Improving outcome of Inflammatory Bowel Disease in children
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1 Improving outcome of Inflammatory Bowel Disease in children Dinesh Pashankar, MD Pediatric Gastroenterologist Director- Pediatric IBD program Yale University School of Medicine Pediatric Gastroenterology Conference,14 June 2016, Philadelphia
2 Yale New Haven Hospital
3 Objectives To discuss Features of IBD Therapy and Advances in IBD Quality Improvement Multicenter approach Quality Improvement at Yale
4 IBD in children Chronic inflammation of bowel Ulcerative colitis Colon involvement only Crohn s disease Entire gastrointestinal tract
5 Clinical Features
6 Crohn s disease Presentation Symptoms* Abdominal pain Diarrhea Bloody stools Weight loss Mouth ulcers Perianal lesions
7 Ulcerative colitis Presentation Symptoms* Diarrhea Abdominal pain Rectal bleeding Nocturnal diarrhea Weight loss
8 Nutritional deficiency Poor weight gain* Anemia Vitamin deficiency Iron deficiency B vitamins, vitamin D Hypoproteinemia
9 Impaired Linear Growth* Patients % Occurrence Pediatric IBD 35 Prepubertal CD Children with UC 6 12
10 IBD course Remission * Lack of clinical symptoms and good growth Relapses Flare with clinical symptoms and growth failure
11 Treatment
12 5 ASA / Mesalamine Steroids Immunomodulators Biologics Nutritional therapy Surgery Treatment options
13 5-ASA- Mesalamine Topical anti-inflammatory Oral /Rectal Useful for mild/moderate disease Used for long term Adverse effects mild Rare diarrhea, rash, renal toxicity Effective dose 30 to 70 mg/kg/day
14 Steroids Prednisone Oral/ iv Strong anti-inflammatory action Used for acute relapses Taper over few days Adverse effects Acne, cushingoid features, hyperglycemia, growth failure, infection, bone Avoid long-term use*
15 Immunomodulators 6-mercaptopurine /Azathioprine Methotrexate Indications Moderate/severe disease Prevention of loss of response to biologics Prevention of post-operative recurrence
16 Adverse effects 6 Mercaptopurine Myelosuppression:(5-10%) severe (< 2%) Hepatotoxicity (10-15%) Pancreatitis (< 5%) Rare malignancy- Rare lymphoma cases reported. Methotrexate Nausea Hepatotoxicity, Pulmonary toxicity rare Teratogenic effects Possible malignancy
17 Immunomodulators Dose and monitoring important 6-Mercaptopurine (6-MP) mg/kg/day po * Azathioprine mg/kg/day po Methotrexate 0.4 mg/kg sc/im or po once per week*
18 Biologic Therapy
19 Biologic Therapy for Crohn s Disease Anti-TNF agents Infliximab (Remicade ) chimeric mab Adalimumab (Humira ) humanized mab Combination (Biologics +immunomodulator) therapy More effective over long-term
20 Infliximab (Remicade) IV infusion over 2 hours Pre-medications 5 to 10 mg/kg dose* Given 4 to 8 weekly Very effective
21 Biologic therapy Adverse effects Hypersensitivity reactions Infection (TB) Loss of response Testing for TB necessary prior to initiation of biologics* Dosing of doses important
22 Improving Outcomes Advances in therapy QI principles + same therapy
23 Advances in IBD therapy Combination therapy high efficacy Anti-TNF therapy monitoring New agents Enteral Nutrition
24 Advances in IBD therapy Combination therapy Sonic study 508 adults Well designed study Infliximab, Azathioprine, Combination groups Combo > Infliximab> Aza Columbel, NEJM 2010 Recent evidence addition of methotrexate
25 Advances in IBD therapy Monitoring Ant-TNF therapy Single center Ped study 72 patients on infliximab had 191 levels 34% - subtherapeutic intensification Adjustment to achieve levels Improvement in clinical remission Minar P, JPGN, 2016
26 Advances in IBD therapy New Agents Vedolizumab Anti-integrin antibody Ustekinumab Interleukin antibody Tofaticinib JAK inhibitor
27 Advances in IBD therapy Enteral Nutrition Common in Euprope, other countries Comparison of Exclusive enteral nutrition with steroids Similar efficacy Less side effects Day, Dig Dis Sci 2015 Addition of nutrition beneficial
28 QI principals
29 IBD Chronic Disease Model Life-long disease Relapses and Remission Growth issues Choice of multiple medications Adverse effects Regular follow up
30 IBD Treatment Aim Keep patient in remission Remission steroid free and long-term Achieve satisfactory nutrition and growth status Appropriate use of medications
31 Quality Improvement Achieving outcome using consistent evidence based diagnostic and treatment guidelines Measuring outcome and ongoing continuous quality improvement to improve outcome
