3/2/2018 Treating Crohn’s and Colitis in the ASC Kimberly M Persley, MD Texas Digestive Disease consultants TASC Meeting Outline • IBD 101 • Diagnosis • Treatment • Burden of Disease • Role of ASC Inflammatory Bowel Disease Indeterminate colitis 1
3/2/2018 Inflammatory Bowel disease 2015 report‐‐‐3 million US adults with Inflammatory bowel disease Dahlhamer J. MMWR 2016;65(42)1166‐69 Inflammatory Bowel Disease Worldwide Inflammatory Bowel Disease • Chronic inflammation • IBD is not IBS • Remission/Relapses • Lifelong condition • Young age of onset • Second peak in 6 th decade • Women and men are affected equally 2
3/2/2018 Normal vs inflammatory bowel disease Environmental triggers Clinical Features: UC vs CD Ulcerative Colitis Crohn’s Disease Abdominal pain Less frequent frequent Bloody diarrhea frequent occasional Abdominal mass never frequent Intestinal obstruction never frequent Perianal disease Almost never frequent Fistula never common Effect of smoking protective detrimental Systemic symptoms Less common common 3
3/2/2018 Crohn’s Disease • Inflammation can involve any part of the GI tract • Inflammation is transmural • Fistula • Abscesses • Surgery is not a cure Endoscopic Appearance of Crohn’s Disease • Apthous ulceration • Deep fissure • Cobblestoning • Inflammation is segmental • Rectal spraring • Terminal ileum involved • Granuloma on biopsies Ulcerative colitis • Inflammation in limited to the colon • Inflammation in the mucosa • Surgery will cure • Eligible for Jpouch 4
3/2/2018 Endoscopic Appearance of Ulcerative Colitis • Inflammation is superficial • Diffuse • Rectal involvement • Normal terminal ileum Assessment of Disease Activity • Crohn’s Disease Activity Index (CDAI) • Harvey‐Bradshaw Index • Mayo UCDAI • Sutherland UCDAI • Inflammatory Bowel Disease Questionnaire (IBDQ) • Endoscopic scoring system Treatment Pyramid Research Severe Biologics Cyclosporine 6mercaptopurine Moderate azathioprine corticosteroids Mild Budesonide Antibiotics 5ASA 5
3/2/2018 Medical Therapy Prednisone Budesonide Asacol HD Pentasa Remicade Lialda Humira Apriso Cimzia Balsalazide corticosteroids Entyvio Sulfasalazine Simponi Canasa Stelara Rowasa Azathioprine 6Mercaptopurine Methotrexate Biologics Mesalamines Cyclosporine Immunosuppressive Inflammatory Bowel Disease • Expensive disease • Lifelong condition • No known cure • Significant health cost • Significant economic cost Burden of Disease‐Use of Healthcare Crohn’s Disease Ulcerative colitis • 1.1 ambulatory care visits a yr • 716,000 ambulatory care visit a yr • 1.8 million prescription written • 2.1 million prescription written for CD medications for UC medications • 187,000 hospitalization • 107,000 hospitalizations specifically for CD specifically for UC • 75% will require surgery • 25% will require surgery Crohn’s and Colitis Foundation Website, 2004 data 6
3/2/2018 Burden of Disease‐Psychological Health • Flare ups can be painful, unpredictable, inconvenient and embarrassing • Patient may present with anger, anxiety and fear • Anxiety and Depression are higher in IBD populations and it is recommended that ALL patient with IBD get screened for anxiety and depression. Burden of Disease‐Financial Burden • Direct Cost • Indirect Cost • Hospitalization • Value of lost earnings or • Physician services productivity • Value of leisure time lost • Prescription drugs • OTC medications • Nursing care • procedures Cost of IBD • Annual direct cost Annual Cost $20,000 • CD and UC patient $18,000 • Marketscan data base $16,000 $14,000 $12,000 $10,000 $8,000 $6,000 $4,000 $2,000 $0 annual cost CD UC control 7
3/2/2018 Case Presentation • ET is a 36 yo woman with Crohn’s colitis • In 2008, she was diagnosed with left sided colitis treated with Asacol and steroids • In 2012, stopped medications when she became pregnancy • In 2014, she was seen as a new patient. She complaint of diarrhea 8 to 10 bowel movement a day, abdominal pain and weight loss. She started on Lialda • 1/2015, EGD, colonoscopy and CT small bowel performed for ongoing symptoms. • Colonoscopy with right sided inflammation with a stricture. Diagnosis of Crohn’s disease • Normal CT small bowel • Started Humira Case Presentation • 8/2015 repeat colonoscopy with stricture and active inflammation in the right colon. The stricture dilated. • 7/2016 recurrent right sided abdominal pain and diarrhea. Colonoscopy with dilation of stricture • Recurrent symptoms and referred to CRS for limited ileocolonic resection Case Presentation • 12/2017 underwent post operative colonoscopy and found to have active ileitis at the neo‐terminal ileum • Changed to Remicade 8
3/2/2018 Role of Endoscopy • Confirm diagnosis • Differentiate between Ulcerative Colitis vs Crohn’s Disease • Obtain histologic confirmation • Assess disease severity and distribution • Assess mucosal healing • Surveillance for dysplasia Role of Endoscopy in IBD • Pouchoscopy • Dilation of anorectal stricture • Upper endoscopy • Chromoendoscopy • Surveillance for dysplasia Pouchoscopy A gastroscope typically used Biopsies taken Dilation of IPAA Endoscopic Jpouch images 9
3/2/2018 Chromoendoscopy • Dilute spray applied to the colon • Increase yield of dysplastic lesion Bowel Preparation • Split dose prep is recommended for all patients • Avoid Sodium Phosphate bowel preps • Increase mucosal injury • Erosions may be seen Procedure Comfort • Quick check in • Privacy in Pre‐op area • Adequate anesthesia • Allow for time of questions following the procedure • Patient/family have a lot questions about diagnosis and treatment • Patient/family will have questions regarding diet • Resources • www.crohnscolitisfoundation.org 10
3/2/2018 Healthcare Today • US Healthcare is the most costly in the world (17% GDP) • National Healthcare Expenditure Projections, 2010‐2020. Centers for Medicare and Medicaid Services, Office of the Actuary. • Aging populations and increased longevity, coupled with chronic health problems, have become a global challenge, putting new demands on medical and social service • The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance The Triple Aim Berwick, DM et al. Health Aff (Millwood). 27(3):759‐69. 2008. Berwick, DM et al. Health Aff (Millwood). 27(3):759‐69. 2008. ASC and the Triple AIM • Berwick, DM et al. Health Aff (Millwood). 27(3):759‐69. 2008. Improve the value of healthcare Control cost quality Value = cost Integrate care Improve outcomes Improve the patient care experience 11
3/2/2018 Procedural Cost Anesthesia Professional Fee Drugs Professional Fee Facility Fee Pathology Office Endoscopy Ambulatory Surgery Center (ASC) Professional Fee Hospital Outpatient Department (HOPD) Technical Component Special Stains Cost Variation in Colonoscopy James C. Robinson and Kimberly MacPherson. Health Affairs 2012,31:9 Conclusions • IBD is an EXPENSIVE disease • Medications • Procedures • The incidence of IBD is rising • IBD is a lifelong disease • ASCs are integral in providing quality care at a lower cost 12
3/2/2018 Thank you! • Questions 13
Recommend
More recommend
