Most gastroenterologists do not use Australia IBD guidelines to inform their treatment decisions, despite more than 92% reporting high levels of confidence in the recommendations provided by them.

In a national survey of 198 gastroenterologists only 21.7% reported regularly referring to Australian guidance on inflammatory bowel disease while 43% frequently used European guidelines .

Time shortages and difficulty in remembering specific advice came up as the main barriers to adhering to official guidance, with 62% and 61%, respectively, citing these issues. 

Meanwhile, 46% of respondents said they intentionally did not follow the guidelines because of their own clinical experience, according to investigators from Liverpool Hospital in Sydney. 

Despite this, the survey found the respondents performed poorly on several questions testing their knowledge of European Crohn’s and Colitis Organisation (ECCO) recommendations. 

According to the survey, gastroenterologists who had practised for more than 10 years were significantly less likely to refer to IBD guidelines than their colleagues who had been practicing less than 10 years.

“Whilst more experienced clinicians may be thought to provide higher quality care due to their accumulated knowledge, unless they remained informed of the latest evidence, their knowledge can easily become outdated,” said the authors in their paper published this week in Internal Medicine Journal.

Speaking to the limbic, lead author Dr Ria Kanazaki, consultant gastroenterologist and hepatologist, said several published studies both locally and internationally have identified suboptimal IBD care despite the availability of evidence-based guidelines, prompting her interest in investigating barriers to guidelines use.

“The Crohn’s and Colitis Australia National IBD audit similarly identified issues of suboptimal care and also variation in care depending on where patient care was received. There is little published research on the barriers to guideline adherence particularly in the inflammatory bowel disease space, so our aim was to identify the barriers to IBD guideline adherence for gastroenterologists and understand their attitudes towards guidelines, assess their IBD knowledge in specific areas and determine their preferred mode of education delivery,” she told the limbic.

Clinician confidence

Of the nine IBD management areas included in the survey, respondents reported the highest levels of confidence in monitoring and optimising immunomodulators (93.9%) and discussing risks of medical therapy with patients (93.9%).

Lowest confidence was reported in pregnancy and IBD (34.1%) and managing anti-tumour necrosis factor (anti-TNF) loss of response (29.1%).

The areas of IBD management that clinicians rated as the most difficult to manage were fistulising CD (26.8%) and loss of response to therapy, including primary and secondary loss of response, and treatment refractory disease (22.7%).

Meanwhile knowledge scores on 13 items relating to European guideline recommendations ranged from 3-12 with a mean score of 8.02.

Dr Kanazaki said there was a  ‘mismatch’ between clinician confidence in managing specific IBD areas and knowledge of guidelines.

For instance, participants reported high levels of confidence in managing immunomodulators but had limited knowledge of the ECCO guideline recommendations indicating altered dosing of a thiopurine in the setting of an abnormal TPMT result.

“Clinicians are time poor. Guidelines in their standard format are difficult to use at point-of-care to assist with decision making as the information needed is often hard to find. Our more recent studies are exploring how guidelines might be improved to better address these issues.”

While the results of those studies will be published later this year Dr Kanazaki has also conducted a study assessing an online intervention linked to an evidence-based guideline to evaluate its usability for clinicians.

“I think the current method of guidelines dissemination to educate clinicians can certainly be improved. What the best way is to do that  is still yet to be determined, but I hope our upcoming studies will help answer this question.”