Knowledge and acceptability of the Lémann Index as a tool to measure disease progression and bowel damage in Crohn’s disease: results from an international survey
Article information
Abstract
Background/Aims
Crohn’s disease (CD) progresses to structural bowel damage (SBD). The Lémann Index (LI) captures stricture extent/severity, penetrating disease and surgery as a SBD score, and is earmarked for future CD modification trials. Understanding knowledge gaps and perceived barriers is critical to wider adoption.
Methods
A multinational, cross-sectional study was distributed through a survey link (REDCap, Research Electronic Data Capture) to gastrointestinal professional societies with snowball sampling using 23 questionnaire items in 5 sections to determine SBD and LI knowledge, and LI acceptability. Factors associated with acceptability and perception were evaluated.
Results
Of the 107 respondents, 49 (45.8%) were female; 87 (81.3%) were from Europe. Most were inflammatory bowel disease specialists (n = 80, 74.8%) or general gastroenterologists (n = 22, 20.6%), managing > 40 CD patients per month (n = 35, 32.7%). A total of 98 (91.6%) knew about SBD; “very important” rating for clinical trials and clinical practice was 56.1% and 41.4%, respectively. A 39.3% describe LI scoring as “very difficult” or “difficult”; 33.6% reported “significant” or “a lot” of effort. Acceptability (composite scores of > 36) were significantly associated with respondents who had received LI training (P<0.001). Automated methods, intestinal ultrasound and evidence of benefit would encourage LI use in clinical trials, while additional time and automated methods would promote use in clinical practice. The top 3 perceived adoption barriers were: lack of time (60.7%), limited automated methods (47.7%) and need for dedicated radiologists (38.3%).
Conclusions
Most respondents had baseline knowledge of SBD. The LI was perceived as important for advancing future CD research and care. More training and automation will facilitate LI adoption.
INTRODUCTION
Crohn’s disease (CD) is a chronic inflammatory intestinal disorder, characterised by periods of clinical remission interspersed by periods of relapse. Persistent and under-treated inflammation leads to progressive structural bowel damage (SBD) which manifests as fibro-stenotic strictures, abscesses or fistulae formation often requiring surgical intervention including bowel resection [1-3]. The evolution of therapeutic targets from symptom-based endpoints to endoscopic, radiologic biochemical and more histologic targets [4,5] aims to mitigate disease progression and reduce cumulative SBD, thereby improving long-term disease outcomes [6,7]. SBD is a well recognised complication and therapeutic target in clinical trials assessing disease modification [2].
Accurate global assessment of therapeutic response and intestinal healing is challenging. Several clinical and endoscopic scoring indices exist for measuring CD activity and health-related quality of life [8]. However, current measurement instruments have inherent limitations, using individual clinical, endoscopic and imaging modalities to give a localised assessment of disease activity at a specific time point rather than measuring the longitudinal cumulative impact of CD or SBD [9].
The Lémann Index (LI) was developed to overcome these limitations and provide a comprehensive composite tool to quantify SBD and measure disease progression in CD based on a unique combination of surgical history, endoscopic and radiological evaluation [1,10]. An advantage is its applicability to different settings, such as early or advanced CD, patients with or without surgical history, or different disease locations and extent. The scoring is performed by dividing the entire digestive tract into 4 organs (upper tract, small bowel, colon and rectum, and anus), that are further subdivided into segments. For each segment, stricturing and penetrating lesions are graded on 3-point severity scale to calculate a segmental score (0 for no lesions and 1 for complete resection). The sum of segmental damage evaluations and damage from surgical resection provides the cumulative damage evaluation. A global score is calculated after taking into account 4 organ damage scores [9].
