Article Text

Download PDFPDF

Stratification of inflammatory bowel disease outpatients by disease activity and risk of complications to guide out-of-hospital monitoring: a patient-centred quality improvement project
  1. Rishi K Fofaria1,
  2. Susan Barber2,
  3. Yewande Adeleke2,
  4. Tom Woodcock2,
  5. Nikolaos Kamperidis1,
  6. Alaa Mohamed1,
  7. Ravi Misra1,
  8. Ajit Shah3,
  9. Susan Bailey-Fee4,
  10. Howard Bluston4,
  11. Denise Robinson1,
  12. Tracey Tyrrell1,
  13. Naila Arebi1
  1. 1St Mark's Hospital, London, UK
  2. 2NIHR Collaboration for Leadership in Applied Health Research and Care for Northwest London, London, UK
  3. 3NHS Brent Clinical Commissioning Group, Wembley, London, UK
  4. 4Patient Panel, St Mark's Hospital, London, UK
  1. Correspondence to Dr Rishi K Fofaria; rishi.fofaria{at}


Background Inflammatory bowel disease (IBD) is a chronic relapsing-remitting condition affecting 600 000 people in the UK. Traditionally, patients attend outpatient clinics for monitoring regardless of their symptoms or risk of developing complications. This can lead to a mismatch between need and access: patients in remission given elective appointments displace those in need of urgent specialist attention. Novel initiatives implemented in the UK to improve outpatient monitoring have often required a well-maintained patient registry, empowered patients and significant information technology support.

Design and strategy In this large-scale quality improvement project at St Mark’s Hospital, a tertiary centre for IBD, we stratified over 1000 patients attending three non-complex IBD clinics over 12 months according to disease activity and risk profile. The aim was to offer a choice and subsequently transfer 50% of eligible patients to specialist nurse-led telephone clinics and demonstrate non-inferior satisfaction levels to existing outpatient follow-up. We also sought to ensure there was timely access to a newly established rapid access clinic for patients requiring urgent specialist attention.

A core project team consisting of healthcare professionals, patients and quality improvement scientists met regularly. The team tested and scaled up interventions using ‘Plan-Do-Study-Act’ cycles within the ‘Model for Improvement’ framework and analysed data continuously using statistical process charts.

Results Over 12 months, the average number of eligible patients transferred to telephone clinics rose from 17.6% (42/239) using a questionnaire method to 59.3% (73/123) using active discussion in clinic. Patient satisfaction scores remained high and non-inferior to baseline scores in face-to-face clinics. The median waiting time to be seen in the rapid access clinic was 6.5 days.

Conclusion This is the first published study to report on the successful stratification of patients with IBD based on disease activity and risk of complications to create a more responsive, sustainable and patient-centred model for IBD monitoring.

  • chronic disease management
  • hospital medicine
  • patient-centred care
  • quality improvement
  • outpatients

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

View Full Text

Statistics from


  • Contributors NA conceived the initial design for the study and chaired weekly project meetings with guidance from SB and YA. RKF, NK, AM, AS, SBF, HB, DR and TT helped codesign and implement the interventions with RKF, AM, NK and RM responsible for data collection and analysis. Senior quality improvement and data analysis expertise was provided by SB, YA and TW. All authors critically revised the manuscript and gave their approval for publication.

  • Funding This work was supported by a service improvement grant (IP103) awarded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Northwest London (NIHR CLAHRC NWL).

  • Disclaimer The views expressed in this article are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.