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Background: Delays in biologic or small molecule medication administration are associated with increased adverse events, hospitalization, and surgery in inflammatory bowel disease (IBD). We evaluated the impact of a quality improvement (QI) intervention on the time to administration of biologics or small molecules (TABS) in IBD. Methods: Data were retrospectively extracted for IBD patients prescribed biologics or small molecules from a convenience sample of providers participating in an accredited QI educational intervention (baseline cohort). Subsequent to the intervention, data were prospectively collected from patients prescribed these medications (postintervention cohort). Dates related to steps between a treatment decision to medication administration were collected. The primary outcome compared TABS in baseline and postintervention cohorts. Results: Eighteen physicians provided survey and patient data for 200 patients in each cohort (n=400). The median time to medication administration (TABS) decreased from baseline to postintervention cohorts (30 vs. 26 d, P=0.04). Emergency room visits before medication administration also decreased (25.5% vs. 12.5%, P=0.001). Similar numerical TABS reductions were observed in subgroups limited to physicians providing patients to both cohorts and for individual medications prescribed. Primary contributors to delays included filling prescriptions subsequent to insurance approval and dispensation subsequent to this. Conclusions: A QI intervention successfully reduced medication administration times (TABS) by accelerating provider-dependent steps. This intervention was associated with reduced emergency room visits. We propose TABS as a quality metric to assess the effective delivery of therapies in IBD. Further evaluation of QI interventions, patient education on prescription drug insurance, and quality metrics are warranted.

Patients with penicillin allergy labels often receive alternative antibiotics for peri-operative prophylaxis, as opposed to firstline cephalosporins (cefazolin/cefuroxime). Provider misconceptions about the risk of cross-reactivity likely drive this prescribing behavior, which is problematic because due to association with an increased risk of surgical site infections. We created and implemented an algorithm intended to guide appropriate peri-operative antibiotic selection in the setting of penicillin allergy. METHODS: A multidisciplinary group developed the algorithm for antibiotic selection in penicillin-allergic surgical patients, to optimize cephalosporin use. The percentage of patients receiving a first-line cephalosporin was compared before and after algorithm utilization. Safety was assessed via chart reviews performed on any patient who received epinephrine in the operating room or diphenhydramine in the twenty-four hours post-operatively, as surrogates for immediate and delayed reactions to cephalosporin administration. RESULTS: Between September 2016 and May 2019, 7.9% of surgical patients had documented penicillin allergy-38% were not detailed further, 27% were consistent with type I hypersensitivity, 21% rash or itching, 7% a side effect, 5% unknown, and 1% consistent with severe delayed reactions. At baseline, ;22% of these patients received a cephalosporin, with an increase to >80% following algorithm implementation (p<0.0000001). No immediate allergic reactions requiring epinephrine were identified; one patient had a delayed rash that did not require cephalosporin discontinuation and three patients received diphenhydramine for "itching'' without rash in the setting of concomitant narcotic administration. CONCLUSIONS: Using a streamlined algorithm, we were able to significantly limit use of second-line alternatives in penicillin-allergic surgical patients without severe adverse reactions.

INTRODUCTION: Most quality improvement (QI) initiatives in inflammatory bowel disease (IBD) address clinical processes such as screening and vaccinations. Applying the principles and methods of QI, we conducted an initiative that encompassed insurance-related workflow processes required for prompt patient access to biologic IBD therapies. METHODS: The QI cohort comprised 22 gastroenterologists who were attending staff in an academic medical center (N = 14) or center-affiliated community clinics (N = 8). At baseline, the gastroenterologists completed a survey designed to assess their self-reported knowledge and practices involving insurance-related processes. We retrospectively audited the charts for 200 of the gastroenterologists' patients with confirmed active ulcerative colitis or Crohn's disease who had been prescribed a biologic medication. Assessments included the number of days between prescription request and various milestones involving prior authorization (PA) and prescriptions being filled and dispensed. In the intervention phase, the gastroenterologists and their clinical teams participated in a series of accredited grand rounds activities. Participants received audit feedback and developed action plans to reduce identified delays in patient access to biologic medications. Six months after the interventions, we audited the charts of 100 additional patients, assessing the same temporal measures as in the baseline review. RESULTS: The baseline survey findings indicated that 41% (21% academic vs 75% community) of gastroenterologists reported having limited or no confidence in understanding pre-authorization requirements; 18% (29% vs 0%) had standardized letters of necessity for patients needing biologics; and 9% (7% vs 13%) received approval for treatment coverage within 3-4 days. Patient characteristics were similar across the 2 sampling periods; median age was 37 (19-82) years, 54% were female, 62% had Crohn's disease, and 88% were covered by commercial insurance (Table 1). Across the baseline to follow-up audits, the mean number of days was reduced for key milestones, including prescription request to PA approval (11 vs 7 days), prescription written (18 vs 10 days), and prescription dispensed (43 vs 21 days; Figure 1). CONCLUSION: These findings reflect the potential for extending QI principles and methods to workflow processes in order to reduce insurance-related delays and facilitate prompt patient access to needed biologic therapies.

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