1.
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Value-Based Health Care for Inflammatory
Bowel Diseases
Welmoed K. van Deen, Eric Esrailian, Daniel W. Hommes
Division of Digestive Diseases, Department of Medicine, University of California Los Angeles, Los Angeles, California
Journal of Crohn's and Colitis May 2015, 9 (5) 421-427; DOI: 10.1093/ecco-jcc/jjv036
Abstract
Increasing healthcare costs worldwide put the current healthcare systems under pressure. Although many efforts
have aimed to contain costs in medicine, only a few have achieved substantial changes. Inflammatory bowel diseases
rank among the most costly of chronic diseases, and physicians nowadays are increasingly engaged in health
economics discussions. Value-based health care [VBHC] has gained a lot of attention recently, and is thought to be the
way forward to contain costs while maintaining quality. The key concept behind VBHC is to improve achieved
outcomes per encountered costs, and evaluate performance accordingly. Four main components need to be in place
for the system to be effective: [1] accurate measurement of health outcomes and costs; [2] reporting of these
outcomes and benchmarking against other providers; [3] identification of areas in need of improvement based on
these data and adjusting the care delivery processes accordingly; and [4] rewarding high-performing participants. In
this article we will explore the key components of VBHC, we will review available evidence focusing on inflammatory
bowel diseases, and we will present our own experience as a guide for other providers.

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The Effect Of A Coordinated Care Program
For Inflammatory Bowel Diseases On Health
Care Utilization
W. K. van Deen*1
, M. Skup2
, A. Centeno1
, N. Duran1
, P. Lacey1
, D. Jatulis3
, E. Esrailian1
, M. G. van Oijen4
, D.W. Hommes1
1
UCLA Centre for Inflammatory Bowel Diseases, Division of Digestive Diseases, University of California, Los Angeles,
California, United States, 2
AbbVie, US Immunology, North Chicago, Illinois, United States, 3
Anthem Blue Cross,
California, Woodland Hills, California, United States, 4
Academic Medical Centre, Amsterdam, Department of Medical
Oncology, Amsterdam, Netherlands
Journal of Crohn's and Colitis Mar 2016, 10 (suppl 1) S347; DOI: 10.1093/ecco-jcc/jjw019.606
Background
To bend the cost curve, value-based health care (VBHC) is thought to be the way forward. Central in this concept are a
coordinated care infrastructure and the measurements of outcomes and costs. Despite that many institutions have
implemented key components of VBHC, the evidence-base is still limited. We aimed to evaluate the performance of a VBHC
programme specifically for inflammatory bowel diseases (IBD) management, in the first year after implementation. Key
components of the programme were care coordination, task differentiation, and remote patient monitoring.
Methods
Administrative data from Anthem California were used to identify IBD patients treated by participating IBD centre providers
using the coordinated care protocol. A control population of IBD patients treated by other academic providers in California
was identified, as well. IBD Centre patients were matched 1:3 with controls based on comorbidities, IBD subtype, age, and
relapse rate in the index year (2012). IBD-specific outcomes in 2013 were compared between groups, including medication
use, office visits, IBD-specific tests, ED visits, and hospitalisations.
Results
In total, 98 IBD centre patients were matched to 293 control patients. We observed 52% less corticosteroid use (p = 0.027)
and 77% less long-term corticosteroid use (p = 0.13) in IBD centre patients, 6% more biologics use (p = 0.77), and 22% more
immunomodulator use. IBD-specific office visits increased with 20% (p = 0.009), whereas overall office visits decreased with
12% (p = 0.54). No difference in colonoscopy rates was observed (0.3% difference, p = 0.86), whereas EGD use decreased by
72% (p = 0.062). More biomarker testing was performed (increase of 36%, 6%, and 7% in CRP, ESR, and calprotectin testing,
respectively), whilst less imaging studies were performed (26%, 28%, and 50% decrease in the number of CT, MR, and US,
respectively). Hospitalisations decreased by 43% (p = 0.96), ED visits by 66% (p = 0.36), and 40% less surgeries were
performed (p = 0.38).
Conclusion
The first-year results of an IBD=specific VBHC programme show significantly less steroid use and more IBD-specific office
visits compared with matched IBD patients treated by other academic gastroenterologists. Overall, beneficial trends
towards less imaging studies, more biomarker testing, and less ED visits and hospitalisations were observed. More long-
term larger sample data are warranted to assess the long-term effect of VBHC in IBD.

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Quantification of Patients' Preferences for
Outcome Metrics in Inflammatory Bowel
Diseases Using a Choice Based Conjoint Analysis
W. K. van Deen*1
, D. Nguyen1
, N. Duran1
, E. Kane1
, M. G. van Oijen2
, D.W. Hommes1
1
UCLA Centre for Inflammatory Bowel Diseases, Division of Digestive Diseases, University of California, Los Angeles,
California, United States, 2
Academic Medical Centre, Amsterdam, Department of Medical Oncology, Amsterdam,
Netherlands
Gastroenterology April 2016, Volume 150 (Issue 4, Supplement 1): S169; doi:10.1016/S0016-5085(16)30656-4
Background
Incorporation of patient preferences in medical decision making, a process referred to as shared decision making, has
been shown to improve patients’ satisfaction and patients’ knowledge. The importance of measuring and reporting
outcomes of care delivery is increasingly recognised to be crucial for quality improvement. However, no method to
quantify the incorporation of patient driven decisions in the care process is available. In this study we quantified
inflammatory bowel disease (IBD) patients’ preferences for 3 disease outcomes: disease control (DC), quality of life
(QoL), and productivity (Pr) using a choice based conjoint analysis (CBC).
Methods
IBD patients were recruited through e-mail and were asked to fill out an online CBC questionnaire. The questionnaire
assessed current levels of DC, QoL, and Pr, and 10 CBC questions, in which patients were asked to choose 1 out of 2
scenarios with different levels of DC, QoL, and Pr. A hierarchical Bayes model was run to estimate the importance
individual patients assigned to each of the 3 outcomes. A single patient-centred outcome metric was developed
based on the individual weight assigned to the outcomes.
Results
In total, 210 IBD patients were included with a median age of 40 years (range 20–83). Of these, 51% had Crohn’s
disease; 46% ulcerative colitis; and 3% indeterminate colitis. Large variations in individual patients’ preferences were
observed. On average, QoL was valued higher than DC and Pr, and for all 3 outcomes, increases from low to
intermediate levels were felt to be more important compared with increases from intermediate to high levels. No
clinical characteristics were shown to be associated with different preferences. Individual preference weighted scores
were calculated and were shown to be significantly different from scores without individual weightings in patients
with active disease.
Conclusion
We showed that CBC can be used to quantify individual patients’ preferences for different outcome metrics. These
preferences can be used to quantify a single patient-centred outcome metric for IBD patients. Because measured
outcomes are significantly different when weighted based on individual patients’ preferences, we propose that
outcomes of care should be measured and rewarded accordingly.

