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Lee HD. Things We Do for No Reason™: Withholding pharmacologic venous thromboembolism prophylaxis in hospitalized patients with inflammatory bowel disease. J Hosp Med 2023; 18:1038-1040. [PMID: 37244870 DOI: 10.1002/jhm.13137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/16/2023] [Accepted: 05/10/2023] [Indexed: 05/29/2023]
Affiliation(s)
- Howard D Lee
- Department of Medicine, Division of Gastroenterology and Hepatology, San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas, USA
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Harindranath S, Varghese J, Afzalpurkar S, Giri S. Standard and Extended Thromboprophylaxis in Patients with Inflammatory Bowel Disease: A Literature Review. Euroasian J Hepatogastroenterol 2023; 13:133-141. [PMID: 38222957 PMCID: PMC10785145 DOI: 10.5005/jp-journals-10018-1401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 10/04/2023] [Indexed: 01/16/2024] Open
Abstract
Patients with inflammatory bowel disease (IBD), both Crohn's disease and ulcerative colitis, frequently experience venous thromboembolism (VTE), a potentially fatal consequence. The pathophysiological mechanisms contributing to VTE include inflammation, modifications in coagulation factors, endothelial dysfunction, and platelet activation. Numerous pro-inflammatory cytokines and markers, such as tumor necrosis factor-alpha and interleukin-6, have a significant impact on the thrombotic cascade. Patients with IBD are more likely to suffer VTE for a variety of causes. Exacerbations of preexisting conditions, admission to the hospital, surgical intervention, immobilization, corticosteroid usage, central venous catheterization, and hereditary susceptibility all fit into this category. The mainstay of therapy for VTE in IBD patients includes anticoagulation that is individualized for each patient depending on the thrombosis site, severity, bleeding risk, and interaction with other drugs. In some high-risk IBD patients, such as those having major surgery or hospitalized with severe flare, preventive anticoagulation may play a role. However, the acceptance rate for this recommendation is low. Additionally, there is a subset of patients who would require extended thromboprophylaxis. The majority of the studies that looked into this question consisted of patients in the surgical setting. Emerging data suggest that risk factors other than surgery can also dictate the duration of anticoagulation. While extending anticoagulation in all patients may help reduce VTE-related mortality, identifying these risk factors is important. Hence, the decision to initiate prophylaxis should be individualized, considering the overall thrombotic and bleeding risks. This review explores the relationship between IBD and VTE, including risk factors, epidemiology, and prevention. A multifactorial approach involving aggressive management of underlying inflammation, identification of modifiable risk factors, and judicious use of anticoagulant therapy is essential for reducing the burden of VTE in this vulnerable population. How to cite this article Harindranath S, Varghese J, Afzalpurkar S, et al. Standard and Extended Thromboprophylaxis in Patients with Inflammatory Bowel Disease: A Literature Review. Euroasian J Hepato-Gastroenterol 2023;13(2):133-141.
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Affiliation(s)
- Sidharth Harindranath
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Jijo Varghese
- Department of Gastroenterology, NS Hospital, Kollam, Kerala, India
| | - Shivaraj Afzalpurkar
- Department of Gastroenterology, Nanjappa Multispecialty Hospital, Davangere, Karnataka, India
| | - Suprabhat Giri
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India
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Khuwaja S, Kohn N, Sanghani SS, Khan S, Swaminath A, Sultan K. The Risk of Blood Transfusion With the Use of Pharmacologic Venous Thromboembolism Prophylaxis During Hospitalization for Inflammatory Bowel Disease Exacerbation: A Time to Event Analysis. Am J Ther 2023; 30:e288-e291. [PMID: 37278710 DOI: 10.1097/mjt.0000000000001534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Samreen Khuwaja
- Department of Medicine, Northwell Health Forest Hills Hospital, Forest Hills, NY
| | - Nina Kohn
- Departments of Biostatistics, Feinstein Institute for Medical Research, Manhasset, NY
| | - Shreya S Sanghani
- Department of Bioinformatics, Feinstein Institute of Biomedical Research, Manhasset, NY
| | - Sundas Khan
- Feinstein Institute of Biomedical Research, Manhasset, NY
| | - Arun Swaminath
- Department of Medicine, Division of Gastroenterology, Northwell Health Lenox Hill Hospital, New York, NY
| | - Keith Sultan
- Department of Medicine, Division of Gastroenterology, Northwell Health North Shore University Hospital, Manhasset, NY
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Park H, Brown C, Wilson DL, Huang PL, Hernández-Con P, Horne P, Goodin A, Joseph A, Segal R, Cabrera R, Cook RL. Clinician barriers, perceptions, and practices in treating patients with hepatitis C virus and substance use disorder in the United States. Prev Med Rep 2023; 32:102138. [PMID: 36865395 PMCID: PMC9971512 DOI: 10.1016/j.pmedr.2023.102138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 12/19/2022] [Accepted: 02/10/2023] [Indexed: 02/16/2023] Open
Abstract
The likelihood of clinicians prescribing direct-acting antiviral (DAA) therapy for patients with chronic hepatitis C virus (HCV) and substance use disorder (SUD) was assessed via a survey emailed throughout the United States to clinicians (physicians and advanced practice providers) in gastroenterology, hepatology, and infectious disease specialties. Clinicians' perceived barriers and preparedness and actions associated with current and future DAA prescribing practices of HCV-infected patients with SUD were assessed. Of 846 clinicians presumably receiving the survey, 96 completed and returned it. Exploratory factor analyses of perceived barriers indicated a highly reliable (Cronbach alpha = 0.89) model with five factors: HCV stigma and knowledge, prior authorization requirements, and patient- clinician-, and system-related barriers. In multivariable analyses, after controlling for covariates, patient-related barriers (P < 0.01) and prior authorization requirements (P < 0.01) were negatively associated with the likelihood of prescribing DAAs. Exploratory factor analyses of clinician preparedness and actions indicated a highly reliable (Cronbach alpha = 0.75) model with three factors: beliefs and comfort level; action; and perceived limitations. Clinician beliefs and comfort levels were negatively associated with the likelihood of prescribing DAAs (P = 0.01). Composite scores of barriers (P < 0.01) and clinician preparedness and actions (P < 0.05) were also negatively associated with the intent to prescribe DAAs. Conclusion These findings underscore the importance of addressing patient-related barriers and prior authorization requirements-significant problematic barriers-and improving clinicians' beliefs (e.g., medication-assisted therapy should be prescribed before DAAs) and comfort levels for treating patients with HCV and SUD to enhance treatment access for patients with both HCV and SUD.
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Affiliation(s)
- Haesuk Park
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Carolyn Brown
- Health Outcomes, College of Pharmacy, University of Texas, Austin, TX, United States
| | - Debbie L Wilson
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Pei-Lin Huang
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Pilar Hernández-Con
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Patrick Horne
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Amie Goodin
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Amanda Joseph
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Rich Segal
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Roniel Cabrera
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Robert L Cook
- Department of Epidemiology, College of Health and Health Professions and College of Medicine, University of Florida, Gainesville, FL, United States
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Aiken TJ, King R, Russell MM, Regenbogen SE, Lawson E, Zafar SN. Venous thromboembolism prophylaxis following colorectal surgery: a survey of American Society of Colon and Rectal Surgery (ASCRS) member surgeons. J Thromb Thrombolysis 2023; 55:376-381. [PMID: 36454476 DOI: 10.1007/s11239-022-02733-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Postoperative venous thromboembolism (VTE) is associated with significant morbidity. Evidence from other surgical specialties demonstrate inadequate use of extended VTE prophylaxis following cancer surgery. While guidelines recommend extended VTE prophylaxis for patients undergoing surgery for colorectal cancer (CRC), it is unknown to what extent colon and rectal surgeons adhere to these recommendations. METHODS An 18-question online survey was distributed to all surgeon members of the American Society of Colon and Rectal Surgeons (ASCRS). The survey was designed to capture knowledge, attitudes, and practices regarding ASCRS VTE prevention guidelines. Questions were also designed to elucidate barriers to adopting these guidelines. RESULTS The survey was distributed to 2,316 ASCRS-member surgeons and there were 201 complete responses (8.7% response rate). Most respondents (136/201, 68%) reported that they were familiar with ASCRS VTE prevention guidelines and used them to guide their practice. Extended VTE prophylaxis was reported to be routinely prescribed by the majority of surgeons following CRC resection (109/201, 54%), with an additional 27% reporting selective prescribing (55/201). The most frequently reported reasons for not prescribing extended VTE chemoprophylaxis following CRC resection included patient compliance and insurance/copay issues. CONCLUSION Most ASCRS-member surgeon respondents reported that they are familiar with ASCRS VTE prevention guidelines, though only 54% surgeons reported routinely prescribing extended VTE prophylaxis following CRC surgery. Patient compliance and insurance issues were identified as the most common barriers. Targeted interventions at the surgeon, patient, and payer level are required to increase the use of extended VTE prophylaxis following CRC resection.
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Affiliation(s)
- Taylor J Aiken
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, WI, USA
| | - Ray King
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, WI, USA.,Division of Colorectal Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | - Marcia M Russell
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Department of Surgery, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | | | - Elise Lawson
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, WI, USA.,Division of Colorectal Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | - Syed Nabeel Zafar
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, WI, USA. .,Division of Surgical Oncology, University of Wisconsin-Madison, Madison, WI, USA.
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Sleutjes JAM, Roeters van Lennep JE, de Vries AC. Spotlight on Cardiovascular Risk Assessment in Patients with Inflammatory Bowel Disease. Dig Dis Sci 2022; 67:4326-4329. [PMID: 35304651 DOI: 10.1007/s10620-022-07449-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 12/09/2022]
Affiliation(s)
- Jasmijn A M Sleutjes
- Department of Gastroenterology and Hepatology, Dr. Molewaterplein 40, 3015GD, Room Na-6, Erasmus Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | | | - Annemarie C de Vries
- Department of Gastroenterology and Hepatology, Dr. Molewaterplein 40, 3015GD, Room Na-6, Erasmus Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
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S Y, Kedia S, Teja V, Vuyyuru SK, Yadav N, Sahu P, Jain S, Yadav DP, Bopanna S, Mouli VP, Madhu D, Sharma R, Das P, Makharia G, Ahuja V. Thromboembolism is associated with poor prognosis and high mortality in patients with inflammatory bowel disease: A case-control study. Indian J Gastroenterol 2022; 41:325-335. [PMID: 36063357 DOI: 10.1007/s12664-021-01237-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 12/22/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The information on the risk of thromboembolism (TE) in inflammatory bowel disease (IBD) and its predictors are lacking, especially from developing countries. The present study evaluated the prevalence, predictors, and prognosis of TE in IBD. METHODS This case-control study included 35 patients with IBD (ulcerative colitis [UC, n = 25]; Crohn's disease [CD], n = 10) and history of TE, from a cohort of 3597 patients (UC n = 2752, CD n = 845) under follow-up from 2005 to 2018. Details on demographics, extraintestinal manifestations (EIMs), patient status, type and outcomes of TE, treatment details, and disease course were compared with IBD patients without TE (age, gender, and duration of follow-up matched) in the ratio of 1:4. RESULTS Prevalence of TE in IBD was 0.9% (UC-0.89%, CD-1.2%). Among TE patients (mean age: 34.9 ± 13.1 years, 48.6% males), median duration from diagnosis to TE was 12 (inter-quartile range [IQR]: 3-36) months, 37% had other EIMs, 94.1% had moderate/severe disease at time of TE, 62.8% had steroid-dependent/refractory disease, and 5 patients (14.2%) died because of disease-related complications. Lower limb was the commonest site (57.1%), 14.3% had pulmonary TE, and 31.4% had involvement of multiple sites. Phenotypically, more patients with TE (among UC) had steroid-dependent disease (60% vs. 25%, p = 0.001), pancolitis (76% vs. 36%, p = 0.002), chronic continuous disease course (44% vs. 19%, p = 0.009), and acute severe colitis (48% vs. 18%, p = 0.002), of which the latter three were also independent predictors of TE. CONCLUSION Approximately 1% of patients with IBD develop thromboembolism relatively early during their disease course, and TE is associated with severe disease and higher disease-related complications including mortality.
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Affiliation(s)
- Yadukrishna S
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Saurabh Kedia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Varun Teja
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Sudheer Kumar Vuyyuru
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Nidhi Yadav
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Pabitra Sahu
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Saransh Jain
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Dawesh P Yadav
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Sawan Bopanna
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Venigalla Pratap Mouli
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Deepak Madhu
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Raju Sharma
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Prasenjit Das
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Govind Makharia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Vineet Ahuja
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110 029, India.
