Brief Article
Copyright ©2012 Baishideng Publishing Group Co., Limited. All rights reserved.
World J Gastroenterol. Mar 14, 2012; 18(10): 1085-1092
Published online Mar 14, 2012. doi: 10.3748/wjg.v18.i10.1085
Framework for assessing quality of care for inflammatory bowel disease in Sweden
Martin Rejler, Jörgen Tholstrup, Mattias Elg, Anna Spångéus, Boel Andersson Gäre
Martin Rejler, Jörgen Tholstrup, Department of Medicine, Highland Hospital, S-57581 Eksjö, Sweden
Boel Andersson Gäre, Jönköping Academy for Improvement of Health and Welfare, The School of Health Sciences, Jönköping University, Jönköping Academy, PO Box 1026, S 55111 Jönköping, Sweden
Mattias Elg, Division of Quality Management and Technology and HELIX Vinn Excellence Centre, Linköping University, S 58183, Sweden
Anna Spångéus, Department of Medical and Health Sciences, Faculty of Health Sciences, Linköping University, S 58183, Sweden
Author contributions: All authors contributed equally to the ideas and analysis; Rejler M was the main writer.
Supported by The Futurum Research Council, Jönköping County Council, the Foundation for Clinical Cancer Research in Jönköping County; and VINNVÅRD-research program for more effective and better health care
Correspondence to: Martin Rejler, MD, Department of Medicine, Highland Hospital, S-57581 Eksjö, Sweden. martin.rejler@lj.se
Telephone: +46-381-35501 Fax: +46-381-35509
Received: June 1, 2011
Revised: August 26, 2011
Accepted: January 22, 2012
Published online: March 14, 2012

Abstract

AIM: To create and apply a framework for quality assessment and improvement in care for inflammatory bowel disease (IBD) patients.

METHODS A framework for quality assessment and improvement was created for IBD based on two generally acknowledged quality models. The model of Donabedian (Df) offers a logistical and productive perspective and the Clinical Value Compass (CVC) model adds a management and service perspective. The framework creates a pedagogical tool to understand the balance between the dimensions of clinical care (CVC) and the components of clinical outcome (Df). The merged models create a framework of the care process dimensions as a whole, reflecting important parts of the IBD care delivery system in a local setting. Clinical and organizational quality measures were adopted from clinical experience and the literature and were integrated into the framework. Data were collected at the yearly check-up for 481 IBD patients during 2008. The application of the quality assessment framework was tested and evaluated in a local clinical IBD care setting in Jönköping County, Sweden.

RESULTS: The main outcome was the presentation of how locally-selected clinical quality measures, integrated into two complementary models to develop a framework, could be instrumental in assessing the quality of care delivered to patients with IBD. The selected quality measures of the framework noted less anemia in the population than previously reported, provided information about hospitalization rates and the few surgical procedures reported, and noted good access to the clinic.

CONCLUSION: The applied local quality framework was feasible and useful for assessing the quality of care delivered to IBD patients in a local setting.

Key Words: Quality measures, Inflammatory bowel disease, Value compass, Donabedian, Quality improvement


Citation: Rejler M, Tholstrup J, Elg M, Spångéus A, Gäre BA. Framework for assessing quality of care for inflammatory bowel disease in Sweden. World J Gastroenterol 2012; 18(10): 1085-1092
INTRODUCTION

In modern healthcare, there is often a gap between the expected level of healthcare delivery and the actual healthcare provided, as shown by McGlynn et al[1]. This is also true for the care of inflammatory bowel disease (IBD), as highlighted recently in an editorial by Siegel[2] and previously by Reddy et al[3] as well as by the American Gastroenterology Association[4] several years ago. There is still no framework or general quality measures for IBD as noted by Kappelman[5], who called for action and challenged the gastroenterology community to correct this.

