Julianne H. Wagnon

Survey of gastroenterologists' awareness and implementation of AGA guidelines on osteoporosis in inflammatory bowel disease patients: Are the guidelines being used and what are the barriers to their use?†

Background: The American Gastroenterology Association (AGA) published guidelines to assist clinicians in the evaluation and management of osteoporosis in inflammatory bowel disease (IBD) patients. Two studies suggest that when clinicians utilized the guidelines, the majority of their IBD patients were appropriately screened and treated for metabolic bone disease. The aim was to study whether physicians who say they use the AGA Guidelines are, in fact, following the recommendations, and to assess the barriers preventing the use of the guidelines in the management of osteoporosis in their IBD patients. Methods: In all, 1000 physicians were selected from the AGA membership list and mailed a survey inquiring into awareness and implementation of the guidelines on osteoporosis in IBD patients. The barriers to implementation of the guidelines were also assessed. The sum of 21 self‐reported clinical practices (absence = 0, presence = 1) was used to evaluate adherence to the guidelines. A value of 0 implied no adherence while a score of 21 meant complete adherence. Results: Of 304 responders, 27 fellows, 8 retirees, and 11 incomplete responses were not included in the analysis; thus, 258 respondents were the subject of this analysis. Slightly less than half of the responders used the guidelines in decision‐making (126, 49%) or in the management (110, 42%) of their IBD patients. Using the scoring system described above, clinicians self‐reporting use of the guidelines had a significantly higher clinical practice score than those who did not use the guidelines (Wilcoxon rank sum test; P < 0.0001). Only 18% (12 of 68) of clinicians whose practice was comprised of ≤25% IBD patients used the guidelines compared to 60% (113/187) physicians who cared for more IBD patients (chi‐square test; P < 0.0001). Physicians who saw more IBD patients (>25%) were also more likely (97/187 = 52%) to assess and treat osteoporosis in their IBD patients. Conversely, only 16% (11/68) of physicians who saw ≤25% IBD patients treated osteoporosis (chi‐square test; P < 0.0001). The main reason physicians (n = 115) gave for not utilizing the guidelines was because they felt that IBD should be the focus of the visit (48, 42%); 34 (30%) reported that osteoporosis should be managed by another physician. Other barriers cited were lack of time (13, 11%), cost (10, 9%), and lack of knowledge (10, 9%). Conclusions: Most of the responding physicians do not utilize the AGA Guidelines on metabolic bone disease in IBD patients. The physicians who self‐reported utilizing the guidelines were actually adhering to the recommendations. Further education regarding the impact of metabolic bone disease in IBD patients and the importance of the guidelines is needed, particularly as it addresses the barriers set forth above.

Mo1376 Depression and the Cost of Outpatient Treatment of Crohn's Disease in an US Academic Medical Center

Background: There are over 700,000 Americans affected by Crohns disease (CD). A number of previous studies have looked at the cost of treating CD but they have focused primarily on inpatient costs. This study examines the cost of CD treatment in an outpatient setting and the economic burden of the comorbidity of depression among CD patients at a US academic medical center. Method: This is a retrospective study examining hospital cost data of all new patients with CD based on ICD-9 coding seen in an academic medical centers Inflammatory Bowel Disease Center from November 2010-November 2011. Chart review confirmed that billing was only for CDrelated issues. Cost data represent the actual cost to the institution of providing the service and was obtained from the institutions cost accounting database. The presence of depression was measured with the Patient Health Questionnaire-9 (PHQ-9), a self-report instrument used as part of the regular clinical practice in the Inflammatory Bowel Disease (IBD) Center. Multiple regression analysis was used to examine the relationship between patients PHQ-9 score and cost, adjusting for age, race, and gender, as well as an interaction between gender and severity of depression. Results: 650 patients (377 female [58%]) were included in the study. The average age of the patients is 39.7 years [(malesM.39.4 (SD. 15.85) femalesM39.9,( SD. 15.85)]. The average PHQ9 score is 6.80. Females had a higher average PHQ-9 score of 7.80 (SD. 6.40 ) vs. males-

Depression and Inflammatory Bowel Disease Patients: A Tertiary Care Center Experience

G A A b st ra ct s clinical depression was not significant. Using corticosteroids was associated with less fatigue (OR 0.12; 95% CI 0.03-0.52). The different hospitals settings (academic vs general), age and other medication use were not associated with higher fatigue scores. In group B, 545 pts were included (64% female, 77.4% CD, 22.6% UC, mean age 42 (SD 14)) and this group verified the results of group A. However, overall only 60% experienced fatigue and mean CIS score was lower (mean 37 (range 8-56) compared with group A. Furthermore, the use of anti-TNF and male gender were associated with lower percentage of fatigue in CD pts. Conclusion: A high percentage of IBD pts experience severe fatigue. Depression and disease activity were associated with fatigue in these patients. The use of anti-TNF and male gender in CD pts showed the opposite effect and were associated with less fatigue. In UC pts the use of corticosteroids showed less fatigue.

W1310 Split Dosing of Certolizumab Pegol for Crohn's Disease: A Tertiary Care Center Experience

G A A b st ra ct s prevent colectomy. At present it is not known if infliximab, FDA approved for outpatient use, is being employed as an in-hospital “rescue” agent for patients requiring hospitalization. We performed a retrospective analysis of IBD hospitalization records to determine patterns of infliximab use at a tertiary referral institution. Methods: De-identified data from a comprehensive electronic medical record from a single tertiary referral center was reviewed from the years 2002 2008. Patients with IBD were identified with ICD9 codes and indexed terms and these records were reviewed. Demographic and clinical data, history of infections (Clostridium difficile and Cytomegalovirus (CMV)), and treatment records, including use of biologic therapy and colectomy, were recorded. Results: Annual admissions and rates of colectomy were analyzed for the years 2002 2008. Among 216 IBD patients admitted for severe colitis (92% UC, 3% CD, 5% indeterminate colitis) there were 85 colectomies (overall rate 39%; range 28-46% per year). The majority of hospitalized IBD patients did not receive biologic therapy during hospitalization. Rates of biologic therapy during hospitalization rose from 6% in 2002 to 13% in 2008 (peak ultilization 25% in 2003). Overall rates of colectomy among hospitalized IBD patients were similar between patients who received biologic therapy during admission and those who did not. Infectious complications related to IBD were low. Clostridium difficile was identified in 17 patients, 2 of whom required colectomy (6 received infliximab with no colectomies). CMV was identified in 3 patients, all of whom received infliximab and 1 underwent colectomy. Conclusions: Despite the fact that colectomy rates remain unchanged, infliximab is used infrequently in hospitalized IBD colitics. Infectious complications were low in the biologic treated patients and these individuals had low rates of colectomy. Defining algorithms for the optimal use of biologic therapy in hospitalized IBD patients are warranted.