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Dawwas GK, Cuker A, Schaubel DE, Lewis JD. Effectiveness and safety of prophylactic anticoagulation among hospitalized patients with inflammatory bowel disease. Blood Adv 2024; 8:1272-1280. [PMID: 38163322 PMCID: PMC10918481 DOI: 10.1182/bloodadvances.2023011756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 12/01/2023] [Accepted: 12/01/2023] [Indexed: 01/03/2024] Open
Abstract
ABSTRACT Hospitalized patients with inflammatory bowel disease (IBD) are at increased risk of venous thromboembolism (VTE). We aimed to evaluate the effectiveness and safety of prophylactic anticoagulation compared with no anticoagulation in hospitalized patients with IBD. We conducted a retrospective cohort study using a hospital-based database. We included patients with IBD who had a length of hospital stay ≥2 days between 1 January 2016 and 31 December 2019. We excluded patients who had other indications for anticoagulation, users of direct oral anticoagulants, warfarin, therapeutic-intensity heparin, and patients admitted for surgery. We defined exposure to prophylactic anticoagulation using charge codes. The primary effectiveness outcome was VTE. The primary safety outcome was bleeding. We used propensity score matching to reduce potential differences between users and nonusers of anticoagulants and Cox proportional-hazards regression to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs). The analysis included 56 194 matched patients with IBD (users of anticoagulants, n = 28 097; nonusers, n = 28 097). In the matched sample, prophylactic use of anticoagulants (vs no use) was associated with a lower rate of VTE (HR, 0.62; 95% CI, 0.41-0.94) and with no difference in the rate of bleeding (HR, 1.05; 95% CI, 0.87-1.26). In this study of hospitalized patients with IBD, prophylactic use of heparin was associated with a lower rate of VTE without increasing bleeding risk compared with no anticoagulation. Our results suggest potential benefits of prophylactic anticoagulation to reduce the burden of VTE in hospitalized patients with IBD.
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Affiliation(s)
- Ghadeer K. Dawwas
- Division of Epidemiology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Adam Cuker
- Departments of Medicine and Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Douglas E. Schaubel
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - James D. Lewis
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Angkeow J, Rothman A, Chaaban L, Paul N, Melia J. Systematic Review: Outcome Prediction in Acute Severe Ulcerative Colitis. GASTRO HEP ADVANCES 2023; 3:260-270. [PMID: 39129959 PMCID: PMC11307437 DOI: 10.1016/j.gastha.2023.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 11/06/2023] [Indexed: 08/13/2024]
Abstract
Background and Aims Approximately 1 in 4 patients with ulcerative colitis experiences a severe exacerbation of disease requiring hospitalization, termed acute severe ulcerative colitis (ASUC). These episodes pose a major burden on patients with ulcerative colitis and early prediction of their outcomes based on clinical data is crucial to optimize therapy. Methods A systematic review was performed using Embase and Medline for articles between 2000 and 2023. Studies obtained from the databases were uploaded on Covidence for screening by 2 independent reviewers. Quality appraisal for each study was done using the Critical Appraisals Skills Program depending on study design. Results A total of 48 eligible studies were included in the review. The key predictors of ASUC identified in this review included clinical, endoscopic, and radiographic biomarkers, which were summarized. The main outcomes assessed in the studies were intravenous corticosteroid failure, need for rescue therapy, and need for colectomy. Score-based predictions and some novel markers were also included in the results. Conclusion Utilization of evidence-based predictors of outcome in ASUC could serve as a powerful tool in customizing therapeutic measures and a step forward toward personalized patient care. Despite promising candidates, there remains a significant opportunity to identify and test additional clinical and laboratory-based predictors, especially early in the hospitalization and as the clinical practice and medical therapies evolve.
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Affiliation(s)
- Julia Angkeow
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alissa Rothman
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lara Chaaban
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nicole Paul
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joanna Melia
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Gomez DA, Ahmad-Waqar M, Brookes MJ, Kumar A. IBD-related mental health disorders: where do we go from here? Frontline Gastroenterol 2023; 14:512-520. [PMID: 37854787 PMCID: PMC10579553 DOI: 10.1136/flgastro-2023-102403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 06/08/2023] [Indexed: 10/20/2023] Open
Abstract
Inflammatory bowel disease is a complex and debilitating disease which is known to cause mental burden for patients. Even though few studies look at mental health disease in this cohort of patients, there is growing evidence of a correlation between disease activity and prevalence of mental health conditions such as anxiety, depression and post-traumatic stress disorder. In this literature review, the relationship between inflammatory bowel disease and mental health disorders is explored, with an emphasis on recognition, screening and therapeutic options and special considerations for these complex comorbidities. The relationship between medical and psychological disease is not often considered and less well understood and there is a need for further research in these fields. Patients would have much to gain both medically and psychologically from a multidisciplinary approach to this chronic disease association.
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Affiliation(s)
| | - Muhammad Ahmad-Waqar
- Department of Gastroenterology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Matthew James Brookes
- Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK
- Research Institute in Healthcare Science (RIHS), University of Wolverhampton, Wolverhampton, UK
| | - Aditi Kumar
- Department of Gastroenterology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Charilaou P, Mohapatra S, Doukas S, Kohli M, Radadiya D, Devani K, Broder A, Elemento O, Lukin DJ, Battat R. Predicting inpatient mortality in patients with inflammatory bowel disease: A machine learning approach. J Gastroenterol Hepatol 2023; 38:241-250. [PMID: 36258306 PMCID: PMC10099396 DOI: 10.1111/jgh.16029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 07/25/2022] [Accepted: 10/13/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Data are lacking on predicting inpatient mortality (IM) in patients admitted for inflammatory bowel disease (IBD). IM is a critical outcome; however, difficulty in its prediction exists due to infrequent occurrence. We assessed IM predictors and developed a predictive model for IM using machine-learning (ML). METHODS Using the National Inpatient Sample (NIS) database (2005-2017), we extracted adults admitted for IBD. After ML-guided predictor selection, we trained and internally validated multiple algorithms, targeting minimum sensitivity and positive likelihood ratio (+LR) ≥ 80% and ≥ 3, respectively. Diagnostic odds ratio (DOR) compared algorithm performance. The best performing algorithm was additionally trained and validated for an IBD-related surgery sub-cohort. External validation was done using NIS 2018. RESULTS In 398 426 adult IBD admissions, IM was 0.32% overall, and 0.87% among the surgical cohort (n = 40 784). Increasing age, ulcerative colitis, IBD-related surgery, pneumonia, chronic lung disease, acute kidney injury, malnutrition, frailty, heart failure, blood transfusion, sepsis/septic shock and thromboembolism were associated with increased IM. The QLattice algorithm, provided the highest performance model (+LR: 3.2, 95% CI 3.0-3.3; area-under-curve [AUC]:0.87, 85% sensitivity, 73% specificity), distinguishing IM patients by 15.6-fold when comparing high to low-risk patients. The surgical cohort model (+LR: 8.5, AUC: 0.94, 85% sensitivity, 90% specificity), distinguished IM patients by 49-fold. Both models performed excellently in external validation. An online calculator (https://clinicalc.ai/im-ibd/) was developed allowing bedside model predictions. CONCLUSIONS An online prediction-model calculator captured > 80% IM cases during IBD-related admissions, with high discriminatory effectiveness. This allows for risk stratification and provides a basis for assessing interventions to reduce mortality in high-risk patients.
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Affiliation(s)
- Paris Charilaou
- New York Presbyterian Hospital/Weill-Cornell Medical College - Jill Roberts Center for Inflammatory Bowel Disease, Weill Cornell Medicine, New York, New York, USA
| | - Sonmoon Mohapatra
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Sotirios Doukas
- Department of Medicine, Saint Peter's University Hospital/Rutgers-RWJ Medical School, New Brunswick, New Jersey, USA
| | - Maanit Kohli
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Dhruvil Radadiya
- Division of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Kalpit Devani
- Division of Gastroenterology and Hepatology, Prisma Health Greenville Memorial Hospital, Greenville, South Carolina, USA
| | - Arkady Broder
- Division of Gastroenterology and Hepatology, Saint Peter's University Hospital/Rutgers-RWJ Medical School, New Brunswick, New Jersey, USA
| | - Olivier Elemento
- Weill Cornell Medical College - Caryl and Israel Englander Institute for Precision Medicine, Institute for Computational Biomedicine, Weill Cornell Medicine, New York, New York, USA
| | - Dana J Lukin
- New York Presbyterian Hospital/Weill-Cornell Medical College - Jill Roberts Center for Inflammatory Bowel Disease, Weill Cornell Medicine, New York, New York, USA
| | - Robert Battat
- Department of Gastroenterology and Hepatology, Centre Hospitalier de l' Universite de Montreal, Montreal, Quebec, Canada
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Thavamani A, Umapathi KK, Sferra TJ, Sankararaman S. Cytomegalovirus Infection Is Associated With Adverse Outcomes Among Hospitalized Pediatric Patients With Inflammatory Bowel Disease. Gastroenterology Res 2023; 16:1-8. [PMID: 36895701 PMCID: PMC9990534 DOI: 10.14740/gr1588] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 12/27/2022] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Adults with inflammatory bowel disease (IBD) are at increased risk of developing cytomegalovirus (CMV) colitis, which is associated with adverse outcomes. Similar studies in pediatric IBD patients are lacking. METHODS We analyzed non-overlapping years of National Inpatient Sample (NIS) and Kids Inpatient Database (KID) between 2003 and 2016. We included all patients < 21 years with a diagnosis of Crohn's disease (CD) or ulcerative colitis (UC). Patients with coexisting CMV infection during that admission were compared with patients without CMV infection for outcome measures such as in-hospital mortality, disease severity, and healthcare resource utilization. RESULTS We analyzed a total of 254,839 IBD-related hospitalizations. The overall prevalence rate of CMV infection was 0.3% with an overall increasing prevalence trend, P < 0.001. Approximately two-thirds of patients with CMV infection had UC, which was associated with almost 3.6 times increased risk of CMV infection (confidence interval (CI): 3.11 to 4.31, P < 0.001). IBD patients with CMV had more comorbid conditions. CMV infection was significantly associated with increased odds of in-hospital mortality (odds ratio (OR): 3.58; CI: 1.85 to 6.93, P < 0.001) and severe IBD (OR: 3.31; CI: 2.54 to 4.32, P < 0.001). CMV-related IBD hospitalizations had increased length of stay by 9 days while incurring almost $65,000 higher hospitalization charges, P < 0.001. CONCLUSIONS The prevalence of CMV infection is increasing in pediatric IBD patients. CMV infections significantly corelated with increased risk of mortality and severity of IBD leading to prolonged hospital stay and higher hospitalization charges. Further prospective studies are needed to better understand the factors leading to this increasing CMV infection.
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Affiliation(s)
- Aravind Thavamani
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, UH Rainbow Babies and Children’s Hospital/Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | | | - Thomas J. Sferra
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, UH Rainbow Babies and Children’s Hospital/Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Senthilkumar Sankararaman
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, UH Rainbow Babies and Children’s Hospital/Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Sheehan GT, Twardus SW, Cagan A, Ananthakrishnan AN. E-cigarette Use and Disease Outcomes in Inflammatory Bowel Diseases: A Case-Control Study. Dig Dis Sci 2023; 68:208-213. [PMID: 35579793 DOI: 10.1007/s10620-022-07539-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/20/2022] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Traditional cigarette use adversely impacts disease outcomes in Crohn's disease (CD). There has been a worldwide increase in the use of e-cigarettes over the past decade. The impact of use of nicotine containing e-cigarettes on disease outcomes in CD or ulcerative colitis (UC) has not been well defined. METHODS This was a retrospective case-control study of patients with CD or UC who were current users of nicotine containing e-cigarettes (cases). Each case was matched to two non-vaping controls. Our primary study outcome was a composite of new biologic initiation, switch of existing biologic therapy, or IBD-related hospitalization or surgery over 2 years. Multivariable models adjusting for relevant covariates were construction. RESULTS The study consisted of 127 patients with IBD who were current e-cigarette users compared to 251 controls. Current e-cigarette users were younger than non-users and were more likely to have had an IBD-related surgery previously. On multivariable analysis among those with CD, current e-cigarette use was not associated with higher risk of study outcome (OR 0.82, 95% CI 0.36-1.87). No difference was observed separately among those who were current or former smokers. Similarly, in those with UC, current e-cigarette use was not associated with the primary outcome (OR 1.05, 95% CI 0.33-3.39). CONCLUSION Current e-cigarette use was not associated with worse outcomes among patients with IBD. However, larger studies particularly of patients de novo initiating vaping are needed to draw robust conclusions. Patients should be discouraged from initiating vaping recognizing overall adverse health effects.
