Inflammatory Bowel Disease Guidelines Research Articles

DOP02 Developing explicit thresholds for outcomes to inform (GRADE) Evidence to Decision frameworks for Inflammatory Bowel Disease guidelines

Abstract Background Evidence to decision (EtD) frameworks are a key recent development in Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology. They aim to ensure that decisions about healthcare interventions are based on a thorough, transparent and unbiased assessment of the available evidence. Core to this is to agree the importance of outcomes to be used, the specific measures for each outcome that have the most consensus and finally to develop explicit thresholds for interpretation of effect sizes of outcomes to inform (GRADE) evidence to decision frameworks. This ensures decisions are made in an unbiased fashion and allows stakeholders to focus on discussions based on their significant experience and expertise, rather than interpretation of evidence. Therefore, our study aims to develop these thresholds for the EtD framework to establish their use in several key IBD guidelines. Methods This online survey using Survey Monkey was conducted by inviting experts and stakeholders from the United Kingdom and British Society of Gastroenterology. Each expert was asked to select important clinically relevant outcomes and were asked about what magnitude of the effect they consider large, moderate, small, or trivial for each of the clinical, endoscopic, radiological, biochemical, histological outcomes and adverse events. Questions were framed as neutral statements without introducing a specific direction. Response options included sliding bars going from 1 to 100% for the desirable magnitude of effect for each outcome (Figure 1). The mean average of responses of experts were calculated. Results A total of 89 clinical experts/stakeholders participated in this online survey. Clinical remission, clinical response, endoscopic remission, withdrawal due to adverse events, and serious adverse events were considered critical outcomes. Trivial to small, small to moderate and moderate to large thresholds were as follows - clinical remission (10%, 20% and 31%), clinical response (13 %, 24% and 36%), endoscopic remission (9%, 17% and 28%), withdrawal due to AE (7 %, 14% and 23%), serious AE (6%, 11% and 17%) (Table 1). Conclusion This is the first study to develop thresholds for outcomes in IBD which can be used in EtD for the development of IBD guidelines. These thresholds have been used in the development of upcoming British Society of Gastroenterology guidelines for the management of IBD.

Attitude and influencing factors on exercise in patients with moderately to severely active inflammatory bowel disease: a qualitative study

ObjectivesTo explore the attitudes towards exercise, factors influencing exercise and exercise-related needs of patients with moderately to severely active inflammatory bowel disease.DesignA qualitative phenomenological research.SettingThe study was conducted at a...

Pneumococcal Vaccination Recommendation and Completion Rates Among Patients With Inflammatory Bowel Disease and Barriers to Vaccination.

Guidelines for inflammatory bowel disease (IBD) patients receiving immunosuppression encouraged both the pneumococcal polysaccharide vaccine (PPSV23) and the pneumococcal conjugate vaccine (PCV13). We aimed to evaluate which pneumococcal vaccines are recommended and administered, and to understand provider and IBD patient knowledge regarding pneumococcal vaccinations. We performed a retrospective, cross-sectional analysis of 357 adult IBD patients on immunosuppression in our health care system. Patient demographics and clinical characteristics were collected. The primary outcome was rate of documented vaccinations recommended by providers; the secondary outcome was rate of receipt of the vaccines. We identified factors associated with receipt of any pneumococcal vaccine through multivariable logistic regression. We also performed provider and IBD patient surveys to understand provider and patient knowledge regarding pneumococcal vaccines. We used χ 2 and Fisher exact tests to assess survey responses. Fifty seven percent of IBD patients had any pneumococcal vaccination recommended and 35% had recommendations for both PPSV23 and PCV13. Forty percent received any pneumococcal vaccine and 18% received both vaccines. In multivariable analyses, increasing age (adjusted odds ratio: 1.03, 95% CI: 1.01-1.05) was associated with receipt of any pneumococcal vaccine, after adjusting for gender, race, insurance, disease activity, and time seen in our gastroenterology clinics. In the survey study, on average, 59% of providers correctly answered questions regarding pneumococcal vaccination indications. In our health care system, while recommendation for any pneumococcal vaccination was >50%, receipt of both PPSV23 and PCV13 was low. Simplified vaccine regimens (ie, PCV20) will likely improve vaccination rates.

