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Adimadhyam S, Lewis JD, Simon AL, Wolfe AE, Smith S, Hou L, Moyneur É, Reynolds JS, Toh S, Dobes A, Parlett L, Haynes K, Burris J, Dorand JE, Long MD, Kappelman MD. Real-world Evidence Comparing Tofacitinib and Vedolizumab in Anti-TNF-experienced Patients With Ulcerative Colitis. Inflamm Bowel Dis 2024; 30:554-562. [PMID: 37358904 DOI: 10.1093/ibd/izad115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Antitumor necrosis factor (anti-TNF) inhibitors are first-line treatment among patients with ulcerative colitis (UC). With time, patients tend to lose response or become intolerant, necessitating switching to small cell biologics such as tofacitinib or vedolizumab. In this real-world study of a large, geographically diverse US population of TNF-experienced patients with UC, we evaluated the effectiveness and safety of newly initiating treatment with tofacitinib vs vedolizumab. METHODS We conducted a cohort study using secondary data from a large US insurer (Anthem, Inc.). Our cohort included patients with UC newly initiating treatment with tofacitinib or vedolizumab. Patients were required to have evidence of treatment with anti-TNF inhibitors in the 6 months prior to cohort entry. The primary outcome was treatment persistence >52 weeks. Additionally, we evaluated the following secondary outcomes as additional measures of effectiveness and safety: (1) all-cause hospitalization; (2) total abdominal colectomy; (3) hospitalization for infection; (4) hospitalization for malignancy; (5) hospitalization for cardiac events; and (6) hospitalization for thromboembolic events. We used fine stratification by propensity scores to control for confounding by demographics, clinical factors, and treatment history at baseline. RESULTS Our primary cohort included 168 new users of tofacitinib and 568 new users of vedolizumab. Tofacitinib was associated with lower treatment persistence (adjusted risked ratio, 0.77; 95% CI, 0.60 -0.99). Differences in secondary measures of effectiveness or safety between tofacitinib initiators vs vedolizumab initiators were not statistically significant (all-cause hospitalization, adjusted hazard ratio, 1.23; 95% CI, 0.83-1.84; total abdominal colectomy, adjusted HR, 1.79; 95% CI, 0.93-3.44;and hospitalization for any infection, adjusted HR, 1.94; 95% CI, 0.83-4.52). DISCUSSION Ulcerative colitis patients with prior anti-TNF experience initiating tofacitinib demonstrated lower treatment persistence compared with those initiating vedolizumab. This finding is in contrast to other recent studies suggesting superior effectiveness of tofacitinib. Ultimately, head-to-head randomized, controlled trials that focus on directly measured end points may be needed to best inform clinical practice.
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Affiliation(s)
- Sruthi Adimadhyam
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - James D Lewis
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew L Simon
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Audrey E Wolfe
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Samantha Smith
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Laura Hou
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | | | - Juliane S Reynolds
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Sengwee Toh
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Angela Dobes
- Crohn's and Colitis Foundation, New York City, New York, USA
| | | | | | | | | | - Millie D Long
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Kastl AJ, Weaver KN, Zhang X, Strople JA, Adler J, Kelsen JR, Dubinsky MC, Bousvaros A, Watkins R, Dai C, Cross RK, Higgins PDR, Ungaro R, Bewtra M, Bellaguarda EA, Farraye FA, Chun K, Zikry M, Bastidas M, Boccieri ME, Firestine A, Long MD, Kappelman MD. Humoral immune response and safety of SARS-CoV-2 vaccination in very early onset inflammatory bowel disease. J Pediatr Gastroenterol Nutr 2024; 78:871-877. [PMID: 38356293 DOI: 10.1002/jpn3.12142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 11/09/2023] [Accepted: 11/09/2023] [Indexed: 02/16/2024]
Abstract
Children with very early onset inflammatory bowel disease (VEO-IBD) may respond differently to coronavirus disease 2019 (COVID-19) immunization compared to healthy children or other patients with IBD. We recruited children with VEO-IBD <6 years of age and younger following receipt of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine. Demographics, IBD characteristics, medication use, adverse events (AEs) and IBD exacerbations were collected. Blood draws (optional) were obtained for measurement of antireceptor binding domain (RBD) IgG antibodies following vaccination. Of 41 participants, none required emergency department visit or hospitalization due to AE, and only one experienced IBD exacerbation. Detectable antibody was present in 19/19 participants who provided blood sample; 6/7 participants (86%) had durable humoral response 12 months postvaccination. Children with VEO-IBD experience robust humoral immune response to COVID-19 immunization. Severe AEs were rare. These findings provide reassurance that children with VEO-IBD respond well and safely to SARS-CoV-2 vaccination.
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Affiliation(s)
- Arthur J Kastl
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Kimberly N Weaver
- Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Xian Zhang
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jennifer A Strople
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Jeremy Adler
- Susan B. Meister Child Health Evaluation and Research Center and Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Judith R Kelsen
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Marla C Dubinsky
- Department of Pediatrics, Susan and Leonard Feinstein IBD Center, Icahn School of Medicine, Mount Sinai, New York, USA
| | | | - Runa Watkins
- Division of Pediatric Gastroenterology and Nutrition, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Colin Dai
- Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Raymond K Cross
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Peter D R Higgins
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Ryan Ungaro
- Department of Medicine, Susan and Leonard Feinstein IBD Center, Icahn School of Medicine, Mount Sinai, New York, USA
| | - Meenakshi Bewtra
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emanuelle A Bellaguarda
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Kelly Chun
- Esoterix Specialty Laboratory, LabCorp, Calabasas, California, USA
| | - Michael Zikry
- Esoterix Specialty Laboratory, LabCorp, Calabasas, California, USA
| | - Monique Bastidas
- Esoterix Specialty Laboratory, LabCorp, Calabasas, California, USA
| | - Margie E Boccieri
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ann Firestine
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Millie D Long
- Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michael D Kappelman
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Ebach DR, Jester TW, Galanko JA, Firestine AM, Ammoury R, Cabrera J, Bass J, Minar P, Olano K, Margolis P, Sandberg K, Linnville TM, Kaplan J, Pitch L, Steiner SJ, Bass D, Moses J, Adler J, Gulati AS, Wali P, Pashankar D, Ivanova A, Herfarth H, Wohl DA, Benkov KJ, Strople J, Sullivan J, Tung J, Molle-Rios Z, Saeed SA, Bousvaros A, Kappelman MD. High Body Mass Index and Response to Anti-Tumor Necrosis Factor Therapy in Pediatric Crohn's Disease. Am J Gastroenterol 2024:00000434-990000000-01056. [PMID: 38445644 DOI: 10.14309/ajg.0000000000002741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 02/14/2024] [Indexed: 03/07/2024]
Abstract
INTRODUCTION Obesity is common among patients with pediatric Crohn's disease (PCD). Some adult studies suggest obese patients respond less well to anti-tumor necrosis factor (TNF) treatment. This study sought compares anti-TNF response and anti-TNF levels between pediatric patients with normal and high body mass index (BMI). METHODS The COMBINE trial compared anti-TNF monotherapy with combination therapy with methotrexate in patients with PCD. In this secondary analysis, a comparison of time-to-treatment failure among patients with normal BMI vs BMI Z -score >1, adjusting for prescribed anti-TNF (infliximab [IFX] or adalimumab [ADA]), trial treatment assignment (combination vs monotherapy), and relevant covariates. Median anti-TNF levels across BMI category was also examined. RESULTS Of 224 participants (162 IFX initiators and 62 ADA initiators), 111 (81%) had a normal BMI and 43 (19%) had a high BMI. High BMI was associated with treatment failure among ADA initiators (7/10 [70%] vs 12/52 [23%], hazard ratio 0.29, P = 0.007) but not IFX initiators. In addition, ADA-treated patients with a high BMI had lower ADA levels compared with those with normal BMI (median 5.8 vs 12.8 μg/mL, P = 0.02). IFX trough levels did not differ between BMI groups. DISCUSSION Overweight and obese patients with PCD are more likely to experience ADA treatment failure than those with normal BMI. Higher BMI was associated with lower drug trough levels. Standard ADA dosing may be insufficient for overweight children with PCD. Among IFX initiators, there was no observed difference in clinical outcomes or drug levels, perhaps due to weight-based dosing and/or greater use of proactive drug monitoring.
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Affiliation(s)
- Dawn R Ebach
- Division of Gastroenterology, Hepatology, Pancreatology, and Nutrition, University of Iowa, Iowa City, Iowa, USA
| | - Traci W Jester
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Joseph A Galanko
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ann M Firestine
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Rana Ammoury
- Department of Pediatrics, Children's Hospital of The King's Daughters, Norfolk, Virginia, USA
| | - Jose Cabrera
- Department of Pediatrics, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Julie Bass
- Department of Pediatrics, Children's Mercy Medical Center, UMKC School of Medicine, Kansas City, Missouri, USA
| | - Phillip Minar
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio, USA
| | - Kelly Olano
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio, USA
| | - Peter Margolis
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio, USA
| | - Kelly Sandberg
- Boonshoft School of Medicine, Wright State University and Department of Medical Affairs, Dayton Children's Hospital, Dayton, Ohio, USA
| | - Tiffany M Linnville
- Department of Pediatrics, Atrium Health Levine Children's Hospital, Charlotte, North Carolina, USA
| | - Jess Kaplan
- Division of Pediatric Gastroenterology, Mass General Hospital for Children, Boston, Massachusetts, USA
| | | | - Steven J Steiner
- Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dorsey Bass
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford Medicine Children's Health, Palo Alto, California, USA
| | - Jonathan Moses
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford Medicine Children's Health, Palo Alto, California, USA
| | - Jeremy Adler
- Department of Pediatrics, University of Michigan-C.S. Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Ajay S Gulati
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Prateek Wali
- Karjoo Family Center for Pediatric Gastroenterology, Hepatology, and Nutrition, Upstate Golisano Children's Hospital, SUNY Upstate Medical Center, Syracuse, New York, USA
| | - Dinesh Pashankar
- Pediatric Gastroenterology and Hepatology, Yale New Haven Children's Hospital, Yale School of Medicine, New Haven, Connecticut, USA
| | - Anastasia Ivanova
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Hans Herfarth
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - David A Wohl
- University of North Carolina Institute of Global Health and Infectious Diseases, Chapel Hill, North Carolina, USA
| | - Keith J Benkov
- Division of Pediatric Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jennifer Strople
- Division of Pediatric Gastroenterology, Ann & Robert Lurie Children's Hospital, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jillian Sullivan
- Children's Hospital of Vermont, University of Vermont, Burlington, Vermont, USA
| | - Jeanne Tung
- Oklahoma Children's Hospital, University of Oklahoma, Oklahoma City, Oklahoma, USA
| | | | - Shehzad A Saeed
- Boonshoft School of Medicine, Wright State University and Department of Medical Affairs, Dayton Children's Hospital, Dayton, Ohio, USA
| | - Athos Bousvaros
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Michael D Kappelman
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Berenblum Tobi C, Vu M, Díaz-González de Ferris ME, Semerzier S, Kappelman MD, deJong NA. Adolescent and caregiver perceptions of addressing mental health in inflammatory bowel disease. J Child Health Care 2024:13674935241241350. [PMID: 38530035 DOI: 10.1177/13674935241241350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
Adolescents with inflammatory bowel disease (IBD) are at an increased risk of anxiety and depression compared to peers, but availability of mental health services in IBD clinics does not meet patients' needs, and use of primary care services for mental health screening and care is low. This study provides qualitative data regarding adolescent and caregiver perspectives on addressing mental health in IBD. Interviews were conducted with adolescents with IBD and caregivers of adolescents with IBD. Interview transcripts were coded and analyzed for prominent themes. Thirteen adolescents and fourteen caregivers were interviewed. Three primary themes emerged: mental health stigma makes discussing it more difficult, physician-adolescent trust makes conversations about mental health easier, and asking about mental health directly can help adolescents feel comfortable. Adolescents and caregivers highlighted the importance of considering each patient and their family individually when choosing how to discuss mental health. Fostering trust with adolescents with IBD is vital to addressing mental health. While encouraging standardized screening is important, the most patient-centered approach to mental health involves considering families individually to identify and address mental health challenges. Given the increased risk of anxiety and depression in pediatric patients with IBD, all providers encountering these patients should be equipped to discuss mental health non-judgmentally.
