PTH-32 development of a novel electronic referral grading & triage system

Introduction: prior to Covid-19, demand for secondary care appointments continued to rise year on year suggesting unsustainable future post-pandemic demand. Now is thus the right time to invest in triage and clinical pathway innovation.Methods: anew fully-integrated digital triage system was built at our institution allowing for document upload and electronic triage. Data pertaining to referral time, triage decision, outpatient appointments and direct-to-test was extracted from the backend to plot empirical cumulative distribution functions, interquartile ranges and allow statistical comparison using the Kruskal-Wallis’ test.Results: we analysed the first 704 luminal Gastroenterology referrals through the new triage system with the following sub-specialty classifications: Iron deficiency anaemia (IDA) – 200, Upper gastrointestinal symptoms (UGI) – 152, Inflammatory bowel disease (IBD) – 116, Irritable bowel syndrome (IBS/Functional) – 95, Lower gastrointestinal symptoms/change in bowel habit alone (LGI/CIBH) – 59, Coeliac – 27, Surgical – 25, Complex Functional – 12, Intestinal failure (IF/Nutrition) – 12, Hepatology – 4. 664 (95%) of referrals were accepted with 179 (27%) being sent direct to test. Of these only 42 (23.5%) had a subsequent clinic appointment booked, vs 436 (90%) for those not going direct to test. In addition, sending patients direct to test increased the proportion of subsequent routine clinic appointments from 55% to 70%. Median timelag from referral to grading was four days with grading taking a single day and appointments occurring 17 days later on average. Direct-to-test was most common amongst patients in the UGI (52.6%) and IBD (50%) sub-cohorts. This was significantly different vs other groups at the (p<0.05) level. [PTH-32 Figure 1 Subspecialty Referrals vs Direct-To-Test Numbers not included].Conclusions: using a system as described here substantially improves data capture and efficiency. Direct to test reduces both need for clinic appointments and the urgency of subsequent appointments. IBD and UGI are the subspecialties most likely to benefit from direct to test approaches. IDA could be another suitable specialty and the plan is to address this in the future

MicroRNA-31 and MicroRNA-155 Are Overexpressed in Ulcerative Colitis and Regulate IL-13 Signaling by Targeting Interleukin 13 Receptor α-1

Interleukin-13 (IL-13) is an important Type 2 T helper (Th2) cytokine, controlling biological functions in epithelium and has been linked to asthma, atopic dermatitis and ulcerative colitis (UC). Interleukin-13 signals through IL-13 receptor α-1 (IL13RA1 (gene) and IL13Rα1 (protein)), a receptor that can be regulated by microRNAs (miRs). MicroRNAs are small non-coding single-stranded RNAs with a role in several pathologies. However, their relevance in the pathophysiology of UC, a chronic inflammatory condition of the colonic mucosa, is poorly characterised. Here, we determined the expression of IL13Rα1 in UC, its potential regulation by miRs and the subsequent effect on IL-13 signalling. Inflamed mucosa of UC patients showed decreased mRNA and protein expression of IL13RA1 when compared to healthy controls. We show that miR-31 and miR-155 are upregulated in inflamed UC mucosa and that both directly target the 3′ untranslated region of IL13RA1 mRNA. Transfection of miR-31 and miR-155 mimics reduced the expression of IL13RA1 mRNA and protein, and blocked IL-13-dependent phosphorylation of signal transducer and activator of transcription 6 (STAT6) in HT-29 cells, a gut epithelium cell line. Interleukin-13 activation of suppressor of cytokine signaling 1 (SOCS1) and eotaxin-3 (CCL26) expression was also diminished. MicroRNA-31/microRNA-155 mimics also downregulated IL13RA1 in ex vivo human inflamed UC biopsies. We propose that miR-31 and miR-155 have an important role in limiting IL-13 signalling in UC disease

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

PTH-36 identification & service evaluation of a primary sclerosing cholangitis cohort using natural language processing

Introduction: primary sclerosing cholangitis (PSC) is a rare and difficult to treat condition. PSC is strongly associated with malignancy, therefore screening and surveillance are paramount. PSC however does not have a unique UK ICD-10 diagnostic code, hence reliable patient cohort identification and thorough service evaluation is challenging. We used natural language processing (NLP) to identify the PSC patient cohort at University Hospital Southampton (UHS) and audited associated outcomes against recently updated British Society of Gastroenterology (BSG) management guidelines.Method: records of all patients with PSC at our institution between 2008-2020 were identified using our NLP methodology. We used fuzzy matching to analyse clinical records, and tokenized and lemmatized key paragraphs to identify key diagnostic patterns and exclude diagnostically uncertain or exclusive sentences. Anonymised discharge summaries, clinic letters, radiology reports, endoscopy records and histology were extracted and digitally trawled to identify the cohort characteristics.Results: we identified 125 patients with PSC followed-up at UHS. 39.2% (49) of these patients were missed in a parallel criterion-based review of case notes.We calculated an age-standardised point prevalence of 12.52 cases per 100,000 patients, 124% higher than typically cited UK figures. Service evaluation revealed high rates of clinic follow-up however lower than recommended rates of screening with colonoscopy and imaging (see Table 1). Introduction of a combined PSC/IBD clinic as a targeted service delivery intervention is addressing this shortfall with significant impact after 1 year. [PTH-36 Table 1 not included].Conclusions: PSC cohorts are difficult to identify due to a lack of a UK clinical code. An NLP based methodology proved highly effective at identifying all cases within our institution, with a 64.5% increase compared to conventional methods. This allowed rapid patient cohort identification and conversion of unstructured data to clinically useful structured data and could be reproduced at other institutions and for other diseases

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

P319 natural language processing and named entity recognition in inflammatory bowel disease referrals

Introduction: clinical natural language processing (NLP) techniques are evolving, such that over the next few years they will start to support clinicians to interpret clinical information. Named entity recognition and linkage (NER+L) to standard ontologies with millions of concepts, such as The Unified Medical Language System (UMLS) add value to otherwise unstructured textual data. However, little research has been done in the field of Inflammatory Bowel Disease (IBD).Methods: anonymised GP referral letters triaged between 1st January 2017 to 31st March 2021 using an agreed protocol by a panel of Gastroenterologists as likely new or recurrent IBD were randomly extracted. NLP in python was applied to referral free text using MedCAT, a model trained on the UMLS database.Manual validation was performed to determine sensitivity vs ground truth for finding positive mentions of four cardinal clinical signs and symptoms. Sensitivity = TP/(TP + FN) was the outcome of greatest interest. Chi2 was used for statistical comparison at the p&lt;0.05 level.Results: 125 referral letters were included in this study. Median age: 39(IQR:[30-50]), 51.2% Male[95%CI:42.4-60.1]. 22.4%(n=28) of the cohort had pre-existing IBD. Table 1 summarises the performance of the algorithm against the correct human validations: [P319 Table 1 NLP model outcome parameters not included]. Diarrhoea and abdominal pain were both most mentioned and most successfully detected by MedCAT, however, significant differences were flagged in all cases.Conclusions: significant differences were observed between human validations and model predictions for four common IBD signs and symptoms, suggesting that these models are not yet mature enough for use in clinical practice. Annotations for more difficult concepts, such as rectal bleeding and weight loss need to be improved in major open-source NLP corpora