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To explore current thinking and decision-making in the management of mild-to-moderate ulcerative colitis (UC), we recently undertook detailed, survey-based research with healthcare professionals experienced in its routine management [1]. Results demonstrated that the current management approach for mild-to-moderate UC was guided by patients’ perspectives and goals as well as assessment of their medical and disease history. Optimization of 5-aminosalicylic acid (5-ASA) was considered a central tenet of this management approach as was providing patients with disease education and long-term support [1]. It is recognized, however, that the approach to treatment and management of UC varies with the experience of the treating clinician. For example, it has been reported that adherence to clinical guidelines for UC and 5-ASA optimization was more common among inflammatory bowel disease (IBD) specialists than general gastroenterologists [2]. To further investigate how clinical experience influences decision-making in UC, we assessed this aspect in a sub-analysis of our study.
The study methodology and participation have been fully described elsewhere [1]. In brief, 157 factors potentially related to the management of patients with mild-to-moderate UC were cataloged across 2 meetings with 11 IBD specialists from different countries (Supplementary File 1). This catalog formed the basis of a structured, online questionnaire that objectively assessed the importance and contribution of each of the factors when considering one of 3 defined scenarios: (1) when your patient presents with active mild-to-moderate UC; (2) when your patient achieves remission following a mild-to-moderate UC flare; and (3) self-management and empowerment of patients with mild-to-moderate UC (Supplementary File 1). For each scenario, individual factors were scored on end-anchored analogue scales from zero (very unimportant) to 100 (very important). Factors could also be scored as “not relevant.” Demographic details including country of practice, position (job title), years’ experience in gastroenterology, and time spent managing patients with IBD were captured as optional fields on the questionnaire.
In the present analysis, the following questions were addressed: (1) Is level of experience a valid differentiator of decision-making? (2) If so, what factors are considered by the different experience level groups? (3) How do the factors fit together in a decision network for each group?
Question 1 was addressed using Q-factor discriminant function analysis (DFA) in which respondents were categorized according to their level of experience (1–3, 4–5, 6–10, or > 10 years in gastroenterology). In contrast to standard DFA, Q-factor DFA reverses the analytical role of the respondents and factors, by using respondents as independent variables and factors as cases. As such, the results of the analysis provide insight as to how respondents group together around scenarios (as opposed to how factors group together around scenarios). Question 2 was addressed using principal component analysis, which identified the most important factors across all 3 scenarios. And question 3 by hierarchical cluster analysis, which assembled and stacked hierarchically individual factors with mean scores one standard deviation above 50 (for positive associations) or below 50 (for negative associations) within a scenario. In both cases, analyses were carried out in those respondents with ≤ 10 years’ experience versus > 10 years in gastroenterology. For all analyses, missing data were handled using the individual factor mean for each scenario.
Fifty-six responses were received from Europe and North America (n = 25, 45%), South America (n = 19, 34%), and the Middle East, Asia and Australia (n = 12, 21%). Among the respondents, 93% (n = 52) were consultant/specialist level, 5% (n = 3) trainees and 2% (n = 1) unknown. Most respondents were from academic centers (n = 47, 89%), whilst just over two-thirds (n = 38; 68%) spent ≥ 25% of their time managing patients with IBD. The majority (n = 33, 58%) of respondents had > 10 years’ experience, 18% (n = 10) had 6–10 years, 14% (n = 8) had 4–5 years and 4% (n = 2) had 1–3 years; 5% (n = 3) were unknown and excluded from the analyses described herein.
The level of experience of respondents was found to be associated with different decision-making across the 3 scenarios, with clear discrimination between respondents with > 10 years’ experience and the other groups (DFA component 1 [91.0% of variance] top 3 loadings 0.122 to 0.158 vs. –0.187 to –0.319, respectively).
Among the clinicians with > 10 years’ experience, there was a strong focus on patient education, discussion of treatment options and understanding the patient’s perspective and priorities. These made up the top 13 most important factors and 17 of the top 25 overall, with the remainder being more clinically-related (Table 1).
Among the group with ≤ 10 years’ experience, the focus was less marked, with a more even split between patient-related (11/25) and clinically-related (14/25) factors. This was further elucidated in the decision network, where the more experienced clinicians focused on fewer (n = 7) patient-related factors as overarching themes in their decision-making (Fig. 1A), whereas the less experienced clinicians considered a far greater number of patient and clinical factors (n = 42) as being of overall importance (Fig. 1B). Conversely, experienced clinicians tended to consider more factors when focused on the individual management scenarios than their less experienced counterparts (47 vs. 29, respectively), driven, in particular, by patients with active disease (33 vs. 18).
In patients with active disease, experienced clinicians relied on lessons from previous response to treatment, indicators of disease severity, adherence history and the role of 5-ASA optimization in successfully re-establishing and maintaining disease control. For self-management, the focus was on giving the patient the right information, tools and access to advice to prepare them for taking greater control of their own treatment. The remission scenario was strongly associated with the need for predictive biomarkers, such as fecal calprotectin. A similar array of factors was considered by the less experienced clinicians, though with more apparent overlap between scenarios. For example, there was greater overlap in the factors that were important to the active disease and remission following flare scenarios (17 factors in common vs. 2 in common in the more experienced group). Overall, experienced clinicians considered approximately 30% fewer factors as important for decision-making (71 vs. 100 for ≤ 10 years’ experience).
The results of this analysis suggest that all clinicians, regardless of experience, take a patient-focused approach to management. However, those with greater experience appear more confident, or put more general emphasis on, ensuring patients fully understand their disease, available treatment options and requirements of long-term therapy as the foundation for treatment decisions, independent of the patient’s disease status. With studies reporting that direct patient engagement as part of the management approach can improve adherence and treatment outcomes in UC [3,4], the broad recognition of the importance of such considerations seen in our study is encouraging. Optimization of 5-ASA therapy was a key theme for both more and less experienced clinicians. Considerations around optimization reflect the available strategies advocated in the literature, including combined oral and topical therapy and use of increased doses [5,6].
Less experienced clinicians tended to give greater weight to a broader range of factors across all 3 scenarios resulting in a more complex and “top-heavy” decision network. This suggests less confidence in a patient-led approach than in the more experienced group, with a tendency to try and consider more factors at every stage. It probably indicates more variability in decision-making by less experienced clinicians. These results are perhaps not surprising and highlight the importance of educating younger clinicians on how best to treat mild-to-moderate UC, since this is a disease requiring a holistic approach to management. Further training may involve educational meetings and webinars, courses supported by key societies, such as the Asian Organization for Crohn’s and Colitis and the European Crohn’s and Colitis Organisation, and, for those clinicians practicing in more general hospitals, the shadowing of specialists in major IBD centers. Important aspects to cover would include the adoption of a treat-to-target strategy [7], with an additional focus on interactions with patients.
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