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Wong C, Bassett P, Kamperidis N, Misra R, Younge L, Dyall L, Yeung K, Rejee C, Arebi N. Prolonged time to treatment of biologics in inflammatory bowel disease: disparities from a retrospective study in a tertiary referral centre in the UK. BMC Gastroenterol 2025; 25:352. [PMID: 40346554 PMCID: PMC12063266 DOI: 10.1186/s12876-025-03909-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2025] [Accepted: 04/17/2025] [Indexed: 05/11/2025] Open
Abstract
BACKGROUND Several disparities in healthcare utilisation and delivery are reported in inflammatory bowel disease (IBD). We examined disparities for delays in biologic administration. METHODS This is a tertiary centre, retrospective, cohort study of consecutive adult IBD outpatients referred to the biologics clinic (BC) for initiation of therapy over 2 years. We collected patient-, disease- and service-related data in addition to adverse clinical outcomes (primary non-response, corticosteroid prescription, IBD hospital admission and surgery) within 6 months of the first dose of therapy. The primary outcome was time-to-therapy (TTT): time interval from referral to the first drug dose. Univariate and multivariate regression analyses examined associations between variables and TTT. RESULTS 240 patients started biologics: 87 (36%) ulcerative colitis (UC) and 153 (64%) Crohn's disease (CD). Median referral age was 43 years (IQR 34-56) and 128 (53%) were male. Charlson Comorbidity Index was ≤ 1 in 185 patients (77%) and 141 (59%) were biologic naïve. 91 (37.9%) were White British, 88 (36.7%) Asian (Indian or Pakistani), 61 (25.4%) were from other ethnic groups. Median TTT was 76 (IQR 56-97) days. In multivariable analysis, longer TTT was associated with CD, other ethnic groups and Adalimumab. Lack of funding at the time of BC and referral age were of borderline statistical significance. Adverse outcomes at 6 months was significantly associated with C-reactive protein level > 10 mg/L (OR 2.13; p = 0.03) but not with longer TTT. CONCLUSIONS Delays in initiating biologic therapy are significantly associated with IBD type, ethnicity and therapy type. Unwarranted variation in IBD care can be mitigated by concerted initiatives to address modifiable factors for timely access to effective therapies.
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Affiliation(s)
- Charlotte Wong
- Department of Inflammatory Bowel Disease, St Mark's National Bowel Hospital, London, UK.
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK.
| | | | - Nikolaos Kamperidis
- Department of Inflammatory Bowel Disease, St Mark's National Bowel Hospital, London, UK
| | - Ravi Misra
- Department of Inflammatory Bowel Disease, St Mark's National Bowel Hospital, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Lisa Younge
- Department of Inflammatory Bowel Disease, St Mark's National Bowel Hospital, London, UK
| | - Lovesh Dyall
- Department of Inflammatory Bowel Disease, St Mark's National Bowel Hospital, London, UK
| | - Katie Yeung
- Department of Inflammatory Bowel Disease, St Mark's National Bowel Hospital, London, UK
| | - Christy Rejee
- Department of Inflammatory Bowel Disease, St Mark's National Bowel Hospital, London, UK
| | - Naila Arebi
- Department of Inflammatory Bowel Disease, St Mark's National Bowel Hospital, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
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Kuenzig ME, Stukel TA, Carroll MW, Kaplan GG, Otley AR, Singh H, Bitton A, Fung SG, Spruin S, Coward S, Cui Y, Nugent Z, Griffiths AM, Mack DR, Jacobson K, Nguyen GC, Targownik LE, El-Matary W, Bernstein CN, Dummer TJB, Jones JL, Lix LM, Murthy SK, Peña-Sánchez JN, Nasiri S, Benchimol EI, On behalf of the Canadian Gastro-Intestinal Epidemiology Consortium. Variation in the Care of Children with Inflammatory Bowel Disease Within and Across Canadian Provinces: A Multi-Province Population-Based Cohort Study. Clin Epidemiol 2024; 16:91-108. [PMID: 38374886 PMCID: PMC10875172 DOI: 10.2147/clep.s449183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 01/25/2024] [Indexed: 02/21/2024] Open
Abstract
Purpose The incidence of childhood-onset inflammatory bowel disease (IBD) is rising. We described variation in health services utilization and need for surgery among children with IBD between six and 60 months following IBD diagnosis across Canadian pediatric centers and evaluated the associations between care provided at diagnosis at each center and the variation in these outcomes. Patients and Methods Using population-based deterministically-linked health administrative data from four Canadian provinces (Alberta, Manitoba, Nova Scotia, Ontario) we identified children diagnosed with IBD <16 years of age using validated algorithms. Children were assigned to a pediatric center of care using a hierarchical approach based on where they received their initial care. Outcomes included IBD-related hospitalizations, emergency department (ED) visits, and IBD-related abdominal surgery occurring between 6 and sixty months after diagnosis. Mixed-effects meta-analysis was used to pool results and examine the association between center-level care provision and outcomes. Results We identified 3784 incident cases of pediatric IBD, of whom 2937 (77.6%) were treated at pediatric centers. Almost a third (31.4%) of children had ≥1 IBD-related hospitalization and there were 0.66 hospitalizations per person during follow-up. More than half (55.8%) of children had ≥1 ED visit and there were 1.64 ED visits per person. Between-center heterogeneity was high for both outcomes; centers where more children visited the ED at diagnosis had more IBD-related hospitalizations and more ED visits during follow-up. Between-center heterogeneity was high for intestinal resection in Crohn's disease but not colectomy in ulcerative colitis. Conclusion There is variation in health services utilization among children with IBD and risk of undergoing intestinal resection in those with Crohn's disease, but not colectomy among children with ulcerative colitis, across Canadian pediatric tertiary-care centers. Improvements in clinical care pathways are needed to ensure all children have equitable and timely access to high quality care.
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Affiliation(s)
- M Ellen Kuenzig
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children (Sickkids), Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Therese A Stukel
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Matthew W Carroll
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Gilaad G Kaplan
- Departments of Medicine & Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Anthony R Otley
- Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Harminder Singh
- Univeristy of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Research Institute at CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Alain Bitton
- McGill University Health Centre, Division of Gastroenterology and Hepatology, Montreal, Québec, Canada
| | - Stephen G Fung
- CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
| | - Sarah Spruin
- ICES, Toronto, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Stephanie Coward
- Departments of Medicine & Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Yunsong Cui
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Zoann Nugent
- Univeristy of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Anne M Griffiths
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children (Sickkids), Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - David R Mack
- CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Kevan Jacobson
- Department of Pediatrics, BC Children’s Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Geoffrey C Nguyen
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Laura E Targownik
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Wael El-Matary
- Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Charles N Bernstein
- Univeristy of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Trevor J B Dummer
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Jennifer L Jones
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Lisa M Lix
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sanjay K Murthy
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Division of Gastroenterology, The Ottawa Hospital IBD Centre, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Juan Nicolás Peña-Sánchez
- Department of Community Health & Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Soheila Nasiri
- CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
| | - Eric I Benchimol
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children (Sickkids), Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - On behalf of the Canadian Gastro-Intestinal Epidemiology Consortium
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children (Sickkids), Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- Departments of Medicine & Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
- Univeristy of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Research Institute at CancerCare Manitoba, Winnipeg, Manitoba, Canada
- McGill University Health Centre, Division of Gastroenterology and Hepatology, Montreal, Québec, Canada
- CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- Department of Pediatrics, BC Children’s Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Division of Gastroenterology, The Ottawa Hospital IBD Centre, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Department of Community Health & Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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Dorofeyev A, Dorofeyeva A, Borysov A, Tolstanova G, Borisova T. Gastrointestinal health: changes of intestinal mucosa and microbiota in patients with ulcerative colitis and irritable bowel syndrome from PM 2.5-polluted regions of Ukraine. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2023; 30:7312-7324. [PMID: 36038689 DOI: 10.1007/s11356-022-22710-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 08/21/2022] [Indexed: 06/15/2023]
Abstract
Here, clinical studies of patients were conducted to assess changes in patients with ulcerative colitis (UC) and irritable bowel syndrome (IBS) associated with air pollution by PM. A comparative study of 100 patients with UC and 75 with IBS from highly (HPRs) and low (LPRs) PM2.5-polluted regions of Ukraine was conducted. Biopsy of the intestinal mucosa of patients with UC from HPRs showed severe cellular infiltration. Patients with IBS from HPRs had changes in the superficial epithelium (focal desquamation), and inflammatory-cellular infiltration of mucous membrane of the colon. In patients with UC, changes in mucus production were found, which were more significant in HPR patients. PAS response did not depend on the residence; the level of MUC2 was significantly lower in HPR patients with UC (1.12 vs 2.15 au). In patients with UC from HPRs, a decrease in Bacteroidetes (34.0 vs. 39.0 small intestinal bacterial overgrowth (SIBO), ppm) and an increase in Proteobacteria compared to LPRs were shown. In IBS patients, significant differences were found in the level of Proteobacteria, which was higher in HPRs. The level of regulatory flora Akkermansia muciniphila and Faecalibacterium prausnitzii reduced in patients with UC from HPRs. In patients from LPRs, the level of Akkermansia muciniphila raised above normal (2.8 vs 4.7 SIBO, ppm). Similar changes of regulatory flora have been identified in patients with IBS from different regions. Therefore, a more severe course of the disease (more pronounced cellular infiltration and violation of the microbiota) was shown in patients with UC from HPRs as compared to LPRs.
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Affiliation(s)
| | - Anna Dorofeyeva
- D. F. Chebotarev State Institute of Gerontology of the National Academy of Medical Sciences of Ukraine, Kiev, Ukraine
| | - Arsenii Borysov
- Department of Neurochemistry, Palladin Institute of Biochemistry, National Academy of Sciences of Ukraine, 9 Leontovicha Street, Kiev, 01054, Ukraine
| | | | - Tatiana Borisova
- Department of Neurochemistry, Palladin Institute of Biochemistry, National Academy of Sciences of Ukraine, 9 Leontovicha Street, Kiev, 01054, Ukraine.
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Sariahmed K, Kurian J, Singh AK, Leyton C, Minuti A, Jerschow E, Arora S, Jariwala SP. Social, political, and economic determinants of access to biologics: A scoping review of structural determinants in the clinical disparities literature. Res Social Adm Pharm 2022; 18:4038-4047. [PMID: 35963767 DOI: 10.1016/j.sapharm.2022.07.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 05/05/2022] [Accepted: 07/28/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The number of biologics among new medication approvals is increasing. Social, political, and economic factors influence access to these expensive medications. Disparities in access to new medications can exacerbate health disparities. The notion of "structural determinants" provides a theoretical framework for broadly evaluating the integration of upstream social, political, and economic determinants in the clinical study of access. OBJECTIVE To review the literature on access to FDA approved biologic medications with particular focus on the integration of social, political, and economic determinants into study design and interpretation. METHODS We used PRISMA guidelines to review studies on racial and socioeconomic disparities in biologic access through August 2020. We assessed whether the design or interpretation of studies considered key economic determinants of access: the biologics supply chain, trade agreements, patents, drug research and development, insurance reimbursement, and non-insurance drug policies. RESULTS 100 studies met our inclusion criteria. Sixty-six studies considered insurance reimbursement, but trade law, patents, and other key economic determinants were rarely considered. The literature focuses on a small number of older biologics. CONCLUSIONS A small number of studies model the integration of structural determinants into clinical research on access to biologics, but overall this literature has many limitations and lacks integration of structural determinants. Increased interdisciplinary collaboration, availability of manufacturer data, and use of disease registries can help create structurally grounded understandings of the relationship between the political economy of expensive medications and clinical disparities.
