A chronic care model significantly decreases costs and healthcare utilisation in patients with inflammatory bowel disease

INTRODUCTION

Inflammatory bowel disease (IBD) is a chronic condition, yet the model of care is often reactive. We sought to examine whether a formal IBD service (IBDS) reduced inpatient healthcare utilisation or lowered costs for inpatient care.

MATERIAL AND METHODS

With protocols, routine nurse phone follow-up a help-line, more proactive care was delivered, with many symptoms and concerns dealt with prior to routine presentation. Over two five month periods before (2007/8) and after (2009/10) introducing a formal IBDS two discrete cohorts of admitted IBD patients were identified at a single centre. Each patient was assigned five contemporaneously admitted, age and gender matched controls. Inpatient healthcare utilisation was compared between patients and controls and disease-specific factors amongst the two IBD cohorts.

RESULTS

The initial audit captured 102 admitted IBD patients (510 controls, median age 44 years, 57% female); the second audit 95 patients (475 controls, median age 46 years, 45.3% female). In 2009/10, the number of admissions was lower in IBD patients than in controls (mean 1.53+/-1.03 vs. 2.54+/-2.35; p<0.0001). This contrasts with the first audit, where IBD patients had more admissions than controls. Following IBDS introduction, the mean total cost of inpatient care was lower for IBD patients than controls (US$12,857.48 (US$15,236.79) vs. US$ 30,467.78 (US$ 53,760.20), p=0.005). In addition, patients known to a specialist gastroenterologist (GE) and the IBD Service tended to have the lowest mean number of admissions (GE and IBDS 1.14 (+/-0.36) vs. no GE/IBDS 1.64 (+/-1.25)).

CONCLUSIONS

Healthcare utilisation and disease burden in IBD decreased significantly since introducing an IBDS. These data suggest that proactive management improved outcomes. Contact with a gastroenterologist and IBDS seemed to give best results.

Constitutive beta cell expression of IL-12 does not perturb self-tolerance but intensifies established autoimmune diabetes

To analyze the function of the Th1-promoting cytokine IL-12 in vivo, we generated transgenic (tg) mice (RIP-IL12 mice) whose pancreatic beta cells constitutively express bioactive IL-12 or one of its components, p35 or p40. In contrast to non-tg littermates or single-tg RIP-p35 and RIP-p40 mice, RIP-IL12 mice developed a marked pancreatic infiltration of lymphocytes and macrophages, mainly around islets. Expression of bioactive IL-12 primarily upregulated transcript levels of IFN-inducible protein-10 (IP-10), RANTES, IFN-gamma, and TNF-alpha in the pancreas. Despite the substantial recruitment of mononuclear cells, no biochemical or clinical disease was evident in the exocrine or endocrine pancreas. Coexpression of lymphocytic choriomeningitis virus (LCMV) proteins with IL-12 in the beta cells failed to spontaneously activate or expand antigen-specific anti-self/viral T cells in uninfected tg animals. However, when RIP-IL12 x RIP-LCMV tg mice were infected with LCMV, antigen-specific anti-self/viral T cells were induced, which led to an acceleration in the kinetics and severity of insulin-dependent diabetes mellitus (IDDM). Thus, the ectopic expression of IL-12 does not spontaneously break tolerance and activate antigen-specific T cells in the periphery, but it does worsen ongoing autoimmune disease.