Frank Scott, MD, on Creation of an IBD Referral Pathway

Dr Scott discusses the development of a referral pathway based on specific diagnostic criteria that indicate the need to refer patients with inflammatory bowel disease to specialist centers.

Frank I. Scott, MD, is an associate professor at the University of Colorado Anschutz Medical Campus in Denver, Colorado.

TRANSCRIPT:

Rebecca Mashaw:

Welcome to this podcast from the Gastroenterology Learning Network. I'm your moderator, Rebecca Mashaw. Today I'm joined by Dr. Frank Scott, an associate professor of medicine at the Crohn's and Colitis Center at the University of Colorado in Denver. He and colleagues recently conducted a review to identify key diagnostic criteria that should prompt appropriate referral to IBD specialists. Thanks for taking the time to talk with me today, Dr. Scott.

Dr. Frank Scott:

Thank you for the opportunity to talk about our work. It's great meeting you.

Rebecca Mashaw:

Would you tell us a bit about why you decided to take on the task of developing a referral pathway? Is this really a significant need in IBD?

Dr. Frank Scott:

Fantastic question, and I think it gets at the heart of what drove us to pursue this research. I think there are several unmet needs for our patients who are being managed by providers, especially out in the community, with regards to when they should be referred to make the diagnosis of inflammatory bowel disease. But also, for when they should be referred to have their inflammatory bowel disease managed by a subspecialist who spends most of their time caring for patients with inflammatory bowel disease.

I've personally been interested in sort of delays in care for some time, and really strongly feel that this sort of care pathway that would help us triage patients for when they might most benefit from an IBD subspecialist consultation is really an unmet need for our patients at this time.

Rebecca Mashaw:

So how did you structure this review and who participated?

Dr. Frank Scott:

Another great question. We started with 2 phases. The first phase was working with our collaborators at the Research Triangle Institute in North Carolina to conduct a scoping literature review to identify the factors that we might want to include that are associated with having a poor outcome for patients with inflammatory bowel disease. In that phase of this research, we reviewed 280 articles and whittled that down to about 47 articles total. And then from there, extracted the clinical factors or history related factors that we thought were most relevant for identifying patients that should be referred.

We then took these factors to a panel of 11 experts, and it's important to note that in order to capture a sort of 360 degree view of the factors, we used, not only IBD subspecialists but GI physicians, primary care doctors who may be managing patients with IBD, and we included 2 patient representatives as well to ensure this sort of aligned with the patient experience as well.

Rebecca Mashaw:

Is this pathway designed for patients who've already been diagnosed with IBD? Or can it help identify patients who should be further assessed to get a final diagnosis?

Dr. Frank Scott:

This pathway specifically targets those with a known diagnosis and helps clinicians both in primary care and in gastroenterology identify those factors that may prompt referral to a subspecialist. It's important to note though that there are several similar efforts underway for helping expedite referral for patients who do not carry a diagnosis of Crohn's disease or ulcerative colitis yet, to get it further evaluated either endoscopically or through inflammatory markers. Two of the sort of the most well-known efforts in that regard though thus far are the Red Flags Index, which uses a number of clinical and family history related factors and IBD Refer, which also incorporates some biochemical markers as well.

And then there are several research efforts that are using retrospective data or previously collected samples to also examine biochemical markers, metabolomics in the microbiome to identify those who might be at future risk of a diagnosis of Crohn's or UC. The purpose of this pathway specifically though just to reiterate is for those that have already been diagnosed to help us identify those that are particularly high risk.

Rebecca Mashaw:

You assessed 43 features. I'm assuming you mean possible symptoms or indicators of complex IBD. Can you tell us about some of the major criteria you included in the pathway and why they were chosen?

Dr. Frank Scott:

Absolutely. So as you mentioned, we sort took the criteria that we identified from those 47 articles that we had reviewed and we extracted from them 43 criteria. And then we took those to our panel of experts and asked that they help us stratify them into major and minor buckets. The major buckets or major criteria were those for which, if an individual had one of those elements related to their inflammatory bowel disease, that should trigger a referral to an IBD subspecialist. For the minor criteria, if individuals had two of those criteria, then they should be referred. It required more than just one.

For the major criteria, for those of us that care for patients with Crohn's disease or ulcerative colitis, or not that unfamiliar, they include endoscopic features like deep ulceration for our patients with Crohn's disease or signs of systemic illness like positive inflammatory markers, or anemia, or weight loss, or signs of already existing complex disease like the current use of an advanced therapy like a biologic or small molecule, a known IBD surgery in the past, or even a history of perianal fistula or abscess, or PS, primary sclerosing cholangitis, or PSC, in which we know individuals are already sort of predisposed to a more intensive or severe course of their inflammatory bowel disease.

