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Jayasooriya N, Pollok RC, Blackwell J, Bottle A, Petersen I, Creese H, Saxena S. Adherence to 5-aminosalicylic acid maintenance treatment in young people with ulcerative colitis: a retrospective cohort study in primary care. Br J Gen Pract 2023; 73:e850-e857. [PMID: 37666511 PMCID: PMC10498382 DOI: 10.3399/bjgp.2023.0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 05/16/2023] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND Maintenance treatment with 5-aminosalicylic acid (5-ASA) is recommended in ulcerative colitis (UC), but accurate estimates of discontinuation and adherence in adolescents transitioning to young adulthood are lacking. AIM To determine rates and risk factors for discontinuation and adherence to oral 5-ASA in adolescents and young adults 1 year following diagnosis of UC. DESIGN AND SETTING Observational cohort study using the UK Clinical Practice Research Datalink among adolescents and young adults (aged 10-24 years) diagnosed with UC between 1 January 1998 and 1 May 2016. METHOD Time to oral 5-ASA discontinuation (days) and adherence rates (proportion of days covered) were calculated during the first year of treatment using Kaplan-Meier survival analysis. Cox regression models were built to estimate the impact of sociodemographic and health-related risk factors. RESULTS Among 607 adolescents and young adults starting oral 5-ASA maintenance treatment, one-quarter (n = 152) discontinued within 1 month and two- thirds (n = 419) within 1 year. Discontinuation was higher among those aged 18-24 years (74%) than younger age groups (61% and 56% in those aged 10-14 and 15-17 years, respectively). Adherence was lower among young adults than adolescents (69% in those aged 18-24 years versus 80% in those aged 10-14 years). Residents in deprived versus affluent postcodes were more likely to discontinue treatment (adjusted hazard ratio [aHR] 1.46, 95% confidence interval [CI] = 1.10 to 1.92). Early corticosteroid use for an acute flare lowered the likelihood of oral 5-ASA discontinuation (aHR 0.68, 95% CI = 0.51 to 0.90). CONCLUSION The first year of starting long-term therapies in adolescents and young adults diagnosed with UC is a critical window for active follow-up of maintenance treatment, particularly in those aged 18-24 years and those living in deprived postcodes.
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Affiliation(s)
- Nishani Jayasooriya
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Richard C Pollok
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Alex Bottle
- School of Public Health, Imperial College London, London, UK
| | - Irene Petersen
- Department of Primary Care and Population Health, University College London, London, UK; Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| | - Hanna Creese
- School of Public Health, Imperial College London, London, UK
| | - Sonia Saxena
- School of Public Health, Imperial College London, London, UK
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Pollok RC, Jayasooriya N, Baillie S, Blackwell J, Petersen I, Bottle A, Saxena S. Letter: delays to diagnosis of IBD-Challenges requiring a systematic approach. Authors' reply. Aliment Pharmacol Ther 2023; 57:1479. [PMID: 37243462 DOI: 10.1111/apt.17548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 04/28/2023] [Indexed: 05/28/2023]
Affiliation(s)
- Richard C Pollok
- Department of Gastroenterology, St George's Healthcare NHS Trust, St George's University, London, UK
- Institute of Infection and Immunity, St George's University, London, UK
- School of Public Health, Imperial College London, London, UK
| | - Nishani Jayasooriya
- Department of Gastroenterology, St George's Healthcare NHS Trust, St George's University, London, UK
- Institute of Infection and Immunity, St George's University, London, UK
- School of Public Health, Imperial College London, London, UK
| | - Samantha Baillie
- Department of Gastroenterology, St George's Healthcare NHS Trust, St George's University, London, UK
- Institute of Infection and Immunity, St George's University, London, UK
- School of Public Health, Imperial College London, London, UK
| | - Jonathan Blackwell
- Department of Gastroenterology, St George's Healthcare NHS Trust, St George's University, London, UK
- Institute of Infection and Immunity, St George's University, London, UK
- School of Public Health, Imperial College London, London, UK
| | - Irene Petersen
- Department of Primary Care and Population Health, University College London, London, UK
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| | - Alex Bottle
- School of Public Health, Imperial College London, London, UK
| | - Sonia Saxena
- School of Public Health, Imperial College London, London, UK
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Jayasooriya N, Saxena S, Pollok RC. Letter: fulminant onset complicated inflammatory bowel disease (IBD) - a unique subtype? Authors' reply. Aliment Pharmacol Ther 2023; 57:1194-1195. [PMID: 37094302 DOI: 10.1111/apt.17445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Affiliation(s)
