"Best practice" in inflammatory bowel disease: an international survey and audit

Systematic review: advice lines for patients with inflammatory bowel disease

OBJECTIVE

Advice lines for patients with inflammatory bowel diseases (IBD) have been introduced internationally. However, only a few publications have described the advice line service and evaluated the efficiency of it with many results presented as conference posters. A systematic synthesis of evidence is needed and the aim of this article was to systematically review the evidence of IBD advice lines.

MATERIALS AND METHODS

A broad systematic literature search was performed to identify relevant studies addressing the effect of advice lines. The process of selection of the retrieved studies was undertaken in two phases. In phase one, all abstracts were review by two independent reviewers. In phase two, the full text of all included studies were independently reviewed by two reviewers. The included studies underwent quality assessment and data synthesis.

RESULTS

Ten published studies and 10 congress abstracts were included in the review. The studies were heterogeneous both in scientific quality and in the focus of the study. No rigorous evidence was found to support that advice lines improve disease activity in IBD and correspondingly no studies reported worsening in disease activity. Advice lines were found to be health economically beneficial with clear indications of the positive impact of advice lines from the patient perspective.

CONCLUSION

The levels of evidence of the effect of advice lines in IBD are low. However, the use of advice lines was found to be safe, and cost-effective. Where investigated, patients with IBD overwhelmingly welcome an advice line with high levels of patient satisfaction reported.

Patient satisfaction in the management of mild-to-moderate ulcerative colitis: Results of a Delphi study among patients and physicians

GOALS

To determine factors contributing to satisfaction with treatment in mild-to-moderate ulcerative colitis (UC) from both the patients and the physicians perspectives.

BACKGROUND

Despite the impact of UC on different aspects of daily life, patient's and physician's satisfaction with clinical management has been poorly evaluated.

STUDY

A Delphi study involving 22 patients and 20 clinicians was conducted. The patient's questionnaire included 285 items regarding diagnosis, treatment, and follow-up, whereas the physician's questionnaire added 32 specific items for clinicians. Relevance of items was scored from 1 (not at all important) to 9 (very important). Recommendations were based on very highly rated items.

RESULTS

Most items were rated consistently by patients and physicians with some exceptions. Patients emphasized the choice of moderate flare-ups to be followed at the hospital setting rather than in primary care as well as to be informed on aspects, such as diet and impact of UC on their health and lifestyle. Treatment-related efficacy, safety, and improved quality of life were relevant for both patients and physicians. Physicians believed that to reduce pill burden was a crucial aspect to improve patient's satisfaction. Patients preferred oral administration treatment over rectal treatment.

CONCLUSIONS

The study identified specific aspects related to the management of mild-to-moderate UC that both patients and physicians considered to be highly relevant for patient satisfaction. Recommendation based on these factors would be important at the time of designing and implementing strategies targeting satisfaction in UC patients.

Optimising the Inflammatory Bowel Disease Unit to Improve Quality of Care: Expert Recommendations

INTRODUCTION

The best care setting for patients with inflammatory bowel disease [IBD] may be in a dedicated unit. Whereas not all gastroenterology units have the same resources to develop dedicated IBD facilities and services, there are steps that can be taken by any unit to optimise patients' access to interdisciplinary expert care. A series of pragmatic recommendations relating to IBD unit optimisation have been developed through discussion among a large panel of international experts.

METHODS

Suggested recommendations were extracted through systematic search of published evidence and structured requests for expert opinion. Physicians [n = 238] identified as IBD specialists by publications or clinical focus on IBD were invited for discussion and recommendation modification [Barcelona, Spain; 2014]. Final recommendations were voted on by the group. Participants also completed an online survey to evaluate their own experience related to IBD units.

RESULTS

A total of 60% of attendees completed the survey, with 15% self-classifying their centre as a dedicated IBD unit. Only half of respondents indicated that they had a defined IBD treatment algorithm in place. Key recommendations included the need to develop a multidisciplinary team covering specifically-defined specialist expertise in IBD, to instil processes that facilitate cross-functional communication and to invest in shared care models of IBD management.

CONCLUSIONS

Optimising the setup of IBD units will require progressive leadership and willingness to challenge the status quo in order to provide better quality of care for our patients. IBD units are an important step towards harmonising care for IBD across Europe and for establishing standards for disease management programmes.

Delphi consensus statement: Quality Indicators for Inflammatory Bowel Disease Comprehensive Care Units

BACKGROUND AND AIMS

While it is commonly accepted that Inflammatory bowel disease (IBD) Comprehensive Care Units (ICCUs) facilitate the delivery of quality care to Crohn's disease and ulcerative colitis patients, it remains unclear how an ICCU should be defined or evaluated. The aim of the present study was to develop a comprehensive set of Quality Indicators (QIs) of structure, process, and outcomes for defining and evaluating an ICCU.

