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Lendner N, Perry S, Sferra TJ, Moses J, Young DD. Standardizing steroid protocols for newly diagnosed inflammatory bowel disease patients: A quality improvement initiative. J Pediatr Gastroenterol Nutr 2024; 79:76-83. [PMID: 38769760 DOI: 10.1002/jpn3.12246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 04/26/2024] [Accepted: 04/30/2024] [Indexed: 05/22/2024]
Abstract
OBJECTIVES Systemic steroids can be used for induction of inflammatory bowel disease (IBD), but are not recommended as long-term therapy. Steroid weaning requires rigorous monitoring of symptoms, which may be cumbersome and lead to missed opportunities. We aim to describe our local quality improvement (QI) initiative to improve and standardize the steroid weaning process. METHODS After identifying drivers of steroid weaning, a protocol was developed and implemented for newly diagnosed IBD patients started on steroids and subsequently initiated on anti-TNF-α therapy. Interventions included development of a tapering schedule, and standardizing communication with patients and evaluation of symptoms. The primary aim was to increase the percent of patients called on a weekly basis by 20%; secondary aims were to decrease the median steroid days by 25% and to increase the number of our patients weaned off steroids at 8 weeks from 35% to 75% by 1 year after the initiative. RESULTS The median percent of patients called on a weekly basis to assess clinical symptoms and to wean steroids increased to 80% after 1 year. The median number of systemic corticosteroid days decreased from 67.5 to 50.5 days post-protocol implementation with 61.1% patients weaned off by 8 weeks from discharge. Zero patients were admitted for flares with the protocol implementation. CONCLUSION Our experience illustrates that QI methodology can be used successfully to improve and standardize the steroid weaning process, leading to shortened steroid duration and without increased flares and hospitalizations.
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Affiliation(s)
- Nuphar Lendner
- Pediatrix Gastroenterology of the Rocky Mountains, Denver, Colorado, USA
| | - Sharon Perry
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, UH Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Thomas J Sferra
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, UH Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Jonathan Moses
- Division of Pediatric Gastroenterology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Denise D Young
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, UH Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
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Quera R, Núñez P, Sicilia B, Flores L, Gomollón F. Corticosteroids in inflammatory bowel disease: Are they still a therapeutic option? GASTROENTEROLOGIA Y HEPATOLOGIA 2023; 46:716-726. [PMID: 36375697 DOI: 10.1016/j.gastrohep.2022.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 10/26/2022] [Accepted: 10/30/2022] [Indexed: 11/13/2022]
Abstract
Despite the development and incorporation of new therapeutic strategies, such as biologic therapy and small molecules, corticosteroids still play an important role in inducting inflammatory bowel diseases (IBD) remission. Variables like indicating the right doses at the right time, in adequate intervals, the security of these drugs and the pharmacological alternatives available must be considered by the providers when they are indicated to patients with IBD. Although the use of corticosteroids is considered as a marker of quality of care in patients with IBD, the use of these drugs in the clinical practice of IBD is far from being the correct one. This review article is not intended to be just a classic review of the indications for corticosteroids. Here we explain the scenarios in which, in our opinion, steroids would not be an appropriate option for our patients, as well as the most frequent mistakes we make in our daily practice when using them.
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Affiliation(s)
- Rodrigo Quera
- Programa Enfermedad Inflamatoria Intestinal, Centro de Enfermedades Digestivas, Universidad de los Andes, Santiago, Chile
| | - Paulina Núñez
- Programa Enfermedad Inflamatoria Intestinal, Centro de Enfermedades Digestivas, Universidad de los Andes, Santiago, Chile; Sección de Gastroenterología, Departamento de Medicina Interna, Hospital San Juan de Dios, Facultad Medicina Occidente, Universidad de Chile, Santiago, Chile
| | - Beatriz Sicilia
- Unidad de Enfermedad Inflamatoria Intestinal, Servicio de Aparato Digestivo, Hospital Universitario de Burgos, Burgos, España
| | - Lilian Flores
- Programa Enfermedad Inflamatoria Intestinal, Centro de Enfermedades Digestivas, Universidad de los Andes, Santiago, Chile
| | - Fernando Gomollón
- Facultad de Medicina, Hospital Clínico Universitario, Instituto de Investigación Sanitaria de Aragón, CIBEREHD, Zaragoza, España.
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Ahmed W, Billing W, Stump TE, Strobel T, Sagi S, Fischer M, Bohm M. Opioid Legislation in Patients With Inflammatory Bowel Disease: A State-wide Retrospective Cohort Study. Inflamm Bowel Dis 2023; 29:1355-1361. [PMID: 36271877 DOI: 10.1093/ibd/izac218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Indiana State opioid prescription legislation has been shown to decrease overall opioid prescriptions. However, this effect has not been studied in specific diseases associated with chronic pain such as inflammatory bowel disease (IBD). We aimed to determine the effect of state opioid prescription legislation on opioid prescribing patterns in IBD. METHODS A retrospective cohort analysis using an interrupted time-series from December 15, 2010 to July 1, 2018, with 2 time periods separated by Title 844 of the Indiana Administrative Code, in a statewide health care system capturing the majority of the state's population including all adult patients with IBD. The primary outcome was opioid prescription rate per person-year. RESULTS In total, 9436 patients met inclusion criteria. After legislation, the total number of opioid orders per patient-year continued to increase (0.543, 95% CI, 0.528-0.558, to 0.663, 95% CI, 0.654-0.672), with fewer scripts from the emergency department (0.113, 95% CI, 0.106-0.120, to 0.092, 95% CI, 0.088-0.095) and more from outpatient providers (0.303, 95% CI, 0.292-0.314 to 0.432, 95% CI, 0.424-0.439). There were increases in biologic (0.206, 95% CI, 0.197-0.215 to 0.517, 95% CI, 0.509-0.525) and steroid (0.182, 95% CI, 0.173-0.190 to 0.237, 95% CI, 0.232-0.243) prescriptions per person-year following legislation. Factors associated with heavy opioid use included chronic steroids (odds ratio, 5.030; 95% CI, 4.176-6.054), history of IBD-related surgery (odds ratio, 2.807; 95% CI, 2.367-3.323) and current smoking (odds ratio, 2.650; 95% CI, 2.223-3.158). CONCLUSIONS Despite legislation and the increased use of disease-modifying drugs, statewide opioid prescriptions continued to increase. The increase in opiate use, high steroid use, and significant health care utilization suggests poor underlying disease control.
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Affiliation(s)
- Waseem Ahmed
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Wade Billing
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Timothy E Stump
- Indiana University School of Medicine, Department of Biostatistics, Indianapolis, Indiana, USA
| | - Thomas Strobel
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sashidhar Sagi
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Monika Fischer
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mathew Bohm
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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4
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Xu F, Liu Y, Greenlund K, Carlson S. Trends and demographic patterns in biologic and corticosteroid prescriptions for inflammatory bowel disease: findings from electronic medical records, 2011-2020. J Investig Med 2022; 70:1771-1776. [PMID: 36455956 PMCID: PMC10468819 DOI: 10.1136/jim-2022-002486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2022] [Indexed: 11/03/2022]
Abstract
Prescriptions for biologic therapy for treatment of Crohn's disease (CD) and ulcerative colitis (UC) have increased during the past two decades; however, trends are less clear regarding corticosteroid prescriptions in this context. We designed a cross-sectional study using the IQVIA Ambulatory Electronic Medical Records databases. Weighted linear regressions by age group were used to estimate annual percentage change from 2011 to 2020 in prescriptions for biologics and for corticosteroids among patients with or without biologic prescriptions within the same calendar year. Using 2019 data, we compared patient demographic and lifestyle risk factors using χ2 test for biologic prescriptions and corticosteroids with or without biologics prescriptions. There was an 11% (CD) and 16% (UC) annual increase in the percentage of patients prescribed biologics during the study period. The percentage of patients with biologics prescriptions prescribed corticosteroids decreased by 2% (CD) and 3% (UC) annually after 2015, while the percentage remained unchanged for corticosteroid prescriptions among patients without biologics. In 2019, differences in medication prescriptions existed by patient's demographic and lifestyle factors for patients with CD (n=52,892) and UC (n=52,280), including a higher percentage prescribed biologics among younger patients, men, those with fewer comorbidities, and current alcohol drinkers, and a higher percentage prescribed corticosteroids without biologics among women, those with more comorbidities, and a history of smoking. While medications continue to evolve during the biologic era, it is important to continue to monitor trends and differences in prescription patterns to assess progress toward optimizing treatment for patients with CD or UC.
