Background: A “Treat to Target” (T2T) approach has been proposed for ulcerative colitis (UC), with a target of combined clinical and endoscopic remission. This has yet to be evaluated in real-world care.
Methods: A multicentre, retrospective, cross-sectional review of patients with UC attending outpatient services in South Australia between Jul 2013 and Nov 2015 was conducted. Clinician assessment of disease activity and objective assessment (endoscopy, histology, and/or biomarkers) were recorded. An on-line survey of local Gastroenterologists evaluated their perceptions of T2T in UC. Multivariate logistic regression, Fisher's exact tests and Kappa statistics were performed.
Results: Of 246 patients with UC, 61% were documented to be in clinical remission (normal bowel habit and no rectal bleeding), 35% documented to be in clinical and endoscopic remission (Mayo endoscopic sub-score ≤1), and 16% documented to be in concordant clinical, endoscopic and histological (Truelove and Richards' Index) remission.
Rather than disease-related factors (extent/activity), clinician-related factors dominated outcome. The hospital location at which care was delivered and choice of therapy predicted combined clinical and endoscopic remission (OR 3.6, 95% CI 1.6–8.7, p<0.001; OR 3.3, 95% CI 1.1–12.5, p=0.04, respectively)
Clinicians used C-reactive protein (CRP) more often than endoscopy as a biomarker for disease activity (75% vs 47%, p<0.001), despite observed random discordance between CRP and endoscopy (kappa 0.13, 95% CI 0.0–0.27). In the survey, 45/61 Gastroenterologists responded, with significant disparity between clinician estimates of targets achieved in practice and real-world data (p<0.001 for clinical and endoscopic remission)
Conclusions: Most patients with UC do not achieve composite clinical and endoscopic remission in real-world practice. Clinicians overestimate their achievements and practice behaviour is a barrier to achieving stipulated targets.