The Burden of Hospital Readmissions among Pediatric Patients with Inflammatory Bowel Disease

Children and Young Adults With Inflammatory Bowel Disease Have an Increased Incidence and Risk of Developing Mental Health Conditions: A UK Population-Based Cohort Study

BACKGROUND

The burden of mental health conditions in children and young adults with inflammatory bowel disease remains unclear. We assessed this using a primary care database in the United Kingdom.

METHODS

A retrospective, observational study compared children and young adults with incident inflammatory bowel disease 5 to 25 years of age (2010-2020) against population control subjects. Outcomes comprised incident depression, anxiety disorder, eating disorders, body image disorders, attention-deficit disorders, behavioral disorders, adjustment disorders, acute stress disorder, schizophrenia, bipolar disorder, posttraumatic stress disorder, self-harm, parasuicide (including suicide), and sleep disturbance. The any mental health condition category comprised any of these conditions.

RESULTS

A total of 3898 young patients with incident inflammatory bowel disease were matched to 15 571 control subjects. Inflammatory bowel disease patients were significantly more likely to develop new posttraumatic stress disorder (adjusted hazard ratio [aHR], 2.47; 95% confidence interval [CI], 1.23-4.94), eating disorders (aHR, 1.85; 95% CI, 1.05-3.26), self-harm (aHR, 1.49; 95% CI, 1.00-2.21), sleep disturbance (aHR, 1.40; 95% CI, 1.15-1.71), depression (aHR, 1.34; 95% CI, 1.16- 1.56), anxiety (aHR, 1.25; 95% CI, 1.06-1.48), and any mental health condition (aHR, 1.28; 95% CI, 1.12-1.46). Male inflammatory bowel disease patients aged 12 to 17 years, and patients with Crohn's disease appear to have the highest risk for developing new mental health conditions.

CONCLUSIONS

Young inflammatory bowel disease patients have a significantly higher incidence and risk of new mental health conditions. Mental health remains a critically overlooked aspect of inflammatory bowel disease patient management. Further research into identifying optimal monitoring tools and support for these patients is required to improve patient care. The study protocol was specified and registered a priori.ClinicalTrials.gov study identifier: NCT05206734.

Impact of sex and socioeconomic status on the likelihood of surgery, hospitalization, and use of medications in inflammatory bowel disease: a systematic review and meta-analysis

BACKGROUND

Inflammatory bowel diseases (IBDs) are associated with high healthcare utilization. This systematic review aimed to summarize what is known about the impact of sex, income, and education on the likelihood of bowel surgery, hospitalization, and use of corticosteroids and biologics among patients with IBD.

METHODS

We used EMBASE, MEDLINE, CINAHL, and Web of Science to perform a systematic literature search. Pooled hazard ratios (HRs) and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random effects meta-analysis for the impact of sex on the likelihood of surgery and hospitalization. In addition, we performed subgroup analyses of the effect of IBD type (Crohn's disease or ulcerative colitis) and age. Finally, meta-regression was undertaken for the year of publication.

RESULTS

In total, 67 studies were included, of which 23 studies were eligible for meta-analysis. In the main meta-analysis, male sex was associated with an increased likelihood of bowel surgery (HR 1.42 (95% CI 1.13;1.78), which was consistent with the subgroup analysis for UC only (HR 1.78, 95% CI 1.16; 2.72). Sex did not impact the likelihood of hospitalization (OR 1.05 (95% CI 0.86;1.30), although the subgroup analysis revealed an increased likelihood of hospitalization in CD patients (OR 1.42, 95% CI 1.28;1.58). In 9 of 10 studies, no significant sex-based differences in the use of biologics were reported, although in 6 of 6 studies, female patients had lower adherence to biologics. In 11 of 13 studies, no significant sex-based difference in the use of corticosteroids was reported. The evidence of the impact of income and education on healthcare utilization was sparse and pointed in different directions. The substantial heterogeneity between studies was explained, in part, by differences in IBD type and age.

