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A Structured Care Pathway Improves Quality of Care for Acute Severe Ulcerative Colitis
AGA Abstracts
FIT positive colonoscopy compared to direct colonoscopy (50.5% vs 37.2%; adjusted OR 1.83, 95% CI: 1.38 - 2.42; p<0.001) (Table 1). Mean male-specific ADR was also higher among colonoscopy for positive FIT versus direct colonoscopy (65.4% vs 43.3%; adjusted OR 2.19, 95% CI: 1.55 - 3.09; p<0.001). Likewise, FIT positive colonoscopy has higher mean overall AADR than direct colonoscopy (22.3% vs 5.9%; adjusted OR 4.86; 95% CI: 3.08 - 7.66; p<0.001). Finally, overall APC was 1.2 in colonoscopy for positive FIT, which was significantly higher than the APC of 0.8 in direct colonoscopy (adjusted OR 1.59; 95% CI: 1.39 - 1.82; p<0.001). Conclusions: The ADR, AADR and APC were higher in FIT positive colonoscopy compared to direct screening colonoscopy. Higher ADR targets maybe warranted as quality indicators for endoscopists performing colonoscopy for positive FIT. Table 1: Comparison of ADR, AADR and APC between direct screening colonoscopy versus FIT positive colonoscopy
measured included length of stay, time till seen by GI team, stool C&S and C Difficile being sent, endoscopy during admission, steroid prescription, bone protection, VTE prophylaxis, dietician referral, IBD nurse referral, weight recording, stool chart recorded, PFA on admission and investigation of anaemia Results A total of 67 patients with a primary discharge diagnosis of colitis were identified. 26 patients were excluded (elective admission for surgery or endoscopy). 41 patients were considered eligible for further study. The outcomes in this cohort were compared to those in the January 2010-November 2011 study and later to the UK IBD Audit 2014 (Fig 1). M:F ratio 25:16 (61%:39 vs 68%:32%). Median age was 32 (+/- 13.8) vs 47 (+/−17.68). Notable results included a statistically significant reduction in hospital length of stay (mean 7 days vs 13 days, log rank p<0.001). There was also a significant reduction in time to administration of VTE prophylaxis (log rank p<0.0001). Otherwise, there were improvements in patients who: Were seen by a specialist gastrointestinal team within 1 day (87.8% vs 78.9%) Had stool samples sent for culture, sensitivity and C Difficile (85.4% vs 76.9%). Were prescribed bone protection(97.6% vs 73%). Were seen by an IBD specialist nurse during admission (63% vs 10%). Had anaemia evaluated (70.6% vs 28.6%). Had a CRP measured on admission (98% vs 61%). Conclusion The introduction of a structured care pathway for ASUC resulted in an overall improvement in inpatient care and adherence to UK IBD Audit recommendations, with a significant reduction in hospital length of stay.
