COVID-19 Vaccine Hesitancy in Patients with Inflammatory Bowel Disease.

BACKGROUND AND AIMS: COVID-19 vaccine hesitancy varies across the USA. Data on COVID-19 vaccine hesitancy in patients with inflammatory bowel disease (IBD) are lacking. We assessed COVID-19 vaccine hesitancy and its associated variables in patients with IBD. METHODS: We evaluated voluntary patient survey responses during routine clinical visits to our IBD center. Data collected included demographic and clinical characteristics. Descriptive statistics, univariate and multivariate analyses were performed to evaluate significant associations with COVID-19 vaccine hesitancy. RESULTS: A total of 239 individuals completed the survey. Over a third of respondents (35.6%) expressed hesitancy toward receiving the COVID-19 vaccine due to vaccine safety concerns (49.4%) and efficacy (23.5%), while others reported non-specific concerns (34.1%). On univariate analysis, Crohn's disease (OR 2.33 CI 1.28-4.25 p = 0.0056), use of biologic medications (OR 1.93 CI 1.16-3.23, p = 0.012), previous self-reported vaccine refusal (OR 8.13 CI 2.90-22.82 p = 0.0001), earlier date of survey administration (OR 2.01 CI 1.17-3.44 p = 0.011), and self-reported COVID infection (OR 2.55 CI 1.16-5.61 p = 0.0056) were more likely to be associated with COVID-19 vaccine hesitancy. On multivariate analysis, patient age, previous vaccine refusal and date of survey administration were more likely to be associated with COVID-19 vaccine hesitancy. CONCLUSIONS: Over one-third of patients with IBD expressed COVID-19 vaccine hesitancy. Vaccine safety and efficacy were the most common reasons. Younger age, previous vaccine refusal and earlier date of survey were more likely to be associated with hesitancy. Our findings suggest that there is room for targeted education to improve COVID-19 vaccine uptake in patients with IBD.

Abdominal pain in quiescent inflammatory bowel disease.

OBJECTIVES: Inflammation is an important driver of abdominal pain in inflammatory bowel disease (IBD). However, some patients in remission still experience pain. We aimed to identify risk factors associated with abdominal pain in quiescent IBD (QP-IBD) and to characterize differences from patients with active disease experiencing pain (AP-IBD). METHODS: We performed a retrospective analysis utilizing data from our institution's IBD Natural History Registry (January 1, 2015-August 31, 2018). Endoscopic evaluation, concurrent laboratory studies, and validated surveys were completed by participants. Demographic and clinical data were also abstracted. RESULTS: We recruited 122 patients with quiescent disease (65f:57 m; 93CD:26UC:3Indeterminate) for participation in this study, 74 (60.7%) had QP-IBD. QP-IBD patients were more likely to have anxiety/depression (71.6% vs. 25.0%, p < 0.001) or to use antidepressants (47.3% vs. 22.9%, p < 0.010), opiates (18.9% vs. 2.1%, p < 0.010), other pain medications (50.0% vs. 18.8%, p < 0.010), or corticosteroids (18.9% vs. 2.1%, p < 0.010). On logistic regression analysis, corticosteroid use, anxious/depressed state, and female gender were each independently associated with QP-IBD (p < 0.050 or less). Compared with AP-IBD patients (n = 110, 59f:51 m; 69CD:38UC:3Indeterminate), QP-IBD patients were more likely to use antidepressants (45.6% vs. 26.4%, p < 0.010). Platelet, white blood cell, C-reactive protein, and sedimentation rate levels were all less likely to be elevated in QP-IBD (all p < 0.050), though 44% exhibited pathological elevation in at least one. DISCUSSION: QP-IBD was independently associated with corticosteroid use, anxiety/depression, and female gender. Compared with AP-IBD, QP-IBD patients were more likely to use antidepressants and less likely to exhibit elevated inflammatory markers. However, many QP-IBD patients still demonstrated pathological elevation of these tests, demonstrating the need to develop new noninvasive screening methods for this condition.

Improving Provider Compliance With Adult Inflammatory Bowel Disease Patient Care Guidelines in the Ambulatory Setting Through the Use of Electronic Health Records.

