2. !
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Quantification of Patients' Preferences for
Outcome Metrics in Inflammatory Bowel
Diseases Using a Choice Based Conjoint Analysis
W. K. van Deen*1
, D. Nguyen1
, N. Duran1
, E. Kane1
, M. G. van Oijen2
, D.W. Hommes1
1
UCLA Centre for Inflammatory Bowel Diseases, Division of Digestive Diseases, University of California, Los Angeles,
California, United States, 2
Academic Medical Centre, Amsterdam, Department of Medical Oncology, Amsterdam,
Netherlands
Gastroenterology April 2016, Volume 150 (Issue 4, Supplement 1): S169; doi:10.1016/S0016-5085(16)30656-4
Background
Incorporation of patient preferences in medical decision making, a process referred to as shared decision making, has
been shown to improve patients’ satisfaction and patients’ knowledge. The importance of measuring and reporting
outcomes of care delivery is increasingly recognised to be crucial for quality improvement. However, no method to
quantify the incorporation of patient driven decisions in the care process is available. In this study we quantified
inflammatory bowel disease (IBD) patients’ preferences for 3 disease outcomes: disease control (DC), quality of life
(QoL), and productivity (Pr) using a choice based conjoint analysis (CBC).
Methods
IBD patients were recruited through e-mail and were asked to fill out an online CBC questionnaire. The questionnaire
assessed current levels of DC, QoL, and Pr, and 10 CBC questions, in which patients were asked to choose 1 out of 2
scenarios with different levels of DC, QoL, and Pr. A hierarchical Bayes model was run to estimate the importance
individual patients assigned to each of the 3 outcomes. A single patient-centred outcome metric was developed
based on the individual weight assigned to the outcomes.
Results
In total, 210 IBD patients were included with a median age of 40 years (range 20–83). Of these, 51% had Crohn’s
disease; 46% ulcerative colitis; and 3% indeterminate colitis. Large variations in individual patients’ preferences were
observed. On average, QoL was valued higher than DC and Pr, and for all 3 outcomes, increases from low to
intermediate levels were felt to be more important compared with increases from intermediate to high levels. No
clinical characteristics were shown to be associated with different preferences. Individual preference weighted scores
were calculated and were shown to be significantly different from scores without individual weightings in patients
with active disease.
Conclusion
We showed that CBC can be used to quantify individual patients’ preferences for different outcome metrics. These
preferences can be used to quantify a single patient-centred outcome metric for IBD patients. Because measured
outcomes are significantly different when weighted based on individual patients’ preferences, we propose that
outcomes of care should be measured and rewarded accordingly.
3. !
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Assessment of Differences Between
Academic and Non-Academic Providers in
Inflammatory Bowel Diseases Related
Utilization Using a Large Administrative
Dataset
Welmoed K. van Deen, Martha Skup, Adriana Centeno, Natalie E. Duran, Precious Lacey, Darius Jatulis, Eric Esrailian,
Martijn G. van Oijen, Daniel Hommes
Gastroenterology 150(4, Supplement 1): S72, April 2016; DOI:10.1016/S0016-5085(16)30357-2
Background
Wide practice variations in inflammatory bowel disease (IBD) related care have previously been observed in the US. A
variety of reasons for guideline non-adherence have been described, which include insufficient access to guidelines,
misaligned financial incentives, and physicians' culture, beliefs, and habits. In this study we used a large California
administrative database to assess the extent of differences between academic and non- academic
gastroenterologists in California.
Methods
Academic and non-academic gastroen- terologists were identified in an administrative database from Anthem
California. Patients with an IBD related office visit with an academic gastroenterologist were identified, and patients
with an IBD-related office visit with a non-academic gastroenterologist were selected as controls. Patients treated at
academic institutions were matched 1:2 with controls based on age, IBD subtype, comorbidities, and relapse rate in
the index year (2012). Differences in IBD specific outcomes were assessed in 2013, which included medication use, IBD
related office visits, ED visits, hospitalizations, imaging, and lab tests.