Sa1007 DEVELOPMENT AND VALIDATION OF A NOVEL, SEMI-AUTOMATED ADENOMA DETECTION RATE REPORTING SYSTEM UTILIZING NATURAL LANGUAGE PROCESSING IN A VETERANS AFFAIRS GASTROENTEROLOGY DEPARTMENT Richard M. Wu, David E. Kaplan, Nabeel Khan ADR: Adenoma detection rate, AADR: Advanced adenoma detection rate; APC: Adenoma per colonoscopy, FIT: Fecal immunochemical test, OR: Odds ratio *adjusted for age, sex, diabetes, ASA/NSAID use, smoking status, alcohol use, body mass index
Purpose: The Veterans Affairs is the largest integrated healthcare system in the United States but currently does not have a standardized automated Adenoma Detection Rate (ADR) reporting system for quality reporting among gastroenterologists. We aim to develop, validate and prospectively implement a semi-automated natural language processing (NLP) program that interfaces with Veterans Affairs' electronic medical record to capture colonic adenomas detected from real time pathology reporting. Methods: Utilizing an existing clinical surveillance platform, Theradoc® (Premier Inc, Charlotte,NC), a NLP program with Boolean search was developed via a prospective iterative process to automatically capture real time pathology reporting as well as endoscopic variables derived from EndoSoft® (EndoSoft LLC, Schenectady,NY) text reporting into the ViSTA architecture. The variables automatically captured include endoscopist name, colonoscopy indication (screening, surveillance, and diagnostic), and pathological categorization of detected colonic polyps. The total numbers of screening, surveillance and diagnostic colonoscopies were confirmed using existing EndoSoft® queries. Adenomas detected per indication for each gastroenterologist was calculated with the platform and cross validated with manual review of colonoscopies performed and its associated pathology. Results: A 6 week validation period captured a total of 135 adenomas over 291 colonoscopies (including 12 flexible sigmoidoscopies) via this platform. The overall ADR was 47%, including 46% for screening colonoscopy (range 27-67%), 52% for surveillance colonoscopy, and 39% for diagnostic colonoscopy. The pathological validation revealed minimal discrepancies in adenoma reporting. 100% of all adenomas, tubulovillous adenomas, sessile serrate polyps, or adenocarcinomas were correctly captured. There were no incidents of false positive detection of hyperplastic polyps. The screening colonoscopy adenoma detection rate was identical with the NLP method versus manual validation. A preoperative diagnosis of "polyposis" without neoplastic findings in 1/136 cases triggered a false positive detection, resulting in iteration of the NLP coding. Pathology report addendums after initial reporting can result in double-counting, currently requiring manual review; however, modification of data processing likely can obviate this obstacle to full automation. Requirements for specific field reporting by endoscopic software preclude retrospective calculation of ADRs from time periods prior to implementation. Conclusions: A semi-automated NLP-based ADR reporting program is feasible and accurate in the Veterans Affairs electronic medical record system. Further refinement will likely yield a fully automated ADR reporting process.
Sa1005 PATIENTS CARED FOR IN AN INTEGRATED ACADEMIC IBD PRACTICE HAVE LOWER READMISSION RATES: A KEY QUALITY INDICATOR David Hudesman, Shannon Chang, Lisa Malter, Jessica Kimmel, Vineet S. Rolston, Brian P. Bosworth Background: Direct medical costs for the treatment of inflammatory bowel disease (IBD) in the United States are greater than $6 billion per year. Average treatment costs are estimated to be greater than $8000 and $5000 per patient per year for Crohn's disease and ulcerative colitis, respectively; 30% to 40% of these costs are tied to hospitalizations. Large practice variations exist between community gastroenterologists and academic IBD physicians in the care of both outpatient and IBD patients. In this study, we compared hospital admission rates, readmission rates, and costs between our academic, integrated IBD practice and a group of community gastroenterologists. Methods: We compared 909 IBD patients treated by our academic, integrated IBD practice and 899 IBD patients treated by community gastroenterologists from November 2015 to October 2016. The cumulative admission rates and readmission rates were determined using hospital billing records and medical record numbers. Readmission was defined as any unanticipated, repeat hospitalization within 30 days of discharge in accordance with CMS rules. Results: The percentage of patients admitted in both the academic and community practices were not significantly different (16.61% vs 17.58% respectively). However, the readmission rate for the IBD practice was <1% as compared to 12% for the community gastroenterologists. The absolute reduction in readmission rate of 11%. Based on CMS data the average cost for a readmission for any given cause is $11,200 which translates to an annual cost reduction of approximately $265,000 for IBD readmissions. Conclusion: Comprehensive, integrated care by an academic IBD practice can reduce hospital readmissions, thus reducing hospital expenditure and improving quality of care. Hospital readmissions not only interrupt patients' work and home lives but also place patients at increased risk of infections and complications. In this study, an integrated, academic IBD practice had lower readmission rates as compared to community gastroenterologists. Integrated IBD teams including gastroenterologists, nurses, surgeons, dieticians, psychologists, and others, in centers of excellence optimizing care and providing support for patients suffering from IBD [2]. An integrated IBD practice may improve patient care by facilitating physician collaboration, increasing patient accessibility to providers, and optimizing treatment. 1. Rizzo E. Six stats on the cost of readmission for CMS-tracked conditions. Beckers Hospital Review 2013. Available at: http://www.beckershospitalreview.com/quality/ 6-stats-on-the-cost-of-readmission-for-cms-tracked-conditions.html. 2. Panes J, O'Connor M, Peyrin-Biroulet L, Irving P, Petersson J, Colombel JF. Improving quality of care in inflammatory bowel disease: what changes can be made today? J Crohns Colitis. 2014;8(9):919-26. doi:10.1016/j.crohns.2014.02.022.
