902 DOI: 10.1016/j.amjmed.2021.09.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/08/2021] [Accepted: 09/22/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND We introduced an inpatient pancreatitis consultative service aimed to 1) provide guideline-based recommendations to acute pancreatitis inpatients and 2) educate inpatient teams on best practices for acute pancreatitis management. We assessed the impact of pancreatitis service on acute pancreatitis outcomes. METHODS Inpatients with acute pancreatitis (2008-2018) were included in this cohort study. Primary outcomes included length of stay and refeeding time. The educational intervention was a guideline-based decision support tool, reinforced at hospital-wide educational forums. In Part A (n = 965), we compared outcomes pre-service (2008-2010) to post-service (2012-2018), excluding 2011, when the pancreatitis service was introduced. In Part B (n = 720, 2012-2018), we divided patients into 2 groups based on if co-managed with the pancreatitis service, and compared outcomes, including subgroup analysis based on severity, focusing on mild acute pancreatitis. RESULTS In Part A, for mild acute pancreatitis, length of stay (111 vs 88.4 h, P = .001), refeeding time (61.8 vs 47.4 h, P = .002), and infections (10.0% vs 1.87%, P < .001) were significantly improved after the pancreatitis service was introduced, with multivariable analysis showing reduced length of stay (odds ratio 0.83; 95% confidence interval, 0.82-0.84; P < .001) and refeeding time (odds ratio 0.75; 95% confidence interval, 0.74-0.77; P < .001). In Part B, for mild acute pancreatitis, refeeding time (44.2 vs 50.3 h, P = .123) and infections (5.58% vs 4.70%, P = .80) were similar in patients cared for without and with the service. Length of stay was higher in the pancreatitis service group (93.3 vs 81.2 h, P = .05), as they saw more gallstone acute pancreatitis patients who had greater length of stay and magnetic resonance cholangiopancreatography. In the post-service period, a majority of patients with moderate/severe acute pancreatitis and nearly all intensive care unit admits received care from the pancreatitis service. CONCLUSIONS Implementation of an inpatient pancreatitis service was associated with improved outcomes in mild acute pancreatitis. Guideline-based educational interventions have a beneficial impact on management of mild acute pancreatitis by admitting teams even without pancreatitis consultation.
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Affiliation(s)
| | - Ishani Shah
- Division of Gastroenterology & Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - William Yakah
- Division of Gastroenterology & Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Awais Ahmed
- Division of Gastroenterology & Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | | | | | - Steven D Freedman
- Division of Gastroenterology & Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Darshan J Kothari
- Division of Gastroenterology, Duke University Medical Center, Durham, NC; Division of Gastroenterology, Durham VA Medical Center, NC
| | - Sunil G Sheth
- Division of Gastroenterology & Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
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Goren I, Barkan R, Biron IA, Leibovitzh H, Golan MA, Eran HB, Snir Y, Broitman Y, Konikoff T, Amir-Barak H, Yafee H, Adani E, Shiber S, Steiner H, Drescher MJ, Dotan I, Yanai H. Specialized Emergency Department Assessment and Multidisciplinary Intervention After Discharge Improve Management of Patients With Inflammatory Bowel Diseases. J Clin Gastroenterol 2022; 56:148-153. [PMID: 33471484 DOI: 10.1097/mcg.0000000000001490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 12/07/2020] [Indexed: 01/04/2023]
Abstract
GOAL The aim was to assess proactive specialized inflammatory bowel diseases (IBD) emergency department (ED) consultation and multidisciplinary IBD team (IBD-MDT) intervention on IBD-related patient outcomes after discharge. BACKGROUND Despite advances in patient care, IBD-related ED visits have increased and substantially contribute to the IBD burden. METHODS Consecutive patients with IBD (below 50 y) who visited the ED during November 2017 to April 2018 (intervention group) were compared with patients with IBD that visited the same ED during 2014 to 2017 (standard-care group). The primary outcomes were hospitalization and ED revisits at 30, 90, and 180 days. RESULTS The intervention group (45 patients, mean age 32.43±8.6 y, 57.8% male) and the standard-care group (237 patients) had comparable baseline characteristics, including age, sex, and IBD type, and similar rates of hospital admissions from the ED (46.7% vs. 38.8%, P=0.32). The intervention group more frequently underwent computed tomography (40% vs. 8%, P<0.001) and surgical interventions (13.3% vs. 0.8%, P<0.001) within the same hospital admission, compared with the standard-care group. In the intervention group, 24 patients were discharged from the ED, of whom 17 patients visited the IBD clinic (median 5 d postdischarge) and the majority were referred to ambulatory IBD-MDT services (dietitian: 46.7%, psychologist: 6.7%, advanced endoscopist: 8.9%, and proctology services: 6.7%). The intervention group had significantly fewer ED revisits than the standard-care group (30 d: 4.4% vs. 19.8%, P=0.013; 90 d: 4.4% vs. 35.9%, P<0.001; 180 d: 6.7% vs. 43%, P<0.001). CONCLUSION Proactive specialized ED assessments and IBD-MDT interventions after a hospital discharge were preferable; they significantly reduced the ED revisit rate for at least 6 months.
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Affiliation(s)
- Idan Goren
- Division of Gastroenterology, IBD Center
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Irit A Biron
- Division of Gastroenterology, IBD Center
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Haim Leibovitzh
- Division of Gastroenterology, IBD Center
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Maya A Golan
- Division of Gastroenterology, IBD Center
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hagar B Eran
- Division of Gastroenterology, IBD Center
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yifat Snir
- Division of Gastroenterology, IBD Center
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yelena Broitman
- Division of Gastroenterology, IBD Center
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tom Konikoff
- Division of Gastroenterology, IBD Center
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hadar Amir-Barak
- Division of Gastroenterology, IBD Center
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hadar Yafee
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Edna Adani
- Department of Emergency Medicine, Rabin Medical Center, Beilinson Campus, Petah Tikva
| | - Shachaf Shiber
- Department of Emergency Medicine, Rabin Medical Center, Beilinson Campus, Petah Tikva
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hadas Steiner
- Department of Emergency Medicine, Rabin Medical Center, Beilinson Campus, Petah Tikva
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael J Drescher
- Department of Emergency Medicine, Rabin Medical Center, Beilinson Campus, Petah Tikva
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Iris Dotan
- Division of Gastroenterology, IBD Center
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Henit Yanai
- Division of Gastroenterology, IBD Center
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Schlünsen ADM, Christiansen DH, Fredberg U, Vedsted P. Effectiveness of a 24-hour access outpatient clinic for patients with chronic conditions in hospital outpatient follow-up: a registry-based controlled cohort study of healthcare utilisation and mortality. INTEGRATED HEALTHCARE JOURNAL 2022. [DOI: 10.1136/ihj-2020-000069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
ObjectiveTo evaluate the effectiveness of a 24-hour telephone access outpatient clinic (24-hour access clinic) in terms of healthcare utilisation and mortality in patients with five chronic conditions (chronic obstructive pulmonary disease, atrial fibrillation/flutter, congestive heart failure, inflammatory bowel disease and chronic liver disease).Methods and analysisThis was a registry-based controlled cohort study. The 24-hour access clinic was established at Silkeborg Regional Hospital in Central Denmark Region. The five other regional hospitals served as comparison hospitals. The 24-hour access clinic allowed patients with five chronic conditions with ongoing hospital outpatient follow-up to call the hospital outpatient clinic in case of an exacerbation. Outcomes were use of hospital admissions, length of stay (LOS), outpatient visits, contacts to general practice and all-cause mortality during 18 months of follow-up.ResultsThe study included 992 the 24-hour access patients and 3878 usual care patients. For the five conditions combined, the 24 hours access patients had fewer all-cause admissions (incidence rate ratio (IRR) 0.81, 95% Cl 0.71 to 0.92), general practice out-of-hours contacts (IRR 0.81, 95% C 0.71 to .92) and shorter LOS (IRR 0.71, 95% CI 0.57 to 0.88). The rate of all-cause outpatient visits tended to be higher (IRR 1.07, 95% CI 0.99 to 1.15). General practice daytime contacts were similar between the groups, and there was no significant difference in mortality.ConclusionsThe results suggest that a 24-hour telephone access clinic may lead to enhanced integration of care measured as unplanned acute care substituted with planned outpatient care.