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Medgyesy K, Horrigan J, Tadros M. Bilateral Pulmonary Embolism in a Hospitalized Ulcerative Colitis Patient. Cureus 2022; 14:e21861. [PMID: 35273841 PMCID: PMC8901111 DOI: 10.7759/cureus.21861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2022] [Indexed: 01/13/2023] Open
Abstract
Patients with inflammatory bowel disease (IBD) are at higher risk of venous thromboembolism (VTE), though physicians may be unaware of this risk or hesitant to start pharmacologic VTE prophylaxis in the presence of active gastrointestinal bleeding. We report a case of a 38-year-old patient hospitalized with acute severe ulcerative colitis (UC) who was not placed on pharmacologic VTE prophylaxis and developed bilateral pulmonary embolism (PE). The patient's UC did not respond to medical therapy. Due to his PE, the patient’s total proctocolectomy was delayed six months. He also developed a large pelvic hematoma after colectomy requiring further surgical intervention. Hospitalized inflammatory bowel disease (IBD) patients require pharmacologic VTE prophylaxis unless they have life-threatening bleeding.
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9
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Kim SY, Cho YS, Kim HS, Lee JK, Kim HM, Park HJ, Kim H, Kim J, Kang DR. Venous Thromboembolism Risk in Asian Patients with Inflammatory Bowel Disease: A Population-Based Nationwide Inception Cohort Study. Gut Liver 2021; 16:555-566. [PMID: 34789583 PMCID: PMC9289840 DOI: 10.5009/gnl210190] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 07/27/2021] [Accepted: 08/03/2021] [Indexed: 11/22/2022] Open
Abstract
Background/Aims Inflammatory bowel disease (IBD) is associated with the occurrence of venous thromboembolism (VTE). However, to date, there have been few studies on the risk of VTE in Asian IBD patients. We aimed to estimate the incidence of VTE in Asian IBD patients and to determine if IBD is related to increased VTE risk. Methods We performed a population-based cohort study between 2004 and 2015 using Korean National Health Insurance data. IBD and VTE were defined by ICD-10 codes. Incidence rates of VTE were calculated among patients with IBD and among age- and sex-matched controls. Hazard ratios were estimated using Cox regression with adjustment for multiple variables. We performed additional analyses stratifying by age, sex, Charlson comorbidity index (CCI) score, and disease type. Results Among the 45,037 patients with IBD (IBD cohort) and 133,019 matched controls (non-IBD cohort) included in our analysis, 411 IBD patients and 641 controls developed VTE. The IBD cohort had a higher incidence rate ratio and risk of VTE than the non-IBD cohort (incidence rate ratio 1.92 and hazard ratio 1.93). Older age, female sex, higher CCI scores, cardiovascular disease, chronic kidney disease, use of steroids, and hospitalization were significant risk factors for VTE in patients with IBD. Conclusions The IBD patients in this study were approximately two times more likely to develop VTE than the non-IBD individuals. Our findings support the need for thromboprophylaxis in Asian IBD patients with various factors that further increase the risk of VTE.
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Affiliation(s)
- Su Young Kim
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yeon Seo Cho
- Department of Medicine, Wonju Severance Christian Hospital, Wonju, Korea
| | - Hyun-Soo Kim
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jung Kuk Lee
- Center of Biomedical Data Science, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hee Man Kim
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hong Jun Park
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hyunil Kim
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jihoon Kim
- Department of Medicine, Wonju Severance Christian Hospital, Wonju, Korea
| | - Dae Ryong Kang
- Center of Biomedical Data Science, Yonsei University Wonju College of Medicine, Wonju, Korea
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10
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Soriano CR, Powell CR, Chiorean MV, Simianu VV. Role of hospitalization for inflammatory bowel disease in the post-biologic era. World J Clin Cases 2021; 9:7632-7642. [PMID: 34621815 PMCID: PMC8462259 DOI: 10.12998/wjcc.v9.i26.7632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/17/2021] [Accepted: 08/12/2021] [Indexed: 02/06/2023] Open
Abstract
Treatment for inflammatory bowel disease (IBD) often requires specialized care. While much of IBD care has shifted to the outpatient setting, hospitalizations remain a major site of healthcare utilization and a sizable proportion of patients with inflammatory bowel disease require hospitalization or surgery during their lifetime. In this review, we approach IBD care from the population-level with a specific focus on hospitalization for IBD, including the shifts from inpatient to outpatient care, the balance of emergency and elective hospitalizations, regionalization of specialty IBD care, and contribution of surgery and endoscopy to hospitalized care.
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Affiliation(s)
- Celine R Soriano
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
| | - Charleston R Powell
- Department of Internal Medicine, Madigan Army Medical Center, Tacoma, WA 98431, United States
| | - Michael V Chiorean
- Department of Gastroenterology, Swedish Medical Center, Seattle, WA 98109, United States
| | - Vlad V Simianu
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
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11
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Arvanitakis KD, Arvanitaki AD, Karkos CD, Zintzaras EΑ, Germanidis GS. The risk of venous thromboembolic events in patients with inflammatory bowel disease: a systematic review and meta-analysis. Ann Gastroenterol 2021; 34:680-690. [PMID: 34475739 PMCID: PMC8375648 DOI: 10.20524/aog.2021.0631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 02/18/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Inflammatory bowel disease (IBD), comprising Crohn's disease (CD) and ulcerative colitis (UC), is a chronic inflammatory disorder of the gastrointestinal tract that has been associated with increased risk of extraintestinal manifestations, amongst which is venous thromboembolism (VTE). We assessed the risk for VTE in patients with IBD through systematic review and meta-analysis. METHODS A systematic search for English language studies was conducted in Medline, Scopus, and the Cochrane Library of publications from database inception till August 10, 2020, to identify relevant studies reporting the risk of VTE in patients with IBD. The random-effects and fixed-effect models were used to estimate relative risks (RRs) with their respective 95% confidence intervals (CIs). The quality of the included studies was assessed using the Newcastle-Ottawa scale. RESULTS Eleven observational studies were included in this meta-analysis, involving 3,175,012 patients with IBD and 920,144,253 controls without IBD. The overall RR for VTE in patients with IBD compared to non-IBD individuals was 2.03 (95%CI 1.72-2.39). An analysis of studies with larger population size demonstrated a lower risk for VTE (RR 1.77, 95%CI 1.48-2.13) among patients with IBD, whereas studies with a smaller population size yielded a greater risk for VTE (RR 2.67, 95%CI 1.97-2.93). After adjustment for smoking and body mass index, the RR for VTE was moderately increased (RR 2.65, 95%CI 1.51-4.65). CONCLUSIONS The present meta-analysis shows that IBD is linked to a 2-fold increased risk for VTE. Thus, primary prevention against VTE is of the utmost importance.
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Affiliation(s)
- Konstantinos D. Arvanitakis
- Department of Biomathematics, University of Thessaly, School of Medicine, Larissa, Greece (Konstantinos D. Arvanitakis, Alexandra D. Arvanitaki, Christos D. Karkos, Elias A. Zintzaras)
- 1 Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Greece (Konstantinos D. Arvanitakis, Georgios S. Germanidis)
| | - Alexandra D. Arvanitaki
- Department of Biomathematics, University of Thessaly, School of Medicine, Larissa, Greece (Konstantinos D. Arvanitakis, Alexandra D. Arvanitaki, Christos D. Karkos, Elias A. Zintzaras)
- Department of Cardiology III – Center for Adult Congenital and Valvular Heart Disease, University Hospital of Muenster, Muenster, Germany (Alexandra D. Arvanitaki)
| | - Christos D. Karkos
- Department of Biomathematics, University of Thessaly, School of Medicine, Larissa, Greece (Konstantinos D. Arvanitakis, Alexandra D. Arvanitaki, Christos D. Karkos, Elias A. Zintzaras)
- Vascular Unit, 5th Department of Surgery, Medical School, Aristotle University of Thessaloniki, Hippokratio Hospital, Thessaloniki, Greece (Christos D. Karkos)
| | - Elias Α. Zintzaras
- Department of Biomathematics, University of Thessaly, School of Medicine, Larissa, Greece (Konstantinos D. Arvanitakis, Alexandra D. Arvanitaki, Christos D. Karkos, Elias A. Zintzaras)
| | - Georgios S. Germanidis
- 1 Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Greece (Konstantinos D. Arvanitakis, Georgios S. Germanidis)
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12
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Click B, Barnes EL, Cohen BL, Sands BE, Hanson JS, Regueiro M, Rubin DT, Dubinsky MC, Gazis DR, Dalfonso L, Hildebrand JS, Crawford JM, Long MD. Methodology and Initial Results From a Real-World Observational Cohort of Patients With Inflammatory Bowel Disease: TARGET-IBD. CROHN'S & COLITIS 360 2021; 3:otab023. [PMID: 36776639 PMCID: PMC9802086 DOI: 10.1093/crocol/otab023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Indexed: 12/13/2022] Open
Abstract
Background Data on care patterns for inflammatory bowel disease (IBD) from large-scale, diverse clinical cohorts in real-world practice are sparse. We developed a real-world cohort of patients receiving care at academic and community sites, for comparative study of therapies and natural history of IBD. Methods We describe novel methodology of central abstraction of clinical data into a real-world IBD registry with patient reported outcomes (PROs). Baseline demographics, clinical characteristics, healthcare utilization, and disease metrics were assessed. Bivariate statistics were used to compare demographic and clinical data by Crohn disease (CD) or ulcerative colitis (UC) and site of care (academic, community). Results In 1 year, 1343 IBD patients (60.1% CD, 38.9% UC) were recruited from 27 academic (49.5%) and community (50.5%) sites, exceeding expectations (110% enrolled). Most participants also consented to provide PROs (59.5%) or biosamples (85.7%). Overall, 48.7% of the cohort provided a baseline PRO, and 62.6% provided a biosample. Compared to UC, CD subjects had higher prior (34.1% CD vs 7.7% UC; P < 0.001) and current (72.1% vs 47.9%; P < 0.001) biologic utilization. CD participants from academic sites had more complicated disease than those from community sites (62.5% vs 46.8% stricturing/penetrating; 33.5% vs 27% perianal; 36.8% vs 14.5% prior biologic, respectively). Nearly all (90.4%) participants had endoscopic data of whom 37.7% were in remission. One-year retention was 98.4%. Conclusions Centralized data abstraction and electronic PRO capture provided efficient recruitment into a large real-world observational cohort. This novel platform provides a resource for clinical outcomes and comparative effectiveness research in IBD.
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Affiliation(s)
- Benjamin Click
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA,Address correspondence to: Benjamin Click, MD, MS, Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA ()
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Benjamin L Cohen
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Bruce E Sands
- Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John S Hanson
- Atrium Health Gastroenterology and Hepatology, Charlotte, NC, USA
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Marla C Dubinsky
- Division of Pediatric Gastroenterology, The Susan & Leonard Feinstein IBD Clinical Center at Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | | | - Millie D Long
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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13
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Pepe M, Carulli E, Forleo C, Moscarelli M, Di Cillo O, Bortone AS, Nestola PL, Biondi-Zoccai G, Giordano A, Favale S. Inflammatory Bowel Disease and Acute Coronary Syndromes: From Pathogenesis to the Fine Line Between Bleeding and Ischemic Risk. Inflamm Bowel Dis 2021; 27:725-731. [PMID: 32592478 DOI: 10.1093/ibd/izaa160] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Indexed: 02/05/2023]
Abstract
Inflammatory bowel disease (IBD) is a pathological condition that first involves the gastrointestinal wall but can also trigger a systemic inflammatory state and thus extraintestinal manifestations. Systemic inflammation is probably secondary to the passage of bacterial products into the bloodstream because of altered intestinal permeability and the consequent release of proinflammatory mediators. Inflammation, through several diverse pathophysiological pathways, determines both a procoagulative state and systemic endothelial dysfunction, which are both deemed to be responsible for venous and arterial thromboembolic adverse events. The management of systemic thrombotic complications is particularly challenging in this category of patients, who also present a high bleeding risk; what is more, both bleeding and thrombotic risks peak during the active phases of the disease. The literature suggests that treating physicians have been, so far, more heavily influenced by concerns about bleeding than by the thrombotic risk. Despite the absence of data provided by large cohorts or randomized studies, the high risk of arterial and venous atherothrombosis in patients with IBD seems unquestionable. Moreover, several reports suggest that when arterial thromboembolism involves the coronary vessels, causing acute coronary syndromes, ischemic complications from antithrombotic drug undertreatment are frequent and severe. This review aims to shed light on the tricky balance between the ischemic and hemorrhagic risks of patients with IBD and to highlight how difficult it is for clinicians to define a tailored therapy based on a case-by-case, careful, and unprejudiced clinical evaluation.
