Modifiable Risk Factors for Hospital Readmission Among Patients with Inflammatory Bowel Disease in a Nationwide Database

Systematic review and meta-analysis: Impact of depression on prognosis in inflammatory bowel disease

BACKGROUND AND AIM

Depression is highly prevalent in patients with inflammatory bowel disease (IBD), which may affect the prognosis of IBD. This aimed to investigate the impact of depression on prognosis in IBD.

METHODS

A systematic literature search was performed in four databases (Medline, Embase, Web of Science, and PsycINFO) up to December 31, 2023. Studies were included if they investigated the impact of depression on prognosis in IBD. The primary outcome was flare in IBD, and secondary outcomes were hospitalization, readmission, emergency visits, surgery, and escalation of medical therapy. Relative risks (RRs) were utilized to estimate the risk in each of the above prognostic indicators.

RESULTS

Fourteen cohort and 10 case-control studies matched our entry criteria, comprising 630 408 patients with IBD. Twenty-two of included studies were considered to have a low risk of bias. Depression was found to significantly increase the risk of flare (RR = 1.37, 95% CI 1.16-1.63), hospitalization (RR = 1.11, 95% CI 1.00-1.23), readmission (RR = 1.32, 95% CI 1.04-1.67), emergency visits (RR = 1.33, 95% CI 1.12-1.59), surgery (1.38, 95% CI 1.08-1.76), and escalation of medical therapy (RR = 1.38, 95% CI 1.13-1.69) in IBD. Of note, patients with depression in ulcerative colitis had significant differences in readmission (RR = 1.38, 95% CI 1.19-1.60) and escalation of medical therapy (RR = 1.78, 95% CI 1.55-2.04). Additionally, the association was observed in patients with Crohn's disease in terms of flare (RR = 1.47, 95% CI 1.08-2.01) and hospitalization (RR = 1.20, 95% CI 1.03-1.40).

CONCLUSIONS

Current evidence suggested that depression could significantly increase the risk of poor prognosis worsening in patients with IBD. However, the association varied in IBD subtypes.

Clinical and health care utilization variables can predict 90-day hospital re-admission in adults with Crohn's disease for point of care risk evaluation

BACKGROUND

Hospital re-admission for persons with Crohn's disease (CD) is a significant contributor to morbidity and healthcare costs. We derived prediction models of risk of 90-day re-hospitalization among persons with CD that could be applied at hospital discharge to target outpatient interventions mitigating this risk.

METHODS

We performed a retrospective study in persons with CD admitted between 2009 and 2016 for an acute CD-related indication. Demographic, clinical, and health services predictor variables were ascertained through chart review and linkage to administrative health databases. We derived and internally validated a multivariable logistic regression model of 90-day CD-related re-hospitalization. We selected the optimal probability cut-point to maximize Youden's index.

RESULTS

There were 524 CD hospitalizations and 57 (10.9%) CD re-hospitalizations within 90 days of discharge. Our final model included hospitalization within the prior year (adjusted odds ratio [aOR] 3.27, 95% confidence interval [CI] 1.76-6.08), gastroenterologist consultation within the prior year (aOR 0.185, 95% CI 0.0950-0.360), intra-abdominal surgery during index hospitalization (aOR 0.216, 95% CI 0.0500-0.934), and new diagnosis of CD during index hospitalization (aOR 0.327, 95% CI 0.0950-1.13). The model demonstrated good discrimination (optimism-corrected c-statistic value 0.726) and excellent calibration (Hosmer-Lemeshow goodness-of-fit p-value 0.990). The optimal model probability cut point allowed for a sensitivity of 71.9% and specificity of 70.9% for identifying 90-day re-hospitalization, at a false positivity rate of 29.1% and false negativity rate of 28.1%.

CONCLUSIONS

Demographic, clinical, and health services variables can help discriminate persons with CD at risk of early re-hospitalization, which could permit targeted post-discharge intervention.

Close outpatient follow-up associated with reduced readmission rates in patients with inflammatory bowel disease

Background

Few studies have shown the effects of prompt outpatient follow-up in relation to reducing readmission rates in patients hospitalized with inflammatory bowel disease (IBD). Our study evaluated whether postdischarge follow-up was associated with fewer IBD-related readmissions.

Methods

This single-center retrospective study included 477 patients with Crohn's disease (CD) or ulcerative colitis (UC) who were readmitted to our tertiary care hospital from January 1, 2016, to June 1, 2022. Rehospitalization admissions were defined as admissions that occurred within 90 days after discharge date. We used a chi-square or Fisher's exact test to test for bivariate comparisons to determine if there was an association in patients readmitted for IBD and primary care or gastroenterology follow-up at 1, 2, 3, and 4 weeks versus no follow-up.

Results

In UC patients, there were 118 admissions from 2016 to 2022; 36/118 (31%) and 41/118 (34.7%) of the patients were readmitted at 30 days and 90 days, respectively. In the CD group, there were 101 (36.73%) readmissions among 277 patients, with 174 nonreadmissions (63.27%).

Conclusions

Gastroenterology follow-up within 1 month was associated with reduced rates of admission in both groups (P < 0.05). This study highlights the importance of close gastroenterology follow-up for IBD-related hospitalizations.

Psychological symptoms and quality of life in patients with inflammatory bowel disease in China: A multicenter study

AIMS

To investigate the current situation of mental psychology and quality of life (QoL) in patients with inflammatory bowel disease (IBD) in China, and analyze the influencing factors.

METHODS

A unified questionnaire was developed to collect clinical data on IBD patients from 42 hospitals in 22 provinces from September 2021 to May 2022. Multivariate Logistic regression analysis was conducted, and independent influencing factors were screened out to construct nomogram. The consistency index (C-index), receiver operating characteristic (ROC) curve, area under the ROC curve (AUC), calibration curve, and decision curve analysis (DCA) were used to evaluate the discrimination, accuracy, and clinical utility of the nomogram model.

RESULTS

A total of 2478 IBD patients were surveyed, including 1371 patients with ulcerative colitis (UC) and 1107 patients with Crohn's disease (CD). Among them, 25.5%, 29.7%, 60.2%, and 37.7% of IBD patients had anxiety, depression, sleep disturbance and poor QoL, respectively. The proportion of anxiety, depression, and poor QoL in UC patients was significantly higher than that in CD patients (all p < 0.05), but there was no difference in sleep disturbance between them (p = 0.737). Female, higher disease activity and the first visit were independent risk factors for anxiety, depression and sleep disturbance in IBD patients (all p < 0.05). The first visit, higher disease activity, abdominal pain and diarrhea symptoms, anxiety, depression and sleep disturbance were independent risk factors for the poor QoL of patients (all p < 0.05). The AUC value of the nomogram prediction model for predicting poor QoL was 0.773 (95% CI: 0.754-0.792). The calibration diagram of the model showed that the calibration curve fit well with the ideal curve, and DCA showed that the nomogram model could bring clinical benefits.

CONCLUSION

IBD patients have higher anxiety, depression, and sleep disturbance, which affect their QoL. The nomogram prediction model we constructed has high accuracy and performance when predicting QoL.

Recent trends and risk factors associated with Clostridioides difficile infections in hospitalized patients with inflammatory bowel disease

BACKGROUND

Clostridioides difficile infections (CDIs) are common among patients with inflammatory bowel disease (IBD) and can mimic and exacerbate IBD flares, thus warranting appropriate testing during flares.

AIMS

To examine recent trends in rates of CDI and associated risk factors in hospitalized IBD patients, which may better inform targeted interventions to mitigate the risk of infection.

METHODS

This is a retrospective analysis using the Nationwide Readmissions Database from 2010 to 2020 of hospitalized individuals with Crohn's disease (CD) or ulcerative colitis (UC). Longitudinal changes in rates of CDI were evaluated using International Classification of Diseases codes. Multivariable logistic regression evaluated the association between patient- and hospital-related factors and CDI.

RESULTS

There were 2,521,935 individuals with IBD who were hospitalized at least once during the study period. Rates of CDI in IBD-related hospitalizations increased from 2010 to 2015 (CD: 1.64%-3.32%, p < 0.001; UC: 4.15%-5.81%, p < 0.001), followed by a steady decline from 2016 to 2020 (CD: 3.15%-2.27%, p < 0.001; UC: 5.04%-4.27%, p < 0.001). In multivariable models, CDI was associated with the Charlson-Deyo comorbidity index, public insurance, and hospital size. CDI was associated with increased mortality.

CONCLUSIONS

Rates of CDI among hospitalized patients with IBD had initially increased, but have declined since 2015. Increased comorbidity, large hospital size, public insurance, and urban teaching hospitals were associated with higher rates of CDI. CDI was associated with increased mortality in hospitalized patients with IBD. Continued vigilance, infection control, and treatment of CDI can help continue the trend of declining infection rates.

Oral vs Intravenous Discharge Antibiotic Regimens in the Management of Intra-abdominal Abscesses in Penetrating Crohn's Disease

BACKGROUND

Antibiotics are a cornerstone in management of intra-abdominal abscesses in Crohn's disease (CD). Yet, the optimal route of antibiotic administration is poorly studied. We aimed to compare surgical and nonsurgical readmission outcomes for patients hospitalized for intra-abdominal abscesses from CD discharged on oral (PO) or intravenous (IV) antibiotics.

