Limited uptake of ulcerative colitis 'treat to target' recommendations in real-world practice.
Bryant RV., Costello SP., Schoeman S., Sathananthan D., Knight E., Lau S-Y., Schoeman MN., Mountifield R., Tee D., Travis SPL., Andrews JM.
A 'Treat to Target' (T2T) approach has been proposed for ulcerative colitis (UC), with a target of combined clinical and endoscopic remission. The aim of the study was evaluate the extent to which proposed targets are achieved in real-world care, along with clinician perceptions and potential challenges.A multicentre, retrospective, cross-sectional review of patients with UC attending outpatient services in South Australia was conducted. Clinical and objective assessment of disease activity (endoscopy, histology, and/or biomarkers) was recorded. A survey evaluated Gastroenterologists' perceptions of T2T in UC. Statistical analysis included logistic regression and Fisher's exact tests.Of 246 patients with UC, 61% were in clinical remission (normal bowel habit and no rectal bleeding), 35% in clinical and endoscopic remission (Mayo endoscopic sub-score ≤1), and 16% in concordant clinical, endoscopic and histological (Truelove and Richards' Index) remission. Rather than disease-related factors (extent/activity), clinician-related factors dominated outcome. Hospital location and the choice of therapy predicted combined clinical and endoscopic remission (OR 3.6, 95% CI 1.6-8.7, p<0.001; OR 3.3, 95% CI 1.1-12.5, p=0.04, respectively). Clinicians used C-reactive protein (CRP) more often than endoscopy as a biomarker for disease activity (75% vs. 47%, p<0.001). In the survey, 45/61 Gastroenterologists responded, with significant disparity between clinician estimates of targets achieved in practice and real-world data (p<0.001 for clinical and endoscopic remission).Most patients with UC do not achieve composite clinical and endoscopic remission in 'real-world' practice. Clinician uptake of proposed 'Treat to Target' guidelines is a challenge to their implementation.