2008 Pediatric Academic Societies' & Asian Society for Pediatric Research Joint Meeting

Title: Improving Care of Pediatric Inflammatory Bowel Disease: Preliminary Results of a Multicenter Improvement Collaborative

Michael D Kappelman, MD (1), Stanley A Cohen, MD (2), Wallace Crandall, MD (3), Lynn Duffy, MD (4), Benjamin D Gold, MD (2), John Grunow, MD (5), Sandra C Kim, MD (1), Ian Leibowitz, MD (4), Peter A Margolis, MD, PhD (6), Devendra I Mehta, MD (7), David E Milov, MD (7), M.Susan Moyer, MD (6), Sarah Myers (6), Ashish S Patel, MD (8), Bess Schoen, MD (2), Boris Sudel, MD (9), Jeffrey A Bornstein, MD (7) and Richard B Colletti, MD (10). (Sponsored by Richard B Colletti,) (1) University of North Carolina, Chapel Hill, NC; (2) Children's Healthcare of Atlanta, Atlanta, GA; (3) Nationwide Children's Hospital, Columbus, OH; (4) Inova Fairfax Hospital, Fairfax, VA; (5) University of Oklahoma, Oklahoma City, OK; (6) Cincinnati Children's Hospital Medical Center, Cincinnati, OH; (7) Nemours Children's Clinic, Orlando, FL; (8) University of Texas Southwestern, Dallas, TX; (9) University of Minnesota, Minneapolis, MN and (10) University of Vermont, Burlington, VT. 

Background: There is considerable variation in the management of pediatric inflammatory bowel disease (IBD) with little improvement in outcomes in the past 30 years. Achieving consistent reliable care processes using quality improvement (QI) methods is a first step towards improving outcomes. 

Objective: To determine whether a pediatric IBD improvement collaborative can increase the rates of complete diagnostic evaluation and systematic assessment of severity, phenotype, and location of disease. 

Design/Methods: 8 centers formed an IBD improvement network (2 centers joined later). Guidelines and targets for care were established. Centers attended 2 learning sessions and participated in monthly conference calls to review evidence for recommended care, receive training in QI methods and share tools to support more reliable care. Centers were encouraged to test small changes in healthcare delivery processes, and to share and expand upon successful ones. Performance of a complete diagnostic evaluation and documentation of disease severity, phenotype, anatomic location, growth and nutrition at each patient encounter were recorded. Control charts and run charts were used to assess initial and ongoing performance. Pre and post-intervention data were compared using Fisher s exact test. 

Results: In the first 7 months centers enrolled a total of 1062 patients, comprising 1986 visits. Initial control charts showed unstable care delivery across centers (variation). Following initiation of QI, there has been improvement for numerous care processes. Complete diagnostic evaluation increased from 31% to 50% (p=NS). Documentation of disease phenotype and location increased from 62% to 71% (p= 0.03). Evaluation of growth increased from 57% to 86% and nutrition from 57% to 86% (p<0.0001). Visits at which severity was documented was high at baseline (90%) and did not change. Control charts reveal reduced variation across centers. 


The application of QI methods by pediatric GI practices is feasible and effective, resulting in a reduction of variation across practices. A more stable system of care delivery increases the statistical power to test interventions to improve outcomes.

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