ABSTRACT
Introduction The COVID-19 pandemic resulted in a forced shift to providing remote (telephone and online) consultations following disruptions to traditional in-person care. As the pandemic wanes and IBD services recover, there is a need to rebalance provision of care and align with patient preference rather than provider convenience. Better knowledge of preferences for remote versus in-person care among people with IBD, and of the factors associated with such preferences, will guide this realignment. We report the results of a large-scale, UK-wide follow-up survey of patients who had completed the COVID-19 IBD Risk Tool during the early pandemic.1 Methods Adult patients who consented for research (n=35,329) were invited by e-mail. The survey included sociodemographics, place of residence, self-reported diagnosis, drug treatments, PRO-2 symptoms, IBD-Control Questionnaire and items relating to experience of, and future preference for, mode of IBD consultations. We investigated factors associated with: 'In-person preference' for future consultations (response option: 'Never by telephone or video' versus all other options);and 'Remote preference' (response: 'Mainly by telephone or video' versus all others) in bivariate and multivariable binary logistic regression analyses, with results expressed as adjusted odds ratios (aOR) and 95% CI. Results 7,341 respondents of which 6,015 (82%) had experienced a remote IBD consultation since the first UK lockdown. Of these, 4,396 (73%) said their first experience of a remote consultation was during the pandemic. A significant minority (9.6%) would prefer to avoid future remote consultations entirely (in-person preference) whereas a quarter (24.5%) wished to have mainly remote consultations (remote preference). The following factors were associated with in-person preference (aOR [95% CI]): Older age (>50 years;1.40 [1.19-1.63]), male gender (1.31 [1.11-1.53]), less-well controlled disease (IBD-Control-8 score <13, 2.06 [1.74-2.45]), and residents of more deprived areas (Quintile 5 [most deprived];1.72 [1.31-2.25] vs Quintile 1 [least deprived]). Conversely, we found the following associations for remote preference: Younger age (<50 years;1.24 [1.12-1.39]), Ulcerative Colitis or IBD-U (1.23 [1.10-1.37]), well-controlled disease (IBD-Control-8 score 13+, 1.55 [1.38-1.73]), not having sought emergency care during the pandemic (1.21 [1.06- 1.37]) and living in least deprived areas (Quintile 1;1.29 [1.05-1.59] vs Quintile 5). Conclusions A number of sociodemographic and clinical variables predicted future consultation preference at the time of survey. These included relatively fixed characteristics (e.g. age, gender, diagnosis, and deprivation status) and more dynamic factors (e.g. current disease control). Better understanding of factors associated with patient preference can inform efforts to realign services to provide the right mix of in-person and remote provision.
ABSTRACT
Introduction The first wave of the COVID-19 pandemic saw a sharp rise in UK cases during March 2020. We analysed UK IBD Registry data to investigate changes in contacts and prescribing in the immediate post-COVID period to gain insights into the impact of the pandemic on IBD care. Methods We aggregated quarterly data (Jan-Mar 2019 to Apr- Jun 2020), extracting counts of clinical events (outpatient contacts and biologics reviews), contact types (face-to-face, 'F2F';or telephone/virtual, 'non-F2F'), new diagnoses and drug starts (oral steroids, further categorised as prednisolone and non- prednisolone;thiopurines;biologics). Rates are expressed as counts per 1,000 clinical events. Results Comparing Apr-Jun 2020 (post-COVID) to Apr-Jun 2019 (pre-COVID): Total clinical event fell (9975 to 8208;- 18%), with a sharp drop in F2F OPD (3436 to 1203;-65%) accompanied by a compensatory rise in non-F2F (1777 to 3161;+78%). Rate of new diagnoses fell (49 to 13 per 1,000 events;-74%). Prescription rates reduced sharply for thiopurines (26 to 5;-81%), with lesser reductions for biologics (89 to 55;-38%) and oral prednisolone (25 vs 20;-20%) but with a rise for non-prednisolone steroids (5 vs 8;+60%). No change in relative proportion of different biologic classes. Conclusions Records of patient contacts were reduced in the immediate post-COVID period with a rapid shift from F2F to non-F2F. The drop in new patient records may reflect delayed pathways. Prescribing trends suggest a selective reduction in thiopurine and some shift from systemic to more topically-acting steroids. Longer term trends will be presented.
