Feasibility, acceptability and cost efficiency of using webinars to deliver firstline patient education for people with Irritable Bowel Syndrome as part of a dieteticled gastroenterology service in primary care

7 Background: Irritable bowel syndrome (IBS) is a chronic functional gastrointestinal disorder. 8 International research suggests dietary intervention as a first line approach, but dietetic services are 9 struggling to cope with demand. Digital technology may offer a solution to deliver appropriate patient 10 education. 11 Aim: To assess the feasibility, acceptability and cost efficiency of using webinars to deliver first line 12 IBS advice to patients as part of a dietetic-led gastroenterology service in primary care. 13 Methods: Patients were directed to an IBS First Line Advice webinar on a specialist NHS website. 14 Data were collected from patients pre and post webinar use using an on-line survey. 15 Results: A total of 1171 attendees completed the pre-webinar survey and 443 completed the post-16 webinar survey. Attendees ranged from under 17 to over 75 years. 95% found the webinar easy to 17 access, and 91% were satisfied with the content of the webinar. Those with excellent or good 18 knowledge rose from 25% pre-webinar to 67% post-webinar, confidence in managing their condition 19 improved for 74% of attendees. Using the webinars led to a 44% reduction in referrals for one to one 20 appointments with a specialist dietitian in the first year of use. The value of the clinical time saved is 21 estimated at £3,593 per annum. The cost of creating the webinar was £3317.


Introduction
Irritable Bowel Syndrome (IBS) is a non-life-threatening chronic and relapsing functional gastrointestinal disorder with a global prevalence of 11% (1) .The burden on health care systems and society worldwide is substantial.Data shows that in the United Kingdom (UK) the estimated total annual costs for IBS treatment ranges from £45.6 million to £200 million (1) .In the United States of America (USA) 25-49% of IBS patients will consult a primary care general practitioner (GPs) each year with reattendance being common (2) .In the UK, despite guidance from the National Institute for Health and Care Excellence (NICE), around half of IBS patients continue to be inappropriately referred for endoscopic investigation (3) with IBS accounting for 36% of all new patient referrals to gastroenterologists (1) .
Since 2008 UK NICE guidance has recognised dietary intervention as a successful first line approach for IBS with subsequent professional guidelines establishing clear pathways for the dietary treatment of IBS patients (4,5) .However, delivery of this treatment requires dietetic input and the demand currently exceeds capacity despite the use of alternative approaches, such as group sessions.Because many dietetic departments are unable to cope with demand the burden continues to fall on GP and secondary care services (6,7) .A solution is required to deliver high quality dietetic advice to the large patient population as a first line intervention, freeing up time for specialist care of more complex or intractable cases.
Due to the advancement and broad adoption by the public of digital technologies, the UK National Health Service (NHS) is embracing digital transformation as a way to meet increasing demand in a financially restricted environment (8,9) .Up to 75% of the population now seek health information online and convenient access is becoming an expectation (10) .Virtual education shifts responsibility to the patient and can overcome many of the barriers to face to face education, such as lack of mobility or time, distance to travel to attend appointments, lack of funds, long waiting lists for appointments, and caring commitments (10,11) .Evidence suggests that some patients actually prefer remote contact with health care providers rather than travel to appointments (12) .The use of pre-recorded on-demand webinars allows access to virtual health education for unlimited numbers of patients, enabling selfcare using appropriate expert formulated advice at first point of need, and potentially releasing time across the health care system.This project aimed to assess the feasibility, acceptability and cost efficiency of using webinars to deliver first line advice to patients with suspected or newly diagnosed IBS.

Methods
A single-group pre-post study design was used to evaluate the feasibility, acceptability and cost efficiency of a webinar as the first line advice for people with IBS in primary care.The webinar directly reflected first line IBS advice from the 2016 British Dietetic Association evidence based practice guidelines for the dietary management of IBS in adults. (13)Data were collected between 26 th March 2018 and 15 th April 2020.The project is registered as a service evaluation with Somerset Partnership NHS Foundation Trust and data were collected anonymously, therefore further ethical approval was not required.
Health care professionals (HCPs) working locally referred adult patients (aged of 18 years and over) with IBS to a newly developed 'IBS First Line Advice' webinar hosted on the NHS Community Dietetic website.Carers or friends were directed to the website if appropriate in order to support the patient.Before and after completion of the webinar individuals were given the option to complete an anonymous survey.

