Systematic Reviews and Meta-analyses
Interventions to Decrease Unplanned Healthcare Utilization and Improve Quality of Care in Adults With Inflammatory Bowel Disease: A Systematic Review

https://doi.org/10.1016/j.cgh.2021.08.048Get rights and content

Background & Aims

Inflammatory bowel disease (IBD) care and outcomes exhibit substantial variability, suggesting quality gaps. We aimed to identify interventions to narrow these gaps.

Methods

We performed a systematic review of Medline, Embase, and Web of Science through May 2021 to find manuscripts and abstracts reporting quality improvement (QI) interventions in IBD. We included studies with interventions that addressed acute care utilization, vaccination, or Crohn’s and Colitis Foundation quality indicators for care processes, including pre-therapy testing, tobacco cessation, colorectal cancer surveillance, Clostridium difficile infection screening in flares, sigmoidoscopy in patients hospitalized with ulcerative colitis, and use of steroid-sparing therapy. The primary objective was to identify successful QI interventions. Risk of bias assessment was conducted using the Joanna Briggs Institute critical appraisal checklist.

Results

Twenty-three manuscripts and 23 meeting abstracts met inclusion criteria. Influenza and pneumococcal vaccination were the most studied indicators (24 references), followed by emergency room and/or hospital utilization, tobacco cessation, and pre-therapy testing (17, 11, and 10 references, respectively). Electronic medical record-based interventions were the most frequent, whereas other initiatives used strategies that included changes to care structure or delivery, vaccination protocols, or physician and patient education. Successful interventions matched the complexity of the metric to the intervention including making changes to care structure or delivery, empowered non-physician staff, and used electronic medical record changes to prompt clinicians.

Conclusions

The quality of IBD care can be improved with diverse interventions that range from simple to complex. However, these interventions are not universally successful. Clinicians should emulate successful interventions and design new initiatives to narrow gaps in care quality.

Section snippets

Methods

We performed a systematic review of the literature by searching Medline, Embase, and Web of Science using search terms that reflected Crohn’s and Colitis Foundation quality indicators regarding processes of care as well as improving rates of vaccination against influenza and pneumococcus, hospitalization, and ER utilization.21 The search was performed by using a predetermined protocol developed in conjunction with a medical reference librarian and was registered with PROSPERO (CRD42021233548).

Study Selection

The initial search identified 6475 unique potentially relevant references. After initial review, 588 titles were identified as potentially appropriate, and the corresponding abstracts were reviewed. Of these, 20 meeting abstracts were initially selected for inclusion, and 24 manuscripts were retrieved for full text review. From these, 20 manuscripts were selected for inclusion. In addition, 3 selected meeting abstracts had been published subsequently in manuscript form during the inclusion

Discussion

We identified nearly four dozen publications that have analyzed the effects of QI interventions on process measures as well as rates of hospitalization and ER utilization in IBD. In studying a broad array of metrics, these works used a diverse set of interventions that range from the very complex, such as the establishment of a specialty medical home, to the more straightforward, such as the implementation of structured documentation through an EMR template. Although interventions were in most

CRediT Authorship Contributions

David I. Fudman, MD (Conceptualization: Lead; Data curation: Lead; Formal analysis: Lead; Methodology: Equal; Writing – original draft: Lead; Writing – review & editing: Equal)

Andrea Escala Perez-Reyes (Data curation: Equal; Formal analysis: Supporting; Writing – original draft: Supporting; Writing – review & editing: Equal)

Blake A. Niccum (Data curation: Supporting; Writing – review & editing: Equal)

Gil Y. Melmed (Formal analysis: Supporting; Writing – review & editing: Equal)

Hamed Khalili

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    • Conflicts of interest These authors report the following: Dr Fudman reports serving as a consultant for Pfizer. Dr Melmed reports consulting for AbbVie, Arena, Boehringer-Ingelheim, Bristol-Meyers Squibb/Celgene, Entasis, GlaxoSmith Kline, Janssen, Medtronic, Pfizer, Samsung Bioepis, Takeda, and Techlab. Dr Khalili reports serving as a consultant for Takeda and AbbVie and receiving grant support from Takeda and Pfizer. The remaining authors disclose no conflicts.

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