Multinational evaluation of clinical decision-making in the treatment and management of mild-to-moderate ulcerative colitis

Figures & data

Table 1. Top 25 factors contributing most strongly to clinical decision-making across all three scenarios in multivariate analysis.^a

Rank	Factor	Loading^b
1	Empower the patient to comply with treatment by education about taking control of their lifelong disease	1.56
2	Spending time with patients to educate them about their disease	1.51
3	Educating patients that after 8 years of remission under self-management they may need to think about getting checked for colon cancer	1.50
4	Consideration of the patient’s priorities	1.46
5	Communicating with the patient and fully discussing the therapeutic options	1.45
6	Discussion of other treatment options including dose optimisation if the patient is complaining	1.36
7	Engaging the patient in their management through education and understanding their disease	1.34
8	Evaluation of patient reported outcomes	1.34
9	Informing the patient about different treatment options in case of relapse	1.21
10	Education of the patient that adherence to treatment contributes to staying in remission	1.21
11	Reassuring the patients who may be worried or anxious or feel stigmatised about a diagnosis of UC	1.18
12	Whether the patient has more than 2 relapses within a year	1.17
13	Evaluate disease activity e.g., frequency of bowel movement, blood in stool, abdominal pain to guide treatment choices	1.14
14	Consideration of good quality of life as the ultimate goal	1.11
15	Goals of therapy may change with time	1.11
16	Educating the patient on when to seek hospital help or simply communicate with nurses or physicians	1.08
17	Establishing contingency plans with the patient in case of relapse	1.07
18	Consideration of how to increase adherence to treatment by discussing different treatment options	1.04
19	Consideration of whether steroids were used to treat the last flare and for how long	1.02
20	Ensuring that the patient is still in full remission	1.02
21	Keeping on 5-ASA for maintenance	1.00
22	Patient's history of prior treatment(s) and response(s)	1.00
23	If the diagnosis is mainly proctitis, then the focus should be on topical therapy	1.00
24	Usefulness of "top and tail' (oral and rectal) therapy for proctitis and distal colitis	1.00
25	Understanding how the previous flare was treated	0.99

UC: ulcerative colitis.

^aPrincipal component analysis that contained 88.2% of the data variance. Shaded factors are those related more to patient communication, education and feedback versus more clinically related factors.

^bThe loading is the relative weighting of each factor within the principal component as evaluated from the pole with which the scenarios are most closely associated.

Table 2. Top 10 factors contributing most strongly to clinical decision-making across all three scenarios in univariate analysis.

Rank	Item	Mean	SD
1	Empower the patient to comply with treatment by education about taking control of their lifelong disease	82.1	22.6
2	Communicating with the patient and fully discussing the therapeutic options	81.3	21.9
3	Educating patients that after 8 years of remission under self-management they may need to think about getting checked for colon cancer	80.9	23.4
4	Spending time with patients to educate them about their disease	80.9	22.1
5	Consideration of the patient’s priorities	80.7	21.2
6	Discussion of other treatment options including dose optimisation if the patient is complaining	80.3	19.8
7	Education of the patient that adherence to treatment contributes to staying in remission	80.0	23.0
8	Evaluation of patient reported outcomes	79.9	21.0
9	Engaging the patient in their management through education and understanding their disease	79.9	21.8
10	Evaluate disease activity e.g., frequency of bowel movement, blood in stool, abdominal pain to guide treatment choices	79.5	22.9

Shaded factors are those related more to patient communication, education and feedback versus more clinically related factors. SD: standard deviation.

