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We agree with Dr Beaugerie's comments regarding gaps in the quality of inflammatory bowel disease (IBD) management.[1] There are many potential reasons for this disconnect. Our analyses[2] did not show consistent patient- or facility-level predictors of adherence to myelosuppression monitoring, thus suggesting that the observed practice variation is related to individual provider practices.

However, administrative datasets such as the one used in our study cannot address the reasons for providers’ adherence to guideline-recommended care. Altschuler et al. addressed this question in a qualitative analysis of semi-structured, open-ended interviews among gastroenterologists in Kaiser Permanete Northern California, and found that the focus on disease activity during clinic visits, the belief that screening was the responsibility of another physician, cost and lack of time and knowledge were barriers to adherence to guidelines.[3] These observations support the need for building clinical and administrative infrastructure, such as nurse co-ordinators or information technology-based clinical decision support tools embedded in electronic health records, to support physicians in following IBD practice guidelines.

Data regarding thiopurine methyltransferase (TPMT) testing prior to immunomodulator initiation were not available in our dataset. However, close myelosuppression monitoring after immunomodulator initiation is recommended regardless of TPMT testing.[4] Only 2% of index white blood cell count tests in our study were performed in the inpatient setting, suggesting that only a small proportion of testing was performed as a result of a complication. However, our analyses were not intended or well suited to look at complication rates as hospitalisations at non-VA facility are not captured in our dataset, and subjects who died within 90 days of immunomodulator initiation were excluded from analyses. We agree that these remain important questions and deserve further study.

Acknowledgement

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  2. Acknowledgement
  3. References

The authors’ declarations of personal and financial interests are unchanged from those in the original article.2

References

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  2. Acknowledgement
  3. References