Interventions and targets aimed at improving quality in inflammatory bowel disease ambulatory care

Over the past decade,there has been increasing focus on improving the quality of healthcare delivered to patients with chronic diseases,including inflammatory bowel disease.Inflammatory bowel disease is a complex,chronic condition with associated morbidity,health care costs,and reductions in quality of life.The condition is managed primarily in the outpatient setting.The delivery of high quality of care is suboptimal in several ambulatory inflammatory bowel disease domains including objective assessments of disease activity,the use of steroid-sparing agents,screening prior to anti-tumor necrosis factor therapy,and monitoring thiopurine therapy.This review outlines these gaps in performance and provides potential initiatives aimed at improvement including reimbursement programs,quality improvement frameworks,collaborative efforts in quality improvement,and the use of healthcare information technology.

Transition of pediatric to adult care in inflammatory bowel disease: Is it as easy as 1, 2, 3?

Inflammatory bowel disease(IBD)is a heterogeneous group of chronic diseases with a rising prevalence in the pediatric population,and up to 25%of IBD patients are diagnosed before 18 years of age.Adolescents with IBD tend to have more severe and extensive disease and eventually require graduation from pediatric care toadult services.The transition of patients from pediatric to adult gastroenterologists requires careful preparation and coordination,with involvement of all key players to ensure proper collaboration of care and avoid interruption in care.This can be challenging and associated with gaps in delivery of care.The pediatric and adult health paradigms have inherent differences between health care models,as well as health care priorities in IBD.The readiness of the young adult also influences this transition of care,with often times other overlaps in life events,such as school,financial independence and moving away from home.These patients are therefore at higher risk for poorer clinical disease outcomes.The aim of this paper is to review concepts pertinent to transition of care of young adults with IBD to adult care,and provides resources appropriate for an IBD pediatric to adult transition of care model.

Quality of care in inflammatory bowel diseases: What is the best way to better outcomes?

Inflammatory bowel disease(IBD) is a lifelong, progres-sive disease that has disabling impacts on patient's lives. Given the complex nature of the diagnosis of IBD and its management there is consequently a large economic burden seen across all health care systems. Quality in-dicators(QI) have been created to assess the different fa?ades of disease management including structure, process and outcome components. Their development serves to provide a means to target and measure quality of care(Qo C). Multiple different QI sets have been published in IBD, but all serve the same purpose of trying to achieve a standard of care that can be attained on a national and international level, since there is still a major variation in clinical practice. There have been many recent innovative developments that aim to improve Qo C in IBD including telemedicine, home biomarker assessment and rapid access clinics. These are some of the novel advancements that have been shown to have great potential at improving Qo C, while offloading some of the burden that IBD can have vis-a-vis emergency room visits and hospital admissions. The aim of the current review is to summarize and discuss available QI sets and recent developments in IBD care including telemedicine, and to give insight into how the utilization of these tools could benefit the Qo C of IBD patients. Additionally, a treating-to-target structure as well as evidence surrounding aggressive management directed at tighter disease control will be presented.