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High Rates of Mortality in Geriatric Patients Admitted for Inflammatory Bowel Disease Management. J Clin Gastroenterol 2022; 56:e20-e26. [PMID: 33234880 DOI: 10.1097/mcg.0000000000001458] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 09/20/2020] [Indexed: 01/04/2023]
Abstract
GOAL The goal of this study was to evaluate the inpatient mortality risk among geriatric patients with inflammatory bowel disease (IBD). BACKGROUND The challenges of caring for elderly patients with IBD will increase with the aging of the US population. Given the complications of hospitalization, we set to examine if elderly patients age older than 65 were at higher risk of mortality. MATERIALS AND METHODS All patients with ulcerative colitis (UC) or Crohn's disease (CD) in the National Inpatient Sample (NIS) from 2016 and 2017 as the primary diagnosis or secondary diagnosis with an IBD-related cause of admission were included. Outcomes for patients aged above 65 were compared with below 65 using multivariable survey-adjusted regression. CD and UC were analyzed separately. RESULTS In 2016-2017, there were an estimated 162,800 admissions for CD and related complications compared with 96,450 for UC. In total, 30% of UC and 20% of CD admissions were geriatric. Geriatric status was associated with higher odds of mortality for CD [odds ratio (OR)=3.47, 95% confidence interval (CI): 2.72-4.44] and UC (OR=2.75, 95% CI: 2.16-3.49) after adjustment for comorbidities, admission type, hospital type, inpatient surgery, and IBD subtype. The cause of death was ∼80% infectious in both CD and UC in all groups. An average of 0.19 days (95% CI: 0.05-0.34) and $2467 (95% CI: 545-4388) increase was seen for geriatric CD patients. No significant change was seen for UC. CONCLUSIONS Age over 65 was independently associated with higher odds of death in both UC and CD patients, even after appropriate adjustment. Further research is needed to optimize care for this growing patient population.
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22
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Peña-Sánchez JN, Osei JA, Rohatinsky N, Lu X, Risling T, Boyd I, Wicks K, Wicks, M, Quintin CL, Dickson A, Fowler SA. OUP accepted manuscript. J Can Assoc Gastroenterol 2022; 6:55-63. [PMID: 37025513 PMCID: PMC10071297 DOI: 10.1093/jcag/gwac015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Rural dwellers with inflammatory bowel disease (IBD) face barriers to accessing specialized health services. We aimed to contrast health care utilization between rural and urban residents diagnosed with IBD in Saskatchewan, Canada. Methods We completed a population-based retrospective study from 1998/1999 to 2017/2018 using administrative health databases. A validated algorithm was used to identify incident IBD cases aged 18+. Rural/urban residence was assigned at IBD diagnosis. Outpatient (gastroenterology visits, lower endoscopies, and IBD medications claims) and inpatient (IBD-specific and IBD-related hospitalizations, and surgeries for IBD) outcomes were measured after IBD diagnosis. Cox proportional hazard, negative binomial, and logistic models were used to evaluate associations adjusting by sex, age, neighbourhood income quintile, and disease type. Hazard ratios (HR), incidence rate ratios (IRR), odds ratios (OR), and 95% confidence intervals (95% CI) were reported. Results From 5,173 incident IBD cases, 1,544 (29.8%) were living in rural Saskatchewan at IBD diagnosis. Compared to urban dwellers, rural residents had fewer gastroenterology visits (HR = 0.82, 95% CI: 0.77-0.88), were less likely to have a gastroenterologist as primary IBD care provider (OR = 0.60, 95% CI: 0.51-0.70), and had lower endoscopies rates (IRR = 0.92, 95% CI: 0.87-0.98) and more 5-aminosalicylic acid claims (HR = 1.10, 95% CI: 1.02-1.18). Rural residents had a higher risk and rates of IBD-specific (HR = 1.23, 95% CI: 1.13-1.34; IRR = 1.22, 95% CI: 1.09-1.37) and IBD-related (HR = 1.20, 95% CI: 1.11-1.31; IRR = 1.23, 95% CI: 1.10-1.37) hospitalizations than their urban counterparts. Conclusion We identified rural-urban disparities in IBD health care utilization that reflect rural-urban inequities in the access to IBD care. These inequities require attention to promote health care innovation and equitable management of patients with IBD living in rural areas.
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Affiliation(s)
- Juan Nicolás Peña-Sánchez
- Correspondence: Juan Nicolás Peña-Sánchez, MD, MPH, PhD, Room 3232—E-Wing Health Sciences, 104 Clinic Place, Saskatoon, SK S7N5E5, Canada, e-mail:
| | - Jessica Amankwah Osei
- Department of Community Health and Epidemiology, College of Medicine, University of Saskatchewan, Canada
| | | | - Xinya Lu
- Health Quality Council, Saskatchewan, Canada
| | | | | | | | | | | | | | - Sharyle A Fowler
- Department of Medicine, College of Medicine, University Saskatchewan, Canada
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Kandasamy C, Kothari DJ, Sheth SG. Tackling clinical complexity: how inpatient subspecialty gastroenterology services enhance patient care. Gastroenterol Rep (Oxf) 2021; 9:606-607. [PMID: 34925861 PMCID: PMC8677542 DOI: 10.1093/gastro/goab047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/22/2021] [Accepted: 09/30/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- Cinthana Kandasamy
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Darshan J Kothari
- Division of Gastroenterology, Duke University Medical Center, Durham, NC, USA.,Division of Gastroenterology, Durham VA Medical Center, Durham, NC, USA
| | - Sunil G Sheth
- Division of Gastroenterology & Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Implementation of an Inpatient IBD Service Is Associated with Improvement in Quality of Care and Long-Term Outcomes. Dig Dis Sci 2021; 66:3753-3759. [PMID: 33474649 DOI: 10.1007/s10620-020-06749-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 11/25/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND There is wide variation in the quality of care of hospitalized patients with inflammatory bowel disease (IBD). Prior studies have demonstrated that a specialized inpatient IBD service improves short-term outcomes. In this study, we assessed the impact of a dedicated IBD service on the quality of care and long-term outcomes. METHODS This retrospective cohort study included adult patients admitted for a complication of IBD between March 2017 and February 2019 to a tertiary referral center. In March 2018, a dedicated inpatient IBD service co-managed by IBD gastroenterologists and colorectal surgeons was implemented. Quality of care outcomes included C. difficile stool testing, confirmed VTE prophylaxis administration and opiate avoidance. Long-term outcomes were clinical remission, IBD-related surgery, ED visits, and hospital readmissions at 90 days and 12 months. RESULTS In total, 143 patients were included; 66 pre- and 77 post-implementation of the IBD service. Fifty-two percent had ulcerative colitis and 48% had Crohn's disease. After implementation, there was improvement in C.difficile testing (90% vs. 76%, P = 0.04), early VTE prophylaxis (92% vs. 77%, P = 0.01) and decreases in narcotic use (14% vs. 30%, P = 0.02), IBD-related ED visits at 90 days (7% vs 18%, P = 0.03) and 12 months (16% vs 30%, P = 0.04), and IBD readmissions at 90 days (16% vs. 30%, P = 0.04). There were no differences in rates of clinical remission or surgery. CONCLUSIONS The creation of a dedicated inpatient IBD service improved quality of IBD care and reduced post-discharge ED visits and readmissions and broader implementation of this strategy may help optimize care of hospitalized IBD patients.
