Quality improvement in pediatric inflammatory bowel disease: Moving forward to improve outcomes

Table 1 Definitions of common quality improvement terms[17,18,22,23]

Term	Definition
Quality improvement	The overall framework used to describe the process of implementing evidence-based interventions to bridge the disparities currently present in various healthcare systems
Quality indicators	A set of measures used to assess the appropriateness and quality of health care. Quality indicators are considered the fundamental building blocks of quality improvement efforts
Structural indicators	Indicators having to do with the structure of the healthcare system (e.g., staffing, equipment, environment, electronic health records)
Process indicators	Indicators having to do with the process of providing care (e.g., investigations, treatments, interaction with patients)
Outcome indicators	Indicators having to do with assessing the outcome of patients (e.g., mortality, morbidity, quality of life, patient satisfaction)

Table 2 ImproveCareNow quality indicators assessed in Crandall et al[25,27] (of 19 total indicators developed)

Original set of quality indicators	Modified set of quality indicators	Results of quality improvement
Process: Diagnostic evaluation, disease phenotype, disease severity, body mass index including height and weight are all presented as separate measures under the domain titled: "Initial Diagnostic Evaluation"	Process: Assessing disease phenotype, disease severity, body mass index including height and weight were combined into a single "bundled" domain titled: Model classification	Increase in complete disease classification through the "bundled" measures: CD 38%b increase, UC 27%b increase
Outcome: Nutritional and growth status (those "at risk" with evaluation plans and those currently experiencing "failure" with treatment plans) are presented as separate domains	Outcome: Nutritional and growth status (those "at risk" and those currently experiencing "failure") are combined into the same domain, with no reference to further intervention plans based on the assessed status	Nutritional status: No changes in BMI z-scores for CD, however there was a 0.11 decrease in BMI z-score for UC (P = 0.01)
		Growth status did not change for CD and UC
Process: Treatment measures listed consist of measuring TPMT levels to ensure appropriate doses of thiopurine are prescribed	Process: Several other treatment quality indicators were included under the domain titled Treatment Measures which were not included in the original set such as anti-TNF therapy, skin test, screening for tuberculsois, appropriate infliximab and methotrexate dosage, among several others	Improved compliance with TPMT status assessment before prescribing thiopurines: CD 20%b increase, UC 23% increase
		Improvement in appropriate dose: CD 8%b increase, UC 41%b increase
	Outcome: Remission as an outcome measure was added (overall remission, prednisone free remission and sustained remission)	Only those with mild disease had significant changes to disease activity for CD and UC
	The absence of prescribing prednisone was also an added outcome measure	Remission rate (sPCDAI) increased 4% (P < 0.0001)
		Proportion with inactive disease improved: CD 13%, UC 11%
		Proportion who were not on prednisone increased by 4% for CD

^bP < 0.01. CD: Crohn’s disease; UC: Ulcerative colitis; BMI: Body mass index; TPMT: thiopurine methyltransferase; TNF: Tumor necrosis factor; sPCDAI: Short pediatric Crohn’s disease activity index.