Understanding the role of the primary care physician in the management of patients with Crohn’s perianal fistulas

Figures & data

Table 1. Demographics of PCP survey respondents (N = 151).

Practice type
Family medicine	53.6%
Internal medicine	46.4%
Practice setting
Academic	9.3%
Community	90.7%
Years in practice, mean (SD)	22 (8.4)
Number of patients managed per week, mean (SD)	116 (78.4)
Number of patients with Crohn’s disease managed per month, mean (SD)	14 (20.5)
Patients with new or existing perianal fistulas managed in a typical month, mean (SD)	2.7 (5.4)
Practice location
Urban	29.8%
Suburban	57.6%
Rural	12.6%

PCP, primary care physician; SD, standard deviation.

Figure 1. PCP respondents' insights regarding the initial referral and evaluation of the patient with CPF presented in Case Vignette 1.

CPF, Crohn’s perianal fistula; CT, computed tomography; MRI, magnetic resonance imaging; PCP, primary care physician.

Table 2. Expectations of specialist management among PCP survey respondents (N = 151, Case Vignette 1).

What surgical management approach would you expect for this patient’s fistula? (select only one)
Seton placement only	8.6%
Seton placement as a bridge to definitive surgical therapy	46.4%
Medical management only	22.5%
Unsure	22.5%
Other	0.0%
In addition to the antibiotic, would you expect the gastroenterologist to begin any medications for this patient’s perianal fistula? (select only one)
Yes	54.3%
No	13.2%
Unsure	32.5%
How likely are you to do each of the following at follow-up with this patient? (mean of 1–5 scale, 1 = not at all likely; 5 = extremely likely)
Ask about his Crohn’s disease symptoms	4.5
Ask about fistula drainage and associated symptoms	4.5
Perform a rectal exam	3.1
Review specialist’s consultation notes	4.7
Review and update his vaccination status	4.0
[After initial management] What medical management would you expect the gastroenterologist to recommend for the patient’s fistula now? (select only one)^a
Continue current medical therapy	51.0%
Increase the dose of infliximab	27.8%
Discontinue infliximab and begin other medication(s)	9.9%
Add other medication(s) to the current regimen	10.6%
Other	0.7%
[After initial management] What surgical management approach would you expect the surgeon to recommend at this time? (select only one)
Continuation of the seton	24.5%
Seton removal	23.2%
Proceed with surgery (e.g. advancement flap, fistula tract ligation, fecal diversion)	43.0%
Refer for enrollment in a clinical trial for stem cell therapy	0.0%
Unsure	9.3%
Other	0.0%

^aWhen referring to what medical management PCPs expected gastroenterologists to recommend for the patient’s fistula, the option for PCPs to prescribe/alter biologics was not provided.

PCP, primary care physician.

Table 3. PCP survey respondents' perspectives on CPF treatment goals and their role in the management of recurrent CPF (N = 151, Case Vignette 2).

Please rank the following goals of long-term treatment of this patient’s fistula, mean rank 1–5, with 1 being the most important and 5 being the least important (% of PCPs indicating each goal as #1)
Improving quality of life	2.0 (49.0%)
Achieving fistula healing	2.4 (31.8%)
Resolving fistula symptoms	2.8 (11.3%)
Avoiding major surgery and/or preserving continence	3.7 (6.6%)
Minimizing medication risks and side effects	4.1 (1.3%)
How likely are you to discuss each of the following with this patient? (mean of 1–5 scale, 1 = not at all likely; 5 = extremely likely)
Medical management options	3.8
Medication adverse effects	3.8
Surgical management options	3.6
General operative and post-op complications	3.5
Investigational treatment options	2.5
Quality of life issues	4.2
In what way(s) would you assist the patient in making a decision regarding treatment for her fistula? (select all that apply)
Have a discussion with the patient about her goals and preferences	82.1%
Provide a treatment recommendation to the patient	41.7%
Contact one or both of the specialists to discuss the treatment options	77.5%
Educate myself about perianal fistulas to further understand the treatment options	70.2%
Refer the patient to another specialist for a second opinion	23.8%
Search for clinical trials for which the patient may be eligible	8.6%
None	0.7%
Other	0.0%

CPF, Crohn’s perianal fistula; PCP, primary care physician.

Figure 2. PCP respondents' insights on their role in the management of the patient with CPF presented in Case Vignette 2.

Owing to rounding, totals may not equal 100%.

CPF, Crohn’s perianal fistula; PCP, primary care physician.

Table 4. PCP respondents' (N = 151) insights into multidisciplinary team composition and the coordination of care in patients with CPF.

Which clinicians and staff comprise the management team for your recent or current patients with complex perianal fistulas? (select all that apply)
Advanced practice provider (e.g. NP, PA)	19.2%
Clinical psychologist or therapist	11.9%
Colorectal surgeon	78.1%
Dietitian or nutritionist	26.5%
Gastroenterologist	87.4%
Gastroenterology nurse	13.2%
General surgeon	25.2%
Nurse	23.2%
Pharmacist	15.9%
Radiologist	19.9%
Research coordinator	2.6%
Social worker	11.9%
Other (please specify)	1.3%
What method(s) do you use to communicate and coordinate care with specialists who are mutually managing your patients with complex perianal fistulas? (select all that apply)
Scheduled multidisciplinary team meetings	12.6%
Informal in-person discussions	28.5%
Phone calls	67.5%
Email	28.5%
Messaging within a shared EMR	39.7%
Review of consult notes in a shared EMR	62.9%
Written requests for medical records (e.g. by fax)	38.4%
Other	0.0%
If a specialist orders an imaging study for a mutual patient with complex perianal fistula, which best describes how you would be notified of the results?
I would see the results in a shared EMR	47.0%
I would review the results with the specialist in a multidisciplinary team meeting	6.0%
I would expect the specialist to notify me of pertinent results	23.2%
I would request the results from the specialist’s office	20.5%
I do not typically review the results of studies that specialists order	2.0%
Other (please specify)	1.3%
How satisfied are you with the current processes and methods of communication and coordination of care in your patients with complex perianal fistula?
Unsure/not applicable	2.0%
Not at all satisfied	3.3%
Slightly satisfied	15.2%
Moderately satisfied	46.4%
Very satisfied	28.5%
Extremely satisfied	4.6%

CPF, Crohn’s perianal fistula; EMR, electronic medical record; NP, nurse practitioner; PA, physician’s assistant; PCP, primary care physician.

Data availability statement

The data supporting the results reported in this article will be made available within 3 months from initial request to researchers who provide a methodologically sound proposal. The data set will be provided after its deidentification, in compliance with applicable privacy laws, data protection, and requirements for consent and anonymization.