Introduction

While early intervention with biologics improves clinical response in Crohn’s disease (CD), the optimal timing to reduce healthcare resource utilisation (HCRU) and direct costs remains unclear. This study examined the impact of biologic initiation on HCRU and direct costs over 5 years in adults recently diagnosed with CD in the US.

Aims & Methods

Adults with >2 non-ancillary outpatient claims (30 days apart) or 1 inpatient claim for CD (ICD-10: K50.x) from 1/1/2015 to 7/31/2024 were identified using Optum® Clinformatics® Data Mart. Patients with CD who started biologic treatment within 2 years of diagnosis (index date) and had continuous enrollment for 1 year pre- and 5 years post-index were stratified into early (<12 months) or late (>12-24 months) initiators. Due to skewed distributions, CD-related and non-CD-related costs at 5-year post-index were analysed using gamma log. Poisson or negative binomial (with zero-inflated models in some cases) were used to model HCRU. All models were adjusted for demographic and clinical characteristics at biologic initiation.

Results

Early initiators (EI) were significantly younger (mean[SD] age: 43.2[16.9] vs 48.0[16.6] years, p<0.001), predominantly male (50.6% vs 44.5%), had significantly higher commercial insurance (84.5% vs 77.2%, p=0.004) than late initiators (LI), and had similar Deyo Charlson comorbidity index scores (mean[SD]: 0.7[1.2] vs 0.7[1.3]). EI had significantly lower total mean medical costs ($63,761 vs $66,282), significantly lower IBD-related mean medical and pharmacy costs ($1074 vs $1494), as well as significantly lower mean pharmacy costs to treat depression ($28 vs $346), and anxiety ($38 vs $79) than LI (Table). Additionally, EI had fewer emergency visits (1.5 vs 1.6), fewer all-cause (4.2 vs 4.9 days), and CD-related hospitalisations days (3.9 vs 4.7 days) than LI. Other HCRUs and costs were similar between the two groups.

	Early initiator (EI) (N=1273)	Late initiator (LI) (N=290)	Adjusted P-value
Costs in US Dollars
Medical and pharmacy costs Medical costs Anxiety/depression outpatient costs Non-IBD pharmacy costs Opioid pharmacy costs Anti-depression pharmacy costs Anti-anxiety medication costs CD-related medical and pharmacy costs CD-related medical costs IBD-related medical and pharmacy costs	$290,491 (239,398) $63,761 (128,352) $11,492 (48,843) $225,657 (194,145) $170 (1697) $28 (393) $38 (476) $108,293 (116,124) $42,451 (70,935) $1,074 (5,567)	$298,162 (246,492) $66,282 (97,089) $12,203 (41,583) $230,385 (210,412) $189 (1285) $346 (4746) $79 (690) $100,574 (112,197) $45,547 (74,554) $1,494 (6,971)	0.794 0.0497 0.763 0.711 0.825 <.001 0.007 0.070 0.159 0.046
HCRU
Number of emergency department visits Number of outpatient visits Number of CD outpatient visits Number of CD-related emergency department visits Number of CD-related hospitalisations Number of IBD-related diagnostic procedures Number of CD-related management procedures Patients having pharmacy claim, n (%) Patients having IBD-related pharmacy, n (%) Patients having Extraintestinal manifestation, n (%) Days of hospitalisation Days of CD-related hospitalisations Length of hospitalisation in days	1.5 (4.1) 56.6 (49.8) 23.7 (19.2) 0.7 (2.3) 0.6 (1.2) 0.8 (1.0) 0.1 (0.3) 1240 (97.4%) 184 (14.5%) 58 (4.6%) 4.2 (10.4) 3.9 (9.5) 2.0 (3.8)	1.6 (4.0) 60.1 (53.6) 24.1 (19.9) 0.8 (2.3) 0.7 (1.4) 0.9 (1.0) 0.1 (0.3) 277 (95.5%) 33 (11.4%) 17 (5.9%) 4.9 (12.3) 4.7(12.2) 2.1 (4.5)	0.004 0.402 0.357 0.071 0.886 0.398 0.417 0.289 0.163 0.458 0.013 <.001 0.102
Data are presented as mean (SD=standard deviation) unless otherwise specified. CD, Crohn’s disease; IBD, inflammatory bowel disease