Quality of care for patients with inflammatory bowel disease in East China

AIM: To investigate the quality of care for a hospital based-cohort of patients with inflammatory bowel disease (IBD) from East China according to the current practice guidelines. METHODS: A retrospective review was conducted,involving 177 patients with IBD admitted to Sir Run Run Shaw Hospital,College of Medicine,Zhejiang University between June 2000 and June 2006. Data regarding demographic and clinical characteristics as well as medical therapy including use of oral aminosalisylates,topical therapy,corticosteroid agents,immunomodulatory agents (such as azathioprine) at admission and outpatient clinic visit were analyzed. RESULTS: A total of 177 eligible patients were evaluated in this study,including 71 patients with Crohn's disease (CD) and 106 with ulcerative colitis (UC). All were the Han nationality Chinese with active disease at baseline. All the 106 patients with ulcerative colitis received optimal doses of aminosalisylate while 27 of 68 (39.7%) patients with ileal or colonic CD received the suboptimal doses of aminosalisylate. The incidence of suboptimal dose of aminosalisylate was significantly higher in CD patients with small intestine involvement only (52.8% vs 25.0%,P = 0.019). Thirty-one (54.4%) patients with active distal or left-sided ulcerative colitis received topical therapy,and 27.8% of patients suffering from severe in? ammatory bowel disease did not receive oral or intravenous steroid therapy. Among the 51 patients for whom thiopurine was indicated,only 10 (19.6%)received immunomodulatory agents,and more than half of the 8 patients received a suboptimal dose of azathiopurine with no attempt to increase its dosage. CONCLUSION: The quality of care for IBD patients can be further improved. A suboptimal dose of aminosalicylate is used in treatment of patients with CD,especially in those with small intestine involved only. Topical mesalazine is inadequately used in patients with distal or left-sided colitis. Oral or intravenous steroid therapy is not used in some patients with severe IBD. Use of immunomodulatory medication is limited. Larger prospective studies are needed to investigate the quality of care for patients with IBD to establish our own evidence-based guidelines.

Disparity in clinical care for patients with inflammatory bowel disease between specialists and non-specialists

Background: Although inflammatory bowel disease (IBD) patients have been increasing and new thera-peutic options for IBD have been developed, there are relatively few clinicians who specialize in IBD. Patients treated by a non-specialist of IBD may not receive appropriate treatment. This study aimed to compare disease and medication status between IBD patients treated by a specialist and those treated by a non-specialist. Methods: Medical charts of ambulating IBD patients in two hospitals were examined. All patients in one hospital were treated by one of the IBD specialists, while in the other hospital, patients were treated by one of the gastroenterologists who was a non-specialist of IBD. Results: The numbers of IBD patients were 255 (hospital with specialists) and 74 (hospital without specialists), respectively. Disease activity of the patients was not well-controlled in the hospital without specialists compared to in the hospi- tal with specialists (ulcerative colitis (UC): p = 0.0006 and Crohn’s disease: p = 0.012, respectively). The proportion of UC patients who received an insufficient dose of mesalazine (Pentasa < 3 g/day or Asacol < 3.6 g/day) was higher in the hospital without specialists (47% vs. 15%, p < 0.0001). In the hospital without specialists, more patients received long-term corticosteroids (UC: 23% vs. 5%, p < 0.0001), while fewer patients received immunomodulators (UC: 8% vs. 46%, p < 0.0001). Conclusions: IBD patients of the hospital without specialists were not well-controlled and were not prescribed appropriately with thera-peutic drugs. Fostering and placement of the specialist of IBD is an urgent problem.

Transition care in inflammatory bowel disease: A needs assessment survey of Quebec gastroenterologists and allied nurses

AIM To determine the tools needed and problems encountered during the transition of inflammatory bowel disease(IBD) patients from pediatric to adult gastroenterologists(GIs) in Québec, Canada.METHODS We conducted a needs assessment survey of Quebec health care professionals(HCPs). The survey was handed out to 136 Québec HCPs at a local conference in 2013. Additionally, it was emailed to any other HCPs in Quebec involved in caring for IBD patients. The completed surveys were compiled to derive descriptive data. Further specific subgroup analysis was then conducted. RESULTS Among the conference attendees and individuals emailed 77(28.2%) completed the questionnaire. Respondents included adult GIs(61.3%), pediatric GIs(20.8%) and IBD nurses(18.3%). The majority of respondents believed that a standardized structure is important for a successful transition. Adult and pediatric GIs equally felt that patients were inadequately prepared for the transition(P = 0.6). There were significant differences between adult and pediatric GIs when it came to resource availability(55.6% vs 90.9%, P = 0.002) and perceived need of a formal transition clinic(21.7% vs 68.8%, P = 0.0006). Both transition program and medical summaries were identified as the most valuable tools to improve transition. CONCLUSION As described in previous studies, our survey reinforces the importance of a transition program, education for young adult IBD patients and the need to improve communication between adult and pediatric GIs.

