Increasing hospitalizations in inflammatory bowel disease among children in the United States, 1988-2011

Burden and Cost of Gastrointestinal, Liver, and Pancreatic Diseases in the United States: Update 2021

BACKGROUND & AIMS

Gastrointestinal diseases account for considerable health care use and expenditures. We estimated the annual burden, costs, and research funding associated with gastrointestinal, liver, and pancreatic diseases in the United States.

METHODS

We generated estimates using data from the National Ambulatory Medical Care Survey; National Hospital Ambulatory Medical Care Survey; Nationwide Emergency Department Sample; National Inpatient Sample; Kids' Inpatient Database; Nationwide Readmissions Database; Surveillance, Epidemiology, and End Results program; National Vital Statistics System; Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research; MarketScan Commercial Claims and Encounters data; MarketScan Medicare Supplemental data; United Network for Organ Sharing registry; Medical Expenditure Panel Survey; and National Institutes of Health (NIH).

RESULTS

Gastrointestinal health care expenditures totaled $119.6 billion in 2018. Annually, there were more than 36.8 million ambulatory visits for gastrointestinal symptoms and 43.4 million ambulatory visits with a primary gastrointestinal diagnosis. Hospitalizations for a principal gastrointestinal diagnosis accounted for more than 3.8 million admissions, with 403,699 readmissions. A total of 22.2 million gastrointestinal endoscopies were performed, and 284,844 new gastrointestinal cancers were diagnosed. Gastrointestinal diseases and cancers caused 255,407 deaths. The NIH supported $3.1 billion (7.5% of the NIH budget) for gastrointestinal research in 2020.

CONCLUSIONS

Gastrointestinal diseases are responsible for millions of health care encounters and hundreds of thousands of deaths that annually costs billions of dollars in the United States. To reduce the high burden of gastrointestinal diseases, focused clinical and public health efforts, supported by additional research funding, are warranted.

National Trends in Hospitalization, Surgical Resection, and Comorbidities in Pediatric Inflammatory Bowel Disease in the United States, 2002-2015

BACKGROUND AND OBJECTIVE

Therapeutic options for pediatric inflammatory bowel disease (PIBD) have dramatically changed over the last 20 years. However, the impact of modern medical management on PIBD outcomes remains unclear. We aimed to fill this gap in the literature by using a large, validated, national database, to study the change in hospitalization rates, surgical rates, and postoperative complications in PIBD over the last decade.

METHODS

The National Inpatient Sample (NIS) Database and ICD-9-CM codes were utilized to identify inpatient admissions with a primary or secondary diagnosis of pediatric Crohn's disease (CD) or ulcerative colitis (UC) from 2002-2015. Trends in hospitalizations, comorbidities (including malnutrition and weight loss), surgical procedures, and postoperative complications were examined using joinpoint regression analysis, a statistical modeling approach to evaluate the extent to which the rate of a condition changes over time.

RESULTS

There were 119,282 admissions for PIBD during the study period. The annual incidence of hospitalization increased significantly over time for both CD (average annual percent change [AAPC] 6.0%) and UC (AAPC 7.2%). The rate of intestinal resection decreased in CD patients (AAPC -6.4%) while postoperative complications remained unchanged. However, comorbidities increased significantly in CD patients (AAPC 6.8%). For pediatric UC patients, postoperative complications (AAPC 6.7%), and comorbidities (AAPC 10.2%) increased significantly over time while intestinal resection rates remained stable. Intestinal resection rate in pediatric CD has decreased over time, but not in pediatric UC.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

Annual incidence of hospitalization and comorbidities continue to increase in PIBD. Intestinal resection rate in pediatric CD has decreased over time, but not in pediatric UC. Our findings emphasize the critical need for prevention and novel therapeutic options for this vulnerable patient population.

Shifting Health Care Use from Hospitalisations and Surgeries to Outpatient Visits in Children with Inflammatory Bowel Disease: A Population-based Cohort Study from Ontario, Canada

BACKGROUND

Modern, specialised care for children with inflammatory bowel disease [IBD] may have resulted in changes in health services use. We report trends over time in health services utilisation and surgery for children with IBD and children without IBD.

