Individualized Infliximab Treatment Guided by Patient-managed eHealth in Children and Adolescents with Inflammatory Bowel Disease

Telemonitoring with TECCU of active Inflammatory Bowel Disease is Not Inferior to Standard Care: Short-term Results of a Multicentre Randomized Controlled Trial of GETECCU

BACKGROUND

Telemonitoring is not consistently superior to standard care for inflammatory bowel disease (IBD), yet non-inferiority may be an acceptable outcome if remote care is more efficient.

OBJECTIVE

To compare the remission time and quality of life of patients with an active IBD controlled by standard care or through the TECCU App (Telemonitoring of Crohn´s Disease and Ulcerative Colitis).

METHODS

A 2-arm, randomized, multicentre trial with a non-inferiority design was performed at 24 Spanish hospitals on adult patients with IBD who initiated immunosuppressant or biological therapy. Patients were randomized into telemonitoring (G_TECCU) or standard care groups (G_Control). The follow-up schedule was based on telemonitoring contacts through the TECCU App in G_TECCU, and on in-person visits and telephone calls in G_Control, as in clinical practice. In both groups, treatment was adjusted according to the evolution of disease activity and medication adherence, which were measured through specific indices and biological markers at each check-up. The primary outcome was time in remission after 12-weeks, with quality of life, medication adherence, adverse events and patient satisfaction as secondary outcomes.

RESULTS

Of 169 patients enrolled, 158 were randomized, and 150 were analyzed per protocol: telemonitoring (n=71); control (n=79). After 12-week, the time in clinical remission was not inferior after telemonitoring (4.20 ±3.73 weeks) to that in the controls (4.32 ±3.28 weeks), with a mean difference between arms of -0.12 weeks (95% CI -1.25-,1.01), non-inferiority p=0.017). The mean reduction of CRP values was -15.40 mg/L (SD=90.15, P =0.195) in G_TECCU and -13.16 mg/L (SD=54.61, P =0.053) in G_control, without significant differences between the two arms (P=.726). Similarly, the mean improvement of FC levels was 832.3 mg/L (SD=1825.0, P=.003) in G_TECCU and 1073.5 mg/L in G_Control (SD=3105.7, P=.03), but differences were not significant (P=.965). Quality of life improved in both groups, with a mean rise in the IBDQ-9 score of 13.44 points in G_TECCU (SD=19.1; P<.001) and 18.23 points [SD=22.9]; P=.001) in G_Control. Moreover, the proportion of patients who adhered to their medication rose significantly from 35.2% (25/71) to 67.6% (48/71) in G_TECCU (P=.001) and from 45.6% (36/79) to 73.4% (58/79) in G_Control (P=.001). Satisfaction remained stable around 90%, although non-inferiority was not demonstrated for secondary outcomes.

CONCLUSIONS

Telemonitoring patients with active IBD is not inferior to standard care to achieve and maintain short-term remission. TECCU may be an alternative follow-up tool if the improved health outcomes and costs are confirmed in the long-term.

CLINICALTRIAL

The trial is registered at ClinicalTrials.gov with the identifier NCT06031038; https://classic.clinicaltrials.gov/ct2/show/NCT06031038.

INTERNATIONAL REGISTERED REPORT

RR2-10.2196/resprot.9639.

STABILITY (Symptomatic Review during Biologic Therapy) of Inflammatory Bowel Disease Patients Receiving Infusion Therapy Improves Clinical Outcomes

Several studies have correlate improved patient outcomes with increased physician-patient contacts, particularly in chronic diseases. Extending this approach to inflammatory bowel disease (IBD) care presents a promising means of improving outcomes. At LSU Health Shreveport (LSUHS), a new approach called "STABILITY" (Symptomatic Review during Biologic Therapy) was implemented during infusion therapy visits for IBD patients. These brief 15 min physician-patient interviews aimed to discuss the patients' current IBD-related symptoms and evaluate the need for any changes in their treatment plan. Our goal was to remove a care gap and prevent intensifying symptoms created by missed appointments and loss of contact. To analyze the effectiveness of the STABILITY approach, a retrospective chart review was conducted on 111 IBD patients (18 with ulcerative colitis, 93 with Crohn's disease) seen at LSUHS between 2011 and 2022. Since March 2019, STABILITY has been mandatory for all infusion therapy visits. The data collected included patients' demographics, lab levels for biomarkers (fecal calprotectin, C-reactive protein, and erythrocyte sedimentation rates), hospitalizations, medication changes, and diagnosis dates before and after the implementation of STABILITY. Additionally, voluntary, anonymous infusion patient satisfaction surveys post-STABILITY were used to gather patient responses. In males with IBD, disease severity and hospitalizations were reduced significantly (p = 0.004 and 0.0234, respectively). In females with IBD, disease severity and hospitalizations were also reduced significantly (p = 0.0001 and 0.0072, respectively). In patients with UC and CD, there were significant improvements in disease severity (p = 0.043 and p = 0.0001, respectively), and CD hospitalizations were also improved (p = 0.0013). In males and females with UC, disease severity was marginally and significantly reduced (p = 0.0781 and p = 0.0379, respectively). In males and females with CD, disease severity was significantly reduced (p = 0.0161 and 0.0003, respectively), and CD male and female hospitalizations were also reduced significantly (p = 0.0436 and 0.013). Analyzing of survey responses, we found that the most patients reported improved IBD symptoms (56%), gained understanding of their condition (84%) and were in favor of continuing STABILITY consultations during infusion therapy (93%). To further investigate the impact of STABILITY, we conducted a comparative analysis between IBD patients undergoing STABILITY infusion therapy and LSUHS patients solely on self-injectable biologics. Our paired data analysis showed significant improvements in disease severity in female IBD patients (1.69 ± 0.13 vs. 1.41 ± 0.12, p = 0.0001) and male IBD patients (1.58 ± 0.16 vs. 1.2 ± 0.135, p = 0.004), in UC patients (1.833 ± 0.4.2 vs. 1.444, p = 0.043), in all CD patients (1.59 ± 0.11 vs. 1.29 ± 0.01, p = 0.0001), in male CD patients (1.52 ± 0.167 vs. 1.15 ± 0.15, p = 0.016), in female CD patients (1.66 ± 0.15 vs. 1.4 ± 0.13, p = 0.0003), in female UC patients (1.82 ± 0.32 vs. 1.45 ± 0.31, p = 0.0379), and marginally in male UC patients (p = 0.0781). Similarly, hospitalizations were significantly reduced in CD patients considered in aggregate (0.21 ± 0.04 vs. 0.11 ± 0.03, p = 0.0013), in male IBD patients (0.175 ± 0.06 vs. 0.05 ± 0.035, p = 0.024), in female IBD patients (0.21 ± 0.05 vs. 0.11 ± 0.04, p = 0.0072), in male CD patients (0.18 ± 0.07 vs. 0.06 ± 0.042, p = 0.0436), and in females with CD (0.23 ± 0.06 vs. 0.13 ± 0.04, p = 0.013). Although average values for fecal calprotectin, CRP, and sedimentation rate were frequently reduced after STABILITY interviews, these data did not reach statistical significance. These preliminary findings suggest that STABILITY may be effective in maintaining low disease activity or remission in IBD patients.

Improving Medication Adherence Levels in Inflammatory Bowel Disease (IBD) Patients: A Narrative Evidence-Based Review

Inflammatory bowel disease (IBD) management is typified by a long-term medication regimen which can comprise multiple medications prescribed in different combinations, doses, frequencies, and with various administration routes. This complexity can make medication adherence (MA) - patients taking their medications per the prescription - for patients with IBD a challenge. The research corpus contains diverse interventions aimed at improving MA in patients with IBD. Therefore, to condense the evidenced strategies for ease of reference, this narrative evidence-based review broadly outlines the patient-level interventions reported. The interventions are grouped as educational, behavioural, cognitive-behavioural, and multicomponent. They, however, present mixed results as to their efficacy at improving MA, with those employing combined approaches being the most promising. This reflects the reality that MA is impacted by multiple factors encompassing those pertaining to the patient, disease, therapy, patients' socioeconomic status, and health system. Hence, the most ideal interventions would likely be multifaceted patient-level interventions alongside policy/system-level strategies, to maximise the potential for successfully improving patients' MA. These findings might have been impacted by the heterogeneity of the studies in terms of the method of MA assessment, duration of interventions, and more besides.

