Postoperative health-care utilization in Crohn's disease: the impact of specialist care

Association of hospital volume with postoperative outcomes in Crohn's disease

AIM

Most patients diagnosed with Crohn's disease (CD) require surgery during their lifetime. While the literature has shown that certain cancer patients have superior postoperative outcomes at high-volume hospitals, there remains a paucity of data on the hospital volume-outcome relationship in CD. Given the complexities in both medical and surgical management, this study aims to determine whether patients with CD have superior postoperative outcomes at high-volume hospitals.

METHOD

A retrospective analysis of patients undergoing abdominal surgery for CD in New York hospitals between 2012 and 2018 was performed using data from the Statewide Planning and Research Cooperation System. Outcomes included postoperative mortality, 30-day readmission and postoperative complications. Using a penalized B-spline plot, high-volume centres were defined as those performing more than 160 abdominal surgeries for CD each year.

RESULTS

A total of 13,221 surgeries were performed across 176 hospital centres in New York State. Of these, 73.9% of procedures occurred at low-volume centres. High-volume hospitals had lower in-hospital mortality (0.5% vs. 1.5%; p < 0.001) and 30-day readmission rates (8.3% vs. 10.4%; p < 0.001) than low-volume centres. Major postoperative complications and reoperation rates did not differ by hospital volume. On multivariate analysis, patients at high-volume hospitals had lower odds of in-hospital mortality (OR 0.54, 95% CI 0.38-0.75) and 30-day readmission (OR 0.79, 95%CI 0.64-0.98). Hospital volume remained an independent predictor of 30-day readmission for emergent admissions (OR 0.72, 95% CI 0.61-0.85) and in-hospital mortality for nonemergent admissions (OR 0.39, 95% CI 0.19-0.82).

CONCLUSION

Patients undergoing abdominal surgery for CD have lower odds of postoperative mortality and 30-day readmission when the operation occurs at a high-volume hospital. These findings suggest that surgical patients with CD may benefit from care at specialized centres.

Contemporary Risk of Surgery in Patients With Ulcerative Colitis and Crohn's Disease: A Meta-Analysis of Population-Based Cohorts

BACKGROUND & AIMS

We conducted a systematic review with meta-analysis to estimate rates and trends of colectomy in patients with ulcerative colitis (UC), and of primary and re-resection in patients with Crohn's disease (CD), focusing on contemporary risks.

METHODS

Through a systematic review until September 3, 2019, we identified population-based cohort studies that reported patient-level cumulative risk of surgery in patients with UC and CD. We evaluated overall and contemporary risk (after 2000) of surgery and analyzed time trends through mixed-effects meta-regression.

RESULTS

In patients with UC (26 studies), the overall 1-, 5-, and 10-year risks of colectomy was 4.0% (95% CI, 3.3-5.0), 8.8% (95% CI, 7.7-10.0), and 13.3% (95% CI, 11.3-15.5), respectively, with a decrease in risk over time (P < .001). Corresponding contemporary risks were 2.8% (95% CI, 2.0-3.9), 7.0% (95% CI, 5.7-8.6), and 9.6% (95% CI, 6.3-14.2), respectively. In patients with CD (22 studies), the overall 1-, 5-, and 10-year risk of surgery was 18.7% (95% CI, 15.0-23.0), 28.0% (95% CI, 24.0-32.4), and 39.5% (95% CI, 33.3-46.2), respectively, with a decrease in risk over time (P < .001). Corresponding contemporary risks were 12.3% (95% CI, 10.8-14.0), 18.0% (95% CI, 15.4-21.0), and 26.2% (95% CI, 23.4-29.4), respectively. In a meta-analysis of 8 studies in patients with CD with prior resection, the cumulative risk of a second resection at 5 and 10 years after the first resection was 17.7% (95% CI, 13.5-22.9) and 31.3% (95% CI, 24.1-39.6), respectively.

CONCLUSIONS

Patient-level risks of surgery have decreased significantly over time, with a 5-year cumulative risk of surgery of 7.0% in UC and 18.0% in CD in contemporary cohorts. This decrease may be related to early detection and/or better treatment.