METHODS

Children aged <18 years, diagnosed with IBD between 1994 and 2013 [n = 5518] and followed until 2015 in Ontario, Canada, were identified from health administrative data and matched to children without IBD on age, sex, rural/urban household, and income [n = 26,677]. We report the annual percentage change [APC] with 95% confidence intervals [CI] in the rate of outpatient visits, emergency department [ED] visits, and hospitalisations, using negative binomial regression for events within 5 years from the diagnosis/index date. We used Cox proportional hazards regression models to report APC in hazards of intestinal resection [Crohn's disease; CD] and colectomy [ulcerative colitis; UC].

RESULTS

IBD-specific hospitalisation rates decreased by 2.5% [95% CI 1.8-3.2%] annually, and all-cause hospitalisation rates in children without IBD decreased by 4.3% [95% CI 3.5-5.1%] annually. Intestinal resection risk in CD decreased by 6.0% [95% CI 4.6-7.3%] annually and colectomy risk in UC decreased by 3.0% [95% CI 0.7-5.2%] annually. In contrast, IBD-specific outpatient visit rates increased after 2005 by 4.0% [95% CI 3.1-4.9%] annually. Similar trends in outpatient visits were not observed in children without IBD.

CONCLUSIONS

Hospitalisations and surgeries decreased over time while outpatient visits increased after 2005. Decreasing hospitalisations were mirrored in children without IBD, likely resulting from a combination of changes in disease management and health system factors.

Biologic therapy is associated with a mild decrease in the rate of hospitalizations in pediatric IBD

Background

The effect of biologic therapy on the incidence of inflammatory bowel disease (IBD)-related hospitalizations is controversial. The high efficacy of biologic agents is weighted against potential therapy-related adverse events, however, there are no data on the effect of biologic therapy on the indications for hospitalization in IBD. We aimed to evaluate the impact of biologic therapy on the indications and rate of hospitalization in pediatric IBD.

Methods

This retrospective cohort study included all children (< 18 years of age) with IBD who were hospitalized in our medical center from January 2004 to December 2019. Data on demographics, disease characteristics and course, and therapy were collected, as were the indications for and course of hospitalizations. We evaluated the relationship between therapy with biologic agents, indications and rates of hospitalization.

Results

Included were 218 hospitalizations of 100 children, of whom 65 (65%) had Crohn’s disease and 35 (35%) had ulcerative colitis. The indications for hospitalization were IBD exacerbations or complications in 194 (89%) and therapy-related adverse events in 24 (11%). The patients of 56 (25.7%) hospitalizations were receiving biologic therapy. In a multivariate analysis, no correlation between therapy and indication for hospitalization was found (p = 0.829). Among children under biologic therapy, a decrease in the rate of hospitalizations from 1.09 (0.11–3.33) to 0.27 (0–0.47) per year was observed for patients that were hospitalized during 2016–2019 (p = 0.043).

Conclusion

Biologic therapy did not influence the indication for hospitalization, but were associated with a decrease in the rate of hospitalization during 2016–2019 in pediatric IBD.

Regional Incidence of Inflammatory Bowel Disease in a Czech Pediatric Population: 16 Years of Experience (2002-2017)

OBJECTIVES

Inflammatory bowel disease (IBD) is today a global disease, the incidence of which is growing in the pediatric population. This prospective study aims to decipher IBD incidence and its trend in a pediatric population through 16 years in the South Moravian Region of the Czech Republic.

METHODS

We evaluated data concerning 358 pediatric patients with newly diagnosed IBD at University Hospital Brno, which is a gastroenterology center for the entire pediatric population (0-18 years) and cares for all pediatric IBD patients in the South Moravian Region (1,187,667 inhabitants).

RESULTS

The study encompassed 3,488,907 children during 16 years. We diagnosed 192 children (53.6%) with Crohn disease (CD), 123 (34.4%) with ulcerative colitis (UC), and 43 (12.0%) with IBD-unclassified (IBD-U). The incidence of IBD increased from 3.8 (CD 2.9, UC 0.9, and IBD-U 0.0) per 100 000/year in 2002 to 14.7 (CD 9.8, UC 4.0, and IBD-U 0.9) per 100,000/year in 2017 (P < 0.001). The overall IBD incidence per 100,000/year was 9.8 (95% confidence interval [CI]: 8.8--10.9). Constituent incidences per 100,000/year were CD 5.2 (95% CI: 4.5--6.0), UC 3.4 (95% CI: 2.8--4.0), and IBD-U 1.2 (95% CI: 0.9--1.6). IBD incidence was projected to reach 18.9 per 100,000/year in 2022.

