1
|
Dziegielewski C, Gupta S, Begum J, Pugliese M, Lombardi J, E K, Jd M, Sy R, N S, T R, Ei B, Sk M. 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. BMC Gastroenterol 2024; 24:172. [PMID: 38760679 PMCID: PMC11102236 DOI: 10.1186/s12876-024-03226-7] [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: 09/10/2023] [Accepted: 04/10/2024] [Indexed: 05/19/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- C Dziegielewski
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - S Gupta
- Department of Medicine, University of Toronto, Toronto, Ontario, ON, Canada
| | - J Begum
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
- ICES uOttawa, Ottawa, ON, Canada
| | - M Pugliese
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
- ICES uOttawa, Ottawa, ON, Canada
| | - J Lombardi
- Department of Medicine, McMaster University, Hamilton, Ontario, ON, Canada
| | - Kelly E
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - McCurdy Jd
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital IBD Centre, 501 Smyth Rd, K1H 8L6, Ottawa, ON, Canada
| | - R Sy
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital IBD Centre, 501 Smyth Rd, K1H 8L6, Ottawa, ON, Canada
| | - Saloojee N
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital IBD Centre, 501 Smyth Rd, K1H 8L6, Ottawa, ON, Canada
| | - Ramsay T
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Benchimol Ei
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Murthy Sk
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.
- ICES uOttawa, Ottawa, ON, Canada.
- The Ottawa Hospital IBD Centre, 501 Smyth Rd, K1H 8L6, Ottawa, ON, Canada.
| |
Collapse
|
2
|
Ji Y, Li H, Dai G, Zhang X, Ju W. Systematic review and meta-analysis: Impact of depression on prognosis in inflammatory bowel disease. J Gastroenterol Hepatol 2024. [PMID: 38655853 DOI: 10.1111/jgh.16568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 01/19/2024] [Accepted: 03/25/2024] [Indexed: 04/26/2024]
Abstract
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.
Collapse
Affiliation(s)
- Yuejin Ji
- Department of Clinical Pharmacology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Hongxiao Li
- College of Acupuncture Moxibustion and Tuina, Nanjing University of Chinese Medicine, Nanjing, China
| | - Guoliang Dai
- Department of Clinical Pharmacology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Xu Zhang
- School of Medicine and Holistic Integrative Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Wenzheng Ju
- Department of Clinical Pharmacology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| |
Collapse
|
3
|
Wang Y, Liu L, Han J, Fan X, Guo Q, Wu Z. Evaluating the Impact of Obesity and Different Metabolic Statuses on the Prognosis of Hospitalized Patients with Inflammatory Bowel Disease: A Cohort Study. Obes Facts 2023; 16:475-483. [PMID: 37552971 PMCID: PMC10601683 DOI: 10.1159/000531994] [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: 11/20/2022] [Accepted: 06/27/2023] [Indexed: 08/10/2023] Open
Abstract
INTRODUCTION Obesity is associated with an increased risk of inflammatory bowel disease (IBD), whereas not all obese individuals have the same effect. In individuals with obesity, the role of metabolic status in the readmission of IBD remains unclear. Our study aimed to evaluate the association between different obesity metabolic phenotypes and the prognosis of IBD patients. METHODS We conducted a longitudinal cohort study using Nationwide Readmissions Database (NRD) (2018 sample). Out of 12,928,231 discharge records, 63,748 records with a discharge diagnosis of IBD were identified for analysis. Cox proportional hazard ratio (HR) with 95% confidence interval (CI) was calculated, adjusting for potential confounders. RESULTS During a 180-day follow-up in IBD patients with different obesity metabolic phenotypes, all-cause readmission rate, inpatient mortality rate, unplanned readmission rate, total charge, hospitalized length of stay were statistically different (all p < 0.001). After multivariate Cox regression analysis, IBD patients with metabolically unhealthy nonobese (MUNO) had higher risk of readmission (all-cause and unplanned) (HR 1.04, 95% CI: 1.00-1.08 and HR 1.06, 95% CI: 1.02-1.10), and those with metabolically unhealthy obesity (MUO) had higher risk of unplanned readmission (HR 1.08, 95% CI: 1.02-1.15). In subgroup analysis, both the MUNO group and MUO group had higher risk of readmission (all-cause and unplanned) in the ulcerative colitis (UC) subgroup, but only the MUNO group had higher risk of readmission (all-cause and unplanned) (HR 1.05, 95% CI: 1.00-1.10 and HR 1.06, 95% CI: 1.01-1.12) in the Crohn's disease (CD) subgroup. CONCLUSION Metabolic abnormalities were associated with an increased risk of readmission in patients with IBD, regardless of obesity.
