Variation in care in pediatric Crohn disease.
OBJECTIVE
Variation in medical care can be a barrier to improving clinical outcomes. We aim to describe the variation in care of Crohn disease as provided by a broad sample of pediatric gastroenterologists.


METHODS
Two hundred forty-six Crohn disease patients of 93 pediatric gastroenterologists from 48 practice sites starting treatment with either thiopurine or infliximab were studied. We assessed variation in diagnostic testing that had been performed to establish the diagnosis of Crohn disease and to assess the phenotype, extent, and severity of disease. We also assessed variation in initial thiopurine and infliximab dosage and in nutritional therapy.


RESULTS
Diagnostic studies in which care was uniform included complete blood count, performed in 100% of patients, erythrocyte sedimentation rate and colonoscopy in 96%, and upper endoscopy in 89%. However, imaging of the small bowel had not been performed in 19%, and a stool test for pathogens had not been performed in 29%. Thiopurine methyltransferase (TPMT) had been measured in 61% of patients before treatment with a thiopurine; in 85%, TPMT was normal. Nonetheless, even when TPMT was normal, 40% of patients received an initial dose of thiopurine that was lower than recommended. Testing for tuberculosis before initiating treatment with infliximab was not performed in 30%. In addition, 36% of severely underweight patients were not receiving a multivitamin supplement, supplemental formula, or tube feeding.


CONCLUSIONS
There is variation in diagnostic and therapeutic interventions in the management of pediatric Crohn disease, and gaps exist between recommended and actual care.
Colletti
Richard B
RB
University of Vermont, Burlington, 05405-0068, USA. Richard.Colletti@UVM.EDU
Baldassano
Robert N
RN
Milov
David E
DE
Margolis
Peter A
PA
Bousvaros
Athos
A
Crandall
Wallace V
WV
Crissinger
Karen D
KD
D'Amico
Michael A
MA
Day
Andrew S
AS
Denson
Lee A
LA
Dubinsky
Marla
M
Ebach
Dawn R
DR
Hoffenberg
Edward J
EJ
Kader
Howard A
HA
Keljo
David J
DJ
Leibowitz
Ian H
IH
Mamula
Petar
P
Pfefferkorn
Marian D
MD
Qureshi
M Azim
MA
D000293:Adolescent; D000893:Anti-Inflammatory Agents / Q000627:therapeutic use; D000911:Antibodies, Monoclonal / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D003424:Crohn Disease / Q000175:diagnosis / Q000188:drug therapy / Q000628:therapy*; D005260:Female; D005762:Gastroenterology / Q000592:standards*; D006801:Humans; D000069285:Infliximab; D008297:Male; D008780:Methyltransferases / Q000378:metabolism; D011787:Quality of Health Care; D013851:Thinness / Q000178:diet therapy; D014376:Tuberculosis / Q000175:diagnosis
D000893:Anti-Inflammatory Agents; D000911:Antibodies, Monoclonal; D000069285:Infliximab; D008780:Methyltransferases; C022745:thiopurine methyltransferase