Correlation of rapid point-of-care vs send-out fecal calprotectin monitoring in pediatric inflammatory bowel disease

AIM To assess the correlation between the send-out enzymelinked immuno sorbent assay(ELISA) and the point-ofcare(POC) calprotectin test in pediatric inflammatory bowel disease(IBD) patients.METHODS We prospectively collected stool samples in pediatric IBD patients for concomitant send-out ELISA analysis and POC calprotectin testing using the Quantum Blue?(QB) Extended immunoassay. Continuous results between 17 to 1000 μg/g were considered for comparison. Agreement between the two tests was measured by a Bland-Altman plot and statistical significance was determined using Pitman's test.RESULTS Forty-nine stool samples were collected from 31 pediatric IBD patients. The overall means for the rapid and ELISA tests were 580.5 and 522.87 μg/g respectively. Among the 49 samples, 18(37.5%) had POC calprotectin levelsof ≤ 250 μg/g and 31(62.5%) had levels > 250 μg/g.Calprotectin levels ≤ 250 μg/g show good correlation between the two assays. Less correlation was observed at quantitatively higher calprotectin levels. CONCLUSION In pediatric IBD patients, there is better correlation of between ELISA and POC calprotectin measurements at clinically meaningful, low-range levels. Future adoption of POC calprotectin testing in the United States may have utility for guiding clinical decision making in real time.

Transitions of care across hospital settings in patients with inflammatory bowel disease

BACKGROUND Inflammatory bowel disease(IBD) is a chronic, inflammatory disorder characterised by both intestinal and extra-intestinal pathology. Patients may receive both emergency and elective care from several providers, often in different hospital settings. Poorly managed transitions of care between providers can lead to inefficiencies in care and patient safety issues. To ensure that the sharing of patient information between providers is appropriate, timely, accurate and secure, effective data-sharing infrastructure needs to be developed. To optimise inter-hospital data-sharing for IBD patients, we need to better understand patterns of hospital encounters in this group.AIM To determine the type and location of hospital services accessed by IBD patients in England.METHODSThis was a retrospective observational study using Hospital Episode Statistics, a large administrative patient data set from the National Health Service in England.Adult patients with a diagnosis of IBD following admission to hospital were followed over a 2-year period to determine the proportion of care accessed at the same hospital providing their outpatient IBD care, defined as their ‘home provider'. Secondary outcome measures included the geographic distribution of patient-sharing, regional and age-related differences in accessing services, and type and frequency of outpatient encounters.RESULTS95055 patients accessed hospital services on 1760156 occasions over a 2-year follow-up period. The proportion of these encounters with their identified IBD‘home provider' was 73.3%, 87.8% and 83.1% for accident and emergency,inpatient and outpatient encounters respectively. Patients living in metropolitan centres and younger patients were less likely to attend their ‘home provider' for hospital services. The most commonly attended specialty services were gastroenterology, general surgery and ophthalmology.CONCLUSION Transitions of care between secondary care settings are common for patients with IBD. Effective systems of data-sharing and care integration are essential to providing safe and effective care for patients. Geographic and age-related patterns of care transitions identified in this study may be used to guide interventions aimed at improving continuity of care.

视频和节点提醒用于结肠镜检查肠道准备患者药学服务效果分析

目的探讨临床药师利用视频和节点提醒的药学服务对结肠镜检查肠道准备质量、不良反应发生情况、健康教育指导满意度的影响。方法选取医院消化内科2021年1月至12月接受结肠镜检查的住院患者216例,按肠道准备指导方式分为干预组和对照组,各108例。对照组患者给予肠道准备方案及复方聚乙二醇电解质散,以及传统纸质肠道准备指导单进行健康教育指导;干预组患者在对照组基础上由临床药师利用视频和节点提醒进行肠道准备健康教育。比较两组患者肠道准备质量的合格率和不良反应发生率,并同时调查患者对临床药师健康教育指导的满意度。结果干预组肠道准备质量合格率为87.96%,显著高于对照组的67.59%(P<0.05);干预组患者波士顿肠道准备评分量表(BBPS)评分显著高于对照组(P<0.05);干预组患者呕吐、腹胀不良反应发生率分别为5.56%和7.41%,均显著低于对照组的12.96%和13.89%(P<0.05)。干预组患者对临床药师健康教育指导的满意率为90.82%。结论临床药师利用视频和节点提醒的药学服务可显著提高结肠镜检查患者的肠道准备质量,减少呕吐、腹胀等不良反应,且患者满意度高。

