Racial and geographic disparities in the use of parenteral nutrition among inflammatory bowel disease inpatients diagnosed with malnutrition in the United States

Inequalities in Healthcare Access, Experience and Outcomes in Adults With Inflammatory Bowel Disease: A Scoping Review

BACKGROUND

Inflammatory bowel diseases (IBDs) are incurable diseases that require lifelong access to health services. Accumulating evidence of inequalities in health care access, experience, and outcomes for individuals with IBD is apparent. This review aimed to describe the inequalities in healthcare access, experiences, and outcomes of care for adults with IBD, to identify research gaps, and to identify future research priorities in this area.

METHODS

A scoping review was conducted to retrieve quantitative, qualitative, and mixed methods evidence from 3 databases (EMBASE, Medline, and CINAHL) published between January 1, 2000, and September 27, 2023.

RESULTS

Fifty-one studies met the criteria for inclusion. The majority (42 of 51) focused on IBD health outcomes, followed by healthcare access (24 of 51). Significantly fewer investigated patient experiences of IBD healthcare (8 of 51). Most available studies reported on race/ethnic disparities of healthcare (33 of 51), followed by inequalities driven by socioeconomic differences (12 of 51), rurality (7 of 51), gender and sex (3 of 51), age (2 of 51), culture (2 of 51), literacy (1 of 51), and sexuality (1 of 51). Inflammatory bowel disease patients from Black, Asian, and Hispanic ethnic groups had significantly poorer health outcomes. A lack of research was found in the sexual and gender minority community (1 of 51). No research was found to investigate inequalities in IBD patients with learning disabilities or autism.

CONCLUSIONS

Further research, particularly utilizing qualitative methods, is needed to understand health experiences of underserved patient populations with IBD. Cultural humility in IBD care is required to better serve individuals with IBD of Black and Asian race/ethnicity. The lack of research amongst sexual and gender minority groups with IBD, and with learning disabilities, poses a risk of creating inequalities within inequalities.

Enteral and Parenteral Nutrition Timing in eICU Collaborative Research Database by Race: A Retrospective Observational Study

INTRODUCTION

Racial and ethnic disparities in malnutrition are well-known, but it is unknown if there are disparities in early nutrition delivery for intensive care unit (ICU) patients, which is associated with better outcomes. We investigated the timing of enteral nutrition (EN) and parenteral nutrition (PN) initiation in the ICU, examining for racial differences.

METHODS

Using the eICU-Collaborative Research Database (eICU-CRD) from 2014 to 2015, we analyzed patients eligible for EN and PN from 208 hospitals. EN and PN delivery was captured through intake/output entries. Exclusions included pre-existing EN/PN and short (<4 d) mechanical ventilation. Severity-of-illness was assessed using the sequential organ failure assessment (SOFA) score. Self-identified race was defined as the primary exposure, and Cox proportional hazards models were used to examine the association between race and time to EN and PN initiation, adjusting for patient, ICU, and hospital characteristics.

RESULTS

Of 1914 patients from 14 hospitals with EN data (5.3% Black, 42.4% female, median age 65 y), 888 received EN. Among Black and White patients, the median [Q1, Q3] time from mechanical ventilation to EN was 1.5 [1.0, 2.8] d. Race was not associated with time until EN initiation (hazard ratio = 0.961, 95% confidence interval 0.693, 1.333). Rather, other variables including sex, SOFA score, hospital characteristics and ICU unit type appeared to account for variation in EN initiation. Among 31,551 patients from 59 hospitals with PN data (11.3% Black, 45.1% female, median age 67 y), 1140 received PN, with a median [Q1, Q3] time to PN initiation of 7.4 [4.2, 12.4] d amongst Black and White patients. Race was not associated with time until PN initiation (hazard ratio = 1.095, 95% confidence interval = 0.901, 1.331). Instead, sex, body mass index, SOFA score, hospital characteristics and ICU unit type appeared to account for variation in PN initiation.

CONCLUSIONS

Disparities in EN and PN delivery in the eICU-CRD dataset from 2014 to 2015 were not associated with race, but rather with sex, body mass index, SOFA, hospital characteristics and ICU unit type. Further investigations using more current data are needed.

ASPEN survey of parenteral nutrition access issues: How the system fails the patient

BACKGROUND

Product shortages and a lack of qualified providers to manage care may impact the safety and efficacy of parenteral nutrition (PN). This survey assessed the frequency and extent to which limitations to PN-related access affects patients.

METHODS

Outpatient/patients receiving home PN were surveyed. Questions were developed to characterize the population and determine the extent and severity of PN access issues with components, devices, healthcare professionals, and transfers of care. Reimbursement issues surveyed included insurance coverage, contribution of healthcare costs to annual income, and the extent to which adjunctive therapy was reimbursed. Burdens surveyed included impact on disease symptoms and medical outcomes as well as the types and frequency of medical or system errors experienced, adverse events, or resultant nutrition problems.

