Assessment of steroid use as a key performance indicator in inflammatory bowel disease—analysis of data from 2385 UK patients

Abstract

Summary Background Patients with IBD are at risk of excess corticosteroids. Aims To assess steroid excess in a large IBD cohort and test associations with quality improvement and prescribing. Methods Steroid exposure was recorded for outpatients attending 19 centres and associated factors analysed. Measures taken to avoid excess were assessed. Results Of 2385 patients, 28% received steroids in the preceding 12 months. 14.8% had steroid excess or dependency. Steroid use was significantly lower at ‘intervention centres’ which participated in a quality improvement programme (exposure: 23.8% vs 31.0%, P < .001; excess 11.5% vs 17.1%, P < .001). At intervention centres, steroid use fell from 2015 to 2017 (steroid exposure 30.0%‐23.8%, P = .003; steroid excess 13.8%‐11.5%, P = .17). Steroid excess was judged avoidable in 50.7%. Factors independently associated with reduced steroid excess in Crohn's disease included maintenance with anti‐TNF agents (OR 0.61 [95% CI 0.24‐0.95]), treatment in a centre with a multi‐disciplinary team (OR 0.54 [95% CI 0.20‐0.86]) and treatment at an intervention centre (OR 0.72 [95% CI 0.46‐0.97]). Treatment with 5‐ASA in CD was associated with higher rates of steroid excess (OR 1.72 [95% CI 1.24‐2.09]). In ulcerative colitis (UC), thiopurine monotherapy was associated with steroid excess (OR 1.97 [95% CI 1.19‐3.01]) and treatment at an intervention centre with less steroid excess (OR 0.72 [95% CI 0.45‐0.95]). Conclusions This study validates steroid assessment as a meaningful quality measure and provides a benchmark for this performance indicator in a large cohort. A programme of quality improvement was associated with lower steroid use.

Editorial: determining disability in IBD – ‘See(k) and you shall find’

“…Future studies should explore the determinants of disability even in wider population-based cohorts, wherein the hidden burden of 'under-treated' disease as indeed steroid dependency arguably also exists. 9 Furthermore, the potential for the disk to track changes in disease burden over time, setting and 're-setting' short-and longterm goals, impact of care pathways and therapeutic strategies on disease course should also be explored.…”

“…That said, the linearity of correlation between IBD‐disk scores has been assessed previously by the authors against quality of life and disease activity scores 6,7 Real‐time assessment may unmask functional from inflammatory drivers, bolstering future potential for the IBD‐disk to analyse these psychological and somatic co‐morbidities. Future studies should explore the determinants of disability even in wider population‐based cohorts, wherein the hidden burden of ‘under‐treated’ disease as indeed steroid dependency arguably also exists 9 . Furthermore, the potential for the disk to track changes in disease burden over time, setting and ‘re‐setting’ short‐ and long‐term goals, impact of care pathways and therapeutic strategies on disease course should also be explored.…”

Common mistakes with steroids

“…Dedicated IBD clinics, telephone helplines, rapid access clinics, and multidisciplinary teams can reduce the excess use of corticosteroids. 3,4 It is also important to educate and engage patients and general practitioners about corticosteroid use in IBD care. Further, patients must be involved in the treatment decision-making process allowing their key concerns and expectations to be heard.…”

“…2 Recent studies have shown that 30-50% of IBD patients continue to be exposed to corticosteroids each year, with 10-20% exposed to excess corticosteroids, which are potentially avoidable in around half of these cases. 3,4 Why then is corticosteroid misuse still a problem? Conventional corticosteroids are effective, inexpensive, widely available, and easy to administer.…”

What is the Real Impact of Corticosteroids in the Contemporary Treatment of Crohn’s Disease?

“…Alarming, roughly half of these patients were deemed to have inappropriate steroid dependency or excess. 6 In a recent review covering the historical role and contemporary use of corticosteroids in IBD, Dorrington et al 7 discuss health care and patient-level factors associated with the risk of corticosteroid exposure. Logistical and financial barriers for rapid access to some steroidsparing therapies, and a lack of confidence in the management of steroid-sparing agents, particularly in primary care, are factors often associated with the risk of steroid exposure.…”