Faculty Bibliography

BACKGROUND:Inflammatory bowel disease (IBD) management has become increasingly complex, and education varies across fellowship programs. IBD 101 was designed to introduce first-year gastroenterology (GI) fellows to IBD care and training. METHODS:In 2019, a cohort of fellows participated in a 1-day course with small group learning and group observed structured clinical examinations. Pre- and postcourse surveys were administered to evaluate the course. To assess the long-term impact, surveys were emailed in May 2022 to all third-year fellows from previously participating programs. The primary outcome was comfort managing IBD scenarios and information regarding each fellow's exposure to IBD education. RESULTS:Fifty-five fellows from 32 programs participated. A total of 49 (89%) of 55 completed pre- and postcourse surveys. All fellows agreed that the course content was appropriate. In the postcourse survey, all fellows reported increased comfort managing IBD patients. Ninety-six percent of attendees stated that they would strongly recommend this course. Thirty-six fellows completed surveys in 2022, 21 (58%) attendees and 15 (42%) nonattendees. Attendees reported equivalent or higher levels of comfort compared with nonattendees. Higher global competence was noted among attendees (odds ratio, 5.21; 95% confidence interval, 0.91-29.9; P = .06) after adjusting for presence of a local IBD specialist, number of IBD patients seen monthly (≤5 vs >5), and rotation through an IBD service. CONCLUSIONS:IBD 101, an introductory course for first-year GI trainees, was associated with increased comfort managing IBD with a durable benefit independent of individual access to IBD education. Continuation of this program will further enhance the IBD education of future GI fellows.

BACKGROUND/UNASSIGNED:Patients with Crohn's disease (CD) or ulcerative colitis (UC) often cycle through conventional therapies (CT) with different mechanisms of action (MOA) before initiating advanced therapy (AT). We describe treatment patterns among patients with CD/UC. METHODS/UNASSIGNED:Using Merative MarketScan Research databases, adult patients with CD/UC were identified from medical/pharmacy claims (2017-2021). Patients had ≥1 hospitalization or ≥2 outpatient visits (≥30 days apart within 1 year) for CD/UC. Two cohorts were established; cohort 1: Newly diagnosed patients (index date is the date of first diagnosis) and cohort 2: Patients initiating AT (index date is the date of first AT). First-line treatment patterns (cohort 1) and CT pathways before AT initiation (cohort 2) by the number of episodes (ie, adding a new therapy, switching to another therapy, or restarting the same therapy after ≥60 days) and MOA are reported. RESULTS/UNASSIGNED: = 2431), the mean number of CT episodes before AT initiation was 4.0 ± 4.3 (CD) and 5.9 ± 5.0 (UC). Among those with ≥1 corticosteroid episode (CD: 82.2%; UC: 91.5%), the mean number of episodes was 4.6 ± 4.3 (CD) and 6.3 ± 5.0 (UC). Overall, 13.3% (CD) and 23.7% (UC) of patients cycled through 3 MOAs before AT initiation. CONCLUSIONS/UNASSIGNED:Despite treatment recommendations, few newly diagnosed CD/UC patients initiated AT as their first treatment. Moreover, patients cycled through multiple CTs before initiating AT.

The treatment armamentarium for inflammatory bowel disease has expanded rapidly in the past several years with new biologic and small molecule-agents approved for moderate-to-severe ulcerative colitis and Crohn's disease. This has made treatment selection more challenging with limited but evolving guidance as to where to position each medication. In this review, we discuss the efficacy data for each agent approved in the United States by reviewing their phase 3 trial data and other comparative effectiveness studies. In addition, safety considerations and use in special populations are summarized with proposed algorithms for positioning therapies. The aim is to provide a synopsis of high-impact data and aid in outpatient treatment decision-making for patients with inflammatory bowel disease.

The Crohn's & Colitis Foundation has grown to appreciate the needs of gastroenterology trainees with numerous initiatives designed to provide education, academic opportunities, and mentoring in inflammatory bowel disease (IBD) in recent years. The editors and staff at Crohn's and Colitis 360 (CC360) have launched 2 new initiatives, the Fellow's Corner and the CC360 Editorial Fellowship, to support trainees in gaining knowledge and skills regarding peer review and publication as well as offering guidance on training in IBD and an opportunity for publication in this peer-reviewed, open access, quarterly online journal. These opportunities are described in this manuscript.

Introduction: The care of inflammatory bowel disease (IBD) has become increasingly complex and specialized. IBD education of gastroenterology (GI) trainees needs improvement and standardization. IBD 101, an annual course designed to introduce first-year GI fellows to various clinical topics in the management of IBD, was held on September 14, 2019. In this inaugural program, a select group of fellows (N=55 from 32 different programs) participated in a one-day course involving small group didactic sessions and Group Observed Structured Clinical Examinations (OSCEs) led by expert faculty members in seven clinical topics.
Method(s): To assess the long-term impact of IBD 101, email surveys were administered in May 2022 (the graduating year of the inaugural IBD 101 cohort) to all third-year GI fellows from participating programs, inclusive of both attendees and non-attendees. The primary outcome was comfort level discussing the 7 topics addressed at IBD 101, graded using a Likert scale (15 "strongly disagree" to '45 "strongly agree"). Information regarding each fellow's exposure to IBD education was collected.
Result(s): Thirty-six fellows completed surveys, of whom 21 (58%) were IBD 101 attendees and 15 (42%) were non-attendees. Overall, attendees reported equivalent or higher levels of comfort in each of the 7 topics than did non-attendees (Figure). In particular, a higher proportion of attendees strongly agreed with comfort in discussing pregnancy and IBD (43% vs. 13%; P=0.04) and loss of response to biologics (62% vs. 27%; P=0.13) than non-attendees. When assessing overall confidence, 76% of attendees reported comfort in all 7 categories, compared with 53% of non-attendees (P=0.15). Attending IBD 101 was associated with overall confidence (OR 5.21 [95% CI 0.91-29.9]; P=0.06) even after adjusting for presence of an IBD specialist at a fellow's home institution, number of IBD patients seen per month (<=5 vs. >5) and rotating through an IBD-only clinic or inpatient service (Table).
Conclusion(s): IBD 101, a primer for first-year GI trainees, was associated with increased comfort in the management of IBD, with more pronounced impact on challenging topics. IBD 101 is a valuable learning opportunity for first-year GI fellows with a durable benefit independent of individual access to IBD education, and we plan continued development, expansion and assessment of this program in collaboration with the ACG to further enhance the IBD education of the pipeline of GI trainees. (Figure Presented)