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Affiliation(s)
- Gabriel T Sheehan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, 9th Floor, Boston, MA, 02114, USA
| | - Shaina W Twardus
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, 9th Floor, Boston, MA, 02114, USA
| | - Andrew Cagan
- Research Information Science and Computing, Mass General Brigham, Somerville, MA, USA
| | - Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, 9th Floor, Boston, MA, 02114, USA.
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Paliienko K, Korbush M, Krisanova N, Pozdnyakova N, Borysov A, Tarasenko A, Pastukhov A, Dudarenko M, Kalynovska L, Grytsaenko V, Garmanchuk L, Dovbynchuk T, Tolstanova G, Borisova T. Similar in vitro response of rat brain nerve terminals, colon preparations and COLO 205 cells to smoke particulate matter from different types of wood. Neurotoxicology 2022; 93:244-256. [DOI: 10.1016/j.neuro.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 09/17/2022] [Accepted: 10/12/2022] [Indexed: 11/07/2022]
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Li Y, Cai H, Sussman DA, Donet J, Dholaria K, Yang J, Panara A, Croteau R, Barkin JS. Association Between Immunosuppressive Therapy and Outcome of Clostridioides difficile Infection: Systematic Review and Meta-Analysis. Dig Dis Sci 2022; 67:3890-3903. [PMID: 34554365 DOI: 10.1007/s10620-021-07229-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 08/11/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients with Clostridioides difficile infection (CDI) often have coexisting medical problems requiring immunosuppressive therapy. However, limited data are available on the association between immunosuppressive therapy and CDI outcomes. AIM To determine the association between immunosuppressive therapy and CDI outcomes. METHODS PubMed, Embase, and Cochrane Library were searched through February 2021. Two reviewers independently reviewed and included studies that compared adult CDI patients who received immunosuppressive therapy to those who did not. The primary outcome was complicated CDl, including death, surgery, shock, or ICU admission. Raw data or unadjusted odds ratios (ORs) were used to calculate pooled ORs with 95% confidence intervals (CIs). RESULTS Twenty-two studies with a total of 5759 CDI patients were selected. Immunosuppressive therapy was significantly associated with both primary outcome and death, with pooled ORs of 1.61 (95% CI 1.33-1.96) and 1.73 (95% CI 1.39-2.15) separately. The association between corticosteroids and primary outcome was also significant with OR of 1.73 (95% CI 1.41, 2.12). In subgroup analysis, the factors explaining differences in study results included study quality, patient age, and whether individual studies had adjusted for potential confounders. In a systematic review, most studies suggested a positive association between immunosuppressive therapy and complicated outcomes of CDI in patients comorbid for IBD. CONCLUSIONS Our systematic review and meta-analysis demonstrate that immunosuppressive therapy is a risk factor for complicated outcomes of CDI.
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Affiliation(s)
- Yiting Li
- Department of Internal Medicine, Saint Francis Medical Center, Trenton, NJ, USA
- Division of Gastroenterology and Hepatology, University of New Mexico, School of Medicine, Albuquerque, NM, USA
| | - Haifeng Cai
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Childrens Hospital of Wenzhou Medical University, 109 Xue Yuan Xi Road, Wenzhou, 325000, Zhejiang, China
| | - Daniel A Sussman
- Division of Gastroenterology, Department of Medicine, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Jean Donet
- Department of Gastroenterology and Hepatology, University of California, San Francisco, Fresno, CA, USA
| | | | - Jiajia Yang
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Ami Panara
- Division of Gastroenterology, Department of Medicine, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Ryan Croteau
- Department of Gastroenterology, Wellspan Digestive Health, York, PA, USA
| | - Jamie S Barkin
- Division of Gastroenterology, Department of Medicine, University of Miami, Miller School of Medicine, Miami, FL, USA.
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Yu K, Faye AS, Wen T, Guglielminotti JR, Huang Y, Wright JD, D'Alton ME, Friedman AM. Outcomes during delivery hospitalisations with inflammatory bowel disease. BJOG 2022; 129:1073-1083. [PMID: 35152548 DOI: 10.1111/1471-0528.17039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/22/2021] [Accepted: 11/05/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To characterise inflammatory bowel disease (IBD) trends and associated risk during delivery hospitalisations. DESIGN Cross-sectional. SETTING US delivery hospitalisations. POPULATION Delivery hospitalisations in the 2000-2018 National Inpatient Sample. METHODS This study analysed a nationally representative hospital discharge database based on the presence of IBD. Temporal trends in IBD were analysed using joinpoint regression to estimate the average annual percent change (AAPC). IBD severity was characterised by the presence of diagnoses such as penetrating and stricturing disease and history of bowel resection. Risks for adverse outcomes were analysed based on presence of IBD. Poisson regression models were performed with unadjusted and adjusted risk ratios (aRR) as measures of effect. MAIN OUTCOME MEASURE Prevalence of IBD and associated adverse outcomes. RESULTS Of 73 109 790 delivery hospitalisations, 89 965 had a diagnosis of IBD. IBD rose from 0.06% in 2000 to 0.21% in 2018 (AAPC 7.3%, 95% CI 6.7-7.9%). Among deliveries with IBD, IBD severity diagnoses increased from 4.1% to 8.1% from 2000 to 2018. In adjusted analysis, IBD was associated with increased risk for preterm delivery (aRR 1.50, 95% CI 1.47-1.53), severe maternal morbidity (aRR 1.93, 95% CI 1.83-2.04), venous thrombo-embolism (aRR 2.76, 95% CI 2.39-3.18) and surgical injury during caesarean delivery hospitalisation (aRR 5.03, 95% CI 4.76-5.31). In the presence of a severe IBD diagnosis, risk was further increased for all adverse outcomes. CONCLUSION IBD is increasing in the obstetric population and is associated with adverse outcomes. Risk is increased in the presence of a severe IBD diagnosis. TWEETABLE ABSTRACT Deliveries among women with inflammatory bowel disease are increasing. Disease severity is associated with adverse outcomes.
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Affiliation(s)
- K Yu
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - A S Faye
- Department of Medicine, Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Division of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY, USA
| | - T Wen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California-San Francisco, San Francisco, CA, USA
| | | | - Y Huang
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - J D Wright
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - M E D'Alton
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - A M Friedman
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
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Xu F, Wheaton AG, Liu Y, Greenlund KJ. Major ambulatory surgery among US adults with inflammatory bowel disease, 2017. PLoS One 2022; 17:e0264372. [PMID: 35202440 PMCID: PMC8870533 DOI: 10.1371/journal.pone.0264372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 02/09/2022] [Indexed: 01/13/2023] Open
Abstract
Background Patients with inflammatory bowel disease (IBD) have higher health services use than those without IBD. We investigated patient and hospital characteristics of major ambulatory surgery encounters for Crohn’s disease (CD) or ulcerative colitis (UC) vs non-IBD patients. Methods We conducted a cross-sectional study using 2017 Nationwide Ambulatory Surgery Sample. Major ambulatory surgery encounters among patients aged ≥18 years with CD (n = 20,635) or UC (n = 9,894) were compared to 9.4 million encounters among non-IBD patients. Weighted percentages of patient characteristics (age, sex, median household income, primary payers, patient location, selected comorbidities, discharge destination, type of surgeries) and hospital-related characteristics (hospital size, ownership, location and teaching status, region) were compared by IBD status (CD, UC, and no IBD). Linear regression was used to estimate mean total charges, controlling for these characteristics. Results Compared with non-IBD patients, IBD patients were more likely to have private insurance, reside in urban areas and higher income zip codes, and undergo surgeries in hospitals that were private not-for-profit, urban teaching, and in the Northeast. Gastrointestinal surgeries were more common among IBD patients. Some comorbidities associated with increased risk of surgical complications were more prevalent among IBD patients. Total charges were 9% lower for CD patients aged <65 years (Median: $16,462 vs $18,106) and 6% higher for UC patients aged ≥65 years (Median: $16,909 vs $15,218) compared to their non-IBD patient counterparts. Conclusions Differences in characteristics of major ambulatory surgery encounters by IBD status may identify opportunities for efficient resource allocation and positive surgical outcomes among IBD patients.
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Affiliation(s)
- Fang Xu
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
- * E-mail:
| | - Anne G. Wheaton
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Yong Liu
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Kurt J. Greenlund
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
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Verma A, Varma S, Freedberg DE, Axelrad JE. A Simple Emergency Department-Based Score Predicts Complex Hospitalization in Patients with Inflammatory Bowel Disease. Dig Dis Sci 2022; 67:629-638. [PMID: 33606139 PMCID: PMC8373997 DOI: 10.1007/s10620-021-06877-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/24/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND AIMS Thirty percent of inflammatory bowel disease (IBD) patients hospitalized with flare require salvage therapy or surgery. Additionally, 40% experience length of stay (LOS) > 7 days. No emergency department (ED)-based indices exist to predict these adverse outcomes at admission for IBD flare. We examined whether clinical, laboratory, and endoscopic markers at presentation predicted prolonged LOS, inpatient colectomy, or salvage therapy in IBD patients admitted with flare. METHODS Patients with ulcerative colitis (UC) or colonic involvement of Crohn's disease (CD) hospitalized with flare and tested for Clostridioides difficile infection (CDI) between 2010 and 2020 at two urban academic centers were studied. The primary outcome was complex hospitalization, defined as: LOS > 7 days, inpatient colectomy, or inpatient infliximab or cyclosporine. A nested k-fold cross-validation identified predictive factors of complex hospitalization. RESULTS Of 164 IBD admissions, 34% (56) were complex. Predictive factors included: tachycardia in ED triage (odds ratio [OR] 3.35; confidence interval [CI] 1.79-4.91), hypotension in ED triage (3.45; 1.79-5.11), hypoalbuminemia at presentation (2.54; 1.15-3.93), CDI (2.62; 1.02-4.22), and endoscopic colitis (4.75; 1.75-5.15). An ED presentation score utilizing tachycardia and hypoalbuminemia predicted complex hospitalization (area under curve 0.744; CI 0.671-0.816). Forty-four of 48 (91.7%) patients with a presentation score of 0 (heart rate < 99 and albumin ≥ 3.4 g/dL) had noncomplex hospitalization. CONCLUSIONS Over 90% of IBD patients hospitalized with flare with an ED presentation score of 0 did not require salvage therapy, inpatient colectomy, or experience prolonged LOS. A simple ED-based score may provide prognosis at a juncture of uncertainty in patient care.
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Affiliation(s)
- Abhishek Verma
- Department of Medicine, NYU Langone Health, New York, NY 10016, USA
| | - Sanskriti Varma
- Department of Medicine, New York Presbyterian Columbia University Medical Center, New York, NY, 10032, USA
| | - Daniel E Freedberg
- Division of Digestive and Liver Diseases, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY, 10032, USA
| | - Jordan E Axelrad
- Division of Gastroenterology, NYU Langone Health, Inflammatory Bowel Disease Center at NYU Langone Health, New York, NY 10016, USA
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12
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Soriano CR, Powell CR, Chiorean MV, Simianu VV. Role of hospitalization for inflammatory bowel disease in the post-biologic era. World J Clin Cases 2021; 9:7632-7642. [PMID: 34621815 PMCID: PMC8462259 DOI: 10.12998/wjcc.v9.i26.7632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/17/2021] [Accepted: 08/12/2021] [Indexed: 02/06/2023] Open
Abstract
Treatment for inflammatory bowel disease (IBD) often requires specialized care. While much of IBD care has shifted to the outpatient setting, hospitalizations remain a major site of healthcare utilization and a sizable proportion of patients with inflammatory bowel disease require hospitalization or surgery during their lifetime. In this review, we approach IBD care from the population-level with a specific focus on hospitalization for IBD, including the shifts from inpatient to outpatient care, the balance of emergency and elective hospitalizations, regionalization of specialty IBD care, and contribution of surgery and endoscopy to hospitalized care.