IBD is a chronic disease with two primary subtypes; Crohn’s disease (CD), and ulcerative colitis (UC)[6]. The incidence of CD and UC in Sweden is approximately 6 and 15 per 100  000 inhabitants, respectively, and the prevalence is approximately 150 and 300 per 100  000, respectively[7]. Because of the early age at onset and the absence of curative treatment, the vast majority of patients require lifelong medical care, which periodically leads to intensive outpatient contact, hospitalizations, and occasionally surgery. Improved quality of care aims to minimize the symptoms of the disease, improve quality of life, and meet the goal of delivering the best possible value of care to the patient[8]. These targets are well captured in the Institute of Medicine’s mnemonic, stressing the need for safe, timely, efficient, evidence-based, effective, and patient-centered care (STEEEP)[9].

During the first years of the new millennium, the structure of care for IBD patients within the Gastroenterology Unit at the Department of Internal Medicine, Highland Hospital, Eksjö, Sweden was significantly redesigned as previously reported[10,11]. Along with the redesign, the need to be able to monitor the changes and the quality of care became obvious. Obvious also was the absence of any known framework and quality measures for the assessment of quality of care for IBD. To bridge this gap, a selection of clinical and organizational parameters were integrated into two generally acknowledged quality models adopted from Donabedian (Df)[12] and the Clinical Value Compass (CVC)[13], and were merged to form a quality framework. The collection of quality measures was accomplished as a part of the ordinary yearly check performed by a specialist nurse or by a gastroenterologist. The selected measures were integrated and applied to the quality framework as a means to assess the quality of IBD care in the local setting.

A quality assessment tool may be developed in several ways, and there are several critical steps when creating a quality framework; these include design, implementation, and utilization. Each of these factors must be addressed before the framework can be used. Furthermore, before the process of introducing a framework begins, insight into the complexity of care, an understanding of the systems used, and sound professional knowledge, all coupled with both enthusiasm and leadership, are required[8,14,15].

In this study, two generally acknowledged quality models were used. The first, according to Df[12], has been discussed previously by Kappelman et al[5] and testing on IBD care was suggested. Donabedian advises that the following questions are to be asked before using a quality framework[12]: “who and what activities are to be assessed”; “how are these activities supposed to be conducted”; and “what are they to accomplish?” These are all important questions to raise and are possible to apply to health care institutions. The model according to Donabedian derives the quality of care from the components of structure, process, and outcome. Structure denotes the attributes of the setting and includes the facilities, equipment, human resources, and organizational structure. Processes are defined by what is actually done in delivering and receiving care. Furthermore, outcome denotes the effects of care on the health status of patients and populations, conveys a production management perspective, and frames a delivery-focused approach by the organization.

The second model is the CVC[13]. It was derived from a management customer area, and offers a flexible framework where the outcomes of health care are perceived in four dimensions as follows: (1) functional; (2) economic; (3) satisfaction with health care; and (4) clinical outcome. The use of already existing measures is favored to avoid add-on routines, making it possible to fulfill the intertwined assignment to both manage the patient and improve care by measuring outcomes[16].

The Df offers a logistical, productive perspective to the studied case, and the CVC adds a management and service perspective. The framework creates a pedagogical tool to understand the balance between the dimensions of clinical care (CVC) and the components of clinical outcome (Df). Together they create a framework of the care process dimensions as a whole, reflecting important parts of the IBD care delivery system in a local setting.

Quality measures are valuable means of improving clinical practice. The use of quality measures may be defined as the process of collecting, computing, and presenting quantified constructs for the managerial purposes of following up, monitoring, and improving organizational performance[17]. The basis of this argument is that they play a significant role in the coordination of organizational activity[18], decision-making, prioritization[19], comparisons, and initiation of improvement processes[20]. In every effort to measure the performance, it is important to consider the desired application of the information obtained. The application of the information may be to control, budget, motivate, or improve the care[21]. As part of the explorative case study, well established measures such as hemoglobin, quality of life, medication, and access to care, which were practical to perform and used in daily clinical life, were chosen after a review of relevant literature and from clinical experience[22-24].

The aim of this study was two fold; firstly, to apply a generally acknowledged quality framework to the assessment and improvement of care for IBD, and secondly, to study and evaluate its application in a local clinical IBD care setting in Jönköping County, Sweden.