Results
We identified in total 985 IBD patients treated by academic providers, which were matched to 1965 controls. We
observed 26% less steroid use (p=0.0003), 14% less mesalamine use (p=0.005), 52% more mesalamine suppositories
use (p=0.001), 206% more MTX use (<0.00001) and 45% more biologics use (p<.00001) in patients treated at an
academic institution. Additionally, we observed more biomarker testing (61%, 101%, and 149% more CRP, ESR, and
calprotectin testing, respectively, p<0.00001), 29% more colonoscopies (p=0.0005), and 41% more MR scans (p=0.02)
in patients treated at academic centers, while CT scan usage decreased with 15% (p=0.02). While 35% more surgeries
were performed at academic centers (p=0.03), we did not observe significant differences in the number of ED visits
and hospitalizations.
Conclusion
Large variations in practice patters between academic and non-academic provid- ers in California were observed,
including variations in medication use and IBD related tests and procedures. However, surrogate outcomes such as
ED visits and hospitalization rates were comparable in both groups. In future studies the causes and consequences of
practice variation need to be addressed in more detail.
4. !
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The Effect Of A Coordinated Care Program
For Inflammatory Bowel Diseases On Health
Care Utilization
W. K. van Deen*1
, M. Skup2
, A. Centeno1
, N. Duran1
, P. Lacey1
, D. Jatulis3
, E. Esrailian1
, M. G. van Oijen4
, D.W. Hommes1
1
UCLA Centre for Inflammatory Bowel Diseases, Division of Digestive Diseases, University of California, Los Angeles,
California, United States, 2
AbbVie, US Immunology, North Chicago, Illinois, United States, 3
Anthem Blue Cross,
California, Woodland Hills, California, United States, 4
Academic Medical Centre, Amsterdam, Department of Medical
Oncology, Amsterdam, Netherlands
Journal of Crohn's and Colitis Mar 2016, 10 (suppl 1) S347; DOI: 10.1093/ecco-jcc/jjw019.606
Background
To bend the cost curve, value-based health care (VBHC) is thought to be the way forward. Central in this concept are a
coordinated care infrastructure and the measurements of outcomes and costs. Despite that many institutions have
implemented key components of VBHC, the evidence-base is still limited. We aimed to evaluate the performance of a VBHC
programme specifically for inflammatory bowel diseases (IBD) management, in the first year after implementation. Key
components of the programme were care coordination, task differentiation, and remote patient monitoring.
Methods
Administrative data from Anthem California were used to identify IBD patients treated by participating IBD centre providers
using the coordinated care protocol. A control population of IBD patients treated by other academic providers in California
was identified, as well. IBD Centre patients were matched 1:3 with controls based on comorbidities, IBD subtype, age, and
relapse rate in the index year (2012). IBD-specific outcomes in 2013 were compared between groups, including medication
use, office visits, IBD-specific tests, ED visits, and hospitalisations.
Results
In total, 98 IBD centre patients were matched to 293 control patients. We observed 52% less corticosteroid use (p = 0.027)
and 77% less long-term corticosteroid use (p = 0.13) in IBD centre patients, 6% more biologics use (p = 0.77), and 22% more
immunomodulator use. IBD-specific office visits increased with 20% (p = 0.009), whereas overall office visits decreased with
12% (p = 0.54). No difference in colonoscopy rates was observed (0.3% difference, p = 0.86), whereas EGD use decreased by
72% (p = 0.062). More biomarker testing was performed (increase of 36%, 6%, and 7% in CRP, ESR, and calprotectin testing,
respectively), whilst less imaging studies were performed (26%, 28%, and 50% decrease in the number of CT, MR, and US,
respectively). Hospitalisations decreased by 43% (p = 0.96), ED visits by 66% (p = 0.36), and 40% less surgeries were
performed (p = 0.38).
Conclusion
The first-year results of an IBD=specific VBHC programme show significantly less steroid use and more IBD-specific office
visits compared with matched IBD patients treated by other academic gastroenterologists. Overall, beneficial trends
towards less imaging studies, more biomarker testing, and less ED visits and hospitalisations were observed. More long-
term larger sample data are warranted to assess the long-term effect of VBHC in IBD.
5. !
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Integrated Care Pathways For Inflammatory
Bowel Disease Surgery: Design And First
Analysis.