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Carvello M, Watfah J, Spinelli A. The Management of the Hospitalized Ulcerative Colitis Patient, the Medical-Surgical Conundrum. Curr Gastroenterol Rep 2021; 23:25. [PMID: 34716521 DOI: 10.1007/s11894-021-00820-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW In this study we present the evidence based management for patients hospitalized for UC with a special focus on the synergic approach of the two key actors of the inflammatory bowel disease multidisciplinary team (IBD-MDT): gastroenterologist and surgeon. RECENT FINDINGS Focused treatment by a specialized IBD-MDT and early involvement of the colorectal surgeon in the management of hospitalized ulcerative colitis patients is advocated. The colectomy rate has not changed over the years. Moreover delayed surgery after admission is burden by increase complication and mortality. Thus, it is pivotal to identify the patients who are likely to undergo surgery, by mean of predictors of outcome, and to not prolong ineffective medical treatment. The perfect timing based on clinical close monitoring is crucial. Up to 25% of patients with ulcerative colitis (UC) may require hospitalization. The aim of admission is to evaluate severity of the disease, exclude infections and establish proper treatment while monitoring the response. During admission, the patient has to be closely observed for the possible development of toxic megacolon or perforation, which should prompt emergency colectomy. Up to 30% of UC patients will fail to respond to initial intravenous corticosteroid. Non responder or partial responder to medical therapy should be evaluated for timely surgery or could be considered for rescue medical therapy.
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Affiliation(s)
- Michele Carvello
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Joseph Watfah
- Department of General Surgery, Northwick Park Hospital, London, UK
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy. .,Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy.
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Soriano CR, Powell CR, Chiorean MV, Simianu VV. Role of hospitalization for inflammatory bowel disease in the post-biologic era. World J Clin Cases 2021; 9:7632-7642. [PMID: 34621815 PMCID: PMC8462259 DOI: 10.12998/wjcc.v9.i26.7632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/17/2021] [Accepted: 08/12/2021] [Indexed: 02/06/2023] Open
Abstract
Treatment for inflammatory bowel disease (IBD) often requires specialized care. While much of IBD care has shifted to the outpatient setting, hospitalizations remain a major site of healthcare utilization and a sizable proportion of patients with inflammatory bowel disease require hospitalization or surgery during their lifetime. In this review, we approach IBD care from the population-level with a specific focus on hospitalization for IBD, including the shifts from inpatient to outpatient care, the balance of emergency and elective hospitalizations, regionalization of specialty IBD care, and contribution of surgery and endoscopy to hospitalized care.
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Affiliation(s)
- Celine R Soriano
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
| | - Charleston R Powell
- Department of Internal Medicine, Madigan Army Medical Center, Tacoma, WA 98431, United States
| | - Michael V Chiorean
- Department of Gastroenterology, Swedish Medical Center, Seattle, WA 98109, United States
| | - Vlad V Simianu
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
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Ding Z, Patel A, Izanec J, Pericone CD, Lin JH, Baugh CW. Trends in US emergency department visits and subsequent hospital admission among patients with inflammatory bowel disease presenting with abdominal pain: a real-world study from a national emergency department sample database. JOURNAL OF MARKET ACCESS & HEALTH POLICY 2021; 9:1912924. [PMID: 33968334 PMCID: PMC8079064 DOI: 10.1080/20016689.2021.1912924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 03/16/2021] [Accepted: 03/31/2021] [Indexed: 06/12/2023]
Abstract
Background/Objective: This study evaluated emergency department (ED) visit trends, subsequent inpatient admissions for patients with inflammatory bowel disease (IBD) diagnosis and IBD-related abdominal pain (AP), and hospital-level variation in inpatient admission rates in the USA (US). Methods: This population-based, cross-sectional study included data from Nationwide Emergency Department Sample (NEDS, 2006─2013) database. Patients ≥18 years of age with primary ED diagnosis of IBD/IBD-related AP were included. Variables included demographics, insurance information, household income, Quan-Charlson comorbidity score, ED discharge disposition, and length of hospital stay (2006, 2010, and 2013). Variation between hospitals using risk-adjusted admission ratio was estimated. Results: Annual ED visits for IBD/100,000 US population increased (30 in 2006 vs 42 in 2013, p = 0.09), subsequent admissions remained stable (20 in 2006 vs 23 in 2013, p = 0.52). ED visits for IBD-related AP increased by 71% (7 in 2006 vs 12 in 2013; p = 0.12), subsequent admissions were stable (0.50 in 2006 vs 0.58 in 2013; p = 0.88). Proportion of patients with subsequent hospitalization decreased (IBD: 65.7% to 55.7%; IBD-related AP: 6.9% to 4.9%). Variation in subsequent inpatient admissions was 1.42 (IBD) and 1.96 (IBD-related AP). Conclusions: An increase in annual ED visits was observed for patients with IBD and IBD-related AP; however, subsequent inpatient admission rate remained stable.
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Affiliation(s)
- Zhijie Ding
- Janssen Scientific Affairs, Janssen Pharmaceuticals, Horsham, PA, USA
| | - Aarti Patel
- Janssen Scientific Affairs, Janssen Pharmaceuticals, Titusville, NJ, USA
| | - James Izanec
- Janssen Scientific Affairs, Janssen Pharmaceuticals, Horsham, PA, USA
| | | | - Jennifer H. Lin
- Janssen Scientific Affairs, Janssen Pharmaceuticals, Titusville, NJ, USA
| | - Christopher W. Baugh
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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A systemic review and metaanalysis of postoperative outcomes in urgent and elective bowel resection in patients with Crohn's disease. Int J Colorectal Dis 2021; 36:253-263. [PMID: 33048241 DOI: 10.1007/s00384-020-03786-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE The study examined whether urgency of surgical intervention affects postoperative outcomes in patients with Crohn's disease (CD) undergoing bowel resection. METHOD The review was conducted according to a predefined, published study protocol in Prospero which is an international database of prospectively registered systematic reviews in health. The study reported according to PRIMSMA guidelines. We searched Embase and Pubmed for articles reporting postoperative outcome after urgent and elective surgery in patients with CD undergoing bowel resection. Primary outcome variable was 30-day overall postoperative complications while secondary outcome variables were intraabdominal septic complications (IASCs), mortality, reoperation, and readmission. Assessment of bias was performed using Newcastle-Ottawa score. Two authors independently extracted data on each study, patients, and outcome measures. RESULTS The search identified 22 studies in which 955 patients underwent urgent surgeries while 6518 patients underwent elective surgeries. Based on the quality assessment, 19 studies were classified as having high risk of bias, one study as having a medium risk of bias and 2 studies as having low risk of bias (≥ 8 stars). Random-effect metaanalysis showed urgent surgery was associated with ~ 40% increase in overall complications compared to elective surgery (RR = 1.43, 95% CI [1.09; 1.87], p = 0.010). IASCs also increased in patients who had urgent surgery (RR = 1.44, 95% CI [1.08; 1.92], p = 0.013). No significant difference was shown in mortality and readmission rates. CONCLUSION Urgent bowel resection in patients with CD is associated with higher risk of overall postoperative complications and IASCs.
