P357 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
1UCLA Center for Inflammatory Bowel Diseases, Division of Digestive Diseases, Los Angeles, United States, 2LUMC, Gastroenterology and Hepatology, Leiden, Netherlands, 3UCLA, Division of General Surgery, Los Angeles, United States, 4UCLA, Division of Radiological Sciences, Los Angeles, United States
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.
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.
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.
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.