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P388 Clinical care pathways are needed to decrease variability in the management of the hospitalised ulcerative colitis patient

S. Shah*, S. Naymagon, B. Cohen, B. Sands, M. Dubinsky

Mount Sinai Hospital, Gastroenterology, New York, New York, United States

Background

Timely initiation of effective therapy for hospitalised ulcerative colitis (UC) patients failing outpatient medical management is key to optimising clinical outcomes. However, variability in management is common. Clinical care pathways (CCPs) optimise outcomes by reducing variability in the management of specific clinical entities. We designed a survey assessing practice pattern variability across a single metropolitan-based hospital system to identify the relevance of a CCP in guiding the management of hospitalised UC patients.

Methods

A survey was distributed to providers in the divisions of gastroenterology (GI) and colorectal surgery assessing 3 components: 1) provider clinical experience, practice setting, and comfort level in managing hospitalised UC patients; 2) practice patterns based on a clinical vignette of 32 year-old hospitalised UC patient with severe hypoalbuminemia (< 3g/dL), rising CRP, anaemia, and Mayo 3 endoscopy not improving clinically; and 3) providers’ opinions on implementation of a CCP for the management of hospitalised UC patients. Descriptive and univariate analyses were performed.

Results

Of the 40/131 (30.5%) respondents, 75% were at least second year GI fellows/faculty, with 60% at least 5 years post-training. 95% manage or have recently managed hospitalised UC patients, with over 97% reporting comfort in managing such patients. Over 85% use IV steroids (IVS) as initial medical therapy in a hospitalised UC patient failing outpatient therapy, whereas 8.8% would initiate infliximab (IFX) or cyclosporine. Nearly 73% continue IVS for 3 days before deeming a patient steroid-refractory, with 23% using 5 days as the cut-off. In a patient failing IVS, 80% would initiate IFX, with over 70% choosing 5mg/kg and the remainder 10mg/kg as the initial dose. Dose choice was independent of level of training (p = 1). Those favouring 10mg/kg based their decision on hypoalbuminemia (75%), CRP (50%), symptom severity (50%), and endoscopy (37.5%), with 37.5% responding that dosing 10mg/kg is their standard practice in hospitalised UC patients. Over 90% favoured CCP implementation, citing benefits of improved quality of care (96.7%), decreased variability in medical management (80%), length of stay (63.3%), readmission (56.7%) and earlier surgical consult (50%).

Conclusion

In this survey of providers across a single metropolitan-based hospital system with experience and self-reported comfort in managing hospitalised UC patients, there was marked variability in care, most notably amongst steroid-refractory patients. The great majority of respondents favour implementation of a CCP. Prospective trials evaluating the effect of a CCP on outcomes and quality measures in the management of the hospitalised UC patient are needed.