Understanding the role of the primary care physician in the management of patients with Crohn's perianal fistulas.

OBJECTIVES: To understand the role of primary care physicians (PCPs) in the recognition, diagnosis, and management of Crohn's perianal fistulas (CPF) and their referral patterns and treatment expectations. METHODS: This survey-based study was conducted between September 2020 and October 2020. US-based PCPs managing at least one patient with Crohn's disease per week were included. Participants were presented with two case vignettes relevant to primary care practice; Case Vignette 1 comprised three parts and focused on initial CPF presentation and progression to partial response; Case Vignette 2 focused on recurrent CPF. Survey questions elicited the physician's clinical approach to each case. Data were presented as descriptive statistics. RESULTS: Overall, 151 PCPs (median 23 years in practice) who saw about three patients per month with new/existing CPF responded. For Case Vignette 1, upon identification of a fistulous tract, 89% of respondents would refer the patient, mostly to a colorectal surgeon or gastroenterologist. Most PCPs (69%) would begin the patient on medication; 46% would conduct a diagnostic/imaging study. Treatment expectations after referral varied: 55% of respondents believed surgeons would place a seton or use one prior to surgery; 23% expected medical management only; 23% were unsure. Case Vignette 2 revealed that 98% of PCPs preferred to be involved in patient care after referral; however, only 49% were. Of these, 76% considered reinforcing patient treatment adherence as their primary role. While 80% of PCPs were at least moderately satisfied with communication and care coordination with multidisciplinary teams, 52% considered lack of access to specialists as at least a moderate barrier to multidisciplinary team management. CONCLUSION: PCPs want more involvement in multidisciplinary management of patients with CPF. Continuing education providing PCPs with up-to-date information on diagnostic modalities, treatment options, early diagnosis, the role of PCPs within a multidisciplinary team, and effective initial CPF care is required.

What were the study's aims?To understand how primary care physicians recognize, treat, and monitor patients with Crohn's disease-related perianal fistulas (small tunnels between the bowel and skin near the anus).How was the study done?US-based primary care physicians, including internists, were included if they had experience in treating patients with Crohn's disease. Descriptions of the history and symptoms of two hypothetical patients were provided: one patient who may have Crohn's perianal fistulas and another patient whose Crohn's perianal fistulas had returned after being treated. After reading these descriptions, the physicians completed a questionnaire designed to show how they would help each patient.What did the study find out?Not all physicians treat patients with Crohn's perianal fistulas in the same way in terms of diagnostic tests and medical treatments, although most said they would refer them to a specialist if a fistula was identified. Many wanted to be involved in patient care after referral to a specialist but only half were. Of those, most thought their main role was to ensure patients followed the treatments given by specialists. More than half of primary care physicians thought a lack of access to specialists could be a barrier to care.How does this impact care?The physicians surveyed want more involvement in multidisciplinary teams who look after patients with Crohn's perianal fistulas. To do this, they need more education about the diagnosis and treatment of Crohn's perianal fistulas, and clarity around their role within multidisciplinary teams who manage these patients.

Management of short-bowel syndrome: A survey of unmet educational needs among healthcare providers.

BACKGROUND: Management of short-bowel syndrome with intestinal failure (SBS-IF) is complex and requires a multidisciplinary approach. Because of the rarity of SBS-IF, healthcare professionals (HCPs) often lack clinical experience with the disease and may benefit from education regarding SBS-IF and its management. This study identified unmet educational needs related to the management of patients with SBS-IF. METHODS: This was a prospective, web-based survey (December 2019-January 2020) in which a series of clinical questions were posed to US HCPs after presenting three standardized SBS-IF cases to assess current practice patterns. HCPs were then asked a series of questions to identify potential knowledge gaps and unmet educational needs relating to SBS-IF management. RESULTS: Overall, 558 HCPs completed the survey, with 12%-38% having a formal SBS-IF multidisciplinary team currently available to make treatment decisions within their institution. Clinicians involved in care included gastroenterologists (93%), registered dietitians (79%), gastroenterology nurse practitioners and physician assistants (37%), registered nurses (43%), social workers (45%), and psychologists/psychiatrists (27%). There was underuse of published guidelines and limited understanding of the course of intestinal adaptation. Responses to the clinical scenarios highlighted disparities in SBS-IF care delivery, including diagnosis, management goals, medications prescribed, and nutrition practices. CONCLUSIONS: Future SBS-IF educational interventions for HCPs should aim to improve awareness and understanding of the disease, facilitate timely diagnosis, and standardize management practices to ensure patients receive optimal interdisciplinary care as widely as possible.

P036 Disparities in Diagnosis and Management of Patients with Crohn's Perianal Fistulas: Results of a US National Patient and Caregiver Survey.

BACKGROUND: Crohn's perianal fistulas (CPF) contribute to lowered quality of life for patients with Crohn's disease. Previous research has indicated potential racial and/or ethnic disparities in diagnosis and management of patients with CPF. This study aimed to expand on previous investigations in the management of patients with CPF to identify educational needs and explore potential disparities in care. METHODS: To understand specific educational needs of US patients and caregivers of patients with CPF, a survey instrument was developed and fielded to patients and caregivers in September/October 2020. Subanalysis and inferential statistics were used to segment the patient/caregiver sample by race/ethnicity and determine potential areas of care disparities. RESULTS: Of 148 patient/caregiver responses analyzed, 28 were non-white (including American/Alaskan Native Indian, Black/African American, Hispanic/Latino, Native Hawaiian/Pacific Islander, and multiethnic); 12/28 were CPF patients and 16/28 were parents or caregivers of CPF patients. The reported mean age of the CPF patient was 32 years for non-whites and 35 for whites. Insurance coverage varied between groups, with non-whites mainly covered by Medicare/Medicaid (68% vs 32% whites), and whites mainly covered by private insurance (64% vs 25% non-whites). Non-white patient/caregivers reported a longer mean time between symptoms and diagnosis (2.08 yr) than white patients/caregivers (less than 1 yr). White patients/caregivers reported more (50%) current use of biologics than non-whites (36%); however, past use of biologics was near equal (51%) for whites and (50%) for non-whites. Of patients who had undergone surgical procedures (86.5%), non-whites had a lower number of different surgery types (1.64) than whites (2.31). The top two reported goals of treatment for both groups were decreasing pain and healing the fistula. Less non-white patients/caregivers agreed or strongly agreed they were satisfied with their current quality of care (39%) and access to care (57%) than white patients/caregivers (72% and 69%, respectively). Non-whites were more likely to disagree or strongly disagree that the main doctor who treats CPF is knowledgeable about their CPF and its treatments (25% vs 3% whites), and that they agree or strongly agree they know more about CPF than their doctor (21% vs 15% whites). Patients/caregivers (non-whites vs whites) perceived somewhat, very or extremely significant barriers to care to be inadequate community social services for CPF care (82% vs 79%), out-of-pocket costs of care (71% vs 84%), limited information to make difficult decisions for their CPF treatment (82% vs 86%), physical/emotional stress of managing their CPF (82% vs 79%), lack of access to specialist care (89% vs 88%) and lack of effective treatments (86% vs 89%). Only 50% of non-white patients/caregivers and 69% of white patients/caregivers agreed or strongly agreed that they know where to go to get CPF information. CONCLUSION: Disparities in diagnosis and management of CPF exist between non-white and white patients/caregivers, including length of time to diagnosis, perceptions of quality of care and barriers to treatment. Further research into disparities in the management of CPF is needed, as is CPF education for patients/caregivers and HCP education on managing CPF in minority populations.