R. Jacobs*1, 2
, S. Reardon3
, D. Sagar1
, T.J. Hommes1, 2
, D. Margolis4
, E. Kane1
, W.K. Van Deen1
, L. Eimers1
, E.K. Inserra1
, N.
Duran1
, J.M. Choi1
, C.Y. Ha1
, B. Roth1
, A.D. Ho1
, E. Esrailian1
, J. Sack3
, D.W. Hommes1
1
UCLA Center for Inflammatory Bowel Diseases, Division of Digestive Diseases, Los Angeles, United States, 2
LUMC,
Gastroenterology and Hepatology, Leiden, Netherlands, 3
UCLA, Division of General Surgery, Los Angeles, United States,
4
UCLA, Division of Radiological Sciences, Los Angeles, United States
Gastroenterology 148(4): S-828, April 2015; DOI: http://dx.doi.org/10.1016/S0016-5085(15)32818-3
Background
Surgery has become an essential care component in Inflammatory Bowel Diseases (IBD) management. Although surgical
and medical teams often work closely together, no integrated care pathways have been reported. In an existing IBD
coordinated care program we aimed to fully integrate pre-operative, operative and post-operative IBD care.
Methods
The UCLA value-based care program for IBD consists of 9 highly coordinated medical care pathways. The surgical pathway
was designed by a multidisciplinary team of specialists and nurses with patient input. Pre-operatively the indication for
surgery was agreed upon during multidisciplinary case presentations. Coordination of pre-assessment, time of surgery,
surgical quality indicators, and discharge was completed by the surgical IBD team. A 4-week post-surgery pathway included
continuous tele-monitoring of pain, weight, temperature, nutrition, bowel function, pain medication, quality of life and
productivity. In addition, tele-wound-monitoring was introduced. The surgical pathway was completed after a week 4 clinic
visit and patients were assigned to their subsequent medical pathway. Included patients were compared to matched
historic controls for initial performance analysis.
Results
Of the 1163 IBD patients enrolled in the IBD value-based care program, 46 patients undergoing major abdominal surgery
entered the surgical care pathway and were compared to 41 controls. Characteristics: mean age 39 (20-70); 63%-CD, 35%-
UC and 2%-IBD-U; surgery type: bowel resection (46%), stricturoplasty (33%), enteric fistula surgery (8%), lysis of adhesions
(10%), and abscess drainage (4%). A 27% reduction in post-operative complications was observed; most common
complications were ileus and infection. All patients completed the care pathway with a clinic follow up within 30 days after
hospital discharge. In the controls 27% of patients had no GI clinic follow up and 49% had no surgical follow up after
discharge. Emergency department (ED) visits (<30 days after surgery) were reduced by 7.5%; primary indications were
abdominal pain, fever, and nausea/vomiting. On average, we observed 2-3 phone calls/patient and 10-15 eConsults/patient,
as a result of which 9 ED visits/readmissions were likely prevented. Monitoring of post-surgery parameters and tele-wound
monitoring was feasible and demonstrated meaningful provider decision support.
Conclusion
This integrated care pathway for IBD surgery was successfully implemented and strongly decreased post-surgical loss to
follow up. In summary, this pathway showed clinically relevant Results with respect to enhancing patient value and
controlling utilization-associated costs.
6. !
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The Impact of a Value-Based Health Care in
Inflammatory Bowel Diseases on Health
Care Utilization
W.K. van Deen*1
, A.B. Ozbay2
, M. Skup2
, M.G. van Oijen1
, A. Centeno1
, N. Duran1
, P. Lacey1
, D. Jatulis3
, M. Belman3
, E.
Esrailian1
, D.W. Hommes1
1
UCLA Center for Inflammatory Bowel Diseases, Division of Digestive Diseases, University of California, Los Angeles, Los
Angeles, United States, 2
AbbVie, US Immunology, Nort Chicago, United States, 3
Anthem Blue Cross, California, Woodland
Hills, United States
Gastroenterology 150(4, Supplement 1): S70-S71, April 2015; DOI :10.1016/S0016-5085(16)30354-7
Background
Standardized care pathways, task differentiation, and knowledge of costs in clinical decision making are all likely to
contribute to improved outcomes and cost-effective care delivery. The UCLA Center for Inflammatory Bowel Diseases (IBD)
launched a value-based health program for IBD management in February 2012 including all these aspects. The aim of this
study was to compare utilization patterns observed at the UCLA Center for IBD to IBD care across California.