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Affiliation(s)
- Karim Sariahmed
- Montefiore Medical Center Department of Medicine, United States.
| | - Joshua Kurian
- Montefiore Medical Center Department of Medicine, United States
| | - Anjani K Singh
- Montefiore Medical Center Division of Allergy/Immunology, United States
| | | | - Aurelia Minuti
- D. Samuel Gottesman Library at Albert Einstein College of Medicine, United States
| | - Elina Jerschow
- Montefiore Medical Center Division of Allergy/Immunology, United States
| | - Shitij Arora
- Montefiore Medical Center Division of Hospital Medicine, United States
| | - Sunit P Jariwala
- Montefiore Medical Center Division of Allergy/Immunology, United States
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Fudman DI, Perez-Reyes AE, Niccum BA, Melmed GY, Khalili H. Interventions to Decrease Unplanned Healthcare Utilization and Improve Quality of Care in Adults With Inflammatory Bowel Disease: A Systematic Review. Clin Gastroenterol Hepatol 2022; 20:1947-1970.e7. [PMID: 34481951 DOI: 10.1016/j.cgh.2021.08.048] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/25/2021] [Accepted: 08/30/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Inflammatory bowel disease (IBD) care and outcomes exhibit substantial variability, suggesting quality gaps. We aimed to identify interventions to narrow these gaps. METHODS We performed a systematic review of Medline, Embase, and Web of Science through May 2021 to find manuscripts and abstracts reporting quality improvement (QI) interventions in IBD. We included studies with interventions that addressed acute care utilization, vaccination, or Crohn's and Colitis Foundation quality indicators for care processes, including pre-therapy testing, tobacco cessation, colorectal cancer surveillance, Clostridium difficile infection screening in flares, sigmoidoscopy in patients hospitalized with ulcerative colitis, and use of steroid-sparing therapy. The primary objective was to identify successful QI interventions. Risk of bias assessment was conducted using the Joanna Briggs Institute critical appraisal checklist. RESULTS Twenty-three manuscripts and 23 meeting abstracts met inclusion criteria. Influenza and pneumococcal vaccination were the most studied indicators (24 references), followed by emergency room and/or hospital utilization, tobacco cessation, and pre-therapy testing (17, 11, and 10 references, respectively). Electronic medical record-based interventions were the most frequent, whereas other initiatives used strategies that included changes to care structure or delivery, vaccination protocols, or physician and patient education. Successful interventions matched the complexity of the metric to the intervention including making changes to care structure or delivery, empowered non-physician staff, and used electronic medical record changes to prompt clinicians. CONCLUSIONS The quality of IBD care can be improved with diverse interventions that range from simple to complex. However, these interventions are not universally successful. Clinicians should emulate successful interventions and design new initiatives to narrow gaps in care quality.
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Affiliation(s)
- David I Fudman
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Andrea Escala Perez-Reyes
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Blake A Niccum
- Department of Medicine, Massachusetts General Hospital, Harvard University, Boston, Massachusetts
| | - Gil Y Melmed
- Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, New York, New York
| | - Hamed Khalili
- Division of Gastroenterology, Massachusetts General Hospital, Harvard University, Boston, Massachusetts
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Vutcovici M, Sewitch M, Kachan N, Stone M, Morin I, Bouchard S, Heatherington J, Devitt KS, Nguyen GC, Bitton A. Patient Perspectives of IBD Care and Services: An Integral Part of a Pan-Canadian Quality Improvement Initiative. J Can Assoc Gastroenterol 2021; 4:229-233. [PMID: 34738068 PMCID: PMC8561267 DOI: 10.1093/jcag/gwaa044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/15/2020] [Indexed: 12/12/2022] Open
Abstract
Background As beneficiaries of health service improvement initiatives, patients should have their perspectives of and gaps in care elicited to inform and guide the development of quality indicators to assess health care services. The purpose of this study was to identify patient perspectives amenable for conversion into measurable inflammatory bowel disease (IBD) care quality indicators. Methods Crohn’s and Colitis Canada’s Promoting Access and Care through Centres of Excellence (PACE) program organized four patient focus groups in three Canadian provinces in 2016 to capture the perspective of patients on IBD care services. The RQDA package in R was used for transcript analysis, theme identification and for building a theme hierarchy based on the number of citations. The main themes were converted into patient-derived quality indicators. Results Several perceived unmet needs were elicited from participants that could be converted into measurable quality indicators. These unmet needs addressed the need for information, access to multidisciplinary services and specialized care, and access to psychological support. Patient unmet needs informed the selection of nine quality indicators that were included in the final list of PACE indicators to assess IBD care services across Canada. Conclusions Our study provides a detailed description of patient perspectives on IBD care services that were an integral part of the development of measurable indicators of the quality of care in the context of a universal health care system.
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Affiliation(s)
- Maria Vutcovici
- Division of Gastroenterology and Hepatology, McGill University Health Center, Montreal, Canada
| | - Maida Sewitch
- Division of Gastroenterology and Hepatology, McGill University Health Center, Montreal, Canada.,McGill University, Montreal, Canada
| | | | - Marlene Stone
- Division of Gastroenterology and Hepatology, McGill University Health Center, Montreal, Canada
| | - Isabelle Morin
- Division of Gastroenterology and Hepatology, McGill University Health Center, Montreal, Canada
| | | | | | - Katharine S Devitt
- Department of Research and Patient Programs, Crohn's and Colitis Canada, Toronto, Canada
| | | | - Alain Bitton
- Division of Gastroenterology and Hepatology, McGill University Health Center, Montreal, Canada
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Chen D, Fulmer C, Gordon IO, Syed S, Stidham RW, Vande Casteele N, Qin Y, Falloon K, Cohen BL, Wyllie R, Rieder F. Application of Artificial Intelligence to Clinical Practice in Inflammatory Bowel Disease - What the Clinician Needs to Know. J Crohns Colitis 2021; 16:460-471. [PMID: 34558619 PMCID: PMC8919817 DOI: 10.1093/ecco-jcc/jjab169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Artificial intelligence [AI] techniques are quickly spreading across medicine as an analytical method to tackle challenging clinical questions. What were previously thought of as highly complex data sources, such as images or free text, are now becoming manageable. Novel analytical methods merge the latest developments in information technology infrastructure with advances in computer science. Once primarily associated with Silicon Valley, AI techniques are now making their way into medicine, including in the field of inflammatory bowel diseases [IBD]. Understanding potential applications and limitations of these techniques can be difficult, in particular for busy clinicians. In this article, we explain the basic terminologies and provide a particular focus on the foundations behind state-of-the-art AI methodologies in both imaging and text. We explore the growing applications of AI in medicine, with a specific focus on IBD to inform the practising gastroenterologist and IBD specialist. Finally, we outline possible future uses of these technologies in daily clinical practice.
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Affiliation(s)
- David Chen
- Medical Operations, Cleveland Clinic Foundation, Cleveland, OH, USA,Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Clifton Fulmer
- Department of Pathology, Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ilyssa O Gordon
- Department of Pathology, Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Sana Syed
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, School of Medicine, University of Virginia, Charlottesville, VA, USA,School of Data Science, University of Virginia, Charlottesville, VA, USA
| | - Ryan W Stidham
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA,Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, USA
| | | | - Yi Qin
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Katherine Falloon
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Benjamin L Cohen
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Robert Wyllie
- Medical Operations, Cleveland Clinic Foundation, Cleveland, OH, USA,Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Florian Rieder
- Corresponding author: Florian Rieder, MD, Department of Inflammation and Immunity, and Department of Gastroenterology, Hepatology, & Nutrition, Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195, USA. Tel: (216) 445-5631; Fax: (216) 636-0104; E-mail:
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Factors Influencing Drug Disposition of Monoclonal Antibodies in Inflammatory Bowel Disease: Implications for Personalized Medicine. BioDrugs 2020; 33:453-468. [PMID: 31301024 DOI: 10.1007/s40259-019-00366-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Monoclonal antibody (mAb) therapies have revolutionized the treatment of several chronic inflammatory diseases, including the inflammatory bowel diseases (IBD), Crohn's disease, and ulcerative colitis. While efficacious, responses to these therapies vary considerably from patient to patient, due in part to inter- and intra-individual variability in pharmacokinetics (PK) and drug exposure. The concept of personalized medicine to monitor drug exposure and to adjust dosing in individual patients is consequently gaining acceptance as a powerful tool to optimize mAb therapy for improved outcomes in IBD. This review provides a brief overview of the different mAbs currently approved or in development for the treatment of IBD, including their presumed mechanisms of action and PK properties. Specifically described are (1) the factors known to affect mAb PK and drug exposure in patients with IBD, (2) the value of population PK/pharmacodynamic (PD) modeling to identify and understand the influence of these factors on drug exposure and effect, and (3) the clinical evidence for the potential of therapeutic drug monitoring (TDM) to improve IBD outcomes in response to mAb-based therapy. Incorporation of PK/PD parameters into clinical decision support tools has the potential to guide therapeutic decision making and aid implementation of personalized medicine strategies in patients with IBD.
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Abstract
Parents of teens with inflammatory bowel disease must prepare their children for independent disease self-management. This study characterizes the stressors and coping strategies adopted among parents of teens with inflammatory bowel disease. Teens aged 16-22 years with inflammatory bowel disease who were consecutively seen by a pediatric gastroenterologist prior to transition to adult-centered care and their parents completed sociodemographic data, and two validated questionnaires for coping (Coping Health Inventory for Parents) and stress (Pediatric Inventory for Parents). Sixty-six patient-parent pairs were enrolled in this study-impairment was highest in role function (e.g., trying to attend to the needs of other family members, being unable to go to work, and feeling uncertain about how to maintain consistent discipline). These concerns seemed to be most pronounced among parents of children 18 years and older (χ (df) = 1, p = .04) with Crohn disease (χ (df) = 1, p = .02). The top five listed concerns differed depending on the caregiver's gender. Parents of teens with inflammatory bowel disease are concerned about parenting role function. Parents of teens 18 years and older with Crohn disease reported the highest stress. Caregiver gender differences were noted.
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10
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Han M, Jung YS, Cheon JH, Park S. Regional variations in the use of biologics and immunomodulators among Korean patients with inflammatory bowel diseases. J Gastroenterol Hepatol 2019; 34:1166-1174. [PMID: 30672608 DOI: 10.1111/jgh.14609] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 01/01/2019] [Accepted: 01/16/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM Variation in medical care can be an obstacle to improving quality and outcome of treatment. We conducted a nationwide, population-based study to identify regional variations in medication prescription rates in Korean patients with inflammatory bowel diseases (IBDs). METHODS Using the National Health Insurance claims, we collected data on patients diagnosed with IBD (8974 cases of Crohn's disease [CD] and 17 167 cases of ulcerative colitis [UC]) between 2010 and 2016. RESULTS Overall rates of biologics (infliximab or adalimumab) use in CD and UC were 19.6% and 6.1%, respectively, and those of immunomodulator (azathioprine or 6-mercaptopurine) use were 66.9% and 20.4%, respectively. The average periods from diagnosis to first biologics use for CD and UC were 1.6 and 1.8 years, respectively, and those of immunomodulators were 0.6 and 1.3 years, respectively. In Seoul, Daegu, and Busan, three major cities in Korea, biologics prescription rates for CD were 20.7%, 22.9%, and 14.6%, respectively, and those for UC were 7.3%, 6.7%, and 4.5%, respectively. In the top 7 regions with the highest number of patients in Seoul, there were 3.6-fold and 3.2-fold variations between regions with the highest and lowest frequency of biologics use in CD and UC, respectively. In addition, there were 1.6-fold and 2.8-fold variations between regions with the highest and lowest frequency of immunomodulator use for CD and UC, respectively. CONCLUSIONS Regional variation exists in medication prescription rates within a single city as well as nationwide, suggesting that standardization of IBD treatment is necessary in Korea.