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How Does a Gastroenterologist Show Value?
Daniel W. Hommes, MD, PhD , Eric Esrailian, MD, MPH
Division of Digestive Diseases, Department of Medicine, University of California Los Angeles, Los Angeles, California
Clinical Gastroenterology and Hepatology 13(3): 616-617, March 2015;
DOI: http://dx.doi.org/10.1016/j.cgh.2014.10.024
Dear Editor:
We read with pleasure the article “Strategic Update on Health Value” by Kosinski1
in the October issue of Clinical
Gastroenterology and Hepatology. In today’s world of health care reform and the trend of accountable care organizations
and shared saving contracts, we are in the midst of a seismic shift from the volume-based fee-for-service model to a value-
based payment model of care.2, 3
We were grateful to see Dr Kosinski address this critical transition in the context of
gastroenterology. We agree with his observation that the global definition of “value = quality/cost” excludes direct
measurement of health outcomes and therefore will not benefit this transition directly. Although we appreciate the insights
underpinning his proposed “value equation” of “population health/cost,” many providers will have difficulty using this
aggregate equation in daily clinical practice as they prepare for bundled payments in their individual practices and hospital
systems.
To answer the question, “How does a gastroenterologist demonstrate value?” we have taken a somewhat different
approach. Since 2012 we have introduced a comprehensive, integrated, and holistic approach to value care in the chronic
disease management of inflammatory bowel diseases (IBDs). In close collaboration with system stakeholders—foremost,
our patients—we developed and introduced the “value-quotient” (vQ) for value-based and cost-effective IBD management.4,
5
The vQ is defined as patient value/provider costs. Our composite definition and aligned metrics for patient value have
emerged directly from the outcomes most sought or valued by IBD patients, as follows: (1) disease control, as assessed
using a well-established model for clinical remission; (2) quality of life, as assessed by our validated short-form IBD
Questionnaire; and (3) daily life productivity (work, school, and so forth), as assessed by our validated Work Productivity
and Activity Impairment questionnaire. For provider costs, we use a cost model that focuses on provider-dependent
metrics, including patient services utilization (eg, clinic visits, laboratory tests, and endoscopic procedures) and pharmacy
use. In summary, the vQ model of chronic disease management entails tightly controlled, coordinated, and integrated
transdisciplinary team care, with a robust health information technology support infrastructure serving continuously
updated patient health status profiling through a host of web-based/eHealth tools and utilities. The latter functionalities
include eLearning modules for patients and a care-complementary Wellness Program in direct response to their expressed
needs. The applications are being integrated with the institutional electronic medical record system (examples available in
the App Store and Google Play under University of California Los Angeles [UCLA] electronic Inflammatory Bowel Diseases).
They enable and foster patient engagement and provider point-of-care decision support for direct intervention when
needed—in short, the right care, in the right dose, at the right time. The vQ can be assessed annually both on an individual
level and on a population level, and providers will have data on distinct vQ components that need improvement either to
decrease provider costs or to increase individual patient value.6
The preliminary data on more than 1000 IBD patients at
UCLA Health show that patient value can be tracked easily and provider costs can be well managed through highly
coordinated care pathways.7
Why does a gastroenterologist need to quickly move beyond quality indicators and focus on models of value-based care and
bundled payments? The business-case scenario answer is transparent from the vQ formulation: value-oriented care drives
value-based payments/insurance design in the form of shared savings contracts between networks of specialty care
providers and payers. At UCLA Health, this part of the value care implementation currently is underway for IBD, followed by
multiple other chronic disease areas. We hope to launch the first IBD shared savings contract in the spring of 2015 and
contribute to the ongoing discussions about how gastroenterologists can show value.

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References
1. Kosinsky, L. Clin Gastroenterol Hepatol. 2014; 12: 1584–1586
2. Schroeder, S.A. et al. N Engl J Med. 2013; 368: 2029–2032
3. Shortell, S.M. et al. JAMA. 2008; 300: 95–97
4. Hommes, D.W. et al. J Crohns Colitis. 2012; 6: S224–S234
5. Ghosh, S. et al. J Crohns Colitis. 2014; 8: 1246–1253
6. Value quotient eLearning modules: value quotient vision, available from: http://youtu.be/da7dRLSQPEI;
value quotient procedures, available from: http://youtu.be/HdmsL7GVmMg.
7. van Deen, W. et al. Gastroenterology. 2014; 146: S-376

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The Impact of a Value-Based Health Care in
Inflammatory Bowel Diseases on Health
Care Utilization
W.K. van Deen*1
, A.B. Ozbay2
, M. Skup2
, M.G. van Oijen1
, A. Centeno1
, N. Duran1
, P. Lacey1
, D. Jatulis3
, M. Belman3
, E.
Esrailian1
, D.W. Hommes1
1
UCLA Center for Inflammatory Bowel Diseases, Division of Digestive Diseases, University of California, Los Angeles, Los
Angeles, United States, 2
AbbVie, US Immunology, Nort Chicago, United States, 3
Anthem Blue Cross, California, Woodland
Hills, United States
Gastroenterology 150(4, Supplement 1): S70-S71, April 2015; DOI :10.1016/S0016-5085(16)30354-7
Background
Standardized care pathways, task differentiation, and knowledge of costs in clinical decision making are all likely to
contribute to improved outcomes and cost-effective care delivery. The UCLA Center for Inflammatory Bowel Diseases (IBD)
launched a value-based health program for IBD management in February 2012 including all these aspects. The aim of this
study was to compare utilization patterns observed at the UCLA Center for IBD to IBD care across California.
Methods
Administrative data were obtained from Anthem Blue Cross California. IBD patients and UCLA IBD Center providers were
identified, as well as IBD non-program patients who were included as control group. Controls were matched 5:1 with the
cases based on disease type, age, relapse rate, and Charlson Comorbidity Index in 2012. IBD-related office visits, laboratory
tests, imaging studies, procedures, emergency department (ED) visits, hospitalizations, and pharmacy use in 2013 were
compared.
Results
Forty-nine UCLA IBD Center patients were matched to 245 controls. Demographics were similar in groups with a mean age
of 39 years (SD 12), 57% Crohn's disease and 43% ulcerative colitis, and 22% severe disease course in the year prior to
analysis. We observed significantly less corticosteroid use in the UCLA IBD Center group (12% and 31%, respectively, p=0.03)
and numerically more methotrexate (1% and 6%, p=0.11) and adalimumab (15% and 21%, p=0.43) use. Thiopurine (35% and
33%, p=1.00) and infliximab (14% and 15%, p=1.00) use were comparable in both groups. Patients in the UCLA IBD group
had 25% fewer IBD-related office visits per year (1.7 and 2.2 visits per year, p=0.06), 12% to 100% fewer imaging studies
(p=0.99), 10% less colonoscopies (p=0.91) and 1.3 to 3.4 times more biomarker testing (p<0.0002). Lastly, we observed 89%
fewer hospitalizations (p=0.06) in the UCLA IBD Center group and 75% fewer ED visits (p=0.52).
Conclusion
An administrative database was utilized to identify IBD patients treated at the UCLA Center for IBD and to compare those
patients with a matched control population in California. We found a significant decrease in corticosteroid use and a trend
towards more use of steroid-sparing medications in the UCLA IBD group. Furthermore, UCLA IBD Center patients' disease
activity was monitored more frequently using biomarkers, and fewer hospitalizations and ED visits were observed. This
study indicates that a comprehensive, value-based care pathway is likely to improve outcomes and decrease unnecessary
health care utilization. Future more powerful larger sample studies will be needed to confirm these positive findings.

