- Email: [email protected]
Sa1298 Telephone Encounters in Inflammatory Bowel Disease Patient Management
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disease (Montreal classification, Harvey Bradshaw index), perianal disease (UFS classification, PDAI) and ongoing treatments were prospectively collected. The description of ulcerations and their healing rates were analyzed. Results: A total of 154 patients (male =55, female = 99; mean age 36 ± 16 years) had at least, one anal ulceration : it was one or more severe ulcerations (U2) in 77 cases. Mean follow-up was 84 ± 86 weeks but 15 were examined once. The ulcerations were associated with suppuration (with surgical drainage) or anal stenosis in 87 (57%) and 40 (26%) patients respectively. The treatment for CD was infliximab, adalimumab, and azathioprine in 109 (71%), 44 (29%) and 111 (77%) patients respectively. The mean time to healing of ulcerations was 56±74 weeks: 45 (32%) patients did not heal permanently at the end of follow-up. New surgical drainage was performed in 37 (43%) patients but only 4 of 36 patients (11%) with initially non-fistulizing disease had suppurative complication de novo. Patients in whom anal ulcerations persisted, had, at follow-up, a higher Harvey Bradshaw score (4 ± 21 vs. 2± 13) and a higher PDAI (6 ± 20 vs. 1 ± 10), but they had less surgical drainage and surgical reconstruction. Multivariate analysis showed, that the nature of the ulceration (U2) (but not therapeutic interventions: biotherapy, surgery) was associated with a lower chance of healing (OR 0.275, 95% CI: 0.09 to 0.85, p <0.05). Conclusion: Anal ulcerations of CD are associated with suppuration in more than half cases and suffered from a more severe disease activity on both luminal and anal locations. A third has not healed after 18 months of follow-up (including U2). These findings call for trials specifically focused on the treatment of anal ulcerations.
AGA Abstracts
Predictors for Subsequent Need for Immunosuppressive Therapy in Early Ulcerative Coltis Carsten Schmidt, Luisa Beltz, Bernd Bokemeyer, Dietrich Hueppe, Wolfgang Kruis, Susanna Nikolaus, Jan C. Preiss, Andreas Sturm, Niels Teich, Andreas Stallmach Background and Aims: The clinical course of ulcerative colitis (UC) is highly variable with a subgroup of patients developing a progressive disease course necessitating immunosuppressive therapy (IT). However, reliable, stable and non-invasive individual clinical parameters in order to identify patients at risk for undergoing subsequent IT have not yet been sufficiently established. We therefore aimed to identify such clinical parameters. Methods: A retrospective, multicenter analysis of UC patients from 8 German tertiary IBD centers was performed. Patients were classified into two groups depending on requiring IT or not. Personal data, clinical and laboratory parameters during the first 3 months after initial UC diagnosis as well as effects of initial medical therapy were compared between these two groups. Results: In 104 (39.7%) of the 262 patients the UC course necessitated IT. Those patients were significantly more often hospitalized at the first flare of UC, suffered from extraintestinal manifestations more often, had a greater extent of UC, required significantly more often a systemic corticosteroid therapy and responded less well to this treatment. Furthermore, significant differences in serological markers of inflammation were observed. Age at diagnosis (OR 0.981 per year), gender (OR 1,33 for women), extent of the disease (OR 1,4-2,1 compared to proctitis), need for hospitalisation (OR 2,5) or steroid therapy at the first flare (OR 2,4) and the effect of initial steroid therapy (OR 5,2 - 50,8 compared to no streoids) were used to develop a prognostic model predicting the individual probability of necessitating immunosuppressive therapy during the course of UC. This probability ranges from less than 2% up to 100% after 5 years, depending on the presence of individual risk factors. Conclusions: The simple clinical items age at diagnosis, gender, extent of disease, need for hospitalisation or systemic steroid therapy at the first flare and effect of initial steroid therapy can predict a progressive disease course in early UC. Our model based on these parameters allows an individualized estimation of each patient's risk to develop a progressive disease course. Thereby, our model can help in deciding if patients will need immunosuppressive drugs early in the disease course or if immunosuppressive therapy can be avoided.
Sa1297 The Relationship Between Perceived Psychological Support, Health-Related Quality of Life, and Disease Activity in Newly Diagnosed Inflammatory Bowel Disease Patients Kristy L. Engel, Karla Helvie, Jeremy Adler, Ellen Zimmermann, Caitlyn M. Plonka, Rie Suzuki Individuals adjusting to the diagnosis of inflammatory bowel disease (IBD) encounter diseaserelated obstacles that can affect their physical, mental, and social health. Education and psychological support can mitigate these negative effects. The purpose of the study was to examine the relationship between patient's perceived psychological support, health-related quality of life, and disease activity. We tested the hypothesis that patients who are satisfied with their psychological support will report a higher health-related quality of life (HRQOL) and improved disease activity. Methods: Patients were at least fourteen years of age with an IBD diagnosis within three years. HRQOL was measured using the Short Form Inflammatory Bowel Disease Questionnaire (SIBDQ). Patients' perceived psychological support was measured using a modified Medical Outcomes Study-Social Support Survey (GI MOSS). Crohn's disease activity (HBI, PCDAI) and ulcerative colitis activity (SCCAI, PUCAI) were measured. The Spearman Rho correlation and logistical regression were used in data analysis. Results: Sixty-two patients completed the survey ranging in age from 17 to 72 years: 44% female; 56% male. 37% had Crohn's disease (n=23), 59% ulcerative colitis (n=37), and 3% indeterminate colitis (n=2). Patient preferences for medical information were selected from a list of options. Fifty-three percent of patients preferred receiving written information in booklet form, 50% preferred visiting disease specific websites, 40% preferred an IBD informational pamphlet, 39% wanted the option of meeting with a health educator following diagnosis, and 39% wanted to be able to communicate directly with their gastroenterologist by email. Patients expressed receiving the emotional and psychological support they needed “Sometimes” (29%), “Always” (27%), “Usually” (17%), “Rarely” (17%), and “Never” (10%). Patients highlighted the lack of psychological support in their current treatment plans (82%). Finally, patients expressed a perceived benefit of counseling if it was provided (37%). There was no relationship detected between the perceived psychological support (GI MOSS) and SIBDQ (R=0.20, p=0.12). Additionally, no relationship was present between psychological support and disease activity with Crohn's disease patients (R= -0.31, p=.18) or ulcerative colitis patients (R= -0.12, p=.47). As expected SIBDQ strongly correlated with disease activity (ulcerative colitis: R= -0.76, p<.0001; Crohn's disease: R= -0.56, p=.0076). Conclusion: Newly diagnosed IBD patients crave information and psychological support. A variety of methods of communication are cited. Many patients lack emotional and psychological support which is not part of most patient's treatment plan. Our study did not support a link between perceived psychological support and disease activity or health-related quality of life.
