P58 anonymous electronic IBD patient service feedback

Introduction: collecting structured patient feedback is challenging, particularly during the pandemic with many virtual appointments. Our electronic IBD-patient feedback covers outpatient (OP), endoscopy and flare-line experiences.Methods: IBD patients provide anonymous feedback at the time-of-service contact. GATHER, a survey platform hosted by our institution, collects anonymous information via QR codes (scan QR codes for surveys), electronic links or handheld tablet. Demographics, disease characteristics and medication were noted in all 3 surveys. The OP survey collated clinic type/modality and feedback on individual health care professionals based on an adapted Royal College of Physicians questionnaire as well as preferences for future appointments. Endoscopy surveys gathered information on referral pathway, endoscopy type, treatment advice, length of wait and pre-test information. Flare line surveys allowed individual feedback on IBD nurses, assessed response time and outcomes. Patients’ attitudes regarding use of our online portal My Medical Record (MyMR) were explored. All surveys allowed sign up for MyMR. Patients could leave individual comments.Results: since September 2021, 425 patients responded. Figure 1 outlines the findings of the surveys. [P58 Figure 1 not included].Conclusion: electronic surveys are well accepted by our IBD patients and provides useful demographic data. It gives patients the option to inform the service of their preferences for future appointments and allows clinicians to get personal patient feedback for appraisals. Furthermore, it provides feedback on new services such as direct access endoscopy service and the acceptability of patient directed online healthcare (MyMR). Patient-centred feedback enables the user to help shape their future local IBD service

O69 outcome of direct access IBD physician delivered endoscopy for general practice referrals with suspected IBD

Introduction: patients with suspected IBD referred by primary care (GP) are traditionally seen in gastroenterology outpatient clinics followed by endoscopic investigations. This 2 phase model leads to delay in diagnosis and treatment, increasing pressure on gastroenterology outpatient services while still requiring endoscopic intervention. Our novel pilot project compared outcomes between direct-access IBD physician-delivered endoscopy versus the traditional clinic model for patients with suspected IBD.Method: a prospective cohort of consecutive patients referred by GP with suspected IBD were triaged either direct to IBD endoscopy (n=50) or to outpatient IBD clinic followed by IBD endoscopy (n=50) at the discretion of 10 gastroenterology consultants grading GP referrals. Data on demographics, faecal calprotectin, C-reactive protein, endoscopy outcomes, treatment, and follow up was collected. (Group A = direct to IBD endoscopy and Group B = IBD endoscopy via IBD clinic).Results: both groups were age and gender-matched. Group A had a higher mean calprotectin (1363 ug/g vs 302 ug/g) and a higher C-reactive protein (10.6 mg/l vs 4.5 mg/l). In Group A only 38% had a full colonoscopy versus 86% in Group B. Definitive diagnosis and treatment at time of IBD endoscopy took 27 days in Group A versus 212 days in Group B. Treatment with immunomodulators and biologics was similar in both groups but mesalazine and steroid use was higher in Group A due to more severe disease and higher rate of ulcerative colitis, table 1 shows the diagnostic breakdowns from both groups following endoscopy. The IBD pick up was significantly higher in Group A with 70% vs 42%. Endoscopy DNA rate was twice as high in Group B (n=6). The direct to IBD endoscopy pathway resulted in 50 less initial IBD consultant clinics (100% reduction) with a follow-up shift from IBD consultant to IBD nurse clinics. [O69 Table 1 Diagnostic breakdown not included].Conclusion: triaging patients referred with suspected IBD directly to IBD physician delivered endoscopy resulted in more than a 26-week reduction in time to diagnosis and treatment while saving 100% of initial IBD consultant clinics. IBD pick up was high at 70% in direct to IBD endoscopy group, identifying a higher-need IBD population. Triaging GP referrals with suspected IBD direct to IBD endoscopy delivers rapid assessment and treatmen

MicroRNA23a overexpression in Crohn’s Disease targets Tumour Necrosis Factor Alpha Inhibitor Protein 3, increasing sensitivity to TNF and modifying the epithelial barrier

