Telemedicine in IBD: MyIBDCoach

MyIBDCoach is a patient-centred application for smartphones and tablets. It monitors disease activity, therapy compliance, side effects of medicines, nutritional status, smoking behaviour, participation in (paid) labour, quality of life, anxiety symptoms, signs of depression and major life events. Users are periodically asked to complete questionnaires. Answers to these questionnaires appear in a dashboard, creating insight for not only the patient but also the IBD MDT. If the answers exceed a predefined upper or lower limit, the nurse or doctor will receive an alarm signal indicating the need to contact the patient directly to discuss further treatment.

An RCT has demonstrated that use of MyIBDCoach to monitor patient-reported outcome measures (PROM), in combination with provision of patient-tailored information, a personal care plan and easy access to an IBD Nurse, is efficient and safe [3]. Patients using MyIBDCoach (n=465) paid significantly fewer visits to the gastroenterologist in the outpatient clinic and were admitted to hospital 50% less often than patients receiving regular care (n=444). No significant difference was found between these groups with regard to the number of flare-ups, corticosteroid use or the numbers of emergency room visits and IBD-related surgeries. Moreover, adherence to medication among people using MyIBDCoach improved significantly, as did patients’ perception of communication with the hospital and their insight into their illness. After 12 months, all patients were very satisfied with the quality of care [8.16±1.37 SD in the telemedicine group vs 8.27±1.28 SD in the standard care group; difference 0.10 (–0.13 to 0.32); p=0.411] [3]. The cost-effectiveness of the app has also been investigated: Due to 36% fewer outpatient visits and 50% fewer hospital admissions, € 547 per patient/year was saved [4]. This is beneficial for doctors and patients.

Patients with IBD often experiment with their dietary intake in an attempt to avoid dietary complaints or postpone a flare, although these experiments may in fact worsen their nutritional status. To enhance nutritional status in patients with IBD, a screening tool that identifies patients requiring dietary guidance is needed. In MyIBDCoach app, the Short Nutritional Assessment Questionnaire (SNAQ) screens for malnutrition every 1–3 months [5]. The SNAQ comprises three questions on unintentional weight loss (2 or 3 points depending on the amount of loss and period), decreased appetite during the last month (1 point) and use of supplemental drinks or tube feeding during the last month (1 point). In a recent study in which screening with SNAQ was performed every 1–3 months, impaired nutritional status was defined as SNAQ≥2 and/or BMI <18.5 kg/m² [6]. During a one-year follow-up period using the app, 12.7% (n=53) of the users were at a higher risk of an impaired nutritional status and 11.8% (n=49) of all patients flared. Furthermore, impaired nutritional status was associated with incidence of flares [OR 2.61 (95% CI 1.02–6.69)]. This highlights the importance of screening for malnutrition in IBD outpatients as well as inpatients. The importance of nutrition in IBD management has also been demonstrated by another study showing a prevalence of malnutrition between 20% and 85% [7] and a recent systematic review revealing that impaired nutritional status is strongly associated with a higher risk of IBD-related hospitalisation [8]. In addition, a recent digital oral presentation during the last ECCO Congress demonstrated that psychosocial factors and lifestyle factors (including SNAQ) monitored via telemedicine better predicted flares than clinical baseline variables [9].

A recent survey completed by IBD practitioners on the use of telemedicine during the COVID-19 pandemic revealed that only 6.2% of the respondents regularly used IBD apps; 67.7% of the respondents expressed a desire to implement an app in their future clinic setup [10]. This suggests that the use of apps like MyIBDCoach could become more commonplace in IBD monitoring. It is vital that dietitians, as part of the core MDT, lead the nutrition aspects of their development so that appropriate nutrition screening is embedded in these tools and nutritional issues are addressed.

References

1. Colombel J-F, Narula N, Peyrin-Biroulet L. Management strategies to improve outcomes of patients with inflammatory bowel diseases. Gastroenterology. 2017;152:351–61.e5. Available from: http://dx.doi.org/10.1053/j.gastro.2016.09.046
2. van den Heuvel TRA, Jeuring SFG, Zeegers MP, et al. A 20-year temporal change analysis in incidence, presenting phenotype and mortality, in the Dutch IBDSL cohort—Can diagnostic factors explain the increase in IBD incidence? J Crohn’s Colitis. 2017;11:1169–79. Available from: http://academic.oup.com/ecco-jcc/article/11/10/1169/3744989/A-20Year-Temporal-Change-Analysis-in-Incidence
3. de Jong MJ, van der Meulen-de Jong AE, Romberg-Camps MJ, et al. Telemedicine for management of inflammatory bowel disease (myIBDcoach): a pragmatic, multicentre, randomised controlled trial. Lancet. 2017;6736:1–10. Available from: http://linkinghub.elsevier.com/retrieve/pii/S0140673617313272
4. de Jong MJ, Boonen A, van der Meulen-de Jong AE, et al. Cost-effectiveness of telemedicine-directed specialized vs standard care for patients with inflammatory bowel diseases in a randomized trial. Clin Gastroenterol Hepatol. 2020;18:1744–52. Available from: https://linkinghub.elsevier.com/retrieve/pii/S1542356520305358 
5. Kruizenga HM, Seidell JC, de Vet HCW, Wierdsma NJ, van Bokhorst–de van der Schueren MAE. Development and validation of a hospital screening tool for malnutrition: the short nutritional assessment questionnaire (SNAQ©). Clin Nutr. 2005;24:75–82. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0261561404001244
6. Spooren CEGM, Wintjens DSJ, de Jong MJ, et al. Risk of impaired nutritional status and flare occurrence in IBD outpatients. Dig Liver Dis. 2019;51:1265–9. Available from: https://linkinghub.elsevier.com/retrieve/pii/S1590865819306255 
7. Balestrieri P, Ribolsi M, Guarino MPL, Emerenziani S, Altomare A, Cicala M. Nutritional aspects in inflammatory bowel diseases. Nutrients. 2020;12:372. Available from: https://www.mdpi.com/2072-6643/12/2/372 
8. Rocha R, Sousa UH, Reis TLM, Santana GO. Nutritional status as a predictor of hospitalization in inflammatory bowel disease: A review. World J Gastrointest Pharmacol Ther. 2019;10:50–6. Available from: https://www.wjgnet.com/2150-5349/full/v10/i2/50.htm 
9. Lalisang RCA, Adriaans G, de Jong M, et al. DOP20 Can lifestyle and psychosocial factors predict flares of IBD; an exploratory study using telemedicine. J Crohn’s Colitis. 2020;14(Supplement 1):S059–60. Available from: https://academic.oup.com/ecco-jcc/article/14/Supplement_1/S059/5705559 
10. Lees CW, Regueiro M, Mahadevan U, International Organization for the Study of Inflammatory Bowel Disease. Innovation in IBD care during the COVID-19 Pandemic: Results of a global telemedicine survey by the International Organization for the Study of Inflammatory Bowel Disease. Gastroenterology. 2020;110:697–700. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC7161520