Innovation in Inflammatory Bowel Disease Care During the COVID-19 Pandemic: Results of a Global Telemedicine Survey by the International Organization for the Study of Inflammatory Bowel Disease.

The increasing incidence of inflammatory bowel disease (IBD) in the developing world and compounding prevalence in the West has increased the demand for IBD care.1, 2, 3 The prevalence of IBD across most of North America and Europe is now 0.7%–0.8% with the expectation that >1% of the population will be living with IBD within a decade. ,

The traditional model of IBD care has centered around face-to-face consultations in the outpatient clinic. Although Crohn’s disease and ulcerative colitis are heterogeneous conditions, most IBD centers offer the same type of routine follow-up visits irrespective of demographics, disease history, geographic location, and distance to the clinic. The only significant variation in the visits are the frequency of appointments, depending on disease phenotype, activity, and current treatment. Additionally, treat-to-target goals and the desire for a more holistic approach to care has expanded management to a battery of regular monitoring tests (bloodwork, fecal calprotectin, endoscopy, and imaging) and an enhanced multidisciplinary team: gastroenterologists, surgeons, nurse practitioners, psychologists, and dietitians. All of this care has been delivered in often crowded, understaffed clinics.

The Coronavirus Disease-19 Pandemic and Forced Changes in IBD Care

Against this backdrop, the coronavirus disease-19 (COVID-19) pandemic has resulted in a dramatic, unprecedented shift in the provision of medical care, breaking through provider resistance and fueling innovation. Multiple factors have contributed to a global suspension of traditional face-to-face out-patient clinics. Social distancing and lockdown have been central to reducing the transmission rate of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the virus responsible for COVID-19 disease. Reports from Hubei and Lombardy highlighted that hospitals were hotspots for transmission of the virus. At the time of writing, most countries are past the peak of new COVID-19 cases and deaths. However, the threat of a second wave has necessitated the maintenance of at least partial lockdown in many countries, with social distancing looking to be the new normal until an effective vaccine is available.

Guidance for the management of IBD during the pandemic has focused on maintaining medical therapies to prevent the disease from flaring.4, 5, 6, 7, 8 This has required a number of key strategies including maintaining a functional IBD team (helplines, infusions suites, homecare delivery, etc), on-going proactive monitoring of stable patients, and rapid reactive management of flaring patients. Successful implementation of such strategies should minimize the need for systemic corticosteroids, hospital admission, and emergency surgery, thus decreasing the risk of SARS-CoV-2 infection and the severity of COVID-19 disease.

The challenge faced by IBD teams has been the implementation of new systems of care after the almost overnight closure of outpatient clinics. This occurred while many doctors and nurses were being redeployed to care for patients with COVID-19. Massive hospital reorganization has taken place, with all but emergency endoscopy and surgical activity cancelled. In this climate, the monitoring of stable outpatients, many of whom have chronic diseases, has not been a priority. Anecdotally, there has been widespread variation in how different centers have responded to this challenge. For many, the only alternative to face-to-face clinics has been the telephone. For others, widespread change has been more streamlined with the rapid implementation of preexisting technological solutions. Indeed, a wide range of secure, validated video consultation solutions have existed for some time. In addition to this, a number of IBD specific smartphone applications are available to record patient-reported outcomes (PROs) and to facilitate 2-way communication between provider and patient. Remote monitoring of gut inflammation can even be facilitated by validated point-of-care fecal calprotectin assays. In fact, almost all of the components needed to deliver IBD care remotely have been available and underused. However, it is unclear how much telemedicine was used in the prepandemic period. Structured change in health care systems is notoriously slow at the best of times. This pandemic however, is perhaps an opportunity to transform systems of IBD care that were increasingly broken.

International Organization for the study of IBD Telemedicine Survey

Working as part of a taskforce on telemedicine for the International Organization for the study of IBD, we were interested to answer a number of questions:

What was the use of telemedicine in prepandemic times?

How would telemedicine fill the service provision gap exposed by COVID-19?

What would the landscape look like after the pandemic had gone?

To address these issues, we designed a 9-item questionnaire on telemedicine in IBD using Google Forms. After a successful trial among International Organization for the study of IBD members (48/64 respondents), we refined our survey questions with a view to obtaining a truly global picture. The modified survey was distributed to IBD teams via email, Twitter, and LinkedIn.

Survey Results

The survey was open for 10 days and had a total of 802 responses from 56 different countries across North and South America, Europe, Australia, Asia, and Africa. The countries with the largest number of respondents were the United Kingdom (11.6%), the United States (11.0%), Italy (10.9%), Brazil (5.6%), Israel (4.6%), Denmark (4.0%), New Zealand (3.7%), India (3.6%), Romania (3.3%), Canada (3.0%), Spain (3.0%), China (2.6%), and South Africa (2.8%) (full listing in Supplementary Table 1). The survey was mostly completed by gastroenterologists with an interest in IBD (82.4%) and IBD nurse practitioners (10.2%), with the remainder (7.5%) comprising surgeons, dietitians, and psychologists. Of the respondents, 61.8% worked solely in the public sector, 14.0% solely in the private sector, and 22.0% in both. When asked if reimbursement was an important factor in their clinic setup (face-to-face versus video versus phone consultations) 38.0% said “yes,” 42.7% said “no,” and 19.3% said “some of the time.” Naturally, responses to the survey vary widely by country and the manner in which health care is reimbursed.