Telemedicine in inflammatory bowel disease from its origin to the post pandemic golden age: A narrative review

Inflammatory bowel disease (IBD), a chronic intestinal inflammatory disorder encompassing ulcerative colitis and Crohn's disease can be disabling and often requires lifelong treatment and follow-up. Digital health technologies and distance-management tools are less costly alternatives for IBD management and clinical monitoring. This review discusses how telephone/videoconference appointments enable treatment optimization from an early disease stage, provide complementary value-based patient care and educational resources, and allow consistent follow-up with a high standard of care. Replacing/supplementing traditional clinical consultations with telemedicine reduces healthcare utilization costs and the need for in-person consultations. The COVID-19 pandemic has accelerated the evolution of telemedicine in IBD, with several studies conducted since 2020 reporting high levels of patient satisfaction. Home-based injectable formulations coupled with telemedicine may become permanently embedded in healthcare systems in the post-pandemic period. While telemedicine consultations are well-accepted by many patients with IBD, they do not suit all patients or are not preferred (e.g., by elderly who do not have the means or ability to understand the associated technology). Ultimately, use of telemedicine should be decided by the patient and careful consideration is required to ensure that the patient is willing and capable of a successful remote visit.

What Do We Know about Medication Adherence Interventions in Inflammatory Bowel Disease, Multiple Sclerosis and Rheumatoid Arthritis? A Scoping Review of Randomised Controlled Trials

Purpose

Between 53% and 75% of people with inflammatory bowel disease, 30%-80% with rheumatoid arthritis, and up to 50% with multiple sclerosis do not take medications as prescribed to maintain remission. This scoping review aimed to identify effective adherence interventions for inflammatory bowel disease, but with few studies found, multiple sclerosis and rheumatoid arthritis were included to learn lessons from other conditions.

Methods

Full and pilot randomised controlled trials testing medication adherence interventions for inflammatory bowel disease, multiple sclerosis, and rheumatoid arthritis conducted between 2012 and 2021 were identified in six electronic databases.

Results

A total of 3024 participants were included from 24 randomised controlled trials: 10 pilot and 14 full studies. Eight investigated inflammatory bowel disease, 12 rheumatoid arthritis, and four multiple sclerosis. Nine studies (37.5%) reported significantly improved medication adherence, all involving tailored, personalised education, advice or counselling by trained health professionals, with five delivered face-to-face and 1:1. Quality of effective interventions was mixed: five rated high quality, two medium and two low quality. Interventions predominantly using technology were likely to be most effective. Secondary tools, such as diaries, calendars and advice sheets, were also efficient in increasing adherence. Only 10 interventions were based on an adherence theory, of which four significantly improved adherence.

Conclusion

Tailored, face-to-face, 1:1 interactions with healthcare professionals were successful at providing personalised adherence support. Accessible, user-friendly technology-based tools supported by calendars and reminders effectively enhanced adherence. Key components of effective interventions should be evaluated and integrated further into clinical practice if viable, whilst being tailored to inflammatory conditions.

Monitoring of Inflammatory Bowel Disease in Pregnancy: A Review of the Different Modalities

Inflammatory Bowel Disease (IBD) significantly affects women in their reproductive years. Understanding the relationship between IBD and pregnancy is crucial, given its impact across pre-gestational, gestational, and postpartum phases. Monitoring IBD activity during pregnancy involves various modalities. This review discusses these modalities, focusing on the efficacy and safety of Small Intestine Ultrasound (IUS) as a noninvasive and reliable option. While IUS has gained popularity, its technique-sensitive nature necessitates trained staff for optimal usage.

The change of healthcare service in Chinese patients with inflammatory bowel disease during the pandemic: a national multicenter cross-sectional study

The pandemic of COVID-19 was a major public health events and had a deeply impact on the healthcare acquired by patients with inflammatory bowel disease (IBD). The purpose of this study was to evaluate the long-term impacts on healthcare service in Chinese IBD patients under the dynamic zero-COVID strategy. The study was performed in the Inflammatory Bowel Disease Quality of Care Centers in mainland China in 2021. The data about the healthcare was collected by a 44-item questionnaire. Totally 463 were from ulcerative colitis (UC) patients and 538 from Crohn's disease (CD) patients were included in the study. The pandemic impacted 37.5% patients on their treatment, and the biggest problem was unable to follow up timely (77.9%). There was a significant increase in healthcare costs in CD (P < 0.001) and no significant change in UC (P = 0.14) after the outbreak. Both UC and CD had an increase in the frequency of outpatient visits (UC 5.07 vs. 4.54, P = 0.001; CD 6.30 vs. 5.76, P = 0.002), and hospitalizations (UC 1.30 vs. 1.02, P < 0.001; CD 3.55 vs. 2.78, P < 0.001). The hospitalization rate in UC reduced slightly (40.2% vs. 42.8%, P = 0.423) after the outbreak, but it significantly increased in CD (75.8% vs. 67.8%, P = 0.004). The rate of biologics had significant increased (UC 11.2% vs. 17.7%, P = 0.005; CD 53.2% vs. 71.0%, P < 0.001). Besides, the proportion of people using telemedicine also increased from 41.6% to 55.1% (P < 0.001). However, 82.8% patients still preferred face-to-face visits. Recurrent outbreaks and the regular pandemic prevention and control policy had a long-term impact on medical care service for IBD patients. The preferred mode of healthcare was still face-to-face visit. It will be a long way to go in the construction of telemedicine in China.

Management of Inflammatory Bowel Disease Using E-health Technologies: A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

Technological advances have provided innovative, adaptive, and responsive models of care for inflammatory bowel diseases [IBD]. We conducted a systematic review to compare e-health interventions with standard care in management of IBD.

METHODS

We searched electronic databases for randomised, controlled trials [RCT] comparing e-health interventions with standard care for patients with IBD. Effect measures were standardised mean difference [SMD], odds ratio [OR], or rate ratio [RR], calculated using the inverse variance or Mantel-Haenszel statistical method and random-effects models. Version 2 of the Cochrane tool was used to assess the risk of bias. The certainty of evidence was appraised with the GRADE framework.

RESULTS

Fourteen RCTs [n = 3111; 1754 e-health and 1357 controls] were identified. The difference in disease activity scores (SMD 0.09, 95% confidence interval [CI]: -0.09-0.28) and clinical remission (odds ratio [OR] 1.12, 95% CI: 0.78-1.61) between e-health interventions and standard care were not statistically significant. Higher quality of life [QoL] [SMD 0.20, 95% CI: 0.05-0.35) and IBD knowledge [SMD 0.23, 95% CI: 0.10-0.36] scores were noted in the e-health group, and self-efficacy levels [SMD -0.09, 95% CI: -0.22-0.05] were comparable. E-health patients had fewer office [RR 0.85, 95% CI: 0.78-0.93] and emergency [RR 0.70, 95% CI: 0.51- 0.95] visits, with no statistically significant difference in endoscopic procedures, total health care encounters, corticosteroid use, and IBD related hospitalisation or surgery. The trials were judged to be at high risk of bias or to have some concerns for disease remission. The certainty of evidence was moderate or low.

CONCLUSION

E-health technologies may have a role in value-based care in IBD.

Remote care through telehealth for people with inflammatory bowel disease

BACKGROUND

People with inflammatory bowel disease (IBD) require intensive follow-up with frequent consultations after diagnosis. IBD telehealth management includes consulting by phone, instant messenger, video, text message, or web-based services. Telehealth can be beneficial for people with IBD, but may have its own set of challenges. It is important to systematically review the evidence on the types of remote or telehealth approaches that can be deployed in IBD. This is particularly relevant following the coronavirus disease 2019 (COVID-19) pandemic, which led to increased self- and remote-management.

OBJECTIVES

To identify the communication technologies used to achieve remote healthcare for people with inflammatory bowel disease and to assess their effectiveness.

SEARCH METHODS

On 13 January 2022, we searched CENTRAL, Embase, MEDLINE, three other databases, and three trials registries with no limitations on language, date, document type, or publication status.