MATERIALS AND METHODS

The measures in this study originate from the Gastroenterological Unit responsible for all IBD care in the area, which is a part of the Department of Internal Medicine at the Highland Hospital in Eksjö, Jönköping County, Sweden. The unit includes an outpatient clinic, an inpatient ward with 15 beds, and an affiliated unit for endoscopic examinations[11]. The Highland health care system consists of eight health care centers for primary care, and the 280-bed Highland Hospital responsible for secondary and acute care, in all serving 110  000 inhabitants. The health care delivered is tax financed, and the county council functions both as insurer and provider of the care.

To date, no quality measures for IBD care have been generally approved. Feasible and practical quality measures were selected in order to evaluate the quality of care delivered within the local setting. The first act was to organize a registry with information, including patient addresses, diagnosis, disease duration, smoking habits, weight, and sex. Further information about the current prescribed medication and whether any surgical intervention had been performed was added to the files. Hemoglobin was chosen as the clinical marker to find anemia in the population, which may go undetected in many patients[25]. Further quality measures assessing the access to care[10] and quality of life (QoL) were chosen and integrated into the framework. Access was measured as the number of days from the referral being sent from the primary care physician until the patient received a scheduled consultation at the outpatient clinic, as well as the clinic’s ability to offer an acute visit within two days after contact by a known patient. QoL was measured by using the short health scale (SHS)[26,27]. SHS is a questionnaire consisting of four questions about symptoms, function, worry and general health associated with the disease, reported on a 6-point graded likert scale. Patients were diagnosed according to clinical, endoscopic, and microscopic findings, and were sub-typed as having UC or CD. A senior gastroenterologist confirmed the diagnosis and registration of each patient. The status of the disease, i.e., subjectively experienced activity, was reported by the patients on the day of the annual check-up. Tumor surveillance colonoscopy was offered and performed according to guidelines for more than 95% of relevant patients. At the end of 2008, 481 patients were included in the local registry.

During the year, all patients were offered an annual check-up, which was preceded by a letter including a quality of life questionnaire and instructions for laboratory testing (hemoglobin) that could be performed at any of the primary care centers. An important part of the annual check-up was to remind the patient to contact the nurse by telephone with any questions or worries raised during the remainder of the year. Reinforcing this opportunity for telephone access was aimed toward avoiding misdirected care for IBD to other care settings such as the Emergency Department. In the redesigned clinical model, there was also a guarantee that access to an unscheduled visit for acute symptoms would be available within two days at all times. Data was collected by the specialist nurse or gastroenterologist at the time of the check-up, and computed every quarter but presented once a year.

In Table 1 an overview of the definitions, quality dimensions and components, purposes behind the measures, operational definitions, and data sources of the quality measures are integrated into the two quality models together creating the framework.

Table 1 Overview of the quality framework presenting definitions, purposes, data sources and operational definitions for the adopted quality measures as well as properties of the applied models.
Characteristics of measures included in the frameworkProperties of the models included in the framework