CONCLUSIONS

The overall incidence of pediatric IBD in the Czech Republic is increasing, and especially that of CD, whereas trends in UC and IBD-U appear to be constant. These data highlight the need to identify risk factors involved in the rising incidence of IBD.

Updates in diagnosis and management of inflammatory bowel disease

Worldwide incidence of inflammatory bowel disease (IBD) is stable in developed countries, but rising in developing countries. Presenting symptoms of IBD can be highly variable. New imaging modalities, a greater armamentarium of therapeutic options, and a greater understanding of complication risks have changed the diagnosis and management of pediatric inflammatory bowel diseases. Effective teamwork among those who care for pediatric patients with IBD minimizes complications and maximizes desired outcomes.

Meta-Analysis of Expression Profiling Data Indicates Need for Combinatorial Biomarkers in Pediatric Ulcerative Colitis

BACKGROUND

Unbiased studies using different genome-wide methods have identified a great number of candidate biomarkers for diagnosis and treatment response in pediatric ulcerative colitis (UC). However, clinical translation has been proven difficult. Here, we hypothesized that one reason could be differences between inflammatory responses in an inflamed gut and in peripheral blood cells.

METHODS

We performed meta-analysis of gene expression microarray data from intestinal biopsies and whole blood cells (WBC) from pediatric patients with UC and healthy controls in order to identify overlapping pathways, predicted upstream regulators, and potential biomarkers.

RESULTS

Analyses of profiling datasets from colonic biopsies showed good agreement between different studies regarding pathways and predicted upstream regulators. The most activated predicted upstream regulators included TNF, which is known to have a key pathogenic and therapeutic role in pediatric UC. Despite this, the expression levels of TNF were increased in neither colonic biopsies nor WBC. A potential explanation was increased expression of TNFR2, one of the membrane-bound receptors of TNF in the inflamed colon. Further analyses showed a similar pattern of complex relations between the expression levels of the regulators and their receptors. We also found limited overlap between pathways and predicted upstream regulators in colonic biopsies and WBC. An extended search including all differentially expressed genes that overlapped between colonic biopsies and WBC only resulted in identification of three potential biomarkers involved in the regulation of intestinal inflammation. However, two had been previously proposed in adult inflammatory bowel diseases (IBD), namely, MMP9 and PROK2.

CONCLUSIONS

Our findings indicate that biomarker identification in pediatric UC is complicated by the involvement of multiple pathways, each of which includes many different types of genes in the blood or inflamed intestine. Therefore, further studies for identification of combinatorial biomarkers are warranted. Our study may provide candidate biomarkers for such studies.

Predictors for poor outcome of hospitalized children with inflammatory bowel disease

Inflammatory bowel disease (IBD) exacerbations may lead to prolonged and complicated hospitalizations. The characteristics of exacerbation-related hospitalizations and predictors for poor outcome of pediatric patients hospitalized due to IBD have not been thoroughly described. All children who were hospitalized due to IBD exacerbation in a tertiary referral center between 2004 and 2017 were enrolled. Data on demographic and disease characteristics before and during hospitalization were retrospectively reviewed, as was the course of hospitalization, including laboratory findings, diagnostic work-up, and management. Poor outcomes were defined as prolonged hospitalization (≥ 7 days) and/or the need for surgery during hospitalization. There were 181 hospitalizations of 78 IBD children with a median (IQR) age of 14.8 (11.8-16.2) years. They included 53 (67.9%) with Crohn's disease and 25 (32.1%) with ulcerative colitis. In a multivariate analysis, severe disease activity at hospitalization (odds ratio [OR] = 3.33, P = 0.013), lower weight percentile (OR = 0.98, P = 0.009), treatment with antibiotics (OR = 5.03, P = 0.001), blood transfusion (OR = 8.03, P = 0.003), undergoing endoscopy (OR = 2.73, P = 0.027), and imaging studies during hospitalization (OR = 3.61, P = 0.001) predicted prolonged hospitalization. Surgical intervention was performed in 16 patients (8.8%), due to penetrating (OR = 7.73, P = 0.019) and stricturing disease (OR = 12.38, P < 0.001).Conclusion: We identified predictors for poor outcomes of children hospitalized due to IBD. Among the variables that can be measured at the beginning of the admission, severe disease activity was the most significant predictor recognition of these predictors that may contribute to modification of patient management.What is Known:• Inflammatory bowel disease (IBD) patients may require hospitalization due to disease exacerbation or treatment-related complications.• Hospitalizations of IBD patients constitute a heavy emotional burden on patients and families.What is New:• Lower weight percentile, severe disease activity, and a lower albumin level were predictors for prolonged hospitalization in children with IBD.• Recognition of these predictors may contribute to modification of patient management.