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Validation Of The Mobile Health Index (mHI)
For Remote Monitoring Of IBD Disease Activity
W.K. van Deen*1
, A.E. van der Meulen- de Jong2
, N.K. Parekh3
, Y. Muyshondt3
, E. Kane1
, L. Eimers1
, E.K. Inserra1
, A.
Zand1
, C.A. DiNicola1
, S. Bhatia3
, J.M. Choi1
, C.Y. Ha1
, M.G. van Oijen1
, E. Esrailian1
, D.W. Hommes1
1
UCLA Center for Inflammatory Bowel Diseases, Division of Digestive Diseases, University of California, Los Angeles, Los
Angeles, United States, 2
Leiden University Medical Center, Gastroenterology and Hepatology, Leiden, Netherlands, 3
UC
Irvine, Digestive Disease Center, Irvine, United States
Gastroenterology, Volume 148, Issue 4, S-446, April 2015; DOI: http://dx.doi.org/10.1016/S0016-5085(15)31501-
8
Background
Mobile health technologies are increasingly used to monitor patients remotely in chronic disease management such as
diabetes mellitus and congestive heart failure. In IBD several monitoring systems have been studied but the use of mobile
devices is still limited. We developed two 4-question indices to monitor disease activity using a smartphone in Crohn's
disease (CD) and ulcerative colitis (UC) patients; the mobile Health Index (mHI) -CD and mHI-UC. The aim of this study was
to validate the mHI in an independent cohort of IBD patients.
Methods
Patients with a diagnosis of CD or UC were included in 3 specialized IBD centers. During clinic visits, clinical disease activity
indices (Harvey Bradshaw index for CD, partial Mayo score for UC) were completed by the physician, and patients filled out
the mHI and the short-IBDQ for quality of life (QoL) assessment. During endoscopic visits the physician also completed an
endoscopic score (Mayo for UC, SES-CD for CD). Spearman rho was calculated to assess correlation of the mHI with clinical
and endoscopic disease activity indices. Patients were followed over time to assess responsiveness to change; a Spearman
rho was calculated to estimate the correlation between changes in scores. A subset of patients filled out a second mHI
within 24 hours after the clinic visit, and the intraclass correlation (ICC) was calculated to assess test-retest reliability.
Results
In total 194 UC patients (19% active) and 217 CD patients (19% active) were included. The correlation of the mHI with clinic
scores was 0.73 (p<0.001) for CD and 0.70 (p<.0001) for UC. Sensitivity and specificity to detect active disease were 93% and
66% for CD and 67% and 93% for UC, respectively. Both scores were responsive to change with a correlation of 0.37 (n=46)
for CD and 0.65 (n=27) for UC between the change in scores. Test-retest reliability was good with an ICC of 0.91 (n=28) for the
UC mHI and 0.95 (n=23) for the CD mHI. The CD mHI did correlate with endoscopic healing, though predictive values were
poor (sensitivity 69%, specificity 51%, rho=0.31 (p=0.0062)). For UC the mHI correlated strongly with mucosal healing
(rho=0.57 (p<0.0001), sensitivity 56%, specificity 88%). Furthermore, both scores have a strong inverse correlation with QoL
(rhoi=-0.78 for CD and rho=-0.80 for UC, p<.0001)
Conclusion
The developed mHI scores for CD and UC have excellent test characteristics to monitor patients' symptoms remotely.
Because the scores consist of 4 simple questions answered by patients, the score is ideal for implementation in a mobile
smartphone app for home monitoring. As previously shown CD symptoms do correlate poorly with mucosal healing, while
UC symptoms are strongly correlated with mucosal lesions.

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A Nationwide 2010–2012 Analysis of U.S.
Health Care Utilization in Inflammatory
Bowel Diseases
van Deen, Welmoed K. MD *,+; van Oijen, Martijn G. H. PhD *; Myers, Kelly D. BS ++; Centeno, Adriana BA *; Howard,
William PhD ++; Choi, Jennifer M. MD *; Roth, Bennett E. MD *; McLaughlin, Erin M. BS ++; Hollander, Daniel MD *;
Wong-Swanson, Belinda PhD ++; Sack, Jonathan MD [S]; Ong, Michael K. MD, PhD ||; Ha, Christina Y. MD *; Esrailian,
Eric MD, MPH *; Hommes, Daniel W. MD, PhD *
(*)UCLA Center for Inflammatory Bowel Diseases, Melvin and Bren Simon Digestive Diseases Center, David Geffen School
of Medicine, University of California Los Angeles, Los Angeles, California;
(+)Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands;
(++)Qforma Inc., Santa Fe, New Mexico; and
([S])Department of Surgery, and
(||)Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of
California Los Angeles, Los Angeles, California.
Inflammatory Bowel Diseases. 20(10):1747-1753, October 2014; DOI: 10.1097/MIB.0000000000000139
Background
Implementation of the 2010 Affordable Care Act (ACA) calls for a collaborative effort to transform the U.S. health care
system toward patient-centered and value-based care. To identify how specialty care can be improved, we mapped
current U.S. health care utilization in patients with inflammatory bowel diseases (IBD) using a national insurance
claims database.
Methods
We performed a cross-sectional study analyzing U.S. health care utilization in 964,633 patients with IBD between 2010
and 2012 using insurance claims data, including pharmacy and medical claims. Frequency of IBD-related care
utilization (medication, tests, and treatments) and their charges were evaluated. Subsequently, outcomes were put
into the framework of current U.S. guidelines to identify areas of improvement.
Results
A disproportionate usage of aminosalicylates in Crohn's disease (42%), frequent corticosteroid use (46%, with 9%
long-term users), and low rates of corticosteroid-sparing drugs (thiopurines 15%; methotrexate 2.7%) were observed.
Markers for inflammatory activity, such as C-reactive protein or fecal calprotectin were not commonly used (8.8% and
0.13%, respectively). Although infrequently used (11%), anti-TNF antibody therapy represents a major part of
observed IBD charges.
Conclusions
This analysis shows 2010-2012 utilization and medication patterns of IBD health care in the United States and
suggests that improvement can be obtained through enhanced guidelines adherence.