RESULTS

Respondents (N = 170) were well educated, rented or owned their own home, and were either employed or retired. All age populations were represented. Patients made frequent contact with care providers. Most were able to manage PN costs but feared losing insurance or changes to insurance. Patients used additional prescribed therapies that are poorly covered by insurance. Patients reported symptoms or exacerbation of disease, development or worsening of malnutrition, and episodes of nutrient deficiency. Patients noted errors occur, especially during periods of transitions of care, when they also often encounter clinicians with little understanding of PN. These are high-acuity patients who have difficulty finding providers for their care.

CONCLUSION

This patient survey provides evidence that access issues can result in the "failure of the PN system" to assure care is consistently safe and effective.

The Use of Parenteral Nutrition and Disparities in Its Allocation Following Traumatic Injury

INTRODUCTION

Severe traumatic injury requires rapid and extensive deployment of resources to save the lives of the critically injured. The sequelae of traumatic injuries frequently require extensive intervention obligating patients to a complicated recovery process devoid of meaningful nutrition. In this setting, parenteral nutrition (PN) is key in enabling appropriate wound healing, recovery, and rehabilitation. We sought to examine the use of PN in adult trauma management and to highlight any disparities in the utilization of PN in adult trauma patients.

METHODS

We queried the 2017-2019 Trauma Quality Improvement Program (TQIP) for adult patients (aged > 18 y) who sustained blunt or penetrating traumatic injuries and received PN as part of their hospitalization. We compared time to PN administration based on demographics. We then used a multivariable logistic regression model to identify factors associated with the use of PN. We hypothesized that PN would be less commonly employed in the uninsured and minority groups.

RESULTS

We identified 2,449,498 patients with sufficient data for analysis. Of these, 1831 patients were treated with PN. On univariate analysis, PN patients were more commonly male (74.7% PN versus 60.2% non-PN; P < 0.001). PN use was more frequent in the Black population (24.3% PN versus 15.5% non-PN; P < 0.001) and less frequent in the White population (72.7% PN versus 81.2% non-PN; P < 0.001). PN use was also much more common among patients covered by Medicaid. Penetrating trauma was over twice as common among PN recipients relative to non-PN patients (% PN versus % non-PN). PN patients had higher injury severity scores (ISSs), more intensive care unit days, longer hospitalizations, and increased mortality compared to non-PN patients. PN patients were half as likely to discharge home and twice as likely to discharge to a long-term care facility. Multivariable analysis including age, race, trauma mechanism, primary payer, and ISS, demonstrated an association of PN use with increasing age (OR 1.01, P < 0.001), cases of penetrating trauma (odds ratio [OR], 2.47; P < 0.001), and patients with high ISS (OR, 0.1.06; P < 0.001). There was decreased use in Uninsured patient (OR, 0.54; P < 0.001).

CONCLUSIONS

PN use following traumatic injury is rarely required. Patients treated with PN typically have a resource-intense hospital course. More severe injuries, penetrating trauma, and increased age are more likely to result in PN use. Variations in PN use are apparent based on insurance payer, further examination into allocation of hospital and intensive care resources, as it pertains to patient socioeconomic status, is warranted in light of these findings.

Malnutrition and Adverse Outcomes After Surgery for Head and Neck Cancer

Importance

Patients with head and neck cancer (HNC) have an increased risk of malnutrition, partly due to disease location and treatment sequelae. Although malnutrition is associated with adverse outcomes, there is little data on the extent of outcomes and the sociodemographic factors associated with malnutrition in patients with HNC.

Objectives

To investigate the association of race, ethnicity, and payer type with perioperative malnutrition in patients undergoing HNC surgery and how malnutrition affects clinical outcomes.

Design, Setting, and Participants

This retrospective cohort study used data from the Premier Healthcare Database to assess adult patients who had undergone HNC surgery from January 2008 to June 2020 at 482 hospitals across the US. Diagnosis and procedure codes were used to identify a subset of patients with perioperative malnutrition. Patient characteristics, payer types, and hospital outcomes were then compared to find associations among race, ethnicity, payer type, malnutrition, and clinical outcomes using multivariable logistic regression models. Analyses were performed from August 2022 to January 2023.

Exposures

Race, ethnicity, and payer type for primary outcome, and perioperative malnutrition status, race, ethnicity, and payer type for secondary outcomes.

Main Outcomes and Measures

Perioperative malnutrition status. Secondary outcomes were discharge to home after surgery, hospital length of stay (LOS), total cost, and postoperative pulmonary complications (PPCs).

