The impact of Hispanic ethnicity and race on post-surgical complications in patients with inflammatory bowel disease

Inequalities in Healthcare Access, Experience and Outcomes in Adults With Inflammatory Bowel Disease: A Scoping Review

BACKGROUND

Inflammatory bowel diseases (IBDs) are incurable diseases that require lifelong access to health services. Accumulating evidence of inequalities in health care access, experience, and outcomes for individuals with IBD is apparent. This review aimed to describe the inequalities in healthcare access, experiences, and outcomes of care for adults with IBD, to identify research gaps, and to identify future research priorities in this area.

METHODS

A scoping review was conducted to retrieve quantitative, qualitative, and mixed methods evidence from 3 databases (EMBASE, Medline, and CINAHL) published between January 1, 2000, and September 27, 2023.

RESULTS

Fifty-one studies met the criteria for inclusion. The majority (42 of 51) focused on IBD health outcomes, followed by healthcare access (24 of 51). Significantly fewer investigated patient experiences of IBD healthcare (8 of 51). Most available studies reported on race/ethnic disparities of healthcare (33 of 51), followed by inequalities driven by socioeconomic differences (12 of 51), rurality (7 of 51), gender and sex (3 of 51), age (2 of 51), culture (2 of 51), literacy (1 of 51), and sexuality (1 of 51). Inflammatory bowel disease patients from Black, Asian, and Hispanic ethnic groups had significantly poorer health outcomes. A lack of research was found in the sexual and gender minority community (1 of 51). No research was found to investigate inequalities in IBD patients with learning disabilities or autism.

CONCLUSIONS

Further research, particularly utilizing qualitative methods, is needed to understand health experiences of underserved patient populations with IBD. Cultural humility in IBD care is required to better serve individuals with IBD of Black and Asian race/ethnicity. The lack of research amongst sexual and gender minority groups with IBD, and with learning disabilities, poses a risk of creating inequalities within inequalities.

Towards Equitable Surgical Management of Inflammatory Bowel Disease: A Systematic Review of Disparities in Surgery for Inflammatory Bowel Disease

BACKGROUND

Existing evidence for disparities in inflammatory bowel disease is fragmented and heterogenous. Underlying mechanisms for differences in outcomes based on race and socioeconomic status remain undefined. We performed a systematic review of the literature to examine disparities in surgery for inflammatory bowel disease in the United States.

METHODS

Electronic databases were searched from 2000 through June 11, 2021, to identify studies addressing disparities in surgical treatment for adults with inflammatory bowel disease. Eligible English-language publications comparing the use or outcomes of surgery by racial/ethnic, socioeconomic, geographic, and/or institutional factors were included. Studies were grouped according to whether outcomes of surgery were reported or surgery itself was the relevant end point (utilization). Quality was assessed using the Newcastle-Ottawa Scale for observational studies.

RESULTS

Forty-five studies were included. Twenty-four reported surgical outcomes and 21addressed utilization. Race/ethnicity was considered in 96% of studies, socioeconomic status in 44%, geographic factors in 27%, and hospital/surgeon factors in 22%. Although study populations and end points were heterogeneous, Black and Hispanic patients were less likely to undergo abdominal surgery when hospitalized; they were more likely to have a complication when they did have surgery. Differences based on race were correlated with socioeconomic factors but frequently remained significant after adjustments for insurance and baseline health.

CONCLUSIONS

Surgical disparities based on sociologic and structural factors reflect unidentified differences in multidisciplinary disease management. A broad, multidimensional approach to disparities research with more granular and diverse data sources is needed to improve health care quality and equity for inflammatory bowel disease.

Experiences of ethnic minority patients who are living with a primary chronic bowel condition: a systematic scoping review with narrative synthesis

Background

Prevalence of chronic gastrointestinal diseases has been rising amongst ethnic minority populations in Western countries, despite the first-generation migrants originating from countries of low prevalence. Differences caused by genetic, environmental, cultural, and religious factors in each context may contribute towards shaping experiences of ethnic minority individuals living with primary bowel conditions. This review aimed to explore the experiences of ethnic minority patients living with chronic bowel conditions.

Methods

We conducted a systematic scoping review to retrieve qualitative, quantitative, and mixed methods studies from eight electronic databases, and manually searched reference lists of frequently cited papers.

Results

Fourteen papers met the inclusion criteria: focussing on inflammatory bowel disease, irritable bowel syndrome, and coeliac disease. Core themes were narratively analysed. South Asians had limited understanding of inflammatory bowel disease and coeliac disease, hindered by language and literacy barriers, particularly for older generations, suggesting that culturally relevant information is needed. Family support was limited, and Muslim South Asians referred to religion to understand and self-manage inflammatory bowel disease. Ethnic minority groups across countries experienced: poor dietary intake for coeliac disease and inflammatory bowel disease, cultural conflict in self-managing diet for inflammatory bowel disease which increased anxiety, and there was a need for better quality of, and access to, healthcare services. British ethnic minority groups experienced difficulties with IBD diagnosis/misdiagnosis.

