Quality of Care in Inflammatory Bowel Disease

Geom Seog Seo

doi:10.4166/kjg.2015.65.3.139

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Seo: Quality of Care in Inflammatory Bowel Disease

Review Article

Korean J Gastroenterol 2015;65(3):139-144.

Published online: 4 October 2015

DOI: https://doi.org/10.4166/kjg.2015.65.3.139

Quality of Care in Inflammatory Bowel Disease

Geom Seog Seo

Department of Internal Medicine, Digestive Disease Research Institute, Wonkwang University College of Medicine, Iksan, Korea

Correspondence to: Geom Seog Seo, Department of Internal Medicine, Digestive Disease Research Institute, Wonkwang University College of Medicine, 460 Iksan- daero, Iksan 570-749, Korea. Tel: +82-63-859-2565, Fax: +82-63-855-2025, E-mail: medsgs@wonkwang.ac.kr

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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.

Keywords: Quality, Care, Indicator, Inflammatory bowel disease

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Table 1.

Ten Most Highly Rated Process Measures ^a

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.

^a All measures had median ratings of 8 or higher on a 1 through 9 rating scale.

^b 6-MP, 1.0 to 1.5 mg/kg daily; azathioprine, 2.0 to 2.5 mg/kg daily (if normal TPMT metabolism); methotrexate 25 mg injected subcutaneously weekly, or appropriately dosed biological therapy.

^c L-sided for ulcerative colitis, or 1/3 or more for Crohn's disease.

^d If a patient with ulcerative colitis has coexisting primary sclerosing cholangitis (of any duration), THEN surveillance colonoscopy should be performed every 1 to 3 years.

Table 2.

Ten Most Highly Rated Outcome Measures ^a

Steroid use

Proportion of patients with steroid-free clinical remission for >12 month period

Proportion of patients currently taking prednisone (excluding those diagnosed within the last 112 days)

Number of days per month/year lost from school/work attributable to IBD

Number of days per year in the hospital attributable to IBD

Number of emergency room visits per year for IBD

Proportion of patients with malnutrition

Proportion of patients with anemia

Proportion of patients with normal disease-targeted health-related quality of life

Proportion of patients currently taking narcotic analgesics

Proportion of patients with nighttime bowel movement or leakage

Proportion of patients with incontinence in the last month.

IBD, inflammatory bowel disease.

^a All measures had median ratings of 8 or higher on a 1 through 9 rating scale.

Table 3.

Quality Indicators for IBD Care, Defined by the Emerging Practice in IBD Collaborative (EPIC) ^a

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.

IBD, inflammatory bowel disease; CD, Crohn disease; UC, ulcerative colitis.

^a Following a comprehensive literature review, it was agreed that there is insufficient evidence at present to support the inclusion of quality indicator 12: “There should be objective measurement of response to medical therapy for IBD patients on maintenance therapy”.

^b Consideration should be given to shortening the time frame for salvage treatment implementation to three days in patients with a more fulminant presentation.

Table 4.

Items Included in QUOTE-IBD

Generic: Doctors, nurses and other health care workers
(CM)	1	Should have a good understanding of the patient's problems
(AU)	2	Should allow the patient to have input in decisions regarding treatment received
(CO)	3	Should take the patient seriously
(CO)	4	Should keep appointments punctually
(A)	5	Should not keep the patient in the waiting room for more than 15 minutes
(I)	6	Should inform the patient about medicines that are prescribed
(C)	7	Should prescribe medicines which are fully covered by insurance
(A)	8	Should be easy to reach by telephone
(CC)	9	Should make sure that the patient can consult a(nother) specialist within 2 weeks after referral
(CC)	10	Should communicate with other health care workers about required services IBD-specific
(AC)	11	Waiting areas and consulting rooms should be clean and orderly
(CM)	12	Doctors and nurses should also approach my physical complaints from a psychological point of view
(I)	13	Doctors and nurses should inform me clearly about the examinations I am subjected to
(CC)	14	I should usually be seen by the same doctor
(I)	15	Doctors should inform me clearly about other possible physical problems due to IBD, e.g., joint pain
(CM)	16	Nurses at the endoscopy department should have specific expertise in IBD
(AC)	17	Hospitals and medical practice rooms should have good toilet facilities
(A)	18	If my doctor is absent an adequately competent substitute should be available
(I)	19	In health institutions adequate information about nutrition and IBD should be available to me
(CC)	20	It should be possible for me to consult my doctor regularly
(A)	21	In case of acute problems a doctor should be available within 24 hours
(CO)	22	Doctors and nurses should pay attention to the influence of my IBD on my family life and/or work situation
(CO)	23	As an IBD patient I should have confidence in my doctor

QUOTE, Quality of Care through the Patient's Eyes; IBD, inflammatory bowel disease; CM, competence; AU, autonomy; CO, courtesy; A, accessibility; I, information; C, cost; CC, continuity of care; AC, accommodation.

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