Results

The study population comprised 13 895 adult patients who had undergone HNC surgery during the study period; they had a mean (SD) age of 63.4 (12.1) years; 9425 male (67.8%) patients; 968 Black (7.0%), 10 698 White (77.0%), and 2229 (16.0%) individuals of other races; and 887 Hispanic (6.4%) and 13 008 non-Hispanic (93.6%) individuals. Among the total sample, there were 3136 patients (22.6%) diagnosed with perioperative malnutrition. Compared with White patients and patients with private health insurance, the odds of malnutrition were higher for non-Hispanic Black patients (adjusted odds ratio [aOR], 1.31; 95% CI, 1.11-1.56), Medicaid-insured patients (aOR, 1.68; 95% CI, 1.46-1.95), and Medicare-insured patients (aOR, 1.24; 95% CI, 1.10-1.73). Black patients and patients insured by Medicaid had increased LOS, costs, and PPCs, and lower rates of discharge to home. Malnutrition was independently associated with increased LOS (β, 5.20 additional days; 95% CI, 4.83-5.64), higher costs (β, $15 722 more cost; 95% CI, $14 301-$17 143), increased odds of PPCs (aOR, 2.04; 95% CI, 1.83-2.23), and lower odds of discharge to home (aOR, 0.34; 95% CI, 0.31-0.38). No independent association between malnutrition and mortality was observed.

Conclusions and Relevance

This retrospective cohort study found that 1 in 5 patients undergoing HNC surgery were malnourished. Malnourishment disproportionately affected Black patients and patients with Medicaid, and contributed to longer hospital stays, higher costs, and more postoperative complications.

A National Inpatient Sample Analysis of Racial Disparities After Segmental Colectomy for Inflammatory Colorectal Diseases

BACKGROUND

Racial disparities and poor access to care are common among African Americans (AA), potentially adversely affecting surgical outcomes in inflammatory bowel conditions. We aimed to analyze the effect of race on outcomes in patients undergoing segmental colectomy for inflammatory bowel conditions.

METHODS

Retrospective review of data from the National Inpatient Sample between 2010 and 2015 identified patients who underwent segmental colectomy without ostomy for Crohn's or diverticular disease. AA patients were compared with Caucasians using a multivariable analysis model. Primary outcomes of interest were overall complications, mortality, and extended hospital stay.

RESULTS

38,143 admissions were analyzed; AA patients constituted 8% of the overall cohort. Diagnoses included Crohn's (11%) and diverticular disease (89%). After multivariable analysis, AA patients had significantly higher overall risk of complications (OR = 1.27; 95% CI, 1.15-1.40) and extended hospital stay (OR = 1.59; 95% CI, 1.45-1.75) than Caucasians. On bivariate analysis, there was no significant difference in mortality between AA and Caucasian patients. AA patients had significantly higher rates of Medicaid insurance (14% vs 6%, P < .001), lower rates of private insurance (35% vs 47%, P < .001), and were less likely to undergo surgery at a private hospital (31% vs 41%, P < .001).

CONCLUSIONS

AA patients requiring segmental colectomy for inflammatory colorectal conditions experience significantly higher rates of postoperative complications, longer hospital stays, and lower rates of private insurance. Direct correlation between insurance status and postoperative outcomes could not be established, but we speculate such great disparity in outcomes may stem from these socioeconomic differences.

Barriers to Urogynecologic Care for Racial and Ethnic Minority Women: A Qualitative Systematic Review

IMPORTANCE

Studies have sought to evaluate factors that have perpetuated disparities in health care, including urogynecologic care. However, there remains a lack of understanding of barriers to care specific to racial/ethnic minority populations.

OBJECTIVES

We aimed to report identified barriers to urogynecologic care (eg, care for symptoms/diagnoses of urinary incontinence [UI], accidental bowel leakage [ABL], and pelvic organ prolapse [POP]) for underrepresented racial and ethnic minority (URM) women in the United States.

STUDY DESIGN

We conducted a systematic search for studies through 5 electronic bibliographic databases. Inclusion criteria for eligible studies included the following: (1) studies reporting barriers to care for those with urogynecologic symptoms/diagnoses, (2) publication date year 2000 or later. Exclusion criteria included study cohorts with children, exclusively non-U.S. populations, cohorts without URM participants, and studies without qualitative research methodology. Study methodology, characteristics, as well as barriers and facilitators to urogynecologic care were captured using a thematic synthesis approach.

RESULTS

There were 360 studies identified. Twelve studies met criteria: 6 had study populations with UI, 3 with POP, 2 on UI and/or POP, and 1 on ABL. There were 7 focus group studies (total 44 groups, n = 330), 4 interview studies (total 160 interviews, n = 160), and 1 had both (10 interviews, 6 groups, n = 39). Most studies reported on patient-associated barriers (n = 10/12) and physician/provider-associated barriers (n = 10/12), whereas only half reported system-associated barriers (n = 6/12).

