John K. Marshall, MD
Volume 2 | Issue 10
A strong therapeutic alliance is fundamental to chronic disease management.(1) Unfortunately, patients with inflammatory bowel disease (IBD) may be reluctant to accept long-term therapy, as their decisions may be informed not only by their healthcare team, but by unfiltered information circulating on the internet. Negative attitudes to therapy can interfere with developing the trust in healthcare providers that is necessary for effective disease management. Shared decision-making, as part of the treat-to-target approach, can strengthen the physician-patient therapeutic alliance. Patients have a strong vested interest in improving their outcomes and avoiding complications, and they may become more engaged in their treatment by understanding the relevance of this strategy to long-term outcomes rather than the immediate process of disease management. The treat-to-target approach respects patient decisions and allows exploration of treatment alternatives, in concert with ongoing objective disease monitoring. Measuring progress toward the goal and discussing treatment adjustments facilitates patient engagement, increases patient confidence in the health care team, improves adherence and empowers patients.
An assessment of gastroenterologists’ perspectives on the use of shared decision-making in treatment selection for patients with IBD used interviews and online surveys (N=106).(2) The majority of gastroenterologists were familiar with shared decision-making and attempted to implement it in their practice, but only 12 % used a systematic, consistent, and documented approach. Important barriers to shared decision-making were lack of time, limited reimbursement, and poor access to appropriate tools. The study demonstrated that clinicians lack systematic approaches to implement shared decision-making.
The American Gastroenterological Association Institute clinical support tool, “Identification, Assessment, and Initial Medical Treatment In Crohn’s Disease,” incorporates clinical symptomatology, endoscopic assessment, risk stratification, and treatment selection into a practical algorithm to help clinicians assess patients and determine appropriate therapy.(3) This clinical support tool is complementary to the treat-to-target strategy. Quality indicators for IBD management have been proposed. Their integration into a treat-to-target strategy can reduce unnecessary practice variations, improve care, and optimize outcomes.
On average, biologic therapy is demonstrably more effective when administered early in the course of CD. However, our ability to identify patients who would benefit from this approach remains limited.(4) An individualized, web-based tool for patients and clinicians attempts to bridge this gap by predicting an individual patient’s risk of complications. The prediction model incorporates age; sex; disease duration, location, and phenotype; dates of disease complications and medication exposure; serologic immune responses; and NOD2 genotype status. After the prediction model was validated in external pediatric and adult patient cohorts, a patient-facing web-based tool was developed. This tool, which displays the 3-year individualized probability of complication development (Your Crohn’s Disease) and summarizes the benefits and risks of treatment options (Your Treatment Options), facilitates shared decision-making. Pilot testing with clinicians and patients found excellent comprehension. The risk stratification incorporated in this tool may also prove useful in supporting the cost-effectiveness of intensive therapy with payors and other accountable organizations. It will be critical for physicians to explain the predictions of this tool and review the therapy options with patients to ensure correct interpretation.(5)
The development of new tools to support shared decision-making can enhance the therapeutic alliance, especially in the context of the treat-to-target strategy.
Special Edition IBD Dialogue 2016 Volume 02: Treat-to-Target in IBD is made possible by an unrestricted educational grant from…