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Affiliation(s)
- Celine R Soriano
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
| | - Charleston R Powell
- Department of Internal Medicine, Madigan Army Medical Center, Tacoma, WA 98431, United States
| | - Michael V Chiorean
- Department of Gastroenterology, Swedish Medical Center, Seattle, WA 98109, United States
| | - Vlad V Simianu
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
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13
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Abstract
Despite the recent emergence of expensive biologic therapies, hospitalization and surgery remain important contributors for the overall costs of inflammatory bowel disease (IBD). In this study, we aimed to describe the burden of reoperations in patients with IBD by evaluating reoperation rates, charges, and risk factors over 16 years.
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14
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Charilaou P, Mohapatra S, Joshi T, Devani K, Gadiparthi C, Pitchumoni CS, Goldstein D. Opioid Use Disorder Increases 30-Day Readmission Risk in Inflammatory Bowel Disease Hospitalizations: a Nationwide Matched Analysis. J Crohns Colitis 2020; 14:636-645. [PMID: 31804682 DOI: 10.1093/ecco-jcc/jjz198] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIMS The opioid epidemic has become increasingly concerning, with the ever-increasing prescribing of opioid medications in recent years, especially in inflammatory bowel disease [IBD] patients with chronic pain. We aimed to isolate the effect of opioid use disorder [OUD] on 30-day readmission risk after an IBD-related hospitalization. METHODS We retrospectively extracted IBD-related adult hospitalizations and 30-day, any-cause, readmissions from the National Readmissions Database [period 2010-2014]. OUD and 30-day readmission trends were calculated. Conventional and exact-matched [EM] logistic regression and time-to-event analyses were conducted among patients who did not undergo surgery during the index hospitalization, to estimate the effect of OUD on 30-day readmission risk. RESULTS In total, 487 728 cases were identified: 6633 [1.4%] had documented OUD And 308 845 patients [63.3%] had Crohn's disease. Mean age was 44.8 ± 0.1 years, and 54.3% were women. Overall, 30-day readmission rate was 19.4% [n = 94,546], being higher in OUD patients [32.6% vs 19.2%; p < 0.001]. OUD cases have been increasing [1.1% to 1.7%; p-trend < 0.001], while 30-day readmission rates were stable [p-trend = 0.191]. In time-to-event EM analysis, OUD patients were 47% more likely (hazard ratio 1.47; 95% confidence interval [CI]:1.28-1.69; p < 0.001) to be readmitted, on average being readmitted 32% earlier [time ratio 0.68; 95% CI: 0.59-0.78; p < 0.001]. CONCLUSION OUD prevalence has been increasing in hospitalized IBD patients from 2010 to 2014. On average, one in five patients will be readmitted within 30 days, with up to one in three among the OUD subgroup. OUD is significantly associated with increased 30-day readmission risk in IBD patients and further measures relating to closer post-discharge outpatient follow-up and pain management should be considered to minimize 30-day readmission risk.
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Affiliation(s)
- Paris Charilaou
- Saint Peter's University Hospital/Rutgers-RWJ Medical School, New Brunswick, NJ, USA
| | - Sonmoon Mohapatra
- Saint Peter's University Hospital/Rutgers-RWJ Medical School, New Brunswick, NJ, USA
| | - Tejas Joshi
- Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Kalpit Devani
- East Tennessee State University/James H. Quillen College of Medicine, Johnson City, TN, USA
| | | | | | - Debra Goldstein
- Saint Peter's University Hospital/Rutgers-RWJ Medical School, New Brunswick, NJ, USA
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15
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Ananthakrishnan AN, Kaplan GG, Ng SC. Changing Global Epidemiology of Inflammatory Bowel Diseases: Sustaining Health Care Delivery Into the 21st Century. Clin Gastroenterol Hepatol 2020; 18:1252-1260. [PMID: 32007542 DOI: 10.1016/j.cgh.2020.01.028] [Citation(s) in RCA: 178] [Impact Index Per Article: 35.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 12/29/2019] [Accepted: 01/27/2020] [Indexed: 02/07/2023]
Abstract
Crohn's disease and ulcerative colitis have emerged as global diseases. They affect over 2 million individuals in the North America, 3.2 million in Europe, and millions more worldwide. The recent decades have been characterized by several important changes in the epidemiology of these diseases, in particularly an increasing incidence rates in newly industrialized countries experiencing a westernization of lifestyle. While rates of surgery have experienced a temporal decline attributable in part to increasing availability of medical treatments, earlier initiation of effective therapy, and changes in clinical practice, the healthcare costs associated with these diseases have continued to increase, in part due to costly therapies. Robust epidemiologic and experimental studies have defined the role of the external environment and microbiome on disease pathogenesis and have offered opportunities for disease prevention by modifying such factors. We propose several important steps that are necessary to provide globally sustainable inflammatory bowel disease care in the 21st century.
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Affiliation(s)
- Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Gilaad G Kaplan
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
| | - Siew C Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Diseases, LKS Institute of Health Science, Chinese University of Hong Kong, Hong Kong, China
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16
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Moore AC, Bressler B. Acute Severe Ulcerative Colitis: The Oxford Criteria No Longer Predict In-Hospital Colectomy Rates. Dig Dis Sci 2020; 65:576-580. [PMID: 31093812 DOI: 10.1007/s10620-019-05668-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 05/08/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Patients admitted to hospital with acute severe ulcerative colitis have a short-term in-hospital colectomy rate of 30%. The Oxford criteria state that if the CRP is greater than 45 mg/l or there are more than eight bowel movements in 24 h at day 3 of intravenous corticosteroids, there is an 85% risk of an in-hospital colectomy. AIM The aim of this study was to determine whether this high rate of colectomy continues to be accurate in this medically refractory patient population. METHODS We performed a retrospective chart review of 80 patients admitted to a tertiary hospital between 2013 and 2017 with acute severe ulcerative colitis. RESULTS Sixteen (20%) patients required an in-hospital colectomy. Of the 33 patients that fulfilled the Oxford criteria, 12 (36%) patients required a colectomy during admission. Only four (9.5%) patients who did not fulfill the Oxford criteria required a colectomy during admission. Twenty-two patients that had fulfilled the Oxford criteria received infliximab as second-line medical therapy. CONCLUSION In a patient population that fulfilled the Oxford criteria, the in-hospital colectomy rate has reduced from 85% in 1996 to 36% in 2017. These results should be considered when discussing with patients the opportunity to commence infliximab or cyclosporine as second-line medical therapy.
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Affiliation(s)
- Alice C Moore
- Department of Gastroenterology, Faculty of Medicine, University of British Columbia, 2775 Laurel Street, 10th Floor, Vancouver, BC, V5Z 1M9, Canada.
| | - Brian Bressler
- Department of Gastroenterology, Faculty of Medicine, University of British Columbia, 2775 Laurel Street, 10th Floor, Vancouver, BC, V5Z 1M9, Canada
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17
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Abstract
Acute severe ulcerative colitis (ASUC) is a potentially life-threatening presentation of ulcerative colitis that in nearly all cases requires inpatient management and coordinated care from hospitalists, gastroenterologists, and surgeons. Even with ideal care, a substantial proportion of patients will ultimately require colectomy, but most patients can avoid surgery with intravenous corticosteroid treatment and if needed, appropriate rescue therapy with infliximab or cyclosporine. In-hospital management requires not only therapies to reduce the inflammation at the heart of the disease process, but also to avoid complications of the disease and its treatment. Care for ASUC must be anticipatory, with patient education and evaluation starting at the time of admission in advance of the possible need for urgent medical or surgical rescue therapy. Here we outline a general approach to the treatment of patients hospitalized with ASUC, highlighting the common pitfalls and critical points in management.
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Affiliation(s)
- David I Fudman
- Department of Medicine and Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas
| | - Lindsey Sattler
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Joseph D Feuerstein
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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18
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Goren I, Brom A, Yanai H, Dagan A, Segal G, Israel A. Risk of bacteremia in hospitalised patients with inflammatory bowel disease: a 9-year cohort study. United European Gastroenterol J 2019; 8:195-203. [PMID: 32213075 DOI: 10.1177/2050640619874524] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Patients with inflammatory bowel disease might be at increased risk of invasive bacterial infections. OBJECTIVES The objective of this study was to identify the rate of bacteremia in hospitalised patients with inflammatory bowel disease and risk factors. METHODS An observational cohort of hospitalised patients with inflammatory bowel disease, aged 16-80 years, from 2008 to 2017 in a large tertiary hospital. Patients with Charlson comorbidity index of 2 or greater were excluded. Patients with one or more positive blood culture were reviewed. Logistic regression was used to evaluate risk factors for bacteremia. RESULTS Of 5522 admitted patients, only 1.3% had bacteremia (73/5522) (39, Crohn's disease; 25, ulcerative colitis; nine, unclassified inflammatory bowel disease). The most common pathogen was Escherichia coli (19/73 patients). The mortality rate at 30 days of patients with bacteremia was 13.7% (10/73). Longer hospitalisations (mean length of stay (21.6 ± 31.0 vs. 6.4 ± 16.0 days; P < 0.0001) and older age (mean age 47.5 ± 18.0 vs. 40.2 ± 15.4 years, P < 0.0001)) were associated with an increased risk of bacteremia. In multivariate analysis, treatment with either anti-tumour necrosis factor α, purine analogues, steroids or amino salicylates was not associated with an increased risk of bacteremia. Risk was greatest among patients aged 65 years or older (relative risk 2.84, 95% confidence interval 1.6-4.8; P = 0.0001) relative to those under 65 years. CONCLUSION Age over 65 years, but not inflammatory bowel disease-related medications, is associated with an increased risk of bacteremia in hospitalised patients with inflammatory bowel disease.
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Affiliation(s)
- Idan Goren
- Division of Gastroenterology, Rabin Medical Center * , Petah Tikva, Israel
| | - Adi Brom
- Internal Medicine T, Chaim Sheba Medical Center * , Tel-Hashomer, Ramat-Gan, Israel
| | - Henit Yanai
- Division of Gastroenterology, Rabin Medical Center * , Petah Tikva, Israel
| | - Amir Dagan
- Rheumatology Unit, Assuta Medical Center, Ashdod, Israel
| | - Gad Segal
- Internal Medicine T, Chaim Sheba Medical Center * , Tel-Hashomer, Ramat-Gan, Israel
| | - Ariel Israel
- Clalit Jerusalem Research Center, Clalit Health Services, Jerusalem, Israel
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19
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Sebastian S, Myers S, Argyriou K, Martin G, Los L, Fiske J, Ranjan R, Cooper B, Goodoory V, Ching HL, Jayasooriya N, Brooks J, Dhar A, Shenoy AH, Limdi JK, Butterworth J, Allen PB, Samuel S, Moran GW, Shenderey R, Parkes G, Lobo A, Kennedy NA, Subramanian S, Raine T. Infliximab induction regimens in steroid-refractory acute severe colitis: a multicentre retrospective cohort study with propensity score analysis. Aliment Pharmacol Ther 2019; 50:675-683. [PMID: 31456297 DOI: 10.1111/apt.15456] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 06/23/2019] [Accepted: 07/19/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Accelerated induction regimens of infliximab have been proposed to improve response rates in patients with steroid-refractory acute severe colitis. AIM To determine the differences in outcome for acute severe ulcerative colitis between accelerated and standard-dose infliximab METHODS: We collected data on hospitalised patients receiving differing regimens of rescue therapy for steroid-refractory acute severe ulcerative colitis. Our primary outcome was 30-day colectomy rate. Secondary outcomes were colectomy within index admission, and at 90 days and 12 months. We used propensity score analysis with optimal calliper matching using high risk covariates defined a priori to reduce potential provider selection bias. RESULTS We included 131 patients receiving infliximab rescue therapy; 102 received standard induction and 29 received accelerated induction. In the unmatched cohort, there was no difference by type of induction in the 30-day colectomy rates (18% vs 20%, P = .45), colectomy during index admission (13% vs 20%, P = .26) or overall colectomy (20% vs 24%, P = .38). In the propensity score-matched cohort of 52 patients, 30-day colectomy (57% vs 27%, P = .048) and index admission colectomy (53% vs 23%, P = .045) rates were higher in those receiving standard induction compared to accelerated induction but there was no difference in overall colectomy rates (57% vs 31%, P = .09). There was no significant difference in length of stay or in complication and infection rates. CONCLUSION In a propensity score-matched cohort, steroid-refractory acute severe ulcerative colitis patients, short-term, but not long-term, colectomy rates appear to be lower in those receiving an accelerated induction regimen.