Electronic health record (EHR) systems have the ability to improve the quality of patient care, patient safety, and provide benefits to providers and clinic practices. These systems can transform quality measurement and quality improvement methods, facilitate workflow, and track patients over time to ensure that they receive guideline-recommended, evidence-based care. Simply having an EHR system, however, may not be enough to improve the quality and safety of healthcare, especially if the system is not designed to include features specific to the treatment population. A comprehensive literature review of the evidence on EHRs and the implementation of clinical guidelines was conducted. The positive outcomes in this review supports the notion that using well-designed, evidence-based clinical decision tools or checklists within the workflow of the EHR system can improve provider compliance with inflammatory bowel disease (IBD) clinical practice guidelines. Critical content to include in the IBD checklist for the adult patient in the ambulatory setting is also recommended.

Improving outpatient care in adult inflammatory bowel disease: effect of implementation of a reminder checklist in the electronic health records (IBD-ERS)-a pilot study.

Studies have shown that patients with inflammatory bowel disease (IBD) do not receive age appropriate preventive care services at the same rate as the general population. Providers extract information on preventive measures compliance by chart review, discussion with patients or deferment to primary care providers to ensure and document compliance. The aim of this pilot study was to evaluate the effectiveness of our standardised template which was incorporated in the electronic health records in order to provide the highest quality of clinical care and improve efficiency. We compared the outcomes before and after implementation of the template. In our preimplementation phase, we performed retrospective single-centre chart review of all patients diagnosed with IBD and treated with an immune modulator therapy between years January 2015-December 2016 and December 2019-July 2020. Preventive care measures included influenza and pneumonia, smoking cessation, checking thiopurine methyltransferase (TPMT) enzyme activity prior to starting thiopurines, screening for hepatitis B status, and tuberculosis (TB) testing prior to starting anti-TNF therapy. A total of 200 patients were included. Prior to the template implementation, manual extraction of data showed about 43% and 31% of the patients with IBD received influenza vaccination in 2015 and 2016, respectively. There were 40.9% who received pneumococcal vaccination, 57.5% with TPMT activity prior to thiopurine use, 60% had hepatitis B testing and only 12.5% had documented TB test. Post intervention, there was a significant increase in vaccination rates with 93.1% and 87.6% received influenza and pneumococcal vaccination, respectively (p<0.0005). About 94.7% had TPMT activity, 96.8% had hepatitis B and 98.9% had TB test completed (p<0.0005). The average time (minutes) to obtain information for each patient decreased from 12.27 to 4.62. Our study demonstrated a significant improvement in documented immunisation rates and quality of preventive care after implementation of standardised template.

Symptoms and Extraintestinal Manifestations in Active Cannabis Users with Inflammatory Bowel Disease.

Introduction: Cannabis use is common in the setting of inflammatory bowel disease (IBD). Patients frequently use cannabis to treat IBD-associated symptoms, and there is evidence that cannabis and its derivatives are helpful for this purpose. However, it is unclear how the symptom profiles of active IBD cannabis users and nonusers compare and how these symptoms may relate to their underlying disease state and/or complications. Materials and Methods: We performed a retrospective cohort study using a consented IBD natural history registry from a single tertiary care referral center between January 1, 2015 and August 31, 2020. We asked patients about current cannabis use and frequency. We also abstracted demographic and clinical characteristic information, including endoscopic severity, and totals and subscores of surveys assessing IBD characteristics, presence of anxiety/depression, and IBD-associated symptoms. We compared clinical and demographic factors of cannabis users and nonusers and developed a logistic regression model to evaluate for independent associations with cannabis use. Results: Three hundred eighty-three IBD patients met the inclusion criteria (206 females, 177 males; 258 Crohn's disease [CD], 118 ulcerative colitis, and 7 indeterminate colitis). Thirty patients (7.8%) were active cannabis users, consuming it for an average of 2.7 times per week. Cannabis users were more likely to report abdominal pain (83.3% vs. 61.7%), gas (66.7% vs. 45.6%), tenesmus (70.0% vs. 47.6%), and arthralgias (53.3% vs. 20.3%) compared to those that did not use cannabis (p<0.05 for each). Incidence of moderate-severe endoscopic inflammation was similar between cannabis users and nonusers, while CD-associated complications were more common in nonusers (39.1% vs. 69.7%, p<0.05). The only factor that demonstrated a significant association with cannabis use on multivariable analysis was arthralgia (p<0.01). Discussion: Active IBD cannabis users were more likely to report a variety of symptoms, including abdominal pain, gas, tenesmus, and arthralgias. However, they did not demonstrate more frequent active disease or IBD-associated complications, suggesting that other nonluminal factors influence their symptoms and/or decision to use cannabis. These findings demonstrate the importance of evaluating for extraintestinal contributors to symptom burden in IBD cannabis users, as well as the ongoing need to develop safer and more effective methods for recognizing and managing abdominal pain and other symptoms in this setting.