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Measurement Of IBD Disease Activity Using
Home-Based E-Health Technologies
W. van Deen, J. Choi, A. Zand, C. Ha, E. Inserra, L. Eimers, A. Centeno, B. Roth, D. Cole, T. Getzug, E. Kane, L. Connoly,
M. Ovsiowitz, A. Ho, M. van Oijen, E. Esrailian, D.W. Hommes
UCLA Center for Inflammatory Bowel Diseases, Division of Digestive Diseases, University of California, Los Angeles, Los
Angeles, United States
Journal of Crohn's and Colitis Feb 2014, 8 (Supplement 1) S58; DOI: 10.1016/S1873-9946(14)60114-8
Background
Development of e-health technologies is accelerating due to a shift from ‘symptom-oriented’ to ‘prevention oriented’
care. The potential of monitoring patients at home offers great potential for preventive care. However, accurate e-
health monitoring tools have yet to be developed. We (1) evaluated how patient reported outcomes predict disease
activity and relate to quality of life; (2) tested the feasibility of collecting patient reported outcomes through e-health;
and (3) developed an ‘IBD app’ for iOS and Android that allows easy and user-friendly collection of health outcomes
and easy communication between healthcare provider and patient.
Methods
Disease activity indices were assessed in consecutive IBD patients. The predictive value of each patient-reported
component was assessed using logistic regression analyses. As gold standards SCCAI and partial Mayo were used for
UC, and CDAI and HBI for CD. The added value of the biomarkers CRP and fecal calprotectin was assessed as well. The
feasibility of using e-health for the reporting of patient reported outcomes was evaluated using a web based
application, which was subsequently developed into a mobile app for iOS and Android.
Results
107 UC patients and 78 CD patients were included, of which 31 (29%) and 17 (22%) had active disease respectively. For
UC, strong predictors of disease activity were urgency (73% with urgency had active disease, 5% without urgency had
active disease) and blood in stool (68% with blood in stool had active disease, 3% that did not). Addition of
calprotectin increased specificity to 100%, though sensitivity decreased to 67%. Abdominal pain predicted disease
activity in CD; 71% of patients with abdominal pain had active disease, versus 4% without pain. 93% of CD patients
with more than 2 stools per day had active disease, versus 6% that had 2 or less. Combining the outcomes abdominal
pain and >2 stools per day predicted active disease with 70% sensitivity and 100% specificity. We did not detect
additional value of a biomarker in CD. In September 2012 we launched a web-based application that is effectively
utilized now by 335 patients. A mobile IBD app, co-created with patients, was tested and approved as of November 24,
2013 (search ‘UCLA eIBD’ in iTunes and Google Play stores).
Conclusion
E-health development offers great potential for continuous monitoring of patients at home, allowing early detection
of disease activity and improving care delivery. Patients can participate in their care by signaling meaningful health
outcomes during year-round monitoring. We showed that disease activity can be predicted using patient reported
outcomes, and can be readily collected through e-health applications.

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Work Related Problems And Impaired
Productivity In Patients With Inflammatory
Bowel Diseases (IBD)
A. Zand, W.K. Van Deen, C.H. Ha, E. Kane, J.M. Choi, B.E. Roth, A. Centeno, E. Esrailian, D.W. Hommes
UCLA Center for Inflammatory Bowel Diseases, Division of Digestive Diseases, University of California, Los Angeles, Los
Angeles, United States
Journal of Crohn's and Colitis Feb 2014, 8 (Supplement 1) S27; DOI: 10.1016/S1873-9946(14)60051-9
Background
Indirect costs in IBD are major contributors to health expenditures. It has been estimated that 63% of US medical
costs is due to presenteeism, defined as decreased productivity at work. In IBD, the effects of absenteeism (missed
hours from work due to disease) on indirect medical costs have been estimated, but the effects of presenteeism have
not been studied. In addition, patients can be in ‘job-lock’, which means they are not able to change their job because
of employer provided health-insurance and fear of loss of employee benefits. In order to understand these work
productivity components, we performed a study analyzing absenteeism, presenteeism, work limitations and job lock
in IBD.
Methods
Questionnaires were completed by patients of the UCLA Center for Inflammatory Bowel Diseases. The Work
Productivity and Activity Impairment (WPAI) questionnaire was used, which measures absenteeism, presenteeism
and loss of leisure in the past 7 days. Furthermore, we developed a work limitations questionnaire that inquired
specifically about work related problems including job lock. In addition, assessments of clinical disease activity, and
quality of life (QoL, using the short IBDQ) were performed.
Results
In total, 365 patients completed the WPAI questionnaire, 146 of 365 also completed the work limitations
questionnaire. 36% of 365 patients were not employed. In the employed cohort (n = 231) we found a prevalence of
21% absenteeism, 62% presenteeism, and 66% loss of leisure. Employed patients had an average QoL of 50 (SD 12)
while unemployed had an average QoL of 44 (SD 15). Looking at work limitations among others we found that 69% of
employed IBD patients could not or have not made adjustments to avoid taking sick days off due to their disease, 40%
of employed IBD patients miss work due to doctor appointments, 47% of employed IBD patients are affected by
fatigue in their performance at work and 50% of employed IBD-patients experience stress or pressure when taking
sick time off from work. In regards to job-lock, 58% of employed IBD patients (n = 146) had employer-provided health
insurance of which 20% experienced job-lock.
Conclusion
A high prevalence of absenteeism and presenteeism in employed IBD patients continues to be a problem, patients are
absent from work because of doctor appointments and are stressed or pressured if they have to take sick days off due
to their disease. Job-lock occurred in 20% of employed IBD patients with employer-provided health insurance. These
high percentages indicate that IBD patients continue to have difficulties finding and maintaining employment.

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Presenteeism in Inflammatory Bowel
Diseases: A Hidden Problem with Significant
Economic Impact
Zand, Aria *,+; van Deen, Welmoed K. MD *; Inserra, Elizabeth K. RN *; Hall, Laurin RN *; Kane, Ellen RN *; Centeno,
Adriana BA *; Choi, Jennifer M. MD *; Ha, Christina Y. MD *; Esrailian, Eric MD, MPH *; D'Haens, Geert R. MD, PhD +;
Hommes, Daniel W. MD, PhD *
(*)UCLA Center for Inflammatory Bowel Diseases, Melvin and Bren Simon Digestive Diseases Center, David Geffen School
of Medicine, University of California, Los Angeles, Los Angeles, California; and
(+)Center for Inflammatory Bowel Diseases, Department of Gastroenterology and Hepatology, Academic Medical Center,
Amsterdam, the Netherlands.
Inflammatory Bowel Diseases. 21(7):1623-1630, July 2015; DOI: 10.1097/MIB.0000000000000399
Background
Indirect costs associated with impaired productivity at work (presenteeism) due to inflammatory bowel disease (IBD)
are a major contributor to health expenditures. Studies estimating indirect costs in the United States did not take
presenteeism into account. We aimed to quantify work limitations and presenteeism and its associated costs in an
IBD population to generate recommendations to reduce presenteeism and decrease indirect costs.
Methods
We performed a prospective study at a tertiary IBD center. During clinic visits, work productivity, work-related
problems and adjustments, quality of life, and disease activity were assessed in patients with IBD. Work productivity
and impairment were assessed in a control population as well. Indirect costs associated with lost work hours
(absenteeism) and presenteeism were estimated, as well as the effect of disease activity on those costs.
Results
Of the 440 included patients with IBD, 35.6% were unemployed. Significantly more presenteeism was detected in
patients with IBD (62.9%) compared with controls (27.3%) (P = 0.004), with no significant differences in absenteeism.
Patients in remission experienced significantly more presenteeism than controls (54.7% versus 27.3%, respectively, P
< 0.01), and indirect costs were significantly higher for remissive patients versus controls ($17,766 per yr versus $9179
per yr, respectively, P < 0.03). Only 34.3% had made adjustments to battle work-related problems such as fatigue,
irritability, and decreased motivation.
Conclusions
Patients with IBD in clinical remission still cope with significantly more presenteeism and work limitations than
controls; this translates in higher indirect costs and decreased quality of life. The majority have not made any
adjustments to battle these problems.

