Inequities in inflammatory bowel disease care: a Tasmanian case study with proposed solutions

Abstract

There is well‐recognised inequity of care for people treated with inflammatory bowel disease (IBD) between metropolitan and regional areas. We aim to describe these barriers to care using Tasmania as a case example and to suggest solutions for addressing these barriers that can be used in Tasmania and beyond. Tasmania has some of the highest rates of IBD in the world, with high rates of advanced therapy use reflecting a more complex population. The landscape of IBD care in Tasmania is marked by diverse challenges, some of which are unique to the state and others shared across regional Australia, all of which we appreciate negatively affects IBD outcomes in Tasmania. We formed a multidisciplinary working group from all three health services in Tasmania and identified keys issues facing Tasmanian's with IBD. The issues identified and proposed solutions were guided by Australian IBD reports and care standards, major society guidelines and our experience within the health service. The key barriers we describe include the underserviced IBD workforce, lack of multidisciplinary care, the isolation of the North West, inadequate expertise in certain areas and the absence of research and administrative infrastructure. We have developed a set of solutions designed to provide an actionable framework for improving care for Tasmanians living with IBD. These solutions encompass the development of multidisciplinary care in a regional setting, enhancing the IBD workforce, developing support for remote areas, upgrading diagnostic output, creating statewide research databases and investing in local training pathways. This action plan may serve as a model for other regional settings to deliver more equitable care in Australia and beyond.

Abbreviations

FTE

full‐time equivalent role

IBD

inflammatory bowel disease

IUS

intestinal ultrasound

LGH

Launceston General Hospital

MDT

multidisciplinary team

RHH

Royal Hobart Hospital

THS

Tasmanian Health Service

UK

United Kingdom

Introduction

Inflammatory bowel disease (IBD), in the forms of ulcerative colitis and Crohn's disease, are chronic, immune‐mediated conditions affecting the gastrointestinal tract and are associated with significant morbidity and reduced quality of life. IBD is often diagnosed at a young age, with a peak age of diagnosis in the 15–30‐year‐old age group. An increasing prevalence is forecasted to reach 1% of the population in many industrialised nations. Crohn's and Colitis Australia recently published the ‘State of the Nation in Inflammatory Bowel Disease’ report, outlining key issues in IBD care across the country, and proposed solutions. ¹

Building on this work, we aim to discuss the barriers faced to treating people with IBD in a regional and remote setting, using Tasmania as a case study. Tasmania provides an excellent case study given its unique healthcare challenges, many of which are shared by other regional areas. We aim to detail the current state of IBD care in Tasmania and propose evidence‐based solutions. These insights are proposed to be helpful for other regional areas in Australia facing similar challenges. In writing this article, an author group was created to represent the three major branches of the Tasmanian Health Service (THS South–Hobart, THS North–Launceston, and THS North West–Devonport and Burnie) including doctors, nurses and allied health professionals (Table 1). The views of this article are those of the authors and do not represent the views of the THS.

Table 1.

Authorship group

Name	Healthcare professional	Region
Mrs Linda Boxhall	IBD Nurse	THS‐North West
Mr Zachiary Cooke	Pharmacist	THS‐South
Dr Alex Elford	Gastroenterologist	THS‐South†
Dr Scott Fanning	Gastroenterologist	THS‐North
Mrs Alyssa Pettersen	IBD Nurse	THS‐South
Dr Anna Prebble	Paediatric Gastroenterologist	THS‐South‡
Dr Jennifer Shoobridge	Radiologist	THS‐South
Dr Jarrad Wilson	Gastroenterologist	THS‐South†
Mrs Emily Woods	IBD Nurse	THS‐North

^†Dr Elford has spent significant time working across all three regions and Dr Wilson has spent significant time working across THS‐South and THS North West.

^‡Dr Anna Prebble is based in Hobart; however, she provides a statewide service.

