Raquel Faubel

Telemedicine in Inflammatory Bowel Disease: Opportunities and Approaches

Abstract:This review article summarizes the evidence about telemedicine applications (e.g., telemonitoring, teleconsulting, and tele-education) in the management of patients with inflammatory bowel disease (IBD), and we aim to give an overview of the acceptance and impact of these interventions on health outcomes. Based on the literature search on “inflammatory bowel disease,” “Crohns disease” and “ulcerative colitis” in combination with “e-health,” “telemedicine,” and “telemanagement,” we selected 58 titles and abstracts published up to June 2014 and searched in PubMed, EMBASE, MEDLINE, Cochrane Database, Web of Science and Conference Proceedings. Titles and abstracts were screened for a set of inclusion criteria: e-health intervention, IBD as the main disease, and a primary study performed. Finally, 16 were included for full reading, data extraction, and critical appraisal of the evaluation. Most studies use telemonitoring (home telemanagement system or web portal) and telecare (real-time telephone and image) as telemedicine applications and assessed the feasibility and acceptance of these systems, adherence to treatment, quality of life, and patient knowledge, particularly in patients with ulcerative colitis. Furthermore, some of these studies evaluated the patients empowerment, health care costs, and safety of telemonitoring in IBD. In conclusion, the health outcomes of telemedicine applications in IBD suggest that these could be implemented in clinical practice because they are safe and feasible applications that are well accepted by the patient and improve adherence, quality of life, and disease knowledge. Further studies with large sample sizes and complex diseases are needed to confirm these results.

Telemedicine in Inflammatory Bowel Disease: Opportunity Ahead.

To the Editor: Inflammatory bowel disease (IBD), which includes ulcerative colitis (UC) and Crohn’s disease, is a chronic and relapsing gastrointestinal disorder requiring continuous and personalized follow-up to achieve long remission and minimize short-term and long-term damage. Beyond a medical problem, IBD also generates a significant social and financial impact. To provide a response to these difficulties, information and communication technologies have recently been used to proportion health care services remotely, also known as telemedicine. These technological systems have successfully been used in patients with IBD, allowing for a closer follow-up with better communication between physicians and patients, promoting patients’ empowerment with treatment optimization and better medication adherence. Our research group reviewed the evidence about telemedicine applications in the management of patients with IBD, to give an overview of the acceptance and impact of these interventions on health outcomes. A ground-breaking evaluation of telemonitoring in patients with IBD was developed by Cross et al using a home-automated telemanagement system (HAT system). This telemanagement system was well accepted with high satisfaction, increased knowledge about the disease, and facilitated greater control of their IBD symptoms in most patients. However, in a randomized controlled trial with 47 patients in remission or with mild activity UC, no significant differences were noted in disease activity and quality of life between patients followed with the HAT system and the usual care with medical visits after 12 months, because in part of a higher discontinuation rate in the HAT group and low variation in the disease course in these patients with remission or mild disease. Nevertheless, the HAT system required home installation and eventual repairs, which could impair patient recruitment and participation. To avoid this problem, there is actually an ongoing multicenter, randomized, clinical trial to determine whether patients’ control with a web-based system using text messages to participants’ mobile phones could improve adherence and consequently disease activity and quality of life. Web-based systems to control patients with IBD were previously implemented by Elkjaer et al This group compared a web versus standard care in 333 patients, from Denmark and Ireland, with mild-to-moderate UC treated with 5-aminosalicylic acid for 12 months. The remote care method was shown to be safe and feasible, and most patients wanted to continue using it. There was a trend toward higher medication adherence in web patients and, the duration of relapses was shorter than in the control group, associated with the ability of the web program to empower patients to self-initiate 5-aminosalicylic acid in case of flare-ups. Therefore, these patients performed less outpatient visits and more phone calls and e-mails than control group with cost saving per patient-year. However, improvement in quality of life and disease knowledge questionnaires was inconsistent between both countries, reflecting variations in reproducibility according to the population and health care system in which it was applied. The same web program was used to optimize the dose of multi matrix system (MMX) mesalazine in a single-arm trial with 95 patients with mild-to-moderate active UC, and it was associated with significant improvement of disease activity and quality of life after 12 weeks, with better medication adherence than reported previously. Beyond providing good physician– patient communication, telemedicine has also been used with the aim of giving a multidisciplinary advice. Krier et al developed a “collaborative system,” which was based on remote patient consultation by different specialists contacted in a hospital where access to subspecialties was not possible. They compared this approach with conventional in-person encounter, and there was a high level of patient satisfaction, similar to that achieved with a direct clinical encounter. As a result of the development of telemedicine in recent years, different distance management projects have been designed to improve collaboration and delivery of health services in the community, especially in remote areas. Casellas-Jordá et al implemented a continuous care program in their Crohn-Colitis Care Unit. This model made possible an integrated patient control and empowered patients through education programs, as demonstrated by an increase in distance demands and a reduction of inperson visits. Nevertheless, there are some practical and medico-legal limitations to application of telemedicine in clinical practice, especially web-based systems. Confidentiality requires safe servers, but not all institutions have the infrastructure and economic resources needed. In addition, transcription errors in writing e-mails could induce incorrect decisions. It is important to select trained patients and those technologically unqualified to distance control may use other follow-up methods. In summary, telemedicine systems provide safe and feasible management of IBD, with excellent patient acceptance. The use of information and communication technologies allows continuous and personalized care, also in areas with decreased access to health services. These technologies can be implemented to improve treatment adherence and education, empowering patients to control their disease and optimize medication during flare-ups. Moreover, telemedicine applications are a promising option that could modify the structure of health systems if they demonstrate to be cost-effective. However, randomized controlled trials are still necessary to evaluate the effectiveness of telemedicine programs in comparison with conventional clinical The authors have no conflict of interest to disclose. Supported by grants from the Instituto de Salud Carlos III-Fondo de Investigaciones Sanitarias (FIS PI12/00277). Copyright