METHODS

A Delphi consensus-based approach with a standardized three-step process was used to identify a core set of QIs. The process included an exhaustive search using complementary approaches to identify potential QIs, and two Delphi voting rounds to select the QIs defining the core requirements for an ICCU.

RESULTS

The consensus selected a core set of 56 QIs (12 structure, 20 process and 24 outcome). Structure and process QIs highlighted the need for multidisciplinary management and continuity of care. The minimal IBD team should include an IBD nurse, gastroenterologists, radiologists, surgeons, endoscopists and stoma management specialists. ICCUs should be able to provide both outpatient and inpatient care and admission should not break the continuity of care. Outcome QIs focused on the adequate prophylaxis of disease complication and drug adverse events, the need to monitor appropriateness of treatment and the need to reinforce patient autonomy by providing adequate information and facilitating the patients' participation in their own care.

CONCLUSIONS

The present Delphi consensus identified a set of core QIs that may be useful for evaluating and certifying ICCUs.

Assessing patient satisfaction in inflammatory bowel disease using the QUOTE-IBD survey: a small step for clinicians, a potentially large step for improving quality of care

BACKGROUND

Patient satisfaction is thought integral to high quality of care (QoC) in chronic disease models, including inflammatory bowel disease (IBD). Here we utilized the QUOTE-IBD survey in IBD clinic patients, in order to examine potential deficiencies in QoC from the patients' perspective, thus possibly amenable to change.

METHODS

Consecutive patients attending a single clinic were asked to complete the QUOTE-IBD survey, where 22 items (in seven domains) were rated for importance (I), and actual performance (P), and a quality index (QI) was derived. A QI <9.0 indicated suboptimal satisfaction. Other data were extracted from hospital records and CRP was measured. Factorial ANOVA examined effects of relevant clinical and demographic factors on satisfaction (QI) scores per domain.

RESULTS

Of 367 potential participants, 187 (51%) responded. 86 (46%) had Crohn's disease, 101 (54%) ulcerative colitis; 52% were females, and median age was 45y (range 18,82). The only QI score <9.0 was 'kept in waiting room >15min' (QI 8.73). In bivariate analyses, those with Crohn's, post-resection and longer IBD duration each had lower domain QI's than their respective counterparts, whereas those on concurrent anti-TNF therapy gave higher QI scores (each p<0.05). Factorial ANOVA showed female gender and IBD duration ≥ 5years were each associated with significantly lower mean QI scores in multiple domains.

CONCLUSIONS

Patients with adverse disease characteristics (e.g. longer duration, post-resection) and females reported lower satisfaction. Conversely, those on anti-TNF therapy reported higher satisfaction. Targeting these 'at-risk' groups and assessing satisfaction longitudinally may enhance QoC in IBD.

Design and development of EMR supporting medical process management

Current EMR system benefits physicians by facilitating order entry and reducing errors. It can improve the safety and effectiveness of medical services, but cannot manage the whole medical process and the quality of medical services. In addition to physicians, EMR should be designed for all medical professionals because medical services cannot be accomplished by physicians alone, but also requires the involvement of other medical professionals. Therefore, we applied PDCA, the famous quality management cycle to design a comprehensive and coherent EMR system which can be used throughout the entire treatment process. EMR with the PDCA Cycle can record every order state and every treatment procedure in order to monitor the whole medical process. This extends the safety from planning the treatment to fulfilling it. By analyzing the records, doctors and hospital managers can perfect the medical process and improve healthcare quality. The EMR we designed with the PDCA Cycle provides a record entry interface for physicians and a worksheet interface for nurses and other professionals. Every treatment procedure and every change of orders or tasks will be fed back to medical professionals. So information generated from the beginning to the end of treatment will link with each other to avoid any information islands. Furthermore, the EMR can display the additional information intuitively and real-timely without increasing the burden of medical professionals' work.

Contribution of nurses to the quality of care in management of inflammatory bowel disease: a synthesis of the evidence

BACKGROUND

The purpose of quality of care programs is to improve patient outcomes. In programs targeting patients with inflammatory bowel disease (IBD), nurses play a key role.

AIM

To know the available scientific evidence on the quality of care in IBD management, at the levels of structure, process and outcome, in relation to nurses.

METHODS

Systematic search in MEDLINE, EMBASE, Índice Médico Español, Cochrane Library, and grey literature. Inclusion criteria were: 1) documents referring IBD; 2) documents providing relevant information on nurses' involvement in the management of IBD; and 3) an original article.

