The British National Health Service has been focusing on patients with bowel disorders for several years, and a recent audit brings good news for ulcerative colitis (UC) patients in the UK: lower death rates and fewer hospital readmissions. The encouraging results show the benefit of advances in care that are also experienced by UC patients in the United States, and they offer useful insights into further improvements.
These data were gathered in 2010 by the UK Royal College of Physicians for the third round of a national clinical audit of adult inflammatory bowel disease (IBD) inpatient care. Two previous audits were conducted in 2006 and 2008.
The report documents “sustained improvements in the quality of care for IBD inpatients,” the authors wrote recently in The Lancet.
The report describes substantial continued improvements, particularly for patients admitted with UC, whose mortality has dropped by half since 2006. Readmission rates have been declining, and the percentage of patients being seen by an IBD nurse specialist during admission has doubled since the first round.
An important advance is improvement in the collection of stool samples for standard stool culture and Clostridium difficile toxin (CDT). Stool samples are now being submitted significantly more often for UC patients recorded as having diarrhea during the first full day following admission, and the number of stool samples positive for CDT has dropped by about half.
This reduction came as a surprise to David A. Schwartz, MD, Director of the Inflammatory Bowel Disease Center at Vanderbilt University. Cases of C difficile colitis have been increasing in the United States, he says. British patients are now benefiting from a targeted nationwide initiative to reduce CDTs. A related effort is also under way as one part of the US government’s broader Action Plan to Reduce Healthcare-Associated Infections.
Notably, there has been a statistically significant reduction (from half to one-third) in the number of UK patients admitted to the hospital for UC since the previous audit. The authors attribute this drop in readmission rates to more responsive outpatient services.
Meanwhile, the prescription of prophylactic heparin(Drug information on heparin) has continued to rise. The study also noted a significant improvement in the response rates for anti–tumor necrosis factor (anti‐TNF) therapy. Significant numbers of British doctors appear to have changed their choice of rescue therapy to anti-TNF. For patients who fail to respond to intravenous corticosteroids, about 1 of 6 now receive anti‐TNF therapy, while the use of cyclosporine has dropped slightly.
The overall increase in use of anti-TNF agents for UC in this study “shows an increasing understanding on how best to use these agents,” observes Vanderbilt’s Dr Schwartz. Pointing out that the authors attribute the reduction in readmission rates for UC patients to better outpatient care, he suggests that more appropriate use of these drugs is likely one explanation for this change. The reduction in deaths demonstrates that “improvements have been made in both the treatments available to treat IBD and in our practice guidelines,” he adds.
Some of the key recommendations from the third audit include:
• All IBD patients who have diarrhea should have their stools tested for standard cultures and CDT;
• Prophylactic heparin should be prescribed to lower the risk of thromboembolism during non-elective admissions; and
• Bone-protective drugs should be prescribed for patients given corticosteroids.