Quality of Surgical Care for Inflammatory Bowel Disease and Trends in Surgical Workload and Outcomes in the Biologic Era in Australia

Australia has one of the highest incidences of inflammatory bowel disease (IBD) in the world. Currently nearly 180,000 Australians are living with IBD, and the prevalence is predicted to increase by over 250% by 2030. Advances in medical management, most importantly the introduction of biologic therapy, have resulted in a reduction in the need for surgery internationally. The volume of IBD surgery occurring in Australia, and how the widespread introduction of biologic therapy has affected this, remain unknown and form a major focus of this thesis. Despite increasing use of biologics, it is evident that surgery remains a cornerstone of IBD management. Ensuring high-quality IBD surgical care is occurring in Australia is prudent. The Donabedian model has become the predominant framework for holistically assessing quality of care, highlighting the importance of evaluating a healthcare system’s structure, process, and outcomes. This quality framework is used within this thesis to provide a comprehensive overview and identify any inequality of IBD surgical care that may be occurring in Australia. Hospital-level structural factors, including a volume-outcome relationship, are of great interest in quality of IBD surgical care initiatives. This thesis systematically reviews existing evidence for the association between hospital-structural factors and outcomes following IBD ileal-pouch surgery. Additionally, evidence of an association following UC colectomies and ileal-pouch surgery within NSW Australia is explored using population-level data. The findings of this thesis represent a significant advance in the evidence base for IBD surgery trends and outcomes in Australia. The studies within this thesis align with the visions and strategies championed by Crohn’s Colitis Australia in conjunction with the greater IBD community. It is hoped that the findings of this thesis provide evidence to inform future national healthcare initiatives that improve the outcomes for IBD patients.