Indicators of Quality of Care in Inflammatory Bowel Disease: Seeking the Right Path for Patients
Because inflammatory bowel disease (IBD) is a chronic health condition with a typical course of remissions and relapses, defining and implementing quality of care indicators and outcomes are crucial for patients with IBD especially with significant variations of care given across different IBD centers.2 Developing evidence-based quality indicators could be a challenging process but a much more challenging task is implementing those indicators in routine clinical practice. The majority of the current quality indicators in IBD care are based on consensus agreements and expert opinions. Clinical quality indicators are quantitative endpoints used to guide, monitor, and improve the quality of patient care.3The ImproveCareNow (ICN) pediatric network demonstrated quality improvement by learning how to apply quality improvement methods to improve the care of pediatric patients with IBD, a model that has been adopted by other practitioners.4,5 Several outcome measures have developed including those of The American Gastroenterological Association and Crohn's and Colitis Foundation of America.3,6 The Emerging Practice in IBD Collaborative (EPIC) group generated 11 quality indicators for best-practice management of IBD in Canada.7 These indicators included pharmacological prophylaxis against deep vein thrombosis for hospitalized patients with acute IBD, testing for Clostridium difficile for these patients, counseling to improve smoking cessation for patients with Crohn's disease, proper documentation of diagnosis (Crohn's disease versus ulcerative colitis [UC]); disease location; and disease severity during initial diagnostic colonoscopy, using steroid-sparing agents in corticosteroid-dependent IBD, screening for tuberculosis and hepatitis B before initiating tumor necrosis factor antagonists, implementing rescue therapy for patients with acute severe UC after a maximum period of 7 days on intravenous corticosteroids, assessment and treatment for bone loss in high-risk patients for metabolic bone disease, screening for dysplasia in patients with colonic IBD with annual screening in those with concomitant primary sclerosing cholangitis, objective assessment for disease recurrence 6 to 12 months postsurgery in those who underwent intestinal resection for Crohn's disease, and recommending pneumococcal and annual influenza vaccination for patients with IBD especially for those on immunosuppression.7
In this issue of Inflammatory Bowel Diseases, Nguyen et al conducted a multicenter study of IBD hospitalizations among IBD tertiary-care centers in Canada's four largest metropolitan areas (Toronto, Montreal, Vancouver, and Ottawa) to determine the frequency to which inpatient quality indicators were being followed.8 The investigators chose pharmacological venous thromboembolism (VTE) prophylaxis, C. difficile testing, medical rescue therapy for steroid-refractory UC, rates of VTE, C. difficile infections, and IBD-related surgery as quality indicators. There were significant variations in clinical practice not only among different centers but also if the admitting practitioner was a gastroenterologist as opposed to a surgeon. Over 75% of hospitalized patients had received VTE prophylaxis and C. difficile testing. Of interest, there was no statistically significant difference in the rate of VTE among those who received VTE prophylaxis versus those who did not.
Of those patients with UC and inadequate or lack of response to systemic corticosteroids, 79% received rescue therapy with 70% receiving their rescue therapy within 7 days of starting steroids.