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Nguyen NH, Koola J, Dulai PS, Prokop LJ, Sandborn WJ, Singh S. Rate of Risk Factors for and Interventions to Reduce Hospital Readmission in Patients With Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol 2020; 18:1939-1948.e7. [PMID: 31470176 PMCID: PMC7044053 DOI: 10.1016/j.cgh.2019.08.042] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/15/2019] [Accepted: 08/21/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We investigated 30- and 90-day rates and causes of, risk factors for, and interventions to reduce hospital readmission in patients who received medical treatment for inflammatory bowel diseases (IBD). METHODS We performed a systematic search of publications through July 1, 2018 for studies of rates of hospital readmission and associated causes and risk factors in patients who received medical treatments for IBD. Our final analysis included 17 cohort studies (6324 patients) of hospitalized adults with IBD who had received medical treatment, along with reported readmission rates with detailed chart review. We performed random effects meta-analysis to estimate 30- and 90-day rates of readmission and identified causes and risk factors associated with readmission. We also performed qualitative analyses of studies that focused on interventions to reduce readmission. RESULTS Overall, the 30-day rate of readmission was 18.1% (95% CI, 14.4-22.4) and the 90-day rate was 26.0% (95% CI, 22.7-29.6). On meta-regression, studies with higher proportions of patients with ulcerative colitis than Crohn's disease reported higher risks for readmission. Most common reasons for readmission were IBD flare, infection, or complications from unplanned surgeries during hospitalizations. Consistent risk factors for 30-day readmission were admission for pain control (odds ratio [OR], 2.27; 95% CI, 1.69-3.03), need for total parenteral nutrition on discharge (OR, 2.13; 95% CI, 1.36-3.35), and prior or unplanned surgery during admission (OR, 3.11; 95% CI, 2.27-4.25). Only 1 study focused on interventions (specialized inpatient IBD service) to reduce risk of readmission. CONCLUSIONS Overall 30- and 90-day rates of readmission for patients who received medical treatment for IBD are 18.1% and 26.0%, respectively. IBD flares and infections are common reasons for readmission, and inadequate pain control and need for parenteral nutrition were common risk factors. Interventional studies to reduce risk of readmission are needed.
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Affiliation(s)
- Nghia H. Nguyen
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Jejo Koola
- Division of Hospital Medicine, Department of Medicine, University of California San Diego, La Jolla, California,Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, California
| | - Parambir S. Dulai
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Larry J. Prokop
- Department of Library Services, Mayo Clinic, Rochester, Minnesota
| | - William J. Sandborn
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Siddharth Singh
- Division of Gastroenterology, University of California, San Diego, La Jolla, California; Division of Biomedical Informatics, Department of Medicine, University of California, San Diego, La Jolla, California.
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Scharitzer M, Koizar B, Vogelsang H, Bergmann M, Primas C, Weber M, Schima W, Mang T. Crohn's disease: prevalence, MR features, and clinical significance of enteric and colonic sinus tracts. Eur Radiol 2020; 30:5358-5366. [PMID: 32458171 PMCID: PMC7476978 DOI: 10.1007/s00330-020-06935-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/15/2020] [Accepted: 05/04/2020] [Indexed: 12/11/2022]
Abstract
Objectives Enteric and colonic sinus tracts are inflammatory complications that precede intestinal fistulas in patients with Crohn’s disease (CD). The aim of this study was to retrospectively determine the prevalence, morphologic features, and outcome of sinus tracts using MR imaging. Methods A consecutive cohort of 642 patients with known CD, referred for MR enterography or MR enteroclysis (study period 01/2014–09/2019), was evaluated retrospectively for the presence of sinus tracts, their locations, presence and length of coexisting strictures, bowel wall thickness, CDMI score, upstream dilation, and bowel distension. Clinical outcome was assessed using medical records. For metric data, means and standard deviation, as well as one-way ANOVA and Pearson’s correlation coefficient, were calculated. Results In 36/642 patients with CD undergoing MRE, 49 sinus tracts (forty in small intestine, nine in left-sided colon) were detected with a prevalence of 6.9% in patients with MR-visible signs of CD (n = 519, overall prevalence of 5.6%). Mean segmental bowel wall thickness was 8.9 mm, and mean CDMI score was 9.3. All sinus tracts were located within a stenotic segment, showing mesenteric orientation within the small bowel and upstream dilation in 13 patients. Of 36 patients, 19 underwent immediate surgery and seven developed clinical progression within the segment containing the sinus tract. Conclusions Sinus tracts occur in 6.9% of patients with visible signs of CD. They are located within stenotic, severely thickened bowel segments with high MR inflammation scores. Their detection is clinically important, because they indicate a more aggressive phenotype and, if left untreated, may show severe progression. Key Points • Sinus tracts occur in 6.9% of patients with MR-visible signs of Crohn’s disease. • Sinus tracts are a radiological indicator of early penetrating Crohn’s disease, with a high risk of progression, and require dedicated treatment. • Sinus tracts can be recognized by characteristic findings and typically occur in stenotic, severely thickened bowel segments with high MR inflammation scores.
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Affiliation(s)
- Martina Scharitzer
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Bernd Koizar
- Department of Internal Medicine I, Klinikum Wels-Grieskirchen, Grieskirchner Straße 42, 4600, Wels, Austria
| | - Harald Vogelsang
- Department of Internal Medicine III, Division of Gastroenterology & Hepatology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Michael Bergmann
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Christian Primas
- Department of Internal Medicine III, Division of Gastroenterology & Hepatology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Michael Weber
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Wolfgang Schima
- Department of Diagnostic and Interventional Radiology, KH Goettlicher Heiland, KH der Barmherzigen Schwestern, St. Josef-KH, Dornbacher Straße 20-30, 1170, Vienna, Austria
| | - Thomas Mang
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Carvello M, Watfah J, Włodarczyk M, Spinelli A. The Management of the Hospitalized Ulcerative Colitis Patient: the Medical-Surgical Conundrum. Curr Gastroenterol Rep 2020; 22:11. [PMID: 32040642 DOI: 10.1007/s11894-020-0750-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW In this study, we present the evidence-based management for patients hospitalized for ulcerative colitis (UC) with a special focus on the synergic approach of the two key actors of the inflammatory bowel disease multidisciplinary team (IBD-MDT): gastroenterologist and surgeon. RECENT FINDINGS Focused treatment by a specialized IBD-MDT and early involvement of the colorectal surgeon in the management of hospitalized UC patients is advocated. The colectomy rate has not changed over the years. Moreover, delayed surgery after admission is burden by increase complication and mortality rates. Thus, it is pivotal to identify the patients who are likely to undergo surgery, by mean of predictors of outcome, and not to prolong ineffective medical treatment. The perfect timing based on clinical close monitoring is crucial. Up to 25% of patients with ulcerative colitis (UC) may require hospitalization. The aim of admission is to evaluate severity of the disease, exclude infections and establish proper treatment while monitoring the response. During admission, the patient has to be closely observed for the possible development of toxic megacolon or perforation, which should prompt emergency colectomy. Up to 30% of UC patients will fail to respond to initial intravenous corticosteroid. Non-responder or partial responder to medical therapy should be evaluated for timely surgery or could be considered for rescue medical therapy.
