Institution of an interdisciplinary IBD centre is associated with improved healthcare utilisation

Despite the institution of an interdisciplinary Inflammatory Bowel Disease (IBD) centre is encouraged, how it may improve patient care is still unknown. In a 5-year period following organisation of an IBD centre, hospitalisations per patient/year decreased (0.41-0.17) and patients on biologics increased (7.7%-26.7%). Total number of hospitalisations (-18.4%) and length of hospitalisation (-29.4%) improved compared with a preceding 5-year period. These findings suggest that institution of an interdisciplinary IBD centre is associated with improved healthcare utilisation.


| INTRODUCTION
Inflammatory Bowel Diseases (IBD) are chronic, disabling diseases that impact various aspects of patients' life, and that can determine complex interactions involving both medical and psychosocial well-being. 1 The coordinated collaboration, possibly within the same centre, of physicians involved in the management of the gastroenterological, surgical, nutritional, and psychological issues that may arise in patients with IBD, and the close collaboration with physicians involved in the diagnosis (pathologists, radiologists) and management of IBD and its associated comorbidities (rheumatologists, dermatologists), is highly recommended in order to improve the quality and timeliness of care delivered to these patients. 2Likewise, dedicated and expert nursing personnel is of essence in order to ensure an optimal support to patients with IBD. 3 Lastly, other services such as telephone line, or email service, dedicated to patients, as well as streamlined access to endoscopy are key elements that may help improve the management of patients with IBD.However, a coordinated multidisciplinary approach for is not always feasible due to the presence of several barriers that ultimately represent an obstacle to the delivery of a higher-level care to these patients.Moreover, how the institution of a coordinated IBD care centre increase the retention of patients and improve their healthcare utilisation are issues that have not been extensively demonstrated in clinical practice, and therefore its potential benefit remains theoretical.
In this study we aimed to describe how, following the establishment of an interdisciplinary IBD centre, how several issues related to the management of patients with IBD, such as hospitalisation rate and duration of hospital stay, changed over time, describing also the trajectory of biological treatment uptake and of the number of IBD patients consistently in care.

| METHODS
In 2014, care of patients with IBD at our Unit was reorganised with the institution of an IBD centre where the activities of an IBD surgeon, a Rheumatologist, a Dermatologist, a Radiologist, a Pathologist, a Nutritionist, and a Psychologist were integrated within an interdisciplinary programme coordinated by a Gastroenterologist specialised in IBD, and were supported by dedicated nurses.Moreover, collaboration with a paediatric hospital was established to enhance the transition from paediatric to adult care, with the activation a formal paediatric-toadult transition programme that included, besides a clear pathway for referral with a direct link to adult care, concomitant consultations provided by both adult and paediatric specialists in IBD.
With the aim to improve patients' management, since 2014 the IBD centre also offered a dedicated email service and a telephone line, while access to endoscopy was streamlined with slots dedicated to patients with IBD.Personalised pathways for out-patient visits were also developed to ensure consistent care by IBD specialists, and the IBD centre was also provided with outpatient facilities where biological drugs could be administered intravenously.Lastly, timely access to radiological imaging (e.g.computed tomography, magnetic resonance imaging) was ensured with dedicated slots.These figures fulfil the structure and process quality of care standards that the European Crohn's and Colitis Organisation (ECCO) deemed essential, in 2020, for an IBD unit. 4n order to assess the clinical reflexes of the institution of the IBD centre, we evaluated the number of patients who were consistently (i.e. at least two visits attendance within 1 year) in care at the IBD centre in a 5-year period following its institution (2014-2018), and assessed the number of hospitalisations, the rate of hospitalisations in Gastroenterology wards, the length of hospital stay, and the uptake of biological treatments in patients with IBD in this time-frame.
The hospitalisation data in the 5-year period following the establishment of the IBD centre were compared to those recorded within the same hospital in a 5-year period (2009-2013) preceding its institution, while uptake of biological treatment was assessed from 2014 onwards only.Data regarding the length of hospitalisation in patients with IBD in Italy were obtained from a national survey. 5

| RESULTS
Following the establishment of the IBD centre, the number of patients with IBD consistently in care increased by 284%, from 169 patients in 2014 to 480 patients in 2018.Within the same period, the proportion of hospitalisation episodes per patient with IBD decreased from 0.41 in 2014 to 0.17 in 2018.Lastly, the proportion patients receiving biological treatment consistently increased from 7.7% in 2014 to 26.7% in 2018 (Figure 1).The total number of hospitalisation episodes and the proportion of hospitalisation episodes in a Gastroenterology ward in patients with IBD were compared with the same figures observed in the preceding 5-year period (2009-2013).The overall number of hospitalisation episodes for patients with IBD decreased by 18.4%, from a median of 98/year in 2009-2013 to 80/year in 2014-2018, while the proportion of hospitalisation episodes in a Gastroenterology ward progressively increased year-over-year, from 8.2% in 2009 to 28.8% in 2018, with a median of 9.2% in the period 2009-2013 that increased to a median of 18.7% in the period 2014-2018 (Figure 2).
Since the establishment of the IBD centre, the median length of hospital stay decreased by 29.4%, from 17 days in the period 2009-2013 to 12 days in the period 2014-2018, with a median length of hospital stay for patients with IBD that, from 2014 onwards, was consistently below the mean duration of hospitalisation for these patients (i.e. 15 days) (Figure 3).