Methods
Administrative data were obtained from Anthem Blue Cross California. IBD patients and UCLA IBD Center providers were
identified, as well as IBD non-program patients who were included as control group. Controls were matched 5:1 with the
cases based on disease type, age, relapse rate, and Charlson Comorbidity Index in 2012. IBD-related office visits, laboratory
tests, imaging studies, procedures, emergency department (ED) visits, hospitalizations, and pharmacy use in 2013 were
compared.
Results
Forty-nine UCLA IBD Center patients were matched to 245 controls. Demographics were similar in groups with a mean age
of 39 years (SD 12), 57% Crohn's disease and 43% ulcerative colitis, and 22% severe disease course in the year prior to
analysis. We observed significantly less corticosteroid use in the UCLA IBD Center group (12% and 31%, respectively, p=0.03)
and numerically more methotrexate (1% and 6%, p=0.11) and adalimumab (15% and 21%, p=0.43) use. Thiopurine (35% and
33%, p=1.00) and infliximab (14% and 15%, p=1.00) use were comparable in both groups. Patients in the UCLA IBD group
had 25% fewer IBD-related office visits per year (1.7 and 2.2 visits per year, p=0.06), 12% to 100% fewer imaging studies
(p=0.99), 10% less colonoscopies (p=0.91) and 1.3 to 3.4 times more biomarker testing (p<0.0002). Lastly, we observed 89%
fewer hospitalizations (p=0.06) in the UCLA IBD Center group and 75% fewer ED visits (p=0.52).
Conclusion
An administrative database was utilized to identify IBD patients treated at the UCLA Center for IBD and to compare those
patients with a matched control population in California. We found a significant decrease in corticosteroid use and a trend
towards more use of steroid-sparing medications in the UCLA IBD group. Furthermore, UCLA IBD Center patients' disease
activity was monitored more frequently using biomarkers, and fewer hospitalizations and ED visits were observed. This
study indicates that a comprehensive, value-based care pathway is likely to improve outcomes and decrease unnecessary
health care utilization. Future more powerful larger sample studies will be needed to confirm these positive findings.
7. !
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Time-Driven Activity Based Costing: Measuring
the Costs of Implementing Quality Measures in
Inflammatory Bowel Disease (IBD)
Andrew D. Ho, Christine Y. Yu, Welmoed K. van Deen, Adriana Centeno, Laurin Eimers, Elizabeth K. Inserra, Natalie
Duran, Jennifer M. Choi, Christina Ha, Bennett E. Roth, Eric Esrailian, Daniel W. Hommes
Gastroenterology 148(4): S-828-S-829, April 2015; DOI: http://dx.doi.org/10.1016/S0016-5085(15)32819-5
Background
!
Quality improvement (QI) has become increasingly important with respect to IBD care delivery. Gastroenterologists
can distinguish themselves by reporting on the 8 quality measures developed by the AGA. Moreover, with the
introduction of Physician Quality Reporting System (PQRS) registration, reporting on QI metrics will positively impact
future reimbursement rates. For 2015, Medicare will apply a 1.5% penalty for non-compliance to QI reporting.
However, QI implementation has the potential to be a significant cost driver for providers. Therefore, we aimed to
analyze the cost burden of QI implementation for a GI practice.
Methods
!
An IBD QI program was implemented including documentation of quality measures from 4/2014 to 10/2014. A ‘Six
Sigma' process map was developed for the implementation of the QI measures. Time-Driven Activity-Based Costing
(TDABC) was then used to estimate costs associated with performing the QI measures for the GI practice. Expenses
encountered outside the GI practice, such as radiology and laboratory costs, were excluded. Separate models were
created depending on use of chronic steroids or biologic therapy. The personnel, space, and equipment needed for
each resource was identified and time spent with each resource was documented. The cost of each process step was
calculated by multiplying the time spent with the cost per unit of time.