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Affiliation(s)
- Minkyung Han
- Department of Public Health, Graduate School, Yonsei University, Seoul, Korea
| | - Yoon Suk Jung
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Sohee Park
- Department of Biostatistics, Graduate School of Public Health, Yonsei University, Seoul, Korea
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11
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deBruyn JCC, Soon IS, Fonseca K, Feng S, Purtzki M, Goedhart C, Kuhn S, Vanderkooi OG, Wrobel I. Serologic Status of Routine Childhood Vaccines, Cytomegalovirus, and Epstein-Barr Virus in Children With Inflammatory Bowel Disease. Inflamm Bowel Dis 2019; 25:1218-1226. [PMID: 30551205 DOI: 10.1093/ibd/izy366] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Data on the serologic status of childhood vaccines, cytomegalovirus (CMV) and Epstein-Barr virus (EBV), are limited in inflammatory bowel disease (IBD). Therefore, we evaluated vaccine coverage and seroprotection, along with CMV and EBV seropositivity, in pediatric IBD. METHODS In a cross-sectional study, demographic data, IBD history, vaccine records, and serum for antibodies against measles, mumps, rubella, diphtheria, tetanus, varicella, hepatitis B (HBV), CMV, and EBV were collected from children with IBD. We evaluated potential factors associated with serologic status. RESULTS Of 156 subjects, vaccine coverage was up to date for age in 93.5% for measles, mumps, rubella, 95.6% for diphtheria, tetanus, pertussis, polio, hemophilus influenza B, 75.8% for HBV, and 93.5% for varicella, including past infection and vaccination. Seroprotection was present in 65.8% for measles, 60.5% for mumps, 79.1% for rubella, 79.5% for diphtheria, 80.8% for tetanus, 70.5% for varicella, and 62.8% for HBV of subjects. Older age at diagnosis was associated with seroprotection among subjects with complete HBV (odds ratio [OR], 1.20; 95% confidence interval [CI], 1.03-1.39) and rubella series (OR, 1.18; 95% CI, 1.02-1.37). Older age at serum collection was associated with seroprotection among subjects with prior varicella vaccination or infection (OR, 1.69; 95% CI, 1.33-2.15). Only 25.2% and 37.8% demonstrated seropositivity to CMV and EBV, respectively. Among subjects on immunosuppressive medications, 75.3% and 62.4% were seronegative for CMV and EBV, respectively. CONCLUSIONS Children with IBD have low serologic protection to childhood vaccines in spite of high vaccine coverage and universal vaccinations. Children with IBD, including a large proportion on immunosuppressive medications, have low seropositivity to CMV and EBV.
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Affiliation(s)
- Jennifer C C deBruyn
- Section of Paediatric Gastroenterology, Department of Paediatrics, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Ing Shian Soon
- Section of Paediatric Gastroenterology, Department of Paediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Kevin Fonseca
- Virology, Provincial Laboratory for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Sharon Feng
- Section of Paediatric Gastroenterology, Department of Paediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Melanie Purtzki
- Section of Paediatric Gastroenterology, Department of Paediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Caitlin Goedhart
- Section of Paediatric Gastroenterology, Department of Paediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Susan Kuhn
- Section of Infectious Diseases, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Otto G Vanderkooi
- Section of Infectious Diseases, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada.,Department of Pathology & Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Iwona Wrobel
- Section of Paediatric Gastroenterology, Department of Paediatrics, University of Calgary, Calgary, Alberta, Canada
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12
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Krishnakumar C, Ballengee CR, Liu C, Kim MO, Baker SS, Baldassano RN, Cohen SA, Crandall WV, Denson LA, Dubinsky MC, Evans J, Gokhale R, Griffiths A, Guthery SL, Oliva-Hemker M, Heyman MB, Keljo D, Kellermayer R, Leleiko NS, Mack DR, Markowitz JF, Moulton DE, Noe JD, Otley AR, Patel AS, Pfefferkorn M, Rabizadeh S, Rosh JR, Snapper S, Walters TD, Ziring D, Mondal K, Kappelman MD, Hyams JS, Kugathasan S. Variation in Care in the Management of Children With Crohn's Disease: Data From a Multicenter Inception Cohort Study. Inflamm Bowel Dis 2019; 25:1208-1217. [PMID: 30601983 DOI: 10.1093/ibd/izy363] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Variation in care is common in medical practice. Reducing variation in care is shown to improve quality and increase favorable outcomes in chronic diseases. We sought to identify factors associated with variation in care in children with newly diagnosed Crohn's disease (CD). METHODS Prospectively collected data from a 28-site multicenter inception CD cohort were analyzed for variations in diagnostic modalities, treatment, and follow-up monitoring practices, along with complicated disease outcomes over 3 years in 1046 children. Generalized linear mixed effects models were used to investigate the intercenter variations in each outcome variable. RESULTS The mean age at diagnosis was 12 years, and 25.9% were nonwhite. The number of participants ranged from 5 to 112 per site. No variation existed in the initial diagnostic approach. When medication exposure was analyzed, steroid exposure varied from 28.6% to 96.9% (P < 0.01) within 90 days, but variation was not significant over a 3-year period (P = 0.13). Early anti-tumor necrosis factor (anti-TNF) exposure (within 90 days) varied from 2.1% to 65.7% (P < 0.01), but variation was not significant over a 3-year period (P > 0.99). Use of immunomodulators (IMs) varied among centers both within 90 days (P < 0.01) and during 3 years of follow-up (P < 0.01). A significant variation was seen at the geographic level with follow-up small bowel imaging and colonoscopy surveillance after initial therapy. CONCLUSIONS Intercenter variation in care was seen with the initial use of steroids and anti-TNF, but there was no difference in total 3-year exposure to these drugs. Variation in the initiation and long-term use of IMs was significant among sites, but further research with objective measures is needed to explain this variation of care. Small bowel imaging or repeat colonoscopy in CD patients was not uniformly performed across sites. As our data show the widespread existence of variation in care and disease monitoring at geographic levels among pediatric CD patients, future implementation of various practice strategies may help reduce the variation in care.
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Affiliation(s)
- Chenthan Krishnakumar
- Division of Pediatric Gastroenterology, Department of Pediatrics, Emory University School of Medicine & Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Cortney R Ballengee
- Division of Pediatric Gastroenterology, Department of Pediatrics, Emory University School of Medicine & Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Chunyan Liu
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mi-Ok Kim
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Susan S Baker
- Department of Digestive Diseases and Nutrition Center, University at Buffalo, Buffalo, New York
| | - Robert N Baldassano
- Division of Gastroenterology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Stanley A Cohen
- Department of Pediatrics, Children's Center for Digestive Health Care, LLC, Atlanta, Georgia
| | - Wallace V Crandall
- Department of Pediatric Gastroenterology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Lee A Denson
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Marla C Dubinsky
- Department of Pediatrics, Mount Sinai Hospital, New York, New York
| | - Jonathan Evans
- Department of Pediatrics, Nemours Children's Specialty Care, Jacksonville, Florida
| | - Ranjana Gokhale
- Department of Pediatrics, The University of Chicago, Chicago, Illinois
| | - Anne Griffiths
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Maria Oliva-Hemker
- Department of Pediatrics, John Hopkins University School of Medicine, Baltimore, Maryland
| | - Melvin B Heyman
- Department of Pediatrics, University of California at San Francisco, San Francisco, California
| | - David Keljo
- Department of Gastroenterology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Philadelphia
| | - Richard Kellermayer
- Section of Pediatric Gastroenterology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Neal S Leleiko
- Department of Pediatrics, Hasbro Children's Hospital, Brown Medical School, Providence, Rhode Island
| | - David R Mack
- Department of Pediatrics, Children's Hospital of Eastern Ontario IBD Centre and University of Ottawa, Ottawa, Ontario, Canada
| | - James F Markowitz
- Department of Pediatrics, Cohen Children's Medical Center of New York, Northwell Health, New Hyde Park, New York
| | - Dedrick E Moulton
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Joshua D Noe
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anthony R Otley
- Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ashish S Patel
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Marian Pfefferkorn
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Indiana University School of Medicine, Indianapolis, Indiana
| | - Shervin Rabizadeh
- Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, California
| | - Joel R Rosh
- Department of Pediatrics, Goryeb Children's Hospital, Morristown, New Jersey
| | - Scott Snapper
- Department of Gastroenterology and Nutrition, Boston Children's Hospital, Boston, Massachusetts
| | - Thomas D Walters
- Department of Pediatrics, The University of Chicago, Chicago, Illinois
| | - David Ziring
- Department of Pediatrics, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Kajari Mondal
- Division of Pediatric Gastroenterology, Department of Pediatrics, Emory University School of Medicine & Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Michael D Kappelman
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jeffrey S Hyams
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Indiana University School of Medicine, Indianapolis, Indiana.,Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center, Hartford, Connecticut
| | - Subra Kugathasan
- Division of Pediatric Gastroenterology, Department of Pediatrics, Emory University School of Medicine & Children's Healthcare of Atlanta, Atlanta, Georgia
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13
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Bitton A, Devitt KS, Bressler B, Heatherington J, Jairath V, Jones J, Moayyedi P, Weizman AV, Dubé C, MacIntosh D, Nguyen GC. Development of a Global Rating Scale for Inflammatory Bowel Disease. J Can Assoc Gastroenterol 2019; 3:4-16. [PMID: 34169223 PMCID: PMC8218537 DOI: 10.1093/jcag/gwz017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 06/07/2019] [Indexed: 11/30/2022] Open
Abstract
Background The Global Rating Scale (GRS) is a web-based self-assessment quality improvement tool used to identify gaps in health care, change the focus to patient-centred care and standardize care. There are four levels of achievement ranging from basic-(D) to excellent-(A) service delivery. The goal was to develop a GRS for inflammatory bowel disease (IBD) to improve the quality of care for patients on a system level. Methods The IBD GRS was developed through an iterative process and modeled upon the successful endoscopy GRS programs in the United Kingdom and Canada. Dimensions, items and statements were drafted based on expert opinions, patient-informed quality indicators and best available evidence, then reviewed and modified by a core committee. A working group of IBD and GRS experts voted in-person to establish consensus on the inclusion and quality of statements. Results Two dimensions (Clinical Quality and Quality of Patient Experience), 10 items and 89 statements made up the IBD GRS. There was a 100% response rate for each of the 40 votes for statements in the IBD GRS. All statements within each level received a mean rating score between four (agree) and five (strongly agree). Revisions agreed upon during the voting process were incorporated into the IBD GRS. Group consensus was achieved on the inclusion of statements, and 10 items were selected as standards within the two dimensions. Conclusions We have developed the first IBD GRS with the aim of improving quality of care through ongoing evaluations and improvements by health care teams, focusing on patient-centred care.
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Affiliation(s)
- Alain Bitton
- Division of Gastroenterology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Katharine S Devitt
- Department of Research and Patient Programs, Crohn's and Colitis Canada, Toronto, Ontario, Canada
| | - Brian Bressler
- Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Joan Heatherington
- Division of Gastroenterology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Jennifer Jones
- Division of Digestive Care & Endoscopy, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paul Moayyedi
- Department of Medicine, Farncombe Family Digestive Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Adam V Weizman
- Division of Gastroenterology, Department of Medicine, Mount Sinai Centre for Inflammatory Bowel Disease, University of Toronto, Toronto, Ontario, Canada
| | - Catherine Dubé
- Division of Gastroenterology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Donald MacIntosh
- Division of Digestive Care & Endoscopy, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Geoffrey C Nguyen
- Division of Gastroenterology, Department of Medicine, Mount Sinai Centre for Inflammatory Bowel Disease, University of Toronto, Toronto, Ontario, Canada
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14
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Fiorino G, Allocca M, Chaparro M, Coenen S, Fidalgo C, Younge L, Gisbert JP. 'Quality of Care' Standards in Inflammatory Bowel Disease: A Systematic Review. J Crohns Colitis 2019; 13:127-137. [PMID: 30423033 DOI: 10.1093/ecco-jcc/jjy140] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Inflammatory bowel disease [IBD] includes chronic, disabling and progressive conditions that need a complex approach and management. Although several attempts have been made to standardize the care of IBD patients, no clear definitions of a global 'standard of care' are currently available. METHODS We performed a systematic review of the available literature, searching for all relevant data concerning three main domains of standards of quality of care in IBD patients: structure, process and outcomes. From the literature search, 2394 abstracts were retrieved, and 62 relevant papers were included in the final review. RESULTS Standards of quality of care in IBD include several aspects that can be summarized in three identified domains: structure, process and outcomes. The suggested structure of an IBD Unit includes a multi-disciplinary approach, effective referral processes, improved access using helplines, and departmental guidelines/pathways with identification of measurable quality indicators. Coordinated care models which incorporate a multi-disciplinary approach, structured clinical pathways or processes for the diagnosis, monitoring and treatment of IBD, fast-track recovery from IBD surgery, designated IBD clinics, virtual clinics and telemanagement are currently considered the main standards for process, although supporting data are limited. Several consensus statements on outcomes and quality indicators have been reported, focusing on outcomes in symptoms, function and quality of life restoration, survival and disease control, in addition to effective healthcare utilization. CONCLUSIONS The results of this systematic review can provide the basis for general recommendations for standards of quality of care in IBD.