标准化团体心理护理对炎症性肠病患者负性情绪的影响

目的:分析标准化团体心理护理对炎症性肠病患者负性情绪的影响。方法:选取2020年1月—2022年12月兰州大学第二医院200例炎症性肠病患者,采取随机数字表法分为对照组(常规护理)与观察组(标准化团体心理护理),对比干预效果。结果:干预后,与对照组相比,观察组抑郁自评量表(SDS)、焦虑自评量表(SAS)评分、匹兹堡睡眠质量指数(PSQI)评分更低(P<0.05),自我管理行为、生活质量、护理满意度方面评分均更高(P<0.05)。结论:标准化团体心理护理在炎症性肠病患者护理中应用效果明显,不仅可以减轻患者负面情绪,提高患者自我行为管理能力,同时有助于提高护理满意度及改善生活质量,值得临床进一步推广。

基于炎症性肠病小组的延续性护理对炎症性肠病病人自我管理能力及生活质量的改善效果

目的:探讨基于炎症性肠病(IBD)小组的延续性护理对IBD病人自我管理能力及生活质量的改善效果。方法:选取2021年12月-2022年12月医院接收的98例IBD病人为研究对象,按照随机数字表法将其分为对照组、观察组,每组49例。对照组行常规护理,观察组实施基于IBD小组的延续性护理。比较两组心理情绪状况、自我管理能力、病情控制效果及生活质量。结果:观察组护理后自我感受负担量表(SPBS)评分比对照组低,Herth希望量表(HHI)评分比对照组高(P<0.05);观察组护理后的炎症性肠病病人自我管理行为量表评分比对照组高(P<0.05);观察组护理后炎症性肠病症状量表(IBDSI)评分比对照组低(P<0.05);观察组护理后炎症性肠病生活质量量表(IBDQ)评分比对照组高(P<0.05)。结论:基于IBD小组的延续性护理应用于IBD病人中可有效改善其心理状况,提高其自我管理能力,有效控制病情,进一步改善其生活质量。

Inflammatory bowel disease:Efficient remission maintenance is crucial for cost containment

The inflammatory bowel diseases(IBD) are chronicincurable inflammatory disorders of the gut. Some 10% run a downhill course, requiring emergency medical support and often surgery; another small subset are monogenic, and, threatening pediatric patients, are the challenge of these days. The majority of the IBDs, however, are polygenic low-penetrance diseases, running a lifetime waxing-and-waning course. The prevalent trend is towards a slow worsening and steady cost increase. Each and all drugs of the available arsenal exhibit strengths and weaknesses: Mesalamines are chiefly effectively for mildmoderate colitis, and do not work in Crohn's; steroids do not control some 40% of the ulcerative colitis cases, and are not indicated for Crohn's; thiopurines are effective in the maintenance of the IBDs but do not prevent relapses on withdrawal; biologics are still being used empirically(not monitored) causing further increase of their cost over that of hospitalization. Against all these caveats, two simple rules still hold true: Strict adherence maintenance and avoidance of colitogenic drugs. This matter is expanded in this minireview.