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Affiliation(s)
- Fang Xu
- Division of Population Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Yong Liu
- Division of Population Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Kurt Greenlund
- Division of Population Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Susan Carlson
- Division of Population Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Rabinowitz LG, Zylberberg HM, Yang J, Gold SL, Chesner J, Ji J, Hu L, Dubinsky M. De Novo Ostomy Placement Is Associated with Increased Outpatient Opioid Use In Patients with Inflammatory Bowel Disease. Dig Dis Sci 2022; 67:4033-4042. [PMID: 34613501 DOI: 10.1007/s10620-021-07257-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 09/13/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND/AIMS Opioid use is associated with poor outcomes in patients with inflammatory bowel disease (IBD). We aimed to identify novel factors associated with increased outpatient opioid (OPRx) use following IBD-related hospitalization. METHODS This was a retrospective cohort study of IBD patients ≥ 18 years old, hospitalized during 2018. The primary outcome was receiving ≥ 1(OPRx) in the year following index hospitalization (IH), excluding prescriptions written within 2 weeks of discharge. Secondary outcomes included having 1-2 vs ≥ 3 OPRx and rates of healthcare utilization. Univariate and multivariate analyses tested associations with OPRx. RESULTS Of 526 patients analyzed, 209 (40%) received at least 1 OPRx; with a median of 2 [1-3] OPRx. Presence or placement of ostomy at IH, exposure to opioids during IH, ulcerative colitis (UC), mental health comorbidities, admission for surgery and managed on the surgical service, and IBD surgery within 1 year prior to IH were associated with ≥ 1 OPRx on univariate analysis. On multivariable analysis, UC, ostomy placement during IH, anxiety, and inpatient opioid exposure were independently associated with ≥ 1 OPRx. A majority (> 70%) of both inpatient and outpatient opioid prescriptions were written by surgeons. Patients requiring ≥ 3 OPRx had the highest rates of unplanned IBD surgery (56% p = 0.04), all-cause repeat hospitalization (81%, p = 0.003), and IBD-related repeat hospitalization (77%, p = 0.007) in the year following IH. CONCLUSIONS A multimodal approach to pain management for IBD patients, as well as increased recognition that any patient with a de novo ostomy is at particular risk of opioid use, is needed.
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Affiliation(s)
- Loren G Rabinowitz
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA.
| | - Haley M Zylberberg
- Division of Gastroenterology, Department of Medicine, New York Presbyterian Hospital-Columbia University, New York, NY, USA
| | - Jeong Yang
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Stephanie Lauren Gold
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jaclyn Chesner
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jiayi Ji
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Liangyuan Hu
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Marla Dubinsky
- Department of Pediatrics, Susan and Leonard Feinstein Inflammatory Bowel Disease Clinical Center, Icahn School of Medicine Mount Sinai, New York, NY, USA
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Wong D, Matini L, Kormilitzin A, Kantschuster R, Simadibrata DM, Lyden S, Wilson J, Brain OA, Palmer R, Ambrose T, Satsangi J, South M, Geddes J, Bodger K, Travis SPL, Walsh A. Patient-reported Outcomes: the ICHOM Standard Set for Inflammatory Bowel Disease in Real-life Practice Helps Quantify Deficits in Current Care. J Crohns Colitis 2022; 16:1874-1881. [PMID: 35868223 PMCID: PMC9721458 DOI: 10.1093/ecco-jcc/jjac099] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patient-reported outcome measures [PROMs] are key to documenting outcomes that matter most to patients and are increasingly important to commissioners of health care seeking value. We report the first series of the ICHOM Standard Set for Inflammatory Bowel Disease [IBD]. METHODS Patients treated for ulcerative colitis [UC] or Crohn's disease [CD] in our centre were offered enrolment into the web-based TrueColours-IBD programme. Through this programme, e-mail prompts linking to validated questionnaires were sent for symptoms, quality of life, and ICHOM IBD outcomes. RESULTS The first 1299 consecutive patients enrolled [779 UC, 520 CD] were studied with median 270 days of follow-up (interquartile range [IQR] 116, 504). 671 [52%] were female, mean age 42 years (standard deviation [sd] 16), mean body mass index [BMI] 26 [sd 5.3]. At registration, 483 [37%] were using advanced therapies. Median adherence to fortnightly quality of life reporting and quarterly outcomes was 100% [IQR 48, 100%] and 100% [IQR 75, 100%], respectively. In the previous 12 months, prednisolone use was reported by 229 [29%] patients with UC vs 81 [16%] with CD, p <0.001; 202 [16%] for <3 months; and 108 [8%] for >3 months. An IBD-related intervention was reported by 174 [13%] patients, and 80 [6%] reported an unplanned hospital admission. There were high rates of fatigue [50%] and mood disturbance [23%]. CONCLUSIONS Outcomes reported by patients illustrate the scale of the therapeutic deficit in current care. Proof of principle is demonstrated that PROM data can be collected continuously with little burden on health care professionals. This may become a metric for quality improvement programmes or to compare outcomes.
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Affiliation(s)
- Darren Wong
- Corresponding author: Dr Alissa Walsh, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Headley Way, Headington, Oxford OX3 9DU, UK. E-mail:
| | - Lawrence Matini
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | | | - Ramona Kantschuster
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Daniel Martin Simadibrata
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK,Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Sara Lyden
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Jean Wilson
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Oliver A Brain
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Rebecca Palmer
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Tim Ambrose
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Jack Satsangi
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Matthew South
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - John Geddes
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Keith Bodger
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Simon P L Travis
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Alissa Walsh
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
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7
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Shariff S, Moran G, Grimes C, Cooney RM. Current Use of EEN in Pre-Operative Optimisation in Crohn's Disease. Nutrients 2021; 13:4389. [PMID: 34959941 PMCID: PMC8709272 DOI: 10.3390/nu13124389] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 11/24/2021] [Accepted: 11/30/2021] [Indexed: 12/12/2022] Open
Abstract
Despite the increasing array of medications available for the treatment of Crohn's disease and a focus on mucosal healing, approximately 35% of patients with Crohn's disease undergo bowel surgery at some stage. The importance of nutritional optimisation before Crohn's surgery is well-highlighted by surgical, nutritional, and gastroenterological societies with the aim of reducing complications and enhancing recovery. Surgical procedures are frequently undertaken when other treatment options have been unsuccessful, and, thus, patients may have lost weight and/or required steroids, and are therefore at higher risk of post-operative complications. EEN is used extensively in the paediatric population to induce remission, but is not routinely used in the induction of remission of adult Crohn's disease or in pre-operative optimisation. Large prospective studies regarding the role of pre-operative EEN are lacking. In this review, we evaluate the current literature on the use of EEN in pre-operative settings and its impact on patient outcomes.
