IBD Drive Time: Corey Siegel, MD, on Defining Quality Care for IBD
Host Raymond Cross, MD, and Dr Corey Siegel delve into the factors that constitute quality care for patients with IBD today, and how the definition of quality care has evolved over time.
Raymond Cross, MD, is director of the IBD Center at Mercy Medical Center in Baltimore, Maryland, and professor of medicine at the University of Maryland.
Corey Siegel, MD, is the section chief of Gastroenterology and Hepatology and the codirector of the Inflammatory Bowel Disease Center at the Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire.
TRANSCRIPT:
Welcome everyone to IBD Drive Time. I'm Raymond Cross from Mercy Medical Center in Baltimore and I'm delighted to have a return guest, Corey Siegel, my friend from Dartmouth. And we're going to talk about quality care in IBD. Corey, welcome back to IBD Drive time.
Dr Siegel:
Thanks Ray. Pleasure to be here and I appreciate being invited back. Thank you.
Dr Cross:
So Corey, we talk about quality in IBDI think pretty frequently. Do we know what quality IBD care is?
Dr Siegel:
Yeah, you started with an easy one. I mean it's an evolving question with the answer of we're learning about what quality means in IBD and what good care looks like. And really I think the question is what does high quality care look like and can we measure it, right? I mean that's really kind of what we get at. And I say it's evolving because I recently look back at our original publication that Gil Melman and I did with the Crohn's and Colitis Foundation and many others that all of a sudden it's 2013 and it's almost a history lesson because when we look at it, we're talking about really low hanging fruit. There were only 10 quality indicators and one of them was checking C diff for flares in the hospital. Now it's not that it's not important, but it shows that at the time we weren't doing a good job at that because we thought it was important enough to make our top 10 list.
Another historical relic is checking TPMT every time we use thiopurines. Now it's no less important now, but in the landscape of IBD, it's become a lot less important. So things are evolved and then we recognize that those were mostly process measures that we really wanted to get at this concept of outcome measures and that's what we care about. So we got some traction on these processes, but one, we started talking about emergency room utilization, hospitalization, steroid use, opioid use, that's when it got more interesting and that's really where the focus has moved — let's keep people out of the hospital, out of the emergency room, off of corticosteroids. And I would argue now treat to target is something we're all thinking about, not just saying but doing. And really it all comes down to if you were to say what is the quality metric, now it's treating the right patient with the right treatment at the right time while protecting them from harm. And I think that kind of sums up. It's a very high level, but that sums up where we've come, from “We have to tell patients who smoke to stop and we should do TPMT testing” to what we need to use our medications in the right way.
Dr Cross:
Yeah, I think that's really, really well said. We've gone from basically checkbox quality to the bigger target of people getting their quality of life back without harming. I think it's well said. I think one other thing I think about is when I'm looking at someone who's not being taken care of well is CAT scan, CAT scan, CAT scan, CAT scan. Part of that is showing up in the emergency room, where it's automatic. But I think that's another metric of harm that you see — like you and I aren't doing 6 CAT scans in a year on a patient. That's not something that in our practice that we would do.
Dr Siegel:
Yeah, I've said the reason we picked ED as something that we wanted to focus on around outcomes, and when I say we, again working with Gil Melmed and the Crohn's and Colitis Foundation and a project, if we have time we can talk about, called IBD Qorus. But the reason we picked ED is every time somebody lands in the ED, they're at risk for what I refer to as the evil hat trick, which is you get a CT scan before they even examine you, they get a corticosteroid prescription, and opioids, and it's automatic. You get those 3 and then we'll figure out the rest. So ED seemed to be a confluence of things that happened that if we could prevent that, a lot of the downstream stuff gets prevented too.
Dr Cross:
And some of this is a bit nuanced and everything is nuanced in IBD, but I've thought about this—how you would give someone a report card and we can all think of that patient who you're really trying to get them off corticosteroids but you can't find the right therapy and they're stuck and that would look bad for you. But I think you're really looking at more like a population of patients that you're managing, correct. Not just the one individual patient.