Conclusions

Cultural, religious, and social contexts, together with language barriers and limited health literacy influenced experiences of health inequalities for ethnic minority patients living with chronic bowel diseases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-021-01857-8.

Effects of Race and Ethnicity on Diagnosis and Management of Inflammatory Bowel Diseases

Although Crohn's disease (CD) and ulcerative colitis (UC) have been considered as disorders that affect individuals of European ancestry, the epidemiology of the inflammatory bowel diseases (IBDs) is changing. Coupled with the increasing incidence of IBD in previously low-incidence areas, the population demographics of IBD in the United States are also changing, with increases among non-White races and ethnicities. It is therefore important to fully understand the epidemiology and progression of IBD in different racial and ethnic groups, and the effects of race and ethnicity on access to care, use of resources, and disease-related outcomes. We review differences in IBD development and progression among patients of different races and ethnicities, discussing the effects of factors such as access to care, delays in diagnosis, and health and disease perception on disparities in IBD care and outcomes. We identify research priorities for improving health equity among minority patients with IBD.

Racial disparities exist in surgical outcomes for patients with inflammatory bowel disease

BACKGROUND

Racial disparities in surgical outcomes exist for Black patients with IBD compared to White patients. However, previous studies fail to include other racial/ethnic populations. We hypothesized these disparities exist for Hispanic and Asian patients.

METHODS

This is a retrospective cohort study of patients undergoing surgery for IBD using the American College of Surgeons National Surgical Quality Improvement Program (ACS- NSQIP) database (2005-2017). Bivariate comparisons and adjusted multivariable regressions were performed to evaluate associations between race and outcomes.

RESULTS

Of 23,901 patients with IBD, the racial/ethnic makeup were: 88.7% White, 7.6% Black, 2.4% Hispanic and 1.4% Asian. Overall mean LOS was 8 days (SD 8.2) and significantly varied between groups (8d for White, 10d for Black, 8.5d for Hispanic, and 11.1d for Asian; p < 0.001). Hispanic patients had the highest odds of readmission (OR: 1.4; 95% CI 1.1-1.8). Black patients had increased odds of renal insufficiency (OR: 1.8; 95% CI 1.1-2.9), bleeding requiring transfusions (OR: 1.7; 95% CI 1.4-1.9), and sepsis (OR: 1.7; 95% CI 1.4-2.02) compared to White patients.

CONCLUSIONS

Racial disparities exist among IBD patients undergoing surgery. Black, Hispanic and Asian IBD patients experience major disparities in post-operative complications, readmissions and LOS, respectively, when compared to White patients with IBD. Future research is needed to better understand the mechanisms of these disparities including evaluation of social determinants of health.

Racial disparities in surgical outcomes of patients with Inflammatory Bowel Disease

BACKGROUND

Inflammatory Bowel Disease (IBD) has not historically been a focus of racial health disparities research. IBD has been increasing in the black community. We hypothesized that outcomes following surgery would be worse for black patients.

METHODS

A retrospective cohort study of death and serious morbidity (DSM) of patients undergoing surgery for IBD was performed using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP 2011-2014). Multivariable logistic regression modeling was performed to evaluate associations between race and outcomes.

RESULTS

Among 14,679 IBD patients, the overall rate of DSM was 20.3% (white: 19.3%, black 27.0%, other 23.8%, p < 0.001). After adjustment, black patients remained at increased risk of DSM compared white patients (OR: 1.37; 95% CI 1.14-1.64).

CONCLUSIONS

Black patients are at increased risk of post-operative DSM following surgery for IBD. The elevated rates of DSM are not explained by traditional risk factors like obesity, ASA class, emergent surgery, or stoma creation.

Clinical Activity and Quality of Life Indices Are Valid Across Ulcerative Colitis But Not Crohn's Disease Phenotypes

BACKGROUND

Clinical activity and quality of life (QOL) indices assess disease activity in Crohn's disease (CD) and ulcerative colitis (UC). However, a paucity of data exists on the validity of these indices according to disease characteristics.

AIMS

To examine the correlation between QOL and clinical activity indices and endoscopic disease activity according to disease characteristics.

METHODS

We used a prospective registry to identify CD and UC patients ≥18 years old with available information on Short Inflammatory Bowel Disease Questionnaire scores (SIBDQ), Harvey-Bradshaw Index (HBI) and simple endoscopic scores for CD (SES-CD), and Simple Clinical Colitis Activity Index (SCCAI) and Mayo endoscopic score for UC. We used Spearman rank correlations to calculate correlations between indices and Fisher transformation to compare correlations across disease characteristics.

RESULTS

Among 282 CD patients, we observed poor correlation between clinical activity and QOL indices to SES-CD with no differences in correlation according to disease characteristics. Conversely, among 226 UC patients, clinical activity and QOL had good correlation to Mayo endoscopic score (r = 0.55 and -0.56, respectively) with better correlations observed with left-sided versus extensive colitis (r = 0.73 vs. 0.45, p = 0.005) and shorter duration of disease (r = 0.61 vs. 0.37, p = 0.04).

CONCLUSIONS

Our data suggest good correlation between SCCAI and endoscopic disease activity in UC, particularly in left-sided disease. Poor correlations between HBI or SIBDQ and SES-CD appear to be consistent across different disease phenotypes.