METHODS

Data for patients with CD hospitalized for an intra-abdominal abscess were obtained from 3 institutions from January 2010 to December 2020. Baseline patient characteristics were obtained. Primary outcomes of interest included need for surgery and hospital readmission within 1 year from hospital discharge. We used multivariable logistic regression models and Cox regression analysis to adjust for abscess size, history of prior surgery, history of penetrating disease, and age.

RESULTS

We identified 99 patients discharged on antibiotics (PO = 74, IV = 25). Readmissions related to CD at 12 months were less likely in the IV group (40% vs 77% PO, P = .01), with the IV group demonstrating a decreased risk for nonsurgical readmissions over time (hazard ratio, 0.376; 95% confidence interval, 0.176-0.802). Requirement for surgery was similar between the groups. There were no differences in time to surgery between groups.

CONCLUSIONS

In this retrospective, multicenter cohort of CD patients with intra-abdominal abscess, surgical outcomes were similar between patients receiving PO vs IV antibiotics at discharge. Patients treated with IV antibiotics demonstrated a decreased risk for nonsurgical readmission. Further prospective trials are needed to better delineate optimal route of antibiotic administration in patients with penetrating CD.

Evaluating Changes in Surgical Outcomes for Patients With Inflammatory Bowel Disease Following Medicaid Expansion

BACKGROUND

Little is known about the impact of Medicaid expansion on the surgical care of inflammatory bowel disease. We sought to determine whether Medicaid expansion is associated with improved postsurgical outcomes for patients with inflammatory bowel disease undergoing a colorectal resection.

METHODS

We performed a risk-adjusted difference-in-difference study examining postsurgical outcomes for patients ages 26 to 64 with Crohn's disease or ulcerative colitis undergoing a colorectal resection across 15 states that did and did not expand Medicaid before (2012-2013) and after (2016-2018) policy reform. Primary study outcomes included 30-day readmission and postoperative complication.

RESULTS

Study population included 11 394 patients with inflammatory bowel disease that underwent a colorectal resection. States that underwent Medicaid expansion were associated with a rise in Medicaid enrollment following policy reform (11.8% pre-Medicaid expansion vs 19.7% post-Medicaid expansion). Difference-in-difference analysis revealed a statistically significant lower odds of 30-day readmission in patients undergoing a colorectal resection in expansion states following policy reform relative to patients in nonexpansion states prior to reform (odds ratio, 0.56; 95% confidence interval, 0.36-0.86). No changes in odds of postoperative complication were noted across expansion and nonexpansion states.

CONCLUSIONS

Medicaid expansion is associated with a rise in Medicaid enrollment in expansion states following policy reform. There were greater improvements in postoperative outcomes associated with patients in expansion states following policy reform relative to patients in nonexpansion states prior to reform, which may have been related to improved perioperative care and medical management.

Benefits and Challenges of Treat-to-Target in Inflammatory Bowel Disease

There is notable disparity between symptomatology and disease activity in a significant proportion of patients with inflammatory bowel disease (IBD), and escalation of treatment based on symptoms alone can fail to significantly alter the course of disease. The STRIDE-II position statement, published in 2021 by the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) initiative of the International Organisation for the Study of IBD (IOIBD) provides the most current recommendations for a treat-to-target (T2T) approach in IBD. Despite the benefits offered by a T2T approach in IBD, there are numerous drawbacks and current limitations to its widespread implementation in real-world clinical practice. Owing to the lack of a standardised definition of MH, outcome data are heterogeneous and limit the comparability of existing data. Further, studies investigating the likelihood of achieving MH with a T2T approach are limited and largely retrospective. Evidence of the real-world feasibility of tight monitoring is currently minimal and demonstrates sub-optimal adherence among patients. Further, the few studies on the acceptability and uptake of a T2T approach in real-world practice demonstrate the need for increased acceptability on both patients' and clinicians' behalf. Real-world applicability is further limited by the need for repeated endoscopic assessments of MH as well as a lack of guidance on how to incorporate the various treatment targets into therapeutic decision-making. We aim to review the benefits and challenges of the T2T approach and to discuss potential solutions to further patient care.

Association of Anxiety and Gastrointestinal Comorbidities in Repeat Hospital Admissions in Pediatric Cyclic Vomiting Syndrome

INTRODUCTION

Cyclic vomiting syndrome (CVS) is a functional gastrointestinal disorder with recurrent episodes of intense nausea and vomiting and thus may require frequent hospitalizations. There is paucity of data exploring the association of psychiatric and gastrointestinal comorbidities in repeat hospitalizations among pediatric patients with CVS.

METHODS

We analyzed the Pediatric Health Information System database and included all patients up to 18 years of age with a diagnosis of CVS between 2016 and 2020. We excluded patients with chronic conditions, which mimic CVS. The primary outcome variable was 90-day admission rate, which was defined as a visit to emergency department or admission to observation/inpatient unit with a primary diagnosis of CVS within 90 days after an index CVS hospitalization.

RESULTS

We evaluated a total of 2,604 hospitalizations represented by 1,370 unique individuals. The overall 90-day admission rate was 28.5%, which steadily decreased from 35.7% in 2016 to 23% in 2019 ( P < 0.001). Patients in the repeat hospitalization cohort were slightly older and more often men. Patients with repeat admissions had an increased proportion of anxiety and other gastrointestinal disorders. Multivariable logistic regression showed that anxiety, gastroesophageal reflux disease, functional dyspepsia, and abdominal migraine were associated with increased odds of repeat admissions.

DISCUSSION

Ninety-day admission rates in pediatric CVS are decreasing overall, although still contributing to significant healthcare expenditure. Anxiety and gastrointestinal comorbidities were associated with increased risk of repeat admissions. Further prospective studies are needed to better understand the complex interactions of these comorbidities and their management affecting the natural course of CVS.

Identification of the informational and supportive needs of patients diagnosed with inflammatory bowel disease: a scoping review

Background

Inflammatory Bowel Disease (IBD) affects the quality of life. Patient education and support needs are crucial components of comprehensive chronic illness care. The main purposes of this review were to (i) explore the informational and supportive needs of these patients to improve the quality of life in the existing literature and (ii) identify the gaps related to the needs of the patients in articles.

Methods

The scoping review is based on the Daudt methodological framework, a modified version of Arksey and O'Malley. Electronic databases were extensively searched from January 01, 2000 to April 30, 2022. Four electronic databases (PubMed/Medline, CINAHL, APA PsycInfo, Psychology and Behavioral Sciences Collection, APA PsycArticles, and ProQuest) were searched using controlled vocabulary, and specific keywords. The searched terms were matched to each database. We manually searched two key journals, namely the Journal of Inflammatory Bowel Disease and the Journal of Crohn's and Colitis.

Results

In the review, 75 studies on the assessment of the information and support needs of patients with IBD were reviewed. In this regard, 62 and 53 studies were regarding information needs and support needs, respectively. Most of the information needs of patients with IBD reported in the studies were related to diet needs, and educational needs were the most essential support needs.

Conclusions

Health policymakers and managers can develop care and educational programs related to this disease in health centers according to the needs of the patients. Health professionals, especially gastroenterologists, are the primary referral sources for information on patients. Therefore, gastroenterologists can take the lead in planning and educating the patients and sharing their decisions.

Systematic review registration

OSF, https://doi.org/10.17605/OSF.IO/3MWGJ.

The Impact of Incarceration on Readmissions Among Patients With Inflammatory Bowel Disease Hospitalized at a Community Hospital

Background and Aims

Individuals who are incarcerated often have limited access to first-line treatment and comprehensive health care. In this study, we aimed to compare the frequency of readmissions among patients with inflammatory bowel disease (IBD) receiving care at a community hospital who were and were not incarcerated at the time of hospitalization.

Methods

We analyzed records from Lemuel Shattuck Hospital for all patients admitted between January 1, 2011, and December 31, 2019. Patients with IBD were identified using International Classification of Diseases codes. The primary outcome was all-cause readmission at 1 year following an IBD-related admission. Secondary outcomes were (1) all-cause readmission at 30 days, (2) IBD-related readmission at 30 days, and (3) IBD-related readmission at 1 year. Our indicator of interest was incarceration. Multivariable logistic regression models were built to describe predictors of all-cause readmissions at 1 year.

Results

Among the 6511 individuals hospitalized at Lemuel Shattuck Hospital between 2011 and 2019, 90 individuals (1.4%) had International Classification of Diseases codes for IBD, either ulcerative colitis (n = 44) and/or Crohn's disease (n = 39). Half (n = 46) of patients with IBD were incarcerated during hospital admission. Individuals who were incarcerated had a higher rate of all-cause readmissions at 1 year than those who were not incarcerated at the time of hospitalization (76.0% vs 41.5%, P = .005). Multivariable analysis showed patients who were incarcerated had 3.98 (95% confidence interval: 1.39-12.78) increased odds of all-cause readmission within 1 year.

Conclusion

Our results suggest individuals with IBD who are incarcerated may experience worse health outcomes than individuals who are not incarcerated, adding to a body of literature documenting the negative impact of incarceration on health.

Cannabis Use and Its Association With Thirty- and Ninety-Day Hospital Readmissions for Patients Admitted for an Inflammatory Bowel Disease Exacerbation

Background

Though viewed as a potentially safer palliative alternative to opioids, studies of cannabis use for inflammatory bowel disease (IBD) are limited. The impact of opioids on hospital readmissions for IBD has been extensively examined, but cannabis has not been similarly studied. Our goal was to examine the relationship between cannabis use and the risk of 30- and 90-day hospital readmissions.

