Avaliação estrutural das unidades de atenção integral às doenças inflamatórias intestinais no Brasil

QUARESMA, Abel Botelho; GUEDES, Ludmila Resende; BARROS, Jaqueline Ribeiro de; BAIMA, Júlio Pinheiro; IMBRIZI, Marcello; ZERÔNCIO, Marco Antônio; KOTZE, Paulo Gustavo; FLORES, Cristina; ,

Abel Botelho QUARESMA

designed and drafted the manuscript

gave important intellectual contribution

reviewed the final version of the manuscript

Universidade do Oeste de Santa Catarina, Joaçaba, SC, Brasil.

Pontifícia Universidade Católica do Paraná, Programa de Pós-Graduação em Ciências da Saúde, Curitiba, PR, Brasil.

https://orcid.org/0000-0002-3985-7402

Ludmila Resende GUEDES

designed and drafted the manuscript

gave important intellectual contribution

reviewed the final version of the manuscript

Hospital das Clínicas da Universidade Federal de Minas Gerais, Instituto Alfa de Gastroenterologia, Belo Horizonte, MG, Brasil.

Hospital Mater Dei, Belo Horizonte, MG, Brasil.

https://orcid.org/0000-0002-2524-1615

Jaqueline Ribeiro de BARROS

designed and drafted the manuscript

gave important intellectual contribution

reviewed the final version of the manuscript

Clínica Cliged, Macaé, RJ, Brasil.

https://orcid.org/0000-0003-1451-8794

Júlio Pinheiro BAIMA

designed and drafted the manuscript

gave important intellectual contribution

reviewed the final version of the manuscript

Universidade Nove de Julho, Bauru, SP, Brasil.

Hospital das Clínicas de Botucatu, Botucatu, SP, Brasil.

https://orcid.org/0000-0002-4035-3113

Marcello IMBRIZI

designed and drafted the manuscript

gave important intellectual contribution

reviewed the final version of the manuscript

Universidade Estadual de Campinas, Campinas, SP, Brasil.

https://orcid.org/0000-0001-5397-0084

Marco Antônio ZERÔNCIO

designed and drafted the manuscript

gave important intellectual contribution

reviewed the final version of the manuscript

Hospital Geral Promater do Grupo United Health, Natal, RN, Brasil.

https://orcid.org/0000-0002-1006-1101

Paulo Gustavo KOTZE

designed and drafted the manuscript

gave important intellectual contribution

reviewed the final version of the manuscript

Pontifícia Universidade Católica do Paraná, Programa de Pós-Graduação em Ciências da Saúde, Curitiba, PR, Brasil.

https://orcid.org/0000-0002-2053-5315

Cristina FLORES

designed and drafted the manuscript

gave important intellectual contribution

reviewed the final version of the manuscript

Centro de Doenças Inflamatórias Intestinais do Rio Grande do Sul, Porto Alegre, RS, Brasil.

https://orcid.org/0000-0003-1623-4525

On behalf of GEDIIB

Corresponding author: Abel Botelho Quaresma. E-mail: abel@proctoclinic.com.br

Declared conflict of interest of all authors: none

Calvet et al	ECCO	PANCCO and GETECCU	Chen and Shen
Hospital characteristics	1. An IBD unit provides an interdisciplinary approach to the patient	1. The Center of Excellence	1. IBD center should have a fixed MDT that includes gastroenterologists and surgeons, radiologists, pathologist, pharmacist, psychologist, obstetricians and gynecologist, and pediatrician to handle special cases. The team holds multidisciplinary case discussion regularly at least twice a month.
1. The Inflammatory Bowel Disease Comprehensive Care Units (ICCU) should have a dedicated outpatient clinic with nurse care.	2. A structured interdisciplinary team for IBD has:	(COE) must have installations for outpatient care, at which drugs can be intravenously administered.	2. IBD center has a fixed clinical dietitian.
2. The ICCU should have outpatient facilities where drugs can be administered intravenously.	- an identified specialist	2. The COE must be affiliated with a hospital that has an emergency service.	3. IBD center should have specialized nurses.
3. The ICCU should be integrated in a hospital with an Emergency Department.	- an identified nurse	3. The COE must be affiliated with a gastroenterology department that has hospitalization installations.	4. Specialized outpatient unit is necessary in IBD center.
4. The ICCU should be integrated in a Digestive Disease Department that has hospitalization facilities.	- an identified surgeon and clear referral pathway for complex IBD surgery such as ileoanal pouch	4. The COE must be affiliated with a hospital with a gastrointestinal endoscopy service.	5. IBD centers require a relatively fixed and reasonable number of hospital beds or specialized wards for IBD patients.
5. The ICCU should be integrated in a hospital with an Endoscopy Unit. Specific ICCU facilities	- an identified pathologist	5. The COE must provide specialized outpatient consultation for patients with IBD.	6. All centers should have an electronic database.
6. There should be outpatient specialized clinics for IBD patients.	- an identified radiologist	6. The COE must have at least one nurse that is specialized in IBD.	7. In these evaluation centers, standard operating procedure (SOP), including standardized screening, biological agent infusion process is necessary.
7. The ICCU should have a telephone service for patient consultation.	- an identified dietician/nutritionist or a clear pathway for referral	7. The COE must have a colorectal surgeon or a surgical team with experience in the surgical treatment of patients with IBD.	8. Capsule endoscopy and enteroscopy should be the regular routine examination items.
Registers	- an identified stoma management specialist or a clear pathway for referral an identified endoscopist	8. The COE must include a radiologist with experience in IBD.
8. The ICCU should have a registry of all the IBD patients.	- an identified psychologist or a clear pathway for referral	9. The COE must have access to computed tomography (CT) imaging.
9. The ICCU should have a registry of IBD patients receiving biological drugs.	- a link to a pharmacist or a health care	10. The COE must have access to MRE and pelvic magnetic resonance imaging (MRI).
Personnel	3. At least one member of the multidisciplinary team provides patient education, counselling, emotional support, liaison, and continuity	11. The COE must have access to a diagnostic and therapeutic endoscopy unit with expertise in IBD.
10. The ICCU should have at least one IBD specialized nurse.	4. An IBD unit provides access to other ap- propriate medical specialties [e.g., rheumatologists, dermatologists, infectious disease specialists] to manage specific situations related to IBD in a timely manner
	5. An IBD unit has a named lead for the service
	6. An IBD unit develops and updates in-house departmental guidelines
	7. An IBD unit develops and updates quality indicators
	8. An IBD unit provides a contact line for the patient
	9. An IBD unit has outpatient facilities where