Developing the webinar
A webinar subscription was acquired with Go To Webinar Pro Version (LogMeIn, Inc.Boston, MA, USA) and the webinar platform was approved for use by Somerset Partnership NHS Foundation Trust Information Governance.An un-branded webinar was recorded using a PowerPoint (Microsoft Corporation, Redmond, Washington, USA) presentation delivered by three specialist gastroenterology community dietitians (MW, CM, LS).The recording was edited and uploaded to the YouTube channel, 'Patient Webinars'.The YouTube link was then embedded into the community dietetic department website.With access to 4G or Wi-Fi, the webinars were then available 'ondemand' to any patient via smart phone, laptop, tablet or computer at a time and place of their choosing.Patients could also download patient education resources directly from the website, for example NICE accredited dietary advice, constipation advice, information on additional dietary approaches etc.
The cost of creating the webinar was £3,597, including the webinar subscription (£2,363/year), microphone (£120 one-off cost), business card cost (£280 one-off cost), and staff costs (£834).(See Supplementary Information 1 for illustration of the staff time and process used to create the webinar).
Local GPs and other HCPs were given the website address and asked to direct adult patients to the website if the patient needed first line IBS advice.No referral letter was necessary from the referring clinician.To ensure that HCPs were aware of the webinar, emails with the website address were sent monthly to all Somerset senior GPs, practice managers, pharmacists and health visitors.Business cards were created for HCPs to give to patients with the website address and these were distributed to secondary care gastroenterology departments, endoscopy nurses, pharmacists, acute dietitians and GPs locally.Talks were given at county-wide GP education days highlighting the webinar and the website.

Data Collection
Pilot pre and post IBS webinar surveys were developed using Survey Monkey between 29 th June 2017 and 19 th February 2019 with data collect from 112 patients pre webinar and 66 patients post webinar.Data for this service evaluation was then collected between 26 th March 2018 and 15 th April 2020 using Questback (Questback, Bridgeport, USA).
Basic demographic data were collected including: age; gender; location within the UK; who gave the webinar details to the patient; whether IBS had been diagnosed by an HCP; whether the patient was registered with a Somerset GP; whether the webinar was being accessed by a patient, carer, friend or HCP.HCPs and carers were noted and then automatically directed out of the survey and were not included in the survey outcome data.
The surveys focused on collecting data on accessibility, acceptability, knowledge, confidence and examined use of health care services.Survey questions allowed for only one answer per question with the exception of questions 8 and 14 where multiple answers were allowed.(See Supplementary Information 2 for the survey questions).Patients were also asked what other information, if any, they would like to see included in the webinar.This information was regularly reviewed in order to ensure that the webinar was meeting patient needs.(See Supplementary Information 5 for patient answers) Data were also collected for referral rates to the dietetic-led gastroenterology service for one-to-one appointments for the year prior and year following the launch of the webinar.The estimated value of dietetic time in clinic was calculated using figures for an NHS band 6 dietitian for 2017 to 2019 including on-costs (approximately £23.18/hr).Data were analysed using SPSS (IBM, New York, USA) and are presented as frequencies.
Comparisons between pre and post surveys compare proportions in two unequal samples using medcalc.orgcomparisons of proportions calculator.