The LI has been validated prospectively in a multicenter cohort of patients [10], updated and was applied to investigate predictors of bowel damage in a retrospective real-world cohort [11]. It is currently undergoing prospective evaluation in an inception cohort (CROCO Study) to understand the long-term evolution of CD and the impact of different therapeutic strategies on SBD (ClinicalTrials.gov. ID NCT05420233). Current evidence shows that progression in LI score corresponds to SBD progression and predicts higher risk of corticosteroid and biological therapy use, healthcare utilisation and abdominal surgery [12,13] underscoring its promising use for patient stratification and prognostication in CD. Furthermore, homogeneity in the quantification of SBD and disease progression in CD will facilitate improved and consistent reporting in baseline datasets [14] and clinical effectiveness outcomes [15] in inflammatory bowel disease (IBD) research.
Within medical research, acceptability has been poorly defined yet there is increasing awareness of its importance when developing, evaluating and implementing complex healthcare interventions. Acceptability was defined as a “multi-faceted construct that reflects the extent to which people delivering or receiving a healthcare intervention consider it to be appropriate based on anticipated or experienced cognitive or emotional responses to that intervention” by Sekhon et al. [16] using evidence from the systematic review. This led to the development of the theoretical framework of acceptability (TFA) [17] and its 7 constructs represent areas which influence acceptability including affective attitude, burden, perceived effectiveness, ethicality, intervention coherence, opportunity costs, and self-efficacy. In IBD, it has been used to evaluate acceptance of the European Crohn’s and Colitis e-guide and acceptability was a recognised dimension to clinician use of this tool [18].
Here, our aim was to assess knowledge, perceptions and acceptability of the LI as a measurement instrument for SBD. The primary aim was to measure the rate of SBD knowledge and factors associated with knowledge. The secondary aims were to assess acceptability and perceptions of the LI through various dimensions, and to explore barriers to adoption.
METHODS
1. Study Design
The study was conducted and reported in accordance with the Checklist Reporting of Survey Studies (CROSS) [19] that is included as a checklist in Supplementary Fig. 1. in the supplementary file. This was a multinational, cross-sectional study conducted between March to October 2023, targeting healthcare professionals involved in the care of patients with IBD.
An anonymised, online, English-language, structured questionnaire was developed through an iterative process to ensure that qualitative themes corresponded to the constructs of the TFA (Supplementary Fig. 2) and aligned with the adapted version of the generic TFA questionnaire [20].
The final survey consisted of 5 main sections with a total of 24 items, including respondent demographics, knowledge of SBD, knowledge of the LI, perceptions of the LI, perceptions about future LI adoption. An optional case review was included at the end (Supplementary Fig. 2).
Eleven items, incorporating a combination of binary questions and 5-point Likert scales (1=strongly disagree/not important/very difficult/significant effort; 5=strongly agree/very important/not difficult at all/no effort at all), were used to assess the TFA constructs as follows: (1) intervention coherence (knowledge of SBD and LI assessed intervention coherence, including understanding of the concepts and prior training in LI calculation); (2) affective attitude (perceptions of the LI and individual sentiment toward its use); (3) ethicality (the extent to which SBD and/or the LI fits align with the individual’s values); (4) burden (perceived difficulty and effort required in using the LI); (5) opportunity costs (perceived benefits, profits or values that are foregone to engage with LI use); (6) perceived effectiveness (extent of belief that the LI will achieve its intended purpose); and (7) self-efficacy (confidence and likelihood that the LI will be used for clinical cases). Additional 10-point visual analog scales (VAS) were included to identify barriers to future adoption of the LI.
Content validity and comprehension were assessed by and agreed with all authors before formal dissemination of the questionnaire. There was no predetermined sample size as this was mainly an exploratory study and descriptive in nature. Participants were invited to participate through several channels, the REDCap (Research Electronic Data Capture) survey link was circulated through various gastroenterology professional societies and email communication with affiliates through a snowball sampling approach.
2. Outcomes and Definitions
The primary outcome was knowledge of SBD and the LI. Secondary outcomes included attitudes relating to perception of the LI, barriers to LI adoption and overall acceptability of the LI. Acceptability was determined based on pre-defined criteria in this study, which established objective thresholds for strong agreement with each TFA domain: (1) 5-point Likert scales–a score of 4 or above indicated strong agreement; (2) 10-point VAS–a score of 7 and above indicated strong agreement; and (3) Binary responses–a “yes” response scored 1 and indicated strong agreement.
