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Quality Indicators for Inflammatory Bowel Disease: Development of Process and Outcome Measures

Melmed, Gil Y. MD, MS1,2; Siegel, Corey Allan MD, MS3,4; Spiegel, Brennan M. MD, MDHS2,5,6,7; Allen, John I. MD8; Cima, Robert MD9; Colombel, Jean-Frederic MD10; Dassopoulos, Themistocles MD11; Denson, Lee A. MD12; Dudley-Brown, Sharon PhD, RNP-BC, FAAN13; Garb, Andrew JD, MS, LLM14; Hanauer, Stephen B. MD15; Kappelman, Michael D. MD, MPH16; Lewis, James D. MD, MS18; Lynch, Isabelle RN, MBA19; Moynihan, Amy RN3,4; Rubin, David T. MD15; Sartor, R. Balfour MD17; Schwartz, Ronald M. MD20; Wolf, Douglas C. MD21; Ullman, Thomas A. MD22

doi: 10.1097/mib.0b013e31828278a2
Clinical Guidelines

Introduction: Variation in adherence to management guidelines for inflammatory bowel disease (IBD) suggests variable quality of care. Quality indicators (QIs) can be developed to measure the structure, processes, and outcomes of health care delivery. The RAND/UCLA appropriateness method was used to develop a set of process and outcome QIs to define quality of care for IBD.

Methods: Guidelines and position papers for IBD published from 2006 to 2011 were reviewed for potential QIs, which were rated by a multidisciplinary panel. Potential process and outcome QIs were discussed at 3 moderated in-person meetings, with pre-meeting and post-meeting confidential electronic voting. Panelists rated the validity and feasibility of QIs on a 1 through 9 scale; disagreement was assessed using a validated index. QIs rated above 8 were selected for the final set.

Results: More than 500 potential process QIs were extracted from guidelines. Following ratings and discussion by the first panel, 35 process QIs were selected for literature review. After the second panel, 10 process QIs were included in the final set. Candidate outcome QIs were then derived from physician, nurse, and patient input and ratings, in addition to outcomes associated with candidate process QIs. None of the top QIs exhibited disagreement.

Conclusions: A set of QIs for IBD was developed with expert interpretation of the literature and multidisciplinary input. Outcome QIs focused largely on remission and quality of life, whereas process QIs were aimed at therapeutic optimization and patient safety. Evaluation of these QIs in clinical practice is needed to assess the correlation of performance on process QIs with performance on outcome QIs.

Supplemental Digital Content is Available in the Text.Article first published online 6 February 2013

1Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California

2David Geffen School of Medicine at UCLA, Los Angeles, California

3Department of Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire

4New Hampshire and Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire

5Department of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, California

6CURE Digestive Diseases Research Center, Los Angeles, California

7UCLA/VA Center for Outcomes Research and Education, Los Angeles, California

8Department of Gastroenterology, Minnesota Gastroenterology, Minneapolis, Minnesota

9Department of Surgery, Mayo Clinic, Rochester, Minnesota

10Icahn School of Medicine at Mount Sinai, New York, New York

11Department of Gastroenterology, Washington University School of Medicine, St Louis, Missouri

12Department of Pediatrics, Cincinnati Children’s Hospital, Cincinnati, Ohio

13JSchool of Medicine & Nursing, Johns Hopkins University, Baltimore, Maryland

14Loeb & Loeb, Los Angeles, California

15Department of Medicine and Gastroenterology, University of Chicago, Chicago, Illinois

16Department of Pediatrics

17Departments of Medicine, Microbiology and Immunology, University of North Carolina, Chapel Hill, North Carolina

18Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania

19Department of Gastroenterology, VA San Francisco, San Francisco, California

20Minnesota Gastroenterology, Minneapolis, Minnesota

21Atlanta Gastroenterology Associates, Atlanta, Georgia

22The Dr. Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Mt. Sinai School of Medicine, New York, New York.

Reprints: Gil Y. Melmed, MD, 8730 Alden Dr., #203B, Los Angeles, CA 90048 (e-mail:

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Supported by the Crohn’s and Colitis Foundation of America.

Author disclosures are available in the Acknowledgements.

Received October 19, 2012

Accepted October 30, 2012

© Crohn's & Colitis Foundation of America, Inc.
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