Variation in care in the management of children with Crohn's disease: Data from a multicenter inception cohort study

Chenthan Krishnakumar, Cortney R. Ballengee, Chunyan Liu, Mi Ok Kim, Susan S. Baker, Robert N. Baldassano, Stanley A. Cohen, Wallace V. Crandall, Lee A. Denson, Marla C. Dubinsky, Jonathan Evans, Ranjana Gokhale, Anne Griffiths, Stephen L. Guthery, Maria Oliva-Hemker, Melvin B. Heyman, David Keljo, Richard Kellermayer, Neal S. Leleiko, David R. MackJames F. Markowitz, Dedrick E. Moulton, Joshua D. Noe, Anthony R. Otley, Ashish S. Patel, Marian Pfefferkorn, Shervin Rabizadeh, Joel R. Rosh, Scott Snapper, Thomas D. Walters, David Ziring, Kajari Mondal, Michael D. Kappelman, Jeffrey S. Hyams, Subra Kugathasan

Research output: Contribution to journalArticle

Abstract

Background: 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). Methods: 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. Results: 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. Conclusions: 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.

Original languageEnglish (US)
Pages (from-to)1208-1217
Number of pages10
JournalInflammatory bowel diseases
Volume25
Issue number7
DOIs
StatePublished - Jun 18 2019

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Crohn Disease
Cohort Studies
Immunologic Factors
Colonoscopy
Steroids
Child Care
Chronic Disease
Therapeutics
Research
Pharmaceutical Preparations
Pediatric Crohn's disease

All Science Journal Classification (ASJC) codes

  • Immunology and Allergy
  • Gastroenterology

Cite this

Krishnakumar, C., Ballengee, C. R., Liu, C., Kim, M. O., Baker, S. S., Baldassano, R. N., ... Kugathasan, S. (2019). Variation in care in the management of children with Crohn's disease: Data from a multicenter inception cohort study. Inflammatory bowel diseases, 25(7), 1208-1217. https://doi.org/10.1093/ibd/izy363
Krishnakumar, Chenthan ; Ballengee, Cortney R. ; Liu, Chunyan ; Kim, Mi Ok ; Baker, Susan S. ; Baldassano, Robert N. ; Cohen, Stanley A. ; Crandall, Wallace V. ; Denson, Lee A. ; Dubinsky, Marla C. ; Evans, Jonathan ; Gokhale, Ranjana ; Griffiths, Anne ; Guthery, Stephen L. ; Oliva-Hemker, Maria ; Heyman, Melvin B. ; Keljo, David ; Kellermayer, Richard ; Leleiko, Neal S. ; Mack, David R. ; Markowitz, James F. ; Moulton, Dedrick E. ; Noe, Joshua D. ; Otley, Anthony R. ; Patel, Ashish S. ; Pfefferkorn, Marian ; Rabizadeh, Shervin ; Rosh, Joel R. ; Snapper, Scott ; Walters, Thomas D. ; Ziring, David ; Mondal, Kajari ; Kappelman, Michael D. ; Hyams, Jeffrey S. ; Kugathasan, Subra. / Variation in care in the management of children with Crohn's disease : Data from a multicenter inception cohort study. In: Inflammatory bowel diseases. 2019 ; Vol. 25, No. 7. pp. 1208-1217.
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abstract = "Background: 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). Methods: 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. Results: 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. Conclusions: 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.",
author = "Chenthan Krishnakumar and Ballengee, {Cortney R.} and Chunyan Liu and Kim, {Mi Ok} and Baker, {Susan S.} and Baldassano, {Robert N.} and Cohen, {Stanley A.} and Crandall, {Wallace V.} and Denson, {Lee A.} and Dubinsky, {Marla C.} and Jonathan Evans and Ranjana Gokhale and Anne Griffiths and Guthery, {Stephen L.} and Maria Oliva-Hemker and Heyman, {Melvin B.} and David Keljo and Richard Kellermayer and Leleiko, {Neal S.} and Mack, {David R.} and Markowitz, {James F.} and Moulton, {Dedrick E.} and Noe, {Joshua D.} and Otley, {Anthony R.} and Patel, {Ashish S.} and Marian Pfefferkorn and Shervin Rabizadeh and Rosh, {Joel R.} and Scott Snapper and Walters, {Thomas D.} and David Ziring and Kajari Mondal and Kappelman, {Michael D.} and Hyams, {Jeffrey S.} and Subra Kugathasan",
year = "2019",
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language = "English (US)",
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Krishnakumar, C, Ballengee, CR, Liu, C, Kim, MO, Baker, SS, Baldassano, RN, Cohen, SA, Crandall, WV, Denson, LA, Dubinsky, MC, Evans, J, Gokhale, R, Griffiths, A, Guthery, SL, Oliva-Hemker, M, Heyman, MB, Keljo, D, Kellermayer, R, Leleiko, NS, Mack, DR, Markowitz, JF, Moulton, DE, Noe, JD, Otley, AR, Patel, AS, Pfefferkorn, M, Rabizadeh, S, Rosh, JR, Snapper, S, Walters, TD, Ziring, D, Mondal, K, Kappelman, MD, Hyams, JS & Kugathasan, S 2019, 'Variation in care in the management of children with Crohn's disease: Data from a multicenter inception cohort study', Inflammatory bowel diseases, vol. 25, no. 7, pp. 1208-1217. https://doi.org/10.1093/ibd/izy363