1	Public or private health?
2	Localization and name of the center
3	Ambulatory care only, hospitalized patient or both
4	Multidisciplinary team at the center or referral
5	Nutritionist, nurse, psychologist
6	Ophthalmologist, rheumatologist, digestive surgeon, proctologist, radiologist, gastroenterologist, endoscopist, psychiatrist, pathologist, dermatologist, nutrologist
7	Surgeon with IBD experience
8	Scientific meetings and frequency
9	Fellows in IBD
10	Telemedicine
11	Easy access if flare
12	Emergency service
13	Hospitalized care with IBD specialist
14	Endoscopic exams and interventions
15	Endoscopy, colonoscopy, enteroscopy
16	Endoscopic dilatation
17	Radiologic exams
18	Computed tomography enterography and magnetic resonance enterography
19	Radiologist with experience in IBD
20	Infusion center for intravenous and subcutaneous drugs
21	IBD patient’s registry
22	IBD specialized nurse
23	Evidence based protocols
24	Patient’s satisfaction methodology

Public Centers			Private Centers
Region	Frequency	%	Region	Frequency	%
Midwest	5	11.9	Midwest	5	10.9
North	1	24	North	0	0
Northeast	9	21.4	Northeast	7	15.2
South	5	11.9	South	8	17.4
Southeast	22	52.4	Southeast	26	56.5
Total	42	100	Total	46	100

Public center city	Public centers	State	Private center city	Private centers	State
Belo Horizonte	2	MG	Avaré	1	SP
Botucatu	1	SP	Barretos	1	SP
Brasília	2	DF	Belo Horizonte	3	MG
Campinas	1	SP	Blumenau	1	SC
Cascavel	1	PR	Botucatu	1	SP
Cuiabá	1	MT	Brasília	1	DF
Curitiba	1	PR	Campina Grande	1	PB
Dourados	1	MS	Campinas	1	SP
Fortaleza	1	CE	Campo Grande	1	MS
Gama	1	DF	Canoas	1	RS
Guarulhos	1	SP	Cascavel	1	PR
Itajaí	1	SC	Curitiba	1	PR
João Pessoa	1	PB	Divinópolis	1	MG
Juiz de Fora	1	MG	Goiânia	2	GO
Maceió	1	AL	Ipatinga	1	MG
Manaus	1	AM	Joaçaba	1	SC
Natal	1	RN	Juazeiro do Norte	2	CE
Niterói	1	RJ	Macaé	1	RJ
Passo Fundo	1	RS	Marília	1	SP
Porto Alegre	1	RS	Mossoró	1	RN
Recife	1	PE	Natal	1	RN
Rio de Janeiro	4	RJ	Niterói	1	RJ
Salvador	1	BA	Porto Alegre	3	RS
Santos	1	SP	Rio de Janeiro	3	RJ
São José do Rio Preto	1	SP	Salvador	1	BA
São Paulo	4	SP	Santo André	1	SP
Aracajú	1	SE	Santos	2	SP
Serra	1	ES	São Carlos	1	SP
Teresina	2	PI	São Paulo	4	SP
Uberlândia	2	MG	Sinop	1	MT
Vitória	2	ES	Teresina	1	PI
			Três Rios	1	RJ
			Vitória	1	ES
			Volta Redonda	1	RJ
Total	42		Total	46

