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Background Transition in care is defined as the “purposeful and planned movement of adolescents and young adults with a chronic medical condition from pediatric to adult-oriented healthcare systems/care providers.” Currently, there are no Level 1 evidence-based interventions to improve the care of transitioning adolescents and young adults (AYAs) with inflammatory bowel disease (IBD). The development of a transition program using a biopsychosocial approach will improve the standards for healthcare delivery to transitioning IBD patients. This is a protocol for a structured randomized controlled trial (RCT) to assess the clinical and implementation effectiveness of a multimodal intervention focused on improving patient function, transition readiness and outcomes among AYA patients with IBD being cared for at pediatric centers in Canada. Methods This multi-center RCT is a type 1 hybrid effectiveness-implementation trial to evaluate effectiveness of the intervention and how it can be implemented more widely after the trial. We will include patients aged 16.0–17.5 years. The intervention program consists of 4 core components: (1) individualized assessment, (2) transition navigator, (3) virtual patient skills-building with a focus on building resilience, self-management and self-efficacy, and (4) a virtual structured education program. The control group will undergo standard-of-care defined by each participating center. The primary outcome will be the IBD Disability Index, a validated measure to assess patient functioning. Secondary outcomes include transition readiness and success, anxiety and depression scales, and health service utilization rates. Additionally, we will measure implementation outcomes and related barriers and facilitators for the intervention program. Discussion The type 1 hybrid effectiveness-implementation design will allow for the development of a feasible, sustainable, and acceptable final intervention model. The intervention will consist of modules that can be accessed in an online, virtual platform. The implementation will allow centralization of interventions and funding in order to minimize the impact on local clinical practice or hospital resources. The authors anticipate that the main study limitation will relate to study subjects not completely adhering to every component of the intervention, which will be evaluated and addressed using the implementation science approach. Trial registration NCT05221281. Registry: ClinicalTrials.gov. Date of registration: February 2, 2022. https://clinicaltrials.gov/ct2/show/NCT05221281.

Background In patients with inflammatory bowel disease, we strive to achieve mucosal healing, as this has been shown to decrease the risk of disease flares, hospitalization, and surgery. For this reason, we must use objective measures of mucosal healing to inform our clinical decision-making and can no longer rely on patient symptoms alone. Assessment of small bowel Crohn’s disease (SBCD) is particularly challenging given its lack of accessibility via standard endoscopic techniques. Ultrasound (US) represents a readily available, cost-effective, minimally invasive, radiation-free alternative for the assessment of small bowel disease. In this study, we performed a systematic review to determine the accuracy of ultrasound in diagnosing SBCD and its complications as compared with endoscopic visualization, surgery, and/or pathology. Methods We searched MEDLINE, EMBASE, and CENTRAL. Prospective cohort studies published up to March 2017 were reviewed. References meeting all eligibility criteria were assessed at the full-text level by 2 independent reviewers. Sensitivity and specificity were collected where available. Results A total of 2817 unique references were identified. Twenty-two studies were included. All studies were at low–moderate risk of bias based on the Quality Assessment of Diagnostic Accuracy Studies criteria. Transabdominal US (TAUS) yielded moderately high sensitivity and specificity for the diagnosis of SBCD and its postoperative recurrence. Detection was more accurate for severe postoperative recurrence. The diagnostic accuracy of US in stricture and abscess detection was high. Contrast enhancement improved the detection of abscess. Diagnostic detection of fistulas was of moderate accuracy. Entero-enteric fistulization and entero-mesenteric fistulization were most clearly identified. Conclusions Ultrasound can be used to diagnose SBCD in those with known or suspected Crohn’s disease. It can be used to detect postoperative recurrence and can accurately identify abscesses and fistulas, especially with the aid of contrast enhancement.

