Time for a Gut Check: A Qualitative Study of Proposed Interventions to Address Gender Inequality in Gastroenterology.

Background: Gender inequalities persist in medicine, particularly in some speciality fields where fewer women are employed. Although previous research has suggested potential interventions to broadly address gender inequality in medicine, no research has focused on interventions in the field of gastroenterology. The purpose of this research was to engage women in the field of gastroenterology in Canada, to identify interventions with potential to be effective in addressing gender inequality. Methods: A World Café was hosted in 2019 to discuss gender inequality and interventions in gastroenterology. Twelve women employed in the field of gastroenterology (i.e. physicians, nurses, research staff, and trainees) were purposively recruited and participated in the event. The discussion rounds were audio-recorded, transcribed, and thematic analyses was conducted using Braun and Clarke's principles. Results: Three key themes identifying potential interventions to address gender inequality in gastroenterology were generated: (1) Education; (2) Addressing institutional structures and polices; and 3) Role modelling and mentorship. Participants indicated that interventions should target various stakeholders, including both women and men in gastroenterology, young girls, patients, and administrators. Conclusion: Many of the interventions identified by participants correspond with existing research on interventions in general medicine, suggesting that institutional changes can be made for maximum effectiveness. Some novel interventions were also identified, including publicizing instances of gender parity and supporting interventions across the educational and professional lifecourse. Moving forward, institutions must assess their readiness for change and evaluate existing policies, programs, and practices for areas of improvement.

Patient-Centered Access to IBD Care: A Qualitative Study.

Background: Canada has the highest global age-adjusted incidence and prevalence rates of inflammatory bowel disease (IBD). Due to IBD patient volumes and limited resources, challenges to timely access to specialty care have emerged. To address this gap, the aim of this paper was to understand the experiences and perspectives of persons living with IBD with a focus on accessing health care. Methods: Using a qualitative descriptive approach, patients diagnosed with IBD (≥18 years of age) were purposively sampled from rural and urban gastroenterology clinics and communities across Canada. Co-facilitated by a researcher and patient research partner, 14 focus groups were recorded, transcribed, and coded for themes. Thematic analysis was used to ascertain the congruence or discordance of IBD specialty care access experiences. Results: A total of 63 individuals participated in the study. The majority of participants were female (41/63, 65%) and from urban/suburban regions (33/63, 52%), with a mean age of 48.39 (range 16-77 years). The analysis generated three main themes: (1) need for patient to be partner, (2) adapting IBD care access to individual context, and (3) patient-defined care priorities should guide access to IBD care. Conclusions: The complexity of specialty care access for IBD patients cannot be underestimated. It is vital to possess a robust understanding of healthcare system structures, processes, and the impact of these factors on accessing care. Using a patient-centered exploration of barriers and facilitators, IBD specialty care access in Canada can be better understood and improved on provincial and national levels.

Patient Experiences in the Management of Inflammatory Bowel Disease: A Qualitative Study.

Background: Inflammatory bowel disease (IBD) can lead to substantial impairments of quality-of-life. Clinical guidelines and quality indicators aid physicians in practice but may not reflect the perspectives and experiences of patients with IBD. To address this, the objectives of this study were to understand patient experiences with IBD care and to explore priorities. Methods: Based on a convenience sample of 36 participants, five focus groups were completed at four sites across Canada. Data were analyzed using a deductive thematic analysis approach to assess emergent themes and variability in participants' experiences. Results: Our results are organized by themes of structure, process and outcomes to illustrate common issues with respect to how care is organized in the healthcare system, how patients receive and experience care and how patients perceive the outcomes of their care. Our results frame a health systems quality approach that signal needed improvements in access to care, the need for innovation with respect to virtual medicine, the potential expansion of multidisciplinary team-based care and the importance of addressing the psychosocial dimensions for patients with IBD and their caregivers in order to better deliver patient-centred care. Conclusions: The issues identified have the potential to impact priority areas in the system, IBD care delivery, and how outcomes can be improved by focusing on 'lived experience' and patient-centred care. The differing values and perspectives of all those involved in caring for patients with IBD underscore the importance of good communication with patients, caregivers and family members, as well as staying responsive to evolving needs.

