Allen, John I.

INTRODUCTION: Chronic gastrointestinal (GI) conditions, including irritable bowel syndrome and other disorders of gut-brain interaction, are prevalent and costly, and fragmented care contributes to suboptimal outcomes. Virtual and multidisciplinary care models may improve outcomes. Objectives: We aimed to (i) characterize patients receiving virtual GI care, (ii) report patient engagement with and patient-reported outcomes after virtual multidisciplinary care, and (iii) report healthcare utilization and costs from a payer perspective among patients vs propensity score-matched controls identified from claims data. METHODS: We collected descriptive data on patient demographics, clinic provider visits, symptoms, and patient-reported outcomes from 3/2021 to 9/2022. To evaluate healthcare utilization and costs, we conducted difference-in-difference analyses using claims data compared with a propensity score-matched control group. RESULTS: Among 234 patients (71% women, mean age 45.4 ± 13.2 years), 51% received a new GI diagnosis, predominately disorders of gut-brain interaction (63%). Engagement criteria were met by 80% (n = 187), who completed a mean of 10 visits and median time-to-first appointment of 6 days. Dietitians (93%), psychologists (76%), and health coaches (64%) were frequently used. Engaged patients exhibited significant improvements from preclinic to postclinic in irritable bowel syndrome severity (226.7–145.6), symptom control (20.2%–86.6%), quality-of-life dysphoria (27.5–32.8), missed workdays (1.0–0.7), and satisfaction (37.4%–96.3%) (all P < 0.05). Compared with matched controls, a significantly smaller percent of patients had imaging (15% vs 44%; P < 0.0001) and GI-related emergency department visits (4% vs 10%; P = 0.0028), which contributed to reductions in GI-related costs ($443 per member per month; P = 0.047) and all-cause costs ($676 per member per month; P = 0.043), equating to annualized savings of $5,316 and $8,112, respectively. DISCUSSION: Virtual multidisciplinary GI care was associated with high engagement, improved clinical outcomes, and reduced healthcare utilization and costs.

INTRODUCTION: Modeling supporting recommendations for colonoscopy and stool-based colorectal cancer (CRC) screening tests assumes 100% sequential participant adherence. The impact of observed adherence on the long-term effectiveness of screening is unknown. We evaluated the effectiveness of a program of screening colonoscopy every 10 years vs annual high-sensitivity guaiac-based fecal occult blood testing (HSgFOBT) using observed sequential adherence data. METHODS: The MIcrosimulation SCreening ANalysis (MISCAN) model used observed sequential screening adherence, HSgFOBT positivity, and diagnostic colonoscopy adherence in HSgFOBT-positive individuals from the National Colonoscopy Study (single-screening colonoscopy vs ≥4 HSgFOBT sequential rounds). We compared CRC incidence and mortality over 15 years with no screening or 10 yearly screening colonoscopy vs annual HSgFOBT with 100% and differential observed adherence from the trial. RESULTS: Without screening, simulated incidence and mortality over 15 years were 20.9 (95% probability interval 15.8–26.9) and 6.9 (5.0–9.2) per 1,000 participants, respectively. In the case of 100% adherence, only screening colonoscopy was predicted to result in lower incidence; however, both tests lowered simulated mortality to a similar level (2.1 [1.6–2.9] for screening colonoscopy and 2.5 [1.8–3.4] for HSgFOBT). Observed adherence for screening colonoscopy (83.6%) was higher than observed sequential HSgFOBT adherence (73.1% first round; 49.1% by round 4), resulting in lower simulated incidence and mortality for screening colonoscopy (14.4 [10.8–18.5] and 2.9 [2.1–3.9], respectively) than HSgFOBT (20.8 [15.8–28.1] and 3.9 [2.9–5.4], respectively), despite a 91% adherence to diagnostic colonoscopy with FOBT positivity. The relative risk of CRC mortality for screening colonoscopy vs HSgFOBT was 0.75 (95% probability interval 0.68–0.80). Findings were similar in sensitivity analyses with alternative assumptions for repeat colonoscopy, test performance, risk, age, and projection horizon. DISCUSSION: Where sequential adherence to stool-based screening is suboptimal and colonoscopy is accessible and acceptable—as observed in the National Colonoscopy Study—offering screening colonoscopy can increase screening effectiveness.