32 QI Principal We can not improve what we can not measure!
33 Yale Pediatric IBD Program Clinical Care Research Education IBD Program QI Patient Support
34 QI-Improvecarenow Multicenter, international QI project Improve care for children with IBD 87 centers (2 in UK) 24,000 IBD patients Database in Cincinnati
35 What do we do Model care guidelines Guidelines on diagnosis, therapy, Medication dosing, nutrition and growth monitoring
36 What do we do Pre-visit Planning Weekly meeting Data entry at every patient visit Population Management monthly meeting PDSA cycle
37 Data In God we trust. For everything else Show me the data!!!
38 Results Export Center Data To Excel Dashboard With Sparkline Measure Group Clinical Measures All Center Measures - Small Multiples Graphs All Measures Per Center - Small Multiples Graphs All Centers Performance Report Gap Analysis Report Sub Group Measure Title Network Target Clinical Remission Adequate Nutrition and Growth Model Classification Model Treatment All Graphs Per Center Report >=75% cohort Teams' Performance Team's Performance Percent of patients in remission Percent of patients with prednisone-free remission Percent of patients with sustained remission Percent of patients not taking prednisone Percent of patients with satisfactory nutritional status Percent of patients with at risk of nutritional failure 8 10 Percent of patients in nutritional failure 1 1 Percent of patients with satisfactory growth status Percent of patients with at risk of growth failure 5 14 Percent of patients in growth failure 2 0 Percent of visits with a complete bundle Percent of patients with a documented visit within the last 200 days Percent of patients whose dose of thiopurine is at least the dose recommended in the ICN Model Care Guidelines Percent of Patients where the dose of infliximab is at least 4.5 mg/kg Percent of Patients where the dose of methotrexate is at least 10 mg/m2 or 15 mg/wk Data Quality Percent of population registered AND active in registry Percent of actual visits recorded in registry 74 0 Percent of visits with all critical data recorded Percent of visits meeting the consistency bundle Percent of active patients in registry with visit recorded in last 13 months Was there at least one hospital discharge within the last 90 days? Key: At or above Network Target Scoring below the Cohort Team Performance and Network Target
39 Clinical remission Clinical Measures
40 Prednisone-free remission Clinical Measures
41 Not taking prednisone
42 Sustained Remission Clinical Measures
43 Nutritional status Clinical Measures
44 Growth status Clinical Measures
45 Completeness of bundle Clinical Measures
46 Our QI projects Optimal dose of mesalamine in children with IBD Checking vitamin D status in children with IBD
47 QI principal - PDSA
48 07/22/13 (n=08) 07/29/13 (n=05) 08/05/13 (n=08) 08/12/13 (n=05) 08/19/13 (n=05) 08/26/13 (n=08) 09/02/13 (n=02) 09/09/13 (n=05) 09/16/13 (n=01) 09/30/13 (n=02) 10/07/13 (n=06) Weekly Average Percent Mesalamine- dosing By September 2013, 90% of IBD patients will be on an adequate dose of mesalamine (>30 mg/kg/day) (PDSA) (PDSA) Weeks Weekly Average (%) Median Goals
49 Percentage of Pt who have had a Vit D level drawn 02/22/15 (n=110) 03/01/15 (n=110) 03/08/15 (n=110) 03/15/15 (n=110) 03/22/15 (n=110) 03/29/15 (n=110) 04/05/15 (n=110) 04/12/15 (n=110) 04/19/15 (n=110) 04/26/15 (n=110) 05/03/15 (n=110) 05/10/15 (n=110) 05/17/15 (n=110) 05/24/15 (n=110) 05/31/15 (n=110) 06/07/15 (n=110) 06/14/15 6/21/20105 Vitamin D level check In Spring 2015, 90% of patients will have Vitamin D levels checked PDSA 10 0 Week of Visit Monthly Averages Median Goal (90)
50 Quality Improvement Quality Patient Care Benefits patients Improving outcome Integral part of health care Govt programs and insurers demand P4P Pay for performance
51 Acknowledgement YNHCH & Yale Pediatrics Yale Pediatric IBD Team Patients and families