Quality measure
Definition of measure
Data source and data collection
Operational definition of measure
Purposes for the measure adapted from Behn
Quality dimensionaccording to the clinical value compass
Quality components as part of the quality model of Donabedian
Patient dataDiagnosisInflammatory bowel diseaseLocal gastro registryCrohn’s disease and ulcerative colitisControl, evaluationClinical dimensionOutcome
GenderSexLocal gastro registryfemale:maleControl, learningClinical dimensionStructure
AgeLocal gastro registryAge [mean (SD)] rangeControl, learningClinical dimensionStructure
Disease durationDébut yearLocal gastro registryYears since time of diagnosis [mean (SD)] rangeControl, evaluationClinical dimensionOutcome
Laboratory measuresHemoglobinBlood sample enabling detection of anemia associated with chronic disease, blood loss, or iron deficiencyLocal gastro registry Tests were performed at the nearest primary care center and reported electronicallyCut-off points were defined as: mean (SD) normal ≥ 120 g/L, anemia 100-119 g/L severe anemia < 100 g/L missingControl, evaluationClinical dimensionOutcome
MedicationPrescribed medicineCurrently prescribed preventive medicationLocal gastro registryPrescribed medication: 5-ASA cortisone immunosuppressive anti-TNF-α no medicationControl, evaluationClinical dimensionProcess
Surgical interventionsIncidence of surgerySurgical interventions associated with IBDERS, searched for ICD codes for surgical interventions and IBD once a yearType and numbers of surgical interventions: colectomy hemicolectomy loop ileostomy perianal/fistula/ stricture incision revision abdominal scarEvaluationClinical and cost dimensionProcess
Tumor incidenceIncidence of gastrointestinal tumors associated with IBDData from the national tumor registry retrieved once a yearNumber and type of intestinal tumors associated with IBD according to diagnosis in records as ICD codeEvaluationClinical and cost dimensionOutcome
Quality of lifeThe Short Health Scale, SHSSHS is a health related quality of life questionnaire consisting of four questions graded on a 6 point Likert scale.Local gastro registryPercent scoring 1 to 3 representing that the goal of the care was reached symptoms functioning worry wellbeingEvaluationFunctional dimensionOutcome
Access to careWaiting timeReferral from primary to secondary careLocal administrative data baseNumber of days from the referral being sent from the primary care physician until the patient received a scheduled consultation at the outpatient clinicMotivation, budget, learning, evaluation, promotionA proxy for the satisfaction dimensionProcess and outcome
Waiting time for known patientsAn acute visit is used for an urgent need of assessment due to deteriorating diseaseLocal administrative data baseThe clinic’s ability to offer an acute visit within two days after contact for known IBD patientsMotivation, budget, learning, evaluation, promoteA proxy for the satisfaction dimensionProcess
Contact route (before being admitted to hospital)The place for the decision to admit the patient for inpatient care, i.e. either at the ER or the outpatient clinicERS Contact route was decided after finding indicators such as: where the note was written, if the note was written by an on call colleague or a gastroenterologistThe ERS was searched to find out where the decision was either at the ER or from the outpatient clinicLearningCost and a proxy for the satisfaction dimensionProcess
HospitalizationHospitalizationIndividual and total numbers of admittances for IBD patientsERS was searched for ICD codes and national data was retrieved from the National Board of Health and WelfareERS documented ICD code for IBD and hospitalisationMotivation, budget, evaluationCost dimensionProcess and outcome
Ethical considerations

The ethical committee at the University of Linköping, Sweden, approved this study.

RESULTS

The first main finding is the presentation regarding how locally-selected clinical quality measures, integrated into two complementary models to create a framework, could be instrumental in assessing the quality of care delivered to patients with IBD. Further, the second main finding is the results presented in Table 2 for the local IBD population using the framework. The data describe the epidemiology of a patient population in the local care setting for IBD. To be stressed is the fact that more than 95% of the patients with IBD in the area are cared for by our care unit. The incidence of IBD was slightly below the expected level according to Swedish data[7]. This is probably explained by the older age distribution in the studied rural area. The prevalence of anemia is less than previously reported. Medication is presented for Crohn’s disease and ulcerative colitis. Immunosuppressive medication, cortisone and anti-TNF-alpha are prescribed more for Crohn’s disease compared to ulcerative colitis. Further, 5-aminosalicylic acid is prescribed more for ulcerative colitis compared to Crohn’s disease. Table 2 show good access to care. Few surgical interventions were performed over the year. Three patients with ulcerative colitis underwent colectomy and three patients with Crohn’s disease underwent incisions due to fistulas or strictures. No tumor was found in the population. Data was not processed statistically for differences between groups.