| DISCUSSION
We observed that establishment of an interdisciplinary IBD centre is associated with a significant decrease in the proportion of patients with IBD requiring hospitalisation, despite a steady increase in the number of patients consistently in care at the centre within the same period.Indeed, the number of patients that were consistently in care showed a nearly three-fold increase within a 5-year period following the establishment of an IBD centre that fulfilled the majority of quality standards indicated by ECCO and suggested by experts. 4,6,7These findings were associated with a dramatic decrease in the number of hospitalisation episodes per patient/year in patients with IBD, and was also associated with an increase in the proportion of hospitalisation episodes in a Gastroenterology Unit, with a significant decrease in the median length of hospital stay.These positive healthcare figures were paralleled by a progressive increase in the proportion of patients treated with biologics, reflecting an improved appropriateness of treatment, in keeping with recent findings from both Europe and the US. 8,9espite interdisciplinary management of patients with IBD is recommended by experts, and is reputedly associated with improved care, there are no studies assessing whether actual institution of an IBD centre providing coordinated care may truly improve patients' management. 7Indeed, organisation of a coordinated team of healthcare specialists in the diagnosis and management of IBD and its associated diseases, availability of a dedicated psychologist, establishment of a paediatric-to-adult transition programme, support of specialised nurses, and availability of streamlined processes to access endoscopy, imaging and surgery are essential to improve the level of care delivered to patients.In this study, we showed that establishment of such an organised IBD centre is associated with several positive aspects for patients with IBD like a decrease in the rate of hospitalisation, an increase in the rate of hospitalisations in Gastroenterology wards, a decrease in the length of hospital stay, and an increase in the uptake of biological therapies.All these figures are hallmark of improved healthcare utilisation, and were also paralleled by a progressive increase in the number of patients consistently in care.In 2020, ECCO identified some structure and process quality indicators that a centre should fulfil in order to provide the highest level of care to patients with IBD, and although the institution of our IBD centre preceded these indications, the vast majority of structure and process standards that were deemed essential by ECCO were fulfilled by our centre. 4In this regard, the results of our study tend to indirectly support the evidence that adherence to these standards is associated with clinical benefit.Moreover, the progressive increase in the number of patients consistently followed at the IBD centre is testimonial to the fact that providing comprehensive assistance is associated with increased retention in care.
A critical aspect of our findings is that the comparison of some figures with a preceding period when understanding of the disease and availability of drugs might have been different, might introduce a bias.Moreover, despite the consistent increase in the proportion of patients treated with biologics, we were not able to directly assess whether this finding, as reported elsewhere, might have directly contributed to the decrease in the rate of hospitalisation, or whether this finding was just due to improved patients' management independently of increased access to biological treatment. 9This notwithstanding, the net result is that a comprehensive care of patients with IBD was associated with an improvement in several indicators, and therefore benefit patients and the community.Another drawback of this study is that economic aspects were not evaluated, and therefore the complex balance between organisation of a coordinated care, drug expense, and hospitalisation costs could not be determined.Moreover, we did not record either Patient-Reported Experience Measures or Patient-Reported Outcome Measures, and therefore we do not have a measure reported directly by the patient, or by the caregiver, that may enable us to confidently conclude that institution of the IBD centre had a positive impact on their impressions and perceptions of care. 10Lastly, this was a single centre analysis, without comparison with other centres that do not benefit from specialised programmes, although we feel that using data from the same institution in period preceding the establishment of the centre as control may represent a positive aspect rather than a weak point of our study.
To conclude, we feel that establishment of a comprehensive and organised IBD centre supported by interdisciplinary management may benefit patients, and that every effort should be taken in order to pursue the institution of such centres in hospitals where there is availability of IBD specialists.These centres should fulfil the indications set forth by ECCO, and possibly report the trajectories of some process indicators such as those explored in this study as well as economic indicators and patients reported outcomes in order to assess the improvement in patients' care over time and the benefit to the community.
AUTHOR CONTRIBUTIONS Edoardo G. Giannini: study concept and study design, interpretation of the data, formal statistical analysis, writing of the manuscript, critical revision of the manuscript for intellectual content.Giorgia Bodini: data collection, interpretation of the data, critical revision of the manuscript for intellectual content.Tommaso Testa, Federica Grillo, Luca Mastracci, Serena Arrigo, Piero Cai, Sabrina Paolino, Martina Burlando, Livia Pisciotta, Elena Formisano, Giuseppe Cittadini, Sabrina Tuo, Francesco Copello: data collection, critical revision of the manuscript for intellectual content.

F I G U R E 2
Proportion of patients hospitalised in a Gastroenterology unit, per year and 5-year period of observation (2009-2016 vs. 2014-2018).of the IBD centre Number of hospitalisaƟon episodes in paƟents with Inflammatory Bowel Disease (IBD)

F I G U R E 3
Median duration of hospitalisation, per year (light grey bars, 2009-2013; dark grey bars, 2014-2018), with mean National duration of hospitalisation in patients with Inflammatory Bowel Disease (dashed line).
E 1 Number of patients with Inflammatory Bowel Disease consistently followed at the Inflammatory Bowel Disease centre since its inception (light grey bars), proportion of patients on biological treatment (dark grey bars), and proportion of hospitalisations per patient in 2014 and 2018 (pie-charts).