Tasmanian context

Tasmania's population was approaching 600 000 people as of 2024, ² 110 000 of whom were children, with close to 20% of the population living in a rural area. ³ An estimated 4070 Tasmanians are affected by IBD, representing 0.7% of the total population. ¹ Approximately 50% of the population is serviced by THS South, and the rest is serviced between THS North and THS North West. Tasmania has the lowest health literacy in Australia, with only 37% of Tasmanians having adequate health literacy. ⁴ As of 2022, Tasmania has the highest proportion of residents with at least one chronic health condition (58.4%), the highest rates of overweight/obesity (70.5%), second highest smoking prevalence (12.4%) and second highest rate of mental health and behavioural conditions (29.5%). ⁴ Tasmania has a high level of socio‐economic disadvantage, with 37% of the population living in the most disadvantaged areas of the country, ⁵ leading to an increased reliance on public health services for people with IBD. This combination of low socio‐economic status, poor health literacy, elevated levels of mental health disorders and long travel distances for some people leads to negative impacts on medication adherence, self‐management, healthcare engagement, preventive health measures, good dietary choices and shared decision‐making. These statistics highlight the need for targeted interventions to address multiple risk factors that are associated with poorer outcomes for people living with IBD.

Current challenges specific to IBD care

Limited workforce

Like many regional areas, there is a shortage of employed healthcare workers servicing people with IBD across all health professions and in all regions of the state. The Australian IBD Standards describe the minimum required staffing of IBD staffing per capita, and there is a mismatch between recommended staffing and current staffing (Table 2). ⁶ This workforce shortage is magnified given our patients have poorer health literacy and more comorbidities, requiring more time to educate, to tailor management plans and to undertake more frequent follow‐up. The shortage is most problematic in North West Tasmania, where IBD clinics are serviced by locum gastroenterologists and one IBD nurse employed at 0.4 FTE. It is estimated that 570 public patients are on an advanced therapy in Tasmania, necessitating a minimum of 1140 appointments per year for prescription renewal alone, further demonstrating the mismatch between service requirements and availability.

Table 2.

Australian standards staffing versus Tasmanian Staffing ⁶

Role	Australian standards per 500 000 FTE†	Tasmanian staffing FTE‐Adult	Tasmanian staffing FTE–Paediatric
IBD Gastroenterologist‡	4	1.5	0.5
Colorectal surgeon	4	¶	¶
IBD nurse specialist	3	2.4	0
Stoma nurse specialist	3	2	0
Dietician allocated to GI§	1	0.2	0
Administrative support	1	0	0
UK Guidelines 17
Expert IBD pharmacist	1.2	0	0
Psychologist	1	0	0
Radiologist with special interest in GI	1	0	0

^†Current population of Tasmania 580 000 total, 110 000 children (0–17 years inclusive).

^‡Gastroenterologist focused on delivering IBD care.

^§Dietician allocated to gastroenterology.

^¶Difficult to determine given these professionals are shared across the total service with none allocated to IBD with no allocated time in their job plans to attend specific IBD meetings or services. IBD, inflammatory bowel disease; FTE, full‐time equivalent.

Perhaps a larger problem than the medical staff shortage is the lack of IBD nurses and allied health professionals. IBD nurses perform a critical role in the provision of high‐quality IBD care. The role focuses on providing education, managing the IBD advice line, coordinating care and nursing support. Increasingly in Australia and around the world, advanced practice IBD nursing can include assessments, diagnostic and prescribing skills to provide a timely response to the unpredictable changes IBD can present. ⁷ Given the health illiteracy in Tasmania, there is a great demand for nursing time for education and reiteration of treatment plans. Given the shortage of IBD doctor FTE, the nurses take on a greater workload for flare management and interim appointments. The recommended number of IBD nurses for public patients in Tasmania would equate to 3.6; however, given the issues discussed, we would suggest Tasmania requires a minimum of five nursing FTE to provide equitable care. Tasmania currently has no IBD nurse practitioners, in contrast to many tertiary IBD services, which usually have at least one nurse practitioner. Nurse practitioners are associated with improved service delivery, optimised gastroenterologist time, timely access to care, improved patient outcomes and cost savings. ⁷ Data from an Australian tertiary centre demonstrated their specialist IBD nursing service avoided an estimated 29 emergency department visits, 1925 outpatient clinic visits and 137 general practitioner visits over a 12‐month period. ⁸ Importantly, this was highly cost‐effective, with a net estimated annual saving of up to AUD $570 838 achieved. The IBD nurses also facilitated faster access to investigations, education provision, delivery of biologic services and medication changes.