Results
The IBS webinar was viewed 2,300 times via the local NHS website, between 1 st July 2017 and 17 th March 2020.A total of 1171 attendees accessed the pre-webinar survey and 443 (38%) engaged with the post-webinar survey.There is no record of the number of patients who were offered the webinar but did not access it.The majority of patients had been diagnosed with IBS by a HCP (68%) and of those that completed the post webinar survey most were registered with a Somerset GP (84%).
Respondents were principally female (75%).(See Supplementary Information 3 for details on age, location of the patient, referral source and whether the attendee was a patient, carer or health care professional).
Figure 1a, b, c, & d highlight the patient acceptability of using the webinar.The majority of patients found the webinar easy to join, were satisfied with the overall content, and would recommend the webinar to friends with IBS.Reasons for attending the webinar were varied but the most frequently cited were access to accurate and reliable information, ability to re-watch the webinar, and that there was no need to travel or take time off work.
The change in patient confidence and knowledge in managing their IBS symptoms with diet is shown in figure 2a and 2b.This data shows that patients' confidence and knowledge increased after the webinar.The categories were dischotomised (very, fairly and some level of confidence=confident; Neither, not and not at all confident=Not confident.Excellent, good, fair knowledge=good; limited, poor, no knowledge=poor).45% (n=1171) were not confident to manage their IBS pre-webinar and this decreased to 16% (n=375) post-webinar (difference=29% (95% CI: 24-34%) p<0.0001).44% (n=1171) reported poor knowledge pre-webinar and this decreased to 5% (n=443) post-webinar (difference=39% (95% CI: 35-43%) p<0.0001).
Figure 4 shows how attendees adjusted their understanding of which healthcare professional would be most useful to seek advice from for IBS.Reliance on GPs and secondary care gastroenterology reduced, whilst the understanding that a specialist dietitian was the most appropriate professional increased.Assuming 'specialist dietitian' is the correct answer; 62% (n=1171) were correct prewebinar and 86% (n=375) post-webinar (difference=24% (95% CI: 19-28%) p<0.0001).
Patients were also asked if they would like to attend a webinar specifically on the low FODMAP diet; 64% of patients confirmed they would and a further 27% answered 'maybe'.
Patients reported what other information they would like to see included in the webinar (See Supplementary Information 5 for answers from patients).
In the year before the webinars were available, September 2016 to August 2017, the dietetic-led gastroenterology service received 350 referrals.In the year following the availability of the webinar, September 2017 to August 2018, 195 referrals were received into this service, showing a 44% drop in referral numbers.The value of the dietetic time saved by this project is estimated at £2,759 per annum.The time saved as a result of the reduced referral rate has allowed the provision of a service for patients with coeliac disease and inflammatory bowel disease in remission, which were both previously unmet needs.(See Supplementary Information 4 for financial modelling showing money saved with the use of dietetic IBS first line advice webinar).

