DAY 2: The Future of IBD Clinical Practice

Corey A. Siegel, MD, MS, from Dartmouth Hitchcock Medical Center, delivered the Berk Lecture, “Redesigning the Delivery of IBD Care for the Future.” He identified five major concerns in the GI field that need to be addressed. First, the number of people with IBD is going to continue to grow, affecting an estimated 1 in every 100 people by 2030. In addition, GIs are not co-located with patients, and training more GIs faster is not going to fill this need. Second, Dr. Siegel suggested that patients are being undertreated and not treated early enough, before IBD complications arise. As of 2021, only 14% of patients with CD and 6% of patients with UC had ever used any advanced IBD therapy in the first 2 years since diagnosis, but more than 80% had been on corticosteroids. Third, he acknowledged that IBD treatment is getting significantly more complex, with an explosion of treatment options in the last 5 years. This has led to decision paralysis, with GIs trying to remember all the details on what treatment might be best for each patient. Fourth, Dr. Siegel explained that good IBD care is multidisciplinary, but multidisciplinary care is hard to operationalize. He referred to the “IBD disk” that captures the 10 domains that describe the burden of IBD on patients, but only 2 domains are routinely treated by GIs – abdominal pain and bowel movement frequency. The remaining 8 domains also need to be considered (e.g., energy level, joint pain, body image, emotions, sleep, etc.), but GIs do not have time to ask patients or address these other domains. Finally, Dr. Siegel described that GIs are disincentivized to spend more time in clinic with patients, leading to too much “phone on the shoulder” time in the endoscopy suite trying to take care of all of their patients’ needs.

Dr. Siegel asked “Should IBD be managed by all GIs?” He suggested that a subspecialty in IBD needs GIs who want to and are comfortable with aggressive and early treatment, with the ability to dedicate time and attention to caring for IBD patients. He noted a similar evolution of the oncology field, which shifted toward sub-specialization in specific cancer types when treatment became highly complex.

Other possible approaches to addressing the 5 issues above include the use of telemedicine and virtual clinics to reduce barriers to IBD care, diversification of specialist teams to include multidisciplinary health care professionals, integration of advanced practice providers (APPs) into clinics to ease the clinical burden, and support of healthcare innovations such as remote monitoring.

Dr. Siegel described an approach at Dartmouth that applies a hub and spoke model to GI practice and turns the traditional referral pathway upside down. The initiative, IBD RADIUS (Rural APPs Delivering IBD Care in the United States) addresses three key observations: advanced IBD therapies are used more often in urban areas, rural providers (who are mostly APPs) are less comfortable with using advanced IBD therapies, and transportation is an obstacle to multidisciplinary care. Most patients must drive up to 4 hours to get to Dartmouth, the only IBD center available north of Massachusetts.

In the IBD RADIUS initiative, a patient has an initial in-person consultation at Dartmouth (a hub), seeing the GI, a dietician, a psychologist, and a pharmacist, then continues with routine follow-up with APPs at their local community clinic (spoke). The hub Coordinator and GI at Dartmouth meet with spoke APPs every 1-2 months, run through the list of patients, and provide 1:1 mentoring, similar to fellowship training. Patients can return to Dartmouth if needed, but it rarely happens. This flips the current referral pattern, with diagnosis made by a specialist and initial care and education provided by their multidisciplinary team, then referral to a local provider in the community for continuation of care.

Early outcomes in 365 patients found that 86% were optimized or initiated on an advanced IBD therapy, and 92% were improved by insurance. The program has been expanded to three additional hubs (Vanderbilt, University of Colorado, and Oregon Clinic), with spokes that reach deep into rural areas. 

Papers of interest:
Sameer K. Berry, MD, MBA, from NYU Langone Health, described the evaluation of a Virtual Multidisciplinary Clinic (VMC) in a propensity-matched prospective observational study. Multidisciplinary GI care has been shown to improve outcomes but also increases costs, and is difficult to provide outside a tertiary center setting. The VMC combines telehealth with multidisciplinary care from GI specialists, dieticians, and mental health professionals to improve access and reduce costs. A total of 1,491 patients with various GI diagnoses were enrolled into the VMC for 1 year. Pre/post surveys found significant improvements in patient experience and access to care, as well as patient satisfaction and patient reported outcomes on symptom severity and symptom control. Future studies are focused on integrating the VMC with in-person care and identifying model components associated with improved patient satisfaction.

In a companion poster, Dr. Berry reported on the study’s findings for a subset of 120 adults with IBD. In 1 year, patients enrolled in the VMC had a mean of 11 visits and exchanged 164 messages, 86% received care from dietitians and 68% from psychologists. Compared to baseline, patients in the VMC experienced significant reductions in symptom severity and improvements in symptom control, and 98% indicated that they were satisfied with care. Relative to controls, patients enrolled in the VMC showed decreased GI-related healthcare utilization (for GI surgery, ED visits, inpatient stays, endoscopy, and imaging) which translated to annual cost savings of $16,751 and prescription cost savings of $12,426. (P1152)

Laurie Keefer, PhD, FACG, from the Icahn School of Medicine at Mount Sinai, described the results of a comparative effectiveness trial of low-touch (TECH) and high-touch (TEAM) models of a subspeciality IBD “medical home” that would provide clinical and emotional support. The TEAM model provides behavioral care delivered in person by social workers and psychologists, whereas the TECH intervention provides patients with digital tools for behavioral health support. The trial included 657 patients with confirmed CD and mild to severe behavioral health symptoms (depression and anxiety). At 1-year follow-up, both models were associated with a decrease in IBD symptom and behavioral symptom severity, and increases in quality of life and self-efficacy. The study concluded that digital “low-touch” tools are as effective as high-touch care and could alleviate some of the burden and cost of the current high-touch approach to multidisciplinary IBD care. Future work will focus on identifying patients who may benefit most from each intervention, for example, based on age and disease severity.

Michael Mills, MD, MPH, FACG, from the University of Arizona, Arizona Digestive Health/GI Alliance, reported the results of a 6-month pilot study of a novel IBD dashboard to improve patient adherence to care. The IBD dashboard aggregates real-time EMR information; users can search for specific patient demographics, lab results, medications, last visit date, and colonoscopy results. The dashboard also reports key performance indicators such as annual patient attrition rate, annual laboratory protocol adherence, colonoscopy completion rate every 2 years for those on advanced therapy, and advanced therapy use in high-risk patients. For the pilot study, EMR data for 9,795 patients with IBD from 6 practices in 4 states were loaded into the dashboard. Use of the IBD dashboard decreased patient attrition from 33% to 26%, increased lab testing from 23% to 26%, increased colonoscopy completion from 63% to 67%, and increased treatment with advanced therapy from 25% to 28%. Of 501 patients identified in the dashboard as inactive, 407 patients returned to care and 89% of these patients were put on advanced therapy or had a therapy change.