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Affiliation(s)
| | - Maihan Vu
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | - Michael D Kappelman
- Division of Pediatric Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Neal A deJong
- Department of Pediatrics, University of North Carolina at Chapel Hill Chapel Hill, NC, USA
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Brenner EJ, Weaver KN, Zhang X, Kastl AJ, Strople JA, Adler J, Dubinsky MC, Bousvaros A, Watkins R, Dai X, Chen W, Cross RK, Higgins PDR, Ungaro RC, Bewtra M, Bellaguarda EA, Farraye FA, Chun KY, Zikry M, Bastidas M, Firestine A, Craig RG, Boccieri ME, Long MD, Kappelman MD. Long-Term Effectiveness and Durability of COVID-19 Vaccination Among Patients With Inflammatory Bowel Disease. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00203-9. [PMID: 38369224 DOI: 10.1016/j.cgh.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 01/19/2024] [Accepted: 02/01/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND AND AIMS COVID-19 vaccination prevents severe disease in most patients with inflammatory bowel disease (IBD), but immunosuppressive medications can blunt serologic response. We followed adults with IBD for >1 year post-COVID-19 vaccination to describe factors associated with SARS-CoV-2 infection after vaccination, evaluate for a protective SARS-CoV-2 antibody level, characterize SARS-CoV-2 antibody persistence, and identify factors associated with humoral immune response durability. METHODS Using a prospective cohort of COVID-19 immunized adults with IBD, we analyzed factors associated with SARS-CoV-2 infection after vaccination. We evaluated for an association between SARS-CoV-2 antibody level 12 weeks postvaccination and subsequent SARS-CoV-2 infection and assessed for a threshold of protection using receiver-operating characteristic curve analysis. We then conducted a separate analysis evaluating factors associated with persistence of SARS-CoV-2 antibodies 52 weeks postimmunization. RESULTS Almost half (43%) of 1869 participants developed COVID-19 after vaccination, but most infections were mild, and <1% required hospitalization. Older age and corticosteroid use were associated with a decreased risk of SARS-CoV-2 infection postvaccination (50-59 years of age vs 18-29 years of age: adjusted hazard ratio, 0.57; 95% confidence interval, 0.44-0.74; steroid users vs nonusers: adjusted hazard ratio, 0.58; 95% confidence interval, 0.39-0.87). Most (98%) participants had detectable antibody levels at 52 weeks postvaccination. Antibody levels at 12 weeks and number of vaccine doses were positively associated with higher antibody levels at 52 weeks, while anti-tumor necrosis factor α therapy was negatively associated. CONCLUSIONS COVID-19 vaccination generates an effective and durable protective response for the vast majority of adults with IBD, including vulnerable populations such as corticosteroid users and older individuals. Patients with IBD benefit from COVID-19 booster vaccination.
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Affiliation(s)
- Erica J Brenner
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Kimberly N Weaver
- Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Xian Zhang
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Arthur J Kastl
- Division of Gastroenterology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer A Strople
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jeremy Adler
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Marla C Dubinsky
- Dr. Henry D. Janowitz Division of Gastroenterology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Athos Bousvaros
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Runa Watkins
- Division of Pediatric Gastroenterology and Nutrition, University of Maryland School of Medicine, Baltimore, Maryland
| | - Xiangfeng Dai
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Wenli Chen
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Raymond K Cross
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Peter D R Higgins
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Ryan C Ungaro
- Dr. Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Meenakshi Bewtra
- Division of Gastroenterology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Kelly Y Chun
- Research and Development, LabCorp, Calabasas, California
| | - Michael Zikry
- Research and Development, LabCorp, Calabasas, California
| | | | - Ann Firestine
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Riley G Craig
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Margie E Boccieri
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Millie D Long
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Michael D Kappelman
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Brenner EJ, Zhang X, Long MD, Dubinsky MC, Kappelman MD. High Use of Estrogen-based Contraceptives in Young Women With Inflammatory Bowel Disease in the United States. Clin Gastroenterol Hepatol 2024; 22:427-429.e28. [PMID: 37482173 PMCID: PMC10800639 DOI: 10.1016/j.cgh.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/29/2023] [Accepted: 07/11/2023] [Indexed: 07/25/2023]
Affiliation(s)
- Erica J Brenner
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Xian Zhang
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Millie D Long
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Marla C Dubinsky
- Dr. Henry D. Janowitz Division of Gastroenterology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michael D Kappelman
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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7
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Boccieri M, Craig R, Zhang X, Firestine AM, Long MD, Kappelman MD. Racial and ethnic differences in the degree of participation and retention in a decentralized cohort study of COVID-19 immunization in patients with inflammatory bowel diseases. J Clin Transl Sci 2024; 8:e31. [PMID: 38384911 PMCID: PMC10880004 DOI: 10.1017/cts.2024.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 12/14/2023] [Accepted: 01/03/2024] [Indexed: 02/23/2024] Open
Abstract
Introduction Disparities in the recruitment of minority populations in research are well-documented. However, the degree of participation and retention of minorities following enrollment is less known, particularly in decentralized studies. Although decentralized clinical research methods may allow researchers to engage broader study populations with less participation burden, they may present different retention challenges. To evaluate racial and ethnic differences in the degree of participation after enrollment in a decentralized study, we analyzed data from a cohort of patients with inflammatory bowel diseases following COVID-19 immunization. Methods We compared by race and ethnicity the following post-enrollment participation metrics: response to > 50% of follow-up surveys, donation of a blood sample for antibody testing, consent to use of bio samples for future research, and withdrawal prior to study completion. Results Overall, we observed higher levels of post-enrollment study participation among non-Hispanic White (NHW) participants as compared to Black or Hispanic participants: 95% of NHW participants completed follow-up versus 87% of Black participants and 91% of Hispanic participants, 73% of NHW participants provided bio samples versus 64% Black participants and 67% Hispanic participants, and 65% of NHW participants provided consent for future research versus 62% of Black participants and 52% of Hispanic participants. Conclusions Our findings demonstrate that the degree of study participation after enrollment in this decentralized study differed by race and ethnicity, indicating that attention to diversity, equity, and inclusion is needed not only in clinical research recruitment but also throughout study administration.
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Affiliation(s)
- Margie Boccieri
- Pediatric Gastroenterology, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Riley Craig
- Pediatric Gastroenterology, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Xian Zhang
- Pediatric Gastroenterology, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Ann M. Firestine
- Pediatric Gastroenterology, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Millie D. Long
- Gastroenterology, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Michael D. Kappelman
- Pediatric Gastroenterology, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
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Gaines LS, Kappelman MD, Schwartz DA, Horst SN, Beaulieu DB, Scoville ES, Dalal RL, Pabla BS, Slaughter JC. The Comorbidity of Patient-Reported Crohn's Disease Activity and Depression: The Role of Health Behavior Mediators. Crohns Colitis 360 2024; 6:otad080. [PMID: 38188701 PMCID: PMC10771267 DOI: 10.1093/crocol/otad080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Indexed: 01/09/2024] Open
Abstract
Background Longitudinal research reveals a unidirectional relationship between a nonsomatic symptom of depression, a negative view of the self, and later reported Crohn's disease (CD) activity. We evaluated whether health behaviors mediated this association using a longitudinal design. Methods We studied 3304 adult volunteers with a self-reported diagnosis of CD who completed a baseline survey that included demographics, CD activity, a symptom-specific index of depression, and measures of physical activity, smoking, and sleep quality. Crohn's disease status and the cognitive index of depression were also measured 6 and 12 months after the baseline evaluation. We specified single-mediator and multiple-mediator models to elucidate the depression-disease activity relationship. Results Among 2395 females and 909 males, we found a significant mediation effect for activity level (P < .001) after adjusting for age, sex, and body mass index. There was no evidence that sleep quality and smoking are significant single mediators. When we considered multiple mediation models, smoking and less activity partially mediate the depression-CD association. Conclusions Smoking and lower levels of physical activity are potential mediators of the unidirectional association between a nonsomatic symptom of depression-a negative view of the self-and patient-reported CD activity. Evaluating and treating specific symptoms of depression may reduce the frequency of CD exacerbations.
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Affiliation(s)
- Lawrence S Gaines
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael D Kappelman
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - David A Schwartz
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sara N Horst
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dawn B Beaulieu
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elizabeth S Scoville
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robin L Dalal
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Baldeep S Pabla
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - James C Slaughter
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
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9
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Motwani KK, Hashash JG, Farraye FA, Kappelman MD, Weaver KN, Zhang X, Long MD, Cross RK. Impact of Holding Immunosuppressive Therapy in Patients with Inflammatory Bowel Disease Around mRNA COVID-19 Vaccine Administration on Humoral Immune Response and Development of COVID-19 Infection. J Crohns Colitis 2023; 17:1681-1688. [PMID: 37232444 DOI: 10.1093/ecco-jcc/jjad085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND AND AIMS The BNT162b2 and mRNA-1273 COVID-19 vaccines are efficacious in patients with inflammatory bowel disease; but there is a lack of data examining if holding immunosuppressive therapy around vaccination improves immune response. We studied the effect of holding IBD medications around the time of vaccination on antibody response and breakthrough COVID-19 infection. METHODS Partnership to Report Effectiveness of Vaccination in populations Excluded from iNitial Trials of COVID is a prospective cohort of individuals with IBD receiving COVID-19 vaccination. Quantitative measurement of anti-receptor binding domain IgG antibodies to SARS-CoV-2 was performed 8 weeks after completing a vaccination series. RESULTS A total of 1854 patients were included; 59% were on anti-tumour necrosis factor [TNF] [10% of these on combination therapy], 11% on vedolizumab, and 14% on ustekinumab; 11% of participants held therapy before or after vaccine administration for at least 2 weeks. Antibody levels were similar in participants continuing versus holding anti-TNF monotherapy before or after the second vaccine [BNT162b2: 10 μg/mL vs 8.9 μg/mL; mRNA-1273: 17.5 μg/mL vs 14.5 μg/mL]. Comparable results were seen in those on combination therapy. Antibody titres in those on ustekinumab or vedolizumab were higher compared with anti-TNF users, but there was no significant difference if the drug was held or continued [BNT162b2: 22.5 μg/mL vs 23 μg/mL; mRNA-1273: 88 μg/mL vs 51 μg/mL]. Holding therapy was not associated with decreased rate of COVID-19 infection compared with those not holding therapy [BNT162b2: 28% vs 29%; mRNA-1273: 19% vs 31%]. CONCLUSION We recommend continuing IBD medications while receiving mRNA COVID-19 vaccination without interruption.