Methods

We conducted a review of all adults admitted for an IBD exacerbation from January 1, 2016 to March 1, 2020 within the Northwell Health Care system. Patients with an IBD exacerbation were identified by primary or secondary ICD10 code (K50.xx or K51.xx) and administration of intravenous (IV) solumedrol and/or biologic therapy. Admission documents were reviewed for the terms "marijuana", "cannabis", "pot" and "CBD".

Results

A total of 1,021 patient admissions met inclusion criteria, of whom 484 (47.40%) had Crohn's disease (CD) and 542 (53.09%) were female. Pre-admission cannabis use was reported by 74 (7.25%) patients. Factors found to be associated with cannabis use included younger age, male gender, African American/Black race, current tobacco and former alcohol use, anxiety, and depression. Cannabis use was found to be associated with 30-day readmission among patients with ulcerative colitis (UC), but not among patients with CD, after respectively adjusting each final model by other factors (odds ratio (OR): 2.48, 95% confidence interval (CI): 1.06 - 5.79 and OR: 0.59, 95% CI: 0.22 - 1.62, respectively). Cannabis use was not found to be associated with 90-day readmission on univariable analysis (OR: 1.11, 95% CI: 0.65 - 1.87) nor in the final multivariable model after adjusting for other factors (OR: 1.19, 95% CI: 0.68 - 2.05).

Conclusion

Pre-admission cannabis use was found to be associated with 30-day readmission among patients with UC, but not with 30-day readmission for patients with CD nor with 90-day readmission, following an IBD exacerbation.

Effects of temperature, weather, seasons, atmosphere, and climate on the exacerbation of inflammatory bowel diseases: A systematic review and meta-analysis

BACKGROUND

Exacerbation of inflammatory bowel disease (IBD) is common. Identification of the exacerbating factors could facilitate interventions for forecastable environmental factors through adjustment of the patient's daily routine. We assessed the effect of natural environmental factors on the exacerbation of IBD.

METHODS

In this systematic review and meta-analysis, studies published from January 1, 1992 to November 3th, 2022 were searched in the MEDLINE, Embase, CINAHL Complete and Cochrane Library databases. We extracted data related to the impact of environmental variations on IBD exacerbation, and performed a meta-analysis of the individual studies' correlation coefficient χ2 converted into Cramér's V (φc) with 95% confidence intervals (CI).

RESULTS

A total of 7,346 publications were searched, and 20 studies (sample size 248-84,000 cases) were selected. A meta-analysis with seven studies was performed, and the pooled estimate of the correlation (φc) between the seasonal variations and IBD exacerbations among 4806 cases of IBD exacerbation was 0.11 (95% CI 0.07-0.14; I2 = 39%; p = 0.13). When divided into subtypes of IBD, the pooled estimate of φc in ulcerative colitis (six studies, n = 2649) was 0.07 (95% CI 0.03-0.11; I2 = 3%; p = 0.40) and in Crohn's disease (three studies, n = 1597) was 0.12 (95% CI 0.07-0.18; I2 = 18%; p = 0.30).

CONCLUSION

There was a significant correlation between IBD exacerbation and seasonal variations, however, it was difficult to synthesize pooled results of other environmental indicators due to the small number of studies and the various types of reported outcome measures. For clinical implications, additional evidence through well-designed follow-up studies is needed.

PROTOCOL REGISTRATION NUMBER (PROSPERO)

CRD42022304916.

Quality of Life in Inflammatory Bowel Diseases (IBDs) Patients after Surgery

Inflammatory Bowel Diseases (IBDs) are chronic, relapsing and disabling diseases that affect the gastrointestinal tract. This relapsing course is often unpredictable with severe flares and the need for intensive medical treatment, hospitalization, or emergent/urgent surgery, all of which significantly impact patients' quality of life (QoL). QoL in IBD patients is significantly lower than in the general population, and depression and anxiety have been shown to have a higher prevalence than in healthy individuals, especially during disease flares. Complications requiring hospitalization and repeated surgeries are not uncommon during the disease course and significantly affect QoL in IBD patients. Patient-reported outcome measures (PROMs) can be used to measure the impact of chronic disease on QoL from the patient's perspective. The use of PROMs in IBD patients undergoing surgery could help to investigate the impact of the surgical procedure on QoL and determine whether there is any improvement or worsening. This review summarizes the use of PROMs to assess QoL after various surgical procedures required for IBD treatment.

Risk of Postpartum Flare Hospitalizations in Patients with Inflammatory Bowel Disease Persists After Six Months

BACKGROUND

Although patients with IBD are at higher risk for flares during the postpartum period, little is known about the risk factors, timeline, and healthcare-associated costs of a readmission flare.

AIMS

To ascertain the timeline in which patients are hospitalized for postpartum inflammatory bowel disease (IBD) flares, and the associated risk factors.

METHODS

This is a nationwide retrospective cohort study of 7054 patients with IBD who delivered between 2010-2014 obtained from the National Readmissions Database. The presence of IBD was defined using previously validated International Classification of Diseases codes, and univariable and multivariable regression models were performed to assess risk factors associated with a postpartum flare hospitalization over the nine-month observation period.

RESULTS

A total of 353 (5.0%) patients were hospitalized for a postpartum IBD flare, with approximately one-third (30.0%) readmitted after 6 months. On multivariable analysis, having Crohn's disease (aRR 1.47, 95%CI 1.16-1.88), Medicare insurance (aRR 3.30, 95%CI 2.16-5.02), and ≥ 2 comorbidities (aRR 1.34, 95%CI 1.03-1.74) were independently associated with a higher risk of an IBD flare hospitalization. Compared to patients aged 25-29, those 20-24 were at higher risk for an IBD flare readmission (aRR 1.58, 95%CI 1.17-2.13), whereas patients aged 35-39 years were at lower risk (aRR 0.63, 95%CI 0.43-0.92).

CONCLUSIONS

Among patients with IBD, Crohn's disease, Medicare insurance, multiple comorbidities, and younger age were independent risk factors for a postpartum IBD flare hospitalization. As approximately one-third of these readmissions occurred after 6 months, it is imperative to ensure adequate follow-up and treatment for postpartum IBD patients, particularly in the extended postpartum period.

Impact of Comorbid Psychiatric Disorders on Healthcare Utilization in Patients with Inflammatory Bowel Disease: A Nationally Representative Cohort Study

BACKGROUND AND AIMS

Patients with inflammatory bowel disease (IBD) frequently experience comorbid psychiatric disorders, which negatively impact quality of life. We characterized the longitudinal burden of hospitalization-related healthcare utilization in adults with IBD with and without comorbid anxiety, depression, or bipolar disorder.

METHODS

In the 2017 Nationwide Readmissions Database (NRD), we identified 40,177 patients with IBD who were hospitalized between January 1, 2017 and June 30, 2017 and who were followed until December 31, 2017. In this cohort, we compared the annual burden (i.e., total days spent in hospital), costs, risk of readmission, inpatient mortality, and IBD-related surgery in patients with and without comorbid psychiatric disorders (anxiety, depression, or bipolar disorder).

RESULTS

Of the 40,177 adults who were hospitalized for IBD, 25.7% had comorbid psychiatric disorders. Over a 10 month-long period of follow-up, patients with comorbid psychiatric disorders spent more days in the hospital (median, 7 days vs. 5 days, p < 0.01), experienced higher 30-day (31.3 vs. 25.4%; p < 0.01) and 90-day (42.6 vs. 35.3%, p < 0.01) readmission rates, and had higher hospitalization-related costs (median, $41,418 vs. $39,242, p < 0.01). However, they were less likely to undergo IBD-related procedures or surgeries. There were no differences in risk of mortality. On Cox proportional hazard analysis, the presence of comorbid psychiatric disorders was associated with a 16% higher risk of readmission (HR, 1.16; 95% CI, 1.13-1.20) and a 13% higher risk of severe IBD-related hospitalization (HR, 1.13; 95% CI, 1.08-1.16).

CONCLUSIONS

In adults with IBD, comorbid psychiatric disorders were independently associated with a higher burden and cost of hospitalization, without an increase in the risk of IBD-related surgery or procedures. Population-based interventions aimed at treating psychiatric comorbidities may decrease the risk of unplanned healthcare utilization.

Patient-Reported Outcomes and Risk of Hospitalization and Readmission in Patients with Inflammatory Bowel Diseases

BACKGROUND AND AIMS

Patient-reported outcome measures (PROMs) provide a wholesome view of patient well-being. We conducted a retrospective cohort study to evaluate whether PROMs inform risk of unplanned healthcare utilization in patients with IBD.

METHODS

We identified adult patients with IBD who completed at least two surveys in a large Internet-based cohort within 1 year. We evaluated the association between baseline patient characteristics, disease activity indices, medication use, and PROMs, assessed using NIH Patient-Reported Outcome Measurement Information System (PROMIS) and subsequent risk of incident hospitalization (at time of first follow-up) within 1 year, and readmission within 1 year (in patients with hospitalization at first follow-up), using multivariable logistic regression.

RESULTS

Of 7902 patients with IBD (45.5 year, 72% females, 63% Crohn's disease), 1377 (17.4%) were hospitalized within 1 year. Among PROMs, pain interference (adjusted OR per 5-point increase in PROMIS, 1.09; 95% CI 1.05-1.14), but not depression, anxiety, fatigue or sleep disturbance, was predictive of higher risk of hospitalization. Prior surgery or hospitalization, symptomatic disease, biologic, and corticosteroid use were also associated with higher risk of hospitalization. Of 521 patients hospitalized with IBD, 133 (25.5%) were readmitted within 1 year. Anxiety and pain interference were predictive of higher risk of readmission, whereas depression was associated with lower risk of readmission.