Transforming Access to Specialist Care for Inflammatory Bowel Disease: The PACE Telemedicine Program

Background

There are significant geographic disparities in the delivery of IBD healthcare in Ontario which may ultimately impact health outcomes. Telemedicine-based health services may potentially bridge gaps in access to gastroenterologists in remote and underserved areas.

Methods

We conducted a needs assessment for IBD specialist care in Ontario using health administrative data. As part of a separate initiative to address geographic disparities in access to care, we described the development and implementation of our Promoting Access and Care through Centres of Excellence (PACE) Telemedicine Program. Over the first 18 months, we measured wait times and potential cost savings.

Results

We found substantial deficiencies in specialist care early in the course of IBD and continuous IBD care in regions where the number of gastroenterologists per capita were low. The PACE Telemedicine Program enabled new IBD consultations within a median time of 17 days (interquartile range [IQR], 7–32 days) and visits for active IBD symptoms with a median time of 8.5 days (IQR, 4–14 days). Forty-five percent of new consultations and 83% of patients with active IBD symptoms were seen within the target wait time of two weeks. Telemedicine services resulted in an estimated cost savings of $47,565 among individuals who qualified for Ontario’s Northern Travel Grant.

Conclusions

The implementation of telemedicine services for IBD is highly feasible and can reduce wait times to see gastroenterologists that meet nationally recommended targets and can lead to cost savings.

Management of Crohn's Disease After Surgical Resection

Approximately 25% to 35% of patients with Crohn's disease (CD) who undergo surgery require repeat surgery. Active smoking, multiple prior surgeries, and penetrating or perianal disease are risk factors for recurrence of CD after surgical resection. Early initiation of prophylactic therapy is effective in decreasing the risk of recurrence. Active colonoscopic surveillance for the early detection of endoscopic recurrence within 6 to 12 months of surgery is recommended. In symptomatic patients without evidence of endoscopic recurrence, noninflammatory causes should be sought.

Risk of Surgery and Mortality in Elderly-onset Inflammatory Bowel Disease: A Population-based Cohort Study

BACKGROUND

As the prevalence of inflammatory bowel disease (IBD) increases in the elderly population, we sought to characterize IBD-related outcomes in this population.

METHODS

We identified incident IBD cases in Ontario, Canada between 1999 and 2008 and categorized subjects by age at diagnosis as young adults (18-40 yr); middle-age adults (41-64 yr); and elderly (≥65 yr) from within population-based health administrative data. We determined the risk of IBD-related surgery and mortality in those with elderly-onset IBD compared with other age groups.

RESULTS

Of 21,218 persons with IBD, there were 1749 cases of elderly-onset ulcerative colitis (UC) and 725 cases elderly-onset Crohn's disease (CD). Elderly UC had higher rates of IBD-related surgery than those with young-adult UC (adjusted hazard ratio, 1.34; 95% CI, 1.16-1.55), although there was no difference in surgical rates between age groups in CD. IBD-specific mortality was higher in elderly-onset CD (33.1/10,000 person-year) compared with that in middle-age CD (5.6/10,000 person-year, P < 0.0001) and young adult CD (1.0/10,000 person-year) but was not different by age in UC. The leading cause of death in elderly UC and CD was solid malignancies accounting for 22.9% and 26.4% of deaths, respectively, whereas IBD was third most frequent cause of death accounting for 6.3% and 9.1% of deaths, respectively.

CONCLUSIONS

Elderly-onset patients with UC were more likely to undergo surgery while elderly-onset patients with CD exhibited higher IBD-specific mortality than those with younger-onset disease. These findings should prompt more optimized disease management in elderly IBD.

Mortality Trends in Crohn's Disease and Ulcerative Colitis: A Population-based Study in Québec, Canada

BACKGROUND

Mortality rates greater than in the general population have been reported in the population with Crohn's disease (CD), but reports for ulcerative colitis (UC) are conflicting. Trends with time were rarely described. We aimed to assess whether CD and UC mortality in Québec differs from that in the general population and to describe the trends over a 10-year observation period.