Table 2 Quality framework applied to the inflammatory bowel disease care setting at the Department of Internal Medicine in Highland Hospital, Eksjö, Jönköping County, Sweden.
Quality measures from 2008Crohn’s diseaseUlcerative colitis
Patient dataDiagnosis194261
Gender
Female:male44%:56%42%:58%
Age (yr)
Mean (SD)53 (± 15)51 (± 15)
Range18-9020-91
Disease duration
Years since time of diagnosis
Mean (SD)20 (± 13)14 (± 10))
Range0-580-53
Laboratory measuresHemoglobin
Mean (SD)140 (± 12)143 (± 13)
Normal ≥ 120 g/L95%96%
Anemia 100-119 g/L4%4%
Severe anemia < 100 g/L< 1%0
Missing16%17%
MedicationPrescribed medicine
5-ASA43%56%
Cortisone16%4%
Immunosuppressant34%12%
Anti-TNF-α8%2%
No medication31%40%
SurgicalIncidence of surgery
interventionsType and numbers of surgical interventions:
Colonectomy3
Hemicolectomy11
Loop ileostomy1
Perianal/fistula/stricture incision31
Revision abdominal scar1
Tumor incidence
Number and type of intestinal tumors associated with IBD according to diagnosis in records as ICD code00
Quality of lifeThe Short Health Scale, SHS
Percent scoring 1 to 3 representing that the goal of the care was reached
symptoms95%98%
functioning88%95%
worry91%94%
wellbeing97%96%
Access to careWaiting time
Number of days from the referral being sent from the primary care physician until the patient received a scheduled consultation at the outpatient clinic< 3 wk< 3 wk
Waiting time for known patients
The clinic’s ability to offer an acute visit within two days after contact for known IBD patients< 2 d< 2 d
Contact route (before being admitted to hospital)
The ERS was searched to find out where the decision was either at the ER or from the outpatient clinic50%/50%50%/50%
HospitalizationHospitalization
ERS documented ICD code for IBD and hospitalisation2917

In the years before 2008, an average of 75% of the registered patients had a complete annual check-up documented, i.e., a telephone call or a visit in combination with QoL and/or laboratory tests. In 2008, patients without complete annual check-ups were offered a new visit or telephone call at the end of the year. Using this approach, 98% (471/481) of the IBD population had a documented annual check-up during 2008. Of nine patients not receiving a check-up, four refrained from participating in the study and five were missing. One patient (with CD) was excluded from the study because of particularly severe disease demanding various levels of hospitalization on a more or less continuous basis.

DISCUSSION

Quality improvement (QI) forms a link between the study of disease (science) and clinical care (management)[28] and provides better management of the planning, delivery, and assessment of care. The need for a general assessment tool for IBD care has been emphasized several times over a number of years[3,5]. This study is, to the best of our knowledge, one of the first to present how two generally acknowledged quality models[12,13] with integrated clinical quality measures can be applied as a quality framework and tested in clinical practice at a single center in an IBD population. The intent was to evaluate the quality of care delivered to a population of patients with IBD in the Highland health care area, Jönköping County, Sweden. Because there are few other frameworks currently available, there are problems with comparing results and usage, which needs to be done when future research is available.

The framework offers a map of the epidemiology of all patients affected by IBD in a local setting. This is a prerequisite and a foundation for any further analysis and improvement effort. Interesting results were found in the population as presented in the framework. Anemia is a well-known complication of IBD, caused by a combination of bone marrow suppression secondary to chronic inflammation and blood loss from intestinal bleeding. The reported prevalence of anemia from different IBD care settings and patient populations ranges from 9% to 74%[29]. In this study, anemia was detected in 4% of UC patients and 5% of CD patients, as shown in Table 1. Less than 1% had severe anemia. However, the mean hemoglobin for all study groups was comparable to that of a healthy control population. The detected prevalence of anemia has even improved compared to previous findings in the same population[10]. The clinic has used the findings of incipient anemia to offer extra visits to the outpatient clinic, and/or more thorough laboratory investigations to identify the reasons behind these findings. The analysis of hemoglobin is inexpensive, valid, and simple to perform. Treatment of anemia on an individual level is well established. Altogether, it is a feasible and useful finding to apply as a quality measure within a population.

Knowledge of how well guidelines for medication are implemented in an IBD patient population is sparse. The prescription pattern presented is in line with reports from centers in Norway[30,31] and Canada[32]. It provides an example of how quality measures can be directly related to guidelines and thus provides important information about the quality of care delivered[33]. The incidence and type of surgery is presented in Table 1. Surgical intervention rates were low in our study, and should be interpreted cautiously. The figures of access and number of hospital admittances for IBD could be used in future work as a benchmark for other clinics and as comparisons to national trends in Sweden or in America[34,35].