Use of telemedicine in inflammatory bowel disease: a real monitoring option?

Inflammatory bowel disease (IBD), which includes ulcerative colitis (UC) and Crohn’s disease (CD), is a chronic and relapsing disorder characterized by inflammation of the gastrointestinal tract. The natural progression includes periods of flares and remission, requiring continuous and personalized follow-up to achieve long remission and minimize short and long term damage. In fact, IBD patients show significantly higher rates of utilization of healthcare resources than patients with other conditions [1]. It is important to emphasize that 30-45% of adults are nonadherents [2], making these patients five times more likely to suffer relapses and consequently increasing health care costs [3]. The high percentage of nonadherence may be due to the difficulty in accessing specialized IBD care and behavioral factors. Furthermore, IBD is associated with high levels of school and work disability [4], interference with social activities and impairment of quality of life [5]. For these reasons, IBD generates a signi...

Telemedicina en el manejo de pacientes con enfermedad inflamatoria intestinal

Inflammatory bowel disease (IBD) is a chronic and relapsing disorder with significant medical, social and financial impacts. IBD patients require continuous follow-up, and healthcare resource use in this context increases over time. In the last decade, telemedicine has influenced the treatment of chronic diseases like IBD via the application of information and communication technologies to provide healthcare services remotely. Telemedicine and its various applications (telemanagement, teleconsulting and tele-education) enable closer follow-up and provide education resources that promote patient empowerment, encouraging treatment optimisation over the entire course of the disease. We describe the impact of using telemedicine on IBD health outcomes and discuss the limitations of implementing these systems in the real-life management of IBD patients.

Development and evaluation of an Innovative Chronic Disease Management Program in Valencia-La Fe Health Department

Valencia La Fe-Health Department, aligned with the Regional Ministry of Health, is pushing an Innovative Chronic Diseases Management Program, by introducing a new, proactive, care model based on current policies, best practices and evidence available aiming to a greater control of the patients while they are at homes. The program has been developed working on the seven courses of action, covering all the components required according to experts. This includes a) identification and stratification of the population, b) care processes design in coordination with all health care resources involved according to case management methodology, c) guidelines and protocols documentation and design of educational programs, d) Service portfolio development and care planning and coordination across care level e) promotion of new technologies, f) continuous assessment and improvement of quality of care g) alignment of resources and incentives in the Health Department. The predictive model developed identifies 3.28% of the total population, related to 72% annual consumption of unplanned weighted resources in our reference population. Chronic management program was evaluated through both a quasi-experimental study including 1900 patients enrolled in the case management program and a randomized clinical trial (RCT) including 495 patients on 3 branches (standard practice, phone supported intervention and technology based intervention). RCT preliminary results regarding health-related quality of life and other outcomes variables will be available during the first quarter of 2014.