Conclusion

Early initiators of biologics had lower HCRU and reduced non-CD medication pharmacy costs at 5 years post-index compared to starting biologics after a year, potentially leading to overall cost savings and improving patient health outcomes.

Disclosure

Alyssa M. Parian: None to disclose
Deborah A. Fisher, Alan James Michael Brnabic, Nicholas Bires, Debbie Tinsley, Zbigniew Kadziola, Wai Man Maria Chan: employees and shareholders of Eli Lilly and Company

Introduction

Endoscopic Retrograde Cholangio-Pancreatography (ERCP) is performed to treat pathology within the biliary system. Patients undergoing this may be on systemic anticoagulation. ERCP is classed as a high-risk bleeding procedure within BSG guidelines. This would necessitate anticoagulation interruption to prevent bleeding. It is recognised however, that resumption of antiplatelets and anticoagulants is associated with improved survival and reduced incidence of thrombotic complications. Thus, all patients should have a clear anticoagulation plan.

Aims & Methods

Attendances for ERCP over a 6-month period were analysed. Of the 132 patients, 33 (25%) were taking either an antiplatelet, warfarin or a Direct Oral Anticoagulant (DOAC). Medical records were reviewed in relation to pre-procedure management of these medications, advice from the endoscopist regarding resumption and whether these medicines were managed appropriately thereafter.
Several interventions were then made; a change to the reporting software led to a prompt relating to antiplatelet/anticoagulant medications, an education campaign for post graduate doctors in training and medication guidance summaries visible in the endoscopy department.
A second 6-month review was then undertaken to evaluate if there had been any improvement in outcomes. In this time frame, 143 patients underwent ERCP of whom 27 (16.7%) were taking antithrombotic therapy.

Results

Results are in Table 1:

	Pre-Intervention	Post Intervention
Pre-procedure appropriate management	48.5%	70.9%
Documented advice on endoscopy report	10%	30%
Post procedure appropriate prescribing	36.3%	70%

One common error was holding of anticoagulation/antiplatelet medication from admission in anticipation of ERCP. This led to long periods off anticoagulation whilst awaiting ERCP.
Documented advice was given more frequently on Endoscopy reports in cases where the patient required further procedure.
It was challenging to analyse post procedural management for inpatients, as the quality of ward round documentation and discharge letters was variable.

Conclusion

Further education to junior staff around utility of BSG anticoagulation guidelines greatly improved pre and post procedure management and thus forms a cornerstone to improve care. Further education to more senior staff may also improve decision rationale and medication advice in ward round documentation and discharge paperwork. Human factors also need to be considered; limited advice is likely related to high endoscopy workload pressures, with sub analysis showing that advice is improved when further intervention is required or in higher risk settings, illustrating that antithrombotic decisions are considered by the endoscopist. Improved documentation at procedure with the support of upgrades to reporting software will enhance post procedure care and consequently reduce demands on the service.​

References

Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline updateVeitch AM, Radaelli F, Alikhan R, et al. Gut 2021;70:1611–1628
UEG poster: Improving documented advice regarding anticoagulants and antiplatelets in acute upper gastrointestinal bleeds. Authors: Dr Emily Creed, Dr Vanessa Theis, Dr Katie Clark, Dr Sweekriti Gurung, Dr Abdullah Motam and Dr Gregor Farrell Bins.

Introduction

Blueberry ingestion resulted in significant abdominal symptom relief, improved Gastrointestinal Symptom Rating (GSRS) and quality-of-life and life functioning scores by Outcome Questionnaire (OQ 45.2) in patients with DGBI¹. It is unclear via which mechanisms blueberries exert their beneficial effect in DGBI².