Collapse
Affiliation(s)
- Yanyan Wang
- Department of Endocrinology, Shandong Provincial Hospital, Shandong University, Jinan, China
- Key Laboratory of Endocrine Glucose and Lipids Metabolism and Brain Aging, Ministry of Education; Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Shandong Clinical Research Center of Diabetes and Metabolic Diseases, Jinan, China
- Shandong Institute of Endocrine and Metabolic Diseases, Jinan, China
- Shandong Engineering Laboratory of Prevention and Control for Endocrine and Metabolic Diseases, Jinan, China
- Feicheng Hospital Affiliated to Shandong First Medical University, Tai’an, China
| | - Luna Liu
- Department of Endocrinology, Shandong Provincial Hospital, Shandong University, Jinan, China
- Key Laboratory of Endocrine Glucose and Lipids Metabolism and Brain Aging, Ministry of Education; Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Shandong Clinical Research Center of Diabetes and Metabolic Diseases, Jinan, China
- Shandong Institute of Endocrine and Metabolic Diseases, Jinan, China
- Shandong Engineering Laboratory of Prevention and Control for Endocrine and Metabolic Diseases, Jinan, China
| | - Junming Han
- Key Laboratory of Endocrine Glucose and Lipids Metabolism and Brain Aging, Ministry of Education; Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Shandong Clinical Research Center of Diabetes and Metabolic Diseases, Jinan, China
- Shandong Institute of Endocrine and Metabolic Diseases, Jinan, China
- Shandong Engineering Laboratory of Prevention and Control for Endocrine and Metabolic Diseases, Jinan, China
| | - Xiude Fan
- Key Laboratory of Endocrine Glucose and Lipids Metabolism and Brain Aging, Ministry of Education; Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Shandong Clinical Research Center of Diabetes and Metabolic Diseases, Jinan, China
- Shandong Institute of Endocrine and Metabolic Diseases, Jinan, China
- Shandong Engineering Laboratory of Prevention and Control for Endocrine and Metabolic Diseases, Jinan, China
| | - Qingling Guo
- Key Laboratory of Endocrine Glucose and Lipids Metabolism and Brain Aging, Ministry of Education; Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Shandong Clinical Research Center of Diabetes and Metabolic Diseases, Jinan, China
- Shandong Institute of Endocrine and Metabolic Diseases, Jinan, China
- Shandong Engineering Laboratory of Prevention and Control for Endocrine and Metabolic Diseases, Jinan, China
| | - Zhongming Wu
- Key Laboratory of Endocrine Glucose and Lipids Metabolism and Brain Aging, Ministry of Education; Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Shandong Clinical Research Center of Diabetes and Metabolic Diseases, Jinan, China
- Shandong Institute of Endocrine and Metabolic Diseases, Jinan, China
- Shandong Engineering Laboratory of Prevention and Control for Endocrine and Metabolic Diseases, Jinan, China
| |
Collapse
|
4
|
Bischoff SC, Bager P, Escher J, Forbes A, Hébuterne X, Hvas CL, Joly F, Klek S, Krznaric Z, Ockenga J, Schneider S, Shamir R, Stardelova K, Bender DV, Wierdsma N, Weimann A. ESPEN guideline on Clinical Nutrition in inflammatory bowel disease. Clin Nutr 2023; 42:352-379. [PMID: 36739756 DOI: 10.1016/j.clnu.2022.12.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 12/05/2022] [Indexed: 01/15/2023]
Abstract
The present guideline is an update and extension of the ESPEN scientific guideline on Clinical Nutrition in Inflammatory Bowel Disease published first in 2017. The guideline has been rearranged according to the ESPEN practical guideline on Clinical Nutrition in Inflammatory Bowel Disease published in 2020. All recommendations have been checked and, if needed, revised based on new literature, before they underwent the ESPEN consensus procedure. Moreover, a new chapter on microbiota modulation as a new option in IBD treatment has been added. The number of recommendations has been increased to 71 recommendations in the guideline update. The guideline is aimed at professionals working in clinical practice, either in hospitals or in outpatient medicine, and treating patients with IBD. General aspects of care in patients with IBD, and specific aspects during active disease and in remission are addressed. All recommendations are equipped with evidence grades, consensus rates, short commentaries and links to cited literature.
Collapse
Affiliation(s)
- Stephan C Bischoff
- Institute of Nutritional Medicine, University of Hohenheim, Stuttgart, Germany.
| | - Palle Bager
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.
| | - Johanna Escher
- Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands.
| | - Alastair Forbes
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.
| | - Xavier Hébuterne
- Department of Gastroenterology and Clinical Nutrition, CHU of Nice, University Côte d'Azur, Nice, France.
| | - Christian Lodberg Hvas
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.
| | - Francisca Joly
- Department of Gastroenterology and Nutrition Support, CHU de Beaujon, APHP, University of Paris, Paris, France.
| | - Stansilaw Klek
- Surgical Oncology Clinic, Maria Sklodowska-Curie National Cancer Institute, Krakow, Poland.
| | - Zeljko Krznaric
- Department of Gastroenterology, Hepatology and Nutrition, University Hospital Centre Zagreb, University of Zagreb, Croatia.
| | - Johann Ockenga
- Medizinische Klinik II, Klinikum Bremen-Mitte, Bremen FRG, Bremen, Germany.
| | - Stéphane Schneider
- Department of Gastroenterology and Clinical Nutrition, CHU de Nice, University Côte d'Azur, Nice, France.
| | - Raanan Shamir
- Institute for Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Kalina Stardelova
- University Clinic for Gastroenterohepatology, Clinical Campus "Mother Theresa", University St Cyrul and Methodius, Skopje, North Macedonia.
| | - Darija Vranesic Bender
- Unit of Clinical Nutrition, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia.
| | - Nicolette Wierdsma
- Department of Nutrition and Dietetics, Amsterdam University Medical Centers, Amsterdam, the Netherlands.
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany.
| |
Collapse
|
5
|
Oseni EA, Blumenthal M, Izard S, Qiu M, Mone A, Swaminath A, Sultan K. Cannabis Use and Its Association With Thirty- and Ninety-Day Hospital Readmissions for Patients Admitted for an Inflammatory Bowel Disease Exacerbation. J Clin Med Res 2023; 15:99-108. [PMID: 36895626 PMCID: PMC9990718 DOI: 10.14740/jocmr4846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 02/09/2022] [Indexed: 03/06/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Ellen A Oseni
- Division of Gastroenterology, Northshore University Hospital, Manhasset, NY, USA
| | - Miriam Blumenthal
- Division of Gastroenterology, Northshore University Hospital, Manhasset, NY, USA
| | - Stephanie Izard
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Michael Qiu
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Anjali Mone
- Division of Gastroenterology, Lenox Hill Hospital, New York, NY, USA
| | - Arun Swaminath
- Division of Gastroenterology, Lenox Hill Hospital, New York, NY, USA
| | - Keith Sultan
- Division of Gastroenterology, Northshore University Hospital, Manhasset, NY, USA
| |
Collapse
|
6
|
Sheehan JL, Jacob J, Berinstein EM, Greene-Higgs L, Steiner CA, Berry SK, Shannon C, Cohen-Mekelburg SA, Higgins PDR, Berinstein JA. The Relationship Between Opioid Use and Healthcare Utilization in Patients With Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis. Inflamm Bowel Dis 2022; 28:1904-1914. [PMID: 35230420 PMCID: PMC9924039 DOI: 10.1093/ibd/izac021] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Indexed: 12/12/2022]
Abstract
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.