Results
!
In total, 369 patients were enrolled into the IBD QI Program. 100% had documented disease activity (Crohn's disease -
Harvey Bradshaw Index; Ulcerative colitis - partial Mayo Score), 100% screened for tobacco use, 49% received an
influenza vaccination and 23% a pneumococcal vaccination. Of patients on steroids, 100% were then started on
steroid sparing therapies and 30% underwent bone loss assessment. Prior to biologic therapy initiation, tuberculosis
and hepati- tis B screening occurred in 96% and 99% of patients, respectively. A process map was created for
implementation of IBD QI measures (Figure 1). In total, 7 types of personnel were involved in ordering and
documenting the measures. Using TDABC, the cost of performing the general IBD measures, including documenting
disease activity, vaccinations, and tobacco use, was $80.33 per patient per year (PPPY). For patients on chronic
steroids, the cost of performing the QI measures including bone loss assessment was $91.41 PPPY. For patients on
biologic therapy, the process cost including checking hepatitis B and tuberculosis status was $108.76 PPPY.
Conclusions
!
Effective implementation of QI metrics was feasible using a lean process map and TBABC to estimate associated GI
practice costs. The financial burden on the GI practice seems limited; therefore this study demonstrates that there
can be significant value for gastroenterologists to implement QI metrics in order to become eligible for associated
payer reimbursements.
8. !
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The Value Of Social Media In Inflammatory
Bowel Diseases
J.M. Choi, W.K. van Deen, L. Nguyen, A. Zand, M. Berns, N. Duran, D.W. Hommes, M.G. van Oijen
UCLA Center for Inflammatory Bowel Diseases, Division of Digestive Diseases, University of California, Los Angeles, Los
Angeles, United States
Journal of Crohn's and Colitis Feb 2014, 8 (Supplement 1) S201; DOI: 10.1016/S1873-9946(14)60448-7
Background
An increasing number of patients with chronic illnesses, including inflammatory bowel diseases (IBD), are turning to
social media sites such as Twitter and Facebook to share about their conditions. The use of social media in healthcare
promotes patient engagement, communication, and education, while enabling providers to better recognize patient
interests and increase their online visibility for patient recruitment. This study aims to describe the strategies and
experiences of an IBD tertiary referral center to develop a social media presence among patients using Twitter and
Facebook and its outcomes after one year.
Methods
A Twitter profile and Facebook page were established for the IBD center. Analytic tools Twitonomy and Facebook
Insights were used to capture data on posts, including the data media format. Information on Twitter followers and
Facebook users who liked the center's Facebook page was acquired. The number of recognizable patients with IBD
and the online topics of interest to social media users were tracked and categorized manually.
Results
Within the first 15 months, a total of 2212 Twitter users began following our Twitter account, and 469 Facebook users
liked the center's Facebook page. The growth in the number of Twitter followers and those who liked the center's
Facebook page was proportionate to the number of posts per week. Among Twitter followers, 971 (44%) were IBD
patients, of which 6 were patients from our IBD center. Twitter users retweeted and favorited IBD-related topics more
frequently than non-IBD topics. The most popular retweeted Twitter topics were risk factors (70% retweeted), surgery
(63% retweeted), and complications/symptoms (62% retweeted). The most commonly favorited Twitter topics were
about sex/fertility (43% favorited). For Facebook, the most frequently liked posts were about the center's specific IBD
programs (92% liked, 5.9 likes per post), value in healthcare (90% liked, 5.3 likes per post), and therapies (91% liked,
5.3 likes per post). The Facebook posts that drew the most comments were posts on diet (67% commented on, 2.7
comments per post). Photographs were the most liked media format of postings (90% liked, 7.9 likes per
photograph).
Conclusion
Twitter and Facebook are valuable tools to interact with patients who are part of the greater online community.
Disease-specific information was most popular among social media users, and photographs were the most popular
media format. Despite the low patient recruitment over the first year, we demonstrated that patients were engaged
and communicated through social media about their disease, which can be viewed as additional measures of return
on investment from social media programs in healthcare