Sa1295 Development of Process and Outcome Quality Indicators for Inflammatory Bowel Disease (IBD) Gil Melmed, Corey A. Siegel, Brennan M. Spiegel, John I. Allen, Robert R. Cima, JeanFrederic Colombel, Themistocles Dassopoulos, Lee Denson, Sharon Dudley-Brown, Andy Garb, Stephen B. Hanauer, Michael Kappelman, James D. Lewis, Isabelle Lynch, Amy Moynihan, David T. Rubin, Ryan B. Sartor, Ronald Schwartz, Douglas C. Wolf, Thomas A. Ullman Introduction: Variations in adherence to management guidelines for IBD suggest variable quality of care. Quality indicators (QIs) can be developed to measure the structure, processes and outcomes of health care delivery; implementing these QIs may limit variations in care and ultimately improve quality of care. The RAND/UCLA appropriateness method, a widely utilized, evidence-based, iterative approach used to establish QIs in several chronic illnesses was utilized to develop a set of Process and Outcome QIs to define quality of care for IBD. Methods: Guidelines and position papers for IBD published from 2006-2011 were reviewed for potential QIs. These were rated by a multidisciplinary panel comprised of representatives of the ACG, AGA, CCFA, and ECCO, with academic and private practice physicians, nurses, and patients. Potential Process and Outcome QIs were discussed at 3 moderated in-person meetings, with pre- and post-meeting confidential electronic voting. Panelists rated the validity and feasibility of QIs on 1-9 scale; disagreement was assessed using a validated index. QIs rated >7 underwent literature review for evidence linking processes to an outcome, and the resulting 135-page compendium was distributed to panelists. QIs rated above 8 were selected for the final set. Results: Over 600 potential Process QIs were extracted from Guidelines. Following ratings and discussion by the first panel, 35 process QIs were selected for literature review in categories of diagnosis, treatment, drug safety, healthcare maintenance, surgery, and cancer prevention. After the second panel, 10 Process QIs were included in the final set. Highly rated Process QIs included advocating avoidance of long-term steroids by recommending steroid-sparing therapy or surgery, TB testing in those initiating antiTNF therapy, testing for C difficile with flares, use of aminosalicylates in patients with mildmoderate colitis, and colectomy or reassessment of low grade dysplasia in UC. Candidate Outcome QIs were then derived from Process QIs, as well as from physician, nurse, and patient input before a moderated third and final panel. Outcomes were rated in the categories of disease activity, health-related quality of life, healthcare utilization, and preventable complications. Highly rated Outcome QIs included steroid-free clinical remission, days lost from work/school, ER visits and hospitalization for IBD, and incontinence episodes. None of the top QIs exhibited disagreement. Conclusion: A set of QIs for IBD was developed with expert interpretation of the literature, and multidisciplinary input. Outcome QIs focused largely on remission and quality of life while process QIs were aimed at therapeutic optimization and patient safety. Evaluation of these QIs in clinical practice is needed to assess the correlation of performance on process QIs with performance on outcome QIs.
Sa1298 Telephone Encounters in Inflammatory Bowel Disease Patient Management Miguel Regueiro, Claudia M. Ramos Rivers, Anwar Dudekula, Linda Kontur, Eva Szigethy, Michael A. Dunn, Arthur Barrie, Marc Schwartz, Jason M. Swoger, Leonard Baidoo, David G. Binion Introduction: Management of complex chronic diseases, including inflammatory bowel disease (IBD; Crohn's disease, ulcerative colitis) requires regular office visits, occasional hospitalizations and frequent telephone communication between patients, health care providers and insurers. The majority of telephone contact in healthcare is unreimbursed and will often require considerable effort on the part of nurses/support staff, in addition to physician time. There is limited data regarding the nature of telephone calls encountered in the management of IBD, as well as the reasons for calls and the distribution of calls among patients. Methods: This study utilized the IBD center database at an academic referral center. Administrative data on telephone calls received and performed by IBD nursing staff over a 2 year period was prospectively tabulated and categorized based on the nature of the call: problem/ followup, resolution/plan, refill request, insurance authorization, completion of forms, record request. Telephone encounters recorded in an electronic medical record over a 10 month time period in a consented IBD patient registry were analyzed, including patient disease demographics. Results: The number of telephone calls received/made by the IBD nursing staff rose from 21,979 in 2009 to 32,667 in 2010 (p<0.0001). This corresponded with a 26% rise in the IBD patient population seen during those years from 2475 to 3118. The monthly call volume in 2009 was 1831, ranging from 1588 (January) to 2130 (December). In 2010, monthly call volume rose to 2722, ranging from 2077 (January) to 3297 (July). Over the two years 44% of telephone calls were problem/followup, 25% were resolution/ plan, 12% were refill requests, 10% were insurance authorizations and the remaining were
Sa1296 Anal Ulceration in Crohn's Disease: Natural History at the Time of Biotherapy Timothee Wallenhorst, Guillaume Bouguen, Isabelle Berkelmans, Jean-François Bretagne, Laurent Siproudhis Background: Anal ulcerations represent one of the characteristics of perianal Crohn's disease (CD), but their natural history is poorly understood. Using the largest published series of anal ulcerations, the aim of this study was to clarify their outcomes at the time of biotherapy. Methods: Clinical features of 282 consecutive patients constituted a single-centered prospective database of anal lesions of CD (from 01 /01/2007 to 08 /30/2011). The data for luminal
