Division of Pediatric Gastroenterology, Department of Pediatrics, Emory University School of Medicine & Children's Healthcare of Atlanta, Atlanta, Georgia.
Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
Inflamm Bowel Dis. 2019 Jun 18;25(7):1208-1217. doi: 10.1093/ibd/izy363.
Variation in care is common in medical practice. Reducing variation in care is shown to improve quality and increase favorable outcomes in chronic diseases. We sought to identify factors associated with variation in care in children with newly diagnosed Crohn's disease (CD).
Prospectively collected data from a 28-site multicenter inception CD cohort were analyzed for variations in diagnostic modalities, treatment, and follow-up monitoring practices, along with complicated disease outcomes over 3 years in 1046 children. Generalized linear mixed effects models were used to investigate the intercenter variations in each outcome variable.
The mean age at diagnosis was 12 years, and 25.9% were nonwhite. The number of participants ranged from 5 to 112 per site. No variation existed in the initial diagnostic approach. When medication exposure was analyzed, steroid exposure varied from 28.6% to 96.9% (P < 0.01) within 90 days, but variation was not significant over a 3-year period (P = 0.13). Early anti-tumor necrosis factor (anti-TNF) exposure (within 90 days) varied from 2.1% to 65.7% (P < 0.01), but variation was not significant over a 3-year period (P > 0.99). Use of immunomodulators (IMs) varied among centers both within 90 days (P < 0.01) and during 3 years of follow-up (P < 0.01). A significant variation was seen at the geographic level with follow-up small bowel imaging and colonoscopy surveillance after initial therapy.
Intercenter variation in care was seen with the initial use of steroids and anti-TNF, but there was no difference in total 3-year exposure to these drugs. Variation in the initiation and long-term use of IMs was significant among sites, but further research with objective measures is needed to explain this variation of care. Small bowel imaging or repeat colonoscopy in CD patients was not uniformly performed across sites. As our data show the widespread existence of variation in care and disease monitoring at geographic levels among pediatric CD patients, future implementation of various practice strategies may help reduce the variation in care.
医疗实践中普遍存在护理差异。减少护理差异已被证明可提高慢性病的质量并增加有利的结果。我们试图确定与新诊断的克罗恩病（CD）患儿护理差异相关的因素。
对 28 个地点的多中心发病 CD 队列前瞻性收集的数据进行了分析，以确定诊断方式、治疗和随访监测实践的差异，以及 1046 名儿童 3 年内复杂疾病结局的差异。使用广义线性混合效应模型研究每个结局变量的中心间差异。
诊断时的平均年龄为 12 岁，25.9%为非白人。每个地点的参与者人数从 5 到 112 不等。初始诊断方法无差异。当分析药物暴露情况时，皮质类固醇暴露在 90 天内从 28.6%到 96.9%（P <0.01）变化，但在 3 年内无显著差异（P=0.13）。早期使用抗肿瘤坏死因子（anti-TNF）（90 天内）从 2.1%到 65.7%（P <0.01）变化，但在 3 年内无显著差异（P>0.99）。免疫调节剂（IMs）的使用在 90 天内（P <0.01）和 3 年随访期间（P <0.01）均存在中心间差异。在初始治疗后进行小肠成像和结肠镜检查监测方面，在地理水平上观察到显著差异。
在初始使用皮质类固醇和抗 TNF 时，护理差异明显，但在这 3 年中，这些药物的总暴露量没有差异。在各个地点之间，IMs 的起始和长期使用的差异显著，但需要进一步研究客观措施来解释这种护理差异。CD 患者的小肠成像或重复结肠镜检查并未在所有站点普遍进行。正如我们的数据所示，儿科 CD 患者在地理层面上的护理和疾病监测差异广泛存在，未来实施各种实践策略可能有助于减少护理差异。