Perceived Barriers to Professional Equality Among Women in Gastroenterology.

Although significant progress relating to professional equality among men and women in medicine has been made over the past few decades, evidence derived from the medical literature suggests that inequity persists with respect to income, attainment of leadership positions, and professional advancement. These inequities have been observed to be more pronounced in gastroenterology. Literature relating to gender-specific barriers to professional equity in gastroenterology is limited. This qualitative study explored perceived barriers to professional equality among women in gastroenterology in Canada through focus groups using a World Café Approach. Several perceived barriers to professional equality were identified. Identification of barriers to professional equality is an important first step to creating meaningful interventions that address the root causes of gender-related inequity in gastroenterology.

Stakeholder Perspectives on Access to IBD Care: Proceedings From a National IBD Access Summit.

Background: Canada has among the highest incidence and prevalence rates of inflammatory bowel disease (IBD) in the world. While access to IBD specialty care can have a direct impact on health-related outcomes, the complexity of accessing IBD specialty care within Canada is not well understood and presents a barrier to implementation and evaluation of IBD specialty care. Aim: The IBD Summit was held in partnership with Crohn's & Colitis Canada to identify barriers and facilitators of IBD specialty care by exploring the perceptions and experiences of key stakeholders of IBD care across Canada. Results: A total of 20 key stakeholders attended, including gastroenterologists, patients, researchers and policymakers. Perceptions and experiences of stakeholders were transcribed, coded and thematically analyzed. Three key categories relating to access to IBD care arose: (1) inadequate system structure, (2) process inefficiencies and (3) using outcomes to guide system change. The IBD Summit identified similar perceptions and experiences among stakeholders and across provinces, highlighting common barriers and facilitators that transcended provincial and health care system boundaries. Conclusions: Key suggestions identify the clinical importance of comprehensive integrated multidisciplinary care approaches with enhanced communication between patient and health care providers, greater information sharing among team members, streamlined referral and triage processes, and improved incorporation of best practice into clinical care. Stakeholders across Canada and in other countries may benefit from the suggestions presented herein, as well as the successful use of collaborative and inclusive methods of gathering the perceptions and experiences of key stakeholders from diverse backgrounds.

Models of Care for Inflammatory Bowel Disease: A National Cross-sectional Survey to Characterize the Landscape of Inflammatory Bowel Disease Care in Canada.

Background: Collaborative care models improve inflammatory bowel disease (IBD) patient outcomes, yet little is known about the capacity or available resources to deliver such model of care in Canada. We aimed to describe the structure and process characteristics of clinical care delivery models for IBD across Canada, including the number of collaborative care centers. Methods: A cross-sectional study was conducted between November 2017 and October 2018 through an online survey. This survey was distributed to gastroenterologists at community and academic centers across Canada who provide care for IBD patients. Comparisons between collaborative and non-collaborative centers were analyzed using chi-squares or t-tests. Descriptive statistics of respondent demographics were also generated. Results: Seventy-two gastroenterologists from 62 unique IBD centers completed the survey. A total of 7 unique collaborative centers and 55 unique non-collaborative centers were identified. There were significant differences between collaborative and non-collaborative centers in some aspects of access to IBD care, patient assessment and referral process, and patent education and empowerment. Notably, very few centers had processes for implementing and evaluating evidence-based clinical pathways, and auditing quality indicators. Conclusions: Our findings identify areas for improving the quality of IBD care in Canada. Expanding the number of and access to collaborative care centers in Canada is needed, in addition to increased focus on patient education, communication, and implementation of evidence-based care pathways.

Access to inflammatory bowel disease speciality care: the primary healthcare physician perspective.