SELECTION CRITERIA

All published, unpublished, and ongoing randomised controlled trials (RCTs) that evaluated telehealth interventions targeted at people with IBD versus any other type of intervention or no intervention. We did not include studies based on digital patient information resources or education resources, unless they formed part of a wider package including an element of telehealth. We excluded studies where remote monitoring of blood or faecal tests was the only form of monitoring.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from the included studies and assessed their risk of bias. We analysed studies on adult and paediatric populations separately. We expressed the effects of dichotomous outcomes as risk ratios (RRs) and the effects of continuous outcomes as mean differences (MDs) or standardised mean differences (SMDs), each with their 95% confidence intervals (CIs). We assessed the certainty of the evidence using GRADE methodology.

MAIN RESULTS

We included 19 RCTs with a total of 3489 randomised participants, aged eight to 95 years. Three studies examined only people with ulcerative colitis (UC), two studies examined only people with Crohn's disease (CD), and the remaining studies examined a mix of IBD patients. Studies considered a range of disease activity states. The length of the interventions ranged from six months to two years. The telehealth interventions were web-based and telephone-based. Web-based monitoring versus usual care Twelve studies compared web-based disease monitoring to usual care. Three studies, all in adults, provided data on disease activity. Web-based disease monitoring (n = 254) is probably equivalent to usual care (n = 174) in reducing disease activity in people with IBD (SMD 0.09, 95% CI -0.11 to 0.29). The certainty of the evidence is moderate. Five studies on adults provided dichotomous data that we could use for a meta-analysis on flare-ups. Web-based disease monitoring (n = 207/496) is probably equivalent to usual care (n = 150/372) for the occurrence of flare-ups or relapses in adults with IBD (RR 1.09, 95% CI 0.93 to 1.27). The certainty of the evidence is moderate. One study provided continuous data. Web-based disease monitoring (n = 465) is probably equivalent to usual care (n = 444) for the occurrence of flare-ups or relapses in adults with CD (MD 0.00 events, 95% CI -0.06 to 0.06). The certainty of the evidence is moderate. One study provided dichotomous data on flare-ups in a paediatric population. Web-based disease monitoring (n = 28/84) may be equivalent to usual care (n = 29/86) for the occurrence of flare-ups or relapses in children with IBD (RR 0.99, 95% CI 0.65 to 1.51). The certainty of the evidence is low. Four studies, all in adults, provided data on quality of life. Web-based disease monitoring (n = 594) is probably equivalent to usual care (n = 505) for quality of life in adults with IBD (SMD 0.08, 95% CI -0.04 to 0.20). The certainty of the evidence is moderate. Based on continuous data from one study in adults, we found that web-based disease monitoring probably leads to slightly higher medication adherence compared to usual care (MD 0.24 points, 95% CI 0.01 to 0.47). The results are of moderate certainty. Based on continuous data from one paediatric study, we found no difference between web-based disease monitoring and usual care in terms of their effect on medication adherence (MD 0.00, 95% CI -0.63 to 0.63), although the evidence is very uncertain. When we meta-analysed dichotomous data from two studies on adults, we found no difference between web-based disease monitoring and usual care in terms of their effect on medication adherence (RR 0.87, 95% CI 0.62 to 1.21), although the evidence is very uncertain. We were unable to draw any conclusions on the effects of web-based disease monitoring compared to usual care on healthcare access, participant engagement, attendance rate, interactions with healthcare professionals, and cost- or time-effectiveness. The certainty of the evidence is very low.

AUTHORS' CONCLUSIONS

The evidence in this review suggests that web-based disease monitoring is probably no different to standard care in adults when considering disease activity, occurrence of flare-ups or relapse, and quality of life. There may be no difference in these outcomes in children, but the evidence is limited. Web-based monitoring probably increases medication adherence slightly compared to usual care. We are uncertain about the effects of web-based monitoring versus usual care on our other secondary outcomes, and about the effects of the other telehealth interventions included in our review, because the evidence is limited. Further studies comparing web-based disease monitoring to standard care for the clinical outcomes reported in adults are unlikely to change our conclusions, unless they have longer follow-up or investigate under-reported outcomes or populations. Studies with a clearer definition of web-based monitoring would enhance applicability, enable practical dissemination and replication, and enable alignment with areas identified as important by stakeholders and people affected by IBD.

Are we ready for telemonitoring inflammatory bowel disease? A review of advances, enablers, and barriers

This review summarizes the evidence about telemonitoring in patients with inflammatory bowel disease (IBD). To give an overview of the advances performed, as well as the enablers and barriers which favoured/hindered telemonitoring implementation. We performed a literature search in PubMed, EMBASE, MEDLINE, Cochrane Database, Web of Science and Conference Proceedings. Titles and abstracts published up to September 2022 were screened for a set of inclusion criteria: telemonitoring intervention, IBD as the main disease, and a primary study performed. Ninety-seven reports were selected for full review. Finally, 20 were included for data extraction and critical appraisal. Most studies used telemonitoring combined with tele-education, and programs evolved from home telemanagement systems towards web portals through mHealth applications. Web systems demonstrated patients’ acceptance, improvement in quality of life, disease activity and knowledge, with a good cost-effectiveness profile in the short-term. Initially, telemonitoring was almost restricted to ulcerative colitis, but new patient reported outcome measures, home-based tests and mobile devices favoured its expansion to different patients´ categories. However, technological and knowledge advances led to legal, ethical, economical and logistic issues. Standardization of remote healthcare is necessary, to improve the interoperability of systems as well as to address liability concerns and users´ preferences. Telemonitoring IBD is well accepted and improves clinical outcomes at a lower cost in the short-term. Funders, policymakers, providers, and patients need to align their interests to overcome the emerging barriers for its full implementation.

Health-Related Quality of Life, Anxiety, and Self-Image in Young Patients With Crohn's Disease and Ulcerative Colitis

We examined health-related quality of life, anxiety, and self-image in patients aged 10-20 years with Crohn's disease (CD) and ulcerative colitis (UC) in remission. These areas are key concerns in clinical care. We used the IMPACT-III for health-related quality of life and The Beck Youth Inventory-II for anxiety and self-image. Linear regression models were used to compare CD to UC. We included 67 patients, 44 (66%) with CD and 23 (34%) with UC. The mean score for IMPACT-III, anxiety, and self-image for CD versus UC was 78 (±SD: 13) versus 78 (±SD: 15), 44 (±SD: 9) versus 45 (±SD: 8), and 10 (±SD: 9) versus 9 (±SD: 6), respectively. We found no difference between CD and UC. Despite remission, we found an elevated score of anxiety and a low score of self-image. When evaluating mental health status, a varied approach may be beneficial for researchers.

Measures used to assess interventions for increasing patient involvement in Danish healthcare setting: a rapid review

OBJECTIVE

To identify measures used within Denmark evaluating any type of intervention designed to facilitate patient involvement in healthcare.

DESIGN

Environmental scan employing rapid review methods.

DATA SOURCES

MEDLINE, PsycInfo and CINAHL were searched from 6-9 April 2021 from database inception up to the date of the search.

ELIGIBILITY CRITERIA

Quantitative, observational and mixed methods studies with empirical data on outcomes used to assess any type of intervention aiming to increase patient involvement with their healthcare. Language limitations were Danish and English.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data from 10% of the included studies and, due to their agreement, the data from the rest were extracted by first author. Data were analysed with reference to existing categories of measuring person-centred care; findings were synthesised using narrative summaries. Adapted Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines were used to guide reporting.

RESULTS

Among 3767 records, 43 studies met the inclusion criteria, including 74 different measures used to evaluate interventions aimed at increasing patient involvement within healthcare in Danish hospital and community settings. Generic measures assessed: patient engagement (n=3); supporting self-management (n=8); supporting shared decision-making (n=9); patient satisfaction and experiences of care (n=11); health-related patient-reported outcome (n=20).

CONCLUSIONS

Across Denmark, complex interventions designed to improve patient involvement with healthcare vary in their goals and content. Some targeting healthcare professionals, some patient health literacy and some service infrastructure. A plethora of measures assess the impact of these interventions on patient, professional and service delivery outcomes. Few measures assessed patient involvement directly, and it is unclear which proxy measures capture indicators of perceived involvement. Lack of conceptual clarity between intervention goals, the components of change and measures makes it difficult to see what types of intervention can best support change in services to ensure patients are more effectively involved in their healthcare.

Health-Related Quality of Life in Pediatric Inflammatory Bowel Disease During COVID-19 Pandemic: A Prospective Study

OBJECTIVES

The aims of our study were to evaluate health-related quality of life (HRQoL) in children affected by inflammatory bowel disease (IBD) during the first wave of Coronavirus disease 2019 (COVID-19) pandemic and after 12 months.