CONCLUSION

Identified barriers to urogynecologic care for URM populations were examined. Findings likely do not fully reflect barriers to urogynecologic care for URM populations. Comprehensive evaluation of social determinants of health and systemic racism within studies is needed to understand the unique barriers present for racially/ethnically diverse populations.

Malnutrition among Hospitalized Children in the United States: A 2012-2019 Update of Annual Trends

BACKGROUND

Malnutrition is associated with adverse clinical outcomes and increased health care utilization for hospitalized children. Yet pediatric malnutrition often goes undiagnosed and national prevalence research in this population is scarce.

OBJECTIVE

The aim was to assess change in the coded diagnosis of malnutrition (CDM) among US hospitalized children given increased awareness of the need for improved recognition and standardized diagnosis.

DESIGN

Retrospective, cross-sectional analysis using nationally representative data from the Nationwide Inpatient Sample.

PARTICIPANTS/SETTING

Our sample was 13.2 million hospitalizations from 2012 to 2019 among pediatric patients between age 1 month and 17 years.

MAIN OUTCOME MEASURE

CDM using International Classification of Diseases Ninth and 10th Revision-Clinical Modification diagnosis codes.

STATISTICAL ANALYSES

Descriptive statistics and sampling weights were used to estimate the national frequency and prevalence of CDM. Temporal trends in CDM overall and stratified by age, race/ethnicity, and hospital type were analyzed using joinpoint regression.

RESULTS

CDM prevalence increased from 3.9% in 2012 to 6.4% in 2019. During this period, failure to thrive decreased from 40.6% to 23.3% of all cases with concomitant increases in the diagnosis of protein-calorie malnutrition and children identified with more than one malnutrition subtype. Differences in CDM diagnoses are evident by hospital type, race/ethnicity, and age of the patient.

CONCLUSIONS

Although pediatric malnutrition continues to be underdiagnosed in hospital settings, this study demonstrates improvement over time. There continues to be a need for continued professional education regarding best practices for diagnosis to improve health care provider knowledge and self-efficacy on this topic, especially in nonteaching hospitals.

Trends Regarding Racial Disparities Among Malnourished Patients With Percutaneous Endoscopic Gastrostomy (PEG) Tubes

INTRODUCTION

Percutaneous endoscopic gastrostomy (PEG) is performed in patients who cannot tolerate oral intake and who may require more than 30 days of nutritional support. These patients are at high risk for malnutrition, which itself can contribute to worsening clinical status. Racial disparities regarding access to sources of nutrition have been established. We aim to determine if such racial disparities regarding the diagnosis of malnutrition exist in this high-risk population.

METHODS

The National Inpatient Sample (NIS) was queried for patients with International Classification of Diseases, Ninth Revision (ICD-9) diagnoses coding for PEG tube placement with or without a diagnosis of malnutrition. Results were stratified by race. Rates of PEG tube complications were assessed. Categorical and continuous data were assessed via chi-squared and analysis of variance (ANOVA) tests respectively. Binary and multiple logistic regression was used to control for confounders.

RESULTS

Black patients had the highest rates of malnutrition diagnoses, mechanical complications from gastrostomy placement, and the lowest rates of palliative care discussions. Asian or Pacific Islander patients had the highest rates of aspiration pneumonia, gastrointestinal bleeding, the greatest mortality rates, and the longest hospital stays.

DISCUSSION

Racial minorities had worse outcomes while Caucasians had shorter hospital stays and lower complication rates. Such disparities can be multifactorial in etiology, with lack of nutritional access, poor doctor-patient communication, and differential rates of insurance coverage contributing to poorer outcomes among racial minorities. More change is required to promote equity when managing patients with end-of-life diseases necessitating methods of nutritional support.

Malnutrition Increases Hospital Length of Stay and Mortality among Adult Inpatients with COVID-19

Background: Malnutrition has been linked to adverse health economic outcomes. There is a paucity of data on malnutrition in patients admitted with COVID-19. Methods: This is a retrospective cohort study consisting of 4311 COVID-19 adult (18 years and older) inpatients at 5 Johns Hopkins-affiliated hospitals between 1 March and 3 December 2020. Malnourishment was identified using the malnutrition universal screening tool (MUST), then confirmed by registered dietitians. Statistics were conducted with SAS v9.4 (Cary, NC, USA) software to examine the effect of malnutrition on mortality and hospital length of stay among COVID-19 inpatient encounters, while accounting for possible covariates in regression analysis predicting mortality or the log-transformed length of stay. Results: COVID-19 patients who were older, male, or had lower BMIs had a higher likelihood of mortality. Patients with malnutrition were 76% more likely to have mortality (p < 0.001) and to have a 105% longer hospital length of stay (p < 0.001). Overall, 12.9% (555/4311) of adult COVID-19 patients were diagnosed with malnutrition and were associated with an 87.9% increase in hospital length of stay (p < 0.001). Conclusions: In a cohort of COVID-19 adult inpatients, malnutrition was associated with a higher likelihood of mortality and increased hospital length of stay.