The future use of the framework is associated with the way in which data retrieval could be improved. This could be done in several ways. One way would be to retrieve the data directly from the electronic medical record (EMR), and a second way would be to provide opportunities for the patient to deliver self-reported outcome measures directly into the EMR. In order to achieve this for additional quality measures, several steps are required. First, the suggested framework and measures need to be tested, discussed, and refined in a broader setting. Secondly, the measures need to be presented and followed as “real time” data on both an individual and a group/subgroup level in order to allow benchmarking. Thirdly, it should be possible to correlate quality measures with prescriptions, days off from work, and further changes in medication and/or treatment. An example of a “feed-forward” quality register[36] is already in place for patients with rheumatoid arthritis within the Swedish Rheumatoid Arthritis Registry (SRAR)[37,38]. In the SRAR register, it is possible to track individual patients as well as patient populations both locally and nationally and use this information to, for example, correlate their clinical status with the timing of newly prescribed biological drugs and days off from work[39]. The SRAR is regarded as one of the best quality registries in Sweden, and can serve as a model for future IBD registry work.

This study presents how locally-selected clinical quality measures, integrated into two complementary models to develop a framework, could be instrumental in assessing the quality of care delivered to patients with IBD. The selected quality measures noted less anemia in the population than previously reported, provided information about hospitalization rates and the few surgical procedures reported, and noted good access to the clinic. We believe that this approach of organizing and regularly utilizing data within our system is sustainable, and will enable future improvement in the quality and value of care for our IBD patients. We propose that the suggested framework and quality measures should be further tested, evaluated, and refined within the gastroenterological community.

COMMENTS
Background

In modern healthcare, there is often a gap between the expected level of healthcare delivery and the actual healthcare provided. This is also true for the care of inflammatory bowel disease (IBD) as highlighted by the American Gastroenterology Association. These stakeholders have called for action and challenged the gastroenterology community to find systems for quality assessment and improvement in IBD.

Research frontiers

Since the publication “Crossing the Quality Chasm” by the Institute of Medicine in America on the brink of the new millennium, the urge to improve quality of care has been one of the main focuses in health care research. Unfortunately, few publications connecting this area to IBD have been published since that time.

Innovations and breakthroughs

The main outcome was the presentation of how locally-selected clinical quality measures, integrated into two complementary models to develop a framework, could be instrumental in assessing the quality of care delivered to patients with IBD. The selected quality measures of the framework noted less anemia in the population than previously reported, provided information about hospitalization rates and the few surgical procedures reported, and also noted good access to the clinic.

Applications

The framework offers a map of the epidemiology of all patients affected by IBD in a local setting. This is a prerequisite and a foundation for any further analysis and improvement effort.

Peer review

In this study, the authors created and applied a framework for quality assessment and improvement in IBD. They showed that the locally selected clinical quality measures, integrated into two complementary models to create a framework, could be instrumental in assessing the quality of care delivered to patients with IBD.

Footnotes

Peer reviewers: John B Schofield, MB, BS, MRCP, FRCP, Department of Cellular Pathology, Preston Hall, Maidstone, Kent, ME20 7NH, United Kingdom; Masahiro Iizuka, MD, PhD, Director, Akita Health Care Center, Akita Red Cross Hospital, 3-4-23, Nakadori, Akita 010-0001, Japan

