Physicians who care for patients with inflammatory bowel disease (IBD) must be aware of the unique health maintenance issues facing these patients in order to deliver appropriate medical care.1 Studies have shown that patients with IBD do not receive routine preventive care at the same rate as patients with other medical conditions.2 Recent data also suggests that the quality of care among patients admitted to the hospital with IBD is variable.3 It is crucial that as gastroenterologists we are familiar with the complex health maintenance issues that our IBD patients face and advise our colleagues in primary care.
“It is crucial that as gastroenterologists we are familiar with the complex health maintenance issues that our IBD patients face and advise our colleagues in primary care.”
In 2011, AGA released the Adult IBD Physician Performance Measures Set. These measures, updated in 2015, were designed to identify core areas for gastroenterologists to focus on to improve the quality of care delivered to patients. Five of the seven measures detailed in AGA’s document are specifically geared towards preventative health maintenance care in the IBD patient (Table 1).
The key measures include the use of corticosteroid sparing therapies in patients on steroid treatment and screening for osteoporosis in patients who have had a cumulative use of steroid therapy for more than three months. It is well accepted that steroid treatment in IBD patients can have significant health maintenance implications, as steroid use can lead to hypertension, osteoporosis and infectious complications, etc. We also monitor vitamin D status in our IBD patients and refer appropriate patients to their primary care provider for dual energy X-ray absorptiometry (DEXA) bone density scans. While monitoring vitamin D status is not an existing measure, we know that vitamin D sufficiency appears to be associated with better health outcomes in patients with IBD and therefore we consider this a health maintenance issue.
In addition to patients on steroid therapy, patients over the age of 60, post-menopausal patients, and patients with a history of low trauma fractures should be screened for osteoporosis. Patients with T-score of less than 1 should take vitamin D and calcium supplementation, and have these levels checked at regular intervals.
Patients with IBD are at increased risk for vaccine-preventable illnesses. Administering both the influenza and pneumococcal vaccinations to all patients with IBD is a key component to the preventative health care of IBD patients. Lastly, tobacco use should be addressed with patients at each visit and smoking cessation should be strongly encouraged.
The measures proposed by AGA also allow for tracking of practice patterns to facilitate quality improvement interventions, though the challenge of implementing these measures in a busy office practice may be difficult. We have found that the best time to discuss health maintenance issues with patients is during their initial visit.
This often allows time for vaccinations to be administered before patients start immunosuppressive therapy. In our practice, we store and administer the hepatitis A and B vaccines as well as pneumococcal vaccines (PCV13 – Prevnar 13© and PRSV 23 – Pneumovax23©) and the injectable flu vaccine. As these are inactivated vaccines, they can be administered to all IBD patients, including those on immunosuppressive therapy. We also recommend the live zoster vaccine for patients who are 50 and older, including those on thiopurines and methotrexate. Ongoing studies are addressing the safety of administering the zoster vaccine to patients on anti-tumor necrosis factor (anti-TNF) drugs. Additionally, patients on vedolizumab may receive the zoster vaccine. Finally, we recommend the HPV vaccine to our eligible male and female patients and refer them to either their primary care provider or, in women, their gynecologist, to receive this vaccine. Patients with IBD, regardless of medication use, also have an increased risk of developing melanoma.
Patients with IBD who are exposed to thiopurines have an increased risk of developing nonmelanoma skin cancer and anti-TNFs increase the risk of melanoma. We have identified several dermatologists in our practice interested in managing patients with IBD-related skin disorders who also see our IBD patients for skin cancer screening. We encourage our female patients, and in particular those on immunosuppressive agents or anti-TNFs, to see their primary care provider or gynecologist for regular Pap tests. Lastly, certain subsets of patients with long-standing and extensive ulcerative colitis and Crohn’s disease of the colon are at increased risk for developing colorectal cancer and practices must have processes in place to identify these patients and assure that they undergo appropriate screening tests and procedures.