Supplementary Table 1

Countries with number and percent of respondents to the Telemedicine and IBD Survey

In which country do you practice?	No.r	%
United Kingdom	90	11.6
United States	86	11.0
Italy	85	10.9
Brazil	44	5.6
Israel	36	4.6
Denmark	31	4.0
New Zealand	29	3.7
India	28	3.6
Romania	26	3.3
Canada	23	3.0
Spain	23	3.0
China	22	2.8
South Africa	22	2.8
Australia	13	1.7
Greece	21	2.7
Ireland	21	2.7
Kuwait	17	2.2
Saudi Arabia	17	2.2
Belgium	16	2.1
Lebanon	16	2.1
Sweden	15	1.9
Norway	12	1.5
Hong Kong	8	1.0
Colombia	7	0.9
Japan	7	0.9
Germany	6	0.8
Netherlands	6	0.8
Egypt	5	0.6
Korea, Republic of	5	0.6
Argentina	0	0.0
United Arab Emirates	4	0.5
Croatia	3	0.4
Czech Republic	3	0.4
France	3	0.4
Malaysia	3	0.4
Turkey	3	0.4
Costa Rica	2	0.3
Hungary	2	0.3
Portugal	2	0.3
Switzerland	2	0.3
Tanzania, United Republic of	2	0.3
Algeria	0	0.0
Austria	0	0.0
Bulgaria	1	0.1
Chile	1	0.1
Estonia	1	0.1
Faroe Islands	1	0.1
Lithuania	1	0.1
Malta	1	0.1
Moldova, Republic of	1	0.1
Niger	1	0.1
Nigeria	1	0.1
Poland	1	0.1
Qatar	1	0.1
San Marino	1	0.1
Slovenia	1	0.1

Impact of COVID-19 on IBD Service Provision

The main focus of the survey was designed to document the split in clinic provision between face-to-face, telephone, and video consultations before, during, and after COVID-19. Figure 1 demonstrates that the most striking result was the almost complete suspension of face-to-face clinics during COVID-19, decreasing from >75% beforehand to <25% currently (Figure 1). Prepandemic telemedicine consisted of only a fraction by video consultation; this is now approximately 25%. Telephone consultations have seen the biggest increase and currently account for more than one-half of all IBD consultations. This is largely explained because 53.3% of respondents said they do not have access to a video consultation setup. Of those who did, many used systems either fully integrated into (Epic was the most commonly used) or linked to (eg, American Well, NHS NearMe/Attend Anywhere, Doxy.me) the electronic health care record. Many others reported using non-integrated solutions such as Zoom for Healthcare, GoToMeeting, Blu Jeans, Skype for Business, FaceTime, Google, Microsoft Teams, WeChat, and WhatsApp. After COVID-19, we asked how much they anticipated or intended for clinical provision to be offered by the different modalities. Consultation by phone drops back to prepandemic levels (approximately 25%). Face-to-face provision remained the most popular format, but is lower than at prepandemic times. It is noteworthy that a significant proportion of future IBD visits will be by video consultation.

Figure 1

Stacked bar chart showing proportion of inflammatory bowel disease (IBD) clinics that were conducted face-to-face, by telephone and by video consultation before the coronavirus disease-19 (COVID-19) (top), during the COVID-19 pandemic (middle), and anticipated proportions after COVID-19 (bottom).

Regional Variation in Telemedicine

We were interested in the provision of telemedicine by video consultation in the current climate and geographical variation (Figure 2 ). As we expected, the highest proportion of video consultation was in the United States. Interestingly, the only other regions that reported almost as much video as phone consultation were South America and India. Other examples were noteworthy. In Sweden, there is a newly developed telemedicine capability connected to the National IBD Register (SWIBREG/1177). In South Africa, it was reported that Internet connectivity is a major challenge in impoverished communities.

