From the AGA Journals

Referral centers varied significantly in IBD treatment approaches

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The next step

Jack Wennberg, a pioneer in quality improvement, was the first to recognize the association between significant variation in health care utilization and poor quality of care. The problem is that Wennberg published this in Science in 1973 (182:1102-8), and now, over 40 years later, we are just making progress for patients with Crohn’s disease and ulcerative colitis.

As a field, we now need to catch up and learn how to address this variation. It won’t be by solely measuring the differences between practices. As a proverb that was taught to me by experts at the Institute for Healthcare Improvement says, “You can’t fatten a cow by weighing it.” We could measure our practice patterns, quality metrics, and report them every day to claim our appropriate reimbursement from the Centers for Medicare & Medicaid Services, but this won’t improve patient outcomes or our understanding of what drives a better quality of life for our patients.

We need to take what Dr. Ananthakrishnan and his team have taught us to the next level. We need to learn from the Model for Improvement (Langley G.J., The improvement guide: A practical approach to enhancing organizational performance. San Francisco: Jossey-Bass, 2009), which teaches us that, to improve, we need to answer three questions: What are we trying to accomplish? How will we know that a change is an improvement? and What changes can we make that will result in an improvement? If we can apply these questions to changes that we want to make in our practices and systematically pursue answers, we will start to improve the quality of care delivered to our patients, as opposed to simply reporting that it is poor.

Dr. Corey A. Siegel, M.S., is director of the Dartmouth-Hitchcock Inflammatory Bowel Disease Center at Dartmouth-Hitchcock Medical Center, Lebanon, N.H. He is supported by AHRQ grant 1R01HS021747-01 and serves as consultant or on an advisory board for Abbvie, Amgen, Lilly, Janssen, Salix, Pfizer, Prometheus, Takeda, Theradiag, and UCB. He serves as a speaker for CME activities for AbbVie, Janssen, and Takeda, and has received grant support from Abbvie, Janssen, Salix, Takeda, and UCB. He is cochair of the Crohn’s and Colitis Foundation of America’s Quality of Care Program.




Even high-volume referral centers varied significantly in their use of immunomodulators and some other therapies for patients with inflammatory bowel disease, particularly Crohn’s disease, a prospective cohort study found.

“The development and implementation of evidence-based standards of care may reduce variations and improve patient outcomes,” Dr. Ashwin Ananthakrishnan of Massachusetts General Hospital in Boston and his associates wrote in the June issue of Clinical Gastroenterology and Hepatology (2014 Nov. 21 [doi: 10.1016/j.cgh.2014.11.020]). “Because adherence to guidelines frequently is inadequate, a reduction of practice variation also requires continual improvement, including setting goals and repeated measurement of processes to identify how standardizing care impacts outcomes.”

Dr. Ashwin Ananthakrishnan

Dr. Ashwin Ananthakrishnan

New biologics have created increasingly diverse treatment options for patients with inflammatory bowel disease (IBD), but few studies have looked at how clinicians and patients choose treatment regimens in daily practice, the researchers noted. To explore the issue, they prospectively studied 1,659 adults with Crohn’s disease (CD) and 946 patients with ulcerative colitis who were treated at one of seven academic medical centers, all of which see a high volume of IBD patients.

Referral centers varied about threefold in their use of immunomodulators for CD (odds ratio for between-center differences, 3.34; 95% confidence interval, 2.09-5.32) in a model that controlled for age at diagnosis, sex, race, smoking status, and duration and extent or behavior of disease, the researchers reported. Use of immunomodulators for ulcerative colitis varied by more than twofold, they found (OR, 2.32; 95% CI, 1.05 to 5.13). Furthermore, they uncovered significant differences in use of oral mesalamine in both forms of IBD, and in the use of corticosteroids and immunomodulator-tumor necrosis factor antagonist combinations for CD, they said.

Treatment practices tended to vary more for CD than for ulcerative colitis, perhaps because CD spans a broader spectrum of pathologies or because clinicians have not yet reached consensus on early aggressive therapy or treatment strategies for CD, the researchers said. “Variations in treatment generally occur when there is uncertainty about the best practice,” they commented. “It is possible that the variations will diminish as evidence on effective IBD therapy grows and evidence-based guidelines become available and are implemented. The continued variation suggests that there is significant potential for standardization of care across referral and community practices.”

The study did not pinpoint reasons for discrepancies in practice, which could have reflected differences related to referring physicians’ or patients’ behaviors or expectations, the researchers said. But the findings did not reflect a single outlier center, and the cohort was not chosen to study variations between centers, which should have helped eliminate selection bias, they added.

The Leona M. and Harry B. Helmsley Charitable Trust funded the study. Dr. Ananthakrishnan reported advisory board payments from Cubist Pharmaceuticals and AbbVe. One coauthor reported financial conflicts of interest with numerous pharmaceutical companies. The other authors reported no conflicts of interest.

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