METHODS

This was a single-center, prospective, observational study conducted between April 2020 and April 2021. Children from 10 to 18 years with a confirmed diagnosis of IBD were enrolled during the first COVID-19-related national quarantine. The following information was collected at the baseline and after 12 months: IBD subtype, location and phenotype, disease activity, current and previous therapies. Patients were asked to complete the PROMIS Anxiety and IMPACT III questionnaires.

RESULTS

One hundred and eighteen patients were enrolled, of whom 54 (46%) were affected by Crohn disease (CD) and 64 (54%) with ulcerative colitis (UC; median age: 15.5 years, range 10.3-18; M/F: 68/50). Median HRQoL was significantly decreased after 12 months compared with the beginning of COVID-19-related quarantine (T1: 76.7 vs T2: 72.8; P < 0.001). At 12 months, a higher number of children were reported to be in active disease when compared with the enrollment [T2: 22/108 (20.4%) vs T1: 12/118 (10%); P = 0.02]. Multivariate analysis showed a significant influence on HRQoL of quarantine period ( P < 0.001), female sex ( P = 0.016), biologic therapy ( P = 0.011), and active disease ( P < 0.001).

CONCLUSIONS

A deterioration of HRQoL after 12 months from COVID-19-related quarantine was observed. Additionally, the higher number of children with active disease at 12 months compared with enrollment may suggest detrimental consequences of the reduced disease control, contributing to decreased HRQoL.

Point-of-Care Testing and Home Testing: Pragmatic Considerations for Widespread Incorporation of Stool Tests, Serum Tests, and Intestinal Ultrasound

Breaking through the biologic therapy efficacy plateau for inflammatory bowel disease requires the strategic development of personalized biomarkers in the tight control model. After risk stratification early in the disease course, targeted serial monitoring consistently to assess clinical outcomes in response to therapy allows for quick therapeutic adjustments before bowel damage can occur. Point-of-care intestinal ultrasound performed by the treating gastroenterologist is an accurate cross- sectional biomarker that monitors intestinal inflammation in real-time, enhances patient care, and increases shared understanding to help achieve common treatment goals. Combining intestinal ultrasound during a clinic visit with existing serum and stool biomarkers in a home testing setup with electronic health monitoring allows for an optimized, patient-centered personalized treatment algorithm that may improve treatment outcomes. Here, we review the current state, pragmatic considerations, and future implications of point-of-care testing and home testing for noninvasive inflammatory bowel disease monitoring in the tight control model.

Digital Health Technologies for Remote Monitoring and Management of Inflammatory Bowel Disease: A Systematic Review

INTRODUCTION

Digital health technologies may be useful tools in the management of chronic diseases. We performed a systematic review of digital health interventions in the management of patients with inflammatory bowel diseases (IBD) and evaluated its impact on (i) disease activity monitoring, (ii) treatment adherence, (iii) quality of life (QoL) measures, and/or (iv) health care utilization.

METHODS

Through a systematic review of multiple databases through August 31, 2020, we identified randomized controlled trials in patients with IBD comparing digital health technologies vs standard of care (SoC) for clinical management and monitoring and reporting impact on IBD disease activity, treatment adherence, QoL, and/or health care utilization or cost-effectiveness. We performed critical qualitative synthesis of the evidence supporting digital health interventions in patients with IBD and rated certainty of evidence using Grading of Recommendations Assessment, Development and Evaluation.

RESULTS

Overall, we included 14 randomized controlled trials (median, 98 patients; range 34-909 patients; follow-up <12 months) that compared web-based interventions, mobile applications, and different telemedicine platforms with SoC (clinic-based encounters). Although overall disease activity and risk of relapse were comparable between digital health technologies and SoC (very low certainty of evidence), digital health interventions were associated with lower rate of health care utilization and health care costs (low certainty of evidence). Digital health interventions did not significantly improve patients' QoL and treatment adherence compared with SoC (very low certainty of evidence). Trials may have intrinsic selection bias due to nature of digital interventions.

DISCUSSION

Digital health technologies may be effective in decreasing health care utilization and costs, though may not offer advantage in reducing risk of relapse, QoL, and improving treatment adherence in patients with IBD. These techniques may offer value-based care for population health management.

E-Health and remote management of patients with inflammatory bowel disease: lessons from Denmark in a time of need

In Denmark, remote monitoring and management of inflammatory bowel disease (IBD) started two decades ago with the web application Constant Care. The disease monitoring in Constant Care consists of simple disease activity questionnaires and home measurement of faecal calprotectin, a stool biomarker for inflammation. It has now been implemented in clinical practice at North Zealand University Hospital in Denmark. Digital health care solutions facilitate remote contact between patients and healthcare providers and have been shown to reduce time to remission, outpatient visits and hospital admissions, and increase adherence to medical therapy, quality of life and disease and treatment knowledge. In Australia, E-Health is an area of increasing interest, particularly given the significant distances travelled by rural patients to access specialist care. There are several foreseeable benefits to incorporating E-Health/remote monitoring into Australian IBD management, including reduced burdens of time and cost on rural patients, and more efficient management of well outpatients, thereby increasing clinic availability for acutely unwell patients. The significant portion of IBD patients managed in private practice in Australia, and the infrastructure within private practice that is well suited to implementation of E-Health makes Australia a viable setting for an E-Health IBD management model like Denmark's Constant Care model. One pilot study is currently underway investigating the feasibility of rapid and remote IBD monitoring and E-Health in an Australian IBD population. The current COVID-19 pandemic has further illustrated the importance of telehealth as a means of maintaining health services to patients in geographic, or social, isolation.

IBD goes home: from telemedicine to self-administered advanced therapies

Introduction: Major challenges have been posed by the coronavirus disease 2019 pandemic in the routine management of patients with inflammatory bowel disease (IBD). The need for constant monitoring of diseases activity and prompt adjustment of therapy have been balanced with the risk of contagion related to face-to-face consultations. Therefore, digital health initiatives have been pursued for safety reasons as vicarious instruments to avoid overcrowding of the IBD clinics. However, concerns and skepticism about the feasibility of digital health and telemedicine modalities limited their uptake in clinical practice in the pre-pandemic period.Areas covered: We conducted a literature overview on the current state of the art and the potential future benefits deriving from the integration of telemedicine systems, home-based laboratory tests, and self-administered drugs into IBD daily practice.Expert opinion: Digital health and telemedicine approaches at distance have been experimented as effective tools to avoid overcrowding of clinics and reduce risk from SARS-CoV2 exposure. Home-based point of care testing, such as fecal calprotectin and dried blood samples, might represent an effective method of remote monitoring of patients particularly when in-person visits are precluded. High expectations are placed on the use of self-administered advanced therapies, such as new subcutaneous formulation of biologics.

Costs of electronic health vs. standard care management of inflammatory bowel disease across three years of follow-up-a Danish register-based study

BACKGROUND

Costs of using eHealth in inflammatory bowel disease (IBD) management has only been assessed for short follow-up periods. The primary aim was to compare the direct costs of eHealth (cases) relative to standard care (matched controls) for IBD during three years of follow-up.

METHODS

The study design was a retrospective, registry-based follow-up study of patients diagnosed with IBD two years prior, and three years subsequent, to their enrolment in eHealth. Cases were matched 1:4 with controls receiving standard care based on diagnosis, gender, biologics (yes/no) and age (+/- 5 years).

RESULTS

We identified 116 cases (76 (66%) with ulcerative colitis (UC) and 40 (34%) with Crohn's disease (CD)) and matched them with 433 controls. IBD-related outpatient costs were only significantly higher for cases in the year of their inclusion in eHealth (€2,949 vs. €1,621 per patient, p =.01). Mean IBD-related admission costs tended to fall after enrolment in eHealth, with mean admission costs per patient at year 3 of follow-up of €74 for cases and €383 for controls (p = .02). Linear extrapolation of the reduction in costs beyond year 3 after enrolment in eHealth revealed that eHealth would be cost neutral or saving, relative to standard care, from year 4.

CONCLUSION

IBD-related outpatient costs in both groups were similar and only significantly higher for cases in the year of their enrolment in eHealth, with admission costs typically falling after a patient's inclusion in eHealth. Estimation revealed eHealth to be cost neutral or saving from year 4.