S- Editor Lv S L- Editor Logan S E- Editor Zhang DN

References
1.  McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348:2635-2645.  [PubMed]  [DOI]
2.  Siegel CA, Melmed GY, Ullman TA. Improving quality of care in IBD: a STEEEP challenge. Inflamm Bowel Dis. 2010;16:134-136.  [PubMed]  [DOI]
3.  Reddy SI, Friedman S, Telford JJ, Strate L, Ookubo R, Banks PA. Are patients with inflammatory bowel disease receiving optimal care? Am J Gastroenterol. 2005;100:1357-1361.  [PubMed]  [DOI]
4.  Brotman M, Allen JI, Bickston SJ, Campbell DR, Huddleston JM, Peterson LE, Schoenfeld PS, Sennett CS, Willis JR. AGA Task Force on Quality in Practice: a national overview and implications for GI practice. Gastroenterology. 2005;129:361-369.  [PubMed]  [DOI]
5.  Kappelman MD, Palmer L, Boyle BM, Rubin DT. Quality of care in inflammatory bowel disease: a review and discussion. Inflamm Bowel Dis. 2010;16:125-133.  [PubMed]  [DOI]
6.  Nikolaus S, Schreiber S. Diagnostics of inflammatory bowel disease. Gastroenterology. 2007;133:1670-1689.  [PubMed]  [DOI]
7.  Ekbom A. The epidemiology of IBD: a lot of data but little knowledge. How shall we proceed? Inflamm Bowel Dis. 2004;10 Suppl 1:S32-S34.  [PubMed]  [DOI]
8.  Porter ME, Teisberg EO. How physicians can change the future of health care. JAMA. 2007;297:1103-1111.  [PubMed]  [DOI]
9.  Institute of Medicine Committee on Quality of Health Care in America.  In: Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001;.  [PubMed]  [DOI]
10.  Rejler M, Spångéus A, Tholstrup J, Andersson-Gäre B. Improved population-based care: Implementing patient-and demand-directed care for inflammatory bowel disease and evaluating the redesign with a population-based registry. Qual Manag Health Care. 2007;16:38-50.  [PubMed]  [DOI]
11.  Porter ME, Baron JF, Rejler M.  Highland District Country Hospital: Gastroenterology Care in Sweden. Boston, MA: Harvard Business School Press; 2009;.  [PubMed]  [DOI]
12.  Donabedian A. Criteria and standards for quality assessment and monitoring. QRB Qual Rev Bull. 1986;12:99-108.  [PubMed]  [DOI]
13.  Nelson EC, Mohr JJ, Batalden PB, Plume SK. Improving health care, Part 1: The clinical value compass. Jt Comm J Qual Improv. 1996;22:243-258.  [PubMed]  [DOI]
14.  Berwick DM. The science of improvement. JAMA. 2008;299:1182-1184.  [PubMed]  [DOI]
15.  Plsek PE, Greenhalgh T. Complexity science: The challenge of complexity in health care. BMJ. 2001;323:625-628.  [PubMed]  [DOI]
16.  Nelson EC, Godfrey MM, Batalden PB, Berry SA, Bothe AE, McKinley KE, Melin CN, Muething SE, Moore LG, Wasson JH. Clinical microsystems, part 1. The building blocks of health systems. Jt Comm J Qual Patient Saf. 2008;34:367-378.  [PubMed]  [DOI]
17.  Elg M, Kollberg B. Alternative arguments and directions for studying performance measurement. Total Quality Management. 2009;20:409-421.  [PubMed]  [DOI]
18.  Södergren B, Söderholm J. Sifferledning eller kunskapsledarskap? Osynlig företagsledning. Stockholm: Ekonomiska forskningsinstitutet vid Handelshögsk (EFI); 1999;246-264.  [PubMed]  [DOI]
19.  Kaplan RS, Norton DP.  The Balanced Scorecard. Boston, MA: Harvard Business School Press; 1996;.  [PubMed]  [DOI]
20.  Bergman B, Klefsjö B.  Kvalitet från behov till användning. 3 ed. Lund: Studentlitteratur; 2001;.  [PubMed]  [DOI]
21.  Behn RD. Why Measure Performance? Different Purposes Require Different Measures. Public Administration Review. 2003;63:586-606.  [PubMed]  [DOI]
22.  Wells CW, Lewis S, Barton JR, Corbett S. Effects of changes in hemoglobin level on quality of life and cognitive function in inflammatory bowel disease patients. Inflamm Bowel Dis. 2006;12:123-130.  [PubMed]  [DOI]
