Quality Improvement Initiatives for patients with Inflammatory Bowel Disease

20 September 2019

Dr Kevin Barrett, GP and RCGP and Crohn’s and Colitis UK Clinical Champion for Inflammatory Bowel Disease  

Consensus guidelines for Inflammatory Bowel Disease in adults Crohns Disease Flare Pathway Ulcerative Colitis Flare Pathway

Crohn’s Disease and Ulcerative Colitis have been thought to affect up to one in 210 patients in the UK, although this now seems likely to be an underestimate as research in Scotland in 2019 has found the prevalence to be one in 125.

Quality improvement (QI) activities designed by the RCGP can be applied to the treatment of this diverse group to improve prescribing, cancer surveillance and support for patients whose care can sometimes get lost in the gap between primary and secondary care.

There are several opportunities for quality improvement in primary care for patients with IBD:

  1. Steroid prescribing: There is evidence that some patients with Inflammatory Bowel Disease (IBD) are under- or over-prescribed steroids in primary care. The RCGP, Crohn’s & Colitis UK, the British Society of Gastroenterology (BSG), and the Primary Care Society for Gastroenterology have endorsed a set of flare pathways to help primary care identify and treat patients with IBD (see images). Steroid excess is associated with an increase in mortality. A QI initiative would be to set up a regular audit of patients with IBD and prescriptions for oral steroids.
  2. Osteoporosis prevention and management: Patients with IBD are at a greater risk of osteoporosis because of a combination of inflammation, dietary restriction, malabsorption and corticosteroid use. The BSG Consensus on the management of IBD in adults, launched in June 2019, contains a pathway that can be followed when prescribing steroids (see images). Education and audits can show whether this guidance is being followed in primary care.
  3.  Mental health: All patients with chronic inflammation are at greater risk of anxiety and depression. Screening questions can be used to identify patients in need of support so they can then be signposted or referred to Cognitive Behavioural Therapy, IAPT (Improving Access to Psychological Therapies) or voluntary support from organisations such as Crohns and Colitis UK and CICRA.
  4. Bowel cancer screening: Patients with IBD have a greater risk of colorectal cancer; typically, 18% risk 30 years after diagnosis. The 2019 BSG IBD Guidance states “IBD patients with colonic disease should be offered ileocolonoscopy eight years after symptom onset to screen for neoplasia, to determine disease extent and decide on the frequency of ongoing surveillance”. Patients may be lost to secondary care follow up, therefore a QI project could involve reviewing the notes of patients diagnosed eight or more years ago to see if they have had the appropriate screening.

As the number of patients with IBD is relatively small compared to those with other conditions, a pharmacist working across a primary care network could invite all patients with IBD for an annual health check to cover:

  • compliance with medication (as this can reduce the risk of developing colorectal cancer)
  • what to do in the event of a suspected flare
  • dietary advice
  • the benefits of physical activity for patients with IBD
  • contraception
  • fertility and pregnancy.

 The 2019 IBD Standards supports this work, and further guidance on all these areas can be found on the RCGP and Crohn’s & Colitis UK Inflammatory Bowel Disease Spotlight Project Toolkit. A 30-minute e-learning module provides further educational opportunity. Look out for the next EKU release which will cover Crohn’s and Colitis.

The IBD Spotlight Project has Regional Champions based in Bristol, London, Hertfordshire, Birmingham, Manchester, Cardiff, Gwynedd, and Scotland. Northern Ireland and the East of England are currently looking for Regional Champions. If you are interested, please get in touch with kevin.barrett@nhs.net, RCGP Clinical Champion for Inflammatory Bowel Disease.  

 

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