New Zealand National Audit of Outpatient Inflammatory Bowel Disease Standards of Care.

AIM: This study audits the delivery and standards of New Zealand (NZ) inflammatory bowel disease (IBD) care against international standards, with emphasis on the IBD nursing role. METHODS: Utilising international standards in IBD care, a 3 phase national multicentre survey study was performed between 2015 and 2019. We 1) evaluated the current role and practices of IBD nurses, 2) evaluated IBD service provision and identified areas for improvement, and 3) audited key aspects of IBD patient care, directly comparing nurse-led and doctor-led outpatient clinics. RESULTS: The median duration spent in an IBD nursing role was 21 months (range 2 to 120 months) with the majority (12/15) performing two or more nursing roles. The median IBD nurse full-time equivalent (FTE) was 0.8 (range 0.2 to 1.25). The average number of hours spent undertaking IBD nursing tasks was 22.2 - a 6.8-hour shortfall compared to rostered hours. No service had a per capita IBD multidisciplinary team (MDT) FTE which met international standards. Just under two-thirds (62.5%) of departments held a regular MDT meeting. All responding services could be contacted directly by IBD patients and respond within 48 hours of contact. During 492 doctor-led and 196 nurse-led scheduled outpatient clinic visits, nurses were significantly more likely to document weight, smoking status and organise appropriate colonoscopic surveillance than doctors. CONCLUSION: Multiple nursing job roles resulted in rostered hours being insufficient to complete IBD specific tasks. IBD FTE did not meet international standards. The IBD care was patient-centred, encouraging direct contact from patients with prompt response. IBD nurses in NZ provide high-quality outpatient care when measured against auditable standards. As the IBD nursing role continues to develop, following the implementation of an educational framework and education programme, an increase in numbers is required in order to achieve the recommended minimum FTE per 250 000 population.

VITALITY: impact of adalimumab on health and disability outcomes in patients with Crohn's disease, rheumatoid arthritis, or psoriasis treated in clinical practice in New Zealand.

Objective: VITALITY, a 6-month, multicenter, prospective, observational study, assessed the effects of originator adalimumab (HUMIRA) on health and disability outcomes in patients with Crohn's disease (CD), rheumatoid arthritis (RA), or psoriasis treated in routine clinical practice in New Zealand (NZ). Methods: Biologic-naïve adults initiating adalimumab in accordance with NZ funding requirements were recruited. The primary endpoint was 6-month change from baseline in World Health Organization Disability Assessment Schedule (WHODAS) 2.0 score in all participants completing the study (full analysis set). Secondary endpoints included 6-month change in other patient-reported outcomes (PROs) of work activity and wellbeing (Work Productivity and Activity Impairment Questionnaire: General Health, Kessler Psychological Distress Scale, Flourishing Scale, and Subject Vitality Scale) and in disease-specific PRO measures. Results: In total, 164 participants with severe disease initiating adalimumab completed the WHODAS 2.0 at baseline, of whom 114 (69.5%) completed the study at 6 months. Mean WHODAS 2.0 score halved from 15.2 points (SD = ±9.1) at baseline to 7.3 points (SD = ±7.2) after 6 months' adalimumab treatment (mean difference = 7.9 points; 95% CI = 6.4-9.4; p < .001), with statistically significant improvements seen as early as 2 months after adalimumab initiation (p < .001). The proportion of participants with a WHODAS 2.0 score ≥ 10 more than halved, from 68.3% to 28.9%, between baseline and 6 months. Other PROs also improved significantly at 6 months, as did disease-specific measures. No new adalimumab safety signals were observed. Conclusions: Health and disability outcomes improved significantly after 6 months of adalimumab use in NZ patients with severe CD, RA, or psoriasis. Clinicaltrials.gov: NCT02451839.

Agreement of triage decisions between gastroenterologists and nurses in a hospital endoscopy unit.

INTRODUCTION: Efficient and accurate triage of endoscopy referrals is essential. Many of the decisions made are based on national and local triage criteria. Standardizing this approach for nurse use could maintain quality, address clinical risk and significantly improve resource utilization. AIMS: This study aimed to compare gastroenterologist and nurse triage of unselected gastroenterology referrals in order to evaluate the proportion of referrals felt able to be triaged to endoscopy and the inter-rater agreement between a triage gastroenterologist and endoscopy nurses for clinical triage decisions regarding the urgency of gastroscopy and colonoscopy. METHODS: The proportion of referrals triaged to endoscopy by a consultant gastroenterologist performing triage as a part of normal practice and two endoscopy nurses using a decision algorithm was measured. The inter-rater agreement for the triage category decision (urgency of referral) between the three triage clinicians was assessed. An adjudication panel provided a consensus decision triage category decision in cases where there was not complete agreement between the three triage clinicians. RESULTS: Each clinician assessed 105 referrals. Nurse A was able to triage 54 (51%) referrals to a triage category and Nurse B 44 (42%) referrals. Cohen's κ was run to determine if there was agreement between clinicians for the triage categories allocated. The agreement between the two nurses was substantial (k=0.645, P<0.0005). Between the gastroenterologist and each nurse, moderate agreement was seen (Nurse A, k=0.589, P<0.0005; Nurse B, k=0.437, P<0.0005). Moderate agreement was seen between the nurses and an adjudication panel (Nurse A, k=0.423, P<0.0005; Nurse B, k=0.464, P<0.0005). However, there was only slight agreement between the adjudication panel and the gastroenterologist (k=0.099, P=0.010). CONCLUSION: Nurse triage using a decision algorithm is feasible, and inter-rater agreement is substantial between nurses and moderate to substantial between the nurses and a gastroenterologist. An adjudication panel demonstrated moderate agreement with the nurses but only slight agreement with the triage gastroenterologist. This suggests that nurse triage using a decision algorithm can approximate decision making by an experienced gastroenterologist.

