Crandall WV, Margolis PA, Kappelman MD, King EC, Pratt JM, Boyle BM, Duffy LF, Grunow JE, Kim SC, Leibowitz I, Schoen BT, Colletti RB, for the ImproveCareNow Collaborative. Improved outcomes in a quality improvement collaborative for pediatric inflammatory bowel disease. Pediatrics 2012;129:e1030e1041

There is evidence of significant variation in the care of pediatric patients with ulcerative colitis. 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 ulcerative colitis 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.   Of these 9 centers, 6 have enrolled at least 75% of their patients with inflammatory bowel disease and are included in this report.  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 completion of a disease classification bundle, thiopurine dosing, mesalamine dosing, and disease activity based on Physician Global Assessment (PGA) were assessed at each visit and reported to each site monthly.  Data from the first 6 months of the collaborative were excluded from analysis to reduce the effect of any differential enrollment of sicker patients during the early phase of network formation

Results: Data were available for 843 children with CD and 345 with UC. Changes in care delivery were associated with an increase in the proportion of visits with complete disease classification, measurement of thiopurine methyltransferase (TPMT) before initiation of thiopurines, and patients receiving an initial thiopurine dose appropriate to their TPMT status. These were significant in both populations for all process variables (P , .01) except for measurement of TPMT in CD patients (P = .12). There were significant increases in the proportion of CD (55%68%) and UC (61%72%) patients with inactive disease. There was also a significant increase in the proportion of CD patients not taking prednisone (86%90%). Participating centers varied in the success of achieving these changes.

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.

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