IntroductionIt has become increasingly recognised that outpatient management is more cost-effective in inflammatory bowel disease (IBD). IBD Standards (Revised 2013) recommend telephone advice for patients with regard to symptoms and medication management. This report attempts to quantify the net financial impact of this service at our hospital since it was introduced in August 2013.MethodThe Royal Alexandra Hospital in Paisley (National Health Service, Greater Glasgow and Clyde) is a district general hospital with a catchment population of 200 000 with approximately 2500 patients with IBD. Data relating to the use of the IBD telemedicine service were prospectively recorded on a daily basis for a period of 5 months. We documented reasons for calling and the likely action taken by the patient had the telephone advice line not been available. Cost savings based on alternative outcomes were made in accordance with the Department of Health figures (Department of Health reference costs 2011–2012).ResultsThe mean number of calls per month was 88 (IQR 24)—(the mean number of calls which were deemed non-IBD issues was 30 calls per month (IQR 8.0)) The mean cost of staffing the IBD advice line with an IBD clinical nurse specialist was £482.00 per month (IQR 195.5). The mean time spent on calls per month was 28.5 h (IQR 11.5). Cost savings over 5 months for avoidance of general practitioner (GP) consultation was £3408.00. Savings for avoidance of a consultant appointment made over the 5-month period was £27 454.00. Savings made from patients avoiding either an accident and emergency (A&E) or a hospital admission were £540.00 and £11 488.00, respectively, over the 5-month period. The net saving was £42 890.00.ConclusionsA nurse-led telephone advice line appears to be a cost-effective intervention. It may prevent patients from unnecessary hospital attendance. Savings can be made to both primary care and secondary care. Overall, it appears that the advice line is providing a highly valuable service not just in terms of accessible treatment decisions and guidance for patients, but cost savings when IBD clinic nurse specialist time is compared with that of GPs, consultants or hospital facilities.
IBD services must continue to adapt to changes within the National Health Service bearing in mind long-term sustainability and continued care provision. The 'flare card' goes further in an attempt to optimise Crohn's disease and ulcerative colitis management by harmonising clinician evaluation and patient's self-initiation of therapy and investigation.
Anti-tumour necrosis factor (anti-TNF) therapy is recognised as an effective treatment for inflammatory bowel disease (IBD). However, when to withdraw patients from treatment remains a matter of debate. This observational study, carried out in 2013, assessed the impact of applying National Institute for Health and Care Excellence (NICE) guidelines relating to this therapy to a local IBD service. Data was captured on 45 patients receiving infliximab or adalimumab. After applying the hospital's exclusion criteria, the data were matched with the NICE guidelines in place. Ten patients were deemed to be in remission and were withdrawn, two had dosing of adalimumab reduced from weekly to fortnightly, and investigations were ordered for the remaining patients. The audit provided up-to-date information on the demographics of patients receiving anti-TNF and a platform for clinical assessment. This article will discuss the NICE guidelines within the context of therapy withdrawal, their use in clinical practice and the unanswered questions they raise.
ObjectiveInflammatory bowel disease (IBD) is increasingly managed with the use of biologic therapies. National guidelines (National Institute for Health and Care Excellence (NICE)) suggest considering cessation after 1 year of therapy but lack detailed criteria for this. We aimed to describe clinical outcomes from the introduction of a biologic review panel (BRP) to implement modified criteria for cessation of antitumour necrosis factor (anti-TNF) therapy and step down to single-agent immunomodulator.DesignRetrospective review of patient outcomes following BRP implementation.PatientsAll patients on biologic therapy discussed in the BRP within a 5-year period.SettingSingle IBD network covering three hospital sites.InterventionsModified criteria for biologic cessation were based on published evidence; they excluded individuals with no suitable maintenance immunomodulator, previous surgery or evidence of active disease, additional indications for anti-TNF therapy and previous relapse on biologic cessation. All patients with IBD on a biologic were discussed at the BRP.Main outcome measuresRelapse following IBD cessation and relative cost of BRP.Results136 patients with IBD were reviewed, with 45 patients meeting the NICE guideline criteria for cessation. The BRP and modified criteria affected decision to withdraw therapy in 38% of these. Therapy was withdrawn in 27 patients, with a 20% 24-month relapse rate. Younger age at cessation was significantly associated with relapse (p=0.01).ConclusionThe BRP approach has proved a safe and effective means of decision making in stopping biologic therapy. Future work to inform exclusion criteria is required.
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