Intravenous Iron Replacement Improves Quality of Life in Hypoferritinemic Inflammatory Bowel Disease Patients with and without Anemia.

BACKGROUND: No study has compared changes in quality of life (QoL) following iron therapy between anemic and non-anemic, hypoferritinemic patients. This study compares the impact of parenteral iron replacement on QoL in inflammatory bowel disease (IBD) patients with anemia, or in those with hypoferritinemia alone. METHODS: Consecutive IBD patients diagnosed with anemia or hypoferritinemia were enrolled. IBD questionnaire (IBDQ) and 36-Item Short Form Survey (SF36) at diagnosis and 6 weeks post treatment were measured. RESULTS: Ten patients with anemia and 13 with hypoferritinemia were treated with intravenous iron polymaltose. Across all patients, there was a significant improvement in median SF36 mental component score by 8.5 (p = 0.004) and median IBDQ by 12 (p = 0.02). There was a trend towards improved median SF36 physical component score by 3.2 (p = 0.6). These changes were not significantly different when comparing anemic with hypoferritinemic patients. In IBDQ, there was a trend toward greater improvement in hypoferritinemic vs. anemic patients (20 vs. 1.5, p = 0.31). CONCLUSIONS: This is the first study to show that improvements in QoL in hypoferritinemic patients are similar to those with anemia. Based on these results, patients with IBD should be offered the option of iron therapy when they are found to be hypoferritinemic, even in the absence of anemia.

New Zealand Society of Gastroenterology Guidelines for the Management of Refractory Ulcerative Colitis.

The management of patients with ulcerative colitis who are dependent on corticosteroid for control of symptoms, or refractory to corticosteroids or standard immunosuppressive therapy, is challenging. The development of newer medical therapies has increased the options for managing patients in this situation, but access and funding remain limited. This guideline summarises the literature regarding this situation and provides guidance as to the management of refractory colitis in the New Zealand setting.

Adalimumab for Crohn's disease in New Zealand--a prospective multicentre experience.

AIM: Adalimumab is an effective treatment for Crohn's disease (CD). We aimed to describe the early patterns of use, efficacy and response to adalimumab in four regions of New Zealand. METHODS: Prospectively collected CDAI data were used to examine adalimumab continuation rates in CD patients. Reasons for adalimumab cessation were determined and phenotypic characteristics of those remaining on adalimumab were examined. RESULTS: 194 patients (100 female) from four centres were included. Indications for adalimumab included CDAI>300 (59.8%), extensive small intestinal disease (21.1%), stoma with active disease (4.6%), risk of short gut syndrome (7.7%) and other (6.7%). The mean follow-up was 20 months (252.8 patient years of data). Adalimumab continuation rates at 6, 12, 24 and 30 months were 92.7%, 87.3%, 76.6% and 67.4%, respectively. Patients with penetrating disease behaviour were more likely to continue on adalimumab (p<0.005). There was a significant reduction in mean CDAI from 357 to 110 (p<0.0001) over a 6-month period. The mean (range) number of days spent in hospital per patient in the year prior and after adalimumab initiation were 3.5 (0-38) days and 1.9 (0-67) days, respectively (p<0.0001). CONCLUSIONS: Adalimumab continuation rate in this multicentre CD population was higher than other populations. This may be due to adalimumab being used more commonly as the initial biologic drug in New Zealand.

Eosinophilic oesophagitis: an emerging important cause for undiagnosed dysphagia.

BACKGROUND: The finding of an eosinophilic infiltration of the oesophageal epithelium has long been thought to be a result of gastro-oesophageal reflux disease. The association between this finding, an abnormal endoscopic appearance to the oesophagus with ridges and furrows in the oesophagus, and an association with recurrent food impactions in young men has also been described. It was first proposed that this was a distinct clinicopathological syndrome in 1993. Since that series, there have been increasing reports in the literature. AIMS AND METHODS: This retrospective case series describes eight patients with eosinophilic oesophagitis. The mode of presentation, history, endoscopic findings, and histopathology of this condition are discussed. The first of these cases is described to illustrate the features of this condition, the salient features from the remaining cases are presented in tabular form. CONCLUSIONS: The syndrome of eosinophilic oesophagitis is considered a rare cause of dysphagia, however we report eight recent presentations to our general gastroenterological practice in Wellington, New Zealand and propose that it may be an important cause for dysphagia where no diagnosis has been forthcoming.