Monitoring Enables Progress: A Nationwide Quality Improvement Program In Children With Crohn Disease

Objectives: In this quality improvement program, named quality in pediatric inflammatory bowel disease, we constructed a nation-wide platform that prospectively recorded clinically important quality indicators in pediatric inflammatory bowel diseases (PIBD), aiming at improving clinical management across the country.Methods: Representatives of all 21 PIBD facilities in Israel formed a Delphi group to select quality indicators (process and outcomes), recorded prospectively over 2 years in children with Crohn's disease 2-18 years of age seen in the outpatient clinics. Monthly anonymized reports were distributed to all centers, allowing comparison and improvement. Trends were analyzed using the Mann-Kendall test, reporting tau (tau) values.Results: The indicators of 3254 visits from 1709 patients were recorded from September 2017 to September 2019 (mean age 14.7 +/- 3.1 years, median disease duration 1.8 years (interquartile range 0.69-4.02)). An increase in three of five process indicators was demonstrated: obtaining drug levels of anti-tumor necrosis factor (TNF) (tau = 0.4; P = 0.005), utilization of fecal calprotectin (tau = 0.38; P= 0.008) and bone density testing (tau = 0.45; P= 0.002). Among outcome indicators, three of nine improved as measured during the preceding year: calprotectin <300 mu g/mg = 0.35; P=0.015), and "resolution of inflammation" defined as a composite of endoscopy, imaging and fecal calprotectin (tau = 0.39; P = 0.007). Endoscopic healing reached borderline significance (tau = 0.28; P=0.055). An increase in the use of biologics throughout the study was observed (tau = 0.47; P= 0.001) with a concurrent decrease in the use of immunomodulators (tau = -0.47; P= 0.001).Conclusions: Quality improvement nationwide programs can be implemented with limited resources while facilitating standardization of care, and may be associated with improvements in measured indicators.