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20
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Candido FD, Fiorino G, Spadaccini M, Danese S, Spinelli A. Are Surgical Rates Decreasing in the Biological Era In IBD? Curr Drug Targets 2019; 20:1356-1362. [PMID: 31465283 DOI: 10.2174/1389450120666190426165325] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 02/12/2019] [Accepted: 03/15/2019] [Indexed: 02/08/2023]
Abstract
Crohn's Disease (CD) and Ulcerative Colitis (UC), known as Inflammatory Bowel Diseases (IBD), are multifactorial, potentially debilitating diseases with probable genetic heterogeneity and unknown etiology. During the disease course of IBD, periods of inflammatory activity alternate with periods of remission. Severe complications in IBD often result in surgery. In the last two decades, major advances in medical treatment have changed the management of IBD. The advent of monoclonal antibodies targeting cytokines and adhesion molecules has brought a revolution in the treatment of IBD refractory to conventional therapy. However, it is not well established if these treatments could influence the long-term course of the diseases and the need for surgical treatment, though they have no severe adverse effects and improve quality of life. It has been shown that in the era of biologic agents, there has been a relative reduction in surgery rate for mild disease presentation, while the incidence of emergency or urgent surgery both for CD and UC remains unmodified. We summarized key data about current surgical rates in IBD after the advent of biologic agents.
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Affiliation(s)
- Francesca Di Candido
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Gionata Fiorino
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.,Department of Biomedical Science, Humanitas University, Rozzano, Milan, Italy
| | - Marco Spadaccini
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Silvio Danese
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.,Department of Biomedical Science, Humanitas University, Rozzano, Milan, Italy
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.,Department of Biomedical Science, Humanitas University, Rozzano, Milan, Italy
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21
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Sebastian S, Myers S, Nadir S, Subramanian S. Systematic Review: Efficacy and Safety of Accelerated Induction Regimes in Infliximab Rescue Therapy for Hospitalized Patients with Acute Severe Colitis. Dig Dis Sci 2019; 64:1119-1128. [PMID: 30535888 DOI: 10.1007/s10620-018-5407-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 11/29/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pharmacokinetic data suggest that standard induction dosing schedules may not be sufficient in patients with acute severe colitis (ASUC). Hence, intensified induction regimes are increasingly used in the rescue treatment of hospitalized patients with ASUC to avoid the need for colectomy although the evidence for this is uncertain. AIM To conduct a systematic review of short- and long-term efficacy outcomes from accelerated infliximab induction studies. METHODS Systematic search of relevant databases (MEDLINE, EMBASE, Cochrane Database of Systematic Reviews) and relevant conference proceedings (Digestive Diseases Week, European Colitis and Crohn's Organisation Congress, United European Gastroenterology Week) was done. RESULTS We identified ten relevant studies with a total of 705 patients, of whom 308 received an intensified infliximab regime. Pooled analysis showed no difference in short-term or long-term colectomy rates in those receiving accelerated induction regimes when compared to standard induction. No significant differences in complication rates were identified. CONCLUSIONS The available uncontrolled studies so far do not suggest short-term or long-term benefit in using accelerated induction in hospitalized ASUC. The overall poor quality of available studies with confounding variables indicates the need for a randomized controlled trial with personalized risk stratification.
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Affiliation(s)
- S Sebastian
- IBD Unit, Hull and East Yorkshire NHS Trust, Hull, UK.
- Hull York Medical School, Hull, UK.
| | - S Myers
- IBD Unit, Hull and East Yorkshire NHS Trust, Hull, UK
| | - S Nadir
- IBD Unit, Hull and East Yorkshire NHS Trust, Hull, UK
| | - S Subramanian
- The Royal Liverpool and Broad Green University Hospitals NHS Foundation Trust, Liverpool, UK
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22
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Kruger AJ, Hinton A, Afzali A. Index Severity Score and Early Readmission Predicts Increased Mortality in Ulcerative Colitis Patients. Inflamm Bowel Dis 2019; 25:894-901. [PMID: 30247551 DOI: 10.1093/ibd/izy297] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Readmissions are common after hospitalization related to ulcerative colitis (UC). A risk score to stratify the severity of UC hospitalizations and risk of colectomy has been previously reported. Our aim was to predict hospital-related outcomes after hospitalizations for UC utilizing this severity score. METHODS We utilized the Nationwide Readmissions Database (2010-2014) for hospitalized patients with UC and differentiated patients by index severity (low, intermediate, high). Baseline characteristics, surgical rates, readmissions, mortality, and hospital outcomes were collected. The primary outcomes of interest included readmission and mortality rates. RESULTS There were 133,819 patients admitted with UC with 22,762 (17%) readmitted within 30 days. Those readmitted within 30 days had a 4.5% calendar year mortality rate, compared with 0.45% in those not readmitted within 30 days (P < 0.001). Index surgery rates (19.2% vs 12.3%), length of stay (6.9 vs 5.4 days), and hospital costs ($13,530 vs $10,366; P < 0.001 for all) were higher in those readmitted within 30 days. Patients with high-severity presentations had higher surgical rates (31.6%), higher 30-day and calendar year readmission rates (24.3% and 46.0%, respectively), increased index and calendar year mortality (2.5% and 2.0%, respectively), longer length of stay (15.1 days), and increased costs ($31,136) compared with those with low severity (P < 0.001 for all). Calendar-year survival rates in those with intermediate and high scores were significantly lower than in those with low scores. CONCLUSIONS An index severity score of intermediate or high and early readmissions are predictors of calendar year mortality. Future efforts should emphasize more focused care in high-risk patients, as this may reduce readmissions and improve outcomes.
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Affiliation(s)
- Andrew J Kruger
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Alice Hinton
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, Ohio
| | - Anita Afzali
- Inflammatory Bowel Disease Center at The Ohio State University Wexner Medical Center, Columbus, Ohio.,Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio
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23
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Cohen-Mekelburg S, Rosenblatt R, Gold S, Shen N, Fortune B, Waljee AK, Saini S, Scherl E, Burakoff R, Unruh M. Fragmented Care is Prevalent Among Inflammatory Bowel Disease Readmissions and is Associated With Worse Outcomes. Am J Gastroenterol 2019; 114:276-290. [PMID: 30420634 DOI: 10.1038/s41395-018-0417-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Inflammatory bowel disease (IBD) is a complex chronic disease that often requires a multispeciality approach; thus, IBD patients are prone to care fragmentation. We aim to determine the prevalence of fragmentation among hospitalized IBD patients and identify associated predictors and visit-level outcomes. METHODS The State Inpatient Databases for New York and Florida were used to identify 90-day readmissions among IBD inpatients from 2009 to 2013. The prevalence of fragmentation, defined as a readmission to a non-index hospital, was reported. Characteristics associated with fragmented care were identified using multivariable logistic regression. Multivariable models were utilized to determine the association between fragmentation and outcomes (in-hospital mortality, readmission length of stay, and inpatient colonoscopy). RESULTS Among IBD inpatients, 25,241 and 29,033 90-day readmission visits were identified, in New York and Florida, respectively. The prevalence of fragmentation was 26.4% in New York and 32.5% in Florida. Younger age, a non-emergent admission type, public payer or uninsured status, mood disorder, and substance abuse were associated with fragmented care, while female gender and a primary diagnosis of an IBD-related complication had an inverse association. Fragmented inpatient care is associated with a higher likelihood of in-hospital death, higher rates of inpatient colonoscopy, and a longer readmission length of stay. CONCLUSIONS Over one in four IBD inpatient readmissions are fragmented. Disparities and differences in fragmentation exist and contribute to poor patient outcomes. Additional efforts targeting fragmentation should be made to better coordinate IBD management, reduce healthcare gaps, and promote high-value care.
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Affiliation(s)
- Shirley Cohen-Mekelburg
- Division of Gastroenterology & Hepatology, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Russell Rosenblatt
- Division of Gastroenterology & Hepatology, New York Presbyterian Weill Cornell Medicine, New York, NY, 10021, USA
| | - Stephanie Gold
- Department of Medicine, New York Presbyterian Weill Cornell Medicine, New York, NY, 10021, USA
| | - Nicole Shen
- Division of Gastroenterology & Hepatology, New York Presbyterian Weill Cornell Medicine, New York, NY, 10021, USA
| | - Brett Fortune
- Division of Gastroenterology & Hepatology, New York Presbyterian Weill Cornell Medicine, New York, NY, 10021, USA
| | - Akbar K Waljee
- Division of Gastroenterology & Hepatology, University of Michigan, Ann Arbor, MI, 48109, USA.,VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, 48105, USA.,Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor, MI, 48109, USA
| | - Sameer Saini
- Division of Gastroenterology & Hepatology, University of Michigan, Ann Arbor, MI, 48109, USA.,VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, 48105, USA
| | - Ellen Scherl
- Division of Gastroenterology & Hepatology, New York Presbyterian Weill Cornell Medicine, New York, NY, 10021, USA
| | - Robert Burakoff
- Division of Gastroenterology & Hepatology, New York Presbyterian Weill Cornell Medicine, New York, NY, 10021, USA
| | - Mark Unruh
- Department of Healthcare Policy & Research, New York Presbyterian Weill Cornell Medicine, New York, NY, 10021, USA
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24
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Xu F, Liu Y, Wheaton AG, Rabarison KM, Croft JB. Trends and Factors Associated with Hospitalization Costs for Inflammatory Bowel Disease in the United States. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2019; 17:77-91. [PMID: 30259396 PMCID: PMC10498392 DOI: 10.1007/s40258-018-0432-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Few studies have addressed recent trends in hospitalization costs for inflammatory bowel disease (IBD). OBJECTIVE We explored trends and described patient and hospital factors associated with hospitalization costs for IBD. METHODS Using data from the 2003-2014 National Inpatient Sample for adults aged ≥ 18 years, we estimated costs using multivariable linear models and assessed linear trends by time periods using piecewise linear regressions. RESULTS In 2014, there were an estimated 56,290 hospitalizations for Crohn's disease (CD), with a mean cost of US$11,345 and median cost of US$7592; and 33,585 hospitalizations for ulcerative colitis (UC), with a mean cost of US$13,412 and median cost of US$8873. Higher costs were observed among Hispanic [adjusted cost ratio (ACR) = 1.07; 95% confidence interval (CI) = 1.00-1.14; p = 0.04] or other non-Hispanic (ACR = 1.09; 95% CI = 1.02-1.17; p = 0.01) CD patients than for non-Hispanic White CD patients. For UC patients, higher costs were observed among men (ACR = 1.09; 95% CI = 1.05-1.13; p < 0.001) compared with women and among patients aged 35-44 years, 45-54 years, and 55-64 years compared with those aged 18-24 years. Among all patients, factors associated with higher costs included higher household income, more comorbidities, and hospitals that were government nonfederal versus private, were large versus small, and were located in the West versus Northeast regions. From 2003 to 2008, total costs increased annually by 3% for CD (1.03; 95% CI = 1.02-1.05; p < 0.001) and 4% for UC (1.04; 95% CI = 1.02-1.06; p < 0.001), but remained unchanged from 2008 to 2014. CONCLUSIONS The findings are important to identify IBD patients with higher hospitalization costs and to inform policy plans on hospital resource allocation.