Recently, studies detailing quality improvement interventions that increase gastroenterologists’ adherence to quality measures through systemic education and CME (Continuing Medical Education) have been reported.4-5 At our practice, we have implemented a quality improvement project to increase the vaccination rate for influenza and pneumococcal pneumonia in our IBD patient population.6 Our one-page handout assessed a patient’s vaccination status, provided educational information on vaccinations, and the opportunity to be vaccinated was offered to our IBD patients during their routine office appointments. We found that we were able to achieve a significant increase in vaccination rates with this simple intervention.
In other chronic diseases, we are beginning to see promising results in studies that look at text messaging as a means to provide patients with reminders to take their medications. However, studies are needed to determine if such modalities have a role in improving the care of patients with IBD. A key tenet of quality improvement is to measure your personal or practice performance. ImproveCareNow is a consortium of multiple pediatric GI practices that share data on the health of their patients. The organization has increased remission rates in pediatric IBD patients through collaborative data-sharing networks across patients, hospitals and providers while lowering costs, and provides a helpful model for other practices interested in forming similar consortiums.
Cornerstones Health has developed a valuable health maintenance checklist at www. cornerstoneshealth.org/checklist that allows both providers and patients to keep track of key health maintenance issues such as vaccines, bone health and cancer prevention online. And with the advent of electronic health records, gastroenterologists can embed health maintenance checklists directly into patients’ charts. In our practice, we have developed an IBD outpatient form in our electronic health record software, Epic, which populates the encounter with vaccination dates, important lab data and hepatitis A and B antibody status, allowing easy access to these data. The Crohn’s and Colitis Foundation of America is also developing an Epic IBD encounter form that will be available to sites using their software.
Despite many of these advancements and new techniques that we have listed above, more research is still needed to see if implementation of such technologies, screenings and informational methods can improve adherences to measures detailed by AGA, and ultimately improve the care we provide to our IBD patients.
Dr. Reich has no conflicts to disclose.
Dr. Wasan has no conflicts to disclose.
Dr. Farraye has no conflicts to disclose.
1. Reich JS, Farraye FA, Wasan SK. Preventative Care in the Patient with Inflammatory Bowel Disease: What Is New? Dig Dis Sci. 2016 Apr 9. [Epub ahead of print]
2. Selby L, Kane S, Wilson J, et al. Receipt of preventive health services by IBD patients is significantly lower than by primary care patients. Inflamm. Bowel Dis. 2008;14:253–8.
3. Lee, NS, Pola, S, Groessl, EJ, Rivera-Nieves, J,Ho, SB (2016). Opportunities for Improvement in the Care of Patients Hospitalized for Inflammatory Bowel Disease-Related Colitis. Dig. Dis. Sci. Article in Press
4. Christensen, KR, Steenholdt, C, Buhl, SS, Ainsworth, MA, Thomsen, OÃ˜, Brynskov, J (2015). Systematic Information to Health-Care Professionals about Vaccination Guidelines Improves Adherence in Patients With Inflammatory Bowel Disease in Anti-TNFÎ±Therapy. Am. J. Gastroenterol., 110, 11:1526-32.
5. Sapir, T, Moreo, K, Carter, JD, Greene, L, Patel, B, Higgins, PD (2016). Continuing Medical Education Improves Gastroenterologists’ Compliance with Inflammatory Bowel Disease Quality Measures. Dig. Dis. Sci. Article in Press
6. Reich JS, Miller HL, Wasan SK, Noronha A, Ardagna E, Sullivan K, Jacobson B, Farraye FA.Improving Influenza and Pneumococcal Vaccination Rates in Patients with Inflammatory Bowel Disease. Gastroenterol Hepatol (N Y). 2015: 11, 6:396-401
7. Adult inflammatory bowel disease physician performance measures set. [Internet]. Bethesda (MD): American Gastroenterological Association [cited 2011 Aug]. Available from: http://www.gastro.org/practice/ quality-initiatives/IBD_ Measures.pdf