Variation in Care in the Management of Children With Crohn's Disease: Data From a Multicenter Inception Cohort Study
Chenthan Krishnakumar1, Cortney R Ballengee1, Chunyan Liu2
1Division of Pediatric Gastroenterology, Department of Pediatrics, Emory University School of Medicine & Children's Healthcare of Atlanta, Atlanta, Georgia.
Insights
Care variation exists in pediatric Crohn's disease (CD) treatment. Significant differences were found in medication use and monitoring, highlighting a need for standardized practices to improve outcomes for children with CD.
Area of Science:
- Pediatric Gastroenterology
- Clinical Practice Variation
- Inflammatory Bowel Disease Research
Background:
- Variation in medical care is common and impacts chronic disease outcomes.
- Reducing care variation can improve quality and patient results.
- This study investigates factors contributing to care variation in newly diagnosed pediatric Crohn's disease (CD).
Purpose of the Study:
- To identify factors associated with variations in diagnostic, treatment, and monitoring practices for children with newly diagnosed CD.
- To analyze intercenter variations in care and their correlation with disease outcomes over three years.
- To provide insights for implementing practice strategies to reduce care variation in pediatric CD.
Main Methods:
- Analysis of prospectively collected data from a 28-site, multicenter inception CD cohort (1046 children).
- Evaluation of variations in diagnostic modalities, treatment (steroids, anti-tumor necrosis factor [anti-TNF], immunomodulators [IMs]), and follow-up monitoring over three years.
- Utilized generalized linear mixed effects models to assess intercenter variations.
Main Results:
- No variation in the initial diagnostic approach was observed.
- Significant intercenter variation in the initial use of steroids and anti-tumor necrosis factor (anti-TNF) was noted, though not over a 3-year period.
- Significant variation existed in the initiation and long-term use of immunomodulators (IMs) and in follow-up small bowel imaging and colonoscopy surveillance across centers.
Conclusions:
- Intercenter variation in initial steroid and anti-TNF use was observed, but not in total 3-year exposure.
- Significant variation in the initiation and long-term use of immunomodulators (IMs) among sites warrants further investigation.
- Non-uniform performance of small bowel imaging and colonoscopy surveillance indicates a need for standardized monitoring practices in pediatric CD patients.
Background:
Variation in care is common in medical practice. Reducing variation in care is shown to improve quality and increase favorable outcomes in chronic diseases. We sought to identify factors associated with variation in care in children with newly diagnosed Crohn's disease (CD).
Methods:
Prospectively collected data from a 28-site multicenter inception CD cohort were analyzed for variations in diagnostic modalities, treatment, and follow-up monitoring practices, along with complicated disease outcomes over 3 years in 1046 children. Generalized linear mixed effects models were used to investigate the intercenter variations in each outcome variable.
Results:
The mean age at diagnosis was 12 years, and 25.9% were nonwhite. The number of participants ranged from 5 to 112 per site. No variation existed in the initial diagnostic approach. When medication exposure was analyzed, steroid exposure varied from 28.6% to 96.9% (P < 0.01) within 90 days, but variation was not significant over a 3-year period (P = 0.13). Early anti-tumor necrosis factor (anti-TNF) exposure (within 90 days) varied from 2.1% to 65.7% (P < 0.01), but variation was not significant over a 3-year period (P > 0.99). Use of immunomodulators (IMs) varied among centers both within 90 days (P < 0.01) and during 3 years of follow-up (P < 0.01). A significant variation was seen at the geographic level with follow-up small bowel imaging and colonoscopy surveillance after initial therapy.
Conclusions:
Intercenter variation in care was seen with the initial use of steroids and anti-TNF, but there was no difference in total 3-year exposure to these drugs. Variation in the initiation and long-term use of IMs was significant among sites, but further research with objective measures is needed to explain this variation of care. Small bowel imaging or repeat colonoscopy in CD patients was not uniformly performed across sites. As our data show the widespread existence of variation in care and disease monitoring at geographic levels among pediatric CD patients, future implementation of various practice strategies may help reduce the variation in care.
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