Evaluation of Racial/Ethnic Disparities in the Surgical Management of Inflammatory Bowel Disease

The impact of rurality on racial disparities in costs of bowel obstruction treatment

Background

Black race has been associated with increased resource utilization after operation for small bowel obstruction (SBO). While prior literature has similarly demonstrated differences between urban and rural institutions, limited work has defined the impact of rurality on resource utilization by race.

Methods

The 2016-2020 National Inpatient Sample was used to identify adults undergoing adhesiolysis after non-elective admission for SBO. The primary endpoint was hospitalization costs. Additional outcomes included surgical delay (≥ hospital day 3), length of stay (LOS), and nonhome discharge. Regression models were developed to identify the impact of Black race and rurality on the outcomes of interest with an interaction term to examine the incremental association of Black race on rurality.

Results

Of an estimated 132,390 patients, 11.4 % were treated at an annual average of 377 rural hospitals (18.5 % of institutions). After adjustment, rural hospitals had higher costs (β + $4900, 95 % Confidence Interval [CI] [4200, 5700]), compared to others. However, rurality was associated with reduced odds of surgical delay (Adjusted Odds Ratio [AOR] 0. 76, CI[0.69, 0.85]), decreased LOS (β -1.66 days, CI[-1.99, -1.36]), and nonhome discharge (AOR 0.78, CI[0.70, 0.87]). While White patients experienced significant cost reductions at urban centers ($26,100 [25,800-26,300] vs $31,000 [30,300-31,700]), this was not noted for Black patients ($30,100 [29,400-30,700] vs $30,800 [29,300-32,400]).

Conclusions

We found that Black patients do not benefit from the same cost protection afforded by urban settings as White patients after operative SBO admission. Future work should focus on setting-specific interventions to address drivers of disparities within each community.

Factors Associated with Delays in Initiating Biologic Therapy in Patients with Inflammatory Bowel Disease

INTRODUCTION

Expeditious initiation of biologic therapy is important in patients with inflammatory bowel disease (IBD). However, initiation of biologics in the outpatient setting may be delayed by various clinical, social, and financial variables.

AIM

To evaluate the delay in initiation of an advanced therapy in IBD and to identify factors that contributed to this delay.

METHODS

This was a multi-center retrospective study. Outpatients who were initiated on a biologic therapy from 3/1/2019 to 9/30/20 were eligible for the study. Univariate and multivariate linear regression analyses were performed to identify variables associated with a delay in biologic treatment initiation. Delay was defined as the days from decision date (prescription placement) to first infusion or delivery of medication.

RESULTS

In total 411 patients (Crohn's disease, n = 276; ulcerative colitis, n = 129) were included in the analysis. The median [interquartile range-(IQR)] delay for all drugs was 20 [12-37] days (infliximab, 19 [13-33] days; adalimumab, 10 [5-26] days; vedolizumab, 21 [14-42] days; and ustekinumab, 21 [14-42] days). Multivariate linear regression analysis identified that the most important variables associated with delays in biologic treatment initiation was self-identification as Black, longer distance from treatment site, and lack of initial insurance coverage approval.

CONCLUSION

There may be a significant delay in biologic treatment initiation in patients with IBD. The most important variables associated with this delay included self-identification as Black, longer distance from site, and lack of initial insurance coverage approval.

Is it "all in the bag?" Multidisciplinary perspectives on ostomy surgery in pediatric IBD across the ImproveCareNow network

Objectives

Pediatric inflammatory bowel disease (IBD) is a chronic illness with various treatments, including ostomy surgery. Ostomy-related medical decision-making (MDM) is complex for multidisciplinary healthcare professionals (HCPs). This study sought to understand national multidisciplinary HCPs' perceptions about pediatric IBD ostomy surgery in the United States.

Methods

This cross-sectional REDCap survey recruited HCPs in pediatric IBD HCP roles from the ImproveCareNow (ICN) Learning Health System. The survey gathered data on, (1) demographics, (2) participants' perspectives on patients/families' ostomy perceptions, (3) participants' own perspectives on ostomies, and (4) participants' perspectives on multidisciplinary collaboration in ostomy surgery.

Results

Participants (n = 69, across n = 30 American ICN sites) were 84% White, 62% female, and 54% gastroenterologists. In reflecting on patients/families' perceptions, participants endorsed most (86%) view ostomies as a "failure," various psychosocial concerns (e.g., 97% endorsed body image concerns), and most (81%) have moderate to significant stigma about ostomies. In reflecting on their own perceptions, nearly half (44%) endorsed some to moderate stigma about ostomies and felt ostomy discussions were difficult when families had negative perceptions (88%). Over half (54%) endorsed currently having multidisciplinary care for pediatric IBD surgery. Most (70%) endorsed variability in the amount and/or quality of multidisciplinary collaboration.