Tasmania has limited allied health services available for people living with IBD and limited IBD‐specific expertise available. IBD is increasingly recognised as a multisystem disease, ⁹ resulting in nutritional deficiencies and high rates of mental health disorders, with data demonstrating that depression can induce flares in IBD. ¹⁰ Quality IBD treatment is no longer merely medical or surgical but relies on allied health input including dietetics, psychology and pharmacy. The role of dietary intervention is increasingly important for all people living with IBD, reflected in major guidelines recommending at least one dietician appointment for all people diagnosed with IBD. ¹¹ , ¹² In addition, many evidence‐based treatments used in routine IBD practice require dietetic expertise. These include the provision of exclusive enteral nutrition and the Crohn's disease exclusion diet, both of which are associated with remission and reduced corticosteroid use, as well as low‐residue diets for strictures and the complex dietary management of short gut syndrome. ¹¹ , ¹² Without skilled dietetic input, there is a risk of worse clinical outcomes such as unplanned stoma formation after a bowel resection. ¹³

Mental health care provision for people living with IBD in Tasmania is lacking, with up to 51.8% of people living with IBD found to be affected by a mental health issue in a previous Australian survey. In this survey, 21.8% of those with a mental health issue were currently receiving mental health support. ¹⁴ There is no provision of psychology services for people with IBD in the public sector. Compounding this issue is the workforce shortage of psychologists in the private sector and the cost‐prohibitive nature of these services to many patients. Inadequate mental health care can impact treatment adherence and patient resilience, leading to negative outcomes including IBD flares, avoidable emergency presentations and hospitalisation. ¹⁰ , ¹⁴

In many IBD units, medication counselling and monitoring are performed by IBD pharmacists, which is associated with improved outcomes ¹⁵ ; however, there are no specialist IBD pharmacists in Tasmania. Therefore, medication counselling and therapeutic monitoring can be suboptimal, and there are barriers to prescribing non‐PBS therapies, primarily due to concerns around adequate monitoring or practical barriers for clinicians in attaining the medications through special access schemes. Medications such as calcineurin inhibitors, budesonide MMX, which has a superior safety profile to prednisolone, ¹⁶ and dual biologic therapy for refractory patients are challenging to access in the Tasmanian context. Pharmacists have an important role in adjunct therapy management, such as smoking cessation therapies, with smoking linked to adverse outcomes in IBD. IBD pharmacists play an important role in medication interaction, with a growing proportion of the IBD population now considered elderly, many of whom are at risk of polypharmacy. ¹

In addition to allied health support, guidelines suggest specific IBD administration support, ¹⁷ which does not currently exist in Tasmania. This leads to inefficient patient scheduling, delayed communication, increased workload on clinical staff and fragmentation of care.

From a paediatric perspective, the workforce issues are more pronounced. There is one paediatric gastroenterologist serving the state employed at 0.5 FTE; however, there is no nursing, junior medical, administrative or IBD allied health staff to support the care for paediatric patients, of whom a substantial proportion are on biologic therapies. Tasmania is the only state with no paediatric IBD nurses.

Lack of coordinated multidisciplinary care

The Australian IBD standards describe high‐quality IBD care ‘should be based on a multidisciplinary team collaborating within recognised organisational structures and boundaries’. ⁶ There is currently no formal model of coordinated IBD care in Tasmania; therefore, healthcare provision can be uncoordinated, with advice differing between healthcare professionals, and timely intervention is lacking, which is associated with substantially worse outcomes in IBD. Contributing to these problems is the lack of formal IBD meetings, most importantly a formal IBD multidisciplinary team meeting (MDT). IBD MDTs are critical to confirm diagnoses, clarify investigative findings and determine ongoing management plans. ¹⁷ This is especially important for people with complex phenotypes, of whom there are many in Tasmania. Previous Australian survey data found a 22% reduction in IBD admissions through emergency departments, better safety monitoring and more common provision of patient information for IBD services with partial multidisciplinary services as compared to those without multidisciplinary services. ¹⁸