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The Development Of Coordinated Care
Pathways And Feasibility Testing In
Inflammatory Bowel Disease Management
W. van Deen, J. Choi, E. Inserra, L. Eimers, E. Kane, M. Ovsiowitz, A. Centeno, M. van Oijen, B. Roth, D. Hollander, W. Ho,
D. Cole, T. Getzug, L. Connoly, A. Ho, C. Ha, E. Esrailian, D.W. Hommes
UCLA Center for Inflammatory Bowel Diseases, Division of Digestive Diseases, University of California, Los Angeles, Los
Angeles, United States
Gastroenterology 146(5, Supplement 1): S-376, May 2014; DOI :10.1016/S0016-5085(14)61354-8
Background
Guideline non-adherence and inefficient care delivery are main drivers of health care costs. Coordinated care
pathways have been proposed to assist in decreasing health expenditures and increasing patient value. We
developed an evidence based multidisciplinary care pathway and tested its feasibility. In order to introduce cost
awareness at the practice level, a model was developed to estimate procedural costs per care pathway and costs per
additional procedure.
Methods
IBD related guidelines were collected and complemented with relevant literature and consensus statements. Care
scenarios were designed based on patients' disease activity and treatment strategy. Appropriate tests, procedures
and office visits were incorporated in the care scenarios, including standards for task differentiation and quality
indicators. Outcomes were assessed using clinical disease activity indices (DAI) (Harvey–Bradshaw Index for CD and
partial Mayo score for UC) and quality of life (QoL) scores. Healthcare utilization rates were analyzed using insurance
claims from patients insured through Wellpoint California. UCLA charges were used to develop a cost model.
Results
Five annual care scenarios were developed for remissive patients, and five 6-week care scenarios for active patients.
We assumed that 6 week intensive care scenarios would offer sufficient time to induce remission. A cost model
estimating procedural costs (per care scenario, and per individual procedure) was developed (Table 1). As of October
2013 642 IBD patients (50% CD, 48% UC, 2% IBDU) had been treated accordingly (mean age 41.8 years (SD 15.7 years),
52% male). Patients were managed at 2 locations by 11 physicians and 3 IBD nurse coordinators. Task differentiation
was introduced through SOPs (e.g. nurse coordinators were responsible for order management and contacting and
monitoring patients). In active CD the average DAI was 4.2 (QoL 44.5), versus 1.2 in remission (QoL 53.0). For active UC
the average DAI was 3.6 (QoL 43.4), versus 1.4 in remission (QoL 53.0). The annual relapse rate was 10% (8% CD, 13%
UC). Average annual utilization rates were: 2.7 clinic visits, 1.1 colonoscopies, 0.6 hospital admissions, and 0.9 ER
visits.

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Table 1 (abstract P333). Designed care scenarios based on patients' disease activity and treatment regimen a
Medication
scenario
Procedural
costs
Total duration
Labs (CBC, CRP and/or
calprotectin, CMP)
Office visit
e-health contact
with provider
Remission induction scenarios
5ASA/SAS
Antibiotics
$3,143
$3,143
6 weeks Week 0 + 6 Week 0 + 6 Every 2 weeks
Corticosteroids
Biologics
$3,783
$4,336
6 weeks Every 2 weeks Week 0 + 6 Every 2 weeks
Post-surgery $1,734
4 weeks post-
surgery
Week 4 Week 4
Decreasing from daily
to weekly
Maintenance scenarios
No medication
5ASA/SAS
$5,257
$5,257
Continuous Every 6 months Yearly Every 2 months
Immunomodulator
Biologics
Combination
$8,381
$8,038
$7,485
Continuous Every 2 months
Every 6
months
Every 2 months
Costs $306–624 $629–812 $40
a
This model does not yet include medication costs.
b
Optional lab tests, stool cultures, and endoscopic or radiologic procedures can be added at the physicians'
discretion.
Conclusion
We developed and analyzed multidisciplinary coordinated IBD care pathways, which are designed to be adopted into
Accountable Care Organizations. These pathways allow individual flexibility and harmonize care across providers. The
monitoring of health related outcomes and associated health care expenditures was feasible.

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Assessment of Differences Between
Academic and Non-Academic Providers in
Inflammatory Bowel Diseases Related
Utilization Using a Large Administrative
Dataset
Welmoed K. van Deen, Martha Skup, Adriana Centeno, Natalie E. Duran, Precious Lacey, Darius Jatulis, Eric Esrailian,
Martijn G. van Oijen, Daniel Hommes
Gastroenterology 150(4, Supplement 1): S72, April 2016; DOI:10.1016/S0016-5085(16)30357-2
Background
Wide practice variations in inflammatory bowel disease (IBD) related care have previously been observed in the US. A
variety of reasons for guideline non-adherence have been described, which include insufficient access to guidelines,
misaligned financial incentives, and physicians' culture, beliefs, and habits. In this study we used a large California
administrative database to assess the extent of differences between academic and non- academic
gastroenterologists in California.
Methods
Academic and non-academic gastroen- terologists were identified in an administrative database from Anthem
California. Patients with an IBD related office visit with an academic gastroenterologist were identified, and patients
with an IBD-related office visit with a non-academic gastroenterologist were selected as controls. Patients treated at
academic institutions were matched 1:2 with controls based on age, IBD subtype, comorbidities, and relapse rate in
the index year (2012). Differences in IBD specific outcomes were assessed in 2013, which included medication use, IBD
related office visits, ED visits, hospitalizations, imaging, and lab tests.
Results
We identified in total 985 IBD patients treated by academic providers, which were matched to 1965 controls. We
observed 26% less steroid use (p=0.0003), 14% less mesalamine use (p=0.005), 52% more mesalamine suppositories
use (p=0.001), 206% more MTX use (<0.00001) and 45% more biologics use (p<.00001) in patients treated at an
academic institution. Additionally, we observed more biomarker testing (61%, 101%, and 149% more CRP, ESR, and
calprotectin testing, respectively, p<0.00001), 29% more colonoscopies (p=0.0005), and 41% more MR scans (p=0.02)
in patients treated at academic centers, while CT scan usage decreased with 15% (p=0.02). While 35% more surgeries
were performed at academic centers (p=0.03), we did not observe significant differences in the number of ED visits
and hospitalizations.
Conclusion
Large variations in practice patters between academic and non-academic provid- ers in California were observed,
including variations in medication use and IBD related tests and procedures. However, surrogate outcomes such as
ED visits and hospitalization rates were comparable in both groups. In future studies the causes and consequences of
practice variation need to be addressed in more detail.