CONCLUSIONS

In a large Internet-based cohort study, PROMs may have a modest effect on modifying risk of unplanned healthcare utilization in patients with IBD, with pain interference being most consistently associated with increased risk of hospitalization and readmission.

Increasing thirty-day readmissions of Crohn’s disease and ulcerative colitis in the United States: A national dilemma

BACKGROUND

The prevalence of Crohn’s disease (CD) and ulcerative colitis (UC) is on the rise worldwide. This rising prevalence is concerning as patients with CD and UC may frequently relapse leading to recurrent hospitalizations and increased healthcare utilization.

AIM

To identify trends and adverse outcomes for 30 d readmissions for CD and UC.

METHODS

This was a retrospective, interrupted trends study involving all adult (≥ 18 years) 30 d readmissions of CD and UC from the National Readmission Database (NRD) between 2008 and 2018. Patients < 18 years, elective, and traumatic hospitalizations were excluded from this study. We identified hospitalization characteristics and readmission rates for each calendar year. Trends of inpatient mortality, mean length of hospital stay (LOS) and mean total hospital cost (THC) were calculated using a multivariate logistic trend analysis adjusting for age, gender, insurance status, comorbidity burden and hospital factors. Furthermore, trends between CD and UC readmissions were compared using regression of the interaction coefficient after adjusting for age and gender to determine relative trends between the two populations. Stata^® Version 16 software (StataCorp, TX, United States) was used for statistical analysis and P value ≤ 0.05 were considered statistically significant.

RESULTS

Total number of 30 d readmissions increased from 6202 in 2010 to 7672 in 2018 for CD and from 3272 in 2010 to 4234 in 2018 for UC. We noted increasing trends for 30-day all-cause readmission rate of CD from 14.9% in 2010 to 17.6% in 2018 (P-trend < 0.001), CD specific readmission rate from 7.1% in 2010 to 8.2% in 2018 (P-trend < 0.001), 30-day all-cause readmission rate of UC from 14.1% in 2010 to 15.7% in 2018 (P-trend = 0.003), and UC specific readmission rate from 5.2% in 2010 to 5.6% in 2018 (P-trend = 0.029). There was no change in the risk adjusted trends of inpatient mortality and mean LOS for CD and UC readmissions. However, we found an increasing trend of mean THC for UC readmissions. After comparison, there was no statistical difference in the trends for 30 d all-cause readmission rate, inpatient mortality, and mean LOS between CD and UC readmissions.

CONCLUSION

There was an increase in total number of 30 d readmissions for CD and UC with a trend towards increasing 30 d all-cause readmission rates.

The Relationship Between Opioid Use and Healthcare Utilization in Patients With Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Pain is commonly experienced by patients with inflammatory bowel disease (IBD). Unfortunately, pain management is a challenge in IBD care, as currently available analgesics are associated with adverse events. Our understanding of the impact of opioid use on healthcare utilization among IBD patients remains limited.

METHODS

A systematic search was completed using PubMed, Embase, the Cochrane Library, and Scopus through May of 2020. The exposure of interest was any opioid medication prescribed by a healthcare provider. Outcomes included readmissions rate, hospitalization, hospital length of stay, healthcare costs, emergency department visits, outpatient visits, IBD-related surgeries, and IBD-related medication utilization. Meta-analysis was conducted on study outcomes reported in at least 4 studies using random-effects models to estimate pooled relative risk (RR) and 95% confidence interval (CI).

RESULTS

We identified 1969 articles, of which 30 met inclusion criteria. Meta-analysis showed an association between opioid use and longer length of stay (mean difference, 2.25 days; 95% CI, 1.29-3.22), higher likelihood of prior IBD-related surgery (RR, 1.72; 95% CI, 1.32-2.25), and higher rates of biologic use (RR, 1.38; 95% CI, 1.13-1.68) but no difference in 30-day readmissions (RR, 1.17; 95% CI, 0.86-1.61), immunomodulator use (RR, 1.13; 95% CI, 0.89-1.44), or corticosteroid use (RR, 1.36; 95% CI, 0.88-2.10) in patients with IBD. On systematic review, opioid use was associated with increased hospitalizations, healthcare costs, emergency department visits, outpatient visits, and polypharmacy.

DISCUSSION

Opioids use among patients with IBD is associated with increased healthcare utilization. Nonopioid alternatives are needed to reduce burden on the healthcare system and improve patient outcomes.

Risk Factors Affecting 90-day Readmission of Patients with Inflammatory Bowel Disease

BACKGROUND: The rate of hospital readmission is seen as a measure of quality and accountability. Knowing the risk factors that can be changed could reduce the cost burden on patients with inflammatory bowel disease (IBD) and the health system. METHODS: Retrospective analysis was performed on the data extracted from hospital records during a 4-year period. The study setting encompassed three referral hospitals in Tehran and the south of Iran. The primary outcome was hospital readmission of patients with IBD. The factors associated with binary and categorical dependent variables were analyzed using robust logistic regression and multinomial logistic regression, respectively. The significance level was set at P=0.05. RESULTS: 187 patients were admitted during the 4-year study period for an IBD-related reason, among whom 131 patients (70.1%) had ulcerative colitis (UC), and 56 patients (29.9%) had Crohn's disease (CD). Moreover, 29% (55) of the participants had been readmitted at least once during the study period, and seven patients with IBD had been readmitted five or more times during the study period. Corticosteroids (OR=4.55, 95% confidence interval CI: 1.65- 12.55) and chronic pain (OR=6.65, 95% CI: 1.73-25.62) were two factors associated with their readmission within 90 days. For the patients with five or more times of readmissions, Corticosteroids (RRR=5.68), chronic pain (RRR=5.05), length of hospital stay (RRR=0.69), and age (RRR=0.9) could significantly explain the hospital readmissions. CONCLUSION: About one in seven hospitalizations of patients with IBD leads to 30-day readmission. Moreover, younger patients with IBD and shorter length of hospital stay were more likely to be readmitted five or more times during the study period. The use of corticosteroids and the presence of chronic pain were predictors of 90-day readmission. More studies are needed to detect the best management plan for chronic pains.

Crohn's disease in total knee arthroplasty patients correlates with increased rates of 90-day and overall postoperative complications and readmissions

BACKGROUND

Joint involvement is a common extraintestinal manifestation of Crohn's Disease (CD) that may require total knee arthroplasty (TKA). There is a paucity of evidence regarding the relationship between CD and postoperative outcomes after TKA surgery. This study seeks to evaluate the impact of CD on 90-day and ≥2-year follow-up postoperative outcomes of TKA patients.

METHODS

We retrospectively analyzed the Statewide Planning and Research Cooperative System database (2009-2013) and isolated ICD-9 codes for TKA patients (8154), while excluding those with any revision of knee replacements (0080-0084) and split into 2 groups with or without CD (5550-5559). Patient demographics and postoperative outcomes were compared. Logistic regression analyses with covariates (sex, race, Deyo score, age, and insurance) were utilized to evaluate the association of CD with 90-day and overall postoperative outcomes.

RESULTS

A total of 89,134 TKA patients were identified, 244 of whom had CD. Significant differences in age, race distribution, insurance, and Deyo score (all, p < 0.05) were found. Multivariable analysis demonstrated CD was an independent risk factor for 90-day and overall medical complications, surgical complications, and readmission. Univariate and multivariable analyses report CD had significant increased rates and was a predictor, respectively, of overall blood transfusions (OR 1.5 [95% CI 1.1-2.0] p < 0.01), acute renal failure (OR 1.7 [95% CI 1.1-2.6] p = 0.03), and pulmonary embolism (OR 2.5 [95% CI 1.3-4.6] p = 0.01).

CONCLUSION

Patients with CD undergoing TKA have increased risk both 90-day and overall surgical and medication complications, as well as readmissions compared to patients without CD.

Increasing Prevalence of Frailty and Its Association with Readmission and Mortality Among Hospitalized Patients with IBD

BACKGROUND

Although age is often used as a clinical risk stratification tool, recent data have suggested that adverse outcomes are driven by frailty rather than chronological age.

AIMS

In this nationwide cohort study, we assessed the prevalence of frailty, and factors associated with 30-day readmission and mortality among hospitalized IBD patients.

METHODS

Using the Nationwide Readmission Database, we examined all patients with IBD hospitalized from 2010 to 2014. Based on index admission, we defined IBD and frailty using previously validated ICD codes. We used univariable and multivariable regression to assess risk factors associated with all-cause 30-day readmission and 30-day readmission mortality.

RESULTS

From 2010 to 2014, 1,405,529 IBD index admissions were identified, with 152,974 (10.9%) categorized as frail. Over this time period, the prevalence of frailty increased each year from 10.20% (27,594) in 2010 to 11.45% (33,507) in 2014. On multivariable analysis, frailty was an independent predictor of readmission (aRR 1.16, 95% CI: 1.14-1.17), as well as readmission mortality (aRR 1.12, 95% CI 1.02-1.23) after adjusting for relevant clinical factors. Frailty also remained associated with readmission after stratification by IBD subtype, admission characteristics (surgical vs. non-surgical), age (patients ≥ 60 years old), and when excluding malnutrition, weight loss, and fecal incontinence as frailty indicators. Conversely, we found older age to be associated with a lower risk of readmission.