Diagnostic delays

There are significant diagnostic delays from endoscopic, histologic and radiological perspectives. Timely diagnosis is critical to IBD outcomes, particularly in Crohn's disease, with accumulating bowel damage leading to stricturing and penetrating complications. ¹⁹ Gastroenterology has some of the longest clinic waiting times compared to other specialties in Tasmania, ²⁰ and Tasmania has historically had some of the longest colonoscopy waiting list times in the country (up to 235 days for a CAT 1 colonoscopy historically). ²¹ , ²² Similarly, magnetic resonance imaging (MRI) waiting times are long, limiting clinicians’ ability to make timely diagnoses or assessments. These delays may have resulted in numerous unnecessary emergency presentations, admissions and avoidable surgeries.

The THS has responded to delayed colonoscopy waiting times by upgrading endoscopy facilities and employing more gastroenterologists, which has helped; however, there is difficulty recruiting the desired quota of gastroenterologists, likely given the regional nature of Tasmania. Waiting lists remain long, and the THS has outsourced colonoscopies and MRI scans to the private sector to reduce waiting times. The drawback is that many people with IBD are not appropriate for outsourcing. Quality IBD colonoscopy requires using formal scoring systems, recommended biopsy protocols and advanced techniques for dysplasia screening, ²³ which is not part of routine colonoscopy training. Currently, a large proportion of MRI is being outsourced to private practices and reported by general radiologists, which can reduce the diagnostic accuracy of reports. This stands in contrast to larger Australian centres, where IBD‐related imaging is often reported by abdominal radiologists who have greater expertise and work closely with clinical teams to provide high quality and clinically relevant reports.

Data and research deficiencies

There are no formal IBD databases in Tasmania. Each service has a PBS advanced therapy database (biologics and small molecules), which is maintained in the most up‐to‐date and accurate manner possible, within the limitations of insufficient administrative and nursing hours. We are concerned there are diagnostic delays, increased emergency presentations, admissions, surgeries and delays in dysplasia screening; however, we do not have the data to support this in the absence of a database. This negatively affects our ability to plan, benchmark and apply for appropriate resources and does not meet the Australian IBD standards. ⁶ We do not have data on important key outcomes, such as adherence to dysplasia surveillance practices or rates of colorectal cancer in our IBD population. With the probable introduction of national IBD benchmarking, this will become increasingly problematic from an accreditation perspective.

The lack of formal databases also limits IBD research, which is one of the key priorities of the IBD state of the nation report. ¹ Without research, local trainees are less competitive for gastroenterology training positions, jeopardising the future workforce in a state already facing difficulty in recruiting gastroenterologists. Without significant research infrastructure, recruiting IBD specialists is difficult, given they usually have significant research interests which develop during their IBD‐related fellowships or PhDs, which has become the standard training pathway for IBD physicians in Australia. Similarly, employing an IBD fellow, an important member in many major Australian IBD services, is improbable without offering significant research opportunities and funding. Lack of research infrastructure has also limited participation in clinical trials and deprived us of the ability to offer Tasmanians the latest lines of therapies, such as IL‐23 p19 inhibitors ²⁴ and TL1A inhibitors, ²⁵ which would be highly useful for those with medically refractory disease.

Proposed solutions: the Tasmanian IBD action plan

We have formulated the Tasmanian IBD action plan (Table 3), representing a strategic initiative developed by a diverse, multidisciplinary team of healthcare professionals. This plan provides a unified direction towards achieving significant improvements in IBD care for Tasmanians. Furthermore, it establishes a formal collaborative framework to serve as a cornerstone for advocacy efforts targeting policymakers and stakeholders on behalf of Tasmanians living with IBD.

Table 3.

