Assessment of steroid use as a key performance indicator in inflammatory bowel disease-analysis of data from 2385 UK patients.

BACKGROUND: Patients with IBD are at risk of excess corticosteroids. AIMS: To assess steroid excess in a large IBD cohort and test associations with quality improvement and prescribing. METHODS: Steroid exposure was recorded for outpatients attending 19 centres and associated factors analysed. Measures taken to avoid excess were assessed. RESULTS: Of 2385 patients, 28% received steroids in the preceding 12 months. 14.8% had steroid excess or dependency. Steroid use was significantly lower at 'intervention centres' which participated in a quality improvement programme (exposure: 23.8% vs 31.0%, P < .001; excess 11.5% vs 17.1%, P < .001). At intervention centres, steroid use fell from 2015 to 2017 (steroid exposure 30.0%-23.8%, P = .003; steroid excess 13.8%-11.5%, P = .17). Steroid excess was judged avoidable in 50.7%. Factors independently associated with reduced steroid excess in Crohn's disease included maintenance with anti-TNF agents (OR 0.61 [95% CI 0.24-0.95]), treatment in a centre with a multi-disciplinary team (OR 0.54 [95% CI 0.20-0.86]) and treatment at an intervention centre (OR 0.72 [95% CI 0.46-0.97]). Treatment with 5-ASA in CD was associated with higher rates of steroid excess (OR 1.72 [95% CI 1.24-2.09]). In ulcerative colitis (UC), thiopurine monotherapy was associated with steroid excess (OR 1.97 [95% CI 1.19-3.01]) and treatment at an intervention centre with less steroid excess (OR 0.72 [95% CI 0.45-0.95]). CONCLUSIONS: This study validates steroid assessment as a meaningful quality measure and provides a benchmark for this performance indicator in a large cohort. A programme of quality improvement was associated with lower steroid use.

Using a Scenario-Neutral Framework to Avoid Potential Maladaptation to Future Flood Risk.

This study develops a coherent framework to detect those catchment types associated with a high risk of maladaptation to future flood risk. Using the "scenario-neutral" approach to impact assessment the sensitivity of Irish catchments to fluvial flooding is examined in the context of national climate change allowances. A predefined sensitivity domain is used to quantify flood responses to +2 °C mean annual temperature with incremental changes in the seasonality and mean of the annual precipitation cycle. The magnitude of the 20-year flood is simulated at each increment using two rainfall-runoff models (GR4J, NAM), then concatenated as response surfaces for 35 sample catchments. A typology of catchment sensitivity is developed using clustering and discriminant analysis of physical attributes. The same attributes are used to classify 215 ungauged/data-sparse catchments. To address possible redundancies, the exposure of different catchment types to projected climate is established using an objectively selected subset of the Coupled Model Intercomparison Project Phase 5 ensemble. Hydrological model uncertainty is shown to significantly influence sensitivity and have a greater effect than ensemble bias. A national flood risk allowance of 20%, considering all 215 catchments is shown to afford protection against ~48% to 98% of the uncertainty in the Coupled Model Intercomparison Project Phase 5 subset (Representative Concentration Pathway 8.5; 2070-2099), irrespective of hydrological model and catchment type. However, results indicate that assuming a standard national or regional allowance could lead to local over/under adaptation. Herein, catchments with relatively less storage are sensitive to seasonal amplification in the annual cycle of precipitation and warrant special attention.