23.  Metge CJ, Blanchard JF, Peterson S, Bernstein CN. Use of pharmaceuticals by inflammatory bowel disease patients: a population-based study. Am J Gastroenterol. 2001;96:3348-3355.  [PubMed]  [DOI]
24.  Bergman R, Parkes M. Systematic review: the use of mesalazine in inflammatory bowel disease. Aliment Pharmacol Ther. 2006;23:841-855.  [PubMed]  [DOI]
25.  Gasche C, Berstad A, Befrits R, Beglinger C, Dignass A, Erichsen K, Gomollon F, Hjortswang H, Koutroubakis I, Kulnigg S. Guidelines on the diagnosis and management of iron deficiency and anemia in inflammatory bowel diseases. Inflamm Bowel Dis. 2007;13:1545-1553.  [PubMed]  [DOI]
26.  Hjortswang H, Järnerot G, Curman B, Sandberg-Gertzén H, Tysk C, Blomberg B, Almer S, Ström M. The Short Health Scale: a valid measure of subjective health in ulcerative colitis. Scand J Gastroenterol. 2006;41:1196-1203.  [PubMed]  [DOI]
27.  Stjernman H, Grännö C, Järnerot G, Ockander L, Tysk C, Blomberg B, Ström M, Hjortswang H. Short health scale: a valid, reliable, and responsive instrument for subjective health assessment in Crohn's disease. Inflamm Bowel Dis. 2008;14:47-52.  [PubMed]  [DOI]
28.  Batalden PB, Davidoff F. What is "quality improvement" and how can it transform healthcare? Qual Saf Health Care. 2007;16:2-3.  [PubMed]  [DOI]
29.  Wilson A, Reyes E, Ofman J. Prevalence and outcomes of anemia in inflammatory bowel disease: a systematic review of the literature. Am J Med. 2004;116 Suppl 7A:44S-49S.  [PubMed]  [DOI]
30.  Henriksen M, Jahnsen J, Lygren I, Aadland E, Schulz T, Vatn MH, Moum B. Clinical course in Crohn's disease: results of a five-year population-based follow-up study (the IBSEN study). Scand J Gastroenterol. 2007;42:602-610.  [PubMed]  [DOI]
31.  Henriksen M, Jahnsen J, Lygren I, Sauar J, Kjellevold Ø, Schulz T, Vatn MH, Moum B. Ulcerative colitis and clinical course: results of a 5-year population-based follow-up study (the IBSEN study). Inflamm Bowel Dis. 2006;12:543-550.  [PubMed]  [DOI]
32.  Hilsden RJ, Verhoef MJ, Best A, Pocobelli G. A national survey on the patterns of treatment of inflammatory bowel disease in Canada. BMC Gastroenterol. 2003;3:10.  [PubMed]  [DOI]
33.  Travis SP, Stange EF, Lémann M, Oresland T, Chowers Y, Forbes A, D'Haens G, Kitis G, Cortot A, Prantera C. European evidence based consensus on the diagnosis and management of Crohn's disease: current management. Gut. 2006;55 Suppl 1:i16-i35.  [PubMed]  [DOI]
34.  Nguyen GC, Tuskey A, Dassopoulos T, Harris ML, Brant SR. Rising hospitalization rates for inflammatory bowel disease in the United States between 1998 and 2004. Inflamm Bowel Dis. 2007;13:1529-1535.  [PubMed]  [DOI]
35.   Available from: http//www.sos.se.  [PubMed]  [DOI]
36.  Hvitfeldt H, Carli C, Nelson EC, Mortenson DM, Ruppert BA, Lindblad S. Feed forward systems for patient participation and provider support: adoption results from the original US context to Sweden and beyond. Qual Manag Health Care. 2009;18:247-256.  [PubMed]  [DOI]
37.  Carli C, Ehlin AG, Klareskog L, Lindblad S, Montgomery SM. Trends in disease modifying antirheumatic drug prescription in early rheumatoid arthritis are influenced more by hospital setting than patient or disease characteristics. Ann Rheum Dis. 2006;65:1102-1105.  [PubMed]  [DOI]
38.  Carli C, Bridges JF, Ask J, Lindblad S. Charting the possible impact of national guidelines on the management of rheumatoid arthritis. Scand J Rheumatol. 2008;37:188-193.  [PubMed]  [DOI]
39.  Askling J, Fored CM, Geborek P, Jacobsson LT, van Vollenhoven R, Feltelius N, Lindblad S, Klareskog L. Swedish registers to examine drug safety and clinical issues in RA. Ann Rheum Dis. 2006;65:707-712.  [PubMed]  [DOI]