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Affiliation(s)
- Sharafaath Shariff
- Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, Birmingham B15 2GW, UK; (S.S.); (R.M.C.)
| | - Gordon Moran
- Room D1406 West Block: Queen’s Medical Centre, University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2UH, UK
| | - Caris Grimes
- Medway NHS Foundation Trust, Windmill Road, Gillingham ME7 5NY, UK;
| | - Rachel Margaret Cooney
- Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, Birmingham B15 2GW, UK; (S.S.); (R.M.C.)
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Cohen-Mekelburg S, Yu X, Costa D, Hofer TP, Krein S, Hollingsworth J, Wiitala W, Saini S, Zhu J, Waljee A. Variation in Provider Connectedness Associates With Outcomes of Inflammatory Bowel Diseases in an Analysis of Data From a National Health System. Clin Gastroenterol Hepatol 2021; 19:2302-2311.e1. [PMID: 32798705 PMCID: PMC9131729 DOI: 10.1016/j.cgh.2020.08.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/28/2020] [Accepted: 08/11/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Inflammatory bowel diseases (IBD) often require multidisciplinary care with tight coordination among providers. Provider connectedness, a measure of the relationship among providers, is an important aspect of care coordination that has been linked to higher quality care. We aimed to assess variation in provider connectedness among medical centers, and to understand the association between this established measure of care coordination and outcomes of patients with IBD. METHODS We conducted a national cohort study of 32,949 IBD patients with IBD from 2005 to 2014. We used network analysis to examine provider connectedness, defined using network properties that measure the strength of the collaborative relationship, team cohesiveness, and between-facility collaborations. We used multilevel modeling to examine variations in provider connectedness and association with patient outcomes. RESULTS There was wide variation in provider connectedness among facilities in complexity, rural designation, and volume of patients with IBD. In a multivariable model, patients followed in a facility with team cohesiveness (odds ratio, 0.38; 95% CI, 0.16-0.88) and where providers often collaborated with providers outside their facility (odds ratio, 0.48; 95% CI, 0.31-0.75) were less likely to have clinically active disease, defined by a composite of outpatient flare, inpatient flare, and IBD-related surgery. CONCLUSIONS A national study found evidence for heterogeneity in patient-sharing among IBD care teams. Patients with IBD seen at health centers with higher provider connectedness appear to have better outcomes. Understanding provider connectedness is a step toward designing network-based interventions to improve coordination and quality of care.
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Affiliation(s)
- Shirley Cohen-Mekelburg
- Division of Gastroenterology & Hepatology, University of Michigan, Ann Arbor, Michigan; VA Center for Clinical Management Research, Ann Arbor, Michigan; Institute of Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan.
| | - Xianshi Yu
- Department of Statistics, University of Michigan, Ann Arbor, Michigan
| | - Deena Costa
- Institute of Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan, University of Michigan School of Nursing, Ann Arbor, Michigan
| | - Timothy P. Hofer
- VA Center for Clinical Management Research, Ann Arbor, Michigan, Institute of Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Sarah Krein
- VA Center for Clinical Management Research, Ann Arbor, Michigan, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - John Hollingsworth
- Institute of Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Wyndy Wiitala
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Sameer Saini
- Division of Gastroenterology & Hepatology, University of Michigan, Ann Arbor, Michigan, VA Center for Clinical Management Research, Ann Arbor, Michigan, Institute of Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Ji Zhu
- Department of Statistics, University of Michigan, Ann Arbor, Michigan
| | - Akbar Waljee
- Division of Gastroenterology & Hepatology, University of Michigan, Ann Arbor, Michigan, VA Center for Clinical Management Research, Ann Arbor, Michigan, Institute of Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan
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9
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Chhibba T, Guizzetti L, Seow CH, Lu C, Novak KL, Ananthakrishnan AN, Bernstein CN, Kaplan GG, Panaccione R, Ma C. Frequency of Opioid Prescription at Emergency Department Discharge in Patients with Inflammatory Bowel Disease: A Nationwide Analysis. Clin Gastroenterol Hepatol 2021; 19:2064-2071.e1. [PMID: 32683099 DOI: 10.1016/j.cgh.2020.07.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 07/05/2020] [Accepted: 07/08/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with inflammatory bowel disease (IBD) frequently experience chronic pain. Patients will often seek out care in the emergency department (ED) where short-term opioid use may be associated with potential treatment-related complications. We aimed to assess the rate and factors associated with opioid prescription in IBD patients discharged from the ED. METHODS We conducted a cross-sectional analysis of data collected in the US National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2006-2017. We determined the proportion of adult patients (≥18 years) with IBD prescribed an opioid in ED or at ED discharge. Logistic regression was used to evaluate predictors of opioid prescription. Time-trend analysis was performed to evaluate temporal patterns in opioid use. All analyses were adjusted for complex survey design. RESULTS We identified ∼965,000 weighted discharges from the ED for patients with IBD. In total, 51.9% [95% CI: 42.2% -61.6%] of visits resulted in opioid administration in ED and 35.3% [95% CI: 26.5% -45.2%] of IBD-related ED discharges were associated with an opioid prescription. IBD patients with moderate/severe pain (adjusted odds ratio aOR 5.06 [95% CI: 1.72 -14.90], p < 0.01) were more likely to receive opioids whereas older age (aOR 0.73 per decade [95% CI: 0.55 -0.98], p = 0.04) were less likely. In temporal analysis, a trend towards decreasing opioid use in ED and opioid prescriptions at discharge was observed in 2015-2017. CONCLUSIONS More than one third of IBD patients are prescribed an opioid at discharge from ED, highlighting a potential gap in care for accessing effective pain management solutions in this population.
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Affiliation(s)
- Tarun Chhibba
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Leonardo Guizzetti
- Alimentiv (formerly Robarts Clinical Trials, Inc), London, Ontario, Canada
| | - Cynthia H Seow
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cathy Lu
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kerri L Novak
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Charles N Bernstein
- Inflammatory Bowel Disease Clinical and Research Centre, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gilaad G Kaplan
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Remo Panaccione
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Ma
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Alimentiv (formerly Robarts Clinical Trials, Inc), London, Ontario, Canada.
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10
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Shrestha MP, Taleban S. Colectomy Rates Are Increasing Among Inpatients With Concomitant Ulcerative Colitis and Clostridioides difficile. J Clin Gastroenterol 2021; 55:709-715. [PMID: 32804686 DOI: 10.1097/mcg.0000000000001412] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/12/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Clostridioides difficile infection (CDI) is an important cause of inflammatory bowel disease (IBD) exacerbation and is associated with increased risk of hospitalization, colectomy, and mortality. Previous analysis have reported an increasing rate of CDI and associated mortality in IBD patients. We examined the trends in CDI-associated outcomes in hospitalized patients with Crohn's disease (CD) and ulcerative colitis (UC) over the last decade. MATERIALS AND METHODS We used data from the National Inpatient Sample to identify patients hospitalized with both CDI and IBD from 2006 to 2014. Outcomes included in-hospital mortality, partial/total colectomy, hospital length of stay, and charges. Analysis included univariate and multivariate regression analysis. RESULTS Between 2006 and 2014, CDI-related hospitalizations increased in both CD (1.6% to 3.2%; P<0.001) and UC (4.9% to 8.6%; P<0.001). CDI-associated mortality in CD and UC patients decreased from 2.4% to 1.2% (P<0.001) and 11.3% to 9.7% (P<0.001), respectively. CDI-associated colectomy rate increased from 4.3% to 8.8% (P<0.001) in UC but decreased from 4.5% to 2.8% (P<0.001) in CD. In multivariable analysis, compared with 2006, there was a nonsignificant decrease in mortality in 2014 in both CD [adjusted odds ratio (AOR) 0.56, 95% confidence interval (CI) 0.25-1.24] and UC (AOR 0.81, 95% CI 0.61-1.07), but a significant increase in colectomy in 2014 only in UC (AOR 2.12, 95% CI 1.46-3.06). CONCLUSIONS CDI rates have increased in CD and UC over the last decade. Although there has been a significant increase in colectomies in UC, CDI-associated mortality in CD and UC has not increased over this time.
