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Abstract
The carbon footprint of the National Health Service (NHS) is estimated to be responsible for 5.9% of the total UK carbon footprint. The NHS has committed to reach carbon net zero by 2040, and therefore, all healthcare professionals have a role to play in identifying ways to help achieve this goal within their individual clinical areas. While specific research focusing on the carbon footprint of inflammatory bowel disease (IBD) care is limited, by combining principles of sustainable healthcare with work done in other healthcare areas, we can start to develop ideas to inspire our own sustainable IBD care. The aim of this review article is to examine each part of the IBD care pathway and consider where improvements in sustainability can be made or future research should be focused.
- IBD
- ENVIRONMENTAL HEALTH
- INFLAMMATORY BOWEL DISEASE
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Climate change poses a significant threat to human health and healthcare is a major contributor to global carbon emissions.
The National Health Service has committed to reach carbon net zero by 2040.
WHAT THIS STUDY ADDS
This study highlights areas within inflammatory bowel disease (IBD) care where we can help to reduce emissions including by reducing patient travel, reducing unnecessary investigations, increasing use of digital technology and aiming to optimise care and patient education.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
We highlight where further research is needed such as work to understand the carbon footprint related to medical treatment of IBD.
Introduction
Climate change poses a significant threat to public health.1 The National Health Service (NHS) is the largest public greenhouse gas contributor in the UK and is estimated to be responsible for 5.9% of all UK environmental emissions.1 2 This means our actions as healthcare providers can have a big impact and 92% of the UK public think it is important for health systems to function more sustainably.3 The NHS has committed to reach carbon (CO2) net zero by 2040 and with 24% of carbon emissions coming from direct patient care and 10% from staff, patient or visitor travel we have multiple avenues with which we can help achieve this goal.1 Inflammatory bowel diseases (IBDs) are chronic diseases requiring lifelong care and through investigations, hospital admissions, outpatient visits, endoscopies and medicines pose a significant financial and environmental burden. For further context, there are an estimated 500 000 patients with IBD in the UK.4
Calculating the carbon footprint of specific elements of patient care can be challenging. However, there are simple approaches that we can take to reduce the environmental cost while supporting and improving patient outcomes as described by the Centre for Sustainable Healthcare’s Principles of Sustainable Clinical practice (CSH)(Box 1).5
Centre for Sustainable Healthcare’s Principles of Sustainable Clinical Practice:
Prevention
Patient empowerment and self-care
Lean care systems
Low carbon alternatives
In this review article, we aim to consider a standard journey for a person with IBD and, by using the aforementioned Principles of Sustainable Clinical Practice, show potential opportunities to reduce our carbon footprint and importantly highlight areas for future research (see figure 1). It is important to recognise that in many areas the evidence is only beginning to emerge and therefore recommendations often rely on extrapolation from small studies or larger studies from other disease areas. Future research calculating any tangible reduction in carbon footprint resulting from these changes will be important.
Easily adoptable suggestions for clinicians aiming to reduce their carbon footprint. IBD, inflammatory bowel disease.
Referrals
Patients are typically referred into IBD services from primary care. In IBD when we consider the first principle of sustainable healthcare ‘prevention’, we commonly mean prevention of poor disease control or complications. A recent meta-analysis demonstrated delays in diagnosis were associated with increased odds of stricturing, penetrating disease and intestinal surgery in Crohn’s disease (CD) and higher odds of colectomy in patients with ulcerative colitis (UC).6 Furthermore, delayed diagnosis is associated with higher IBD-related hospital admissions.7 It is, therefore, likely that delayed diagnosis results in a more complex disease course, therefore, more hospital visits, investigations and treatment, and consequently a higher carbon footprint than well-controlled disease.
The delays in diagnosis are in part related to patient, primary and secondary care delays and understanding where delays come from may help us prevent them.7 Public knowledge regarding IBD is limited, which may result in delayed help-seeking behaviour.8 Public health campaigns provide patient education and are shown to improve uptake and awareness of cancer screening although evidence to suggest ‘awareness days’ such as world IBD day increase related web searches is limited.9 10
Time from primary care referral to diagnosis in secondary care and time to treatment following diagnosis have now been suggested as key performance indicators, which may empower clinicians to develop lean care systems such as stream-lined referral pathways.11 Traditionally, patients are referred and seen in a clinic prior to endoscopy. The introduction of faecal calprotectin (FCP) has allowed for appropriate triage of referrals for young adults with suspected IBD and straight-to-test colonoscopy.12 Furthermore, introduction of a direct-access IBD physician-led endoscopy pathway has been shown to reduce time to diagnosis and treatment by 86.4% (21.9 weeks p<0.0001).13 Combining endoscopic investigations with outpatient appointments will also result in less patient-related travel which accounts for a significant environmental burden within health services.