Background and Aims: Mucosal healing is important in Crohn's disease therapies. Epithelial homeostasis becomes dysregulated in Crohn's, with increased permeability, inflammation, and diarrhoea. MicroRNAs are small non-coding RNAs that regulate gene expression and show changes in inflammatory bowel disease. Tumour necrosis factor alpha [TNFα] inhibitor protein 3 is raised in Crohn's and regulates TNFα-mediated activation of NFκB. We investigated TNFα regulation by microRNA in Crohn's disease [CD], and studied effects on epithelial permeability and inflammation. Methods: Colonic epithelium from CD and healthy donor biopsies was isolated using laser capture microdissection, and microRNA was quantified. Tumour necrosis factor alpha inhibitor protein 3 was characterised immunohistochemically on serial sections. Expression effect of microRNA was confirmed with luciferase reporter assays. Functional barrier permeability studies and innate cytokine release were investigated with cell and explant culture studies. Results: MicroRNA23a levels significantly increased in colonic Crohn's epithelium compared with healthy epithelium. Luciferase reporter assays in transfected epithelial cells confirmed that microRNA23a repressed expression via the 3' untranslated region of tumour necrosis factor alpha inhibitor protein 3 mRNA, coinciding with increased NFκB-mediated transcription. Immunohistochemical staining of TNFAIP3 protein in colonic biopsies was reduced or absent in adjacent Crohn's sections, correlating inversely with microRNA23a levels and encompassing some intercohort variation. Overexpression of microRNA23a increased epithelial barrier permeability in a colonic epithelial model and increased inflammatory cytokine release in cultured explant biopsies, mimicking Crohn's disease characteristics. Conclusions: MicroRNA23a overexpression in colonic Crohn's epithelium represses tumour necrosis factor alpha inhibitor protein 3, enhancing sensitivity to TNFα, with increased intestinal permeability and cytokine release.</p

Early real-world effectiveness of ustekinumab for Crohn's disease

Objective: To understand the effectiveness of ustekinumab in treating Crohn's disease (CD) in a UK real-world setting. Design: Retrospective cohort study using prospectively maintained clinical records. Setting: Single UK inflammatory bowel disease centre. Patients: Adult patients with an established diagnosis of CD prescribed ustekinumab outside of clinical trials at University Hospital Southampton (UHS). Interventions: Ustekinumab, a monoclonal antibody to the shared p40 subunit of interleukin (IL) 12 and IL-23 as part of routine clinical care. Main outcome measures: Effectiveness as measured by an improvement in physician's global assessment, drug persistence and improvement in biomarkers (C-reactive protein (CRP), albumin and calprotectin). Results: 84 patients were included, 72 had a postinduction review and 49 had 1-year data. At postinduction clinical review, clinical response occurred in 53% of patients and clinical remission occurred in 8%. For patients on ustekinumab at 1 year, clinical response occurred in 71% and remission in 14%. Adverse events included four patients with infections requiring admission, one drug-related rash, five CD surgeries and two CD exacerbations. Conclusions: Ustekinumab was well tolerated in a complex UK CD population and demonstrated benefit to patients in terms of clinical response and improvement of biomarkers and with some patients attaining clinical remission. No unexpected safety signals were seen.</p

P318 electronic referral grading system that puts patients and clinicians first

Introduction: the NHS Long Term Plan estimates demand for gastroenterology outpatient appointments (OPA) will continue to increase with the Royal College of Physicians deeming up to 20% of new referrals unnecessary. Bespoke electronic referral grading provides direct access to all community and hospital electronic patient records allowing fully informed immediate decision making. This can avoid unnecessary OPAs by redirecting/rejecting and sending appropriate patients direct-to-test while getting the right patient to the right clinician through sub-speciality tagging.Methods Outcomes: proportion/number of first OPA appointments saved, time to first appointment and subspecialty focus. Pre-grading period: Sep 2018–Mar 2020. Post-grading period: Aug 2020–Feb 2022. The separate 2WW IDA pathway was excluded. Cardiology/rheumatology were used as controls. Wait in days at the 50th percentile was calculated. One-tailed Mann Whitney U test calculated statistical significance at the p&lt;0.05 level. Number of appointments saved per year and resultant financial implications were estimated.Results: GI received 3,768 consultant-graded referrals (Sep 2018–Mar 2020) and 3,908 (Aug 2020–Feb 2022).Referral sub-specialty groupings:1) Inflammatory Bowel Disease–765(19.6%)1. Irritable Bowel Syndrome–755(19.3%)2. Upper GI Diseases–753(19.3%)3. Non–IBD Colorectal–426(10.9%)4. Non–2WW Iron Deficiency Anaemia–345(8.8%)5. Unexplained Weight Loss–165(4.2%)6. Surgical/Hepatology–159(4.1%)7. Coeliac–139(3.6%)8. Endoscopy–126(3.2%)9. Complex Functional–106(2.7%)10. Not Tagged–88(2.3%)11. Intestinal Failure–81(2.1%)Documented referral rejection rates increased from 1% to 19% (n=745/3908) in the second period. 456 (11.6%) of patients were diverted directly to endoscopy, cumulatively saving 30.7% (n=1201) first OPA appointments equivalent to 150 new patient clinics. Total savings = £101,731/year in first GI OPA alone given the current block contract structure. Time to first appointment reduced by 58% but no improvement was seen in comparator specialties: [P318 Table 1Clinic wait times compared @ the 50th percentile not included]. Conclusions: use of a consultant-led electronic grading system had dramatic effects on the quality of data collected and significantly reduced first OPA waits at the trust. The reasons for this were triage direct-to-test and proactive rejection/redirection of referrals using sub-speciality tagging to get the right patient to the right clinician

Impact of direct-access IBD physician delivered endoscopy on clinical outcomes: a pre-implementation and post-implementation study