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Affiliation(s)
- Manish P Shrestha
- Division of Gastroenterology and Hepatology, University of New Mexico School of Medicine, Albuquerque, NM
| | - Sasha Taleban
- Division of Gastroenterology, University of Arizona College of Medicine
- Department of Medicine, Arizona Center of Aging, Tucson, AZ
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11
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Chen F, Liu Q, Xiong Y, Xu L. Current Strategies and Potential Prospects of Nanomedicine-Mediated Therapy in Inflammatory Bowel Disease. Int J Nanomedicine 2021; 16:4225-4237. [PMID: 34188471 PMCID: PMC8236271 DOI: 10.2147/ijn.s310952] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 06/07/2021] [Indexed: 12/12/2022] Open
Abstract
Inflammatory bowel diseases (IBD) such as Crohn's disease and ulcerative colitis are highly debilitating. IBDs are associated with the imbalance of inflammatory mediators within the inflamed bowel. Conventional drugs for IBD treatment include anti-inflammatory medications and immune suppressants. However, they suffer from a lack of bioavailability and high dose-induced systemic side effects. Nanoparticle (NP)-derived therapy improves therapeutic efficacy and increases targeting specificity. Recent studies have shown that nanomedicines, based on bowel disease's pathophysiology, are a fast-growing field. NPs can prolong the circulation period and reduce side effects by improving drug encapsulation and targeted delivery. Here, this review summarizes various IBD therapies with a focus on NP-derived applications, whereas their challenges and future perspectives have also been discussed.
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Affiliation(s)
- Fengqian Chen
- Translational Research Program, Department of Anesthesiology and Center for Shock Trauma Anesthesiology Research, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Qi Liu
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - Yang Xiong
- College of Pharmaceutical Science, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, 310053, People’s Republic of China
| | - Li Xu
- Department of Anorectal Surgery, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine), Hangzhou, Zhejiang, 310006, People’s Republic of China
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12
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Progress in Corticosteroid Use in the Era of Biologics With Room for Improvement. Am J Gastroenterol 2021; 116:1187-1188. [PMID: 33840728 DOI: 10.14309/ajg.0000000000001261] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 03/12/2021] [Indexed: 12/11/2022]
Abstract
With the early success of their trials for the treatment of ulcerative colitis, corticosteroids gained popularity as a treatment for inflammatory bowel disease (IBD). However, when used chronically, corticosteroids are not effective in maintaining remission and associated with toxic effects. Steroid-free remission has become a major treatment goal. Prolonged corticosteroid use is currently a sign of suboptimal quality of care. Trends over the past 2 decades, spanning the emergence of biologic therapies for IBD, are explored here in the University of Manitoba IBD Epidemiologic Database.
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13
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Niccum B, Moninuola O, Miller K, Khalili H. Opioid Use Among Patients With Inflammatory Bowel Disease: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2021; 19:895-907.e4. [PMID: 32835841 DOI: 10.1016/j.cgh.2020.08.041] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 08/04/2020] [Accepted: 08/14/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Despite reported adverse effects of opioids in patients with inflammatory bowel disease (IBD), the burden of opioid use in this population appears to be high. We performed a systematic review and meta-analysis of prior studies to determine the prevalence of opioid use among patients with IBD as well as risk factors and outcomes associated with opioid use in this population. METHODS We conducted a systematic search of MEDLINE, Embase, Web of Science, and the Cochrane Library through November of 2019. Primary outcomes included the prevalence of opioid use and demographic and clinical variables associated with opioid use in patients with IBD. Quality was assessed using the Newcastle-Ottawa scale. We used random-effect meta-analysis to estimate pooled relative risks (RRs) and 95% CIs. RESULTS Of 780 citations identified, 31 were included in our study. The prevalence of opioid use was 21% (95% CI, 13%-30%) in the outpatient setting. Likewise, 62% (95% CI, 25%-92%) of patients received opioids while hospitalized for IBD. Opioid use was associated with female sex (RR 1.20; 95% CI 1.03-1.40), depression (1.99; 95% CI 1.80-2.19), substance abuse (4.67; 95% CI 2.87-7.60), prior gastrointestinal surgery (2.33; 95% CI 1.66-3.26), biologic use (1.36; 95% CI 1.06-1.74), and steroid use (1.41; 95% CI 1.04-1.91). Based on the systematic review, opioid use also appeared to be associated with increased IBD activity, healthcare use, infection, and mortality. CONCLUSION In a systematic review and meta-analysis, we found that 21% of outpatients with IBD (and 62% of hospitalized patients) are opioid users; use is associated with more severe IBD and increased healthcare use. Further studies are required to determine whether opioids are the cause or an effect of these associations. Nonetheless, urgent interventions are needed to reduce opioid use, improve disease-related outcomes and reduce healthcare costs.
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Affiliation(s)
- Blake Niccum
- Department of Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Oluwatoba Moninuola
- Department of Internal Medicine, Saint Peter's University Hospital, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Kaia Miller
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hamed Khalili
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts; Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden.
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Szigethy EM, Murphy SM, Ehrlich OG, Heller CA, Engel-Nitz NM, Meadows P, Allen JI. Opioid Use Associated With Higher Costs Among Patients With Inflammatory Bowel Disease. CROHN'S & COLITIS 360 2021; 3:otab021. [PMID: 36778940 PMCID: PMC9802349 DOI: 10.1093/crocol/otab021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Indexed: 11/12/2022] Open
Abstract
Background Opioid use by patients with inflammatory bowel disease (IBD) has been associated with poorer health outcomes. This study describes socioeconomic characteristics; health utilization trends; and costs of patients with IBD and either no opioid prescriptions, or in 1 of 3 opioid duration categories based on Center for Disease Control guidelines: acute (0-30 days), moderate (31-90 days), or chronic (>90 days). We utilized the Cost of IBD Care Optum research database results for this study. Methods The Optum Research Database from years 2007 to 2016 including IBD patients with commercial or Medicare Advantage insurance in the United States was used. Additional inclusion criteria included continuous enrollment with medical and pharmacy benefit coverage for at least 24 months (12 months before and 12 months after the index date of IBD diagnosis). The association between costs and patient characteristics were assessed across a no opioid use group during this period and the 3 opioid duration groups. Results Among 51,178 IBD patients, 33,229 (64.93%) were part of the no opioid use group, while 13,635 (26.64%) were in acute, 1698 (3.32%) were in moderate, and 2616 (5.11%) were in chronic use groups, as determined by pharmacy claims data. Patients in the chronic group were more likely to be white (75.38%) compared to all the other groups (no opioid use, acute, and moderate), have attained less education (only high school diploma), have had lower incomes, and have had Medicare instead of commercial insurance. Patients across all opioid prescription groups were more likely to have had diagnoses associated with pain in the prior year, with rates increasing by the length of opioid prescription (63.68%, 80.17%, and 86.11% for acute, moderate, and chronic groups). Compared to the no-use group, the acute group had more ambulatory (outpatient) visits, while the chronic group had fewer. Emergency department visits and inpatient hospitalizations were higher in all 3 opioid groups compared to the no opioid use group. Ambulatory, emergency department, inpatient, and total (medical + pharmacy) costs were higher in all 3 opioid groups, compared to the no opioid use group, even after adjusting for demographic and clinical patient characteristics. Conclusions Among patients with IBD, increasing opioid use was associated with higher healthcare resource utilization and, concomitantly, higher healthcare costs during this period.
