Although IBD was once considered a rare disorder in Asia compared with Western countries,
the incidence and prevalence of IBD in Asia have both recently increased. Until now,
many Asian physicians treating IBD patients have referred to consensus guidelines
provided by Western committees. However, the characteristics of IBD patients differ
geographically with respect to epidemiology, phenotype, and genetic susceptibility.
The variability of IBD across different countries may alter the practices of different
public health care systems, including health insurance coverage, greatly impacting
patient outcome. Therefore, it is timely to survey many Asian countries for the current
status of IBD patient care with respect to public medical insurance systems, diagnosis,
treatment, and quality of care.1
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This survey was originally planned by the organizing committee of the Asian Organization
for Crohn's and Colitis (AOCC) and designed for one program of the 2nd annual AOCC
meeting, which was held in Seoul, Korea in June 2014. The aim of the survey was to
identify how Asian physicians diagnose and treat their IBD patients. A survey to determine
differences in public medical insurance systems and the quality of care across countries
was also performed. This survey consisted of 4 parts including general information
(9 items), diagnosis of IBD (18 items), treatment of IBD (30 items), and quality of
IBD care (36 items). The survey was conducted through a web-based system between March
2014 and May 2014. The questionnaire was sent to medical doctors caring for IBD patients
in Asia via e-mail by members of the organizing committee of the AOCC representing
each Asian country. A total of 353 Asian medical doctors treating IBD patients responded
to the survey (114 in China, 88 in Japan, 116 in Korea, 17 in Taiwan, 8 in Hong Kong,
4 in India, 3 in Singapore, and 1 each in the Philippines, Malaysia, and Indonesia).
In Western countries, IBD affected the personal lives of patients and caused substantial
costs to health care systems.5 Wei et al.1 investigated the current status of public
medical insurance systems among Asian countries using questionnaires about the costs
and insurance coverage rate of costs for IBD, including diagnosis using endoscopy
and treatment with 5-aminosalicylic acid (5-ASA) and biologics. The results of this
survey showed that the public health insurance coverage rate of costs was high in
Taiwan, Japan, South Korea, China, Hong Kong, and Singapore, but low in Malaysia and
India. This difference affected use of expensive medications, especially biologics.
The percentage of CD cases treated with biologics was 30%–40% in Japan, whereas the
percentage was only 1% in India. Costs for conventional therapies, such as 5-ASA,
steroids, and immunomodulators, were paid by public health insurance in Taiwan, Japan,
China, Hong Kong, and Korea, whereas these costs were paid by patients in Singapore,
Malaysia, and India. The fecal calprotectin test was available in clinical practice
in Singapore and India, costing about US $40 to US $80. However, it was only available
for research purposes in Taiwan, Japan, South Korea, and Malaysia. Tests for anti-tumor
necrosis factor (TNF) agent serum levels and antibodies against anti-TNF agents were
not yet available in all Asian countries.
Kim et al.2 analyzed how Asian physicians approached diagnosis of IBD. It is often
difficult to accurately diagnose IBD in Asia due to the presence of various infectious
diseases that mimic IBD, which may delay accurate diagnosis. For instance, intestinal
tuberculosis, which is relatively prevalent in Asia, presents with similar symptoms
as CD. The national diagnostic guidelines for IBD were commonly used in Korea,6
7 China, and Japan,8 but other Asian countries frequently used the "European Crohn's
and Colitis Organisation" (ECCO) guidelines. For clinical assessment of disease activity
of UC, most physicians used the Mayo Scoring System except Chinese physicians, who
commonly used the Truelove and Witts severity index score. The CD activity index was
overwhelmingly chosen for the clinical assessment of CD activity by physicians from
all Asian countries. For small bowel evaluation in CD, there was a wide range of variation
among countries. Physicians from Korea and China predominantly performed CT enterography,
whereas those from Japan and other countries preferred small bowel follow through
or balloon-assisted enteroscopy. For evaluation of perianal lesions, pelvic MRI was
the most commonly used examination in all Asian countries. Across all Asian countries,
over 20% of patients were given anti-tuberculosis treatment before CD diagnosis, reflecting
the difficulty in discriminating between CD and intestinal tuberculosis, especially
in the small bowel.9
Nakase et al.3 investigated IBD treatment protocols throughout Asia and showed that
clinical management of IBD patients varied among Asian countries. For example, the
frequency of use of certain drugs for IBD treatment such as budesonide and tacrolimus
differed among Asian countries, and induction therapies for mild to moderate inflammatory
small bowel CD also differed. However, common therapeutic strategies for refractory
IBD and active UC were employed throughout Asian countries. Treatment strategies for
steroid-refractory acute severe UC were as follows: after initially using intravenous
steroids for 5–7 days, most Asian physicians with the exception of those in Japan
selected anti-TNF agents, followed by cyclosporine.