Sa1008 EARLY USE OF THERAPEUTIC DRUG MONITORING TO INDIVIDUALIZE INFLIXIMAB THERAPY IN PAEDIATRIC IBD: A MULTICENTRE PROSPECTIVE COHORT STUDY Eileen Crowley, Nicholas Carman, Valerie Arpino, Karen Frost, Amanda Ricciuto, Mary Sherlock, Jeffrey Critch, David R. Mack, Eric Benchimol, Kevan Jacobson, Sally Lawrence, Jennifer deBruyn, Wael El-Matary, Anthony Otley, Hien Q. Huynh, Peter Church, Thomas D. Walters, Anne M. Griffiths BACKGROUND: Therapeutic drug monitoring (TDM) during infliximab (ifx) maintenance therapy is regularly used in Canadian IBD centres both to assess loss of response and allow dose optimization, with pre-infusion trough levels in the range of 5-10 ug/ml recommended as targets. Levels achieved at the start of maintenance among pediatric patients are highly variable, and often suboptimal even at week 12. Limited data exist in adults or children concerning the role of TDM and target levels during induction. Within the Canadian Children IBD Network (CIDsCANN), we proposed to measure ifx levels during induction, aiming to determine the optimal levels required to achieve target 5-10 ug/ml at the start of maintenance. METHODS: Beginning in May 2016, children initiating ifx at SickKids Hospital and at other centres within the CIDsCANN inception cohort study had trough levels measured by ELISA at the time of the of final induction and first maintenance infusions (doses 3 and 4). Induction regimens were at the discretion of the treating physician, but often intensified among patients with severe UC. Influence of patient demographics and baseline clinical disease activity (physician global assessment and wPCDAI or PUCAI) on early trough levels were assessed. Physicians were advised to consider administering first maintenance dose early if IFX level prior to dose 3 suggested such need. RESULTS: From May to December 2016 at 9 participating sites, 66 children (median age 11.8 years, 53% male, 52% CD, 48% UC/IBD-U were included. Time to biologic therapy was 4.3 mos (IQR 0.2 - 13.5 mos). Induction regimen was "standard" (0,2, 6 weeks) in 77% and intensified in 23% (O,1, 4 weeks; all steroid refractory colitis).