METHODS

This is a population-based cohort study using the Québec administrative health databases and death certificates registry. All-cause and cause-specific standardized mortality ratios (SMRs) were computed for 1999 to 2008. A time trend analysis was used to assess changes in the SMR with the calendar year.

RESULTS

All-cause mortality was significantly increased in CD and UC compared to the general population: SMR: CD 1.45 (95% confidence interval: 1.34-1.58), UC 1.21 (95% confidence interval: 1.12-1.32). In CD, mortality from digestive conditions, all neoplasms, digestive neoplasms, and colorectal, lymphatic, and lung cancer was significantly higher than in the general population. In UC, mortality from digestive, respiratory, and infectious conditions was also significantly increased. In both CD and UC, there was a decrease with time in all-cause SMRs and in digestive conditions, digestive neoplasms, colorectal cancer, and infectious diseases. SMRs for lung cancer and respiratory conditions increased over time in CD.

CONCLUSIONS

All-cause mortality was significantly higher in CD and UC populations than in the general population. However, a decreasing trend with time was observed in all-cause and some cause-specific SMRs. In CD, SMRs for lung cancer and respiratory conditions increased during the observation period.

Direct retrospective comparison of adalimumab and infliximab in preventing early postoperative endoscopic recurrence after ileocaecal resection for crohn's disease: results from the MULTIPER database

BACKGROUND AND AIMS

Both adalimumab [ADA] and infliximab [IFX] seem to be effective in the prevention of early postoperative endoscopic recurrence [EPER] after ileocaecal resection in Crohn's disease [CD] patients. There is lack of data with direct comparison between the two agents in the postoperative scenario. The aim of this study was to compare the rates of EPER in patients treated with ADA and IFX after ileocaecal resection for CD.

METHODS

This was a multicentre retrospective analysis of EPER rates in CD patients after ileocaecal resections, from seven referral centres in three countries. Endoscopic recurrence was defined as Rutgeerts' score ≥ i2. The patients were allocated according to treatment to two groups: ADA or IFX. The EPER rates were compared between the two treatment groups.

RESULTS

Among the 168 patients included in the database, 96 received anti-tumour necrosis factor [TNF] agents after resection [37 in the ADA and 59 in the IFX groups] and were included in this comparative study. The groups were comparable in all baseline characteristics, mainly age, gender, previous resections, perianal CD, and mono or combination therapy. EPER was identified in 9/37 [24.32%] in the ADA group vs 16/59 [27.12%] in the IFX group [p = 0.815].

CONCLUSIONS

In this retrospective direct comparison between ADA and IFX therapy after ileocaecal resection, there was no significant difference between the two anti-TNF agents in terms of EPER rates. However, prospective randomised studies are needed to confirm these data and better define the role of each agent in the prevention of EPER.

Health Care utilization in elderly onset inflammatory bowel disease: a population-based study

BACKGROUND

There is an increasing burden of inflammatory bowel disease (IBD) among the elderly. We sought to characterize health care utilization of elderly onset IBD.

METHODS

We identified incident IBD cases in Ontario, Canada between 1999 and 2008 and categorized subjects by age at diagnosis as young (18-40 yr), middle-age (41-64 yr), and elderly (≥65 yr). We compared IBD-specific health utilization indicators, including outpatient visits, emergency department visits, and hospitalizations.

RESULTS

The elderly accounted for 8.1% (N = 725) and 11.6% (N = 1749) of incident Crohn's disease (CD) and ulcerative colitis (UC), respectively. They were less likely than young adults to have any IBD-specific gastroenterology visit in the first year after diagnosis (CD, 63% versus 71%, P < 0.001; UC, 63% versus 69%, P < 0.001). They less frequently received continuous gastroenterology care (CD, 36% versus 46%, P < 0.001; UC, 33% versus 43%, P < 0.001). Elderly patients with IBD were less likely than young adults to require an IBD-specific emergency department visit in the first year (CD, 8.8% versus 18.5%, P < 0.001; UC, 7.8% versus 11.6%, P < 0.001). Similarly, elderly patients with CD exhibited lower hospitalization rates (incidence rate ratio, 0.62; 95% confidence interval, 0.59-0.65). Hospitalization rates were modestly higher among those elderly patients with UC compared with young adults during the first year (incidence rate ratio, 1.14; 95% confidence interval: 1.02-1.28), but this association reversed thereafter (incidence rate ratio, 0.64; 95% confidence interval: 0.57-0.71).

