Accepted Manuscript. Improving Outcomes in Patients with Inflammatory Bowel Disease through Integrated Multi-Disciplinary Care the Future of IBD Care

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1 Accepted Manuscript Improving Outcomes in Patients with Inflammatory Bowel Disease through Integrated Multi-Disciplinary Care the Future of IBD Care Kaci Christian, MD, Raymond K. Cross, MD, MS PII: S (18) DOI: /j.cgh Reference: YJCGH To appear in: Clinical Gastroenterology and Hepatology Accepted Date: 17 July 2018 Please cite this article as: Christian K, Cross RK, Improving Outcomes in Patients with Inflammatory Bowel Disease through Integrated Multi-Disciplinary Care the Future of IBD Care, Clinical Gastroenterology and Hepatology (2018), doi: /j.cgh This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

2 Improving Outcomes in Patients with Inflammatory Bowel Disease through Integrated Multi- Disciplinary Care the Future of IBD Care Kaci Christian, MD and Raymond K. Cross, MD, MS University of Maryland School of Medicine Department of Medicine, Division of Gastroenterology and Hepatology Baltimore, MD Conflicts of Interest: None Corresponding Author: Raymond K. Cross, MD, MS, AGAF, FACG 685 W. Baltimore Street, Suite 8-00 Baltimore, MD Fax The complex care of patients with inflammatory bowel diseases (IBD) including Crohn s disease (CD) and ulcerative colitis (UC), often requires coordination between gastroenterologists, surgeons, mental health providers, dieticians, and other providers. Patientcentered medical homes (PCMH), intended to centralize primary care needs amongst patients while decreasing costs and improving the quality of care, have not yet been utilized in specialty

3 practice. Regueiro et al. 1 evaluated the achievability, durability and impact of an IBD specialty medical home (SMH), based out of the University of Pittsburgh Medical Center (UPMC), termed UPMC Total-Care IBD. The authors previously outlined the details of the SMH, with a focus on close communication between providers and payers to provide value-based care for patients known to utilize a large proportion of their health expenditure on IBD care. 2,3 Three hundred and twenty two adults aged years with a confirmed diagnosis of CD or UC with UPMC health plan insurance were enrolled in Total-Care IBD and followed for one year. All patients were initially assessed by a gastroenterologist, dietician, social worker, advanced practice provider, and registered nurse; psychiatric and pain evaluations were performed based on comorbid conditions and scores on baseline depression and anxiety questionnaires. Data regarding medication use, quality of life (QoL), disease activity, imaging, and endoscopic and surgical procedures were prospectively collected; unplanned care, defined as emergency department (ED) visits and hospitalizations, were compared to the three months and one year prior to enrollment. The majority of patients were Caucasian (81.1%), women (57.6%), and had CD (62%). Most CD patients had undergone at least one surgery (44.4%) and previously received anti-tnf therapy (59%). Nearly one fifth (19.4%) of UC patients were on steroids at study enrollment and 12.1% had a previous colectomy. Almost half of patients had a poor QoL (49.1%) and 28.3 and 18.6% met criteria for depression and anxiety respectively at enrollment; only 45.6% of CD and 31.5% of UC patients had active disease at the time of enrollment. In the three months following enrollment, it was evident that Total-Care IBD positively impacted unplanned care, as there was a significant reduction in ED visits and hospitalizations

4 compared to the three months prior to enrollment; this reduction remained significant when comparing one year prior and post enrollment. Multivariate analysis demonstrated that baseline steroids and opioids and low QoL (SIBDQ score <50) were independently predictive of healthcare utilization. Harvey Bradshaw Index (HBI) and Ulcerative Colitis Activity Index (UCAI) scores were significantly reduced, which was most notable in those with the highest quartile values at enrollment (median HBI 9 to 6, p<0.001 and median UCAI 9 to 5, p<0.001). Similarly, those with the highest depression and anxiety scores and the lowest QoL scores at enrollment improved the most. In the short-term, Total-Care IBD was sustainable with only 18 patients leaving the SMH. Regueiro and colleagues should be congratulated for studying the SMH healthcare delivery model in patients with IBD. They address a clear unmet need in the care of patients with IBD, namely how to improve outcomes in excess utilizers of healthcare resources and in those with comorbid psychiatric disease. Despite just 46% of CD patients and 32% of UC patients having active disease at baseline, nearly half of patients reported poor QOL. This finding supports prior studies linking chronic opioid use and comorbid depression and anxiety as important drivers of reduced QoL and high healthcare utilization in patients with IBD. 4-7 The SMH was able to connect 35% of patients with a psychiatrist, 73% with a social worker and 8% with a pain specialist, with improved short-term outcomes. UPMC was uniquely positioned to conduct this study as they have a large healthcare plan which covers many patients in the region. In addition, UPMC had already integrated psychiatric care in the treatment of IBD patients with co-morbid conditions, albeit, not under a single roof. Despite the positive findings, there a number of important limitations to consider.