Conclusion

MDM related to pediatric IBD ostomy surgery presents nuanced clinical complexities for HCPs. This work underscores interest in multidisciplinary care, notable ostomy-related psychosocial needs, and ostomy-related stigma. Future work should develop systematic approaches to multidisciplinary pediatric IBD ostomy care, bolster psychosocial support, and evaluate how systematic care may impact psychosocial, and healthcare utilization outcomes.

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.

Role of Age as a Predictor of Major Complications After Elective Surgery for Ulcerative Colitis

BACKGROUND

The incidence of ulcerative colitis (UC) in the elderly population is increasing. The aim of this study was to assess the degree to which age and other factors increase the risk of developing major complications in patients undergoing elective surgery for UC.

METHODS

Using the ACS-NSQIP database from 2016 to 2020, patients undergoing elective surgery for UC were divided into four categories: younger than 30, 30-49, 50-69, and 70 or older. A composite outcome was created including major complications and multivariable analysis was performed to identify factors associated with composite major complications.

RESULTS

5946 patients diagnosed with ulcerative colitis who underwent elective surgery were included in the analysis. 14.1% of all patients developed a major complication. For patients with UC, factors associated with the development of a major complication were age 50-69 (OR 1.31, P = .034), male sex (OR 1.38, P < .001), Black race (OR 1.47, P = .049), dependent status (OR 2.06, P = .028), hypoalbuminemia (OR 1.92, P < .001), preoperative steroid treatment (OR 1.27, P = .038), preoperative transfusion (OR 1.91, P < .001), open surgical approach (OR 1.44, P = .002), and partial colectomy (OR 1.51, P = .007). Specifically in patients aged 70 or older, hypoalbuminemia (OR 3.20, P < .001) and preoperative transfusion (OR 2.78, P = .019) were associated with a major complication.

CONCLUSION

Age is a risk factor for the development of a major complication in UC patients undergoing elective surgery. However, it is not the only risk factor nor is it the one that increases the risk the most.

Ethnic Variation Trends in the Use of Ileal Pouch-Anal Anastomosis in Patients With Ulcerative Colitis

Background

Approximately 15%-20% of patients with ulcerative colitis (UC) will require surgery during their lifetime. Ileal pouch-anal anastomosis (IPAA) is the preferred surgical option, which typically requires access to a specialist experienced in surgery for inflammatory bowel diseases (IBD).

Methods

The aims of this study are the assessment of the comparative use of IPAA for UC among different racial/ethnic groups and observe trends over the past decade in the United States as well as the comparative assessment of their respective postoperative outcomes. This was an observational retrospective study using the National Inpatient Sample (NIS) 2009-2018 dataset. All patients with ICD-9/10CM codes for UC were included. The primary outcome was comparative trends in IPAA construction across races/ethnicities in the past decade, which was compared to White patients as reference. Multivariate regression analyses were used to adjust for age, gender, Charlson comorbidity index, income in patient zip code, insurance status, hospital region, location, size, and teaching status.

Results

The number of patients discharged from US hospitals with an associated diagnosis of UC increased between 2009 and 2018, but the number of patients undergoing an IPAA decreased during that time period. Of 1 153 363 admissions related to UC, 60 688 required surgery for UC, of whom 16 601 underwent IPAA in the study period. Of all the patients undergoing surgery for UC, 2862 (4.7%) were Black, while 44 351 were White. This analysis indicated that Black patients were less likely to undergo IPAA both in 2009 and in 2018 compared to Whites. Hispanic patients were significantly less likely to receive IPAA in 2009 but were no longer less likely to receive IPAA in 2018 when compared to Whites.

Conclusions

The use of IPAA among Black patients requiring surgery for UC remains less common than amongst their White counterparts. Further research is needed to determine if racial disparity is a factor in decreased access to specialized care.

Racial disparities in postoperative outcomes persist for patients with inflammatory bowel disease under a colorectal enhanced recovery program

INTRODUCTION

Enhanced recovery programs (ERPs) reduce racial disparities in surgical outcomes for general colorectal surgery populations. It is unclear, however, if disparities in IBD populations are impacted by ERPs.

METHODS

Retrospective study comparing IBD patients undergoing major elective colorectal operations before (2006-2014) and after (2015-2021) ERP implementation using ACS-NSQIP data. The primary outcome of length of stay (LOS) was analyzed by negative binomial regression, and secondary outcomes (complications and readmissions) by logistic regression.

RESULTS

Of 466 IBD patients, 47% were pre-ERP and 53% were ERP patients. In multivariable analysis stratified by ERP period, Black race was associated with increased odds of complications in the pre-ERP (OR 3.6, 95%CI 1.4-9.3) and ERP groups (OR 3.1 95%CI 1.3-7.6). Race was not a predictor of LOS or readmission in either group. High social vulnerability was associated with increased odds of readmission pre-ERP (OR 15.1, 95%CI 2.1-136.3), but this disparity was mitigated under ERPs (OR 1.4, 95%CI 0.4-5.6).

CONCLUSION

While ERPs mitigated some disparities by social vulnerability, racial disparities persist in IBD populations even under ERPs. Further work is needed to achieve surgical equity for IBD patients.