Evaluating Appropriateness of Treatment for Crohn’s Disease: Feasibility of an Explicit Approach

Abstract

Background: Situations where practical therapeutic decisions differ from guidelines in the management of patients with Crohn’s disease (CD) have been described through opinion surveys. The feasibility of actually documenting these situations using an explicit approach has not been examined. Objective: The aim of this study was to evaluate the feasibility of a retrospective application of appropriateness criteria to a population of CD patients. Methods: Medical records of a cohort of patients diagnosed with CD were systematically reviewed. We used appropriateness criteria for treatment of CD that had been developed by the European Panel on the Appropriateness of Crohn’s Disease Therapy (EPACT). First we evaluated the level of precision of the elements abstracted from medical records needed in order to be able to apply these criteria. We then assessed the appropriateness of treatment for different CD categories. Only participants with at least one physician encounter during the preceding 6 months were included. Results: 260 patient medical records were reviewed on site at 22 gastroenterologists’ offices over a 2-month period in 2005. 116 (44%) patients were excluded because they had not had at least one medical visit at their referred gastroenterologist during the preceding 6 months. Medical records for 8 additional patients (3%) were not accessible. 136 (53%) medical records including 148 encounters were available for analysis. Overall, elements necessary to determine the appropriateness of treatment were available in 94% (139/148) of encounters. These elements were available in more than 90% of cases for all CD categories except for mild-moderate luminal active CD where 66% were available. Among those with all necessary elements available, 18% of treatments were judged as appropriate, 29% inappropriate, 38% uncertain according to the EPACT criteria, and for the other 15%, appropriateness had not been rated by the EPACT panel. Conclusions: The information necessary to assess the appropriateness of treatment of major types of CD was generally both present and precise in medical records. Therefore, in addition to the intended prospective use of these criteria, retrospective evaluation of the appropriateness of CD treatment using medical records is also feasible with the EPACT criteria.

Appropriateness of Crohn’s Disease Therapy in Gastroenterological Rehabilitation

“…This finding provides independent support of an earlier retrospective, multicenter, population-based study conducted by EPACT members, who proved the feasibility of the EPACT criteria in medical records of gastroenterologist offices [5]. In contrast to that study, the luminal, fistulizing and fibrostenotic types of CD manifestation were equally represented in our patients (table 1).…”

“…This was considerably less than the 43% found by Guessous et al [5] in their 7 patients with steroid-dependent or -refractory CD. However, this group rated the appropriateness of treatments irrespective of doses given.…”

“…In contrast to that study, the luminal, fistulizing and fibrostenotic types of CD manifestation were equally represented in our patients (table 1). In this sense, we present the first evidence that meaningful application of the EPACT website may not be restricted to luminal CD, which prevails in gastroenterologist offices [5]. …”

“…Although the criteria were designed to be used prospectively, we were interested in evaluating the appropriateness of care in rehabilitation at baseline, retrospectively, using rehabilitation medical records. This kind of approach has been successful in a retrospective feasibility study by members of the EPACT panel in CD patients from gastroenterologist offices [5]. Therefore, we analyzed the 1-year patient charts from our inpatient rehabilitation center.…”

EPACT II: Project and Methods

“…The criteria established then have been presented at various national and international gastroenterology meetings [43,44,45,46], published in the medical literature [47] and are available on the Internet (www.epact.ch). The feasibility of a retrospective application of these appropriateness criteria to a population of CD patients was confirmed in a local cohort of patients [48] and in a European population-based inception cohort (EC-IBD) [49, 50]. As the previous version of these criteria was the first attempt to systematically develop detailed, explicit criteria for the appropriateness of treatment of CD, it became rapidly apparent that some of the criteria were impracticable to implement or had become outdated by recent therapeutic advances.…”