You are here

  • Home
  • Archive
  • Volume 11, Issue 12
  • Heterogeneity in outcome assessment for inflammatory bowel disease in routine clinical practice: a mixed-methods study in a sample of English hospitals

Article Text

Article menu
Gastroenterology and hepatology
Original research
Heterogeneity in outcome assessment for inflammatory bowel disease in routine clinical practice: a mixed-methods study in a sample of English hospitals
  1. Violeta Razanskaite1,
  2. Constantinos Kallis1,
  3. Bridget Young2,
  4. Paula R Williamson1,
  5. Keith Bodger1,3
  1. 1Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
  2. 2Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
  3. 3Digestive Diseases Unit, Aintree University Hospital, Liverpool, UK
  1. Correspondence to Dr Keith Bodger; kbodger{at}liverpool.ac.uk

Abstract

Objectives Knowledge of the extent of variation in outcome assessment for inflammatory bowel disease (IBD) in routine practice is limited. We aimed to describe and quantify variation in outcome coverage and to explore patient, clinician and practitioner factors associated with it.

Design Prospective exploratory mixed-methods study.

Setting IBD clinics at six hospitals in North West England with differing electronic health record (EHR) systems.

Methods Mixed-methods study comprising: (a) structured observations of outcomes elicited during consultations (102 patients consulting 24 clinicians); (b) retrospective analysis of outcomes recorded in the EHR (909 consultations; 127 clinicians) and (c) semistructured interviews with the 24 observed clinicians. We determined whether specific outcome ‘sets’ were elicited or recorded, including: (1) a minimum set of symptom pairs (‘PRO-2’); (2) symptom sets from disease activity indices and (3) a reference list of 37 symptoms, signs and impacts. Factors associated with variation were explored in univariate and multivariate binary logistic regression analyses and from clinician interviews.

Results PRO-2 coverage was not invariable (elicited during 81% of observed consultations; recorded in 56% of EHR) and infrequent for complete activity indices (all domains from Harvey-Bradshaw Index: elicited, 18%; recorded, 5%). The median number of outcomes from the reference list elicited per consultation was 12 (13-fold variation) and recorded in EHR was 7 (>20-fold variation). Symptom quantification (PRO-2) seldom adhered closely to standardised descriptors and an explicit timeframe was defined rarely. PRO-2 recording in EHR was associated with a diagnosis of ulcerative colitis (OR: 2.09 (95% CI 1.15 to 3.80)) and nurse-led consultations (OR: 6.98 (95% CI 3.28 to 14.83)) and a three-way model suggested 26% of total variability lay between clinicians, 17% between patients but the remainder was unexplained. Most clinicians expressed preference for individualised health status evaluations versus standardised outcome assessments.

Conclusions There was little evidence for standardised assessment and recording of IBD outcomes and substantial intra-clinician and inter-clinician variation from one consultation to another. Nurses demonstrated a greater tendency to standardised practice.

  • inflammatory bowel disease
  • quality in healthcare
  • gastroenterology

Data availability statement

Data are available upon reasonable request. The data that support the findings of this study are available from the corresponding author upon reasonable request.

https://creativecommons.org/licenses/by/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

https://doi.org/10.1136/bmjopen-2021-056413

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    Data availability statement

    Data are available upon reasonable request. The data that support the findings of this study are available from the corresponding author upon reasonable request.

    View Full Text

    Supplementary materials

    • Supplementary Data

      This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

    Footnotes

    • Twitter @Violeta_Raz

    • Contributors VR and KB wrote the article; VR, KB, PRW and BY designed the research; VR performed the research; VR and CK analysed the data. All authors approved the final version of the article, including the authorship list. KB is guarantor for the work.

    • Funding This work was supported by the Medical Research Council (MRC) Hubs for Trials Methodology Research (HTMR) Network (grant number MR/L004933/2).

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.