S898 Are Gastroenterologists Complying With the Preventive Care Guidelines for Inflammatory Bowel Disease?

S898 Are Gastroenterologists Complying With the Preventive Care Guidelines for Inflammatory Bowel Disease?

Complementary and alternative medicine mention and recommendations in inflammatory bowel disease guidelines: systematic review and assessment using AGREE II

BackgroundMany patients with inflammatory bowel disease (IBD) use complementary and alternative medicine (CAM) for disease management. There is, however, a communication gap between patients and healthcare professionals regarding CAM use, where patients are hesitant to disclose CAM use to providers. The purpose of this study was to identify the quantity and assess the quality of CAM recommendations in IBD clinical practice guidelines (CPGs) using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument.MethodsMEDLINE, EMBASE, and CINAHL were systematically searched from 2011 to 2022 to find CPGs for the treatment and/or management of IBD. The Guidelines International Network (GIN) and National Center for Complementary and Integrative Health (NCCIH) websites were also searched. Eligible CPGs were assessed using the AGREE II instrument.ResultsNineteen CPGs made CAM recommendations for IBD and were included in this review. Average scaled domain percentages of CPGs were as follows (overall CPG, CAM section): scope and purpose (91.5%, 91.5%), clarity of presentation (90.3%, 64.0%), editorial independence (57.0%, 57.0%), stakeholder involvement (56.7%, 27.8%), rigour of development (54.7%, 45.9%), and applicability (14.6%, 2.1%).ConclusionsThe majority of CPGs with CAM recommendations were of low quality and their CAM sections scored substantially lower relative to other therapies in the overall CPG. In future updates, CPGs with low scaled-domain percentages could be improved in accordance with AGREE II and other guideline development resources. Further research investigating how CAM therapies can best be incorporated into IBD CPGs is warranted.

Clinician Adherence to Inflammatory Bowel Disease Guidelines: Results of a Qualitative Study of Barriers and Enablers.

With the evolving inflammatory bowel disease (IBD) management landscape, it is critical that gastroenterologists keep up to date with the clinical practice guidelines (CPGs). Several studies in IBD have documented suboptimal adherence to CPGs. We aimed to gain an in-depth understanding of guideline adherence barriers reported by gastroenterologists and determine how evidence-based education can best be delivered. Interviews were conducted with a purposive sample of gastroenterologists' representative of the current workforce. Questions focused on previously identified problematic areas and shaped by the theoretical domains framework, a theory-informed approach to understanding clinician behavior, to assess all determinants of behavior. Questions explored perceived barriers to adherence and clinicians' preferred content and modes of delivery for an educational intervention. Interviews were conducted by a single interviewer and qualitative analysis performed. A total of 20 interviews were conducted before data saturation was achieved (male = 12, work in a metropolitan area = 17). Five dominant subthemes for barriers to adherence emerged: negative experiences impacting future decisions, time constraints, long guidelines are impractical, unfamiliar with guideline specifics and prescribing restrictions. Adherence enablers were identified including features that improved the usability of CPGs. Computer- or smart phone-based educational interventions were preferred. This study identified several barriers and enablers for IBD guideline adherence and gained insight into how gastroenterologists prefer to receive evidence-based education. These results will inform the development of a targeted intervention to improve IBD guideline adherence. Improving guideline adherence is expected to facilitate standardized IBD care, ultimately leading to improved patient outcomes.

Survey of barriers to adherence to international inflammatory bowel disease guidelines: does gastroenterologists' confidence translate to high adherence?

