Increasing chronic disease preventive care in community mental health services: clinician-generated strategies.

BACKGROUND: People with a mental health condition experience a high prevalence of chronic disease risk behaviours e.g., tobacco smoking and physical inactivity. Recommended 'preventive care' to address these risks is infrequently provided by community mental health services. This study aimed to elucidate, among community mental health managers and clinicians, suggestions for strategies to support provision of preventive care. METHODS: Three qualitative focus groups (n = 14 clinicians) were undertaken in one regional community mental health service to gather perspectives of barriers to preventive care provision, deductively coded against the domains of the Theoretical Domains Framework (TDF). Drawing on the learnings from the focus groups, individual interviews (n = 15 managers and clinicians) were conducted in two services to identify suggestions for strategies to increase preventive care. Strategies were inductively coded and mapped into TDF domains. RESULTS: Barriers were identified across a wide range of TDF domains, most notably knowledge and environmental context and resources. Nine strategies were identified across three themes: training, resources and systems changes; mapping to all 14 TDF domains. CONCLUSION: Future research seeking to increase implementation of preventive care may be guided by these findings. There is need for greater recognition and resourcing of preventive care as a priority and integral component of mental health treatment.

Design considerations for an eHealth decision support tool in inflammatory bowel disease self-management.

BACKGROUND: Electronic health (eHealth) decision support tools have the potential to: facilitate inflammatory bowel disease (IBD) self-management, reduce health care utilisation and alleviate the pressure on overburdened outpatient clinics. The purpose of this study was to explore the perspectives of key stakeholders on the potential use of a decision support tool for IBD patients. METHODS: A qualitative study using focus group methodology was conducted at a tertiary IBD centre in Melbourne, Australia in February 2015. Key stakeholders, including physicians, nurses and patients, were included in the study. Two independent reviewers undertook inductive coding and generated themes. RESULTS: In total, 31 participants were included in the study (including 16 males; 11 physicians; 6 nurses). An eHealth decision support tool was thought to be beneficial to facilitate IBD self-management. Four themes emerged: (i) Framework for the decision support tool - the tool should be an adjunct to current models of care and facilitate shared decision-making and patient engagement; (ii) Target population - stable patients with mild to moderate disease; (iii) Functionalities of the intervention - a web-based platform encompassing patient-reported outcomes, objective markers of disease and clinical algorithms based on international guidelines; and (iv) Design and Implementation - patients should be involved in the design. CONCLUSIONS: eHealth interventions are thought to be an important strategy to facilitate self-management for patients with IBD. A multi-stage iterative approach should be adopted in the design and implementation process of eHealth interventions. Patient perspectives need to be sought prior to and throughout the development of an eHealth decision support tools for IBD.

Examination of the relationship between disease activity and patient-reported outcome measures in an inflammatory bowel disease cohort.

BACKGROUND: The extent to which disease activity impacts patient-reported outcomes (PRO) is unclear. AIMS: To examine the relationship between disease activity and PRO. METHODS: Adult inflammatory bowel disease (IBD) patients attending a tertiary clinic from May to June 2015 were included. Assessment of disease activity (Simple Clinical Colitis Activity Index (SCCAI), Harvey Bradshaw Index (HBI)), IBD knowledge (CCKNOW), medication adherence (MMAS8), psychological distress (Hospital Anxiety and Depression Scale (HADS)), work productivity (WPAI) and quality of life (IBDQ) was performed to investigate any correlations between disease activity and PRO. RESULTS: A total of 81 participants was included: 49% female, 57% Crohn disease (CD), 38% ulcerative colitis (UC) and 5% IBD-unclassified, with a median age of 34 years. At least mild levels of depression were present in 21 of 81 (26%) of patients; 37 of 81 (46%) expressed some level of anxiety. A moderate-to-strong correlation was found between disease activity and depression in UC (r = 0.84, P = 0.002) but not in CD (r = 0.53, P = 0.29). Disease activity correlated with: overall work impairment due to health (r = 0.85, P = 0.001), health-related impairment while working (r = 0.76, P = 0.02) and percentage of activity impaired due to health (r = 0.83, P = 0.002) in UC only. CONCLUSIONS: Disease activity significantly affects mood and work productivity in patients with UC. Monitoring patients' ability to function and work, rather than minimising disease activity alone, should become a routine part of IBD care.

eHealth for inflammatory bowel disease self-management - the patient perspective.