- Nishani Jayasooriya
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London, UK
- Institute for Infection and Immunity, St George's University, London, UK
- School of Public Health, Imperial College London, London, UK
| | - Sonia Saxena
- School of Public Health, Imperial College London, London, UK
| | - Richard C Pollok
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London, UK
- Institute for Infection and Immunity, St George's University, London, UK
- School of Public Health, Imperial College London, London, UK
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Pollok RC, Baillie S, Jayasooriya N, Blackwell J, Petersen I, Bottle A, Saxena S. Letter: diagnostic delay in inflammatory bowel disease-Authors' reply. Aliment Pharmacol Ther 2023; 57:1205-1206. [PMID: 37094317 DOI: 10.1111/apt.17493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 03/17/2023] [Indexed: 04/26/2023]
Affiliation(s)
- Richard C Pollok
- Department of Gastroenterology, St George's Healthcare NHS Trust, St George's University, London, UK
- Institute of Infection and Immunity, St George's University, London, UK
- School of Public Health, Imperial College London, London, UK
| | - Samantha Baillie
- Department of Gastroenterology, St George's Healthcare NHS Trust, St George's University, London, UK
- Institute of Infection and Immunity, St George's University, London, UK
- School of Public Health, Imperial College London, London, UK
| | - Nishani Jayasooriya
- Department of Gastroenterology, St George's Healthcare NHS Trust, St George's University, London, UK
- Institute of Infection and Immunity, St George's University, London, UK
- School of Public Health, Imperial College London, London, UK
| | - Jonathan Blackwell
- Department of Gastroenterology, St George's Healthcare NHS Trust, St George's University, London, UK
- Institute of Infection and Immunity, St George's University, London, UK
- School of Public Health, Imperial College London, London, UK
| | - Irene Petersen
- Department of Primary Care and Population Health, University College London, London, UK
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| | - Alex Bottle
- School of Public Health, Imperial College London, London, UK
| | - Sonia Saxena
- School of Public Health, Imperial College London, London, UK
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Jayasooriya N, Baillie S, Blackwell J, Bottle A, Petersen I, Creese H, Saxena S, Pollok RC. Systematic review with meta-analysis: Time to diagnosis and the impact of delayed diagnosis on clinical outcomes in inflammatory bowel disease. Aliment Pharmacol Ther 2023; 57:635-652. [PMID: 36627691 DOI: 10.1111/apt.17370] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/29/2022] [Accepted: 12/10/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND The impact of diagnostic delay on the clinical course of inflammatory bowel disease (IBD) remains uncertain. AIM To perform a systematic review of time to diagnosis and the impact of delayed diagnosis on clinical outcomes in Crohn's disease (CD) and ulcerative colitis (UC). METHODS We searched EMBASE and Medline from inception to 30th November 2022 for studies reporting diagnostic interval, from symptom onset to IBD diagnosis. We calculated the median, interquartile range (IQR) and pooled weighted median, of median diagnostic intervals of eligible studies. We defined delayed diagnosis as individuals above the 75th centile of longest time to diagnosis in each study. Using random effects meta-analysis, we pooled odds ratios (ORs) with 95% confidence intervals (CI) for studies reporting clinical outcomes, according to delayed diagnosis. RESULTS One hundred and one studies representing 112,194 patients with IBD (CD = 59,359; UC = 52,835) met inclusion criteria. The median of median times to diagnosis was 8.0 (IQR: 5.0-15.2) and 3.7 months (IQR: 2.0-6.7) in CD and UC, respectively. In high-income countries, this was 6.2 (IQR: 5.0-12.3) and 3.2 months (IQR: 2.2-5.3), compared with 11.7 (IQR: 8.3-18.0) and 7.8 months (IQR: 5.2-21.8) in low-middle-income, countries, for CD and UC respectively. The pooled weighted median was 7.0 (95% CI: 3.0-26.4) and 4.6 (95% CI: 1.0-96.0) months, for CD and UC respectively. Eleven studies, representing 6164 patients (CD = 4858; UC = 1306), were included in the meta-analysis that examined the impact of diagnostic delay on clinical outcomes. In CD, delayed diagnosis was associated with higher odds of stricturing (OR = 1.88; CI: 1.35-2.62), penetrating disease (OR = 1.64; CI: 1.21-2.20) and intestinal surgery (OR = 2.24; CI: 1.57-3.19). In UC, delayed diagnosis was associated with higher odds of colectomy (OR = 4.13; CI: 1.04-16.40). CONCLUSION Delayed diagnosis is associated with disease progression in CD, and intestinal surgery in both CD and UC. Strategies are needed to achieve earlier diagnosis of IBD.