Rates and trends for inpatient surgeries in pediatric Crohn's disease in the United States from 2003 to 2012

BACKGROUND

Pediatric Crohn's disease (CD) is increasing in incidence globally. Trends in specific types of inpatient pediatric CD-related surgical procedures have not been widely reported.

METHODS

Patients ≤20 years of age with CD were identified in the Kids' Inpatient Database for 2003, 2006, 2009, and 2012. Bowel resection, stoma creation, and perianal or percutaneous drainage procedures were identified using ICD-9 procedure codes, and trends were identified. Logistic regression was used to identify factors associated with surgical intervention and trends.

RESULTS

Rates of overall bowel resection (including ileocolic resection, other small bowel resection, or other colon resection) did not change significantly over time. However, the odds of having a laparoscopic colon resection increased by 41% annually (p<0.001). Rates of subsequent ileostomy formation increased (odds ratio 1.09, p<0.001). Older age, male sex, fewer comorbidities, and treatment in large urban teaching hospitals were also associated with higher odds of undergoing bowel resection.

CONCLUSIONS

This study noted a stable rate of all types of bowel resections and increase in post resection ileostomy formation in US pediatric inpatients with CD from 2003-2012. Other rates of many CD-related procedures have remained stable. Further studies correlating the effects of biologic agents on surgical rates are warranted.

TYPE OF STUDY

Treatment Study LEVEL OF EVIDENCE: Level III.

Catheter-Related Venous Thrombosis in Hospitalized Pediatric Patients with Inflammatory Bowel Disease: Incidence, Characteristics, and Role of Anticoagulant Thromboprophylaxis with Enoxaparin

OBJECTIVE

To describe the incidence and characteristics of central venous catheter (CVC)-related thrombosis in hospitalized pediatric patients with active inflammatory bowel disease (IBD) and report the potential usefulness of anticoagulant thromboprophylaxis (AT).

STUDY DESIGN

We conducted a retrospective study of patients who were admitted to our children's hospital in the last 2 years with active IBD and required a CVC and identified all patients with an objectively confirmed symptomatic CVC-related thrombosis. To assess the usefulness of a recently implemented institutional AT protocol, we compared the frequency of CVC-related thrombosis, nadir hemoglobin, and red blood cell transfusion requirements in patients who received AT with those who did not during the study period.

RESULTS

A total of 40 patients with IBD who required 47 consecutive hospitalizations were included. AT was administered during 24 of 47 hospitalizations (51%). Patients who received AT were similar to those who did not receive AT with regard to demographics, IBD phenotypes, extent of colonic involvement, and thrombotic risk factors. CVC-related thrombosis occurred in 5 of 23 hospitalizations (22%) in which AT was withheld compared with 0 of 24 hospitalizations (0%) in which patients received AT (P = .02). The red blood cell transfusion requirements and nadir hemoglobin were not significantly different between the 2 groups.

CONCLUSIONS

We observed a high incidence of CVC-related thrombosis in hospitalized children with IBD. Administration of AT in our population was associated with significant reduction in CVC-related thrombosis without evidence of increased bleeding.