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The Outcomes Of A Clinical Care Pathway
For Inflammatory Bowel Disease Surgery
A. Platt*1
, A. Lightner2
, R. Jacobs1
, D. Sagar1
, W. van Deen1
, T. Hommes1
, S. Reardon3
, J. Sack3
, D. Hommes1
1
UCLA Centre for Inflammatory Bowel Diseases, Department of Digestive Diseases, Los Angeles, California, United States,
2
Mayo Clinic College of Medicine, Division of Colon and Rectal Surgery, Rochester, Minnesota, United States, 3
UCLA,
Department of Colorectal Surgery, Los Angeles, California, United States
Journal of Crohn's and Colitis Mar 2016, 10 (suppl 1) S289; DOI: 10.1093/ecco-jcc/jjw019.497
Background
Inflammatory bowel disease (IBD) patients undergoing surgery are being discharged earlier because of increased
financial pressure on hospitals, shifting postoperative care towards an outpatient setting. We introduced a care
pathway for IBD surgery designed to tightly monitor patients at home using tele-monitoring tools. The measured
health outcomes included pain, wound healing, bowel function, and quality of life (QoL), and additionally, allowed for
on-demand eConsulting between patient and provider. Here we report our first outcomes.
Methods
Through this 4-week programme, we developed a cohesive pathway focused on heightened connectivity and
accurate assessments via tele-monitoring. In addition, we established optimal care delivery by streamlining transition
back to GI care. Data was collected from patient reports, clinic visit summaries, and the EMR. During the pathway,
pain was measured with a 01–0 Likert scale; wound healing was assessed through wound photos; bowel function was
assessed with ostomy output and stool frequency; and QoL was measured with the short IBD questionnaire (sIBDQ).
Results
In total 54 patients, who underwent 70 surgeries, were enrolled. Mean age was 38 years (197–4) and 50% were male.
Of all surgeries, 49% (n = 34) were for CD, 47% (n = 33) for UC, and 4% (n = 3) for indeterminate. Surgeries involved
bowel resection (64%), ostomy formation/reversal (64%), and other procedures (39%), including fistula repair and
adhesiolysis. Patients were connected to providers and monitored accurately through a series of tele-monitoring
eTools: mean number of wound photos sent was 3 (range 0–11); average daily stool frequency was 6, whereas average
ileostomy output was 930 mL; an initial pain score of ≥ 5 was reported in 34% of patients, and an average 2-point
decrease was observed during the programme. Of note, 30-day ED rates were higher in high-pain vs low-pain patients
(33% vs 22%). Finally, care delivery was optimised with follow-up visits: higher GI clinic follow-up rates were observed
in compliant vs non-compliant patients (65% vs 49%). For those who had a 30-day GI follow-up, average QoL was 49
(SD = 16), as compared with 42 (SD = 14) for those who did not.
Conclusion
Increased connectivity and accurate tele-monitoring are helpful in identifying patients who may be at risk for ED visits
during their recovery period. Moreover, increased GI follow-up visits in highly compliant patients may indicate the
benefit of postoperative communication in care delivery; the higher QoL scores in these patients may further support
this notion. Thus, coordinated care for surgery might be an effective way to manage and monitor IBD patients
postoperatively and transition them back to the GI clinic for long-term medical treatment.

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The Effect Of Inflammatory Bowel Disease
On Patients’ Caregivers
A. Zand*, A. Platt, W. K. Van Deen, D. W. Hommes
UCLA Centre for Inflammatory Bowel Diseases, Division of Digestive Diseases, Los Angeles, California, United States
Journal of Crohn's and Colitis Mar 2016, 10 (suppl 1) S451; DOI: 10.1093/ecco-jcc/jjw019.806
Background
Crohn’s disease (CD) and ulcerative colitis (UC) usually follow a relapsing clinical course with phases of remission
alternating with periods of active inflammation. This dramatically affects the quality of life (QoL) of IBD patients.
However, the impact on informal caregivers of IBD patients is frequently overlooked by clinicians. Caregivers – often
family members or close friends – aid IBD patients with medical tasks and activities of daily life without receiving
compensation. In this study, we aim to assess the impact associated with caregiving for an IBD patient, and to identify
potential predictors of such impact that might inform future interventions.
Methods
Online questionnaires were distributed via e-mail in November 2015 to adult IBD patients of the UCLA Centre for
Inflammatory Bowel Diseases and their self-identified caregivers. IBD patients filled out the Work Productivity and
Activity Impairment (WPAI) questionnaire, the short Inflammatory Bowel Disease Questionnaire (sIBDQ) for QoL and
the Mobile Health Index (mHI) for disease activity. The caregivers filled out the Zarit Burden Interview (ZBI) and a
caregiver version of the WPAI. Both groups provided information about their demographics and medical history. The
survey results were then analysed to assess caregiver burden in different subsets of IBD patient and caregiver
populations.
Results
51 IBD patients (41,7 ± 13,9 years, 59% females, 82% employed, 47% CD) and 18 caregivers (45,5 ± 17,5 years, 61%
females, 83% wife/husband of patient, 56% employed) responded thus far. Using the mHI, we calculated that 78% of
the IBD patients were in remission. An average of 5.8 ± 11 hours were spent on caregiving per week. Also, 22% of the
caregivers suffer from a chronic disease. Further, 30% of the employed caregivers had missed work hours as a result
of caring for an IBD patient and 70% of the employed caregivers experienced decreased productivity at work due to
caregiving. Use of the ZBI showed that 44% of caregivers experienced mild-to-moderate burden as a result of
caregiving. Additionally, the ZBI showed that 67% of caregivers felt they could do a better job in caregiving.
Conclusion
The burden that caregivers face as a result of caring for IBD patients is possibly influenced by multiple factors,
including both patient and caregiver characteristics. Our results show that, although a large majority of our IBD
patients are in remission, a substantial impact remains on the productivity and emotional well-being of their
respective caregivers. As this problem is frequently overlooked by clinicians, potential interventions might seek to
provide caregiver support to those who care for IBD patients.

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The Value Of Social Media In Inflammatory
Bowel Diseases
J.M. Choi, W.K. van Deen, L. Nguyen, A. Zand, M. Berns, N. Duran, D.W. Hommes, M.G. van Oijen
UCLA Center for Inflammatory Bowel Diseases, Division of Digestive Diseases, University of California, Los Angeles, Los
Angeles, United States
Journal of Crohn's and Colitis Feb 2014, 8 (Supplement 1) S201; DOI: 10.1016/S1873-9946(14)60448-7
Background
An increasing number of patients with chronic illnesses, including inflammatory bowel diseases (IBD), are turning to
social media sites such as Twitter and Facebook to share about their conditions. The use of social media in healthcare
promotes patient engagement, communication, and education, while enabling providers to better recognize patient
interests and increase their online visibility for patient recruitment. This study aims to describe the strategies and
experiences of an IBD tertiary referral center to develop a social media presence among patients using Twitter and
Facebook and its outcomes after one year.
Methods
A Twitter profile and Facebook page were established for the IBD center. Analytic tools Twitonomy and Facebook
Insights were used to capture data on posts, including the data media format. Information on Twitter followers and
Facebook users who liked the center's Facebook page was acquired. The number of recognizable patients with IBD
and the online topics of interest to social media users were tracked and categorized manually.
Results
Within the first 15 months, a total of 2212 Twitter users began following our Twitter account, and 469 Facebook users
liked the center's Facebook page. The growth in the number of Twitter followers and those who liked the center's
Facebook page was proportionate to the number of posts per week. Among Twitter followers, 971 (44%) were IBD
patients, of which 6 were patients from our IBD center. Twitter users retweeted and favorited IBD-related topics more
frequently than non-IBD topics. The most popular retweeted Twitter topics were risk factors (70% retweeted), surgery
(63% retweeted), and complications/symptoms (62% retweeted). The most commonly favorited Twitter topics were
about sex/fertility (43% favorited). For Facebook, the most frequently liked posts were about the center's specific IBD
programs (92% liked, 5.9 likes per post), value in healthcare (90% liked, 5.3 likes per post), and therapies (91% liked,
5.3 likes per post). The Facebook posts that drew the most comments were posts on diet (67% commented on, 2.7
comments per post). Photographs were the most liked media format of postings (90% liked, 7.9 likes per
photograph).
Conclusion
Twitter and Facebook are valuable tools to interact with patients who are part of the greater online community.
Disease-specific information was most popular among social media users, and photographs were the most popular
media format. Despite the low patient recruitment over the first year, we demonstrated that patients were engaged
and communicated through social media about their disease, which can be viewed as additional measures of return
on investment from social media programs in healthcare