A total summative score of 36 was established as the minimum threshold for adequate agreement across all 7 TFA domains, and therefore a score of 36 or greater indicated respondent acceptability of the LI and its use.
A statistical analysis of the internal consistency and reliability of the specific questionnaire items assessing acceptability was performed using the Cronbach alpha coefficient. A score of 0.777 was achieved for all 11 items evaluating the TFA constructs, where values of >0.70 indicate acceptable internal consistency, reliability and good item intercorrelation.
3. Data Collection
The survey was conducted through an email link to REDCap. Responses were captured as binary data, 5-point Likert scales, 10-point VAS and free-text comments (Supplementary Fig. 2) and exported onto an Excel spreadsheet.
4. Data Analysis
We conducted data pre-processing by excluding incomplete responses that contained only demographic information without any knowledge or attitudinal data. Where data was captured, we ensured that Likert scale responses were correctly coded, with a score of 1 representing disagreement and a score of 5 representing strong agreement with the statements.
Continuous data were reported as means with associated standard deviations or medians with the interquartile ranges (IQR). Categorical data were reported as numbers and percentages (%). Descriptive analyses were used for responses from all sections of the questionnaire and free text responses were categorised into themes. We conducted subgroup analyses based on the following categories: (1) age group, (2) sex, (3) IBD specialists and other professional roles, (4) academic IBD centers, (5) degree of clinical experience, and (6) number of CD patients managed per month. We used the chi-square and Mann-Whitney U non-parametric tests to compare differences between 2 independent groups, and the Kruskal-Wallis H test for comparison of more than 2 groups, with P-values <0.05 for statistical significance. Statistical analysis was performed using the Statistical Package for the Social Sciences (IBM SPSS Statistics, version 29.0.2.0; Armonk, NY, USA) software.
RESULTS
1. Respondent Characteristics
There were 189 responses on REDCap where 19 did not contain data. From the remaining 170 questionnaires, 63 were excluded as they only contained demographic information without knowledge or attitudinal data which did not align with the study objectives (Fig. 1, Appendix Table 1). In the study population (n=107, 62.9%), 58 (54.2%) were male and a larger proportion were under the age of 40 (n=50, 46.7%). A greater number lived in Europe (n=87, 81.3%) followed by Asia (n=10, 9.3%) shown in Table 1.
Flow diagram survey responses and inclusion in data analysis.
Respondent Demographic Data and Professional Settings (n=107)
The majority were IBD specialists (n=80, 74.8%) with the remainder defined themselves as general gastroenterologists (n=22, 20.6%) and 5 (4.7%) other allied health professionals (2 clinical researchers, 1 gastroenterology fellow, 1 paediatric gastrointestinal (GI) radiologist and 1 internal medicine specialist). Most worked in an academic center with a specialist IBD center (n=83, 77.6%), had 10 to 15 years of professional practice (n=27, 25.2%) and managed >20 CD patients per month (n=67, 62.6%). Most had access to a GI radiologist (n=99, 92.5%), and it took 2 weeks or less to obtain a magnetic resonance imaging (MRI) report after requesting a scan (n=35, 32.7%). The results are summarized in Table 1.
2. Background Knowledge of SBD
Almost all included respondents had knowledge of SBD (n=98, 91.6%), but only a minority had received dedicated training in calculating the LI (n=21, 19.6%). A large proportion incorrectly believed that SBD involved active mucosal inflammation (n=36, 33.6%) or ulceration (n=46, 43.0%). A larger proportion correctly understood that strictures (n=105, 98.1%), fistulae (n=101, 94.3%), intra-abdominal abscess formation (n=63, 58.9%), and bowel resection (n=87, 81.3%) represented SBD. Twenty-two respondents (20.6%) selected all 4 correct options and were mostly IBD specialists (n=17, 10%). Full results in Supplementary Table 1.