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Affiliation(s)
- Michele Carvello
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Via Alessandro Manzoni, 56, Rozzano, 20089, Milan, Italy
| | - Joseph Watfah
- Department of General Surgery, Northwick Park Hospital, London, UK
| | - Marcin Włodarczyk
- Department of General and Colorectal Surgery, Medical University of Lodz, Haller 1 Sq, 90-364, Lodz, Poland
| | - Antonino Spinelli
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Via Alessandro Manzoni, 56, Rozzano, 20089, Milan, Italy.
- Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy.
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Pellino G, Keller DS, Sampietro GM, Annese V, Carvello M, Celentano V, Coco C, Colombo F, Cracco N, Di Candido F, Franceschi M, Laureti S, Mattioli G, Pio L, Sciaudone G, Sica G, Villanacci V, Zinicola R, Leone S, Danese S, Spinelli A, Delaini G, Selvaggi F. Inflammatory bowel disease (IBD) position statement of the Italian Society of Colorectal Surgery (SICCR): general principles of IBD management. Tech Coloproctol 2020; 24:105-126. [PMID: 31983044 DOI: 10.1007/s10151-019-02145-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 12/23/2019] [Indexed: 02/08/2023]
Abstract
The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a Position Statement of Italian colorectal surgeons to address the surgical aspects of inflammatory bowel disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the general principles of surgical treatment of inflammatory bowel disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.
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Affiliation(s)
- G Pellino
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università Degli Studi Della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy.
| | - D S Keller
- Division of Colon and Rectal Surgery, Department of Surgery, NewYork-Presbyterian, Columbia University Medical Center, New York, USA
| | | | - V Annese
- Gastroenterology Unit, DEA-Medicina E Chirurgia Generale E D'Urgenza, University Hospital Careggi, Firenze, Italy
| | - M Carvello
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - V Celentano
- Portsmouth Hospitals NHS Trust, Portsmouth, UK
- University of Portsmouth, Portsmouth, UK
| | - C Coco
- UOC Chirurgia Generale 2, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
| | - F Colombo
- L. Sacco University Hospital Milano, Milan, Italy
| | - N Cracco
- Department of General Surgery, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy
| | - F Di Candido
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - M Franceschi
- IBD Surgery, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - S Laureti
- Surgery of the Alimentary Tract, Sant'Orsola Hospital, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - G Mattioli
- Pediatric Surgery Unit, Istituto Giannina Gaslini, and Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - L Pio
- Pediatric Surgery Department, Hôpital Robert-Debré and Université de Paris, Paris, France
| | - G Sciaudone
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università Degli Studi Della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy
| | - G Sica
- Minimally Invasive and Gastro-Intestinal Unit, Department of Surgery, Policlinico Tor Vergata, Rome, Italy
| | - V Villanacci
- Institute of Pathology, Spedali Civili Brescia, Brescia, Italy
| | - R Zinicola
- Department of Emergency Surgery, University Hospital Parma, Parma, Italy
| | - S Leone
- CEO, Associazione Nazionale Per Le Malattie Infiammatorie Croniche Dell'Intestino "A.M.I.C.I. Onlus", Milan, Italy
| | - S Danese
- Division of Gastroenterology, IBD Center, Humanitas University, Rozzano, Milan, Italy
| | - A Spinelli
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - G Delaini
- Department of Surgery, "Pederzoli" Hospital, Peschiera del Garda, Verona, Italy
| | - F Selvaggi
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università Degli Studi Della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy
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Grob L, Bluemel S, Biedermann L, Fournier N, Rossel JB, Vavricka SR, Zeitz J, Rogler G, Stallmach A, Scharl M. Effect of distance to specialist care for the diagnosis and disease outcome of inflammatory bowel disease in the Swiss inflammatory bowel disease cohort study. Therap Adv Gastroenterol 2020; 13:1756284819895217. [PMID: 32047533 PMCID: PMC6984432 DOI: 10.1177/1756284819895217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 11/20/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Inflammatory bowel disease (IBD) needs early interventions and an individual specialist-patient relationship. Distance from a tertiary IBD center might affect patient's disease course and outcome. We investigated whether the patient-to-specialist distance has an impact on the disease course using the well-defined patient collective of the Swiss Inflammatory Bowel Disease Cohort Study (SIBDCS). METHODS Patient's home address at diagnosis (postal zip code) was extracted from the SIBDCS database. Distance between each zip code and the nearest located IBD specialist center was calculated and classified into the following three sections based on proximity: <10 km (group 1); 10-35 km (group 2); >35 km (group 3). RESULTS Our study included in total 408 IBD patients [234 Crohn's disease (CD), 154 ulcerative colitis (UC), 20 IBD unclassified (IBDU)]. Median age was lowest in group 2 at diagnosis (G1: 28 years; G2: 21 years, G3: 26 years, p < 0.01). The diagnostic delay did not differ between groups. CD patients in group 1 were treated more often with anti-tumor necrosis factor (TNF) agents (72% versus 56%, p = 0.04) and 5-aminosalicylates (44% versus 28%, p = 0.04) than in group 3. UC/IBDU patients in group 1 were treated more often with corticosteroids than patients in group 3 (83% versus 58%, p < 0.01). The occurrence of IBD-related surgeries did not differ between groups. CONCLUSIONS Patient-to-specialist distance might affect drug treatment. However, disease course and the need for IBD-related surgery does not seem to be associated with a longer distance to specialist care in Switzerland.