Finally, the mode of referral should be considered to ensure prioritisation of low-carbon alternatives. With a goal to reduce paper usage by 50% in secondary care by increasing digitalisation, electronic referrals are preferable and this reduction in paper usage should be seen throughout the care pathway including in clinic and endoscopy.14
Clinics
Clinic appointments are an essential component to IBD care. An estimated 3.5% of all UK journeys are thought to be healthcare related, therefore, considering low-carbon alternatives could have a significant impact and patients appreciate a choice between face-to-face, telephone or video appointments.15 16 King et al demonstrated telephone appointments reduced carbon emissions dramatically when compared with face-to-face appointments (1159.92 kg CO2e, 99.37%; p=0.0001).17 While rates of non-attendance were higher in the telephone group, fewer blood tests were requested and importantly there was no significant difference between 90-day admission rates or mortality.17 Clearly, face-to-face appointments are preferable in certain circumstances, for example, when complex discussions or physical assessment is required, however, nationwide audits have shown that over 75% of patients are in clinical remission or have mild disease when attending clinic.18 Further work is needed to establish how patient behaviour and engagement may be influenced by a longer-term focus on remote appointments. This may affect adherence to medication or the patient’s relationship with the clinical teams, for example, impacting willingness to discuss sensitive information remotely. Reconsideration of traditional appointment schedules may be appropriate, with long-term stable patients undergoing telephone follow-up and initiation of ‘flare’ appointment slots, that is, keeping a small number of appointment slots free each week to allow timely review of any patients with flaring symptoms or urgent issues. Improved availability of appointments could be facilitated using patient-initiated follow-up. Some hospitals have protocols allowing stable patients to request follow-up at a time which is relevant for them, rather than dictated by clinicians. There are many possible iterations of this and an example protocol and patient information sheet is provided by IBD-UK.19 These have been shown to reduce hospital admission and outpatient appointments.20 21
The introduction of ‘lean-care systems’ could also help reduce patient-related travel. A ‘one-stop-shop’ clinic for managing flares has been tested by one team. They demonstrated that by booking patients with a possible flare onto a specific IBD-flare endoscopy slot (following negative stool testing for infection) patients who were scoped by an IBD physician were more likely to be initiated on treatment than those who were not and this subsequently led to a reduction in outpatient appointments.22
Finally, our best opportunity to provide patient education and empowerment is in clinic. By providing patient education, we can promote self-care ensuring patients understand the importance of medication compliance and how to manage and report flares allowing early optimisation. This can be facilitated by web-based patient management portals which have been demonstrated to reduce clinic backlogs, improve patient education and satisfaction.23 Final considerations in clinic should be to reduce paper documentation and ensure lights and computers are turned off at the end of each session.
Investigations
Bloods and stools
Blood tests often involve patient travel, not to mention the tubes and testing in the pathology lab. A systematic review demonstrated up to 20.6% of bloods requested are not clinically indicated therefore prevention of unnecessary blood tests is a simple way to reduce our carbon footprint.24 An Australian study estimated the carbon footprint of commonly used blood tests to be 82–116 g CO2e.25 While UK calculations would vary due to travel differences for consumables the main sources of CO2 emissions were sample collection consumables (64%), rather than reagents or lab power. This highlights the importance of combining blood tests, for example, for secondary and primary care and aiming to reduce total number of procedures undertaken. With this in mind, we should also aim to work with our primary care colleagues to reduce the distance patients need to travel. Finally, there are limited data available on the frequency of blood monitoring required for medications such as thiopurines and this area requires further research.
In terms of biochemistry, we must consider FCP as a potentially low carbon alternative. While endoscopy will still be required for first diagnosis, FCP has been shown to correlate with endoscopic inflammation in UC and CD and can be considered as an alternative to endoscopy for monitoring and flare management, which will be discussed in more detail below.26 With evidence suggesting home calprotectin tests are associated with improved return and compliance rates, this also gives us an opportunity to reduce patient travel.27
Radiology
The green radiology movement is also gathering momentum. Focus is on decreasing energy and water use, switching to biodegradable materials, recycling, decreasing and improving disposal of waste.28 29 From an IBD perspective, imaging is more commonly used in CD where it is important throughout the patient’s journey. Nevertheless, there needs to be clear patient benefit from imaging and avoidance of unnecessary investigations when results will not change patient management should be prioritised. To this end, there are well published guidelines that focus on the appropriate utilisation of imaging.26 30
When imaging is required, the next question is which type of scan is best. Commonly computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound (USS) are used, with which to use guided by several factors including the clinical question, local resources and patient factors, for example, age, ability to breath-hold, accumulated imaging induced radiation burden and ability to tolerate the preparation or scan. While meta-analysis show no significant difference in diagnostic accuracy for CD between CT-enterography (CTE), MR-enterography (MRE) or small bowel USS (SBUS), a large head-to-head multicentre, prospective cohort study, demonstrated MRE was more sensitive for small bowel disease than SBUS, although SBUS was superior to MRE for colonic disease.26 31 Most patients prefer the experience of USS than MRE; nevertheless, notably patients rated test accuracy as more important than scan burden.32
McAlister et al reviewed the carbon footprint of hospital diagnostic imaging; demonstrating lower carbon emissions for USS and higher carbon emissions for MRI (0.8 kg/scan for US, 9.2 kg/scan for CT and 17.5 kg/scan for MRI)33 with similar results found by Martin et al.34 MRI requires a continuous power supply even when not scanning for helium cooling, therefore, consumes vast amounts of energy. While manufacturers are reviewing this and investing in new cooling systems, more power efficient standby modes and post processing/artificial intelligence/optimised workflows, it is hard to ignore the current environmental burden MRI poses.