Collapse
Affiliation(s)
- Jessica L Sheehan
- Address correspondence to: Jessica L. Sheehan, MD, MS, 1500 E. Medical Center Drive, Ann Arbor, MI 48109, USA ()
| | - Janson Jacob
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Elliot M Berinstein
- Department of Medicine, St. Joseph Mercy Ann Arbor Hospital, Ypsilanti, MI, USA
| | | | - Calen A Steiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Colorado, Aurora, Colorado, USA
| | - Sameer K Berry
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Carol Shannon
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, Michigan, USA
| | - Shirley A Cohen-Mekelburg
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA,VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI, USA,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | | | | |
Collapse
|
7
|
Bai D, Li L, Shen Z, Huang T, Wang Q, Wang Y, Zhang Y, Guo Z, Li K, Xiao JA. Risk factors for developing high-output ileostomy in CRC patients: a retrospective study. BMC Surg 2021; 21:300. [PMID: 34174862 PMCID: PMC8235810 DOI: 10.1186/s12893-021-01288-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 06/06/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Anastomotic leakage is one of the most serious postoperative complications of rectal cancer. Prophylactic ileostomy has been widely used to reduce the risk and severity of complications of anastomotic leakage. However, prophylactic ileostomy itself has some complications, and ileostomy high output syndrome (HOS) is one of them. This study was performed to explore the risk factors of HOS in ileostomy. METHODS A total of 114 patients with HOS were screened out from 494 eligible ileostomy patients in the last 5 years. The relationship between HOS and the clinicopathological data was analyzed using the Chi-square test and Fisher's exact probability. Multivariate analysis was performed by logistic regression. RESULTS The incidence of HOS was 23.07% in this study. Dehydration was the most common symptom of HOS (37.7%). There was no clear correlation between HOS occurrence with sex, age, gross typing, histological grade, tumor location, lymph node metastasis, and TNM stage (p > 0.05). The incidence of HOS was 14/18 in inflammatory bowel disease patients, 18/28 in diabetes mellitus patients, and 23/72 in neoadjuvant chemoradiotherapy patients, 13/17 in total colectomy and abdominal infection patients. Multivariate analysis showed that they are risk factors for HOS (p < 0.05). CONCLUSION HOS occurred occasionally but rarely studied and lacks attention. Inflammatory bowel disease, diabetes mellitus, neoadjuvant radiotherapy chemotherapy, total colectomy and abdominal infection are the risk factors for HOS.
Collapse
Affiliation(s)
- Dongxiao Bai
- Department of Surgery, Anyang Tumor Hospital, No. 1 Huanbin North Road, Anyang, 455000, Henan, China
| | - Lei Li
- Department of Surgery, Anyang Tumor Hospital, No. 1 Huanbin North Road, Anyang, 455000, Henan, China
| | - Zhiling Shen
- Department of Surgery, Anyang Tumor Hospital, No. 1 Huanbin North Road, Anyang, 455000, Henan, China
| | - Tianchen Huang
- Department of Surgery, Anyang Tumor Hospital, No. 1 Huanbin North Road, Anyang, 455000, Henan, China
| | - Qingbing Wang
- Department of Surgery, Anyang Tumor Hospital, No. 1 Huanbin North Road, Anyang, 455000, Henan, China
| | - Yanjun Wang
- Department of Surgery, Anyang Tumor Hospital, No. 1 Huanbin North Road, Anyang, 455000, Henan, China
| | - Yong Zhang
- Department of Surgery, Anyang Tumor Hospital, No. 1 Huanbin North Road, Anyang, 455000, Henan, China
| | - Zhipeng Guo
- Department of Surgery, Anyang Tumor Hospital, No. 1 Huanbin North Road, Anyang, 455000, Henan, China
| | - Kan Li
- Department of Surgery, Anyang Tumor Hospital, No. 1 Huanbin North Road, Anyang, 455000, Henan, China
| | - Jian An Xiao
- Department of Surgery, Anyang Tumor Hospital, No. 1 Huanbin North Road, Anyang, 455000, Henan, China.
| |
Collapse
|
8
|
Milajerdi A, Abbasi F, Esmaillzadeh A. A systematic review and meta-analysis of prospective studies on obesity and risk of inflammatory bowel disease. Nutr Rev 2021; 80:479-487. [PMID: 34157115 DOI: 10.1093/nutrit/nuab028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 11/09/2020] [Accepted: 03/16/2021] [Indexed: 12/16/2022] Open
Abstract
CONTEXT There are only a few systematic reviews on the association of obesity with risk of inflammatory bowel disease (IBD) to date. OBJECTIVE The current study was undertaken to systematically review prospective cohort studies on the association between body mass index (BMI) and risk of IBD. It was carried out according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. DATA SOURCES Relevant prospective cohort studies published from 1969 to July 2020 were searched through PubMed, MEDLINE, SCOPUS, EMBASE, and Google Scholar, using suitable keywords. DATA EXTRACTION Hazard ratios (HRs) or relative risks (RRs) and 95% confidence intervals (CIs) for IBD or its subtypes across categories of BMI were extracted. DATA ANALYSIS The log HRs/RRs, including standard errors, were calculated based on reported HRs or RRs and their 95% CIs, and overall effect size was calculated using a fixed-effects model. All statistical analyses were done using STATA version 14.0 (Stata Corp LP, College Station, TX, USA). CONCLUSION Overall, 9 studies were included. Combining findings from 5 studies, a statistically significant 21% lower risk of ulcerative colitis incidence was found in patients with obesity than in those with normal weight (RR, 0.79; 95% CI, 0.68-0.92; I2= 0.0%), but not with risk of ulcerative colitis exacerbation, as found by meta-analysis of 3 studies. Pooling data from 5 studies, no significant differences were seen in the risk of Crohn's disease incidence between patients in the highest range of BMI and those in the normal range. In addition, no significant nonlinear association was found between BMI and risk of Crohn's disease (P=0.94). A significant inverse association was found between obesity and total IBD incidence (RR, 0.76; 95% CI, 0.66-0.88; I2=93.2%), but not between increasing BMI and IBD exacerbation, or between increasing BMI and IBD incidence.