BACKGROUND: There is little literature related to access to inflammatory bowel disease (IBD) care that incorporates the perspective of key system stakeholders, such as primary healthcare providers (PHCP), despite their clear and integral role in facilitating access. OBJECTIVE: This study aimed to identify barriers to referring patients to speciality IBD care as perceived by referring PHCP. In particular, we sought to understand PHCP satisfaction with the current IBD specialist referral system, as well as indicators of geographic variance to access. METHODS: A population-based survey was mailed out to currently practising PHCPs who have referred or who are currently referring patients to IBD speciality care in Nova Scotia (Canada). Descriptive statistics and multivariate analyses were performed. Qualitative comments were themed using framework analysis to identify key barriers. RESULTS: The majority of PHCP (57%) were dissatisfied with the current referral process due to long patient wait times and perceived system inefficiency. Key areas of geographic variance in access included access to speciality care in the community and patient wait times. PHCPs suggested ideas to improve access including increased gastroenterologist supply, particularly in rural areas, and the creation of a provincial centralized referral and triage process. CONCLUSIONS: PHCPs play an important role in identifying and managing patients with IBD in partnership with gastroenterologists. This study identifies key PHCP perceived barriers that may prevent patients from accessing speciality IBD care. Understanding and addressing barriers to access from multiple stakeholder perspectives, including PHCPs, has the potential to support informed system redesign and overcome access inequities.

Primary healthcare providers (e.g. family doctors and nurse practitioners) play an important role in connecting patients with speciality health care. Patients with digestive diseases, such as inflammatory bowel diseases (e.g. Crohn's and colitis), may rely on primary healthcare providers to connect them with inflammatory bowel disease specialists (e.g. gastroenterologists). Past research on access to inflammatory bowel disease care has focused on the patient perspective; however, almost no research has focused on how primary healthcare providers perceive access to inflammatory bowel disease speciality care, despite their important role in facilitating access. This paper focuses on what 155 primary healthcare providers in Nova Scotia (Canada) perceive as key barriers for their patients when accessing speciality Inflammatory bowel disease care. This paper also presents potential improvements to the referral process and healthcare system, as suggested by primary healthcare providers, which may improve global access to inflammatory bowel disease care.

Examining the Association Between Referral Quality, Wait Time and Patient Outcomes for Patients Referred to an IBD Specialty Program.

BACKGROUND: Most speciality inflammatory bowel disease (IBD) care can only be accessed through a referral. Timely access to specialty care has been associated with improved disease-related outcomes. To receive appropriate care, the referral needs to include high-quality information. To date, no research has explored the association between referral quality and IBD patient outcomes. The study objectives were to determine if the quality of referrals to a collaborative IBD program influenced triage accuracy, wait times and patient outcomes. METHODS: Two hundred referrals to a collaborative IBD program in Canada for patients with confirmed or suspected IBD were reviewed. Referral quality was evaluated using an evidence- and consensus-based metric. The association between referral quality and patient outcomes (wait time, hospitalizations, disease flares and additional referrals) for semi-urgent referrals was assessed through multivariate analysis. RESULTS: The majority of referrals for IBD speciality care were categorized as being low quality. Referral quality was not significantly associated with any of the patient outcomes; however, longer wait times significantly increased the occurrence of disease flares, hospitalizations and additional referrals while waiting for an IBD specialist appointment. CONCLUSION: Prolonged wait times for IBD patients are significantly associated with poor patient outcomes and increased costs for the health care system. Although there is literature that suggests that referral quality may be associated with wait time, it is still unclear how it relates to wait time and patient outcomes. Moving forward, the current referral process needs to be critically addressed in order to improve wait times and patient outcomes.

Micronutrient Absorption and Related Outcomes in People with Inflammatory Bowel Disease: A Review.

Inflammatory Bowel Disease (IBD) is a chronic disorder associated with immune dysregulation and chronic inflammation of the digestive tract. While it is poorly understood, the role of nutrition and nutrient status in the etiology of IBD and its associated outcomes has led to increased research relating to micronutrient deficiency. This review offers an overview of recent literature related to micronutrient absorption and outcomes in adults with IBD. Although the absorption and IBD-related outcomes of some micronutrients (e.g., vitamin D and iron) are well understood, other micronutrients (e.g., vitamin A) require further research. Increased research and clinician knowledge of the relationship between micronutrients and IBD may manifest in improved nutrient screening, monitoring, treatment, and outcomes for people living with IBD.