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as it relates to QOL and styles of coping in persons caring for adult patients with IBD. Methods: Adult patients with IBD at 6 tertiary centers were identified and asked if they had a caregiver. Caregivers refer to parent, spouse, significant other, child (over age 18), sibling, or friend. If a caregiver was present at the visit, he/she was asked to fill out an anonymous survey. Survey consisted of demographics, QOL Scale, Zarit Burden Interview to assess level of stress from acting as caregiver, and Brief COPE to assess how caregiver copes with stress. Results: Cohort included 162 patients with mean age of 49, 67% female, 79% were Caucasian and 73% living in the same home. Caregiver breakdown was 51% spouse, 23% parent, 17% child, 5% significant others, 2% sibling and 2% friend. Education level was 54% completing high school and 25% completing college, with 47% working full time and only 1.2% stopped working because of caregiving responsibilities. Sixty percent reported religious involvement and 68% reported having more than one dependent in the home. Caregivers reported 58% of loved ones had Crohn's disease and 36% with UC with a mean of 9.3 years since diagnosis and caring for mean of 8.1 years. Twenty percent of caregivers reported a psychiatric illness and 24% sought professional consultation. Female caregivers reported more adaptive coping skills(p<.0002). Caregivers who participated in religious activities also reported more adaptive coping skills but also a higher index of burden (p<.05). QOL was lower and burden was higher for those who took care of more severely ill patients (p<.05). Caregivers with psychiatric illness reported more adaptive coping with a lower QOL p<.05). Attending a support group was significantly correlated to greater use of both maladaptive and adaptive coping skills (p<.05). Having more than one dependent correlated with higher burden (p<.02). There was no association between coping, QOL or burden with type of IBD, years of disease, number of years caring for IBD patient or surgery. Conclusions: Certain characteristics appear to pre-dispose caregivers of IBD patients to greater level of burden. Further research is warranted in identifying means of support for caregivers to improve their lives as well as the overall care for IBD patients.
Sa1299 Coronary Artery Disease in Inflammatory Bowel Disease: A Look at the Percutaneous Coronary Intervention Outcomes Ashish Aggarwal, Ashish Atreja, Samir Kapadia, Jean-Paul Achkar Introduction There is evidence of increased risk of premature coronary artery disease (CAD) in inflammatory diseases like systemic lupus erythematosus (SLE) and inflammatory bowel disease (IBD). Also, outcomes after Percutaneous coronary intervention (PCI) have been found to be worse in SLE patients. Little is known regarding PCI outcomes in IBD patients with CAD. Objectives To compare traditional risk factors in patients with and without IBD and angiographically proven CAD. To compare PCI outcomes in IBD patients and non IBD patients. Methods We identified adult IBD patients who were diagnosed with CAD on cardiac catheterization. Patients with other inflammatory diseases were excluded. Four non-IBD controls were gender, index date, race matched to each IBD case. Data on patient demographics, clinical characteristics, laboratory values, cardiovascular risk factors, catheterization findings, Framingham Risk Score (FRS), and PCI cardiovascular outcomes were extracted. Results: 131 IBD cases with CAD (97 males, 54 Crohn's disease) and 517 non-IBD CAD controls were included. There were no differences with respect to prior myocardial infarction (24 % vs 22%, p= 0.76), prior cerebrovascular events (5% vs 8%, p=0.35), prevalence of hypertension, or diabetes between the two groups (Table 1). The IBD cohort was significantly less likely to have traditional CAD risk factors such as older age (65.3 + 10 years of IBD pts vs 67.8 + 11.3 years, p = 0.01), active smoking (10.69 % vs 18.76%, p= 0.02), high LDL (85.6 + 31.4 vs 92.8 + 38. 4, p = 0.04). IBD patients also weighed less compared to controls (82.5 + 18.9 kg vs 86.4 + 20.3 kg, p = 0.04). The 10 year CAD risk predicted by FRS based on traditional risk factors was lower in the IBD group compared to controls (12.8 + 8.4% vs 14.1 + 9.2%, p = 0.06). There was no significant difference in frequency of triple vessel disease between the 2 groups (44% vs 50%, p=0.17). 31% of IBD patients with CAD underwent PCI as compared to 39% of non IBD patients. Multivariate cox regression analysis showed no difference in the major adverse cardiovascular events (including mortality, recurrence of MI, and need for repeat vascularization) or stent thrombosis following PCI, in the two groups (Table 2). Conclusions: IBD patients are likely to develop coronary artery disease at a younger age compared to non-IBD controls. FRS, which is based on traditional CAD risk factors, tends to be lower in IBD patients who develop CAD as compared to non IBD patients developing CAD. In addition, IBD patients have lower LDL, weigh less and are less likely to be active smokers. These findings suggest a greater role of non conventional risk factors such as inflammation in IBD patients. Outcomes of PCI in IBD patients are equivalent to those in non IBD patients. Table 1: Conventional Risk factors in IBD vs controls