The Tasmanian IBD action plan

Enhance multidisciplinary care

Formation of an IBD faculty Appoint IBD service leads at RHH and LGH Introduce Tasmanian statewide IBD MDT IBD education meetings

2 Enhanced IBD workforce

Increase medical FTE Increase nursing FTE Nurse practitioners appointed across the health services Increased allied health FTE Train allied healthcare professionals in IBD Create IBD pharmacist positions in the North and South Establish mentoring relationships with large tertiary IBD units Centralise IBD service delivery to special interest healthcare professionals Form paediatric IBD unit Establish IBD transition clinic

3 Supporting the North West

Allocate funding to Launceston to care for complex IBD patients from the North West Implement telehealth infrastructure to improve access to care Restructure allied health referral pathways from the North West for IBD care Create an IBD advice line for doctors from the North West to seek advice

4 Improve diagnostic output

Implementation of an intestinal ultrasound service IBD imaging to be performed publicly and reported by radiologists with a special interest in IBD IBD endoscopy to be performed by those with training in IBD endoscopy

5 Establish statewide IBD database and research infrastructure

Conduct epidemiology study Conduct population outcomes studies Create research partnerships with local research organisations Create wider research collaborations

6 Invest in local training pathways

Improve training and research opportunities for early career doctors Create IBD Fellow position

Enhance multidisciplinary care

We propose a formal IBD faculty in Tasmania, with the authorship group forming its foundation. This is to facilitate the implementation of this action plan and continue championing the cause of Tasmanians with IBD. The Royal Hobart and Launceston General Hospital have sufficient catchments to warrant formal IBD leads in accordance with national guidelines to drive the local services forward. ⁶ The formation of a collaborative faculty is important to support the North West of Tasmania, which has traditionally been a challenging and often isolated area of the state to provide quality healthcare. In forming the faculty, establishing and running an IBD MDT should be more readily achievable and functional. Facilitating IBD education in the form of meetings and sharing educational resources will be another important benefit, improving quality and consistency of care for people living with IBD.

Enhance IBD workforce

With this plan, the IBD State of the Nation report, and future state audit data, we aim to increase the number of gastroenterologists with a special interest in IBD to meet the demands of the IBD population. Increasing IBD nursing FTE to five across the state will be important, with a minimum of two FTE at RHH and LGH and one FTE in the North West, as well as a dedicated paediatric IBD nurse. Having nurse practitioners at the RHH, LGH and ideally the North West will result in substantial improvements in service delivery and reduce some of the need for medical FTE. From an allied health perspective, creating dedicated weekly IBD dietician clinics at the two major centres, as well as a paediatric IBD dietitian clinic based in Hobart, will improve access to dietetic therapies, patient satisfaction and local expertise. Central to this plan will be training selected allied health professionals who are already in the Tasmania system to provide IBD care and establishing formal mentoring relationships with major IBD centres in Australia. We suggest establishing a formal IBD transition clinic in line with national recommendations to help young people with IBD manage the changes as they move from paediatric to adult IBD care.

Supporting the North West

We suggest allocating specific funding to Launceston (medical, surgical and allied health) to care for the complex IBD patients from the North West, which will improve continuity of care, management and access to allied health services. Launceston currently admits and covers after‐hours emergencies for IBD patients from the North West; however, allocated funding will increase service provision to transition from a largely reactive model of care to a proactive approach. Establishing telehealth services will address travel issues and has proved effective for managing people with IBD in the Australian context. ²⁶ We also propose developing an IBD advice line from the North West to IBD experts in Tasmania to help support with managing patients locally.

Improve diagnostic outputs

Intestinal ultrasound (IUS) is fast becoming standard of care in IBD. ²⁷ Compared to MRI and colonoscopy, it is much better tolerated and inexpensive, allows immediate treatment decision making and has a reduced environmental impact. ²⁷ Many metropolitan Australian IBD centres have implemented and scaled up their intestinal ultrasound services to improve their long waiting list times for colonoscopy and MRI. An IUS service is planned to start at the Royal Hobart Hospital to achieve similar goals. The service will facilitate local gastroenterologists completing the “hands‐on” component of the IUS training, which has not been available in Tasmania. We plan to perform the majority of IBD imaging in the public hospitals to be reviewed by radiologists with an interest in IBD, who will closely collaborate with the clinical team and participate in MDT meetings.