Prokinetics are recommended for the treatment of functional dyspepsia (FD) but systematic reviews give conflicting results on the efficacy of these agents. We have therefore conducted an updated systematic review to support the 2017 joint ACG/CAG dyspepsia guidelines. Electronic databases, including MEDLINE, EMBASE, and CENTRAL, were searched until September 2017 for randomized controlled trials (RCTs) comparing either prokinetics and placebo or two types of prokinetics to improve FD symptoms. The primary outcome was absence or improvement of dyspeptic symptoms at the end of treatment. Double-blind eligibility assessment and data extraction was performed. Pooled risk ratios of symptoms persisting or adverse events occurring, and standardized mean difference of quality-of-life (QoL) scores with 95% CI, using a random effects model, were calculated. Quality of evidence was assessed using GRADE. The search identified 1388 citations; 38 studies in 35 papers were included. Of these, 29 trials comparing prokinetics with placebo were found. There was a statistically significant effect of prokinetic treatment in reducing global symptoms of FD (RR 0.81, 95% CI 0.74 to 0.89; I2 91%; NNT 7), regardless of FD subtype or ethnicity. When comparing two types of prokinetic, the most commonly used comparator was domperidone. There was no difference in reducing global symptoms (RR 0.94, 95% CI 0.83 to 1.07). QoL was not improved with prokinetic treatment. The adverse events with individual prokinetics were not different from placebo, except for cisapride. The GRADE assessment rated the quality of the evidence in each outcome as very low. From the current evidence, prokinetics may be effective for the treatment in all subtypes of FD, with very low quality of evidence. There was no difference between prokinetics for dyspeptic symptom improvement. High-quality RCTs with large sample sizes of FD patients are needed to verify the efficacy of prokinetics.

Background Patients diagnosed with inflammatory bowel disease (IBD) during childhood require transfer to an adult gastroenterologist, in Ontario usually just before their 18th birthday. Pediatric onset IBD is a complex phenotype with demonstrated noncompliance risk that may require targeted measures to optimize health care outcomes in the adult care setting. Purpose The purpose of this study was to determine the impact of posttransfer health care setting (academic versus community gastroenterologist) on emergent health resource utilization. Methods This was a population-based retrospective cohort study using health care administrative data from Ontario, Canada. A cohort of patients with Pediatric onset IBD was identified and health resource utilization during a 2-year pretransfer period, transfer of care period and 2-year posttransfer period was analyzed. Posttransfer health care setting was defined as academic (i.e., gastroenterologists providing care in a university affiliated tertiary care center) versus community. A third comparator group, loss to follow-up, was also identified. The primary outcome of this study comprised emergency department utilization. Secondary outcomes included hospitalizations, surgeries, ambulatory visits, endoscopic investigations, and radiological investigations. Results Overall, there were no significant differences found in emergency department use, ambulatory care visits (aside from the expected drop in the lost to follow-up group), hospitalizations, endoscopic procedures, or radiological procedures between exposure groups. Conclusions Posttransfer health care setting does not seem to significantly impact emergent health resource utilization in the posttransfer period.

Background Inflammatory bowel disease (IBD)-related Emergency Department (ED) visits are a costly component to current healthcare expenditures. Patients who are discharged directly from the ED for nonurgent issues (aka “treat and release” ED visits) present an opportunity for quality improvement. Purpose To determine the impact of private insurance on IBD-related treat and release ED visits. The secondary outcome was cost per IBD-related ED visit. Methodology A retrospective cohort study was performed on the 2006 Nationwide Emergency Department Sample (NEDS). Comparisons were made between patients with access to private insurance vs those without. Multivariable survey-weighted logistic and linear regression models with clustering by hospital were created for the primary and secondary outcomes, respectively. Results In total, 19,324 patient encounters were included in the stratified analytic sample. Of these, 9272 (47.98%) patients reported private insurance as their primary payment method. An additional 10,052 (52.02%) patients reported an alternative payment form. The private insurance group was statistically younger, less likely to reside in an urban setting and had more representation within the highest income quartile. The OR of a treat and release ED visit was 1.47 (95% confidence interval 1.34–1.62) for no private insurance compared to private insurance. On average, the cost per ED visit of patients without private insurance was $214.80 ± 48.48, P < 0.001 less than those with private insurance. Conclusions Lack of private insurance is an important predictor of IBD-related treat and release ED visits.

Background. Aseptic abscesses (AA) are sterile lesions that represent an extraintestinal manifestation (EIM) of inflammatory bowel disease (IBD). Though Canada has the highest prevalence of IBD in the world, reports of IBD-associated AA are absent in Canada. This may represent a different IBD phenotype or underrecognition and underreporting.Purpose. To explore AA as a possible EIM of IBD and evaluate clinical and investigative findings among patients with IBD-associated AA.Methods. Retrospective chart and literature reviews were performed to find cases of IBD-associated AA at our institution and in the literature.Results. We identified 2 cases of IBD-associated AA in our institution. Both patients had ulcerative colitis and presented with fever, abdominal pain, and weight loss. Radiological workup and aspiration showed sterile splenic abscesses. The AA were unresponsive to antibiotics. One patient improved on corticosteroids and one underwent splenectomy. We retrieved 37 cases of IBD-associated AA from the literature. All patients showed no evidence of infection, failed to resolve with antibiotics, and, if attempted, improved on corticosteroids.Conclusions. Our cases are the first reported in Canada. They support literature which suggests AA as an EIM of IBD and may help increase recognition and reporting of this phenomenon.