3. Perceptions about the Importance of SBD and Calculating the LI
A greater number of participants believed that training in LI scoring was “fairly” or “very important” (n=73, 68.2%). When asked about the importance of measuring cumulative SBD in different settings, more respondents felt that it was “very important” for clinical trials (n=60, 56.1%), clinical practice (n=44, 41.1%) and higher numbers thought that the LI should be calculated annually (n=55, 51.4%). The results are summarized in Supplementary Table 2 and Supplementary Fig. 3.
4. Perceptions about LI Utility
More respondents perceived it to be “fairly difficult” (n=36, 33.6%) and “difficult” (n=34, 31.8%), and involving “a fair amount of effort” (n=48, 44.9%) followed by “a lot of effort” (n=27, 25.2%) to complete the LI for each case and 48 (44.9%) felt they would be able to complete the LI on a clinical case. Almost equal numbers “agreed” (n=36, 33.6%) or gave an unequivocal response (n=33, 30.8%) for LI measurement being an efficient use of clinician time. More individuals felt that the LI would improve long-term outcomes in CD (n=56, 52.3%) and facilitate achievement of treatment targets (n=75, 70.1%). The results are summarized in Supplementary Table 3 and Supplementary Fig. 4.
5. Acceptability Scores
The median composite score was 32 (IQR, 29–36) and, based on our definition of acceptability (composite scores >36), 24 (22.4%) found the LI to be acceptable. Acceptability was higher in females (n=14, 13.1%), respondents aged ≤ 40, clinicians working at an academic IBD center (n=19, 17.8%), 10 to 15 years of clinical experience and those managing more than 40 CD patients per month. There was no significant difference in acceptability scores between different subgroups (Supplementary Table 4).
6. Perceptions about the Future Adoption of the LI
Respondents were asked to rate the importance of a number of predetermined factors motivating them to apply the LI as a measurement instrument for SBD in future therapeutic clinical trials and clinical practice.
In the context of clinical trials, “automated methods for calculating the LI” and “more evidence of its impact” obtained the highest median VAS scores for importance. For clinical practice, “automated methods” and “more time” had the highest median values.
Overall, “easier access to imaging results” was deemed less important (median, 7; IQR, 5–9) for clinical trials and “centralised reading of images via an imaging bank” for clinical practice (median, 6; IQR, 5–8). Most participants believed that barriers existed to prevent wider adoption of the LI (n=80, 74.8%) and the most commonly acknowledged factors were: lack of time (n=65, 60.7%), lack of automated methods (n=51, 47.7%) and lack of a dedicated GI radiologist to work alongside the parent clinical team (n=41, 38.3%). The full results are summarized in Supplementary Fig. 5.
Lack of time (n=65, 60.7%), automated methods (n=51, 47.7%), dedicated radiologist (n=41, 38.3%) were the most frequently selected barriers to LI use. Free-text comments included the need for easier LI scoring with “automated” methods where results could also be integrated into electronic health records, “standardised radiology reports” and the availability of a “dedicated research associate” or other staff to apply scoring and documentation in order to reduce time burden on clinicians. Two individuals reported they were unlikely to use the LI in their own practice (Supplementary Table 5).
7. Subgroup Analysis
We performed a separate analysis for the following subgroups to identify associations with perceptions of SBD and the LI: age groups, professional roles (IBD specialists vs. non-specialists), professional settings (academic IBD centers vs. non-academic IBD or other centers), number of years of practice and number of CD patients seen per month. Supplementary Table 6 shows the results of subgroup analysis of perceptions based on age group, years of experience and number of CD patients managed per month using the Kruskal-Wallis H test, whereas Supplementary Table 7 subgroup analysis based on gender, professional role and professional setting using the Mann-Whitney U test. Subgroup analysis of acceptability of the LI (composite score >36) based on age group, sex, professional role, professional setting, clinical experience, number of CD patients seen per month and previous LI training using the chi-square test are shown in Supplementary Table 8.
There was a significant difference (P=0.011) in perceived importance of measuring the LI in clinical trials between individuals working at an academic IBD center (n=83; mean rank 50.34) and those who worked in non-academic centers (n=24; mean rank 66.65) (Supplementary Table 7).