CONCLUSIONS

The results of this systematic review indicate that male patients with IBD are significantly more likely to have surgery than female patients with IBD but are not, overall, more likely to be hospitalized, whereas female patients appear to have statistically significantly lower adherence to biologics compared to male patients. Thus, clinicians should not underestimate the impact of sex on healthcare utilization. Evidence for income- and education-based differences remains sparse.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022315788.

Adolescent and caregiver perceptions of addressing mental health in inflammatory bowel disease

Adolescents with inflammatory bowel disease (IBD) are at an increased risk of anxiety and depression compared to peers, but availability of mental health services in IBD clinics does not meet patients' needs, and use of primary care services for mental health screening and care is low. This study provides qualitative data regarding adolescent and caregiver perspectives on addressing mental health in IBD. Interviews were conducted with adolescents with IBD and caregivers of adolescents with IBD. Interview transcripts were coded and analyzed for prominent themes. Thirteen adolescents and fourteen caregivers were interviewed. Three primary themes emerged: mental health stigma makes discussing it more difficult, physician-adolescent trust makes conversations about mental health easier, and asking about mental health directly can help adolescents feel comfortable. Adolescents and caregivers highlighted the importance of considering each patient and their family individually when choosing how to discuss mental health. Fostering trust with adolescents with IBD is vital to addressing mental health. While encouraging standardized screening is important, the most patient-centered approach to mental health involves considering families individually to identify and address mental health challenges. Given the increased risk of anxiety and depression in pediatric patients with IBD, all providers encountering these patients should be equipped to discuss mental health non-judgmentally.

Impact of mental health comorbidity in children and young adults with inflammatory bowel disease: a UK population-based cohort study

OBJECTIVE

To evaluate the impact of mental health comorbidity in children and young adults with inflammatory bowel disease (IBD).

DESIGN

Retrospective observational study.

SETTING

Representative population, routinely collected primary care data from the UK Optimum Patient Care Research Database (2015-2019).

PARTICIPANTS

Patients with IBD aged 5-25 years with mental health conditions were compared with patients with IBD of the same age without mental health conditions.

PRIMARY AND SECONDARY OUTCOME MEASURES

Outcomes comprised quality-of-life indicators (low mood, self-harm, parasuicide, bowel symptoms, absence from school or work, unemployment, substance use and sleep disturbance), IBD interventions (medication, abdominal surgery, stoma formation and nutritional supplements) and healthcare utilisation (primary care interactions and hospital admissions).

RESULTS

Of 1943 individuals aged 5-25 years with IBD, 295 (15%) had a mental health comorbidity. Mental health comorbidity was associated with increased bowel symptoms (adjusted incident rate ratio (aIRR) 1.82; 95% CI 1.33 to 2.52), sleep disturbance (adjusted HR (aHR) 1.63; 95% CI 1.02 to 2.62), substance use (aHR 3.63; 95% CI 1.69 to 7.78), primary care interactions (aIRR 1.33; 95% CI 1.12 to 1.58) and hospital admissions (aIRR 1.87; 95%CI 1.29 to 2.75). In individuals ≥18 years old, mental health comorbidity was associated with increased time off work (aHR 1.55; 95% CI 1.21 to 1.99).

CONCLUSIONS

Mental health comorbidity in children and young adults with IBD is associated with poorer quality of life, higher healthcare utilisation and more time off work. It is imperative that affected young patients with IBD are monitored and receive early mental health support as part of their multidisciplinary care.

TRIAL REGISTRATION NUMBER

The study protocol was specified and registered a priori (ClinicalTrials.gov study identifier: NCT05206734).

The contributions of clinical disease activity, functional disability, and illness intrusiveness to depressive symptoms in pediatric inflammatory bowel disease

BACKGROUND

Clinical disease activity associated with inflammatory bowel disease (IBD) can place physical limitations on youths' activities of daily living. In turn, functional limitations potentially contribute to youths' heightened experience of IBD-induced intrusions on a wide range of routine and valued activities (i.e., illness intrusiveness), which can increase their risk for depressive symptoms. The present study examined the contributions of clinical disease activity, functional disability, and illness intrusiveness to depressive symptoms in youth with IBD.

METHODS

Youth (N = 180) completed the Functional Disability Inventory (FDI), Illness Intrusiveness Scale-Child (IIS-C), and Children's Depression Inventory-2 (CDI-2). Physicians completed the Physicians Global Assessment of disease activity (PGA).

