Quality Improvement in Gastroenterology Clinical Practice

Rakhi Kheraj; Sumeet K. Tewani; Gyanprakash Ketwaroo; Daniel A. Leffler


Clin Gastroenterol Hepatol. 2012;10(12):1305-1314. 

In This Article

Inflammatory Bowel Disease

Bone mineral density (BMD) tests, vaccinations, and dysplasia screens are important components of quality outpatient care for patients with inflammatory bowel disease (IBD).

Osteoporosis and Osteopenia

Patients with IBD are at increased risk for developing osteoporosis and osteopenia; about 15% of patients with IBD also have osteoporosis.[26] Several risk factors for osteoporosis have been identified and include a course of steroid therapy longer than 3 months or recurring use of steroids, age >50 years, postmenopausal status, history of low-impact fracture, and hypogonadism. Using these risk factors to identify patients who should be tested for BMD led to the finding that 69% of patients with IBD were prescribed specific therapy.[27] Currently, the AGA recommends dual-energy x-ray absorptiometry screening for high-risk patients (grade D).[26] However, despite these recommendations and their validation in a prospective cohort, only 23% of patients with risk factors at a representative tertiary institution were tested.[28]


Although immunosuppressive agents have significantly improved medical management of Crohn's disease and ulcerative colitis, they increase the risk of infection, so vaccinations are important.[29,30] Appropriate routine vaccinations are recommended by the Advisory Committee for Immunization Practices (Table 1).[31,32] Live vaccines, such as varicella, generate concern among patients with IBD, who are likely to receive immunosuppressive therapy. Consideration of vaccination at initial visit could allow for safe vaccination before initiation of immunosuppressive therapy. Many common vaccines, such as hepatitis A virus, hepatitis B virus (HBV), pneumococcal, injectable influenza, and human papillomavirus, are recommended for individuals on or being considered for immunosuppressive regimens. Despite recommendations, vaccination of patients with IBD is underutilized in general practice.[30]

On the basis of major society guidelines, adequate bone health and infection prevention through appropriate testing and vaccination are considered important parts of outpatient IBD QI. An example of QI initiatives in these areas could include the following steps: (1) development of an evidence-based practice standard for BMD testing and vaccination in patients with IBD; (2) retrospective evaluation of appropriately tested or vaccinated patients; and (3) development or enhancement of a mechanism that increases rates of BMD testing or vaccination in appropriate individuals. Possibilities include patient-completed forms and templated notes in patients' charts to serve as reminders to ordering physicians. Potential initiatives include automated reminder letters for vaccinations, such as influenza, that are needed on a recurring basis. For BMD testing, patients could receive a standardized test referral when they check out from the clinic. QI initiatives should also include (4) a prospective audit of IBD patients to assess rates of appropriate vaccination or referral for BMD testing and (5) evaluations for any potential shortcomings of the system. After this step, healthcare workers should return to step 3.

Screening for Dysplasia

The risk of colorectal cancer and dysplasia is increased in patients with ulcerative and Crohn's colitis, compared with the general population. This risk of colorectal cancer is estimated to be 2% for patients who have had ulcerative colitis for 10 years or more and as high as 18% for those with the disease for 30 years.[33] To reduce the risk of colorectal cancer in patients with IBD, the AGA recommends that all patients undergo surveillance colonoscopy a maximum of 8 years after onset of IBD symptoms[34] (grade B*). Surveillance schedules can then be based on family history, extent and activity of disease, and the presence of primary sclerosing cholangitis or abnormal findings such as polyps and strictures.[19,35,36] The sensitivity of endoscopic screening for dysplasia can be increased by including chromoendoscopy, performance by an experienced endoscopist, and adequate sampling of the colon.[37] When dysplasia or cancer is found, it should be confirmed by a histology analysis by an expert gastrointestinal pathologist.[36,38]

An example of a QI initiative in dysplasia screening would involve the following steps: (1) establish an evidence-based practice guideline for dysplasia screening in patients with longstanding colitis; (2) evaluate the tests performed in a cohort of at-risk IBD patients to identify those who have been screened for dysplasia, have had an adequate number of biopsies analyzed, and those who are undergoing appropriate surveillance; (3) identify patient-based and system-based risk factors for insufficient dysplasia screening and develop a mechanism to improve screening by addressing these risk factors (possible approaches include sending reminder letters, which are generated at initial visit and at each procedure for surveillance colonoscopy and mailed before the suggested appointment); and (4) audit patients who are receiving dysplasia screening under the new quality intervention to evaluate any potential shortcomings and assure that the QI initiative has been modified appropriately.

Medications in Inflammatory Bowel Disease

Infliximab and other anti–tumor necrosis factor-alpha therapies increase the risk of infection and reactivation of tuberculosis (TB) and HBV.[39,40] The ACG therefore recommends routine testing for TB and HBV before anti–tumor necrosis factor therapy begins.[41] Although the rate of screening is increasing, there is a substantial need for QI efforts to improve these rates.[42]

Before patients are treated with 6-mercaptopurine or azathioprine, AGA guidelines recommend thiopurine methyltransferase testing by activity or genotype to identify patients at risk for developing severe bone marrow suppression (grade B).[43] Likewise, it is equally important to monitor patients while they are receiving therapy; systems to ensure appropriate interval laboratory tests and routine follow-up examinations could be included in QI plans.

An example of a QI project to promote the safe use of appropriate medications, such as infliximab, would involve the following steps: (1) an initial retrospective review of patients who are receiving infliximab to ensure documentation of appropriate tests for TB and HBV; (2) implementation of interventions to ensure that patients were tested for these diseases before therapy began (such as a checklist for the ordering physician or the pharmacist to confirm that tests for TB and HBV have been completed before they dispense infliximab); and (3) confirmation of the efficacy of the quality initiative via prospective audit of patients who are receiving infliximab and room for further modification of the initiative to achieve 100% compliance with prescreening for HBV and TB.