BACKGROUND: Electronic health (eHealth) solutions may help address the growing pressure on IBD outpatient services as they encompass a component of self-management. However, information regarding patients' attitudes towards the use of eHealth solutions in IBD is lacking. OBJECTIVE: The aim of this study was to evaluate eHealth technology use and explore the perspectives of IBD patients on what constitutes the ideal eHealth solution to facilitate self-management. METHODS: A mixed methods qualitative and quantitative analysis of the outcomes of a discussion forum and an online survey conducted at a tertiary hospital in Melbourne, Australia between November 2015 and January 2016 was undertaken. RESULTS: Eighteen IBD patients and parents participated in the discussion forum. IBD patients expressed interest in eHealth tools that are convenient and improve access to care, communication, disease monitoring and adherence. Eighty six patients with IBD responded to the online survey. A majority of patients owned a mobile phone (98.8%), had access to the internet (97.7%), and felt confident entering data onto a phone or computer (73.3%). Most patients (98.8%) were willing to use at least one form of information and communication technology to help manage their IBD. Smartphone apps and internet websites were the two most preferred technologies to facilitate IBD self-management. CONCLUSIONS: This study demonstrates the willifngness of patients to engage with eHealth as a potential solution to facilitate IBD self-management. Future development and testing of eHealth solutions should be informed by all major stakeholders including patients to maximise their uptake and efficacy to facilitate IBD self-management.

Clinicians' adherence to international guidelines in the clinical care of adults with inflammatory bowel disease.

BACKGROUND: Although evidence-based guidelines have been developed for inflammatory bowel disease (IBD), the extent to which they are followed is unclear. The objective of this study was to review clinicians' adherence to international IBD guidelines. METHODS: Retrospective data collection of patients attending a tertiary Australian hospital IBD clinic over a 12-month period. Management practices were audited and compared to ECCO (European Crohn's and Colitis Organization) guidelines. RESULTS: Data from 288 patients were collected: 47% (136/288) male; mean age 43; 140/288 (49%) patients had ulcerative colitis (UC); 145/288 (50%) patients had Crohn's disease (CD); 3/288 (1%) patients had IBD-unclassified (IBD-U). Patient care was undertaken by gastroenterologists, trainees and general practitioners. DISEASE MANAGEMENT: Overall adherence to disease management guidelines occurred in 204/288 (71%) of patient encounters. Discrepancies between guidelines and management were found in: 25/80 (31%) of patients with UC in remission receiving oral 5-aminosalicyclates (5-ASAs) as maintenance therapy, and; 46/110 (42%) of patients with small bowel and/or ileo-cecal CD receiving 5-ASA. Preventive Care: Adherence to ≥1 additional component of preventive care was observed in 73/288 (25%) of patient encounters: 12/133 (9%) on thiopurines underwent annual skin checks; 61/288 (21%) of patients with IBD underwent a bone scan; 46/288 (16%) patients were reminded to have their influenza vaccine. Psychological care: Assessment of psychological wellbeing was undertaken in only 16/288 (6%) of patients. CONCLUSIONS: There remains a gap between adherence to international guidelines and clinical practice. Standardizing practice using evidence-based clinical pathways may be a strategy towards improving the quality of IBD outpatient management.

Health care costs associated with Australian tertiary inflammatory bowel disease care.