Elderly patients may be at increased risk for poor outcomes after surgery for inflammatory bowel disease (IBD). We investigated postoperative mortality and the incidence of complications in elderly patients with IBD.We identified patients who underwent major IBD-related abdominal surgery using the American College of Surgeons National Surgical Quality Improvement Program Participant Use Files, from 2005 through 2012. We compared mortality and postoperative complications between elderly patients (≥65 years old) and nonelderly patients (65 years old).We identified 15,495 IBD patients who underwent surgery; of these, 1707 (11%) were elderly. Postoperative 30-day mortality was higher among elderly patients with Crohn's disease (CD) (4.2% vs 0.3% in nonelderly patients; P.001) or ulcerative colitis (UC) (6.1% vs 0.7%; P .001). After accounting for potential confounders, the adjusted odds ratio (aOR) of postoperative mortality in patients with CD was 11.67 (95% confidence interval [CI], 5.99-22.74), and in patients with UC was 4.39 (95% CI, 2.49-7.72). Postoperative complications were more common among elderly patients with CD (28.0% vs 19.4% in nonelderly patients; P.001) or UC (39.3% vs 23.6% in elderly patients; P.001). The aOR for any postoperative complication (excluding death) was 1.40 (95% CI, 1.16-1.69) in patients with CD and 1.74 for patients with UC (95% CI, 1.49-2.05). Elderly patients with UC were at increased risk for infectious complications, compared with nonelderly patients (aOR, 1.52; 95% CI, 1.27-1.82). The risk of postoperative venous thromboembolism was higher in elderly patients with CD (aOR, 1.68; 95% CI, 1.04-2.73). A higher proportion of elderly patients was still in the hospital more than 30 days after surgery (5.0% vs 1.8% for nonelderly patients; P.001).Elderly patients with IBD have substantially higher postoperative mortality and more complications than nonelderly patients with IBD. These increased risks should be considered when comparing risks of surgical vs medical therapy in this population.

Canada has one of the highest rates of inflammatory bowel disease (IBD) and the disease represents a significant health, social, and economic burden. There is currently no cure for IBD, although earlier diagnosis and new therapies have improved the overall health outcomes and quality of life for patients. Crohn’s and Colitis Canada is Canada’s only national, volunteer-based charity dedicated to finding cures for IBD and improving the lives of those affected, through research, education, patient programs, advocacy, and increased awareness. On April 30, 2015, Crohn’s and Colitis Canada hosted the “Patient and Healthcare Professional Summit on the Burden of Disease in IBD” to obtain a deeper understanding of the unmet needs of IBD patients and their caregivers. Through personal vignettes, patients articulated a pressing need to increase understanding of the challenges faced by people suffering from IBD among both health care professionals and the general public, develop best practices for navigating life transitions and addressing the unique challenges faced by children with IBD, and provide equitable access to appropriate, effective, and affordable treatments. The recommendations that emerged from the summit will inform about efforts to increase public awareness, inform about advocacy strategies, and contribute to the development of research priorities.

The incidence of inflammatory bowel disease (IBD), comprising Crohn’s disease (CD) and ulcerative colitis (UC), has increased in pediatric populations over the last decade. Patients diagnosed during childhood often survive well into adulthood, and therefore their healthcare requires transfer to an adult gastroenterologist, usually at age 18 years. Transition has been defined in the literature as the “purposeful planned movement of adolescents and young adults with chronic conditions from child-centered to adult-oriented health care systems” (Blum et al., 1993). The purpose of this review is to establish the current state of knowledge regarding the transition from pediatric to adult care in IBD. This review highlights that developmentally appropriate transitional care is now recognized as a healthcare priority and thoughtful targeted intervention is needed.