Introduction Patients with suspected inflammatory bowel disease (IBD) referred from primary care often face diagnostic and treatment delays. This study aimed to compare a novel direct-access IBD endoscopy pathway with the traditional care model. Method Single centre real-world study analysing primary care referrals with suspected IBD. Group A: patients triaged to direct-access IBD endoscopy. Group B: patients undergoing traditional outpatient appointments before the availability of direct-access IBD endoscopy. Demographics, fecal calprotectin (FCP), C-reactive protein (CRP), disease activity score, endoscopy findings, treatment and follow-up were collected and statistically analysed. Ranked semantic analysis of IBD symptoms contained within referral letters was performed. Results Referral letters did not differ significantly in Groups A and B. Demographic data, FCP and CRP values were similar. Referral to treatment time (RTT) at the time of IBD endoscopy was reduced from 177 days (Group B) to 24 days (Group A) (p&lt;0.0001). Diagnostic yield of IBD was 35.6% (Group B) versus 62.0% (Group A) (p=0.0003). 89.2% of patients underwent colonoscopy in Group B versus 46.4% in Group A. DNA rates were similar in both groups. The direct to IBD endoscopy pathway saved 100% of initial IBD consultant clinics with a 2.5-fold increase in IBD nurse-led follow-up. Conclusion Our novel pathway resulted in an 86% reduction in RTT with associated increased diagnostic yield while saving 100% of initial IBD consultant outpatient appointments. Replication in other trusts may improve patient experience and accelerate time to diagnosis/treatment while optimising the use of healthcare resources

High incidence of glucocorticoid-induced hyperglycaemia in inflammatory bowel disease: metabolic and clinical predictors identified by machine learning

Background: glucocorticosteroids (GC) are long-established, widely used agents for induction of remission in inflammatory bowel disease (IBD). Hyperglycaemia is a known complication of GC treatment with implications for morbidity and mortality. Published data on prevalence and risk factors for GC-induced hyperglycaemia in the IBD population are limited. We prospectively characterise this complication in our cohort, employing machine-learning methods to identify key predictors of risk.Methods: we conducted a prospective observational study of IBD patients receiving intravenous hydrocortisone (IVH). Electronically triggered three times daily capillary blood glucose (CBG) monitoring was recorded alongside diabetes mellitus (DM) history, IBD biomarkers, nutritional and IBD clinical activity scores. Hyperglycaemia was defined as CBG ≥11.1 mmol/L and undiagnosed DM as glycated haemoglobin ≥48 mmol/mol. Random forest (RF) regression models were used to extract predictor-patterns present within the dataset.Results: 94 consecutive IBD patients treated with IVH were included. 60% (56/94) of the cohort recorded an episode of hyperglycaemia, including 57% (50/88) of those with no history of DM, of which 19% (17/88) and 5% (4/88) recorded a CBG ≥14 mmol/L and ≥20 mmol/L, respectively. The RF models identified increased C-reactive protein (CRP) followed by a longer IBD duration as leading risk predictors for significant hyperglycaemia.Conclusion: hyperglycaemia is common in IBD patients treated with intravenous GC. Therefore, CBG monitoring should be included in routine clinical practice. Machine learning methods can identify key risk factors for clinical complications. Steroid-sparing treatment strategies may be considered for those IBD patients with higher admission CRP and greater disease duration, who appear to be at the greatest risk of hyperglycaemia

Transitioning from intravenous to subcutaneous vedolizumab in patients with inflammatory bowel disease (TRAVELESS)

Background and aims: subcutaneous (SC) vedolizumab presents the opportunity for inflammatory bowel disease (IBD) patients to manage their treatment at home. There is currently no data on the process of transitioning patients established on intravenous (IV) to SC as part of routine clinical care. The aim of this programme is to evaluate the clinical and biochemical outcomes of switching a cohort of IBD patients established on IV vedolizumab to SC 12 weeks following the transition.Methods: 178 adult patients were offered the opportunity to transition to SC vedolizumab. Patients who agreed were reviewed prior to switching and at week 12 (W12) after their first SC dose. Evaluation outcomes included disease activity scores, the IBD-Control patient-reported outcome measures (PROMs) and faecal calprotectin (FCP). Reasons for patients declining or accepting transitioning, pharmacokinetics, adverse drug reactions and risk factors for a poor outcome in SARS-CoV-2 infection were also assessed.Results: 124 patients agreed to transition, of which 106 patients had been on IV vedolizumab for at least 4 months. There were no statistically significant differences in disease activity scores or IBD-Control PROMs between baseline and W12. A statistically significant increase in FCP was observed (31µg/g vs. 47µg/g; p=0.008), although this was unlikely to be clinically relevant. The most common adverse drug reaction reported was injection site reactions (15%). Based on this cohort of patients, an expected reduction of £572,000 per annum is likely to be achieved.Conclusions: transitioning patients established on IV vedolizumab to SC appears to be safe and effective, with high patient satisfaction and multiple benefits for the health service.</p