CONCLUSIONS

Frailty, independent of age, comorbidities, and severity of admission, is associated with a higher risk of readmission and mortality among IBD patients, and is increasing in prevalence. Given frailty is a potentially modifiable risk factor, future studies prospectively assessing frailty within the IBD patient population are needed.

Obesity in Inflammatory Bowel Disease Is Associated with Early Readmissions Characterised by an Increased Systems and Patient-level Burden

BACKGROUND AND AIMS

Rates of obesity are rising in patients with inflammatory bowel disease [IBD]. We conducted a US population-based study to determine the effects of obesity on outcomes in hospitalised patients with IBD.

METHODS

We searched the Nationwide Readmissions Database 2016-2017 to identify all adult patients hospitalised for IBD, using ICD-10 codes. We compared obese (body mass index [BMI] ≥ 30) vs non-obese [BMI < 30] patients with IBD to evaluate the independent effects of obesity on readmission, mortality, and other hospital outcomes. Multivariate regression and propensity matching were performed.

RESULTS

We identified 143 190 patients with IBD, of whom 9.1% were obese. Obesity was independently associated with higher all-cause readmission at 30 days {18% vs 13% (adjusted odds ratio [aOR] 1.16, p = 0.005)} and 90 days (29% vs 21% [aOR 1.27, p < 0.0001]), as compared with non-obese patients, with similar findings upon a propensity-matched sensitivity analysis. Obese and non-obese patients had similar risks of mortality on index admission [0.24% vs 0.31%, p = 0.18] and readmission [1.5% vs 1.8% p = 0.3]. Obese patients had longer [5.3 vs 4.9 days] and more expensive [USD12,195 vs USD11,154] hospitalisations on index admission. Obesity did not affect the risk of intestinal surgery or bowel obstruction. Compared with index admissions, readmissions were characterised by increased mortality [6-fold], health care use, and bowel obstruction [3-fold] [all p < 0.0001].

CONCLUSIONS

Obesity in IBD appears to be associated with increased early readmission, characterised by a higher burden, despite the introduction of weight-based therapeutics. Prevention of obesity should be a focus in the treatment of IBD to decrease readmission and health care burden.

Role of hospitalization for inflammatory bowel disease in the post-biologic era

Treatment for inflammatory bowel disease (IBD) often requires specialized care. While much of IBD care has shifted to the outpatient setting, hospitalizations remain a major site of healthcare utilization and a sizable proportion of patients with inflammatory bowel disease require hospitalization or surgery during their lifetime. In this review, we approach IBD care from the population-level with a specific focus on hospitalization for IBD, including the shifts from inpatient to outpatient care, the balance of emergency and elective hospitalizations, regionalization of specialty IBD care, and contribution of surgery and endoscopy to hospitalized care.

Improving Follow-ups With Gastroenterologists Utilizing an Appointment Scheduling Protocol in Inflammatory Bowel Disease: A Quality Improvement Project

Approximately one in four patients with inflammatory bowel disease are readmitted within 90 days. To reduce hospitalizations, regular follow-up appointments with gastroenterologists are essential. However, the mean wait time for gastroenterology clinic appointments significantly exceeded the target goal of 14 days in North America. Based on literature review, we developed and implemented a new appointment scheduling protocol. The inclusion criteria were adult patients with inflammatory bowel disease who were recently hospitalized or newly referred to a gastroenterology clinic. At weeks 0 and 12, wait times were extrapolated from chart review, and patient satisfaction rates were collected via surveys. Patient demographics and outcome data were examined using descriptive statistics. A total of 16 patients were included. Following the intervention, the mean wait time decreased from 40.4 (SD = 31.9) to 21.9 days (SD = 11.4), but the change was statistically insignificant (p = .408). Poor response rates (47%) limited the interpretation of the patient satisfaction data. Despite the small sample size, our project was the first quality improvement initiative that implemented an evidence-based appointment scheduling protocol among adult patients with inflammatory bowel disease. Further studies are warranted with a larger sample size to better evaluate its efficacy in achieving timely outpatient gastroenterology care.

Burden of comorbid anxiety and depression in patients with inflammatory bowel disease: a systematic literature review

INTRODUCTION

Patients with inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis, often have comorbid anxiety and depression that affects their quality of life (QoL) and management of their IBD.

AREAS COVERED

A systematic literature review (SLR) was conducted to identify articles and conference abstracts on comorbid anxiety and depression in IBD patients using MEDLINE® and Embase® (January 2003 - June 2018). The impact of these psychological comorbidities on QoL and economic burden was examined. Non-pharmacologic interventions and disease-specific unmet clinical needs associated with these comorbidities were also evaluated.

EXPERT OPINION

There is evidence that individual and group-based cognitive behavioral therapy can reduce rates of anxiety and depression in adults and adolescents with IBD. Patients with IBD and anxiety or depression had an increased risk of hospitalization, emergency department visits, readmission, and used outpatient services more often than people without these conditions. Several disease-specific unmet clinical needs for IBD patients were identified. These included lack of reimbursement for mental-health care, inconsistent screening for psychological comorbidities and patients not consulting mental-health professionals when needed. IBD patients may benefit from integrated medical and psychological treatment, and should be considered for behavioral treatment.Plain Language Summary.

BACKGROUND

People with IBD may have mental-health conditions, such as anxiety and depression. These conditions can affect people's quality of life and how they manage their IBD.

WHAT DID THIS REVIEW LOOK AT?

We found 79 publications on anxiety or depression in people with IBD, published between January 2003 and June 2018. In people with IBD and anxiety or depression, researchers looked at: the impact on health-related quality of life and healthcare utilization, including access to and reimbursement for mental-health services how effective interventions that do not involve the use of medicines were (known as non-pharmacologic therapy).

WHAT WERE THE MAIN FINDINGS FROM THIS REVIEW?

People with IBD and anxiety or depression were more likely to be admitted to hospital and visit emergency departments than people without these conditions. Access to mental-health care varied and some people with IBD were not screened for depression.Individual and group-based talking therapy (known as cognitive behavioral therapy) reduced rates of anxiety and depression in some people with IBD.

WHAT WERE THE MAIN CONCLUSIONS FROM THIS REVIEW?

We found evidence that people with IBD and anxiety or depression may benefit from certain non-pharmacologic interventions. However, many people with IBD and anxiety or depression did not have access to mental-health services. Healthcare professionals should address gaps in patient care to improve outcomes in people with IBD and anxiety or depression.See Additional file 1 for an infographic plain language summary.

Longitudinal follow-up study: effect of psychological co-morbidity on the prognosis of inflammatory bowel disease

BACKGROUND

Psychological co-morbidity is more common in patients with inflammatory bowel disease (IBD), compared with the general population, but little is known about the cumulative effect of increasing psychological burden on disease behaviour.

AIMS

To examine the effect of psychological co-morbidity on inflammatory bowel disease in a longitudinal follow-up study.

METHODS

We collected complete demographic, symptom and psychological co-morbidity data (anxiety, depression and somatisation scores) at baseline from adults with IBD in biochemical remission (faecal calprotectin <250 µg/g). Objective markers of disease activity, including glucocorticosteroid prescription or flare of disease activity, escalation of therapy, hospitalisation or intestinal resection, were reviewed ≥2 years of follow-up. We performed multivariate Cox regression, controlling for patient characteristics and follow-up duration, to examine cumulative effect of psychological co-morbidities on subsequent IBD behaviour.

RESULTS

Among 218 participants, 48 (22.0%) had one, 13 (6.0%) two and nine (4.1%) three psychological co-morbidities at baseline. Following multivariate Cox regression analysis, glucocorticosteroid prescription or flare, and escalation of medical therapy were significantly higher among those with two (hazard ratio [HR] = 3.18; 95% confidence interval [CI] 1.44-7.02, and HR = 2.48; 95% CI 1.03-5.93, respectively) or three (HR = 3.53; 95% CI 1.26-9.92, and HR = 8.19; 95% CI 2.88-23.23, respectively) psychological co-morbidities. Occurrence of at least one endpoint of interest was significantly higher with increasing psychological co-morbidity (HR = 1.74; 95% CI 1.07-2.82 for one, HR = 2.47; 95% CI 1.12-5.46 for two and HR = 4.93; 95% CI 1.84-13.17 for three psychological co-morbidities).

CONCLUSIONS

Individuals with IBD in biochemical remission experienced a worse disease course with increasing psychological co-morbidity at baseline.

Increased Mortality and Healthcare Costs Upon Hospital Readmissions of Ulcerative Colitis Flares: A Large Population-Based Cohort Study

Background

Ulcerative colitis (UC) flares often result in prolonged hospitalization and considerable mortality. Nevertheless, large-scale analyses evaluating the frequency and characteristics of hospital readmissions for UC remain limited. We aimed to examine these clinical outcomes in a nationwide cohort of patients hospitalized with UC.

Methods

We queried the 2017 Nationwide Readmission Database using ICD-10-CM codes to identify all adult patients admitted for UC. Outcomes including mortality, readmission rates, predictors of readmission and mortality, and healthcare usage were assessed. Multivariate analysis was used to adjust for potential confounders.

