How should immunomodulators be optimized when used as combination therapy with anti-tumor necrosis factor agents in the management of inflammatory bowel disease?

Distance to Specialist Care and Disease Outcomes in Inflammatory Bowel Disease

BACKGROUND

Optimal treatment of inflammatory bowel disease (IBD) requires specialized health care. Patients frequently travel long distances to obtain care for IBD, which may hinder regular care and affect outcomes adversely.

METHODS

This study included patients with established Crohn's disease or ulcerative colitis receiving care at a single referral center between January 2005 and August 2016. Distance to our health care center from the zip code of residence was determined for each patient and classified into quartiles. Our primary outcome was need for IBD-related surgery with secondary outcomes being need for biological and immunomodulator therapy. Logistic regression models adjusting for relevant covariates examined the independent association between travel distance and patient outcomes.

RESULTS

Our study included 2136 patients with IBD (1197 Crohn's disease, 939 ulcerative colitis), among which just over half were women (52%), and the mean age was 41 years. The mean distance from our hospital was 2.5, 8.8, 22.0, and 50.8 miles for the first (most proximal) through fourth (most distant), respectively. We observed a statistically significant and meaningful higher risk among patients in the most distant quartile in the need for immunomodulator use (OR, 1.69; 95% CI, 1.29-2.22), biological therapy (OR, 2.19; 95% CI, 1.69-2.85), and surgery (OR, 2.44; 95% CI, 1.80-3.32). Differences remained significant on multivariable analysis and by type of IBD.

CONCLUSIONS

Greater distance to referral health care center was associated with increased risk for needing IBD-related surgery in patients with Crohn's disease or ulcerative colitis.