Dr Siegel:
Right. Well yes, but there are different ways to look at it. So in again the Crohn's and Colitis Foundation's IBD course program, which is this national quality of care program, which we refer to as a learning health system that now includes 70 sites throughout the country. You get monthly reports about your practice's behavior in how many people are getting advanced therapy and which drugs, how many people were in the emergency room, how many people have been admitted, corticosteroids, opioids, scans, and then some really interesting metrics around treat to target, which is if your patient is not in remission, what are you going to do about it? And we force people to answer what your plan is if your patient's not in corticosteroid-free remission. So as you said, right now it's at a practice level, but it's not hard to take it a step further and think about it at a personal level and how you're doing. We just have chosen not to report it that way.
Dr Cross:
Are there other quality indicators that we haven't talked about? Corey? I love the evil hat trick. That's a good one.
Dr Siegel:
Yeah, thank you. I think there are other quality indicators, but I think one that we collectively as a field have to evolve towards is when is it appropriate to start advanced therapy and more so, when's it inappropriate not to? It's the same question looked in a different way, but for those of us who take care of a lot of IBD patients, the biggest frustration we are recognizing is that yeah, patients got on advanced therapy but they got on it 3 years too late. And how could we have done differently if we were to do a do over with that patient? And in most cases the answer is they should have been started on advanced therapy at diagnosis. So I think we have to do 2 things. One is how do we define when people really should be on advanced therapy? And two, how do we define when optimization is the right thing to do or switching drugs is the right thing to do in a treat to target environment? So we haven't really defined what the metric is to do that, but there is some metric that has something to do about appropriate medication utilization and you brought up causing harm with CT scans, but the biggest way we cause harm is under treatment. So we have to put that in the formula too.
Dr Cross:
Yeah, a couple of follow up. One is, I think it was you that said this, is we shouldn't be thinking about which Crohn's patient needs an advanced therapy. We should be thinking about what Crohn's patient doesn't need an advanced because the majority of Crohn's patients have moderate to severe disease. So when you get past that and you think of it a different way, then it sort of opens up the door for your advanced therapy. And I think you said that correct?
Dr Siegel:
I have said it. Maybe others have as well, but I think that's right. We focus too much on when to pull the trigger, but if we flipped it and said this small group of patients, it's fewer than 20% of patients can get away without advanced therapy and find those, then everybody else gets treated with effective drugs. Granted, Crohn's is a little bit different than ulcerative colitis here. I think what I just said is really more for Crohn's disease than with UC. There's a nice group of patients who do well on 5-ASAs, but there's also a nice group of patients who are on 5-ASAs for years who've never had healing and could have easily been advanced and kind of tolerate mild symptoms while their colon cancer risk accumulates over time. So I think we do have to change the mindset in our field that it's kind of like you get advanced therapy until proven otherwise.
Dr Cross:
And I wanted to circle back to another thing you said, the worst thing that we do for patients is undertreat them and don't control their inflammation. And now when I talk to patients about advanced therapy and the risks, I always follow that up by, and “by the way, poorly controlled disease is worse than anything I just mentioned and corticosteroids is far worse than that.” So that is a really, really important point. So maybe we've covered this already a bit, but what improvements have we made in quality do you think in the last decade? We'll come back to Qorus because that's specific, but just in general thinking nationally, have we made improvements in quality, do you think?
Dr Siegel:
So yes and no. I do think we've gotten better on the process measures that we talked about earlier. I think that it's likely unusual that patients aren't getting C diff testing when they get to the hospital. I think everyone's aware that smoking is bad for Crohn's disease. Whether you educate your patients well or not is another thing. I think we understand dysplasia surveillance better than we did 15 years ago, but I think this utilization of medications, at least the data would show that we're not making a lot of progress. And I find this a real source of frustration that I want us to all be frustrated about because there's a way to do better. And I have done work in this area where we looked at advanced therapy use in patients in the United States, not just at tertiary care centers and not just at IBD centers, but all players who are prescribing these medications for people with a diagnosis of Crohn's and colitis.
