This CME-certified activity was supported by an independent educational grant from AbbVie.

For more information, please contact Jelena Spyropoulos at jspyropoulos@medscape.net.

The Effect of Physician Education on Improving Quality of Life in Patients With Crohn Disease

Conclusions

Acknowledgments

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The study demonstrated that online CME activities, designed using adult learning principles, not only can effectively improve physician concerns and barriers related to the treatment of CD and promote performance change but also can improve patients’ quality of life.

• Significantly fewer participants compared to nonparticipants indicated that concerns such as the risk of the patient developing HSTCL, antibodies, or uncertainty on how to taper steroid therapy to avoid dependence as barriers to the early initiation of biologic therapy for patients with CD

• Based on the scores of the modified SIBDQ portion of the survey, patients of participants, but not patients of nonparticipants, showed a significantly improved quality of life from baseline to follow-up.

Additional education should focus on:

• Improving physician confidence to initiate biologic therapy in appropriate patients

• Selecting early, aggressive therapy in appropriate patients to improve quality of life

Introduction

Methods

Crohn disease (CD) is a chronic, relapsing, inflammatory disorder with a high burden of disease that manifests at an early age and requires lifelong therapy.1 The conventional “step-up” approach to the treatment of CD, often used today, can be ineffective for many patients leading to the prolonged use of agents with poor long-term efficacy and symptom control.2,3 Despite the available evidence on the need for a more aggressive, early-treatment approach, a health survey revealed that a substantial proportion of gastroenterologists underutilize immunomodulators and fail to prescribe biologic agents

for appropriate patients with moderate-to-severe disease.4 Delayed and less aggressive treatment of patients with CD may result in the development of strictures, obstructions, perforations, or fistulas and contribute to the need for surgery in approximately 75% of patients, resulting in a negative effect on patients’ quality of life.5 The objective of this study was to evaluate the effectiveness of online continuing medical education (CME) activities in improving physician practices related to treatment of CD and the subsequent effect on patient health-related quality of life.

Physician Concerns and Barriers

Physicians who participated in the online CME activities (n = 58) reported significantly fewer barriers to the early initiation of biologic therapy in appropriate patients with CD compared to nonparticipants (n = 40), indicating the education was successful in increasing physician confidence in overcoming barriers to care (Figure 2).

Effect on Patient Quality of Life

Physician participation in online education also had measurable effects on the health and perceptions of their patients with CD. Patients of physician participants in online CME activities showed a significantly improved SIBDQ score from baseline to follow-up (P =.02) compared with no change seen in the scores of the control group (P =.16) (Figure 3)

1. Physician survey

• Gastroenterologists who participated in either of 2 CME online activities on the Medscape Education website6,7 were sent an invitation to complete a survey.

• The survey included 9 questions to ascertain physician practice patterns, attitudes, and perceived barriers regarding the use of early aggressive therapy in appropriate patients with CD.

• The invitation contained a link directing the physician to a website containing information about the study, the physician survey for immediate completion, and downloadable handouts containing a link to direct their patients to a website for their survey.

• To obtain the control group, practicing US gastroenterologists who did not participate in the education received a study invitation by email.

• If they responded, stating that they wished to be included, they were emailed the same information as the participant physician group to complete their survey and distribute information to their patients.

• Professionally appropriate honorarium was provided to participant and control groups upon completion of their portion of the study and at least 5 corresponding patient surveys.

AnAlysis

A statistical analysis package for the social sciences (IBM SPSS Statistics 20) was used in data extraction, transformation, and statistical analyses. To assess the effectiveness of the education, change between the 2 time points of participants was compared to the time point change of the nonparticipant patient control. Findings were found to be significant at P ≤ .05.

Both activities were available on the Medscape Mobile application, ensuring real-time access by the many clinicians who rely on mobile devices for education.

inclusion criteriA

Physicians

• US-based practicing gastroenterologists

• Involved in management of at least 10 patients a week with CD

Patients

• US-based adults over the age of 21 who can communicate in English

• Have been diagnosed with CD

• Currently taking medication for their CD

The complete protocol for this study was approved by the Western Institutional Review Board (WIRB) on November 5, 2012.

References

1. Everhart JE. The burden of digestive diseases in the United States. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington, DC: US Government Printing Office, 2008; NIH Publication No. 09-6443.

2. Devlin SM, Panaccione R. Evolving inflammatory bowel disease treatment paradigms: top-down versus step-up. Med Clin N Am. 2010;94:1-18.

3. Loftus EV, Feagan BG, Colombel JF, et al. Effects of adalimumab maintenance therapy on health-related quality of life of patients with Crohn’s disease: patient-reported outcomes of the CHARM trial. Am J Gastroenterol. 2008;103:3132-3141.

4. Donovan M, Lunney K, Carter-Pokras O, Cross RK. Prescribing patterns and awareness of adverse effects of infliximab: a health survey of gastroenterologists. Dig Dis Sci. 2007;52:1798-1905.

5. Dudley-Brown S, Nag A, Cullinan C, et al. Health-related quality-of-life evaluation of Crohn’s disease patients after receiving natalizumab therapy. Gastroenterol Nurs. 2009;32:327-339.

6. Rubin DT, Siegel CA. Optimizing use of biologics in moderate to severe Crohn disease: a practical approach. http://www.medscape.org/viewarticle/767665. Accessed April 13, 2015.

7. Lashner BA. Case studies in moderate to severe Crohn disease. http://www.medscape.org/viewarticle/768905. Accessed April 13, 2015.