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Affiliation(s)
- Gionata Fiorino
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Institute, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy
| | - Mariangela Allocca
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Institute, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy
| | - Maria Chaparro
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Sofie Coenen
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Catarina Fidalgo
- Gastroenterology Division, Hospital Beatriz Ângelo, Loures, Portugal
| | - Lisa Younge
- Barts Health - Royal London Hospital, London, UK
| | - Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
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15
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Georgy M, Negm Y, El-Matary W. Quality improvement in healthcare for patients with inflammatory bowel disease. Transl Pediatr 2019; 8:77-82. [PMID: 30881901 PMCID: PMC6382498 DOI: 10.21037/tp.2019.01.02] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Since inflammatory bowel diseases (IBD) are chronic disorders with typical remission and relapses and no cure, maintaining high quality of provided healthcare to patients with IBD plays a major role in the management and reducing disease-related morbidity. To hone process-based quality indicators in order to ameliorate quality of care, the indicators must be based on high quality evidence and expert consensus. ImproveCareNow (ICN) group gave us a great example of quality improvement (QI) by gaining experience in how to exercise, apply and implement QI methods in the care of children with IBD. "The American Gastroenterological Association" has developed an adult "IBD physician performance measures set" and both "Crohn's and Colitis Foundation of America" (CCFA) and "Crohn's and Colitis Canada" (CCC) have developed sets of most highly rated process and outcome measures. "The Emerging Practice in IBD Collaborative (EPIC) Canadian group" developed definitions of quality indicators for best-practice management of IBD in Canada. "Quality of Care through the Patient's Eyes (QUOTE-IBD)" was honed as a questionnaire to quantify quality of care in the eyes of patients with IBD. This is now widely used in several European countries. The current concepts of quality of care as well as quality indicators will be discussed in this article.
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Affiliation(s)
- Michael Georgy
- Section of Pediatric Gastroenterology, Winnipeg Children's Hospital, Max Rady College of Medicine, Rady Faculty of Health Sciences, Winnipeg, MB, Canada
| | - Yasser Negm
- Section of Pediatric Gastroenterology, Winnipeg Children's Hospital, Max Rady College of Medicine, Rady Faculty of Health Sciences, Winnipeg, MB, Canada
| | - Wael El-Matary
- Section of Pediatric Gastroenterology, Winnipeg Children's Hospital, Max Rady College of Medicine, Rady Faculty of Health Sciences, Winnipeg, MB, Canada
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16
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Egberg MD, Kappelman MD, Gulati AS. Improving Care in Pediatric Inflammatory Bowel Disease. Gastroenterol Clin North Am 2018; 47:909-919. [PMID: 30337040 DOI: 10.1016/j.gtc.2018.07.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Pediatric patients with inflammatory bowel disease (IBD) stand to benefit from quality improvement (QI) due to the chronic nature of the disease, frequent interaction with the health care system, and exposure to high-risk treatments. The use of QI in health care has led to significant improvements in quality and reliability of care. Despite these advances, significant deficits in providing high-quality pediatric IBD care persist. This article describes a brief history of health care QI, identifies gaps and challenges in delivery of quality pediatric IBD care, highlights several IBD QI initiatives, and concludes with future directions for improving pediatric IBD outcomes.
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Affiliation(s)
- Matthew D Egberg
- Department of Pediatrics, University of North Carolina at Chapel Hill, 130 Mason Farm Road, Bioinformatics Building, CB# 7229, Chapel Hill, NC 27599, USA.
| | - Michael D Kappelman
- Department of Pediatrics, University of North Carolina at Chapel Hill, 130 Mason Farm Road, Bioinformatics Building, CB# 7229, Chapel Hill, NC 27599, USA; Department of Epidemiology, University of North Carolina at Chapel Hill, 130 Mason Farm Road, Bioinformatics Building, CB# 7229, Chapel Hill, NC 27599, USA
| | - Ajay S Gulati
- Department of Pediatrics, University of North Carolina at Chapel Hill, 230 MacNider, CB# 7229, Chapel Hill, NC 27599, USA; Department of Pathology, University of North Carolina at Chapel Hill, 230 MacNider, CB# 7229, Chapel Hill, NC 27599, USA
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17
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Ramsey LB, Mizuno T, Vinks AA, Margolis PA. Learning Health Systems as Facilitators of Precision Medicine. Clin Pharmacol Ther 2018; 101:359-367. [PMID: 27984650 DOI: 10.1002/cpt.594] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 12/05/2016] [Accepted: 12/07/2016] [Indexed: 12/24/2022]
Affiliation(s)
- L B Ramsey
- Division of Research in Patient Services, Pharmacy Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - T Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - A A Vinks
- Division of Research in Patient Services, Pharmacy Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - P A Margolis
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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18
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Egberg MD, Gulati AS, Gellad ZF, Melmed GY, Kappelman MD. Improving Quality in the Care of Patients with Inflammatory Bowel Diseases. Inflamm Bowel Dis 2018; 24:1660-1669. [PMID: 29718299 PMCID: PMC6231366 DOI: 10.1093/ibd/izy030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Indexed: 02/06/2023]
Abstract
Efforts to improve healthcare quality were firmly established before the Institute of Medicine (IOM) historic 2000 and 2001 reports, To Err is Human Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century Despite the long-standing healthcare quality improvement (QI) efforts that date back to the turn of the 20th century, the IOM reports significantly advanced the awareness of healthcare quality deficits and the resulting risk to patients from those gaps in care. Studies immediately following the IOM reports emphasized and verified the presence of detrimental care gaps and highlighted a myriad of contributing factors. Studies focused specifically on the inflammatory bowel diseases (IBD), Crohn's disease and ulcerative colitis , demonstrated suboptimal patient outcomes stemming from, in part, system and provider variation. In the years that have followed, research studies have shown the persistence of suboptimal outcomes in IBD despite an awareness of key drivers for poor care quality and concerted efforts in advancing QI initiatives. In 2017, IBD advocacy groups and provider networks have demonstrated progress in furthering both pediatric and adult IBD outcomes through the use of QI methods and tools including collaborative learning networks. A significant amount of work lies ahead, however, to build upon these advances and improve IBD outcomes further. This article reviews the history of quality initiatives in healthcare, identifies ongoing gaps in IBD care with a review of current IBD improvement efforts taking place, and identifies several targets for improving IBD care quality moving forward into the 21st century.
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Affiliation(s)
- Matthew D Egberg
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Division of Pediatric Gastroenterology, Chapel Hill, NC
- Institute for Healthcare Improvement, Cambridge, MA
| | - Ajay S Gulati
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Division of Pediatric Gastroenterology, Chapel Hill, NC
- University of North Carolina at Chapel Hill, Departments of Pediatrics and Pathology and Laboratory Medicine. Chapel Hill, NC
| | - Ziad F Gellad
- Durham VA Medical Center, Durham, NC
- Division of Gastroenterology, Duke University Medical Center, Durham, NC
| | - Gil Y Melmed
- Inflammatory Bowel and Immunobiology Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Michael D Kappelman
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Division of Pediatric Gastroenterology, Chapel Hill, NC
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19
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Assuring Quality for Non-hospital-based Biologic Infusions in Pediatric Inflammatory Bowel Disease: A Clinical Report From the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2018; 66:680-686. [PMID: 29324477 PMCID: PMC5866197 DOI: 10.1097/mpg.0000000000001890] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The primary aim of this Clinical Report by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition is to provide formal guidance to pediatric gastroenterologists and clinicians, health systems, and insurance payers regarding home- and office-based infusions for biologic therapies in pediatric inflammatory bowel disease. Patients in North America are increasingly denied coverage by payers based on "place of service" codes at hospital-based infusion units where the treating clinicians primarily provide care. A task force with topic expertise generated 8 best practice recommendations to ensure quality of care for pediatric patients with inflammatory bowel disease receiving non-hospital-based biologic infusions. Pragmatic considerations discussed in this report include patient safety, pediatric-trained nurse availability, care coordination, patient-centeredness, shared liability, administrative support, clinical governance, and costs of care.
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Le B, Yang SH. Efficacy of Lactobacillus plantarum in prevention of inflammatory bowel disease. Toxicol Rep 2018; 5:314-317. [PMID: 29854599 PMCID: PMC5977373 DOI: 10.1016/j.toxrep.2018.02.007] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 02/21/2018] [Accepted: 02/21/2018] [Indexed: 12/15/2022] Open
Abstract
L. plantarum have effects on inflammation for the prevention and management IBD. The mechanisms of action of L. plantarum on IBD are complex. Further clinical studies are needed to validate its potential use in IBD in humans. L. plantarum are considered safe overall for use as feed additives and humans. The incidence of inflammatory bowel disease (IBD) is increasing globally. Altered gut bacteria and bacterial metabolic pathways are two important factors in the initiation and progression of IBD. Lactobacillus plantarum is distributed in a variety of ecological niches, has a proven ability to survive gastric transit, and can colonize the intestinal tract of human and other mammals. Several studies have described the effects of L. plantarum consumption on human physiology. This review summarizes the safety and the effects of L. plantarum in vitro and in animal models for the prevention and management of IBD. L. plantarum modulates the ratio of Th1 and Th2 cells by stimulating the production of different inflammatory cytokines such as tumor necrosis factor-alpha, interleukin (IL)-1β, IL-6, IL-10, IL-12, and interferon-gamma. The blocking of cyclooxygenase-2 in Th1 also is an apoptotic inhibition mechanism. This overview of the molecular studies addresses the activity of L. plantarum in the human gut environment and its’ potential for remission of IBD.
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Affiliation(s)
- Bao Le
- Department of Biotechnology, Chonnam National University, Yeosu, 59626, Republic of Korea
| | - Seung Hwan Yang
- Department of Biotechnology, Chonnam National University, Yeosu, 59626, Republic of Korea
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Berry SK, Melmed GY. Quality indicators in inflammatory bowel disease. Intest Res 2018; 16:43-47. [PMID: 29422796 PMCID: PMC5797270 DOI: 10.5217/ir.2018.16.1.43] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 06/06/2017] [Accepted: 06/07/2017] [Indexed: 01/05/2023] Open
Abstract
Inflammatory bowel disease (IBD), which includes Crohn's disease and ulcerative colitis, is a chronic, debilitating, and expensive condition affecting millions of people globally. There is significant variation in the quality of care for patients with IBD across North America, Europe, and Asia; this variation suggests poor quality of care due to overuse, underuse, or misuse of health services and disparity of outcomes. Several initiatives have been developed to reduce variation in care delivery and improve processes of care, patient outcomes, and reduced healthcare costs. These initiatives include the development of quality indicator sets to standardize care across organizations, and learning health systems to enable data sharing between doctors and patients, and sharing of best practices among providers. These programs have been variably successful in improving patient outcomes and reducing healthcare utilization. Further studies are needed to demonstrate the long-term impact and applicability of these efforts in different geographic areas around the world, as regional variations in patient populations, societal preferences, and costs should inform local quality improvement efforts.
