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Michael D. Kappelman, MD, MPH
Many children with Crohn’s disease and ulcerative colitis who received treatment through ImproveCareNow, a national quality improvement network, ceased to have symptoms and no longer needed to take steroids for disease management. These are the findings from a study appearing in Pediatrics that examined the network’s quality improvement efforts and their impact on outcomes. In this study, the proportion of children with Crohn’s disease in remission increased from 55 percent to 68 percent, with a similar improvement in ulcerative colitis patients.
“Improvement we observed took place over a relatively short period of time during which no new therapies were introduced into routine clinical practice,” said the study’s co-author, Michael Kappelman MD, MPH, assistant professor of pediatrics at the University of North Carolina at Chapel Hill. “These results suggest that collaborative quality improvement methods focused on improving chronic illness care can lead to improved process and outcome measures in children with IBD.”
Crohn’s disease and ulcerative colitis, also called inflammatory bowel disease (IBD), are gastrointestinal disorders that lead to intestinal inflammation as a result of an overactive immune reaction. ImproveCareNow formed in 2007 to improve care and outcomes of children and adolescents with IBD, with UNC as one of the original sites. It has since grown to include 33 centers with 300 gastroenterologists and 10,000 patients.
“IBD management varies greatly throughout the country due to a lack of consensus on best practices and inadequate care delivery systems,” said study author Wallace Crandall, MD, director of the Center for Pediatric and Adolescent Inflammatory Bowel Disease at Nationwide Children’s Hospital. “Nationally, IBD patients receive differing diagnostic, treatment and nutritional interventions, suboptimal medication dosages, prolonged prescription of corticosteroids, and fail to receive steroid-sparing agents.”
There is evidence to suggest redesigning specific elements of chronic care delivery can improve quality and outcomes for patients. Although most of this work has taken place in adult primary care practices, ImproveCareNow is an important exception, accelerating research in pediatric IBD. After its formation, the network developed new recommendations for diagnosis and treatment, classification of disease severity, and evaluating nutritional and growth status. These were adopted as updated standards network wide, including at N.C. Children’s Hospital, where more than 90 percent of the 300 IBD patients are enrolled in the network’s data registry.
Few pediatric centers have enough patients to determine if changes in care delivery are making a difference,” said co-author Peter Margolis MD, PhD, senior director of ImproveCareNow and director of research at the James M. Anderson Center for Health Systems Excellence at Cincinnati Children’s Hospital.
But with network data, these centers can make such determinations. N.C. Children’s Hospital, for example, is using data from ImproveCareNow’s registry to monitor a variety of process and outcome measures, both internally and through benchmarking with the 33 other pediatric GI practices involved in the network. Kappelman, whose research was supported by the NIH Clinical and Translational Science Awards (CTSA) at UNC, reports 80 percent of the pediatric IBD patients at UNC are now in remission, and over 90 percent have satisfactory growth and nutrition statuses.
Data for the study appearing in Pediatrics study was collected from six participating centers, including N.C. Children’s Hospital, and included 1,188 children treated between July 2007 and April 2010. Findings showed improvements in specific care processes. The proportion of Crohn’s disease and ulcerative colitis patients in remission increased; the percentage of Crohn’s disease patients taking corticosteroids decreased.
“These improvements were likely the result of changes in the care delivery systems rather than a single specific intervention,” said Richard Colletti, MD, network director of ImproveCareNow and professor of pediatrics at the University of Vermont. Further study is needed to determine which combination of interventions is most important to improve the outcomes of these patients.
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