Integration of eHealth Into Pediatric Inflammatory Bowel Disease Care is Safe: 3 Years of Follow-up of Daily Care

OBJECTIVES

The aim of the study was to evaluate integration of an eHealth solution, www.young.constant-care.com, into daily care (I-eHealth).

METHODS

The I-eHealth solution was offered to inflammatory bowel disease (IBD) patients ages 10 to 17 years old in nonbiological treatment. The application was used monthly and in case of flare-ups. Blood and fecal calprotectin (FC) were tested every 3 months and during flare-ups. A total inflammation score (based on symptoms and FC) was visualized for the patient in a traffic light curve. An IBD nurse followed up on the registrations every 2 weeks. Patients had 1 yearly planned visit at the hospital. On-demand visits were arranged depending on the total inflammation. I-eHealth results were compared with data from a previous randomized clinical trial (RCT)-eHealth study (the control group of which had 4 planned annual visits).

RESULTS

Thirty-six IBD patients were followed by I-eHealth, mean age 14.7 years (SD 7.75). The median (interquartile range [IQR]) duration of using I-eHealth was 1.9 years (0.29-2.51), equal to 66.11 patient-years, compared with 40.45 in the RCT-eHealth group and 46.49 in the RCT-control group. On-demand visits per patient-year did not differ between the groups: 1.13 (I-eHealth), 1.16 (RCT-eHealth), and 0.84 (RCT-control) (P = 0.84/0.85). Hospitalizations and acute outpatient visits per patient-year did not differ between the groups: 0.11 and 0.11 (I-eHealth), 0.05 and 0.02 (RCT-eHealth), 0.11 and 0.11 (RCT-control) (P = 0.17/0.81 and 0.12/0.81). Time to first escalation of medication, and time to first on-demand visit, did not differ between the I-eHealth group and data from the clinical trial (Log rank: P = 0.25 and P = 0.61).

CONCLUSIONS

I-eHealth is comparably with results from eHealth under RCT supervision.

Applying Telemedicine to Multidisciplinary Pediatric Inflammatory Bowel Disease Care

Multidisciplinary care is essential to the delivery of comprehensive, whole-person care for children and adolescents with inflammatory bowel disease (IBD). Team members may include medical, psychosocial, and ancillary providers as well as patient and family advocates. There is significant variability in how this care is delivered from center to center, though prior to the COVID-19 pandemic, most care occurred during in-person visits. At the onset of the pandemic, medical systems world-wide were challenged to continue delivering high quality, comprehensive care, requiring many centers to turn to telemedicine technology. The aim of this manuscript is to describe the process by which we converted our multidisciplinary pediatric and adolescent IBD visits to a telemedicine model by leveraging technology, a multidisciplinary team, and quality improvement (QI) methods. Finally, we put our experience into context by summarizing the literature on telemedicine in IBD care, with a focus on pediatrics and multidisciplinary care.

Efficacy of digital health interventions in youth with chronic medical conditions: A meta-analysis

BACKGROUND

Digital health interventions might extend service provisions for youth with chronic medical conditions (CC) and comorbid mental health symptoms. We aimed to comprehensively evaluate the efficacy of Internet- and mobile-based interventions (IMIs) for different psychological and disease-related outcomes in children and adolescents with CC.

METHOD

Studies were identified by systematic searches in CENTRAL, Embase, MEDLINE/PubMed and PsycINFO, complemented by searches in reference lists of eligible studies and other reviews. We included studies, when they were randomized controlled trials (RCTs) comparing the efficacy of an IMI to control conditions in improving psychological and disease-related outcomes in youth (mean age ≤ 18 years) with CC. Study selection, data extraction and risk of bias assessment were conducted independently by two reviewers. Meta-analyses were performed within a random-effects model, and Hedges' g (with 95% confidence intervals) was calculated as effect size measure. Primary outcomes were comorbid mental health symptoms (i.e., depression, anxiety and stress), as well as quality of life and self-efficacy.

RESULTS

A total of 19 randomized controlled trials (2410 patients) were included in this meta-analysis. IMIs were associated with improvements in self-efficacy (g = 0.38; 95% CI, 0.15 to 0.61; I 2 = 0) and combined disease-related outcomes (g = -0.13; 95% CI, -0.25 to -0.01; I 2 = 21). Meta-analyses on other outcomes were non-significant, and some pre-planned analyses were not feasible because of a shortage of studies.

CONCLUSION

The available evidence on IMIs for improving mental and health-related outcomes in youth with CC is limited. Our findings point to a rather small benefit and limited efficacy. Future research is needed, to comprehensively assess the potential of IMIs to extend collaborative care, and to identify factors contributing to improved user-centered interventions with better treatment outcomes.

Management of paediatric IBD after the peak of COVID-19 pandemic in Italy: A position paper on behalf of the SIGENP IBD working group

Coronavirus Disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2, spreading in Italy during the first months of 2020, abruptly changed the way of practicing medicine in this country. As a consequence of the lockdown, the diagnostic and therapeutic management of paediatric chronic conditions, such as inflammatory bowel disease (IBD) has been affected. During the peak of COVID-19 pandemic, elective visits, endoscopies and infusions have been postponed, with potential clinical and psychological impact on disease course and a high likelihood of increasing waiting lists. While slowly moving back towards normality, clinicians need to recognize the best ways to care for patients with IBD, carefully avoiding risk factors for new potential epidemic outbreaks. In this uncertain scenario until the development and spread of COVID-19 vaccine, it is necessary to continue to operate with caution. Hereby we provide useful indications for a safer and gradual restarting of routine clinical activities after COVID-19 peak in Italy.

Self-monitoring with home based fecal calprotectin is associated with increased medical treatment. A randomized controlled trial on patients with inflammatory bowel disease

OBJECTIVES

Self-monitoring of inflammatory bowel disease (IBD) with the assistant of telemedicine and home-based fecal calprotectin (FC) tests is evolving in the management of IBD. We performed a randomized controlled trial to investigate the compliance and effects of the model IBD-Home in patients with IBD.

MATERIALS AND METHODS

Patients were randomized to IBD-Home + standard care (n = 84) or standard care alone (n = 74). Intervention with IBD-Home included IBDoc^® FC test kits and a digital application used for answering symptom questionnaires (Abbvie/Telia). They were instructed to use these on demand during a 12-month period. Data was collected retrospectively from medical records. Patients who completed the intervention were phoned and asked to answer a survey about the experience of IBD-Home.

RESULTS

The compliance to IBD-Home was low (29%). Women were more compliant compared with men (43% vs 17%, p < .001). A significantly higher proportion of patients in the IBD-Home group increased their medical treatment during the study period in comparison to control subjects (33% vs 15% p = .007) and there was an association between an increase in treatment and compliance to IBD home (multivariate odds ratio 3.22; 95^th confidence interval 1.04 - 9.95). Overall patients reported a positive experience with slight technical difficulties.

CONCLUSION

Self-monitoring with home based fecal calprotectin and a digital application was found feasible and appreciated by compliers. Compliance to the IBD-Home model was more common in women and associated with an increased treatment for IBD.

Scenario-based design for a hospital setting: An exploratory study of opportunities and barriers for personal health records usage

Personal health records (PHRs) offer patients the opportunity to be more actively involved in their own care. There is limited research into the application during hospital admissions for elective or emergency presentations. We used techniques from scenario-based design to test the opportunities and boundaries of a commercially available PHR in a simulated environment. Scenarios included a patient in his 80s admitted for hip surgery with his son, and a younger patient admitted with pneumonia. A catastrophic deterioration was demonstrated with a mannequin in a high-fidelity simulation. Workflows were summarised in swim-lane diagrams. The PHR allowed patients to file information prior to the interaction with the clinical team. This led to shorter time requirements for acquisition of data. The elderly patient required assistance from a relative but this aided verification of history prior to the encounter with the clinical team. Ward rounds could be prepared by the patient with specific 'what matters' questions. Documentation in the PHR environment during a simulated life-threatening emergency did not result in information that was unintelligible or useful for the 'patient'. Usage of a commercially available PHR during hospital admission is feasible and might aid workflow. Documentation of emergencies might require different documentation formats.