Collapse
Affiliation(s)
- Alireza Milajerdi
- A. Milajerdi is with Research Center for Biochemistry and Nutrition in Metabolic Diseases, Institute for Basic Sciences, Kashan University of Medical Sciences, Kashan, Iran. A. Milajerdi and A. Esmaillzadeh are with the Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran. A. Milajerdi is with the Department of Health, Science and Research Branch, AJA University of Medical Sciences, Tehran, Iran. F Abbasi is with the Department of Sports Injuries, Faculty of Physical Education and Sports Sciences, Allameh Tabataba'i University, Tehran, Iran. A. Esmaillzadeh is with the Obesity and Eating Habits Research Center, Endocrinology and Metabolism Molecular - Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran. A Esmaillzadeh is with the Food Security Research Center, Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fatemeh Abbasi
- A. Milajerdi is with Research Center for Biochemistry and Nutrition in Metabolic Diseases, Institute for Basic Sciences, Kashan University of Medical Sciences, Kashan, Iran. A. Milajerdi and A. Esmaillzadeh are with the Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran. A. Milajerdi is with the Department of Health, Science and Research Branch, AJA University of Medical Sciences, Tehran, Iran. F Abbasi is with the Department of Sports Injuries, Faculty of Physical Education and Sports Sciences, Allameh Tabataba'i University, Tehran, Iran. A. Esmaillzadeh is with the Obesity and Eating Habits Research Center, Endocrinology and Metabolism Molecular - Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran. A Esmaillzadeh is with the Food Security Research Center, Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ahmad Esmaillzadeh
- A. Milajerdi is with Research Center for Biochemistry and Nutrition in Metabolic Diseases, Institute for Basic Sciences, Kashan University of Medical Sciences, Kashan, Iran. A. Milajerdi and A. Esmaillzadeh are with the Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran. A. Milajerdi is with the Department of Health, Science and Research Branch, AJA University of Medical Sciences, Tehran, Iran. F Abbasi is with the Department of Sports Injuries, Faculty of Physical Education and Sports Sciences, Allameh Tabataba'i University, Tehran, Iran. A. Esmaillzadeh is with the Obesity and Eating Habits Research Center, Endocrinology and Metabolism Molecular - Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran. A Esmaillzadeh is with the Food Security Research Center, Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| |
Collapse
|
9
|
Weissman S, Sharma, S, Fung BM, Aziz M, Sciarra M, Swaminath A, Feuerstein JD. Increased Mortality and Healthcare Costs Upon Hospital Readmissions of Ulcerative Colitis Flares: A Large Population-Based Cohort Study. CROHN'S & COLITIS 360 2021; 3:otab029. [PMID: 36776672 PMCID: PMC9802231 DOI: 10.1093/crocol/otab029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Indexed: 12/15/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Simcha Weissman
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, New Jersey, USA,Address correspondence to: Simcha Weissman, DO, Department of Medicine, Hackensack Meridian Health Palisades Medical Center, 7600 River Road, North Bergen, NJ 07047, USA ()
| | - Sachit Sharma,
- Department of Medicine, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Brian M Fung
- Division of Gastroenterology and Hepatology, University of Arizona College of Medicine—Phoenix, Phoenix, Arizona, USA
| | - Muhammad Aziz
- Division of Gastroenterology, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Michael Sciarra
- Department of Gastroenterology and Hepatology, Hackensack Meridian Health Palisades Medical Center, North Bergen, New Jersey, USA
| | - Arun Swaminath
- Division of Gastroenterology, Inflammatory Bowel Disease Program, Lenox Hill Hospital, New York, New York, USA
| | - Joseph D Feuerstein
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
10
|
Sbeit W, Khoury T, Kadah A, Shahin A, Shafrir A, Kalisky I, Hazou W, Katz L, Mari A. Nonattendance to gastroenterologist follow-up after discharge is associated with a thirty-days re-admission in patients with inflammatory bowel disease: a multicenter study. Minerva Med 2021; 112:467-473. [PMID: 33881281 DOI: 10.23736/s0026-4806.21.07442-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) is a set of chronic inflammatory diseases associated with significant morbidity and high hospitalization rate. IBD patients are particularly prone to rehospitalization resulting in high medical cost and morbidity. The aim of this study was to assess laboratory and clinical predictors of readmission in patients who were hospitalized with IBD flare. METHODS A multicenter, retrospective, cross-sectional analysis included IBD patients who were admitted with disease exacerbation from January 1, 2019 to January 1, 2020 in three Israeli university hospitals (Nazareth Hospital, Galilee Medical Center and Hadassah Medical Organization). RESULTS Overall, a total of 176 hospitalizations for IBD flares were included. Seventeen patients were readmitted within 30 days after discharge (group A), as compared to 159 patients who were not (group B). The average age was 35.3±19.2 years in group A vs. 38.6±16 years in group B. Eight (47.1%) and 9 (52.9%) patients had Crohn's disease (CD) and ulcerative colitis (UC) in group A as compared to 102 (64.2%) and 57 (35.9%) in group B, respectively. On univariate analysis, only the attendance to gastroenterology clinic follow-up after discharge from hospitalization due to IBD flare was significantly protective factor to with 30-days readmission (OR=0.37, 95% CI: 0.13-1, P=0.05). There were no associations with the other assessed clinical and laboratory parameters and importantly IBD type (OR=1.99, 95% CI: 0.74-5.34, P=0.17). Notably, there was no effect of the day of discharge white blood counts, albumin and C reactive protein (CRP) values on readmission rates (odds ratio [OR]=1.07, 95% CI: 0.96-1.20, P=0.19, OR=0.86, 95% CI: 0.39-1.91, P=0.71 and OR=0.99, 95% CI: 0.97-1.01, P=0.59), respectively. CONCLUSIONS Attendance to out-patient gastroenterologist follow-up is the only significant protective parameter to 30-days readmission in patients with IBD. This finding highlights the vital need of adequate gastroenterological follow-up of these patients after hospital discharge. Further studies are warranted to precisely define timing and role of outpatient follow-up in reducing IBD readmissions.