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Affiliation(s)
- Eva M Szigethy
- Department of Psychiatry and Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA,Address correspondence to: Eva M. Szigethy, MD, PhD, Department of Psychiatry and Medicine, University of Pittsburgh Medical Center, 3708 Fifth Avenue, Suite 401, Pittsburgh, Pennsylvania 15213, USA ()
| | - Sean M Murphy
- Department of Population Health Sciences, Weill Cornell Medical College, New York, New York, USA
| | - Orna G Ehrlich
- Research Department, Crohn’s & Colitis Foundation, New York, New York, USA
| | - Caren A Heller
- Research Department, Crohn’s & Colitis Foundation, New York, New York, USA
| | - Nicole M Engel-Nitz
- Health Economics and Outcomes Research Department, Optum, Eden Prairie, Minnesota, USA
| | - Perry Meadows
- Department of Government Programs, Medical Director, Government Programs, Geisinger Health Plan, Danville, Pennsylvania, USA
| | - John I Allen
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
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15
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Dorrington AM, Selinger CP, Parkes GC, Smith M, Pollok RC, Raine T. The Historical Role and Contemporary Use of Corticosteroids in Inflammatory Bowel Disease. J Crohns Colitis 2020; 14:1316-1329. [PMID: 32170314 DOI: 10.1093/ecco-jcc/jjaa053] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The use of corticosteroids to treat patients with inflammatory bowel disease [IBD] has been the bedrock of IBD therapeutics since the pioneering work of Truelove and Witts in the UK in the 1950s and subsequent large cohort studies in the USA and Europe. Nevertheless, although effective for induction of remission, these agents do not maintain remission and are associated with a long list of recognised side effects, including a risk of increased mortality. With the arrival of an increasing number of therapies for patients with IBD, the question arises as to whether we are using these agents appropriately in contemporary practice. This review discusses the historical background to steroid usage in IBD, and also provides a brief review of the literature on side effects of corticosteroid treatment as relevant to IBD patients. Data on licensed medications are presented with specific reference to the achievement of corticosteroid-free remission. We review available international data on the incidence of corticosteroid exposure and excess, and discuss some of the observations we and others have made concerning health care and patient-level factors associated with the risk of corticosteroid exposure, including identification of 'at-risk' populations.
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Affiliation(s)
- Alexander M Dorrington
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Gareth C Parkes
- Department of Gastroenterology, Royal London Hospital, Barts Health, London, UK
| | - Melissa Smith
- Department of Gastroenterology, Brighton and Sussex University Hospitals, Brighton, UK
| | - Richard C Pollok
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Tim Raine
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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16
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Coates MD, Seth N, Clarke K, Abdul-Baki H, Mahoney N, Walter V, Regueiro MD, Ramos-Rivers C, Koutroubakis IE, Bielefeldt K, Binion DG. Opioid Analgesics Do Not Improve Abdominal Pain or Quality of Life in Crohn's Disease. Dig Dis Sci 2020; 65:2379-2387. [PMID: 31758431 PMCID: PMC7831884 DOI: 10.1007/s10620-019-05968-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 11/16/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Abdominal pain and opioid analgesic use are common in Crohn's disease (CD). AIMS We sought to identify factors associated with abdominal pain in CD and evaluate the impact of opioid analgesics on pain and quality-of-life scores in this setting. METHODS We performed a longitudinal cohort study using a prospective, consented IBD natural history registry from a single academic center between 2009 and 2013. Consecutive CD patients were followed for at least 1 year after an index visit. Data were abstracted regarding pain experience (from validated surveys), inflammatory activity (using endoscopic/histologic findings), laboratory studies, coexistent psychiatric disorders, medical therapy, opioid analgesic, and tobacco use. RESULTS Of 542 CD patients (56.6% women), 232 (42.8%) described abdominal pain. Individuals with pain were more likely to undergo surgery and were more frequently prescribed analgesics and/or antidepressants/anxiolytics. Elevated ESR (OR 1.79; 95%CI 1.11-2.87), coexistent anxiety/depression (OR 1.87; 95%CI 1.13-3.09), smoking (OR 2.08; 95%CI 1.27-3.40), and opioid use (OR 2.46; 95%CI 1.33-4.57) were independently associated with abdominal pain. Eighty patients (14.8%) were prescribed opioids, while 31 began taking them at or after the index visit. Patients started on opioids demonstrated no improvement in abdominal pain or quality-of-life scores on follow-up compared to patients not taking opioids. CONCLUSIONS Abdominal pain is common in CD and is associated with significant opioid analgesic utilization and increased incidence of anxiety/depression, smoking, and elevated inflammatory markers. Importantly, opioid use in CD was not associated with improvement in pain or quality-of-life scores. These findings reinforce the limitations of currently available analgesics in IBD and support exploration of alternative therapies.
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Affiliation(s)
- M. D. Coates
- Division of Gastroenterology and Hepatology, Department of Medicine, Penn State College of Medicine, Hershey, PA 17033, USA
| | - N. Seth
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Texas Southwestern, Houston, TX, USA
| | - K. Clarke
- Division of Gastroenterology and Hepatology, Department of Medicine, Penn State College of Medicine, Hershey, PA 17033, USA
| | - H. Abdul-Baki
- Division of Gastroenterology and Hepatology, Department of Medicine, Allegheny Health System, Pittsburgh, PA, USA
| | - N. Mahoney
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - V. Walter
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - M. D. Regueiro
- Division of Gastroenterology and Hepatology, Department of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - C. Ramos-Rivers
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - I. E. Koutroubakis
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - K. Bielefeldt
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - D. G. Binion
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Blackwell J, Selinger C, Raine T, Parkes G, Smith MA, Pollok R. Steroid use and misuse: a key performance indicator in the management of IBD. Frontline Gastroenterol 2020; 12:207-213. [PMID: 33907617 PMCID: PMC8040510 DOI: 10.1136/flgastro-2019-101288] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 03/06/2020] [Accepted: 03/18/2020] [Indexed: 02/04/2023] Open
Abstract
Corticosteroids remain an important tool for inducing remission in inflammatory bowel disease (IBD) but they have no role in maintenance of remission. The significant adverse side effect profile of these drugs means their use should be avoided where possible or measures taken to reduce their risk. Despite an expanding array of alternative therapies, corticosteroid dependency and excess remain common. Appropriate steroid use is now regarded a key performance indicator in the management of IBD. This article aims to outline indications for corticosteroid use in IBD, their risks and strategies to reduce their use and misuse.