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Affiliation(s)
- Sameer K Berry
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Gil Y Melmed
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Berry SK, Siegel CA, Melmed GY. Quality Improvement Initiatives in Inflammatory Bowel Disease. Curr Gastroenterol Rep 2017; 19:41. [PMID: 28730508 DOI: 10.1007/s11894-017-0581-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW This article serves as an overview of several quality improvement initiatives in inflammatory bowel disease (IBD). RECENT FINDINGS IBD is associated with significant variation in care, suggesting poor quality of care. There have been several efforts to improve the quality of care for patients with IBD. Quality improvement (QI) initiatives in IBD are intended to be patient-centric, improve outcomes for individuals and populations, and reduce costs-all consistent with "the triple aim" put forth by the Institute for Healthcare Improvement (IHI). Current QI initiatives include the development of quality measure sets to standardize processes and outcomes, learning health systems to foster collaborative improvement, and patient-centered medical homes specific to patients with IBD in shared risk models of care. Some of these programs have demonstrated early success in improving patient outcomes, reducing costs, improving patient satisfaction, and facilitating patient engagement. However, further studies are needed to evaluate and compare the effects of these programs over time on clinical outcomes in order to demonstrate long-term value and sustainability.
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Affiliation(s)
- Sameer K Berry
- Department of Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA
| | - Corey A Siegel
- Department of Medicine, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH, 03766, USA
| | - Gil Y Melmed
- Department of Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA. .,Inflammatory Bowel Disease Center, 8730 Alden Drive, Second Floor East, Los Angeles, CA, 90048, USA.
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Singh S, Chowdhry M, Umar S, Bilal M, Clarke K. Variations in the medical treatment of inflammatory bowel disease among gastroenterologists. Gastroenterol Rep (Oxf) 2017; 6:61-64. [PMID: 29479445 PMCID: PMC5806403 DOI: 10.1093/gastro/gox005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 12/24/2016] [Accepted: 12/29/2016] [Indexed: 02/06/2023] Open
Abstract
Background and aims With expanding available treatment options and evolving understanding of the risks and benefits of medical therapies for inflammatory bowel disease (IBD), there is the possibility of significant variations in treatment and outcomes. Little is known about the variation in treatment between IBD specialists and other gastroenterology (GI) physicians. Evaluating possible variations is an important first step to help address standardized care and optimize treatment. We studied the differences in use of biologics and immunomodulators in the management of IBD patients at a tertiary care hospital between IBD-trained physicians and other gastroenterologists. Methods A total of 325 IBD patients were included in the analysis. Of these, 216 patients received care with an IBD physician and 109 had other GI/non-IBD physicians as their main caregivers. Results The unadjusted use of immunomodulators (35.6% vs 16.5%, p = 0.001), biologics (45.8% vs 22.9%, p =0.001) and dual therapy (biologics and immunomodulator) (14.4% vs 3.7%, p =0.001) was significantly higher in the IBD-physician group. These differences in therapy between the two groups remained after adjusting for patient and disease characteristics. Conclusion There are significant variations in the treatment of patients with IBD by GI physicians. The use of biologics and immunomodulators is higher in GI physicians with dedicated IBD interest and training.
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Affiliation(s)
- Shailendra Singh
- Division of Gastroenterology, Allegheny Health Network, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Monica Chowdhry
- Department of Internal Medicine, Charleston Area Medical Center, West Virginia University, Charleston, WV, USA
| | - Shifa Umar
- Division of Gastroenterology, Allegheny Health Network, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Mohammad Bilal
- Division of Gastroenterology, Allegheny Health Network, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Kofi Clarke
- Division of Gastroenterology, Allegheny Health Network, Allegheny General Hospital, Pittsburgh, PA, USA
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Abstract
BACKGROUND/AIM Although international guidelines in inflammatory bowel disease (IBD) management are currently available, variations in IBD care still exist. The aim of this study was to determine the extent of the variation in IBD care among Saudi pediatric gastroenterologists. MATERIALS AND METHODS A cross-sectional survey was conducted among all pediatric gastroenterologists who were members of the Saudi Society of Pediatric Gastroenterology, Hepatology, and Nutrition (SASPGHAN) from August 2015 to December 2015. The questionnaire included items on demographic characteristics and utilization of different diagnostic and therapeutic interventions in IBD care. RESULTS Of the 45 registered pediatric gastroenterologists surveyed, 37 (82%) returned the survey from 20 centers across the country; 75.7% were practicing in tertiary care centers. There was a considerable variation in the use of different diagnostic tests during the initial evaluation of the disease. Utilization of calprotectin assays, magnetic resonance imaging enterography, and bone densitometry seemed to vary the most between physicians practicing at tertiary and secondary care centers. There were statistically significant differences in the prescription of biological therapy between the two groups. CONCLUSIONS We found a considerable variation in the use of different diagnostic and therapeutic interventions in the management of pediatric IBD patients. Such variations could lead to unintended differences in patient outcomes. Implementation of the available evidence-based guidelines may limit such variations and ultimately could improve the quality of IBD care provided.
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Affiliation(s)
- Ahmed A. Al-Sarkhy
- Gastroenterology Unit, Pediatric Department, King Khalid University Hospital, Riyadh, Saudi Arabia,Prince Abdullah Bin Khalid Celiac Disease Research Chair, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia,Address for correspondence: Dr. Ahmed A. Al-Sarkhy, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia. E-mail:
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Trends in Pharmacologic Interventions for Preventing Recurrence of Crohn's Disease After Ileocolonic Surgery. Inflamm Bowel Dis 2016; 22:2432-41. [PMID: 27631599 DOI: 10.1097/mib.0000000000000898] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND Prophylactic treatment of postoperative Crohn's disease (CD) plays a critical role in maintaining clinical remission. We performed the first study in the last decade to examine secular trends in the use of pharmacologic interventions after ileocolonic resection in the United States, to understand whether clinical practice converges with recent advances in scientific knowledge. METHODS A retrospective study of a U.S. national claims database was performed. The study cohort included 106 CD patients in the years 1999 to 2001 (prebiologic era) and 294 CD patients in the years 2009 to 2011 (postbiologic era), who underwent ileocolonic resection. Medication use in the 12 months after the surgery was examined. RESULTS Significant variations in care were evident in both study periods. Across the 2 study periods, there was an increased use of biologics (from 0% to 36.4%) and a substantial reduction in the use of 5-aminosalicylic acid (from 50.9% to 28.2%; P < 0.0001). Therapeutic interventions that have been found ineffective in published studies continued to be widely applied: one-third of patients were prescribed corticosteroids, and several cases of prolonged use of corticosteroids or antibiotics were observed in both cohorts. Disease behavior (penetrating, stricturing, or nonpenetrating and nonstricturing) was not associated with the choice of postoperative therapeutic interventions, with the exception of an increased use of antibiotics among patients with penetrating disease. CONCLUSIONS There is a substantial gap between advances in postoperative care for ileocolonic CD and clinical practice. Strategies to expedite the integration of new knowledge and evidence into practice are urgently needed.
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Knowledge, Attitudes, and Beliefs Regarding the Role of Nutrition in IBD Among Patients and Providers. Inflamm Bowel Dis 2016; 22:2474-81. [PMID: 27598738 DOI: 10.1097/mib.0000000000000901] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Malnutrition is common in inflammatory bowel disease (IBD). Identifying patients who are malnourished or at risk for malnutrition may lead to early intervention and improve patient outcomes. To date, little is known about the role of nutritional assessment and management in IBD care. We aimed to evaluate knowledge, attitudes, and beliefs regarding nutrition in IBD among patients and providers. METHODS Surveys were mailed electronically to patients and providers identified through their membership in the Crohn's & Colitis Foundation of America. In addition, patient and provider focus groups were conducted to explore nutrition-related themes. These surveys and focus groups were designed to evaluate knowledge and perceived importance of nutrition, patient-provider interactions regarding nutrition and use of nutritional resources. RESULTS There were 223 provider respondents (65.5% gastroenterologists, 15.2% nurses, and 6.7% dietitians). Forty-one percent of the gastroenterologists rated their knowledge of nutrition in IBD as "very good" compared with 87% of dietitians and 16% of nurses (P < 0.001). Thirty-three percent of the gastroenterologists reported not routinely screening their IBD patients for malnutrition. The patient survey had 567 respondents with 27% rating their knowledge of nutrition in IBD as "very good." In the focus groups, a lack of adequate IBD nutritional resources was evident along with a desire for improved access to nutrition specialists. CONCLUSIONS Significant gaps in knowledge relating to nutrition in IBD seem to exist. Targeted educational initiatives and improved access to nutritional experts are warranted. In addition, a standardized process for the assessment of malnutrition among patients with IBD should be developed.
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Clostridium difficile Infection in Inflammatory Bowel Disease: A Nursing-Based Quality Improvement Strategy. J Healthc Qual 2016; 38:283-9. [DOI: 10.1097/jhq.0000000000000002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Kolho KL, Ainamo A. Progress in the treatment and outcome of pediatric inflammatory bowel disease patients. Expert Rev Clin Immunol 2016; 12:1337-1345. [PMID: 27322874 DOI: 10.1080/1744666x.2016.1201422] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION The number of pediatric patients with inflammatory bowel disease (IBD), namely Crohn´s disease, ulcerative colitis and unclassified colitis, has rapidly increased in Western countries. Areas covered: This review discusses how the treatment of pediatric IBD patients has improved,with attention given to therapeutic quality and cost. The literature search covers Medline-PubMed and the Cochrane Library, with February 2016 as the last search dates. Similarly to what has been the trend in the management of adult IBD, pediatric IBD therapy has become more active than before. High use of immunosuppressants and the availability of biological therapeutic agents has helped to control the extensive and aggressive course of pediatric IBD. Full disease control at an early phase has advantages such as preserving normal child growth and development, maintaining overall good health and quality of life, as well as decreasing the psychosocial burden of the disease. Expert commentary: A key research direction is to tailor treatment modalities according to anticipated individual phenotype and disease course. Another is to reduce healthcare costs by decreasing the so-far high rate of surgery of pediatric IBD patients, and, instead, to develop a more active approach to treatment than before.
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Affiliation(s)
- Kaija-Leena Kolho
- a Children´s Hospital , Helsinki University Central Hospital, University of Helsinki , Helsinki , Finland
| | - Antti Ainamo
- b Science Park , University of Borås, Sweden , Borås , Sweden.,c Aalto University School of Business , Helsinki , Finland
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Practice Variations in the Management of Inflammatory Bowel Disease Between Pediatric and Adult Gastroenterologists. J Pediatr Gastroenterol Nutr 2016; 62:372-7. [PMID: 26284542 DOI: 10.1097/mpg.0000000000000943] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Different practice guidelines and consensus statements for both pediatric- and adult-onset inflammatory bowel disease exist. Although variations in medical care among gastroenterologists are common, it is unknown whether there are fundamental differences between disciplines. The primary aim of the present study was to investigate differences in common practices across disciplines. METHODS This was a prospective, questionnaire-based survey of gastroenterologists attending gastroenterology meetings in Israel. The questionnaire covered attitudes to medical resources, diagnostic and follow-up measures as well as therapeutic approaches. RESULTS Overall, 120 (60%) of the approached adult gastroenterologists (AGs) and 49 (75%) pediatric gastroenterologists (PGs) completed the questionnaire. The 2 groups differed significantly in various practice areas. Pediatric patients are seen more frequently and for longer appointments. PGs tend to assess thiopurine metabolites (96% vs 47%) more often during treatment. There is a significant variation in practice between groups concerning infectious serology status and vaccinations. Methotrexate in Crohn patients is used more commonly by PGs (55% vs 22%). Long-term combination therapy of thiopurines and anti-tumor necrosis factorα agents is used more often by AGs. In patients with ulcerative colitis AGs use oral 5-aminosalicylic acid once daily (51% vs 21%) and add rectal agents from the first day of treatment (72% vs 35%) more often as compared with PGs. CONCLUSIONS This study demonstrates that common practices in inflammatory bowel disease patients differ significantly between adult and pediatric practitioners. These findings call for investigating the reasons for these differences and promoting strategies to diminish these gaps.