Discussion
This service evaluation showed that the delivery of a webinar as the first form of patient education to those diagnosed with IBS in primary care was feasible, acceptable and cost effective.The webinar was feasible to develop and incorporate into a clinical dietetic service with very modest set up costs.
It was acceptable to patients in a number of ways and data indicated that patients' knowledge improved.The cost of development and delivery of the webinar were more than off-set by time savings, which were significant enough to allow the expansion of the service to other patient groups.
The growth of internet use is changing the landscape of global health care and health seeking behaviour; 60% of people surveyed acknowledged that online advice would influence their health care decisions (14) .One in three adults in the USA use the internet to diagnose or learn about a health concern (15) , and over 83% of Europeans look on-line for health information (16,17) .UK research indicates that patients are increasingly happy to embrace new technology, such as video consultations with their GP (14,18) .Webinars are a simple and effective digital innovation potentially offering populations unprecedented immediate access to health advice.It is acknowledged that trust and confidence in online information remain important (19)(20)(21) and these webinars give patients convenient remote access to the most up-to-date guidelines and evidence-based advice directly from specialists working in the field.The most common reason for attending the webinars was 'access to accurate and reliable information' reflecting the patients' trust in the information provided.This corresponds with international research underlining the desire for easy access to trustworthy health care on the internet (15,20,21) .This need for trustworthy information also highlights the importance of specialist health care professionals developing the content and delivering the patient-focused webinars.
During the evaluation period over 2,300 people viewed the webinar indicating that it was a feasible form of patient education.Furthermore the vast majority of patients found the webinar easy to use and would recommend it.All ages were represented in the sample, with a maximum 14% difference in the numbers accessing the webinar aged between 25-74 years.Recent research suggests that age is not a barrier to technology use (11) and this is reflected in our results; 33% of the sample were aged 55-74 years.Research shows that IBS is a more common disease in women with an odds ratio of 1.67.Our data showed a 75% female dominance which is higher than expected and may reflect a male reluctance to engage in online education and/or a female response bias to completing questionnaires. (3,22) -demand webinar could be accessed unlimited times at any time of day, making this an easy and convenient way to encourage patient self-management and consolidate knowledge, allowing patients to take the time they required to make sense of the complex medical and dietary information (23) .This approach may be particularly useful in chronic health conditions (11,23) such as IBS, and may explain why the ability to re-watch the webinar was the second most popular reason for accessing this form of patient education.Our data demonstrates that not only did attendees self-report an improvement in their knowledge after accessing the webinar, they also showed an increase in the proportion of correctly answered test questions post webinar, suggesting that the attendees had listened, assimilated and understood the information.Research shows that virtual education may be as effective or more effective than a routine physician appointment.It may be that the opportunity to re-watch the webinar and consolidate knowledge in part explains this finding (10) .The increase in knowledge is also likely to be associated with the improvements seen in self-reported confidence Odata showed clearly that preventing the need to travel and preventing the need to take time off work were important to patients who accessed the webinars.Travelling to appointments may pose a significant problem in both rural and urban areas to those who have limited mobility, insufficient funds, lack of access to transport, lack of child or respite care cover or other time constraints.For these patients on-demand webinars could significantly improve access to health education allowing them to choose when and where they attend (18) .The overwhelming majority of patients were satisfied with the content of the webinar and most would recommend it to friends, indicating that patients found the webinar acceptable.Additional comments on the survey consistently suggested that webinar content was comprehensive and extensive (see Supplementary Information 5).Requests for further information were focused predominantly on second-line dietary advice, specifically the low FODMAP diet.Based on this feedback we created a low FODMAP diet webinar (available at www.patientwebinars.co.uk), which has had 6,000 views in the first 12 months, suggesting that the feedback from our sample reflected a need in the general IBS population.
The symptoms of IBS e.g.abdominal pain, bloating, stool changes, can be very similar to those of bowel or ovarian cancer and inflammatory bowel disease, and are likely to explain why 4% of those identified with IBS are later diagnosed with a serious organic disorder (24) .Hence, any symptoms suggestive of more serious pathology (also known as 'red flags') such as blood in stools, unintended weight loss, unexplained low iron levels should be further investigated.For this reason, the webinar clearly informs patients of these 'red flags', to ensure patient safety by encouraging earlier care (see figure 5).Feedback indicated that patients did understand the safety issues, as illustrated by this quote,

