There remains a gap in adherence to Canadian care guidelines in patients with ulcerative colitis.¹

A team, led by Steven Li Fraine, MD, MSc, Division of Gastroenterology, McGill University Health Centre, examined whether a standardized admission order set could result in improved adherence to the current best practice guidelines in Canada for patients with ulcerative colitis.

“Individuals hospitalized with severe ulcerative colitis represent a complex group of patients,” the authors wrote. “Variation exists in the quality of care of admitted patients with inflammatory bowel disease.”

Guidelines in Canada

In Canada there has been a coordinated approach to caring for this patient population called the Treatment of hospitalized adult patients with severe Ulcerative Colitis - Toronto Consensus Statements.

However, there remains a variation in care for patients with ulcerative colitis.

An example of this is a recent group of investigators found from a multicenter study of patients admitted for IBD-related issues significant variations for inpatient quality indicators, including venous thromboembolism prophylaxis (VTE) and C difficile testing across centers and admitting services.

One study showed adherence to the international guidelines for IBD management for patients admitted to the hospital was 71%, while another study showed variations exists, even among gastroenterologist subspecialities.

“Since efforts to promote adoption of guidelines through multimodal educational interventions alone may not result in improved adherence to standard of care, additional measures may be warranted to ensure adherence to the Toronto Consensus Statements,” the authors wrote.

Indicators

In the retrospective cohort study, the investigators identified patients with severe ulcerative colitis admitted to a Montreal tertiary center. The participants were split into 2 cohorts based on pre- and post-implementation of a standardized order set.

The pre-intervention cohort involved patients that were hospitalized between April 1, 2014 and October 31, 2016 and was compared to the post-intervention cohort of patients admitted between July 1, 2017 and June 30, 2018.

The investigators sought a primary outcome of the difference in adherence, defined as the proportion of the quality indicator that was completed in each cohort, to each of the 11 individual quality indicators in the pre-intervention group compared to the post-intervention group.

The team assessed the adherence to 11 quality indicators, including Clostridioides difficile and stool cultures testing, ordering an abdominal X-ray and CRP, organizing a flexible sigmoidoscopy, documenting latent tuberculosis, initiating thromboprophylaxis, use of intravenous steroids, prescribing infliximab if refractory to steroids, limiting narcotics, and surgical consultation if refractory to medical therapy both before and after the implementation of the intervention.

The results ultimately show adherence to 6 quality indicators was linked to improvements in the post-intervention cohort with significant increases in C difficile testing (75.5% versus 91.9%, P <0.05), CRP testing (71.4% versus 94.6%, P <0.01), testing for latent tuberculosis (38.1% versus 84.6%, P < 0.01), thromboprophylaxis (28.6% versus 94.6%, P <0.01), adequate corticosteroids prescription (72.9% versus 94.6%, P <0.01), and limitation of narcotics prescribed (68.8% versus 38.9%, P <0.01).

On the other hand, there were no significant differences in stool cultures performed, flexible sigmoidoscopy within 72 hours, abdominal X-ray, or use of infliximab as a rescue therapy and appropriate surgical consultation after inadequate response to 5 to 7 days of medical therapy was identical between the 2 groups.

“Implementation of a standardized order set, focused on pre-defined quality indicators for hospitalized patients with severe UC, was associated with meaningful improvements to most quality indicators defined by the Toronto Consensus Statements,” the authors wrote.

References

Steven Li Fraine, MD, MSc, Isabelle Malhamé, MD, MSc, Teresa Cafaro, MD, MSc, Camille Simard, MD, MSc, Elizabeth MacNamara, MD, Myriam Martel, MSc, Alan Barkun, MD, MSc, Jonathan M Wyse, MD, MSc, A Simple Admission Order-set Improves Adherence to Canadian Guidelines for Hospitalized Patients With Severe Ulcerative Colitis, Journal of the Canadian Association of Gastroenterology, 2023;, gwac032, https://doi.org/10.1093/jcag/gwac032