Adaptation of TECCU App Based on Patients´ Perceptions for the Telemonitoring of Inflammatory Bowel Disease: A Qualitative Study Using Focus Groups

Background: Despite the continuous adaptation of eHealth systems for patients with inflammatory bowel disease (IBD), a significant disconnection persists between users and developers. Since non-adherence remains high, it is necessary to better understand the patients’ perspective on telemonitoring for IBD. Accordingly, this study aimed to adapt the TECCU telemonitoring app to the preferences and needs of IBD patients. Methods: A qualitative study was carried out using successive focus groups of IBD patients. Meetings were audio-recorded and a thematic analysis was employed until data saturation was achieved. The first group included patients who had used the TECCU App in a pilot clinical trial, and subsequent meetings included patients with Crohn’s disease and ulcerative colitis recruited from the Spanish Confederation of patient associations. The information collected at each meeting guided consecutive changes to the platform. Results: Data saturation was reached after three focus groups involving a total of 18 patients. Three main themes emerged: (1) platform usability, (2) the communication process, and (3) platform content. All participants indicated that TECCU is easy to use, permitting continuous and personalized feedback. According to patients´ perspectives, the platform was adapted to foster a flexible follow-up and shared decision-making using open and safe communication networks. Many participants appreciated the educational elements and, consequently, the app was connected to reliable and continuously updated webpages. Conclusions: IBD patients valued the usability and personalized monitoring offered by the TECCU App. Improvements in the messaging system and continuously updated educational content were introduced to address patients´ needs and favor their engagement.

Telemonitoring of Crohn's Disease and Ulcerative Colitis (TECCU): Cost-Effectiveness Analysis

BACKGROUND

Although electronic health interventions are considered safe and efficient, evidence regarding the cost-effectiveness of telemonitoring in inflammatory bowel disease is lacking.

OBJECTIVE

We aimed to evaluate the cost-effectiveness and cost-utility of the Telemonitorización de la Enfermedad de Crohn y Colitis Ulcerosa (Telemonitoring of Crohn's Disease and Ulcerative Colitis [TECCU]) Web platform (G_TECCU intervention group) for telemonitoring complex inflammatory bowel disease, compared with standard care (G_control) and nurse-assisted telephone care (G_NT intervention group).

METHODS

We analyzed cost-effectiveness from a societal perspective by comparing the 3 follow-up methods used in a previous 24-week randomized controlled trial, conducted at a tertiary university hospital in Spain. Patients with inflammatory bowel disease who initiated immunosuppressants or biologic agents, or both, to control inflammatory activity were recruited consecutively. Data on the effects on disease activity (using clinical indexes) and quality-adjusted life-years (using the EuroQol 5 dimensions questionnaire) were collected. We calculated the costs of health care, equipment, and patients' productivity and social activity impairment. We compared the mean costs per patient, utilities, and bootstrapped differences.

RESULTS

We included 63 patients (21 patients per group). TECCU saved €1005 (US $1100) per additional patient in remission compared with G_control (95% CI €-13,518 to 3137; US $-14,798 to 3434), with a 79.96% probability of being more effective at lower costs. Compared with G_NT, TECCU saved €2250 (US $2463) per additional patient in remission (95% CI €-15,363 to 11,086; US $-16,817 to 12,135), and G_NT saved €538 (US $589) compared with G_control (95% CI €-6475 to 5303; US $-7088 to 5805). G_TECCU and G_NT showed an 84% and 67% probability, respectively, of producing a cost saving per additional quality-adjusted life-year (QALY) compared with G_control, considering those simulations that involved negative incremental QALYs as well.

CONCLUSIONS

There is a high probability that the TECCU Web platform is more cost-effective than standard and telephone care in the short term. Further research considering larger cohorts and longer time horizons is required.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02943538; https://clinicaltrials.gov/ct2/show/NCT02943538 (http://www. webcitation.org/746CRRtDN).

Digital Health Apps in the Clinical Care of Inflammatory Bowel Disease: Scoping Review

Background

Digital health is poised to transform health care and redefine personalized health. As Internet and mobile phone usage increases, as technology develops new ways to collect data, and as clinical guidelines change, all areas of medicine face new challenges and opportunities. Inflammatory bowel disease (IBD) is one of many chronic diseases that may benefit from these advances in digital health. This review intends to lay a foundation for clinicians and technologists to understand future directions and opportunities together.

Objective

This review covers mobile health apps that have been used in IBD, how they have fit into a clinical care framework, and the challenges that clinicians and technologists face in approaching future opportunities.

Methods

We searched PubMed, Scopus, and ClinicalTrials.gov to identify mobile apps that have been studied and were published in the literature from January 1, 2010, to April 19, 2019. The search terms were (“mobile health” OR “eHealth” OR “digital health” OR “smart phone” OR “mobile app” OR “mobile applications” OR “mHealth” OR “smartphones”) AND (“IBD” OR “Inflammatory bowel disease” OR “Crohn's Disease” (CD) OR “Ulcerative Colitis” (UC) OR “UC” OR “CD”), followed by further analysis of citations from the results. We searched the Apple iTunes app store to identify a limited selection of commercial apps to include for discussion.

Results

A total of 68 articles met the inclusion criteria. A total of 11 digital health apps were identified in the literature and 4 commercial apps were selected to be described in this review. While most apps have some educational component, the majority of apps focus on eliciting patient-reported outcomes related to disease activity, and a few are for treatment management. Significant benefits have been seen in trials relating to education, quality of life, quality of care, treatment adherence, and medication management. No studies have reported a negative impact on any of the above. There are mixed results in terms of effects on office visits and follow-up.

Conclusions

While studies have shown that digital health can fit into, complement, and improve the standard clinical care of patients with IBD, there is a need for further validation and improvement, from both a clinical and patient perspective. Exploring new research methods, like microrandomized trials, may allow for more implementation of technology and rapid advancement of knowledge. New technologies that can objectively and seamlessly capture remote data, as well as complement the clinical shift from symptom-based to inflammation-based care, will help the clinical and health technology communities to understand the full potential of digital health in the care of IBD and other chronic illnesses.

The role of the transition clinic from pediatric to adult inflammatory bowel disease care

PURPOSE OF REVIEW

The transition of patients from pediatric to adult centered care represents not only the means to transfer medical care to a group of providers who specialize in adult care but also is part of the process of the transfer of healthcare responsibility from the family to a patient. The intent of this review is to provide a summary of some of the important studies published in the past 2 years that advance this knowledge.

RECENT FINDINGS

Progress has been made in the recognition of the process of transition, including developing tools to assess transition readiness, improving routes of communication along with patient education. Other studies provided information on patients' preferences for information seeking, types of family interactions, and factors that improved transition success.

SUMMARY

In general, reported clinics and programs did demonstrate improvements in adherence, clinic retention, and even quality of life. Further studies should focus on clinical outcomes of transition programs and risk assessment for transitioning patients.

Pharmacodynamic Monitoring of Biological Therapies in Chronic Inflammatory Diseases

BACKGROUND

Psoriasis, psoriatic arthritis, spondyloarthritis, rheumatoid arthritis, ulcerative colitis, and Crohn disease share similar underlying pathophysiological processes, providing the opportunity to treat the patients using similar biological therapies. Failure of biological treatments due to underexposure can be managed by therapeutic drug monitoring. Adjusting the treatment based on pharmacokinetic monitoring can be further improved by taking pharmacodynamic parameters such as clinical and molecular markers into account.

METHODS

Here, we critically evaluate the existing evidence, the hurdles to be taken, and the opportunities for a widespread implementation of pharmacodynamic monitoring.

RESULTS

Pharmacodynamic monitoring typically is the monitoring of biochemical markers. A pharmacodynamic marker preferably is specific for the pharmacological action of a drug, but most of the time nonspecific pharmacodynamic markers are used, such as C-reactive protein and the erythrocyte sedimentation rate. Clinical pharmacodynamic markers typically evaluate physical variables or symptoms. Although physician-reported outcomes have been studied for a longer time and often have been shown to correlate well with molecular pharmacodynamic markers and treatment outcomes, the introduction of mobile health or mHealth technologies caused a shift toward patient-reported outcomes, with the associated challenge to consistently reflect the inflammatory state, thereby preventing undertreatment or unnecessary overdosing of patients.

CONCLUSIONS

The primary goal of pharmacodynamic monitoring is to optimize the response, but it can also have an impact on safety, costs, patient adherence, etc. Ideally, the constant remote monitoring of patient-reported disease activity is expected to become the standard, facilitated by mHealth technologies.