Dedicated Psychiatry Clinic for Inflammatory Bowel Disease Patients Has a Positive Impact on Depression Scores.

Background: Psychiatric disorders, including anxiety and depression, are significantly more common in patients with inflammatory bowel disease (IBD). We established an integrated psychiatry clinic for IBD patients at our tertiary center IBD clinic to provide patients with critical, but frequently unavailable, coordinated mental health services. We undertook this study to evaluate the impact of this service on psychiatric outcomes, quality of life, and symptom experience. Methods: We performed a longitudinal prospective study comparing patients who had been cared for at our integrated IBD-psychiatry clinic to those who had not. We abstracted demographic and clinical information as well as contemporaneous responses to validated surveys. Results: Thirty-six patients cared for in the IBD psychiatry clinic were compared to a control cohort of 35 IBD patients. There was a significant reduction in the Hospital Anxiety and Depression Scale (HADS) depression score over time in the study cohort (p = 0.001), though not in the HADS anxiety score. When compared to the control group, the study cohort showed a significant reduction in the HADS depression score. No significant differences were observed in the Harvey-Bradshaw Index, Simple Clinical Colitis Activity Index, or Short IBD Questionnaire. Conclusions: This is the first study to evaluate the impact of an integrated psychiatry clinic for IBD patients. Unlike their control counterparts, individuals treated in this clinic had a significant reduction in the mean HADS depression score. Larger scale studies are necessary to verify these findings. However, this study suggests that use of an integrated psychiatry IBD clinic model can result in improvement in mental health outcomes, even in the absence of significant changes in IBD activity.

Symptoms associated with healthcare resource utilization in the setting of inflammatory bowel disease.

Several symptoms have been connected to increased healthcare resource utilization (HRU) in the context of inflammatory bowel disease (IBD), including both Crohn's disease (CD) and ulcerative colitis (UC). This study was designed to investigate the prevalence of IBD-associated symptoms and to determine whether any are independently associated with HRU. We undertook a retrospective analysis of data related to consecutive IBD patient encounters from a tertiary care referral center between 1/1/2015 and 8/31/2019. Demographics, clinical activity, endoscopic severity, IBD-related symptom scores, anxiety and depression scores, and other key clinical data were abstracted. Four hundred sixty-seven IBD patients [247f.: 220 m; 315 CD, 142 UC and 11 indeterminate colitis] were included in this study. The most common symptoms were fatigue (83.6%), fecal urgency (68.2%) and abdominal pain (63.5%). Fatigue, abdominal pain, anxiety or depression, corticosteroids, and opioids were each positively associated with HRU, while NSAID and mesalamine use were inversely associated on bivariate analysis. The only factor that demonstrated a statistically significant association with HRU in the whole cohort on multivariable analysis was abdominal pain. Abdominal pain is independently associated with HRU and should be specifically screened for in IBD patients to identify individuals at risk of undergoing expensive interventions. This study also reinforces the importance of optimizing diagnostic and therapeutic management of abdominal pain in IBD.

Why Is There Low Utilization of Biosimilars in Inflammatory Bowel Disease Patients by Gastroenterology Advanced Practice Providers?

Aim: To assess knowledge, practice patterns and attitudes toward the use of biosimilars by Advanced Practice Providers (APPs) treating patients with inflammatory bowel disease (IBD). Background: APPs provide care in a variety of healthcare settings including medical specialties. In Gastroenterology, they are an integral part of providing care to a complex group of patients with IBD. There has been an increase in options of medical therapies for treating IBD. These include small molecules, biologics, and biosimilars. Adoption of biosimilars for treatment of IBD patients by gastroenterologists in the United States compared to Europe has been slow for several reasons. There is lack of data on their use by APPs who provide frontline IBD clinical care in the United States. Methods: Questionnaire-based survey of APPs attending Gastroenterology conferences with a focus on IBD. Results: APPs in gastroenterology do not routinely consider the use of biosimilars in their practice. Conclusions: There is low utilization of biosimilars in treating IBD patients by APPs. In addition, there are significant concerns about risk of side effects as well as perceived lack of APP targeted educational resources.

Impact of a nurse navigator on a dedicated inflammatory bowel disease-focused gastroenterology clinic.