"I need to see my GP as I have some of what you call red flags."
Recent systematic reviews from Australia and Canada have found that virtual education can lead to a more efficient use of clinical time offering a direct alternative to seeing an HCP face-to-face (10,11) , a finding that is supported by our data showing a 44% reduction in face-to-face referrals into the dietetic-led gastroenterology service in the first year following the start of the webinars.This significant release in clinical time has allowed the dietetic team to assess unmet needs, leading to new regional care pathways for both coeliac disease and inflammatory bowel disease in remission.
Additionally, from a cost-saving perspective, this cohort of patients did not require administration of appointments and could download resources directly from the website on to their own device, leading to further savings from printing and postage costs.NHS estates costs for room hire, staff and patient travel costs, parking and patient time should also be considered in any long-term financial savings assessments.
Other data from evaluation of face-to-face IBS group sessions shows that patients are frequently uncomfortable discussing bowel related symptoms in a group environment (unpublished data).The webinar allows anonymity, a factor identified as a reason for attending the webinar.This factor may explain the stark contrast between numbers of patients engaging in the different forms of patient education: only 48 patients attending monthly in-person group sessions over a 20 month period utilising only 22% of possible capacity (7) .
The un-branded IBS webinar is now also available on www.nhs.uk/conditions/irritable-bowelsyndrome-ibs/ibs-diet-video-guide/ and has had over 32,000 views between April 2019 and April 2020.Access on this national website is further enabling other UK departments to use the webinar free of charge.This prevents the need for replication of identical webinars by different Clinical Commissioning Groups (CCG), and importantly allows departments to benefit from financial savings without the need for developmental costs.The 44% drop in referral rates led to a £3.5K staff cost saving in our small service.However, the real difference will come when the concept of webinars is scaled up and rolled out nationally to other larger areas of need, for example muscoskeletal back pain, diabetes, cardiovascular disease, or post-cancer care, particularly allowing for a reduction in followup reviews after hospital procedures and ongoing specialist input for long term health conditions (8) .
The 2019 NHS Long Term Plan aims to remove a third of face-to-face hospital outpatient appointments, equivalent to 30 million outpatient visits per year, freeing up significant clinical time and allowing outpatient teams to work differently (8) .Reduction in referrals through the use of webinars could significantly contribute to this release in clinical time (see Figure 5), while money saved could lead to effective reallocation of clinical funding at a national level.It would be logical for NHS UK to act as a site for a national repository of webinars in the long term, but this requires further discussion.
The webinar specifically sought to educate patients on who to consult for IBS advice, and results showed that patients felt that a specialist dietitian was the most appropriate healthcare professional to deliver dietary advice for IBS.This is an important finding because it is well known that the high costs of treating IBS are associated with inappropriate reliance on GPs and secondary care (25)(26)(27)(28) .One in twelve GP consultations are for gastrointestinal problems and IBS is by far the most common gastrointestinal condition seen by GPs (29) .Therefore, the demand on GP time can be addressed by dietitian-led treatment including the use of webinars in order to manage the IBS workload in primary care.Evidence already highlights the ability of dietitians to work autonomously and effectively with IBS patients in a one-to-one setting in primary care, assessing patients without medical correspondance, recommending appropriate treatment and/or onward referral (30) .The webinars are a further development of this role, providing patients with faster access to the right care while encouraging patient self management and reducing the need for expensive referrals to secondary care.
Care of IBS is an example of where dietitians could take on roles as first contact practitioners (FCP) in the frontline of general practice in order to reduce GP workload.
The data collected for this feasibility study has several limitations.The anonymity of the on-line data collection made it impossible to cross-match responses pre and post webinar; we do not know which post resposes match which pre responses.The data collection also does not allow for long term follow up of patients to determine if watching the webinar led to improvements in symptoms; this should form the basis for future research.Only 38% of those completing the pre-survey completed the postsurvey and data collection did not allow assessment of the numbers of people who opted out of the surveys or who declined to engage with the webinar.This may mean there are inherent biases related to the type of person who was willing to complete both surveys.
From an equity accessibility perspective, it would be important to now look at ways of making these webinars available to all patient groups including other languages, those with hearing and/or sight disability.Discussions are already ongoing with the Deafness Support Network and NHS UK.

Conclusion
Patient webinars for first line advice for IBS are an innovative and novel use of digital technology offering those with IBS unprecedented access to patient education.At very little cost to the health service patients can increase their knowledge and confidence with trustworthy dietitian-led advice, while providing a simple cost-effective solution to help release time across the health care system.
As virtual communication becomes ubiquitous within society, the use of this form of patient education is likely to become mainstream, enabling patient's needs to be addressed as early as possible and empowering patients to better self-manage and understand their condition, potentially leading to improved clinical outcomes.More research is urgently needed to better assess the benefits, feasibility and challenges of implementing this technology at scale.

Figure 1a :Figure 1b :Figure 2a : 4 c
Figure 1a: Patient feedback on how easy it was to join the webinar n=443

Figure 2b :Figure 4 :
Figure 2b: Patient feedback comparing answers before and after watching the webinar on how they would rate their knowledge on managing their IBS symptoms through diet.Pre n=1171 and Post n=443

Figure 5 :
Figure 5: This diagram shows the potential benefits to the health care system of using webinars for first line IBS patient education How confident are you in managing IBS symptoms with diet?