Quality of health care in the United States: implications for pediatric inflammatory bowel disease

Healthcare service use in paediatric inflammatory bowel disease: a questionnaire on patient and parent care experiences in Germany

BACKGROUND

Paediatric inflammatory bowel disease (PIBD) patients require chronic care over the lifespan. Care for these patients is complex, as it is adapted for childrens' life stages and changing disease activity. Guideline based care for this patient group recommends a multidisciplinary approach, which includes in addition to paediatric gastroenterologists, nutritional and psychological care services. For PIBD patients, a discrepancy between available guideline-based multidisciplinary care and actual care has been found from the provider side, but to what extent patients experience this is unclear.

OBJECTIVES

To identify which healthcare services were used and whether socio-demographic, geographic or disease related factors have an influence on health service utilisation.

METHODS

A standardised questionnaire (CEDNA) was distributed amongst parents of children aged 0-17 diagnosed with PIBD and adolescents (aged 12-17) with a PIBD. Items related to health service use were analysed, these included specialist care, additional care services, reachability of services and satisfaction with care. Logistic regression models on additional service use were calculated. Service availability and reachability maps were made.

RESULTS

Data was analysed for 583 parent and 359 adolescent questionnaires. Over half of the respondents had Crohn's Disease (CD, patients n = 186 parents n = 297). Most patients and parents reported their paediatric gastroenterologist as their main care contact (patients 90.5%; parents 93%). Frequently reported additional services were nutritional counselling (patients 48.6%; parents 42.2%) and psychological support (patients 28.1%; parents 25.1%). Nutritional counselling was more frequently reported by CD patients in both the patient (OR 2.86; 95%CI 1.73-4.70) and parent (OR 3.1; 95%CI 1.42-6.71) sample. Of the patients, 32% reported not using any additional services, which was more likely for patients with an illness duration of less than one year (OR 3.42; 95%CI 1.26-9.24). This was also observed for the parent population (OR 2.23; 95%CI 1.13-4.4). The population-based density of specialised paediatric gastroenterologists was not proportionate to the spatial distribution of patients in Germany, which may have an influence on access.

CONCLUSIONS

Parents and children reported highly specialised medical care. Multidisciplinary care offers do not reach the entire patient population. Access to multidisciplinary services needs to be ensured for all affected children.

[Quality of care in inflammatory bowel disease]

Since inflammatory bowel disease (IBD) is a chronic and relapsing disorder, maintaining high quality of care plays an important role in the management of patients with IBD. To develop process-based quality indicator set to improve quality of care, the indicator should be based directly on evidence and consensus. Initially, ImproveCareNow group demonstrated quality improvement by learning how to apply quality improvement methods to improve the care of pediatric patients with IBD. The American Gastroenterological Association has developed adult IBD physician performance measures set and Crohn's and Colitis Foundation of America (CCFA) has developed a set of ten most highly rated process and outcome measures. Recently, The Emerging Practice in IBD Collaborative (EPIC) group generated defining quality indicators for best-practice management of IBD in Canada. Quality of Care through the Patient's Eyes (QUOTE-IBD) was developed as a questionnaire to measure quality of care through the eyes of patients with IBD, and it is widely used in European countries. The current concept of quality of care as well as quality indicator will be discussed in this article.

Measuring satisfaction with health care in young persons with inflammatory bowel disease--an instrument development and validation study

Background

Patient satisfaction is a relevant prognostic factor in young persons with chronic disease and may be both age and disease specific. To assess health care quality from the patient’s view in young persons with inflammatory bowel disease, an easy to use, valid, reliable and informative specific instrument was needed.

Methods

All parts of the study were directed at persons with inflammatory bowel disease aged 15 to 24 (“youth”). A qualitative internet patient survey was used to generate items, complemented by a physician survey and literature search. A 2nd internet survey served to reduce items based on perceived importance and representativeness. Following pilot testing to assess ease of use and face validity, 150 respondents to a postal survey in patients from a paediatric clinical registry were included for validation analyses. Construct validity was assessed by relating summary scores to results from global questions on satisfaction with care using ANOVA. To assess test-retest reliability using intraclass correlation coefficients (ICC), a subset of patients were assessed twice within 3 months.

Results

302 persons with IBD and 55 physicians participated in the item generating internet survey, resulting in 3,954 statements. After discarding redundancies 256 statements were presented in the 2nd internet survey. Of these, 32 items were retained. The resulting instrument assesses both the perceived relevance (importance) of an item as well as the performance of the care giver for each item for calculation of a summary satisfaction score (range 0 to 1). Sensibility testing showed good acceptance for most items. Construct validity was good, with mean scores of 0.63 (0.50 to 0.76), 0.71 (0.69 to 0.74) and 0.81 (0.79 to 0.83) for no, some and good global satisfaction (ANOVA, p < 0.001). Test-retest reliability was satisfactory (ICC 0.6 to 0.7).

Conclusions

We developed an easy to use, patient oriented, valid instrument to assess satisfaction with care in young persons with IBD for use in survey research.

Physician density and hospitalization for inflammatory bowel disease

BACKGROUND

Inflammatory bowel diseases (IBDs) are chronic illnesses that require frequent and regular healthcare contact. Regular maintenance care may reduce complications or the need for hospitalization. Availability of physicians may be an important determinant of IBD hospitalizations.

METHODS

Using 2008 inpatient data from the Wisconsin Hospital Association, we identified all IBD hospitalizations through ICD-9-CM discharge codes. County-level rates of primary care physicians and gastroenterologists were calculated for each county (using data from the American Medical Association and the US Census Bureau), with counties in the highest tertile by physician density being classified as "high density" counties. Multivariate regression analysis was performed to identify the independent effect of physician density on IBD outcomes.

RESULTS

A total of 26 counties were defined as high density (mean physician density 162/100,000 population; 2090 IBD hospitalizations) with the remaining 46 counties being low density counties (mean physician density 78/100,000 population; 3441 hospitalizations). The overall rate of IBD hospitalizations was similar for residents of high and low density counties. However, hospitalizations from low physician density counties were more likely to have hypovolemia (26% versus 22%, P=0.003), malnutrition (5.6% versus 4.3%, P=0.04), Clostridium difficile infection (4.1% versus 1.9%, P<0.001), require total parenteral nutrition (TPN) (4.3% versus 2.5%, P<0.001), or be admitted emergently (41.5% versus 35.1%, P<0.001). Residence in a county with high physician density was associated with 4% shorter length of stay and 10% lower hospitalization charges.

CONCLUSIONS

Residence in counties with high physician density is associated with less complicated disease on hospitalization and lower hospitalization charges for IBD.