Despite the availability of evidence-based inflammatory bowel disease (IBD) guidelines, suboptimal care persists. There is little published research assessing barriers to IBD guideline adherence. To identify barriers to IBD guideline adherence including gastroenterologists' knowledge and attitudes towards guidelines. An online cross-sectional survey of 824 Australian gastroenterologists was conducted from April to August 2018, with 198 (24%) responses. A novel survey was developed that was informed by the theoretical domain's framework. Confidence in guideline recommendations was high; however, referral to them was low. The European Crohn's and Colitis Organisation guidelines were referred to most commonly (43.6%). In multivariate analysis, significant predictors of frequent versus infrequent guideline referral were: high confidence in the guideline (odds ratio (OR) 7.70; 95% confidence interval (CI): 2.43-24.39; P = 0.001), and low (≤10 years) clinical experience (OR 3.62; 95% CI: 1.11-11.79; P = 0.03). The most common barriers to guideline adherence were not having time (62%), followed by guideline specifics being difficult to remember (61%). Low confidence was reported in managing pregnancy and IBD (34%) and loss of response to therapy (29%). High confidence was reported in managing immunomodulators; however, only 43% answered the associated knowledge question correctly. Although gastroenterologists have high confidence in guidelines, they use them infrequently, primarily due to specifics being difficult to remember and lack of time. Self-reported confidence in an area of IBD management does not always reflect knowledge. An intervention targeting these barriers, for example, computer-based clinical decision support tools, might improve adherence and standardise care.

INFLAMMATORY BOWEL DISEASE RISK STRATIFICATION AND MANAGEMENT IN A COMMUNITY PRACTICE SETTING

Abstract INTRODUCTION Risk stratification of patients with Inflammatory Bowel Disease (IBD) is integral for patient management according to care pathways and IBD guidelines. We examined explicit IBD risk stratification and the extent of its influence on patient management in a community-based practice setting. MATERIAL AND METHODS This was a single-center, retrospective study of adult patients with IBD followed at Genesis Healthcare Partners between January 1, 2016 and December 31, 2018. 250 consecutive IBD charts were reviewed for (a) patient demographics; (b) disease characteristics; (c) explicit risk stratification and disease activity documented by clinician provider; (d) management and treatment. Patients were independently risk stratified based on AGA clinical care pathway risk factors (implicit risk stratification). CD high risk factors include: age under 30 at diagnosis, extensive anatomic involvement, perianal and/or severe rectal disease, deep ulcers on endoscopy, stricturing and/or penetrating behavior, prior surgical resection. UC high risk factors include age under 40 at diagnosis, extensive anatomic involvement, deep ulcers on endoscopy, high CRP and/or ESR, steroid requiring disease, C Difficile or CMV infection, prior hospitalization for UC. RESULTS 211 eligible patients: 77 (36.5%) with Crohn’s Disease (CD) and 134 (63.5%) with Ulcerative Colitis (UC) were included; 52% female, 85% Caucasian, median age at diagnosis was 33 years, median length of CD was 16 years, and the median length of UC was 8 years. 18 (2%) had explicit risk stratification documented. Implicit risk stratification was: CD: 9 (12%) low risk [zero high risk factors], 68 (88%) high risk [one or more high risk factors]. UC: 27 patients (20%) low risk [zero high risk factors]; 107 patients (80%) high risk [one or more high risk factor]. Medication management for low-risk CD: 5-ASAs: 5 (56%); locally acting steroids: 5 (56%); systemic steroids: 1 (11%); immunomodulators (IMM): 2 (22%); and biologics: 4 (44%) and high-risk CD: 5-ASAs: 17 (25%); locally acting steroids 18 (27%); systemic steroids 20 (30%); IMM: 21 (31%); biologics: 46 (69%). Medication management for low-risk UC: 5-ASAs: 24 (92%); locally acting steroids: 5 (19%); systemic steroids: 4 (15%); IMM: 2 (8%); biologics: and 1 (4%) and high-risk: 5-ASAs: 97 (91%); locally acting steroids: 42 (39%); systemic steroids: 45 (42%); IMM: 16 (15%); biologics: 44 (41%). Of 182 UC endoscopy procedures explicit Mayo endoscopic sub-scores was documented in 3 (2%). Implicit Mayo Scoring was: 21% Mayo 0, 34% Mayo 1, 26% Mayo 2 and 16% Mayo 3. CONCLUSIONS Explicit risk stratification and Mayo endoscopy scoring was infrequently documented. Embedding risk stratification tools and standardized Mayo endoscopy scoring into EMRs would help to standardize documentation.

INFLAMMATORY BOWEL DISEASE RISK STRATIFICATION AND MANAGEMENT IN A COMMUNITY PRACTICE SETTING

Risk stratification of patients with Inflammatory Bowel Disease (IBD) is integral for patient management according to care pathways and IBD guidelines. We examined explicit IBD risk stratification and the extent of its influence on patient management in a community-based practice setting.