Sa1301 Patterns of Clinical Recurrence and Health Care Utilization in Post-Operative Crohn's Disease: Two Year Outcomes Mahesh Gajendran, Andrew R. Watson, Wolfgang H. Schraut, Miguel Regueiro, Eva Szigethy, Michael A. Dunn, Claudia M. Ramos Rivers, David G. Binion Background: Surgery rapidly induces remission in patients with ileocolonic and small bowel Crohn's disease (CD). There are limited data regarding the durability of surgically induced remission and patterns of clinical recurrence in CD pts beyond 1 year. In addition, the patterns of specific health care utilization during CD recurrence during the present era of post-operative (post-op) maintenance therapy and stapled anastomosis have not been fully characterized. Methods: Retrospective, single referral center observational study of CD pts requiring small bowel resection/reanastomosis with 2 year post-op followup. De-identified data were obtained through an IRB approved honest broker. Specific data regarding patterns of clinical recurrence, and health care utilization with CT imaging (CT), colonoscopy (COL), emergency department (ED) visits, hospital admission (HA) and repeat surgery (RS) were obtained and analyzed. Results: There were 44 out of 62 CD small bowel resection/reanastomosis patients with medical followup available for analysis (mean age 40.5 years (range 19.7 - 68.2, + 13.4 years) with equal male/female ratio; 22.7% active smokers; 31% with previous resection). All had stapled side to side anastomosis, with laparoscopic hand assisted (63.5%), laparoscopic converted to open (20.5%) and open laparotomy (16%) procedures. The average length of stay was 7.2 days (range 3-47, + 6.6 days). Within 2 years of surgery, CT was required in 52.3% of pts (mean time to CT: 301 days), ED visits occurred in 31.8% (mean time to ED: 296 days), HA was required in 27.3% (mean time to HA: 301 days) and RS was required in 8.5% (mean time to RS: 504 days). COL was performed in 84.1% of postop patients (mean time to COL: 354 days). Analysis of patients requiring ED, HA and RS within 2 years showed that 14 patients utilized 73 ED visits within 2 years of surgery, despite 79% of these pts being on post-op immunomodulator and/or biologic therapy and colonoscopic evidence of no to mild inflammation in 71%. 12 patients were responsible for 42 HA, and 23 underwent 82 CT within 2 years of surgery. Among these patients objective inflammation was identified on 28.5% of scans. Male pts accounted for 83.5% of ED visits, 66.7% of HA, 69.5% of CT but only 25% of RS. Conclusion: Up to one third of post-op CD pts experience abdominal pain prompting CT, ED evaluation and hospitalization within 2 years of surgery. Objective inflammation was not identified in the majority of these pts who were on effective maintenance therapy. Further studies evaluating mechanisms contributing to post-op pain in the absence of inflammation in CD including psychological factors are warranted.
Table 2: Comparison of post PCI outcomes in IBD vs controls (p=0.29) Sa1302 Multiparity in Inflammatory Bowel Disease Patients Amar S. Naik, Yelena Zadvornova, Daniel J. Stein, Lilani P. Perera, Kia Saeian, Nanda Venu Pregnancy management strategies are well established in inflammatory bowel disease (IBD) patients. Data on the impact of multiple pregnancies upon the course of IBD [both Crohn's disease (CD) and ulcerative colitis (UC)] is lacking. We set out to assess the experience IBD patients with multiple pregnancies with emphasis on IBD disease course, IBD maintenance medications, quality of life, and rates of hospitalizations and surgeries. Methods: This was a retrospective observational study of all IBD patients treated at a single IBD center between 1998 and 2011. We identified patients with at least 1 live birth pregnancy and those with multiple live birth pregnancies. Patient demographics and disease characteristics were recorded. We evaluated disease course using the inflammatory marker C-reactive protein (CRP) and health related quality of life using the Short Inflammatory Bowel Disease Questionnaire (SIBDQ). IBD medical therapy and disease complications including hospitalizations and operations along with Vitamin D 25,OH levels were recorded. Results: We identified 118 IBD patients (80 CD and 38 UC) who were pregnant in our cohort. CD extent was [25% sb, 17% lb, 48% sb/lb, and 10% pan-GI] and CD phenotype was [32% inflammatory, 43% stricturing, 25% fistulizing]. UC extent was [45% left-sided and 55% pan-colon]. 75 patients had a single pregnancy (SP) and 43 patients were multiparous (MP). Mean disease duration was 71 ± 8 months in the SP group and 74 ± 11 months in the MP group. In the
Sa1300 Effects of Caregiver Burden on Quality of Life and Coping Strategies Utilized by Caregivers of Adult Patients With Inflammatory Bowel Disease Nimisha K. Parekh, Kristin McMaster, Gil Y. Melmed, Shamita Shah, Laura Yun, Alissa Speziale, Sunanda V. Kane Background: Research has shown chronic illness affects not only the patient, but the entire family unit. While research has been conducted to evaluate caregivers' quality of life (QOL), burnout, and stress amongst other chronic illnesses such as mental illness and Alzheimer's, few studies have been done in inflammatory bowel disease (IBD). Studies investigated the impact of IBD in pediatrics from parents' perspectives, but little research has been conducted on caregivers' for adult IBD patients. Aim: This is a pilot study to assess caregiver burden
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form completion and record requests. Between 2009-2010, the mean number of calls per IBD patient was 4.9. Next we analyzed telephone encounters recorded in the IBD registry to determine the distribution among patients. From 1/1/11 to 11/15/11 there were 5704 telephone encounters among 1160 patients (range 0 - 142 calls; mean 5.4), which corresponded with 2251 office visits. Distribution of telephone encounters was not even, as the top 14% of patients made 10 or more calls, accounting for 53% of all telephone encounter volume. Among patients making 20 or more calls, 65% were on neuropsychiatric medications and 51% were on chronic narcotics. Conclusion: Telephone encounters are a significant part of IBD patient management, occuring twice a frequently as office visits. Insurance authorization/form completion is >10% of annual IBD call volume. Telephone encounters are not evenly distributed with a subgroup of patients accounting for the majority of telephone contact. These high frequency callers may highlight an unmet need for improved IBD patient management.