As requestors of medical imaging, we must consider the carbon impact of our modality of choice. While MRE is relatively widely available throughout the UK, access to SBUS is poor and this further limits the ability to reduce the dependence on MRE.35 Where available SBUS has a significant role in patient care alongside an economical benefit.36 A national roll-out of SBUS alongside a training initiative for clinicians to learn how to perform this is urgently required. This would also allow us to perform a one-stop clinic for flares as is done more commonly in Europe.37
Endoscopy
The national census of UK endoscopy services in 2021 demonstrated that over a million endoscopic procedures are performed each year38 and consequently endoscopy has been recognised as a high yield opportunity to reduce the carbon footprint within gastroenterology.39 The British Society of Gastroenterology (BSG), Joint Accreditation Group and CSH developed consensus guidelines on practical measures for environmental sustainability in endoscopy, which are an important read for all endoscopists and cover important issues including nitrous oxide use and capture.40 Within IBD specifically there are certain areas which should be considered further.
With a focus on preventing unnecessary procedures, we must consider the indications for endoscopies in IBD care:
Diagnosis.
Flare assessment.
Surveillance.
For diagnosis of both UC and CD, full ileocolonoscopy and biopsy is advised by the BSG.26 However, for flares, as discussed above, FCP may be an appropriate low carbon alternative. If endoscopy is required, as previously discussed, the use of a specific flare endoscopy slot can reduce the number of patient journeys while speeding up treatment.
Rates of colorectal cancer are higher for patients with colonic IBD.41 Surveillance colonoscopies are advised for patients with a history of colonic IBD with the aim of detecting premalignant lesions or early cancers.26 Incidence rates of advanced colorectal cancer have fallen since the introduction of surveillance and while the incidence rate of dysplasia has increased, the incidence rate of colectomy has decreased, perhaps due to endoscopic management.41 Fewer operations and cancer diagnoses likely means a lower carbon footprint burden therefore the benefits of surveillance are plentiful. However, we need to ensure this is done in accordance with current surveillance guidelines, in particular, patients with proctitis 8 years after diagnosis do not require surveillance nor patients with CD who have never had large bowel disease.26 Second, we need to consider at what point surveillance is discontinued. A specific age cut-off is inappropriate, but the appropriateness of ongoing surveillance must be discussed with older patients on an individual basis. Furthermore, the current BSG guidelines on this subject are under review and will consider whether patients whose inflammation has been well controlled for many years need ongoing 5-yearly surveillance.
Next, when patients attend for colonoscopy, we must aim to reduce the need for repeat procedures, which would essentially double the carbon footprint. First, we should consider bowel preparation as often insufficient bowel clearing needs to repeat investigations. Studies have shown that patient education and timing of bowel preparation have an impact so preassessment patient education is vital.42 43 Preassessments can be done effectively over the telephone to reduce patient travel.44 45 For diagnosis, endoscopists should be educated regarding the importance of terminal ileal intubation to avoid delayed diagnosis and repeat procedures. Furthermore, high-quality endoscopy reports with appropriate digital images also reduce the need for repeat procedures.40
Finally, we need to consider when to biopsy. While there is now significant evidence that chromoendoscopy is superior to white light endoscopy for identification of dysplasia,46 there is still evidence of dysplasia being identified on random biopsy and so for now the guidance remains to perform random biopsies in addition to targeted biopsies of lesions identified under chromoendoscopy in high-risk patients including those with primary sclerosing cholangitis, previous neoplasia or dysplasia, strictures or ongoing active inflammation.47 48
Treatments
When we think about treatments for IBD, we usually consider medications first. However, there are important lifestyle changes we should advocate. Smoking worsens outcomes for patients with CD and is linked to multiple medical conditions therefore smoking cessation advice is essential to prevent worsening disease, comorbidity and the associated CO2 burden.49 All clinicians should also promote general healthy lifestyle advice, with a focus on moving more, eating a balanced diet and managing stress. This can reduce health-related CO2 emissions by improving health and reducing healthcare utilisation.
