Abstract
Since inflammatory bowel disease (IBD) is a chronic and relapsing disorder, maintaining high quality of care plays an important role in the management of patients with IBD. To develop process-based quality indicator set to improve quality of care, the indicator should be based directly on evidence and consensus. Initially, ImproveCareNow group demonstrated quality improvement by learning how to apply quality improvement methods to improve the care of pediatric patients with IBD. The American Gastroenterological Association has developed adult IBD physician performance measures set and Crohn's and Colitis Foundation of America (CCFA) has developed a set of ten most highly rated process and outcome measures. Recently, The Emerging Practice in IBD Collaborative (EPIC) group generated defining quality indicators for best-practice management of IBD in Canada. Quality of Care through the Patient's Eyes (QUOTE-IBD) was developed as a questionnaire to measure quality of care through the eyes of patients with IBD, and it is widely used in European countries. The current concept of quality of care as well as quality indicator will be discussed in this article.
References
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Table 1.
Treatment |
IF a patient with IBD is initiating anti-tumor necrosis factor therapy, THEN tuberculosis risk assessment should be documented, and tuberculin skin testing or interferon gamma release assay should be performed. |
IF a patient with IBD is initiating therapy with anti-TNF, THEN risk assessment for hepatitis B virus should be documented. |
IF a patient with IBD requires at least 10 mg prednisone (or equivalent) for 16 weeks or longer, THEN an appropriately dosed steroid-sparing agent b or operation should be recommended. |
IF a hospitalized patient with severe colitis is not improving on intravenous steroids within 3 days, THEN sigmoidoscopy with biopsy should be performed to exclude cytomegalovirus, AND surgical consultation should be obtained. |
IF a patient in whom a flare of IBD is suspected with new or worsening diarrhea THEN the patient should undergo Clostridium difficile testing at least once. |
IF a patient with IBD is initiating 6 MP/AZA, THEN TPMT testing should be performed before starting therapy. |
Surveillance |
IF a patient with ulcerative colitis is found to have confirmed low-grade dysplasia in flat mucosa, THEN proctocolectomy or repeat surveillance within 6 months should be offered. |
IF a patient with extensive c ulcerative colitis or Crohn's disease involving the colon has had their disease for 8 to 10 years, THEN surveillance colonoscopy should be performed every 1 to 3 years.d |
Health care maintenance. |
IF a patient with IBD is on immunosuppressive therapy, THEN patients should be educated about appropriate vaccinations, including (1) annual inactivated influenza, (2) pneumococcal vaccination with a 5-year booster, and (3) general avoidance of live virus vaccines. |
IF a patient with Crohn's disease is an active tobacco smoker, THEN smoking cessation should be recommended, and treatment should be offered or suitable referral provided at least annually. |
IBD, inflammatory bowel disease; TNF, tumor necrosis factor; 6-MP, 6-mercaptopurine; AZA, azathioprine; TPMT, thiopurine methyltransferase.
Table 2.
Table 3.
1. Patients who are hospitalized for the treatment of acute IBD (flare) should be offered pharmacological prophylaxis against venous thromboembolism or mechanical prophylaxis when the former is contraindicated. |
2. Hospitalized IBD patients with diarrheal symptoms should undergo testing for Clostridium difficile. |
3. CD patients who smoke should be informed about the poor clinical outcomes associated with ongoing smoking and, where available, they should be offered specialized counselling to improve smoking cessation rates. |
4. To accurately diagnose, treat and prognosticate, clinicians performing colonoscopy in patients with IBD should document the following: diagnosis (CD versus UC); disease location; and disease severity. |
5. In patients with corticosteroid-dependent IBD, an efficacious steroid-sparing therapy should be recommended. |
6. Patients with IBD should be assessed for tuberculosis and hepatitis B before initiation of tumor necrosis factor antagonists. |
7. In patients hospitalized for acute severe UC who have not responded to intravenous steroid therapy, implementation of salvage therapy should not be delayed beyond seven days from the start of intravenous corticosteroids. b |
8. All IBD patients with risk factors for metabolic bone disease, including prolonged steroid use, should be assessed for bone loss and treated if indicated. |
9. Patients with long-standing UC and Crohn's colitis should undergo routine surveillance colonoscopy to detect dysplasia. IBD patients with concomitant primary sclerosing cholangitis should undergo surveillance at the time of primary sclerosing cholangitis diagnosis and annually thereafter. |
10. CD patients who have undergone resection should have objective assessment for disease recurrence within six to 12 months, regard-less of current therapy. |
11. Pneumococcal vaccination and annual influenza vaccination should be administered to IBD patients, especially those on immunosuppressive therapies. Pneumococcal vaccination should be administered as early as possible after diagnosis. |