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If variety is the spice of life, we need to rethink our recipe: variation in inflammatory bowel disease practice among tertiary centers. Clin Gastroenterol Hepatol 2015; 13:1201-3. [PMID: 25638587 DOI: 10.1016/j.cgh.2015.01.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 01/22/2015] [Accepted: 01/22/2015] [Indexed: 02/07/2023]
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Ananthakrishnan AN, Kwon J, Raffals L, Sands B, Stenson WF, McGovern D, Kwon JH, Rheaume RL, Sandler RS. Variation in treatment of patients with inflammatory bowel diseases at major referral centers in the United States. Clin Gastroenterol Hepatol 2015; 13:1197-200. [PMID: 25460565 PMCID: PMC4440845 DOI: 10.1016/j.cgh.2014.11.020] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 10/16/2014] [Accepted: 11/03/2014] [Indexed: 02/07/2023]
Abstract
We performed a prospective study of patients with inflammatory bowel diseases to examine variations in treatment among medical centers. In a prospective cohort study of 1659 patients with Crohn's disease and 946 patients with ulcerative colitis seen at 7 high-volume referral centers, we collected data on demographics, disease characteristics, and medical and surgical treatments. We used logistic regression to determine differences in treatment among centers, controlling for potential confounders. We found significant variations among centers in the treatment of Crohn's disease with immunomodulators (odds ratio [OR], 3.34; 95% confidence interval [CI], 2.09-5.32) but not anti-tumor necrosis factor agents (OR, 1.64; 95% CI, 0.97-2.77). There was less variation in the treatment of ulcerative colitis; we found no difference in use of immunomodulators (OR, 1.83; 95% CI, 1.00-3.36) or anti-tumor necrosis factor therapy (OR, 0.81; 95% CI, 0.40-1.65). The development and implementation of evidence-based standards of care for inflammatory bowel disease may help reduce variation and improve outcomes.
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Affiliation(s)
| | - Jennifer Kwon
- Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai
| | | | - Bruce Sands
- Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai
| | | | - Dermot McGovern
- Inflammatory Bowel Disease and Immunobiology Research Institute, Cedars-Sinai Medical Center
| | - John H Kwon
- Division of Gastroenterology, Hepatology, and Nutrition, University of Chicago
| | | | - Robert S. Sandler
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine
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Forrest CB, Crandall WV, Bailey LC, Zhang P, Joffe MM, Colletti RB, Adler J, Baron HI, Berman J, del Rosario F, Grossman AB, Hoffenberg EJ, Israel EJ, Kim SC, Lightdale JR, Margolis PA, Marsolo K, Mehta DI, Milov DE, Patel AS, Tung J, Kappelman MD. Effectiveness of anti-TNFα for Crohn disease: research in a pediatric learning health system. Pediatrics 2014; 134:37-44. [PMID: 24935993 PMCID: PMC4531278 DOI: 10.1542/peds.2013-4103] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVES ImproveCareNow (ICN) is the largest pediatric learning health system in the nation and started as a quality improvement collaborative. To test the feasibility and validity of using ICN data for clinical research, we evaluated the effectiveness of anti-tumor necrosis factor-α (anti-TNFα) agents in the management of pediatric Crohn disease (CD). METHODS Data were collected in 35 pediatric gastroenterology practices (April 2007 to March 2012) and analyzed as a sequence of nonrandomized trials. Patients who had moderate to severe CD were classified as initiators or non-initiators of anti-TNFα therapy. Among 4130 patients who had pediatric CD, 603 were new users and 1211 were receiving anti-TNFα therapy on entry into ICN. RESULTS During a 26-week follow-up period, rate ratios obtained from Cox proportional hazards models, adjusting for patient and disease characteristics and concurrent medications, were 1.53 (95% confidence interval [CI], 1.20-1.96) for clinical remission and 1.74 (95% CI, 1.33-2.29) for corticosteroid-free remission. The rate ratio for corticosteroid-free remission was comparable to the estimate produced by the adult SONIC study, which was a randomized controlled trial on the efficacy of anti-TNFα therapy. The number needed to treat was 5.2 (95% CI, 3.4-11.1) for clinical remission and 5.0 (95% CI, 3.4-10.0) for corticosteroid-free remission. CONCLUSIONS In routine pediatric gastroenterology practice settings, anti-TNFα therapy was effective at achieving clinical and corticosteroid-free remission for patients who had Crohn disease. Using data from the ICN learning health system for the purpose of observational research is feasible and produces valuable new knowledge.
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Affiliation(s)
| | - Wallace V. Crandall
- Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children’s Hospital, Columbus, Ohio
| | - L. Charles Bailey
- Department of Pediatrics, and,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Marshall M. Joffe
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Richard B. Colletti
- Department of Pediatrics, The University of Vermont College of Medicine, Burlington, Vermont
| | - Jeremy Adler
- Department of Pediatrics and Communicable Diseases, Division of Pediatric Gastroenterology, University of Michigan, Ann Arbor, Michigan
| | - Howard I. Baron
- Department of Pediatrics, University of Nevada School of Medicine, Pediatric Gastroenterology and Nutrition Associates, Las Vegas, Nevada
| | - James Berman
- Advocate Children's Hospital, UIC College of Medicine, Loyola University School of Medicine, Chicago, Illinois
| | - Fernando del Rosario
- Department of Pediatrics, Division of Pediatric Gastroenterology Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Andrew B. Grossman
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Edward J. Hoffenberg
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado
| | - Esther J. Israel
- Department of Pediatrics, Massachusetts General Hospital for Children, Harvard Medical School, Boston, Massachusetts
| | - Sandra C. Kim
- Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children’s Hospital, Columbus, Ohio
| | | | - Peter A. Margolis
- Department of Pediatrics, James M. Anderson Center for Health Systems Excellence, and
| | - Keith Marsolo
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Devendra I. Mehta
- Department of Pediatrics, Arnold Palmer Hospital for Children, Florida State University, Orlando, Florida
| | - David E. Milov
- Department of Pediatrics, Nemour’s Children’s Hospital, Orlando, Florida
| | - Ashish S. Patel
- Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, Texas;,Department of Pediatrics, Children’s Medical Center, Dallas, Texas
| | - Jeanne Tung
- Department of Pediatric and Adolescent Medicine, Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota; and
| | - Michael D. Kappelman
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Racial and ethnic differences in health care utilization and outcomes among ulcerative colitis patients in an integrated health-care organization. Dig Dis Sci 2014; 59:287-94. [PMID: 24173809 DOI: 10.1007/s10620-013-2908-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 10/03/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Current knowledge of racial disparities in healthcare utilization and disease outcomes for ulcerative colitis (UC) is limited. We sought to investigate these differences among Caucasian, African American, Asian, and Hispanic patients with ulcerative colitis in Kaiser Permanente, a large integrated health-care system in Northern California. METHODS This retrospective cohort study used computerized clinical data from 5,196 Caucasians, 387 African-Americans, 550 Asians, and 801 Hispanics with prevalent UC identified between 1996 and 2007. Healthcare utilization and outcomes were compared at one and five-year follow-up by use of multivariate logistic regression analysis. RESULTS Compared with whites, the male-to-female ratio differed for African-Americans (0.68 vs. 0.91, p < 0.01) and Asians (1.3 vs. 0.91, p < 0.01). Asians had fewer co-morbid conditions (p < 0.01) than whites, whereas more African-Americans had hypertension and asthma (p < 0.01). Use of immunomodulators did not differ significantly among race and/or ethnic groups. Among Asians, 5-ASA use was highest (p < 0.05) and the incidence of surgery was lowest (p < 0.01). Prolonged steroid exposure was more common among Hispanics (p < 0.05 at 1-year) who also had more UC-related surgery (p < 0.01 at 5-year) and hospitalization (<0.05 at 5-year), although these differences were not significant in multivariate analysis. CONCLUSIONS In this population of UC patients with good access to care, overall health-care utilization patterns and clinical outcomes were similar across races and ethnicity. Asians may have milder disease than other races whereas Hispanics had a trend toward more aggressive disease, although the differences we observed were modest. These differences may be related to biological factors or different treatment preferences.
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Crandall W. T3 translational science in gastroenterology: getting to best outcomes. Clin Gastroenterol Hepatol 2013; 11:1559-61. [PMID: 24107397 DOI: 10.1016/j.cgh.2013.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 10/02/2013] [Indexed: 02/07/2023]
Abstract
Achieving the best possible outcomes requires the reliable implementation of best practices for every patient. Specifically, optimizing outcomes requires a spectrum of research spanning basic science, drug development, clinical efficacy and effectiveness, health services, quality improvement, and implementation research. However, our rapid increase in understanding the mechanisms of health and disease and their treatment has far outpaced our ability to reliably provide that care, resulting in poor reliability and enormous variation in care. T3 translational research studies attempt to answer questions surrounding reliable implementation of interventions, decreasing variations in care, and spreading effective therapies. To answer these questions, T3 research may use traditional research methodology such as randomized controlled trials (RCTs); however, various other approaches such as quasiexperimental designs (eg, time-series analysis) are often used. Although uncommon, T3 research has shown promise in not only improving process measures such as correct dosing of medications, but also outcome measures such as improved remission rates in patients with IBD. A more complete integration of T3 translational research into the more traditional research continuum is necessary if we are to achieve the best possible outcomes for our patients.
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Affiliation(s)
- Wallace Crandall
- Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio.
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International variation in medication prescription rates among elderly patients with inflammatory bowel disease. J Crohns Colitis 2013; 7:878-89. [PMID: 23018106 DOI: 10.1016/j.crohns.2012.09.001] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Revised: 08/30/2012] [Accepted: 09/01/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The elderly represent a growing demographic of patients with IBD. No study has previously described variations in care or medication prescriptions in senior patients with IBD. We compared prescription rates among elderly patients with IBD in four countries using health administrative data. METHODS Databases from the United States (US), United Kingdom (UK), Denmark and Canada were queried. Variation in prescription rates between countries was assessed in patients ≥65y with prevalent IBD who had ≥1 prescription for an IBD-related medication in a given quarter between 2004 and 2009. Patients were identified using previously-reported, validated algorithms. Country-specific rates were compared in each quarter using Fisher's exact test. RESULTS In patients with Crohn's disease, Canada and US had higher prescription rates for oral 5-ASA (P<0.0001 in all quarters) and infliximab (P<0.05 in 22/24 quarters), while the US had higher rates of thiopurine usage (P<0.05 in 23/24 quarters). Canada had greater rates of methotrexate prescriptions (P<0.05 in 21/24 quarters analyzed). In patients with ulcerative colitis (UC), rates of oral steroid usage was lowest in the US (P<0.05 in 22/24 quarters) and oral 5-ASA use was highest in the US and Canada (P<0.0001 in all quarters). Canada and Denmark used more rectal therapy than the US. Infliximab usage in UC was significantly higher in the US and Canada after 2006. CONCLUSIONS Significant variation in medication prescription rates exists among countries. Future research should assess whether these differences were associated with disparities in outcomes and health care costs.
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Weizman AV, Nguyen GC. Interventions and targets aimed at improving quality in inflammatory bowel disease ambulatory care. World J Gastroenterol 2013; 19:6375-6382. [PMID: 24151356 PMCID: PMC3801308 DOI: 10.3748/wjg.v19.i38.6375] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 08/15/2013] [Accepted: 08/20/2013] [Indexed: 02/06/2023] Open
Abstract
Over the past decade, there has been increasing focus on improving the quality of healthcare delivered to patients with chronic diseases, including inflammatory bowel disease. Inflammatory bowel disease is a complex, chronic condition with associated morbidity, health care costs, and reductions in quality of life. The condition is managed primarily in the outpatient setting. The delivery of high quality of care is suboptimal in several ambulatory inflammatory bowel disease domains including objective assessments of disease activity, the use of steroid-sparing agents, screening prior to anti-tumor necrosis factor therapy, and monitoring thiopurine therapy. This review outlines these gaps in performance and provides potential initiatives aimed at improvement including reimbursement programs, quality improvement frameworks, collaborative efforts in quality improvement, and the use of healthcare information technology.