Variation in care in the management of children with Crohn's disease : Data from a multicenter inception cohort study. / Krishnakumar, Chenthan; Ballengee, Cortney R.; Liu, Chunyan; Kim, Mi Ok; Baker, Susan S.; Baldassano, Robert N.; Cohen, Stanley A.; Crandall, Wallace V.; Denson, Lee A.; Dubinsky, Marla C.; Evans, Jonathan; Gokhale, Ranjana; Griffiths, Anne; Guthery, Stephen L.; Oliva-Hemker, Maria; Heyman, Melvin B.; Keljo, David; Kellermayer, Richard; Leleiko, Neal S.; Mack, David R.; Markowitz, James F.; Moulton, Dedrick E.; Noe, Joshua D.; Otley, Anthony R.; Patel, Ashish S.; Pfefferkorn, Marian; Rabizadeh, Shervin; Rosh, Joel R.; Snapper, Scott; Walters, Thomas D.; Ziring, David; Mondal, Kajari; Kappelman, Michael D.; Hyams, Jeffrey S.; Kugathasan, Subra.

In: Inflammatory bowel diseases, Vol. 25, No. 7, 18.06.2019, p. 1208-1217.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Variation in care in the management of children with Crohn's disease

T2 - Data from a multicenter inception cohort study

AU - Krishnakumar, Chenthan

AU - Ballengee, Cortney R.

AU - Liu, Chunyan

AU - Kim, Mi Ok

AU - Baker, Susan S.

AU - Baldassano, Robert N.

AU - Cohen, Stanley A.

AU - Crandall, Wallace V.

AU - Denson, Lee A.

AU - Dubinsky, Marla C.

AU - Evans, Jonathan

AU - Gokhale, Ranjana

AU - Griffiths, Anne

AU - Guthery, Stephen L.

AU - Oliva-Hemker, Maria

AU - Heyman, Melvin B.

AU - Keljo, David

AU - Kellermayer, Richard

AU - Leleiko, Neal S.

AU - Mack, David R.

AU - Markowitz, James F.

AU - Moulton, Dedrick E.

AU - Noe, Joshua D.

AU - Otley, Anthony R.

AU - Patel, Ashish S.

AU - Pfefferkorn, Marian

AU - Rabizadeh, Shervin

AU - Rosh, Joel R.

AU - Snapper, Scott

AU - Walters, Thomas D.

AU - Ziring, David

AU - Mondal, Kajari

AU - Kappelman, Michael D.

AU - Hyams, Jeffrey S.

AU - Kugathasan, Subra

PY - 2019/6/18

Y1 - 2019/6/18

N2 - Background: 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). Methods: 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. Results: 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. Conclusions: 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.

AB - Background: 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). Methods: 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. Results: 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. Conclusions: 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.

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DO - 10.1093/ibd/izy363

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