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Affiliation(s)
- Kiran K Motwani
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Jana G Hashash
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Francis A Farraye
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Michael D Kappelman
- Department of Pediatrics, Division of Gastroenterology, University of North Carolina Chapel Hill, NC, USA
| | - Kimberly N Weaver
- Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina Chapel Hill, NC, USA
| | - Xian Zhang
- Department of Pediatrics, Division of Gastroenterology, University of North Carolina Chapel Hill, NC, USA
| | - Millie D Long
- Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina Chapel Hill, NC, USA
| | - Raymond K Cross
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland Medical Center, Baltimore, MD, USA
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10
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Jackson SL, Woodruff RC, Nagavedu K, Fearrington J, Rolka DB, Twentyman E, Carton TW, Puro J, Denson JL, Kappelman MD, Paranjape A, Thacker D, Weiner MG, Goodman AB, Lekiachvili A, Boehmer TK, Block JP. Association Between Hypertension and Diabetes Control and COVID-19 Severity: National Patient-Centered Clinical Research Network, United States, March 2020 to February 2022. J Am Heart Assoc 2023; 12:e030240. [PMID: 37850404 PMCID: PMC10727406 DOI: 10.1161/jaha.122.030240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 08/15/2023] [Indexed: 10/19/2023]
Abstract
Background Hypertension and diabetes are associated with increased COVID-19 severity. The association between level of control of these conditions and COVID-19 severity is less well understood. Methods and Results This retrospective cohort study identified adults with COVID-19, March 2020 to February 2022, in 43 US health systems in the National Patient-Centered Clinical Research Network. Hypertension control was categorized as blood pressure (BP) <130/80, 130 to 139/80 to 89, 140 to 159/90 to 99, or ≥160/100 mm Hg, and diabetes control as glycated hemoglobin <7%, 7% to <9%, ≥9%. Adjusted, pooled logistic regression assessed associations between hypertension and diabetes control and severe COVID-19 outcomes. Among 1 494 837 adults with COVID-19, 43% had hypertension and 12% had diabetes. Among patients with hypertension, the highest baseline BP was associated with greater odds of hospitalization (adjusted odds ratio [aOR], 1.30 [95% CI, 1.23-1.37] for BP ≥160/100 versus BP <130/80), critical care (aOR, 1.30 [95% CI, 1.21-1.40]), and mechanical ventilation (aOR, 1.32 [95% CI, 1.17-1.50]) but not mortality (aOR, 1.08 [95% CI, 0.98-1.12]). Among patients with diabetes, the highest glycated hemoglobin was associated with greater odds of hospitalization (aOR, 1.61 [95% CI, 1.47-1.76] for glycated hemoglobin ≥9% versus <7%), critical care (aOR, 1.42 [95% CI, 1.31-1.54]), mechanical ventilation (aOR, 1.12 [95% CI, 1.02-1.23]), and mortality (aOR, 1.18 [95% CI, 1.09-1.27]). Black and Hispanic adults were more likely than White adults to experience severe COVID-19 outcomes, independent of comorbidity score and control of hypertension or diabetes. Conclusions Among 1.5 million patients with COVID-19, higher BP and glycated hemoglobin were associated with more severe COVID-19 outcomes. Findings suggest that adults with poorest control of hypertension or diabetes might benefit from efforts to prevent and initiate early treatment of COVID-19.
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Affiliation(s)
- Sandra L. Jackson
- Division for Heart Disease and Stroke PreventionNational Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and PreventionAtlantaGA
| | - Rebecca C. Woodruff
- Division for Heart Disease and Stroke PreventionNational Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and PreventionAtlantaGA
| | - Kshema Nagavedu
- Department of Population MedicineHarvard Pilgrim Health Care Institute, Harvard Medical SchoolBostonMA
| | - Julia Fearrington
- Department of Population MedicineHarvard Pilgrim Health Care Institute, Harvard Medical SchoolBostonMA
| | - Deborah B. Rolka
- Division of Diabetes TranslationNational Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and PreventionAtlantaGA
| | - Evelyn Twentyman
- Office of the DirectorNational Center for Immunizations and Respiratory Diseases, Centers for Disease Control and PreventionAtlantaGA
| | | | | | - Joshua L. Denson
- Section of Pulmonary, Critical Care, and Environmental MedicineTulane University School of MedicineNew OrleansLA
| | - Michael D. Kappelman
- Department of Pediatrics, UNC School of MedicineThe University of North Carolina at Chapel HillChapel HillNC
| | | | | | - Mark G. Weiner
- Department of Population Health SciencesWeill Cornell MedicineNew YorkNY
| | - Alyson B. Goodman
- Division of Nutrition, Physical Activity, and ObesityNational Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and PreventionAtlantaGA
| | - Akaki Lekiachvili
- National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and PreventionAtlantaGA
| | - Tegan K. Boehmer
- Office of Public Health Data, Surveillance, and TechnologyCenters for Disease Control and PreventionAtlantaGA
| | - Jason P. Block
- Division of Chronic Disease Research Across the Lifecourse (CoRAL)Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical SchoolBostonMA
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11
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Moon AM, Cook S, Swier RM, Sanoff HK, Kappelman MD, Wagner LI, Barritt AS, Singal AG, Shah ND, Mauro DM, Yanagihara TK, Gerber DA, Fried MW, Brown C, Waheed M, Teal R, Evon DM. Patient-reported symptoms and interest in symptom monitoring in HCC treated with locoregional therapies: A qualitative study. Hepatol Commun 2023; 7:e0315. [PMID: 37930127 PMCID: PMC10629737 DOI: 10.1097/hc9.0000000000000315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/02/2023] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND Patient-reported outcomes (PRO) measures relevant to domains most important to patients with HCC who received locoregional therapies are needed to advance patient-centered research. Furthermore, electronic PRO monitoring in clinical care has been shown to reduce hospitalizations and deaths in patients with other cancers. We conducted a qualitative study among patients with HCC who recently received locoregional therapies to (1) identify common and distressing posttreatment symptoms to prioritize PRO domain selection and (2) gauge interest in an electronic PRO symptom monitoring system. METHODS We performed semi-structured telephone interviews among adult patients who received locoregional therapies (median of 26 days after treatment) for treatment-naïve HCC at a single tertiary care center. Interviews were conducted until thematic saturation was reached. Qualitative content analysis was conducted to identify emerging themes and sub-themes. RESULTS Ten of 26 patients (38%) reported at least 1 symptom before treatment. In contrast, all participants (n = 26) with recently treated HCC reported at least 1 posttreatment physical symptom, with the most common being appetite loss (73%), fatigue (58%), abdominal pain (46%), and nausea (35%). Most participants (77%) stated they saw potential benefits in posttreatment ePRO symptom monitoring. CONCLUSIONS Posttreatment symptoms after HCC locoregional therapies are common and often severe. These data can inform and prioritize PRO domain selection. Patients are interested in ePRO monitoring to monitor and proactively address posttreatment symptoms. Given the clinical benefits in patients with metastatic cancers, ePRO monitoring warrants investigation in patients with HCC.
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Affiliation(s)
- Andrew M. Moon
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Sarah Cook
- Virginia Commonwealth School of Medicine, Richmond, Virginia, USA
| | - Rachel M. Swier
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Hanna K. Sanoff
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
- Division of Oncology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Michael D. Kappelman
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Lynne I. Wagner
- Department of Health Policy and Management, University of North Carolina, Chapel Hill, North Carolina, USA
| | - A. Sidney Barritt
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Amit G. Singal
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Neil D. Shah
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - David M. Mauro
- Division of Vascular Interventional Radiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Ted K. Yanagihara
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - David A. Gerber
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Michael W. Fried
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Cristal Brown
- Department of Medicine, University of Texas at Austin, Austin, Texas, USA
| | - Myra Waheed
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
- Connected Health Applications and Interventions (CHAI) Core, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Randall Teal
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
- Connected Health Applications and Interventions (CHAI) Core, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Donna M. Evon
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
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12
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Kappelman MD, Saeed SA, Bousvaros A. Reply. Gastroenterology 2023; 165:1308. [PMID: 37625495 DOI: 10.1053/j.gastro.2023.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 08/18/2023] [Indexed: 08/27/2023]
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13
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Nowell WB, Barnes EL, Venkatachalam S, Kappelman MD, Curtis JR, Merkel PA, Shaw DG, Larson K, Greisz J, George MD. Racial and Ethnic Distribution of Rheumatic Diseases in Health Systems of the National Patient-Centered Clinical Research Network. J Rheumatol 2023; 50:1503-1508. [PMID: 37657793 DOI: 10.3899/jrheum.2022-1300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2023] [Indexed: 09/03/2023]
Abstract
OBJECTIVE To evaluate the relative prevalence of 8 rheumatic and musculoskeletal diseases (RMDs) across racial and ethnic groups within the National Patient-Centered Clinical Research Network (PCORnet). METHODS Electronic health records from participating PCORnet institutions and systems from January 1, 2013, to December 31, 2018, were used to identify adult patients with ≥ 2 diagnosis codes for rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), osteoporosis (OP), granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), eosinophilic granulomatosis with polyangiitis (EGPA), giant cell arteritis (GCA), and Takayasu arteritis (TAK). Among those with race and ethnicity data available, we compared prevalence of RMDs by race and ethnicity. RESULTS Data from 28,059,546 patients were available for analysis. RA was more common in patients who were American Indian or Alaska Native vs White, with a prevalence of 11.57 vs 10.11/1000 (odds ratio [OR] 1.15, 95% CI 1.09-1.22). SLE was more common in patients who were Black or African American (6.73/1000), American Indian or Alaska Native (3.82/1000), and Asian (3.39/1000) vs White (2.80/1000; OR 2.43, 95% CI 2.39-2.46; OR 1.39, 95% CI 1.25-1.53; OR 1.26, 95% CI 1.21-1.31, respectively). SLE was more common in patients who were Hispanic vs non-Hispanic (prevalence 3.93 vs 3.45/1000, OR 1.14, 95% CI 1.12-1.16). TAK was more common in patients who were Asian vs White (prevalence 0.05 vs 0.04/1000, OR 1.43, 95% CI 1.00-2.03). OP, RA, and the vasculitides were all more common in patients who were White vs Black or African American. CONCLUSION These data provide important information on the prevalence of RMDs by race and ethnicity in the United States. PCORnet can be used as a reliable data source to study RMDs within a large representative population.