Table 3. Top 10 factors contributing most strongly to differences in clinical decision-making between active disease and the other two scenarios in multivariate analysis.^a

Patient presents with active disease		Patient in remission following flare and self-management & empowerment of patients
Factor	Loading^b	Factor	Loading^b
Not regarding histological remission as the primary treatment target	0.130	Not going back to 5-ASA dose at which a flare occurred after remission unless the pattern of disease has changed	−0.089
Educating the patient on when to seek hospital help or simply communicate with nurses or physicians	0.087	Empowerment might include patient control of dose, route or frequency of 5-ASA	−0.054
Understand how treatment remission was achieved previously	0.079	Consideration of decreasing the oral dose of 5-ASA by considering what dose has been administered during the last 12 months	−0.046
Stratifying newly diagnosed patients on the basis of risk factors of progression	0.077	Regularly monitoring of body weight and general health	−0.045
Consideration of lack of sleep as a potential exacerbating factor	0.077	Usefulness of ‘top and tail' (oral and rectal) therapy for proctitis and distal colitis	−0.040
Consideration that flare is not necessarily a treatment failure and, therefore, may not require a change therapy	0.064	Challenges in considering empowerment with some patients	−0.034
Stratifying newly diagnosed patients on the basis of response to therapy	0.058	Checking compliance especially with rectal treatment	−0.026
Consideration of whether remission diagnosis was based on clinical symptoms	0.057	Educating patients that after 8 years of remission under self-management they may need to think about getting checked for colon cancer	−0.023
Consideration of non-flare-related gastro-enteritis as a potential exacerbating factor	0.053	Wide variation in appointment frequency during remission	−0.023
Assessing the severity of a flare	0.040	Potential for patients to stop taking medication when they are doing well	−0.019

^aThis first component of the linear discriminant function analysis separated the active disease scenario from the other two scenarios and accounted for 82.4% of the variance.

^bThe loading is the relative weighting of each factor within the component as evaluated from its opposite pole (decision domains).

Table 4. Top 10 factors contributing most strongly to differences in clinical decision-making between self-management and empowerment of patients and remission in multivariate analysis.^a

Self-management and empowerment of patients		Patient in remission following flare
Factor	Loading^b	Factor	Loading^b
Potentially raising patients’ expectations from therapy and setting higher goals	0.074	Involving GP in decisions about patient dose self-adjustment using calprotectin as guide	−0.093
Lack of indication for azathioprine or biologics when remission has been of long duration	0.072	Use of tele-clinics in busy situations	−0.087
Consideration of the patient’s priorities	0.067	Consideration that relapse every 5–10 years means 5-ASA is effective	−0.084
Patient associations are key to patient self-management process to make sure they don’t feel alone	0.066	Recent reviews showing benefit of higher 5-ASA doses for maintenance	−0.081
Consideration of reduction in relapse by 50% as a therapy goal (rather than relapse free)	0.057	Consideration of the treatment used for management at initial diagnosis	−0.070
Providing the patient with a list of factors to reduce the risk of relapse such as diet, physical activity, rest and so on	0.049	Consideration of increasing the dose of oral 5-ASA	−0.059
Empower the patient to comply with treatment by education about taking control of their lifelong disease	0.047	Use of faecal calprotectin to help optimise 5-ASA therapy	−0.055
Some brands of 5-ASA are re-imbursed, others are paid for by the patients	0.044	Whether the patient experienced a flare on optimised therapy	−0.045
Spending time with patients to educate them about their disease	0.041	Evaluation of endoscopic findings to determine presence of deep ulceration and extent of disease	−0.043
The current difficulty of predicting a good trajectory for newly diagnosed patients	0.038	Evaluation of extra-intestinal manifestations e.g., skin, joints	−0.042

GP: general practitioner.

^aThis second component of the linear discriminant function analysis separated the self-management and empowerment of patients scenario from the remission scenario and accounted for 17.6% of the variance.

^bThe loading is the relative weighting of each factor within the component as evaluated from its opposite pole (decision domains).

Figure 1. Overall decision environment in mild-to-moderate UC*. *Hierarchical cluster analysis. The full list of factors associated with each level of the analysis are available in Supplementary File 7. GP: general practitioner.

Data availability statement

All data supporting the findings of this study are available upon reasonable request to the corresponding author.