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Crandall W, Kappelman M, Colletti RB, Denson L, Duffy L, Grunow J, Kim S, Leibowitz I, Patel A, Schoen B, Tomer G, Milov D, Cohen S, Margolis P, and the ImproveCareNow Collaborative (formerly PIBDNet), Burlington, VT, USA.
There is evidence of significant variation in the care of pediatric Crohn disease patients. Variation in the delivery of effective therapy may reduce the likelihood of favorable outcomes. Quality Improvement (QI) methods aimed at improving systems of care delivery can reduce unwanted variation and improve patient outcomes.
Aim: To determine whether participation in a quality improvement collaborative for Crohn disease was associated with improvement in process measures (e.g., documentation of growth and nutrition parameters, medication dosing) and outcome measures (e.g., improved remission rates—the proportion of children in remission).
Methods: The ImproveCareNow Collaborative was formed in 2007 at 9 pediatric gastroenterology practices. Practices received training in QI, developed care algorithms, enrolled patients into a registry, and began testing small changes in systems of chronic illness care. In early 2008, additional QI tools including a pre-visit planner and population management report were implemented. Several process and outcome measures, including thiopurine dosing, growth and nutritional status, and disease activity based on Physician Global Assessment (PGA) were assessed at each visit. Results were reported monthly and compared by chi square analysis.
Results: Visits of over 1,000 Crohn disease patients were analyzed. The reliability of the assessment of growth, nutrition, disease phenotype and disease severity increased from 21% to 86% (p<0.01). The measurement of TPMT prior to the use of a thiopurine increased from 52% to 92% (p<0.01). Administration of the recommended initial dose of thiopurine increased from 44% to 63% (p=0.07). Satisfactory nutritional status (89%) and growth status (93%) remained the same although variation among sites decreased. Through July 2009, the remission rate had increased from 49% to 67% (p<0.05).
Conclusion: These preliminary results suggest that participation in a QI collaborative is associated with improvement in the process of care and in remission rates. Further work to confirm these findings and determine the key drivers of this improvement is underway.
Platform presentation at the Advances in Inflammatory Bowel Diseases Conference, Hollywood FL, December 2009