Anti–SARS-CoV-2 Antibody Responses in Patients With IBD Treated With Biologics: Are We Finding CLARITY?

Anti–SARS-CoV-2 Antibody Responses in Patients With IBD Treated With Biologics: Are We Finding CLARITY?

Systematic evaluation of the diagnostic approach of inflammatory bowel disease guidelines.

To collect and evaluate the diagnostic approach of inflammatory bowel disease (IBD) guidelines and provide useful feedback for guideline developers and evidence-based clinical information to help physicians make decisions. Diagnostic guidelines for IBD were retrieved by performing systemic and manual searches. Qualified clinical practice guidelines (CPGs) were included and then evaluated by four well-trained evaluators using the AGREE II instrument. To reduce the bias generated in this process, we used the Measurement Scale of Rate of Agreement (MSRA) tool to interpret the results. Guidelines with good recommendation distributions among the diagnostic field were further reclassified and evaluated. Fifteen diagnostic CPGs for IBD were identified and evaluated, and 70.3% (11/15) of the CPGs were above the recommended level. We observed heterogeneity among the diagnostic CPGs for IBD and discrepancies among different domains in one specific guideline. Potential improvements were identified in the fields of stakeholder involvement, rigour of development and applicability. By further analysing the heterogeneity of the recommendations and evidence in 5 UC-CPGs, we found the following issues: no discussion of diagnosing severe complications of UC, disputed significance of serologic and genetic diagnoses of UC, insufficient attention towards medical histories/physical examinations/differential diagnoses and discrepancy in classification criteria. The included diagnostic CPGs for IBD were generally of good quality, but heterogeneity was identified. Addressing these issues will provide useful feedback for the guideline updating process, and it will also benefit current clinical practice and eventually patient outcome.

Evaluation of pharmacotherapy recommendations in guidelines for inflammatory bowel disease.

The aim of this study was to systematically assess drug therapy in the guidelines for inflammatory bowel disease and to provide recommendations for the development of such guidelines. A systematic search was conducted in databases and on websites to identify guidelines for the treatment of inflammatory bowel disease. Qualified guidelines were assessed through the Appraisal of Guidelines for Research and Evaluation (AGREE II). Evidence from the guidelines was extracted from the guidelines themselves. The Oxford Centre for Evidence-based Medicine (OCEBM) evidence grading system was used to regrade and assess this evidence. A total of 11 guidelines for the medical treatment of inflammatory bowel disease (Crohn's disease and ulcerative colitis) (2015-2019) were finally included, and after scoring using the AGREE II tool, the median scores in each domain were as follows: Ⅰ. scope and purpose (median score=88.9%, range: 76.4%-91.7%), Ⅱ. stakeholder involvement (median =38.9%, range: 18.1%-61.1%), Ⅲ. rigour of development (median =69.3%, range: 39.6%-77.6%), Ⅳ. clarity and presentation (median =97.2%, range: 91.7%-100%), Ⅴ. applicability (median =45.8%, range: 24%-68.8%) and Ⅵ. editorial independence (median =94.0%, range: 0-100%). Most of the guidelines scored over 60%, which is worthy of clinical recommendation, but different guidelines suggest that there is a great difference in drug therapy, mainly due to various populations, diverse focuses of attention, distinct efficacy of drugs between Crohn's disease and ulcerative colitis, and the preference of guiding developers for select evidence. The quality of medical treatment guidelines for inflammatory bowel disease varies considerably. Over the past 5years, medical treatment has been heterogeneous among different guidelines. Consideration of factors leading to heterogeneity of recommendations for drug treatment, especially preferences for evidence selection, will help upgrade the guidelines.

Undisclosed payments by pharmaceutical manufacturers to authors of inflammatory bowel disease guidelines in the United States.

