P044  Designing Interventions to Elevate the Quality of IBD Care: A Systematic Review of Quality Improvement Initiatives

P044  Designing Interventions to Elevate the Quality of IBD Care: A Systematic Review of Quality Improvement Initiatives
 

Escala Perez-Reyes Andrea1, Niccum Blake2, Fudman David1, Khalili Hamed3
1 Division of Digestive and Liver Diseases, University of Texas Southwestern Medical School, Dallas, United States, 2 Department of Internal Medicine, Massachusetts General Hospital, Boston, United States, 3 Division of Gastroenterology and Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Harvard University, Boston, United States

BACKGROUND: Inflammatory bowel disease (IBD) care and outcomes are known to exhibit substantial geographic and inter-provider variability, suggesting quality gaps. We aimed to identify data on the design and implementation of interventions to narrow these gaps.

METHODS: A systematic review of Medline, Embase and Web of Science was performed to find reports of quality improvement (QI) interventions in IBD. The search focused on emergency room (ER) and hospital utilization and Crohn’s and Colitis Foundation quality indicators on care processes, including pre-biologic testing, vaccinations, tobacco cessation, colorectal cancer (CRC) surveillance, and C. difficile infection (CDI) screening in flares. We included studies published between January 2009 and January 2020 and abstracts presented between October 2017 and January 2020 that reported on interventions in the United States and Canada for adult patients. Two authors reviewed all records and differences in inclusion were resolved by consensus.

RESULTS: The initial search identified 6257 records; 991 were duplicates and 4734 were excluded after title review. 19 manuscripts and 11 abstracts were included after full review. Most studies used a pre/post design and reported on more than one quality indicator. Flu and pneumonia vaccination were the most studied indicators (17 references), followed by ER/hospital utilization, pre-biologic testing (hepatitis B and tuberculosis assessment) and tobacco cessation (10, 8 and 9 references, respectively). Electronic medical record (EMR)-based interventions were the most frequent, employed by 7 references, and included the use of templates and order sets. These interventions found mixed success among quality metrics but universally led to higher rates of reported vaccination. The creation of clinic protocols to evaluate and act upon patients' vaccination history were also successful in improving vaccination rates, as were efforts to educate patients regarding vaccination. In contrast, efforts to educate physicians regarding quality IBD care led to improvements in rates of vaccination and pre-biologic testing in some cases but were not successful in improving other metrics. Utilizing support staff showed similar mixed results: the use of a scribe was linked to higher rates of vaccination, and a nursing-driven CDI testing protocol for inpatients resulted in higher rates of appropriate CDI testing, but post-discharge phone calls from a pharmacist did not improve rates of 30-day readmission. Novel care models such as remote patient monitoring, Project Sonar, Qorus, and an IBD medical home, as well as the implementation of clinical care pathways, led to decreases in ER and hospital utilization in all but one instance. Qorus was the only intervention associated with higher rates of steroid-sparing therapy; physician education efforts and efforts at standardizing documentation were not successful in improving this metric. Included studies are described in the table and successful QI methods are summarized in the figure.

CONCLUSION(S): The quality of IBD care can be improved with interventions that range from simple to complex. Successful interventions have employed EMR-based changes, such as templates and order sets, physician and patient education, empowerment of support staff, and novel care models. These interventions are not universally effective, however, and prior experience should guide future QI efforts in IBD.