INTRODUCTION: We aimed to describe the total costs of illness for IBD patients and compare the costs of patients with active disease to those with inactive disease. MATERIALS AND METHODS: Resource use for IBD management was itemized for attributable costs (AUD) among all IBD patients over a 12-month period at an Australian hospital. RESULTS: One hundred and eighty-three patients were included (87 ulcerative colitis (UC); 93 Crohn's disease (CD); three IBD-unclassified). The median (IQR) annual overall cost was higher in the CD versus UC group ($15,648 versus $5017; p < .001). The difference in cost between CD and UC was influenced by the difference in outpatient costs for CD patients $9602 ($4311-$29,805) versus $4867 ($3220-$7249), p < .001). The cost of treating patients with active disease was $3461 ($1607-$11,771) and was higher in the CD versus the UC group ($6098 ($2168-$16,471) versus $1638 ($1401-$3767); p = .026) and was influenced by inpatient admissions. The cost of treating patients in remission was $2090 ($1552-$12,954) and was higher in the CD versus the UC group [$7977 ($1579-$14,304) versus $1848 ($1508-$6601); p = .236]. CONCLUSIONS: There is a discrepancy in costs of inpatient versus outpatient IBD management and treating active disease compared with disease in remission. Proactive care may help prevent disease reaching a severity whereby reactive management of active disease is required.

Non-cirrhotic portal hypertension in HIV mono-infected patients.

BACKGROUND AND AIM: Unexplained liver injury including fibrosis and portal hypertension has rarely been reported among patients with HIV in the absence of co-infection with hepatitis B (HBV) or hepatitis C (HCV). We describe a series of HIV mono-infected patients with evidence of non-cirrhotic portal hypertension. METHODS: HIV-infected patients with evidence of portal hypertension who were anti-HBV and anti-HCV negative and HBV and HCV RNA polymerase chain reaction (PCR) negative were identified from patients managed by the Victorian statewide HIV referral service located at The Alfred Hospital, Melbourne. Portal hypertension was defined as either radiological or endoscopic evidence of varices, portal vein flow obstruction, or elevated hepatic venous pressure gradient (HPVG). RESULTS: Five patients were found to have portal hypertension. These patients were male, aged 41 to 65 years, with known duration of HIV infection between 11 to 25 years. All had been treated with antiretroviral therapy, including didanosine. Tests for metabolic, autoimmune, and hereditary causes of liver disease failed to establish an etiology for the liver injury. All had radiological or endoscopic findings of varices, and four patients had radiological features of portal vein obstruction or flow reversal. Only one patient underwent HPVG measurement, which was elevated. Non-invasive fibrosis assessment revealed increased liver stiffness in three (out of four) patients, and no cirrhotic features were found on those who underwent liver biopsy. CONCLUSIONS: To our knowledge, this is the largest published series of non-cirrhotic portal hypertension in HIV mono-infected patients in Australia. Further research is needed to understand what relationship, if any, HIV or its treatments might have on liver injury over time.

Quality of Care in Patients With Inflammatory Bowel Disease.

The rising burden of inflammatory bowel disease (IBD) has the potential to have a negative impact on the quality of care delivered to patients with IBD. Quality of care has been described by the World Health Organization as "the extent to which health care services provided to individuals and patient populations improve desired health outcomes." Variation in care has been identified as a key barrier to achieving quality of care in IBD. Assessment of quality of care attempts to minimize variation in care. Quality indicators have been developed in IBD as a minimum standard of care according to evidence-based guidelines. Models of care to achieve and maintain quality include integrated care, participatory care, and value-based health care. In this review, we outline current approaches to the assessment of quality of care in IBD and explore models of care currently being used to achieve and maintain quality.

Clinical decision support improves quality of care in patients with ulcerative colitis.