disease (Montreal classification, Harvey Bradshaw index), perianal disease (UFS classification, PDAI) and ongoing treatments were prospectively collected. The description of ulcerations and their healing rates were analyzed. Results: A total of 154 patients (male =55, female = 99; mean age 36 ± 16 years) had at least, one anal ulceration : it was one or more severe ulcerations (U2) in 77 cases. Mean follow-up was 84 ± 86 weeks but 15 were examined once. The ulcerations were associated with suppuration (with surgical drainage) or anal stenosis in 87 (57%) and 40 (26%) patients respectively. The treatment for CD was infliximab, adalimumab, and azathioprine in 109 (71%), 44 (29%) and 111 (77%) patients respectively. The mean time to healing of ulcerations was 56±74 weeks: 45 (32%) patients did not heal permanently at the end of follow-up. New surgical drainage was performed in 37 (43%) patients but only 4 of 36 patients (11%) with initially non-fistulizing disease had suppurative complication de novo. Patients in whom anal ulcerations persisted, had, at follow-up, a higher Harvey Bradshaw score (4 ± 21 vs. 2± 13) and a higher PDAI (6 ± 20 vs. 1 ± 10), but they had less surgical drainage and surgical reconstruction. Multivariate analysis showed, that the nature of the ulceration (U2) (but not therapeutic interventions: biotherapy, surgery) was associated with a lower chance of healing (OR 0.275, 95% CI: 0.09 to 0.85, p <0.05). Conclusion: Anal ulcerations of CD are associated with suppuration in more than half cases and suffered from a more severe disease activity on both luminal and anal locations. A third has not healed after 18 months of follow-up (including U2). These findings call for trials specifically focused on the treatment of anal ulcerations.
AGA Abstracts
Predictors for Subsequent Need for Immunosuppressive Therapy in Early Ulcerative Coltis Carsten Schmidt, Luisa Beltz, Bernd Bokemeyer, Dietrich Hueppe, Wolfgang Kruis, Susanna Nikolaus, Jan C. Preiss, Andreas Sturm, Niels Teich, Andreas Stallmach Background and Aims: The clinical course of ulcerative colitis (UC) is highly variable with a subgroup of patients developing a progressive disease course necessitating immunosuppressive therapy (IT). However, reliable, stable and non-invasive individual clinical parameters in order to identify patients at risk for undergoing subsequent IT have not yet been sufficiently established. We therefore aimed to identify such clinical parameters. Methods: A retrospective, multicenter analysis of UC patients from 8 German tertiary IBD centers was performed. Patients were classified into two groups depending on requiring IT or not. Personal data, clinical and laboratory parameters during the first 3 months after initial UC diagnosis as well as effects of initial medical therapy were compared between these two groups. Results: In 104 (39.7%) of the 262 patients the UC course necessitated IT. Those patients were significantly more often hospitalized at the first flare of UC, suffered from extraintestinal manifestations more often, had a greater extent of UC, required significantly more often a systemic corticosteroid therapy and responded less well to this treatment. Furthermore, significant differences in serological markers of inflammation were observed. Age at diagnosis (OR 0.981 per year), gender (OR 1,33 for women), extent of the disease (OR 1,4-2,1 compared to proctitis), need for hospitalisation (OR 2,5) or steroid therapy at the first flare (OR 2,4) and the effect of initial steroid therapy (OR 5,2 - 50,8 compared to no streoids) were used to develop a prognostic model predicting the individual probability of necessitating immunosuppressive therapy during the course of UC. This probability ranges from less than 2% up to 100% after 5 years, depending on the presence of individual risk factors. Conclusions: The simple clinical items age at diagnosis, gender, extent of disease, need for hospitalisation or systemic steroid therapy at the first flare and effect of initial steroid therapy can predict a progressive disease course in early UC. Our model based on these parameters allows an individualized estimation of each patient's risk to develop a progressive disease course. Thereby, our model can help in deciding if patients will need immunosuppressive drugs early in the disease course or if immunosuppressive therapy can be avoided.
Sa1297 The Relationship Between Perceived Psychological Support, Health-Related Quality of Life, and Disease Activity in Newly Diagnosed Inflammatory Bowel Disease Patients Kristy L. Engel, Karla Helvie, Jeremy Adler, Ellen Zimmermann, Caitlyn M. Plonka, Rie Suzuki Individuals adjusting to the diagnosis of inflammatory bowel disease (IBD) encounter diseaserelated obstacles that can affect their physical, mental, and social health. Education and psychological support can mitigate these negative effects. The purpose of the study was to examine the relationship between patient's perceived psychological support, health-related quality of life, and disease activity. We tested the hypothesis that patients who are satisfied with their psychological support will report a higher health-related quality of life (HRQOL) and improved disease activity. Methods: Patients were at least fourteen years of age with an IBD diagnosis within three years. HRQOL was measured using the Short Form Inflammatory Bowel Disease Questionnaire (SIBDQ). Patients' perceived psychological support was measured using a modified Medical Outcomes Study-Social Support Survey (GI MOSS). Crohn's disease activity (HBI, PCDAI) and ulcerative colitis activity (SCCAI, PUCAI) were measured. The Spearman Rho correlation and logistical regression were used in data analysis. Results: Sixty-two patients completed the survey ranging in age from 17 to 72 years: 44% female; 56% male. 37% had Crohn's disease (n=23), 59% ulcerative colitis (n=37), and 3% indeterminate colitis (n=2). Patient preferences for medical information were selected from a list of options. Fifty-three percent of patients preferred receiving written information in booklet form, 50% preferred visiting disease specific websites, 40% preferred an IBD informational pamphlet, 39% wanted the option of meeting with a health educator following diagnosis, and 39% wanted to be able to communicate directly with their gastroenterologist by email. Patients expressed receiving the emotional and psychological support they needed “Sometimes” (29%), “Always” (27%), “Usually” (17%), “Rarely” (17%), and “Never” (10%). Patients highlighted the lack of psychological support in their current treatment plans (82%). Finally, patients expressed a perceived benefit of counseling if it was provided (37%). There was no relationship detected between the perceived psychological support (GI MOSS) and SIBDQ (R=0.20, p=0.12). Additionally, no relationship was present between psychological support and disease activity with Crohn's disease patients (R= -0.31, p=.18) or ulcerative colitis patients (R= -0.12, p=.47). As expected SIBDQ strongly correlated with disease activity (ulcerative colitis: R= -0.76, p<.0001; Crohn's disease: R= -0.56, p=.0076). Conclusion: Newly diagnosed IBD patients crave information and psychological support. A variety of methods of communication are cited. Many patients lack emotional and psychological support which is not part of most patient's treatment plan. Our study did not support a link between perceived psychological support and disease activity or health-related quality of life.