Results

From the 31,063 patients hospitalized for UC, 17.38% were readmitted within 30 days and 28.51% in 90 days. UC accounted for 28.17% and 29.82% of readmissions at 30 and 90 days, respectively. Compared to index admission, 30- and 90-day readmissions were characterized by significantly higher mortality (0.42% vs 1.99% and 1.65%, respectively), longer hospital stays (5.05 vs 6.62 and 6.04 days, respectively), and increased hospital cost ($49,999 vs $62,288 and $59,698, respectively) (all P < 0.01). Numerous factors, including chronic steroid use [hazard ratio (HR) 1.35] and opioid use (HR 1.6, were independently associated with increased 30-day readmission (P < 0.01). Numerous factors, including anxiety (HR 1.21) and venous thromboembolism (HR 5.39), were independently associated with increased 30-day mortality (P < 0.01).

Conclusions

In a large cohort of patients hospitalized for UC, we found that readmission is associated with higher mortality and more lengthy/costly admissions. Additionally, we found independent associations for readmission and mortality that may help identify patients who can benefit from close postdischarge follow-up.

Trends and Outcomes of Hip Fracture Hospitalization Among Medicare Beneficiaries with Inflammatory Bowel Disease, 2000-2017

BACKGROUND

Patients with inflammatory bowel disease (IBD) have a higher risk of hip fracture, but lower likelihood of having arthroplasties than non-IBD patients in Nationwide Inpatient Sample. Little is known about hip fracture-associated hospitalization outcomes.

AIMS

We assessed the trends in hip fracture hospitalization rates from 2000 to 2017 and estimated 30-day readmission, 30-day mortality, and length of stay in 2016 and 2017.

METHODS

We estimated trends of age-adjusted hospitalization rates using a piecewise linear regression. Medicare beneficiaries aged ≥ 66 years with Crohn's disease (CD, n = 2014) or ulcerative colitis (UC, n = 2971) hospitalized for hip fracture were identified. We performed propensity score matching to create 1:3 matched samples on age, race/ethnicity, sex, and chronic conditions and compared hospitalization outcomes between matched samples.

RESULTS

In 2017, the age-adjusted hospitalization rates (per 100) were 1.15 [95% CI = (1.07-1.24)] for CD, 0.86 [95% CI = (0.82-0.89)] for UC, and 0.59 [95% CI = (0.59-0.59)] for no IBD. The hospitalization rates for CD and UC decreased from 2000 to 2012 and then increased from 2012 to 2017. Compared to matched cohorts, CD patients had longer hospital stays (5.55 days vs. 5.30 days, p = 0.01); UC patients were more likely to have 30-day readmissions (17.27% vs. 13.71%, p < 0.001), longer hospital stays (5.59 days vs. 5.40 days, p = 0.02), and less likely to have 30-day mortality (3.77% vs. 5.15%, p = 0.003).

CONCLUSIONS

Prevention of hip fracture is important for older adults with IBD, especially CD. Strategies that improve quality of inpatient care for IBD patients hospitalized for hip fracture should be considered.

Methodology and Initial Results From a Real-World Observational Cohort of Patients With Inflammatory Bowel Disease: TARGET-IBD

Background

Data on care patterns for inflammatory bowel disease (IBD) from large-scale, diverse clinical cohorts in real-world practice are sparse. We developed a real-world cohort of patients receiving care at academic and community sites, for comparative study of therapies and natural history of IBD.

Methods

We describe novel methodology of central abstraction of clinical data into a real-world IBD registry with patient reported outcomes (PROs). Baseline demographics, clinical characteristics, healthcare utilization, and disease metrics were assessed. Bivariate statistics were used to compare demographic and clinical data by Crohn disease (CD) or ulcerative colitis (UC) and site of care (academic, community).

Results

In 1 year, 1343 IBD patients (60.1% CD, 38.9% UC) were recruited from 27 academic (49.5%) and community (50.5%) sites, exceeding expectations (110% enrolled). Most participants also consented to provide PROs (59.5%) or biosamples (85.7%). Overall, 48.7% of the cohort provided a baseline PRO, and 62.6% provided a biosample. Compared to UC, CD subjects had higher prior (34.1% CD vs 7.7% UC; P < 0.001) and current (72.1% vs 47.9%; P < 0.001) biologic utilization. CD participants from academic sites had more complicated disease than those from community sites (62.5% vs 46.8% stricturing/penetrating; 33.5% vs 27% perianal; 36.8% vs 14.5% prior biologic, respectively). Nearly all (90.4%) participants had endoscopic data of whom 37.7% were in remission. One-year retention was 98.4%.

Conclusions

Centralized data abstraction and electronic PRO capture provided efficient recruitment into a large real-world observational cohort. This novel platform provides a resource for clinical outcomes and comparative effectiveness research in IBD.

Follow-up Care in Inflammatory Bowel Disease: An Integrative Review

Inflammatory bowel disease is characterized by chronic inflammation of the gastrointestinal tract and is associated with high risks for complications, surgeries, and frequent hospitalizations. Approximately one in four inflammatory bowel disease patients are readmitted to the hospital within 90 days of discharge in the United States. Although existing literature showed a timely clinic appointment with gastroenterologists is a protective factor for disease flare-ups and hospitalizations, the follow-up appointments were found to be either lacking or significantly delayed. Further, evidence-based guidelines in timely inflammatory bowel disease care are lacking. Thus, this integrative review examined current literature to identify effective strategies for achieving timely clinic appointments with gastroenterologists in inflammatory bowel disease. A comprehensive search of three electronic databases (PubMed, Embase, and Cumulative Index of Nursing and Allied Health Literature [CINAHL] Plus) was conducted from January 2009 to September 2019 using the key terms: inflammatory bowel disease, ulcerative colitis, Crohn's disease, appointments, and time to appointment. Nine articles met the inclusion criteria. The main interventions for timely inflammatory bowel disease care included (i) clinic-wide scheduling protocols, (ii) a dedicated healthcare team, (iii) efficient referral process, (iv) appointment management based on disease acuity and severity, and (v) addressing shortage of inflammatory bowel disease clinicians. Further research is needed to quantify the magnitude of timely inflammatory bowel disease care interventions with controls and evaluate the efficacy with a head-to-head trial. Through timely referrals, evaluations, and treatments, these quality improvement endeavors will ultimately improve quality of care and contribute to reduction in preventable hospitalizations and associated healthcare costs from delayed outpatient inflammatory bowel disease care.

A Phenome-Wide Analysis of Healthcare Costs Associated with Inflammatory Bowel Diseases

INTRODUCTION

Crohn's disease (CD) and ulcerative colitis (UC) are associated with considerable direct healthcare costs. There have been few comprehensive analyses of all IBD- and non-IBD comorbidities that determine direct costs in this population.

METHODS

We used data from a validated cohort of patients with inflammatory bowel disease (IBD). Total healthcare costs were estimated as a sum of costs associated with IBD-related hospitalizations and surgery, imaging (CT or MR scans), outpatient visits, endoscopic evaluation, and emergency room (ER) care. All ICD-9 codes were extracted for each patient and clustered into 1804 distinct phecode clusters representing individual phenotypes. A phenome-wide association analysis (PheWAS) was performed using logistic regression to identify predictors of being in the top decile of costs.

RESULTS

Our cohort is comprised of 10,721 patients with IBD among whom 50% had CD. The median age was 46 years. The median total cost per patient is $11,203 (IQR $2396-30,563). The strongest association with total healthcare costs was intestinal obstruction without mention of hernia (p = 5.93 × 10^-156) and other intestinal obstruction (p = 9.24 × 10^-131). In addition, strong associations were observed for symptoms consistent with severity of IBD including the presence of fluid-electrolyte imbalance (p = 1.90 × 10^-130), hypovolemia (p = 1.65 × 10^-114), abdominal pain (p = 7.29 × 10^-60), and anemia (p = 1.90-10^-83). Cardiopulmonary diseases and psychological comorbidity also demonstrated significant associations with total costs with the latter being more strongly associated with ER visit-related costs.

CONCLUSIONS

Surrogate markers suggesting possible irreversible bowel damage and active disease demonstrate the greatest influence on IBD-related healthcare costs.

Effects of Race and Ethnicity on Diagnosis and Management of Inflammatory Bowel Diseases

Although Crohn's disease (CD) and ulcerative colitis (UC) have been considered as disorders that affect individuals of European ancestry, the epidemiology of the inflammatory bowel diseases (IBDs) is changing. Coupled with the increasing incidence of IBD in previously low-incidence areas, the population demographics of IBD in the United States are also changing, with increases among non-White races and ethnicities. It is therefore important to fully understand the epidemiology and progression of IBD in different racial and ethnic groups, and the effects of race and ethnicity on access to care, use of resources, and disease-related outcomes. We review differences in IBD development and progression among patients of different races and ethnicities, discussing the effects of factors such as access to care, delays in diagnosis, and health and disease perception on disparities in IBD care and outcomes. We identify research priorities for improving health equity among minority patients with IBD.

Association between operational positive depression symptom screen scores on hospital admission and 30-day readmissions

BACKGROUND

Positive scores on inpatient depression symptom screens have been found to be associated with readmissions, yet most studies have used depression screens collected as part of research studies.

OBJECTIVE

We evaluated whether the relationship between depression severity and readmission persisted when depression screening data was obtained for operational purposes.

DESIGN

Retrospective analysis studying prospective use of PHQ data.

SETTING

Large academic medical center.

INTERVENTION

Ward nurses obtained depression screens from patients soon after admission. Patients who answered 'yes' to at least one Patient Health Questionnaire (PHQ)-2 question were screened using the PHQ-9.

MAIN OUTCOMES AND MEASURES

We examined the association between depression severity and 30-day readmissions using logistic regression, adjusting for known predictors of hospital readmission.