Up until 2016, granted that was almost 10 years ago, there were only 19% of patients with Crohn's disease that had ever been exposed to an advanced therapy and an amazing 6% in ulcerative colitis. So you and I just agreed that it's most patients and that I don't know what the right number is, but those aren't it. And so we redid it in 2021 thinking, all right, we've made some progress here, let's just see where we are. And we did it based on the assumption that early advanced therapy is what we should be talking about within the first 2 years. And within the first 2 years, only 14% of patients with Crohn's disease and 6% with UC had been on any advanced therapy while over 70% of them had been on corticosteroids. So it's not like it's a not sick group of patients. So we're doing something wrong. And I want to be very clear, this isn't academic centers versus community practices. Some of the best practitioners we learn from in an IBD course are community practice IBD specialists or community practice at least IBD-interested people who are really focused on this. And we can do better, but there's some major gap here that we're missing about medication utilization early on in their care. So while we have made some progress, I think this part of it we're inching our way forward and not going nearly at the clip that I think we need to.
Dr Cross:
I want to speculate with you here a bit. So I have a sense that—and I agree, there are many community providers and I think the Mid-Atlantic where I practice, I'm very fortunate there are a number of really, really good IBD-interested practitioners who take excellent care of patients. But thinking more globally about this, I feel like there's intense financial pressure on gastroenterologists and what we see more and more is they're spending more time in the endoscopy lab doing procedures and less time in the office. And the advanced practice providers are taking care of quite complex IBD and I feel like they don't have a lot of support and I don't know, do you have that same gestalt of the trends that are happening? And if so, what can we do to support these advanced practice providers and help them? These are super complicated. You and I are 20 years in practice and we're way better now than we were when we started. It's an enormous learning curve. What can we do to help them?
Dr Siegel:
I totally agree with you and I think APPs are a huge part of the solution for the future with the right support. And you and I and others have been part of APP education programs, but I think it's more than just giving lectures and inviting them to AIBD to listen to IBD Drive Time, to come to regionals, that it's more. I mean you and I didn't learn GI from reading books and seeing lectures. We learned it from having great mentoring and really kind of one-on-one feedback on what would you do in this situation.
So I think we need more of that. I think we need more partnerships with APPs with IBD specialists, even outside of the practice that they're working in and our gastroenterology colleagues who are doing endoscopy 8 or 9 out of 10 sessions a day, we need that too, because colon cancer is really important also. So it's not that we don't need that, but I think we have to start recognizing that there are gaps that happen in chronic GI care, not just IBD but chronic GI care when we have such a huge endoscopy burden, all of our practices have thousands and thousands of patients on a wait list for scopes. So it's not like we can just say, okay, we'll just see more patients in clinic. We need some other solution. And I do think APPs are part of that. It's a whole nother talk. We can talk out maybe at another Drive Time.
But we run this rural health program called Radius where we have mentoring programs with APPs and rural community practices. And it's been amazing for so many reasons. But the APPs I work with at these small practices in northern New England are as or more IBD-expert now than many of our colleagues across the country who don't see a lot of IBD, because they really are in it with regular mentoring, feedback on management, a kind of lifeline to call for questions as they go. And I love it. They love it and I think the patients are getting better care. So that's one version of how to do this, but we need to collectively come up with ways to help support our APPs because they can manage complex IBD, but they need it with mentoring just like we got.
Dr Cross:
Yeah, that's really awesome. I just want to remind the listeners that IBD Drive Time is sponsored by the AIBD network. We are on Spotify and Apple Podcast and the next AIBD regional is coming up in Chicago July 26th to July 27th. I'll be there. I hope to see you there.
Corey, let's talk about Qorus. What is Qorus and what are some of the achievements that you and Gil have been able to accomplish with that important study?
Dr Siegel:
Yeah, thank you. And I would say Gil, me, the Crohn's and Colitis Foundation and many others, and actually Frank Scott at the University of Colorado is coming on our leadership team just now as well, which is great. So thank you Qorus.
The idea of Qorus started over a decade ago when quality of care wasn't part of the conversation in IBD really at all. And I remember, I don't know if you were part of this meeting back then, Ray, but the first discussion was, well, how many people should get DEXA scans? That's how we started with quality of care. And guess what? Nobody was interested in putting a lot of time into DEXA scans, not because it's not important just because it's not where we think our biggest gaps are. And only when we started talking about processes and outcomes is I think when Gil and I were able to get the attention of the foundation and Tom Ullman was a big part of this early. So basically it's evolved from convincing the IBD community that quality of care is important to now this nationwide program called Qorus, which is spelled with a Q, it's Q-O-R-U-S. Q stands for quality and the word Qorus meant to be we all sound better together when we work as a group, how can we improve quality?