BACKGROUND: Decision support tools may facilitate shared decision-making and improve quality of care. AIM: To assess the effectiveness of a decision support tool on improving quality of care in ulcerative colitis. METHODS: A prospective quality of care intervention was conducted at two Australian hospitals comparing out-patient-based ulcerative colitis care with, and without, a tablet-based decision support tool. This included questions on disease activity management; psychological well-being; and preventive care, with 13 process indicators relevant to each domain. Participants included adult out-patients with mild-to-moderate ulcerative colitis and their clinicians who were divided into two cohorts. The first cohort were followed up immediately after their clinical review to check whether their clinician had discussed the 13 process indicators during the consultation. The second cohort of patients used the decision support tool immediately prior to their consultation which then generated a suggested management plan for the patient and clinician to discuss during the consultation. Management between the 2 cohorts was compared to assess the effectiveness of the decision support tool in improving the primary outcome, defined as the proportion of quality process indicators used for ulcerative colitis care, with and without the decision support tool. RESULTS: Thirteen physicians and 100 patients participated. Fifty patients were managed without the decision support tool using standard care (median age 40; 44% male), and 50 patients used the decision support tool (median age 40; 46% male) over a 20-week period. Increase in the median use of process indicators overall was observed following use of the decision support tool (27% vs 100%; P < 0.001). Improvements were seen in psychological well-being management (30% vs 100%; P < 0.001), preventive care (16% vs 100%; P < 0.001) and process indicators related to disease activity management (50% vs 100%; P < 0.001). The decision support tool was found to be usable and acceptable. Shared decision-making was greater in the post-intervention group (mean decision conflict score of 18.0 vs 33.5; P = 0.002). CONCLUSIONS: The decision support tool substantially improved the quality of the delivery of care. Decision support tools have the potential to minimise errors of omission via a standardised approach to care.

Algorithms to facilitate shared decision-making for the management of mild-to-moderate ulcerative colitis.

INTRODUCTION: Nonadherence has been a key barrier to the efficacy of medical treatments in ulcerative colitis (UC). Engaging patients in their IBD care via shared decision-making (SDM) to facilitate self-management may improve adherence to therapy. Areas covered: This review aims to summarize the most recent trial evidence from 2012 to 2017 for mild-to-moderate UC in order to develop clinical algorithms that guide SDM to facilitate self-management. A structured literature search via multiple electronic databases was performed using the search terms 'ulcerative colitis,' 'treatment,' 'management,' 'medication,' 'maintenance,' 'remission,' '5-ASA,' and 'inflammatory bowel disease. Expert commentary: Novel formulations of existing oral and topical medications have expanded the treatment options available for the induction and maintenance therapy for mild-to-moderate UC. Daily dosing of 5-ASA therapy is equivalent to twice daily dosing. The combination therapies of oral plus topical 5-ASA therapy and 5-ASA plus corticosteroid therapy are more effective than monotherapy. Budesonide MMX now plays a role in the management of mild-to-moderate UC. This review collates the evidence on drug efficacy and safety, adherence and tolerability, and noninvasive monitoring of mild-to-moderate UC into SDM-orientated algorithms to facilitate self-management.

EHealth Technologies in Inflammatory Bowel Disease: A Systematic Review.

BACKGROUND AND AIMS: Electronic-health technologies (eHealth) such as Web-based interventions, virtual clinics, smart-phone applications, and telemedicine are being used to manage patients with inflammatory bowel disease (IBD). We aimed to: (1) Evaluate the impact of eHealth technologies on conventional clinical indices and patient-reported outcome measures (PROs) in IBD; (2) assess the effectiveness, cost-effectiveness and feasibility of using eHealth technologies to facilitate the self-management of individuals with IBD, and; (3) provide recommendations for their design and optimal use for patient care. METHODS: Relevant publications were identified via a literature search, and 17 publications were selected based on predefined quality parameters. RESULTS: Six randomized controlled trials and nine observational studies utilizing eHealth technologies in IBD were identified. Compared with standard outpatient-led care, eHealth technologies have led to improvements in: Relapse duration [(n = 1) 18 days vs 77 days, p < 0.001]; disease activity (n = 2); short-term medication adherence (n = 3); quality of life (n = 4); IBD knowledge (n = 2); healthcare costs (n = 4); the number of acute visits to the outpatient clinic due to IBD symptoms (n = 1), and; facilitating the remote management of up to 20% of an IBD cohort (n = 2). Methodological shortcomings of eHealth studies include heterogeneity of outcome measures, lack of clinician/patient input, lack of validation against conventional clinical indices and PROs, and limited cost-benefit analyses. CONCLUSIONS: EHealth technologies have the potential for promoting self-management and reducing the impact of the growing burden of IBD on health care resource utilization. A theoretical framework should be applied to the development, implementation, and evaluation of eHealth interventions.