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Integrated Care Pathways For Inflammatory
Bowel Disease Surgery: Design And First
Analysis.
R. Jacobs*1, 2
, S. Reardon3
, D. Sagar1
, T.J. Hommes1, 2
, D. Margolis4
, E. Kane1
, W.K. Van Deen1
, L. Eimers1
, E.K. Inserra1
, N.
Duran1
, J.M. Choi1
, C.Y. Ha1
, B. Roth1
, A.D. Ho1
, E. Esrailian1
, J. Sack3
, D.W. Hommes1
1
UCLA Center for Inflammatory Bowel Diseases, Division of Digestive Diseases, Los Angeles, United States, 2
LUMC,
Gastroenterology and Hepatology, Leiden, Netherlands, 3
UCLA, Division of General Surgery, Los Angeles, United States,
4
UCLA, Division of Radiological Sciences, Los Angeles, United States
Gastroenterology 148(4): S-828, April 2015; DOI: http://dx.doi.org/10.1016/S0016-5085(15)32818-3
Background
Surgery has become an essential care component in Inflammatory Bowel Diseases (IBD) management. Although surgical
and medical teams often work closely together, no integrated care pathways have been reported. In an existing IBD
coordinated care program we aimed to fully integrate pre-operative, operative and post-operative IBD care.
Methods
The UCLA value-based care program for IBD consists of 9 highly coordinated medical care pathways. The surgical pathway
was designed by a multidisciplinary team of specialists and nurses with patient input. Pre-operatively the indication for
surgery was agreed upon during multidisciplinary case presentations. Coordination of pre-assessment, time of surgery,
surgical quality indicators, and discharge was completed by the surgical IBD team. A 4-week post-surgery pathway included
continuous tele-monitoring of pain, weight, temperature, nutrition, bowel function, pain medication, quality of life and
productivity. In addition, tele-wound-monitoring was introduced. The surgical pathway was completed after a week 4 clinic
visit and patients were assigned to their subsequent medical pathway. Included patients were compared to matched
historic controls for initial performance analysis.
Results
Of the 1163 IBD patients enrolled in the IBD value-based care program, 46 patients undergoing major abdominal surgery
entered the surgical care pathway and were compared to 41 controls. Characteristics: mean age 39 (20-70); 63%-CD, 35%-
UC and 2%-IBD-U; surgery type: bowel resection (46%), stricturoplasty (33%), enteric fistula surgery (8%), lysis of adhesions
(10%), and abscess drainage (4%). A 27% reduction in post-operative complications was observed; most common
complications were ileus and infection. All patients completed the care pathway with a clinic follow up within 30 days after
hospital discharge. In the controls 27% of patients had no GI clinic follow up and 49% had no surgical follow up after
discharge. Emergency department (ED) visits (<30 days after surgery) were reduced by 7.5%; primary indications were
abdominal pain, fever, and nausea/vomiting. On average, we observed 2-3 phone calls/patient and 10-15 eConsults/patient,
as a result of which 9 ED visits/readmissions were likely prevented. Monitoring of post-surgery parameters and tele-wound
monitoring was feasible and demonstrated meaningful provider decision support.
Conclusion
This integrated care pathway for IBD surgery was successfully implemented and strongly decreased post-surgical loss to
follow up. In summary, this pathway showed clinically relevant Results with respect to enhancing patient value and
controlling utilization-associated costs.

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Preparing for the Affordable Care Act in
Inflammatory Bowel Diseases: A 2010-2012 US
Insurance Claims Analysis
Daniel W. Hommes, Eric Esrailian, Belinda Wong-Swanson, Adriana Centeno, Erin M. McLaughlin, William Howard,
Jennifer M. Choi, Kelly D. Myers, Martijn G. van Oijen
Gastroenterology 144(5, Supplement 1): S-179-S-180, May 2013; DOI: 10.1016/S0016-5085(13)60638-1
Major health care reform is in progress, moving from fee-for-service to quality-based payments in an attempt to control
spending. In order to identify potential areas for improvement in Inflammatory Bowel Diseases (IBD), we performed an
insurance claims analysis to study cost, utilization, and guideline adherence. Methods: A 2010-2012 US analysis of IBD
pharmacy and medical claims data from Source Healthcare Analytics LLC was performed using predefined methodologies
and algorithms. These data represent a significant fraction of claims enabling quantitative/qualitative assessments,
although some components, especially hospital claims, are less represented. Results: 964,633 unique IBD patients (44%
male, mean age 50.8yr) were identified, 49% CD & 51% UC. Geographical prevalence is presented in Figure 1.
Most prescription claims were processed by commercial plans (39%) and pharmacy benefit managers (30%), with only 14%
Medicare, 8% employer groups, 6% Medicaid, and 3% cash pay. The estimated total annual procedure charges were
$4.6billion; of these, $3.1billion were definitely related to IBD care, of which $1.4billion (45%) was for infliximab (IFX)
infusions alone. The highest procedure expenditure (excluding IFX infusion) was colonoscopy with biopsy: 34% of patients
(pts) underwent this procedure within 2 years. Prescription claim charges were estimated from a smaller data set
representing 366,865 IBD patients. In this data set, 209,570 pts (57% CD) used 5ASA/SAS (46% CD); 207,539 pts (57% CD)
used steroids (57% CD); and in contrast only 94,643 pts (26%) used immunosuppressives (62% CD). Disturbingly, these data
indicate that ~1/3 of patients who received steroids had received them on a long-term basis ( .3 months). Steroids were
infrequently combined with immunosuppressives (25%). A high rate (26%) of antibiotic use was observed. Since inflixi- mab
(IFX) /natalizumab (NAT) are given iv (procedure claim) and adalimumab (ADA) / certolizumab (CZP) sc (pharmacy claim),
biologic treatment analysis was performed using two data sets.
An estimated 13% received biologic
treatment. Of this 13%, the CD pts
received: 55% IFX, 34% ADA, 10% CZP,
and 0.4% NAT. The UC pts received: 71%
IFX, 23% ADA, 6% CZP, and 0.4% NAT.
Over 2 million pharmacy claims were
identified for anti-depressants/anxiolytics
underscoring the impact of IBD on quality
of life. Approximately 31% of IBD patients
use anxiolytic drugs and 39% use anti-
depressants.
Conclusion: Annual IBD-related procedure
charges exceed $3 billion of which
estimated IFX charges are 45%. In
contrast to current guidelines, long-term
use of steroids was strikingly high
compared to the unexpected low usage of
immunosuppressive therapy. Anti-depressant/anxiolytic use is common in IBD patients. New strategies must be identified
to increase and monitor adherence to guidelines in order to improve IBD care.