Genetic variants and pathways implicated in a pediatric inflammatory bowel disease cohort

In the United States, approximately 5% of individuals with inflammatory bowel disease (IBD) are younger than 20 years old. Studies of pediatric cohorts can provide unique insights into genetic architecture of IBD, which includes Crohn's disease (CD) and ulcerative colitis (UC). Large genome-wide association studies have found more than 200 IBD-associated loci but explain a minority of disease variance for CD and UC. We sought to characterize the contribution of rare variants to disease development, comparing exome sequencing of 368 pediatric IBD patients to publicly available exome sequencing (dbGaP) and aggregate frequency data (ExAC). Using dbGaP data, we performed logistic regression for common variants and optimal unified association tests (SKAT-O) for rare, likely-deleterious variants. We further compared rare variants to ExAC counts with Fisher's exact tests. We did pathway enrichment analysis on the most significant genes from each comparison. Many variants overlapped with known IBD-associated genes (e.g. NOD2). Rare variants were enriched in CD-associated loci (p = 0.009) and showed suggestive enrichment in neutrophil function genes (p = 0.05). Pathway enrichment implicated immune-related pathways, especially cell killing and apoptosis. Variants in extracellular matrix genes also emerged as an important theme in our analysis.

Surgical Treatment in Childhood-onset Inflammatory Bowel Disease-A Nationwide Register-based Study of 4695 Incident Patients in Sweden 2002-2014

BACKGROUND AND AIMS

The incidence of childhood-onset [< 18 years] inflammatory bowel disease [IBD] is increasing worldwide, and some studies suggest that it represents a more severe disease phenotype. Few nationwide, population-based studies have evaluated the surgical burden in patients with childhood-onset IBD, and whether the improved medical treatment has influenced the need for gastrointestinal surgery. The aim was to examine whether the surgical treatment at any age of patients with childhood-onset IBD has changed over time.

METHODS

In a nationwide cohort study we identified 4695 children [< 18 years] diagnosed with incident IBD in 2002-2014 through the Swedish Patient Register [ulcerative colitis: n = 2295; Crohn's disease: n = 2174; inflammatory bowel disease-unclassified: n = 226]. Abdominal [intestinal resections and colectomies] and perianal surgeries were identified through the Swedish Patient Register. The cumulative incidences of surgeries were calculated using the Kaplan-Meier method.

RESULTS

In the cohort, 44% were females and 56% males. The median age at inflammatory bowel disease diagnosis was 15 years and the maximum age at end of follow-up was 31 years. The 3-year cumulative incidence of intestinal surgery was 5% in patients with ulcerative colitis and 7% in patients with Crohn's disease, and lower in children aged < 6 years at inflammatory bowel disease diagnosis [3%] than in those aged 15-17 years at diagnosis [7%]. Calendar period of inflammatory bowel disease diagnosis was not associated with risk of surgery.

CONCLUSION

Over the past 13 years, the risk of surgery in childhood-onset inflammatory bowel disease has remained unchanged.

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

OBJECTIVE

To evaluate the burden and predictors of hospital readmissions among pediatric patients with inflammatory bowel disease using the Nationwide Readmissions Database.

STUDY DESIGN

We performed a retrospective cohort study using 2013 Nationwide Readmissions Database. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify patients <18 years with diagnoses of ulcerative colitis (UC) or Crohn's disease (CD). Demographic factors and details of hospitalizations were evaluated using survey procedures in SAS v 9.4 (SAS Institute, Cary, North Carolina). Multivariable logistic regression was used to estimate ORs and 95% CIs of readmission.

RESULTS

Among 2733 hospitalizations (63% CD, 37% UC), 611 (22%) patients were readmitted within 90 days of the index hospitalization. Readmission resulted in weighted estimates of 11 440 excess days of hospitalization and total charges of over $107 million. For CD, male sex (aOR 1.36, 95% CI 1.03-1.81) and co-existing anxiety or depression (aOR 1.89, 95% CI 1.06-3.40) were associated with increased readmissions, while patients who underwent surgery had decreased readmissions (aOR 0.40, 95% CI 0.24-0.65). In patients with UC, an index admission of >7 days was associated with increased readmissions (aOR 1.69, 95% CI 1.09-2.62).

CONCLUSIONS

Readmission occurs frequently in children with inflammatory bowel disease and is associated with significant cost and resource burdens. Among patients with CD, psychiatric comorbidities such as anxiety and depression are apparent drivers of readmission.