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

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

Caregiver and Adolescent Patient Perspectives on Comprehensive Care for Inflammatory Bowel Diseases: Building a Family-Centered Care Delivery Model

BACKGROUND

Children with inflammatory bowel diseases (IBDs) require primary and gastrointestinal (GI) care, but little is known about patient and family preferences for care receipt. We aimed to understand caregiver perceptions of current healthcare quality, describe barriers to receiving healthcare, and elicit caregiver and adolescent preferences for how comprehensive care ideally would be delivered.

METHODS

This was an anonymous survey of caregivers of 2- to 17-year olds with IBD and adolescents with IBD aged 13-17 years at a large, free-standing children's hospital. Surveys assessed patient medical history, family demographics, perceptions of health care quality and delivery, barriers to primary and GI care, and preferences for optimal care delivery.

RESULTS

Two hundred and seventeen caregivers and 140 adolescents were recruited, 214 caregivers and 133 adolescents consented/assented, and 160 caregivers and 84 adolescents completed the survey (75% and 60% response rate, respectively). Mean patient age was 14 years (SD = 3); 51% male; 79% Crohn's disease, 16% ulcerative colitis, and 4% indeterminate colitis. Caregivers were primarily female (86%), Caucasian (94%), and living in a 2-caregiver household (79%). Most caregivers reported that their child's primary care physician (PCP) and GI doctor oversaw their primary care (71%) and their IBD care (94%), respectively. Caregivers were satisfied with communication with their PCP and GI providers (>90%) but did not know how well they communicated with one another (54%). Barriers to primary and GI care varied, and few caregivers (6%) reported unmet healthcare needs. Caregivers and adolescents saw PCPs and GI doctors having important roles in comprehensive care, though specific preferences for care delivery differed.

CONCLUSION

Caregivers and adolescent perspectives are essential to developing family-centered care models for children with IBD.

Factors Associated With Central Line-Associated Bloodstream Infections in a Cohort of Adult Home Parenteral Nutrition Patients

BACKGROUND

Central line-associated bloodstream infection (CLABSI) is a potentially life-threatening complication in home parenteral nutrition (HPN) patients. We investigated potential predictors of CLABSI in a cohort of adult HPN patients METHODS: Patients managed by the HPN service at the Hospital of University of Pennsylvania on January 1, 2018, were included and followed through June 30, 2019, using existing medical records to collect demographic and clinical data. CLABSIs were adjudicated prospectively by infectious disease experts. Variables with P ≤ .2, when comparing patients with CLABSIs and those without, were included in logistic regression models.

RESULTS

Among 114 patients, mean age was 54 ± 16 years, 78/114 were female, and BMI was 25 ± 5.6. Median experience with HPN was 516 days (range, 15-10,281), and 30 had prior CLABSI. Catheter types were peripherally inserted central catheters (83/114), tunneled (27), and implanted (4). The incidence of CLABSI was 0.89 per 1000 catheter days. One multivariate model identified ostomy/wound (odds ratio [OR], 22.0; 95% CI, 4.8-101.7), tunneled/implanted catheter (OR, 4.4; 95% CI, 1.4-13.9), and BMI < 18.5 (OR, 5.9; 95% CI, 1.4-24.2) as predictors of CLABSI. A second model identified patients with 2 potential predictors (OR, 22.9; 95% CI, 5.6-93.5) and tunneled/implanted catheter (OR, 6.7; 95% CI, 2.1-21.8) at high risk of CLABSI. Whether CLABSIrates might be reduced by more intense training in wound or catheter care (especially for those with multiple predictors), different types of catheters, or rapid treatment of malnutrition will require further study.

Minority Pediatric Patients with Inflammatory Bowel Disease Demonstrate an Increased Length of Stay

BACKGROUND

Genetic and other biological factors may lead to differences in disease behavior among children with inflammatory bowel disease of different races, which may be further modified by disparities in care delivery. Using the Kids' Inpatient Database, we aimed to evaluate differences in the management of pediatric patients with inflammatory bowel disease by race, focusing on length of stay (LOS).

METHODS

We performed a cross-sectional analysis using 2000 to 2012 data from the Kids' Inpatient Database, a nationally representative database. We identified pediatric patients (≤18 years of age) with discharge diagnoses of Crohn's disease (CD) or ulcerative colitis (UC). We used multivariable logistic regression to evaluate the relationship between race and LOS, controlling for age, payer status need for surgery, and year of admission.