Aims & Methods

We explored the associations between symptomatic responses to blueberry ingestion, faecal microbiota composition, clinical phenotypes and tests of disease mechanisms in DGBI.
Male and female patients aged 18-60 years with DGBI (irritable bowel syndrome or functional dyspepsia, Rome 4), were randomised to blueberries (30g freeze-dried powder = 180g fresh blueberries) or placebo daily for 6 weeks in a double-blind, cross-over study. GSRS and OQ-45.2 were assessed before and in week 6 of each treatment period. Responders were defined by improved GSRS or OQ-45.2. Demographics, lifestyle and symptom details were documented at baseline³. Further variables were gathered before and in week 6 of treatment: Bristol Stool Scale, breath H_2, CH₄ and symptoms after fructose 35g, cognitive tests (CANTAB®), skin fluorescence for advanced glycation end-products and serum tight junction proteins (claudin-3 and -5, zonula occludens-1). Stool microbiome analysis was performed by DNA extraction and sequencing for shotgun metagenomics. Nonmetric multidimensional scaling ordination plots based on Bray-Curtis dissimilarity were generated at the species level with clinical covariates. Spearman association of microbial species with demographics, clinical phenotype and mechanistic tests at baseline and during treatment were analysed by stratifying data into pre- and post-treatment groups, as well as responders and non-responders by GSRS and OQ-45.2.

Results

In 43 DGBI patients there were significant associations between faecal microbiota composition, clinical phenotypes and tests relating to disease mechanisms that were distinct between blueberry responders and non-responders. Examples of prominent baseline associations were breath gases after fructose with Ruminococcus sp AF41_9 in GSRS responders and with Eggerthella lenta, Lachnospiraceae bacterium AM48_27BH, Phocaeicola vulgatus, Ruminococcus callidus, Mediterraneibacter glycyrrhiznilyticus in non-responders. Cognitive skills were associated with Clostridium sp AF34_13 and Clostridiaceae bacterium Marseille_Q4149 in responders, and with Blautia glucerasea, Eggerthella lenta and Ruminococcus callidus in non-responders. Tight junction protein levels correlated with Clostridiaceae bacterium Marseille_Q4149, Anaerobutyricum hallii and Bacteroides intestinalis in responders and with Anaerostipes hadrus, Blautia faecicola, Blautia glucerasea, Clostridia bacterium UC5_1_1D1 and Ruminococcus gnavus in non-responders. During blueberry ingestion new associations between bacterial taxa and GSRS, breath gases after fructose, tight junction protein levels emerged, which were largely distinct between responder groups. Responders by OQ-45.2 showed associations between bacterial taxa, demographics and mechanistic tests both at baseline and during blueberry dosing that were largely distinct from those of GSRS responders.

Conclusion

In patients with DGBI, GI and general symptom relief with blueberry ingestion were characterised by specific, distinct associations between faecal microbiota, clinical phenotype and tests of disease mechanisms at baseline and during treatment. This first longitudinal blueberry treatment study in DGBI patients suggests an important role of the intestinal microbiota in symptom genesis warranting further study.

References

¹Wilder-Smith CH, Materna A, Olesen SS. Blueberries Improve Abdominal Symptoms, Well-Being and Functioning in Patients with Functional Gastrointestinal Disorders. Nutrients. 2023 May 20;15(10):2396.
²Kalt W, Cassidy A, Howard LR, Krikorian R, Stull AJ, Tremblay F, Zamora-Ros R. Recent Research on the Health Benefits of Blueberries and Their Anthocyanins. Adv Nutr. 2020 Mar 1;11(2):224-236.
³Wilder-Smith CH, Drewes AM, Materna A, Olesen SS. Extragastrointestinal Symptoms and Sensory Responses During Breath Tests Distinguish Patients With Functional Gastrointestinal Disorders. Clin Transl Gastroenterol. 2020 Aug;11(8):e00192.

