Emergency department utilisation for inflammatory bowel disease in the United States from 2006 to 2014

Risk factors for recurrent emergency care utilization for flares in inflammatory bowel disease

OBJECTIVES

Patients with inflammatory bowel disease (IBD) need frequent emergency care due to flares of their disease. However, understanding which patients are most vulnerable to repeat emergency care due to recurrent flares of their disease remains poor.

METHODS

This was a retrospective cohort study of Kaiser Permanente Northern California health plan members aged ≥18 years between 2009 and 2018. Our primary outcome was occurrence of repeat emergency department (ED) visits with a primary diagnosis code of IBD in the 6 months following their index ED visit. Baseline characteristics and clinical service use patterns were extracted. We used multivariable negative binomial regression analysis to measure the incident risk of a recurrent ED visit within 6 months.

RESULTS

We found 2111 patients who met eligibility criteria, of whom 56.7% were female and 39.7% were non-White. During the 6-month observation period, 19.3% (n = 408) returned to the ED for a second IBD flare. In adjusted analyses, we found older age (incident risk ratio [IRR] 0.44, 95% confidence interval [CI] 0.31-0.62 for age 60+ compared to 18-30), higher neighborhood household income (IRR 0.80, 95% CI 0.65-0.98 for income ≥$85,000), and diagnosis of alcohol use disorder were associated with a lower risk of repeat ED utilization (IRR 0.62, 95% CI 0.41-0.93), while presence of mood disorder (IRR 1.26, 95% CI 1.03-1.58), history of opiate prescription (IRR 1.38, 95% CI 1.10-1.73), and corticosteroid prescription (IRR 1.57, 95% CI 1.27-1.95) were associated with increased risk of repeat ED utilization. Prompt outpatient follow-up was not associated with a lower odds of recurrent ED utilization (IRR 0.93, 95% CI 0.75-1.15).

CONCLUSIONS

Our study identified multiple patient characteristics associated with higher recurrent short-term use of the ED for IBD care. Although we did not find prompt outpatient follow-up after initial ED visit to be protective, targeted interventions directed at high-risk individuals based on mood disorders, opiate use, or steroid use may help to optimize care and health care utilization.

Polysubstance use in inflammatory bowel disease is associated with increased risk of emergency department visits: a longitudinal study

Background

Polysubstance use (PSU), the simultaneous use of 2 or more substances of abuse, is common in inflammatory bowel disease (IBD). Preliminary studies suggest it may be associated with poor outcomes. This prospective study evaluated the impact of PSU on disease activity and healthcare resource utilization in IBD.

Methods

This study was conducted in a tertiary IBD center between October 29, 2015, and December 31, 2019. Participants were assessed over 2 time points (index and follow-up outpatient appointments) separated by a minimum of 6 months. Demographics, endoscopic disease activity, and surveys assessing symptoms, healthcare resource utilization and substance use (tobacco, alcohol, marijuana, cocaine, methamphetamine, heroin, opioid, or benzodiazepine) were abstracted. We identified PSU during the index appointment and computed descriptive statistics and contingency table analyses, and multivariate logistic regression models at follow up to evaluate outcomes.

Results

162 consecutively enrolled IBD patients were included. Seventy-five patients (46%) were polysubstance users at the index appointment. The most common cohorts were utilizing tobacco and alcohol (n=40) or tobacco and opioids (n=13). On bivariate and multivariate analyses, PSU during the index visit was positively associated with emergency department (ED) visits (odds ratio [OR] 2.51, 95% confidence interval [CI] 1.24-5.07; P=0.01) and negatively associated with extraintestinal manifestations (OR 0.37, 95%CI 0.18-0.74; P=0.005). Age, sex, disease activity, disease subtype and IBD-related symptoms were not associated with PSU.

Conclusions

IBD patients exhibiting PSU had increased risk of future ED visits. This study highlights the risks of PSU and reinforces the importance of appropriate substance use screening.

Trends in hospital admissions and mortality among inflammatory bowel disease patients with substance use disorder: a 10-year United States nationwide analysis

Background

Patients with inflammatory bowel disease (IBD) and substance use disorder (SUD) may have worse clinical outcomes. However, data specific to the hospital admission and mortality rates among IBD patients with SUD are scarce. Our objective was to assess trends in admission, healthcare expenses, and mortality for IBD patients with SUD.

Methods

We conducted a retrospective study using the National Inpatient Sample database to analyze SUD (alcohol, opioids, cocaine, and cannabis) among IBD hospitalizations from 2009 to 2019.

Results

A total of 132,894 hospitalizations for IBD had a secondary diagnosis of SUD. Of these patients, 75,172 (57%) were men and 57,696 (43%) were women. The IBD-SUD cohort had a longer length of stay than the non-SUD cohort (P < 0.001). The mean inpatient charges for IBD hospitalizations with SUD increased from $48,699 ± $1374 in 2009 to $62,672 ± $1528 in 2019 (P < 0.001). We found a 159.5% increase in IBD hospitalizations with SUD. The hospitalization rate increased from 3492 per 100,000 IBD hospitalizations in 2009 to 9063 per 100,000 in 2019 (P < 0.001). In-hospital mortality for IBD hospitalizations with SUD increased by 129.6% (from 250 deaths per 100,000 IBD hospitalizations in 2009 to 574 deaths per 100,000 IBD hospitalizations in 2019) (P < 0.001).