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Affiliation(s)
- Jonathan Blackwell
- Department of Gastroenterology, St George's Hospitals NHS Foundation Trust, London, UK
- School of Public Health, Imperial College London, London, UK
| | - Christian Selinger
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- The Leeds Institute of Research at St James’, University of Leeds, Leeds, UK
| | - Tim Raine
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Gareth Parkes
- Department of Gastroenterology, Royal London Hospital, London, UK
| | - Melissa A Smith
- Digestives Diseases Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
- Department of Gastroenterology, Brighton and Sussex Medical School, Brighton, UK
| | - Richard Pollok
- Department of Gastroenterology, St George's Hospitals NHS Foundation Trust, London, UK
- Division of Infection and Immunity, St George’s University London, London, UK
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18
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Le Berre C, Ananthakrishnan AN, Danese S, Singh S, Peyrin-Biroulet L. Ulcerative Colitis and Crohn's Disease Have Similar Burden and Goals for Treatment. Clin Gastroenterol Hepatol 2020; 18:14-23. [PMID: 31301452 DOI: 10.1016/j.cgh.2019.07.005] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 05/23/2019] [Accepted: 07/01/2019] [Indexed: 02/07/2023]
Abstract
It is unclear whether ulcerative colitis (UC) is a progressive disease similar to Crohn's disease (CD). Patients with UC often are undertreated because of the possibility of curative colectomy and the perception that the disease burden is lower than that of CD. We discuss findings from studies that aimed to determine whether UC and CD have the same disease burden and should be treated in the same intensive way. We discuss the similarities between CD and UC, including effects on quality of life, long-term complications, strictures, increased risk of cancer, pseudopolyps, functional abnormalities, and anorectal dysfunction. Contrary to the generally accepted idea, surgery cannot cure UC. Postoperative complications, especially pouchitis and fecal incontinence, affect more than one third of patients. CD and UC each pose substantial economic burdens. Monitoring, treatments, and goals of therapy are similar for all inflammatory bowel diseases. Earlier initiation of disease-modifying drugs might reduce the progression of UC and reduce its burden after surgery, although UC might not cause the irreversible damage observed in patients with CD.
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Affiliation(s)
- Catherine Le Berre
- Inserm U954, Department of Gastroenterology, Nancy University Hospital, Université de Lorraine, Vandoeuvre-lès-Nancy, France; Institut des Maladies de l'Appareil Digestif, Nantes University Hospital, Nantes, France
| | | | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Inflammatory Bowel Disease Center, Department of Gastroenterology, Humanitas Clinical and Research Center, Milan, Italy
| | - Siddharth Singh
- Division of Gastroenterology, University of California, San Diego, La Jolla, California
| | - Laurent Peyrin-Biroulet
- Inserm U954, Department of Gastroenterology, Nancy University Hospital, Université de Lorraine, Vandoeuvre-lès-Nancy, France.
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Selinger CP, Parkes GC, Bassi A, Limdi JK, Ludlow H, Patel P, Smith M, Saluke S, Ndlovu Z, George B, Saunders J, Adamson M, Fraser A, Robinson J, Donovan F, Parisi I, Tidbury J, Gray L, Pollok R, Scott G, Raine T. Assessment of steroid use as a key performance indicator in inflammatory bowel disease-analysis of data from 2385 UK patients. Aliment Pharmacol Ther 2019; 50:1009-1018. [PMID: 31595533 DOI: 10.1111/apt.15497] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 04/21/2019] [Accepted: 08/21/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Patients with IBD are at risk of excess corticosteroids. AIMS To assess steroid excess in a large IBD cohort and test associations with quality improvement and prescribing. METHODS Steroid exposure was recorded for outpatients attending 19 centres and associated factors analysed. Measures taken to avoid excess were assessed. RESULTS Of 2385 patients, 28% received steroids in the preceding 12 months. 14.8% had steroid excess or dependency. Steroid use was significantly lower at 'intervention centres' which participated in a quality improvement programme (exposure: 23.8% vs 31.0%, P < .001; excess 11.5% vs 17.1%, P < .001). At intervention centres, steroid use fell from 2015 to 2017 (steroid exposure 30.0%-23.8%, P = .003; steroid excess 13.8%-11.5%, P = .17). Steroid excess was judged avoidable in 50.7%. Factors independently associated with reduced steroid excess in Crohn's disease included maintenance with anti-TNF agents (OR 0.61 [95% CI 0.24-0.95]), treatment in a centre with a multi-disciplinary team (OR 0.54 [95% CI 0.20-0.86]) and treatment at an intervention centre (OR 0.72 [95% CI 0.46-0.97]). Treatment with 5-ASA in CD was associated with higher rates of steroid excess (OR 1.72 [95% CI 1.24-2.09]). In ulcerative colitis (UC), thiopurine monotherapy was associated with steroid excess (OR 1.97 [95% CI 1.19-3.01]) and treatment at an intervention centre with less steroid excess (OR 0.72 [95% CI 0.45-0.95]). CONCLUSIONS This study validates steroid assessment as a meaningful quality measure and provides a benchmark for this performance indicator in a large cohort. A programme of quality improvement was associated with lower steroid use.
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Late-onset Crohn's disease: a comparison of disease behaviour and therapy with younger adult patients: the Italian Group for the Study of Inflammatory Bowel Disease 'AGED' study. Eur J Gastroenterol Hepatol 2019; 31:1361-1369. [PMID: 31567640 DOI: 10.1097/meg.0000000000001546] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Disease phenotype and outcome of late-onset Crohn's disease are still poorly defined. METHODS In this Italian nationwide multicentre retrospective study, patients diagnosed ≥65 years (late-onset) were compared with young adult-onset with 16-39 years and adult-onset Crohn's disease 40-64 years. Data were collected for 3 years following diagnosis. RESULTS A total of 631 patients (late-onset 153, adult-onset 161, young adult-onset 317) were included. Colonic disease was more frequent in late-onset (P < 0005), stenosing behaviour was more frequent than in adult-onset (P < 0003), but fistulising disease was uncommon. Surgery rates were not different between the three age groups. Systemic steroids were prescribed more frequently in young adult-onset in the first year, but low bioavailability steroids were used more frequently in late-onset in the first 2 years after diagnosis (P < 0.036, P < 0.041, respectively). The use of immunomodulators and anti-TNF's even in patients with more complicated disease, that is, B2 or B3 behaviour (Montreal classification), remained significantly inferior (P < 0.0001) in late-onset compared to young adult-onset. Age at diagnosis, Charlson comorbidity index, and steroid used in the first year were negatively associated with the use of immunomodulators and biologics. Comorbidities, related medications and hospitalizations were more frequent in late-onset. Polypharmacy was present in 56% of elderly Crohn's disease patients. CONCLUSION Thirty-two percent of late-onset Crohn's disease presented with complicated disease behaviour. Despite a comparable use of steroids and surgery, immunomodulators and biologics were used in a small number of patients.
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21
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Wang J, Nakamura TI, Tuskey AG, Behm BW. Polypharmacy is a risk factor for disease flare in adult patients with ulcerative colitis: a retrospective cohort study. Intest Res 2019; 17:496-503. [PMID: 31602961 PMCID: PMC6821943 DOI: 10.5217/ir.2019.00050] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 07/29/2019] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Polypharmacy is a common clinical problem with chronic diseases that can be associated with adverse patient outcomes. The present study aimed to determine the prevalence and patient-specific characteristics associated with polypharmacy in an ulcerative colitis (UC) population and to assess the impact of polypharmacy on disease outcomes. Methods A retrospective chart review of patients with UC who visited a tertiary medical center outpatient clinic between 2006 and 2011 was performed. Polypharmacy was defined as major ( ≥ 5 non-UC medications) or minor (2–4 non-UC medications). UC medications were excluded in the polypharmacy grouping to minimize the confounding between disease severity and polypharmacy. Outcomes of interest include disease flare, therapy escalation, UC-related hospitalization, and surgery within 5 years of the initial visit. Results A total of 457 patients with UC were eligible for baseline analysis. Major polypharmacy was identified in 29.8% of patients, and minor polypharmacy was identified in 40.9% of the population. Polypharmacy at baseline was associated with advanced age (P< 0.001), female sex (P= 0.019), functional gastrointestinal (GI) disorders (P< 0.001), and psychiatric disease (P< 0.001). Over 5 years of follow-up, 265 patients remained eligible for analysis. After adjusting for age, sex, functional GI disorders, and psychiatric disease, major polypharmacy was found to be significantly associated with an increased risk of disease flare (odds ratio, 4.00; 95% confidence interval, 1.66–9.62). However, major polypharmacy was not associated with the risk of therapy escalation, hospitalization, or surgery. Conclusions Polypharmacy from non-inflammatory bowel disease medications was present in a substantial proportion of adult patients with UC and was associated with an increased risk of disease flare.
