Coordinating Preventive Medicine in Patients With Inflammatory Bowel Disease: Whose Responsibility Is It Anyway?
Article Outline
Preventive medicine was a concept developed in the early 1970s in response to demands to control medical costs, as well as to improve the value, quality, and outcomes of health care delivery.1 The goals of this concept were to protect, promote, and maintain the health and well-being of patients, while preventing disease, disability, and premature death. The responsibility of health promotion and disease prevention fell on the patient's primary care physician who was able to stratify preventive measures based on the risk factors and existing diseases. Primary disease prevention is given to an asymptomatic individual (eg, immunization), secondary prevention is the treatment given to patients who already have developed risk factors or preclinical disease (eg, mammography), and tertiary prevention is targeted to symptomatic patients (eg, treatment of increased lipids in a patient who has had a myocardial infarct).
Although the responsibility of coordinating preventative medicine has not been in the hands of subspecialists, the article by Long et al2 suggests this role for gastroenterologists who are coordinating the care of patients with inflammatory bowel disease (IBD). Although the preventative medicine delivered to patients with IBD in the era before biologic and immune modulators was not different than that of the general population, immune modulator use has increased the risk of neoplasm and opportunistic infections in patients with IBD. Thus, secondary prevention must be considered in this population whose pharmacologic interventions have increased their baseline risk. It is important that these therapeutic approaches are balanced against potential side effects and risks. Although therapeutic outcome is paramount, limiting harm should be equally important. Unfortunately, the increased potential for harm caused by new therapeutics often is outside the traditional treatment area of the gastroenterologist, and physician responsibility for monitoring side effects remains unclear. Such lack of clarity concerning such responsibility has led to adverse side effects that could have been prevented.
Secondary prevention of cervical dysplasia and neoplasm traditionally has focused on regular-interval Papanicolaou (Pap) smears, but with the advent of an effective and safe human papillomavirus vaccine, prevention of cervical dysplasia caused by human papillomavirus types 16 and 18, which are associated with greater than 70% of cervical cancers, is possible.3 The American College of Gynecologists suggests yearly Pap smears for women younger than age 30 and screenings every 2 to 3 years for older women who have had 3 consecutive normal Pap smears. The American College of Gynecologists further suggests that women who are at greatest risk for cervical dysplasia, as a result of immune suppression, be screened at a greater frequency. The quadrivalent human papilloma virus vaccine (Gardasil; Merck and Co, Inc, Whitehouse Station, NJ) is recommended for women 9 to 26 years of age before initiating sexual activity. No specifications have been made based on immune suppression.4
Long et al studied the rate of cervical cancer screening in patients with IBD and identified risk factors associated with a low incidence of screening. Data are conflicting as to whether there is an increased risk of cervical cancer in patients with IBD, and, if so, whether it is a result of the disease process or of the immune modulator therapy.5, 6 Nonetheless, the authors suggest cervical cancer screening for all women and particularly if women with IBD are at an increased risk of cervical dysplasia.
Long et al used a large administrative database that included claims from 33 states to compare the rate of cervical cancer screening in women with and without IBD, and further evaluated whether the use of immune modulator therapy contributed to the likelihood of screening. Patients were identified by a diagnosis code of ulcerative colitis or Crohn's disease, and a disease-appropriate medication pharmacy claim. Clinical, economic, and social variables were evaluated for an association with cervical testing. The rate of screening was assessed in the high-risk population based on immune modulator use. The cases were matched to controls based on age and geography.
It was reassuring to see that more women with IBD had a primary care visit (P < .01) as compared with the matched controls and, further, that 70.4% of women with IBD (vs 65.2% of controls) received the recommended Pap smear screening over the 3-year window. In the detailed analysis of patients who had exposure to immune modulators, slightly fewer women with IBD underwent cervical testing (68.3% vs 71.7%; P < .01). Most important was that in multivariate analysis, patients with a primary care physician (PCP) had greater odds of undergoing cervical testing. Further, women with IBD who visited a PCP or obstetrician/gynecologist were twice as likely to obtain a Pap smear compared with women without a PCP or obstetrician/gynecologist visit (odds ratio, 2.28; 95% confidence interval, 1.89–2.75).
When the authors specifically evaluated women with IBD who had been exposed to immune suppressants, only 50.1% were screened with a Pap smear over a 15-month window, with those who visited a PCP having a higher rate of screening. Those with Medicaid had a significantly lower rate of Pap smear testing compared with those with commercial insurance (37.8% vs 50.4%; P < .01).
Although this study had limitations related to analysis of a large administrative database and unmeasured confounders such as previous hysterectomy and abstinence, it does raise awareness of the underutilization of cervical cancer screening in the IBD population. This becomes especially important given that a higher rate of abnormal Pap smears has been reported in several studies.7
Gastroenterologists must spearhead the effort of not only evaluating risks associated with current and upcoming therapy, but also establishing guidelines for secondary prevention in patients with IBD. Long et al have raised awareness of underutilization of cervical screening, and as gastroenterologists we must embrace secondary prevention of disease and coordinate the care given to patients with IBD. This coordination should include vaccinations and age-appropriate screenings that are specific for patients with IBD who are on immune modulators. Although the goal of treatment in patients with IBD is clinical remission of disease, the mantra of doing no harm while simultaneously helping the patient should be at the forefront of our treatment strategy.
References
- . Preventative medicine and health system reform (Improving physician education, training and practice). JAMA. 1994;272:688–693
- Suboptimal rates of cervical testing among women with inflammatory bowel disease. Clin Gastroenterol Hepatol. 2009;7:549–553
- . Clinical management guidelines for obstetrician-gynecologists (Number 44, July 2003). Obstet Gynecol. 2003;102:203–213
- . Cancer screening in the United States, 2008: a review of current American Cancer Society guidelines and cancer screening issues. CA Cancer J Clin. 2008;58:161–179
- . Higher incidence of abnormal Pap smears in women with inflammatory bowel disease. Am J Gastroenterol. 2008;103:631–636
- Cervical dysplasia and inflammatory bowel disease: no effect of disease status or immunosuppressants. Gastroenterology. 2008;134:A967
- . Higher incidence of abnormal Pap smears in women with inflammatory bowel disease. Am J Gastroenterol. 2008;103:631–636
Conflicts of interest The author discloses no conflicts.
PII: S1542-3565(09)00143-8
doi:10.1016/j.cgh.2009.02.017
© 2009 AGA Institute. Published by Elsevier Inc. All rights reserved.