Conclusions

Over the last decade, there has been a rise in IBD hospitalizations with SUD. This has resulted in a longer length of stay, higher inpatient charges, and higher mortality rates. Identifying IBD patients potentially at risk for SUD by screening for anxiety, depression, pain, or other factors has become crucial.

Long-term trends in the burden of inflammatory bowel disease in China over three decades: A joinpoint regression and age-period-cohort analysis based on GBD 2019

Background

To study the corresponding strategies to control inflammatory bowel disease (IBD), a comprehensive assessment of the disease burden is required. Herein, we present long-term trends in the burden of IBD in China over the last three decades, as well as its epidemiological features.

Methods

We characterized the burden of IBD in China using the GBD 2019 methods and results, based on prevalence, incidence, mortality, years lost (YLLs), years lived with disability (YLDs), and disability-adjusted life years (DALYs) estimated using the DisMod-MR 2-1. We also used joinpoint and age-period-cohort (apc) analysis methods to interpret IBD epidemiological characteristics and compare them to global prevalence trends.

Results

The age-standardized incidence and mortality rates in both sexes changed from 1.47 (95% CI: 1.24, 1.74) to 3.01 (95% CI: 2.59, 3.50) and from 0.86 (95% CI: 0.59, 1.16) to 0.30 (95% CI: 0.24, 0.35) per 100,000 people in China from 1990 to 2019. The age-standardized DALY rate in China decreased from 24.47 (95% CI: 17.88, 30.19) per 100,000 people in 1990 to 13.10 (95% CI: 10.29, 16.31) per 100,000 people in 2019. The average annual percentage change (AAPC) in age-standardized incidence, prevalence, and mortality rates for IBD in China were 2.51 (95% CI: 2.44, 2.57), 2.53 (95% CI: 2.41, 2.66), and -3.62 (95% CI: -3.85, -3.39). The effects of age, period, and cohort on incidence and mortality rates differed.

Conclusions

The increasing age-standardized prevalence rates are contributed to by the reduction in age-standardized mortality rates and DALYs, compounded by the rise in the age-standardized incidence rates between 1990 and 2019 in China. The burden of IBD in China will be a major public health challenge, given the country's large population base and aging population.

Disparity in hospital admissions and length of stay based on income status for emergency department hypertensive crisis visits

OBJECTIVE

Racial, gender, and socioeconomic status have been shown to impact the delivery of care. How this impacts the management of hypertensive crisis remains unclear. We aim to identify disparities on admission frequency and length of stay (LOS) among those presenting with hypertensive crisis, as a function of household income.

METHODS

This is a cross-sectional analysis of 2016 emergency department visits and supplemental inpatient data from the Nationwide Emergency Department Sample. Median household income quartiles were established. A multivariable logistic regression model was used to estimate odds of admission in each income quartile. A multivariable linear regression model was used to predict LOS.

RESULTS

After applying sample weighting, the total number of emergency department visits was 33 727 with 6906, 25 443, and 1378 visits for hypertensive emergency, hypertensive urgency, and unspecified crisis, respectively. There were 13 191, 8889, 6400, 5247 visits in the (first) lowest, second, third , and fourth (highest) income quartiles, respectively. The median age for the study population was 60. The most common comorbidity was chronic kidney disease. Individuals with the highest income, had a lower likelihood of admission, compared with the lowest quartile (adjusted odds ratio: 0.41, 95% CI 0.22-0.74). There was a significant association between income quartile and LOS among hypertensive emergency patients (beta coefficient: 0.407, P value = 0.019).

CONCLUSION

In this study, patients with lower income were more likely to be admitted, whereas those with higher income exhibited a longer LOS. Clinicians must be made aware these disparities to ensure equitable delivery of care.

Symptoms associated with healthcare resource utilization in the setting of inflammatory bowel disease

Several symptoms have been connected to increased healthcare resource utilization (HRU) in the context of inflammatory bowel disease (IBD), including both Crohn's disease (CD) and ulcerative colitis (UC). This study was designed to investigate the prevalence of IBD-associated symptoms and to determine whether any are independently associated with HRU. We undertook a retrospective analysis of data related to consecutive IBD patient encounters from a tertiary care referral center between 1/1/2015 and 8/31/2019. Demographics, clinical activity, endoscopic severity, IBD-related symptom scores, anxiety and depression scores, and other key clinical data were abstracted. Four hundred sixty-seven IBD patients [247f.: 220 m; 315 CD, 142 UC and 11 indeterminate colitis] were included in this study. The most common symptoms were fatigue (83.6%), fecal urgency (68.2%) and abdominal pain (63.5%). Fatigue, abdominal pain, anxiety or depression, corticosteroids, and opioids were each positively associated with HRU, while NSAID and mesalamine use were inversely associated on bivariate analysis. The only factor that demonstrated a statistically significant association with HRU in the whole cohort on multivariable analysis was abdominal pain. Abdominal pain is independently associated with HRU and should be specifically screened for in IBD patients to identify individuals at risk of undergoing expensive interventions. This study also reinforces the importance of optimizing diagnostic and therapeutic management of abdominal pain in IBD.