	Public (n=42)	Private (n=46)	P
Multidisciplinary team	42	37	0.002
Surgeon with IBD experience	33	39	0.451
Telemedicine	13	25	0.027
Easy access if flare	40	41	0.29
Emergency service	25	25	0.624
Hospitalized care with IBD specialist	36	34	0.17
Endoscopy	39	38	0.147
Colonoscopy	38	39	0.42
Enteroscopy	5	9	0.326
Small bowel capsule endoscopy	4	19	<0.001
Therapeutic endoscopist	33	39	0.451
Enterography (CT or MRI)	34	41	0.28
Radiologist with IBD experience	30	35	0.619
Infusion center	33	24	0.01
IBD patient’s registry	26	39	0.015
Experienced IBD Nurse	13	17	0.553
Evidence-based protocols	34	36	0.755
Patient’s satisfaction methodology	7	22	0.002

	Standard A*	Standard B*	Standard C*
T E A M	MTDs consisting of all members in the same institution (gastroenterologist, surgeon, endoscopist, pathologist, radiologist, nurse, nutritionist, psychologist, rheumatologist, ophthalmologist, dermatologist, OG, social worker and pharmacist), all with experience in IBD. Regular multidisciplinary meeting to discuss cases (minimum monthly). Participation of the MTDs in IBD research.	MTDs**: gastroenterologist, surgeon, endoscopist, nurse, nutritionist with experience in IBD working in the same institution. Referenced professionals with experience in IBD: pathologist, radiologist, psychologist, rheumatologist, ophthalmologist, OG, dermatologist, social worker and pharmacist. Monthly multidisciplinary meeting to discuss cases.	MTDs**: gastroenterologist, surgeon, endoscopist, pathologist, radiologist, nurse, nutritionist, psychologist, rheumatologist, ophthalmologist, dermatologist, OG, social worker, and pharmacist, preferably with experience in IBD, referenced outside the institution.
S T R U C T U R E	Specific clinic for IBD. Diagnostic and therapeutic digestive endoscopy service with double-balloon and/or small bowel capsule endoscopy. Radiology service with CT/MR enterography. Infusion Center. Access to emergency care at the institution. Appropriate structure to deal with cases of severe acute colitis. Specific registry of patients with IBD. Specific record for biological medication. Open appointment for suspected reactivation and possible cases of hospitalization. Active participation of the responsible specialist in decisions during hospitalization. Ease of contact for problems related to treatment. Designation of a specialist doctor for each patient. Self-assessment system and information material for the patient.	Specific Clinic or Outpatient Clinic for IBD. Diagnostic and therapeutic digestive endoscopy service; enteroscopy and/or capsule not mandatory. Radiology service with CT/MR enterography. Infusion of biologicals in the institution according to protocols. Specific record of patients with IBD and for biologicals. Open access for suspected flares. Access to emergency care. Ease of contact for problems related to treatment. Appointment of a responsible specialist physician for each patient in the unit. Information material for the patient.	Clinic or outpatient clinic referred for IBD. Diagnostic and therapeutic digestive endoscopy service referred outside the institution. Radiology service with CT/MR enterography outside the institution. Specific record of patients with IBD. Specific record for biological medication. Appointment of open consultation for suspected flares. Ease of contact for treatment problems. Information material for the patient.
S U R G E R Y	Specific registry for surgical patients. Inpatient service with specialized IBD surgeons. Elective surgeries performed only by staff surgeons. Pre-surgical care with stoma care nurses. Ileal pouch performed only by trained and experienced surgeons. Documentation of pre-surgical risk and benefit guidelines (informed consent).	External access to inpatient service with specialized surgery for IBD	External access to inpatient service with specialized surgery for IBD
P R O T O C O L S	Use of updated protocols or adherence to international diagnostic and treatment guidelines. Use of drug protocols (preparation for immunosuppression and appropriate clinical monitoring for each therapy). Use of a specific protocol for patients treated at the institution’s emergency room. Treatment protocols in pregnancy/lactation. Colorectal cancer prevention program in accordance with international guidelines. Antithrombotic therapy for all inpatients with IBD. Medication consent for patients taking medication.	Use of updated protocols or adherence to international diagnostic and treatment guidelines. Use of drug protocols (preparation for immunosuppression and appropriate clinical monitoring for each therapy). Use of a specific protocol for patients treated at the institution’s emergency room. Treatment protocols in pregnancy/lactation. Colorectal cancer prevention program in accordance with international guidelines. Antithrombotic therapy for all inpatients with IBD. Medication consent for patients taking medication.	Use of updated protocols or adherence to international diagnostic and treatment guidelines. Use of drug protocols (preparation for immunosuppression and appropriate clinical monitoring for each therapy). Use of a specific protocol for patients treated at the institution’s emergency room. Treatment protocols in pregnancy/lactation. Colorectal cancer prevention program in accordance with international guidelines. Antithrombotic therapy for all inpatients with IBD. Medication consent for patients taking medication.

[1] Corresponding author: Abel Botelho Quaresma. E-mail: abel@proctoclinic.com.br

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Avaliação estrutural das unidades de atenção integral às doenças inflamatórias intestinais no Brasil

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