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Affiliation(s)
- Fang Xu
- Division of Population Health, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 4770 Buford Highway NE, Mailstop F-78, Atlanta, GA, 30341, USA.
| | - Yong Liu
- Division of Population Health, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 4770 Buford Highway NE, Mailstop F-78, Atlanta, GA, 30341, USA
| | - Anne G Wheaton
- Division of Population Health, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 4770 Buford Highway NE, Mailstop F-78, Atlanta, GA, 30341, USA
| | - Kristina M Rabarison
- Division of Population Health, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 4770 Buford Highway NE, Mailstop F-78, Atlanta, GA, 30341, USA
| | - Janet B Croft
- Division of Population Health, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 4770 Buford Highway NE, Mailstop F-78, Atlanta, GA, 30341, USA
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Le DV, Gupte R, Gabriel MH, Vaidya V. Inflammatory bowel disease: cost-driving factors and impact of cost sharing on outpatient resource utilization. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2018. [DOI: 10.1111/jphs.12244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Duy Vu Le
- Select Specialty Hospital; Cincinnati OH USA
| | | | | | - Varun Vaidya
- College of Pharmacy and Pharmaceutical Sciences; University of Toledo; Toledo OH USA
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Cohen-Mekelburg S, Rosenblatt R, Gold S, Burakoff R, Waljee AK, Saini S, Schackman BR, Scherl E, Crawford C. The Impact of Opioid Epidemic Trends on Hospitalised Inflammatory Bowel Disease Patients. J Crohns Colitis 2018; 12:1030-1035. [PMID: 29741667 PMCID: PMC6113704 DOI: 10.1093/ecco-jcc/jjy062] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 04/25/2018] [Accepted: 05/05/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS Opioid use disorder [OUD] has become a public health crisis among patients with chronic disease. Inflammatory bowel disease [IBD] patients are at high risk for OUD because they suffer from chronic relapsing-remitting pain. We aimed to describe the prevalence and trends in OUD-related diagnoses among hospitalised IBD patients. METHODS A retrospective study was performed using weighted Nationwide Inpatient Sample data from 2005 to 2014. Adult IBD hospital visits and OUD-related diagnoses were identified using a previously published schema. Annual diagnoses were calculated. Characteristics associated with OUD were assessed using multivariable logistic regression. Associations between OUD and length of stay were assessed overall and separately for surgical and non-surgical stays. RESULTS In all, 2.2% of 2585174 weighted discharges with any diagnosis of IBD also had an OUD-related diagnosis, with an 8.8% average annual increase. In multivariable analysis, Crohn's disease, public payer or no insurance, and psychiatric comorbidities were associated with a higher likelihood of OUD, whereas a primary diagnosis of an IBD-related complication was associated with a lower likelihood. An OUD-related diagnosis was associated with 0.84 days (95% confidence interval [CI] 0.71, 0.97] increased length of stay overall, 2.79 days [95% CI 1.44, 4.14] for surgical stays, and 0.71 days [95% CI 0.59, 0.82] for non-surgical stays. CONCLUSIONS OUD-related diagnoses are increasing among IBD patients and are associated with increased length of stay. With a rising prevalence, it is important to screen and diagnose OUD in IBD and refer patients for evidence-based treatment to address unmet patient needs and reduce health care utilisation.
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Affiliation(s)
- Shirley Cohen-Mekelburg
- Division of Gastroenterology & Hepatology, New York Presbyterian Weill Cornell Medical Center, New York, NY, USA,Corresponding author: Shirley Cohen-Mekelburg, MD, 1305 York Avenue, 4th floor, New York, NY 10021, USA. Tel.: 646-962-4800; fax: 646-962-0399;
| | - Russell Rosenblatt
- Division of Gastroenterology & Hepatology, New York Presbyterian Weill Cornell Medical Center, New York, NY, USA
| | - Stephanie Gold
- Department of Medicine, New York Presbyterian Weill Cornell Medical Center, New York, NY, USA
| | - Robert Burakoff
- Division of Gastroenterology & Hepatology, New York Presbyterian Weill Cornell Medical Center, New York, NY, USA
| | - Akbar K Waljee
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA,VA Ann Arbor Health Services Research and Development Center of Clinical Management Research, Ann Arbor, MI, USA
| | - Sameer Saini
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA,VA Ann Arbor Health Services Research and Development Center of Clinical Management Research, Ann Arbor, MI, USA
| | - Bruce R Schackman
- Department of Healthcare Policy & Research, Weill Cornell Medical College, New York, NY, USA
| | - Ellen Scherl
- Division of Gastroenterology & Hepatology, New York Presbyterian Weill Cornell Medical Center, New York, NY, USA
| | - Carl Crawford
- Division of Gastroenterology & Hepatology, New York Presbyterian Weill Cornell Medical Center, New York, NY, USA
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Ahmad A, Laverty AA, Alexakis C, Cowling T, Saxena S, Majeed A, Pollok RCG. Changing nationwide trends in endoscopic, medical and surgical admissions for inflammatory bowel disease: 2003-2013. BMJ Open Gastroenterol 2018; 5:e000191. [PMID: 29607052 PMCID: PMC5873541 DOI: 10.1136/bmjgast-2017-000191] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 02/14/2018] [Accepted: 02/15/2018] [Indexed: 12/12/2022] Open
Abstract
Background and study aims In the last decade, there have been major advances in inflammatory bowel disease (IBD) management but their impact on hospital admissions requires evaluation. We aim to investigate nationwide trends in IBD surgical/medical elective and emergency admissions, including endoscopy and cytokine inhibitor infusions, between 2003 and 2013. Patients and methods We used Hospital Episode Statistics and population data from the UK Office for National Statistics. Results Age-sex standardised admission rates increased from 76.5 to 202.9/100 000 (p<0.001) and from 69.5 to 149.5/100 000 (p<0.001) for Crohn’s disease (CD) and ulcerative colitis (UC) between 2003–2004 and 2012–2013, respectively. Mean length of stay (days) fell significantly for elective (from 2.6 to 0.7 and from 2.0 to 0.7 for CD and UC, respectively) and emergency admissions (from 9.2 to 6.8 and from 10.8 to 7.6 for CD and UC, respectively). Elective lower gastrointestinal (GI) endoscopy rates decreased from 6.3% to 3.7% (p<0.001) and from 18.4% to 17.6% (p=0.002) for CD and UC, respectively. Elective major abdominal surgery rates decreased from 2.8% to 1.0% (p<0.001) and from 4.9 to 2.4 (p=0.010) for CD and UC, respectively, with emergency rates also decreasing significantly for CD. Between 2006-2007 and 2012-2013, elective admission rates for cytokine-inhibitor infusions increased from 11.1 to 57.2/100 000 and from 1.4 to 12.1/100 000 for CD and UC, respectively. Conclusions Rising IBD hospital admission rates in the past decade have been driven by an increase in the incidence and prevalence of IBD. Lower GI endoscopy and surgery rates have fallen, while cytokine inhibitor infusion rates have risen. There has been a concurrent shift from emergency care to shorter elective hospital stays. These trends indicate a move towards more elective medical management and may reflect improvements in disease control.
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Affiliation(s)
- Ahmir Ahmad
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Anthony A Laverty
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Chris Alexakis
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust and St George's University of London, London, UK
| | - Tom Cowling
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Sonia Saxena
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Richard C G Pollok
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust and St George's University of London, London, UK
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Grossberg LB, Ezaz G, Grunwald D, Cohen J, Falchuk KR, Feuerstein JD. A National Survey of the Prevalence and Impact of Cytomegalovirus Infection Among Hospitalized Patients With Ulcerative Colitis. J Clin Gastroenterol 2018; 52:241-245. [PMID: 27811628 DOI: 10.1097/mcg.0000000000000736] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
GOALS To estimate the effect of cytomegalovirus (CMV) in patients with ulcerative colitis (UC), and compare these outcomes to patients with CMV without UC. BACKGROUND The impact of CMV infection in UC is not well understood. STUDY We analyzed records from the Nationwide Inpatient Sample (NIS) of patients with UC and CMV between 2006 and 2012. Differences in outcomes were determined between patients with UC and CMV and those with UC without CMV. Secondary analysis compared outcomes of patients with UC and CMV to patients with CMV alone. RESULTS Patients with UC and CMV (n=145) had longer length of stay (16.31 vs. 5.52 d, P<0.0001), higher total charges ($111,835.50 vs. $39.895, P=0.001), and were less likely to be discharged home without services (50.0% vs. 81.83%, P<0.0001) compared with patients with UC without CMV (n=32,290). On regression analysis, CMV was significantly associated with higher total charges (P<0.01) and longer length of stay (P<0.01), but not for increased need for colorectal surgery. When comparing patients with UC and CMV to patients with CMV alone (n=14,960), patients with CMV alone had a higher Charlson Comorbidity Index and a trend toward higher in-hospital mortality. CONCLUSIONS CMV infection in hospitalized patients with UC is associated with a longer length of stay, increased total charges, and fewer routine discharges, but not increased surgery or mortality. Patients with CMV alone had the worst outcomes of all groups suggesting that CMV in UC patients may not have the same negative impact as in other diseases.
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Affiliation(s)
- Laurie B Grossberg
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA
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Aquina CT, Fleming FJ, Becerra AZ, Hensley BJ, Noyes K, Monson JR, Temple LK, Cellini C. Who gets a pouch after colectomy in New York state and why? Surgery 2018; 163:305-310. [DOI: 10.1016/j.surg.2017.07.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 07/30/2017] [Accepted: 07/31/2017] [Indexed: 02/08/2023]
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Kelso M, Weideman RA, Cipher DJ, Feagins LA. Factors Associated With Length of Stay in Veterans With Inflammatory Bowel Disease Hospitalized for an Acute Flare. Inflamm Bowel Dis 2017; 24:5-11. [PMID: 29272483 DOI: 10.1093/ibd/izx020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Reducing hospital costs and risk of complications by shortening length of stay has become paramount. The aim of our study was to identify predictors and potentially modifiable factors that influence length of stay among veterans with inflammatory bowel disease admitted for an acute flare. METHODS Retrospective review of patients admitted to the Dallas VA with an acute flare of their inflammatory bowel disease between 2000 and 2015. Patients with a length of stay of ≤4 days were compared with those whose length of stay >4 days. RESULTS A total of 180 admissions involving 113 patients (59 with ulcerative colitis and 54 with Crohn's disease) were identified meeting inclusion criteria. The mean length of stay was 5.3 ± 6.8 days, and the median length of stay was 3.0 days. On multiple logistic regression analysis, initiation of a biologic, having undergone 2 or more imaging modalities, and treatment with intravenous steroids were significant predictors of longer lengths of stay, even after controlling for age and comorbid diseases. CONCLUSIONS We identified several predictors for longer hospital length of stay, most related to disease severity but several of which may be modifiable to reduce hospital stays, including most importantly consideration of earlier prebiologic testing. Future studies are needed to evaluate the impact of interventions targeting modifiable predictors of length of stay on health care utilization and patient outcomes.