Therapeutic strategies in Crohn’s disease in an emergency surgical setting

Crohn’s disease (CD) remains a chronic, incurable disorder that presents unique challenges to the surgeon. Multiple factors must be considered to allow development of an appropriate treatment plan. Medical therapy often precedes or complements the surgical management. The indications for operative management of CD include acute and chronic disease complications and failed medical therapy. Elective surgery comes into play when patients are refractory to medical treatment if they have an obstructive phenotype. Toxic colitis, acute obstruction, perforation, acute abscess, or massive hemorrhage represent indications for emergency surgery. These patients are generally in critical conditions and present with intra-abdominal sepsis and a preoperative status of immunosuppression and malnutrition that exposes them to a higher risk of complications and mortality. A multidisciplinary team including surgeons, gastroenterologists, radiologists, nutritional support services, and enterostomal therapists are required for optimal patient care and decision making. Management of each emergency should be individualized based on patient age, disease type and duration, and patient goals of care. Moreover, the recurrent nature of disease mandates that we continue searching for innovative medical therapies and operative techniques that reduce the need to repeat surgical operations. In this review, we aimed to discuss the acute complications of CD and their treatment.

Patients With Inflammatory Bowel Disease on Treatment Have Lower Rates of Celiac Disease

BACKGROUND

The association between celiac disease and inflammatory bowel disease (IBD) has been studied; however, the impact of IBD therapy on celiac disease is not known. Using a large database, we sought to describe the association of celiac disease and IBD and the impact of IBD treatment.

METHODS

We queried a large multicenter database (Explorys Inc.), an electronic health record data aggregate from 26 American health care systems. We identified a cohort of patients with celiac disease and IBD between 1999 and 2020 and conducted a statistical analysis using a multivariate model.

RESULTS

Of the 72,965,940 individuals in the database, 133,400 had celiac disease (0.18%), 191,570 (0.26%) had ulcerative colitis (UC), and 230,670 (0.32%) had Crohn disease (CD). Patients with IBD were more likely to have a diagnosis of celiac disease (odds ratio [OR], 13.680), with a greater association with CD. Treated patients with UC and with CD, respectively, had a lower risk association with celiac disease compared to those not undergoing IBD treatment, specifically corticosteroids (OR, 0.407 and 0.585), 5-aminosalicylates (OR, 0.124 and 0.127), immunomodulators (OR, 0.385 and 0.425), and anti-tumor necrosis factor drugs (OR, 0.215 and 0.242). There was no lower risk association in the vedolizumab group, but there was a higher risk association among the ustekinumab group.

CONCLUSIONS

In this large dataset, we showed a bidirectional association between celiac disease and IBD that was stronger with CD. Patients with IBD treated using corticosteroids, 5-aminosalicylates, immunomodulators, or anti-tumor necrosis factor drugs had a lower association with celiac disease. Additional studies are required to determine the underlying mechanisms for IBD therapy-related modification of celiac disease incidence.

Specialized Emergency Department Assessment and Multidisciplinary Intervention After Discharge Improve Management of Patients With Inflammatory Bowel Diseases

GOAL

The aim was to assess proactive specialized inflammatory bowel diseases (IBD) emergency department (ED) consultation and multidisciplinary IBD team (IBD-MDT) intervention on IBD-related patient outcomes after discharge.

BACKGROUND

Despite advances in patient care, IBD-related ED visits have increased and substantially contribute to the IBD burden.

METHODS

Consecutive patients with IBD (below 50 y) who visited the ED during November 2017 to April 2018 (intervention group) were compared with patients with IBD that visited the same ED during 2014 to 2017 (standard-care group). The primary outcomes were hospitalization and ED revisits at 30, 90, and 180 days.

RESULTS

The intervention group (45 patients, mean age 32.43±8.6 y, 57.8% male) and the standard-care group (237 patients) had comparable baseline characteristics, including age, sex, and IBD type, and similar rates of hospital admissions from the ED (46.7% vs. 38.8%, P=0.32). The intervention group more frequently underwent computed tomography (40% vs. 8%, P<0.001) and surgical interventions (13.3% vs. 0.8%, P<0.001) within the same hospital admission, compared with the standard-care group. In the intervention group, 24 patients were discharged from the ED, of whom 17 patients visited the IBD clinic (median 5 d postdischarge) and the majority were referred to ambulatory IBD-MDT services (dietitian: 46.7%, psychologist: 6.7%, advanced endoscopist: 8.9%, and proctology services: 6.7%). The intervention group had significantly fewer ED revisits than the standard-care group (30 d: 4.4% vs. 19.8%, P=0.013; 90 d: 4.4% vs. 35.9%, P<0.001; 180 d: 6.7% vs. 43%, P<0.001).

CONCLUSION

Proactive specialized ED assessments and IBD-MDT interventions after a hospital discharge were preferable; they significantly reduced the ED revisit rate for at least 6 months.

Quality of Care Program Reduces Unplanned Health Care Utilization in Patients With Inflammatory Bowel Disease

INTRODUCTION

There is significant variation in processes and outcomes of care for patients with inflammatory bowel disease (IBD), suggesting opportunities to improve quality of care. We aimed to determine whether a structured quality of care program can improve IBD outcomes, including the need for unplanned health care utilization.