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Affiliation(s)
- Martino Pepe
- Cardiovascular Diseases Section, Cardiothoracic Department, University of Bari, Bari, Italy
| | - Eugenio Carulli
- Cardiovascular Diseases Section, Cardiothoracic Department, University of Bari, Bari, Italy
| | - Cinzia Forleo
- Cardiovascular Diseases Section, Cardiothoracic Department, University of Bari, Bari, Italy
| | - Marco Moscarelli
- Cardiothoracic and Vascular Department, Maria Cecilia Hospital GVM Care and Research, Cotignola (RA), Italy
| | - Ottavio Di Cillo
- Chest Pain Unit, Cardiology Emergency, University of Bari, Bari, Italy
| | - Alessandro Santo Bortone
- Division of Heart Surgery, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Palma Luisa Nestola
- Cardiovascular Diseases Section, Cardiothoracic Department, University of Bari, Bari, Italy
| | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.,Mediterranea Cardiocentro, Napoli, Italy
| | - Arturo Giordano
- Invasive Cardiology Unit, Pineta Grande Hospital, Castel Volturno, Caserta, Italy
| | - Stefano Favale
- Cardiovascular Diseases Section, Cardiothoracic Department, University of Bari, Bari, Italy
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14
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Kanazaki R, Smith B, Girgis A, Descallar J, Connor S. Survey of barriers to adherence to international inflammatory bowel disease guidelines: Does gastroenterologists' confidence translate to high adherence? Intern Med J 2021; 52:1330-1338. [PMID: 33755298 DOI: 10.1111/imj.15299] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 03/02/2021] [Accepted: 03/11/2021] [Indexed: 12/07/2022]
Abstract
BACKGROUND & AIMS Despite the availability of evidence-based inflammatory bowel disease (IBD) guidelines, suboptimal care persists. There is little published research assessing barriers to IBD guideline adherence. This study aimed to identify barriers to IBD guideline adherence including gastroenterologists' knowledge and attitudes towards guidelines. METHODS An online cross-sectional survey of 824 Australian gastroenterologists was conducted from April to August 2018, with 198 (24%) responses. A novel survey was developed which was informed by the theoretical domain's framework. RESULTS Confidence in guideline recommendations was high, however referral to them was low. The European Crohn's and Colitis Organisation (ECCO) guidelines were the most commonly referred to (43.6%). In multivariate analysis, significant predictors of frequent versus infrequent guideline referral were: high confidence in the guideline (OR 7.70, 95% CI: 2.43-24.39, p = 0.001), and low (≤10 years) clinical experience (OR 3.62, 95% CI: 1.11-11.79, p = 0.03). The most common barriers to guideline adherence were not having time (62%) followed by guideline specifics being difficult to remember (61%). Low confidence was reported in managing pregnancy and IBD (34%) and loss of response to therapy (29%). High confidence was reported in managing immunomodulators, however only 43% answered the associated knowledge question correctly. CONCLUSION Although gastroenterologists' have high confidence in guidelines, they use them infrequently, primarily due to specifics being difficult to remember and lack of time. Self-reported confidence in an area of IBD management does not always reflect knowledge. An intervention targeting these barriers, for example computer-based clinical decision support tools, may improve adherence and standardise care. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Ria Kanazaki
- South Western Sydney Clinical School, University of New South Wales, Australia
| | - Ben Smith
- South Western Sydney Clinical School, University of New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, Australia
| | - Afaf Girgis
- South Western Sydney Clinical School, University of New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, Australia
| | - Joseph Descallar
- South Western Sydney Clinical School, University of New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, Australia
| | - Susan Connor
- South Western Sydney Clinical School, University of New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, Australia.,Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, Australia
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15
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Solitano V, Fiorino G, D'Amico F, Peyrin-Biroulet L, Danese S. Thrombosis in IBD in the Era of JAK Inhibition. Curr Drug Targets 2020; 22:126-136. [PMID: 32881668 DOI: 10.2174/1389450121666200902164240] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 07/15/2020] [Accepted: 07/15/2020] [Indexed: 01/06/2023]
Abstract
Patients with inflammatory bowel diseases (IBD) have an increased risk of thrombosis. The interaction between inflammation and coagulation has extensively been studied. It is well-- known that some drugs can influence the haemostatic system, but several concerns on the association between therapies and increased risk of thrombosis remain open. While biologics seem to have a protective role against thrombosis via their anti-inflammatory effect, some concerns about an increased risk of thrombosis with JAK inhibitors have been raised. We conducted a literature review to assess the association between biologics/small molecules and venous/arterial thrombotic complications. An increased risk of venous and arterial thrombosis was found in patients treated with corticosteroids, whereas anti-TNFα were considered protective agents. No thromboembolic adverse event was reported with vedolizumab and ustekinumab. In addition, thromboembolic events rarely occurred in patients with ulcerative colitis (UC) after therapy with tofacitinib. The overall risk of both venous and arterial thrombosis was not increased based on the available evidence. Finally, in the era of JAK inhibitors, the treatment should be individualized by evaluating the pre-existing potential thrombotic risk balanced with the intrinsic risk of the medication used.
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Affiliation(s)
- Virginia Solitano
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Gionata Fiorino
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | | | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
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16
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Murthy SK, Robertson McCurdy AB, Carrier M, McCurdy JD. Venous thromboembolic events in inflammatory bowel diseases: A review of current evidence and guidance on risk in the post-hospitalization setting. Thromb Res 2020; 194:26-32. [DOI: 10.1016/j.thromres.2020.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 05/02/2020] [Accepted: 06/01/2020] [Indexed: 02/07/2023]
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17
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Cohen JB, Comer DM, Yabes JG, Ragni MV. Inflammatory Bowel Disease and Thrombosis: A National Inpatient Sample Study. TH OPEN 2020; 4:e51-e58. [PMID: 32435723 PMCID: PMC7234833 DOI: 10.1055/s-0040-1710506] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 04/07/2020] [Indexed: 12/15/2022] Open
Abstract
Introduction
Thrombosis is more common in inflammatory bowel disease (IBD) patients than the general population, but disease-specific correlates of thrombosis remain unclear.
Methods
We performed a retrospective analysis of discharge data from the National Inpatient Sample between 2009 and 2014, using International Disease Classification codes to identify IBD and non-IBD patients with or without thrombosis. We used NIS-provided discharge-level weights to reflect prevalence estimates. Categoric variables were analyzed by Rao-Scott Chi-square test, continuous variables by weighted simple linear regression, and covariates associated with thrombosis by weighted multivariable logistic regression.
Results
Thrombosis prevalence in IBD was significantly greater than in non-IBD, 7.52 versus 4.54%,
p
< 0.0001. IBD patients with thrombosis were older and more likely to be Caucasian than IBD without thrombosis, each
p
< 0.001. Thrombosis occurred most commonly in the mesenteric vein. Thrombotic risk factors in IBD include surgery, ports, malignancy, dehydration, malnutrition, and steroids at 53.7, 13.2, 13.1, 12.4, 8.9, and 8.2%, respectively. Those with thrombosis had greater severity of illness, 1.42 versus 0.96; length of stay, 7.7 versus 5.5 days; and mortality, 3.8 versus 1.5%; all
p
< 0.0001. Adjusting for age and comorbidity, odds ratios for predictors of thrombosis included ports, steroids, malnutrition, and malignancy at 1.73, 1.61, 1.34, and 1.13, respectively, while Asian race, 0.61, was protective, each
p
< 0.001.
Conclusion
Thrombosis prevalence is 1.7-fold greater in IBD than non-IBD patients. Adjusting for age and comorbidity, the odds ratio for thrombosis in IBD was 73% higher with ports, 61% higher with steroids, 34% with malnutrition, and 13% with malignancy. Whether long-term anticoagulation would benefit the latter is unknown.
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Affiliation(s)
- Jessica B Cohen
- Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh Medical Center and Hemophilia Center of Western Pennsylvania, Pittsburgh, Pennsylvania, United States.,University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Diane M Comer
- University of Pittsburgh Center for Research on Health Care Data Center, Pittsburgh, Pennsylvania, United States
| | - Jonathan G Yabes
- University of Pittsburgh Center for Research on Health Care Data Center, Pittsburgh, Pennsylvania, United States
| | - Margaret V Ragni
- Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh Medical Center and Hemophilia Center of Western Pennsylvania, Pittsburgh, Pennsylvania, United States.,University of Pittsburgh, Pittsburgh, Pennsylvania, United States
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18
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Willems P, Orkut S, Ditisheim S, Pohl H, Barkun A, Djinbachian R, Bouin M, von Renteln D. An international polypectomy practice survey. Scand J Gastroenterol 2020; 55:497-502. [PMID: 32267187 DOI: 10.1080/00365521.2020.1749297] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background and study aims: In recent years, cold snare polypectomy (CSP) has been recommended as the preferred approach for removal of small and diminutive colorectal polyps. We conducted an international survey among endoscopists to understand the uptake of CSP and changes in polypectomy practice during recent years.Patients and methods: Endoscopists were invited through gastroenterology, colorectal surgery and endoscopy societies to participate in an online survey. The primary outcome was to identify the predominant polypectomy approach used to remove 4‒10 mm colorectal polyps. Secondary outcomes included the uptake of CSP in the past 5 years, current polypectomy practice patterns for 1‒20 mm polyps, practice changes in recent years, and perceived benefits/concerns related to different polypectomy techniques.Results: The survey was distributed internationally by nine societies and completed by 808 endoscopists (response rate 3.7%). CSP was the predominant polypectomy technique for 4‒5 mm polyps (67.0%, 95% CI, 63.7-70.2%) and 6‒10 mm polyps (55.2%, 95% CI, 51.8-58.6%). For 1‒3 mm polyps, cold forceps remained the predominant technique (78.4%, 95% CI, 75.6-81.3%), whereas hot snare polypectomy (HSP) remained the predominant technique for 10‒20 mm polyps (92.5%, 95% CI, 90.7-94.3%). 87.5% (95% CI, 85.2-89.8%) of endoscopists reported an increase in CSP use during the past 5 years.Conclusions: This survey found a substantial increase in CSP use during recent years. CSP has become the predominant polypectomy approach for 4‒10 mm colorectal polyps, while HSP remained the predominant approach for larger (10‒20 mm) polyps. Clinical practice patterns are well aligned with recently issued guideline recommendations.
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Affiliation(s)
- Philippe Willems
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada.,Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Sinan Orkut
- Faculty of Medicine, University of Strasbourg, Strasbourg, France
| | - Saskia Ditisheim
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada.,Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Heiko Pohl
- Department of Veterans Affairs Medical Center, White River Junction, Hartford, VT, USA.,Dartmouth, Geisel School of Medicine, Hanover, NH, USA
| | - Alan Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Canada
| | | | - Mickael Bouin
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada.,Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Daniel von Renteln
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada.,Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
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19
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Cheng K, Faye AS. Venous thromboembolism in inflammatory bowel disease. World J Gastroenterol 2020; 26:1231-1241. [PMID: 32256013 PMCID: PMC7109271 DOI: 10.3748/wjg.v26.i12.1231] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/04/2020] [Accepted: 03/09/2020] [Indexed: 02/06/2023] Open
Abstract
Patients with inflammatory bowel disease (IBD) are at an increased risk for venous thromboembolism (VTE). VTE events carry significant morbidity and mortality, and have been associated with worse outcomes in patients with IBD. Studies have suggested that the hypercoagulable nature of the disease stems from a complex interplay of systems that include the coagulation cascade, natural coagulation inhibitors, fibrinolytic system, endothelium, immune system, and platelets. Additionally, clinical factors that increase the likelihood of a VTE event among IBD patients include older age (though some studies suggest younger patients have a higher relative risk of VTE, the incidence in this population is much lower as compared to the older IBD patient population), pregnancy, active disease, more extensive disease, hospitalization, the use of certain medications such as corticosteroids or tofacitinb, and IBD-related surgeries. Despite the increased risk of VTE among IBD patients and the safety of pharmacologic prophylaxis, adherence rates among hospitalized IBD patients appear to be low. Furthermore, recent data suggests that there is a population of high risk IBD patients who may benefit from post-discharge prophylaxis. This review will provide an overview of patient specific factors that affect VTE risk, elucidate reasons for lack of VTE prophylaxis among hospitalized IBD patients, and focus on recent data describing those at highest risk for recurrent VTE post-hospital discharge.
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Affiliation(s)
- Kimberly Cheng
- Department of Medicine, NewYork-Presbyterian Columbia University Medical Center, New York, NY 10032, United States
| | - Adam S Faye
- Department of Medicine, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY 10032, United States
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20
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Casanova MJ, Chaparro M, Gisbert JP. Errors in the care of inflammatory bowel disease patients: "Errata" Study. GASTROENTEROLOGIA Y HEPATOLOGIA 2020; 43:233-239. [PMID: 31964522 DOI: 10.1016/j.gastrohep.2019.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 10/29/2019] [Accepted: 11/11/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Errors are very common in daily clinical practice; however, they can be prevented. Our aim was to identify the most common errors in the outpatient management of inflammatory bowel disease (IBD) patients. MATERIAL AND METHODS Patients diagnosed with IBD, being treated at our IBD Unit and who were referred for a second opinion were consecutively enrolled. Data on the strategies implemented by their previous physicians were obtained. These strategies were compared with the currently recommended diagnostic and therapeutic procedures. RESULTS Seventy-four IBD patients were enrolled. Prior to care in our Unit, screening for tobacco use had been performed in 50% of Crohn's disease patients, while smoking cessation counselling had been provided in 29%. At the time of IBD diagnosis, the hepatitis B virus immunization status had been investigated in 16% of the patients, the hepatitis C virus status in 15%, and the varicella status in 7%. Seven percent of the patients had been vaccinated against hepatitis B virus, and 3% against influenza, tetanus and pneumococcus. Sixty-seven percent of the patients with an indication for use of 5-aminosalicylic acid and 37% of those with an indication for immunosuppressants had received the indicated drug. DISCUSSION Errors in the outpatient management of IBD patients are very common and relevant.