RESULTS

From July 2014-June 2016, 18,792 discharged adult medicine inpatients received an initial depression screen (PHQ-2) and 1105 patients (5.90%) had at least one positive response. Of this group, 3163 patients (6.32%) were readmitted within 30 days. 1128 patients received the PHQ-9. Compared to patients with no depression, patients with moderately-severe depression had 3.03 higher odds (95%CI, 1.44-6.38) and patients with severe depression had 1.63 higher odds (95%CI, 0.70-3.78) of being readmitted, after adjusting for known predictors of hospital admission. Adding PHQ-9 results did not significantly improve the predictive power of a readmissions model.

CONCLUSIONS

Our mixed results call into question whether PHQ data obtained for operational purposes may differ compared to data obtained for research purposes. Differences in training of screening staff or patient discomfort with discussing depression in the hospital could explain our findings.

Mental Health Costs of Inflammatory Bowel Diseases

BACKGROUND

Mental health diagnoses (MHDs) were identified as significant drivers of inflammatory bowel disease (IBD)-related costs in an analysis titled "Cost of Care Initiative" supported by the Crohn's & Colitis Foundation. In this subanalysis, we sought to characterize and compare IBD patients with and without MHDs based on insurance claims data in terms of demographic traits, medical utilization, and annualized costs of care.

METHODS

We analyzed the Optum Research Database of administrative claims from years 2007 to 2016 representing commercially insured and Medicare Advantage insured IBD patients in the United States. Inflammatory bowel disease patients with and without an MHD were compared in terms of demographics (age, gender, race), insurance type, IBD-related medical utilization (ambulatory visits, emergency department [ED] visits, and inpatient hospitalizations), and total IBD-related costs. Only patients with costs >$0 in each of the utilization categories were included in the cost estimates.

RESULTS

Of the total IBD study cohort of 52,782 patients representing 179,314 person-years of data, 22,483 (42.6%) patients had at least 1 MHD coded in their claims data with a total of 46,510 person-years in which a patient had a coded MHD. The most commonly coded diagnostic categories were depressive disorders, anxiety disorders, adjustment disorders, substance use disorders, and bipolar and related disorders. Compared with patients without an MHD, a significantly greater percentage of IBD patients with MHDs were female (61.59% vs 48.63%), older than 75 years of age (9.59% vs 6.32%), white (73.80% vs 70.17%), and significantly less likely to be younger than 25 years of age (9.18% vs 11.39%) compared with those without mental illness (P < 0.001). Patients with MHDs had significantly more ED visits (14.34% vs 7.62%, P < 0.001) and inpatient stays (19.65% vs 8.63%, P < 0.001) compared with those without an MHD. Concomitantly, patients with MHDs had significantly higher ED costs ($970 vs $754, P < 0.001) and inpatient costs ($39,205 vs $29,550, P < 0.001) compared with IBD patients without MHDs. Patients with MHDs also had significantly higher total annual IBD-related surgical costs ($55,693 vs $40,486, P < 0.001) and nonsurgical costs (medical and pharmacy) ($17,220 vs $11,073, P < 0.001), and paid a larger portion of the total out-of-pocket cost for IBD services ($1017 vs $905, P < 0.001).

CONCLUSION

Patients whose claims data contained both IBD-related and MHD-related diagnoses generated significantly higher costs compared with IBD patients without an MHD diagnosis. Based on these data, we speculate that health care costs might be reduced and the course of patients IBD might be improved if the IBD-treating provider recognized this link and implemented effective behavioral health screening and intervention as soon as an MHD was suspected during management of IBD patients. Studies investigating best screening and intervention strategies for MHDs are needed.

One-year risk of opioid use disorder after index hospitalization for inflammatory bowel disease

PURPOSE

Patients with inflammatory bowel disease are commonly prescribed opiates for pain. We sought to determine the incidence of opiate use disorder after inflammatory bowel disease (IBD) admission over a 1-year period as well as its impact on mortality and hospital resource utilization.

METHODS

The Nationwide Readmission Database 2016 was used to identify adult patients with a principal diagnosis of IBD who were subsequently readmitted with a primary diagnosis of opioid use disorder. The primary outcome was 1-year readmission rate for opiate use disorder. Predictors were analyzed using multivariate logistic regression. Secondary outcomes were mortality rate, length of stay, and total hospital costs and charges.

RESULTS

Among the 6340 index hospitalizations for IBD, 4.7% (6.0% Crohn's and 2.6% ulcerative colitis) were readmitted within 1 year for opiate use disorder. Readmission hospitalizations were associated with additional mortality (0.32%) and hospital utilization (length of stay 4.80 days, mean total costs $9503, and mean total charges $38,288). Ulcerative colitis had significantly higher mortality and hospital utilization costs compared with Crohn's disease. In multivariable analysis, odds of readmission were associated with female sex (OR 1.51, CI 1.19-1.92), private insurance (OR 0.20, CI 0.11-0.37), Charlson Comorbidity Index (OR 0.20, CI 0.11-0.37), anxiety (OR 1.65, CI 1.02-2.63), and depression (OR 2.07, CI 1.28-3.34). On stratification analysis, psychiatric comorbidities were associated with both Crohn's and ulcerative colitis.

CONCLUSION

Patients with IBD were often readmitted for opiate use disorder and sustained significant mortality and hospital costs. Psychiatric comorbidities, gender, and insurance status impacted the odds of readmission and represent targets for intervention.

Day-by-Day Management of the Inpatient With Moderate to Severe Inflammatory Bowel Disease

Hospitalization for inflammatory bowel disease is common and requires coordination of care. The goals of hospitalization are to markedly improve symptoms, transition management to an outpatient regimen, and prevent complications. Initially, providers should determine the phenotype and severity of disease flare and provide optimal medical salvage therapy for induction of disease remission. In addition, complications of Crohn's disease and ulcerative colitis should be addressed with testing for Clostridioides difficile and cytomegalovirus infections and pharmacologic venous thromboembolism prophylaxis, and early enteral feeding should be encouraged to optimize nutritional status. A standardized daily assessment to determine response to treatment should be performed. Objective measures of response to disease treatment that are measured within 3 to 4 days of hospitalization can predict which patients will benefit from either second-line rescue therapy or surgical intervention. These same measures can be used to determine readiness for hospital discharge. Safe discharge can be optimized with thorough patient education and a comprehensive outpatient follow-up plan.

Rate of Risk Factors for and Interventions to Reduce Hospital Readmission in Patients With Inflammatory Bowel Diseases

BACKGROUND & AIMS

We investigated 30- and 90-day rates and causes of, risk factors for, and interventions to reduce hospital readmission in patients who received medical treatment for inflammatory bowel diseases (IBD).

METHODS

We performed a systematic search of publications through July 1, 2018 for studies of rates of hospital readmission and associated causes and risk factors in patients who received medical treatments for IBD. Our final analysis included 17 cohort studies (6324 patients) of hospitalized adults with IBD who had received medical treatment, along with reported readmission rates with detailed chart review. We performed random effects meta-analysis to estimate 30- and 90-day rates of readmission and identified causes and risk factors associated with readmission. We also performed qualitative analyses of studies that focused on interventions to reduce readmission.

RESULTS

Overall, the 30-day rate of readmission was 18.1% (95% CI, 14.4-22.4) and the 90-day rate was 26.0% (95% CI, 22.7-29.6). On meta-regression, studies with higher proportions of patients with ulcerative colitis than Crohn's disease reported higher risks for readmission. Most common reasons for readmission were IBD flare, infection, or complications from unplanned surgeries during hospitalizations. Consistent risk factors for 30-day readmission were admission for pain control (odds ratio [OR], 2.27; 95% CI, 1.69-3.03), need for total parenteral nutrition on discharge (OR, 2.13; 95% CI, 1.36-3.35), and prior or unplanned surgery during admission (OR, 3.11; 95% CI, 2.27-4.25). Only 1 study focused on interventions (specialized inpatient IBD service) to reduce risk of readmission.

CONCLUSIONS

Overall 30- and 90-day rates of readmission for patients who received medical treatment for IBD are 18.1% and 26.0%, respectively. IBD flares and infections are common reasons for readmission, and inadequate pain control and need for parenteral nutrition were common risk factors. Interventional studies to reduce risk of readmission are needed.

Chronisch entzündliche Darmerkrankungen – die biopsychosoziale Realität im Kindes- und Jugendalter

Chronisch entzündliche Darmerkrankungen (CED) im Kindes- und Jugendalter nehmen zu. Diese komplexen Erkrankungen haben typischerweise einen unvorhersehbaren und oft schubweisen Verlauf. Diese Übersichtsarbeit dient der Darstellung der psychosozialen Folgen und Risiken bei chronisch entzündlichen Darmerkrankungen im Kindes- und Jugendalter vor dem Hintergrund der wesentlichen medizinischen Aspekte.

Diagnostik und Therapie der CED sollten von Kindergastroenterologen gesteuert werden. Obere und untere Endoskopie mit Stufenbiopsien und bildgebende Verfahren sind die Eckpfeiler der Diagnostik. Therapeutisch kommen immunmodulierende und immunsuppressive Medikamente, Ernährungstherapie und chirurgische Interventionen zum Einsatz. Die Erkrankung selbst mit ihren vielfältigen Beschwerden und Komplikationen, aber auch die diagnostischen und therapeutischen Verfahren und die Sorge vor Nebenwirkungen sind für die jungen Patienten und ihre Familien mit vielfältigen Belastungen verbunden. Einschränkungen der Lebensqualität, psychische Erkrankungen und negative Auswirkungen auf Sozialleben, Schule und Berufsausbildung können die Folge sein. Eine interdisziplinäre umfassende Betreuung der Patienten unter Einbeziehung der verschiedenen Berufsgruppen (ärztlich, psychologisch, sozialpädagogisch, ernährungstherapeutisch und pflegerisch) sind notwendige Voraussetzungen, diesen komplex kranken Kindern und Jugendlichen sowie ihren Familien gerecht zu werden.