RESULTS

A total of 284 documents were identified, 15 of which were included: 8 related with structure, 12 with process, and 6 with outcomes. Some documents treated more than one level. At the level of structure, services should incorporate specialist nurses as part of the multidisciplinary team, as well as resources to facilitate patient access to nursing care. Notable at the process level, organizational aspects and nurses' competencies and skills in the management of IBD have been described. Among the outcomes mentioned are clinical outcomes, quality of life, and patient satisfaction attributable to nursing staff. No evidence was found about the association between structure or process issues with patient outcomes. Most of the studies reviewed have methodological limitations.

CONCLUSIONS

The available evidence provide useful information for the design of standards of structure and process relating to nurses' management of IBD. The IBD nurses' challenge is to provide evidence that these standards help improve health outcomes in patients.

Communication of information to patients with inflammatory bowel disease: A European Collaborative Study in a multinational prospective inception cohort

BACKGROUND AND AIMS

Communication to patients of information about their disease has become increasingly important in modern medicine, and particularly with chronic nonfatal disorders like inflammatory bowel disease (IBD), but the subject is not adequately researched or understood.

METHODS

We studied the media and preferences for communication of information in a multi-national community-based inception cohort of European and Israeli patients with IBD and 10 years follow-up, using structured questionnaires categorizing demographics, disease status, current and preferred sources of information, use of electronic media, role of patients' associations, and satisfaction level.

RESULTS

The 917 patients completing the questionnaire were derived from northern (60%) and southern (40%) countries. The mean age was 48.3 years (62% under 50 years); 51% were males; 67% had ulcerative colitis, 33% Crohn's disease. Sixty-six percent of patients designated the specialist as their primary source of information, 77% indicated satisfaction with their current information, and 65% reported not receiving information about medical treatment in the past year. Patient concerns were about new research into their illness (64%), medical treatments (58%), risks and complications (51%) and genetics (42%). Preferred sources of information were paper bulletin (76%), electronic media (30%) and international organization (79%). Diagnosis (ulcerative colitis or Crohn's disease), gender, education level and country impacted significantly on patients' choices.

CONCLUSIONS

In providing health care information to patients with IBD their individual attitudes and preferences must be considered. There should be greater roles for IBD patients' associations and international IBD-research organizations, and an increasing use of electronic media.

The multidisciplinary team for management of inflammatory bowel diseases

Crohn's disease (CD) and ulcerative colitis (UC) are inflammatory bowel diseases (IBD) characterized by a relapsing clinical pattern that typically affect people during their adult and economically productive lives. Affected patients require clinical follow-up because of periodic disease flare-up and of the risk of long-term complications. Extensive diagnostic procedures, medical and surgical treatments are often needed over a lifetime. The challenge posed by management of IBD is better faced by a multidisciplinary team that includes health care providers with complementary diagnostic or therapeutic skills. The team is expected to provide the best practice to manage IBD by defining a realistic "diagnostic and therapeutic pathway" for the patients to follow based on locally available professional, structural and technological resources. This approach appears to improve quality of care for IBD patients and to be cost-effective.

IBD patients need in health quality of care ECCO consensus

INTRODUCTION

: Inflammatory bowel diseases (IBD) is a lifelong disorder with increasing incidence and prevalence. IBD primarily affects young people's productivity in addition to direct and indirect costs. The chronic nature of the disease and the patients' requirement of frequent and easy access to the Health Care providers regarding lifelong medication, social and psychological support and regular follow-up in out-patient clinics are important considerations to address.

AIM AND METHODS

: To define IBD patient needs in Quality of Health Care (QoHC) in Europe based on up- to date available evidence. The working group consisted of doctors, nurses and patient organizations from 12 European countries and Israel. Pub Med searching was performed as defined in the Delta Method. Each recommendation was graded (RG) in accordance with level of evidence (EL) based on Evidence Based Medicine, Oxford Centre. During UEGW 2007 the group reconvened to agree on the final version for each chapter of guideline statement

RESULTS

: Pub Med search led to 6 RCT, 7 reviews, 63 original articles, but no meta-analysis regarding "Information"; "Education"; "Primary Care", "Quality of life", "Psychological help" and "Benchmarking of Health Care systems" in IBD. Seven ECCO statements have been worked out.

CONCLUSION

: Evidence-based medicine in QoHC is limited. It is concluded that optimizing QoHC by "information"; "education", "benchmarking" and "psychological analysis" helps the patient to understand the disease and comply with its therapy, increasing QoL, reducing depression and anxiety. Future aspects regarding more evidence-based science and optimization of QoHC in IBD throughout Europe have been proposed.