METHODS

We used a structured approach to improve adult IBD care in 27 community-based gastroenterology practices and academic medical centers. Patient-reported outcomes (PRO) and health care utilization were collected at clinical visits. Outcomes were monitored monthly using statistical process control charts; improvement was defined by special cause (nonrandom) variation over time. Multivariable logistic regression was applied to patient-level data. Nineteen process changes were offered to improve unplanned health care utilization. Ten outcomes were assessed, including disease activity, remission status, urgent care need, recent emergency department use, hospitalizations, computed tomography scans, health confidence, corticosteroid or opioid use, and clinic phone calls.

RESULTS

We collected data prospectively from 20,382 discrete IBD visits. During the 15-month project period, improvement was noted across multiple measures, including need for urgent care, hospitalization, steroid use, and opioid utilization. Adjusted multivariable modeling showed significant improvements over time across multiple outcomes including urgent care need, health confidence, emergency department utilization, hospitalization, corticosteroid use, and opioid use. Attendance at monthly coached webinars was associated with improvement.

DISCUSSION

Outcomes of IBD care were improved using a structured quality improvement program that facilitates small process changes, sharing of best practices, and ongoing feedback. Spread of these interventions may facilitate broad improvement in IBD care when applied to a large population.

Small Bowel Volvulus as Delayed Presentation of Undiagnosed Crohn's Disease: A Case Report

Introduction

Emergency department (ED) visits related to flare-ups of inflammatory bowel disease (IBD) are becoming more prevalent. There are many potentially dangerous complications and sequelae of uncontrolled IBD.

Case Report

We report a case of a middle-aged woman who presented with a few hours of severe abdominal pain, nausea, and vomiting. Given her hemodynamic instability, she was sent urgently for computed tomography, which showed an incomplete small bowel malrotation, mesenteric volvulus, and high-grade small bowel obstruction with evolving ischemia. The patient underwent exploratory laparotomy to resect most of her small intestines. Biopsies later revealed active Crohn’s disease.

Conclusion

Patients with flare-ups of IBD are common in the ED, but very few present with a midgut volvulus later in life. Our case is unique and adds to the literature due to the dramatic consequences of undiagnosed Crohn’s disease in a patient with intermittent symptoms and extensive workup spanning over two decades.

Frequency of Opioid Prescription at Emergency Department Discharge in Patients with Inflammatory Bowel Disease: A Nationwide Analysis

BACKGROUND & AIMS

Patients with inflammatory bowel disease (IBD) frequently experience chronic pain. Patients will often seek out care in the emergency department (ED) where short-term opioid use may be associated with potential treatment-related complications. We aimed to assess the rate and factors associated with opioid prescription in IBD patients discharged from the ED.

METHODS

We conducted a cross-sectional analysis of data collected in the US National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2006-2017. We determined the proportion of adult patients (≥18 years) with IBD prescribed an opioid in ED or at ED discharge. Logistic regression was used to evaluate predictors of opioid prescription. Time-trend analysis was performed to evaluate temporal patterns in opioid use. All analyses were adjusted for complex survey design.

RESULTS

We identified ∼965,000 weighted discharges from the ED for patients with IBD. In total, 51.9% [95% CI: 42.2% -61.6%] of visits resulted in opioid administration in ED and 35.3% [95% CI: 26.5% -45.2%] of IBD-related ED discharges were associated with an opioid prescription. IBD patients with moderate/severe pain (adjusted odds ratio aOR 5.06 [95% CI: 1.72 -14.90], p < 0.01) were more likely to receive opioids whereas older age (aOR 0.73 per decade [95% CI: 0.55 -0.98], p = 0.04) were less likely. In temporal analysis, a trend towards decreasing opioid use in ED and opioid prescriptions at discharge was observed in 2015-2017.

CONCLUSIONS

More than one third of IBD patients are prescribed an opioid at discharge from ED, highlighting a potential gap in care for accessing effective pain management solutions in this population.

The Impact of Transition Readiness and Stress on Patient-Centered Outcomes in Young Adults With Inflammatory Bowel Disease

Young adults, 18-35 years of age, account for nearly half of all inflammatory bowel disease emergency department visits annually, costing millions of healthcare dollars and signifying undue pain and suffering. To mitigate this sequela, the study aimed to characterize the relationships between transition readiness (self-management ability), stress, and patient-centered outcomes. Outcomes were defined as disease activity and inflammatory bowel disease-related healthcare utilization (emergency department visits and inpatient hospitalization). This was a descriptive, correlational design via online survey of young adults with inflammatory bowel disease. Participants (n = 284) utilized an estimated 2.77 million healthcare dollars in 12 months. Transition readiness decreased the odds of having consistently active disease and healthcare utilization, with adjusted odds ratio ranging from 6.4 to 10.9 (p < .05). Higher stress levels increased the odds of having consistently active disease and healthcare utilization, with adjusted odds ratio ranging from 9.5 to 10.5 (p < .0001). Twenty-five percent (24.7%) of the variation in transition readiness was explained by changes in stress (p < .0001). Transition readiness and stress impacted all patient-centered outcomes. Stress negatively impacted transition readiness. These results are powerful reminders for healthcare providers to assess and treat stress and support transition readiness in young adults with inflammatory bowel disease. The potential to decrease pain, suffering, and healthcare cost is enormous.

