Controversies in Ulcerative Colitis: A Survey Comparing Decision Making of Experts Versus Community Gastroenterologists

Abstract

Background Despite the development of consensus guidelines in ulcerative colitis (UC), there remain several areas of uncertainty in the everyday management of this incompletely understood disease. We performed a national vignette survey to measure variations in decision-making in areas of controversy. Methods We constructed a survey with 3 vignettes to measure decision-making in 4 areas of controversy in UC: (1) dysplasia management, (2) 5-ASA dosing, (3) diagnostic testing for underlying Crohn’s Disease, and (4) treatment of steroid-refractory inpatient UC. We compared responses between a group of community gastroenterologists and UC experts. Results We received 192 responses (36% response). Compared to community gastroenterologists, UC experts were more likely to endorse colectomy for both unifocal and multifocal low grade dysplasia, use narrow band imaging and chromoendoscopy for surveillance colonoscopy, use high-dose 5-ASA for inducing remission, use long-term 5-ASA for cancer chemoprevention, order CT enterography to evaluate for Crohn’s disease, and to have a lower threshold to call for surgery consultation in steroid-refractory UC. There was little agreement regarding the optimal frequency of surveillance colonoscopy, even among experts. Most respondents favored using infliximab over cyclosporin in steroid-refractory UC. Conclusions Community gastroenterologists and UC experts vary dramatically in their approach to many areas of uncertainty in UC. The only area of consensus between groups is the use of infliximab over CSA in steroid-refractory UC – itself a controversial decision. These data suggest that current practice patterns are highly disparate, and focus attention on specific areas of disconnect that should be further investigated.

Use of Surveillance Colonoscopy in Medicare Patients with Inflammatory Bowel Disease prior to Colorectal Cancer Diagnosis

“…Our finding was consistent with prior studies of varied compliance with practice guidelines, in particular the low use of surveillance colonoscopy (25%) for patients with longstanding UC in an integrated healthcare delivery system in the USA [18,19,20,21,22]. IBD patients in our study sample presumably had CRC associated with longstanding colitis, although the retrospective nature of our study precluded detailed information on the duration, extent and severity of colitis.…”

“…Surveys of gastroenterologists showed that most gastroenterologists performed some form of surveillance for UC patients [18,19,20]. However, one survey suggested that only about half of IBD specialists and community gastroenterologists would recommend surveillance colonoscopy for a hypothetical patient with left-sided colitis [21]. Moreover, only 25% of patients with ≥8 years of UC underwent surveillance colonoscopy in an integrated healthcare delivery system in the USA [22].…”

Radiographic staging practices of newly diagnosed colorectal cancer vary according to medical specialty

“…Similar findings of improved guideline adherence among academic providers have been reported in surveillance colonoscopy interval patterns, dyspepsia management, and inflammatory bowel disease care. [22][23][24][25][26] Strengths of the study include the sample population undergoing staging at a diverse range of community and academic facilities, including 6 tertiary-care medical centers and 51 community hospitals. Only patients with available colonoscopy, pathology, and radiology reports were studied, thus increasing the data reliability.…”

Unmet Medical Needs in Ulcerative Colitis: An Expert Group Consensus

“…In addition, gastroenterologists may experience difficulty in assessing disease activity or severity as recommended by guidelines, and in applying treatment recommendations, in daily practice [69]. A survey conducted with community gastroenterologists and UC experts in the United States identified that, when it came to areas of uncertainty in UC treatment, dramatic variations in approach existed between the 2 groups [70].…”