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Affiliation(s)
| | | | - Luc Biedermann
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Nicolas Fournier
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Jean-Benoit Rossel
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Stephan R. Vavricka
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Jonas Zeitz
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland Center of Gastroenterology, Clinic Hirslanden Zurich, Zurich, Switzerland
| | - Gerhard Rogler
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Andreas Stallmach
- Department of Internal Medicine IV, University Hospital Jena, Jena, Germany
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Abstract
OBJECTIVE Few studies report the impact of depression on inflammatory bowel disease (IBD)-related hospitalizations. We evaluated the association between depression and pediatric IBD-related hospitalizations. Our primary aim was to test the hypothesis that depression is associated with hospital length of stay (LOS); our secondary goal was to evaluate if patients with depression are at higher risk for undergoing additional imaging and procedures. METHODS Data were extracted from the 2012 Kids Inpatient Database (KID), the largest nationally representative publicly available all-payer pediatric inpatient cross-sectional database in the United States. Hospitalizations for patients less than 21 years with a primary diagnosis Crohn disease (CD) or ulcerative colitis (UC) by ICD-9 code were included. Multivariable logistic regression was used to predict long LOS controlling for patient- and hospital-level variables and for potential disease confounders. RESULTS For primary IBD-related hospitalizations (N = 8222), depression was associated with prolonged LOS (odds ratio [OR] 1.50; 95% confidence interval [CI] 1.19-1.90) and total parenteral nutrition use (OR 1.54; 95% CI 1.04-2.27). Depression was not associated with increased likelihood of surgery (OR 0.97; 95% CI 0.72-1.30), endoscopy (OR 0.91; 95% CI 0.74-1.14), blood transfusion (OR 0.85; 95% CI 0.58-1.23), or abdominal imaging (OR 1.15; 95% CI 0.53-2.53). CONCLUSIONS Depression is associated with prolonged LOS in pediatric patients with IBD, even when controlling for gastrointestinal disease severity. Future research evaluating the efficacy of standardized depression screening and early intervention may be beneficial to improving inpatient outcomes in this population.
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Lewin SM, McConnell RA, Patel R, Sharpton SR, Velayos F, Mahadevan U. Improving the Quality of Inpatient Ulcerative Colitis Management: Promoting Evidence-Based Practice and Reducing Care Variation With an Inpatient Protocol. Inflamm Bowel Dis 2019; 25:1822-1827. [PMID: 30980712 DOI: 10.1093/ibd/izz066] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Hospitalization for ulcerative colitis is a high-risk period associated with increased risk of Clostridium difficile infection, thromboembolism, and opiate use. The study aim was to develop and implement a quality-improvement intervention for inpatient ulcerative colitis management that standardizes gastroenterology consultant recommendations and improves delivery of evidence-based care. METHODS All adult patients hospitalized for ulcerative colitis between July 1, 2014, and December 31, 2017, who received intravenous corticosteroids were included. On July 1, 2016, the UCSF Inpatient Ulcerative Colitis Protocol was implemented, featuring standardized core recommendations and a daily checklist for gastroenterology consultant notes, a bundled IBD electronic order set, and an opiate awareness campaign. The composite primary outcome was adherence to all 3 evidence-based care metrics: C. difficile testing performed, pharmacologic venous thromboembolism (VTE) prophylaxis ordered, and opiates avoided. RESULTS Ninety-three ulcerative colitis hospitalizations occurred, including 36 preintervention and 57 postintervention. Age, gender, disease duration, disease extent, and medication use were similar preintervention and postintervention. C. difficile testing was performed in 100% of hospitalizations. Venous thromboembolism prophylaxis was ordered on 84% of hospital days before intervention compared with 100% after intervention (P ≤ 0.001). Opiates were administered in 67% of preintervention hospitalizations, compared with 53% of postintervention hospitalizations (P = 0.18). The median daily dose of oral morphine equivalents decreased from 12.1 mg before intervention to 0.5 mg after intervention (P = 0.02). The composite outcome of adherence to all 3 metrics was higher after intervention (25% vs. 47%, P = 0.03). CONCLUSIONS Evidence-based inpatient ulcerative colitis management may be optimized with standardized algorithms that reinforce core principles, reduce care variation, and do not require IBD specialists to implement.
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Affiliation(s)
- Sara M Lewin
- Division of Gastroenterology, University of California, San Francisco, California, USA
| | | | - Roshan Patel
- Kaiser Permanente Medical Group, Walnut Creek, California, USA
| | - Suzanne R Sharpton
- Division of Gastroenterology, University of California, San Francisco, California, USA
| | | | - Uma Mahadevan
- Division of Gastroenterology, University of California, San Francisco, California, USA
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Kruger AJ, Hinton A, Afzali A. Index Severity Score and Early Readmission Predicts Increased Mortality in Ulcerative Colitis Patients. Inflamm Bowel Dis 2019; 25:894-901. [PMID: 30247551 DOI: 10.1093/ibd/izy297] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Readmissions are common after hospitalization related to ulcerative colitis (UC). A risk score to stratify the severity of UC hospitalizations and risk of colectomy has been previously reported. Our aim was to predict hospital-related outcomes after hospitalizations for UC utilizing this severity score. METHODS We utilized the Nationwide Readmissions Database (2010-2014) for hospitalized patients with UC and differentiated patients by index severity (low, intermediate, high). Baseline characteristics, surgical rates, readmissions, mortality, and hospital outcomes were collected. The primary outcomes of interest included readmission and mortality rates. RESULTS There were 133,819 patients admitted with UC with 22,762 (17%) readmitted within 30 days. Those readmitted within 30 days had a 4.5% calendar year mortality rate, compared with 0.45% in those not readmitted within 30 days (P < 0.001). Index surgery rates (19.2% vs 12.3%), length of stay (6.9 vs 5.4 days), and hospital costs ($13,530 vs $10,366; P < 0.001 for all) were higher in those readmitted within 30 days. Patients with high-severity presentations had higher surgical rates (31.6%), higher 30-day and calendar year readmission rates (24.3% and 46.0%, respectively), increased index and calendar year mortality (2.5% and 2.0%, respectively), longer length of stay (15.1 days), and increased costs ($31,136) compared with those with low severity (P < 0.001 for all). Calendar-year survival rates in those with intermediate and high scores were significantly lower than in those with low scores. CONCLUSIONS An index severity score of intermediate or high and early readmissions are predictors of calendar year mortality. Future efforts should emphasize more focused care in high-risk patients, as this may reduce readmissions and improve outcomes.
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Affiliation(s)
- Andrew J Kruger
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Alice Hinton
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, Ohio
| | - Anita Afzali
- Inflammatory Bowel Disease Center at The Ohio State University Wexner Medical Center, Columbus, Ohio.,Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Marín-Jiménez I, Casellas F, Cortés X, García-Sepulcre MF, Juliá B, Cea-Calvo L, Soto N, Navarro-Correal E, Saldaña R, de Toro J, Galindo MJ, Orozco-Beltrán D. The experience of inflammatory bowel disease patients with healthcare: A survey with the IEXPAC instrument. Medicine (Baltimore) 2019; 98:e15044. [PMID: 30946348 PMCID: PMC6456160 DOI: 10.1097/md.0000000000015044] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
To assess inflammatory bowel disease (IBD) patients' experience of chronic illness care and the relationship with demographic and healthcare-related characteristics.This cross-sectional survey used the Instrument to Evaluate the EXperience of PAtients with Chronic diseases (IEXPAC) questionnaire to identify parameters associated with a better healthcare experience for IBD patients. IEXPAC questionnaire responses are grouped into 3 factors - productive interactions, new relational model, and patient self-management, scoring from 0 (worst) to 10 (best experience). Scores were analyzed by bivariate comparisons and multiple linear regression models.Surveys were returned by 341 of 575 patients (59.3%, mean age 46.8 (12.9) years, 48.2% women). Mean (SD) IEXPAC score was 5.9 (2.0); scores were higher for the productive interactions (7.7) and patient self-management factors (6.7) and much lower for the new relational model factor (2.2). Follow-up by a nurse, being seen by the same physician, and being treated with a lower number of medicines were associated with higher (better) overall patient experience score, and higher productive interactions and self-management factor scores. A higher productive interactions score was also associated with patients receiving medication subcutaneously or intravenously. Higher new relational model scores were associated with follow-up by a nurse, affiliation to a patients' association, receiving help from others for healthcare, a lower number of medicines and a higher educational level.In patients with IBD, a better overall patient experience was associated with follow-up by a nurse, being seen by the same physician, and being treated with a lower number of medicines.