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Affiliation(s)
- Nishani Jayasooriya
- Department of Gastroenterology, St George's Healthcare NHS Trust, St George's University, London, UK
- Institute of Infection and Immunity, St George's University, London, UK
- School of Public Health, Imperial College London, London, UK
| | - Samantha Baillie
- Department of Gastroenterology, St George's Healthcare NHS Trust, St George's University, London, UK
- Institute of Infection and Immunity, St George's University, London, UK
- School of Public Health, Imperial College London, London, UK
| | - Jonathan Blackwell
- Department of Gastroenterology, St George's Healthcare NHS Trust, St George's University, London, UK
- Institute of Infection and Immunity, St George's University, London, UK
- School of Public Health, Imperial College London, London, UK
| | - Alex Bottle
- School of Public Health, Imperial College London, London, UK
| | - Irene Petersen
- Department of Primary Care and Population Health, University College London, London, UK
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| | - Hanna Creese
- School of Public Health, Imperial College London, London, UK
| | - Sonia Saxena
- School of Public Health, Imperial College London, London, UK
| | - Richard C Pollok
- Department of Gastroenterology, St George's Healthcare NHS Trust, St George's University, London, UK
- Institute of Infection and Immunity, St George's University, London, UK
- School of Public Health, Imperial College London, London, UK
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Jayasooriya N, Blackwell J, Saxena S, Bottle A, Petersen I, Creese H, Hotopf M, Pollok RCG. Antidepressant medication use in Inflammatory Bowel Disease: a nationally representative population-based study. Aliment Pharmacol Ther 2022; 55:1330-1341. [PMID: 35244961 PMCID: PMC9311162 DOI: 10.1111/apt.16820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/23/2021] [Accepted: 02/01/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite high rates of depression and anxiety, little is known about the use of antidepressants amongst individuals diagnosed with inflammatory bowel disease (IBD). AIMS To evaluate temporal trends in the use of antidepressants; rates of antidepressant initiation and adherence of antidepressant use to international guidelines amongst individuals with IBD. METHODS This is a study of 14,525 incident IBD cases from 2004 to 2016 compared with 58,027 controls matched 1:4 for age and sex from the Clinical Practice Research Datalink. After excluding tricyclic antidepressants, we performed a Cox regression analysis to determine the risk associated with antidepressant use and logistic regression analysis to determine risk associated with antidepressant undertreatment. RESULTS Antidepressant use amongst individuals with IBD increased by 51% during the 12-year study period, who were 34% more likely to initiate antidepressants in the year after IBD diagnosis compared with controls (aHR:1.34, 95% CI 1.21-1.49). In those with IBD starting antidepressants, 67% received treatment lasting less than the duration recommended in international guidelines, of which 34% were treated for 1 month or less. 18-24 year olds were twice as likely to discontinue treatment within 1 month compared with those aged 40-60 years (aHR:2.03, 95% CI 1.40-2.95). Socioeconomic deprivation was also associated with early treatment discontinuation (aHR:1.40, 95% CI 1.07-1.83). CONCLUSIONS In the year following IBD diagnosis individuals are significantly more likely to start antidepressants compared with controls, but treatment duration fell short of recommendations in the majority. Better integration of services may benefit individuals with IBD and psychiatric comorbidity.
