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P333. The development of coordinated care pathways and feasibility testing in inflammatory bowel disease management

W. van Deen, J. Choi, E. Inserra, L. Eimers, E. Kane, M. Ovsiowitz, A. Centeno, M. van Oijen, B. Roth, D. Hollander, W. Ho, D. Cole, T. Getzug, L. Connoly, A. Ho, C. Ha, E. Esrailian, D.W. Hommes, UCLA Center for Inflammatory Bowel Diseases, Division of Digestive Diseases, University of California, Los Angeles, Los Angeles, United States

Background

Guideline non-adherence and inefficient care delivery are main drivers of health care costs. Coordinated care pathways have been proposed to assist in decreasing health expenditures and increasing patient value. We developed an evidence based multidisciplinary care pathway and tested its feasibility. In order to introduce cost awareness at the practice level, a model was developed to estimate procedural costs per care pathway and costs per additional procedure.

Methods

IBD related guidelines were collected and complemented with relevant literature and consensus statements. Care scenarios were designed based on patients' disease activity and treatment strategy. Appropriate tests, procedures and office visits were incorporated in the care scenarios, including standards for task differentiation and quality indicators. Outcomes were assessed using clinical disease activity indices (DAI) (Harvey–Bradshaw Index for CD and partial Mayo score for UC) and quality of life (QoL) scores. Healthcare utilization rates were analyzed using insurance claims from patients insured through Wellpoint California. UCLA charges were used to develop a cost model.

Results

Five annual care scenarios were developed for remissive patients, and five 6-week care scenarios for active patients. We assumed that 6 week intensive care scenarios would offer sufficient time to induce remission. A cost model estimating procedural costs (per care scenario, and per individual procedure) was developed (Table 1). As of October 2013 642 IBD patients (50% CD, 48% UC, 2% IBDU) had been treated accordingly (mean age 41.8 years (SD 15.7 years), 52% male). Patients were managed at 2 locations by 11 physicians and 3 IBD nurse coordinators. Task differentiation was introduced through SOPs (e.g. nurse coordinators were responsible for order management and contacting and monitoring patients). In active CD the average DAI was 4.2 (QoL 44.5), versus 1.2 in remission (QoL 53.0). For active UC the average DAI was 3.6 (QoL 43.4), versus 1.4 in remission (QoL 53.0). The annual relapse rate was 10% (8% CD, 13% UC). Average annual utilization rates were: 2.7 clinic visits, 1.1 colonoscopies, 0.6 hospital admissions, and 0.9 ER visits.

Table 1 (abstract P333). Designed care scenarios based on patients' disease activity and treatment regimen a
Medication scenarioProcedural costsTotal durationLabs (CBC, CRP and/or calprotectin, CMP)Office visite-health contact with provider
Remission induction scenarios
5ASA/SAS
Antibiotics
$3,143
$3,143
6 weeksWeek 0 + 6Week 0 + 6Every 2 weeks
Corticosteroids
Biologics
$3,783
$4,336
6 weeksEvery 2 weeksWeek 0 + 6Every 2 weeks
Post-surgery$1,7344 weeks post-surgeryWeek 4Week 4Decreasing from daily to weekly
Maintenance scenarios
No medication
5ASA/SAS
$5,257
$5,257
ContinuousEvery 6 monthsYearlyEvery 2 months
Immunomodulator
Biologics
Combination
$8,381
$8,038
$7,485
ContinuousEvery 2 monthsEvery 6 monthsEvery 2 months
Costs$306–624$629–812$40
a This model does not yet include medication costs.
b Optional lab tests, stool cultures, and endoscopic or radiologic procedures can be added at the physicians' discretion.

Conclusion

We developed and analyzed multidisciplinary coordinated IBD care pathways, which are designed to be adopted into Accountable Care Organizations. These pathways allow individual flexibility and harmonize care across providers. The monitoring of health related outcomes and associated health care expenditures was feasible.