Risk Factors for and Frequency of CT Scans, Steroid Use, and Repeat Visits in Inflammatory Bowel Disease Patients Seen at a Single-Center Emergency Department: A Retrospective Cohort Study

Patients with inflammatory bowel disease often present to the emergency department due to the chronic relapsing nature of the disease. Previous studies have shown younger patients to have an increased frequency of emergency department visits, resulting in repeated exposure to imaging studies and steroids, both of which are associated with risks. We performed a retrospective cohort analysis of inflammatory bowel disease patients seen at Houston Methodist Hospital’s emergency department from January 2014 to December 2017 using ICD codes to identify patients with Crohn’s disease, ulcerative colitis, or indeterminate colitis from the electronic medical record. Data were collected on demographics, medications, and imaging. Five hundred and fifty-nine patients were randomly selected for inclusion. Older age was associated with decreased risk of CT scan or steroid use. Patients with ulcerative colitis compared to Crohn’s had decreased risk of CT scan, while there was an increased risk of CT in patients on a biologic, immunomodulator, or when steroids were given. Steroid use was also more common in those with inflammatory bowel disease as the primary reason for the visit. Patients in our study frequently received steroids and had CT scans performed. The increased risk of CT in those on a biologic, immunomodulator, or steroids suggests more severe disease may contribute. Guidelines are needed to reduce any unnecessary corticosteroid use and limit repeat CT scans in young inflammatory bowel disease patients to decrease the risk of radiation-associated malignancy over their lifetime.

Lower Rates of Colorectal Cancer in Patients With Inflammatory Bowel Disease Using Anti-TNF Therapy

BACKGROUND

Chronic inflammation is a key factor for the development of colorectal cancer (CRC) among patients with inflammatory bowel disease (IBD). Despite the increased use of biologic agents in patients with IBD, their impact on colorectal carcinogenesis remains unclear. With the use of a large database, we sought to describe the effect of biologics on CRC among patients with IBD.

METHODS

We evaluated a multicenter database (Explorys) consisting of electronic medical records from several U.S. hospitals between 1999 and 2020. A cohort of patients with a diagnosis of IBD was identified. We performed a multivariate analysis to adjust for multiple factors including medical and surgical therapies.

RESULTS

There were a total of 62,007,510 patients in the database between 1999 and 2020. Amongst those, 225,090 (0.36%) individuals had Crohn's disease and 188,420 (0.30%) had ulcerative colitis. After adjusting for confounding factors using multivariate analysis, patients with IBD were more likely to develop CRC. Among the IBD cohort, patients treated with anti-TNF agents were less likely to develop CRC; patients with Crohn's disease: odds ratio, 0.69; 95% confidence interval, 0.66-0.73; P < 0.0001 vs patients with ulcerative colitis: odds ratio, 0.78; 95% confidence interval, 0.73-0.83; P < 0.0001.

CONCLUSIONS

Patients with IBD who were treated with anti-tumor necrosis factor agents were less likely to develop CRC. Prospective studies are needed to evaluate whether anti-tumor necrosis factor drugs provide a chemoprotective effect in patients with IBD by inflammation control and mucosal healing.

Trends in US emergency department visits and subsequent hospital admission among patients with inflammatory bowel disease presenting with abdominal pain: a real-world study from a national emergency department sample database

Background/Objective: This study evaluated emergency department (ED) visit trends, subsequent inpatient admissions for patients with inflammatory bowel disease (IBD) diagnosis and IBD-related abdominal pain (AP), and hospital-level variation in inpatient admission rates in the USA (US). Methods: This population-based, cross-sectional study included data from Nationwide Emergency Department Sample (NEDS, 2006─2013) database. Patients ≥18 years of age with primary ED diagnosis of IBD/IBD-related AP were included. Variables included demographics, insurance information, household income, Quan-Charlson comorbidity score, ED discharge disposition, and length of hospital stay (2006, 2010, and 2013). Variation between hospitals using risk-adjusted admission ratio was estimated. Results: Annual ED visits for IBD/100,000 US population increased (30 in 2006 vs 42 in 2013, p = 0.09), subsequent admissions remained stable (20 in 2006 vs 23 in 2013, p = 0.52). ED visits for IBD-related AP increased by 71% (7 in 2006 vs 12 in 2013; p = 0.12), subsequent admissions were stable (0.50 in 2006 vs 0.58 in 2013; p = 0.88). Proportion of patients with subsequent hospitalization decreased (IBD: 65.7% to 55.7%; IBD-related AP: 6.9% to 4.9%). Variation in subsequent inpatient admissions was 1.42 (IBD) and 1.96 (IBD-related AP). Conclusions: An increase in annual ED visits was observed for patients with IBD and IBD-related AP; however, subsequent inpatient admission rate remained stable.