RESULTS

We identified 27,295 hospitalizations for children with inflammatory bowel disease (62% CD and 38% UC), Compared with white patients with CD, black (adjusted odds ratio 1.37; 95% confidence interval, 1.22-1.53; P < 0.001) and Hispanic patients (adjusted odds ratio: 1.37; 95% confidence interval: 1.19-1.59; P < 0.001) with CD demonstrated increased odds of a LOS greater than the 75th percentile. When compared with white patients with UC, Hispanic patients also demonstrated increased odds of a LOS greater than the 75th percentile (adjusted odds ratio: 1.20; 95% confidence interval, 1.02-1.42, P = 0.015).

CONCLUSIONS

After controlling for age, year of admission, and clinical phenotypes, black and Hispanic patients with CD and Hispanic patients with UC had longer LOS than white patients. These may be due to differences in provider/hospital characteristics, socioeconomic differences, and/or differences in genetics and other biological factors (see Video Abstract, Supplemental Digital Content 1, http://links.lww.com/IBD/B656).

Race Differences in Initial Presentation, Early Treatment, and 1-year Outcomes of Pediatric Crohn's Disease: Results from the ImproveCareNow Network

BACKGROUND

Racially disparate care has been shown to contribute to suboptimal health care outcomes for minorities. Using the ImproveCareNow network, we investigated differences in management and outcomes of pediatric patients with Crohn's disease at diagnosis and 1-year postdiagnosis.

METHODS

ImproveCareNow is a learning health network for pediatric inflammatory bowel disease. It contains prospective, longitudinal data from outpatient encounters. This retrospective study included all patients with Crohn's disease ≤21 years, September 2006 to October 2014, with the first recorded encounter ≤90 days from date of diagnosis and an encounter 1 year ±60 days. We examined the effect of race on remission rate and treatment at diagnosis and 1 year from diagnosis using t-tests, Wilcoxon rank-sum tests, χ statistic, and Fisher's exact tests, where appropriate, followed by univariate regression models.

RESULTS

Nine hundred seventy-six patients (Black = 118 (12%), White = 858 (88%), mean age = 13 years, 63% male) from 39 sites were included. Black children had a higher percentage of Medicaid insurance (44% versus 11%, P < 0.001). At diagnosis, Black children had more active disease according to physician global assessment (P = 0.027), but not by short Pediatric Crohn's Disease Activity Index (P = 0.67). Race differences in treatment were not identified. Black children had lower hematocrit (34.8 versus 36.7, P < 0.001) and albumin levels (3.6 versus 3.9, P = 0.001). At 1 year, Black children had more active disease according to physician global assessment (P = 0.016), but not by short Pediatric Crohn's Disease Activity Index (P = 0.06).

CONCLUSIONS

Black children with Crohn's disease may have more severe disease than White children based on physician global assessment. Neither disease phenotype differences at diagnosis nor treatment differences at 1-year follow-up were identified.

Central venous catheter infections in home parenteral nutrition patients: Outcomes from Sustain: American Society for Parenteral and Enteral Nutrition's National Patient Registry for Nutrition Care

BACKGROUND

Home parenteral nutrition (HPN) is a high-cost, complex nutrition support therapy that requires the use of central venous catheters. Central line-associated bloodstream infections (CLABSIs) are among the most serious risks of this therapy. Sustain: American Society for Parenteral and Enteral Nutrition's National Patient Registry for Nutrition Care (Sustain registry) provides the most current and comprehensive data for studying CLABSI among a national cohort of HPN patients in the United States. This is the first Sustain registry report detailing longitudinal data on CLABSI among HPN patients.

OBJECTIVE

To describe CLABSI rates for HPN patients followed in the Sustain registry from 2011-2014.

METHODS

Descriptive, χ², and t tests were used to analyze data from the Sustain registry.

RESULTS

Of the 1,046 HPN patients from 29 sites across the United States, 112 (10.7%) experienced 194 CLABSI events during 223,493 days of HPN exposure, for an overall CLABSI rate of 0.87 episodes/1,000 parenteral nutrition-days. Although the majority of patients were female (59%), adult (87%), white (75%), and with private insurance or Medicare (69%), CLABSI episodes per 1,000 parenteral nutrition-days were higher for men (0.69 vs 0.38), children (1.17 vs 0.35), blacks (0.91 vs 0.41), and Medicaid recipients (1.0 vs 0.38 or 0.39). Patients with implanted ports or double-lumen catheters also had more CLABSIs than those with peripherally inserted or central catheters or single-lumen catheters. Staphylococci were the most commonly reported pathogens. These data support findings of smaller studies about CLABSI risk for children and by catheter type and identify new potential risk factors, including gender, race, and insurance type.

CONCLUSIONS

Additional studies are needed to determine effective interventions that will reduce HPN-associated CLABSI.