Improved population-based care: Implementing patient-and demand-directed care for inflammatory bowel disease and evaluating the redesign with a population-based registry

The gastroenterology unit at the Höglands Hospital in Eksjö is responsible for the care of all 466 patients with inflammatory bowel disease (IBD) in a geographic area including approximately 115,000 inhabitants. In 2000, the frustration over an inadequate traditional outpatient clinic inspired us to redesign our outpatient unit to become more patient and demand directed. The redesign included the following: A direct telephone line for patients to a specialized nurse, available during working hours; appointments were scheduled in accordance with expected needs, and emergency appointments were available daily; traditional follow-ups of IBD patients were replaced by an annual telephone contact with a specialized nurse; the team agreed on a patient-centered value base for its work, and the redesign was monitored using clinical outcome measures reflecting 4 dimensions (see parentheses below) of the care in a "Value compass"; quality of life (functional) and routine blood samples (clinical) were followed yearly and collected in a computerized IBD registry together with basic information about the patients; access and waiting lists together with patient satisfaction (satisfaction) are followed regularly; and ward utilization (financial) was registered. Our study shows that the new design offers a more efficient outpatient clinic in which waiting lists are markedly reduced although production rates remains the same. Utilization data show a significant decrease in comparison with national data, showing that the new care is economically favorable. The clinical results regarding anemia frequency in the IBD population are highly comparable with or even better than those found in the literature. We also show good results regarding quality of life where more than 88% of patients achieve set goals. In conclusion, our new patient- and demand-directed care seems to be more efficient and with clinical and quality-of-life results remaining on a high standard.

Targeting nanomedicines in the treatment of Crohn's disease: focus on certolizumab pegol (CDP870)

A variety of targets for therapeutic intervention are based upon advances in understanding of the immunopathogenesis of Crohn's disease. Crohn's disease is initiated by an innate immune response, which eventuates in a T-cell driven process, characterized by a T-helper cell 1 type cytokine profile. Several new treatments now focus on suppressing T-cell differentiation or T-cell inflammation. Since inflammatory bowel disease (IBD) represents a state of dysregulated inflammation, drugs that augment the anti-inflammatory response have the potential to downregulate inflammation and thereby hopefully modify the disease. Tumour necrosis factor (TNF) is a major target of research and clinical investigation. TNF has proinflammatory effects in the intestinal mucosa and is a pivotal cytokine in the inflammatory cascade. Certolizumab pegol (CDP870) is a PEGylated, Fab' fragment of a humanized anti-TNF-alpha monoclonal antibody. PEGylation increases the half-life, reduces the requirement for frequent dosing, and possibly reduces antigenicity as well. Certolizumab has been shown in Phase III trials to achieve and maintain clinical response and remission in Crohn's disease patients. It improves the quality of life. Certolizumab pegol will be indicated for moderately to severely active Crohn's disease, but it is not yet licensed in Europe or the US. It is not possible to construct an algorithm for treatment, but when compared with infliximab the two principal advantages are likely to be lower immunogenicity (as shown by anti-drug antibodies, absence of infusion reactions, and low rate of antinuclear antibodies), and a subcutaneous route of administration. These two factors may be sufficient to promote it up the pecking order of anti-TNF agents.

Cost analysis and cost determinants in a European inflammatory bowel disease inception cohort with 10 years of follow-up evaluation

BACKGROUND & AIMS

Economic analysis in chronic diseases is a prerequisite for planning a proper distribution of health care resources. We aimed to determine the cost of inflammatory bowel disease, a lifetime illness with considerable morbidity.

METHODS

We studied 1321 patients from an inception cohort in 8 European countries and Israel over 10 years. Data on consumption of resources were obtained retrospectively. The cost of health care was calculated from the use of resources and their median prices. Data were analyzed using regression models based on the generalized estimating equations approach.

RESULTS

The mean annual total expenditure on health care was 1871 Euro/patient-year for inflammatory bowel disease, 1524 Euro/patient-year for ulcerative colitis, and 2548 Euro/patient-year for Crohn's disease (P < .001). The most expensive resources were medical and surgical hospitalizations, together accounting for 63% of the cost in Crohn's disease and 45% in ulcerative colitis. Total and hospitalization costs were much higher in the first year after diagnosis than in subsequent years. Differences in medical and surgical hospitalizations were the primary cause of substantial intercountry variations of cost; the mean cost of health care was 3705 Euro/patient-year in Denmark and 888 Euro/patient-year in Norway. The outlay for mesalamine, a costly medication with extensive use, was greater than for all other drugs combined. Patient age at diagnosis and sex did not affect costs.

CONCLUSIONS

In this multinational, population-based, time-dependent characterization of the health care cost of inflammatory bowel disease, increased expenditure was driven largely by country, diagnosis, hospitalization, and follow-up year.