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Affiliation(s)
- Nishani Jayasooriya
- Department of Gastroenterology, St George’s Healthcare NHS TrustSt George’s UniversityLondonUK
- Institute for Infection and ImmunitySt George’s UniversityLondonUK
- School of Public HealthImperial College LondonLondonUK
| | - Jonathan Blackwell
- Department of Gastroenterology, St George’s Healthcare NHS TrustSt George’s UniversityLondonUK
- Institute for Infection and ImmunitySt George’s UniversityLondonUK
- School of Public HealthImperial College LondonLondonUK
| | - Sonia Saxena
- School of Public HealthImperial College LondonLondonUK
| | - Alex Bottle
- School of Public HealthImperial College LondonLondonUK
| | - Irene Petersen
- Department of Primary Care and Population HealthUniversity College LondonLondonUK
- Department of Clinical EpidemiologyAarhus UniversityDenmark
| | - Hanna Creese
- School of Public HealthImperial College LondonLondonUK
| | - Matthew Hotopf
- Institute of Psychiatry Psychology & NeuroscienceKing’s College LondonLondonUK
- South London and Maudsley NHS Foundation TrustLondonUK
| | - Richard C. G. Pollok
- Department of Gastroenterology, St George’s Healthcare NHS TrustSt George’s UniversityLondonUK
- Institute for Infection and ImmunitySt George’s UniversityLondonUK
- School of Public HealthImperial College LondonLondonUK
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Pollok RCG, Jayasooriya N. Editorial: early and persistent biological treatment and its impact on long term surgical outcomes in inflammatory bowel disease. Aliment Pharmacol Ther 2022; 55:370-371. [PMID: 35040166 DOI: 10.1111/apt.16747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Richard C G Pollok
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London, UK.,Institute for Infection and Immunity, St George's University of London, London, UK
| | - Nishani Jayasooriya
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London, UK.,Institute for Infection and Immunity, St George's University of London, London, UK
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Rosiou K, Ong Ming San E, Kumar A, Esquivel K, Almas S, Stokes D, Ng T, Jayasooriya N, Ranasinghe I, Pollok R, Brookes M, Selinger CP. Comparative Outcomes of Budesonide MMX versus Prednisolone for Ulcerative Colitis: Results from a British Retrospective Multi-Centre Real-World Study. J Clin Med 2021; 10:jcm10194329. [PMID: 34640345 PMCID: PMC8509767 DOI: 10.3390/jcm10194329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/14/2021] [Accepted: 09/20/2021] [Indexed: 01/08/2023] Open
Abstract
During the COVID-19 pandemic many IBD units chose Budesonide MMX (Cortiment) as the first-line treatment for flares of ulcerative colitis (UC) in outpatients for its favourable side effect profile. This retrospective study of all UC patients treated with oral steroids between 1 March 2019–30 June 2019 and 1 March 2020–30 June 2020 aimed to compare Cortiment with Prednisolone in routine clinical practice. Outcomes included the need for hospitalisation for acute severe ulcerative colitis, symptoms at four weeks and end of treatment, and the need for rescue Prednisolone. The 2019 and 2020 cohorts did not differ at the baseline. Cortiment prescriptions rose from 24.5% in 2019 to 70.1% in 2020 (p < 0.001). At week four there were significant differences between 2019 and 2020 in mean bowel frequency (3.49 vs. 5.85, p = 0.001), rectal bleeding <50% (89.7% vs. 73.1% of patients, p = 0.039), and physician global assessment (PGA) (39.2% vs. 19.8% in remission, p = 0.045). There was no significant difference in hospital admissions, rectal bleeding, and PGA at week eight. Rescue Prednisolone was required in 10% of Cortiment patients in 2019 vs. 31.3% in 2020 (p = 0.058). Active IBD is associated with worse COVID-19 outcomes prompting the careful evaluation of the choice of first-line steroid for UC, as Cortiment was associated with worse outcomes at four weeks.
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Affiliation(s)
- Konstantina Rosiou
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals, Leeds LS9 7TF, UK; (K.R.); (E.O.M.S.)
| | - Elaine Ong Ming San
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals, Leeds LS9 7TF, UK; (K.R.); (E.O.M.S.)
| | - Aditi Kumar
- Department of Gastroenterology, Royal Wolverhampton Hospital, Wolverhampton WV10 0QP, UK; (A.K.); (K.E.); (S.A.); (D.S.); (M.B.)
| | - Kim Esquivel
- Department of Gastroenterology, Royal Wolverhampton Hospital, Wolverhampton WV10 0QP, UK; (A.K.); (K.E.); (S.A.); (D.S.); (M.B.)
| | - Saima Almas
- Department of Gastroenterology, Royal Wolverhampton Hospital, Wolverhampton WV10 0QP, UK; (A.K.); (K.E.); (S.A.); (D.S.); (M.B.)