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Affiliation(s)
- Ignacio Marín-Jiménez
- IBD Unit, Gastroenterology Department; Clinical Research Institute Gregorio Marañón (IiSGM); Gregorio Marañón University Hospital, Madrid
| | - Francesc Casellas
- Crohn-Colitis Care Unit, Hospital Universitari Vall d’Hebron, Barcelona
| | | | | | - Berta Juliá
- Medical Affairs Department, Merck Sharp & Dohme Spain, Madrid
| | - Luis Cea-Calvo
- Medical Affairs Department, Merck Sharp & Dohme Spain, Madrid
| | - Nadia Soto
- Medical Affairs Department, Merck Sharp & Dohme Spain, Madrid
| | | | - Roberto Saldaña
- Confederation of Patients with Inflammatory Bowel Disease of Spain (ACCU)
| | - Javier de Toro
- Rheumatology Department, A Coruña University Hospital, A Coruña
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Borren NZ, Khalili H, Luther J, Colizzo FP, Garber JJ, Ananthakrishnan AN. Second-Look Endoscopy in Hospitalized Severe Ulcerative Colitis: A Retrospective Cohort Study. Inflamm Bowel Dis 2019; 25:750-755. [PMID: 30204864 PMCID: PMC6765053 DOI: 10.1093/ibd/izy282] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Acute severe ulcerative colitis (ASUC) is a serious complication of ulcerative colitis (UC). Management of partial responders to steroids or rescue therapy remains challenging. Whether there is a role for re-look sigmoidoscopic evaluation in disease management is unknown. METHODS Our study cohort consisted of patients who underwent 2 sigmoidoscopic procedures during the same index hospitalization for ASUC at our center. Reasons for repeat endoscopic evaluation and endoscopic and histologic severity of inflammation during both procedures were noted. Multivariable regression models were performed to identify predictors of improvement at the second endoscopic assessment and to determine the independent effect of such an improvement on in-hospital colectomy and at 3, 6, and 12 months. RESULTS Our study included 49 patients (mean age, 42 years; 52% women). Just under one-third of patients (30%) were noted to have improved endoscopic appearance at the second sigmoidoscopy, at a median of 9 days after initial exam. None of the patients who had improvement on the second endoscopy underwent in-hospital colectomy, compared with 46% of those with worsening or persistent disease (P = 0.002). Similar differences in the improved group persisted at 3 months (P = 0.007) and 6 months (P = 0.027). Histologic severity at the first endoscopy was associated with increased risk of colectomy in-hospital (odds ratio, 3.8; 95% confidence interval, 1.02-14.21) and at 3 and 6 months. CONCLUSIONS After a median interval of 9 days, endoscopic improvement was noted in 30% of patients with ASUC undergoing a second sigmoidoscopy, which predicted lower rates of colectomy in-hospital and at 3 and 6 months.
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Affiliation(s)
- Nienke Z Borren
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Hamed Khalili
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jay Luther
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Francis P Colizzo
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - John J Garber
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts,Address correspondence to: Ashwin N. Ananthakrishnan, MD, MPH, Division of Gastroenterology, Massachusetts General Hospital, 165 Cambridge Street, 9th Floor, Boston, MA 02114 ()
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Dulai PS, Buckey JC, Raffals LE, Swoger JM, Claus PL, OʼToole K, Ptak JA, Gleeson MW, Widjaja CE, Chang JT, Adler JM, Patel N, Skinner LA, Haren SP, Goldby-Reffner K, Thompson KD, Siegel CA. Hyperbaric oxygen therapy is well tolerated and effective for ulcerative colitis patients hospitalized for moderate-severe flares: a phase 2A pilot multi-center, randomized, double-blind, sham-controlled trial. Am J Gastroenterol 2018; 113:1516-1523. [PMID: 29453383 DOI: 10.1038/s41395-018-0005-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 11/25/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hyperbaric oxygen therapy (HBOT) markedly increases tissue oxygen delivery. Case series suggest it may have a potential therapeutic benefit in ulcerative colitis (UC). We investigated the therapeutic potential of HBOT as an adjunct to steroids for UC flares requiring hospitalization. METHODS The study was terminated early due to poor recruitment with 18 of the planned 70 patients enrolled. UC patients hospitalized for moderate-severe flares (Mayo score ≥6, endoscopic sub-score ≥2) were block randomized to steroids + daily HBOT (n = 10) or steroids + daily sham hyperbaric air (n = 8). Patients were blinded to study assignment, and assessments were performed by a blinded gastroenterologist. Primary outcome was the clinical remission rate at study day 5 (partial Mayo score ≤2 with no sub-score >1). Key secondary outcomes were: clinical response (reduction in partial Mayo score ≥2, rectal bleeding sub-score of 0-1) and progression to second-line therapy (colectomy or biologic therapy) during the hospitalization. RESULTS A significantly higher proportion of HBOT-treated patients achieved clinical remission at study day 5 and 10 (50 vs. 0%, p = 0.04). HBOT-treated patients less often required progression to second-line therapy during the hospitalization (10 vs. 63%, p = 0.04). The proportion requiring in-hospital colectomy specifically as second-line therapy for medically refractory UC was lower in the HBOT group compared to sham (0 vs. 38%, p = 0.07). There were no serious adverse events. CONCLUSION In this small, proof-of-concept, phase 2A trial, the use of HBOT as an adjunctive therapy to steroids for UC patients hospitalized for moderate-severe flares resulted in higher rates of clinical remission, and a reduction in rates of progression to second-line therapy during the hospitalization. Larger well-powered trials are needed, however, to provided definitive evidence of therapeutic benefit.
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Affiliation(s)
- Parambir S Dulai
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jay C Buckey
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Laura E Raffals
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jason M Swoger
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Paul L Claus
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kevin OʼToole
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Judy A Ptak
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael W Gleeson
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Christella E Widjaja
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - John T Chang
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jeffery M Adler
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nihal Patel
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Laurie A Skinner
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Shawn P Haren
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kimberly Goldby-Reffner
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kimberly D Thompson
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Corey A Siegel
- University of California at San Diego, La Jolla, CA, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Strohl M, Gonczi L, Kurt Z, Bessissow T, L Lakatos P. Quality of care in inflammatory bowel diseases: What is the best way to better outcomes? World J Gastroenterol 2018; 24:2363-2372. [PMID: 29904243 PMCID: PMC6000296 DOI: 10.3748/wjg.v24.i22.2363] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 04/24/2018] [Accepted: 04/24/2018] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel disease (IBD) is a lifelong, progressive disease that has disabling impacts on patient's lives. Given the complex nature of the diagnosis of IBD and its management there is consequently a large economic burden seen across all health care systems. Quality indicators (QI) have been created to assess the different façades of disease management including structure, process and outcome components. Their development serves to provide a means to target and measure quality of care (QoC). Multiple different QI sets have been published in IBD, but all serve the same purpose of trying to achieve a standard of care that can be attained on a national and international level, since there is still a major variation in clinical practice. There have been many recent innovative developments that aim to improve QoC in IBD including telemedicine, home biomarker assessment and rapid access clinics. These are some of the novel advancements that have been shown to have great potential at improving QoC, while offloading some of the burden that IBD can have vis-a-vis emergency room visits and hospital admissions. The aim of the current review is to summarize and discuss available QI sets and recent developments in IBD care including telemedicine, and to give insight into how the utilization of these tools could benefit the QoC of IBD patients. Additionally, a treating-to-target structure as well as evidence surrounding aggressive management directed at tighter disease control will be presented.