CONCLUSIONS

Elderly patients with IBD exhibited lower IBD-specific health care utilization than young adults, which may reflect a multitude of factors including more benign disease and differential health care access.

Variation among United States hospitals in inpatient mortality for cirrhosis

BACKGROUND & AIMS

Little is known about geographic variations in health care for patients with cirrhosis. We studied geographic and hospital-level variations in care of patients with cirrhosis in the United States by using inpatient mortality as an outcome for comparing hospitals. We also aimed to identify features of patients and hospitals associated with lower mortality.

METHODS

We used the 2009 U.S. Nationwide Inpatient Sample to identify patients with cirrhosis, which were based on the International Classification of Diseases, 9th Revision-Clinical Modification diagnosis codes for cirrhosis or 1 of its complications (ascites, hepatorenal syndrome, upper gastrointestinal bleeding, portal hypertension, or hepatic encephalopathy). Multilevel modeling was performed to measure variance among hospitals.

RESULTS

There were 102,155 admissions for cirrhosis in 2009, compared with 74,417 in 2003. Overall inpatient mortality was 6.6%. On multivariable-adjusted logistic regression, patients hospitalized in the Midwest had the lowest odds ratio (OR) of inpatient mortality (OR, 0.54; P < .001). Patients who were transferred from other hospitals (OR, 1.49; P < .001) or had hepatic encephalopathy (OR, 1.28; P < .001), upper gastrointestinal bleeding (OR, 1.74; P < .001), or alcoholic liver disease (OR, 1.23; P = .03) had higher odds of inpatient mortality than patients without these features. Those who received liver transplants had substantially lower odds of inpatient mortality (OR, 0.21; P < .001). Multilevel modeling showed that 4% of the variation in mortality could be accounted for at the hospital level (P < .001). Adjusted mortality among hospitals ranged from 1.2% to 14.2%.

CONCLUSIONS

Inpatient cirrhosis mortality varies considerably among U.S. hospitals. Further research is needed to identify hospital-level and provider-level practices that could be modified to improve outcomes.

Cumulative incidence of second intestinal resection in Crohn's disease: a systematic review and meta-analysis of population-based studies

OBJECTIVES

Approximately 50% of Crohn's disease patients undergo an intestinal resection within 10 years of diagnosis. The risk of second surgery in Crohn's disease and the influence of time are not well characterized. We performed a systematic review and meta-analysis to establish the risk of second abdominal surgery in patients with Crohn's disease among patients who had a previous surgery.

METHODS

We searched Medline, EMBASE, PubMed (March 2014), and conference proceedings for terms related to Crohn's disease and intestinal surgery. We included population-based articles (n=11) and an abstract (n=1) reporting surgical risk for the overall study period and for 5 and 10 years after the first surgery for Crohn's disease. We stratified studies by year (start year before vs. after 1980) to explore the role of time.

RESULTS

For all population-based studies, the overall risk of second surgery was 28.7% (95% confidence interval (CI): 22.6-36.6%). The 5-year risk of second surgery was 24.2% (95% CI: 22.3-26.4%). The 10-year risk of second surgery was 35.0% (95% CI: 31.8-38.6%). A significant difference in the 10-year risk of second surgery was observed over time such that studies conducted after 1980 had a lower risk of second surgery (33.2%; 95% CI: 31.2-35.4%) compared with those that started before 1980 (44.6%; 95% CI: 37.7-52.7%).