RESULTS

Results revealed a mediating effect for functional disability in the association between disease activity and depressive symptoms (PGA → FDI → CDI-2); illness intrusiveness mediated the association between functional disability and depressive symptoms (i.e., FDI → IIS-C → CDI-2). Serial mediation revealed that clinical disease activity conferred an indirect effect on youth depressive symptoms through the sequential effects of functional disability and illness intrusiveness (i.e., PGA → FDI → IIS-C → CDI-2).

CONCLUSIONS

Taken together, these findings indicate that youth who encounter more physical limitations as a function of clinical disease activity are more likely to experience an amplified sense of IBD-related intrusions on their ability to participate in meaningful activities. In turn, heightened illness intrusiveness increases the likelihood of depressive symptoms. Clinical interventions that help youth maintain adequate functional ability in the face of IBD disease activity and encourage involvement in positively valued activities could decrease the negative impact of IBD on youths' emotional adjustment.

A nomogram based on clinical factors to predict calendar year readmission in patients with ulcerative colitis

Background

Readmission shortly after discharge is indicative of an increased disease severity for patients with ulcerative colitis (UC) and ineffectiveness to medical therapy, which may contribute to a dismal prognosis.

Objectives

This study aimed to explore prognostic variables with a nomogram to predict unplanned UC-related readmission within 1 year after discharge.

Design

A retrospective cohort study.

Methods

Electronic medical records of all UC patients treated at our center between 1 January 2014 and 31 June 2021 were reviewed. A comprehensive analysis of various characteristics, such as demographics, comorbidities, medical history, follow-up appointments, admission endoscopy, histopathologic features, etc., was used to determine the primary end point, which was unplanned UC-related calendar year readmission.

Results

We found that the unplanned UC-related readmission rate within 1 year was 20.8%. In multivariable cox analysis, the predictors of the Elixhauser comorbidity index [Hazard ratio (HR): 3.50, 95% confidence interval (CI): 1.93-6.37], regular follow-up (HR: 0.29, 95% CI: 0.16-0.53), any history of corticosteroid use (HR: 3.38, 95% CI: 1.83-6.27), seral level of C-reactive protein (HR: 1.01, 95% CI: 1.00-1.02), and the UC endoscopic index of severity (HR: 1.29, 95% CI: 1.05-1.57) independently predicted calendar year readmission after discharge. The established nomogram had a consistently high accuracy in predicting calendar year readmission in the training cohort, with a concordance index of 0.784, 0.825, and 0.837 at 13, 26, and 52 weeks, respectively, which was validated in both the internal and external validation cohorts. Therefore, UC patients were divided into clinically low-, high-, and extremely high-risk groups for readmission, based on the calculated score of 272.5 and 378.

Conclusion

The established nomogram showed good discrimination and calibration powers in predicting calendar year readmission in high-risk UC patients, who may need intensive treatment and regular outpatient visits.

Psychiatric Disorders in Adult and Paediatric Patients With Inflammatory Bowel Diseases - A Systematic Review and Meta-Analysis

BACKGROUND

Inflammatory bowel diseases [IBD], which are associated with a high disease burden, are also reported to be accompanied by a high prevalence of psychiatric disorders. However, the literature on IBD and psychiatric disorders has not been reviewed.

METHODS

This systematic review followed the PRISMA guidelines, and its protocol was registered at PROSPERO [ID: CRD42020214359]. PubMed, Embase and PsycINFO were consulted for the literature search. Studies reporting on diagnosed psychiatric disorders in IBD were included. Pooled prevalence rates were calculated using random effects meta-analyses. Study quality was assessed using the Newcastle-Ottawa Scale [NOS].