Many Japanese physicians favored tacrolimus, followed by anti-TNF agents, while a
few Japanese physicians selected apheresis therapies. This result suggests there may
be differences in available medical treatments among Asian countries. More than half
of physicians in Korea, China, and Japan always tested for cytomegalovirus infection
in cases of severe UC. However, only 12% of other Asian physicians always performed
this test. Treatment of severe inflammatory small bowel CD greatly differed when comparing
Asian and Western countries.10 Only 3% of Asian physicians selected budesonide, while
most Asian physicians selected a combination of prednisolone and 5-ASA, followed by
anti-TNF agents, nutritional therapy, and thiopurines. Many Asian physicians chose
thiopurines and anti-TNF agents for the treatment of steroid-dependent or refractory
CD and UC patients.
There is a need to identify risk factors for poor prognosis in Asian CD patients to
establish guidelines for early use of anti-TNF therapies. In Western countries, patients
with risk factors such as age <40 years at diagnosis, presence of perianal lesions,
early need for steroid, severe endoscopic lesions, and the existence of an NOD2/CARD15
mutation would be recommended for early treatment with anti-TNF agents (Top-down therapy).11
When patients become resistant to anti-TNF agent therapy, serum levels of anti-TNF
agents or antibodies to infliximab or adalimumab are measured to determine subsequent
therapeutic strategies such as increasing the dose of anti-TNF agents or changing
to another anti-TNF agent.12 However, most Asian physicians answered "No" when asked
whether they monitored serum infliximab levels or antibodies to infliximab. Facilities
for monitoring of these values were limited in Asian countries.
Song et al.4 evaluated the current status of quality of IBD care in Asian countries
using a questionnaire-based survey developed by the American Gastroenterological Association
entitled "an adult IBD physician performance measures set" that comprised 11 specific
measures.13 The results showed that 7 of the 11 performance measures were executed
well by more than 70% of physicians in Asian countries. Tuberculosis screening before
anti-TNF therapy and documentation of IBD were consistently among the highest ranked
measures, whereas pneumococcal immunization and prophylaxis of venous thromboembolisms
(VTEs) in hospitalized patients were the lowest ranked in all countries. These lower
ranked performance measures among Asian countries were comparable to a similarly low
compliance in Western countries.14 In this survey, only 24% of Asian physicians performed
well in considering prophylaxis for VTEs, likely due to limited data about the risk
of VTEs in Asian IBD patients leading physicians to consider this practice unimportant.
Awareness of performance measures differed among Asian countries. For example, 72.4%
of Korean vs. 39.8% of Japanese physicians reported awareness of pneumococcal immunization,
while 60% of Korean vs. 48.9% of Japanese physicians reported awareness of influenza
immunization. Reasons for non-performance varied among countries, especially with
regard to lower ranked performance measures. For instance, pneumococcal and influenza
immunizations were considered unimportant in most Asian countries, whereas lack of
time was the main reason these immunizations were not performed in Korea. This survey
had limitations since relying on the memories of the physicians may not accurately
reflect actual performance in each country.
These 4 articles report the results of the first survey to assess the public medical
insurance system, diagnosis, treatment, and quality of care for IBD in multiple Asian
countries. There is currently no guideline for the diagnosis and treatment of IBD
in Asian patients. Therefore, many Asian physicians commonly use guidelines of Western
countries, such as the ECCO guidelines. These articles in the current issue of Intestinal
Research may be the cornerstone to establishing specific guidelines for the improved
management of IBD patients in Asian countries.