Serum Calprotectin in Adolescents With Inflammatory Bowel Disease-A Pilot Investigation

OBJECTIVES

Fecal calprotectin (FC) is a well-integrated parameter in the monitoring of adolescent patients with inflammatory bowel disease (IBD). However, measurement of FC is limited by day-to-day-variation and by the feces consistency. Furthermore, adolescents are often noncompliant to deliver fecal sampling leading to suboptimal monitoring. Consequently, we see the need of a substitute biomarker whenever measurement of FC fails and aimed to investigate serum calprotectin (SC) in adolescents with IBD.

METHODS

In cross sectional data from 19 ulcerative colitis (UC) patients <18 years old, a Spearman correlation was used to analyze the correlation between SC, FC, C-reactive protein (CRP) and endoscopic and symptom scores. In longitudinal data collected from 20 UC and Crohn disease (CD) patients (10-17 years old), Mixed Effect Models (MEM) were used to analyze the association between SC, FC, CRP, and symptom scores.

RESULTS

We found positive correlations between SC (19 samples) and the endoscopic score, symptom score, and CRP (r = 0.56, P = 0.01; r = 0.64, P = 0.003; r = 0.97, P < 0.0001). We found no significant correlation between SC and FC. In 27 samples from UC patients, the association of SC with FC and CRP were positive and significant (P = 0.004, estimate = 0.32; P = 0.0001, estimate = 0.002). The association between SC and symptom score was insignificant. In 49 samples from CD patients, the association between SC and CRP was significant (P = 0.02, estimate = 0.002) whereas associations between SC and FC and symptom score were insignificant.

CONCLUSIONS

In the current pilot study, we found a correlation between SC and the endoscopically assessed inflammation in UC. SC may have the potential to improve disease monitoring of adolescent patients.

A Personalized eHealth Transition Concept for Adolescents With Inflammatory Bowel Disease: Design of Intervention

BACKGROUND

Transfer from pediatric to adult care is a crucial period for adolescents with inflammatory bowel disease (IBD).

OBJECTIVE

Our aim was to develop a personalized transition-transfer concept including relevant tools in an established eHealth (electronic health) program.

METHODS

Required transition skills and validated patient-reported outcome measures (PROMs) were identified via bibliographic search and clinical experience and were implemented into an existing eHealth program.

RESULTS

The following skills were identified: disease knowledge, social life, disease management, and making well-informed, health-related decisions. The PROMs included the following: self-efficacy (the IBD Self-Efficacy Scale-Adolescents), resilience (the 10-item Connor-Davidson Resilience Scale), response to stress (the Child Self-Report Responses to Stress-IBD), and self-management and health care transition skills (the Self-Management and Transition to Adulthood with Treatment questionnaire). Starting at age 14, the patient will be offered a 1-hour annual transition consultation with an IBD-specialized nurse. The consultation will be based on the results of the PROMs and will focus on the patient's difficulties. Patients will complete the PROMs on the eHealth program at home, allowing nurses and patients to prepare for the meeting. Symptom scores and medication will be filled out on the eHealth program to support disease self-management. The consultation will be a topic-centered dialogue with practical exercises. During routine outpatient visits with the provider, parents will be left out of half of the consultation when the patient is 16 years old; at 17 years old, the parents will not be present. At the transfer consultation, the pediatric provider, the adult gastroenterologist, the pediatric nurse, the patient, and the parents will be present to ensure a proper transfer.

CONCLUSIONS

We have conducted a personalized eHealth transition concept consisting of basic elements that measure, train, and monitor the patients' transition readiness. The concept can be implemented and adjusted to local conditions.

Exploring the Challenges of Implementing a Web-Based Telemonitoring Strategy for Teenagers With Inflammatory Bowel Disease: Empirical Case Study

BACKGROUND

We designed a telemonitoring strategy for teenagers with inflammatory bowel disease to prevent an anticipated disease flare and avert unplanned office visits and day care procedures. The strategy was evaluated in a randomized controlled trial that involved 11 Dutch pediatric gastroenterology centers, each using repeated symptom scores and stool calprotectin measurements. In the telemonitoring arm of the trial, teenagers (n=84) as well as their health providers were alerted to out-of-range results, and suggestions for change in therapy were offered. We demonstrated that the technology was a safe and cost saving alternative to health checks by the specialist at fixed intervals.

OBJECTIVE

The aim of this study was to evaluate whether we could move our telemonitoring strategy from a demonstration project to one that is sustained within existing sites.

METHODS

In this empirical case study, we used the nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework to explore the challenges to implementing our strategy. The framework distinguishes 7 domains: (1) the illness, (2) the technology, (3) the value proposition, (4) the adopter system, (5) the organization, (6) the societal system, and (7) the time dimension. We summarized the challenges across all 7 domains and classified them as simple (+++), complicated (++), or complex (+). Technologies in which multiple domains are complicated have proven difficult to implement, whereas those with multiple complex domains may not even become mainstreamed.

RESULTS

The technology that we used and the linked program (IBD-live) allowed us to select and target the teenagers who were most likely to benefit from a face-to-face encounter with their specialist (+++). The value proposition of the technology was clear, with a distinct benefit for patients and an affordable service model, but health providers had plausible personal reasons to resist (double data entry, ++). The organization was not yet ready for the innovation, as it requires a shift to new ways of working (+). We had no concerns about reimbursement, as Dutch health insurers agreed that screen-to-screen consultations will be reimbursed at a rate equivalent to face-to-face consultations (+++). Finally, the technology was considered easy to adapt and evolve over time to meet the needs of its users (+++).

CONCLUSIONS

The challenges to be addressed are merely complicated (++) rather than complex (+), which means that our program may be difficult but not impossible to sustain within existing sites. After integrating the technology and its use with local workflows first, we believe that our telemonitoring strategy will be ready for sustained adoption. In contrast with what we did ourselves, we recommend others to use the NASSS framework prospectively and in real time to predict and explore the challenges to implementing new technologies.

DIGITAL TECHNOLOGY: Opportunities and barriers for usage of personal health records in hospital - report from a -workshop of the Health Informatics Unit at the Royal -College of Physicians

Personal health records (PHRs) are thought to offer benefits and are promoted by health policy makers and some healthcare systems. Evidence for usage by patients in hospital is limited.  This article reports a one-day workshop hosted by the Royal College of Physicians that considered the evidence of the value to patients and others, the challenges to adoption and use of PHRs and sought to identify the practical and research questions that need to be answered.  The purpose of this article is to provide readers with an overview of the issues and possible future for hospital application of PHRs in the UK's NHS, especially for supporting self-care, family carers and advancing person-centred care. It aims to share the experience and ideas of those taking part in the workshop and reference resources that we have found useful while highlighting areas for future research.

The Use and Effects of Electronic Health Tools for Patient Self-Monitoring and Reporting of Outcomes Following Medication Use: Systematic Review

Background

Electronic health (eHealth) tools are becoming increasingly popular for helping patients’ self-manage chronic conditions. Little research, however, has examined the effect of patients using eHealth tools to self-report their medication management and use. Similarly, there is little evidence showing how eHealth tools might prompt patients and health care providers to make appropriate changes to medication use.

Objective

The objective of this systematic review was to determine the impact of patients’ use of eHealth tools on self-reporting adverse effects and symptoms that promote changes to medication use. Related secondary outcomes were also evaluated.

Methods

MEDLINE, EMBASE, and CINAHL were searched from January 1, 2000, to April 25, 2018. Reference lists of relevant systematic reviews and included articles from the literature search were also screened to identify relevant studies. Title, abstract, and full-text review as well as data extraction and risk of bias assessment were performed independently by 2 reviewers. Due to high heterogeneity, results were not meta-analyzed and instead presented as a narrative synthesis.

Results

A total of 14 studies, including 13 randomized controlled trials (RCTs) and 1 open-label intervention, were included, from which 11 unique eHealth tools were identified. In addition, 14 RCTs found statistically significant increases in positive medication changes as a result of using eHealth tools, as did the single open-label study. Moreover, 8 RCTs found improvement in patient symptoms following eHealth tool use, especially in adolescent asthma patients. Furthermore, 3 RCTs showed that eHealth tools might improve patient self-efficacy and self-management of chronic disease. Little or no evidence was found to support the effectiveness of eHealth tools at improving medication recommendations and reconciliation by clinicians, medication-use behavior, health service utilization, adverse effects, quality of life, or patient satisfaction. eHealth tools with multifaceted functionalities and those allowing direct patient-provider communication may be more effective at improving patient self-management and self-efficacy.