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Affiliation(s)
- Matthew Strohl
- Division of Gastroenterology, McGill University Health Center, Montreal, Québec H4A 3J1, Canada
| | - Lorant Gonczi
- First Department of Medicine, Semmelweis University, Koranyi, Budapest 1083, Hungary
| | - Zsuzsanna Kurt
- First Department of Medicine, Semmelweis University, Koranyi, Budapest 1083, Hungary
| | - Talat Bessissow
- Division of Gastroenterology, McGill University Health Center, Montreal, Québec H4A 3J1, Canada
| | - Peter L Lakatos
- Division of Gastroenterology, McGill University Health Center, Montreal, Québec H4A 3J1, Canada
- First Department of Medicine, Semmelweis University, Koranyi, Budapest 1083, Hungary
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Kelso M, Weideman RA, Cipher DJ, Feagins LA. Factors Associated With Length of Stay in Veterans With Inflammatory Bowel Disease Hospitalized for an Acute Flare. Inflamm Bowel Dis 2017; 24:5-11. [PMID: 29272483 DOI: 10.1093/ibd/izx020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Reducing hospital costs and risk of complications by shortening length of stay has become paramount. The aim of our study was to identify predictors and potentially modifiable factors that influence length of stay among veterans with inflammatory bowel disease admitted for an acute flare. METHODS Retrospective review of patients admitted to the Dallas VA with an acute flare of their inflammatory bowel disease between 2000 and 2015. Patients with a length of stay of ≤4 days were compared with those whose length of stay >4 days. RESULTS A total of 180 admissions involving 113 patients (59 with ulcerative colitis and 54 with Crohn's disease) were identified meeting inclusion criteria. The mean length of stay was 5.3 ± 6.8 days, and the median length of stay was 3.0 days. On multiple logistic regression analysis, initiation of a biologic, having undergone 2 or more imaging modalities, and treatment with intravenous steroids were significant predictors of longer lengths of stay, even after controlling for age and comorbid diseases. CONCLUSIONS We identified several predictors for longer hospital length of stay, most related to disease severity but several of which may be modifiable to reduce hospital stays, including most importantly consideration of earlier prebiologic testing. Future studies are needed to evaluate the impact of interventions targeting modifiable predictors of length of stay on health care utilization and patient outcomes.
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Affiliation(s)
- Michael Kelso
- Department of Medicine, VA North Texas Healthcare System, Dallas, Texas.,Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Daisha J Cipher
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, Texas
| | - Linda A Feagins
- Department of Medicine, VA North Texas Healthcare System, Dallas, Texas.,Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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Peña-Sánchez JN, Lix LM, Teare GF, Li W, Fowler SA, Jones JL. Impact of an Integrated Model of Care on Outcomes of Patients With Inflammatory Bowel Diseases: Evidence From a Population-Based Study. J Crohns Colitis 2017; 11:1471-1479. [PMID: 28981633 DOI: 10.1093/ecco-jcc/jjx106] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 07/30/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Studies evaluating the impact of integrated models of care [IMC] for inflammatory bowel disease [IBD] on disease-related outcomes are needed. We compared the risk of IBD-related outcomes and prescription medication claims between patients exposed and non-exposed to an IMC. METHODS A retrospective population-based matched cohort study was conducted between 2009 and 2015, using administrative health data of Saskatchewan, Canada. Patients aged 18+ years with a diagnosis of IBD were identified with a validated administrative definition. Cases were classified as exposed and non-exposed to the IMC for IBD and matched based on propensity scores and disease duration. IBD-related hospitalisations, surgeries, prescription medication claims, and corticosteroid dependency [CsDep] were measured. Cox and logistic regression models evaluated differences between the groups, estimating hazard [HRs] and odds [ORs] ratios with corresponding confidence intervals [CIs]. RESULTS In total, 2312 matched patients were included; 24.3% were exposed individuals. Compared with non-exposed, exposed patients had a lower risk of IBD-related surgeries [HR = 0.78, 95% CI 0.61-0.99], higher risk of prescriptions of immune modulators [HR = 1.68, 95% CI 1.42-1.99], and biologics [HR = 1.85, 95% CI 1.52-2.27], and a lower risk of 5-aminosalicylic acid prescriptions [HR = 0.81, 95% CI 0.69-0.95]. A lower risk of IBD-related hospitalisations among exposed ulcerative colitis [UC] patients [HR = 0.66, 95% CI 0.49-0.89] was identified in stratified analyses. The odds of CsDep among exposed UC patients was 0.39 [95% CI 0.15-0.98]. CONCLUSIONS The observed differences in disease-related outcomes and use of steroid-sparing maintenance therapies between exposed and non-exposed individuals support the concept that enhanced quality of care can be achieved within IMC for IBD.
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Affiliation(s)
| | - Lisa M Lix
- Department of Community Health Sciences, University of Manitoba, Canada
| | | | - Wenbin Li
- Saskatchewan Health Quality Council, Canada
| | | | - Jennifer L Jones
- Departments of Medicine and Community Health and Epidemiology, Dalhousie University, Canada
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Abstract
BACKGROUND Optimal treatment of inflammatory bowel disease (IBD) requires specialized health care. Patients frequently travel long distances to obtain care for IBD, which may hinder regular care and affect outcomes adversely. METHODS This study included patients with established Crohn's disease or ulcerative colitis receiving care at a single referral center between January 2005 and August 2016. Distance to our health care center from the zip code of residence was determined for each patient and classified into quartiles. Our primary outcome was need for IBD-related surgery with secondary outcomes being need for biological and immunomodulator therapy. Logistic regression models adjusting for relevant covariates examined the independent association between travel distance and patient outcomes. RESULTS Our study included 2136 patients with IBD (1197 Crohn's disease, 939 ulcerative colitis), among which just over half were women (52%), and the mean age was 41 years. The mean distance from our hospital was 2.5, 8.8, 22.0, and 50.8 miles for the first (most proximal) through fourth (most distant), respectively. We observed a statistically significant and meaningful higher risk among patients in the most distant quartile in the need for immunomodulator use (OR, 1.69; 95% CI, 1.29-2.22), biological therapy (OR, 2.19; 95% CI, 1.69-2.85), and surgery (OR, 2.44; 95% CI, 1.80-3.32). Differences remained significant on multivariable analysis and by type of IBD. CONCLUSIONS Greater distance to referral health care center was associated with increased risk for needing IBD-related surgery in patients with Crohn's disease or ulcerative colitis.
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