Establish statewide IBD database and research infrastructure

A decade ago, Tasmania conducted one of the most comprehensive IBD incidence studies in the Southern Hemisphere. ²⁸ We aim to update these data with incidence and prevalence data. This will identify our patient numbers and proportions managed publicly and privately and allow us to identify how we are performing across a multitude of areas. Given the discrete population and single state health service, Tasmania has the unique potential to generate many excellent population‐based studies, much like the Edinburgh IBD group has done. ²⁹ , ³⁰ These will improve service delivery and advocacy and create opportunities to partner with other research bodies such as the Menzies Research Institute, which has numerous other datasets at its disposal, including environmental exposures. An additional benefit of creating a strong IBD research department is to create opportunities for early career Tasmanian doctors to develop and thrive in research, assisting them in being appointed to advanced training pathways, creating a pipeline for a sustainable gastroenterology workforce in Tasmania.

Incorporating digital solutions

Telehealth can improve access to care, particularly for people from the North West to receive care from Launceston. ²⁶ This would help with the significant travel distances which are costly and can be logistically difficult for people suffering from urgency, frequency and fatigue. In the Australian IBD context, telehealth has proved to be an effective model as demonstrated by a retrospective study conducted in Melbourne, which demonstrated high patient satisfaction, reduced work absenteeism and similar attendance rates compared to in‐person appointments. ³¹ Similarly high satisfaction rates were demonstrated by a study reporting results from a Queensland Health service, providing care for a large geographical area. ³² Biologic prescriptions increased over time, suggesting appropriate escalation of therapy can be achieved via telemedicine, and IBD‐related admissions did not increase out of proportion with rising incidence, suggesting quality of care was not compromised.

Incorporating living patient databases such as Crohn's Colitis Care (CCCare) or IBD‐PERFECT to assist with clinical management and auditing is another promising tool to improve clinical care and provide data for quality assurance. ³³ For example, CCCare captures patient‐reported disease activity, medical assessments, medication monitoring, cancer screening and preventive health, facilitates communication channels with the IBD team and referring doctor and has demonstrated good usability for clinicians and better communication channels for patients. ³⁴ CCCare has already published comparative data between centres highlighting where particular units are doing well and where there are areas for improvement. ³⁵ One challenge to adopting such software in resource‐strained settings is the significant ongoing subscription costs to premium clinical software; however, there are growing data demonstrating that eHealth technologies are associated with improved healthcare costs as well as improved clinical care, suggesting implementing them is a cost‐effective strategy. ³⁶

Implementing the action plan

We propose the action plan be conducted over three phases (Table 4). Phase 1 will focus on using the currently available resources to evolve the IBD service across Tasmania without the need for increased funding or infrastructure such as starting the IBD MDT and commencing a transition clinic. This will facilitate prompt change and yield immediate benefits to patient care. Phase 2 will require increased funding across the state to develop the IBD faculty and to increase staffing to more closely align with Australian and International standards. ⁶ Key priorities will include increasing medical and nursing staff to ensure patients can be seen in appropriate timeframes and to improve follow‐up intervals. Phase 2 will also include developing our allied health units, including dietetic and pharmacy services to deliver improved multidisciplinary care. Employing these key people will be important for both meeting clinical demand and providing the workforce required to further develop the service such as instituting an intestinal ultrasound service, engaging in quality research, creating research collaborations, mentoring junior doctors and developing support pathways to the North West. Phase 2 will likely occur over several years, including planning and business cases. Phase 3 will focus on transitioning into a consistently high‐quality multidisciplinary IBD service, like various large metropolitan IBD units, incorporating additional staffing such as IBD fellows and clinical psychologists and developing clinical trial units. The goals of phase 3 can be challenging and take many years, given many Australian IBD services currently do not feature clinical trials units or psychologists. ¹⁸ While we have created these phases, they are not mutually exclusive and may be worked upon simultaneously and create timelines for our goals to be achieved.

Table 4.