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Challenges in the Work Place: Decreased
Work Productivity and Job-Lock in IBD
Patients
Welmoed K. van Deen, Aria Zand, Christina Y. Ha, Ellen Kane, Jennifer M. Choi, Bennett E. Roth, Adriana Centeno, Eric
Esrailian, Daniel W. Hommes
Gastroenterology 146(5): S-206, May 2014; DOI: http://dx.doi.org/10.1016/S0016-5085(14)60729-0
Background
Healthcare costs in IBD are mainly driven by indirect costs due to lost hours from work (absenteeism), decreased
productivity at work (presenteeism) and disability. Presenteeism alone has been estimated to account for 63% of US
medical costs. The effect of absenteeism on indirect medical costs in IBD has been studied previously, but the effects
of presenteeism remain largely unknown. Additionally, many patients are unable to freely change their jobs, because
of doing so will result in the loss of employee benefits and employer provided health-insurance; a process called ‘job-
lock'. In order to identify areas for improvement we assessed the impact of IBD specific work limitations,
absenteeism, presenteeism, and job lock.
Methods
Consecutive IBD patients filled out the Work Productiv- ity and Activity Impairment (WPAI) questionnaire, which
measures absenteeism, presenteeism and loss of leisure in the past 7 days. Specific work related problems (including
job- lock) were also questioned, and clinical disease activity and quality of life (QoL, using the short IBDQ) were
assessed.
Results
In total, 365 patients were included, of which 64% was employed. Twenty-one percent of employed patients
experienced absenteeism, 62% presenteeism, and 66% loss of leisure. Of the employed patients 58% of employed IBD
patients had employer-provided health insurance, of which 20% experienced job-lock. Employed patients had a
higher average QoL (50, SD 12) than unemployed patients (QoL 44, SD 15). The majority of IBD patients was not able
to make adjustments at work to avoid taking sick days off (69%), while 40% of employed IBD patients missed work
due to doctor appointments. Fatigue affected 47% of employed IBD patients in their performance at work and 50% of
employed IBD-patients experienced stress or pressure when taking sick time off from work.
Conclusion
Absenteeism and presenteeism in employed IBD patients are considerable, and are responsible for a significant
fraction of U.S. healthcare costs. Most commonly experienced problems on the workfloor are fatigue, unability to
make adjustments in work time/location, and stress due to taking sick days off. These identified problems could be
potential areas of improvement in the work situation of IBD patients, thereby improving patient value and decreasing
health related costs.

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Using an Automated Diagnostic Algorithm
That Utilizes Electronic Health Records and
Natural Language Processing to Define a
Population With Cirrhosis
Edward K. Chang, Christine Y. Yu, Robin Clarke, Andrew D. Hackbarth, Timothy Sanders, Eric Esrailian, Daniel W.
Hommes, Bruce A. Runyon
Gastroenterology 148(4): S-1074, April 2015; DOI: http://dx.doi.org/10.1016/S0016-5085(15)33669-6
Background
Identification of a population with cirrhosis is challenging given manual data collection is time-intensive and
laborious, while use of International Classification of Diseases Ninth Revision (ICD-9) codes can be inaccurate. Natural
language processing (NLP), a novel computerized approach to analyzing electronic free text, has been used to
automatically identify other patient cohorts with gastrointestinal pathologies such as inflammatory bowel disease
and intraductal papillary mucinous neoplasms.
Aim
To utilize NLP as a supplement to ICD-9 codes and laboratory values to better define and risk-stratify patients with
cirrhosis.
Methods
A cohort of patients with ICD-9 codes for chronic liver disease was identified during March 2013 to September 2014
from an academic medical center's administrative data. Patients with cirrhosis were further characterized using an
algorithm incorporating NLP of radiology reports, ICD-9 codes and laboratory data. Patients who met any of the
inclusion criteria were determined to have cirrhosis. Charts were manually reviewed at random to confirm cases of
cirrhosis. The reviewer was blinded to the algorithm's results. Positive predictive value (PPV), negative predictive
value (NPV), sensitivity and specificity were calculated.
Results
Of 4292 patients with chronic liver disease, the algorithm yielded 801 patients with cirrhosis. Of the 174 manually
reviewed charts, 97 patients had cirrhosis. The algorithm had a PPV of 0.76, NPV of 0.97, sensitivity of 0.97 and
specificity of 0.77.
Conclusion
Combining NLP, ICD-9 codes and laboratory data is a powerful and sensitive way to detect patients with cirrhosis
within a large population. Our algorithm mimics clinicians' manual review process, and therefore shows promise as a
tool for automated identification of patients with cirrhosis for both clinical and research use.

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Figure
Flow sheet demonstrating the automated diagnostic algorithm.

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Time-Driven Activity Based Costing: Measuring
the Costs of Implementing Quality Measures in
Inflammatory Bowel Disease (IBD)
Andrew D. Ho, Christine Y. Yu, Welmoed K. van Deen, Adriana Centeno, Laurin Eimers, Elizabeth K. Inserra, Natalie
Duran, Jennifer M. Choi, Christina Ha, Bennett E. Roth, Eric Esrailian, Daniel W. Hommes
Gastroenterology 148(4): S-828-S-829, April 2015; DOI: http://dx.doi.org/10.1016/S0016-5085(15)32819-5
Background
Quality improvement (QI) has become increasingly important with respect to IBD care delivery. Gastroenterologists
can distinguish themselves by reporting on the 8 quality measures developed by the AGA. Moreover, with the
introduction of Physician Quality Reporting System (PQRS) registration, reporting on QI metrics will positively impact
future reimbursement rates. For 2015, Medicare will apply a 1.5% penalty for non-compliance to QI reporting.
However, QI implementation has the potential to be a significant cost driver for providers. Therefore, we aimed to
analyze the cost burden of QI implementation for a GI practice.
Methods
An IBD QI program was implemented including documentation of quality measures from 4/2014 to 10/2014. A ‘Six
Sigma' process map was developed for the implementation of the QI measures. Time-Driven Activity-Based Costing
(TDABC) was then used to estimate costs associated with performing the QI measures for the GI practice. Expenses
encountered outside the GI practice, such as radiology and laboratory costs, were excluded. Separate models were
created depending on use of chronic steroids or biologic therapy. The personnel, space, and equipment needed for
each resource was identified and time spent with each resource was documented. The cost of each process step was
calculated by multiplying the time spent with the cost per unit of time.
Results
In total, 369 patients were enrolled into the IBD QI Program. 100% had documented disease activity (Crohn's disease -
Harvey Bradshaw Index; Ulcerative colitis - partial Mayo Score), 100% screened for tobacco use, 49% received an
influenza vaccination and 23% a pneumococcal vaccination. Of patients on steroids, 100% were then started on
steroid sparing therapies and 30% underwent bone loss assessment. Prior to biologic therapy initiation, tuberculosis
and hepati- tis B screening occurred in 96% and 99% of patients, respectively. A process map was created for
implementation of IBD QI measures (Figure 1). In total, 7 types of personnel were involved in ordering and
documenting the measures. Using TDABC, the cost of performing the general IBD measures, including documenting
disease activity, vaccinations, and tobacco use, was $80.33 per patient per year (PPPY). For patients on chronic
steroids, the cost of performing the QI measures including bone loss assessment was $91.41 PPPY. For patients on
biologic therapy, the process cost including checking hepatitis B and tuberculosis status was $108.76 PPPY.
Conclusions
Effective implementation of QI metrics was feasible using a lean process map and TBABC to estimate associated GI
practice costs. The financial burden on the GI practice seems limited; therefore this study demonstrates that there
can be significant value for gastroenterologists to implement QI metrics in order to become eligible for associated
payer reimbursements.