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Affiliation(s)
- Jingzhou Wang
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Takahiro I Nakamura
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Anne G Tuskey
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Brian W Behm
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
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Scott FI, Johnson FR, Bewtra M, Brensinger CM, Roy JA, Reed SD, Osterman MT, Mamtani R, Chen L, Yun H, Xie F, Curtis JR, Lewis JD. Improved Quality of Life With Anti-TNF Therapy Compared With Continued Corticosteroid Utilization in Crohn's Disease. Inflamm Bowel Dis 2019; 25:925-936. [PMID: 30535149 DOI: 10.1093/ibd/izy321] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Corticosteroids (CS) and anti-TNF drugs are used to treat Crohn's disease (CD). In this study, we assessed the net health benefit of initiating anti-TNF therapy relative to additional CS use in CD using a novel combination of a retrospective cohort study and a simulation model. METHODS Using Medicaid data from 2001 to 2005 and Medicare data from 2006 to 2013, beneficiaries were identified with CD and CS use who subsequently received either an anti-TNF or reached a cumulative dose of >3000 mg CS during the year. By using overall and latent class-specific remission-time equivalent (RTE) estimates derived from discrete-choice experiments, mean 12-month cumulative RTEs were calculated after propensity score adjustment for baseline characteristics. A Markov model was constructed using transition probabilities derived from the retrospective cohort to perform additional sensitivity analyses of RTE estimates, analytic assumptions, and transition probabilities. Cumulative RTEs were calculated via Monte Carlo simulation in this model. RESULTS In the retrospective cohort, 1563 new anti-TNF initiators and 1563 propensity score-matched prolonged CS users were identified. Anti-TNF use was associated with greater mean RTEs at the end of 1 year (5.34 vs 4.54, incremental benefit: 0.79; 95% CI, 0.53-1.07). This benefit persisted in all latent classes. In the Markov model, anti-TNF therapy was the preferred strategy, and the results were robust in multiple sensitivity analysis and latent class analysis. CONCLUSIONS In both a retrospective cohort study and a simulation model, anti-TNF use was associated with improved quality of life, measured as RTEs, when compared with continued CS utilization for CD.
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Affiliation(s)
- Frank I Scott
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - F Reed Johnson
- Duke Clinical Research Institute, Duke University, Durham North Carolina, USA
| | - Meenakshi Bewtra
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Colleen M Brensinger
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason A Roy
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shelby D Reed
- Duke Clinical Research Institute, Duke University, Durham North Carolina, USA
| | - Mark T Osterman
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ronac Mamtani
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lang Chen
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Huifeng Yun
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Fenlong Xie
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - James D Lewis
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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23
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Chouairi F, Torabi SJ, Mercier MR, Gabrick KS, Alperovich M. Chronic steroid use as an independent risk factor for perioperative complications. Surgery 2019; 165:990-995. [PMID: 30765140 DOI: 10.1016/j.surg.2018.12.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 12/19/2018] [Accepted: 12/21/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Corticosteroid use continues to rise nationally. Studies have evaluated the impact of chronic steroid use on surgical outcomes in smaller populations. This study investigated the impact of chronic steroid use on perioperative surgical outcomes in a surgical cohort of more than 5 million surgical patients, using a statistically rigorous methodology. METHODS The National Surgical Quality Improvement Program Database was queried 2008-2016 to evaluate chronic steroid use. Patient demographics, comorbidities, and outcomes were compared, using χ2 and t test analysis, and then repeated after propensity score matching. Finally, a double-adjustment logistic regression was utilized, yielding odds ratios to assess the effect of chronic steroids on perioperative outcomes within the matched population. RESULTS Between 2008 and 2016, a total of 5,244,588 patients met inclusion criteria, of whom 181,901 (3.5%) were taking steroids for a minimum of 30 days before surgery. Patients on chronic steroids had significantly more comorbidities compared with the remaining population. After propensity score matching and double-adjusted logistic regression, chronic steroid use was found to be associated with increased surgical complications and poorer surgical outcomes. Chronic steroid use significantly increased a patient's risk of having a hospital stay longer than 30 days by 19%, risk of readmission within 30 days by 58%, risk of reoperation by 21%, and risk of death by 32%. CONCLUSION After controlling for differences in comorbidities and demographics, patients on chronic steroids have significantly poorer perioperative outcomes. Chronic steroid use should be evaluated and, if possible, addressed before surgery, given their significant impact on surgical outcomes.
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Affiliation(s)
- Fouad Chouairi
- Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Sina J Torabi
- Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Michael R Mercier
- Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Kyle S Gabrick
- Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Michael Alperovich
- Department of Surgery, Yale University School of Medicine, New Haven, CT.
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24
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Noureldin M, Higgins PDR, Govani SM, Cohen-Mekelburg S, Kenney BC, Stidham RW, Waljee JF, Waljee AK. Incidence and predictors of new persistent opioid use following inflammatory bowel disease flares treated with oral corticosteroids. Aliment Pharmacol Ther 2019; 49:74-83. [PMID: 30430615 PMCID: PMC6594920 DOI: 10.1111/apt.15023] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 09/04/2018] [Accepted: 09/25/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Opioids are commonly prescribed to manage pain associated with inflammatory bowel disease (IBD). It is unknown what percentage of patients develop new persistent opioid use following a steroid-treated IBD flare. AIM To identify the incidence and the predictors of new persistent opioid use following an IBD flare. METHODS We used a national insurance claim dataset to identify patients with IBD who received an opioid medication around the time of a corticosteroid-treated IBD flare. Patients were stratified as previously opioid naïve, intermittent users, or chronic users. The incidence of persistent opioid use among the opioid-naïve cohort was evaluated along with associated predictors. RESULTS We identified 15 119 IBD patients who received opioids around the time of a flare. 5411 (35.8%) were opioid-naïve patients of which 35.0% developed persistent opioid use after the flare. Factors associated with new persistent opioid use include a history of depression (hazard ratio [HR] 1.29, 95% confidence interval [CI] 1.13-1.47), substance abuse (HR 1.36, 95% CI 1.2-1.54), chronic obstructive pulmonary disease (COPD) (HR 1.17, 95% CI 1.04-1.3), as well as, Crohn's disease (HR 1.26, 95% CI 1.14-1.4) or indeterminate colitis (HR 1.6, 95% CI 1.36-1.88). CONCLUSIONS New persistent opioid use is common in IBD patients who experience a flare, especially among those with mental health disorders, COPD, and Crohn's disease or indeterminate colitis. These findings can be helpful in risk-stratifying patients when choosing an acute pain therapy and providing counselling before choosing to prescribe opioids to opioid-naïve patients experiencing an IBD flare.