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Affiliation(s)
- Michael Kelso
- Department of Medicine, VA North Texas Healthcare System, Dallas, Texas.,Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Daisha J Cipher
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, Texas
| | - Linda A Feagins
- Department of Medicine, VA North Texas Healthcare System, Dallas, Texas.,Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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Ramsey M, Krishna SG, Stanich PP, Husain S, Levine EJ, Conwell D, Hinton A, Zhang C. Inflammatory Bowel Disease Adversely Impacts Colorectal Cancer Surgery Short-term Outcomes and Health-Care Resource Utilization. Clin Transl Gastroenterol 2017; 8:e127. [PMID: 29189768 PMCID: PMC5717518 DOI: 10.1038/ctg.2017.54] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Accepted: 10/18/2017] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Inflammatory bowel disease (IBD) is associated with an increased risk of colorectal cancer (CRC) compared to patients without IBD. There is a lack of population-based data evaluating the in-patient surgical outcomes of CRC in IBD patients. We sought to compare the hospital outcomes of CRC surgery between patients with and without IBD. METHODS We used the National Inpatient Sample (2008-2012) and Nationwide Readmissions Database (NRD, 2013) and selected all adult patients (age ≥18 years) with ulcerative colitis (UC) or Crohn's disease (CD) who underwent CRC surgery. Multivariate analysis for in-patient outcomes of postoperative complications, health-care resource utilization, readmission rate, and mortality were performed. RESULTS A total of 397,847 patients underwent CRC surgery from 2008 to 2012, of which 0.8% (3,242) had IBD. Compared to CRC in non-IBD patients, CRC in IBD patients had longer length of stay (adjusted coefficient (AC) 0.86 days, 95% confidence interval (CI): 0.42, 1.30), more likely developed postoperative complications (adjusted odds ratio (AOR) 1.26, 95% CI: 1.06, 1.50), including postoperative infection (AOR 1.69, 95% CI: 1.20, 2.38) and deep vein thrombosis (AOR 2.42, 95% CI: 1.36, 4.28), and more frequently required blood transfusion (AOR 1.59, 95% CI: 1.30, 1.94). CRC in IBD patients was more likely to be readmitted within 30 days (AOR 1.44, 95% CI: 1.01, 2.04). CONCLUSION At a population level, IBD adversely impacts outcomes at the time of CRC surgery.
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Affiliation(s)
- Mitchell Ramsey
- Department of Medicine, The Ohio State
University, Wexner Medical Center, Columbus, Ohio,
USA
| | - Somashekar G Krishna
- Division of Gastroenterology, Hepatology and
Nutrition, The Ohio State University, Wexner Medical Center, Columbus,
Ohio, USA
| | - Peter P Stanich
- Division of Gastroenterology, Hepatology and
Nutrition, The Ohio State University, Wexner Medical Center, Columbus,
Ohio, USA
| | - Syed Husain
- Division Colorectal Surgery, The Ohio State
University, Wexner Medical Center, Columbus, Ohio,
USA
| | - Edward J Levine
- Division of Gastroenterology, Hepatology and
Nutrition, The Ohio State University, Wexner Medical Center, Columbus,
Ohio, USA
| | - Darwin Conwell
- Division of Gastroenterology, Hepatology and
Nutrition, The Ohio State University, Wexner Medical Center, Columbus,
Ohio, USA
| | - Alice Hinton
- Division of Biostatistics, College of Public
Health, The Ohio State University, Columbus, Ohio,
USA
| | - Cheng Zhang
- Division of Gastroenterology, Hepatology and
Nutrition, The Ohio State University, Wexner Medical Center, Columbus,
Ohio, USA
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Abstract
BACKGROUND AND AIMS The rate of hospital readmission after discharge has been studied extensively in chronic conditions such as hepatic cirrhosis, diabetes mellitus, chronic obstructive pulmonary disease, and heart failure. Causative factors associated with hospital readmission have not been adequately investigated in patients with inflammatory bowel disease (IBD). We studied the rate, causes, and factors that predict readmissions at 1 month, 3 months, and 1 year in patients with IBD. METHODS We performed a retrospective cohort study using the electronic medical record of a tertiary academic medical center, encompassing 3 large hospitals to identify patients discharged between January 2007 and December 2010 with a primary discharge diagnosis of either ulcerative colitis or Crohn's disease. The index admission was defined as the first unplanned admission during this period. Readmission was defined as unplanned admission (because of any cause) occurring within 1 week, 1 month, 3 months, and 1 year from the index admission. To identify factors predictive of readmissions, we compared social, demographic, and clinical features at the index admission of patients with readmission and those with no readmissions. Multivariate logistic regression analyses were performed to identify variables associated with 1-month, 3-month, and 1-year readmissions. RESULTS A total of 439 index admissions with a primary discharge diagnosis of either ulcerative colitis or Crohn's disease were eligible for inclusion in the study. These patients accounted for a total of 785 admissions to the health system during the study period. The unplanned readmission rates were 5% at 1 week, 14% at 1 month, 23.7% at 3 months, and 39.2% at 1 year. The most common reasons for readmissions were IBD exacerbations, infections, and abdominal pain. On multivariate analysis, receiving total parenteral nutrition (odds ratio [OR] = 2.3; 95% confidence interval [CI], 1.22-4.30) and intensive care unit stay during index admission (OR = 3.61; 95% CI, 1.38-9.46) predicted both early and late readmissions, whereas sex, race, insurer, and outside hospital transfers predicted 1-year readmission. Receiving steroids (OR = 0.52; 95% CI, 0.23-1.15) at index admission was protective against 1-month readmission; being discharged on biologics (OR = 0.44; 95% CI, 0.19-1.02) was protective against 3-month readmission. CONCLUSIONS Both early and late hospital readmissions are common in patients with IBD. Because frequent readmissions are indicators of poor quality of care, future prospective studies using larger cohorts of patients are needed to identify modifiable factors in patient care before discharge to improve quality of care, prevent readmissions, and consequently reduce health care costs.
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Afrin MR, Arumugam S, Rahman MA, Karuppagounder V, Sreedhar R, Harima M, Suzuki H, Nakamura T, Miyashita S, Suzuki K, Ueno K, Watanabe K. Le Carbone, a charcoal supplement, modulates DSS-induced acute colitis in mice through activation of AMPKα and downregulation of STAT3 and caspase 3 dependent apoptotic pathways. Int Immunopharmacol 2017; 43:70-78. [DOI: 10.1016/j.intimp.2016.10.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 10/15/2016] [Accepted: 10/28/2016] [Indexed: 12/22/2022]
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Early Sigmoidoscopy or Colonoscopy Is Associated With Improved Hospital Outcomes in Ulcerative Colitis-Related Hospitalization. Clin Transl Gastroenterol 2016; 7:e203. [PMID: 27906164 PMCID: PMC5288584 DOI: 10.1038/ctg.2016.61] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 09/01/2016] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES: Performing a sigmoidoscopy or colonoscopy is recommended for assessment of disease activity, excluding infection, and guiding medical treatment during ulcerative colitis (UC)-related hospitalizations. However, it is unknown whether the timing of endoscopy impacts clinical outcomes. The objective of our study was to determine the impact of timing of endoscopy on hospital outcomes in patients with UC-related hospitalizations. METHODS: This is a cross-sectional study using data from the Nationwide Inpatient Sample database (2006–2013). Adult inpatients (≥19 years) with UC-related hospitalizations were identified using appropriate International Classification of Diseases, Ninth revision, Clinical modification codes (ICD-9-CM). Hospital outcomes stratified by disease severity were compared between patients receiving early (<3 days after admission) and delayed endoscopies (between 3 and 7 days after admission). The primary clinical outcomes included mortality, frequency of large intestine surgery, length of stay (LOS), and hospital cost. Results were analyzed using univariate and multivariate analyses. RESULTS: Of a total of 84,359 patients with UC-related hospitalizations, 67.2% (56,657) underwent an early endoscopy and 32.8% (27,702) underwent a delayed endoscopy. Delayed endoscopy was associated with higher mortality (adjusted odds ratio: 1.76 (95% confidence interval (CI): 1.08, 2.88)), prolonged LOS (adjusted coefficient: 2.69 (95% CI: 2.61, 2.77)), and higher hospital cost (adjusted coefficient: $3,394 (95% CI: 3,234, 3,554)). In UC patients with intermediate disease severity, delayed endoscopy was associated with an increased frequency of large intestine surgery (adjusted odds ratio: 1.60 (95% CI: 1.01, 2.53)). CONCLUSIONS: In UC-related hospitalizations, the timing of endoscopic procedures impacts outcomes. Early endoscopy is associated with decreased mortality and better health-care utilization (LOS and hospital cost) compared with delayed endoscopy. In UC patients with intermediate disease severity, early endoscopy is also associated with a decreased frequency of large intestine surgery.
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Lehtola E, Haapamäki J, Färkkilä MA. Outcome of inflammatory bowel disease patients treated with TNF-α inhibitors: two-year follow-up. Scand J Gastroenterol 2016; 51:1476-1481. [PMID: 27686143 DOI: 10.1080/00365521.2016.1218539] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Biological medications, particularly TNF-α inhibitors, are used increasingly for active inflammatory bowel disease (IBD). Even though they are superior to many older medications in achieving remission and mucosal healing, primary nonresponse and loss of response remain significant problems, and a remarkable proportion of patients still need surgery at some point. OBJECTIVE To study the outcome of IBD patients treated with TNF-α inhibitors, either infliximab or adalimumab, with a two-year follow-up. PATIENTS AND METHODS Patient data from the hospital electronic patient documents of IBD patients treated with TNF-α inhibitors were studied. The main targets of interest were treatment response, the remission rate and the number of patients operated, as well as reasons for the discontinuation of treatment. Remission was defined both endoscopically and by faecal calprotectin. RESULTS Altogether 100 patients were included. Only 29% of the patients achieved remission during the two-year follow-up. 26% of the Crohn's disease patients and 36% of the ulcerative colitis patients underwent surgery during the follow-up. A significant proportion of patients experienced side effects of the medication (21%) or discontinued the therapy for other reasons (altogether 63%). CONCLUSIONS In this single centre study of 100 IBD patients treated with TNF-α inhibitors, less than one-third of the patients achieved remission, and a significant proportion had side effects and needed surgery during the two-year follow-up. There is an obvious need for more effective therapies with less side effects for IBD patients.
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Affiliation(s)
- Erika Lehtola
- a Department of Gastroenterology , Helsinki University Central Hospital, University of Helsinki , Helsinki , Finland
| | - Johanna Haapamäki
- a Department of Gastroenterology , Helsinki University Central Hospital, University of Helsinki , Helsinki , Finland
| | - Martti A Färkkilä
- a Department of Gastroenterology , Helsinki University Central Hospital, University of Helsinki , Helsinki , Finland
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Ananthakrishnan AN. Infliximab or ciclosporin for acute severe ulcerative colitis? Lancet Gastroenterol Hepatol 2016; 1:2-3. [PMID: 28404107 PMCID: PMC5651678 DOI: 10.1016/s2468-1253(16)30016-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 05/19/2016] [Indexed: 06/07/2023]
Affiliation(s)
- Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital, 165 Cambridge Street, 9th floor, Boston, MA 02114, USA; Harvard Medical School, Boston, MA, USA.
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An V, Cohen L, Lawrence M, Thomas M, Andrews J, Moore J. Early surgery in Crohn’s disease a benefit in selected cases. World J Gastrointest Surg 2016; 8:492-500. [PMID: 27462391 PMCID: PMC4942749 DOI: 10.4240/wjgs.v8.i7.492] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 03/23/2016] [Accepted: 04/11/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the outcomes of a cohort of Crohn’s disease (CD) patients undergoing early surgery (ES) to those undergoing initial medical therapy (IMT).
METHODS: We performed a review of a prospective database CD patients managed at a single tertiary institution. Inclusion criteria were all patients with ileal or ileocolonic CD between 1995-2014. Patients with incomplete data, isolated colonic or perianal CD were excluded. Primary endpoints included the need for, and time to subsequent surgery. Secondary endpoints included the number and duration of hospital admissions, and medical therapy.
RESULTS: Forty-two patients underwent ES and 115 underwent IMT. The operative intervention rate at 5 years in the ES group was 14.2% vs IMT 31.3% (HR = 0.41, 95%CI: 0.23-0.72, P = 0.041). The ES group had fewer hospital admissions per patient [median 1 vs 3 (P = 0.012)] and fewer patients required anti-TNF therapy than IMT (33.3% vs 57%, P = 0.003). A subgroup analysis of 62 IMT patients who had undergone surgery were compared to ES patients, and showed similar 5 year (from index surgery) re-operation rates 16.1% vs 14.3%. In this subset, a significant difference was still found in median number of hospital admissions favouring ES, 1 vs 2 (P = 0.002).