There was a significant difference (P=0.004) in perceptions about whether the LI would achieve therapeutic targets between different genders. Females had a higher mean rank (n=49; mean rank 57.99) compared to men (n=58; mean rank 50.63), shown in Supplementary Table 7.
Acceptability (composite scores of >36) was significantly associated with respondents who had received LI training (P<0.001) as shown by the differences between the observed and expected counts (Supplementary Table 8).
DISCUSSION
In this cross-sectional study in CD, most respondents had baseline knowledge of SBD, yet knowledge of the LI as a measurement tool was limited. This will require specific training initiatives in the future, particularly as the study also showed that the LI was perceived to be important in future long-term CD research and clinical practice. Several barriers to its acceptability are described, which will need to be overcome before its wider adoption.
Although most respondents reported baseline knowledge of bowel damage (n=98, 91.6%), there was general misunderstanding of the nature of structural abnormalities, whereby only 20.6% (n=22) selected the correct answers in the questionnaire. Among those with knowledge of the LI, around a fifth had received dedicated training in its calculation, highlighting deeper gaps in knowledge amongst specialists. Freetext comments such as “I doubt that I would ever calculate the LI myself in clinical practice” (Supplementary Table 5), suggest limited awareness of the collaborative approach to LI scoring, which typically involves input from gastroenterologists and GI Radiologists. Expanding educational opportunities may enhance awareness, foster interest in the potential role for patient stratification, and encourage engagement with greater adoption of the LI. This is underscored by the significant association between LI training and achieving acceptability scores in this study.
There was a significant difference (P=0.011) in perceived importance of measuring the LI in clinical trials between individuals working at academic IBD centers (n=83; mean rank 50.34) and those from non-academic centers (n=24; mean rank 66.65). The survey was not designed to address the underlying reasons for differences’ however, greater involvement in research, awareness of limitations in LI use and critical appraisal may be contributing factors. Likewise, disparity in scores may have been attributed to the smaller respondent sample size from non-academic centers, which may have influenced the ranking distribution. It was interesting that more females agreed or strongly agreed that the LI will show achievements in treatment targets. Our data showed that marginally more women had received LI training (n=11/21) but more men were IBD specialists (n=37/80) and worked in academic centers with an IBD center (n=48/83). A deeper understanding of the differences in perception between subgroups may warrant further research.
Overall, a larger proportion of respondents perceived there to be difficulty (n=42, 39.3%) and requirement of effort (n=84, 78.5%) with calculating the LI. The most common factors that may hinder LI adoption were lack of time (n=65, 60.7%), automated methods (n=51, 47.7%), and a dedicated GI radiologist to work alongside the parent clinical team (n=41, 38.3%). Such barriers could be addressed to optimise LI adoption. Leveraging the use of software-driven scoring would enhance user experience, allow capture of data within electronic health records and facilitate research in this area.
The demographics of the respondents play a significant factor in the responses. We recognised a response bias as more IBD specialists engaged with the survey compared to general gastroenterologists or other allied health professionals. The study population was skewed towards gastroenterologists with a specialist interest in IBD (n=80, 74%), and we only managed to obtain one response from a GI radiologist. This may be reflective of fewer specialist radiologists holding memberships with gastroenterology and IBD societies that promoted the survey or failure of our survey to attract their attention. Radiologists’ insights on LI utility may differ to physician colleagues and in future it may be necessary to elicit their views separately. Distribution of the survey beyond the UK, Europe, and North America was challenging and dependent on access to professional networks; however, responses were captured from all continents except Africa. Furthermore, the proportions of respondents aged under 40 years (46%) and up to 40 to 60 years (44.9%) were comparable. There were fewer individuals aged over 60 years, likely reflecting the lower number of physicians working beyond this age and reduced interest in novel clinical trial end-points.