Background:Payments from pharmaceutical drug manufacturers to authors of clinical practice guidelines (CPGs) may have an impact on their recommendations. In this study, we aimed to evaluate the accuracy of financial conflict of interest (FCOI) declarations among authors of Inflammatory Bowel Disease (IBD) guidelines.Methods:We collected data on industry payments to authors of IBD guidelines published by the American Gastroenterology Association (AGA), American College of Gastroenterology (ACG) and American Society of Gastrointestinal Endoscopy (ASGE). We reported the accuracy of the authors' declarations by comparing their statements in the FCOI section of the guidelines with the data reported on the Centers for Medicare and Medicaid Services website (CMS-OP). We also investigated the adherence of IBD guidelines to the National Academy of Medicine (NAM) criteria for trustworthy guidelines.Results:A total of eight clinical practice guidelines and 35 individual authors were included. Four authors had no profile identified at CMS-OP. The total payment to all included authors was $10,575,843.06, with a mean payment of $314,242.38 per author. A total of 28/35 authors (80%) received payment from pharmaceutical companies, 23/35 (65.7%) received $10,000 or more, 15/35 (42.8%) received $100,000 or more and 3/35 (8.57%) received $1,000,000 or more. Total discrepancies identified while comparing the authors' declaration of their FCOI and CMS-OP were 28: ACG had 12/14 (85.7%), AGA had 7/12 (53.8%) and ASGE had 9/10 (90%) discrepancies. None of the guidelines met all NAM criteria and 4/8 (50%) guidelines met none.Conclusions:Discrepancies exist between authors' declarations in the FOCI section and data on CMS-OP. Poor compliance with the NAM criteria was prevalent among authors of IBD guidelines. More transparency in reporting and monitoring is needed.

Treat-to-Target Approach in Inflammatory Bowel Disease: The Role of Advanced Practice Providers

Updated therapeutic guidelines for inflammatory bowel disease call for effective disease assessment, early intervention, and personalized patient care using a treat-to-target (T2T) approach. The ongoing, intensive monitoring of a T2T strategy is best facilitated by a multidisciplinary team, but the increased demand on health care systems impedes implementation. Therefore, advanced practice providers have a growing role in bridging the gap between T2T recommendations and clinical practice. Advanced practice providers can effectively facilitate patient-care team communication, deliver patient education, perform in-clinic and remote monitoring of symptoms and treatment response, and assist patients with self-management.

P067 Immunosuppressive therapy in inflammatory bowel disease patients is associated with reactivation of Herpes Zoster: A tertiary center experience

BACKGROUND: Herpes Zoster (HZ), also known as shingles, is the reactivation of the varicella zoster virus (VZV). The incidence of HZ is 4 per 1,000 person-years. Though HZ can occur at any age and in any population, the incidence increases with age and is up to ten times higher in immunocompromised patients. Vaccine guidelines for inflammatory bowel disease (IBD) patients on immunosuppressive therapy recommend obtaining age appropriate non-live attenuated vaccinations while strongly considering risks and benefits when administering the live-attenuated vaccines. Currently, CDC guidelines recommend the new non-live HZ vaccine, Shingrix, in patients over the age of 50. As this is a non-live vaccine it is safe to administer in patients on immunosuppressive therapy. The purpose of our study was to identify risk factors associated with the development of HZ among IBD patients. METHODS: Using our institution’s electronic research data warehouse, we performed a case-control study including IBD patients enrolled in the prospectively maintained IBD patient database at the University of Chicago IBD Center between January 1, 2005 and January 1, 2017. Controls included individuals presenting to the general gastroenterology and hepatology clinics. The diagnosis of HZ was identified using ICD codes (053.9, 053.19, B029, B028) and documentation of a characteristic rash at the corresponding clinic visit. Demographic variables, disease-related and therapy-related factors including HZ vaccination were recorded. Data were analyzed using Wilcoxon rank-sum test for continuous variables and Fischer’s exact test for dichotomous variables. RESULTS: We identified 88 unique patients encounters (57 IBD, 34 non-IBD) with a diagnosis of HZ. The non-IBD controls primarily included individuals with a history of liver disease (n = 21). The IBD patients were predominantly Caucasian (80%) and of younger age when compared to the control population (P < 0.001). Among the 57 IBD patients, 20 (35%) had active disease and 51 (89%) were on active immunosuppression. There were no other statistically significant demographic features between the groups with regards to active smoking or prior HZ vaccination. Only 6 (19%) IBD patients who were over the age of 50 were vaccinated. IBD patients were more likely to be on active immunosuppression or have a history of immunosuppression (P < 0.001) compared to controls. Despite a high level of active disease and immunosuppression, IBD patients had higher albumin and hemoglobin levels compared to the controls. Following the onset of HZ, there was no significant difference in the onset of post-herpetic neuralgia. CONCLUSION(S): Active immunosuppression in IBD patients is a risk for HZ, but no other variables were identified. The disease course with respect to development of post-herpetic neuralgia is not different compared to controls. Only a small number of eligible patients received vaccination for HZ and none of these developed HZ. Further studies should identify independent risk factors for vaccination or expand the eligibility of vaccination to larger cohorts of patients in order to prevent the onset of HZ.