And we've looked at the process measures we, we already talked about emergency room visits and hospitalizations and steroid use. And now we're focused on treat to target and we use IHI Institute for Healthcare Improvement Methodology, something called a Breakthrough series collaborative that really focuses you on exactly what you want to improve and coming up with change ideas and then running quality improvement cycles, what we call PDSA or plan-do-study-act cycles to figure out what are we doing in our practice that could be better. Let's try a different way of doing it and measure it. If that doesn't work, let's try something else. And better yet, it went from just a handful of sites in the country to now, as I mentioned, over 70 sites, pretty close mix of community practice versus academic practices. And we learn from our shared successes and failures and we probably learn more from our failures than our successes. So it's this learning health system that we take the teaching that comes out of course and put it back into the system. And we've been able to do a lot of really cool work together that I think we're moving the needle on some of these quality metrics and even showing cost savings along the way. So we're really proud of where it's come. I still think we have a long way to go and we're thrilled that people are interested in joining our group and being part of it.
Dr Cross:
You want to give the listeners maybe one or two examples of maybe a project that failed, maybe a project that was successful?
Dr Siegel:
Yeah, let me use one project and I'll tell you how parts of it failed and parts were successful.
Dr Cross:
Perfect.
Dr Siegel:
The urgent care program, which was our patients often need urgent care. They might call overnight and get a fellow, they might call and get an answering service, they might call at 4:00 PM and the reflex has always been patient sounds sick, go to the ED. So we put processes in place that would help prevent that. Some of them worked really well, like having urgent care slots in your practice at certain times that are always there. So there's always an answer better than go to the ED.
With that said, some of it failed. We tried to go to the ED and try to educate the ED not to do CT scans all the time and not to do, just give out opioids. And guess what? The ED personnel changed all the time and you couldn't keep up. In fact, we created a card that we jokingly called the Don't Hurt Me card that said, show this to your ED provider if you ever end up in the emergency room and it says something like before you do a CT scan or give me corticosteroids, call my doctor. Well, you can imagine how ED doctors felt about this and you could also imagine that great, I'll call Siegel at midnight and tell him his patient's here, right? So stuff like that didn't work.
We had an urgent care hotline that was if you have an urgent problem, call this separate number. Not the general GI number, not the general IBD center number, but this urgent care number. And it worked for like 5 minutes until we started getting calls of, I'm going on vacation tomorrow, I need my prescription refilled. And oh, do you have an update on my prior auth? It just didn't work. So we abandoned it.
But others created these really nice things that have been sustainable. A very simple idea, something we call the IBD high risk list, means every practice now thinks about which of your patients are you really worried about, which are the ones that are kind of circling the emergency room that you think are going to go there? So don't just wait for it to happen. Let's put them on a list. And every week our IBD team has a meeting where we review that list patient by patient. Anyone has the ability to put a patient on that list. Our schedulers have the ability, our fellows have the ability, the colorectal surgeons have the ability, our nurses have the ability—that you just put 'em on the list and they definitely get discussed, why are you worried about this patient? And we address it proactively as opposed to saying, so-and-so was in the ED last night, what are we going to do about it? It's we're worried about this patient. So within a program like this urgent care process program, we had 25, 30 change ideas that we thought might improve care, but it turns out only really 4 of them made a difference. And we actually studied this. We looked at which ones had the biggest impact. So all the other stuff kind of went away and you end up sifting out which processes are helpful.
Dr Cross:
Just to summarize because the follow-up question I was going to have for practices that aren't part of Qorus or maybe smaller health systems, like some tips, so 3 that I got from what you just told me from that project are one, to have urgent care slots in your clinic, which is very doable. And I could hear the backlash of, well, they won't get filled. They always get filled. Exactly. They always get filled. So it's okay. They will be filled. Educate your patients about the things that can harm. And sometimes it's good to be a difficult patient. Say, do I really need the scan or wait, my doctor doesn't want me on prednisone. So you may not be able to teach the ED, but you can teach your patient. And then I think I forgot the third.
Dr Siegel:
The high risk list.
Dr Cross:
High risk list. Right? The high risk list. Thank you very much. And creating a list of your problem patients and reviewing them, not problem in that they're a problem, but that are high risk, and review them periodically with your team and try to have interventions. Any other tips? And it would seem to me that we could use electronic health records to help us with some of this. We've been thinking about that at Mercy and trying to develop smart reporting that would try to maybe flag people and identify high risk. What other tips do you have before we ask you a fun question?