PURPOSE OF THE REVIEW/OBJECTIVE:As treatment options for Inflammatory Bowel Disease (IBD) expand each class of medication will have specific safety concerns and side-effect profiles that need to be considered for optimal treatment of patients. We will review the most recent safety data for the newly approved immunomodulator therapies for the treatment of IBD. RECENT FINDINGS/RESULTS:There are a growing number of publications outlining safety concerns for medications used to treat IBD. We reviewed safety profile of anti-tumor necrosis factor antibodies (TNF) with specific attention to combination therapy (anti-TNF plus immunomodulator). Recent publications have demonstrated increased risk of serious infection and malignancy (lymphoma and overall cancer rates) in patients receiving anti-TNF combination therapy when compared with patients receiving anti-TNF monotherapy or immunomodulator monotherapy. Recent publications on Janus Kinase Inhibitors indicate an increased risk of infection, specifically Herpes Zoster, and increased risk of major cardiovascular events and venous thromboembolic events resulting in a black box warning for the medication. In contrast, anti-interleukin 12/23 agents and gut selective anti-integrin antibody agents have demonstrated a favorable side-effect profile with low rates of infection and malignancy. The latest class of medications to be approved, sphingosine 1-phosphate (S1P) receptor modulators, have cardiac and infectious precautions. The field of IBD treatment is rapidly evolving with several mechanistic classes of medications now available. While corticosteroids continue to be associated with the greatest, overall, safety risks, each of the newer mechanistic classes have unique safety concerns. In the future, as we gain more experience with these agents, we will need to continue to evaluate the safety profile of our therapies used alone or in combination to make informed treatment decisions with our patients.

BACKGROUND:There is wide variation in the quality of care of hospitalized patients with inflammatory bowel disease (IBD). Prior studies have demonstrated that a specialized inpatient IBD service improves short-term outcomes. In this study, we assessed the impact of a dedicated IBD service on the quality of care and long-term outcomes. METHODS:This retrospective cohort study included adult patients admitted for a complication of IBD between March 2017 and February 2019 to a tertiary referral center. In March 2018, a dedicated inpatient IBD service co-managed by IBD gastroenterologists and colorectal surgeons was implemented. Quality of care outcomes included C. difficile stool testing, confirmed VTE prophylaxis administration and opiate avoidance. Long-term outcomes were clinical remission, IBD-related surgery, ED visits, and hospital readmissions at 90 days and 12 months. RESULTS:In total, 143 patients were included; 66 pre- and 77 post-implementation of the IBD service. Fifty-two percent had ulcerative colitis and 48% had Crohn's disease. After implementation, there was improvement in C.difficile testing (90% vs. 76%, P = 0.04), early VTE prophylaxis (92% vs. 77%, P = 0.01) and decreases in narcotic use (14% vs. 30%, P = 0.02), IBD-related ED visits at 90 days (7% vs 18%, P = 0.03) and 12 months (16% vs 30%, P = 0.04), and IBD readmissions at 90 days (16% vs. 30%, P = 0.04). There were no differences in rates of clinical remission or surgery. CONCLUSIONS:The creation of a dedicated inpatient IBD service improved quality of IBD care and reduced post-discharge ED visits and readmissions and broader implementation of this strategy may help optimize care of hospitalized IBD patients.

BACKGROUND:With the management of inflammatory bowel disease (IBD) becoming increasingly complex, incorporating preventive care health maintenance measures can be challenging. The aim of developing these updated recommendations is to provide more specific details to facilitate their use into a busy clinical practice setting. METHOD:Fifteen statements were formulated with recommendations regarding the target, timing, and frequency of the health maintenance interventions in patients with IBD. We used a modified Delphi method and a literature review to establish a consensus among the panel of experts. The appropriateness of each health maintenance statement was rated on a scale of 1 to 5 (1-2 as inappropriate, and 4-5 as appropriate) by each panelist. Interventions were considered appropriate, and statements were accepted if ≥80% of the panelists agreed with a score ≥4. RESULTS:The panel approved 15 health maintenance recommendations for adults with IBD based on the current literature and expert opinion. These recommendations include explicit details regarding specific screening tools, timing of screening, and vaccinations for adults with IBD. CONCLUSIONS:Patients with IBD are at an increased risk for infections, malignancies, and other comorbidities. Given the complexity of caring for patients with IBD, this focused list of recommendations can be easily incorporated in to clinical care to help eliminate the gap in preventative care for patients with IBD.