CONCLUSION: Our data supports other recent studies suggesting that patients with ileocolonic CD may have a more benign disease course if undergoing early surgical intervention, with fewer admissions to hospital and a trend to reduced overall operation rates.
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Nickerson TP, Merchea A. Perioperative Considerations in Crohn Disease and Ulcerative Colitis. Clin Colon Rectal Surg 2016; 29:80-4. [PMID: 27247531 DOI: 10.1055/s-0036-1580633] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The management of inflammatory bowel disease (IBD) is medically and surgically complex. Numerous patient- and disease-oriented factors must be considered in treating patients with IBD, including nutritional replenishment/support, effect of immunosuppressive medications, extent of resection, and use of proximal diversion. Perioperative planning and optimization of the patient is imperative to ensuring favorable outcomes and limiting morbidity. These perioperative considerations in Crohn disease and ulcerative colitis are reviewed here.
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Affiliation(s)
| | - Amit Merchea
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, Florida
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Zhang C, Krishna SG, Hinton A, Arsenescu R, Levine EJ, Conwell DL. Cytomegalovirus-Related Hospitalization Is Associated With Adverse Outcomes and Increased Health-Care Resource Utilization in Inflammatory Bowel Disease. Clin Transl Gastroenterol 2016; 7:e150. [PMID: 26963000 PMCID: PMC4822090 DOI: 10.1038/ctg.2016.10] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 02/03/2016] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES Impact of cytomegalovirus (CMV)-related hospitalization in inflammatory bowel disease (IBD) patients is unknown. The aim of this study was to determine hospital outcomes of CMV-related hospitalization in IBD patients in a large national in-patient administrative data set. METHODS This was a cross-sectional study using data from the Nationwide In-patient Sample database. IBD- and CMV-related hospitalizations between 2003 and 2011 were identified using appropriate ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes. Impact of CMV-related hospitalization on in-hospital mortality, length of stay (LOS), and hospital charges were quantified. RESULTS CMV-related hospitalization was associated with higher in-hospital mortality (odds ratio (OR) 7.09, 95% confidence interval (CI) 3.38-14.85), prolonged LOS (7.77 days, P<0.0001), and more hospital charge (US$66,495, P<0.0001) in IBD patients. CONCLUSIONS CMV-related hospitalization in IBD is associated with high in-hospital mortality, prolonged LOS, and hospital care costs.
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Affiliation(s)
- Cheng Zhang
- Section of Inflammatory Bowel Disease, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
| | - Somashekar G Krishna
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
| | - Alice Hinton
- Department of Biostatistics, College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - Razvan Arsenescu
- Section of Inflammatory Bowel Disease, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
| | - Edward J Levine
- Section of Inflammatory Bowel Disease, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
| | - Darwin L Conwell
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
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Gupta V, Rodrigues R, Nguyen D, Sauk J, Khalili H, Yajnik V, Ananthakrishnan AN. Adjuvant use of antibiotics with corticosteroids in inflammatory bowel disease exacerbations requiring hospitalisation: a retrospective cohort study and meta-analysis. Aliment Pharmacol Ther 2016; 43:52-60. [PMID: 26541937 PMCID: PMC4673010 DOI: 10.1111/apt.13454] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 09/25/2015] [Accepted: 10/12/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients hospitalised with an exacerbation of inflammatory bowel disease (IBD) often receive antibiotics in addition to intravenous steroids. However, their efficacy in this setting is unclear. AIM To ascertain if the addition of antibiotics to intravenous steroids modifies short and long-term clinical outcomes. METHODS Our study included IBD patients hospitalised between 2009 and 2014 who received intravenous (IV) steroids with or without adjuvant antibiotics. Outcomes of interest included length of stay (LOS), need for medical and surgical rescue therapy during the hospitalisation, and at 90 and 365 days. A meta-analysis of previously published randomised trials was additionally performed. RESULTS A total of 354 patients were included [145 ulcerative colitis (UC); 209 Crohn's disease (CD)]. In CD, combination of IV steroids and antibiotics did not change need for in-hospital medical rescue therapy, surgery or hospitalisations at 1 year but was associated with greater LOS (6.1 vs. 4.6 days, P = 0.02). In UC, patients receiving antibiotics were less likely to require in-hospital medical rescue therapy [odds ratio (OR): 0.42, 95% confidence interval (CI): 0.19-0.93] but experienced no statistically significant differences in LOS, in-hospital surgery, re-hospitalisations or surgery by 1 year. A meta-analysis of three relevant randomised trials demonstrated no difference in clinical improvement with antibiotics over placebo (OR: 1.08, 95% CI: 0.50-2.32). CONCLUSIONS The addition of antibiotics to intravenous steroids for treatment of IBD exacerbations was associated with a reduced need for in-hospital medical rescue therapy in ulcerative colitis without significant long-term benefit, and did not affect short- or long-term outcomes in Crohn's disease.
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Affiliation(s)
- Vikas Gupta
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Deanna Nguyen
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA,Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Jenny Sauk
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA,Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Hamed Khalili
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA,Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Vijay Yajnik
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA,Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Ashwin N Ananthakrishnan
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA,Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
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41
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Abstract
BACKGROUND Care of patients with inflammatory bowel disease (IBD) poses a significant burden to the health-care system. Repeat hospitalization in subgroups of IBD patients seems to be a large part of this issue; however, there are limited data examining the characteristics of these patients. The aim of this study was to characterize admission patterns in patients with IBD at a tertiary-care center and to identify preventable risk factors of 90-day readmission after an index IBD admission. METHODS Retrospective analysis was performed extracting data from an electronic medical record over a 2-year period. RESULTS Three hundred fifty-six patients were admitted at least once during the 2-year study period for an unplanned IBD-related reason. Of these, 48.9% were admitted once, 38.2% were admitted 2 to 4 times, and 12.9% were admitted 5 or more times during the study period. Patients with any admission within 90 days before index were excluded; n = 33. One hundred two patients had experienced a readmission by 90 days after index admission. Numerous demographic and medical factors were examined for association with readmission. The final Cox model included 3 variables: depression (HR = 1.99, 1.33-3.00), chronic pain (HR = 1.88, 1.14-3.10), and steroid use in the previous 6 months (HR = 1.33, 0.92-2.04). CONCLUSIONS Our findings suggest that patients with depression and chronic pain are at greatest risk for a readmission within 90 days after an initial IBD admission. Disease activity, represented by steroid use in the previous 6 months, was not related to readmission. Addressing these problems in the outpatient setting may reduce future hospitalizations.
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42
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Baillie CT, Smith JA. Surgical strategies in paediatric inflammatory bowel disease. World J Gastroenterol 2015; 21:6101-16. [PMID: 26034347 PMCID: PMC4445089 DOI: 10.3748/wjg.v21.i20.6101] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 03/30/2015] [Accepted: 04/09/2015] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel disease (IBD) comprises two distinct but related chronic relapsing inflammatory conditions affecting different parts of the gastrointestinal tract. Crohn's disease is characterised by a patchy transmural inflammation affecting both small and large bowel segments with several distinct phenotypic presentations. Ulcerative colitis classically presents as mucosal inflammation of the rectosigmoid (distal colitis), variably extending in a contiguous manner more proximally through the colon but not beyond the caecum (pancolitis). This article highlights aspects of the presentation, diagnosis, and management of IBD that have relevance for paediatric practice with particular emphasis on surgical considerations. Since 25% of IBD cases present in childhood or teenage years, the unique considerations and challenges of paediatric management should be widely appreciated. Conversely, we argue that the organizational separation of the paediatric and adult healthcare worlds has often resulted in late adoption of new approaches particularly in paediatric surgical practice.
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43
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David G, Gunnarsson C, Lofland JH. Variations in care: a retrospective database analysis of healthcare utilization patterns for patients with inflammatory bowel disease. J Med Econ 2015; 18:137-44. [PMID: 25335098 DOI: 10.3111/13696998.2014.978454] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Biologic therapy has been shown to be effective in achieving and maintaining remission in the treatment of inflammatory bowel disease (IBD). However, their impact on healthcare resource utilization is not well understood. This study explored the impact of biologic use on IBD-related hospital admissions and emergency room visits and healthcare expenditures. METHODS This study used a retrospective cohort design to analyze data from the MarketScan Commercial and Medicare databases (Truven Health Analytics Inc.) for the years 2006-2010. Patients were identified using ICD-9 diagnosis codes for IBD and age 18 or older at time of initial diagnosis. Linear models were used to predict the probability of an IBD-related hospitalization or ER visit and healthcare expenditures with binary variables indicating use of biologics in the current year and in the previous 2 years, as well as patient- and area-level control variables. RESULTS Patients using biologics in the current year were 14.1-17.6% more likely to be hospitalized for IBD. However, biologic use in the previous year was associated with a 3.8-5.6% reduction in hospitalizations, and biologic use 2 years prior was associated with a 1-2.8% reduction in hospitalizations in the current year. Similar results are found for ER visits. All indicators for biologic use were associated with increased expenditures. CONCLUSIONS There was a negative association between lagged use of biologics and the proportion of patients with IBD-related hospitalizations and ER visits. This finding may suggest that increased use of biologics over time is associated with a decrease in IBD-related healthcare utilization.
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Affiliation(s)
- Guy David
- University of Pennsylvania , Philadelphia, PA , USA
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44
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Utilization trends of anti-TNF agents and health outcomes in adults and children with inflammatory bowel diseases: a single-center experience. Inflamm Bowel Dis 2014; 20:1242-9. [PMID: 24846718 PMCID: PMC4227810 DOI: 10.1097/mib.0000000000000061] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Utilization trends and health effects of infliximab and adalimumab in inflammatory bowel disease (IBD) are incompletely understood. We aimed to describe utilization trends of these 2 anti-tumor necrosis factor (TNF) agents, determine the correlation between utilization with rates of hospitalization and surgery and describe differences in use between adults and children. METHODS Longitudinal data were analyzed for drug utilization, hospitalization, and abdominal surgery. Descriptive statistics were used to show trends, and utilization quotients were compared for standardization. Multivariate logistic regression analysis assessed the association between drug use and rates of hospitalization and surgery. RESULTS Four hundred thirty-eight pediatric and 2514 adult patients with IBD generated a total of 51,882 inpatient and outpatient encounters, representing 1185 Crohn's disease, 1531 ulcerative colitis, and 236 indeterminate colitis patients. From 2007 through 2012, utilization quotients declined for hospitalization but remained unchanged for surgery; adalimumab saw a 3-fold increase, despite continued dominance of infliximab. Median band and mean fitted plots showed downward hospitalization trends from 2006 to 2012. Utilization of infliximab peaked in 2008, Q4 with gradual decline to 2012, Q2; and adalimumab showed moderate increased utilization since 2007, Q1. Use of infliximab (odds ratio [OR], 0.76; 95% confidence interval [CI], 0.70-0.83) and adalimumab (OR, 0.79; 95% CI, 0.72-0.87) was associated with decreased hospitalization risk but not associated with reduced abdominal surgery risk. Children had increased hospitalization (OR, 2.68; 95% CI, 2.49-2.88) but decreased risk for abdominal surgery (OR, 0.57; 95% CI, 0.46-0.70). CONCLUSIONS Current infliximab use remains substantially greater than adalimumab use, despite recent increased use of adalimumab. Although trends for hospitalization for IBD are decreasing, it is not reflected in abdominal surgery rates in a tertiary IBD referral center.