Dr Siegel:
I think just going back to what we started with is don't think about who needs advanced therapy. Think about the few who don't. And to me, we're going to keep people out of the emergency room and out of the hospital and operating room and off of steroids and opioids if we treat people appropriately early. And I think early means at diagnosis, and yes, we may be overtreating some, but the undertreatment is what is leading to the harm, as we both said earlier. So in addition to those measures to keep people out of trouble, those are measures for when people are getting sick. Let's actually prevent that from happening. And the way to do that is our effective medications.
Dr Cross:
And for the skeptic listening to this, if there are skeptics, is if you start an advanced therapy, there's no rule of thumb anymore that you have to do it forever. You can give people a 4- or 5-year block. You can have a discussion about pros and cons of continuing versus stopping. And it's not like back when Corey and I were young faculty where if you started an anti-TNF, you had to keep going. If you stopped it, you could get immunogenicity, you would lose a line of therapy. That's not the world we live in now. We have the ability to stop therapies.
Dr Siegel:
I agree. And I predict that the future holds more de-escalation of care in our future, meaning let's treat really aggressively early and then back down for maintenance. And we're not quite there yet, but we're learning. And with all of our different options now and small molecules, I think we're going to be thinking about the paradigm differently. So yeah, I am fully with you. We are far beyond. You only have one biologic drug and after infliximab you're done. We're in a different world now.
Dr Cross:
So Corey, did you have another career path in mind or did you always want to be a doctor? And if you always wanted to be a doctor, what got you interested in IBD? Or maybe you could answer both of those.
Dr Siegel:
Yeah. Well, I have a fantasy career that I'd like to do. I had love to be a chef. Seriously. I would open a restaurant in a minute if I was actually taught how to be a chef.
Dr Cross:
I could be your partner.
Dr Siegel:
Yeah, that's what I'd actually love to do. I could think of many fun GI names also of what we can call it. And yeah, we could definitely partner on this. But with that said, I have no training other than if my kids say it's good, I do that again.
But the way I got interested in IBD was an evolution. I was interested in medicine as a kid. My family was in medicine. I initially thought maybe I'd be a psychiatrist and I actually, right—e all kind of are in a way. And then I thought I'd be a neurologist. And then I was actually in the neurology match in medical school. And then in my fourth year as you were starting to put your schedule together, I got a bad lottery number for electives. And I ended up with this GI elective at the Leahy Clinic, which is outside of Boston. And I was at Tufts in Boston. I didn't even have a car. So the whole thing was bad. It was a topic, it was a group I wasn't interested in working with necessarily in GI and I couldn't get there. But once I borrowed my, at the time, girlfriend, now wife's, car within 3 or 4 days on service, I said, I want to be a gastroenterologist.
And then the next person who came on service when I was there was a guy well named Rick McDermott who, for those who don't know him, I look at as one of the godfathers of our field. The first editor in chief of the IBD Journal, started AIBD, and just an amazing, amazing human. And he was on service. And it was back in the day that when you're on service, many of your own patients kind of come in and I got to know his IBD patients and spent the month with him. And I was smitten from that time. And he's the one who really turned this on for me.
Dr Cross:
Yeah, life is so weird. Serendipity, right? You get a bad lottery number and you get a rotation you don't want to do, and that becomes your career. And what would've happened if you didn't get that? It's interesting.
Dr Siegel:
Yeah, I'd be a chef. Maybe.
Dr Cross:
The greatest gift—coming back to cooking— the greatest gift I've got I received from my mom. She gave me this cookbook in a 3-ring binder of all the family recipes. So I would have them and then other things that she cooked that she added into that for me. And so you said if your kids say it's good, it's good. So if I make something, I keep adding it to my 3-ring binder.
Dr Siegel:
Nice.
Dr Cross:
And on the front of it, she has a picture of the villa we were at that I took her, we did a trip to Italy and that's the cover of the cookbook. So we'll have to share some recipes. Corey, this has been really wonderful. Thanks for doing this, and we hope to have you back again soon.
Dr Siegel:
Fantastic. I always love joining you and again, thanks for inviting me. Thank you.
