Faculty Bibliography

BACKGROUND:Inflammatory bowel disease (IBD) is associated with substantial symptom burden, variability in clinical outcomes, and high direct costs. We sought to determine if a care coordination-based strategy was effective at improving patient symptom burden and reducing healthcare costs for patients with IBD in the top quintile of predicted healthcare utilization and costs. METHODS:We performed a randomized controlled trial to evaluate the efficacy of a patient-tailored multicomponent care coordination intervention composed of proactive symptom monitoring and care coordinator-triggered algorithms. Enrolled patients with IBD were randomized to usual care or to our care coordination intervention over a 9-month period (April 2019 to January 2020). Primary outcomes included change in patient symptom scores throughout the intervention and IBD-related charges at 12 months. RESULTS:Eligible IBD patients in the top quintile for predicted healthcare utilization and expenditures were identified. A total of 205 patients were enrolled and randomized to our intervention (n = 100) or to usual care (n = 105). Patients in the care coordinator arm demonstrated an improvement in symptoms scores compared with usual care (coefficient, -0.68, 95% confidence interval, -1.18 to -0.18; P = .008) without a significant difference in median annual IBD-related healthcare charges ($10,094 vs $9080; P = .322). CONCLUSIONS:In this first randomized controlled trial of a patient-tailored care coordination intervention, composed of proactive symptom monitoring and care coordinator-triggered algorithms, we observed an improvement in patient symptom scores but not in healthcare charges. Care coordination programs may represent an effective value-based approach to improve symptoms scores without added direct costs in a subgroup of high-risk patients with IBD. (ClinicalTrials.gov, Number: NCT04796571).

Irritable bowel syndrome (IBS) is a common symptom-based condition of heterogeneous pathogenesis and clinical phenotype. This heterogeneity and multidimensional nature creates significant diagnostic and treatment challenges. Recent evidence has documented the benefits of diet and behavioral interventions. These nonmedical strategies are causing a shift from the traditional care model to a multidisciplinary care model. Recent evidence suggests that collaborative, team-based integrated care leads to better clinical outcomes and reduced cost per cure compared with traditional care. Although it is growing increasingly clear that integrated care offers significant benefits to IBS patients, widespread dissemination will require solutions to structural, cultural, and financial barriers.

Irritable bowel syndrome (IBS) is a common symptom-based condition of heterogeneous pathogenesis and clinical phenotype. This heterogeneity and multidimensional nature creates significant diagnostic and treatment challenges. Recent evidence has documented the benefits of diet and behavioral interventions. These nonmedical strategies are causing a shift from the traditional care model to a multidisciplinary care model. Recent evidence suggests that collaborative, team-based integrated care leads to better clinical outcomes and reduced cost per cure compared with traditional care. Although it is growing increasingly clear that integrated care offers significant benefits to IBS patients, widespread dissemination will require solutions to structural, cultural, and financial barriers.

BACKGROUND:A potential benefit of electronic health records (EHRs) is that they could potentially save clinician time and improve documentation by auto-generating the history of present illness (HPI) in partnership with patients prior to the clinic visit. We developed an online patient portal called AEGIS (Automated Evaluation of Gastrointestinal [GI] Symptoms) that systematically collects patient GI symptom information and then transforms the data into a narrative HPI that is available for physicians to review in the EHR prior to seeing the patient. OBJECTIVE:This study aimed to compare whether use of an online GI symptom history taker called AEGIS improves physician-centric outcomes vs usual care. METHODS:We conducted a pragmatic controlled trial among adults aged ≥18 years scheduled for a new patient visit at 4 GI clinics at an academic medical center. Patients who completed AEGIS were matched with controls in the intervention period who did not complete AEGIS as well as controls who underwent usual care in the pre-intervention period. Of note, the pre-intervention control group was formed as it was not subject to contamination bias, unlike for post-intervention controls. We then compared the following outcomes among groups: (1) documentation of alarm symptoms, (2) documentation of family history of GI malignancy, (3) number of follow-up visits in a 6-month period, (4) number of tests ordered in a 6-month period, and (5) charting time (difference between appointment time and time the encounter was closed). Multivariable regression models were used to adjust for potential confounding. RESULTS:Of the 774 patients who were invited to complete AEGIS, 116 (15.0%) finished it prior to their visit. The 116 AEGIS patients were then matched with 343 and 102 controls in the pre- and post-intervention periods, respectively. There were no statistically significant differences among the groups for documentation of alarm symptoms and GI cancer family history, number of follow-up visits and ordered tests, or charting time (all P>.05). CONCLUSIONS:Use of a validated online HPI-generation portal did not improve physician documentation or reduce workload. Given universal adoption of EHRs, further research examining how to optimally leverage patient portals for improving outcomes are needed.