Insurance Among Young Adults With Inflammatory Bowel Disease: Changes Under the Affordable Care Act Dependent Provision

BACKGROUND

A total of 20% to 30% of patients with inflammatory bowel disease (IBD) present before age 18 years, eventually requiring transfer to adult care. Vulnerability during transfer may be exacerbated by loss of insurance. A provision of the Affordable Care Act (ACA) allows young adults (YAs) to remain on parental private insurance through age 25 years. There has been a decrease in uninsured YAs since its implementation in 2010. Little is known about whether insurance coverage of YAs with IBD has been affected.

OBJECTIVE

The aim of the present study was to determine whether the proportion of uninsured YAs with IBD has changed following the implementation of extended dependent eligibility under the ACA.

METHODS

We conducted a cross-sectional analysis of hospitalized patients with IBD, identified in the Nationwide Inpatient Sample (NIS) using diagnostic codes, to estimate proportions of insurance coverage during the years 2006-2013. We compared 19 to 25 year olds to 2 to 18 and 26 to 35 year olds, unaffected by the provision, to account for underlying trends.

RESULTS

From 2006 to 2010, 19 to 25 year olds had the highest proportion of uninsured, peaking at 14.1% in 2010. In 2011, the proportion decreased to 10.1%, below the proportion of uninsured 26 to 35 year olds (13.1%), remaining in this range through 2013. Private coverage increased in 2011 for 19 to 25 year olds, remaining stable for 26 to 35 year olds.

DISCUSSION

Previous research cited 5% uninsured among all hospitalized patients with IBD. Our study indicates a higher proportion for YAs, decreasing after the ACA. Lack of insurance increases vulnerability during transfer but may be modifiable through policy change. Furthermore, research should analyze the effects of Medicaid expansion and health care exchanges.

Pediatric hospitalizations for inflammatory bowel disease based on annual case volume: results from the Kids' Inpatient Database 2012

To study differences related to pediatric inflammatory bowel disease (IBD) care among hospitals that were stratified based on annual case volume. This is a cross-sectional study using data from the United States Healthcare Cost and Utilization Project Kids' Inpatient Database (KID). IBD-related hospitalizations were identified using International Classification of Diseases-9-Clinical Modification codes. Hospital volume was divided into low or high by assigning cut-off values of 1-20 and >20 annual IBD hospitalizations. We assessed a total of 8647 pediatric IBD discharges during 2012 from 660 hospitals in the USA. 107 of these hospitals were classified as high-volume centers (HVCs) for pediatric IBD care and 553 low-volume centers (LVCs). HVCs were more likely to be associated with an academic teaching status compared to LVCs (97.1% vs 67.6%, p<0.001). The incidence of transfer of medical care from LVCs to other hospitals was 5.5% but only 0.7% for HVCs (p<0.001). The median number of procedures (medical and surgical) performed on children admitted with IBD was higher at HVCs (2 vs 1, p<0.001). IBD admissions at HVCs were more likely to undergo surgical procedures compared to LVCs (17% vs 10%, p<0.001). The incidence of postoperative complications was not significantly different. There were significantly greater hospital costs (median US$11,000 vs US$6,000, p<0.001) and lengths of stay (median 5 days vs 4 days, p<0.001) associated with HVCs compared to LVCs. Pediatric admissions to HVCs for IBD undergo a greater number of medical and surgical procedures and are associated with higher costs and lengthier hospital stays.

Hospitalization for Varicella and Zoster in Children with Inflammatory Bowel Disease

OBJECTIVE

To evaluate the association between inflammatory bowel disease (IBD) and varicella- and herpes zoster-related pediatric hospitalizations.

STUDY DESIGN

We performed a cross-sectional inpatient study using the triennial Healthcare Cost and Utilization Project Kids' Inpatient Database for years 1997-2012 to evaluate the association between a secondary diagnosis of IBD and a primary diagnosis of varicella or herpes zoster for hospitalized children ages 5-20 years. Billing codes were used to identify varicella, herpes zoster, ulcerative colitis, Crohn's disease, and other immunocompromising conditions. A logistic regression model was fitted to quantify the odds of varicella or zoster between these categories.