Sa1006 A STRUCTURED CARE PATHWAY IMPROVES QUALITY OF CARE FOR ACUTE SEVERE ULCERATIVE COLITIS Barra P. Neary, Glen A. Doherty Background The UK IBD Audit 2014 identified important deficiencies in the care of hospitalised patients with Acute Severe Ulcerative Colitis (ASUC). Our aim was to assess whether the introduction of a structured inpatient care pathway improves adherence to the UK IBD Audit guidelines and improves patient care. Methods A retrospective review of all patients admitted with ASUC between January 2010-November 2011 identified areas for improvement of inpatient care. As a result, a structured pathway was introduced to be used for all admissions for ASUC. A further review of admissions with ASUC was conducted following the introduction of an integrated care pathway from July 2015-September 2016. A comparison was made of key outcomes and quality measures at baseline and following introduction of the care pathway. Comparison was also made with the UK IBD Audit, 2014. Key outcomes
AGA Abstracts
S-218
FIT positive colonoscopy compared to direct colonoscopy (50.5% vs 37.2%; adjusted OR 1.83, 95% CI: 1.38 - 2.42; p<0.001) (Table 1). Mean male-specific ADR was also higher among colonoscopy for positive FIT versus direct colonoscopy (65.4% vs 43.3%; adjusted OR 2.19, 95% CI: 1.55 - 3.09; p<0.001). Likewise, FIT positive colonoscopy has higher mean overall AADR than direct colonoscopy (22.3% vs 5.9%; adjusted OR 4.86; 95% CI: 3.08 - 7.66; p<0.001). Finally, overall APC was 1.2 in colonoscopy for positive FIT, which was significantly higher than the APC of 0.8 in direct colonoscopy (adjusted OR 1.59; 95% CI: 1.39 - 1.82; p<0.001). Conclusions: The ADR, AADR and APC were higher in FIT positive colonoscopy compared to direct screening colonoscopy. Higher ADR targets maybe warranted as quality indicators for endoscopists performing colonoscopy for positive FIT. Table 1: Comparison of ADR, AADR and APC between direct screening colonoscopy versus FIT positive colonoscopy
measured included length of stay, time till seen by GI team, stool C&S and C Difficile being sent, endoscopy during admission, steroid prescription, bone protection, VTE prophylaxis, dietician referral, IBD nurse referral, weight recording, stool chart recorded, PFA on admission and investigation of anaemia Results A total of 67 patients with a primary discharge diagnosis of colitis were identified. 26 patients were excluded (elective admission for surgery or endoscopy). 41 patients were considered eligible for further study. The outcomes in this cohort were compared to those in the January 2010-November 2011 study and later to the UK IBD Audit 2014 (Fig 1). M:F ratio 25:16 (61%:39 vs 68%:32%). Median age was 32 (+/- 13.8) vs 47 (+/−17.68). Notable results included a statistically significant reduction in hospital length of stay (mean 7 days vs 13 days, log rank p<0.001). There was also a significant reduction in time to administration of VTE prophylaxis (log rank p<0.0001). Otherwise, there were improvements in patients who: Were seen by a specialist gastrointestinal team within 1 day (87.8% vs 78.9%) Had stool samples sent for culture, sensitivity and C Difficile (85.4% vs 76.9%). Were prescribed bone protection(97.6% vs 73%). Were seen by an IBD specialist nurse during admission (63% vs 10%). Had anaemia evaluated (70.6% vs 28.6%). Had a CRP measured on admission (98% vs 61%). Conclusion The introduction of a structured care pathway for ASUC resulted in an overall improvement in inpatient care and adherence to UK IBD Audit recommendations, with a significant reduction in hospital length of stay.