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Affiliation(s)
- William Benjamin Nowell
- W.B. Nowell, PhD, MSW, S. Venkatachalam, PhD, MPH, Global Healthy Living Foundation, Upper Nyack, New York;
| | - Edward L Barnes
- E.L. Barnes, MD, MPH, M.D. Kappelman, MD, MPH, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
| | - Shilpa Venkatachalam
- W.B. Nowell, PhD, MSW, S. Venkatachalam, PhD, MPH, Global Healthy Living Foundation, Upper Nyack, New York
| | - Michael D Kappelman
- E.L. Barnes, MD, MPH, M.D. Kappelman, MD, MPH, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
| | - Jeffrey R Curtis
- J.R. Curtis, MD, MS, MPH, Illumination Health, Hoover, and University of Alabama at Birmingham, Birmingham, Alabama
| | - Peter A Merkel
- P.A. Merkel, MD, MPH, J. Greisz, MD, M.D. George, MD, MSCE, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dianne G Shaw
- D.G. Shaw, MA, K. Larson, MA, Vasculitis Foundation, Kansas City, Missouri, USA
| | - Kalen Larson
- D.G. Shaw, MA, K. Larson, MA, Vasculitis Foundation, Kansas City, Missouri, USA
| | - Justin Greisz
- P.A. Merkel, MD, MPH, J. Greisz, MD, M.D. George, MD, MSCE, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael D George
- P.A. Merkel, MD, MPH, J. Greisz, MD, M.D. George, MD, MSCE, University of Pennsylvania, Philadelphia, Pennsylvania
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14
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Barnes EL, Zhang X, Long MD, Herfarth HH, Kappelman MD. Rate of Colectomy Increases Within 12 Months of Sequential Therapy for Ulcerative Colitis. Am J Gastroenterol 2023; 118:2080-2083. [PMID: 37216596 PMCID: PMC10709523 DOI: 10.14309/ajg.0000000000002331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 04/27/2023] [Indexed: 05/24/2023]
Abstract
INTRODUCTION Patients with medically refractory ulcerative colitis who previously would have undergone surgery can now elect for subsequent medical therapy. METHODS In a commercially insured population, we evaluated the proportion of patients initiating second-line, third-line, or fourth-line treatment who underwent colectomy in the following 12 months. RESULTS Among 3,325 patients with ulcerative colitis, the colectomy rate within 12 months of a switch in therapy increased from 12% with the first switch to 17% and 19% with the second and third switches, respectively ( P < 0.001). DISCUSSION Treatment effectiveness declines with successive switching; however, even after initiating fourth-line therapy, most patients remain surgery-free.
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Affiliation(s)
- Edward L. Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Xian Zhang
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Millie D. Long
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Hans H. Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michael D. Kappelman
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
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15
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Yang JY, Lund JL, Funk MJ, Hudgens MG, Lewis JD, Kappelman MD. Utilization of Treat-to-Target Monitoring Colonoscopy After Treatment Initiation in the US-Based Study of a Prospective Adult Research Cohort With Inflammatory Bowel Disease. Am J Gastroenterol 2023; 118:1638-1647. [PMID: 37053548 DOI: 10.14309/ajg.0000000000002294] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 04/04/2023] [Indexed: 04/15/2023]
Abstract
INTRODUCTION Endoscopic healing has been associated with improved long-term clinical outcomes in inflammatory bowel disease (IBD) and is a recommended target for treatment. Evidence is limited regarding real-world uptake and patterns of treat-to-target monitoring to assess endoscopic healing after treatment initiation. We aimed to estimate the proportion of patients in the Study of a Prospective Adult Research Cohort with IBD (SPARC IBD) who received colonoscopy in the 3-15 months after starting a new IBD treatment. METHODS We identified SPARC IBD patients who initiated a new biologic (infliximab, adalimumab, certolizumab pegol, golimumab, vedolizumab, and ustekinumab) or tofacitinib. We estimated the proportion of patients who received colonoscopies in the 3-15 months after IBD treatment initiation and described use by patient subgroups. RESULTS Among 1,708 eligible initiations from 2017 to 2022, the most common medications were ustekinumab (32%), infliximab (22%), vedolizumab (20%), and adalimumab (16%). The median patient age was 38 years, with 66% Crohn's disease; 55% were female, and 12% were non-White. In the 3-15 months after medication initiation, 49.3% (95% confidence interval 46.2%-52.5%) of initiations were followed by a colonoscopy. Colonoscopy use was similar between ulcerative colitis and Crohn's disease, but was higher among male patients, those older than 40 years, and those who received colonoscopy within 3 months of initiation. Colonoscopy use varied between study sites, from 26.6% (15.0%-38.3%) to 63.2% (54.5%-72.0%). DISCUSSION Approximately half of SPARC IBD patients received colonoscopy in the 3-15 months after initiation to a new IBD treatment, suggesting a low uptake of treat-to-target colonoscopy for the assessment of mucosal healing in real-world clinical practice. The variation in colonoscopy use between study sites suggests a lack of consensus and a need for more robust evidence around whether or not the practice of routine monitoring colonoscopy is associated with improved patient outcomes.
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Affiliation(s)
- Jeff Y Yang
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jennifer L Lund
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michele Jonsson Funk
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michael G Hudgens
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - James D Lewis
- Division of Gastroenterology, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Michael D Kappelman
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
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16
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Beukelman T, Chen L, Annapureddy N, Oates J, Clowse MEB, Long M, Kappelman MD, Rhee RL, Merkel PA, Nowell WB, Xie F, Clinton C, Curtis JR. Using pooled electronic health records data to conduct pharmacoepidemiology safety studies: Challenges and lessons learned. Pharmacoepidemiol Drug Saf 2023; 32:969-977. [PMID: 37005701 DOI: 10.1002/pds.5627] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 03/14/2023] [Accepted: 03/17/2023] [Indexed: 04/04/2023]
Abstract
PURPOSE We assessed the suitability of pooled electronic health record (EHR) data from clinical research networks (CRNs) of the patient-centered outcomes research network to conduct studies of the association between tumor necrosis factor inhibitors (TNFi) and infections. METHODS EHR data from patients with one of seven autoimmune diseases were obtained from three CRNs and pooled. Person-level linkage of CRN data and Centers for Medicare and Medicaid Services (CMS) fee-for-service claims data was performed where possible. Using filled prescriptions from CMS claims data as the gold standard, we assessed the misclassification of EHR-based new (incident) user definitions. Among new users of TNFi, we assessed subsequent rates of hospitalized infection in EHR and CMS data. RESULTS The study included 45 483 new users of TNFi, of whom 1416 were successfully linked to their CMS claims. Overall, 44% of new EHR TNFi prescriptions were not associated with medication claims. Our most specific new user definition had a misclassification rate of 3.5%-16.4% for prevalent use, depending on the medication. Greater than 80% of CRN prescriptions had either zero refills or missing refill data. Compared to using EHR data alone, there was a 2- to 8-fold increase in hospitalized infection rates when CMS claims data were added to the analysis. CONCLUSIONS EHR data substantially misclassified TNFi exposure and underestimated the incidence of hospitalized infections compared to claims data. EHR-based new user definitions were reasonably accurate. Overall, using CRN data for pharmacoepidemiology studies is challenging, especially for biologics, and would benefit from supplementation by other sources.
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Affiliation(s)
- Timothy Beukelman
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Lang Chen
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Narender Annapureddy
- Division of Rheumatology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jim Oates
- Division of Rheumatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Megan E B Clowse
- Division of Rheumatology and Immunology, Duke University, Durham, North Carolina, USA
| | - Millie Long
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Michael D Kappelman
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Rennie L Rhee
- Division of Rheumatology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Fenglong Xie
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Cassie Clinton
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Long MD, Parlett L, Lewis JD, Haynes K, Adimadhyam S, Hou L, Wolfe A, Toh S, Burris J, Dorand J, Kappelman MD. Corticosteroids but not Anti-TNF Are Associated With Increased COVID-19 Complications in Patients With Inflammatory Bowel Disease. Inflamm Bowel Dis 2023:izad176. [PMID: 37611117 DOI: 10.1093/ibd/izad176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Indexed: 08/25/2023]
Abstract
BACKGROUND AND AIMS Immunosuppressed individuals are at higher risk for COVID-19 complications, yet data in patients with inflammatory bowel disease (IBD) are limited. We evaluated the risk of COVID-19- severe sequelae by medication utilization in a large cohort of patients with IBD. METHODS We conducted a retrospective cohort study utilizing insurance claims data between August 31, 2019, and August 31, 2021.We included IBD patients identified by diagnosis and treatment codes. Use of IBD medications was defined in the 90 days prior to cohort entry. Study outcomes included COVID-19 hospitalization, mechanical ventilation, and inpatient death. Patients were followed until the outcome of interest, outpatient death, disenrollment, or end of study period. Due to the aggregate nature of available data, we were unable to perform multivariate analyses. RESULTS We included 102 986 patients (48 728 CD, 47 592 UC) with a mean age of 53 years; 55% were female. Overall, 412 (0.4%) patients were hospitalized with COVID-19. The incidence of hospitalization was higher in those on corticosteroids (0.6% vs 0.3%; P < .0001; 13.6 per 1000 person-years; 95% confidence interval [CI], 10.8-16.9) and lower in those receiving anti-tumor necrosis factor α therapy (0.2% vs 0.5%; P < .0001; 3.9 per 1000 person-years; 95% CI, 2.7-5.4). Older age was associated with increased hospitalization with COVID-19. Overall, 71 (0.07%) patients required mechanical ventilation and 52 (0.05%) died at the hospital with COVID-19. The proportion requiring mechanical ventilation (1.9% vs 0.05%; P < .0001; 3.9 per 1000 person-years; 95% CI, 2.5-5.9) was higher among users of corticosteroids. CONCLUSIONS Among patients with IBD, those on corticosteroids had more hospitalizations and mechanical ventilation with COVID-19. Anti-tumor necrosis factor α therapy was associated with a decreased risk of hospitalization. These findings reinforce previous guidance to taper and/or discontinue corticosteroids in IBD.