Point-of-Care Ultrasound Diagnosis of a Crohn's Disease-Related Intraabdominal Abscess in the Emergency Department

The emergency department (ED) diagnosis of Crohn’s disease (CD)-associated complications is typically established with abdominopelvic computed tomography imaging. Ultrasonography has been suggested as an effective alternative modality for diagnosing several CD complications, including intraabdominal abscesses. We report the identification of a CD-related intraabdominal abscess by emergency physician (EP)-performed point-of-care ultrasound (POCUS). This case highlights the feasibility of EPs integrating POCUS into the clinical decision-making for patients with inflammatory bowel disease in the ED.

Gastroenterologist Consultation Is Uncommon but Associated with Improved Care Among IBD Patients Presenting to Emergency Departments in Winnipeg Hospitals

OBJECTIVE

To describe the patterns of care when persons with inflammatory bowel disease (IBD) present to the Emergency Department (ED) and post-ED follow-up.

METHODS

We linked the University of Manitoba IBD Epidemiology Database with the Emergency Department Information System of the Winnipeg Regional Health Authority from January 1, 2010 to December 31, 2012. We then generated a list of all ED attendances by persons with IBD at four of six hospitals within the City of Winnipeg (two academic and two community hospitals). The charts were reviewed by two investigators extracting data on testing, consulting and treatment undertaken in the ED as well as postdischarge follow-up. We focused on outcomes among those attending the ED but not admitted to hospital.

RESULTS

Of 1275 IBD patients with a first visit to the ED, 523 (41%) were for IBD-specific complaints. Three hundred and twenty-seven (62.5%) were discharged from the ED without an in-hospital admission. Nearly 80% had an identified gastrointestinal (GI) specialist (either gastroenterologist or GI surgeon) involved in their care. A gastroenterologist was consulted in the ED 20% of the time. Follow-up post-ED with a gastroenterologist was only documented in 36%. For those who saw a gastroenterologist in the ED, there was more likely to be a change in medications and follow-up arranged with a gastroenterologist. ED consultation with a gastroenterologist was the only predictor of seeing a gastroenterologist in follow-up post-ED.

CONCLUSIONS

ED gastroenterology consultation is more likely to effect IBD management change. When discharged from the ED gastroenterology, follow-up should be arranged and documented.

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

Background

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

Methods

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

Results

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

Conclusion

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

Prediction of Recurrent Emergency Department Visits among Patients with Crohn's Disease: A Retrospective Study

Patients with Crohn’s disease (CD) are frequently subject to symptoms causing them to seek medical care in emergency departments (ED). Recurrent ED visits are frequent after initial discharge. We aimed to identify the characteristics of patients with Crohn’s who tend to have recurrent visits to the ED. We created an electronic data repository of all patients with inflammatory bowel diseases who visited the ED in our tertiary medical center during the period 2012–2018. For this study, we retrieved consecutive Crohn’s patients who presented with CD-related symptoms to the ED and were eventually discharged. Patients who returned to the ED in 7 and 30 days were compared with those who did not. Overall, 2299 patients visited our ED with complaints related to Crohn’s disease exacerbation or complication. A total of 1259 (60% of the adult patients) were admitted for hospitalization. Of the 632 (33%) who were discharged from the ED, 53 (8.4%) and 110 (17.4%) re-visited the ED, in 7 and 30 days from discharge, respectively. In multivariable analysis, tachycardia (odds ratio (OR) = 2.19, 95% confidence interval (CI): 1.11–4.33, p value = 0.02), elevated alkaline phosphatase (OR = 2.09, 95% CI: 1.07–4.07, p value = 0.02), and hyponatremia (OR = 2.52, 95% CI: 1.24–5.10, p value = 0.01) were associated with revisiting the ED within 7 days. Tachycardia (OR 2.88 (95% CI 1.33–6.2)), anemia (OR 2.44 (95% CI 1.24–4.8)), and elevated alkaline phosphatase (OR 2.68 (95% CI 1.25–5.78)) were independently associated with ED returns in 30 days. Knowing these risk factors may assist in minimizing the burden of recurrent ED visits among patients with CD.

Management of Inflammatory Bowel Disease Patients With Clinical Care Pathways Reduces Emergency Department Utilization

Background

Standardizing care through pathways has the potential to reduce emergency department (ED) utilization. We developed and evaluated inflammatory bowel disease (IBD) care pathways for that purpose.

Methods

Over 2014-2016, IBD patients were retrospectively stratified into those managed and not managed by pathways. Patient data were extracted, and negative binomial regression used to predict the annual number of ED visits.

Results

There was a difference of 30.7 ED visits/100 patients between managed and nonmanaged at 12 months (P < 0.001). The incidence rate ratio of total ED visits occurring annually was 0.750 (P = 0.008).

Conclusions

Management with IBD care pathways reduces ED utilization.

The management of emergency hospital visits for inflammatory bowel diseases: A French national expert consensus report

BACKGROUND

Management of inflammatory bowel diseases (IBD) in the emergency department is often suboptimal.

AIMS

To develop a national consensus checklist of indicators to facilitate decision-making in emergency departments concerning hospitalisation and referral for abdominopelvic computed tomography (CT).

METHODS

A Delphi survey was used to obtain consensus on a checklist of clinical and biological variables. 119 healthcare professionals experienced in treating IBD were invited to participate. Panellists were provided with a literature survey and invited to agree or disagree with items on a prototype checklist. Two successive rounds of voting were organised.