Use of an activated beta-catenin to identify Wnt pathway target genes in caenorhabditis elegans, including a subset of collagen genes expressed in late larval development.

The Wnt signaling pathway plays a fundamental role during metazoan development, where it regulates diverse processes, including cell fate specification, cell migration, and stem cell renewal. Activation of the beta-catenin-dependent/canonical Wnt pathway up-regulates expression of Wnt target genes to mediate a cellular response. In the nematode Caenorhabditis elegans, a canonical Wnt signaling pathway regulates several processes during larval development; however, few target genes of this pathway have been identified. To address this deficit, we used a novel approach of conditionally activated Wnt signaling during a defined stage of larval life by overexpressing an activated beta-catenin protein, then used microarray analysis to identify genes showing altered expression compared with control animals. We identified 166 differentially expressed genes, of which 104 were up-regulated. A subset of the up-regulated genes was shown to have altered expression in mutants with decreased or increased Wnt signaling; we consider these genes to be bona fide C. elegans Wnt pathway targets. Among these was a group of six genes, including the cuticular collagen genes, bli-1 col-38, col-49, and col-71. These genes show a peak of expression in the mid L4 stage during normal development, suggesting a role in adult cuticle formation. Consistent with this finding, reduction of function for several of the genes causes phenotypes suggestive of defects in cuticle function or integrity. Therefore, this work has identified a large number of putative Wnt pathway target genes during larval life, including a small subset of Wnt-regulated collagen genes that may function in synthesis of the adult cuticle.

ß-catenin-dependent Wnt signaling in C. elegans: teaching an old dog a new trick.

Wnt signaling is an evolutionarily ancient pathway used to regulate many events during metazoan development. Genetic results from Caenorhabditis elegans more than a dozen years ago suggested that Wnt signaling in this nematode worm might be different than in vertebrates and Drosophila: the worm had a small number of Wnts, too many ß-catenins, and some Wnt pathway components functioned in an opposite manner than in other species. Work over the ensuing years has clarified that C. elegans does possess a canonical Wnt/ß-catenin signaling pathway similar to that in other metazoans, but that the majority of Wnt signaling in this species may proceed via a variant Wnt/ß-catenin signaling pathway that uses some new components (mitogen-activated protein kinase signaling enzymes), and in which some conserved pathway components (ß-catenin, T-cell factor [TCF]) are used in new and interesting ways. This review summarizes our current understanding of the canonical and novel TCF/ß-catenin-dependent signaling pathways in C. elegans.

Tolerance induction via B-cell delivered gene therapy.

A master control of both the innate and adaptive immune system is the body's ability to distinguish between self and foreign entities. This is accomplished by the elimination of autoreactive leukocytes through a series of checkpoints both in the thymus (central deletion) and in the circulating periphery (peripheral tolerance), thus establishing tolerance to self-antigens. When one or more of these controls is disrupted, there is the potential for the development of autoimmune disease. Current available therapies for these diseases often rely on global immune suppression or expensive treatments that are not affordable to all. Herein, we describe a novel therapeutic technique in which tolerance to self can be re-established via B-cell delivered antigen-specific tolerogenic gene constructs. Furthermore, this technique shows promise in the gene therapeutic treatment of monogenic disorders and the acceptance of tissue transplants.