RESULTS

Sixty-nine studies were identified with an average cohort size of 60 114 patients. Pooled prevalence rates were: mood disorders, 10% (95% confidence interval [CI] = 7%; 15%); anxiety disorders, 12% [95% CI = 8%; 18%]; substance misuse, 3% [95% CI = 1%; 7%]; psychotic disorders, 2% [95% CI = 1%; 4%]; behavioural disorders, 1% [95% CI = 0%; 3%]; personality disorders, 3% [95% CI = 1%; 10%]; developmental disorders, 1% [95% CI = 0%; 3%]; and behavioural and emotional disorders with onset usually during childhood, 1% [95% CI = 1%; 3%]. All analyses had high statistical heterogeneity [I2 > 99%]. Seven studies reported an increased risk of suicide in IBD patients compared to controls.

CONCLUSION

The prevalence of psychiatric comorbidities was high [11-82%] in patients with IBD and was higher than in the background population. Addressing mental health problems in patients with IBD can improve their adherence to treatment and the somatic disease course and, consequently, reduce morbidity and mortality.

Pediatric Medical Traumatic Stress in Inflammatory Bowel Disease, Pancreatitis, and Cystic Fibrosis

OBJECTIVES

Known as pediatric medical traumatic stress (PMTS), posttraumatic stress symptoms from medical experiences have not been explored in children with chronic gastrointestinal diseases. This cross-sectional study of children and adolescents with inflammatory bowel disease, chronic pancreatitis and cystic fibrosis, aimed to (1) estimate the prevalence of medical potentially traumatic events (PTEs) and PMTS, (2) explore potential risk factors for PMTS, and (3) explore potential consequences of PMTS.

METHODS

This cross-sectional study used validated, self-report measures to evaluate PTEs and PMTS. Descriptive statistics and regression analyses were used to achieve study objectives.

RESULTS

Over two-thirds of children reported a medical potentially traumatic event (91 of 132, 69%). Forty-eight had PMTS symptoms (36%). PMTS was associated with medication burden, emergency and intensive care visits, and parent posttraumatic stress disorder in multivariate analysis. Potential consequences associated with PMTS included school absenteeism, home opioid use, poor quality of life, and parent missed work.

CONCLUSIONS

A substantial portion of our cohort reported medical PTEs and PMTS. The exploratory analysis identified potential associations between PMTS and illness factors, parent posttraumatic stress disorder, and functional impairments. Further studies of PMTS detection, prevention and treatment are integral to optimizing these children's health and quality of life.

Does surgical approach matter in the treatment of pediatric ulcerative colitis?

BACKGROUND

This study aims to compare the morbidity of open versus laparoscopic colectomy or proctocolectomy for pediatric patients with ulcerative colitis (UC) using national readmission outcomes.

MATERIALS AND METHODS

The 2010-2014 Nationwide Readmissions Database was used to identify patients < 18 years (excluding newborns) who underwent colectomy or proctocolectomy for UC. Patients with planned readmissions for staged procedures were excluded from readmission analysis. Demographics, hospital factors, and outcomes were compared by operative approach (open vs. laparoscopic) using standard statistical analysis. Results were weighted for national estimates.

RESULTS

There were 1922 patients (51% female, age 13 ± 3 years) with UC who underwent colectomy or proctocolectomy during index admission. Most cases were performed open (54%) and as elective admissions (64%). Compared to open approach, laparoscopy was associated with shorter index hospital length of stay (8 [5-17] days vs. 9 [6-18] days, p = 0.015), fewer surgical site infections (< 2% vs. 2%, p = 0.022), and less post-operative gastrointestinal dysfunction (5% vs. 8%, p = 0.008). After stratifying to control for elective and unplanned index admissions, laparoscopic approach was associated with fewer small bowel obstructions during index hospitalizations in both elective (9% vs. 15%, p = 0.003) and unplanned (5% vs. 16%, p<0.001) settings. Readmission for surgical site infection was also less common following laparoscopic approach in both elective (0% vs. 7%, p = 0.008) and unplanned (0% vs. < 7%, p = 0.017) settings.

CONCLUSIONS

In pediatric patients with ulcerative colitis, laparoscopic colectomy or proctocolectomy is associated with shorter hospital length of stay, less post-operative complications, and improved readmission outcomes.