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Affiliation(s)
- María José Casanova
- Unidad de Gastroenterología, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid, Madrid, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, España
| | - María Chaparro
- Unidad de Gastroenterología, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid, Madrid, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, España
| | - Javier P Gisbert
- Unidad de Gastroenterología, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid, Madrid, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, España.
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21
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Ratté MT, Jones AE, Witt DM, Young DC. Survey of current treatment practices for venous thromboembolism in patients with cystic fibrosis. Pediatr Pulmonol 2020; 55:149-155. [PMID: 31502767 DOI: 10.1002/ppul.24512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 08/16/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Patients with cystic fibrosis (CF) and venous thromboembolism (VTE) pose therapeutic challenges including potential drug interactions between CF-related therapies and anticoagulants. Despite these challenges, there are no recommendations for VTE management specific to patients with CF. Our objective was to describe VTE treatment practices among Cystic Fibrosis Foundation (CFF)-accredited care centers and affiliate programs in the United States. METHODS An online survey was distributed to CF center directors. The survey included questions regarding centers' demographics and posed a series of hypothetical clinical scenarios to gather centers' VTE treatment practices including choice of anticoagulant, dosing practices, duration decisions, and monitoring efforts. Descriptive statistics were utilized to summarize the survey results. RESULTS The survey response rate was 56.3%. Most centers reported treating zero to five VTE episodes per year. The following anticoagulants were used most often for VTE treatment: low-molecular-weight heparin (LMWH) (73.2%), apixaban (36.6%), warfarin (35.2%), rivaroxaban (33.8%), and unfractionated heparin (18.3%). On a scale of 0 to 100, the median confidence level in managing anticoagulant therapy was 50. Many centers expressed a desire for a CF-specific VTE treatment guideline. The most commonly cited challenging clinical situations were managing anticoagulant therapy complications (26.5%) and drug-drug interactions (21.3%). For common VTE scenarios, pediatric patients were most often treated with LMWH and warfarin, whereas adult patients were more often treated with apixaban or rivaroxaban. CONCLUSIONS Survey results indicated CF care centers find managing VTE in patients with CF challenging and indicated that a CF-specific VTE treatment guideline would be helpful.
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Affiliation(s)
- Morgan T Ratté
- Department of Pharmacy, University of Utah Health, Salt Lake City, Utah
| | - Aubrey E Jones
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, Utah
| | - Daniel M Witt
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, Utah
| | - David C Young
- Department of Pharmacy, University of Utah Health, Salt Lake City, Utah.,Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, Utah
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22
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Sultan K, Shah D, Bhorania K, Zhou E, Khan S, Kohn N, Qiu M, Spyropoulos A. Increased Transfusion Requirements with Pharmacologic Thromboembolism Prophylaxis During Inflammatory Bowel Disease Exacerbation. Dig Dis Sci 2019; 64:3256-3262. [PMID: 31065899 DOI: 10.1007/s10620-019-05650-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 04/29/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) exacerbation requiring hospitalization increases the risk of venous thromboembolism (VTE), and current guidelines recommend pharmacologic VTE prophylaxis (PVTEP). AIMS Bleeding risks with PVTEP in this population are poorly defined, and no study has investigated packed red blood cell (PRBC) transfusion requirements in this population. METHODS We conducted a chart review of all adult hospitalizations for IBD exacerbation within the Northwell Healthcare system. Patient characteristics recorded included demographics, disease type ulcerative colitis or Crohn's disease, severe disease defined by inpatient corticosteroid or biologic use, and admission hemoglobin. Inpatient use of PVTEP and anti-platelet therapies were identified. The primary outcome was the occurrence of any packed red blood cell (PRBC) transfusion. RESULTS In total, 717 patients met inclusion criteria, accounting for 891 admissions. PVTEP was used during 60.4% of admissions, and 11.1% of patient admissions included a transfusion event. Severe disease patients receiving PVTEP had an 18.6% transfusion risk, versus 11.1% for those not receiving PVTEP, OR 1.82, CI (1.04-3.17). One multivariable analysis transfusion was associated with PVTEP, OR 2.11, 95% CI 1.18, 3.77, p = 0.0120, disease severity OR 3.17, 95% CI 1.81,5.54, p < 0.0001, anti-platelet therapies OR 2.46, 95% CI 1.23-4.90, p = 0.0107, bowel resection OR 3.88, 95% CI 1.97,7.63, p < 0.0001 and decreased admission hemoglobin OR 2.01, 95% CI 1.73-2.32, p < 0.0001, but not disease type ulcerative colitis OR 0.71, 95% CI 0.42-1.20. CONCLUSION PVTEP during IBD exacerbation is associated with increased PRBC transfusions. Our findings do not constitute a contraindication to PVTEP, but may be incorporated into patient counseling during inpatient IBD management.
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Affiliation(s)
- Keith Sultan
- Division of Gastroenterology, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 600 Northern Blvd Suite 111, Great Neck, NY, 11021, USA.
| | - Dev Shah
- Department of Medicine, North Shore University Hospital, Northwell Health, 300 Community Drive, Manhasset, NY, 11030, USA
| | - Kush Bhorania
- Department of Medicine, North Shore University Hospital, Northwell Health, 300 Community Drive, Manhasset, NY, 11030, USA
| | - Elinor Zhou
- Department of Medicine, North Shore University Hospital, Northwell Health, 300 Community Drive, Manhasset, NY, 11030, USA
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Sundas Khan
- The Feinstein Institute for Medical Research, Manhasset, NY, 11030, USA
| | - Nina Kohn
- The Merinoff Center for Patient-Oriented Research, The Feinstein Institute for Medical Research, Manhasset, NY, 11030, USA
- Biostatistics Unit, The Feinstein Institute for Medical Research, Manhasset, NY, 11030, USA
| | - Michael Qiu
- Deptartment of Medicine, Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA
| | - Alex Spyropoulos
- Department of Medicine, Northwell Health Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 100 E 77th St, New York, NY, 10075, USA
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23
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Jackson B, Begun J, Gray K, Churilov L, Liew D, Knowles S, De Cruz P. Clinical decision support improves quality of care in patients with ulcerative colitis. Aliment Pharmacol Ther 2019; 49:1040-1051. [PMID: 30847962 DOI: 10.1111/apt.15209] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 12/30/2018] [Accepted: 02/09/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Decision support tools may facilitate shared decision-making and improve quality of care. AIM To assess the effectiveness of a decision support tool on improving quality of care in ulcerative colitis. METHODS A prospective quality of care intervention was conducted at two Australian hospitals comparing out-patient-based ulcerative colitis care with, and without, a tablet-based decision support tool. This included questions on disease activity management; psychological well-being; and preventive care, with 13 process indicators relevant to each domain. Participants included adult out-patients with mild-to-moderate ulcerative colitis and their clinicians who were divided into two cohorts. The first cohort were followed up immediately after their clinical review to check whether their clinician had discussed the 13 process indicators during the consultation. The second cohort of patients used the decision support tool immediately prior to their consultation which then generated a suggested management plan for the patient and clinician to discuss during the consultation. Management between the 2 cohorts was compared to assess the effectiveness of the decision support tool in improving the primary outcome, defined as the proportion of quality process indicators used for ulcerative colitis care, with and without the decision support tool. RESULTS Thirteen physicians and 100 patients participated. Fifty patients were managed without the decision support tool using standard care (median age 40; 44% male), and 50 patients used the decision support tool (median age 40; 46% male) over a 20-week period. Increase in the median use of process indicators overall was observed following use of the decision support tool (27% vs 100%; P < 0.001). Improvements were seen in psychological well-being management (30% vs 100%; P < 0.001), preventive care (16% vs 100%; P < 0.001) and process indicators related to disease activity management (50% vs 100%; P < 0.001). The decision support tool was found to be usable and acceptable. Shared decision-making was greater in the post-intervention group (mean decision conflict score of 18.0 vs 33.5; P = 0.002). CONCLUSIONS The decision support tool substantially improved the quality of the delivery of care. Decision support tools have the potential to minimise errors of omission via a standardised approach to care.
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He Q. Cardiocerebral and peripheral vascular risks in inflammatory bowel disease. Shijie Huaren Xiaohua Zazhi 2019; 27:341-346. [DOI: 10.11569/wcjd.v27.i5.341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic inflammatory disease that mainly affects the digestive tract. In addition to intestinal manifestations, it also has many extraintestinal manifestations. There have been a number of reports of IBD with secondary opportunistic infections, perforation, cancer, etc. IBD is reported with more and more cardiovascular events, but the conclusions are still controversial. At present, clinicians pay insufficient attention to the assessment of cardiocerebral and peripheral vascular risks in IBD. This article reviews the relevant literature on cardiovascular, cerebrovascular and peripheral vascular risks in IBD published in recent years, with an aim to help clinicians be familiar with these risks and develop individualized management regimens in clinical practice.
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Affiliation(s)
- Qiong He
- Department of Gastroenterology, First Affiliated Hospital of Jinan University, Guangzhou 510630, Guangdong Province, China
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Guideline recommendations for treatment of patients with inflammatory bowel diseases are not implemented in clinical practice-results of a non-representative survey. Int J Colorectal Dis 2019; 34:431-440. [PMID: 30523398 DOI: 10.1007/s00384-018-3215-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE There is a growing evidence for over-, under-, or misuse of health care in patients with inflammatory bowel disease. Most studies looked at treatment variability or used quality measures, which mostly capture supportive interventions rather than treatment of IBD in itself. We aimed to evaluate if current recommendations in clinical practice guidelines regarding the medical treatment of patients with inflammatory bowel diseases are being followed in Germany. METHODS A questionnaire was sent to 1901 patients insured with two large German statutory sickness funds and an ICD 10 diagnosis of Crohn's disease (CD) or ulcerative colitis (UC). The questionnaire asked about drug treatment, indications for drug treatment, provision of surveillance endoscopies in ulcerative colitis patients, and smoking status in Crohn's disease patients. RESULTS Out of 460 evaluable patients, 62.4% of UC patients and 53.9% of CD patients were treated with mesalamine according to guidelines, 91.3% of all patients were treated with glucocorticoids according to guideline recommendations, while only 75.6% received recommended immunosuppressive treatment. Of UC patients, 94.5% had surveillance colonoscopies at the recommended interval and 58.8% of CD patients were non-smokers. No predictor for overall treatment according to guidelines could be found while being of age older than 60 or being treated outside of a dedicated IBD clinic was associated with less immunosuppressive treatment. CONCLUSIONS A large proportion of patients with IBD do not receive drug treatment in accordance with clinical practice guidelines. Quality improvement measures are much needed.
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Egberg MD, Kappelman MD, Gulati AS. Improving Care in Pediatric Inflammatory Bowel Disease. Gastroenterol Clin North Am 2018; 47:909-919. [PMID: 30337040 DOI: 10.1016/j.gtc.2018.07.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Pediatric patients with inflammatory bowel disease (IBD) stand to benefit from quality improvement (QI) due to the chronic nature of the disease, frequent interaction with the health care system, and exposure to high-risk treatments. The use of QI in health care has led to significant improvements in quality and reliability of care. Despite these advances, significant deficits in providing high-quality pediatric IBD care persist. This article describes a brief history of health care QI, identifies gaps and challenges in delivery of quality pediatric IBD care, highlights several IBD QI initiatives, and concludes with future directions for improving pediatric IBD outcomes.
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Affiliation(s)
- Matthew D Egberg
- Department of Pediatrics, University of North Carolina at Chapel Hill, 130 Mason Farm Road, Bioinformatics Building, CB# 7229, Chapel Hill, NC 27599, USA.
| | - Michael D Kappelman
- Department of Pediatrics, University of North Carolina at Chapel Hill, 130 Mason Farm Road, Bioinformatics Building, CB# 7229, Chapel Hill, NC 27599, USA; Department of Epidemiology, University of North Carolina at Chapel Hill, 130 Mason Farm Road, Bioinformatics Building, CB# 7229, Chapel Hill, NC 27599, USA
| | - Ajay S Gulati
- Department of Pediatrics, University of North Carolina at Chapel Hill, 230 MacNider, CB# 7229, Chapel Hill, NC 27599, USA; Department of Pathology, University of North Carolina at Chapel Hill, 230 MacNider, CB# 7229, Chapel Hill, NC 27599, USA
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Doshi R, Vadher A, Mithawala P, Shah P. Oral antiplatelets in primary and secondary prevention of myocardial infarction: a review. Ir J Med Sci 2018; 188:453-467. [PMID: 30178075 DOI: 10.1007/s11845-018-1897-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 08/24/2018] [Indexed: 01/06/2023]
Abstract
There are a number of guidelines and articles available for the use of oral antiplatelets for primary and secondary prevention of myocardial infarction (MI). Antiplatelet medications inhibit platelet activation, aggregation, and other pathways eventually inhibiting clot formation. Aspirin and clopidogrel have been the mainstay in the management of acute coronary syndrome for about a decade. We have discussed the role of aspirin, clopidogrel, ticagrelor, and prasugrel which are the most commonly used oral antiplatelet medications in the current era. We have also considered the role of newer thrombin inhibitor vorapaxar, and dual antiplatelet therapy. In this review paper, we have summarized the continuing controversy about the use of oral antiplatelet therapy and their role in primary as well as secondary prevention of MI by describing results from major clinical trials. The safety and the efficacy of the above medications have been reviewed and described in this paper.