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Affiliation(s)
- Millie D Long
- Department of Medicine and Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - James D Lewis
- Department of Medicine, Perlman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Sruthi Adimadhyam
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Laura Hou
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Audrey Wolfe
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Sengwee Toh
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | | | | | - Michael D Kappelman
- Department of Medicine and Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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18
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Barnes EL, Boynton MH, DeWalt DA, Herfarth HH, Kappelman MD. Patient Reported Outcome Assessments Used in the Evaluation of Patients after Ileal Pouch-Anal Anastomosis: A Systematic Review. Gastro Hep Adv 2023; 2:1044-1049. [PMID: 38125203 PMCID: PMC10732468 DOI: 10.1016/j.gastha.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
BACKGROUND AND AIMS There is a paucity of validated measures to evaluate how patients feel and function after restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis. We performed a systematic review to evaluate all published patient reported outcomes (PROs) to assess symptom burden, functional status, and quality of life (QoL) after IPAA. METHODS An electronic literature search on PubMed, Embase, and Web of Science was performed from inception through October 12, 2021. Eligible full texts were further characterized by the type of assessment as well as the individual domains assessed by questions in the PRO measure. RESULTS Among the 129 full texts analyzed, 51 specific PRO measures were utilized. In the evaluation of all PRO measures, 46% included an assessment of disease-specific QoL with 27% evaluating more general QoL, and 15% assessing symptoms related to pouch function. Among the studies using disease-specific instruments, the Cleveland Clinic Global Quality of Life (42%) and the Inflammatory Bowel Disease Questionnaire (21%) were the most commonly used PRO measures. PRO questions were mapped to individual domains using binning methodology, with the greatest number of questions from individual PRO measures mapped to the bowel function domain (122). CONCLUSION In our assessment of PRO measures among patients after IPAA, the studies and individual measures varied widely in both the patient populations being evaluated as well as outcomes and specific domains being assessed. A valid measure that assesses the range of outcomes after IPAA could standardize assessment and advance the study of patients after IPAA.
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Affiliation(s)
- Edward L. Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Marcella H. Boynton
- Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Darren A. DeWalt
- Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Hans H. Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Michael D. Kappelman
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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19
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Kappelman MD, Long MD, Zhang X, Lin FC, Weisbein L, Chen W, Burris J, Dorand JE, Parlett LE, Fehlmann T, Brensinger CM, Haynes K, Nair V, Kaul AF, Dobes A, Lewis JD. Comparing Patient-Reported Outcomes Among Anti-TNF Experienced Patients With Ulcerative Colitis Initiating Vedolizumab Versus Tofacitinib. Crohns Colitis 360 2023; 5:otad031. [PMID: 37350775 PMCID: PMC10284045 DOI: 10.1093/crocol/otad031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Indexed: 06/24/2023] Open
Abstract
Background Primary and secondary nonresponse to anti-tumor necrosis factor (TNF) therapy is common in patients with ulcerative colitis (UC), yet limited research has compared the effectiveness of subsequent biological therapy. Objective We sought to compare the effectiveness of vedolizumab and tofacitinib in anti-TNF experienced patients with UC, focusing on patient-prioritized patient-reported outcomes (PROs). Methods We conducted a prospective cohort study nested within the Crohn's & Colitis Foundation's IBD Partners and SPARC IBD initiatives. We identified anti-TNF experienced patients with UC initiating vedolizumab or tofacitinib and analyzed PROs reported approximately 6 months later (minimum 4 months, maximum 10 months). Co-primary outcomes were Patient Reported Outcome Measurement Information System (PROMIS) domains of Fatigue and Pain Interference. Secondary outcomes included PRO2, treatment persistence, and need for colectomy. Results We compared 72 vedolizumab initiators and 33 tofacitinib initiators. At follow-up, Pain Interference (P = .04), but not Fatigue (P = .53) was lower among tofacitinib initiators. A trend toward higher Social Role Satisfaction was not significant. The remainder of secondary outcomes (PRO2, treatment persistence, colectomy) did not differ between treatment groups. Conclusions Among anti-TNF experienced patients with UC, Pain Interference 4-10 months after treatment initiation was lower among tofacitinib users as compared with vedolizumab users. Many, but not all, secondary endpoints and subanalyses also favored tofacitinib. Future studies with larger sample sizes are needed to further evaluate these findings.
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Affiliation(s)
- Michael D Kappelman
- Address correspondence to: Michael D. Kappelman, MD, MPH, University of North Carolina at Chapel Hill, Campus Box 7229, Bioinformatics Building, 130 Mason Farm Rd., Chapel Hill, NC 27599-7555, USA ()
| | - Millie D Long
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Xian Zhang
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Feng-Chang Lin
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Laura Weisbein
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Wenli Chen
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | | | | | - Tara Fehlmann
- Crohn’s & Colitis Foundation, New York, New York, USA
| | - Colleen M Brensinger
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Kevin Haynes
- Janssen Research & Development, Titusville, New Jersey, USA
| | | | - Alan F Kaul
- Medical Outcomes Management and the Practice Research Network (PRACnet), Sharon, Massachusetts, USA
| | - Angela Dobes
- Crohn’s & Colitis Foundation, New York, New York, USA
| | - James D Lewis
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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20
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Beukelman T, Long MD, Rhee RL, Kappelman MD, Merkel PA, Nowell WB, Clinton C, Ringold S, Del Gaizo V, Price B, Shaw DG, Venkatachalam S, Cuthbertson D, Xie F, Zhang X, Curtis JR. Assessment of Real-World Patient-Reported Outcomes in Patients Initiating Biologic Agents for the Treatment of Autoimmune Diseases: An Observational Study in Four Patient-Powered Research Networks. Patient Relat Outcome Meas 2023; 14:171-180. [PMID: 37333063 PMCID: PMC10276583 DOI: 10.2147/prom.s392174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/23/2023] [Indexed: 06/20/2023] Open
Abstract
Background The most reliable and meaningful approach for inclusion of patient-reported outcomes (PROs) in the evaluation of real-world clinical effectiveness of biologics in the treatment of autoimmune diseases is u ncertain. This study aimed to assess and compare the proportions of patients who had abnormalities in PROs measuring important general health domains at the initiation of treatment with biologics, as well as the effects of baseline abnormalities on subsequent improvement. Methods PROs were collected for patient participants with inflammatory arthritis, inflammatory bowel disease, and vasculitis using Patient-Reported Outcomes Measurement Information System instruments. Scores were reported as T-scores normalized to the general population in the United States. Baseline PROs scores were collected near the time of biologic initiation, and follow-up scores were collected 3 to 8 months later. In addition to summary statistics, the proportion of patients with PROs abnormalities (scores ≥5 units worse than the population norm) was determined. Baseline and follow-up scores were compared, and an improvement of ≥5 units was considered significant. Results There was wide variation across autoimmune diseases in baseline PROs scores for all domains. For example, the proportion of participants with abnormal baseline pain interference scores ranged from 52% to 93%. When restricted to participants with baseline PROs abnormalities, the proportion of participants experiencing an improvement of ≥5 units was substantially higher. Conclusion As expected, many patients experienced improvement in PROs following initiation of treatment with biologics for autoimmune diseases. Nevertheless, a substantial proportion of participants did not exhibit abnormalities in all PROs domains at baseline, and these participants appear less likely to experience improvement. For PROs to be reliably and meaningfully included in the evaluation of real-world medication effectiveness, more knowledge and careful consideration are needed to select the most appropriate patient populations and subgroups for inclusion and evaluation in studies measuring change in PROs.
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Affiliation(s)
- Timothy Beukelman
- Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Millie D Long
- Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rennie L Rhee
- Department of Medicine, Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael D Kappelman
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Peter A Merkel
- Department of Medicine, Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics; Division of Epidemiology, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Cassie Clinton
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sarah Ringold
- Department of Pediatrics, Division of Rheumatology, Seattle Children’s Hospital, Seattle, WA, USA
| | - Vincent Del Gaizo
- Childhood Arthritis and Rheumatology Research Alliance (CARRA) and PARTNERS PPRN, Milwaukee, WI, USA
| | - Brian Price
- Crohn’s and Colitis Foundation and IBD-Partners, New York, NY, USA
| | - Dianne G Shaw
- Vasculitis Patient Powered Research Network, Kansas City, MO, USA
| | | | - David Cuthbertson
- Health Informatics Institute, University of South Florida, Tampa, FL, USA
| | - Fenglong Xie
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Xian Zhang
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jeffrey R Curtis
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
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21
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Venkatachalam S, Gavigan K, Banerjee S, Gordon J, Emrich L, Sullivan H, Blazer A, Banbury B, Weaver KN, Stradford L, Dronadula V, Degrassi A, Merkel PA, Shaw DG, Larsen K, Curtis JR, McBurney RN, Kappelman MD, George MD, Nowell WB. Engaging Multistakeholder Perspectives to Identify Patient-Centered Research Priorities Regarding Vaccine Uptake Among Adults With Autoimmune Conditions. ACR Open Rheumatol 2023; 5:290-297. [PMID: 37127530 PMCID: PMC10267803 DOI: 10.1002/acr2.11546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 02/12/2023] [Indexed: 05/03/2023] Open
Abstract
OBJECTIVE The study objective was to prioritize topics for future patient-centered research to increase uptake of common vaccines, such as for pneumococcal pneumonia, influenza, herpes zoster, human papillomavirus, and severe acute respiratory syndrome coronavirus 2, among adults living with autoimmune conditions. METHODS A steering committee (SC) was formed that included clinicians, patients, patient advocates, and researchers associated with rheumatic diseases (psoriatic arthritis, rheumatoid arthritis, vasculitis), inflammatory bowel disease, and multiple sclerosis. Through a scoping review and discussions, SC members identified research topics regarding vaccine uptake and/or hesitancy for prioritization. A larger multistakeholder alliance that included patients and patient advocates, clinicians, researchers, policy makers, regulators, and vaccine manufacturers conducted a modified Delphi exercise online with three rating rounds and one ranking round. Frequency analysis and comparisons across stakeholder groups were conducted. A weighted ranking score was generated for each item in the ranking round for final prioritization. RESULTS Through the Delphi process, 33 research topics were identified, of which 13 topics were rated as critical by more than 70% of all stakeholders (n = 31). The two highest ranked critical topics per the full stakeholder group were "How well a vaccine works for adults with autoimmune conditions" and "How beliefs about vaccine safety affect vaccine uptake." CONCLUSION A multistakeholder group identified key topics as critically important priorities for future research to decrease vaccine hesitancy and improve uptake of vaccines for adults with autoimmune conditions.