Biological and Immunomodulator Use in Crohn's Disease in a Medicaid Population

BACKGROUND

Immunomodulator and biological use in African Americans (AA) with Crohn's disease (CD) has been reported to be lower than in whites (W); less data exist for Hispanics (H).

METHODS

Medicaid databases from 3 states were examined for patients with CD from August 1998 to July 2009. CD-related treatments, comorbidities, location, surgery, and health care utilization were assessed from diagnosis until the first biological claim or end of claims. A Cox proportional hazard regression model was used to assess the effect of race on biological initiation.

RESULTS

A total of 5575 patients with CD (3590 W; 924 AA; 494 H; and 567 "other") were analyzed; 18%, 17%, and 17% of W, AA, and H patients, respectively, started immunomodulators (P = not significant); and 7%, 9%, and 5% of W, AA, and H, respectively, initiated biologics after CD diagnosis (P = not significant). After adjusting for demographics and CD-related medications and comorbidities in Cox models, no association was found between AA and W for biological use (hazard ratio 1.19; 95% confidence interval [CI], 0.91-1.54) or H and W (hazard ratio 0.68, 95% CI, 0.45-1.02). Analyzing patients hospitalized after CD diagnosis (n = 3428) to adjust for disease severity demonstrated that H were significantly less likely to use biologics than W (hazard ratio 0.40, 95% CI, 0.22-0.74). No differences between W and AA were found.

CONCLUSIONS

Our findings suggest that differences between AA and W in exposure to immunomodulators or biologics may not exist, although they may be present in H with more severe disease. Further research is needed to confirm these findings.

Time Trends, Clinical Characteristics, and Risk Factors of Chronic Anal Fissure Among a National Cohort of Patients with Inflammatory Bowel Disease

BACKGROUND

Chronic anal fissure (CAF) is a common problem that causes significant morbidity. Little is known about the risk factors of CAF among patients with inflammatory bowel disease (IBD).

AIM

To study the clinical characteristics and prevalence of CAF among a cohort of IBD patients.

METHODS

We performed a population-based study on IBD patients from the National Veterans Affairs administrative datasets from 1998 to 2011. IBD and AF were identified by ICD-9 diagnosis codes.

RESULTS

We identified 60,376 patients with IBD between the ages of 18-90 years, 94% males, 59% diagnosed with ulcerative colitis (UC), and 88% were Caucasians. The overall prevalence of CAF was 4% for both males and females. African Americans (AA) were two times more likely to have CAF compared to Caucasians (8 vs. 4%; OR 2.0, 95% CI 1.6-20.2, p = 0.0001) or Hispanics (8 vs. 4.8%; OR 2.1, 95% CI 1.4-25.2, p = 0.0001). The prevalence of CAF significantly dropped with age from 7% at age group 20-50 to 1.5% at 60-90 (p = 0.0001). CD patients were two times more likely to have CAF than UC patients (6 vs. 3%; OR 1.9, 95% CI 1.5-18.2, p = 0.0001). The initial diagnosis of CAF occurred within 14 years after the initial diagnosis of IBD in 74.5% patients.

CONCLUSIONS

CAF is more prevalent among IBD than what is reported in the general population and diagnosed after the diagnosis of IBD. CAF is more prevalent among patients with CD, younger patients, and AA. The current results lay the groundwork for further outcome studies relate to anal fissure such as utilization, hospitalization, and cost.

Malnutrition diagnoses in hospitalized patients: United States, 2010

Malnutrition is common among hospitalized patients in the United States, and its coded prevalence is increasing. Malnutrition is known to be associated with increased morbidity, mortality and healthcare costs. Although national data indicate that the number of malnutrition diagnoses among hospital discharges has been steadily rising, an in-depth examination of the demographic and clinical characteristics of these patients has not been conducted. We examined data from the 2010 Healthcare Cost and Utilization Project (HCUP), the most recent nationally-representative data describing U.S. hospital discharges. Using ICD-9 codes, we constructed a composite variable indicating a diagnosis of malnutrition. Based on our definition, 3.2% of all U.S. hospital discharges in 2010 had this diagnosis. Relative to patients without a malnutrition diagnosis, those with the diagnosis were older, had longer lengths of stay and incurred higher costs. These patients were more likely to have 27 of 29 comorbidities assessed in HCUP. Finally, discharge to home care was twice as common among malnourished patients, and a discharge of death was more than 5 times as common among patients with a malnutrition diagnosis. Taken together, these nationally representative, cross-sectional data indicate that hospitalized patients discharged with a diagnosis of malnutrition are older and sicker and their inpatient care is more expensive than their counterparts without this diagnosis.

Regional differences in healthcare delivery for gastroparesis

AIM

Few studies have examined the effects of various interventions in gastroparesis. The goal of the present study was to determine whether inpatient management and outcomes differed among states across the United States.