Opioid Use Disorder Increases 30-Day Readmission Risk in Inflammatory Bowel Disease Hospitalizations: a Nationwide Matched Analysis

BACKGROUND AND AIMS

The opioid epidemic has become increasingly concerning, with the ever-increasing prescribing of opioid medications in recent years, especially in inflammatory bowel disease [IBD] patients with chronic pain. We aimed to isolate the effect of opioid use disorder [OUD] on 30-day readmission risk after an IBD-related hospitalization.

METHODS

We retrospectively extracted IBD-related adult hospitalizations and 30-day, any-cause, readmissions from the National Readmissions Database [period 2010-2014]. OUD and 30-day readmission trends were calculated. Conventional and exact-matched [EM] logistic regression and time-to-event analyses were conducted among patients who did not undergo surgery during the index hospitalization, to estimate the effect of OUD on 30-day readmission risk.

RESULTS

In total, 487 728 cases were identified: 6633 [1.4%] had documented OUD And 308 845 patients [63.3%] had Crohn's disease. Mean age was 44.8 ± 0.1 years, and 54.3% were women. Overall, 30-day readmission rate was 19.4% [n = 94,546], being higher in OUD patients [32.6% vs 19.2%; p < 0.001]. OUD cases have been increasing [1.1% to 1.7%; p-trend < 0.001], while 30-day readmission rates were stable [p-trend = 0.191]. In time-to-event EM analysis, OUD patients were 47% more likely (hazard ratio 1.47; 95% confidence interval [CI]:1.28-1.69; p < 0.001) to be readmitted, on average being readmitted 32% earlier [time ratio 0.68; 95% CI: 0.59-0.78; p < 0.001].

CONCLUSION

OUD prevalence has been increasing in hospitalized IBD patients from 2010 to 2014. On average, one in five patients will be readmitted within 30 days, with up to one in three among the OUD subgroup. OUD is significantly associated with increased 30-day readmission risk in IBD patients and further measures relating to closer post-discharge outpatient follow-up and pain management should be considered to minimize 30-day readmission risk.

Rehospitalization rates, costs, and risk factors for inflammatory bowel disease: a 16-year nationwide study

AIMS

We aimed to describe the burden of rehospitalization in patients with inflammatory bowel disease (IBD), by evaluating rehospitalization rates, charges, and risk factors over 16 years.

METHODS

We performed a retrospective analysis of all hospital discharges with a primary diagnosis of IBD in public hospitals between 2000 and 2015 in mainland Portugal from the Central Administration of the Health System (ACSS)'s national registry. We collected data on patient, clinical, and healthcare charges. We used survival analysis to estimate the rate and risk factors of IBD-related rehospitalization.

RESULTS

We found that 33% (n = 15,931) of the IBD-related hospitalizations corresponded to rehospitalizations, which increased by 12% over 16 years. However, IBD rehospitalization rate per 100,000 IBD patients decreased 2.5-fold between 2003 and 2015. Mean IBD-related rehospitalization charges were €14,589/hospitalization-year in 2000 and €17,548 /hospitalization-year in 2015, with total rehospitalization charges reaching €3.1 million/year by 2015. Overall, the 30-day rate of rehospitalization was 24% for Crohn's disease (CD) and 22.4% for ulcerative colitis (UC). Novel risk factors for rehospitalization include penetrating disease in CD patients {hazard ratio (HR) 1.34 [95% confidence interval (CI) 1.20-1.51], p < 0.001} and colostomy in UC patients [HR 2.84 (95% CI 1.06-7.58)].

CONCLUSION

IBD-related rehospitalization should be closely monitored, and efforts to reduce its risk factors should be made to improve the quality of care and, consequently, to reduce the burden of IBD.

Acute Venous Thromboembolism Risk Highest Within 60 Days After Discharge From the Hospital in Patients With Inflammatory Bowel Diseases

BACKGROUND & AIMS

Patients with inflammatory bowel diseases (IBDs) have a high risk of venous thromboembolism (VTE). We assessed the timing and risk factors associated with readmission to the hospital for VTE among patients with IBD.

METHODS

We collected data from the Nationwide Readmissions Database on IBD index admissions resulting in readmission to the hospital for VTE within 60 days, from 2010 through 2014. We used univariable and multivariable regression to assess risk factors associated with VTE readmission with unadjusted risk ratio (RR) and adjusted RR (aRR) as measures of effect. Time to VTE readmission was assessed in 10-day intervals, for up to 90 days.

RESULTS

We identified 872,122 index admissions of patients with IBD; 1160 resulted in readmission with VTE. More than 90% of readmissions occurred within 60 days of discharge from the index admission. Factors associated with hospital readmission with VTE included prior VTE, longer length of hospital stay, comorbidities, having a flexible sigmoidoscopy or colonoscopy at index admission, and age older than 18 years. Additional risk factors included Clostridium difficile infection at index admission (aRR, 1.47; 95% CI, 1.17-1.85) and discharge to a skilled nursing facility or intermediate care facility (aRR, 1.39; 95% CI, 1.14-1.70) or discharge with home health services (aRR, 1.65; 95% CI, 1.41-1.94).

CONCLUSIONS

Among patients admitted to the hospital with IBD, most readmissions with VTE occur within 60 days of discharge. Readmission with VTE is associated with C difficile infection and discharge to a skilled nursing facility, intermediate care facility, or with home health services. Studies are needed to evaluate the potential benefit of extending VTE prophylaxis for patients admitted to the hospital with IBD for up to 2 months after discharge, to minimize risk.

National trends in hospital readmission following transsphenoidal surgery for pituitary lesions

PURPOSE

Several institutions recently published their experiences with unplanned readmissions rates after transsphenoidal surgery for pituitary lesions. Readmission rates on a national level, however, have not been explored in depth. We investigated nationwide trends in this procedure and associated independent predictors, costs, and causes of 30-day readmission.

METHODS

The Nationwide Readmissions Database was queried to identify patients 18 and older who underwent transsphenoidal surgery for pituitary lesion resection (2010-2015). National trends and statistical variances were calculated based on weighted, clustered, and stratified sample means.

RESULTS

Of the weighted total of 44,759 patients treated over the 6-year period, 4658 (10.4%) were readmitted within 30 days. Readmission rates did not change across the survey period (P = 0.71). Patients readmitted had a higher prevalence of comorbidities than those not readmitted (82.5% vs. 78.4%, respectively, P < 0.001), experienced more postoperative complications (47.2% vs. 31.8%, P < 0.001), and had a longer length of stay (6.59 vs. 4.23 days, P < 0.001) during index admission. The most common causes for readmission were SIADH (17.5%) and other hyponatremia (16.4%). Average total readmission cost was $12,080 with no significant trend across the study period (P = 0.25). Predictors for readmission identified included diabetes mellitus, psychological disorders, renal failure, and experiencing diabetes insipidus during the index admission.

CONCLUSION

Unplanned readmission is an important quality metric. While transsphenoidal pituitary surgery is a relatively safe procedure, 30-day readmission rates and costs have not declined. Future studies on institutional protocols targeting these identified predictors to prevent readmission are necessary to decrease readmission rates on a national scale.

Managing Pain and Psychosocial Care in IBD: a Primer for the Practicing Gastroenterologist

PURPOSE OF REVIEW

This review focuses on the relationship between trauma and pain in inflammatory bowel disease (IBD), and offers effective treatment strategies.

RECENT FINDINGS

Recent evidence points to bidirectional pathways between psychiatric disorders and IBD. The impact of trauma and development of post-traumatic stress symptoms on IBD disease course is beginning to be appreciated including its relationship with pain. First-line treatments for both psychiatric and chronic pain disorders include behavioral interventions such as cognitive behavioral therapy, hypnosis, and mindfulness, and there is emerging evidence studying Acceptance and Commitment Therapy and telehealth interventions. Pharmacological treatments using neuromodulators can also be beneficial. An integrated care team, such as a subspecialty medical home model, can provide the best patient experience and address comprehensive care needs efficiently and effectively. Psychosocial factors impact IBD course and necessitate effective management. Despite the significant limitations of research, particularly lack of clinical trials examining behavioral and pharmacotherapy interventions in IBD, effective treatments exist and are best utilized in an integrated care setting.

Antidepressants in inflammatory bowel disease

Gut-brain dysregulation has been recognized by the scientific community as being crucial to the understanding of chronic gastrointestinal conditions, and this has translated into the practice of a newly established discipline, psychogastroenterology. Along with psychotherapy, antidepressants (a subtype of central neuromodulators) have been proposed as treatments for gut-brain disorders that might benefit both psychological and gastrointestinal health. Antidepressants have been found to be effective for the treatment of comorbid anxiety and depression, pain and impaired sleep. Although the efficacy of antidepressants is well established in disorders of gut-brain interaction (DGBI), evidence is only now emerging in IBD. This Perspective discusses the use of antidepressants in DGBI and IBD, focusing on how what we have learnt about the role of antidepressants in DGBI could be applied to help optimize the management of IBD.