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Affiliation(s)
- Rajkumar Doshi
- Department of Internal Medicine, Renown Regional Medical Centre, University of Nevada Reno School of Medicine, 1155 Mill St, W-11, Reno, NV, 89502, USA.
| | - Abhishek Vadher
- Department of Cardiology, North Shore University Hospital, Hofstra Northwell School of Medicine, Manhasset, NY, USA
| | - Priyam Mithawala
- Department of Pharmacy, Presbyterian College School of Pharmacy, Clinton, SC, USA
| | - Priyank Shah
- Department of Cardiology, Phoebe Putney Memorial Hospital, Albany, GA, USA
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Egberg MD, Gulati AS, Gellad ZF, Melmed GY, Kappelman MD. Improving Quality in the Care of Patients with Inflammatory Bowel Diseases. Inflamm Bowel Dis 2018; 24:1660-1669. [PMID: 29718299 PMCID: PMC6231366 DOI: 10.1093/ibd/izy030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Indexed: 02/06/2023]
Abstract
Efforts to improve healthcare quality were firmly established before the Institute of Medicine (IOM) historic 2000 and 2001 reports, To Err is Human Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century Despite the long-standing healthcare quality improvement (QI) efforts that date back to the turn of the 20th century, the IOM reports significantly advanced the awareness of healthcare quality deficits and the resulting risk to patients from those gaps in care. Studies immediately following the IOM reports emphasized and verified the presence of detrimental care gaps and highlighted a myriad of contributing factors. Studies focused specifically on the inflammatory bowel diseases (IBD), Crohn's disease and ulcerative colitis , demonstrated suboptimal patient outcomes stemming from, in part, system and provider variation. In the years that have followed, research studies have shown the persistence of suboptimal outcomes in IBD despite an awareness of key drivers for poor care quality and concerted efforts in advancing QI initiatives. In 2017, IBD advocacy groups and provider networks have demonstrated progress in furthering both pediatric and adult IBD outcomes through the use of QI methods and tools including collaborative learning networks. A significant amount of work lies ahead, however, to build upon these advances and improve IBD outcomes further. This article reviews the history of quality initiatives in healthcare, identifies ongoing gaps in IBD care with a review of current IBD improvement efforts taking place, and identifies several targets for improving IBD care quality moving forward into the 21st century.
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Affiliation(s)
- Matthew D Egberg
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Division of Pediatric Gastroenterology, Chapel Hill, NC
- Institute for Healthcare Improvement, Cambridge, MA
| | - Ajay S Gulati
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Division of Pediatric Gastroenterology, Chapel Hill, NC
- University of North Carolina at Chapel Hill, Departments of Pediatrics and Pathology and Laboratory Medicine. Chapel Hill, NC
| | - Ziad F Gellad
- Durham VA Medical Center, Durham, NC
- Division of Gastroenterology, Duke University Medical Center, Durham, NC
| | - Gil Y Melmed
- Inflammatory Bowel and Immunobiology Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Michael D Kappelman
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Division of Pediatric Gastroenterology, Chapel Hill, NC
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An Electronic Alert System Is Associated With a Significant Increase in Pharmacologic Venous Thromboembolism Prophylaxis Rates Among Hospitalized Inflammatory Bowel Disease Patients. J Healthc Qual 2018; 39:307-314. [PMID: 27153049 DOI: 10.1097/jhq.0000000000000021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Utilization of pharmacologic venous thromboembolism (VTE) prophylaxis in inflammatory bowel disease (IBD) patients seems to be suboptimal with reported rates as low as 50% in some studies. Implementation of an electronic alert system seems to be an effective tool for increasing VTE prophylaxis rates in medical inpatients. To date, no studies have assessed whether this approach is associated with improved rates of pharmacologic VTE prophylaxis specifically in IBD patients. AIMS To determine the efficacy of an electronic alert in improving VTE prophylaxis rates in hospitalized IBD patients. METHODS We conducted a retrospective cohort study of 576 hospitalized IBD patients. The medical record of each patient was then examined to determine whether pharmacologic VTE prophylaxis was both ordered and administered, the timing of pharmacologic VTE prophylaxis, and reasons for any missed doses. RESULTS The VTE pharmacologic prophylaxis rate was improved from 60% to 81.2% following the implementation of the electronic alert system (p < .001). An increase in prophylaxis rates was seen in both medical (26.3% vs. 62.8%, p < .001) and surgical services (83.7% vs. 95.5%, p < .001). In patients who received pharmacologic VTE prophylaxis, 16% of all ordered doses were not administered and 57.3% of missed doses were the result of patient refusal. Hospitalization after implementation of the electronic alert system (odds ratio [OR] 4.71, 95% confidence interval [CI] 2.94-7.57) and admission to a surgical service (OR 14.3, 95% CI 8.62-24.39) were predictive of VTE pharmacologic prophylaxis orders. CONCLUSIONS The introduction of an electronic alert system was associated with a significant increase in rates of pharmacologic VTE prophylaxis. However, orders were often delayed and doses not always administered. The most common reason that ordered doses were not given was patient refusal.
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Practices, attitudes, and knowledge about Crohn's disease and smoking cessation among gastroenterologists. Eur J Gastroenterol Hepatol 2018; 30:155-160. [PMID: 29240002 DOI: 10.1097/meg.0000000000001010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Cigarette smoking is one of the most important, modifiable environmental factors in Crohn's disease (CD) and screening for tobacco use is an official recommendation and quality measure in the care of CD patients. The objective of this study was to learn more about gastroenterologists' practices, opinions, and knowledge in this area. PATIENTS AND METHODS A 15 question survey was sent through email to two national gastroenterology distribution lists. Questions were written in multiple choice formats and were designed to collect information about gastroenterologists' practices, attitudes, and knowledge regarding smoking cessation in CD patients. Responses were stratified by practice setting, experience, and inflammatory bowel disease-focus. Responses were anonymous and were collected in a secure, online database. RESULTS A total of 141 respondents completed the survey. Overall, 89% of participants screened their CD patients for smoking more than 75% of the time. In all, 62% provided smoking cessation counseling more than 75% of the time. Overall, 94% of respondents felt comfortable discussing the benefits of smoking cessation with their patients. In all, 56% felt comfortable discussing smoking cessation strategies with their patients. Overall, 88% of respondents agreed that gastroenterologists should provide smoking cessation counseling; however, 43 and 11% agreed that the gastroenterologist should be the primary counselor and primary prescriber of cessation-related pharmacotherapy, respectively. CONCLUSION Surveyed gastroenterologists agree that smoking cessation is an important part of the care of CD patients and this is reflected in their screening practices. Counseling occurs irregularly and many gastroenterologists do not feel comfortable discussing cessation strategies. Future guidelines should provide further guidance on the gastroenterologist's role in smoking cessation counseling for CD patients.
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Gonczi L, Kurti Z, Golovics PA, Lovasz BD, Menyhart O, Seres A, Sumegi LD, Gal A, Ilias A, Janos P, Gecse KB, Bessisow T, Afif W, Bitton A, Vegh Z, Lakatos PL. Quality of care indicators in inflammatory bowel disease in a tertiary referral center with open access and objective assessment policies. Dig Liver Dis 2018; 50:37-41. [PMID: 29107471 DOI: 10.1016/j.dld.2017.09.137] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 09/28/2017] [Accepted: 09/28/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND In the management of inflammatory bowel diseases, there is considerable variation in quality of care. AIMS The aim of this study was to evaluate structural, access/process components and outcome quality indicators in our tertiary referral IBD center. METHODS In the first phase, structural/process components were assessed, followed by the second phase of formal evaluation of access and management on a set of consecutive IBD patients with and without active disease (248CD/125UC patients, median age 35/39 years). RESULTS Structural/process components of our IBD center met the international recommendations. At or around the time of diagnosis usual procedures were full colonoscopy in all patients, with ileocolonoscopy/gastroscopy/CT/MRI in 81.8/45.5/66.1/49.6% of CD patients. A total of 86.7% of CD patients had any follow-up imaging evaluation or endoscopy. The median waiting time for non-emergency endoscopy/CT/MRI was 16/14/22 days. During the observational period patients with flares (CD/UC:50.6/54.6%) were seen by specialist at the IBD clinic within a median of 1day with same day laboratory assessment, abdominal US, CT scan/surgical consult and change in therapy if needed. Surgery and hospitalization rates were 20.1/1.4% and 17.3/3.2% of CD/UC patients. CONCLUSION Our results highlight that structural components and processes applied in our center are in line with international recommendations, including an open clinic concept and fast track access to specialist consultation, endoscopy and imaging.
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Affiliation(s)
- Lorant Gonczi
- First Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Zsuzsanna Kurti
- First Department of Medicine, Semmelweis University, Budapest, Hungary
| | | | - Barbara Dorottya Lovasz
- First Department of Medicine, Semmelweis University, Budapest, Hungary; Faculty of Health Sciences, Department of Clinical Studies, Semmelweis University, Budapest, Hungary
| | - Orsolya Menyhart
- First Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Anna Seres
- First Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Liza Dalma Sumegi
- First Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Alexander Gal
- First Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Akos Ilias
- First Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Papp Janos
- First Department of Medicine, Semmelweis University, Budapest, Hungary
| | | | - Talat Bessisow
- Division of Gastroenterology, McGill University, MUHC, Montreal General Hospital, Montreal, QC, Canada
| | - Waqqas Afif
- Division of Gastroenterology, McGill University, MUHC, Montreal General Hospital, Montreal, QC, Canada
| | - Alain Bitton
- Division of Gastroenterology, McGill University, MUHC, Montreal General Hospital, Montreal, QC, Canada
| | - Zsuzsanna Vegh
- First Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Peter Laszlo Lakatos
- First Department of Medicine, Semmelweis University, Budapest, Hungary; Division of Gastroenterology, McGill University, MUHC, Montreal General Hospital, Montreal, QC, Canada.
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Jackson BD, Con D, Liew D, De Cruz P. Clinicians' adherence to international guidelines in the clinical care of adults with inflammatory bowel disease. Scand J Gastroenterol 2017; 52:536-542. [PMID: 28128675 DOI: 10.1080/00365521.2017.1278785] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although evidence-based guidelines have been developed for inflammatory bowel disease (IBD), the extent to which they are followed is unclear. The objective of this study was to review clinicians' adherence to international IBD guidelines. METHODS Retrospective data collection of patients attending a tertiary Australian hospital IBD clinic over a 12-month period. Management practices were audited and compared to ECCO (European Crohn's and Colitis Organization) guidelines. RESULTS Data from 288 patients were collected: 47% (136/288) male; mean age 43; 140/288 (49%) patients had ulcerative colitis (UC); 145/288 (50%) patients had Crohn's disease (CD); 3/288 (1%) patients had IBD-unclassified (IBD-U). Patient care was undertaken by gastroenterologists, trainees and general practitioners. DISEASE MANAGEMENT Overall adherence to disease management guidelines occurred in 204/288 (71%) of patient encounters. Discrepancies between guidelines and management were found in: 25/80 (31%) of patients with UC in remission receiving oral 5-aminosalicyclates (5-ASAs) as maintenance therapy, and; 46/110 (42%) of patients with small bowel and/or ileo-cecal CD receiving 5-ASA. Preventive Care: Adherence to ≥1 additional component of preventive care was observed in 73/288 (25%) of patient encounters: 12/133 (9%) on thiopurines underwent annual skin checks; 61/288 (21%) of patients with IBD underwent a bone scan; 46/288 (16%) patients were reminded to have their influenza vaccine. Psychological care: Assessment of psychological wellbeing was undertaken in only 16/288 (6%) of patients. CONCLUSIONS There remains a gap between adherence to international guidelines and clinical practice. Standardizing practice using evidence-based clinical pathways may be a strategy towards improving the quality of IBD outpatient management.