Conclusions

Evidence suggests that the use of eHealth tools may improve patient symptoms and lead to medication changes. Patients generally found eHealth tools useful in improving communication with health care providers. Moreover, health-related outcomes among frequent eHealth tool users improved in comparison with individuals who did not use eHealth tools frequently. Implementation issues such as poor patient engagement and poor clinician workflow integration were identified. More high-quality research is needed to explore how eHealth tools can be used to effectively manage use of medications to improve medication management and patient outcomes.

A Web-Based Telemanagement System for Improving Disease Activity and Quality of Life in Patients With Complex Inflammatory Bowel Disease: Pilot Randomized Controlled Trial

BACKGROUND

The reported efficacy of telemedicine in patients with inflammatory bowel disease (IBD) is inconsistent among studies, and data for complex IBD are lacking.

OBJECTIVE

We aimed to evaluate the impact of remote monitoring using a Web system-Telemonitorización de la Enfermedad de Crohn y Colitis Ulcerosa or Telemonitoring of Crohn's Disease and Ulcerative Colitis (TECCU)-as compared to standard care and telephone care on health outcomes and health care in patients with complex IBD.

METHODS

We performed a 3-arm randomized controlled trial. Adult patients with IBD who received immunosuppressants and biological agents were recruited from the IBD Unit of a tertiary university hospital. The patients were randomized into groups to receive remote monitoring (G_TECCU), nurse-assisted telephone care (G_NT), or standard care with in-person visits (G_control). All patients completed the study visits at baseline and at 12 and 24 weeks in addition to each type of intervention. The primary outcome was the percentage of patients in remission at 24 weeks. Secondary health outcomes were quality of life, medication adherence, adverse effects, satisfaction, and social activities. Data on the number of outpatient visits and telephone calls, emergency visits, hospitalizations, IBD-related surgeries, and corticosteroid courses were also collected.

RESULTS

A total of 63 patients were selected (21 patients in each group). During the study, 90.5% (19/21) of patients in G_control, 95.2% (20/21) in G_NT, and 85.7% (18/21) in G_TECCU were compliant to the intervention. After 24 weeks, the percentage of patients in remission was higher in G_TECCU (17/21, 81%) than in G_NT (14/21, 66.7%) and G_control (15/21, 71.4%). A higher improvement in disease activity was observed in G_TECCU than in G_control in terms of the Harvey-Bradshaw/Mayo (odds ratio=0.12, 95% CI=0.003-2.162, P=.19) and Harvey-Bradshaw/Walmsley (odds ratio=0.11, 95% CI=0.004-1.55, P=.13) indexes. Improvement in disease activity was associated with a larger reduction in fecal calprotectin values in G_TECCU compared to G_control (estimated intervention effect: odds ratio=-0.90; 95% CI=-1.96 to 0.16, P=.11). All completers adhered to treatment in G_TECCU. In addition, the quality of life, social activities, and satisfaction improved in all 3 groups. Although the number of outpatient visits and telephone calls was lower in G_TECCU than in G_NT and G_control, the safety profile was similar in all 3 groups.

CONCLUSIONS

This pilot clinical trial suggests that the TECCU Web-based system is a safe strategy for improving health outcomes in patients with complex IBD and reducing the use of health care resources.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02943538; https://clinicaltrials.gov/ct2/show/NCT02943538 (Archived by WebCite at http://www.webcitation.org/746CRRtDN).

Design considerations for an eHealth decision support tool in inflammatory bowel disease self-management

BACKGROUND

Electronic health (eHealth) decision support tools have the potential to: facilitate inflammatory bowel disease (IBD) self-management, reduce health care utilisation and alleviate the pressure on overburdened outpatient clinics. The purpose of this study was to explore the perspectives of key stakeholders on the potential use of a decision support tool for IBD patients.

METHODS

A qualitative study using focus group methodology was conducted at a tertiary IBD centre in Melbourne, Australia in February 2015. Key stakeholders, including physicians, nurses and patients, were included in the study. Two independent reviewers undertook inductive coding and generated themes.

RESULTS

In total, 31 participants were included in the study (including 16 males; 11 physicians; 6 nurses). An eHealth decision support tool was thought to be beneficial to facilitate IBD self-management. Four themes emerged: (i) Framework for the decision support tool - the tool should be an adjunct to current models of care and facilitate shared decision-making and patient engagement; (ii) Target population - stable patients with mild to moderate disease; (iii) Functionalities of the intervention - a web-based platform encompassing patient-reported outcomes, objective markers of disease and clinical algorithms based on international guidelines; and (iv) Design and Implementation - patients should be involved in the design.

CONCLUSIONS

eHealth interventions are thought to be an important strategy to facilitate self-management for patients with IBD. A multi-stage iterative approach should be adopted in the design and implementation process of eHealth interventions. Patient perspectives need to be sought prior to and throughout the development of an eHealth decision support tools for IBD.

Current Landscape of Telemedicine Practice in Inflammatory Bowel Disease

Inflammatory bowel disease (IBD), comprised of Crohn's disease and ulcerative colitis, affects 1.6 million people in the United States. Although effective medical treatments exist to treat the disease, outcomes are still suboptimal. The reasons for poor outcomes vary but include nonadherence to therapy, inadequate monitoring of patients, limited access to IBD specialty care, concurrent psychiatric disease, limited patient knowledge of the disease and treatments, and patient provider discordance. Telemedicine is a candidate intervention that can be used to improve patient outcomes through more frequent monitoring, patient self-management, delivery of education (patient and provider), and to increase access to multidisciplinary IBD care. Telemedicine includes remote monitoring, telehealth, teleconsultation, and teleconferencing. Telemedicine systems have been used in patients with IBD with widespread patient acceptance of the technology. However, early clinical trials demonstrated high attrition rates among intervention patients. In general, use of telemedicine systems have been associated with improved quality of life, improved patient knowledge, and decreased utilization of health care resources. Early studies evaluating telehealth visits report high patient satisfaction, decreased indirect costs to patients, and no decrease in quality of care delivered. Due to widespread access to computers and smart phones among patients, telemedicine will continue to expand in the care of patients with IBD. To optimize use and effectiveness of telemedicine, barriers for use including concerns over increased liability, need for informed consent, licensure restrictions to providing interstate telehealth visits, and cybersecurity need to be addressed.

Efficacy of Home Telemonitoring versus Conventional Follow-up: A Randomized Controlled Trial among Teenagers with Inflammatory Bowel Disease

BACKGROUND AND AIMS

Conventional follow-up of teenagers with inflammatory bowel diseases [IBD] is done during scheduled outpatient visits regardless of how well the patient feels. We designed a telemonitoring strategy for early recognition of flares and compared its efficacy with conventional follow-up.

METHODS

We used a multicentre randomized trial in patients aged 10-19 years with IBD in clinical remission at baseline. Participants assigned to telemonitoring received automated alerts to complete a symptom score and send a stool sample for measurement of calprotectin. This resulted in an individual prediction for flare with associated treatment advice and test interval. In conventional follow-up the health check interval was left to the physician's discretion. The primary endpoint was cumulative incidence of disease flares. Secondary endpoints were percentage of participants with a positive change in quality-of-life and cost-effectiveness of the intervention.

RESULTS

We included 170 participants [84 telemonitoring; 86 conventional follow-up]. At 52 weeks the mean number of face-to-face visits was significantly lower in the telemonitoring group compared to conventional follow-up [3.6 vs 4.3, p < 0.001]. The incidence of flares [33 vs 34%, p = 0.93] and the proportion of participants reporting positive change in quality-of-life [54 vs 44%, p = 0.27] were similar. Mean annual cost-saving was €89 and increased to €360 in those compliant to the protocol.

CONCLUSIONS

Telemonitoring is as safe as conventional follow-up, and reduces outpatient visits and societal costs. The positive impact on quality-of-life was similar in the two groups. This strategy is attractive for teenagers and families, and health professionals may be interested in using it to keep teenagers who are well out of hospital and ease pressure on overstretched outpatient services.

TRIAL REGISTRATION

NTR3759 [Netherlands Trial Registry].