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45
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Kelly CR, Ihunnah C, Fischer M, Khoruts A, Surawicz C, Afzali A, Aroniadis O, Barto A, Borody T, Giovanelli A, Gordon S, Gluck M, Hohmann EL, Kao D, Kao JY, McQuillen DP, Mellow M, Rank KM, Rao K, Ray A, Schwartz MA, Singh N, Stollman N, Suskind DL, Vindigni SM, Youngster I, Brandt L. Fecal microbiota transplant for treatment of Clostridium difficile infection in immunocompromised patients. Am J Gastroenterol 2014; 109:1065-71. [PMID: 24890442 PMCID: PMC5537742 DOI: 10.1038/ajg.2014.133] [Citation(s) in RCA: 496] [Impact Index Per Article: 45.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 04/21/2014] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Patients who are immunocompromised (IC) are at increased risk of Clostridium difficile infection (CDI), which has increased to epidemic proportions over the past decade. Fecal microbiota transplantation (FMT) appears effective for the treatment of CDI, although there is concern that IC patients may be at increased risk of having adverse events (AEs) related to FMT. This study describes the multicenter experience of FMT in IC patients. METHODS A multicenter retrospective series was performed on the use of FMT in IC patients with CDI that was recurrent, refractory, or severe. We aimed to describe rates of CDI cure after FMT as well as AEs experienced by IC patients after FMT. A 32-item questionnaire soliciting demographic and pre- and post-FMT data was completed for 99 patients at 16 centers, of whom 80 were eligible for inclusion. Outcomes included (i) rates of CDI cure after FMT, (ii) serious adverse events (SAEs) such as death or hospitalization within 12 weeks of FMT, (iii) infection within 12 weeks of FMT, and (iv) AEs (related and unrelated) to FMT. RESULTS Cases included adult (75) and pediatric (5) patients treated with FMT for recurrent (55%), refractory (11%), and severe and/or overlap of recurrent/refractory and severe CDI (34%). In all, 79% were outpatients at the time of FMT. The mean follow-up period between FMT and data collection was 11 months (range 3-46 months). Reasons for IC included: HIV/AIDS (3), solid organ transplant (19), oncologic condition (7), immunosuppressive therapy for inflammatory bowel disease (IBD; 36), and other medical conditions/medications (15). The CDI cure rate after a single FMT was 78%, with 62 patients suffering no recurrence at least 12 weeks post FMT. Twelve patients underwent repeat FMT, of whom eight had no further CDI. Thus, the overall cure rate was 89%. Twelve (15%) had any SAE within 12 weeks post FMT, of which 10 were hospitalizations. Two deaths occurred within 12 weeks of FMT, one of which was the result of aspiration during sedation for FMT administered via colonoscopy; the other was unrelated to FMT. None suffered infections definitely related to FMT, but two patients developed unrelated infections and five had self-limited diarrheal illness in which no causal organism was identified. One patient had a superficial mucosal tear caused by the colonoscopy performed for the FMT, and three patients reported mild, self-limited abdominal discomfort post FMT. Five (14% of IBD patients) experienced disease flare post FMT. Three ulcerative colitis (UC) patients underwent colectomy related to course of UC >100 days after FMT. CONCLUSIONS This series demonstrates the effective use of FMT for CDI in IC patients with few SAEs or related AEs. Importantly, there were no related infectious complications in these high-risk patients.
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Affiliation(s)
- Colleen R. Kelly
- Division of Gastroenterology, Brown Alpert Medical School, Women’s Medicine Collaborative, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Chioma Ihunnah
- Division of Gastroenterology, Brown Alpert Medical School, Women’s Medicine Collaborative, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Monika Fischer
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | | | - Anita Afzali
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Olga Aroniadis
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Amy Barto
- Lahey Clinic Hospital and Medical Center, Tufts University School of Medicine, Burlington, Massachusetts, USA
| | - Thomas Borody
- Centre for Digestive Diseases, Five Dock, Sydney, New South Wales, Australia
| | - Andrea Giovanelli
- Northern California Gastroenterology Consultants, Inc., Oakland, California, USA
| | - Shelley Gordon
- California Pacific Medical Center, San Francisco, California, USA
| | - Michael Gluck
- Virginia Mason Medical Center, Seattle, Washington, USA
| | - Elizabeth L. Hohmann
- Massachusetts General Hospital and Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Dina Kao
- University of Alberta, Edmonton, Alberta, Canada
| | - John Y. Kao
- University of Michigan, Ann Arbor, Michigan, USA
| | - Daniel P. McQuillen
- Lahey Clinic Hospital and Medical Center, Tufts University School of Medicine, Burlington, Massachusetts, USA
| | - Mark Mellow
- Integris Baptist Medical Center, Oklahoma, Oklahoma, USA
| | - Kevin M. Rank
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Krishna Rao
- University of Michigan, Ann Arbor, Michigan, USA
| | - Arnab Ray
- Ochsner Clinic Foundation, New Orleans, Louisiana, USA
| | | | - Namita Singh
- Seattle Children’s Hospital, Seattle, Washington, USA
| | - Neil Stollman
- Northern California Gastroenterology Consultants, Inc., Oakland, California, USA
| | | | | | - Ilan Youngster
- Massachusetts General Hospital and Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lawrence Brandt
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
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Abstract
The position of surgery in the treatment of ulcerative colitis (UC) has changed in the era of biologics. Several important questions arise in determining the optimal positioning of surgery in the treatment of UC, which has long been a challenge facing gastroenterologists and surgeons. Surgery is life-saving in some patients and leads to better bowel function and better quality of life in most patients. The benefits of surgery, however, must be weighed against the potential surgical morbidity and compromised functioning that clearly can occur. The introduction of biologic therapy has added further complexity to decisions about medical management, surgery, and the relative timing of these choices. Appropriate medical management of UC may induce and maintain remission and may prevent surgery. However, medical management also carries risks of adverse effects, and recent data suggest that delay of surgery during ineffective medical therapy can increase the chances of negative surgical outcomes. To make individualized timely treatment decisions, early collaboration between gastroenterologists and surgeons is important and more data on predictors of treatment response and positive outcomes are needed. Early identification of patients who would benefit from biologic therapy or surgery is challenging.
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Frolkis AD, Dykeman J, Negrón ME, Debruyn J, Jette N, Fiest KM, Frolkis T, Barkema HW, Rioux KP, Panaccione R, Ghosh S, Wiebe S, Kaplan GG. Risk of surgery for inflammatory bowel diseases has decreased over time: a systematic review and meta-analysis of population-based studies. Gastroenterology 2013; 145:996-1006. [PMID: 23896172 DOI: 10.1053/j.gastro.2013.07.041] [Citation(s) in RCA: 656] [Impact Index Per Article: 54.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 07/12/2013] [Accepted: 07/24/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The inflammatory bowel diseases (IBDs) are chronic diseases that often require surgery. However, the risk of requirement of surgery over time has not been well characterized. We performed a systematic review and meta-analysis to establish the cumulative risk of surgery among patients with IBD and evaluated how this risk has changed over time. METHODS We searched Medline, EMBASE, PubMed, and conference proceedings (2009-2012) on May 8, 2013, for terms related to IBD and intestinal surgery. Two reviewers screened 8338 unique citations to identify 486 for full-text review. The analysis included population-based studies published as articles (n = 26) and abstracts (n = 4) that reported risks of surgery at 1, 5, or 10 years after a diagnosis of Crohn's disease and/or ulcerative colitis. The trend in risk of surgery over time was analyzed by meta-regression using mixed-effect models. RESULTS Based on all population-based studies, the risk of surgery 1, 5, and 10 years after diagnosis of Crohn's disease was 16.3% (95% confidence interval [CI], 11.4%-23.2%), 33.3% (95% CI, 26.3%-42.1%), and 46.6% (95% CI, 37.7%-57.7%), respectively. The risk of surgery 1, 5, and 10 years after diagnosis of ulcerative colitis was 4.9% (95% CI, 3.8%-6.3%), 11.6% (95% CI, 9.3%-14.4%), and 15.6% (95% CI, 12.5%-19.6%), respectively. The risk of surgery 1, 5, and 10 years after diagnosis of Crohn's disease and 1 and 10 years after diagnosis of ulcerative colitis has decreased significantly over the past 6 decades (P < .05). CONCLUSIONS Based on systematic review and meta-analysis of population-based studies, the risk of intestinal surgery among patients with IBD has decreased over the past 6 decades.
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Affiliation(s)
- Alexandra D Frolkis
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences and Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
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48
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Nationwide temporal trends in incidence of hospitalization and surgical intestinal resection in pediatric inflammatory bowel diseases in the United States from 1997 to 2009. Inflamm Bowel Dis 2013; 19:2423-32. [PMID: 23974991 DOI: 10.1097/mib.0b013e3182a56148] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Data are limited on temporal trends in outcomes of hospitalization and surgery in pediatric Crohn's disease (CD) and ulcerative colitis (UC). Thus, we evaluated the U.S. nationwide temporal trends for incidence of hospitalization and intestinal resection along with associated resource utilization. METHODS We used the Kids' Inpatient Database (1997, 2000, 2003, 2006, and 2009) to identify all admissions for children aged 18 years or younger with a primary CD (International Classification of Diseases, Ninth Revision [ICD-9]: 555.X) or UC (ICD-9: 556.X) diagnosis or a secondary CD or UC diagnosis and procedural code of intestinal resection. Poisson regression analysis was performed to evaluate time trends in the incidence of hospitalization, intestinal resection, and hospital resource utilization. RESULTS The annual incidence of hospitalization was 5.7 and 3.5 per 100,000 children for CD and UC, respectively, with significant increases over time for CD (annual percent increase [API], 3.8%; 95% confidence interval [CI], 3.0%-4.5%) and UC (API, 4.5%; 95% CI, 4.3%-4.7%). Median hospital days per hospitalization for CD and UC remained stable, whereas median charge per hospitalization increased for CD (API, 4.1%; 95% CI, 2.6%-5.6%) and UC (API, 4.7%; 95% CI, 3.5%-5.9%). The annual incidence of intestinal resection remained stable for UC at 0.6 per 100,000 children but climbed for CD (API, 2.1%; 95% CI, 0.1-4.2). CONCLUSIONS The annual incidence of hospitalization is climbing in pediatric inflammatory bowel diseases, accompanied by rising intestinal resection rates for CD and stable colectomy rates for UC. With escalating resource utilization, the economic and health burden of pediatric inflammatory bowel diseases is substantial.
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49
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Abstract
Inflammatory bowel diseases (IBDs; e.g., Crohn's disease [CD] and ulcerative colitis [UC]) are chronic immunologically mediated diseases characterized by frequent relapses, often requiring hospitalization and surgery. There is substantial heterogeneity in the progressive natural history of disease with cumulative accrual of bowel damage and impairment of functioning. Recent advances in therapeutics have significantly improved our ability to achieve disease remission; yet therapies remain expensive and are associated with significant side effects precluding widespread use in all patients with IBD. Consequently, algorithms for the management of patients with IBD require a personalized approach incorporating an individual's projected likely natural history, the probability of response to a specific therapeutic agent and an informed approach to management of loss of response to current therapies.
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Affiliation(s)
- Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, 9th Floor, Boston, MA 02114, USA.
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50
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Bernstein CN, Ng SC, Lakatos PL, Moum B, Loftus EV. A review of mortality and surgery in ulcerative colitis: milestones of the seriousness of the disease. Inflamm Bowel Dis 2013; 19:2001-2010. [PMID: 23624887 DOI: 10.1097/mib.0b013e318281f3bb] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Standardized mortality rates in ulcerative colitis (UC) are no different than that in the general population. Patients who are older and have more comorbidities have increased mortality. Emergent colectomy still carries 30-day mortality rates of approximately 5%. In more recent studies, UC surgery rates at 10 years from diagnosis are nearly 3% in Hungary, <10% in referral center studies from Asia, approximately 10% in Norway, the European Cohort Study of Inflammatory Bowel Diseases and Manitoba, Canada, and nearly 17% in Olmsted County, Minnesota. These rates are for the most part lower than reported colectomy rates from studies completed before 1990. Short-term colectomy rates in severe hospitalized UC have remained stable at 27% for several years. Generally, children seem to have higher rates of extensive colitis at diagnosis than adults. There also seems to be higher rates of colectomy in children than in adults (i.e., at least 20% at 10 years), and perhaps, this reflects a higher rate of extensive disease. Acute severe colitis in patients with UC still represents a condition with a high early colectomy rate and a measurable mortality rate.
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Affiliation(s)
- Charles N Bernstein
- Section of Gastroenterology, IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada.
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