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Affiliation(s)
- Belinda D Jackson
- a Department of Gastroenterology , The Austin Hospital , Melbourne , Australia.,b University of Melbourne, Department of Medicine , Austin Academic Centre , Melbourne , Australia
| | - Danny Con
- a Department of Gastroenterology , The Austin Hospital , Melbourne , Australia.,b University of Melbourne, Department of Medicine , Austin Academic Centre , Melbourne , Australia
| | - Danny Liew
- c School of Public Health and Preventive Medicine, Monash University , Melbourne , Australia
| | - Peter De Cruz
- a Department of Gastroenterology , The Austin Hospital , Melbourne , Australia.,b University of Melbourne, Department of Medicine , Austin Academic Centre , Melbourne , Australia
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Fernández-Urien I, Argüelles-Arias F, Alonso-Aguirre PA, Júdez J, Bermejo B. A survey-based analysis on endoscopic quality indicators compliance among Spanish endoscopists. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2016; 109:33-48. [PMID: 28004966 DOI: 10.17235/reed.2016.4705/2016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Endoscopy plays a key role for the diagnosis and management of gastrointestinal disorders. Therefore, quality indicators have been widely proposed in order to optimize endoscopic practice. The aims of this study, promoted by the Spanish Society of Digestive Diseases (SEPD), were to assess the knowledge and compliance to endoscopy quality indicators among Spanish gastroenterologists. METHODS A 31-questionnaire survey was created based on the endoscopy quality indicators proposed by international guidelines. The survey was distributed among Spanish gastroenterologists who are members of the society. Using only fully completed surveys, a descriptive analysis was performed. Those factors related with a suboptimal quality performance were also investigated. RESULTS A total of 1,543 surveys were sent and 281 (18.2%) were received completed. Based on the answers obtained, the management of 14 (70%) out of 20 assessed quality indicators was poor: 5 (83.3%) out of 6 pre-procedure items, 7 (58.3%) out of 12 intra-procedure items and 2 (100%) out of 2 post-procedure items. CONCLUSIONS A significant proportion of Spanish endoscopists do not comply with main endoscopic quality indicators. Factors such as "young" age, public setting, no colorectal cancer screening program and low volume of procedures/week are related to a poorer management of the assessed quality indicators and should be the target for future formative activities.
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Deye N, Vincent F, Michel P, Ehrmann S, da Silva D, Piagnerelli M, Kimmoun A, Hamzaoui O, Lacherade JC, de Jonghe B, Brouard F, Audoin C, Monnet X, Laterre PF. Changes in cardiac arrest patients' temperature management after the 2013 "TTM" trial: results from an international survey. Ann Intensive Care 2016; 6:4. [PMID: 26753837 PMCID: PMC4709360 DOI: 10.1186/s13613-015-0104-6] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 12/27/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Therapeutic hypothermia (TH between 32 and 34 °C) was recommended until recently in unconscious successfully resuscitated cardiac arrest (CA) patients, especially after initial shockable rhythm. A randomized controlled trial published in 2013 observed similar outcome between a 36 °C-targeted temperature management (TTM) and a 33 °C-TTM. The main aim of our study was to assess the impact of this publication on physicians regarding their TTM practical changes. METHODS A declarative survey was performed using the webmail database of the French Intensive Care Society including 3229 physicians (from May 2014 to January 2015). RESULTS Five hundred and eighteen respondents from 264 ICUs in 11 countries fulfilled the survey (16 %). A specific attention was generally paid by 94 % of respondents to TTM (hyperthermia avoidance, normothermia, or TH implementation) in CA patients, whereas 6 % did not. TH between 32 and 34 °C was declared as generally maintained during 12-24 h by 78 % of respondents or during 24-48 h by 19 %. Since the TTM trial publication, 56 % of respondents declared no modification of their TTM practice, whereas 37 % declared a practical target temperature change. The new temperature targets were 35-36 °C for 23 % of respondents, and 36 °C for 14 %. The duration of overall TTM (including TH and/or normothermia) was declared as applied between 12 and 24 h in 40 %, and between 24 and 48 h in 36 %. In univariate analysis, the physicians' TTM modification seemed related to hospital category (university versus non-university hospitals, P = 0.045), to TTM-specific attention paid in CA patients (P = 0.008), to TH durations (<12 versus 24-48 h, P = 0.01), and to new targets temperature (32-34 versus 35-36 °C, P < 0.0001). CONCLUSIONS The TTM trial publication has induced a modification of current practices in one-third of respondents, whereas the 32-34 °C target temperature remained unchanged for 56 %. Educational actions are needed to promote knowledge translations of trial results into clinical practice. New international guidelines may contribute to this effort.
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Affiliation(s)
- Nicolas Deye
- />Réanimation Médicale et Toxicologique, Unité Inserm U942, Centre Hospitalier Universitaire Lariboisière, Assistance Publique des Hôpitaux de Paris, 2, rue Ambroise Paré, 75010 Paris, France
| | - François Vincent
- />Réanimation Polyvalente, Groupe Hospitalier Inter-Communal Le Raincy-Montfermeil, Montfermeil, France
| | - Philippe Michel
- />Réanimation Polyvalente, Centre Hospitalier Régional René Dubost, Pontoise, France
| | - Stephan Ehrmann
- />Réanimation Polyvalente, Centre Hospitalier Régional Universitaire, Tours, France
| | - Daniel da Silva
- />Réanimation, Centre Hospitalier Delafontaine, Saint-Denis, France
| | - Michael Piagnerelli
- />Department of Intensive Care Experimental Medicine Laboratory, Centre Hospitalier Universitaire, Charleroi, Belgium
| | - Antoine Kimmoun
- />Réanimation Médicale, Centre Hospitalier Universitaire de Nancy Brabois, Vandoeuvre-les-Nancy, France
| | - Olfa Hamzaoui
- />Réanimation Polyvalente, Hôpital Antoine Béclère, APHP, Clamart, France
| | - Jean-Claude Lacherade
- />Réanimation Polyvalente, Centre Hospitalier Départemental Les Oudairies, La Roche-Sur-Yon, France
| | - Bernard de Jonghe
- />Réanimation Médicale, Centre Hospitalier Inter-Communal, Poissy, France
| | - Florence Brouard
- />Réanimation Polyvalente, Centre Hospitalier Régional René Dubost, Pontoise, France
| | | | - Xavier Monnet
- />Réanimation Médicale, Centre Hospitalier Universitaire Paris-Sud, APHP, Kremlin-Bicêtre, France
| | - Pierre-François Laterre
- />Medical-surgical intensive care unit, Saint Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - For the SRLF Trial Group
- />Réanimation Médicale et Toxicologique, Unité Inserm U942, Centre Hospitalier Universitaire Lariboisière, Assistance Publique des Hôpitaux de Paris, 2, rue Ambroise Paré, 75010 Paris, France
- />Réanimation Polyvalente, Groupe Hospitalier Inter-Communal Le Raincy-Montfermeil, Montfermeil, France
- />Réanimation Polyvalente, Centre Hospitalier Régional René Dubost, Pontoise, France
- />Réanimation Polyvalente, Centre Hospitalier Régional Universitaire, Tours, France
- />Réanimation, Centre Hospitalier Delafontaine, Saint-Denis, France
- />Department of Intensive Care Experimental Medicine Laboratory, Centre Hospitalier Universitaire, Charleroi, Belgium
- />Réanimation Médicale, Centre Hospitalier Universitaire de Nancy Brabois, Vandoeuvre-les-Nancy, France
- />Réanimation Polyvalente, Hôpital Antoine Béclère, APHP, Clamart, France
- />Réanimation Polyvalente, Centre Hospitalier Départemental Les Oudairies, La Roche-Sur-Yon, France
- />Réanimation Médicale, Centre Hospitalier Inter-Communal, Poissy, France
- />Clinique des Cèdres-Cornebarrieu, Blagnac, France
- />Réanimation Médicale, Centre Hospitalier Universitaire Paris-Sud, APHP, Kremlin-Bicêtre, France
- />Medical-surgical intensive care unit, Saint Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium
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Algahtani FH, Farag YMK, Aljebreen AM, Alazzam NA, Aleem AS, Jabri FF, Rajab MH, Shoukri MM. Thromboembolic events in patients with inflammatory bowel disease. Saudi J Gastroenterol 2016; 22:423-427. [PMID: 27976637 PMCID: PMC5184742 DOI: 10.4103/1319-3767.195558] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND/AIMS Inflammatory bowel disease (ulcerative colitis and Crohn's disease) is characterized by a chronic inflammatory condition, and is accompanied by abnormalities in coagulation and a hyper-coagulable state. This study was conducted to examine the risk factors for developing Thromboembolic Events in Inflammatory Bowel Disease (IBD) in a population with prevalent consanguinity. PATIENTS AND METHODS Patients with a definitive diagnosis of IBD who were seen in the gastroenterology clinic of King Khalid University Hospital (Riyadh, Saudi Arabia) from 2010- to 2012, were asked to participate in this prospective cohort study, and were followed for one 1 year. Data was collected using specifically designed case report forms (CRF) by trained research personnel. RESULTS A total of 100 Saudi patients with IBD were studied. There were 51 (51%) women and the mean ± standard deviation (SD) age of the group was 31.24 ± 10.78 years. Those with Crohn's disease constituted 72% of the patients, and 28% had ulcerative colitis. Eight patients (8%) had at least one Thrombotic Event ([six deep venous thrombosis (DVT), and two pulmonary embolism (PE)]. Family history of deep venous thrombosis was present in 5%, and family history of pulmonary embolism (PE) in 4% of the patients. After adjusting for age and gender, a family history of Thrombotic event was identified as to be the only statistically significant predictor of thrombosis in IBD patients (RR = 9.22, 95% CI: 2.10--40.43). CONCLUSION In a population with high consanguinity, Thromboembolic events (DVT and PE) had a prevalence of 8% among IBD patients, positive family history of pulmonary embolism was a predictor of thrombosis. Further studies are needed to explore the role of genetic factors in this population.
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Affiliation(s)
- Farjah H. Algahtani
- Department of Medicine, Division of Hematology/Oncology, King Saud University College of Medicine and King Khalid University Hospital, Riyadh, Saudi Arabia,Address for correspondence: Dr. Farjah H. Algahtani, Hematology Consultant, King Saud University, Riyadh, Kingdom of Saudi Arabia. E-mail:
| | - Youssef M. K. Farag
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Nahla A. Alazzam
- Gastroenterology Division, King Saud University College of Medicine, Riyadh, Saudi Arabia
| | - Aamer S. Aleem
- Department of Medicine, Division of Hematology/Oncology, King Saud University College of Medicine and King Khalid University Hospital, Riyadh, Saudi Arabia
| | - Fouad F. Jabri
- AlFaisal University College of Medicine, Riyadh, Saudi Arabia
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Knowledge, Attitudes, and Beliefs Regarding the Role of Nutrition in IBD Among Patients and Providers. Inflamm Bowel Dis 2016; 22:2474-81. [PMID: 27598738 DOI: 10.1097/mib.0000000000000901] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Malnutrition is common in inflammatory bowel disease (IBD). Identifying patients who are malnourished or at risk for malnutrition may lead to early intervention and improve patient outcomes. To date, little is known about the role of nutritional assessment and management in IBD care. We aimed to evaluate knowledge, attitudes, and beliefs regarding nutrition in IBD among patients and providers. METHODS Surveys were mailed electronically to patients and providers identified through their membership in the Crohn's & Colitis Foundation of America. In addition, patient and provider focus groups were conducted to explore nutrition-related themes. These surveys and focus groups were designed to evaluate knowledge and perceived importance of nutrition, patient-provider interactions regarding nutrition and use of nutritional resources. RESULTS There were 223 provider respondents (65.5% gastroenterologists, 15.2% nurses, and 6.7% dietitians). Forty-one percent of the gastroenterologists rated their knowledge of nutrition in IBD as "very good" compared with 87% of dietitians and 16% of nurses (P < 0.001). Thirty-three percent of the gastroenterologists reported not routinely screening their IBD patients for malnutrition. The patient survey had 567 respondents with 27% rating their knowledge of nutrition in IBD as "very good." In the focus groups, a lack of adequate IBD nutritional resources was evident along with a desire for improved access to nutrition specialists. CONCLUSIONS Significant gaps in knowledge relating to nutrition in IBD seem to exist. Targeted educational initiatives and improved access to nutritional experts are warranted. In addition, a standardized process for the assessment of malnutrition among patients with IBD should be developed.
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Tkacz J, Brady BL, Meyer R, Lofland JH, Ruetsch C, Coelho-Prabhu N. An Assessment of the AGA and CCFA Quality Indicators in a Sample of Patients Diagnosed with Inflammatory Bowel Disease. J Manag Care Spec Pharm 2016; 21:1064-76. [PMID: 26521118 PMCID: PMC10398195 DOI: 10.18553/jmcp.2015.21.11.1064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) is a chronic relapsing disease characterized by activation of the mucosal immune system and inflammation of the gastrointestinal tract. Management of IBD places a significant burden on the health care system because of the complexity of treatment, variability in patient outcomes, and chronic nature of the disease. OBJECTIVE To investigate the American Gastroenterological Association (AGA) and Crohn's and Colitis Foundation of America's (CCFA) quality measurement sets in a sample of IBD patients. METHODS Fourteen quality measures were restated for application to a claims database and calculated using Optum Clinformatics DataMart database. Selected measures were calculated over calendar year 2011. RESULTS Performance measures ranged from 0.4% for AGA measure 9, prophylaxis for venous thromboembolism, to 66.9% for AGA measure 8, testing for Clostridium difficile. CCFA outcome measures ranged from 0.6% qualifying for CCFA O10, report of fecal incontinence, to 32.9% for CCFA O1, prednisone usage. In addition to Clostridium difficile testing, the use of appropriate corticosteroid-sparing therapy (51.1%) and testing for latent tuberculosis before initiating anti-tumor necrosis factor therapy (45.0%) were the highest achieved measures. CONCLUSIONS This is the first examination of IBD quality measures using administrative claims. Rates of achievement across measures were variable and likely affected by the ability to calculate certain measures with claims data. Future studies should further examine measurement of IBD quality indicators in claims data to assess the validity of claims-based analyses and to ascertain whether measure attainment translates into better overall health or IBD-related outcomes.