Improving treatment of patients with inflammatory bowel diseases: a controlled trial of a multifaceted intervention in two German cities

Many recommendations from clinical practice guidelines are not implemented. We aimed to develop and evaluate a multifaceted strategy for the implementation of guidelines for Crohn's disease (CD) and ulcerative colitis (UC). In the intervention region (Berlin, Germany), a continuing medical education course was held, brief guidelines for practice were distributed to all family physicians and gastroenterologists, and patient guidelines were distributed to all surveyed patients. Educational outreach visits with local opinion leaders were also conducted. No specific interventions were performed in the control region (Hamburg, Germany). Prior to the intervention and 1year later, 1900 members of three statutory sickness funds were asked about their treatment according to guidelines with (1) long-term aminosalicylates and (2) immunosuppressants, (3) whether they took long-term glucocorticoids for maintenance of remission, (4) if they smoked, in CD patients, and (5) about the surveillance colonoscopies, in UC patients. Response rate after implementation was 20.1%. Responders differed between intervention and control region by age and by distribution between patients with UC or CD. After 1year, more patients were treated according to clinical practice guidelines in the control region than in the intervention region. More patients in the intervention region took immunosuppressants after 1year, and fewer had a surveillance colonoscopy. However, no before-after comparison was statistically significant. This implementation strategy of UC and CD guidelines did not result in a statistically significant effect. Future implementation of guidelines for inflammatory bowel disease might need thorough evaluation of barriers and the support of theory-based concepts.

Financial Conflicts of Interest in Inflammatory Bowel Disease Guidelines.

Industry payments can lead to financial conflicts of interest (FCOI) among authors of clinical practice guidelines (CPGs). Guidelines for inflammatory bowel disease (IBD) may be at particularly high risk. We determined the prevalence of FCOI in IBD CPGs produced by various gastroenterology societies. We conducted a cross-sectional analysis of FCOI disclosure among CPGs related to the management of IBD. We ascertained the prevalence and types of FCOI for each guideline and determined adherence to National Academy of Medicine (NAM) standards. FCOI disclosures were compared between societies producing CPGs. We identified 11 relevant CPGs with 173 total authors. There were 117 (68%) authors who declared a payment. A total of 107 (62%) authors declared FCOI related to a medication recommended in the guideline. There was a significant difference (P < 0.001) between the proportion of authors with FCOI between countries or regions. Authors of US CPGs had a significantly lower FCOI prevalence (19%) compared with other societies. Authors of UK CPGs had a significantly lower FCOI prevalence (56%) compared with Canadian (84%) and European (94%) CPGs. Three (27%) guidelines adhered to both NAM standards. A substantial portion of authors of IBD CPGs had FCOI. Our study found a significant difference in FCOI prevalence based on CPG sponsor nationality. Most CPGs for IBD did not adhere to NAM standards for FCOI disclosure.