Rebecca Mashaw:

You also looked at barriers to implementing such a referral pathway and ways to facilitate the implementation of it. What did you find out about that?

Dr. Frank Scott:

I thought this was really one of the more important pieces of this care pathway, in that we don't want this to just be a document that exists out there, but we wanted to start to understand how we can implement this as the next step. And so we included in this a measurement of factors that the individuals participating in the panel might think would potentially be challenges to implementing it and or might help. We identified from a challenge standpoint that resources that were available to the clinician might be the biggest challenge, such as necessary support from a budgeting, and training, and facility standpoint to implement the pathway or access to IBD sub specialist in an expedited manner.

From an implementation standpoint, we assessed establishing the pathway through the Crohn's and Colitis Foundation or other national foundations, identifying, preparing local champions, involving patients and family members, and allocation of support. All of these factors that we thought might be helpful were felt to be amongst the panel to be strongly helpful.

Rebecca Mashaw:

How would you like to see this change the practice of delivering care to patients with IBD?

Dr. Frank Scott:

As an IBD subspecialist at a major academic center, I often will care for patients that have been referred after they've seen multiple medications and or have had complications related to this disease. And we know from several sort of epidemiologic studies over time that if we can utilize our newer advanced therapies earlier in the course of disease, that this could potentially sort of modify the long-term progression, potentially change the risk of surgeries, and healthcare utilization for our patients with Crohn's and UC. I really hope that primary care physicians and community gastroenterologists recognize that this pathway exists and helps them identify those individuals who might benefit from seeing IBD specialists like myself sooner.

And so that we can assist in using our advanced therapies appropriately and monitoring and interacting both with the provider and the patient. The goal here is not to have created a pathway that would indicate that these patients should only be managed by the IBD subspecialist, but instead to get our input so that we can ensure that the best treatment plans are being used, that the best available therapies are being used. As the armamentarium has become more complex for Crohn's and UC, and more drugs are available, it does become a little bit more confusing and they may not necessarily have the time in there've been busy clinical workload to stay on top of some of the new treatments that we could potentially employ for these patients. And then longer term, through that interaction with the primary care and local GI doctors, sort of improve longer term outcomes for our patients with IBD.

Rebecca Mashaw:

So you're looking forward to building more of a multidisciplinary care team, although you may be in the same discipline, it may be two GI docs talking, but the primary care, perhaps even nurse practitioners and other caregivers who could help facilitate the best possible care for these patients?

Dr. Frank Scott:

Absolutely, and I think I'm uniquely exposed to those interactions here on the front range in Colorado. We care for some patients with IBD that are here right in the metro area, in which case we will often be the main sort of quarterback for patients' care, but we also care for patients on the western slope that are five, six hour drives away that may not even have access to a local gastroenterologist that are being managed by their primary care team for their Crohn's and UC.

And those sort of long distance interactions I think are vital for creating an appropriate sort of medical care and safety net for our patients with IBD that aren't in a large urban area with access to an AMC, wherein we interact with not only the patient but the primary care team that will be eventually prescribing the drugs, doing the laboratory monitoring, sort of improving education on that sort of frontline I think is vital.

Rebecca Mashaw:

Are you planning any future research on implementing this pathway, how you might push it out into the larger community?

Dr. Frank Scott:

We are. The first steps that we think are vital are validating it. And so we've begun to sketch out what that might look like in terms of using retrospective data that we collect here at tertiary care centers to assess what factors patients had before they even show up at our front door, and try to identify the time that they should have been referred if this care pathway had been utilized, and see if there's a delta based on what actually happened versus what might've happened had the initial team caring for the patient had access to this. I think once that validation is completed, then we would like to see some attempts at sort of implementing it in smaller networks of care and seeing if it actually has an impact on care over time.

Rebecca Mashaw:

Any final thoughts to share with your fellow gastroenterologists on this IBD Referral Pathway?

Dr. Frank Scott:

I just hope that this is a really useful tool for providers who do interact with patients who are suffering from inflammatory bowel disease and that it assists them in identifying individuals who might be higher risk, and who might benefit from interacting with me, either just in a single consultation or more longitudinally.

Rebecca Mashaw:

Well, thanks so much for sharing your study with us. It's going to be very interesting to see how things progress. And we look forward to talking to you again before long.

Dr. Frank Scott:

And thanks for your time, Rebecca, and for the opportunity to share my research.