Satisfaction with patient-doctor relationships in inflammatory bowel diseases:Examining patient-initiated change of specialist

AIM:To assess the reasons for,and factors associated with,patient-initiated changes in treating specialist in inflammatory bowel diseases(IBD).METHODS:Prospectively identified IBD patients(n = 256) with ≥ 1 encounter at a metropolitan hospital were surveyed,including whether they had changed treating specialist and why.Negative reasons included loss of confidence,disagreement,and/or personality clash with the specialist.RESULTS:Of 162 respondents,70(43%) had ever changed specialists;30/70(43%) for negative reasons,52/70(74%) in the preceding year.Patients with negative reasons for changing(n = 30) were younger(median,35.2 years vs 45.3 years),had higher IBD knowledge(median,5.0 years vs 4.0 years),yet had lower medication adherence and satisfaction scores(median,19.0 years vs 22.0 years,14.0 years vs 16.0 years respectively,Mann-Whitney tests,all P < 0.05),compared to all other responders(n = 132).Patients with a recent change(for any reason) were more likely to have Crohn's disease,currently active disease,previous bowel resection and recent hospitalization [OR 2.6,95% CI(1.3-5.4),2.2(1.0-4.7),5.56(1.92-16.67),2.0(1.3-3.0),eachP < 0.05].CONCLUSION:Changing specialist appears associated with patient-related(age,nonadherence) and contemporaneous disease-related factors(recent relapse) which,where modifiable,may enhance patient-doctor relationships and therefore quality of care.

心脏外科术后肠功能恢复情况对ICU住院时间的影响

目的分析心脏外科术后肠功能恢复情况对ICU住院时间的影响极其相关性。方法选择2019年10月至2021年10月ICU心脏外科住院患者50例,收集患者临床资料,根据ICU住院时间>10 d、≤10 d分组,将≤10 d的40例患者作为对比组,>10 d的10例患者作为观察组,Logistic回归分析ICU住院时间>10d的危险因素,Pearson分析肠功能恢复指标与ICU住院天数的相关性。结果Logistic回归分析糖尿病、腹胀程度、大量使用抗生素、麻醉药物残留、恢复肠鸣音时间、首次排气时间、首次排便时间是导致心脏外科手术患者ICU住院时间>10 d危险因素(P<0.05)。Pearson分析恢复肠鸣音时间、首次排气时间、首次排便时间与ICU住院天数呈正相关(P<0.05)。结论ICU心脏外科手术患者术后住院时间延长与糖尿病、腹胀程度、大量使用抗生素、麻醉药物残留、恢复肠鸣音时间、首次排气时间、首次排便时间有着极为密切的联系,肠功能恢复情况与住院时间存在一定的相关性。

Prevalence of-and risk factors for work disability in Dutch patients with inflammatory bowel disease

AIM To determine the prevalence of work disability in inflammatory bowel disease(IBD), and to assess risk factors associated with work disability.METHODS For this retrospective cohort study, we retrieved clinical data from the Dutch IBD Biobank on July 2014, containing electronic patient records of 3388 IBD patients treated in the eight University Medical Centers in the Netherlands. Prevalence of work disability was assessed in 2794 IBD patients and compared with the general Dutch population. Multivariate analyses were performed for work disability(sick leave, partial and full disability) and long-term full work disability(> 80% work disability for > 2 years).RESULTS Prevalence of work disability was higher in Crohn's disease(CD)(29%) and ulcerative colitis(UC)(19%) patients compared to the general Dutch population(7%). In all IBD patients, female sex, a lower education level, and extra-intestinal manifestations, were associated with work disability. In CD patients, an age > 40 years at diagnosis, disease duration > 15 years,smoking, surgical interventions, and anti-TNFα use were associated with work disability. In UC patients, an age > 55 years, and immunomodulator use were associated with work disability. In CD patients, a lower education level(OR = 1.62, 95%CI: 1.02-2.58), and in UC patients, disease complications(OR = 3.39, 95%CI: 1.09-10.58) were associated with long-term full work disability.CONCLUSION The prevalence of work disability in IBD patients is higher than in the general Dutch population. Early assessment of risk factors for work disability is necessary, as work disability is substantial among IBD patients.