RESULTS

The prototype checklist included fifteen clinical or laboratory indicators for hospitalisation or CT. Four indicators were not retained in the Delphi process and four additional indicators added. The final indicators retained were: abdominal signs/symptoms of disease exacerbation, intravenous morphine titration, fever, vomiting, dehydration, recent intestinal surgery, ano-perineal abscess, bowel obstruction, haemodynamic instability, anaemia, acute kidney failure and elevated C-reactive protein. Consensus for the retained indicators was >88%.

CONCLUSIONS

Use of this consensus checklist for the management of IBD in the emergency department may help improve standards of care and thus reduce the burden of these diseases.

Benefits of implementing a rapid access clinic in a high-volume inflammatory bowel disease center: Access, resource utilization and outcomes

BACKGROUND

Emergency situations in inflammatory bowel diseases (IBD) put significant burden on both the patient and the healthcare system.

AIM

To prospectively measure Quality-of-Care indicators and resource utilization after the implementation of the new rapid access clinic service (RAC) at a tertiary IBD center.

METHODS

Patient access, resource utilization and outcome parameters were collected from consecutive patients contacting the RAC between July 2017 and March 2019 in this observational study. For comparing resource utilization and healthcare costs, emergency department (ED) visits of IBD patients with no access to RAC services were evaluated between January 2018 and January 2019. Time to appointment, diagnostic methods, change in medical therapy, unplanned ED visits, hospitalizations and surgical admissions were calculated and compared.

RESULTS

488 patients (Crohn’s disease: 68.4%/ulcerative colitis: 31.6%) contacted the RAC with a valid medical reason. Median time to visit with an IBD specialist following the index contact was 2 d. Patients had objective clinical and laboratory assessment (C-reactive protein and fecal calprotectin in 91% and 73%). Fast-track colonoscopy/sigmoidoscopy was performed in 24.6% of the patients, while computed tomography/magnetic resonance imaging in only 8.1%. Medical therapy was changed in 54.4%. ED visits within 30 d following the RAC visit occurred in 8.8% (unplanned ED visit rate: 5.9%). Diagnostic procedures and resource utilization at the ED (n = 135 patients) were substantially different compared to RAC users: Abdominal computed tomography was more frequent (65.7%, P < 0.001), coupled with multiple specialist consults, more frequent hospital admission (P < 0.001), higher steroid initiation (P < 0.001). Average medical cost estimates of diagnostic procedures and services per patient was $403 CAD vs $1885 CAD comparing all RAC and ED visits.

CONCLUSION

Implementation of a RAC improved patient care by facilitating easier access to IBD specific medical care, optimized resource utilization and helped avoiding ED visits and subsequent hospitalizations.

Nationwide improvement in outcomes of emergency admission for ulcerative colitis in England, 2005-2013

BACKGROUND

The UK IBD Audit Programme reported improved inpatient care processes for ulcerative colitis (UC) between 2005 and 2013. There are no independent data describing national or institutional trends in patient outcomes over this period.

AIM

To assess the association between the outcome of emergency admission for UC and year of treatment.

METHODS

Retrospective analysis of hospital administrative data, focused on all emergency admissions to English public hospitals with a discharge diagnosis of UC. We extracted case mix factors (age, sex, co-morbidity, emergency bed days in last year, deprivation status), outcomes of index admission (death and first surgery), 30-day emergency readmissions (all-cause, and selected causes) and outcome of readmission.

RESULTS

There were 765 deaths and 3837 unplanned first operations in 44 882 emergency admissions, with 5311 emergency readmissions (with a further 171 deaths and 517 first operations). Case mix adjusted odds of death for any given year were 9% lower (OR 0.91, 95% CI: 0.89-0.94), and that for emergency surgery 3% lower (OR 0.97, 95% CI: 0.95-0.98) than the preceding year. Results were robust to sensitivity analysis (admissions lasting ≥4 days). There was no reduction in odds for all-cause readmission, but rates for venous thromboembolism declined significantly. Analysis of institutional-level metrics across 136 providers showed a stepwise reduction in outliers for mortality and unplanned surgery.

CONCLUSIONS

Risk of death and unplanned surgery for UC patients admitted as emergencies declined consistently, as did unexplained variation between hospitals. Risk of readmission was unchanged (over 1 in 10). Multiple factors are likely to explain these nationwide trends.

The Impact of Private Insurance Access on Nonurgent Inflammatory Bowel Disease-Related Emergency Department Use

Background

Inflammatory bowel disease (IBD)-related Emergency Department (ED) visits are a costly component to current healthcare expenditures. Patients who are discharged directly from the ED for nonurgent issues (aka “treat and release” ED visits) present an opportunity for quality improvement.

Purpose

To determine the impact of private insurance on IBD-related treat and release ED visits. The secondary outcome was cost per IBD-related ED visit.

Methodology

A retrospective cohort study was performed on the 2006 Nationwide Emergency Department Sample (NEDS). Comparisons were made between patients with access to private insurance vs those without. Multivariable survey-weighted logistic and linear regression models with clustering by hospital were created for the primary and secondary outcomes, respectively.