BACKGROUND:A potential benefit of electronic health records (EHRs) is that they could potentially save clinician time and improve documentation by auto-generating the history of present illness (HPI) in partnership with patients prior to the clinic visit. We developed an online patient portal called AEGIS (Automated Evaluation of Gastrointestinal [GI] Symptoms) that systematically collects patient GI symptom information and then transforms the data into a narrative HPI that is available for physicians to review in the EHR prior to seeing the patient. OBJECTIVE:This study aimed to compare whether use of an online GI symptom history taker called AEGIS improves physician-centric outcomes vs usual care. METHODS:We conducted a pragmatic controlled trial among adults aged ≥18 years scheduled for a new patient visit at 4 GI clinics at an academic medical center. Patients who completed AEGIS were matched with controls in the intervention period who did not complete AEGIS as well as controls who underwent usual care in the pre-intervention period. Of note, the pre-intervention control group was formed as it was not subject to contamination bias, unlike for post-intervention controls. We then compared the following outcomes among groups: (1) documentation of alarm symptoms, (2) documentation of family history of GI malignancy, (3) number of follow-up visits in a 6-month period, (4) number of tests ordered in a 6-month period, and (5) charting time (difference between appointment time and time the encounter was closed). Multivariable regression models were used to adjust for potential confounding. RESULTS:Of the 774 patients who were invited to complete AEGIS, 116 (15.0%) finished it prior to their visit. The 116 AEGIS patients were then matched with 343 and 102 controls in the pre- and post-intervention periods, respectively. There were no statistically significant differences among the groups for documentation of alarm symptoms and GI cancer family history, number of follow-up visits and ordered tests, or charting time (all P>.05). CONCLUSIONS:Use of a validated online HPI-generation portal did not improve physician documentation or reduce workload. Given universal adoption of EHRs, further research examining how to optimally leverage patient portals for improving outcomes are needed.

Our objective was to review and exemplify how selected applications of artificial intelligence (AI) might facilitate and improve inflammatory bowel disease (IBD) care and to identify gaps for future work in this field. IBD is highly complex and associated with significant variation in care and outcomes. The application of AI to IBD has the potential to reduce variation in healthcare delivery and improve quality of care. AI refers to the ability of machines to mimic human intelligence. The range of AI's ability to perform tasks that would normally require human intelligence varies from prediction to complex decision-making that more closely resembles human thought. Clinical applications of AI have been applied to study pathogenesis, diagnosis, and patient prognosis in IBD. Despite these advancements, AI in IBD is in its early development and has tremendous potential to transform future care.

BACKGROUND:Most patients with IBD experience pain, especially during acute disease exacerbations. Opioid use continues to be more prevalent in IBD than any other chronic gastrointestinal condition, and the majority of IBD patients consume narcotics during hospitalization despite the risks of infection and death. METHODS:We performed a retrospective review of 57 subjects aimed at quantifying pain and opiate consumption for IBD-related admissions over a 3-month period. For each patient, the average and maximum of each day's pain scores were used to measure changes in pain from admission to discharge using mixed model regression, with opiate use as a time-dependent covariate. RESULTS:The daily average pain score over the entire hospitalization was 4.23 ± 2.09, and the maximum pain score was 8.28 ± 1.75. Among opioid users (n = 51), the daily average pain score was 4.65 ± 2.16 and the maximum pain score was 7.53 ± 2.56. Across all cases from admission to discharge, there was less than a 1-point change in daily average pain (- 0.96 ± 2.03, p = 0.0009), and no change in maximum pain (- 0.89 ± 3.59, p = 0.0671). Opioid users, a subset of the overall cohort, had a similar less than one-point drop in daily average pain (- 0.94 ± - 0.29, p = 0.0024) and no change in daily maximum pain scores (- 0.81 ± - 0.47, p = 0.0914). Patients on average used 20 ± 25 mg morphine equivalents per day. Opioid-naïve patients used similar doses to those who used opioids prior to admission (PTA). Almost half of all cases (47%) were discharged with an opioid prescription, the majority (71%) of whom were not on opioids PTA. CONCLUSIONS:Pain in IBD is not well controlled through hospitalization, with less than a 1-point change from admission to discharge, despite significant opioid consumption. Alternative analgesic methods should be explored, given the significant impact of narcotics on long-term outcomes including mortality and quality of life.