5 First, it is not clear how much improvement can be attributed to the SMH care model as opposed to the care rendered by providers at UPMC. The authors acknowledge the limitations of a lack of a control group in the study; further studies will need to compare standard IBD specialty care to the SMH model. Further, as pointed out previously, UPMC was uniquely positioned to conduct the study because of integration with the health plan and existing psychiatric support services in place. The results at UPMC are not likely generalizable to other centers. Lastly, information on cost is not included. It will be important to examine not only the cost savings attributed to the SMH, but also the costs attributed to the SMH itself. Even if confirmed to be effective, it may not be sustainable to support all of the personnel needed to establish a SMH as constructed by UPMC. It is likely that IBD specialty care centers will develop unique, customized models to treat the more complex patients with IBD. Telemedicine remains an attractive alternative as an adjunct to or partial replacement of standard care. A large European study of patients from referral and community centers demonstrated that remote monitoring decreased routine office visits and hospitalizations without decreasing QoL. 8 Remote monitoring integrated into standard care has also been shown to decrease healthcare utilization in the University of California system. 9 Our group recently conducted a large study, which included UPMC and Vanderbilt University, which compared telemedicine as an adjunct to care versus standard care. We found that telemedicine decreased hospitalizations at the expense of greater non-invasive diagnostic tests, telephone calls and electronic messages (to be presented at DDW 2018). Neither of these studies focused specifically on high utilizers of healthcare. Electronic medical record systems provide another opportunity to improve care in high utilizers as demonstrated

6 by Project Sonar (PS), of the Illinois Gastroenterology Group. 10 PS partners with a national payer and utilizes a team approach to coordinate IBD care. It relies heavily on patient engagement through disease and QoL assessment, which, in turn triggers care management algorithms that drive therapeutic interventions. The PS system has been shown to reduce health care costs, driven by a reduction in the emergency room and hospital payments. 11 In summary, in a healthcare milieu moving away from fee-for-service to fee-for-value reimbursement models, Regueiro et al. 1 demonstrate that a patient-centered SMH is an achievable alternative model of healthcare delivery to IBD patients that improves disease activity and QoL, while reducing healthcare utilization.

7 1. Regueiro M, Click B, Anderson A, et al. Reduced unplanned care and disease activity and increased quality of life after patient enrollment in an inflammatory bowel disease medical home. Clin Gastroenterol Hepatol doi: S (18) [pii]. 2. Regueiro MD, McAnallen SE, Greer JB, Perkins SE, Ramalingam S, Szigethy E. The inflammatory bowel disease specialty medical home: A new model of patient-centered care. Inflamm Bowel Dis. 2016;22(8): doi: /MIB [doi]. 3. Regueiro M, Click B, Holder D, Shrank W, McAnallen S, Szigethy E. Constructing an inflammatory bowel disease patient-centered medical home. Clin Gastroenterol Hepatol. 2017;15(8): e4. doi: S (17) [pii]. 4. Click B, Ramos Rivers C, Koutroubakis IE, et al. Demographic and clinical predictors of high healthcare use in patients with inflammatory bowel disease. Inflamm Bowel Dis. 2016;22(6): doi: /MIB [doi]. 5. Limsrivilai J, Stidham RW, Govani SM, Waljee AK, Huang W, Higgins PD. Factors that predict high health care utilization and costs for patients with inflammatory bowel diseases. Clin Gastroenterol Hepatol. 2017;15(3): e2. doi: S (16) [pii]. 6. Nugent Z, Singh H, Targownik LE, Strome T, Snider C, Bernstein CN. Predictors of emergency department use by persons with inflammatory bowel diseases: A population-based study. Inflamm Bowel Dis. 2016;22(12): doi: /MIB [doi].

8 7. Conley S, Proctor DD, Jeon S, Sandler RS, Redeker NS. Symptom clusters in adults with inflammatory bowel disease. Res Nurs Health. 2017;40(5): doi: /nur [doi]. 8. de Jong MJ, van der Meulen-de Jong AE, Romberg-Camps MJ, et al. Telemedicine for management of inflammatory bowel disease (myibdcoach): A pragmatic, multicentre, randomised controlled trial. Lancet. 2017;390(10098): doi: S (17) [pii]. 9. van Deen WK, Spiro A, Burak Ozbay A, et al. The impact of value-based healthcare for inflammatory bowel diseases on healthcare utilization: A pilot study. Eur J Gastroenterol Hepatol. 2017;29(3): doi: /MEG [doi]. 10. Kosinski L, Baum C, Sorensen M, et al. P-208 project sonar: Improvement in patient engagement rates using a mobile application platform. Inflammatory Bowel Diseases. 2016;22(S72). 11. Kosinski L, Brill JV, Sorensen M, Baum C, Turpin R, Landsman - Blumberg P. Project sonar: Reduction in cost of care in an attributed cohort of patients with crohn's disease. Gastroenterology. 2016;150(S173).