Cost savings associated with IBD nurse-coordinated anti TNF therapy for Crohn’s
disease at a suburban Melbourne hospital
Background: The equitable implementation of expert, integrated, patient-centred care for
inflammatory bowel disease (IBD) patients is a major challenge to governments, insurers and
health care organisations. In larger centres, multidisciplinary services provide superior care
for patients with chronic complicated disease phenotypes, but this option is usually
unavailable in smaller or regional centres. Alternatively, specialist IBD nurses working cooperatively with individual specialists or via telemedicine can facilitate high-quality, local
IBD care in regional areas. We have reviewed the clinical outcome of IBD nurse-coordinated
anti TNF therapy at a suburban Melbourne hospital.
Methods Since 2008, anti-TNF therapy has been available for Crohn’s disease (CD) patients
attending at Werribee Mercy Hospital, a suburban centre servicing the City of Wyndham
(population of 160,000). In 2011, a dedicated fortnightly IBD clinical outpatient service
staffed by a single gastroenterologist was established, and patients requiring anti-TNF therapy
for Crohn’s disease had their care co-ordinated by an IBD nurse. Hospital admission rates,
corticosteroid usage, mucosal healing and need for surgery were reviewed before and after
anti TNF therapy was started.
Results: 21 CD patients were treated with anti TNF therapy. Median disease duration was 6
years (range 1-17 years) prior to therapy and 4 years (range 1-5 yrs) after commencement of
therapy. Before treatment, all 21 patients had endoscopic evidence of active mucosal
inflammation and required corticosteroids. Before treatment, 8 patients had undergone 11
intestinal resections, 5 required repeated perineal surgery and 14 had been admitted on 23
occasions for medical management of their disease. After treatment, one patient required a
further intestinal resection and drainage of a perianal abscess, another underwent laparoscopy
for adhesive small bowel resection, and one was medically treated for a small bowel
obstruction. After treatment, complete mucosal healing was achieved in 14/19 patients who
had a follow up colonoscopy, and 2 have needed further courses of corticosteroids. Five
women have had 8 successful pregnancies on anti TNF therapy, and all but two patients
electing to work were fully employed.
Conclusion: Although this series is small, the preliminary experience of anti TNF therapy for
CD highlights a dramatic reduction in health care utilization (need for surgery, medical
admissions), corticosteroid usage and disease activity (endoscopic remission). Improvement
in personal quality of life is difficult to measure retrospectively, but the capacity for full time
employment and fecundity are notable beneficial endpoints. Attending to administrative
requirements and safety monitoring regarding anti TNF therapy is detailed, intensive and
time-consuming. These indirect elements of care are best co-ordinated by an IBD nurse. For
individual hospitals and State Governments, the upfront cost associated with employing IBD
nurses is clearly offset by considerable savings resulting from reduced admissions and need
for surgery.