Feasibility and impact of a quality improvement initiative to screen for malnutrition in an Inflammatory Bowel Disease clinic.

BACKGROUND AND AIMS: Inflammatory bowel disease (IBD) is a chronic inflammatory condition of the gastrointestinal tract that is associated with malnutrition. Malnutrition is associated with poor clinical outcomes in patients with IBD and therefore early identification of those at risk for malnutrition is crucial. We aimed to evaluate how frequently nutrition screening occurs in a large, tertiary care outpatient IBD center and to initiate an intervention to improve malnutrition screening for patients with IBD. METHODS: We used a traditional plan-do-study-act quality improvement technique to understand our current malnutrition screening practices and institute an intervention to improve screening. To do this, we utilized a modified Malnutrition Universal Screening Tool (mMUST) and integrated this into the electronic health record. We then evaluated the intervention and the impact on IBD related clinical outcomes. RESULTS: Prior to the intervention, few patients with IBD were screened for malnutrition. However, the number of patients screened for malnutrition significantly improved with the study intervention and those who were identified as high-risk had increased nutrition follow up including serum micronutrient evaluations and referral to a dedicated registered dietician. CONCLUSION: This study demonstrated the feasibility and impact of a malnutrition screening program in ambulatory IBD patients. Those patients identified as high risk for malnutrition who engaged in nutrition care had improved clinical outcomes including reduced hospitalizations and emergency room visits.

Immigration Judges' Perceptionsof Telephonic and In-Person Forensic Mental Health Evaluations.

Clinicians affiliated with medical human rights programs throughout the United States perform forensic evaluations of asylum seekers. Much of the best practice literature reflects the perspectives of clinicians and attorneys, rather than the viewpoints of immigration judges who incorporate forensic reports into their decision-making. The purpose of this study was to assess former immigration judges' perspectives on forensic mental health evaluations of asylum seekers. We examined the factors that immigration judges use to assess the affidavits resulting from mental health evaluations and explored their attitudes toward telehealth evaluations. We conducted semistructured interviews in April and May 2020 with nine former judges and systematically analyzed them using consensual qualitative research methodology. Our findings were grouped in five domains: general preferences for affidavits; roles of affidavits in current legal climate; appraisal and comparison of sample affidavits; attitudes toward telephonic evaluations; and recommendations for telephonic evaluations. Forensic evaluators should consider the practice recommendations of judges, both for telephonic and in-person evaluations, which can bolster the usefulness of their evaluations in the adjudication process. To our knowledge, this is the first published study to incorporate immigration judges' perceptions of forensic mental health evaluations, and the first to assess judges' attitudes toward telephonic evaluations.

A Mixed-methods Assessment of the Impact of Insurance Issues on the Emotional and Physical Health of Patients With Inflammatory Bowel Disease.

BACKGROUND: In patients with inflammatory bowel disease (IBD), failure to adhere to treatment regimens due to insurance issues can lead to disease complications. Our aim was to examine patients' perceptions of the impact of insurance issues on their health. METHODS: Twenty-nine patients with IBD at a large US academic center and an insurance issue participated in a mixed-methods study. Retrospective chart review and an online questionnaire were completed to collect demographic information, IBD characteristics, and validated resilience scores. Semistructured interviews were completed for insurance experiences, which were coded independently by 2 coders for themes. RESULTS: Twenty-nine patients completed the interview, and 24 completed the online survey. Sixteen had Crohn's disease, 13 had ulcerative colitis, and 66% were female. The most common insurance issue was lapsed insurance. Many experienced physical consequences, with 58% having flares, 14% undergoing surgery, and 14% developing antibodies. All emotional responses were negative, with the majority feeling stressed (38%). Providers were uninformed of insurance issues in 28% of cases. When asked about perceived resilience, 41% felt incapable of managing the situation, and 45% gave up trying to solve the problem. When asked how to improve going forward, 38% requested an easily accessible advocate to guide them. CONCLUSIONS: A large proportion of our cohort chose not to inform their provider, felt incapable of managing on their own, and gave up on resolving their insurance issue. This highlights the need to consider restructuring the insurance system, to identify those at risk for insurance issues, and to make advocates available to avoid devastating consequences.

Few studies have qualitatively examined the impact of insurance issues on the health of patients with IBD. We highlight the need to identify patients at risk of insurance issues and when they occur so as to make advocates available to avoid disease complications.