Treatment of Inflammatory Bowel Disease in the Older Patient.

The incidence of inflammatory bowel disease (IBD) is increasing, and as our population ages, there is a growing number of IBD patients who are transitioning into advanced age; 15% to 20% of IBD patients are classified as late-onset (between 60-65 years of age). This has led clinicians to treat a large number of older patients with IBD. The principles of management of IBD in older patients are the same as those who are younger. There are, however, phenotypic differences that are unique to late-onset IBD and age-related concerns that clinicians must consider when initiating therapy for their older patients with IBD. Given the increasing number of older IBD patients, the aim of this article is to present an updated, evidence-based review of the therapeutic options and issues that arise in this unique patient population.

Biomarker-Based Models Outperform Patient-Reported Scores in Predicting Endoscopic Inflammatory Disease Activity.

Background: The Crohn's Disease Activity Index (CDAI), a scoring index including patient-reported outcomes (PROs), has known limitations for measuring intestinal inflammatory disease burden. Noninvasive markers of inflammation could prove more accurate than PROs; thus, regulatory authorities are exploring the use of PROs and endoscopic data as coprimary end points in clinical trials. The aim of this study was to assess the predictive ability of individual components of the CDAI, along with biomarker concentrations, to create models for predicting endoscopic disease activity. Methods: Between 2004 and 2006, 164 patients with established Crohn's disease (CD) undergoing clinically indicated ileocolonoscopy were recruited. Individual CDAI variables and fecal calprotectin (FC) were selected to explore their predictive accuracy for endoscopic disease activity, with the Simple Endoscopic Score-Crohn's Disease (SES-CD) as the outcome variable. Simple Poisson regression was performed on each variable, and 2 multivariate models were created (PRO-exclusive and PRO+FC [PRO+]). Additional analyses explored the patient-level agreement between models. Results: Number of liquid stools, abdominal pain, hematocrit (Hct), FC, and high-sensitivity C-reactive protein (hsCRP) correlated significantly with the SES-CD. For the prediction of SES-CD (>7 vs ≤6), the area under the curve (AUC) was 0.81, with 63% and 88% sensitivity and specificity, for the PRO+ model, compared with a 0.56 AUC, with 61% and 55%, respectively, for the PRO model. Intra-individual comparison revealed the PRO+ model to be superior in the prediction of endoscopically active disease. Conclusions: The inclusion of biomarkers significantly improved predictive accuracy for endoscopic disease activity compared with PRO-exclusive models.

Patient-ly Waiting: A Review of Patient-Centered Access to Inflammatory Bowel Disease Care in Canada.

Canada has one of the highest prevalence estimates of inflammatory bowel disease (IBD) in the world. Like other chronic illnesses, access to specialist care is required for disease management. Traditionally, access to care is evaluated through wait times (actual access); however, new patient-oriented definitions of access (perceived access) highlight other equally important facets of access to care (e.g., appropriateness). Aim: How does access to gastroenterology speciality care influence disease-related outcomes for IBD patients in Canada? A comprehensive literature review was undertaken. Cochrane, PubMed and CINHAL databases were searched for peer-reviewed English language articles published between 2006 and 2016. Inclusion/exclusion criteria focussed on access to IBD care in Canada. Included articles were classified using Levesque et al.'s patient-centered access framework (e.g., affordability, accessibility, appropriateness, acceptability, availability and accommodation). Eight articles were found, including six which addressed patient-centered access. Most of the articles addressed issues of availability (e.g., wait times), appropriateness and affordability. Only one article addressed approachability and acceptability of IBD care. All articles emphasized a need for greater patient-centered measures (e.g., multidisciplinary clinics) with a goal to improve patient access and, ultimately, patient outcomes. Understanding patient-centered access to IBD care is important for managing IBD and improving patient outcomes. Literature examining access to gastroenterology services is limited. Increased investment in patient-oriented research should be made to better understand the relationship between access to specialist care and patient outcomes.