METHODS

Using population statistics and the State Inpatient Database (Agency for Healthcare Research and Quality), regional differences in admissions for gastroparesis, inpatient mortality, length of stay, nursing home transfers, and rates of endoscopy, gastrostomy placement, and nutritional support were assessed.

RESULTS

Admissions for gastroparesis ranged from 24.3 ± 0.8/100,000 in Utah to 117.1 ± 9.7/100,000 in Maryland, with mortality rates similarly varying fourfold from 0.5 ± 0.1/100,000 in Colorado to 2.3 ± 0.1/100,000 in Florida. Intervention rates differed between states (endoscopy: 6.8 ± 0.8 % in Wyoming versus 23.1 ± 0.4 % in Florida; gastrostomy: 0.8 ± 0.1 % in North Carolina versus 3.3 ± 0.8 % in Hawaii; nutritional support: 1.2 ± 0.2 % in West Virginia versus 7.0 ± 0.6 % in New Jersey). Admissions rates were independently predicted by high overall hospitalizations within a state. Higher population density, median incomes and admissions to for-profit hospitals correlated with endoscopy rates. Coexisting heart failure and male gender were associated with higher likelihood of gastrostomy placement, while initiation of nutritional support was predicted by physician supply and insurance status. Age cohort, Medicare coverage, poverty rates and endoscopic testing independently predicted mortality, while length of stay correlated with diagnostic and therapeutic interventions.

CONCLUSIONS

There is a significant variability in admissions, interventions and outcomes for gastroparesis. While biological factors, such as comorbidities and age, contribute to this variability, the data suggest that socioeconomic variables significantly affect approaches to gastroparesis treatment in the United States.

Regional differences in hospitalizations and cholecystectomies for biliary dyskinesia

Background/Aims

Published studies suggest that socioeconomic factors contribute to increasing cholecystectomy rates for biliary dyskinesia (BD). The aim of this study was to identify factors driving admissions and operations for BD by examining regional variability in hospitalizations and cholecystectomies for this disorder.

Methods

Annual hospitalizations and cholecystectomy rates for biliary diseases were assessed using the State Inpatient Databases of the Agency for Healthcare Research and Quality based on diagnosis codes for biliary dyskinesia, cholecystolithiasis and cholecystitis.

Results

Annual admissions for BD varied nearly sevenfold among different states within the United States. Hospitalizations for gallstone disease and its complication showed less variability, differing 2-fold between states. Nearly 70% of admissions for BD and about 85% of admissions for gallstone disease resulted in cholecystectomies. Higher admission rates for BD were best predicted by high overall hospitalization rates, admission rate for gallstone disease and the physician workforce within a state. Cholecystectomy rates for BD were higher in states with low population density and high rates of cholecystectomy for gallstone disease.

Conclusions

These data suggest that established medical practice patterns significantly contribute to the variability in admissions and operations for biliary dyskinesia. The findings also indicate that lower thresholds for operative interventions are an important determinant in the approach to this disorder. Considering the benign course of functional illnesses, the bar for surgical interventions should be raised rather than lowered; in addition active conservative treatment options should be developed for these patients.

Treatment of intra-abdominal abscesses in Crohn's disease: a nationwide analysis of patterns and outcomes of care

BACKGROUND

Abdominal abscesses are a common complication in Crohn's disease (CD). Percutaneous drainage of such abscesses has become increasingly popular and may deliver outcomes comparable to surgical treatment; however, such comparative data are limited from single-center studies. There have been no nationally representative studies comparing different treatment modalities for abdominal abscesses.

METHODS

We identified all adult CD-related non-elective hospitalizations from the Nationwide Inpatient Sample 2007 that were complicated by an intra-abdominal abscess. Treatment modality was categorized into 3 strata-medical treatment alone, percutaneous drainage, and surgery. We analyzed the nationwide patterns in the treatment and outcomes of each treatment modality and examined for patient demographic, disease, or hospital-related disparities in treatment and outcome.

RESULTS

There were an estimated 3,296 hospitalizations for abdominal abscesses in patients with CD. Approximately 39 % were treated by medical treatment alone, 29 % with percutaneous drainage, and 32 % with surgery with a significant increase in the use of percutaneous drainage since 1998 (7 %). Comorbidity burden, admission to a teaching hospital, and complicated Crohn's disease (fistulae, stricture) were associated with non-medical treatment. Use of percutaneous drainage was more common in teaching hospitals. Mean time to percutaneous drainage and surgical treatment were 4.6 and 3.3 days, respectively, and early intervention was associated with significantly shorter hospitalization.

CONCLUSIONS

We describe the nationwide pattern in the treatment of abdominal abscesses and demonstrate an increase in the use of percutaneous drainage for the treatment of this subgroup. Early treatment intervention was predictive of shorter hospitalization.