Factors Related to Pediatric Readmissions of Four Major Diagnostic Categories in Hawai`i

Readmissions are a key quality measure for health care decision making and understanding variables associated with readmissions has become a crucial research area. This study identified patient-level factors that might be associated with pediatric readmissions using a database that included inpatient data from 2008 to 2017 from Hawai`i. Four major diagnostic categories with the most pediatric readmissions in the state were identified: respiratory, digestive, mental, and nervous system diseases and disorders. The associations between readmission and patient-level variables, such as age, sex, race/ethnicity, insurance status, and Charlson Comorbidity Index (CCI), were determined for each diagnosis and for overall readmissions. CCI and insurance were the strongest predictors when all diagnoses were combined. However, for some diagnoses, there was weak or no association between CCI, insurance, and readmission. This suggests that diagnosis-specific analysis of predictors of readmission may be more useful than looking at predictors of readmission for all diagnoses combined. While this study focused on patient variables, future studies should also incorporate how hospital variables may also be related to diagnosis.

Psychiatric comorbidity in childhood onset immune-mediated diseases-A systematic review and meta-analysis

AIM

To estimate psychiatric comorbidity in childhood onset immune-mediated inflammatory diseases (IMID).

METHODS

The PRISMA guidelines were followed, and the protocol was registered at Prospero (ID: CRD42021233890). Literature was searched in PubMed, PsycINFO and Embase. Original papers on prevalence rates of diagnosed psychiatric disorders and/or suicide in paediatric onset inflammatory bowel disease (pIBD), rheumatic diseases (RD) and autoimmune liver diseases were selected. Pooled prevalence rates of psychiatric disorders (grouped according to ICD-10 criteria) within the various IMID were calculated using random-effects meta-analysis. Risk of bias was evaluated by the Newcastle-Ottawa scale.

RESULTS

Twenty-three studies were included; 13 describing psychiatric disorders in pIBD and 10 in RD. Anxiety and mood disorders were mostly investigated with pooled prevalence rates in pIBD of 6% (95% confidence interval (CI): 4%-9%) and 4% (95%CI: 2%-8%), respectively, in register-based studies, and 33% (95%CI: 25%-41%) and 18% (95%CI: 12%-26%), respectively, in studies using psychiatric assessment. In RD, rates were 13% (95%CI: 12%-15%) for anxiety disorders and 20% (95%CI: 15%-26%) for mood disorders based on psychiatric assessment.

CONCLUSION

Anxiety and depression are commonly reported in childhood onset IMID. Physicians should be attentive to mental health problems in these patients as they seem overlooked.

Age- and Diagnosis-Based Trends for Unplanned Pediatric Rehospitalizations in the United States

Background and objectives: Hospital readmission rate helps to highlight the effectiveness of post-discharge care. There remains a paucity of plausible age-based categorization especially for ages below one year for hospital readmission rates.

Methods: Data from the 2017 Healthcare Cost and Utilization Project National Readmissions Database was analyzed for ages 0-18 years. Logistic regression analysis was performed to identify predictors for unplanned early readmissions. 

Results: We identified 5,529,389 inpatient pediatric encounters which were further divided into age group cohorts. The overall rate of readmissions was identified at 3.2%. Beyond infancy, the readmission rate was found to be 6.7%. Across all age groups, the major predictors of unplanned readmission were cancers, diseases affecting transplant recipients and sickle cell patients. It was determined that reflux, milk protein allergy, hepatitis and inflammatory bowel diseases were significant diagnoses leading to readmission. Anxiety, depression and suicidal ideation depicted higher readmission rates in those older than 13 years. Across ages one to four years, dehydration, asthma and bronchiolitis were negative predictors of unplanned readmission. 

Conclusions: Thirty-day unplanned readmissions remain a problem leading to billions of taxpayer dollars lost per annum. Effective strategies for mandatory outpatient follow-up may help the financial aspect of care while also enhancing the quality of care.

Predictors for early readmission in patients hospitalized with new onset pediatric lupus nephritis

OBJECTIVE

The objective is to determine the 30-day hospital readmission rate following a hospitalization due to pediatric lupus nephritis of recent onset and characterize the risk factors associated with these early readmissions.

METHODS

The study included 76 children hospitalized from 01/01/2008 to 4/30/2017 due to a new diagnosis of lupus nephritis. We calculated the 30-day hospital readmission rate and compared the characteristics of the patients that were readmitted to patients that were not readmitted using univariable and multivariable analysis.