Clinical Pharmacokinetic and Pharmacodynamic Considerations in the Treatment of Inflammatory Bowel Disease

According to recent clinical consensus, pharmacotherapy of inflammatory bowel disease (IBD) is, or should be, personalized medicine. IBD treatment is complex, with highly different treatment classes and relatively few data on treatment strategy. Although thorough evidence-based international IBD guidelines currently exist, appropriate drug and dose choice remains challenging as many disease (disease type, location of disease, disease activity and course, extraintestinal manifestations, complications) and patient characteristics [(pharmaco-)genetic predisposition, response to previous medications, side-effect profile, necessary onset of response, convenience, concurrent therapy, adherence to (maintenance) therapy] are involved. Detailed pharmacological knowledge of the IBD drug arsenal is essential for choosing the right drug, in the right dose, in the right administration form, at the right time, for each individual patient. In this in-depth review, clinical pharmacodynamic and pharmacokinetic considerations are provided for tailoring treatment with the most common IBD drugs. Development (with consequent prospective validation) of easy-to-use treatment algorithms based on these considerations and new pharmacological data may facilitate optimal and effective IBD treatment, preferably corroborated by effectiveness and safety registries.

An Appraisal of Clinical Practice Guidelines for Inflammatory Bowel Disease: What Attitude Should We Have Towards the Guidelines?

Introduction: The guideline development process should be precise and rigorous to ensure that the results are reproducible and not vague. Clinical practice guidelines (CPGs) play an important role in healthcare system. To determine the quality of guidelines the Appraisal of Guidelines and Research and Evaluation (AGREEII) instrument was developed and introduced. Methods: Eight databases (included MEDLINE and EMBASE) and guideline websites were searched until/up to April, 2016. The methodological quality of the guidelines was assessed by four authors independently using the AGREEII instrument. Results: From 1366 citations, 58 relevant guidelines were included. The overall agreement among reviewers was moderate (Intra-class correlation coefficient=0.86; 95% confidence interval [CI], 0.46-0.84). The mean scores were moderate for the domains “scope and purpose” (53.54) and “rigor of development” (61.24), however, there were low for the domains “clarity of presentation” (24.36), “stakeholder involvement” (31.27), “applicability” (26.52) and “editorial independence” (28.45). Four sixths domains scores were lower when compared with international average level. There were 10(17.24%) guidelines described the systematic methods for searching. And only 9(15.52%) guidelines reported methodological expertise were included in guideline developing teams. According to the AGREEII instrument, 7 guidelines can be strongly recommended, 16 with provisos and alterations while the remaining cannot be recommended for adaptation due to poor methodological quality. Meanwhile, we didn't find the difference in six domains quality related to publication year of AGREEII (before or after 2010). Meanwhile, guidelines published in guideline databases were significantly have a higher scores than that in journals. Conclusion: Although existing inflammatory bowel disease guidelines may accurately reflect agreed clinical practice, many guidelines lack proper methodological quality. Future guidelines should place more emphasis on these methodological shortcoming and provide high-quality guidelines for clinical decision-making in this field.Figure 1

Preventative care for patients with inflammatory bowel disease in the Veterans Health Administration.

Patients with inflammatory bowel disease (IBD) have underlying immune dysregulation. Immunosuppressive medications put them at risk of infection. This study assessed rates of recommended vaccinations and preventative screening in patients with IBD.Nationwide data on patients diagnosed with IBD in the Veterans Health Administration (VHA) October 2004 to September 2014 were extracted. Variation in vaccination, screenings, and risk of death by demographic factors (age group, gender) were estimated in bivariate and multivariable analyses.During the 10-year study period, 62,002 patients were treated for IBD. Nonmelanoma skin cancer was found in 2.6%, and these patients more commonly accessed dermatology clinic (22.5% vs 15.2%; chi-square = 66.6; df = 1; P < 0.0001). In total, 15% received DEXA scans, especially women (34.7% vs 13.2% men; chi-square = 1415.5; df = 1; P < 0.0001). Eye manifestations were noted in 38.3% yet only 31% were referred to ophthalmology. Abnormal Pap smears were found for 15% of women <65 (compared to 5% among normal patient populations); 34% had no record of Pap smear in VHA data. Vaccination rates were modest: pneumococcal 39%; TDAP 23%; hepatitis B 3%; varicella and PPD <0.5%. In an adjusted logistic regression model, 5-year mortality was lower among those using primary care prior to IBD diagnosis (odds ratio [OR] = 0.61; 95% CI 0.55–0.68).Despite the current IBD guidelines, vaccination and preventative screening rates were unacceptably low among patients diagnosed with IBD. Interventions such as education and increased awareness may be needed to improve these rates.