title: Intercenter variation in initial management of children with Crohn's disease.
abstract: BACKGROUND
  Variation in care is a ubiquitous feature of medical practice and may lead to significant differences in health care costs, quality, and outcomes. We undertook this study to determine the extent of intercenter variation in the initial management of children newly diagnosed with Crohn's disease.
  
  
  METHODS
  We analyzed the utilization of 5 classes of medication (immunomodulators, prednisone, antibiotics, 5-aminosalicylates, and infliximab) among 311 children with newly diagnosed Crohn's disease followed at 10 North American pediatric gastroenterology centers. Multivariate logistic regression was used to compare the utilization rate of each class of medication at each of the 10 centers, adjusting for potential confounders including patient age, sex, race, disease severity, and anatomic location of disease.
  
  
  RESULTS
  Median utilization of each class of medication was: immunomodulators, 56% (range 29%-97%); prednisone, 78% (range 32%-88%); antibiotics, 29% (range 11%-68%); 5-aminosalicylates, 63.5% (range 18%-92%); and infliximab, 7.5% (range 3%-21%). Each of these treatments showed statistically significant intercenter variation in utilization (P < 0.001 for immunomodulators, prednisone, antibiotics, and 5-ASA; P = 0.02 for infliximab). After adjusting for the demographic and clinical factors listed above, intercenter variation remained significant; however, the low utilization of infliximab precluded multivariate analysis.
  
  
  CONCLUSIONS
  Widespread intercenter variation in the medical management of newly diagnosed children with Crohn's disease was observed, even after adjusting for possible differences in case mix between institutions. This variation may lead to unintended differences in health care costs and outcomes.
authors.affiliation: Center for Inflammatory Bowel Disease, Division of Gastroenterology and Nutrition, Children's Hospital Boston, Massachusetts 02115, USA. michael.kappelman@childrens.harvard.edu
authors.forename: Michael D
authors.initials: MD
authors.lastname: Kappelman
authors.forename: Athos
authors.initials: A
authors.lastname: Bousvaros
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Hyams
authors.forename: James
authors.initials: J
authors.lastname: Markowitz
authors.forename: Marian
authors.initials: M
authors.lastname: Pfefferkorn
authors.forename: Subra
authors.initials: S
authors.lastname: Kugathasan
authors.forename: Joel
authors.initials: J
authors.lastname: Rosh
authors.forename: Anthony
authors.initials: A
authors.lastname: Otley
authors.forename: David
authors.initials: D
authors.lastname: Mack
authors.forename: Anne
authors.initials: A
authors.lastname: Griffiths
authors.forename: Jonathan
authors.initials: J
authors.lastname: Evans
authors.forename: Richard
authors.initials: R
authors.lastname: Grand
authors.forename: Christine
authors.initials: C
authors.lastname: Langton
authors.forename: Ken
authors.initials: K
authors.lastname: Kleinman
authors.forename: Jonathan A
authors.initials: JA
authors.lastname: Finkelstein
mesh_terms: D000293:Adolescent; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D000911:Antibodies, Monoclonal / Q000627:therapeutic use; D002170:Canada; D002648:Child; D003424:Crohn Disease / Q000188:drug therapy*; D004363:Drug Utilization; D005260:Female; D005765:Gastrointestinal Agents / Q000627:therapeutic use*; D006801:Humans; D007155:Immunologic Factors / Q000627:therapeutic use; D000069285:Infliximab; D016015:Logistic Models; D008297:Male; D019804:Mesalamine / Q000627:therapeutic use; D015999:Multivariate Analysis; D010818:Practice Patterns, Physicians'; D011239:Prednisolone / Q000627:therapeutic use; D011446:Prospective Studies; D012042:Registries; D014481:United States
chemical_list: D000900:Anti-Bacterial Agents; D000911:Antibodies, Monoclonal; D005765:Gastrointestinal Agents; D007155:Immunologic Factors; D019804:Mesalamine; D011239:Prednisolone; D000069285:Infliximab