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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). Increased remission in a quality improvement collaborative for pediatric Crohn disease. J Pediatr Gastroenterol Nutr 2009;48:e
There is evidence of significant variability of the care of pediatric Crohn disease patients. Variability of 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 variability and improve patient outcomes.
Aim: To determine whether participation in a quality improvement collaborative for Crohn disease was associated with improved remission rates (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. Disease activity was assessed at each visit, using the Physician Global Assessment, as were other process and outcome measures including thiopurine dosing and growth and nutritional status. Results were reported monthly and compared by chi square analysis.
Results: Visits of 1,014 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. The remission rate increased from 48.5% to 64.4% (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.
[Presented at NASPGHAN Annual Meeting 2009]