Resilience-driven care for inflammatory bowel disease leads to sharp drops in ER visits and hospitalizations

A personalized program to increase resilience in patients with inflammatory bowel disease (IBD) can substantially reduce hospitalizations and emergency room visits, Mount Sinai researchers report. The research is being unveiled on October 27 in a plenary presentation at the annual scientific meeting of the American College of Gastroenterology (ACG 2020).

IBD, a group of disorders that includes Crohn's disease (first identified by Mount Sinai physician Burrill B. Crohn, MD, in 1932) and ulcerative colitis, imposes a substantial social and economic burden on patients, their employers, and the overall health system. IBD patients with a behavioral comorbidity—such as depression or anxiety—are at risk of costing the health system three to five times more than other patients due to the expense of unplanned emergency visits and hospital admissions.

The researchers, led by Principal Investigator, Laurie Keefer, Ph.D., Professor of Medicine (Gastroenterology), and Psychiatry, Icahn School of Medicine at Mount Sinai, and inventor of the GRITT (Gaining Resilience Through Transitions) methodology, say the program builds on the principles of positive psychology, which focuses on how people flourish despite obstacles, and supports patients to achieve six key outcomes: optimism, disease acceptance, self-regulation skills, self-efficacy, social support, and resilience.

In a previous study, "High Levels of Psychological Resilience Associated With Less Disease Activity, Better Quality of Life, and Fewer Surgeries in Inflammatory Bowel Disease," published in July in Inflammatory Bowel Disease, Dr. Keefer's team reported for the first time that low resilience was tied to worse IBD outcomes, including low quality of life, higher disease activity, and higher rates of surgery for Crohn's disease.

The current study included 336 patients, who were selected based on their "GRITT Score," an algorithm developed by the researchers to measure resilience in multiple areas including disease management skills, social support, physical symptom experience, psychological symptom experience, and nutritional status.

Of the study group, 126 patients graduated from the program; the remaining 210 patients served as controls. Graduates of the program experienced a 90 percent reduction in emergency department visits and an 88 percent reduction in hospitalizations, compared to no significant reductions in health care utilization in the control group at 1—year follow up. Their GRITT Scores increased by an average of 33 points, demonstrating improved resilience.

"GRITT is about providing highly coordinated expert care that is both holistic and personalized. A chronic condition like Crohn's can be all-encompassing and extremely onerous for the patient to manage alone. The GRITT philosophy is founded on the idea of connection and coordination to support the patient every step of the way," says Dr. Keefer.

The GRITT approach gives low-resilience patients a personalized "playbook" that is implemented by a team that includes social workers, dietitians, pharmacists, and nurse specialists. Patients are deemed graduates upon reaching a set of established resilience targets.

"We are constantly monitoring our patients, particularly with an eye on life transitions that could impact self-management, such as college, pregnancy, or a job change. The pandemic has taken an unprecedented toll on patients, causing an uptick in stress, depression, anxiety, and sleep disturbances. We were thankful to have GRITT available as a source of support in an unusually difficult and uncertain time," says Dr. Keefer.

"The study results we are sharing today underline what we see every day in the clinic at the Feinstein IBD Clinical Center: the extraordinary impact of a resilience-driven care coordination program on the lives of our patients. It is cutting-edge, evidence-based, and extremely patient friendly," says co-author Marla Dubinsky, MD, Co-Director of the Susan and Leonard Feinstein IBD Clinical Center at Mount Sinai Hospital, and Professor of Pediatrics (Pediatric Gastroenterology), and Medicine (Gastroenterology), at the Icahn School of Medicine at Mount Sinai.

Sebastian Toovey, 37, was diagnosed with ulcerative colitis when he was 22; doctors later determined he actually had Crohn's disease, a similar condition.

Mr. Toovey has been hospitalized 15 times for his condition and has had five major gastrointestinal surgeries including the complete removal of his colon and the subsequent creation of a J-pouch, a procedure for severe IBD that creates a pouch from part of the small intestine to serve in place of the colon. He started receiving support through the GRITT program in 2017. The holistic and highly personalized approach of the program has helped him manage the many moving parts of his chronic illness. "While some patients are helped primarily by the psychological support that is part of GRITT, for me, I benefited tremendously from the care coordination that Dr. Keefer has provided. GRITT has helped me navigate the health system, while connecting me with specialized providers such as the staff nutritionist and the clinical pharmacist in addition to mental health support," says Mr. Toovey.

When complications with his insurance arose recently, jeopardizing his access to Stelara, the drug Mr. Toovey credits for keeping him alive, Dr. Keefer's team stepped in to help manage and coordinate the process. "Thankfully, Dr. Keefer and the team at Mount Sinai were able to resolve the situation with the insurance provider. This was an example of the excellent care coordination that defines the GRITT approach," he says.