Sa1007 DEVELOPMENT AND VALIDATION OF A NOVEL, SEMI-AUTOMATED ADENOMA DETECTION RATE REPORTING SYSTEM UTILIZING NATURAL LANGUAGE PROCESSING IN A VETERANS AFFAIRS GASTROENTEROLOGY DEPARTMENT Richard M. Wu, David E. Kaplan, Nabeel Khan ADR: Adenoma detection rate, AADR: Advanced adenoma detection rate; APC: Adenoma per colonoscopy, FIT: Fecal immunochemical test, OR: Odds ratio *adjusted for age, sex, diabetes, ASA/NSAID use, smoking status, alcohol use, body mass index
Purpose: The Veterans Affairs is the largest integrated healthcare system in the United States but currently does not have a standardized automated Adenoma Detection Rate (ADR) reporting system for quality reporting among gastroenterologists. We aim to develop, validate and prospectively implement a semi-automated natural language processing (NLP) program that interfaces with Veterans Affairs' electronic medical record to capture colonic adenomas detected from real time pathology reporting. Methods: Utilizing an existing clinical surveillance platform, Theradoc® (Premier Inc, Charlotte,NC), a NLP program with Boolean search was developed via a prospective iterative process to automatically capture real time pathology reporting as well as endoscopic variables derived from EndoSoft® (EndoSoft LLC, Schenectady,NY) text reporting into the ViSTA architecture. The variables automatically captured include endoscopist name, colonoscopy indication (screening, surveillance, and diagnostic), and pathological categorization of detected colonic polyps. The total numbers of screening, surveillance and diagnostic colonoscopies were confirmed using existing EndoSoft® queries. Adenomas detected per indication for each gastroenterologist was calculated with the platform and cross validated with manual review of colonoscopies performed and its associated pathology. Results: A 6 week validation period captured a total of 135 adenomas over 291 colonoscopies (including 12 flexible sigmoidoscopies) via this platform. The overall ADR was 47%, including 46% for screening colonoscopy (range 27-67%), 52% for surveillance colonoscopy, and 39% for diagnostic colonoscopy. The pathological validation revealed minimal discrepancies in adenoma reporting. 100% of all adenomas, tubulovillous adenomas, sessile serrate polyps, or adenocarcinomas were correctly captured. There were no incidents of false positive detection of hyperplastic polyps. The screening colonoscopy adenoma detection rate was identical with the NLP method versus manual validation. A preoperative diagnosis of "polyposis" without neoplastic findings in 1/136 cases triggered a false positive detection, resulting in iteration of the NLP coding. Pathology report addendums after initial reporting can result in double-counting, currently requiring manual review; however, modification of data processing likely can obviate this obstacle to full automation. Requirements for specific field reporting by endoscopic software preclude retrospective calculation of ADRs from time periods prior to implementation. Conclusions: A semi-automated NLP-based ADR reporting program is feasible and accurate in the Veterans Affairs electronic medical record system. Further refinement will likely yield a fully automated ADR reporting process.
Sa1005 PATIENTS CARED FOR IN AN INTEGRATED ACADEMIC IBD PRACTICE HAVE LOWER READMISSION RATES: A KEY QUALITY INDICATOR David Hudesman, Shannon Chang, Lisa Malter, Jessica Kimmel, Vineet S. Rolston, Brian P. Bosworth Background: Direct medical costs for the treatment of inflammatory bowel disease (IBD) in the United States are greater than $6 billion per year. Average treatment costs are estimated to be greater than $8000 and $5000 per patient per year for Crohn's disease and ulcerative colitis, respectively; 30% to 40% of these costs are tied to hospitalizations. Large practice variations exist between community gastroenterologists and academic IBD physicians in the care of both outpatient and IBD patients. In this study, we compared hospital admission rates, readmission rates, and costs between our academic, integrated IBD practice and a group of community gastroenterologists. Methods: We compared 909 IBD patients treated by our academic, integrated IBD practice and 899 IBD patients treated by community gastroenterologists from November 2015 to October 2016. The cumulative admission rates and readmission rates were determined using hospital billing records and medical record numbers. Readmission was defined as any unanticipated, repeat hospitalization within 30 days of discharge in accordance with CMS rules. Results: The percentage of patients admitted in both the academic and community practices were not significantly different (16.61% vs 17.58% respectively). However, the readmission rate for the IBD practice was <1% as compared to 12% for the community gastroenterologists. The absolute reduction in readmission rate of 11%. Based on CMS data the average cost for a readmission for any given cause is $11,200 which translates to an annual cost reduction of approximately $265,000 for IBD readmissions. Conclusion: Comprehensive, integrated care by an academic IBD practice can reduce hospital readmissions, thus reducing hospital expenditure and improving quality of care. Hospital readmissions not only interrupt patients' work and home lives but also place patients at increased risk of infections and complications. In this study, an integrated, academic IBD practice had lower readmission rates as compared to community gastroenterologists. Integrated IBD teams including gastroenterologists, nurses, surgeons, dieticians, psychologists, and others, in centers of excellence optimizing care and providing support for patients suffering from IBD [2]. An integrated IBD practice may improve patient care by facilitating physician collaboration, increasing patient accessibility to providers, and optimizing treatment. 1. Rizzo E. Six stats on the cost of readmission for CMS-tracked conditions. Beckers Hospital Review 2013. Available at: http://www.beckershospitalreview.com/quality/ 6-stats-on-the-cost-of-readmission-for-cms-tracked-conditions.html. 2. Panes J, O'Connor M, Peyrin-Biroulet L, Irving P, Petersson J, Colombel JF. Improving quality of care in inflammatory bowel disease: what changes can be made today? J Crohns Colitis. 2014;8(9):919-26. doi:10.1016/j.crohns.2014.02.022.