Sa1295 Development of Process and Outcome Quality Indicators for Inflammatory Bowel Disease (IBD) Gil Melmed, Corey A. Siegel, Brennan M. Spiegel, John I. Allen, Robert R. Cima, JeanFrederic Colombel, Themistocles Dassopoulos, Lee Denson, Sharon Dudley-Brown, Andy Garb, Stephen B. Hanauer, Michael Kappelman, James D. Lewis, Isabelle Lynch, Amy Moynihan, David T. Rubin, Ryan B. Sartor, Ronald Schwartz, Douglas C. Wolf, Thomas A. Ullman Introduction: Variations in adherence to management guidelines for IBD suggest variable quality of care. Quality indicators (QIs) can be developed to measure the structure, processes and outcomes of health care delivery; implementing these QIs may limit variations in care and ultimately improve quality of care. The RAND/UCLA appropriateness method, a widely utilized, evidence-based, iterative approach used to establish QIs in several chronic illnesses was utilized to develop a set of Process and Outcome QIs to define quality of care for IBD. Methods: Guidelines and position papers for IBD published from 2006-2011 were reviewed for potential QIs. These were rated by a multidisciplinary panel comprised of representatives of the ACG, AGA, CCFA, and ECCO, with academic and private practice physicians, nurses, and patients. Potential Process and Outcome QIs were discussed at 3 moderated in-person meetings, with pre- and post-meeting confidential electronic voting. Panelists rated the validity and feasibility of QIs on 1-9 scale; disagreement was assessed using a validated index. QIs rated >7 underwent literature review for evidence linking processes to an outcome, and the resulting 135-page compendium was distributed to panelists. QIs rated above 8 were selected for the final set. Results: Over 600 potential Process QIs were extracted from Guidelines. Following ratings and discussion by the first panel, 35 process QIs were selected for literature review in categories of diagnosis, treatment, drug safety, healthcare maintenance, surgery, and cancer prevention. After the second panel, 10 Process QIs were included in the final set. Highly rated Process QIs included advocating avoidance of long-term steroids by recommending steroid-sparing therapy or surgery, TB testing in those initiating antiTNF therapy, testing for C difficile with flares, use of aminosalicylates in patients with mildmoderate colitis, and colectomy or reassessment of low grade dysplasia in UC. Candidate Outcome QIs were then derived from Process QIs, as well as from physician, nurse, and patient input before a moderated third and final panel. Outcomes were rated in the categories of disease activity, health-related quality of life, healthcare utilization, and preventable complications. Highly rated Outcome QIs included steroid-free clinical remission, days lost from work/school, ER visits and hospitalization for IBD, and incontinence episodes. None of the top QIs exhibited disagreement. Conclusion: A set of QIs for IBD was developed with expert interpretation of the literature, and multidisciplinary input. Outcome QIs focused largely on remission and quality of life while process QIs were aimed at therapeutic optimization and patient safety. Evaluation of these QIs in clinical practice is needed to assess the correlation of performance on process QIs with performance on outcome QIs.
Sa1298 Telephone Encounters in Inflammatory Bowel Disease Patient Management Miguel Regueiro, Claudia M. Ramos Rivers, Anwar Dudekula, Linda Kontur, Eva Szigethy, Michael A. Dunn, Arthur Barrie, Marc Schwartz, Jason M. Swoger, Leonard Baidoo, David G. Binion Introduction: Management of complex chronic diseases, including inflammatory bowel disease (IBD; Crohn's disease, ulcerative colitis) requires regular office visits, occasional hospitalizations and frequent telephone communication between patients, health care providers and insurers. The majority of telephone contact in healthcare is unreimbursed and will often require considerable effort on the part of nurses/support staff, in addition to physician time. There is limited data regarding the nature of telephone calls encountered in the management of IBD, as well as the reasons for calls and the distribution of calls among patients. Methods: This study utilized the IBD center database at an academic referral center. Administrative data on telephone calls received and performed by IBD nursing staff over a 2 year period was prospectively tabulated and categorized based on the nature of the call: problem/ followup, resolution/plan, refill request, insurance authorization, completion of forms, record request. Telephone encounters recorded in an electronic medical record over a 10 month time period in a consented IBD patient registry were analyzed, including patient disease demographics. Results: The number of telephone calls received/made by the IBD nursing staff rose from 21,979 in 2009 to 32,667 in 2010 (p<0.0001). This corresponded with a 26% rise in the IBD patient population seen during those years from 2475 to 3118. The monthly call volume in 2009 was 1831, ranging from 1588 (January) to 2130 (December). In 2010, monthly call volume rose to 2722, ranging from 2077 (January) to 3297 (July). Over the two years 44% of telephone calls were problem/followup, 25% were resolution/ plan, 12% were refill requests, 10% were insurance authorizations and the remaining were
Sa1296 Anal Ulceration in Crohn's Disease: Natural History at the Time of Biotherapy Timothee Wallenhorst, Guillaume Bouguen, Isabelle Berkelmans, Jean-François Bretagne, Laurent Siproudhis Background: Anal ulcerations represent one of the characteristics of perianal Crohn's disease (CD), but their natural history is poorly understood. Using the largest published series of anal ulcerations, the aim of this study was to clarify their outcomes at the time of biotherapy. Methods: Clinical features of 282 consecutive patients constituted a single-centered prospective database of anal lesions of CD (from 01 /01/2007 to 08 /30/2011). The data for luminal