Quality improvement in pediatric inflammatory bowel disease: Moving forward to improve outcomes

In recent years,pediatric health care has embraced the concept of quality improvement to improve patient outcomes.As quality improvement efforts are implemented,network collaboration(where multiple centers and practices implement standardized programs)is a popular option.In a collaborative network,improvement in the conduct of structural,process and outcome quality measures can lead to improvements in overall health,and benchmarks can be used to assess and compare progress.In this review article,we provided an overview of the quality improvement movement and the role of quality indicators in this movement.We reviewed current quality improvement efforts in pediatric inflammatory bowel disease (IBD),as well as other pediatric chronic illnesses.We discussed the need to standardize the development of quality indicators used in quality improvement networks to assess medical care,and the validation techniques which can be used to ensure that process indicators result in improved outcomes of clinical significance.We aimed to assess current quality improvement efforts in pediatric IBD and other diseases,such as childhood asthma,childhood arthritis,and neonatal health.By doing so,we hope to learn from their successes and failures and to move the field forward for future improvements in the care provided to children with IBD.

Management of Patients with Inflammatory Bowel Disease during the Prevention of COVID-19

Objective: To explore the disease management methods and effects for patients with inflammatory bowel disease (IBD) in the special period of pandemic. Methods: Medical staffs carried out the management of patients with IBD on the inflammatory disease service platform of this center from February to May of 2020 in addition to routine clinical works. Results: None of the nearly 3000 IBD patients who are being followed up at our center were infected with COVID-19. During this period, no patients experienced drug-related serious side effects or disease recurrence that could not be treated in time due to failure to reach the medical staffs. Conclusion: The disease management methods based on IBD platform allow the patients to be properly managed during this special period.

炎症性肠病亲属照护者照护体验的质性研究

目的:了解炎症性肠病(IBD)的亲属照顾者疾病照护体验与需求,分析存在的问题及其原因,为建设以病人为中心的支持体系,改善病人的生理、社会功能提供依据。方法:运用质性研究中的现象学分析法,对10例炎症性肠病的亲属照顾者进行深入访谈,运用Colaizzi的分析程序进行分析、整理,提炼出主题。结果:提炼出3个主题(9个亚主题):IBD亲属照护者面临多种不确定感;照护经历使照护者成长;照护经历引发对医疗现况的思考。结论:炎症性肠病的照护体验需要得到医护人员的关注和支持,应提升对IBD的社会认知度,提升医护人员的专病管理能力,积极建设IBD的服务管理平台,实现医疗资源的整合,缓解IBD病人就医困境,从而构建以病人为中心的社会支持体系,改善病人生活质量。

Quality of care in Crohn's disease

Crohn's disease(CD) is a chronic and progressive inflammatory disease of the intestine. Overall, healthcare delivery for patients with CD is not optimal at the present time and therefore needs improvement. There are evidences which suggest that there is a variation in the care provided to patients with CD by the inflammatory bowel disease(IBD) experts and community care providers. The delivery of healthcare for patients with CD is often complex and requires coordination between gastroenterologists/IBD specialist, gastrointestinal surgeon, radiologists and IBD nurses. In order to improve the quality of health care for patients with CD, there is need that we focus on large-scale, system-wide changes including creation of IBD comprehensive care units, provision to provide continuous care, efforts to standardize care, and education of the community practitioners.

极早发炎症性肠病患儿疾病活动期的护理

总结20例极早发炎症性肠病患儿疾病活动期的护理。针对该组患儿发病年龄早、疾病因素影响生长发育、透壁性炎性病变易穿透肠壁形成瘘管、评估药物是否应答时肠道准备难度大、因终身性疾病家长心理压力大等问题,采取早期营养管理,改善疾病预后;规范应用生物制剂,警惕过敏性休克发生;瘘管形成与肛周病变的护理,促进瘘口愈合;完善肠道准备,协助评估治疗效果;做好出院指导和随访,提高治疗依从性等护理措施。经积极对症治疗和护理,本组患儿均好转出院。