| | - Daniel Stokes
- Department of Gastroenterology, Royal Wolverhampton Hospital, Wolverhampton WV10 0QP, UK; (A.K.); (K.E.); (S.A.); (D.S.); (M.B.)
| | - Tze Ng
- Department of Gastroenterology, St Georges Hospital, London SW17 0QT, UK; (T.N.); (N.J.); (I.R.); (R.P.)
| | - Nishani Jayasooriya
- Department of Gastroenterology, St Georges Hospital, London SW17 0QT, UK; (T.N.); (N.J.); (I.R.); (R.P.)
| | - Ian Ranasinghe
- Department of Gastroenterology, St Georges Hospital, London SW17 0QT, UK; (T.N.); (N.J.); (I.R.); (R.P.)
| | - Richard Pollok
- Department of Gastroenterology, St Georges Hospital, London SW17 0QT, UK; (T.N.); (N.J.); (I.R.); (R.P.)
| | - Matthew Brookes
- Department of Gastroenterology, Royal Wolverhampton Hospital, Wolverhampton WV10 0QP, UK; (A.K.); (K.E.); (S.A.); (D.S.); (M.B.)
- Research Institute in Healthcare Science (RIHS), University of Wolverhampton, Wolverhampton WV1 1LY, UK
| | - Christian P. Selinger
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals, Leeds LS9 7TF, UK; (K.R.); (E.O.M.S.)
- Correspondence: ; Tel.: +44-113-206-8768
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Blackwell J, Saxena S, Jayasooriya N, Bottle A, Petersen I, Hotopf M, Alexakis C, Pollok RC. Prevalence and duration of gastrointestinal symptoms before diagnosis of Inflammatory Bowel Disease and predictors of timely specialist review: a population-based study. J Crohns Colitis 2020; 15:jjaa146. [PMID: 32667962 DOI: 10.1093/ecco-jcc/jjaa146] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Lack of timely referral and significant waits for specialist review amongst individuals with unresolved gastrointestinal (GI) symptoms can result in delayed diagnosis of Inflammatory Bowel Disease (IBD). AIMS To determine the frequency and duration of GI symptoms and predictors of timely specialist review before the diagnosis of both Crohn's Disease (CD) and ulcerative colitis (UC). METHODS Case-control study of IBD matched 1:4 for age and sex to controls without IBD using the Clinical Practice Research Datalink from 1998-2016. RESULTS We identified 19,555 cases of IBD, and 78,114 controls. 1 in 4 cases of IBD reported gastrointestinal symptoms to their primary care physician more than 6 months before receiving a diagnosis. There is a significant excess prevalence of GI symptoms in each of the 10 years before IBD diagnosis. GI symptoms were reported by 9.6% and 10.4% at 5 years before CD and UC diagnosis respectively compared to 5.8% of controls. Amongst patients later diagnosed with IBD, <50% received specialist review within 18 months from presenting with chronic GI symptoms. Patients with a previous diagnosis of irritable bowel syndrome or depression were less likely to receive timely specialist review (IBS: HR=0.77, 95%CI 0.60-0.99, depression: HR=0.77, 95%CI 0.60-0.98). CONCLUSIONS There is an excess of GI symptoms 5 years before diagnosis of IBD compared to the background population which are likely attributable to undiagnosed disease. Previous diagnoses of IBS and depression are associated with delays in specialist review. Enhanced pathways are needed to accelerate specialist referral and timely IBD diagnosis.
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Affiliation(s)
- J Blackwell
- Dept. Gastroenterology, St George's Healthcare NHS Trust, St George's University London, UK
| | - S Saxena
- School of Public Health, Imperial College London, London, UK
| | - N Jayasooriya
- Dept. Gastroenterology, St George's Healthcare NHS Trust, St George's University London, UK
| | - A Bottle
- School of Public Health, Imperial College London, London, UK
| | - I Petersen
- Dept. Primary Care and Population Health, University College London, London, UK
- Dept. Clinical Epidemiology, Aarhus University, Denmark
| | - M Hotopf
- Institute of Psychiatry, Kings College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - C Alexakis
- Dept. Gastroenterology, St George's Healthcare NHS Trust, St George's University London, UK
| | - R C Pollok
- Dept. Gastroenterology, St George's Healthcare NHS Trust, St George's University London, UK
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