image

The disease progression and chronicity of Crohn’s disease and ulcerative colitis can complicate the delivery of high-quality care. Practice guidelines are available, yet quality remains highly variable.1 Thus, similar to conditions like colorectal cancer,2 a quality-of-care movement is being established for inflammatory bowel disease (IBD).3

The American Gastroenterological Association (AGA) has developed IBD clinical performance measures for adult patients for use in various settings.4 This 10-measure set includes standards for vaccine-preventable illnesses, cancer prevention, bone health assessment, therapy-related testing, and smoking cessation (Table).4 Specifically, the first measure—documentation of type, anatomic location, and activity of IBD—relates to disease diagnosis and management. The aim of this measure is to ensure that the bowel is fully assessed using endoscopic or radiologic data.4

Click here to access the full AGA adult IBD physicians performance measures set.

Table. IBD Quality Measures
Documentation of IBD type, anatomic location, and activity
Documentation that corticosteroid-sparing therapy was recommended for patients unable to taper off corticosteroids
Documentation that bone loss assessment was recommended for patients at risk for corticosteroid-related iatrogenic injury
Documentation that influenza immunization was recommended
Documentation that pneumococcal immunization was recommended
Documentation of screening for latent tuberculosis before initiating anti-TNF therapy
Documentation of hepatitis B virus status assessment before initiating anti-TNF therapy
Documentation of testing for Clostridium difficile–inpatient measure
Prophylaxis for venous thromboembolism–-inpatient measure
Documentation of screening for tobacco use and cessation if relevant
IBD, inflammatory bowel disease; TNF, tumor necrosis factor
Adapted from reference 4.
image
Gil Melmed, MD

“We developed some basic standards to help determine whether physicians are providing good, quality care,” said Gil Melmed, MD, director of clinical trials for the IBD Center at Cedars-Sinai Medical Center in Los Angeles, California, and a member of the AGA working group that developed the measures. “In order to improve quality, you have to be able to measure it.”

At the forefront of this changing practice environment potentially guided by accountability standards are gastroenterology fellows, who will be directly affected by quality-of-care initiatives and have opportunities to shape the dynamic process of implementing and refining the measures. Currently, the effect of these measures on patient care and outcomes is less well known by the field, according to noted gastroenterologists David T. Rubin, MD, and Marla Dubinsky, MD; Dr. Melmed agreed that the long-term effect remains to be clarified for both the AGA measures and parallel initiatives aimed at quality improvement.

“My next questions are: Does it change practice? Does it change patient care? Does it change outcomes and allow patients to have better quality of life? That’s what we don’t have answers for yet,” said Dr. Rubin, who is professor of medicine, co-director of the IBD program, and associate director of educational programs in the Section of Gastroenterology, Hepatology and Nutrition at the University of Chicago School of Medicine in Illinois. Dr. Rubin also presented the topic of quality of care to a national scientific advisory panel of the Crohn’s and Colitis Foundation of America in 2006.

He became involved in quality measures out of concern that “if we as clinicians don’t try to define these things, somebody will do it for us, and we don’t want to be in that position,” Dr. Rubin said. “Although this hasn’t changed how I teach IBD to my fellows, I’m more interested in learning whether this helps the general population of gastroenterologists, or third-party payors or patients, better understand what care patients should be receiving.”

The AGA is publicizing what IBD care it considers outstanding through its Bridges to Excellence IBD Care Recognition Program. Recently, the association announced that 18 clinicians have met these standards and are eligible for benefits like bonus payments per patient or preferred network tiering.5 Such programs may affect how clinicans view superior quality of care in the future.

Dr. Dubinsky, director of the Pediatric IBD Program at Cedars-Sinai Medical Center in Los Angeles, California, said that although there is no evidence to suggest that academic centers have better adherence to these measures than community centers, she feels that the need for such measures may be more acute—and the potential for positive impact greater—among primary or community-based gastroenterologists compared with those at academic or tertiary IBD treatment centers that treat a high volume of patients. “That’s really where the focus is—primary gastroenterologists,” Dr. Dubinsky said. “These measures should be done by the time patients are referred to a tertiary care center, not at the time of a third or fourth referral.”

Dr. Dubinsky would like to see a patient education component included because it is patients who often, for example, push back on initiating biologic therapy. Also, she advocates for making a template from a checklist and scanning it into an electronic medical record system, ensuring a “turn-key” implementation. With Dr. Rubin, Dr. Dubinsky launched an IBD education organization, Cornerstones Health, Inc., which offers an IBD care checklist that may aid clinicians in implementing the measures6; the template was developed in conjunction with the AGA measures and with Dr. Melmed’s input.

Overall, Dr. Melmed said that despite select evidence of the benefit of quality improvement efforts in other areas of medicine, such as cystic fibrosis,7 some gastroenterologists push back against strict adherence to guidelines without more evidence of positive gains due to their use. “Others are skeptical of whether checkboxes and lists can improve outcomes and say it’s a burden to have to comply,” he said. An area that may lead to additional data could be the monitoring of disease over time: Although recognized as critically important in IBD management, disease monitoring is exceedingly difficult to operationalize within the precise construct of a quality measure, Dr. Melmed said. “It’s a very important component of IBD management but is not captured in a measure.”

Within that context, Dr. Melmed said capsule technology is likely to become an even more important clinical tool. “Capsule technology is emerging now into the area of disease monitoring. That is absolutely critical in IBD and, ultimately, may change outcomes more than almost anything else,” he said. “If we monitor the disease closely, and adjust our therapies accordingly, we will achieve better outcomes—but that’s very difficult to operationalize into a quality measure. Maybe as we have more evidence and data to support a way of doing that in very specific scenarios, those measures will be developed.”

Current IBD care has been described as potentially confusing with multiple measure sets and parallel development of accountability measures.1 The scenario is one of opportunity for gastroenterology fellows, who are “emerging into a new era,” said Dr. Melmed, noting that these issues were not being discussed even a few years ago.

“We need fellows to learn about the changes that are occurring in health care because they are going to feel the impact very directly,” he said. “There’s a lot that we don’t know about measuring quality in general, and in measuring gastrointestinal disorders and IBD specifically in a user-friendly way.” Thus, the participation of fellows in the measurement-feedback process will help gastroenterologists “get the reimbursement that they deserve and in a way that’s going to have a positive impact on patients. And we need a lot more work to help us figure that out.”

References

  1. Melmed GY, Siegel CA. Quality improvement in inflammatory bowel disease. Gastroenterol Hepatol (N Y). 2013;9(5):286-292.
  2. Rex DK, Bond JH, Winawer S, et al; U.S. Multi-Society Task Force on Colorectal Cancer. Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol. 2002;97(6):1296-1308.
  3. Siegel CA, Allen JI, Melmed GY. Translating improved quality of care into an improved quality of life for patients with inflammatory bowel disease. Clin Gastroenterol Hepatol. 2013;11(8):908-912.
  4. American Gastroenterological Association. Adult inflammatory bowel disease physician performance measures set. www.gastro.org/​practice/​quality-initiatives/​IBD_Measures.pdf. Accessed September 10, 2013.
  5. American Gastroenterological Association. AGA releases list of excellent IBD doctors. www.gastro.org/​journals-publications/​aga-edigest/​archive/​aga_edigest_sept_5_2013. Accessed September 10, 2013.
  6. Cornerstones Health, Inc. Checklist for IBD Patients. www.cornerstoneshealth.org/​checklist. Accessed September 10, 2013.
  7. Schechter MS, Gutierrez HH. Improving the quality of care for patients with cystic fibrosis. Curr Opin Pediatr. 2010;22(3):296-301.