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Affiliation(s)
| | | | | | | | - Lisa Emrich
- Accelerated Cure ProjectWalthamMassachusetts
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Yang JY, Lund JL, Pate V, Kappelman MD. Utilization of Colonoscopy Following Treatment Initiation in U.S. Commercially Insured Patients With Inflammatory Bowel Disease, 2013-2019. Inflamm Bowel Dis 2023; 29:735-743. [PMID: 35929644 PMCID: PMC10152285 DOI: 10.1093/ibd/izac136] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Evaluation of mucosal healing with colonoscopy is recommended for inflammatory bowel disease (IBD) management; however, little is known about real-world use of treat-to-target monitoring following IBD treatment initiation. We aimed to estimate the proportion of U.S. commercially insured IBD patients who receive colonoscopy in the 3 to 15 months after initiating treatment. METHODS We identified IBD patients, 18 to 64 years of age, in the IBM MarketScan Commercial Claims and Encounters database as those with ≥3 IBD diagnoses prior to initiation of biologic, small molecule, or immunomodulatory treatment. We excluded patients with prior colectomy and with rheumatologic and other indications for these therapies. Colonoscopies were identified using International Classification of Diseases-Ninth Revision, International Classification of Diseases-Tenth Revision, and Current Procedural Terminology procedure codes. We used Kaplan-Meier methods to estimate the proportion of newly treated IBD patients who received colonoscopy in the 3 to 6 months, 3 to 12 months, and 3 to 15 months following treatment initiation, and stratified trends by year, patient age and sex, and region. RESULTS From 2013 to 2019, we identified 39 734 initiators of IBD medications (51.9% female, mean age 39.4 years). We observed similar colonoscopy incidence among ulcerative colitis patients (3-6 months: 14.2% [95% confidence interval (CI), 13.6%-14.8%]; 3-12 months: 37.7% [95% CI, 36.8%-38.6%]; 3-15 months: 46.1% [95% CI, 45.2%-47.1%]) and Crohn's disease patients (3-6 months: 11.2% [95% CI, 10.8%-11.6%]; 3-12 months: 32.2% [95% CI, 31.5%-32.9%]; 3-15 months: CD: 40.1% [95% CI, 39.3%-40.8%]). Overall colonoscopy use was slightly higher among women, patients in the Northeast, and those initiating newer biologic therapies. CONCLUSIONS Fewer than half of newly treated IBD patients underwent colonoscopy within 3 to 15 months of initiating new treatment, suggesting low uptake of treat-to-target endoscopic disease monitoring in real-world practice.
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Affiliation(s)
- Jeff Y Yang
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jennifer L Lund
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Virginia Pate
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Michael D Kappelman
- Division of Pediatric Gastroenterology, Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Iglay K, Bennett D, Kappelman MD, Zhang X, Aldridge M, Karki C, Cook SF. A Systematic Review of Epidemiology and Outcomes Associated with Local Surgical and Intersphincteric Ligation Procedures for Complex Cryptoglandular Fistulas. Adv Ther 2023; 40:1926-1956. [PMID: 36905499 PMCID: PMC10129974 DOI: 10.1007/s12325-023-02452-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/01/2023] [Indexed: 03/12/2023]
Abstract
INTRODUCTION This systematic literature review (SLR) assessed incidence/prevalence of cryptoglandular fistulas (CCF) and outcomes associated with local surgical and intersphincteric ligation procedures for CCFs. METHODS Two trained reviewers searched PubMed and Embase for observational studies evaluating the incidence/prevalence of cryptoglandular fistula and clinical outcomes of treatments for CCF after local surgical and intersphincteric ligation procedures for CCF. RESULTS In total 148 studies met a priori eligibility criteria for all cryptoglandular fistulas and all intervention types. Of those, two assessed incidence/prevalence of cryptoglandular fistulas. Eighteen reported clinical outcomes of surgeries of interest in CCF and were published in the past 5 years. Prevalence was reported as 1.35/10,000 non-Crohn's patients, and 52.6% of non-IBD patients were found to progress from anorectal abscess to fistula over 12 months. Primary healing rates ranged from 57.1% to 100%; recurrence occurred in a range of 4.9-60.7% and failure in 2.8-18.0% of patients. Limited published evidence suggests postoperative fecal incontinence and long-term postoperative pain were rare. Several of the studies were limited by single-center design with small sample sizes and short follow-up durations. DISCUSSION This SLR summarizes outcomes from specific surgical procedures for the treatment of CCF. Healing rates vary according to procedure and clinical factors. Differences in study design, outcome definition, and length of follow-up prevent direct comparison. Overall, published studies offer a wide range of findings with respect to recurrence. Postsurgical incontinence and long-term postoperative pain were rare in the included studies, but more research is needed to confirm rates of these conditions following CCF treatments. CONCLUSION Published studies on the epidemiology of CCF are rare and limited. Outcomes of local surgical and intersphincteric ligation procedures show differing success and failure rates, and more research is needed to compare outcomes across various procedures. (PROSPERO; registration number CRD42020177732).
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Affiliation(s)
- Kristy Iglay
- CERobs Consulting, LLC, 2612 North Lumina Ave., Wrightsville Beach, NC 28480 USA
| | - Dimitri Bennett
- Takeda Pharmaceuticals, Cambridge, MA 02139 USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Michael D. Kappelman
- Pediatric Gastroenterology, University of North Carolina, Chapel Hill School of Medicine, Chapel Hill, NC 27599 USA
| | - Xinruo Zhang
- CERobs Consulting, LLC, 2612 North Lumina Ave., Wrightsville Beach, NC 28480 USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
| | - Molly Aldridge
- CERobs Consulting, LLC, 2612 North Lumina Ave., Wrightsville Beach, NC 28480 USA
| | | | - Suzanne F. Cook
- CERobs Consulting, LLC, 2612 North Lumina Ave., Wrightsville Beach, NC 28480 USA
- Takeda Pharmaceuticals, Cambridge, MA 02139 USA
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Kappelman MD, Lewis JD, Zhang X, Lin FC, Weisbein L, Chen W, Burris J, Dorand JE, Parlett LE, Haynes K, Nair V, Kaul AF, Dobes A, Long MD. Comparing Patient-Reported Outcomes Among Anti-TNF-Experienced Patients with Crohn's Disease Initiating Vedolizumab Versus Ustekinumab. Dig Dis Sci 2023:10.1007/s10620-023-07942-0. [PMID: 37115362 DOI: 10.1007/s10620-023-07942-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/30/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Primary and secondary non-response to anti-tumor necrosis factor (TNF) therapy is common in patients with Crohn's disease (CD), yet limited research has compared the effectiveness of subsequent biological therapy. OBJECTIVE We sought to compare the effectiveness of vedolizumab and ustekinumab in anti-TNF-experienced patients with CD, focusing on patient-prioritized patient-reported outcomes (PROs). METHODS We conducted a prospective, internet-based cohort study nested within IBD Partners. We identified anti-TNF-experienced patients initiating with CD vedolizumab or ustekinumab and analyzed PROs reported approximately 6 months later (minimum 4 months, maximum 10 months). Co-primary outcomes were Patient-Reported Outcome Measurement Information System (PROMIS) domains of Fatigue and Pain Interference. Secondary outcomes included patient-reported short Crohn's disease activity index (sCDAI), treatment persistence, and corticosteroid use. Inverse probability of treatment weighting (IPTW) was used to control for a number of potential confounders and incorporated into linear and logistic regression models for continuous and categorical outcomes, respectively. RESULTS Overall, 141 vedolizumab and 219 ustekinumab initiators were included in our analysis. After adjustment, we found no differences between treatment groups in our primary outcomes of Pain Interference or Fatigue or the secondary outcome of sCDAI. However, vedolizumab was associated with lower treatment persistence (OR 0.4, 95% CI 0.2-0.6) and higher corticosteroid use at follow-up assessment (OR 1.7, 95% CI 1.1-2.6). DISCUSSION Among anti-TNF experienced patients with CD, Pain Interference or Fatigue was not significantly different 4-10 months after starting ustekinumab or vedolizumab. However, reduced steroid use and increased persistence suggest superiority of ustekinumab for non-PRO outcomes.
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Affiliation(s)
- Michael D Kappelman
- University of North Carolina at Chapel Hill, Bioinformatics Building, 130 Mason Farm Rd., Campus Box 7229, Chapel Hill, NC, 27599-7555, USA.
| | - J D Lewis
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - X Zhang
- University of North Carolina at Chapel Hill, Bioinformatics Building, 130 Mason Farm Rd., Campus Box 7229, Chapel Hill, NC, 27599-7555, USA
| | - F C Lin
- University of North Carolina at Chapel Hill, Bioinformatics Building, 130 Mason Farm Rd., Campus Box 7229, Chapel Hill, NC, 27599-7555, USA
| | - L Weisbein
- University of North Carolina at Chapel Hill, Bioinformatics Building, 130 Mason Farm Rd., Campus Box 7229, Chapel Hill, NC, 27599-7555, USA
| | - W Chen
- University of North Carolina at Chapel Hill, Bioinformatics Building, 130 Mason Farm Rd., Campus Box 7229, Chapel Hill, NC, 27599-7555, USA
| | - J Burris
- Yale School of Medicine, New Haven, CT, USA
| | - J E Dorand
- Crohn's & Colitis Foundation, New York, NY, USA
| | | | | | - V Nair
- Medical Outcomes Management and the Practice Research Network (PRACNET), Sharon, MA, USA
| | - A F Kaul
- Medical Outcomes Management and the Practice Research Network (PRACNET), Sharon, MA, USA
| | - A Dobes
- Crohn's & Colitis Foundation, New York, NY, USA
| | - M D Long
- University of North Carolina at Chapel Hill, Bioinformatics Building, 130 Mason Farm Rd., Campus Box 7229, Chapel Hill, NC, 27599-7555, USA
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25
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Brenner EJ, Lin L, Bahnson KM, Long MD, Chen W, Kappelman MD, Reeve BB. Computerized-adaptive testing versus short forms for pediatric inflammatory bowel disease patient-reported outcome assessment. J Clin Transl Sci 2023; 7:e109. [PMID: 37250995 PMCID: PMC10225267 DOI: 10.1017/cts.2023.526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/17/2023] [Accepted: 04/03/2023] [Indexed: 05/31/2023] Open
Abstract
Introduction Computerized-adaptive testing (CAT) may increase reliability or reduce respondent burden for assessing patient-reported outcomes compared with static short forms (SFs). We compared CAT versus SF administration of the Patient-Reported Outcomes Measurement Information System® (PROMIS®) Pediatric measures in pediatric inflammatory bowel disease (IBD). Methods Participants completed 4-item CAT, 5- or 6-item CAT, and 4-item SF versions of the PROMIS Pediatric measures. We compared average T-scores, intra-class correlations (ICCs), floor and ceiling effects, and standard error of measurement (SEM) across forms, along with mean effect sizes between active versus quiescent IBD disease activity groups. Results Average PROMIS T-scores across forms were <3 points (minimally important difference) of each other. All forms correlated highly with each other (ICCs ≥0.90) and had similar ceiling effects, but the CAT-5/6 had lower floor effects. The CAT-5/6 had lower SEM than the CAT-4 and SF-4, and the CAT-4 had a lower SEM than the SF-4. Mean effect sizes were similar across forms when contrasting disease activity groups. Conclusions The CAT and SF forms produced similar score results, but the CAT had better precision and lower floor effects. Researchers should consider PROMIS pediatric CAT if they anticipate that their sample will skew toward symptom extremes.
