Appropriate Treatment for Crohn’s Disease: Methodology and Summary Results of a Multidisciplinary International Expert Panel Approach – EPACTVader J.-P.a · Froehlich F.b, d · Juillerat P.b · Burnand B.a · Felley C.b · Gonvers J.-J.b · Mottet C.b · Pittet V.a · Dubois R.W.c · Wietlisbach V.a, † · Michetti P.b
aInstitute of Social and Preventive Medicine, and bDivision of Gastroenterology, University of Lausanne, Lausanne, Switzerland; cCerner Health Insights, Beverly Hills, Calif., USA; and dDivision of Gastroenterology, University of Basle, Basle, Switzerland
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Article / Publication Details
Background/Aims: For many therapeutic decisions in Crohn’s disease (CD), high-grade evidence is lacking. To assist clinical decision-making, explicit panel-based appropriateness criteria were developed by an international, multidisciplinary expert panel. Methods: 10 gastroenterologists, 3 surgeons and 2 general practitioners from 12 European countries assessed the appropriateness of therapy for CD using the RAND Appropriateness Method. Their assessment was based on the study of a recent literature review of the subject, combined with their own expert clinical judgment. Panelists rated clinical indications and treatment options using a 9-point scale (1 = extremely inappropriate; 9 = extremely appropriate). These scenarios were then discussed in detail at the panel meeting and re-rated. Median ratings and disagreement were used to aggregate ratings into three assessment categories: appropriate (A), uncertain (U) and inappropriate (I). Results: 569 specific indications were rated, dealing with 9 clinical presentations: mild/moderate luminal CD (n = 104), severe CD (n = 126), steroid-dependent CD (n = 25), steroid-refractory CD (n = 37), fistulizing CD (n = 49), fibrostenotic CD (n = 35), maintenance of medical remission of CD (n = 84), maintenance of surgical remission (n = 78), drug safety in pregnancy (n = 24) and use of infliximab (n = 7). Overall, 146 indications (26%) were judged appropriate, 129 (23%) uncertain and 294 (52%) inappropriate. Frank disagreement was low (14% overall) with the greatest disagreement (54% of scenarios) being observed for treatment of steroid-refractory disease. Conclusions: Detailed explicit appropriateness criteria for the appropriate use of therapy for CD were developed for the first time by a European expert panel. Disease location, severity and previous treatments were the main factors taken into account. User-friendly access to EPACT criteria is available via an Internet site, www.epact.ch, allowing prospective evaluation and improvement of appropriateness of current CD therapy.
© 2006 S. Karger AG, Basel
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