Disclosure

This study was supported by a research grant from the US Highbush Blueberry Council.

Introduction

Colorectal cancer is the third most common cancer worldwide and the second leading cause of cancer-related death. Most colorectal cancers arise from benign polyps, especially dysplastic adenomas. Colonoscopy with polypectomy is the gold standard for preventing cancer by interrupting the adenoma-carcinoma sequence. This has led to the development of various techniques and devices for improved prevention and treatment. Hot snare endoscopic mucosal resection (HS-EMR), which combines submucosal injections with electrocautery, is commonly used for excising various colorectal polyps. However, it carries risks of diathermy-related complications, such as perforation, and bleeding. To address these issues, cold snare endoscopic mucosal resection (CS-EMR) has been proposed as an alternative. Concerns about residual adenoma/recurrence have been raised with CS-EMR. Therefore, we conducted this meta-analysis to compare the two techniques.

Aims & Methods

We searched electronic databases, including MEDLINE via PubMed, Scopus, Web of Science, and Cochrane, without restrictions on publication date or language. We included RCTs comparing CS-EMR and HS-EMR for colorectal polyp resection. Primary outcomes included the incidence of delayed bleeding and residual/recurrent adenoma (RRA).

Results

On Nov 5, 2024, our literature search across electronic databases retrieved a total of 1,888 records. Following a meticulous screening process, six studies met the eligibility criteria encompassing 1,449 patients and 1,947 polyps. Regarding safety, the overall effect estimates regarding delayed bleeding showed statistically significant results favoring CS-EMR group [OR 0.31, 95 % CI (0.12–0.76), P = 0.01] with no heterogeneity (P = 0.40; I² = 0 %). However, statistical superiority for CS-EMR could not be detected regarding early bleeding [OR 0.78, 95 % CI (0.31–1.97), P = 0.60]. Only two studies reported data on delayed perforation, showing a numerical difference favoring CS-EMR; however, statistical significance could not be obtained [OR 0.26, 95 % CI (0.03–2.41), P = 0.24]. Regarding efficacy, the overall effect estimates regarding complete resection and RRA did not favor either of the groups [OR 0.62, 95 % CI (0.25–1.53), P = 0.30], [OR 2.81, 95 % CI (0.43–18.47), P = 0.28] respectively.

Conclusion

Evidence obtained from this meta-analysis suggests that CS-EMR offers superior safety compared to HS-EMR for colorectal polyp resection. Current evidence remains limited due to the small number of studies included. Therefore, further high-quality randomized controlled trials with larger sample sizes are needed.

References

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• Winawer SJ, Zauber AG, Ho MN, O'Brien MJ, Gottlieb LS, Sternberg SS, et al. Prevention of colorectal cancer by colonoscopic polypectomy. N Engl J Med. 1993;329(27):1977–81.

• Facciorusso A, Del Prete V, Antonino M, Buccino VR, Muscatiello N. Efficacy of endoscopic polypectomy techniques for colorectal polyps: a systematic review and network meta-analysis. Gastrointest Endosc. 2020;91(4):733–745.e9.

• Pohl H, Srivastava A, Bensen SP, Anderson P, Rothstein RI, Gordon SR, et al. Incomplete polyp resection during colonoscopy—results of the complete adenoma resection (CARE) study. Gastroenterology. 2013;144(1):74–80.e1.

• Tutticci N, Hewett DG. Cold snare polypectomy: A safe, effective technique for sessile polyps. Gastrointest Endosc Clin N Am. 2015;25(2):291–301.

• Kawamura T, Takeuchi Y, Asawa S, Yokota I, Matsuno T, Omori T, et al. A comparison of cold and hot snare polypectomy for small colorectal polyps: a randomized controlled trial. Am J Gastroenterol. 2018;113(3):403–411.