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as it relates to QOL and styles of coping in persons caring for adult patients with IBD. Methods: Adult patients with IBD at 6 tertiary centers were identified and asked if they had a caregiver. Caregivers refer to parent, spouse, significant other, child (over age 18), sibling, or friend. If a caregiver was present at the visit, he/she was asked to fill out an anonymous survey. Survey consisted of demographics, QOL Scale, Zarit Burden Interview to assess level of stress from acting as caregiver, and Brief COPE to assess how caregiver copes with stress. Results: Cohort included 162 patients with mean age of 49, 67% female, 79% were Caucasian and 73% living in the same home. Caregiver breakdown was 51% spouse, 23% parent, 17% child, 5% significant others, 2% sibling and 2% friend. Education level was 54% completing high school and 25% completing college, with 47% working full time and only 1.2% stopped working because of caregiving responsibilities. Sixty percent reported religious involvement and 68% reported having more than one dependent in the home. Caregivers reported 58% of loved ones had Crohn's disease and 36% with UC with a mean of 9.3 years since diagnosis and caring for mean of 8.1 years. Twenty percent of caregivers reported a psychiatric illness and 24% sought professional consultation. Female caregivers reported more adaptive coping skills(p<.0002). Caregivers who participated in religious activities also reported more adaptive coping skills but also a higher index of burden (p<.05). QOL was lower and burden was higher for those who took care of more severely ill patients (p<.05). Caregivers with psychiatric illness reported more adaptive coping with a lower QOL p<.05). Attending a support group was significantly correlated to greater use of both maladaptive and adaptive coping skills (p<.05). Having more than one dependent correlated with higher burden (p<.02). There was no association between coping, QOL or burden with type of IBD, years of disease, number of years caring for IBD patient or surgery. Conclusions: Certain characteristics appear to pre-dispose caregivers of IBD patients to greater level of burden. Further research is warranted in identifying means of support for caregivers to improve their lives as well as the overall care for IBD patients.
Sa1299 Coronary Artery Disease in Inflammatory Bowel Disease: A Look at the Percutaneous Coronary Intervention Outcomes Ashish Aggarwal, Ashish Atreja, Samir Kapadia, Jean-Paul Achkar Introduction There is evidence of increased risk of premature coronary artery disease (CAD) in inflammatory diseases like systemic lupus erythematosus (SLE) and inflammatory bowel disease (IBD). Also, outcomes after Percutaneous coronary intervention (PCI) have been found to be worse in SLE patients. Little is known regarding PCI outcomes in IBD patients with CAD. Objectives To compare traditional risk factors in patients with and without IBD and angiographically proven CAD. To compare PCI outcomes in IBD patients and non IBD patients. Methods We identified adult IBD patients who were diagnosed with CAD on cardiac catheterization. Patients with other inflammatory diseases were excluded. Four non-IBD controls were gender, index date, race matched to each IBD case. Data on patient demographics, clinical characteristics, laboratory values, cardiovascular risk factors, catheterization findings, Framingham Risk Score (FRS), and PCI cardiovascular outcomes were extracted. Results: 131 IBD cases with CAD (97 males, 54 Crohn's disease) and 517 non-IBD CAD controls were included. There were no differences with respect to prior myocardial infarction (24 % vs 22%, p= 0.76), prior cerebrovascular events (5% vs 8%, p=0.35), prevalence of hypertension, or diabetes between the two groups (Table 1). The IBD cohort was significantly less likely to have traditional CAD risk factors such as older age (65.3 + 10 years of IBD pts vs 67.8 + 11.3 years, p = 0.01), active smoking (10.69 % vs 18.76%, p= 0.02), high LDL (85.6 + 31.4 vs 92.8 + 38. 4, p = 0.04). IBD patients also weighed less compared to controls (82.5 + 18.9 kg vs 86.4 + 20.3 kg, p = 0.04). The 10 year CAD risk predicted by FRS based on traditional risk factors was lower in the IBD group compared to controls (12.8 + 8.4% vs 14.1 + 9.2%, p = 0.06). There was no significant difference in frequency of triple vessel disease between the 2 groups (44% vs 50%, p=0.17). 31% of IBD patients with CAD underwent PCI as compared to 39% of non IBD patients. Multivariate cox regression analysis showed no difference in the major adverse cardiovascular events (including mortality, recurrence of MI, and need for repeat vascularization) or stent thrombosis following PCI, in the two groups (Table 2). Conclusions: IBD patients are likely to develop coronary artery disease at a younger age compared to non-IBD controls. FRS, which is based on traditional CAD risk factors, tends to be lower in IBD patients who develop CAD as compared to non IBD patients developing CAD. In addition, IBD patients have lower LDL, weigh less and are less likely to be active smokers. These findings suggest a greater role of non conventional risk factors such as inflammation in IBD patients. Outcomes of PCI in IBD patients are equivalent to those in non IBD patients. Table 1: Conventional Risk factors in IBD vs controls