Collapse
Affiliation(s)
- Wisam Sbeit
- Department of Gastroenterology, Galilee Medical Center, Nahariya, Israel.,Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Tawfik Khoury
- Department of Gastroenterology, Galilee Medical Center, Nahariya, Israel.,Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Anas Kadah
- Department of Gastroenterology, Galilee Medical Center, Nahariya, Israel.,Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Amir Shahin
- Department of Gastroenterology, Galilee Medical Center, Nahariya, Israel.,Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Asher Shafrir
- Department of Gastroenterology, Hadassah Medical Organization-Hebrew University, Jerusalem, Israel
| | - Itai Kalisky
- Department of Gastroenterology, Hadassah Medical Organization-Hebrew University, Jerusalem, Israel
| | - Wadi Hazou
- Department of Gastroenterology, Hadassah Medical Organization-Hebrew University, Jerusalem, Israel
| | - Lior Katz
- Department of Gastroenterology, Hadassah Medical Organization-Hebrew University, Jerusalem, Israel
| | - Amir Mari
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel - .,Unit of Gastroenterology and Endoscopy, The Nazareth Hospital EMMS, Nazareth, Israel
| |
Collapse
|
11
|
El-Dallal M, Stein DJ, Raita Y, Feuerstein JD. The impact of obesity on hospitalized patients with ulcerative colitis. Ann Gastroenterol 2021; 34:196-201. [PMID: 33654359 PMCID: PMC7903582 DOI: 10.20524/aog.2021.0592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/10/2020] [Indexed: 11/11/2022] Open
Abstract
Background Obesity is the fifth leading risk factor for mortality in the world and it has increased among patients with ulcerative colitis in recent years. We examined the impact of obesity on the hospitalized patients admitted primarily with a diagnosis of ulcerative colitis. Methods We used the National Inpatient Sample data for the year 2016 to identify patients with ulcerative colitis and compared obese and non-obese patients in terms of length of hospital stay, total charges, and mortality. We used multiple imputations to estimate missing values and survey analysis to estimate the outcomes, and we adjusted for confounders by implementing the inverse probability of treatment weighting using propensity score. Results A total of 61,075 admissions with ulcerative colitis were identified. Among these, 6020 were diagnosed with obesity. Baseline hospital and patient characteristics between the 2 groups were notable for differences in age and sex. Patients with obesity were found to have a mean hospital stay longer by 0.57 days (95% confidence interval [CI] 0.22-0.93; P=0.002) and charges $6341.71 higher (95%CI 2499.72-10,183.71; P=0.001) compared to non-obese patients. There was no difference in hospital mortality, with an odds ratio of 0.28 (95%CI 0.04-2.05; P=0.212). Conclusion In a comprehensive review of inpatient admissions in 2016, primarily for ulcerative colitis, obesity was associated with a longer hospital stay and higher total charges per admission after balancing of confounders.
Collapse
Affiliation(s)
- Mohammed El-Dallal
- Division of Hospital Medicine, Cambridge Health Alliance and Harvard Medical School, Cambridge, MA (Mohammed El-Dallal).,Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (Mohammed El-Dallal, Joseph D. Feuerstein)
| | - Daniel J Stein
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (Daniel J. Stein)
| | - Yoshihiko Raita
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Yoshihiko Raita), USA
| | - Joseph D Feuerstein
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (Mohammed El-Dallal, Joseph D. Feuerstein)
| |
Collapse
|
12
|
Nguyen NH, Koola J, Dulai PS, Prokop LJ, Sandborn WJ, Singh S. Rate of Risk Factors for and Interventions to Reduce Hospital Readmission in Patients With Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol 2020; 18:1939-1948.e7. [PMID: 31470176 PMCID: PMC7044053 DOI: 10.1016/j.cgh.2019.08.042] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/15/2019] [Accepted: 08/21/2019] [Indexed: 02/07/2023]
Abstract
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.
Collapse
Affiliation(s)
- Nghia H. Nguyen
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Jejo Koola
- Division of Hospital Medicine, Department of Medicine, University of California San Diego, La Jolla, California,Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, California
| | - Parambir S. Dulai
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Larry J. Prokop
- Department of Library Services, Mayo Clinic, Rochester, Minnesota
| | - William J. Sandborn
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Siddharth Singh
- Division of Gastroenterology, University of California, San Diego, La Jolla, California; Division of Biomedical Informatics, Department of Medicine, University of California, San Diego, La Jolla, California.
| |
Collapse
|
13
|
Santiago M, Magro F, Correia L, Portela F, Ministro P, Lago P, Trindade E, Dias CC. Rehospitalization rates, costs, and risk factors for inflammatory bowel disease: a 16-year nationwide study. Therap Adv Gastroenterol 2020; 13:1756284820923836. [PMID: 35154386 PMCID: PMC8832310 DOI: 10.1177/1756284820923836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 04/09/2020] [Indexed: 02/04/2023] Open
Abstract
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.