RESULTS

The 30-day readmission rate was 17.1%. Factors that predicted hospital readmission in unavailable analysis were male gender (38.5 vs 14.3%, p = 0.04), not receiving pulse steroids (30.8 vs 3.2%, p = < .001), receiving diuretic treatment (69.2 vs 34.9%, p = .02), receiving albumin infusions (46.2 vs 12.7%, p = .004), stage 2 hypertension on day one of admission (76.9 vs 41.3%, p = .02), a higher white blood cell count on discharge (13.7 × 10³/mm³ vs 8.8 × 10³/mm3^, p = .023), need for non-angiotensin converting enzyme (ACE) antihypertensive drugs (76.9 vs 46%, p = .042), and being discharged on nonsteroidal anti-inflammatory drugs (NSAIDs) (23.1 vs 4.8%, p = .025). Multivariable analysis demonstrated an increased risk of readmission for patients not treated with intravenous pulse methylprednisolone (IVMP) (OR = 17.5 (1.81-168.32) p = .013), and for those who required intravenous albumin assisted diuresis for hypervolemia (OR=6.25 (1.29-30.30) p = .022).

CONCLUSION

In all, 17% of children hospitalized due to new onset lupus nephritis were readmitted within 30 days of discharge. Absence of IVMP and receiving intravenous albumin assisted diuresis during initial hospitalization increase the risk of early readmission in new onset pediatric lupus nephritis.

Impact of Nutritional Deficiencies on Children and Young Adults with Crohn's Disease Undergoing Intraabdominal Surgery

PURPOSE

We examined the impact of comorbidities on length of stay and total hospital charges for children and young adults with Crohn's Disease (CD) undergoing surgery.

METHODS

Patients (<21 years) were identified with a diagnosis of CD and an intraabdominal surgery in the Kids' Inpatient Database for the years 2006, 2009 and 2012. Length of stay (LOS) and total hospital charges (THC; USD$) were stratified by anemia, anxiety, depression and nutritional deficiency. National estimates were obtained using case weighting and multivariable linear regression was performed.

RESULTS

We identified 3224 CD admissions with an intraabdominal surgery. The population was predominantly male, non-Hispanic white, and high school aged. There was an increase in LOS and THC for nutritional deficiency in all study years, and for depression and anemia in specific years. Multivariable linear regression revealed a 3.3-5.5 day increase in LOS associated with a comorbid diagnosis of nutritional deficiency. However, no increase in THC was seen for any comorbidity under evaluation.

CONCLUSIONS

Behavioral health and, particularly, nutritional status have a significant impact on the care of children and young adults with CD. Nutritional deficiency, anemia, and depression resulted in increased LOS for those undergoing surgery. Improved presurgical management of comorbidities may reduce LOS for these patients.

LEVEL OF EVIDENCE

III.

An Integrated Health-System Specialty Pharmacy Model for Coordinating Transitions of Care: Specialty Medication Challenges and Specialty Pharmacist Opportunities

Adherence and persistence to specialty medications are necessary to achieve successful outcomes of costly therapies. The increasing use of specialty medications has exposed several unique barriers to certain specialty treatments' continuation. Integrated specialty pharmacy teams facilitate transitions in sites of care, between different provider types, among prescribed specialty medications, and during financial coverage changes. We review obstacles encountered within these types of transitions and the role of the specialty pharmacist in overcoming these obstacles. Case examples for each type of specialty transition provide insight into the unique complexities faced by patients, and shed light on pharmacists' vital role in patient care. This insightful and real-world experience is needed to facilitate best practices in specialty care, particularly in the growing number of health-system specialty pharmacies.

Epidemiology and implications of concurrent diagnosis of eosinophilic oesophagitis and IBD based on a prospective population-based analysis

OBJECTIVE

Eosinophilic oesophagitis (EoO) and IBD are immune-mediated diseases of the gastrointestinal tract with possible overlapping pathogenic mechanisms. Our aim was to define the epidemiology and clinical implications of concurrent EoO and IBD diagnoses.

