On the physician-completed and the patient-completed Simple Clinical Colitis Activity Index (SCCAI)

Dear Sir,

We commend Bennebroek Evertsz' et al.¹ on their work comparing a version of the physician-completed Simple Clinical Colitis Activity Index (SCCAI)² with a patient-completed version. We, too, believe this is a way of moving toward patient-centered and patient-initiated care.

The 2 scores as used here, however, show deviation from the original Index in both use and redesign.

Firstly, we note that 14% of the 149 patients had ‘at least one operation’ for ulcerative colitis and that 9.4% had pouches, suggesting that the remainder had ileostomies. The SCCAI was designed to assess ulcerative colitis patients with intact colons.

In addition, like the Simple Crohn's Disease Activity Index of Harvey and Bradshaw,³ the SCCAI was designed to be related to the patient's symptoms in the 72 h preceding the consultation rather than the preceding 7 days used in this study. The shorter assessment period allows for more subtle or rapid changes in the disease to be uncovered and can be done from memory rather than a diary. The study population here is outpatient clinic-based and so misses the more severe patients. This has resulted in a median DrSCCAI of only 2.68. Including hospitalized patients would have overcome this, although the 7-day assessment period may have made that impractical too.

An equally useful cut-off point to that of ‘relapse’ is that of remission. Higgins et al. found a score of ≤ 3.5 to be in best agreement with the patient's assessment of complete remission.⁴ Another important aspect is the agreement of changes in disease activity, now confirmed to be significant at a level of ≥ 2 points.¹,⁴ One way of demonstrating the Index's consistency and subtlety would have been to follow patients consecutively from relapse to remission.

In our own pilot study we compared the doctor and patient-completed SCCAI in 35 consecutive in and out patients on 52 occasions (Fig. 1). Like Evertsz et al.¹ we found an excellent over all correlation with Spearman Rank Correlation of r² = 0.85, and for the questions on stool frequency (r² = 91and r² = 88, for day and night respectively), blood in stool (r² = 0.85) and general well being (r² = 0.82). Urgency of defecation had a poorer correlation (r = 0.62) and in answering the questions on extra-intestinal complications 5 of the 52 patients scored that they had at least one, contrary to the view of the 2 physicians involved.

The SCCAI in its original form has proven robust when validated against other established ulcerative colitis disease activity indices.²,⁴,⁵ Altered versions of the Index have not been validated and we believe the most scientifically sound use of the patient-completed SCCAI is to facilitate the use of the original Index with help from patient and doctor education programs to maximize their congruity and relevance.

Figure 1

Correlation of 52 patient and doctor completed Simple Clinical Colitis Activity Index scores performed by 35 consecutive in and out patients.