Collapse
Affiliation(s)
| | | | - Luís Correia
- Portuguese Inflammatory Bowel Disease (IBD)
Study Group (GEDII), Porto, Portugal,Department of Gastroenterology, Hospital Santa
Maria, University Hospital Center of Lisbon North, Lisbon, Portugal
| | - Francisco Portela
- Portuguese Inflammatory Bowel Disease (IBD)
Study Group (GEDII), Porto, Portugal,Department of Gastroenterology, University
Hospital Center of Coimbra, Coimbra, Portugal
| | - Paula Ministro
- Portuguese Inflammatory Bowel Disease (IBD)
Study Group (GEDII), Porto, Portugal,Department of Gastroenterology, Tondela-Viseu
Hospital Center, Viseu, Portugal
| | - Paula Lago
- Portuguese Inflammatory Bowel Disease (IBD)
Study Group (GEDII), Porto, Portugal,Department of Gastroenterology, Hospital Santo
António, University Hospital Center of Porto, Porto, Portugal
| | - Eunice Trindade
- Portuguese Inflammatory Bowel Disease (IBD)
Study Group (GEDII), Porto, Portugal,Department of Pediatrics, São João Hospital
Center, Porto, Portugal
| | - Cláudia Camila Dias
- Center for Health Technology and Services
Research (CINTESIS), Porto, Portugal,Department of Community Medicine, Information
and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of
Porto, Portugal
| |
Collapse
|
14
|
Rahmani J, Kord Varkaneh H, Hekmatdoost A, Thompson J, Clark C, Salehisahlabadi A, Day AS, Jacobson K. In Reply to (Meta-analysis on obesity and risk of inflammatory bowel disease: re-analysis is needed). Obes Rev 2020; 21:e12956. [PMID: 31691435 DOI: 10.1111/obr.12956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 09/12/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Jamal Rahmani
- Department of Community Nutrition, Student Research Committee, Faculty of Nutrition and Food Technology, National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamed Kord Varkaneh
- Students' Scientific Research Center (SSRC), Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Azita Hekmatdoost
- Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jacqueline Thompson
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, OX3 7LD, UK
| | - Cain Clark
- School of Life Sciences, Coventry University, Coventry, CV1 5FB, United Kingdom
| | - Ammar Salehisahlabadi
- Students' Scientific Research Center (SSRC), Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Andrew S Day
- Department of Paediatrics, University of Otago, Christchurch, Christchurch, New Zealand
| | - Kevan Jacobson
- Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
15
|
Milajerdi A, Larijani B, Esmaillzadeh A. Metaanalysis on obesity and risk of inflammatory bowel disease: Reanalysis is needed. Obes Rev 2020; 21:e12965. [PMID: 31692191 DOI: 10.1111/obr.12965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 09/17/2019] [Indexed: 01/04/2023]
Affiliation(s)
- Alireza Milajerdi
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran.,Students' Scientific Research Center (SSRC), Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmad Esmaillzadeh
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran.,Obesity and Eating Habits Research Center, Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.,Food Security Research Center, Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| |
Collapse
|
16
|
Risk factors for 90-day readmission and return to the operating room following abdominal operations for Crohn’s disease. Surgery 2019; 166:1068-1075. [DOI: 10.1016/j.surg.2019.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/19/2019] [Accepted: 08/11/2019] [Indexed: 12/17/2022]
|
17
|
George LA, Martin B, Gupta N, Shastri N, Venu M, Naik AS. Predicting 30-Day Readmission Rate in Inflammatory Bowel Disease Patients: Performance of LACE Index. CROHN'S & COLITIS 360 2019. [DOI: 10.1093/crocol/otz007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AbstractBackground and AimsReadmission within 30 days in inflammatory bowel disease (IBD) patients increases treatment costs and serves as a quality indicator. The LACE (Length of stay, Acuity of admission, Charlson comorbidity index, Emergency Department visits in past 6 months) index is used to predict the risk of unplanned readmission within 30 days. The aim of this study was to evaluate the accuracy of using the LACE index in IBD.MethodsCalculation of LACE index was done prospectively for IBD patients admitted to a single tertiary care center. Patient, disease, and treatment characteristics, as well as index hospitalization characteristics including indication for admission and disease activity measures were retrospectively recorded. Descriptive statistics and univariable exact logistic regression analyses were performed.ResultsIn total, 64 IBD patients were admitted during the study period. The 30-day readmission rate of IBD patients was 19% and overall median LACE index was 6, with IQR 6–7. LACE index categorized 16% of IBD patients in low-risk group, 82% in moderate risk group, and 2% in high-risk group. LACE index did not predict 30-day readmission (OR 1.35, CI: 0.88–2.18, P = 0.19). There was no significant difference in 30-day readmission rates with inpatient antibiotic or narcotic use, admission C-reactive protein (CRP), anemia, IBD duration, maintenance therapy, or prior IBD operation. For every 1 day increase in length of stay (LOS), patients were 8% more likely (OR: 1.08, 95% CI: 1.00–1.16) to be readmitted within 30 days (P = .05).ConclusionsLACE index does not accurately identify 30-day readmission risk in the IBD population. As increased LOS is associated with higher risk, there may be benefit for targeted strategic resource allocation via specialized services.
Collapse
Affiliation(s)
- Lauren A George
- Division of Gastroenterology and Nutrition, Loyola University Medical Center, Maywood, IL
| | | | - Neil Gupta
- Division of Gastroenterology and Nutrition, Loyola University Medical Center, Maywood, IL
| | - Nikhil Shastri
- Division of Gastroenterology and Nutrition, Loyola University Medical Center, Maywood, IL
| | - Mukund Venu
- Division of Gastroenterology and Nutrition, Loyola University Medical Center, Maywood, IL
| | - Amar S Naik
- Division of Gastroenterology and Nutrition, Loyola University Medical Center, Maywood, IL
| |
Collapse
|
18
|
Warren LR, Clarke JM, Arora S, Barahona M, Arebi N, Darzi A. Transitions of care across hospital settings in patients with inflammatory bowel disease. World J Gastroenterol 2019; 25:2122-2132. [PMID: 31114138 PMCID: PMC6506584 DOI: 10.3748/wjg.v25.i17.2122] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 02/05/2019] [Accepted: 02/23/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Inflammatory bowel disease (IBD) is a chronic, inflammatory disorder characterised by both intestinal and extra-intestinal pathology. Patients may receive both emergency and elective care from several providers, often in different hospital settings. Poorly managed transitions of care between providers can lead to inefficiencies in care and patient safety issues. To ensure that the sharing of patient information between providers is appropriate, timely, accurate and secure, effective data-sharing infrastructure needs to be developed. To optimise inter-hospital data-sharing for IBD patients, we need to better understand patterns of hospital encounters in this group.
AIM To determine the type and location of hospital services accessed by IBD patients in England.
METHODS This was a retrospective observational study using Hospital Episode Statistics, a large administrative patient data set from the National Health Service in England. Adult patients with a diagnosis of IBD following admission to hospital were followed over a 2-year period to determine the proportion of care accessed at the same hospital providing their outpatient IBD care, defined as their ‘home provider’. Secondary outcome measures included the geographic distribution of patient-sharing, regional and age-related differences in accessing services, and type and frequency of outpatient encounters.