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Affiliation(s)
- Mohamed Noureldin
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan,Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan
| | - Peter D. R. Higgins
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Shail M. Govani
- Department of Internal Medicine, Division of Gastroenterology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Shirley Cohen-Mekelburg
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Brooke C. Kenney
- Department of Surgery, University of Michigan, Ann Arbor, Michigan,Michigan Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor, Michigan
| | - Ryan W. Stidham
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jennifer F. Waljee
- Department of Surgery, University of Michigan, Ann Arbor, Michigan,Michigan Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor, Michigan
| | - Akbar K. Waljee
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan,Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan
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25
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Govani SM, Lipson R, Noureldin M, Wiitala W, Higgins PDR, Saini SD, Pugh JA, Velligan DI, Stidham RW, Waljee AK. Adalimumab persistence for inflammatory bowel disease in veteran and insured cohorts. THE AMERICAN JOURNAL OF MANAGED CARE 2018; 24:e374-e379. [PMID: 30586485 PMCID: PMC6907164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVES Identify predictors of persistence with adalimumab (ADA) among veterans and privately insured patients with inflammatory bowel disease (IBD) in the United States. STUDY DESIGN Retrospective cohort study. METHODS Patients with IBD taking ADA as their first biologic were identified from the Veterans Health Administration (VHA) database from 2009 to 2013 and the Truven Health MarketScan database from 2009 to 2012 with a 12-month follow-up. Persistence was defined as continued use 1 year after initiation. Adherence was assessed by calculating a medication possession ratio, which was dichotomized as greater than 0.86 or less than or equal to 0.86. Multivariable logistic regression was used to evaluate predictors of persistence. RESULTS There were 1030 patients in the VHA population compared with 3264 patients in the privately insured (MarketScan) cohort. In MarketScan, 1800 patients (55%) remained on ADA compared with 755 (73%) in the VHA cohort. In multivariable analysis, male sex (odds ratio [OR], 1.38; 95% CI, 1.16-1.63; P <.01), Crohn disease (OR, 1.27; 95% CI, 1.02-1.57; P = .03), greater adherence (OR, 1.83; 95% CI, 1.45-2.30; P <.01), and dose escalation (OR, 1.82; 95% CI, 1.42-2.33; P <.01) were associated with higher ADA persistence in the MarketScan cohort; narcotic use (OR, 0.71; 95% CI, 0.58-0.88; P <.01) and hospitalization or new steroid use after initiation (OR, 0.04; 95% CI, 0.03-0.05; P <.01) were associated with lower persistence. In the VHA cohort, only a hospitalization or new steroid use (OR, 0.50; 95% CI, 0.36-0.70; P <.01) was associated with lower persistence. CONCLUSIONS Despite being older and having more comorbidities, patients in the VHA, which is an integrated healthcare system, appear to be more likely to remain on ADA at 1 year than patients in the MarketScan database. Further studies of system differences are needed to understand the reasons behind this discrepancy.
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Affiliation(s)
- Shail M Govani
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, Mail Code 111D, San Antonio, TX 78229.
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26
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Ballou S, Hirsch W, Singh P, Rangan V, Nee J, Iturrino J, Sommers T, Zubiago J, Sengupta N, Bollom A, Jones M, Moss AC, Flier SN, Cheifetz AS, Lembo A. Emergency department utilisation for inflammatory bowel disease in the United States from 2006 to 2014. Aliment Pharmacol Ther 2018; 47:913-921. [PMID: 29411411 PMCID: PMC5927595 DOI: 10.1111/apt.14551] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 12/11/2017] [Accepted: 01/15/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite advances in treatment, patients with inflammatory bowel disease (IBD) frequently require emergency department (ED) visits and hospitalisations. AIMS To analyse trends in ED visits and subsequent hospitalisations for IBD in the United States (US). METHODS Data were analysed from the Nationwide Emergency Department Sample (NEDS) years 2006-2014. The NEDS is the largest all-payer ED database in the US, weighted to represent 135 million visits/year. IBD was identified using ICD-9 codes for Crohn's disease (CD) or ulcerative colitis (UC). Surgeries were identified using procedure codes. RESULTS The frequency of IBD-ED visits increased 51.8%, from 90 846 visits in 2006 to 137 946 in 2014, which was statistically significant in linear regression. For comparison, all-case ED use between 2006 and 2014 increased 14.8%. In-patient hospitalisations from the ED decreased 12.1% for IBD (from 64.7% rate of hospitalisation from the ED in 2006 to 52.6% in 2014), with a UC:CD ratio of 1.2:1 in 2006 and 1.3:1 in 2014. Chi-square analysis revealed that this was a significant decrease. Surgery rates also showed a statistically significant decrease. The mean ED charge per patient rose 102.5% and the aggregate national cost of IBD-ED visits increased 207.5%. CD accounted for over twice as many visits as UC in both years. UC, age, male gender, highest income quartile, private insurance, Medicaid/Medicare, and tobacco use were associated with in-patient admissions. CONCLUSIONS The number of ED visits due to IBD and associated charges have continued to rise, while the rates of in-patient hospitalisations referred from the ED and surgeries have decreased.
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Affiliation(s)
- Sarah Ballou
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - William Hirsch
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Prashant Singh
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Vikram Rangan
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Judy Nee
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Johanna Iturrino
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Thomas Sommers
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Julia Zubiago
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Neil Sengupta
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medical Center, Chicago, IL
| | - Andrea Bollom
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Mike Jones
- Department of Psychology, Macquarie University, Sydney, NSW, Australia
| | - Alan C. Moss
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Sarah N. Flier
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Adam S. Cheifetz
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Anthony Lembo
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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27
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Increasing Prescription of Opiates and Mortality in Patients With Inflammatory Bowel Diseases in England. Clin Gastroenterol Hepatol 2018; 16:534-541.e6. [PMID: 29079223 DOI: 10.1016/j.cgh.2017.10.022] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 10/12/2017] [Accepted: 10/15/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The prescription of opiate medications is increasing. Individuals with inflammatory bowel diseases (IBD) can develop serious complications from opiate use, but few data are available on the prescription of these drugs to patients with IBD. We examined trends in prescriptions of opiates and their association with all-cause mortality in individuals with IBD. METHODS We performed a retrospective cohort study of 3517 individuals with Crohn's disease (CD) and 5349 with ulcerative colitis (UC) using the primary care database ResearchOne, which holds de-identified clinical and administrative information from the health records of approximately 6 million persons (more than 10% of the total population) in England. We explored trends in prescriptions of all opiates, codeine, tramadol, or strong opiates, separately from 1990 through September 14, 2014. Associations between opiates and all-cause mortality were examined using propensity score-matched analysis. RESULTS There was a statistically significant increase in the prescription of opiate medications, with 10% of subjects receiving an opiate prescription from 1990 through 1993 compared to 30% from 2010 through 2013 (chi-square for trend, P < .005). Prescription of strong opiates was significantly associated with increased premature mortality of patients with CD (heavy use) or UC (moderate or heavy use). There was a significant association between heavy use of any opiate or codeine alone and premature mortality of patients with UC. Use of tramadol alone, or in combination with codeine, was not associated with premature mortality in patients with CD or UC. CONCLUSIONS In an analysis of primary care patients with IBD in England, we found prescriptions for opiate drugs to have increased significantly from 1990 through 2013. Heavy use of strong opiates among patients with IBD associates with increased all-cause premature mortality.
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28
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Letter to Editor Regarding Narula et al, IBD 2017, Budenoside Use Is a Key Quality Marker in the Management of IBD. Inflamm Bowel Dis 2017. [PMID: 28644186 DOI: 10.1097/mib.0000000000001184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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