BACKGROUND: Management of inflammatory bowel disease (IBD) patients can be very challenging. Nurse navigators (NNs) have demonstrated great promise for coordinating care of complex disorders but little is known about their impact on the setting of IBD. We undertook this study to evaluate how the introduction of a NN in a dedicated IBD clinic would influence several outcomes related to patient care. METHODS: A retrospective chart review was performed evaluating Penn State IBD clinic patients receiving care a year before and after the introduction of a dedicated NN to the clinic. No-show rates, new appointments in less than 21 days, total clinic visits per month, and patient enrolment in our IBD registry and biorepository were measured prior to and after hiring of the NN between 2 providers. Each provider and their composite data were statistically compared using univariate analysis. RESULTS: After hiring the NN, there was a statistically significant decrease in combined no-show rates (P=0.02). There was no significant difference in the combined average number of new appointments in less than 21 days (P=0.62) or total clinic visits per month (P=0.09). Enrolment in the database and biorepository increased (from 83% to 90%). Finally, 97% were satisfied with the NN's services, and 94% were satisfied with the IBD education they provided. CONCLUSIONS: Hiring a NN in our clinic was associated with high patient satisfaction, reduced no-show rates, and increased research participation. Thus, incorporation of a NN can improve care in an IBD-centered gastroenterology clinic.

Polysubstance use in inflammatory bowel disease.

OBJECTIVES: We aimed to evaluate the incidence, predisposing factors and impacts of polysubstance use (PSU) (ie, the concurrent use or abuse of two or more drugs or substances) in inflammatory bowel disease (IBD). METHODS: Data of patients enrolled between 1 January 2015 and 31 August 2019 from a single tertiary care referral center were retrospectively collected. Patients' baseline and clinical characteristics and their antidepressant and/or anxiolytic medications were abstracted. Associations between PSU and patients' characteristics were analyzed. Multivariate logistic regression models were fit, incorporating significant clinical factors. RESULTS: Altogether 315 patients with IBD (166 women, 149 men; 214 with Crohn's disease and 101 ulcerative colitis) were enrolled. Of them, 66 (21.0%) exhibited PSU (CD 21.5%, UC 19.8%); 37.5% had moderate to severe disease activity, 34.3% with extraintestinal manifestations (EIM), 41.6% with an anxious or depressed state and 69.8% had used healthcare resources in the prior 12 months. Moreover, 71.2% used two substances, while 27.3% used three substances. In the total cohort, EIM (odds ratio [OR] 1.97, 95% confidence interval [CI] 1.14-3.34, P = 0.019) and antidepressant or anxiolytic use (OR 2.51, 95% CI 1.45-4.39, P < 0.001) were positively associated with PSU on multivariate analysis. PSU was associated with increased rate of IBD-associated imaging (57.6% vs 47.0%, P < 0.05). CONCLUSIONS: PSU is common in IBD. EIM, antidepressant and/or anxiolytic use and imaging studies were independently associated with PSU. This study reinforces the importance of screening patients with IBD for substance use, particularly those with EIM and using antidepressants and/or anxiolytics.

Gastrointestinal hypoalgesia in inflammatory bowel disease.

BACKGROUND: Pain perception is critical for detection of noxious bodily insults. Gastrointestinal hypoalgesia in inflammatory bowel disease (IBD) is a poorly understood phenomenon previously linked to poor patient outcomes. We aimed to evaluate the risk factors associated with this condition and to discern characteristics that might differentiate these patients from pain-free quiescent counterparts. METHODS: We performed a retrospective analysis using an IBD natural history registry based in a single tertiary care referral center. We compared demographic and clinical features in 3 patient cohorts defined using data from simultaneous pain surveys and ileocolonoscopy: a) active IBD without pain (hypoalgesic IBD); b) active IBD with pain; and c) inactive IBD without pain. RESULTS: One hundred fifty-three IBD patients had active disease and 43 (28.1%) exhibited hypoalgesia. Hypoalgesic IBD patients were more likely to develop non-perianal fistulae (P=0.03). On logistic regression analysis, hypoalgesic IBD was independently associated with male sex, advancing age and mesalamine use, and inversely associated with anxious/depressed state and opiate use. Hypoalgesic IBD patients were demographically and clinically similar to the pain-free quiescent IBD cohort (n=59). Platelet count and C-reactive protein were more likely to be pathologically elevated in hypoalgesic IBD (P=0.03), though >25% did not exhibit elevated inflammatory markers. CONCLUSIONS: Hypoalgesia is common in IBD, particularly in male and older individuals, and is associated with an increased incidence of fistulae and corticosteroid use. Novel noninvasive diagnostic tools are needed to screen for this population, as inflammatory markers are not always elevated.