Sa1008 EARLY USE OF THERAPEUTIC DRUG MONITORING TO INDIVIDUALIZE INFLIXIMAB THERAPY IN PAEDIATRIC IBD: A MULTICENTRE PROSPECTIVE COHORT STUDY Eileen Crowley, Nicholas Carman, Valerie Arpino, Karen Frost, Amanda Ricciuto, Mary Sherlock, Jeffrey Critch, David R. Mack, Eric Benchimol, Kevan Jacobson, Sally Lawrence, Jennifer deBruyn, Wael El-Matary, Anthony Otley, Hien Q. Huynh, Peter Church, Thomas D. Walters, Anne M. Griffiths BACKGROUND: Therapeutic drug monitoring (TDM) during infliximab (ifx) maintenance therapy is regularly used in Canadian IBD centres both to assess loss of response and allow dose optimization, with pre-infusion trough levels in the range of 5-10 ug/ml recommended as targets. Levels achieved at the start of maintenance among pediatric patients are highly variable, and often suboptimal even at week 12. Limited data exist in adults or children concerning the role of TDM and target levels during induction. Within the Canadian Children IBD Network (CIDsCANN), we proposed to measure ifx levels during induction, aiming to determine the optimal levels required to achieve target 5-10 ug/ml at the start of maintenance. METHODS: Beginning in May 2016, children initiating ifx at SickKids Hospital and at other centres within the CIDsCANN inception cohort study had trough levels measured by ELISA at the time of the of final induction and first maintenance infusions (doses 3 and 4). Induction regimens were at the discretion of the treating physician, but often intensified among patients with severe UC. Influence of patient demographics and baseline clinical disease activity (physician global assessment and wPCDAI or PUCAI) on early trough levels were assessed. Physicians were advised to consider administering first maintenance dose early if IFX level prior to dose 3 suggested such need. RESULTS: From May to December 2016 at 9 participating sites, 66 children (median age 11.8 years, 53% male, 52% CD, 48% UC/IBD-U were included. Time to biologic therapy was 4.3 mos (IQR 0.2 - 13.5 mos). Induction regimen was "standard" (0,2, 6 weeks) in 77% and intensified in 23% (O,1, 4 weeks; all steroid refractory colitis).
Sa1006 A STRUCTURED CARE PATHWAY IMPROVES QUALITY OF CARE FOR ACUTE SEVERE ULCERATIVE COLITIS Barra P. Neary, Glen A. Doherty Background The UK IBD Audit 2014 identified important deficiencies in the care of hospitalised patients with Acute Severe Ulcerative Colitis (ASUC). Our aim was to assess whether the introduction of a structured inpatient care pathway improves adherence to the UK IBD Audit guidelines and improves patient care. Methods A retrospective review of all patients admitted with ASUC between January 2010-November 2011 identified areas for improvement of inpatient care. As a result, a structured pathway was introduced to be used for all admissions for ASUC. A further review of admissions with ASUC was conducted following the introduction of an integrated care pathway from July 2015-September 2016. A comparison was made of key outcomes and quality measures at baseline and following introduction of the care pathway. Comparison was also made with the UK IBD Audit, 2014. Key outcomes
AGA Abstracts
S-218