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Affiliation(s)
- Joseph Tkacz
- Health Analytics, 9200 Rumsey Rd., Ste. 215, Columbia, MD 21045.
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Song HK, Lee KM, Jung SA, Hong SN, Han DS, Yang SK. Quality of care in inflammatory bowel disease in Asia: the results of a multinational web-based survey in the 2(nd) Asian Organization of Crohn's and Colitis (AOCC) meeting in Seoul. Intest Res 2016; 14:240-7. [PMID: 27433146 PMCID: PMC4945528 DOI: 10.5217/ir.2016.14.3.240] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 04/08/2016] [Accepted: 04/08/2016] [Indexed: 12/13/2022] Open
Abstract
Background/Aims The quality of care in inflammatory bowel disease (IBD) has not been systematically estimated. The aim of this study was to investigate the current status of quality of IBD care in Asian countries. Methods A questionnaire-based survey was conducted between March 2014 and May 2014. The questionnaire was adopted from "An adult inflammatory bowel disease physician performance measure set" developed by the American Gastroenterological Association. If the respondent executed the performance measure in more than 70% of patients, the measure was regarded as well performed. Results A total of 353 medical doctors from Asia completed the survey (116 from Korea, 114 from China, 88 from Japan, 17 from Taiwan, 8 from Hong-Kong, 4 from India, 3 from Singapore, and 1 each from the Philippines, Malaysia and Indonesia). The delivery of performance measures, however, varied among countries. The documentation of IBD and tuberculosis screening before anti-tumor necrosis factor therapy were consistently performed well, while pneumococcal immunization and prophylaxis of venous thromboembolisms in hospitalized patients were performed less frequently in all countries. Physician awareness was positively associated with the delivery of performance measures. Variations were also noted in reasons for non-performance or low performance of quality measures, and the two primary reasons cited were consideration of the measure to be unimportant and lack of time. Conclusions The delivery of performance measures varies among physicians in Asian countries, and reflects variations in the quality of care among the countries. This variation should be recognized to improve the quality of care in Asian countries.
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Affiliation(s)
- Hye Kyung Song
- Department of Internal Medicine, Ewha University College of Medicine, Seoul, Korea
| | - Kang-Moon Lee
- Department of Internal Medicine, St. Vincent's Hospital, The Catholic University College of Medicine, Seoul, Korea
| | - Sung-Ae Jung
- Department of Internal Medicine, Ewha University College of Medicine, Seoul, Korea
| | - Sung Noh Hong
- Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Soo Han
- Department of Internal Medicine, Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Suk-Kyun Yang
- Department of Internal Medicine, Ulsan University College of Medicine, Seoul, Korea
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Ulcerative Colitis Is Associated With an Increased Risk of Venous Thromboembolism in the Postoperative Period: The Results of a Matched Cohort Analysis. Ann Surg 2016; 261:1160-6. [PMID: 24983992 DOI: 10.1097/sla.0000000000000788] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To determine the rates of venous thromboembolism (VTE) during admission and within 30 days of hospital discharge in inflammatory bowel (IBD) patients undergoing colonic resection using the ACS National Surgical Quality Improvement Project (NSQIP) database and to compare these rates to VTE rates in cohorts of patients undergoing colonic resection for several other colonic pathologies. BACKGROUND High rates of VTE have been demonstrated in hospitalized IBD patients. However, rates of postdischarge VTE in IBD patients are understudied. METHODS Demographic, operative, and outcomes data for 96,999 patients undergoing colonic resection for diverticulitis, colorectal cancer (CRC), benign neoplasms, ulcerative colitis (UC), and Crohn's disease (CD) between 2005 and 2011 was obtained. Student t and χ tests were used for univariate analysis. A logistic multivariate analysis was performed with all significant variables. Propensity score matching was utilized to compare the VTE incidences between the groups. RESULTS Highest VTE risk was seen in obese patients [odds ratio (OR) = 1.41], those older than 73 years (OR = 1.58) and with bleeding disorders (OR = 1.44), American Society of Anesthesiology class III/IV (OR = 1.52/1.86), preoperative systemic inflammatory response syndrome (OR = 1.55), sepsis (OR = 1.48) or steroid use (OR = 1.63), and primary diagnosis of UC (OR = 2.10). The UC group had the highest incidence of VTE (2.74%), followed by CRC patients (1.74%). A 1.2% incidence was seen in the CD population, and 41.5% of the UC-VTEs were diagnosed after discharge. CONCLUSIONS This study affirms that inpatient UC patients undergoing colonic resection are at high risk for VTE and suggests that this risk persists into the postdischarge period. Thus, these patients should be given appropriate prophylaxis.
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Opportunities for Improvement in the Care of Patients Hospitalized for Inflammatory Bowel Disease-Related Colitis. Dig Dis Sci 2016; 61:1003-12. [PMID: 26860508 PMCID: PMC5716623 DOI: 10.1007/s10620-016-4046-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 01/18/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Algorithms for the diagnosis, management, and follow-up have been proposed for patients hospitalized for inflammatory bowel disease (IBD) colitis flare. The degree to which providers adhere to these algorithms is unknown. This study evaluated the quality of care in IBD patients hospitalized for disease-associated exacerbations and factors correlated with higher degrees of care. METHODS Retrospective chart review of 34 patients during 60 admissions to the medicine service for IBD colitis exacerbation between 2005 and 2012 at the Veterans Affairs San Diego Medical Center. Examined factors included laboratory testing, timing of consultation and intravenous steroids, abdominal imaging, endoscopic examination, venous thromboembolism (VTE) prophylaxis, narcotic use, Clostridium difficile and cytomegalovirus testing, symptomatology at discharge, timing of follow-up, and rates of readmission and mortality. RESULTS Quality of care varied among the factors studied, ranging from 30.5 % for pharmacologic VTE prophylaxis to 84.7 % for gastroenterology consultation within 24 h. Of 60 admissions, 22 % were not tested for C. difficile. Fifteen percent of patients were discharged before meeting commonly used discharge criteria. Eighty percent were seen in clinic at any time post-discharge; 6.7 % were readmitted; 10 % were lost to follow-up; 1.7 % opted for outside follow-up; and 1.7 % expired. CONCLUSIONS The quality of care for patients admitted with IBD colitis flares is variable. These data outline opportunities for improvement, particularly in regard to pain management, VTE prophylaxis, and follow-up. Further studies are needed to test intervention strategies for practice improvement.
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Saghazadeh A, Rezaei N. Inflammation as a cause of venous thromboembolism. Crit Rev Oncol Hematol 2016; 99:272-85. [DOI: 10.1016/j.critrevonc.2016.01.007] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 11/27/2015] [Accepted: 01/12/2016] [Indexed: 12/12/2022] Open
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Alkim H, Koksal AR, Boga S, Sen I, Alkim C. Etiopathogenesis, Prevention, and Treatment of Thromboembolism in Inflammatory Bowel Disease. Clin Appl Thromb Hemost 2016; 23:501-510. [DOI: 10.1177/1076029616632906] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The close relationship between inflammation and thrombosis affects the progression and severity of inflammatory bowel disease (IBD). The prevalence of venous thromboembolism (VTE) varies between 1% and 7% among patients with IBD. The VTE risk in patients with IBD is at least 3 times higher than that in the normal general population. The absolute risk is very high during hospitalization, active disease, and surgery. The IBD-related VTE occurs at younger ages and recurs more frequently. The development of thrombosis in IBD is due to the interaction of many hereditary and acquired risk factors. Each patient diagnosed with IBD should be evaluated for a personal and family history of thrombosis and for prothrombotic drug use. Although procoagulant factors are increased during the natural course of inflammation, natural anticoagulants and fibrinolytic activity are decreased. Although IBD is accepted as a prothrombotic condition, there is no treatment that can remove this risk from daily practice. Patient training is required to control important factors, such as long-term immobilization and smoking. Oral contraceptives and hormone replacement therapy should be avoided. Inducing permanent disease remission must be the key approach for the prevention of thrombosis. Low-molecular-weight heparin (LMWH) is the basis of prophylactic treatment, which reduces the thrombosis risk by 50%. Prophylaxis with LMWH should be administered to all patients with IBD hospitalized due to disease attack or surgery. Long-term or even life-long anticoagulation therapy should be planned if there is insufficient disease control, recurrent VTE attacks, positive thrombophilia tests, or thrombosis in vital veins.
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Affiliation(s)
- Huseyin Alkim
- Department of Gastroenterology, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Ali Riza Koksal
- Department of Gastroenterology, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Salih Boga
- Department of Gastroenterology, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Ilker Sen
- Department of Gastroenterology, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Canan Alkim
- Department of Gastroenterology, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
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Seah D, De Cruz P. Review article: the practical management of acute severe ulcerative colitis. Aliment Pharmacol Ther 2016; 43:482-513. [PMID: 26725569 DOI: 10.1111/apt.13491] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 09/10/2015] [Accepted: 11/11/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acute severe ulcerative colitis (ASUC) is a life-threatening condition for which optimal management strategies remain ill-defined. AIM To review the evidence regarding the natural history, diagnosis, monitoring and treatment of ASUC to inform an evidence-based approach to management. METHODS Relevant articles addressing the management of ASUC were identified from a search of MEDLINE, the Cochrane Library and conference proceedings. RESULTS Of ASUC, 31-35% is steroid-refractory. Infliximab and ciclosporin salvage therapies have improved patient outcomes in randomised controlled trials. Short-term response rates (within 3 months) have ranged from 40% - 54% for ciclosporin and 46-83% for infliximab. Long-term clinical response rates (≥1 year) have ranged from 42%-50% for ciclosporin and 50-65% for infliximab. Short-term and long-term colectomy rates have been respectively: 26-47% and 36-58% for ciclosporin, and 0-50% and 35-50% for infliximab. Mortality rates for ciclosporin and infliximab-treated patients have been: 0-5% and 0-2%, respectively. At present, management challenges include the selection, timing and assessment of response to salvage therapy, utilisation of therapeutic drug monitoring and long-term maintenance of remission. CONCLUSIONS Optimal management of acute severe ulcerative colitis should be guided by risk stratification using predictive indices of corticosteroid response. Timely commencement and assessment of response to salvage therapy is critical to reducing morbidity and mortality. Emerging pharmacokinetic models and therapeutic drug monitoring may assist clinical decision-making and facilitate a shift towards individualised acute severe ulcerative colitis therapies.
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Affiliation(s)
- D Seah
- Department of Medicine, The University of Melbourne, Melbourne, Vic., Australia.,Department of Gastroenterology, Austin Health, Melbourne, Vic., Australia
| | - P De Cruz
- Department of Medicine, The University of Melbourne, Melbourne, Vic., Australia.,Department of Gastroenterology, Austin Health, Melbourne, Vic., Australia.,Department of Gastroenterology, St Vincent's Hospital, Melbourne, Vic., Australia
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Abstract
Venous thromboembolism (VTE) represents one of the most common and life-threatening extraintestinal complications of inflammatory bowel disease (IBD). Therefore, the prevention of VTE is essential and foremost involves the assessment of individual patient risk factors for VTE and, consequently, the correction of those risk factors that are modifiable. Mechanical and pharmacological prophylaxis are highly effective at preventing VTE in patients hospitalized for acute disease, and they are recommended by the leading guidelines for hospitalized patients with IBD. Unfortunately, several recent surveys reported that prophylaxis against VTE is still poorly implemented because of concerns about its safety and a lack of awareness of the magnitude of thrombotic risk in patients with IBD. Therefore, further efforts are required to increase the thromboprophylaxis rate in these patients to bridge the gap between the best care and standard care and, consequently, to avoid preventable VTE-associated morbidity and mortality. This review provides insight on the critical points that persist on the prevention and treatment of VTE in patients with IBD.
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Park JJ. [Prevention and treatment of thromboembolism in patients with inflammatory bowel disease]. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2015; 65:151-158. [PMID: 25797378 DOI: 10.4166/kjg.2015.65.3.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Although inflammatory bowel disease (IBD) is a chronic disorder that mainly affects the gastrointestinal tract, extraintestinal complications can occur in IBD patients. Among many extraintestinal complications, venous thromboembolism (VTE) is particularly a feared complication due to its significant morbidity and mortality. IBD patients have about 2 to 3 fold higher risk of developing VTE compared with the general population, and the current management guidelines for IBD patients propose recommendations for the prevention of VTE. This review aims to summarize clinical characteristics of VTE in IBD patients and to outline strategies for preventing and treating VTE in these patients.