CONCLUSIONS

Approximately one-quarter of Crohn's disease patients who have a first surgery also have a second, and the majority of these surgeries occur within 5 years of the first surgery. The 10-year risk of second surgery is significantly decreasing over time.

The impact of surgeon volume on postoperative outcomes after surgery for Crohn's disease

BACKGROUND

High hospital procedural volume has been associated with better postoperative inflammatory bowel disease outcomes. We assessed the independent contribution of surgeon volume to health outcomes after surgery for Crohn's disease.

METHODS

We identified 2842 individuals with Crohn's disease who underwent first inflammatory bowel disease-related surgery between 1996 and 2009. We assessed the association between surgeon volume, hospital volume, comorbidity and demographic variables, and postoperative outcomes.

RESULTS

The in-hospital mortality rate was 4.4%. Being in the lowest income, quintile was associated with 3-fold higher mortality compared with the highest income quartile (odds ratio, 3.10; 95% CI, 1.44-6.48). The late hospitalization (>3 mo after surgery) rate among those operated by surgeons in the bottom quartile for inflammatory bowel disease surgery volume was nearly 1.5-fold higher than that of those operated by surgeons in the second, third, and top quartiles (3.4/100 person-years [py] versus 2.4/100 py, 2.1/100 py, and 2.3/100 py, respectively; P < 0.05). After multivariate adjustment, the relative incidence ratio for late hospitalization for surgeons in the second, third, and top quartiles were 0.88 (95% CI, 0.83-0.93), 0.88 (95% CI, 0.83-0.94), and 0.87 (95% CI, 0.79-0.94) compared with the bottom quartile, respectively. The 5-year risk of recurrent surgery was 24.3%, and was not associated with surgeon volume.

CONCLUSIONS

Low surgeon volumes were associated with increased risk of late hospitalizations after Crohn's disease surgery. Prospective studies are warranted to elucidate whether this correlation is a late-onset consequence of surgical inexperience or other healthcare utilization factors that are associated with lower surgeon volume.

Weekend hospitalisations and post-operative complications following urgent surgery for ulcerative colitis and Crohn's disease

BACKGROUND

There is increasing complexity in the management of patients with acute severe exacerbation of inflammatory bowel disease [IBD; Crohn's disease (CD), ulcerative colitis (UC)] with frequent requirement for urgent surgery.

AIM

To determine whether a weekend effect exists for IBD care in the United States.

METHODS

We used data from the Nationwide Inpatient Sample (NIS) 2007, the largest all-payer hospitalisation database in the United States. Discharges with a diagnosis of CD or UC who underwent urgent intestinal surgery within 2 days of hospitalisation were identified using the appropriate ICD-9 codes. The independent effect of admission on a weekend was examined using multivariate logistic regression adjusting for potential confounders.

RESULTS

Our study included 7,112 urgent intestinal surgeries in IBD patients, 21% of which occurred following weekend admissions. There was no difference in disease severity between weekend and weekday admissions. Post-operative complications were more common following weekend than weekday hospitalisations in UC [odds ratio (OR) 1.71, 95% confidence interval (CI) 1.01-2.90]. The most common post-operative complication was post-operative infections (Weekend 30% vs. weekday 20%, P = 0.04). The most striking difference between weekend and weekday hospitalisations was noted for needing repeat laparotomy (OR 11.5), mechanical wound complications (OR 10.03) and pulmonary complications (OR 2.22). In contrast, occurrence of any post-operative complication in CD was similar between weekday and weekend admissions.

CONCLUSION

Patients with UC hospitalised on a weekend undergoing urgent surgery within 2 days have an increased risk for post-operative complications, in particular mechanical wound complications, need for repeat laparotomy and post-operative infections.

Multidisciplinary management of patients with cirrhosis: a need for care coordination

Cirrhosis is a common chronic condition with high rates of morbidity and mortality. Optimal medical management involves a multidisciplinary approach, but coordination between medical specialties needs to be improved. This clinical perspective discusses care coordination interventions that have been successful in other disease states and how they could be applied to the management of cirrhosis.