Integrated Care Model Linked to Better IBD Management in Population-Based Study

Recent research indicates that patients who are treated within an integrated model of care for their inflammatory bowel disease (IBD) have improved outcomes, as they tend to undergo IBD-related surgeries less often and are more likely to receive treatment other than steroids.

The research was presented at Digestive Disease Week, held May 6-9 in Chicago, where lead author Juan-Nicolás Peña-Sánchez, MD, MPH, PhD, clinical assistant professor at the University of Saskatchewan, explained the study’s design, results, and implications to The American Journal of Managed Care^®.

“We conducted a retrospective population-based study that basically means that we used a registry from the provincial Ministry of Health that has data from all patients in the province [of Saskatchewan]," he said. The adult patients in this registry who had a diagnosis of IBD were divided into 2 groups based on whether they had been exposed to the integrated care model between 2009 and 2015. After excluding patients who did not have a full year of data prior to the study available, the researchers ended up with 562 patients who had been exposed to the clinic and 1750 who had not.

According to Peña-Sánchez, this clinic consisted of a “patient-centered multidisciplinary group” that delivered care according to an integrated model. “The idea is that you don’t have 1-to-1 meetings physician to patient,” he said. “It is a patient with a group of a gastroenterologist, a nurse practitioner, nurse clinicians, psychologists, dieticians,” and other specialists, all of whom have been trained in IBD management. Exposure to this model was defined as having both a baseline and at least 1 follow-up visit to the integrated clinic.

“What we found was that individuals who were exposed to the clinic had a lower risk of IBD-related surgeries in comparison to the nonexposed group,” Peña-Sánchez said. The hazard ratio (HR) of surgery for the integrated care patients was 0.78 compared to the control group after adjusting for patient characteristics like disease type, sex, age, and rural/urban residence.

Peña-Sánchez explained that biologics and immune modulators are effective “steroid-sparing maintenance therapies” recommended for specific cases, while 5-ASA is considered “the traditional medication used in IBD.”

The researchers also observed that the integrated care patients were significantly more likely to be prescribed immune modulators (adjusted HR, 1.68) and biologics (adjusted HR, 1.85) than patients who were not exposed. Instead, the nonintegrated care patients were more likely to be prescribed 5-aminosalicyclic acid (5-ASA) for their IBD.

Breaking the study population down by diagnosis of either Crohn’s disease or ulcerative colitis, the researchers found that “the ulcerative colitis group had lower risk of IBD-related hospitalizations and a lower probability of corticosteroid dependence” if they received integrated care. A slightly lower hospitalization rate was seen for integrated care patients in the full study population, but it did not reach statistical significance.

Asked why the Crohn’s disease patients did not exhibit a lowered rate of hospitalizations associated with integrated care, Peña-Sánchez explained the difficulties of comparing this heterogeneous group of patients due to the wide variations in disease severity and also said that the study was not sufficiently powered to detect these differences. He indicated that he and his colleagues are planning to conduct a much larger study across Canada that will let them “corroborate what we’ve found and identify further results.”

Further studies could recruit patients prospectively to measure patient-reported outcomes, like satisfaction, and assess which elements of the integrated care model had the greatest impact. The retrospective registry data

used in the current study could not be used to pinpoint which component drove change, but Peña-Sánchez hypothesized that “having access to the different services in an efficient way” allowed patients to easily receive care without seeking the authorizations and referrals they would need in a disjointed care system.

Peña-Sánchez said that he and his fellow researchers predicted that up to 40% of patients would have been exposed to the integrated model, but were surprised to find that the actual rate was closer to 25%. A potential explanation for this low uptake is the expansive size of Saskatchewan, where it could take rural patients hours to drive to the clinic in the capital of Saskatoon. “That’s a barrier, despite [the fact] that patients do not have to pay anything for accessing the center,” he said.

“Another guess is that not all physicians in the province knew about this model, so there is a need to educate more family practitioners that this model is available,” Peña-Sánchez continued. “We need to work more with the family practitioners, and with the patients so they can demand this service.”

Still, the results of this population-based study show that the integrated IBD clinic’s accomplishments are significant.

“This is strong evidence that patients, practitioners, healthcare providers, and healthcare policy makers should know, because integrated models of care are an innovative way to provide care,” Peña-Sánchez concluded. “This certainly will impact the health of the population, the patients, and [enable] efficient use of healthcare resources.”

REFERENCE

Peña-Sánchez NP, Lix L, Teare GF, Li W, Fowler SA, Jones JL. A population-based study evaluating an integrated care model of care for inflammatory bowel disease. Gastroenterology. 2017;152(5 suppl 1):S790. doi: 10.1016/S0016-5085(17)32735-X.