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Benchimol EI, Hawken S, Kwong JC, Wilson K. Safety and utilization of influenza immunization in children with inflammatory bowel disease. Pediatrics 2013; 131:e1811-20. [PMID: 23650306 DOI: 10.1542/peds.2012-3567] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Influenza immunization is recommended for children with IBD, however safety concerns may limit uptake. This study assessed whether immunization was associated with adverse events in IBD patients using a population-based database of children with IBD. METHODS All children <19 years diagnosed with IBD in Ontario, Canada between 1999-2009 were identified using health administrative data, and matched to non-IBD controls. Self-controlled case series (SCCS) analyses determined health services event rates (outpatient visits, hospitalizations and emergency visits) in any 2-week risk period to 180 days post-immunization compared to a no-risk control period. Relative incidence (RI) was calculated for overall and IBD-related events and rates were compared between IBD cases and controls using relative incidence ratios (RIR). RESULTS A total of 4916 IBD patients were matched to 21 686 controls. IBD patients were more likely to have received immunization than controls (25.3% vs 13.2%, P < .001). No increased event rates existed in IBD cases during risk periods (pooled RI 0.95, 95% CI 0.84-1.07), including hospitalizations and emergency visits. There was a slightly higher event rate in IBD cases versus controls for days 3-14 (RIR 1.60, 95% CI 1.05-2.44, P = .03). IBD-related visit rates were lower in risk periods compared to control period (pooled RI 0.81, 95% CI 0.68-0.96). CONCLUSIONS There was no increase in health services use in the post-vaccine risk period in IBD patients, and there was evidence for a protective effect of influenza immunization against IBD-related health services use. Influenza immunization is safe in children with IBD and should be encouraged to improve poor coverage rates.
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Affiliation(s)
- Eric I Benchimol
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.
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Abstract
INTRODUCTION Variation in adherence to management guidelines for inflammatory bowel disease (IBD) suggests variable quality of care. Quality indicators (QIs) can be developed to measure the structure, processes, and outcomes of health care delivery. The RAND/UCLA appropriateness method was used to develop a set of process and outcome QIs to define quality of care for IBD. METHODS Guidelines and position papers for IBD published from 2006 to 2011 were reviewed for potential QIs, which were rated by a multidisciplinary panel. Potential process and outcome QIs were discussed at 3 moderated in-person meetings, with pre-meeting and post-meeting confidential electronic voting. Panelists rated the validity and feasibility of QIs on a 1 through 9 scale; disagreement was assessed using a validated index. QIs rated above 8 were selected for the final set. RESULTS More than 500 potential process QIs were extracted from guidelines. Following ratings and discussion by the first panel, 35 process QIs were selected for literature review. After the second panel, 10 process QIs were included in the final set. Candidate outcome QIs were then derived from physician, nurse, and patient input and ratings, in addition to outcomes associated with candidate process QIs. None of the top QIs exhibited disagreement. CONCLUSIONS A set of QIs for IBD was developed with expert interpretation of the literature and multidisciplinary input. Outcome QIs focused largely on remission and quality of life, whereas process QIs were aimed at therapeutic optimization and patient safety. Evaluation of these QIs in clinical practice is needed to assess the correlation of performance on process QIs with performance on outcome QIs.
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Kronman MP, Gerber JS, Prasad PA, Adler AL, Bass JA, Newland JG, Shah KM, Zerr DM, Feng R, Coffin SE, Zaoutis TE. Variation in Antibiotic Use for Children Hospitalized With Inflammatory Bowel Disease Exacerbation: A Multicenter Validation Study. J Pediatric Infect Dis Soc 2012; 1:306-13. [PMID: 23687581 PMCID: PMC3656543 DOI: 10.1093/jpids/pis053] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Accepted: 03/06/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND Antibiotics are often given for inflammatory bowel disease (IBD) exacerbations, but their use among pediatric inpatients has not been assessed. We aimed to validate administrative data for identifying hospitalizations for IBD exacerbation and to characterize antibiotic use for IBD exacerbations across children's hospitals. METHODS To validate administrative data for identifying IBD exacerbation, we reviewed charts of 409 patients with IBD at 3 US tertiary care children's hospitals. Using the case definition with optimal test characteristics, we identified 3450 children with 5063 hospitalizations for IBD exacerbation at 36 children's hospitals between January 1, 2007 and December 31, 2009, excluding those with diagnosis codes for specific bacterial infections. We estimated predicted and expected hospital-specific antibiotic utilization rates using mixed-effects logistic regression, adjusting for patient- and hospital-level factors. RESULTS Administrative codes for receipt of intravenous steroids or endoscopy provided 79% positive predictive value and 71% sensitivity for identifying hospitalizations for IBD exacerbation. Antibiotics were administered for ≥2 of the first 3 hospital days during 40.7% of IBD exacerbations in US children's hospitals; however, the proportion of patients receiving antibiotics varied significantly across hospitals from 27% to 71% (P < .001), despite adjustment for several patient- and hospital-level variables. Among those given antibiotics, the 3 most common regimens were metronidazole alone (26.9%), metronidazole with ciprofloxacin (10.3%), and ampicillin with gentamicin and metronidazole (7.0%). CONCLUSIONS Significant variability exists in antibiotic use for children hospitalized with IBD exacerbation, which is unexplained by disease severity or hospital volume. Further study should determine the optimal antibiotic therapy for this condition.
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Affiliation(s)
- Matthew P. Kronman
- Division of Infectious Diseases, Seattle Children's Hospital, University of Washington School of Medicine,Corresponding Author: Matthew P. Kronman, MD, MSCE, Seattle Children's Hospital, Division of Infectious Diseases, M/S R-5441, 4800 Sandpoint Way NE, Seattle, WA. E-mail:
| | - Jeffrey S. Gerber
- Division of Infectious Diseases, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine
| | - Priya A. Prasad
- Division of Infectious Diseases, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine
| | - Amanda L. Adler
- Division of Infectious Diseases, Seattle Children's Hospital, University of Washington School of Medicine
| | | | - Jason G. Newland
- Infectious Diseases, Children's Mercy Hospital and Clinics, University of Missouri-Kansas City School of Medicine
| | | | - Danielle M. Zerr
- Division of Infectious Diseases, Seattle Children's Hospital, University of Washington School of Medicine
| | - Rui Feng
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia
| | - Susan E. Coffin
- Division of Infectious Diseases, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine,Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia
| | - Theoklis E. Zaoutis
- Division of Infectious Diseases, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine,Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia
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Improved outcomes with quality improvement interventions in pediatric inflammatory bowel disease. J Pediatr Gastroenterol Nutr 2012; 55:679-88. [PMID: 22699837 DOI: 10.1097/mpg.0b013e318262de16] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Variations in chronic illness care are common in our health care system and may lead to suboptimal outcomes. Specifically, inconsistent use and suboptimal medication dosing have been demonstrated in the care of patients with inflammatory bowel disease (IBD). Quality improvement (QI) efforts have improved outcomes in conditions such as asthma and diabetes mellitus, but have not been well studied in IBD. We hypothesized that QI efforts would lead to improved outcomes in our pediatric IBD population. METHODS A QI team was formed within our IBD center in 2005. By 2007, we began prospectively capturing physician global assessment (PGA) and patient-reported global assessment. Significant QI interventions included creating evidence-based medication guidelines, joining a national QI collaborative, initiation of preclinic planning, and monitoring serum 25-hydroxyvitamin D. RESULTS From 2007 to 2010, 505 patients have been followed at our IBD center. During this time, the frequency of patients in clinical remission increased from 59% to 76% (P < 0.05), the frequency of patients who report that their global assessment is >7 increased from 69% to 80% (P < 0.05), and the frequency of patients with a Short Pediatric Crohn's Disease Activity Index (sPCDAI) <15 increased from 60% to 77% (P < 0.05). The frequency of repeat steroid use decreased from 17% to 10% (P < 0.05). We observed an association between the use of a vitamin D supplement (P = 0.02), serum 25-hydroxyvitamin D (P < 0.05), and quiescent disease activity. CONCLUSIONS Our results show that significant improvements in patient outcomes are associated with QI efforts that do not rely on new medication or therapies.
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Rosen D, Kathy-Hoffstadter-Thal, Bao R, Tomaino J, Ceballos C, Russell GJM, Benkov KJ. Analysis of current treatments used in clinical practice in a pediatric summer camp population for children with inflammatory bowel disease. Inflamm Bowel Dis 2012; 18:1818-24. [PMID: 22069120 DOI: 10.1002/ibd.22837] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Accepted: 10/26/2011] [Indexed: 01/22/2023]
Abstract
BACKGROUND Many treatment options exist for children with inflammatory bowel disease (IBD), yet the lack of clinical guidelines for management has lead to great variation in care. The purpose of this project was to evaluate current treatment modalities in children from the Northeast US who applied to the 2010 session of Camp Oasis, a Crohn's and Colitis Foundation of America (CCFA)-sponsored camp for children ages 8-17 with medically stable IBD. METHODS Patient demographics, medical history, and current medications were entered into the camp database. The subjects were divided into two groups; Crohn's disease (CD) or ulcerative colitis/indeterminate colitis (UC/IC). In all, 164 applicants were included, 121 (74%) with CD and 43 (26%) with UC/IC. RESULTS There were no significant differences between the two groups with respect to median age at the time of camp, median age at diagnosis, or median length of illness. Of the 121 applicants with CD, 13 (10.7%) were on an antibiotic, 56 (46.3%) were on a 5-aminosalicylate (5-ASA), 10 (8.3%) were on corticosteroids, 57 (47.1%) were on immunomodulators, and 44 (36.4%) were on a biologic agent. Six (5%) were on both an immunomodulator and a biologic agent. Of the 43 subjects with UC/IC, 27 (62.7%) were on a 5-ASA, two (4.7%) were on corticosteroids, 13 (30.2%) were on an immunomodulator, and four (9.3%) were on a biologic agent. The groups were similar with regard to surgery (20.7% for CD and 18.6% for UC/IC). CONCLUSIONS Identifying current treatment patterns may serve to highlight variations in care among this pediatric IBD population.
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Affiliation(s)
- Danya Rosen
- Mount Sinai Medical Center, New York, New York 10029, USA
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Virta LJ, Kolho KL. Trends in early outpatient drug therapy in pediatric inflammatory bowel disease in Finland: a nationwide register-based study in 1999-2009. ISRN GASTROENTEROLOGY 2012; 2012:462642. [PMID: 22957263 PMCID: PMC3431087 DOI: 10.5402/2012/462642] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 06/25/2012] [Indexed: 12/11/2022]
Abstract
Objective. There are limited data on the changes of treatment strategies of disease-modifying drugs used to treat pediatric inflammatory bowel disease (IBD). Methods. We utilized data from two national registers: the Drug Reimbursement Register for drug costs (for identifying children with IBD) and the Drug Purchase Register (for exposure to drugs), both of which are maintained by the Social Insurance Institution of Finland. The frequencies and trends of drug therapy strategies during the first year of pediatric IBD were evaluated between 1999 and 2009. Results. A total of 481 children diagnosed with IBD were identified. During the first six months, 68% of the patients purchased systemic corticosteroids; these combined with 5-aminosalicylic acid in almost all cases. The use of corticosteroids was stable from the early years compared with the end of the study period. In Crohn's disease, there was a trend towards more active use of azathioprine: the therapy was introduced earlier and proportion of pediatric patients purchasing azathioprine increased by up to 51% (P < 0.05). Conclusions. In pediatric IBD, the majority of patients purchased corticosteroid within the first six months, reflecting moderate-to-severe disease. During recent years in pediatric Crohn's disease, the therapeutic strategies of oral medication have changed towards more active immunosuppression with azathioprine.