Background The transition from pediatric to adult care for inflammatory bowel disease (IBD) is poorly understood. Aims To characterize this transfer of care, health resource utilization was assessed. Methods Patients transferred between 1999 and 2008 were studied. Utilization of health resources one year before transfer and one year after transfer was compared. Resource units assessed included: i) emergency department (ED) visits; ii) hospitalizations; iii) clinic visits; iv) surgical procedures; and v) endoscopies. Secondary outcomes included: i) documentation of patient non-compliance; ii) reason(s) for ED visit; iii) diagnoses most responsible for hospital admission; iv) medications; v) indications for surgery; vi) endoscopic findings; vii) and disease activity. Results 95 subjects were identified (48 female), of whom 69 had Crohn's disease (CD) and 26 had ulcerative colitis (UC). The average age of diagnosis was 12.9 years. Over their adult care interval, subjects had fewer clinic visits (2.56 versus 3.05 (p = 0.01)) and more documented non-compliance (43% versus 29% (p = 0.01)). No differences in ED visits (0.15 versus 0.18 (p = 0.71)), hospitalizations (0.13 versus 0.13 (p = 0.23)), surgical intervention (0.03 versus 0.05 (p = 0.53)) or endoscopies (0.37 versus 0.25 (p = 0.11)) were observed. IBD was active 66.7% of endoscopies under pediatric care versus only 23.8% under adult care (p = 0.003). The average activity of CD was also higher during the last year of pediatric care. Conclusions Understanding the transition process can help to develop strategies needed to support patients and their families.

Background & Aims Patients with inflammatory bowel diseases (IBD) are hospitalized frequently. We sought to identify factors associated with risk for IBD-related readmission to the hospital. Methods We performed a retrospective analysis of 26,403 patients hospitalized for IBD from 2004 through 2010 using the Canadian Institute for Health Information Discharge Abstract databases. We examined whether demographic factors, comorbidity, and hospital IBD admission volume were associated with readmission rates, length of stay, bowel resection, and mortality. Results Young, middle-age, and elderly adults were more than twice as likely to undergo surgery during hospitalization than pediatric patients. Elderly patients with IBD had a nearly 40-fold greater in-hospital mortality than pediatric patients (odds ratio, 37.4; 95% confidence interval [CI], 5.17–270.0). In-hospital mortality was lower at hospitals with the highest volume of IBD patients than at those with low volume (odds ratio, 0.20; 95% CI, 0.05–0.97). Rates of readmission were lower for patients with ulcerative colitis than Crohn's disease (hazard ratio, 0.79; 95% CI, 0.72–0.86). The hazard ratios for readmission among young, middle-age, and elderly adults, compared with those of pediatric patients, were 0.79 (95% CI, 0.69–0.90), 0.57 (95% CI, 0.49–0.65), and 0.44 (95% CI, 0.37–0.53), respectively. Rates of readmission were lower at the highest-volume, compared with the lowest-volume, hospitals (hazard ratio, 0.78; 95% CI, 0.64–0.96). Conclusions Based on a retrospective database analysis, pediatric patients with IBD are at greater risk for readmission to the hospital than older patients. Efforts should be made to determine whether factors that contribute to this risk are preventable. The lower risk of readmission at the highest-volume hospitals may reflect optimal management during hospitalization or follow-up evaluation.

Background: Inflammatory bowel disease (IBD) is a chronic inflammatory condition associated with multiple disease-related and treatment-related complications. Population-based, longitudinal data regarding trends of IBD-related complications and rates of bowel resection are lacking in the United States. We aimed to study these temporal trends using a large nationally representative database. Methods: The National Inpatient Sample (NIS) databases (2002-2011), a subset of the Healthcare Cost and Utilization Project by Agency for Healthcare Research and Quality, were utilized for this study. The NIS is the largest all-payer inpatient care database, encompassing approximately 5-8 million hospitalizations from almost 1000 hospitals in the USA. Hospitalizations with diagnosis of IBD were captured by ICD-9 codes (Crohn's disease (CD): 555; Ulcerative colitis (UC): 556). IBD-related complications were identified using various ICD-9 diagnosis codes. Bowel resection was identified using the ICD-9 procedure codes 45.6-45.9. Analyses were performed separately for bowel resection rates for overall IBD, CD and UC. Linear regression was used to assess trends in various complications and resection rates. Analysis was performed using SAS 9.3. Results: Our study sample included 519,459 hospitalizations-related to IBD. The mean age of hospitalizations was 50 years, and the majority of patients were Caucasian (80%) and female (58%). The rate of Clostridium difficile infection increased significantly from 2002 (2.0%) to 2011 (4.04%) (slope 0.222, p