This scoping review developed a conceptual framework of avoidable IBD admissions by synthesising the current evidence surrounding avoidable IBD admissions. The framework builds upon the six themes identified in RQ1, incorporates the additional healthcare components and refinements from RQ2, and organises these components according to the Candidacy Framework as analysed in RQ3. This integration illustrates how avoidable IBD admissions result from inequities in accessing healthcare across the patient journey and highlights the complex interplay between individual, interpersonal, and organisational aspects of IBD care by guidance from the Candidacy Framework (22). Each component of the framework represents a potential point for intervention to reduce avoidable admissions.

Findings from this review identified seven healthcare components - suggesting possible interventions. These included access to: (1) Earlier intervention during flares, (2) specialist clinical advice, (3) rapid access to outpatient care, (4) patient education, (5) self-management support, (6) proactive care strategies and (7) collaborative multidisciplinary care and referral systems (Figure 2). In practice, these components will overlap and are not distinct. We acknowledge that several of these individual components - such as timely specialist access, patient education and multidisciplinary care - are well-recognised principles of high-quality IBD care (31,60). The contribution of this review is not the identification of these components in isolation, but rather their synthesis into a unified, theoretically grounded framework that maps them to stages of the patient journey through healthcare. This integration provides a structured basis for designing and evaluating service-level interventions that address multiple components simultaneously.

New insights presented in this review can inform IBD health service commissioners and healthcare providers of possible interventions to reduce avoidable IBD admissions, adding new knowledge to the limited understanding (61). The findings argue that system driven avoidable IBD admissions results from deficits or inequity in the provision of IBD healthcare (see Figure 2), aligning with outputs from a previous IBD health inequalities review (21). We use the term ‘inequity’ here not to denote demonstrated disparities between specific demographic groups (which most included studies did not report) but rather to denote system-level deficits in access that have the potential to produce unjust differences in outcomes (62). Where services fail to provide timely specialist assessment, education or self-management support, patients who lack the resources, knowledge or relationships to navigate these barriers are most likely to experience avoidable admissions. The absence of sociodemographic reporting in most included studies is itself a limitation. Without such data, the extent to which these access failures differentially affect disadvantaged populations cannot be quantified from the current evidence base. Healthcare implementation research also recognises the structural factors of healthcare systems that impact unequal access, quality, or outcomes of care (63).

Upon exploring terms of “avoidable”, “preventable” and “reducing” IBD admissions, these were found to have similar and overlapping features, and were used interchangeably across articles (64). This lack of consistent terminology is also a recognised issue in research on Ambulatory Care Sensitive Conditions (ACSCs). (14,65). ACSCs are defined as “where effective community and person-centred care can prevent the need for hospital admission”(66). Moreover, recent scoping review research improving the understanding of the preventability of readmissions in heart failure also found significant heterogeneity in definitions and measures (67).

However, unlike ‘unplanned admissions,’ these terms align with the principles of values-based healthcare, which prioritises improving patient experience and outcomes through efficiently organised specialist care.. Values-based healthcare centres on equitable healthcare focused on improving patient experience and outcomes through efficient organisation of care with specialist expertise (68). Future research with those who make use of terms such as avoidable and preventable admissions, such as IBD clinicians, should explore the implications on research and patient care.

The framework developed in this study demonstrates that avoidable IBD admissions reflect inequalities in service access and suboptimal quality of outpatient care. IBD services must promote timely access to multidisciplinary care and referrals, to earlier intervention during flares, and to opportunities to empower and educate PLwIBD. The multi-pronged definition presented is similar to previous research defining avoidable ED presentations (69). Services must aim to address inequalities in; access to specialist assessments, specialist advice, outpatient care, and patient-centered care strategies. Thereby implying that IBD systems are failing to deliver IBD care according to policy standards (31).According to the evidence, IBD services that implement rapid access pathways, IBD nurse support, patient education, and self-management tools may influence admissions by enabling earlier intervention through improving patient knowledge and condition management. Consequently, IBD services and policymakers should consider these evidence-based components when designing interventions and allocating resources to IBD care.

Factors and interventions for reducing IBD admissions included improving access to; outpatient care, follow-up care, earlier intervention, IBD nurses, prompt triaging, education and self-management, multidisciplinary care, personalised care plans and risk stratified care. Inadequate access to timely and rapid IBD care appears to be associated with avoidable unplanned admissions. A potential mechanism of this, which should be explored, is that a lack of timely IBD care results in increased uncontrolled symptoms, escalating to an unplanned admission. PLwIBD often report inadequate experiences and access to IBD care (70–72). However, the appropriate timing and role of outpatient follow-up remains unclear, and warrants further investigation to understand its influence on reducing admissions (73). Future research is necessary to explore changes in the structure of care delivery which incorporate some or all of these mechanisms, to reduce unplanned care use (74).

Yet, despite improvements in patient outcomes reported by studies, persisting issues of patient access, experience, and outcomes of care continue (21). The current model of IBD healthcare is difficult to manage and maintain, impeding quality of care (3,75). In the UK, Crohn’s and Colitis UK (CCUK) have continuously called for faster access to referrals, specialist care and treatment (3,8). We recommend alternative approaches for improving IBD care which may be explored through qualitative research that aims to understand and prioritise new healthcare processes.

The application of the Candidacy Framework revealed that permeability of services and operating conditions and local production of candidacy were the most prominent constructs in the literature. This highlights that organisational factors—such as the ease of using services—and interpersonal aspects, like positive patient-professional relationships, are critically important in reducing avoidable admissions (76). The evidence repeatedly underscored the integral role of IBD nurses in supporting candidacy across the patient journey (49–51,56,59,60), yet most UK services do not meet recommended staffing levels, potentially creating a significant barrier to care (77) (78).

Conversely, less can be inferred about offers and resistance to services and navigation of services, which was anticipated given the review’s focus on system-level rather than individual factors like medication adherence (79,80). Intolerable side effects often make medication-use challenging (79). Future qualitative research is needed to explore these patient-centric aspects of candidacy. Furthermore, newer constructs, such as the embodied relational self from Candidacy 2.0, could offer deeper insights into how intersecting patient identities impact access and should be explored in future IBD research e (26).

No qualitative studies were found that identified these specific system-level factors and future qualitative research is recommended to better understand patient experiences.. Given the CF’s focus on inequalities in access to care within disadvantaged groups, future IBD research should also engage with underserved populations. It is well known that underserved groups which may be defined by ethnicity, race, gender identity, socioeconomic status, disability and other characteristics, experience significant inequalities in health (81). However, very few studies included in this review reporting on characteristics such as race/ethnicity, socioeconomic status or other underserved characteristics. This is an area of unmet need identified in another IBD review (21).