Sa1301 Patterns of Clinical Recurrence and Health Care Utilization in Post-Operative Crohn's Disease: Two Year Outcomes Mahesh Gajendran, Andrew R. Watson, Wolfgang H. Schraut, Miguel Regueiro, Eva Szigethy, Michael A. Dunn, Claudia M. Ramos Rivers, David G. Binion Background: Surgery rapidly induces remission in patients with ileocolonic and small bowel Crohn's disease (CD). There are limited data regarding the durability of surgically induced remission and patterns of clinical recurrence in CD pts beyond 1 year. In addition, the patterns of specific health care utilization during CD recurrence during the present era of post-operative (post-op) maintenance therapy and stapled anastomosis have not been fully characterized. Methods: Retrospective, single referral center observational study of CD pts requiring small bowel resection/reanastomosis with 2 year post-op followup. De-identified data were obtained through an IRB approved honest broker. Specific data regarding patterns of clinical recurrence, and health care utilization with CT imaging (CT), colonoscopy (COL), emergency department (ED) visits, hospital admission (HA) and repeat surgery (RS) were obtained and analyzed. Results: There were 44 out of 62 CD small bowel resection/reanastomosis patients with medical followup available for analysis (mean age 40.5 years (range 19.7 - 68.2, + 13.4 years) with equal male/female ratio; 22.7% active smokers; 31% with previous resection). All had stapled side to side anastomosis, with laparoscopic hand assisted (63.5%), laparoscopic converted to open (20.5%) and open laparotomy (16%) procedures. The average length of stay was 7.2 days (range 3-47, + 6.6 days). Within 2 years of surgery, CT was required in 52.3% of pts (mean time to CT: 301 days), ED visits occurred in 31.8% (mean time to ED: 296 days), HA was required in 27.3% (mean time to HA: 301 days) and RS was required in 8.5% (mean time to RS: 504 days). COL was performed in 84.1% of postop patients (mean time to COL: 354 days). Analysis of patients requiring ED, HA and RS within 2 years showed that 14 patients utilized 73 ED visits within 2 years of surgery, despite 79% of these pts being on post-op immunomodulator and/or biologic therapy and colonoscopic evidence of no to mild inflammation in 71%. 12 patients were responsible for 42 HA, and 23 underwent 82 CT within 2 years of surgery. Among these patients objective inflammation was identified on 28.5% of scans. Male pts accounted for 83.5% of ED visits, 66.7% of HA, 69.5% of CT but only 25% of RS. Conclusion: Up to one third of post-op CD pts experience abdominal pain prompting CT, ED evaluation and hospitalization within 2 years of surgery. Objective inflammation was not identified in the majority of these pts who were on effective maintenance therapy. Further studies evaluating mechanisms contributing to post-op pain in the absence of inflammation in CD including psychological factors are warranted.
Table 2: Comparison of post PCI outcomes in IBD vs controls (p=0.29) Sa1302 Multiparity in Inflammatory Bowel Disease Patients Amar S. Naik, Yelena Zadvornova, Daniel J. Stein, Lilani P. Perera, Kia Saeian, Nanda Venu Pregnancy management strategies are well established in inflammatory bowel disease (IBD) patients. Data on the impact of multiple pregnancies upon the course of IBD [both Crohn's disease (CD) and ulcerative colitis (UC)] is lacking. We set out to assess the experience IBD patients with multiple pregnancies with emphasis on IBD disease course, IBD maintenance medications, quality of life, and rates of hospitalizations and surgeries. Methods: This was a retrospective observational study of all IBD patients treated at a single IBD center between 1998 and 2011. We identified patients with at least 1 live birth pregnancy and those with multiple live birth pregnancies. Patient demographics and disease characteristics were recorded. We evaluated disease course using the inflammatory marker C-reactive protein (CRP) and health related quality of life using the Short Inflammatory Bowel Disease Questionnaire (SIBDQ). IBD medical therapy and disease complications including hospitalizations and operations along with Vitamin D 25,OH levels were recorded. Results: We identified 118 IBD patients (80 CD and 38 UC) who were pregnant in our cohort. CD extent was [25% sb, 17% lb, 48% sb/lb, and 10% pan-GI] and CD phenotype was [32% inflammatory, 43% stricturing, 25% fistulizing]. UC extent was [45% left-sided and 55% pan-colon]. 75 patients had a single pregnancy (SP) and 43 patients were multiparous (MP). Mean disease duration was 71 ± 8 months in the SP group and 74 ± 11 months in the MP group. In the
Sa1300 Effects of Caregiver Burden on Quality of Life and Coping Strategies Utilized by Caregivers of Adult Patients With Inflammatory Bowel Disease Nimisha K. Parekh, Kristin McMaster, Gil Y. Melmed, Shamita Shah, Laura Yun, Alissa Speziale, Sunanda V. Kane Background: Research has shown chronic illness affects not only the patient, but the entire family unit. While research has been conducted to evaluate caregivers' quality of life (QOL), burnout, and stress amongst other chronic illnesses such as mental illness and Alzheimer's, few studies have been done in inflammatory bowel disease (IBD). Studies investigated the impact of IBD in pediatrics from parents' perspectives, but little research has been conducted on caregivers' for adult IBD patients. Aim: This is a pilot study to assess caregiver burden
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form completion and record requests. Between 2009-2010, the mean number of calls per IBD patient was 4.9. Next we analyzed telephone encounters recorded in the IBD registry to determine the distribution among patients. From 1/1/11 to 11/15/11 there were 5704 telephone encounters among 1160 patients (range 0 - 142 calls; mean 5.4), which corresponded with 2251 office visits. Distribution of telephone encounters was not even, as the top 14% of patients made 10 or more calls, accounting for 53% of all telephone encounter volume. Among patients making 20 or more calls, 65% were on neuropsychiatric medications and 51% were on chronic narcotics. Conclusion: Telephone encounters are a significant part of IBD patient management, occuring twice a frequently as office visits. Insurance authorization/form completion is >10% of annual IBD call volume. Telephone encounters are not evenly distributed with a subgroup of patients accounting for the majority of telephone contact. These high frequency callers may highlight an unmet need for improved IBD patient management.