Improving IBD patient care with virtual clinics

Dr Mark Ward, senior author on the study

Monash researchers based at The Alfred are national leaders in improved care for Inflammatory bowel disease (IBD) patients. Their recent study published in Alimentary Pharmacology and Therapeutics outlines the remarkable improvement in both patient outcomes and quality use of therapy using a virtual clinic, compared to standard out-patient care, for the most challenging cases of IBD.

IBD is not one single thing. It is a lifelong autoimmune inflammatory condition of the gastrointestinal tract which can lead to hospitalisations, surgery and a decreased quality of life. The two most common forms of IBD are Crohn’s disease and ulcerative colitis. The causes of IBD appear to be a blend of environmental and genetic factors. So, in brief, it is called a ‘complex disorder’. Almost 75,000 Australian suffer from IBD, one of the highest rates in the world.

The most effective treatment for controlling the immune system response are ‘biologics’. Biologic therapies, which include complex antibodies that block important communication between the immune system and the inflamed intestine, have revolutionised the modern management of IBD. Optimising their use is important; on one hand they are expensive and suppress the immune system, but, on the other, they can be highly effective. However, about one third of patients can lose response to whichever drug they are taking and need further tailoring of their therapy.

Dr Mark Ward, the senior author on the study, is a gastroenterologist at Alfred Health and Monash University researcher, and has been working with IBD patients for a number of years.  Following a Fellowship at St Thomas’ Hospital in London, Dr Ward took the lessons he had learned there about virtual clinics back to Alfred Health.

Inflammatory bowel disease multi-disciplinary team conducting virtual clinic at Alfred Health. L-R: Ms Assmaa Zeno (pharmacist), Ms Alice Davies (Pharmacy Technician), Dr David Gibson (Gastroenterologist), Ms Bhupinder Boparai (Admin), Dr Antony Friedman (Gastroenterologist), Dr Kirstin Taylor (Gastroenterologist), Dr Mark Ward (Gastroenterologist)

A virtual clinic consists of bringing together a multi-disciplinary team of the relevant medical practitioners including a gastroenterologist, pharmacist, and IBD-nurse specialist to coordinate delivery of compassionate intensified treatment to patients who are sick and losing response to therapy.

They review the patient’s progress from the electronic patient record, along with results of investigations, to make an informed decision about the patient’s treatment, and then review outcomes six monthly. The group’s early experience was extremely positive.

“We set up a study with our colleagues at the Austin Hospital, and Eastern Health to compare the virtual clinic model to the standard out-patient care, in patients losing response to biologic therapy.

“What we found with the virtual clinic was a remarkable improvement in both patient outcomes and quality use of therapy. The rate of successful treatment de-escalation was also doubled, which is important; we don’t want to over immune-suppress our patients and these therapies are expensive.”

Their study incorporated 149 patients with 69 treated using the virtual clinic model and 80 patients with the standard outpatient care.  Effective treatment success was seen in nearly two thirds of the virtual clinic patients, compared to a third in the outpatient group, with twice as many patients undergoing appropriate dose intensification, and rates of tight (objective) disease monitoring were nearly tripled.

Dr Ward said, “In a typical outpatient clinic one has very limited time to assess and manage a complicated sick IBD patient. More tests are often needed, which requires further appointments, and a delay in delivering effective treatment. The virtual clinic helps get around this; we can make decisions, supported by the results of non-invasive tests and therapeutic drug monitoring. This facilitates a ‘treat-to-target approach’ that is, healing the bowel, rather than relying on symptoms alone.

“Up to 30-50% of these patients will need biologic therapy. Treating these patients is not straightforward. Are their symptoms due to active disease? Where and how severe is the disease? What tests and interventions are needed? Which is the best biologic? What dosage of medication is needed? Are they responding well? Can we optimise their treatment?

“We’ve had greater capacity to personalise the patients’ care, and to be consistent in our approach.”

The Alfred group has pioneered this approach in Australia. There is now increasing uptake of virtual clinics in IBD centres around Victoria, and Australia.

Dr Ward said, “We’ve found that a collegiate, collaborative approach has really fostered relationships, data sharing and hopefully, use of the protocols in other hospitals around Australia.

“Given the current COVID-19 pandemic requirements for social distancing, we need new models of care which not only manage patients for a better personal outcome for them, but also virtually or remotely to avoid them coming into hospitals,” said Dr Ward.

Reference

Srinivasan A, Langenberg DR, Little R, Sparrow MP, De Cruz P, Ward MG. A virtual clinic increases anti-TNF dose intensification success via treat-to-target approach compared with standard out-patient care in Crohn’s disease. Alimentary Pharmacology and Therapeutics. 2020;00:1-11 DOI: 10.1111/apt.15742

Acknowledgements

• This study was supported by a GESA Ferring IBD Clinical Project Award (Gastroenterology Society of Australia)