Phases of Tasmanian IBD action plan

Phase 1‐short term

Form statewide Tasmanian IBD MDT Appoint IBD service leads Formation of IBD faculty IBD education meeting Establish mentoring relationships with large tertiary IBD units Establish IBD transition clinic IBD endoscopy to be performed by those with training in IBD endoscopy Improve training and research opportunities for early career doctors Create research partnerships with local research organisations Centralise IBD service delivery to special interest healthcare professionals

Phase 2‐medium term

Increase medical FTE Increase nursing FTE Commence training and employment of nurse practitioners across the health services Create IBD pharmacist positions in the North and South Appoint dedicated IBD/gastroenterology dietician positions in the North and South Train allied healthcare professionals in IBD Form paediatric IBD unit Appoint IBD administrative staff Implement telehealth infrastructure to improve access to care Allocate funding to Launceston to care for complex IBD patients from the North West Create an IBD advice line for doctors from the North West to seek advice Implementation of an intestinal ultrasound service IBD imaging to be performed publicly and reported by radiologists with a special interest in IBD Conduct epidemiology study Conduct population outcomes studies Create wider research collaborations

Phase 3‐long term

Incorporate psychologist into the IBD units in the North and South Increase all FTE to match suggested Australian IBD standards including nurse practitioners Restructure allied health referral pathways from the North West for IBD care Create IBD Fellow position Develop clinical trials unit Establish wider research collaborations

Australian data supporting cost‐effectiveness

Establishing funding for full multidisciplinary IBD teams is a challenge in Tasmania and other metropolitan and regional areas in Australia. Demonstrating cost‐effective services is critically important to the success of business cases when reviewed by hospital administration and policymakers. Key Australian data demonstrating cost effectiveness of IBD multidisciplinary teams include the advanced IBD nursing service at a Melbourne tertiary hospital delivering a net estimated annual saving of up to AUD $570 838. ⁸ A study evaluating the provision of integrated psychological care model at a South Australian tertiary IBD service demonstrated a net saving of AU$84 905 over a 2‐year period. ³⁷ As described earlier, previous Australian survey data found a 22% reduction in IBD admissions through emergency departments with IBD units featuring partial IBD multidisciplinary services as compared to none. ¹⁸ Another important avenue of income revenue is clinical and paid investigator‐led trials. Australian data have demonstrated that developing a robust clinical trial unit generates significant profits for respective units and enables these profits to be invested in service delivery, including growing teams, extending staff contracts and purchasing equipment. ³⁸ When considering the savings of described analyses, these focus on hospital savings and do not include savings from primary care in the form of increased GP visits, or wider economic benefits such as missed work days and disability, which compromise more than half of the economic losses due to active IBD in Australia. ¹

While specific data are lacking, many services in Australia and across the developed world have moved to less medical consultant‐dominated outpatient models, utilising other healthcare professionals to conduct outpatient clinic appointments such as nurse practitioners and pharmacists for certain IBD clinical scenarios. This model presents the opportunity for significant cost savings for outpatient clinics given the generally higher salaries of medical consultants and can maintain quality care when executed appropriately. For example, pharmacist led thiopurine monitoring in an Australian IBD unit was non‐inferior to medically led outpatient monitoring with greater persistence and adverse event monitoring associated with pharmacist led monitoring. ¹⁵

Generalisable applicability of these strategies

While this action plan has been created for Tasmania, many of these issues are shared by other regional areas in Australia, who also face inequality of care compared to major tertiary institutions. One of the purposes of our action plan is to share our proposed solutions with other regional areas, in the hope it may be beneficial to their future strategic planning and raise awareness for the challenges regional areas in delivering quality IBD care. We believe collaborating not only within regional communities but also between regional communities is vitally important to improve IBD care across Australia.

Conclusion

Tasmania faces a diverse set of challenges in delivering equitable IBD care, many of which are shared by other regional locations. By identifying these barriers and proposing an action plan, we aim to catalyse statewide improvement while also providing a template for broader national reform. The success of this strategy will depend on coordinated investment in workforce, training, research and collaboration across the state. With the right support, Tasmania can provide a proactive, integrated, multidisciplinary IBD service that offers timely, high‐quality care to all Tasmanians living with IBD.

Disclosures

Alexander Elford has received travel expenses support from Dr Falk Pharma, Ferring Pharmaceuticals and Galapagos and speaking fees from Dr Falk Pharma and AbbVie. Anna Prebble has received travel expenses support from Dr Falk Pharma.

Data availability statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.