People with inflammatory bowel disease can learn to become more resilient when it comes to their condition, and dramatically reduce their use of health services, researchers have found.
Over a one-year period, graduates of a program for resilience-based care coordination “saw a 90% reduction in emergency room visits and an 88% reduction in hospitalizations related to IBD,” reported Laurie Keefer, PhD, the director of psychobehavioral research with the Division of Gastroenterology at the Icahn School of Medicine at Mount Sinai, in New York City.
Resilience is being increasingly recognized as a potentially modifiable factor in a host of chronic conditions, such as cancer, diabetes and chronic obstructive pulmonary disease. In a previous study led by Dr. Keefer, a high degree of resilience was associated with lower IBD activity and better quality of life (Inflamm Bowel Dis 2020 Jul 12. [epub ahead of print]).
The new study assessed whether resilience is modifiable. Dr. Keefer and her colleagues evaluated 126 men and women participating in a program she developed called Gaining Resilience Through Transitions (GRITT-IBD). The program builds on the principles of positive psychology to improve optimism and self-regulation skills, among other components of resilience.
The 126 participants were drawn from more than 300 consecutive patients with low GRITT-IBD scores, meaning they had low levels of resilience in an algorithm measuring factors such as management skills and the experience of both physical and psychological symptoms. Two hundred six patients who did not opt to enter into a six-month personalized care plan served as controls.
The personalized care plan included strategies to build resilience, including psychological, nutritional and educational support for the goals of therapy. One year after enrollment, health care use was compared between those who entered the program and the controls, only 24% of whom declined participation due to lack of interest. Other reasons for not participating included an unacceptable distance to the treatment facility and lack of adequate insurance.
In the group receiving resilience training, women outnumbered men and had a higher percentage of Crohn’s disease. The baseline GRITT-IBD score was lower in the treatment group (45.8 vs. 54.2), but the difference did not reach statistical significance.
Resilience training led to significant gains over time, with the GRITT-IBD score rising by 33 points (P<0.001) relative to baseline in the treatment group, Dr. Keefer reported. When compared with the 12 months prior to the study period, emergency department visits in the treatment group fell from 102 to 10 (90%; P<0.001) and hospitalizations fell from 70 to eight (88%; P<0.001).
In the control group, emergency department visits over the study period were effectively unchanged, dropping from 89 to 85. Hospitalizations climbed from 23 to 38, an increase of 45%.
Dr. Keefer said she is now working to improve the approach, including efforts to “scale care coordination” and improve strategies to engage patients.
Resilience in IBD has already attracted the attention of other investigators, including a multicenter and multidisciplinary group that published a review on the topic (Intern Emerg Med 2020;15:211-223). The paper supported resilience as a potential therapeutic target in IBD.
“Low resilience is associated with poor coping skills and increased health care usage. If we find therapeutic approaches that reproducibly lead to better resilience, many IBD patients could benefit directly,” according to Christian Selinger, MD, the senior author of the review and a consultant gastroenterologist in the IBD service at Leeds Teaching Hospitals NHS Trust, in England. “In addition, by providing more proactive care [to improve resilience], IBD services might actually be able to prevent disease flares in some cases rather than just treat reactively.” Dr. Selinger cautioned that his remarks serve as “more of a vision than a statement based on solid evidence” until more prospective studies confirm clinical benefits.
Insurance Problems Take Toll On IBD Patients
The loss of or disruption in insurance coverage can trigger potentially “devastating” physical and psychological consequences for people with inflammatory bowel disease, according to Laurie Keefer, PhD, the director of psychobehavioral research with the Division of Gastroenterology at the Icahn School of Medicine at Mount Sinai, in New York City, and her colleagues.
In a study presented at the 2021 virtual Digestive Disease Week (abstract Sa568), Dr. Keefer and her colleagues detailed the fallout for 29 IBD patients who had lost their health care coverage or faced another issue with their insurance that threatened to derail their care. Of those, 21% reported feeling “overwhelmed” by the setback, and 41% said they didn’t think they could manage a lapse in coverage. Nearly half (45%) said they’d resigned themselves to not getting their health insurance reinstated.
In addition to the emotional insecurity, patients reported a variety of physical problems linked to the loss of coverage. Nearly six in 10 (58%) said they experienced a flare of their disease as a result of the lapse, and 14% said they required surgery. Fourteen percent also said they developed antibodies to their medication.
Although most patients reported having a support system of friends and family, nine (31%) said they had no such structure in place. Eleven patients (38%) said they did not inform their health care team about their lapse in insurance coverage, according to the researchers.
“Insurance issues can have devastating physical and psychological effects on IBD patients,” Dr. Keefer’s group wrote. “A large proportion of our cohort chose not to inform their provider of their insurance issue, felt incapable of managing it on their own, and gave up on resolving it. … Our study highlights the need to further support IBD patients with insurance issues by identifying them, encouraging them to inform their providers, and making easily accessible advocates available to avoid consequences of periods without access to the health care system.”
—Ted Bosworth
Dr. Keefer reported an ownership interest in Trellus Health, a company that is now developing a connected care platform based on the GRITT-IBD method. Dr. Selinger reported no relevant financial disclosures. The study was presented at the 2020 virtual meeting of the American College of Gastroenterology (abstract 7).