Therapy of Mild to Moderate Luminal Crohn’s Disease

Michetti, Pierre; Juillerat, Pascal; Mottet, Christian; Gonvers, Jean‐Jacques; Burnand, Bernard; Vader, John‐Paul; Froehlich, Florian; Felley, Christian

doi:10.1159/000083866

Cited by 10 publications

(6 citation statements)

References 58 publications

(38 reference statements)

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“…The precision of each CD category was therefore evaluated by documenting criteria included in the definitions proposed for broad clinical categories of CD [6,7,8,9,10,11,12]. If the medical record reported at least one of the criteria from the definitions and included supporting documentation, this element was considered as ‘present and precise’.…”

Section: Methodsmentioning

confidence: 99%

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

et al. 2007

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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.

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Section: Methodsmentioning

confidence: 99%

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

et al. 2007

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“…This was subsequently expanded manually to include references contained in review articles and references suggested by the panelists. The selected studies were arranged hierarchically according to evidence-based medicine criteria and commented on in a series of review articles [2,3,4,5,6,7,8,9,10,11]. References to the primary studies are to be found in those articles.…”

Section: Methodsmentioning

confidence: 99%

Appropriate Treatment for Crohn’s Disease: Methodology and Summary Results of a Multidisciplinary International Expert Panel Approach – EPACT

et al. 2006

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Background/Aims: For many therapeutic decisions in Crohn’s disease (CD), high-grade evidence is lacking. To assist clinical decision-making, explicit panel-based appropriateness criteria were developed by an international, multidisciplinary expert panel. Methods: 10 gastroenterologists, 3 surgeons and 2 general practitioners from 12 European countries assessed the appropriateness of therapy for CD using the RAND Appropriateness Method. Their assessment was based on the study of a recent literature review of the subject, combined with their own expert clinical judgment. Panelists rated clinical indications and treatment options using a 9-point scale (1 = extremely inappropriate; 9 = extremely appropriate). These scenarios were then discussed in detail at the panel meeting and re-rated. Median ratings and disagreement were used to aggregate ratings into three assessment categories: appropriate (A), uncertain (U) and inappropriate (I). Results: 569 specific indications were rated, dealing with 9 clinical presentations: mild/moderate luminal CD (n = 104), severe CD (n = 126), steroid-dependent CD (n = 25), steroid-refractory CD (n = 37), fistulizing CD (n = 49), fibrostenotic CD (n = 35), maintenance of medical remission of CD (n = 84), maintenance of surgical remission (n = 78), drug safety in pregnancy (n = 24) and use of infliximab (n = 7). Overall, 146 indications (26%) were judged appropriate, 129 (23%) uncertain and 294 (52%) inappropriate. Frank disagreement was low (14% overall) with the greatest disagreement (54% of scenarios) being observed for treatment of steroid-refractory disease. Conclusions: Detailed explicit appropriateness criteria for the appropriate use of therapy for CD were developed for the first time by a European expert panel. Disease location, severity and previous treatments were the main factors taken into account. User-friendly access to EPACT criteria is available via an Internet site, www.epact.ch, allowing prospective evaluation and improvement of appropriateness of current CD therapy.

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“…(C) The literature review that constitutes the background of the panel has been an update of previous reviews [25,26,27,28,29,30,31,32,33,34,35] and focuses on the available evidence for pharmaceuticals and other treatments that are commonly used and available to clinicians. The aim was to identify direct evidence for the efficacy of these therapies in a clinical situation where patients require a specific treatment for a variety of problems such as: an acute relapse of CD (chapter 2), steroid-dependent or refractory disease (chapter 3), symptomatic fistula(s) (chapter 4), intestinal stricture (chapter 5), the maintenance of a medically (chapter 6) or surgically induced remission (chapter 7), upper gastrointestinal symptoms (chapter 8), extraintestinal manifestations (chapter 9), and pregnancy (chapter 10).…”

Section: The Rammentioning

confidence: 99%

“…The distribution of these articles in the different chapters has been carried out as follows (one article can be part of several chapters): 20 articles for luminal CD, 6 articles for steroid-dependent or refractory CD, 9 articles for fistulizing CD, 4 articles for fibrostenotic CD, 8 articles for the maintenance of the medically induced remission of CD, 13 articles for the maintenance of the surgically induced remission of CD, 5 articles for extraintestinal manifestations of CD and 6 articles for the pregnancy and breastfeeding in patients with CD. A manual search has also been carried out by each first author of several review articles [26,27,28,29,30,31,32,33,34,35]. Once again, expert panelists are called upon to give their input to complete the updated review of the literature on CD therapy presented in this volume.…”

Section: Literature Search Strategymentioning

confidence: 99%

EPACT II: Project and Methods

Juillerat

Froehlich²,

Felley³

et al. 2007

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Building on the first European Panel on the Appropriateness of Crohn’s Disease Treatment (EPACT I) which was held in Lausanne at the beginning of March 2004, a new panel will be convened in Switzerland (EPACT II, November to December 2007) to update this work. A combined evidence- and panel-based method (RAND) will be applied to assess the appropriateness of therapy for Crohn’s disease (CD). In preparation for the meeting of experts, reviews of evidence-based literature were prepared for major clinical presentations of CD. During the meeting, an international multidis- ciplinary panel that includes gastroenterologists, surgeons and general practitioners weigh the strength of evidence and apply their clinical experience when assessing the appropriateness of therapy for 569 specific indications (clinical scenarios). This chapter describes in detail the process of updating the literature review and the systematic approach of the RAND Appropriateness Method used during the expert panel meeting.

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Therapy of Mild to Moderate Luminal Crohn’s Disease

Cited by 10 publications

References 58 publications

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

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

Appropriate Treatment for Crohn’s Disease: Methodology and Summary Results of a Multidisciplinary International Expert Panel Approach – EPACT

EPACT II: Project and Methods

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