DESIGN

We conducted a prospective cohort analysis using the Truven MarketScan database (2009-2016) to estimate the incidence and prevalence of EoO in patients with Crohn's disease (CD) or UC and vice versa. Cox proportional hazards and Kaplan-Meier methods were used to estimate the risk of EoO-related or IBD-related complications among patients with concurrent diagnoses.

RESULTS

Among 134 013 536 individuals, the incidence of EoO, CD and UC were 23.1, 51.2 and 55.2 per 100 000 person-years, respectively. The risk of EoO was higher among patients with CD (incidence rate ratio [IRR] 5.4, p<0.01; prevalence ratio (PR) 7.8, p<0.01) or UC (IRR 3.5, p<0.01; PR 5.0, p<0.01), while the risk of IBD was higher among patients with EoO (CD: IRR 5.7, p<0.01; PR 7.6, p<0.01; UC: IRR 3.4, p<0.01; PR 4.9, p<0.01) versus individuals without either diagnosis. Concurrent diagnosis of EoO and IBD was associated with greater composite risk of IBD-related complications (CD: adjusted HR (aHR) 1.09, p=0.01; UC: aHR 1.10, p=0.04) but lower composite risk of EoO-related complications (aHR 0.59; p<0.01).

CONCLUSION

Based on a population-based prospective cohort analysis, the risk of EoO is significantly higher among patients with IBD and vice versa. Concurrent diagnoses might modify the risk of IBD-related and EoO-related complications. Studies defining the mechanisms underlying these observations are needed.

Depression Predicts Prolonged Length of Hospital Stay in Pediatric Inflammatory Bowel Disease

OBJECTIVE

Few studies report the impact of depression on inflammatory bowel disease (IBD)-related hospitalizations. We evaluated the association between depression and pediatric IBD-related hospitalizations. Our primary aim was to test the hypothesis that depression is associated with hospital length of stay (LOS); our secondary goal was to evaluate if patients with depression are at higher risk for undergoing additional imaging and procedures.

METHODS

Data were extracted from the 2012 Kids Inpatient Database (KID), the largest nationally representative publicly available all-payer pediatric inpatient cross-sectional database in the United States. Hospitalizations for patients less than 21 years with a primary diagnosis Crohn disease (CD) or ulcerative colitis (UC) by ICD-9 code were included. Multivariable logistic regression was used to predict long LOS controlling for patient- and hospital-level variables and for potential disease confounders.

RESULTS

For primary IBD-related hospitalizations (N = 8222), depression was associated with prolonged LOS (odds ratio [OR] 1.50; 95% confidence interval [CI] 1.19-1.90) and total parenteral nutrition use (OR 1.54; 95% CI 1.04-2.27). Depression was not associated with increased likelihood of surgery (OR 0.97; 95% CI 0.72-1.30), endoscopy (OR 0.91; 95% CI 0.74-1.14), blood transfusion (OR 0.85; 95% CI 0.58-1.23), or abdominal imaging (OR 1.15; 95% CI 0.53-2.53).

CONCLUSIONS

Depression is associated with prolonged LOS in pediatric patients with IBD, even when controlling for gastrointestinal disease severity. Future research evaluating the efficacy of standardized depression screening and early intervention may be beneficial to improving inpatient outcomes in this population.

Depressive symptoms in inflammatory bowel disease: an extraintestinal manifestation of inflammation?

Depressive symptoms are reported by more than 20% of people with inflammatory bowel disease (IBD), while sleep difficulties and fatigue are even more common. Co-morbid depressive symptoms predict a poor IBD course, including increased risk of relapse and surgery, which is inconsistently improved by psychological treatments. Rather than being distinct systems, there is compelling evidence for bidirectional communication between gut and brain, driven by neural, metabolic, endocrine and inflammatory mediators. An emerging concept is that depressive symptoms may be mechanistically linked to excess inflammation and dysregulation of the gut-brain axis. Given the close link between the intestinal microbiota and host immune responses, patients prone to shifts in their intestinal microbiome, including smokers, those with poor diet and early life stress, may be exposed to exaggerated immune responses. Excess inflammation is associated with brain changes (depressive symptoms, fatigue, sleep difficulties) and worsening gastrointestinal symptoms, which are exacerbated by psychological distress. Equally, treatments both for depressive symptoms and IBD provide opportunities to break this cycle by reducing the causes and effects of inflammation. As well as addressing potential risk factors such as smoking and diet, treatments to alter the microbiome may reduce depressive symptoms. Observational evidence suggests that anti-inflammatory treatments for IBD may improve co-morbid depressive symptoms correlating with reduction in inflammation. With a growing range of treatments targeting inflammation centrally, peripherally and in the gut, IBD provides a unique model to understand the interplay between brain and gut in the pathogenesis of depressive symptoms, both in IBD and in the whole population.