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Affiliation(s)
- Jae Jun Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Pittet V, Maillard MH, Lauvergeon S, Timmer M, Michetti P, Froehlich F, Burnand B, Vader JP, Mottet C. Acceptance of inflammatory bowel disease treatment recommendations based on appropriateness ratings: do practicing gastroenterologists agree with experts? J Crohns Colitis 2015; 9:132-9. [PMID: 25518062 DOI: 10.1093/ecco-jcc/jju021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Appropriateness criteria for the treatment of Crohn’s disease (CD) and ulcerative colitis (UC) have been developed by expert panels. Little is known about the acceptance of such recommendations by care providers. The aim was to explore how treatment decisions of practicing gastroenterologists differ from those of experts, using a vignette case study and a focus group. METHODS Seventeen clinical vignettes were drawn from clinical indications evaluated by the expert panel. A vignette case questionnaire asking for treatment options in 9 or 10 clinical situations was submitted to 26 practicing gastroenterologists. For each vignette case, practitioners’ answers on treatments deemed appropriate were compared with panel decisions. Qualitative analysis was performed on focus group discussion to explore acceptance and divergence reasons. RESULTS Two hundred thirty-nine clinical vignettes were completed, 98 for CD and 141 for UC.Divergence between proposed treatments and panel recommendations was more frequent for CD (34%) than for UC (27%). Among UC clinical vignettes, the main divergences with the panel were linked to 5-aminosalicylate (5-ASA) failure assessment and to situations in which stopping treatment was the main decision. For CD, the propositions of care providers diverged from the panel in mild to moderate active disease, for which practitioners were more prone to an accelerated step-up than the panel’s recommendations. CONCLUSIONS In about one-third of vignette cases, inflammatory bowel disease treatment propositions made by practicing gastroenterologists diverged from expert recommendations. Practicing gastroenterologists may experience difficulty in applying recommendations in daily practice.
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Kaplan GG, Lim A, Seow CH, Moran GW, Ghosh S, Leung Y, Debruyn J, Nguyen GC, Hubbard J, Panaccione R. Colectomy is a risk factor for venous thromboembolism in ulcerative colitis. World J Gastroenterol 2015; 21:1251-1260. [PMID: 25632199 PMCID: PMC4306170 DOI: 10.3748/wjg.v21.i4.1251] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 08/05/2014] [Accepted: 09/19/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare venous thromboembolism (VTE) in hospitalized ulcerative colitis (UC) patients who respond to medical management to patients requiring colectomy.
METHODS: Population-based surveillance from 1997 to 2009 was used to identify all adults admitted to hospital for a flare of UC and those patients who underwent colectomy. All medical charts were reviewed to confirm the diagnosis and extract clinically relevant information. UC patients were stratified by: (1) responsive to inpatient medical therapy (n = 382); (2) medically refractory requiring emergent colectomy (n = 309); and (3) elective colectomy (n = 329). The primary outcome was the development of VTE during hospitalization or within 6 mo of discharge. Heparin prophylaxis to prevent VTE was assessed. Logistic regression analysis determined the effect of disease course (i.e., responsive to medical therapy, medically refractory, and elective colectomy) on VTE after adjusting for confounders including age, sex, smoking, disease activity, comorbidities, extent of disease, and IBD medications (i.e., corticosteroids, mesalamine, azathioprine, and infliximab). Point estimates were presented as odds ratios (OR) with 95%CI.
RESULTS: The prevalence of VTE among patients with UC who responded to medical therapy was 1.3% and only 16% of these patients received heparin prophylaxis. In contrast, VTE was higher among patients who underwent an emergent (8.7%) and elective (4.9%) colectomy, despite greater than 90% of patients receiving postoperative heparin prophylaxis. The most common site of VTE was intra-abdominal (45.8%) followed by lower extremity (19.6%). VTE was diagnosed after discharge from hospital in 16.7% of cases. Elective (adjusted OR = 3.69; 95%CI: 1.30-10.44) and emergent colectomy (adjusted OR = 5.28; 95%CI: 1.93-14.45) were significant risk factors for VTE as compared to medically responsive UC patients. Furthermore, the odds of a VTE significantly increased across time (adjusted OR = 1.10; 95%CI: 1.01-1.20). Age, sex, comorbidities, disease extent, disease activity, smoking, corticosteroids, mesalamine, azathioprine, and infliximab were not independently associated with the development of VTE.
CONCLUSION: VTE was associated with colectomy, particularly, among UC patients who failed medical management. VTE prophylaxis may not be sufficient to prevent VTE in patients undergoing colectomy.
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Ananthakrishnan AN, Cagan A, Gainer VS, Cheng SC, Cai T, Scoville E, Konijeti GG, Szolovits P, Shaw SY, Churchill S, Karlson EW, Murphy SN, Kohane I, Liao KP. Thromboprophylaxis is associated with reduced post-hospitalization venous thromboembolic events in patients with inflammatory bowel diseases. Clin Gastroenterol Hepatol 2014; 12:1905-10. [PMID: 24632349 PMCID: PMC4162859 DOI: 10.1016/j.cgh.2014.02.034] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 01/21/2014] [Accepted: 02/19/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with inflammatory bowel diseases (IBDs) have increased risk for venous thromboembolism (VTE); those who require hospitalization have particularly high risk. Few hospitalized patients with IBD receive thromboprophylaxis. We analyzed the frequency of VTE after IBD-related hospitalization, risk factors for post-hospitalization VTE, and the efficacy of prophylaxis in preventing post-hospitalization VTE. METHODS In a retrospective study, we analyzed data from a multi-institutional cohort of patients with Crohn's disease or ulcerative colitis and at least 1 IBD-related hospitalization. Our primary outcome was a VTE event. All patients contributed person-time from the date of the index hospitalization to development of VTE, subsequent hospitalization, or end of follow-up. Our main predictor variable was pharmacologic thromboprophylaxis. Cox proportional hazard models adjusting for potential confounders were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). RESULTS From a cohort of 2788 patients with at least 1 IBD-related hospitalization, 62 patients developed VTE after discharge (2%). Incidences of VTE at 30, 60, 90, and 180 days after the index hospitalization were 3.7/1000, 4.1/1000, 5.4/1000, and 9.4/1000 person-days, respectively. Pharmacologic thromboprophylaxis during the index hospital stay was associated with a significantly lower risk of post-hospitalization VTE (HR, 0.46; 95% CI, 0.22-0.97). Increased numbers of comorbidities (HR, 1.30; 95% CI, 1.16-1.47) and need for corticosteroids before hospitalization (HR, 1.71; 95% CI, 1.02-2.87) were also independently associated with risk of VTE. Length of hospitalization or surgery during index hospitalization was not associated with post-hospitalization VTE. CONCLUSIONS Pharmacologic thromboprophylaxis during IBD-related hospitalization is associated with reduced risk of post-hospitalization VTE.
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Affiliation(s)
- Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Andrew Cagan
- Research IS and Computing, Partners HealthCare, Charlestown, Massachusetts
| | - Vivian S Gainer
- Research IS and Computing, Partners HealthCare, Charlestown, Massachusetts
| | - Su-Chun Cheng
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
| | - Tianxi Cai
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
| | - Elizabeth Scoville
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Gauree G Konijeti
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Peter Szolovits
- Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Stanley Y Shaw
- Harvard Medical School, Boston, Massachusetts; Center for Systems Biology, Massachusetts General Hospital, Boston, Massachusetts
| | - Susanne Churchill
- i2b2 National Center for Biomedical Computing, Brigham and Women's Hospital, Boston, Massachusetts
| | - Elizabeth W Karlson
- Harvard Medical School, Boston, Massachusetts; Division of Rheumatology, Allergy and Immunology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Shawn N Murphy
- Harvard Medical School, Boston, Massachusetts; Research IS and Computing, Partners HealthCare, Charlestown, Massachusetts; Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Isaac Kohane
- Harvard Medical School, Boston, Massachusetts; i2b2 National Center for Biomedical Computing, Brigham and Women's Hospital, Boston, Massachusetts; Children's Hospital Boston, Boston, Massachusetts
| | - Katherine P Liao
- Harvard Medical School, Boston, Massachusetts; Division of Rheumatology, Allergy and Immunology, Brigham and Women's Hospital, Boston, Massachusetts
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Panés J, O'Connor M, Peyrin-Biroulet L, Irving P, Petersson J, Colombel JF. Improving quality of care in inflammatory bowel disease: what changes can be made today? J Crohns Colitis 2014; 8:919-26. [PMID: 24713174 DOI: 10.1016/j.crohns.2014.02.022] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 02/25/2014] [Accepted: 02/26/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS There are a number of gaps in our current quality of care for patients with inflammatory bowel diseases. This review proposes changes that could be made now to improve inflammatory bowel disease care. METHODS Evidence from the literature and clinical experience are presented that illustrate best practice for improving current quality of care of patients with inflammatory bowel diseases. RESULTS Best care for inflammatory bowel disease patients will involve services provided by a multidisciplinary team, ideally delivered at a centre of excellence and founded on current guidelines. Dedicated telephone support lines, virtual clinics and networking may also provide models through which to deliver high-quality, expert integrated patient care. Improved physician-patient collaboration may improve treatment adherence, producing tangible improvements in disease outcomes, and may also allow patients to better understand the benefits and risks of a disease management plan. Coaching programmes and tools that improve patient self-management and empowerment are likely to be supported by payers if these can be shown to reduce long-term disability. CONCLUSIONS Halting disease progression before there is widespread bowel damage and disability are ideal goals of inflammatory bowel disease management. Improving patient-physician communication and supporting patients in their understanding of the evidence base are vital for ensuring patient commitment and involvement in the long-term management of their condition. Furthermore, there is a need to create more centres of excellence and to develop inflammatory bowel disease networks to ensure a consistent level of care across different settings.
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Affiliation(s)
- Julián Panés
- Hospital Clinic University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain.
| | | | | | - Peter Irving
- Department of Gastroenterology, Guy's and St Thomas' Hospital, London, United Kingdom
| | - Joel Petersson
- Global Medical Affairs Gastroenterology, AbbVie, Rungis, France
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Fumery M, Xiaocang C, Dauchet L, Gower-Rousseau C, Peyrin-Biroulet L, Colombel JF. Thromboembolic events and cardiovascular mortality in inflammatory bowel diseases: a meta-analysis of observational studies. J Crohns Colitis 2014; 8:469-79. [PMID: 24183231 DOI: 10.1016/j.crohns.2013.09.021] [Citation(s) in RCA: 131] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 09/22/2013] [Accepted: 09/24/2013] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Patients with inflammatory bowel disease (IBD) are at increased risk of having venous thromboembolism. The magnitude of this risk has yet to be determined. The question of whether IBD patients have an increased risk of arterial thromboembolism and cardiovascular (CV) mortality remains controversial. DESIGN We searched MEDLINE, Cochrane Library, EMBASE and international conference abstracts and included all controlled observational studies that evaluated the incidence of venous and/or arterial thromboembolic events (TE) and CV mortality in adult IBD. RESULTS 33 studies enrolling 207,814 IBD patients and 5,774,898 controls and capturing 3,253,639 hospitalizations of IBD patients and 936,411,223 hospitalizations of controls reported a risk of arterial and/or venous TE or CV mortality were included. The risk of venous TE was increased in IBD patients compared to the general population (RR, 1.96; 95% CI, 1.67-2.30) contrary to the risk of arterial TE (RR, 1.15; 95% CI, 0.91-1.45). There was an increased risk of deep venous thrombosis (RR, 2.42; 95% CI, 1.78-3.30), pulmonary embolism (RR, 2.53; 95% CI, 1.95-3.28), ischemic heart disease (RR, 1.35; 95% CI, 1.19-1.52) and mesenteric ischemia (RR, 3.46; 95% CI, 1.78-6.71). Differences in methodology were great between studies resulting in a significant heterogeneity in all previous analysis. CV mortality in IBD patients was not increased compared to the general population (SMR, 1.03; 95% CI, 0.93-1.14). CONCLUSION The risk of TE is increased in patients with IBD. This difference is mainly due to an increased risk of venous TE. There is no increased risk of arterial TE or CV mortality in IBD patients, but an increased risk of both ischemic heart disease and mesenteric ischemia.
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Affiliation(s)
- Mathurin Fumery
- Department of Hepato-Gastroenterology, Amiens University Hospital, Université Picardie Jules Verne, Amiens, France
| | - Cao Xiaocang
- Department of Hepato-Gastroenterology, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, China; Department of Hepato-Gastroenterology, Université Lille Nord de France, CHRU Lille, Lille, France
| | - Luc Dauchet
- Epidemiology Unit, EA 2694, Université Lille Nord de France, CHRU Lille, Lille, France
| | | | - Laurent Peyrin-Biroulet
- Department of Hepato-Gastroenterology, Nancy University Hospital, Université de Lorraine, Vandoeuvre-les-Nancy, France
| | - Jean-Frédéric Colombel
- Department of Hepato-Gastroenterology, Université Lille Nord de France, CHRU Lille, Lille, France; Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
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