RESULTS 95055 patients accessed hospital services on 1760156 occasions over a 2-year follow-up period. The proportion of these encounters with their identified IBD ‘home provider’ was 73.3%, 87.8% and 83.1% for accident and emergency, inpatient and outpatient encounters respectively. Patients living in metropolitan centres and younger patients were less likely to attend their ‘home provider’ for hospital services. The most commonly attended specialty services were gastroenterology, general surgery and ophthalmology.
CONCLUSION Transitions of care between secondary care settings are common for patients with IBD. Effective systems of data-sharing and care integration are essential to providing safe and effective care for patients. Geographic and age-related patterns of care transitions identified in this study may be used to guide interventions aimed at improving continuity of care.
Collapse
Affiliation(s)
- Leigh R Warren
- Patient Safety Translational Research Centre, Imperial College London, London W2 1NY, United Kingdom
- Department of Surgery and Cancer, Imperial College London, London W2 1NY, United Kingdom
| | - Jonathan M Clarke
- Centre for Health Policy, Imperial College London Centre for Mathematics of Precision Healthcare, Imperial College London, London SW7 2BX, United Kingdom
- Department of Biostatistics, Harvard University, Boston, MA 02115, United States
- Department of Surgery and Cancer, Imperial College London, London W2 1NY, United Kingdom
| | - Sonal Arora
- Patient Safety Translational Research Centre, Imperial College London, London W2 1NY, United Kingdom
- Department of Surgery and Cancer, Imperial College London, London W2 1NY, United Kingdom
| | - Mauricio Barahona
- Centre for Health Policy, Imperial College London Centre for Mathematics of Precision Healthcare, Imperial College London, London SW7 2BX, United Kingdom
- Department of Mathematics, Imperial College London, London SW7 2BX, United Kingdom
| | - Naila Arebi
- Department of Gastroenterology, St. Marks Academic Institute, Harrow HA1 3UJ, United Kingdom
| | - Ara Darzi
- Patient Safety Translational Research Centre, Imperial College London, London W2 1NY, United Kingdom
- Department of Surgery and Cancer, Imperial College London, London W2 1NY, United Kingdom
| |
Collapse
|
19
|
Schmidt T, Feagins LA. How Can We Improve to Keep Our Patients Out of the Hospital? Inflamm Bowel Dis 2019; 25:980-986. [PMID: 30380035 DOI: 10.1093/ibd/izy335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Indexed: 12/21/2022]
Abstract
Many patients with inflammatory bowel disease (IBD) endure a hospital admission during the course of their disease, and there is a portion of patients who are readmitted not infrequently. Time spent in the hospital puts not only a large burden on patients but also accounts for substantial health care costs in the United States. Studies to date evaluating causes for readmission have largely been retrospective and have identified several important risk factors increasing readmission rates, including psychiatric comorbidity, use of steroids, failure to begin biologic therapy, and concomitant infections such as Clostridium difficile. In this review, we explore the risk factors for readmissions in patients with IBD and how we may be able to address these issues moving forward to reduce the burden of hospitalization for this population.
Collapse
Affiliation(s)
- Taylor Schmidt
- Division of gastroenterology and Hepatology, VA North Texas Healthcare System, Dallas, Texas
- Department of Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Linda A Feagins
- Division of gastroenterology and Hepatology, VA North Texas Healthcare System, Dallas, Texas
- Department of Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
20
|
Kruger AJ, Hinton A, Afzali A. Index Severity Score and Early Readmission Predicts Increased Mortality in Ulcerative Colitis Patients. Inflamm Bowel Dis 2019; 25:894-901. [PMID: 30247551 DOI: 10.1093/ibd/izy297] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Readmissions are common after hospitalization related to ulcerative colitis (UC). A risk score to stratify the severity of UC hospitalizations and risk of colectomy has been previously reported. Our aim was to predict hospital-related outcomes after hospitalizations for UC utilizing this severity score. METHODS We utilized the Nationwide Readmissions Database (2010-2014) for hospitalized patients with UC and differentiated patients by index severity (low, intermediate, high). Baseline characteristics, surgical rates, readmissions, mortality, and hospital outcomes were collected. The primary outcomes of interest included readmission and mortality rates. RESULTS There were 133,819 patients admitted with UC with 22,762 (17%) readmitted within 30 days. Those readmitted within 30 days had a 4.5% calendar year mortality rate, compared with 0.45% in those not readmitted within 30 days (P < 0.001). Index surgery rates (19.2% vs 12.3%), length of stay (6.9 vs 5.4 days), and hospital costs ($13,530 vs $10,366; P < 0.001 for all) were higher in those readmitted within 30 days. Patients with high-severity presentations had higher surgical rates (31.6%), higher 30-day and calendar year readmission rates (24.3% and 46.0%, respectively), increased index and calendar year mortality (2.5% and 2.0%, respectively), longer length of stay (15.1 days), and increased costs ($31,136) compared with those with low severity (P < 0.001 for all). Calendar-year survival rates in those with intermediate and high scores were significantly lower than in those with low scores. CONCLUSIONS An index severity score of intermediate or high and early readmissions are predictors of calendar year mortality. Future efforts should emphasize more focused care in high-risk patients, as this may reduce readmissions and improve outcomes.
Collapse
Affiliation(s)
- Andrew J Kruger
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Alice Hinton
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, Ohio
| | - Anita Afzali
- Inflammatory Bowel Disease Center at The Ohio State University Wexner Medical Center, Columbus, Ohio.,Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio
| |
Collapse
|
21
|
Nguyen NH, Ohno-Machado L, Sandborn WJ, Singh S. Obesity Is Independently Associated With Higher Annual Burden and Costs of Hospitalization in Patients With Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol 2019; 17:709-718.e7. [PMID: 30012429 DOI: 10.1016/j.cgh.2018.07.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Revised: 04/10/2018] [Accepted: 07/05/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Approximately 15%-40% patients with inflammatory bowel diseases (IBD) are obese. There is an inconsistent association between obesity and IBD phenotype and course. We conducted a nationally representative cohort study to estimate and compare the burden, costs, and causes for hospitalization in obese vs non-obese patients with IBD. METHODS Using the Nationwide Readmissions Database 2013, we identified obese (based on administrative claims code) and non-obese patients who had been hospitalized at least once, from January through June 2013, and followed them for re-hospitalization until December 2013. We compared annual burden (total days spent in hospital), costs, causes, and outcomes of hospitalization between obese and non-obese patients after 1:1 propensity score matching. RESULTS We identified 42,285 patients with IBD, of which 12.4% were obese. After propensity score matching, we included 5128 obese and 5128 non-obese IBD patients in our analysis. Compared to non-obese patients, obese patients spent more days in hospital annually (median, 8 vs 5 days) (P < .01), with higher hospitalization-related costs (median, $17,277 vs $11,847) (P < .01); this pattern persisted in subsets of high-need and high-cost patients. Compared to non-obese patients, obese patients were more likely to be hospitalized with preventable admissions (19% vs 15%) or cardiopulmonary complications (16% vs 12%). CONCLUSIONS In an analysis of data on patients with IBD from the Nationwide Readmissions Database 2013, we found obesity to be independently associated with higher burden and costs of hospitalizations. Strategies should be considered to target obesity as adjunctive therapy for patients with IBD.
