Treating Crohn s and Colitis in the ASC

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1 Treating Crohn s and Colitis in the ASC Kimberly M Persley, MD Texas Digestive Disease consultants TASC Meeting Outline IBD 101 Diagnosis Treatment Burden of Disease Role of ASC Inflammatory Bowel Disease Indeterminate colitis 1

2 Inflammatory Bowel disease 2015 report 3 million US adults with Inflammatory bowel disease Dahlhamer J. MMWR 2016;65(42) Inflammatory Bowel Disease Worldwide Inflammatory Bowel Disease Chronic inflammation IBD is not IBS Remission/Relapses Lifelong condition Young age of onset Second peak in 6 th decade Women and men are affected equally 2

3 Normal vs inflammatory bowel disease Environmental triggers Clinical Features: UC vs CD Ulcerative Colitis Crohn s Disease Abdominal pain Less frequent frequent Bloody diarrhea frequent occasional Abdominal mass never frequent Intestinal obstruction never frequent Perianal disease Almost never frequent Fistula never common Effect of smoking protective detrimental Systemic symptoms Less common common 3

4 Crohn s Disease Inflammation can involve any part of the GI tract Inflammation is transmural Fistula Abscesses Surgery is not a cure Endoscopic Appearance of Crohn s Disease Apthous ulceration Deep fissure Cobblestoning Inflammation is segmental Rectal spraring Terminal ileum involved Granuloma on biopsies Ulcerative colitis Inflammation in limited to the colon Inflammation in the mucosa Surgery will cure Eligible for Jpouch 4

5 Endoscopic Appearance of Ulcerative Colitis Inflammation is superficial Diffuse Rectal involvement Normal terminal ileum Assessment of Disease Activity Crohn s Disease Activity Index (CDAI) Harvey Bradshaw Index Mayo UCDAI Sutherland UCDAI Inflammatory Bowel Disease Questionnaire (IBDQ) Endoscopic scoring system Treatment Pyramid Research Biologics Cyclosporine 6mercaptopurine azathioprine Severe Moderate corticosteroids Budesonide Antibiotics 5ASA Mild 5

6 Medical Therapy Asacol HD Pentasa Lialda Apriso Balsalazide Sulfasalazine Canasa Rowasa Mesalamines Prednisone Budesonide corticosteroids Azathioprine 6Mercaptopurine Methotrexate Cyclosporine Remicade Humira Cimzia Entyvio Simponi Stelara Biologics Immunosuppressive Inflammatory Bowel Disease Expensive disease Lifelong condition No known cure Significant health cost Significant economic cost Burden of Disease Use of Healthcare Crohn s Disease 1.1 ambulatory care visits a yr 1.8 million prescription written for CD medications 187,000 hospitalization specifically for CD 75% will require surgery Ulcerative colitis 716,000 ambulatory care visit a yr 2.1 million prescription written for UC medications 107,000 hospitalizations specifically for UC 25% will require surgery Crohn s and Colitis Foundation Website, 2004 data 6

7 Burden of Disease Psychological Health Flare ups can be painful, unpredictable, inconvenient and embarrassing Patient may present with anger, anxiety and fear Anxiety and Depression are higher in IBD populations and it is recommended that ALL patient with IBD get screened for anxiety and depression. Burden of Disease Financial Burden Direct Cost Hospitalization Physician services Prescription drugs OTC medications Nursing care procedures Indirect Cost Value of lost earnings or productivity Value of leisure time lost Cost of IBD $20,000 $18,000 $16,000 $14,000 $12,000 $10,000 $8,000 $6,000 $4,000 $2,000 Annual Cost Annual direct cost CD and UC patient Marketscan data base $0 annual cost CD UC control 7

8 Case Presentation ET is a 36 yo woman with Crohn s colitis In 2008, she was diagnosed with left sided colitis treated with Asacol and steroids In 2012, stopped medications when she became pregnancy In 2014, she was seen as a new patient. She complaint of diarrhea 8 to 10 bowel movement a day, abdominal pain and weight loss. She started on Lialda 1/2015, EGD, colonoscopy and CT small bowel performed for ongoing symptoms. Colonoscopy with right sided inflammation with a stricture. Diagnosis of Crohn s disease Normal CT small bowel Started Humira Case Presentation 8/2015 repeat colonoscopy with stricture and active inflammation in the right colon. The stricture dilated. 7/2016 recurrent right sided abdominal pain and diarrhea. Colonoscopy with dilation of stricture Recurrent symptoms and referred to CRS for limited ileocolonic resection Case Presentation 12/2017 underwent post operative colonoscopy and found to have active ileitis at the neo terminal ileum Changed to Remicade 8

9 Role of Endoscopy Confirm diagnosis Differentiate between Ulcerative Colitis vs Crohn s Disease Obtain histologic confirmation Assess disease severity and distribution Assess mucosal healing Surveillance for dysplasia Role of Endoscopy in IBD Pouchoscopy Dilation of anorectal stricture Upper endoscopy Chromoendoscopy Surveillance for dysplasia Pouchoscopy A gastroscope typically used Biopsies taken Dilation of IPAA Endoscopic Jpouch images 9

10 Chromoendoscopy Dilute spray applied to the colon Increase yield of dysplastic lesion Bowel Preparation Split dose prep is recommended for all patients Avoid Sodium Phosphate bowel preps Increase mucosal injury Erosions may be seen Procedure Comfort Quick check in Privacy in Pre op area Adequate anesthesia Allow for time of questions following the procedure Patient/family have a lot questions about diagnosis and treatment Patient/family will have questions regarding diet Resources 10

11 Healthcare Today US Healthcare is the most costly in the world (17% GDP) National Healthcare Expenditure Projections, Centers for Medicare and Medicaid Services, Office of the Actuary. Aging populations and increased longevity, coupled with chronic health problems, have become a global challenge, putting new demands on medical and social service The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance The Triple Aim Berwick, DM et al. Health Aff (Millwood). 27(3): Berwick, DM et al. Health Aff (Millwood). 27(3): ASC and the Triple AIM Berwick, DM et al. Health Aff (Millwood). 27(3): Improve the value of healthcare Control cost Integrate care Improve outcomes Improve the patient care experience Value = quality cost 11

12 Procedural Cost Professional Fee Facility Fee Office Endoscopy Ambulatory Surgery Center (ASC) Hospital Outpatient Department (HOPD) Anesthesia Drugs Professional Fee Pathology Professional Fee Technical Component Special Stains Cost Variation in Colonoscopy James C. Robinson and Kimberly MacPherson. Health Affairs 2012,31:9 Conclusions IBD is an EXPENSIVE disease Medications Procedures The incidence of IBD is rising IBD is a lifelong disease ASCs are integral in providing quality care at a lower cost 12

13 Thank you! Questions 13