We acknowledge the limitations of this survey. Firstly the generic TFA questionnaire was not available at the time of the conception of this study but our questionnaire reflected its principles and evaluated all constructs of acceptability. The sample size, while reasonable, may not be sufficient to make generalised statements about the perceptions and acceptability of the LI across all gastroenterology specialists and allied health professionals but it serves as a starting point to cover themes relevant to specialists in other countries. As a cross-sectional study most results were analysed descriptively so causal inferences could not be made and we did not assess how perceptions evolved over time with an increasing body of evidence relating to utility of the LI. Our definition of acceptability was largely based on a composite score specific to this questionnaire but it allowed us to objectively assess the rates of overall agreement within acceptability constructs. Nevertheless, the results from this study provide important insights into the limiting factors related to implementation and integration of the LI in the future.
The strengths of the study include the inclusion of responses from an international group of clinicians with the majority having a dedicated interest in IBD. To our knowledge, this is the only study using a structured methodology to assess acceptability of a scoring index or new measurement instruments in IBD. Acceptability is emerging as an important consideration in the development of novel health and social interventions but traditionally has been poorly defined in the literature with variability in its assessment. The TFA [17,20] and its associated questionnaire provides a structured method of retrospectively and prospectively assessing this outcome. Since its development, it has been applied in other areas of healthcare including type 2 diabetes [21], oncology [22-24], asthma [23], orthopaedic surgery [25], psychology [26] and areas of social science [27].
The next steps to encourage wider adoption of the LI involve strategies to overcome barriers to LI utility and integration. Reducing time burden for scoring through automated methods is one aspect. Easier access and interpretation of radiological images by replacing MRI with intestinal ultrasound in selected CD patients is an additional one that warrants further research. Ultrasonography-based LI (US-LI) has shown high concordance with MRI [28] supporting its use as a reliable alternative in the scoring of SBD. Ongoing research is being undertaken to validate and standardise radiological parameters for interpreting small bowel strictures to avoid inter-observer variability [29-31]. Other studies are being planned to understand if an intestinal US-LI could be concordant to MRE-based LI which could be used as an alternative in clinical trials and/or clinical practice [32].
In conclusion, this study identified more education is needed about SBD and the LI. In addition, elements of LI scoring should be optimised to reduce the burden on time and clinical resources including automation and the potential use of intestinal ultrasound as a replacement for MRI. Positive enduser experience may be achieved through digitalised calculation that can be synchronized into existing registries to monitor the impact of drug therapy on disease modification. In parallel, ongoing prospective studies to understand the impact of SBD on patients, and its progression in response therapy, will support its merits as a disease modification tool followed by wider adoption.
Notes
Funding Source
This study was carried out as part of the CROCO (Crohn’s Disease Cohort) study, an investigator-initiated study (IIS), funded by AbbVie and the Portuguese Group of Inflammatory Bowel Disease Studies (GEDII). Hospital da Luz Learning Health oversees fund management and coordinates the study personnel responsible for executing the research procedures.
Conflict of Interest
