Improving treatment of patients with inflammatory bowel diseases: a controlled trial of a multifaceted intervention in two German cities
Many recommendations from clinical practice guidelines are not implemented. We aimed to develop and evaluate a multifaceted strategy for the implementation of guidelines for Crohn’s disease (CD) and ulcerative colitis (UC).
In the intervention region (Berlin, Germany), a continuing medical education course was held, brief guidelines for practice were distributed to all family physicians and gastroenterologists, and patient guidelines were distributed to all surveyed patients. Educational outreach visits with local opinion leaders were also conducted. No specific interventions were performed in the control region (Hamburg, Germany). Prior to the intervention and 1 year later, 1900 members of three statutory sickness funds were asked about their treatment according to guidelines with (1) long-term aminosalicylates and (2) immunosuppressants, (3) whether they took long-term glucocorticoids for maintenance of remission, (4) if they smoked, in CD patients, and (5) about the surveillance colonoscopies, in UC patients.
Response rate after implementation was 20.1%. Responders differed between intervention and control region by age and by distribution between patients with UC or CD. After 1 year, more patients were treated according to clinical practice guidelines in the control region than in the intervention region. More patients in the intervention region took immunosuppressants after 1 year, and fewer had a surveillance colonoscopy. However, no before–after comparison was statistically significant.
This implementation strategy of UC and CD guidelines did not result in a statistically significant effect. Future implementation of guidelines for inflammatory bowel disease might need thorough evaluation of barriers and the support of theory-based concepts.
KeywordsInflammatory bowel diseases Guideline implementation Controlled trial Quality improvement
We gratefully acknowledge the support of three German statutory sickness funds, the AOK Nordost (Katrin Peise), TK (Christine Vietor), and the AOK Rheinland/Hamburg (Markus Feger), as well as Annegret Schönberg for secretarial assistance and Mary Louise Grossman for English language support. This manuscript is dedicated to the memory of Wolfgang Höhne (1953–2012) and Martin Zeitz (1950–2013).
This study was funded by the German Federal Ministry of Education and Research (Bundesministerium für Bildung und Forschung), through the Kompetenznetz Entzündliche Darmerkrankungen (grant number 01 GI 0486).
Compliance with ethical standards
Conflict of interest
J.C.P. served as a consultant for MSD, Pfizer, Takeda, and Biogen and received lecture fees from Vifor, Falk, Janssen, Abbvie, Pfizer, Vifor, MSD, and Takeda. B.S. received a research grant from Pfizer, served as consultant for Falk, Janssen, MSD, Abbvie, Celgene, Lilly, Takeda, Pfizer, and Hospira and received lecture fees from Abbvie, Celgene, Falk, Ferring, Janssen, MSD, Merck, and Takeda; all funds were transferred to the Charité - Universitätsmedizin Berlin, Germany. J.C.H. served as consultant for Amgen, Astra, Falk, Hexal, Janssen, Pfizer, Steigerwald, and Takeda, and received lecture fees from Falk, Janssen, MSD, Pfizer, and Takeda.
All procedures performed in this study were in accordance with ethical standards of the institutional research committee (approval number EA4/092/09) and with the 1964 Helsinki declaration and its later amendments. All patient-related data were anonymized after open questions had been resolved in responders who provided contact information. The local data protection commissioner approved the study protocol.
Informed consent was assumed if patients sent in their questionnaire.
- 3.Chauhan BF, Jeyaraman MM, Mann AS, Lys J, Skidmore B, Sibley KM, Abou-Setta A, Zarychanksi R (2017) Behavior change interventions and policies influencing primary healthcare professionals’ practice—an overview of reviews. Implement Sci IS 12:3. https://doi.org/10.1186/s13012-016-0538-8 CrossRefGoogle Scholar
- 5.Kredel LI, Schneidereit O, Hoffmann JC, Siegmund B, Preiß JC (2018) Guideline recommendations for treatment of patients with inflammatory bowel diseases are not implemented in clinical practice—results of a non-representative survey. Int J Color Dis 34:431–440. https://doi.org/10.1007/s00384-018-3215-3 CrossRefGoogle Scholar
