Do patients with inflammatory bowel disease receive optimal care?

Inflammatory bowel disease (IBD) is a chronic recurrent gastrointestinal disease. The disease has a relatively higher morbidity in young adults, in whom growth, education, employment and wellbeing all are adversely influenced. A number of guidelines for management of inflammatory bowel disease are available for bringing evidence-based medicine into full play to improve IBD patient care. What about the actual quality of care for patients with IBD in China?

An article to be published on January 28, 2008 in the World Journal of Gastroenterology addresses this question. The research team led by Dr. Jian-Min Si from Zhejiang University, China, conducted a retrospective review of medical therapy for a hospital based-cohort of patients with IBD, involving 71 patients with Crohn's disease (CD) and 106 with ulcerative colitis (UC). Medical therapy including use of oral aminosalicylates, topical therapy, corticosteroid agents and immunomodulatory agents were analyzed.

This article reported that all the patients with ulcerative colitis received optimal doses of aminosalicylate while 39.7% patients with ileal or colonic CD were suboptimal dosed. The incidence of suboptimal dose of aminosalicylate was significantly higher in CD patients with small intestine involvement only. This phenomenon may be explained by the relatively lower incidence of CD than that of UC in China and therefore less understanding of this disease.

Another finding is that only half of the patients with active distal or left-sided ulcerative colitis received topical therapy. There is a tendency to think topical therapy is less effective in clinical practice, quite reverse to the evidence. In fact, its lower efficacy may be due to the lack of preparations, such as liquid enemas, foams, gels and suppositories, rather than due to the medication itself.

More than a quarter of patients who suffered from severe IBD did not receive oral or intravenous steroid therapy, which is possibly due to the lack of comprehensive evaluation of the patients' baseline states and re-evaluation when exacerbations occurred. In addition, the patients' and even some physicians' fear of adverse effects played a part role.

The most striking finding in this study pertains to the use of immunomodulatory drugs. Among the patients for whom immunomodulatory agents were indicated, only one fifth received these drugs. And half of the patients who received azathiopurine were suboptimal dosed in the absence of leucopenia of hepatotoxicity. The limited use of immunomodulatory drugs may be due to the lack of evidence and limited experience with these drugs in Han nationality Chinese with IBD. Uncertainty regarding the risk for neutropenia deters some physicians from using AZA at effective doses for longer periods of treatment.

The results of this study suggest the quality of care for IBD patients can be further improved. Larger prospective studies are needed to investigate the quality of care for patients with IBD and the association of the reported quality of care with patient outcomes.