8. Irvine EJ, Zhou Q, Thompson AK. The Short Inflammatory Bowel Disease Questionnaire: a quality of life instrument for community physicians managing inflammatory bowel disease. CCRPT Investigators. Canadian Crohn’s Relapse Prevention Trial. Am J Gastroenterol. 1996;91:1571-1578.

Figure 2. PhysiciAn BArriers

Please indicate the significance of each of the following barriers to the early

initiation of biologic therapy for patients with CD

(1, not significant at all; 10, extremely significant: mean responses shown).

27.7030.30

24.8629.52

Nonparticipants Patient Post Survey (n = 71) Nonparticipants Patient Follow-up Survey (n=27)

Participants Patient Follow-up Survey (n=29)Participants Patient Post Survey (n = 63)

7 14 21 28 35 42

NP Post/NP Follow: P = .16

All of the time Some of the time None of the time

Mean Score

P Post/P Follow: P = .02

Jelena Spyropoulos, PhD; Jovana Lubarda, PhD

Medscape Education, New York, NY

Concern for the patient’s risk of developing HSTCL

6.45.2

5.94.1

5.34.0

4.53.4

4.53.1

Fear of the patient developing complications such as anti-TNF antibodies

Availability/access to biologic drugs in the hospital/practice setting

Biologics are considered a last line option

Uncertainty about how to taper the patient’s steroid therapy to avoid steroid dependence

Nonparticipants (n = 40) Participants (n = 58)

0 2 4 6 8 10

P = .04

P = .001

P = .03

P = .05

P = .01

Figure 3. PAtient QuAlity oF liFe

Items from the SIBDQ were utilized to assess how inflammatory bowel disease (IBD)

symptoms affect the daily life of patients with CD. Responses to these items were

collapsed and averaged to provide a mean score of patients of participants

and patients of nonparticipants at 2 time points (higher number indicates fewer problems).

instructionAl Method

The curriculum consisted of 2 online CME activities:

1. A video-based 25-minute discussion with 2 leading experts on management of CD.6 The activity included a transcript of the discussion and a downloadable slide deck to highlight and reinforce key data and recommendations from the video discussion.

2. A case-based activity, including 2 relevant patient scenarios, challenging learners to determine the appropriate treatment and follow-up for the patient.7 After each question, a carefully detailed, fully referenced explanation of the most appropriate response is presented. By combining a case-based format with 4 to 6 questions per case, this format “tests” learners’ level of understanding on each item before delivering any education and “teaches” by correcting or reinforcing their existing understanding.

Both activities were available on the Medscape Mobile application, ensuring real-time access by the many clinicians who rely on mobile devices for education.

2. Patient survey

• Physicians agreeing to participate in the study were asked to distribute handouts containing a link to an online survey to their patients.

• The link directed the patient to a website where they completed a survey based on the Short Inflammatory Bowel Disease Questionnaire (SIBDQ).8

• Additionally, patients were asked to provide their email address so they could be contacted again in 4 to 6 weeks to reassess their symptoms and wellbeing at that time; data from the 2 time points were analyzed to characterize treatment success and overall quality of life and function.

study design

This study comprised 2 components: a healthcare provider and a patient assessment instrument (Figure 1):

HSTCL= Hepatosplenic T-cell lymphoma; TNF= Tumor necrosis factor.

Results

tABle 1. Physician Demographics Participants(n = 58)

Nonparticipants(n = 40)

Patients seen per week with Crohn’s disease, mean 18 11

Degree: MD/DO 100% 100%

Specialty Gastroenterology 100% 100%

Year graduated from medical school, mean 1989 1987

Attended medical school in the United States 76% 72%

Gender Male Female

84%16%

92%8%

Practice Location Urban Suburban Rural

36%53%10%

40%52%8%

Present Employment Solo practice Group practice Medical school HMO Non-governmental hospital Government Other

22%62%5%0%3%2%5%

22%68%8%0%2%0%0%

Major Professional Activity Direct patient care activities Administrative activities Medical education Medical research Other

91%0%3%2%3%

98%2%0%0%0%

tABle 2. Patient Demographics Participants(n = 63)

Nonparticipants(n = 71)

How long ago diagnosed with Crohn’s disease, mean (months) 106 125

Gender Male Female

37%63%

54%46%

Age 18 - 29 years 30 - 39 years 40 - 49 years 50 - 59 years 60 - 69 years 70 - 79 years 80 years or more

27%40%14%11%6%2%0%

20%23%25%17%13%3%0%

Race/Ethnicity American Indian or Alaskan Native Asian or Pacific Islander Black or African American, not of Hispanic orgin Hispanic White, not of Hispanci origin Other

2%2%8%5%

84%0%

8%0%6%7%

79%0%

Highest grade or year of school completed Grade 12 or GED College or technicial school 1-3 years College 4 or more years or college degree Graduated school 1 or more years

17%30%35%17%

15%34%31%20%

Current medications taking for Crohn’s disease Mesalamine Prednisone Azathioprine/other purine Biologic Other

19%16%19%71%5%

28%27%31%58%4%

Figure 1. Study Design

STAGE 1 STAGE 2 STAGE 3 STAGE 4 STAGE 5

CME/CE activities developed and

posted by Medscape. Participant

physician data collected by

Medscape and provided to CE

Outcomes.

Participants and control group

physicians invited to complete

physician survey. Upon competition

of survey, physicians received

materials to invite patients to

complete survey.

Patients from participant and

control group physicians

completed initial survey.

Patients from participant and

control group physicians

completed follow-up survey 4-6

weeks after completing initial

survey.

Data analyzed from physician

and patient surveys.