- 7.Walsh AJ, Weltman M, Burger D, Vivekanandarajah S, Connor S, Howlett M, Radford-Smith G, Selby W, Veillard AS, Grimm MC, Travis SPL, Lawrance IC (2013) Implementing guidelines on the prevention of opportunistic infections in inflammatory bowel disease. J Crohns Colitis 7:e449–e456. https://doi.org/10.1016/j.crohns.2013.02.019 CrossRefGoogle Scholar
- 9.Greene L, Moreo K (2015) Quality improvement education to improve performance on ulcerative colitis quality measures and care processes aligned with national quality strategy priorities. BMJ Qual Improv Rep 4. https://doi.org/10.1136/bmjquality.u208829.w3554
- 11.Christensen KR, Steenholdt C, Buhl SS, Ainsworth MA, Thomsen OØ, Brynskov J (2015) Systematic information to health-care professionals about vaccination guidelines improves adherence in patients with inflammatory bowel disease in anti-TNFα therapy. Am J Gastroenterol 110:1526–1532. https://doi.org/10.1038/ajg.2015.162 CrossRefGoogle Scholar
- 13.Amelung V, Wolf S, Hildebrandt H (2012) Integrated care in Germany—a stony but necessary road! Int J Integr Care 12. https://doi.org/10.5334/ijic.853
- 15.Stange EF, Schreiber S, Fölsch UR, von Herbay A, Schölmerich J, Hoffmann J, Zeitz M, Fleig WE, Buhr HJ, Kroesen AJ, Moser G, Matthes H, Adler G, Reinshagen M, Stein J (2003) Diagnostik und Therapie des M. Crohn—Ergebnisse einer evidenzbasierten Konsensuskonferenz der Deutschen Gesellschaft für Verdauungs-und Stoffwechselkrankheiten. Z Gastroenterol 41:19–20. https://doi.org/10.1055/s-2003-36661
- 16.Hoffmann JC, Zeitz M, Bischoff SC, Brambs HJ, Bruch HP, Buhr HJ, Dignaß A, Fischer I, Fleig W, Fölsch UR, Herrlinger K, Höhne W, Jantschek G, Kaltz B, Keller KM, Knebel U, Kroesen AJ, Kruis W, Matthes H, Moser G, Mundt S, Pox C, Reinshagen M, Reißmann A, Riemann J, Rogler G, Schmiegel W, Schölmerich J, Schreiber S, Schwandner O, Selbmann HK, Stange EF, Utzig M, Wittekind C (2004) Diagnostik und Therapie der Colitis Ulcerosa: Ergebnisse einer evidenzbasierten Konsensuskonferenz der Deutschen Gesellschaft für Verdauungs- und Stoffwechselerkrankungen zusammen mit dem Kompetenznetz chronisch entzündliche Darmerkrankungen. Z Gastroenterol 42:979–983. https://doi.org/10.1055/s-2004-813510 CrossRefGoogle Scholar
- 17.Hiss RG, Macdonald R, David WR (1978) Identification of physician educational influentials (EI’s) in small community hospitals. Annu Conf Res Med Educ 17:283–288Google Scholar
- 18.Münch C, Gottschall M, Hübsch G, Köberlein-Neu J, Schübel J, Bergmann A, Voigt K (2016) Quality of documented diagnosis in primary care—an analysis using the example of thyroid disorders. Z Für Evidenz Fortbild Qual Im Gesundheitswesen 115:56–62. https://doi.org/10.1016/j.zefq.2016.03.016 CrossRefGoogle Scholar
- 20.O’Brien MA, Rogers S, Jamtvedt G et al (2007) Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database Syst Rev:CD000409. https://doi.org/10.1002/14651858.CD000409.pub2
- 21.Forsetlund L, Bjørndal A, Rashidian A et al (2009) Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database Syst Rev:CD003030. https://doi.org/10.1002/14651858.CD003030.pub2
- 22.Flodgren G, Parmelli E, Doumit G, Gattellari M, O'Brien MA, Grimshaw J, Eccles MP, Cochrane Effective Practice and Organisation of Care Group (2011) Local opinion leaders: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD000125.pub4
- 23.Flodgren G, Hall AM, Goulding L, Eccles MP, Grimshaw JM, Leng GC, Shepperd S, Cochrane Effective Practice and Organisation of Care Group (2016) Tools developed and disseminated by guideline producers to promote the uptake of their guidelines. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD010669.pub2
- 24.Fønhus MS, Dalsbø TK, Johansen M, Fretheim A, Skirbekk H, Flottorp SA, Cochrane Effective Practice and Organisation of Care Group (2018) Patient-mediated interventions to improve professional practice. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD012472.pub2
- 25.Melmed GY, Siegel CA, Spiegel BM, Allen JI, Cima R, Colombel JF, Dassopoulos T, Denson LA, Dudley-Brown S, Garb A, Hanauer SB, Kappelman MD, Lewis JD, Lynch I, Moynihan A, Rubin DT, Sartor RB, Schwartz RM, Wolf DC, Ullman TA (2013) Quality indicators for inflammatory bowel disease: development of process and outcome measures. Inflamm Bowel Dis 19:662–668. https://doi.org/10.1097/mib.0b013e31828278a2 CrossRefGoogle Scholar
- 26.ICHOM | inflammatory bowel disease standard set | measuring outcomes. In: ICHOM—Int. Consort Health Outcomes Meas https://www.ichom.org/medical-conditions/inflammatory-bowel-disease/. Accessed 2 Dec 2018
- 27.Fischer F, Lange K, Klose K, Greiner W, Kraemer A (2016) Barriers and strategies in guideline implementation—a scoping review. Healthcare 4. https://doi.org/10.3390/healthcare4030036