Group intervention for pediatric patients with functional constipation: Telehealth as an opportunity for increased access and engagement

Background: Behavioral interventions for functional constipation (FC) are demonstrated to improve success rates and soiling frequency relative to medical treatment alone. Group treatments serving multiple patient-families (PFs) enhance social support and access to behavioral interventions. Intervention for Soiling, fecal Incontinence, and reToileting (I-SIT) is a group treatment for patients diagnosed with FC, with or without fecal incontinence, and their caregivers, implemented at Children's Hospital of Philadelphia. Sessions are facilitated by licensed psychologists and billed as health and behavior group intervention. Satisfaction with the I-SIT program is extremely high (100% of PFs would highly recommend I-SIT to another family) but enrollment has been consistently lower than capacity. Low enrollment has been attributed to logistical barriers (scheduling, distance). Given staffing requirements for in-person I-SIT, low enrollment results in patient:staff ratios that limit access to behavioral interventions. To address enrollment barriers, I-SIT was adapted to a virtual telehealth platform which was able to be implemented during the COVID-19 pandemic. The goal of this quality improvement (QI) project was to increase enrollment to I-SIT by adapting to a telehealth platform while maintaining high PF satisfaction. Method: Gastroenterologists referred patients (ages 5-10) to GI Psychologists for assessment and eligible patients were referred to I-SIT. All enrolled patients had a diagnosis of FC (with or without fecal incontinence). Exclusion criteria included need for individualized intervention due to psychiatric or developmental comorbidity or use of interpreter. Nine families participated in I-SIT across three cohorts during FY2017-2018. In person I-SIT was delivered by two psychologists across 4 weekly, 1 hour sessions with separate child and caregiver groups. Eleven families participated in virtual I-SIT across three cohorts during FY2020-2021. Virtual I-SIT was delivered by one psychologist via family sessions (child and caregiver together). Virtual I-SIT Cohorts 1 and 2 were delivered using the same schedule as in person I-SIT. Virtual I-SIT Cohort 3 was delivered across 3 biweekly, 90 minute sessions due to provider schedule, with caregiver only portions of each session in response to Cohorts 1 and 2 feedback. Content was identical across delivery platforms and included FC education, goal-setting, behavioral strategies for medication adherence and structured toilet sitting, collaborating with schools, and coping with social concerns. Following completion of I-SIT and virtual I-SIT, caregivers completed a 7-item satisfaction survey including quantitative and qualitative items. Completers of virtual I-SIT completed an additional 5 item telehealth survey regarding session duration, frequency, and format to inform QI efforts. Results: Primary outcome of enrollment increased with virtual I-SIT (11 telehealth patients in 3 cohorts compared to 9 in-person patients in 3 cohorts). Given decreased staffing requirements for telehealth format and increased enrollment, access to behavioral interventions for FC is improved with virtual I-SIT (3.67 telehealth patients per psychologist;1.5 in-person patients per psychologist). Engagement is also improved with virtual I-SIT (81% virtual group completers;67% in person group completers). Acceptability of virtual I-SIT was also high for group completers (1 PF prefers in-person;4 PFs prefer virtual;4 PFs unsure). Our balancing metric of patient satisfaction did show signs of decreased satisfaction with Cohort 3 of virtual I-SIT. All group completers from in-person Cohorts 1-3 and virtual Cohorts 1 and 2 would “highly recommend” I-SIT or virtual I-SIT while two PFs in virtual Cohort 3 indicated they would recommend virtual I-SIT and one reported feeling neutral. Duration, frequency, and number of sessions differed for virtual Cohort 3, and one PF was enrolled after brief screening rather than full assessment. Cohort 3 feedback indicated preference for former duration and umber of sessions (60 minutes or less, 4+ sessions) which may explain the decline in satisfaction. Conclusion: Enrollment to a group intervention and access to behavioral interventions for pediatric patients with FC and their families was increased with conversion to a telehealth format while maintaining satisfaction and increasing engagement. Family feedback suggests telehealth group format should include caregiver-only portions and shorter group sessions. To continue our quality improvement effort to increase enrollment, our next intervention will focus on improved advertising and consideration of primary care referrals. Future directions also include inclusion of FC outcome measures and digital adaptation of educational materials (e.g., videos, mobile phone applications).