Collapse
Affiliation(s)
- Nghia H Nguyen
- Department of Internal Medicine, University of California San Diego, La Jolla, California
| | - Lucila Ohno-Machado
- Division of Biomedical Informatics, University of California San Diego, La Jolla, California
| | - William J Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Siddharth Singh
- Division of Biomedical Informatics, University of California San Diego, La Jolla, California; Division of Gastroenterology, University of California San Diego, La Jolla, California.
| |
Collapse
|
22
|
Iqbal A, Sakharuk I, Goldstein L, Tan SA, Qiu P, Li Z, Hughes SJ. Readmission After Elective Ileostomy in Colorectal Surgery Is Predictable. JSLS 2018; 22:JSLS.2018.00008. [PMID: 30275672 PMCID: PMC6158969 DOI: 10.4293/jsls.2018.00008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background and Objectives: Patients who undergo colorectal surgery have high postoperative morbidity, with ileostomates being the most disadvantaged. Recent studies assessing readmission risk factors do not provide a specific prediction model and, if so, do not focus on patients who have had colorectal surgery; thus, the results of these studies have limited applicability to our specialized practice. We wanted to develop a prediction model for readmission within 30 days of discharge after ileostomy creation. Methods: Patients who underwent elective ileostomy creation from 2013 to 2016 at the University of Florida were included in this retrospective study. Factors significantly associated with readmission within 30 days after discharge were identified by comparing a cohort that was readmitted within 30 days with one that was not. A practical, predictive model that stratified a patient's risk of readmission after the index procedure was developed. Results: A total of 86 iliostomates were included; of those, 22 (26%) were readmitted within 30 days. Factors significantly associated with readmission included preoperative steroid use, history of diabetes, history of depression, lack of a hospital social worker or postoperative ostomy education, and the presence of complications after the index procedure. A model predicting readmission within 30 days of discharge that comprised the first 4 factors was developed, with a sensitivity of 73% and a specificity of 77%. Conclusion: Prediction of readmission in patients who undergo ileostomy creation is possible, suggesting interventions addressing predictive factors that may help decrease the readmission rate. Prospective validation of the model in a larger cohort is needed.
Collapse
Affiliation(s)
| | - Ilya Sakharuk
- University of Florida College of Medicine, Gainesville, Florida, USA
| | | | | | - Peihua Qiu
- Biostatistics, University of Florida, Gainesville, Florida
| | - Zhaomian Li
- Biostatistics, University of Florida, Gainesville, Florida
| | | |
Collapse
|
23
|
Singh S, Proudfoot J, Xu R, Sandborn WJ. Impact of Obesity on Short- and Intermediate-Term Outcomes in Inflammatory Bowel Diseases: Pooled Analysis of Placebo Arms of Infliximab Clinical Trials. Inflamm Bowel Dis 2018; 24:2278-2284. [PMID: 29788260 PMCID: PMC6140448 DOI: 10.1093/ibd/izy135] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Indexed: 12/15/2022]
Abstract
Background and aims To assess whether obesity may affect natural history of inflammatory bowel diseases (IBD), we conducted an individual participant data (IPD) pooled analysis of placebo arms, using data from clinical trials of infliximab in IBD and using the Yale Open Data Access (YODA) Project. Methods We obtained IPD from 4 placebo-controlled trials of infliximab in adults with IBD (ACCENT-I and ACCENT-II; ACT-1 and ACT-2). Patients were categorized into quartiles based on body mass index (BMI) or weight at time of trial entry. Primary outcome was clinical remission (Crohn's disease activity index [CDAI]<150, Mayo Clinic Score <3); secondary outcomes were clinical response and mucosal healing. Using multivariable logistic regression analysis, we compared association between quartiles of BMI (or weight) and achieving remission, after adjusting for sex, smoking, disease activity, and concomitant prednisone or immunomodulators. Results We included 575 placebo-treated patients (mean age 38 years, 51.6% males, 16% obese). Obesity was not associated with odds of achieving clinical remission (Q4 vs Q1: adjusted OR, 1.36; 95% CI, 0.65-2.89; P-value for trend = 0.57), clinical response (Q4 vs Q1: adjusted OR, 1.31; 95% CI, 0.61-2.81; P = 0.45), or mucosal healing remission (Q4 vs Q1: adjusted OR, 0.55; 95% CI, 0.12-2.34; P = 0.31). These results were consistent across strata based on disease type (CD and ulcerative colitis) and trial design (induction and maintenance therapy). Conclusions Based on IPD pooled analysis of placebo arms, obesity does not significantly impact short- and intermediate-term clinical outcomes in patients with IBD. The impact of obesity on long-term patient-important outcomes like surgery and hospitalization merits evaluation.
Collapse
Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
- Division of Biomedical Informatics, University of California San Diego, La Jolla, California, USA
| | - James Proudfoot
- Biostatistics Unit, Altman Clinical and Translational Research Institute, University of California San Diego, La Jolla, California, USA
| | - Ronghui Xu
- Department of Family Medicine and Public Health and Department of Mathematics, University of California San Diego, La Jolla, California, USA
| | - William J Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| |
Collapse
|