Wong C has received sponsorship fees from Dr Falk Pharma. Burisch J has received research grants from AbbVie, Janssen-Cilag, MSD, Takeda, Tillots Pharma, Bristol Myers Squibb and Novo Nordisk Foundation; personal fees from AbbVie, Janssen-Cilag, MSD, Takeda, Tillots Pharma, Celgene, Pfizer, Samsung Bioepis, Bristol Myers Squibb, Pharmacosmos, Ferring, Galapagos, and Eli Lilly. Ungaro RC has received research support from AbbVie, Boehringer Ingelheim, Eli Lilly, and Pfizer; consulting and speaker’s fees from AbbVie, Bristol Myers Squibb, Janssen, Pfizer, and Takeda. Buisson A has received research grants from AbbVie, Celltrion Healthcare, Janssen, Lesaffre, Eli Lilly, Pfizer, Sandoz and Takeda; consulting fees from AbbVie, Amgen, Arena, Biogen, Celltrion Healthcare, CTMA, Galapagos/AlfaSigma, GutyCare/Resilience JanssenCilag, Eli Lilly, MSD, Nexbiome, Pfizer, Roche, Sandoz, Takeda and Tillotts; lecture fees from AbbVie, Amgen, Biogen, Celltrion Healthcare Galapagos/AlfaSigma, Janssen-Cilag, Eli Lilly, Mayoly-Spindler, MSD, Nordic Pharma, Norgine, Pfizer, Roche, Takeda, Tillotts and Vifor Pharma. Lambert J has no conflicts of interest. Colombel JF has received research grants from AbbVie, Janssen Pharmaceuticals, Takeda, Prothena and Bristol Myers Squibb; consulting fees from AbbVie, Amgen, AnaptysBio, Allergan, Arena Pharmaceuticals, Astellas, Boehringer Ingelheim, Bristol Myers Squibb, Celgene Corporation, Celltrion, Eli Lilly, Envision Pharma, Ferring Pharmaceuticals, Galmed Research, GlaxoSmithKline, Genentech (Roche), Janssen Pharmaceuticals, Kaleido Biosciences, Immunic, Iterative Scopes, Merck, Landos, Microba Life Science, Novartis, Otsuka Pharmaceutical, Pfizer, Protagonist Therapeutics, Sanofi, Sun, Takeda, TiGenix, Vifor; speaker fees from AbbVie and Takeda, and holds stock options in Intestinal Biotech Development. Torres J has received board, consultancy and speaker fees from AbbVie, Janssen, Sandoz and Pfizer, and research grants from Janssen-Cilag and AbbVie. Arebi N has received speaker fees from Takeda, Janssen-Cilag, Eli Lilly, AbbVie and Pfizer.
Data Availability Statement
Data is available on request from the corresponding author, Dr Charlotte Wong.
Author Contributions
Conceptualization: Arebi N. Data curation: Wong C, Arebi N. Formal analysis: Wong C, Arebi N. Funding acquisition: Torres J. Investigation: Wong C, Arebi N. Methodology: Wong C, Arebi N. Project administration: all authors. Supervision: Arebi N. Visualization: all authors. Writing - original draft: Wong C. Writing - review & editing: all authors. Approval of final manuscript: all authors.
Additional Contributions
We acknowledge the Portuguese Society of Gastroenterology/CEREGA for assisting with the creation of the survey on REDCap (Research Electronic Data Capture).
Supplementary Material
Supplementary materials are available at the Intestinal Research website (https://www.irjournal.org).
Supplementary Table 1.
Knowledge of Structural Bowel Damage (SBD) (n=107)
Supplementary Table 2.
Perception about the Importance of Training in Calculating the Lémann Index, and Its Use in Different Settings (n=107)
Supplementary Table 3.
Perception about Using the Lémann Index (n=107)
Supplementary Table 4.
Acceptability Scores for Subgroups in the Study Population (n=107)
Supplementary Table 5.
Summary of Respondent Comments
Supplementary Table 6.
Subgroup Analysis of Perceptions Based on Age Group, Years of Experience and Crohn’s Disease Caseload
Supplementary Table 7.
Subgroup Analysis of Perceptions Based on Sex, Professional Role and Professional Settin
Supplementary Table 8.
Subgroup Analysis of Acceptability of the LI (Composite Score >36)
Supplementary Fig. 1.
Checklist for Reporting Of Survey Studies (CROSS).
Supplementary Fig. 2.
Design of the questionnaire and relation to the theoretical framework for acceptability (TFA) [17]. SBD, structural bowel damage; CD, Crohn’s disease; LI, Lémann Index; VAS; visual analogue scale; MRE, magnetic resonance enterography; MRI, magnetic resonance imaging.
Supplementary Fig. 3.
Five-point Likert scale responses for importance of measuring structural bowel damage (SBD) and calculating the Lémann Index (LI).
Supplementary Fig. 4.
(A) Five-point Likert scale responses about perception of Lémann Index (LI) utility. (B) Five-point Likert scale responses about perception of LI utility. CD, Crohn’s disease.
Supplementary Fig. 5.
(A-J) Factors which would encourage future application of the Lemann Index (LI) in future therapeutic clinical trials and clinical practice settings. Visual Analogue Scale (VAS) responses where 1=not important and 10=very important. IQR, interquartile range.