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Affiliation(s)
- Erica J. Brenner
- University of North Carolina, Department of Pediatrics, Division of Pediatric Gastroenterology, Chapel Hill, NC, USA
| | - Li Lin
- Duke University School of Medicine, Department of Population Health Sciences, Durham, NC, USA
| | - Kirsten M. Bahnson
- Duke University School of Medicine, Department of Population Health Sciences, Durham, NC, USA
| | - Millie D. Long
- University of North Carolina, Department of Medicine, Division of Gastroenterology, Chapel Hill, NC, USA
| | - Wenli Chen
- University of North Carolina, Department of Medicine, Division of Gastroenterology, Chapel Hill, NC, USA
| | - Michael D. Kappelman
- University of North Carolina, Department of Pediatrics, Division of Pediatric Gastroenterology, Chapel Hill, NC, USA
| | - Bryce B. Reeve
- Duke University School of Medicine, Department of Population Health Sciences, Durham, NC, USA
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Marcovitch L, Focht G, Carmon N, Tersigni C, Ledder O, Lev-Tzion R, Church PC, Hyams JS, Baldassano RN, Bousvaros A, Mack DR, Hussey S, Otley A, Croft NM, Kappelman MD, Griffiths AM, Turner D. Development and Validation of the TUMMY-UC: A Patient-Reported Outcome for Pediatric Ulcerative Colitis. Gastroenterology 2023; 164:610-618.e4. [PMID: 36539016 DOI: 10.1053/j.gastro.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 12/01/2022] [Accepted: 12/09/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND & AIMS The TUMMY-UC is a patient-reported outcome measure for pediatric ulcerative colitis (UC) with an observer-reported outcome version for children aged <8 years. It includes eight items selected by concept elicitation interviews. We aimed to finalize the TUMMY-UC by cognitive interviews (stage 2) and to evaluate the index for its psychometric properties (stage 3). METHODS The TUMMY-UC items were first finalized during 129 cognitive debriefing interviews. Then, in a prospective, multicenter validation study, 84 children who underwent colonoscopy or provided stool for calprotectin completed the TUMMY-UC and various measures of disease activity. Assessments were repeated after 7 and 21 days for evaluating reliability and responsiveness. RESULTS During stage 2, the items were formatted with identical structure to ensure conceptual equivalence and weighted based on ranking of importance. In stage 3, the TUMMY-UC total score had excellent reliability in repeated assessments (intraclass correlation coefficient, 0.90; 95% confidence interval, 0.84-0.94). It also had moderate to strong correlations with all constructs of disease activity: r = 0.70 with UC endoscopic index of severity, r = 0.63 with the IMPACT-III questionnaire, r = 0.43 with calprotectin, r = 0.80 with the Pediatric Ulcerative Colitis Activity Index, r = 0.75 with global assessment of disease activity, and r = 0.46 with C-reactive protein (all P < .015). The index had excellent discrimination of disease activity, with a score of <9 defining remission (area under the receiver operating characteristic curve, 0.95; 95% confidence interval, 0.93-0.99). The ΔTUMMY-UC showed high responsiveness and differentiated well between children who experienced changed from those with no change. CONCLUSIONS The TUMMY-UC, constructed from patient-reported outcome and observer-reported outcome versions, is a reliable, valid and responsive index that can be now used in practice and clinical trials.
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Affiliation(s)
- Liron Marcovitch
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Gili Focht
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Natalie Carmon
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Claudia Tersigni
- Department of Gastroenterology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Oren Ledder
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Raffi Lev-Tzion
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Peter C Church
- Department of Gastroenterology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey S Hyams
- Division of Digestive Diseases, Hepatology and Nutrition, Connecticut Children's Medical Center, Hartford, Connecticut
| | - Robert N Baldassano
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia (CHOP), Philadelphia, Pennsylvania
| | - Athos Bousvaros
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts
| | - David R Mack
- Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario (CHEO) and Research Institute and University of Ottawa, Ottawa, Ontario, Canada
| | - Séamus Hussey
- National Children's Research Centre, University College Dublin (UCD), Dublin, Ireland
| | - Anthony Otley
- Division of Pediatrics, Izaak Walton Killam (IWK) Health Centre, Halifax, Nova Scotia, Canada
| | - Nicholas M Croft
- Blizard Institute, Faculty of Medicine, Queen Mary University of London, London, United Kingdom
| | - Michael D Kappelman
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anne M Griffiths
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Dan Turner
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel.
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Zhang N, Liu C, Steiner SJ, Colletti RB, Baldassano R, Chen S, Cohen S, Kappelman MD, Saeed S, Conklin LS, Strauss R, Volger S, King E, Lo KH. Using multiple imputation of real-world data to estimate clinical remission in pediatric inflammatory bowel disease. J Comp Eff Res 2023; 12:e220136. [PMID: 36799351 PMCID: PMC10402781 DOI: 10.57264/cer-2022-0136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 01/30/2023] [Indexed: 02/18/2023] Open
Abstract
Aim: To evaluate the performance of the multiple imputation (MI) method for estimating clinical effectiveness in pediatric Crohn's disease in the ImproveCareNow registry; to address the analytical challenge of missing data. Materials & methods: Simulation studies were performed by creating missing datasets based on fully observed data from patients with moderate-to-severe Crohn's disease treated with non-ustekinumab biologics. MI was used to impute sPCDAI remission statuses in each simulated dataset. Results: The true remission rate (75.1% [95% CI: 72.6%, 77.5%]) was underestimated without imputation (72.6% [71.8%, 73.3%]). With MI, the estimate was 74.8% (74.4%, 75.2%). Conclusion: MI reduced nonresponse bias and improved the validity, reliability, and efficiency of real-world registry data to estimate remission rate in pediatric patients with Crohn's disease.
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Affiliation(s)
- Nanhua Zhang
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
- University of Cincinnati, Cincinnati, OH 45229, USA
| | - Chunyan Liu
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Steven J Steiner
- Riley Hospital for Children/Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Richard B Colletti
- University of Vermont College of Medicine, Department of Pediatrics, Burlington, VT 05405, USA
| | - Robert Baldassano
- The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Shiran Chen
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Stanley Cohen
- GI Care For Kids, Atlanta, GA 30342, USA
- Morehouse School of Medicine, Atlanta, GA 30310, USA
| | | | - Shehzad Saeed
- Dayton Children's Hospital/Wright State University, Dayton, OH 45404, USA
| | - Laurie S Conklin
- Janssen Research & Development, LLC, Spring House, PA 19477, USA
| | - Richard Strauss
- Janssen Research & Development, LLC, Spring House, PA 19477, USA
| | - Sheri Volger
- Janssen Research & Development, LLC, Spring House, PA 19477, USA
| | - Eileen King
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
- University of Cincinnati, Cincinnati, OH 45229, USA
| | - Kim Hung Lo
- Janssen Research & Development, LLC, Spring House, PA 19477, USA
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Kappelman MD, Wohl DA, Herfarth HH, Firestine AM, Adler J, Ammoury RF, Aronow JE, Bass DM, Bass JA, Benkov K, Berenblum Tobi C, Boccieri ME, Boyle BM, Brinkman WB, Cabera JM, Chun K, Colletti RB, Dodds CM, Dorsey JM, Ebach DR, Entrena E, Forrest CB, Galanko JA, Grunow JE, Gulati AS, Ivanova A, Jester TW, Kaplan JL, Kugathasan S, Kusek ME, Leibowitz IH, Linville TM, Lipstein EA, Margolis PA, Minar P, Molle Rios Z, Moses J, Olano KK, Osaba L, Palomo PJ, Pappa H, Park KT, Pashankar DS, Pitch L, Robinson M, Samson CM, Sandberg KC, Schuchard JR, Seid M, Shelly KA, Steiner SJ, Strople JA, Sullivan JS, Tung J, Wali P, Zikry M, Weinberger M, Saeed SA, Bousvaros A. Comparative Effectiveness of Anti-TNF in Combination with Low Dose Methotrexate vs Anti-TNF Monotherapy in Pediatric Crohn's Disease: a Pragmatic Randomized Trial. Gastroenterology 2023:S0016-5085(23)00538-3. [PMID: 37004887 DOI: 10.1053/j.gastro.2023.03.224] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/02/2023] [Accepted: 03/10/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND AND AIMS Tumor Necrosis Factor inhibitors (TNFi), including infliximab and adalimumab, are a mainstay of pediatric Crohn's disease (PCD) therapy; however, non-response and loss of response is common. As combination therapy with methotrexate may improve response, we performed a multi-center, randomized, double-blind, placebo-controlled pragmatic trial to compare TNFi with oral methotrexate to TNFi monotherapy. METHODS PCD patients initiating infliximab or adalimumab were randomized in 1:1 allocation to methotrexate or placebo and followed for 12-36 months. The primary outcome was a composite indicator of treatment failure. Secondary outcomes included anti-drug antibodies (ADA) and patient reported outcomes (PROs) of pain interference and fatigue. Adverse events (AEs) and Serious AEs (SAEs) were collected. RESULTS Of 297 participants (mean age 13.9 years, 35% female), 156 were assigned to methotrexate (110 infliximab initiators and 46 adalimumab initiators) and 141 to placebo (102 infliximab initiators and 39 adalimumab initiators). In the overall population, time to treatment failure did not differ by study arm (HR 0.69, 95% CI 0.45-1.05). Among infliximab initiators, there were no differences between combination and monotherapy (HR 0.93, 95% CI 0.55-1.56). Among adalimumab initiators, combination therapy was associated with longer time to treatment failure (HR 0.40, 95% CI 0.19-0.81). A trend towards lower ADA development in the combination therapy arm was not significant. [(infliximab OR 0.72 (0.49-1.07); adalimumab OR 0.71 (0.24-2.07)]. No differences in PROs were observed. Combination therapy resulted in more AEs but fewer SAEs. CONCLUSIONS Among adalimumab but not infliximab initiators, PCD patients treated with methotrexate combination therapy experienced a 2-fold reduction in treatment failure with a tolerable safety profile.
