AIBD 2010: Will More Uniform Quality of Care Improve IBD Outcomes?

Defining, measuring, and improving the quality of care gastroenterologists provide to patients with inflammatory bowel disease (IBD) may provide all patients with more uniform care at a higher quality level, according to research presented at the 2010 Advances in Inflammatory Bowel Diseases, the Crohn's & Colitis Foundation's Clinical & Research Conference, being held December 9-12 in Hollywood, FL.

During a clinical session focusing on improving the quality of the care of IBD patients, Corey A. Siegel, MD, MS, of Dartmouth Medical School, Hanover, NH, discussed the current variation in the clinical care of IBD patients, efforts to improve quality of care, and the development of a system to address quality of care improvement.

“Quality of care is a mechanism to ensure that the best new research and ideas do not get left behind in journals, but get applied equally to all patients,” Siegel said. Currently, care varies from region to region in the United States, with higher healthcare spending occurring in Florida and New York, and lower spending occurring in New Hampshire and Minnesota. While many practicing clinicians may have similar access to resources, hospital systems do not appear to be spending effectively. Recent data have demonstrated regional variations based on medication use and colectomy rates, with care being offered differently irrespective of the disease itself.

By way of example, Siegel noted that to improve the treatment of cystic fibrosis, hospitals and clinicians have taken steps to establish a quality of care improvement process. In this approach, a clinical microsystem was established, quality indicators were determined, and data was made transparent, with a continual improvement process that resulted in a gain of 1.1 years of predicted survival annually. This approach provided no new drugs or treatments but rather only focused on the process of quality of care. Siegel said that this approach is also being applied to the treatment of IBD.

Improve Care Now, “an innovative, team-based approach to medical care that is helping children and adolescents with Crohn's Disease and ulcerative colitis” involves three interventions to support large-scale improvement across multiple care centers, and aims to provide clinical practitioners with instruction and ongoing coaching in quality indicators, application of the Chronic Illness Care model, and adaptation of the Breakthrough Series method to support collaborative improvement. “Specific interventions include protocols, registry development, population management, pre-visit planning, microsystem redesign, auditing, model for improvement, and self management,” Siegel said. To date, the program has increased remission rates from 49% to 66% between 2007 and 2010.

The American Gastroenterological Association (AGA) has developed a task force on quality to develop quality indicators and measures that can be assessed to be submitted to the National Quality Forum (NQF) for approval and then sent on to the Physician Quality Reporting Initiative (PQRI), which is a voluntary individual reporting program to provide an incentive payment or those who satisfactorily report data on quality measures.

The Crohn's & Colitis Foundation of America (CCFA) has also become involved in improving quality of care. According to Seigel, the mission statement of the CCFA quality of care committee is to define the standards of care for IBD, identify the processes that will improve patient-centered outcomes, assess the impact of these processes on the quality of care, educating caregivers and patients on the implementation of these processes, and conducting continuous evaluation and refinement of the standards of care through this effort.

For the development and selection of quality indicators, the CCFA is using the RAND/UCLA methodology, which involves a comprehensive review of guidelines, identification of potential quality indicators, face-to-face advisory board meetings to modify quality indicator sets, electronic voting to narrow quality indicator sets, comprehensive review for candidate quality indicators, pre-meeting electronic voting, and a face-to-face RAND/UCLA panel for final validity and feasibility ratings. To date, the CCFA has reviewed all current guidelines and identified 500 quality-of-care indicators, which were narrowed down to 100 by a quality indicator subcommittee. Further deliberations narrowed the quality of care indicator list to 35. A 10-15-item quality indicator list is expected to developed within the near term, but the results have not been finalized.

“The next steps include determining TOP quality indicators, finalizing and publishing IBD quality indicator sets, and working together with these other groups to collectively bring the IBD quality of care movement forward,” Seigel said. By defining, measuring, and improving the quality of care, clinical practitioners will be able to provide improved care for IBD patients, at least providing patients with uniform care that will effectively address and manage their condition.