Figure 2

Global map showing the proportion of inflammatory bowel disease (IBD) clinics during the coronavirus disease-19 (COVID-19) pandemic being conducted face to face, by telephone or by video consultation. The breakdown of regions is as follows: United Kingdom, Western Europe (Austria, Belgium, Denmark, Faroe Islands, France, Germany, Ireland, Italy, Malta, Netherlands, Portugal, San Marino, Spain, Switzerland), Eastern Europe (Bulgaria, Croatia, Czech Republic, Estonia, Greece, Hungary, Lithuania, Republic of Moldova, Poland, Romania, Slovenia), Scandinavia (Denmark, Norway, Sweden), India, Middle East (Israel, Kuwait, Lebanon, Saudi Arabia, Turkey, United Arab Emirates), East Asia (China, Hong Kong, Japan, Malaysia, South Korea), Australasia (Australia, New Zealand), United States of America, Canada, South America (Argentina, Brazil, Chile, Colombia, Costa Rica), South Africa. The division of regions is largely pragmatic and based loosely on geography, health care systems and number of respondents to the survey (see Supplementary Table 1 for complete breakdown of countries).

IBD Patient Apps and Point of Care Fecal Calprotectin Testing

The use of IBD apps to monitor PROs and communicate with patients was reported in occasional use by 13.2% of health care practitioners, and regular use by 6.2%. It should be noted that although many reported using dedicated apps including Epic, HealthPromise, IBD Home, My IBD Care, SWIBREG/1177, Ambuflex, Constant-Care, Haodaifu/Good Doctor, and IBD Konsultace, the most commonly used apps for communication were WhatsApp and WeChat. Although the current use of IBD patient apps is relatively low 67.7%, all of whom have no prior experience, expressed a desire to implement in their future clinic setup.

Fecal calprotectin has become integral to the management of IBD patients using a treat to target strategy. Reflecting this, 89.0% of our survey respondents reported that they had routine access to laboratory fecal calprotectin testing prior to the pandemic. However, as a result of COVID-19, 33.7% reported a decrease and 12.3% a complete suspension in provision of this service. This was attributed to concerns around fecal transmission of SARS-Cov-2 and testing pressures in hospital laboratories.9, 10, 11 A relatively small proportion have been using a point-of-care fecal calprotectin test (mostly either IBDoc or CalproSmart). Of those that have not, the overwhelming majority replied that this is something they are interested in adopting. There is no commercial point of care calprotectin test currently approved in the United States.

Benefits of Telemedicine for IBD

COVID-19 has not only been a global tragedy resulting in significant loss of life; the indirect fallout for individuals and communities will be long lasting. For our IBD patients, this includes a significant amount of fear and anxiety, not least owing to the virus itself, but also employment, health insurance, and system-wide changes that impact every level of their care. However, despite all of the negatives there is also an opportunity to reimagine IBD care for the better. It is our belief that telemedicine should be a core part of IBD management, and our global survey reflects this opinion. New systems of IBD care that are built on telemedicine will be more patient oriented and less expensive for providers and health systems. The ability to remotely collect both PROs and fecal calprotectin levels using existing systems that automatically prepopulate electronic medical records will allow a large-scale implementation of treat-to-target medicine. Tools that enable real-time 2-way communication between patients and health care providers will allow for a more rapidly responsive service and should help to limit unscheduled care (costly for the individual and the provider). Digital systems will enable ready screening of psychological well-being and delivery of solutions such as app-based cognitive–behavioral therapy. This will help to build resilience in patients and free time for health care providers to deliver patient care, in turn limiting physician burnout. Chatbots are already being developed for IBD to collect disease activity, update medications, and obtain information on flares. Medical education can continue as most technologies allow the host to move invited participants in and out of the “room” to present. Additionally, telemedicine can be performed with less office support staff and is currently being reimbursed at rates similar to in-person visits with equal complexity. One restriction is that the patient (and provider) must have the equipment and technological skills to participate. Because much of the world is in possession of a cell phone, access should be available to most. Also, current relaxation of rules allowing telemedicine across state lines and reimbursing telephone visits at the same rate as in-person visits may revert to prepandemic standards, curbing enthusiasm. Yet, the popularity of telemedicine should prevail given its efficiency and effectiveness in delivering care.

The digital implementation of evidence-based approaches and algorithms to managing IBD can drive up standards of care globally and improve patient outcomes. Over time, a digital service collects data about treatment decisions and outcomes. If we use this opportunity to agree on standard data entry criteria including disease type, history and assessment of disease severity, we can then assemble large datasets ripe for machine learning and artificial intelligence to build predictive models. These can then be implemented to effect a true paradigm shift in IBD management.

Planning for the Next Phases of the Pandemic

At the time of this writing, many countries have passed the peak of the COVID-19 pandemic but remain in lockdown. Vaccines and effective antiviral therapies are many months off, and there is a very real threat of a deadly second wave. Some form of social distancing will remain in place for the foreseeable future. It seems inconceivable that we can return to crowded clinic waiting rooms for IBD patients. Through this great tragedy, there is also great opportunity. Our IBD clinics have transformed overnight and virtual care is the new normal. Our global survey demonstrates the importance of telemedicine during the pandemic and desire to continue into the future. Now is the time for a collaborative conversation between providers, payers and patients to determine the best mode of health care delivery. Digital technology is still in a state of relative infancy. Limitless growth and innovation will define the telemedicine of tomorrow.