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Affiliation(s)
- Lauri J Virta
- Research Department, The Social Insurance Institution (Kela), 20720 Turku, Finland
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Crandall WV, Margolis PA, Kappelman MD, King EC, Pratt JM, Boyle BM, Duffy LF, Grunow JE, Kim SC, Leibowitz I, Schoen BT, Colletti RB. Improved outcomes in a quality improvement collaborative for pediatric inflammatory bowel disease. Pediatrics 2012; 129:e1030-41. [PMID: 22412030 PMCID: PMC3313634 DOI: 10.1542/peds.2011-1700] [Citation(s) in RCA: 150] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Unintended variation in the care of patients with Crohn disease (CD) and ulcerative colitis (UC) may prevent achievement of optimal outcomes. We sought to improve chronic care delivery and outcomes for children with inflammatory bowel disease by using network-based quality improvement methods. METHODS By using a modified Breakthrough Series collaborative structure, 6 ImproveCareNow Network care centers tested changes in chronic illness care and collected data monthly. We used an interrupted time series design to evaluate the impact of these changes. RESULTS Data were available for 843 children with CD and 345 with UC. Changes in care delivery were associated with an increase in the proportion of visits with complete disease classification, measurement of thiopurine methyltransferase (TPMT) before initiation of thiopurines, and patients receiving an initial thiopurine dose appropriate to their TPMT status. These were significant in both populations for all process variables (P < .01) except for measurement of TPMT in CD patients (P = .12). There were significant increases in the proportion of CD (55%-68%) and UC (61%-72%) patients with inactive disease. There was also a significant increase in the proportion of CD patients not taking prednisone (86%-90%). Participating centers varied in the success of achieving these changes. CONCLUSIONS Improvements in the outcomes of patients with CD and UC were associated with improvements in the process of chronic illness care. Variation in the success of implementing changes suggests the importance of overcoming organizational factors related to quality improvement success.
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Affiliation(s)
- Wallace V. Crandall
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Nationwide Children’s Hospital, Columbus, Ohio
| | | | - Michael D. Kappelman
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Eileen C. King
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Jesse M. Pratt
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Brendan M. Boyle
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Nationwide Children’s Hospital, Columbus, Ohio
| | - Lynn F. Duffy
- Inova Fairfax Hospital for Children, Fairfax, Virginia
| | - John E. Grunow
- The Children’s Hospital at Oklahoma University Medical Center, Oklahoma City, Oklahoma
| | - Sandra C. Kim
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ian Leibowitz
- Inova Fairfax Hospital for Children, Fairfax, Virginia
| | - Bess T. Schoen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Emory Children’s Center/Children’s Healthcare of Atlanta, Atlanta, Georgia; and
| | - Richard B. Colletti
- Department of Pediatrics, University of Vermont College of Medicine, Vermont Children’s Hospital at Fletcher Allen Health Care, Burlington, Vermont
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Crockett SD, Lipkus IM, Bright SD, Sampliner RE, Wang KK, Boolchand V, Lutzke LS, Shaheen NJ. Overutilization of endoscopic surveillance in nondysplastic Barrett's esophagus: a multicenter study. Gastrointest Endosc 2012; 75:23-31.e2. [PMID: 22100301 PMCID: PMC3961007 DOI: 10.1016/j.gie.2011.08.042] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Accepted: 08/22/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Guidelines suggest that patients with nondysplastic Barrett's esophagus (BE) undergo endoscopic surveillance every 3 to 5 years, but actual use of surveillance endoscopy and the determinants of variation in surveillance intervals are not known. OBJECTIVE To measure use of surveillance endoscopy and its variation in patients with nondysplastic BE. DESIGN Multicenter, cross-sectional study. SETTING Three sites in Arizona, Minnesota, and North Carolina. PATIENTS This study involved patients who had prevalent BE without a history of high-grade dysplasia or esophageal adenocarcinoma. INTERVENTION Participants were given validated measures of quality of life, numeracy, and cancer risk perception, and the total number of prior endoscopic surveillance examinations was measured. MAIN OUTCOME MEASUREMENTS Oversurveillance was defined as >1 surveillance examination per 3-year period. RESULTS Among 235 patients with nondysplastic BE, 76% were male and 94% were white. The average (± standard deviation [SD]) duration of BE was 6.5 ± 5.9 years. The mean (± SD) number of endoscopies per 3-year period was 2.7 ± 2.6. Oversurveillance was present in 65% of participants, resulting in a mean of 2.3 excess endoscopies per patient. Neither numeracy skills nor patient perception of cancer risk were associated with oversurveillance. LIMITATIONS Endoscopies were measured by patient report, which is subject to error. Results may be generalizable only to patients seen in academic centers. CONCLUSION Most patients with nondysplastic BE had more surveillance endoscopic examinations than is recommended by published guidelines. Patient factors did not predict oversurveillance, indicating that other factors may influence decisions about the interval and frequency of surveillance examinations.
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Affiliation(s)
- Seth D. Crockett
- Division of Gastroenterology, University of North Carolina, Chapel Hill, NC
| | | | | | | | | | | | - Lori S. Lutzke
- Division of Gastroenterology, Mayo Clinic, Rochester, MN
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Mercuri M, Gafni A. Medical practice variations: what the literature tells us (or does not) about what are warranted and unwarranted variations. J Eval Clin Pract 2011; 17:671-7. [PMID: 21501341 DOI: 10.1111/j.1365-2753.2011.01689.x] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This paper examines the sources of practice variations and definitions of unwarranted variation, as derived from the literature. The literature suggests variables/factors related to patient health needs, doctor 'practice style' and environmental constraints/opportunities as sources of practice variations. However, this list is likely to be incomplete because of significant unexplained variation in each study. Furthermore, it is unclear which factors are sources of unwarranted variation because the reviewed studies do not clearly discriminate between those variations that are unwarranted and those that are not. It is also unclear if context plays a role in determining if and when a factor is unwarranted. The literature contains few frameworks of what constitutes unwarranted variation. Among those offered, more information is needed regarding the scientific basis for including the selected factors, and how to operationalize the framework provided a particular one is chosen. A clear and consistent framework for unwarranted variation, and a clear indication how each component factor could be measured and integrated can help investigators determine which variables should be included in their studies, such that the sources of unwarranted variations may be identified. A better understanding of the role of patient preference as a potential source of practice variations is also required.
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Affiliation(s)
- Mathew Mercuri
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada.
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Ananthakrishnan AN, McGinley EL, Binion DG, Saeian K. Physician density and hospitalization for inflammatory bowel disease. Inflamm Bowel Dis 2011; 17:633-8. [PMID: 20848540 DOI: 10.1002/ibd.21357] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Inflammatory bowel diseases (IBDs) are chronic illnesses that require frequent and regular healthcare contact. Regular maintenance care may reduce complications or the need for hospitalization. Availability of physicians may be an important determinant of IBD hospitalizations. METHODS Using 2008 inpatient data from the Wisconsin Hospital Association, we identified all IBD hospitalizations through ICD-9-CM discharge codes. County-level rates of primary care physicians and gastroenterologists were calculated for each county (using data from the American Medical Association and the US Census Bureau), with counties in the highest tertile by physician density being classified as "high density" counties. Multivariate regression analysis was performed to identify the independent effect of physician density on IBD outcomes. RESULTS A total of 26 counties were defined as high density (mean physician density 162/100,000 population; 2090 IBD hospitalizations) with the remaining 46 counties being low density counties (mean physician density 78/100,000 population; 3441 hospitalizations). The overall rate of IBD hospitalizations was similar for residents of high and low density counties. However, hospitalizations from low physician density counties were more likely to have hypovolemia (26% versus 22%, P=0.003), malnutrition (5.6% versus 4.3%, P=0.04), Clostridium difficile infection (4.1% versus 1.9%, P<0.001), require total parenteral nutrition (TPN) (4.3% versus 2.5%, P<0.001), or be admitted emergently (41.5% versus 35.1%, P<0.001). Residence in a county with high physician density was associated with 4% shorter length of stay and 10% lower hospitalization charges. CONCLUSIONS Residence in counties with high physician density is associated with less complicated disease on hospitalization and lower hospitalization charges for IBD.
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Affiliation(s)
- Ashwin N Ananthakrishnan
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA.
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Abstract
Advances in the treatment of inflammatory bowel disease (IBD) are published routinely in medical journals. Some treatments are sufficiently helpful that their conclusions are incorporated into clinical guidelines. However, such publications and proclamations may go unheeded among practitioners. Underuse, overuse, and misuse of clinical therapeutics, diagnostics, and routine medical processes are sufficiently prevalent among IBD practitioners that movements are afoot to determine the best methods for achieving a minimal uniformity of effective care. Such explorations are part of an effort to improve the quality of care. In this article, we review the background that has led to a push toward quality improvements in medicine in general, in gastroenterology in general, and within IBD specifically.
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Affiliation(s)
- Brijen Shah
- Mount Sinai School of Medicine, New York, NY 10029, USA
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Bousvaros A. Use of immunomodulators and biologic therapies in children with inflammatory bowel disease. Expert Rev Clin Immunol 2010; 6:659-666. [DOI: 10.1586/eci.10.46] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Weiss B, Lebowitz O, Fidder HH, Maza I, Levine A, Shaoul R, Reif S, Bujanover Y, Karban A. Response to medical treatment in patients with Crohn's disease: the role of NOD2/CRAD15, disease phenotype, and age of diagnosis. Dig Dis Sci 2010; 55:1674-80. [PMID: 19693669 DOI: 10.1007/s10620-009-0936-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2008] [Accepted: 07/16/2009] [Indexed: 12/15/2022]
Abstract
PURPOSE Factors influencing response to medications in Crohn's disease (CD) patients are not fully understood. We aimed to evaluate the relationships between NOD2/CARD15 mutations, disease phenotype and age of CD diagnosis and response to medical treatment with systemic steroids, azathioprine (AZA) or 6-mercaptopurine (6-MP), and infliximab. METHODS A retrospective medical records analysis was made of patients previously tested for the CD-associated NOD2/CARD15 mutations. Harvey- Bradshaw score was used to assess remission or response to therapy. RESULTS CD-associated NOD2/CARD15 mutations were not related to the rate of steroids dependency or clinical response to AZA/6-MP and infliximab. Steroid dependency was associated with colonic involvement. Thirty-three of 127 (26%) patients with colonic disease were steroid dependent, compared with 7/72 (9.7%) patients with isolated small bowel disease (ISBD), (p = 0.009). ISBD was mildly associated with a better remission/response to AZA/6-MP treatment. Disease behavior and age of diagnosis were not related to response to therapy. CONCLUSIONS Response to treatment with systemic steroids, AZA/6-MP and infliximab are not related to NOD2/CARD15 mutations, age of diagnosis and disease behavior. Patients with colonic disease have higher rates of steroid dependency.
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Affiliation(s)
- B Weiss
- Division of Pediatric Gastroenterology and Nutrition, Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel.
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Kappelman MD, Palmer L, Boyle BM, Rubin DT. Quality of care in inflammatory bowel disease: a review and discussion. Inflamm Bowel Dis 2010; 16:125-33. [PMID: 19572335 DOI: 10.1002/ibd.21028] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The Institute of Medicine's publications To Err Is Human and Crossing the Quality Chasm publicized the widespread deficits in U.S. health care quality. Emerging studies continue to reveal deficits in the quality of adult and pediatric care, including subspecialty care. The inflammatory bowel diseases (IBD) Crohn's disease and ulcerative colitis require diligent, long-term management and attention to their impact on intestinal and extraintestinal organ systems. Although the quality of IBD care has not been prospectively or comprehensively evaluated in the United States, several small studies have demonstrated significant variation in care. As variation may indicate underuse, overuse, or misuse of medical services, such variation suggests a clear need for translating evidence-based practices into the actual practice and follow-up provided for patients. This article reviews the history, rationale, and methods of quality measurement and improvement and identifies the unique challenges in adapting these general strategies to the care of the inflammatory bowel diseases.
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Affiliation(s)
- Michael D Kappelman
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of North Carolina Chapel Hill, Chapel Hill, North Carolina 27599, USA.
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