Results

In total, 19,324 patient encounters were included in the stratified analytic sample. Of these, 9272 (47.98%) patients reported private insurance as their primary payment method. An additional 10,052 (52.02%) patients reported an alternative payment form. The private insurance group was statistically younger, less likely to reside in an urban setting and had more representation within the highest income quartile. The OR of a treat and release ED visit was 1.47 (95% confidence interval 1.34–1.62) for no private insurance compared to private insurance. On average, the cost per ED visit of patients without private insurance was $214.80 ± 48.48, P &lt; 0.001 less than those with private insurance.

Conclusions

Lack of private insurance is an important predictor of IBD-related treat and release ED visits.

Development of a Global Rating Scale for Inflammatory Bowel Disease

Background

The Global Rating Scale (GRS) is a web-based self-assessment quality improvement tool used to identify gaps in health care, change the focus to patient-centred care and standardize care. There are four levels of achievement ranging from basic-(D) to excellent-(A) service delivery. The goal was to develop a GRS for inflammatory bowel disease (IBD) to improve the quality of care for patients on a system level.

Methods

The IBD GRS was developed through an iterative process and modeled upon the successful endoscopy GRS programs in the United Kingdom and Canada. Dimensions, items and statements were drafted based on expert opinions, patient-informed quality indicators and best available evidence, then reviewed and modified by a core committee. A working group of IBD and GRS experts voted in-person to establish consensus on the inclusion and quality of statements.

Results

Two dimensions (Clinical Quality and Quality of Patient Experience), 10 items and 89 statements made up the IBD GRS. There was a 100% response rate for each of the 40 votes for statements in the IBD GRS. All statements within each level received a mean rating score between four (agree) and five (strongly agree). Revisions agreed upon during the voting process were incorporated into the IBD GRS. Group consensus was achieved on the inclusion of statements, and 10 items were selected as standards within the two dimensions.

Conclusions

We have developed the first IBD GRS with the aim of improving quality of care through ongoing evaluations and improvements by health care teams, focusing on patient-centred care.

Access to Specialists and Emergency Department Visits in Inflammatory Bowel Disease: A Population-Based Study

BACKGROUND AND AIMS

The number of inflammatory bowel disease [IBD]-related visits to the emergency department [ED] is increasing in North America. This study evaluates the relationship between access to specialists and utilization of ED services.

METHODS

We conducted a population-based study of all IBD patients in Ontario in 2014-2015 to measure utilization of non-emergency IBD care by specialists [NICS] and ED visits. After characterizing regional variation in access to gastroenterologists and region-wide implementation of NICS, we constructed regression models to determine whether they were predictors of individual utilization of NICS and ED services.

RESULTS

The number of gastroenterologists per 1000 IBD patients varied geographically, ranging from 1.13 to 10.65, as did the region-wide proportion of patients who received NICS, ranging from 21% to 52%. Compared with those with low access to gastroenterologists, those living in areas with moderate (odds ratio [OR], 2.37; 95% confidence interval [CI]: 2.27-2.47) and high [OR, 1.83; 95% CI: 1.71-1.95] access were more likely to receive NICS. The risk of visits to the ED was lower among those residing in regions with moderate [OR, 0.78; 95% CI: 0.75-0.82] and high access [OR, 0.74; 95% CI: 0.69-0.80] to gastroenterologists and in regions where implementation of NICS was not low [OR, 0.78; 95% CI: 0.75-0.81].

CONCLUSIONS

Poor access to outpatient IBD specialist care contributes to IBD-related ED visits. Strategies to increase specialist access may reduce the utilization of emergency services.

Disability in inflammatory bowel disease patients is associated with race, ethnicity and socio-economic factors

BACKGROUND

Race, ethnicity and socio-economic status impact clinical outcomes in inflammatory bowel disease (IBD) patients. However, their impact on disability has not been studied.

AIM

To determine the association between race, ethnicity and socio-economic factors with disability in IBD, using the validated IBD disability index (IBD-DI).

METHODS

Ambulatory IBD patients were enrolled at five academic centres participating in the New York Crohn's and Colitis Organization. We assessed the IBD-DI, and collected clinical and socio-economic data. Factors associated with moderate-to-severe disability (IBD-DI score > 35) on univariable analysis were tested in multivariable models with adjusted odds ratios (aOR) and 95% confidence intervals (CI) reported.

RESULTS

In this study, 323 patients (57.3% CD, 51.4% female) were enrolled; 17.7% were Hispanic, 17% were non-Hispanic black, 56.0% were non-Hispanic Caucasian and 9.3% belonged to non-Hispanic non-black minority races. However, 39.0% of patients were publicly insured and 38.4% of patients had low annual household income (<$50 000). 100 (31.0%) patients reported moderate-to-severe disability. On multivariable analysis, Hispanic ethnicity (aOR 2.7, 95% CI 1.3-5.6), non-Hispanic non-black minority race (aOR 3.5, 95% CI 1.3-8.9), public payer (aOR 2.1, 95% CI 1.1-4.0) and low annual household income (aOR 3.0, 95% CI 1.7-5.4) were associated with moderate-to-severe disability controlling for disease characteristics.

CONCLUSIONS

IBD patients who are minorities, have public insurance, or low household income, are 2-3 times more likely to report moderate-to-severe disability independent of disease characteristics in the United States. Future studies are needed to study their complex relationship and to mitigate disability.