ABSTRACT
Background and Aim: Regional and rural populations with chronic hepatitis C virus (HCV) infection remain undertreated due to low primary care uptake, combined with limited access to specialist care and follow-up. Telehealth (TH) addresses many barriers to treatment access, has previously proven successful for HCV management in rural and prison settings, and has been proposed as an alternative for patients who remain geographically and socioeconomically disadvantaged, particularly in the coronavirus 2019 era. We aimed to report the clinical outcomes and the cascade of care of a novel nurse-led HCV TH clinic set in regional Victoria. Methods: We performed a retrospective cohort analysis of all patients referred to a regional HCV TH service between 1 April 2017 and 10 June 2020. Data were collated from outpatient and electronic medical records, as well as prospectively collected qualitative patient surveys. Results: A total of 55 patients were booked into the HCV TH clinic, and the outcomes are shown in Figure 1. Twenty-five patients (54%) had a history of alcohol use disorder, 24 (52%) had psychiatric comorbidity, and five (11%) had obesity. Thirteen of the 14 (93%) who received treatment achieved sustained virological response. We additionally demonstrated successful TH-driven hepatocellular carcinoma surveillance among the subgroup of patients with cirrhosis. An average of 46.48 km of travel, 54.64 min, and A$30.67 was saved per patient for each visit. Overall patient satisfaction gathered via Likert scale surveys was positive, with observed benefits including increased medical engagement, adherence to treatment, and improvement in long-term health outcomes at a personal and cohort level. Conclusion: Nurse-led HCV management via TH has allowed access for a marginalized regional population with high levels of substance misuse and psychiatric comorbidity. Clinical outcomes were comparable to those previously reported from tertiary and community-based cohorts, with additional cost benefit, efficiency gains, and carbon footprint reduction among a previously unreported regional Victorian population with HCV.
ABSTRACT
Background and Aim: The rising burden of chronic disease in the developed world has resulted in an accumulation of patients requiring long-term specialist input in care, despite relatively stagnant capacity in tertiary hospital services. Newer models of care, incorporating specialist input while empowering and enabling community-based treatment in the more cost-effective primary care setting, are urgently needed. Digital health technologies have been proposed as one such novel model. The evolving digital technology paradigm shift instigated by the coronavirus 2019 pandemic has placed further emphasis on the need for evidence-based eHealth interventions. Chronic hepatitis C virus (HCV) represents a model disease in which rapid treatment advances have allowed care to shift from tertiary to community-based treatment models;however, barriers remain in achieving elimination targets and scaling up treatment to at-risk populations. We aimed to explore the efficacy, acceptability, and feasibility of an eHealth model to connect community and prison-based clinicians with specialist teams for HCV treatment. Methods: We conducted a multicenter quasi-experimental pre-post study using a hybrid effectiveness-implementation design with referring community and prison-based clinicians, in consultation with eight tertiary centers in Australia. The pre-intervention control group was treated through existing paper, fax, or remote consultation methods between 1 March 2016 and 28 February 2017. The eHealth model of care (using the HealthELink system) was prospectively implemented from 1 August 2017 to 30 April 2019. Key elements of the web-based eHealth model include HCV-specific clinical decision support, including University of Liverpool drug-drug interaction integration, secure electronic messaging, task management, email alerts, and an electronic patient portal. The primary outcome was sustained virological response at 12 weeks after treatment (SVR12), based on intention-to-treat analysis. Secondary outcomes included an implementation analysis comprising usability, acceptability, quality, safety, and uptake/utilization measures. Results: In total, 249 patients (180 community, 69 prison) were treated in the eHealth group, and 681 (588 community, 87 prison) in the control group. Sixty-one general practitioners, 12 specialists, 24 nurses, and four prison systems registered to use the eHealth system. In the community-based group, SVR12 was confirmed in 106/180 patients (59%), compared with 383/588 (65%) in the control group (P = 0.13), and 44/69 (64%) versus 61/87 (70%) in the prison-based group (P = 0.32). Completion of repeat liver biochemistry at the time of SVR12 testing (88% vs 51%, P = 0.01) and adherence to guideline-based treatment (100% vs 98%, P = 0.03) were higher in the eHealth group. Timeto specialist approval (median, 1 vs 7 days;P < 0.01) and SVR12 confirmation from the intention to treat when adjusted for treatment duration (175 vs 208 days, P = 0.05) were both significantly reduced in the eHealth group. Uptake of the eHealth model was greatest in nurse-led and prison-based cohorts. Low uptake was found among GP users, primarily due to few HCV patients encountered during the study. High levels of usability (median system usability score, 76) and acceptability were found among most users, with the clinical decision support features found to be most useful. Low technological failure rates were seen, with browser compatibility the most frequent issue encountered, in less than 5% of users. Conclusion: This eHealth model of care resulted in similar clinical outcomes to the current standard of care. However, treatment efficiency and adherence to guideline-based care were improved using eHealth. The model was acceptable and displayed good usability for most users. This study shows that a multifaceted eHealth system is a valuable and scalable model to manage HCVand serves as a blueprint for other chronic diseases.