Depression and Health Care Use in Patients With Inflammatory Bowel Disease

BACKGROUND

Depression frequently co-occurs in patients with inflammatory bowel disease [IBD] and is a driver in health care costs and use.

AIM

This study examined the associations between depression and total health care costs, emergency department [ED] visits, computed tomography [CT] during ED/inpatient visits, and IBD-related surgery among IBD patients.

METHODS

Our sample included 331772 IBD patients from a national administrative claims database [Truven Health MarketScan® Database]. Gamma and Poisson regression analyses assessed differences related to depression, controlling for key variables.

RESULTS

Approximately 16% of the IBD cohort was classified as having depression. Depression was associated with a $17,706 (95% confidence interval [CI] [$16,892, 18,521]) increase in mean annual IBD-related health care costs and an increased incidence of ED visits (adjusted incidence rate ratio [aIRR] of 1.5; 95% CI [1.5, 1.6]). Among patients who had one or more ED/inpatient visits, depression was associated with an increased probability of receiving repeated CT [one to four scans, adjusted odds ratio [aOR] of 1.6; 95% CI [1.5, 1.7]; five or more scans, aOR of 4.6; 95% CI [2.9, 7.3]) and increased odds of undergoing an IBD-related surgery (aOR of 1.2; 95% CI [1.1, 1.2]). Secondary analysis with a paediatric subsample revealed that approximately 12% of this cohort was classified as having depression, and depression was associated with increased costs and incidence rates of ED visits and CT, but not of IBD-related surgery.

CONCLUSIONS

Quantifiable differences in health care costs and patterns of use exist among patients with IBD and depression. Integration of mental health services within IBD care may improve overall health outcomes and costs of care.

Systematic review with meta-analysis: anxiety and depression in children and adolescents with inflammatory bowel disease

BACKGROUND

The co-existence of psychological problems and paediatric inflammatory bowel disease (IBD) is receiving increasing attention. Most studies investigated anxiety and depression, with prevalence rates varying from 0% to 50%. A systematic review is necessary to provide clear insight into the prevalence of anxiety and depression in paediatric IBD.

AIM

To systematically evaluate available data on the prevalence of anxiety and depressive symptoms and disorders in paediatric IBD (aged 6-18 years).

METHODS

Comprehensive searches were performed in Embase, Medline Ovid, Web of Science, Cochrane, PubMed, PsychInfo Ovid, and Google scholar for studies published from 1994 to 2017. Pooled prevalence rates were calculated using inverse variance heterogeneity models. Meta-regression was used to study if disease type, disease activity and gender influence prevalence.

RESULTS

Twenty-eight studies (N = 8107, mean age: 14.3) were identified. Pooled prevalence estimates were 16.4% (95% confidence interval [CI] 6.8%-27.3%) for anxiety symptoms and 4.2% (95% CI 3.6%-4.8%) for anxiety disorders. Pooled prevalence estimates were 15.0% (95% CI 6.4%-24.8%) for depressive symptoms and 3.4% (95% CI 0%-9.3%) for depressive disorders. Meta-regression showed no influence of disease type or gender on these prevalence rates, but studies with a higher percentage of active disease had a higher rate of depressive symptoms.

CONCLUSIONS

The described pooled prevalence of anxiety and depressive symptoms is lower than in adult IBD. However, due to varying instruments/cut-offs for measuring symptoms and few studies investigating disorders, the results should be interpreted with caution. Cross-cultural use of the same instruments is needed to gain better insight into prevalence rates.