Racial and Ethnic Minorities with Inflammatory Bowel Disease in the United States: A Systematic Review of Disease Characteristics and Differences

BACKGROUND

Inflammatory bowel disease (IBD) has predominantly affected whites, particularly Ashkenazi Jews. Over the last 2 decades, IBD has "emerged" in minorities. Differences in natural history and disease characteristics have been suggested. The objective of this systematic review is to summarize these differences in studies from the United States.

METHODS

A structured search was performed within the Medline database through PubMed, EMBASE, and Cochrane databases. Published studies of genetics, pathogenesis, prevalence or incidence, disease location and behavior, extraintestinal manifestations, disparities and access to care in patients with IBD who are of African American, Asian, and Hispanic descent living in the United States were eligible.

RESULTS

A total of 47 studies were included for African Americans (n = 20,054), Hispanics (n = 10,762), and Asians (n = 2668). The incidence and prevalence of IBD is increasing among minorities. There is less of a genetic influence in the pathogenesis of IBD among African Americans; however, novel variants have been identified. There is a predilection for pancolonic ulcerative colitis among Hispanics and Asians. Crohn's disease-related hospitalizations are increasing in Asians, whereas African Americans are more likely to use the emergency department. No major differences are seen in disease location and behavior, upper gastrointestinal tract, and perianal involvement and extraintestinal manifestations among races and ethnic groups. Medication utilization seems to be similar. Differences in surgery are likely explained by health insurance status.

CONCLUSIONS

Future prospective studies are needed to fully characterize disease characteristics and treatment response among minorities. With novel IBD therapies in the pipeline, enrollment in clinical trials should emphasize increased representation of all races and ethnic groups.

Manifestations of inflammatory bowel disease in patients of Haitian and Cape Verdean descent

OBJECTIVE

Several studies have reported unique ethnic phenotypes of inflammatory bowel disease (IBD). An appreciation of disease manifestations in different populations may improve clinical outcomes. There are no studies examining IBD in patients of Haitian or Cape Verdean descent. We sought to define the IBD phenotype in these populations.

MATERIALS AND METHODS

This was a retrospective review comparing Haitian and Cape Verdean immigrant IBD patients to Caucasians, all receiving care at Boston Medical Center in Boston, Massachusetts, USA. The following variables were analyzed: family history, smoking history, vaccinations/cancer screening, age of diagnosis, disease duration, disease location, medication use, and complications.

RESULTS

Thirty-one Haitians and 21 Cape Verdeans were matched to Caucasian controls. Haitians (mean age 42 years) and Cape Verdeans (mean age 47 years) with Crohn's disease were diagnosed with IBD later than Caucasians (mean age 31 years, p = 0.04 and 0.02, respectively). Haitians with Crohn's were less likely to have a history of tobacco use compared to Caucasians (13% vs. 51%, p = 0.02). Cape Verdeans with Crohn's were less likely to have perianal involvement (0% vs. 50%, p = 0.01). Haitians with IBD were less likely to have ever used glucocorticoids (48% vs. 76%, p = 0.02). There was no difference in vaccination rates, cancer screening, or disease complications.

CONCLUSIONS

This study demonstrates differences in IBD presentation and disease course among Haitians and Cape Verdeans. Our results suggest a more mild disease in these ethnic groups. Future studies are needed to identify the influence of environmental factors.

Hispanics and inflammatory bowel disease

BACKGROUND

Historically, inflammatory bowel disease (IBD) was considered a disease, which predominately affects whites. As such, the majority of research in IBD has been conducted in this population. However, more research on this suggests that IBD affects other ethnic groups. Rapidly shifting demographics in the United States necessitates a better understanding of how IBD may affect Hispanics. We reviewed the current literature on IBD in Hispanics.

METHODS

A PubMed search was conducted using keywords inflammatory bowel disease, Ulcerative Colitis, Crohn's disease, Hispanics, Latinos, ethnicity, to identify existing literature with a focus on adult populations. Non-English language articles were excluded.

RESULTS

The existing data and literature on Hispanic patients with IBD remains sparse. Limited studies on prevalence suggest IBD may be more common in Hispanics in the United States compared with those in Latin America. Conflicting data exist as to whether Hispanics patients with IBD are more likely to have ulcerative colitis compared with Crohn's disease. One study explored difference in IBD between foreign-born and U.S.-born Hispanics and found that ulcerative colitis was more common only in foreign-born Hispanics, whereas within 1 generation, U.S.-born Hispanics resemble their non-Hispanic white counterparts about development of Crohn's disease. Such a rapid change in the proportion of ulcerative colitis and Crohn's disease points strongly to environmental factors driving the change in proportion of disease subtypes. Additionally, a trend towards less use of biologic and immunomodulators in Hispanics was noted in several studies.

CONCLUSIONS

Additional research is needed to better understand how diversity within the Hispanic population (U.S.-born and foreign-born) may be driving difference in disease manifestations. More investigations should focus on determining the cause of a potential disparity in the use of biologic and immunomodulators in Hispanics.