RESULTS

There were 8 828 712 weighted admissions meeting the study criteria, 4434 with varicella and 4488 with herpes zoster. There was an association of IBD and immunocompromising conditions with hospitalization for varicella and herpes zoster. This association was stronger among children with Crohn's disease (varicella OR, 12.75; 95% CI, 8.30-19.59; zoster OR, 7.91; 95% CI, 5.60-11.18) compared with children with ulcerative colitis (varicella OR 4.25; 95% CI 1.98-9.12, zoster OR 3.90; 95% CI 1.98-7.67).

CONCLUSIONS

IBD in children is associated with hospitalizations for varicella and herpes zoster. These results highlight the importance of efforts to vaccinate patients with IBD without varicella immunity, ideally before the initiation of immunosuppressive therapy. Furthermore, research is needed on the safety and efficacy of the varicella vaccine in children with IBD on immunomodulators or biologic therapy.

Impact of New Treatments on Hospitalisation, Surgery, Infection, and Mortality in IBD: a Focus Paper by the Epidemiology Committee of ECCO

The medical management of inflammatory bowel disease has changed considerably over time with wider use of immunosuppressant therapy and the introduction of biological therapy. To what extent this change of medical paradigms has influenced and modified the disease course is incompletely known. To address this issue, an extensive review of the literature has been carried out on time trends of hospitalization, surgery, infections, cancer, and mortality rates in inflammatory bowel disease [IBD] patients. Preference was given to population-based studies but, when data from these sources were limited, large cohort studies and randomised controlled trials were also considered. In general, data on hospitalisation rates are strikingly heterogeneous and conflicting. In contrast, the consistent drop in surgery/colectomy rates suggests that the growing use of immunosuppressants and biological agents has had a positive impact on the course of IBD. Most clinical trial data indicate that the risk of serious infections is not increased in patients treated with anti-tumour necrosis factor alpha [TNFα] agents, but a different picture emerges from cohort studies. The use of thiopurines increases the risk for non-melanoma skin cancers and to a lesser extent for lymphoma and cervical cancer [absolute risk: low], whereas no clear increase in the cancer risk has been reported for anti-TNF agents. Finally, the majority of studies reported in the literature do not reveal any increase in mortality with immunosuppressant therapy or biologicals/anti-TNF agents.

Risk Factors for Rehospitalization Within 90 Days in Patients with Inflammatory Bowel Disease

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.

Emergency Department Visits Related to Inflammatory Bowel Disease: Results From Nationwide Emergency Department Sample

We analyzed a national US database to study the presentation of children with inflammatory bowel disease (IBD) to the emergency department (ED). Our results indicate that from 2006 to 2010, there was a significant increase in the number of ED visits related to children with IBD accompanied by a contemporaneous decline in the rate of hospitalization that followed these ED visits. Earlier published results have highlighted an increased overall rate of hospitalizations in the United States related to children with IBD. In this context, our results support the evidence for an increased prevalence of pediatric IBD in the United States in recent years.

Disproportionate rise in Clostridium difficile-associated hospitalizations among US youth with inflammatory bowel disease, 1997-2011

OBJECTIVES

Our aim was to characterize the temporal changes in burden that Clostridium difficile infection (CDI) added to the hospital care of children and young adults with inflammatory bowel disease (IBD) in the United States.

METHODS

Retrospective analysis of annual, nationally representative samples of children and young adults with IBD.

RESULTS

There was a 5-fold increase in IBD hospitalizations with CDI from 1997 to 2011 (P for trend <0.01). During the same period, IBD hospitalizations without CDI increased 2-fold (P for trend <0.01). Mean length of stay for IBD hospitalizations with CDI was consistently longer than that for hospitalizations without CDI and did not significantly change over time (P for trend = 0.47). CDI-related total hospital days in the United States rose from 1702 to 10,194 days per million individuals per year from 1997 to 2011 (P for trend <0.01). Children and young adults hospitalized with CDI had a significantly lower odds of colectomy (0.31) compared with those without CDI. Total charges for CDI-related hospitalizations among children and young adults in the United States rose from $8.7 million in 1997 to $68.2 million in 2011.

CONCLUSIONS

A widening gap in burden has opened between IBD hospitalizations with and without CDI during the last decade and a half. CDI-related hospitalizations are associated with disproportionately longer lengths of stay, more hospital days, and more charges than hospitalizations without CDI over time. Further work within health systems, hospitals, and practices can help us better understand this enlarging gap to improve clinical care for this vulnerable population.