The primary goal for medical treatment for IBD is symptomatic control. Historically, this involved a step-up approach of medications, with consideration of surgery where medical therapy failed or was futile. More recently, treatment targets such as mucosal or histological remission have become the focus of research with evidence from meta-analysis suggesting, particularly in UC, that histological remission is associated with lower rates of flare, surgery and hospital admission.50 However, these harder targets remain somewhat contentious.26 The STRIDE II (selecting therapeutic targets in IBD) consensus suggests loose time-specific targets and combines patient-centred targets such as stool frequency and quality of life with biochemical remission, endoscopic healing and the possibility of targeting histological remission.51 The difficulty with these more rigorous targets is that while they may achieve better outcomes and reduce future complications, they require more frequent endoscopic evaluation which comes at a higher financial, environmental and patient burden. The CALM trial randomised patients with CD to ‘tight control’, where medications were escalated based on tight biochemical endpoints and standard care. The ‘tight control’ group was more likely to have endoscopic remission at 1 year and less likely to have been admitted to hospital or had surgery.52 Perhaps further research should focus on understanding in which patients we need to chase harder targets and in which an approach similar to the CALM trial could be appropriate. In general, investigations should only be undertaken when clinicians and patients agree that results may lead to changes in management and when this is unlikely, for example, patients on last-line therapy, unnecessary tests should be avoided.
Before deciding current therapy is ineffective, it is important to assess patient compliance. Non-adherence rates are high and associated with flare, loss of response to medications, higher morbidity and mortality.53 Poor compliance is, therefore, likely to be linked to increasing investigations, admissions, surgery and consequently a higher carbon footprint. It is important to not only recognise non-compliance but also to address causes, for example, inability to afford prescriptions. Discouraging stockpiling and regularly reviewing repeat prescriptions is a priority from the General Practice Committee at the British Medical Association with a goal to reduce waste and we should also play our part in IBD care.54
Further research is needed to allow us to fully understand the carbon footprint of IBD medications. While we await this data, we should ensure that medications are optimally prescribed in terms of dose, for example, reduce mesalazine from treatment dose to maintenance or optimise azathioprine dose based on metabolite levels where appropriate. These simple changes could reduce the number of tablets, and therefore, reduce waste. For some medications, we have a choice between preparations, for example, biologics such as infliximab and vedolizumab. It has been suggested that subcutaneous versions have a lower travel related CO2 footprint, however, these studies did not include travel of medication to the patient in their calculations.55 56 Additional factors add to the complexity of comparing drug formulations including requirement for individual patient sharps bins so further research is required to understand the optimal preparation from an environmental perspective. Recycling schemes for medication packaging should also be highlighted and encouraged.
Patients with IBD frequently need surgery. Clearly, decisions regarding appropriateness of surgery should come down to individual patient factors and preferences rather than carbon footprint concerns. However, there is a growing movement within anaesthesia and surgery to make greener choices, for example, choice of anaesthetic agent which should be encouraged.57 58
Education and advocacy
As healthcare providers we should try to influence sustainable change at all levels. We can use our voices to promote system change at a local hospital level, for example, improved electronic systems, renewable energy sourcing and at a national level, for example, demanding easier and safer access to active travel or good public transport or encouraging pharmaceutical companies to ensure medication packaging is easy to recycle.59 Educational events ran by organisations such as the CSH and the BSG can help us understand our role in this further and guide impactful action.
Conclusion
The climate crisis should be a priority for all clinicians to ensure the future of our planet but also to ensure that patients do not suffer the effects of climate change themselves. While we have a lot to learn, simple, logical steps to reduce unnecessary travel and testing are an easy place to start.
Ethics statements
Patient consent for publication
References
Footnotes
X @IzzyCarbery, @rachelcooney7
Contributors IC developed the idea for the manuscript and wrote the initial draft. IC, GB, RC and CS contributed to writing, reviewing and editing the final manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests IC has received speaker honoraria from Celltrion, research grants from Celltrion and has received a travel grant from Galapagos and Celltrion. CS has received unrestricted research grants from Warner Chilcott, Janssen and AbbVie, has provided consultancy to Warner Chilcott, Dr Falk, AbbVie, Takeda, Fresenius Kabi, Eli Lilly, Galapagos, Ferring, Arena and Janssen, and had speaker arrangements with Warner Chilcott, Dr Falk, AbbVie, MSD, Pfizer, Eli Lilly, BMS, UCB, Fresenius Kabi, Celltrion and Takeda.
Provenance and peer review Commissioned; externally peer reviewed.