52 Yale Pediatric IBD Team Director- Michael Caty & Dinesh Pashankar Nurse Alicia Tirloni Dietician Susann Boroczky Social Worker Ellen Doram Gastroenterologists- Uma Phatak, Anthony Porto, Arik Alper Fellows- Jazmin Foglio, Madhura Phadke,Leina Alrabadi
53 Thank You
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The following slides are provided as presented by the author during the live educa7onal ac7vity and are intended for reference purposes only. If you have any ques7ons, please contact Imedex via email at:
Identifying and Managing Patients with IBD at Risk for Progressive Disease
Transcript Details This is a transcript of a continuing medical education (CME) activity accessible on the ReachMD network. Additional media formats for the activity and full activity details (including
Fistulizing Crohn s Disease: The Aggressive Approach
Fistulizing Crohn s Disease: The Aggressive Approach Bruce E. Sands, MD, MS MGH Crohn s and Colitis Center and Gastrointestinal Unit Massachusetts General Hospital Boston, USA Case Presentation: Summary
Update on Biologics in Ulcerative Colitis. Scott Plevy, MD University of North Carolina Chapel Hill, NC
Update on Biologics in Ulcerative Colitis Scott Plevy, MD University of North Carolina Chapel Hill, NC Objectives Discuss the latest advances in the pharmacologic management of ulcerative colitis Describe
Moderately to severely active ulcerative colitis
Adalimumab in the Treatment of Moderate-to-Severe Ulcerative Colitis: ULTRA 2 Trial Results Sandborn WJ, van Assche G, Reinisch W, et al. Adalimumab induces and maintains clinical remission in patients
ImproveCareNow Collaborative Chronic Care Network
ImproveCareNow Collaborative Chronic Care Network Peter A. Margolis, MD PhD Richard B. Colletti, MD NIH NIDDK R01DK085719 AHRQ R01HS020024 AHRQ U18HS016957 ImproveCareNow Network Care Centers .5 x.5 =.25
Optimizing Immunomodulators and
Optimizing Immunomodulators and Biologics i in Inflammatory Bowel Disease Sunanda Kane, MD, MSPH, FACG Professor of Medicine Division of Gastroenterology and Hepatology Mayo Clinic Rochester, Minnesota,
OUNCE OF PREVENTION WORTH A POUND OF CURE
Healthcare maintenance in the patient with Inflammatory Bowel Disease. OUNCE OF PREVENTION WORTH A POUND OF CURE Your gastroenterologist is NOT your primary care physician Your gastroenterologist is NOT
Crohn's Disease. The What, When, and Why of Treatment
Crohn's Disease The What, When, and Why of Treatment Gary R. Lichtenstein, MD, FACG Professor of Medicine Director, Inflammatory Bowel Disease Program University of Pennsylvania Philadelphia, PA In my
Choosing and Positioning Biologic Therapy for Crohn s Disease: (Still) Looking for the Crystal Ball
Choosing and Positioning Biologic Therapy for Crohn s Disease: (Still) Looking for the Crystal Ball Siddharth Singh, MD, MS Assistant Professor of Medicine Division of Gastroenterology Division of Biomedical
The National Association of Crohn s and Colitis of Trinidad and Tobago CROHN S DISEASE AND ULCERATIVE COLITIS GENERAL PATIENT INFORMATION
The National Association of Crohn s and Colitis of Trinidad and Tobago CROHN S DISEASE AND ULCERATIVE COLITIS GENERAL PATIENT INFORMATION You are reading this pamphlet because you or someone you known
Circle Yes or No Y N. [If no, skip to question 7.] 2. Does the patient have a diagnosis of ulcerative colitis? Y N. [If no, skip to question 4.
![Circle Yes or No Y N. [If no, skip to question 7.] 2. Does the patient have a diagnosis of ulcerative colitis? Y N. [If no, skip to question 4.](/thumbs/85/91758188.jpg "Circle Yes or No Y N. [If no, skip to question 7.] 2. Does the patient have a diagnosis of ulcerative colitis? Y N. [If no, skip to question 4.")
06/01/2016 Prior Authorization AETA BETTER HEALTH OF MICHIGA (MEDICAID) Humira (MI88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
Pediatric Inflammatory Bowel Disease in Less Than 30 Minutes
Pediatric Inflammatory Bowel Disease in Less Than 30 Minutes Shervin Rabizadeh, M.D., M.B.A. Director, Pediatric Gastroenterology and Pediatric Inflammatory Bowel Disease Program Cedars-Sinai Medical Center