DOP35 Ambulatory care management of 70 patients with Acute Severe Ulcerative Colitis in comparison to 700 inpatients: Insights from a multicentre UK cohort study
Patel, K.V.(1);Segal, J.(2);Sebastian, S.(3,4);Subramanian, S.(5,6);Conley, T.(5);Gonzalez, H.(3,4);Kent, A.(7);Saifuddin, A.(7);Hicks, L.(2);Mehta, S.(8);Bhala, N.(9,10);Brookes, M.(11,12);Lamb, C.(13,14);Kennedy, N.(15,16);Walker, G.(17)
(1)St George’s University Hospitals NHS Foundation Trust, Department of Gastroenterology, London, United Kingdom;(2)Imperial College London, Department of Gastroenterology, London, United Kingdom;(3)Hull University Teaching Hospitals NHS Trust, Department of Gastroenterology, Hull, United Kingdom;(4)University of Hull, Faculty of Health Sciences, Hull, United Kingdom;(5)Liverpool University Hospitals NHS Trust, Department of Gastroenterology, Liverpool, United Kingdom;(6)University of Liverpool, Department of Gastroenterology, Liverpool, United Kingdom;(7)King’s College Hospital NHS Foundation, Department of Gastroenterology, London, United Kingdom;(8)University College London Hospitals NHS Foundation Trust, Gastroenterology, London, United Kingdom;(9)Queen Elizabeth Hospital Birmingham NHS Foundation, Department of Gastroenterology, Birmingham, United Kingdom;(10)University of Birmingham, Medicine, Birmingham, United Kingdom;(11)Royal Wolverhampton NHS Trust, Department of Gastroenterology, Wolverhampton, United Kingdom;(12)University of Wolverhampton, Research Institute in Healthcare Science, Wolverhampton, United Kingdom;(13)Newcastle upon Tyne Hospitals NHS Foundation Trust, Department of Gastroenterology, Newcastle, United Kingdom;(14)Newcastle University, Department of Gastroenterology, Newcastle, United Kingdom;(15)Royal Devon and Exeter NHS Foundation Trust, Department of Gastroenterology, Exeter, United Kingdom;(16)University of Exeter, Department of Gastroenterology, Exeter, United Kingdom;(17)Torbay and South Devon NHS Foundation Trust, Department of Gastroenterology, Torbay, United Kingdom; PROTECT ASUC collaborators
Background
Acute severe ulcerative colitis (ASUC) traditionally requires inpatient hospital management for intravenous therapies and/or colectomy. Patients with ASUC can deteriorate rapidly and hence require close monitoring of vital signs correlated with clinical, biochemical and radiological investigations. Traditionally, patients are admitted to hospital to facilitate endoscopic assessment, exclude concomitant infective complications, monitor response to first-line corticosteroid treatment and determine the need for and timing of rescue therapy and/or colectomy. Ambulatory care pathways, which utilise outpatient monitoring and drug delivery, have been shown to deliver safe and effective treatment for conditions which have historically mandated hospitalisation e.g. pulmonary embolus. To date there are a paucity of data regarding the use of ambulatory pathways in ASUC cohorts. We used data from PROTECT, a UK multicentre observational COVID-19 i (IBD) study, to report the extent, safety and effectiveness of ASUC ambulatory pathways.
Methods
Adults (≥ 18 years old) meeting Truelove and Witts criteria between 01/01/2019- 01/06/2019 and 01/03/2020-30/06/2020 were recruited to PROTECT (Figure 1). We utilised demographic, disease phenotype, treatment outcomes and 3-month follow-up data. Primary outcome was rate of rescue therapy and/or colectomy. Secondary outcomes included corticosteroid response, response to rescue therapy, colectomy, mortality and hospital readmission within 3-months. We compared outcomes in 3 cohorts: i) patients treated entirely in inpatient setting; ambulatory patients subdivided into ii) patients hospitalised and subsequently discharged to ambulatory care; iii) patients managed as ambulatory
from diagnosis.
Figure 1
Results
38%(23/60) participating hospitals used ambulatory pathways. Of 770 eligible patients, 700(91%) patients received entirely inpatient care, 55(7%) patients were discharged to ambulatory pathways and 15(2%) patients were managed as ambulatory from diagnosis. The rate of rescue therapy and/or colectomy (49%[339/696] vs 41%[22/54] vs 67%[10/15], respectively, p=0.18) (figure 2) and secondary outcomes were similar among all three cohorts. After 3-months follow up from the index ASUC diagnosis there was no significant difference in either rate of UC flare, readmission to hospital with UC flare or colectomy between the cohorts.
Figure 2. 
Conclusion
In the largest description of ambulatory ASUC care to date, we report an emerging practice which challenges treatment paradigms. Our data suggest ambulatory ASUC treatment may be safe and effective in selected patients but further studies exploring clinical and cost effectiveness as well as patient and physician acceptability are needed.