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Affiliation(s)
- Michael D Kappelman
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - David A Wohl
- Institute of Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC
| | - Ann M Firestine
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jeremy Adler
- Susan B. Meister Child Health Evaluation and Research Center and Division of Pediatric Gastroenterology, University of Michigan, Ann Arbor, MI
| | - Rana F Ammoury
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital of The King's Daughters, Norfolk, VA
| | | | - Dorsey M Bass
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, CA
| | - Julie A Bass
- Department of Pediatrics, School of Medicine, University of Missouri Kansas City, Kansas City, MO, Division of Gastroenterology, Children's Mercy Kansas City, Kansas City, MO
| | - Keith Benkov
- Division of Pediatric Gastroenterology, Icahn School of Medicine at Mt Sinai, New York City, NY
| | | | - Margie E Boccieri
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Brendan M Boyle
- Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, OH
| | - William B Brinkman
- Department of Pediatrics, University of Cincinnati College of Medicine; Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jose M Cabera
- Division of Pediatric Gastroenterology, Department of Pediatrics, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI
| | - Kelly Chun
- Esoterix Specialty Laboratory, Labcorp, Calabasas, CA
| | - Richard B Colletti
- Division of Gastroenterology, Department of Pediatrics, University of Vermont, Burlington, VT
| | - Cassandra M Dodds
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jill M Dorsey
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Nemours Children's Health, Jacksonville, FL
| | - Dawn R Ebach
- Division of Pediatric Gastroenterology, Hepatology, Pancreatology, and Nutrition, University of Iowa, Iowa City, IA
| | - Edurne Entrena
- Progenika Biopharma, a Grifols Company, Derio, Bizkaia Spain
| | | | - Joseph A Galanko
- Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - John E Grunow
- University of Oklahoma Children's Physicians, Pediatric Gastroenterology, Oklahoma City, OK
| | - Ajay S Gulati
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Anastasia Ivanova
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Traci W Jester
- Department of Pediatrics, Division of Gastroenterology, University of Alabama at Birmingham, AL
| | - Jess L Kaplan
- Division of Pediatric Gastroenterology, Mass General for Children and Harvard Medical School, Boston, MA
| | | | - Mark E Kusek
- Division of Gastroenterology, University of Nebraska Medical Center, Omaha, NE
| | - Ian H Leibowitz
- Division of Gastroenterology, Hepatology and Nutrition, Children's National Medical Center, Department of Pediatrics, George Washington University, Washington, DC
| | - Tiffany M Linville
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Levine Children's Hospital, Charlotte, NC
| | - Ellen A Lipstein
- Department of Pediatrics, University of Cincinnati College of Medicine, James M. Anderson Center for Health Systems Excellence, and Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Peter A Margolis
- Department of Pediatrics, University of Cincinnati College of Medicine, James M. Anderson Center for Health Systems Excellence, and Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Phillip Minar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Zarela Molle Rios
- Division of Pediatric Gastroenterology, Nemours Children's Hospital, Wilmington, DE
| | - Jonathan Moses
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, UH Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Kelly K Olano
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Lourdes Osaba
- Progenika Biopharma, a Grifols Company, Derio, Bizkaia Spain
| | - Pablo J Palomo
- Division of Pediatric Gastroenterology, Nemours Children's Hospital, Orlando, FL
| | - Helen Pappa
- Division of Pediatric Gastroenterology, Cardinal Glennon Children's Hospital, Saint Louis University School of Medicine, Saint Louis, MO
| | - K T Park
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, CA
| | - Dinesh S Pashankar
- Section of Pediatric Gastroenterology & Hepatology, Department of Pediatrics, Yale School of Medicine, Yale University, New Haven, CT
| | | | - Michelle Robinson
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Charles M Samson
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Kelly C Sandberg
- Department of Gastroenterology, Dayton Children's Hospital, Boonshoft School of Medicine, Wright State University, Dayton, OH
| | - Julia R Schuchard
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Michael Seid
- Department of Pediatrics, University of Cincinnati College of Medicine; Division Pulmonary Medicine and the James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Kimberly A Shelly
- Division of Pediatric Gastroenterology/Hepatology/Nutrition, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - Steven J Steiner
- Division of Pediatric Gastroenterology/Hepatology/Nutrition, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - Jennifer A Strople
- Division of Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern Feinberg School of Medicine, Chicago, IL
| | - Jillian S Sullivan
- The University of Vermont Children's Hospital and Department of Pediatrics, Larner College of Medicine, The University of Vermont, Burlington, VT
| | - Jeanne Tung
- University of Oklahoma Children's Physicians, Pediatric Gastroenterology, Oklahoma City, OK
| | - Prateek Wali
- Division of Gastroenterology, Hepatology, and Nutrition, State University of New York Upstate Medical University, Syracuse, NY
| | - Michael Zikry
- Esoterix Specialty Laboratory, Labcorp, Calabasas, CA
| | - Morris Weinberger
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Shehzad A Saeed
- Boonshoft School of Medicine, Wright State University, Associate Chief Medical Officer, Physician Lead, Patient and Family Experience, Dayton Children's Hospital, Dayton OH
| | - Athos Bousvaros
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
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Burisch J, Zhao M, Odes S, De Cruz P, Vermeire S, Bernstein CN, Kaplan GG, Duricova D, Greenberg D, Melberg HO, Watanabe M, Ahn HS, Targownik L, Pittet VEH, Annese V, Park KT, Katsanos KH, Høivik ML, Krznaric Z, Chaparro M, Loftus EV, Lakatos PL, Gisbert JP, Bemelman W, Moum B, Gearry RB, Kappelman MD, Hart A, Pierik MJ, Andrews JM, Ng SC, D'Inca R, Munkholm P. The cost of inflammatory bowel disease in high-income settings: a Lancet Gastroenterology & Hepatology Commission. Lancet Gastroenterol Hepatol 2023; 8:458-492. [PMID: 36871566 DOI: 10.1016/s2468-1253(23)00003-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 03/06/2023]
Abstract
The cost of caring for patients with inflammatory bowel disease (IBD) continues to increase worldwide. The cause is not only a steady increase in the prevalence of Crohn's disease and ulcerative colitis in both developed and newly industrialised countries, but also the chronic nature of the diseases, the need for long-term, often expensive treatments, the use of more intensive disease monitoring strategies, and the effect of the diseases on economic productivity. This Commission draws together a wide range of expertise to discuss the current costs of IBD care, the drivers of increasing costs, and how to deliver affordable care for IBD in the future. The key conclusions are that (1) increases in health-care costs must be evaluated against improved disease management and reductions in indirect costs, and (2) that overarching systems for data interoperability, registries, and big data approaches must be established for continuous assessment of effectiveness, costs, and the cost-effectiveness of care. International collaborations should be sought out to evaluate novel models of care (eg, value-based health care, including integrated health care, and participatory health-care models), as well as to improve the education and training of clinicians, patients, and policy makers.
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Affiliation(s)
- Johan Burisch
- Gastro Unit, Medical Division, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark; Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark.
| | - Mirabella Zhao
- Gastro Unit, Medical Division, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark; Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | - Selwyn Odes
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Peter De Cruz
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia; Department of Medicine, Austin Academic Centre, The University of Melbourne, Melbourne, VIC, Australia
| | - Severine Vermeire
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium; Faculty of Medicine, KU Leuven University, Leuven, Belgium
| | - Charles N Bernstein
- IBD Clinical and Research Centre, University of Manitoba, Winnipeg, MB, Canada; Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Gilaad G Kaplan
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Dana Duricova
- IBD Clinical and Research Centre for IBD, ISCARE, Prague, Czech Republic; Department of Pharmacology, Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Dan Greenberg
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel; Guilford Glazer Faculty of Business and Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Hans O Melberg
- Department of Community Medicine, University of Tromsø-The Arctic University of Norway, Tromsø, Norway; Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Mamoru Watanabe
- Advanced Research Institute, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hyeong Sik Ahn
- Department of Preventive Medicine, College of Medicine, Korea University, Seoul, South Korea
| | - Laura Targownik
- Division of Gastroenterology and Hepatology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Valérie E H Pittet
- Department of Epidemiology and Health Systems, Center for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
| | - Vito Annese
- Division of Gastroenterology, Department of Internal Medicine, Fakeeh University Hospital, Dubai, United Arab Emirates
| | - K T Park
- Stanford Health Care, Packard Health Alliance, Alameda, CA, USA; Genentech (Roche Group), South San Francisco, CA, USA
| | - Konstantinos H Katsanos
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Ioannina School of Health Sciences, Ioannina, Greece
| | - Marte L Høivik
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Zeljko Krznaric
- Department of Gastroenterology, Hepatology and Nutrition, University Hospital Zagreb, Zagreb, Croatia
| | - María Chaparro
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Universidad Autónoma de Madrid, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Peter L Lakatos
- Division of Gastroenterology, McGill University Montreal, QC, Canada; Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Javier P Gisbert
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Universidad Autónoma de Madrid, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Willem Bemelman
- Department of Surgery, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Bjorn Moum
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Richard B Gearry
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Michael D Kappelman
- Division of Pediatric Gastroenterology, Department of Pediatrics and Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ailsa Hart
- IBD Unit, St Mark's Hospital, Middlesex, UK
| | - Marieke J Pierik
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Jane M Andrews
- IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA, Australia; Faculty of Health Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Siew C Ng
- Department of Medicine and Therapeutics, Li Ka Shing Institute of Health Sciences, State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Renata D'Inca
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Pia Munkholm
- Department of Gastroenterology, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
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Weaver KN, Zhang X, Dai X, Chen W, Watkins R, Adler J, Dubinsky MC, Kastl A, Bousvaros A, Strople JA, Cross RK, Higgins PDR, Ungaro RC, Bewtra M, Bellaguarda E, Farraye FA, Craig R, Hernandez C, Boccieri ME, Firestine A, Chun KY, Long MD, Kappelman MD. Low Rates of Breakthrough COVID-19 Infection After SARS-CoV-2 Vaccination in Patients With Inflammatory Bowel Disease. Inflamm Bowel Dis 2023; 29:483-486. [PMID: 35830416 PMCID: PMC9384490 DOI: 10.1093/ibd/izac138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Indexed: 12/09/2022]
Abstract
Lay Summary
We demonstrate low rates of breakthrough coronavirus disease 2019 (COVID-19) infection and mild course of illness following severe acute respiratory syndrome coronavirus 2 vaccination in a large cohort of inflammatory bowel disease patients. Residence in southern United States and lower median anti-receptor binding antibody level were associated with development of COVID-19.
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Affiliation(s)
- Kimberly N Weaver
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Xian Zhang
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Xiangfeng Dai
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Wenli Chen
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Runa Watkins
- Division of Pediatric Gastroenterology and Nutrition, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jeremy Adler
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Marla C Dubinsky
- Department of Pediatrics, Susan and Leonard Feinstein IBD Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Arthur Kastl
- Division of Gastroenterology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Athos Bousvaros
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jennifer A Strople
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Raymond K Cross
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Peter D R Higgins
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Ryan C Ungaro
- Department of Medicine, Susan and Leonard Feinstein IBD Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Meenakshi Bewtra
- Division of Gastroenterology, Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Emanuelle Bellaguarda
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA; and
| | - Riley Craig
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Cristian Hernandez
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Margie E Boccieri
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ann Firestine
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Millie D Long
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Michael D Kappelman
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Egberg MD, Zhang X, Phillips M, Kappelman MD. Trends in Surgical Recurrence Among Pediatric Crohn's Disease Patients Using Administrative Claims Data. Crohns Colitis 360 2023; 5:otad003. [PMID: 36846098 PMCID: PMC9951729 DOI: 10.1093/crocol/otad003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Indexed: 02/23/2023] Open
Abstract
Background Despite the growing armamentarium of medical therapies for Crohn's disease (CD), well over half of patients with CD will require surgical intervention. We estimated the surgical recurrence risk and characterized postoperative treatment and colonoscopy use in pediatric CD patients using a large, geographically diverse administrative claims database. Methods We analyzed postresection pediatric (≤18 years) CD patients identified in the 2007-2018 IQVIA Legacy PharMetrics administrative claims database using diagnosis and procedural codes. We estimated the surgical recurrence risk over time, characterized postoperative treatments, and reported the frequency of colonoscopy 6-15 months postoperatively. Results Among 434 pediatric CD patients who underwent intestinal resection (median age 16 years, 46% female), risk of surgical recurrence was 3.5%, 4.6%, and 5.3% at 1, 3, and 5 years, respectively. Patients were most commonly prescribed an immune modulator (33%), anti-tumor necrosis factor agent (32%), or antibiotic (27%) postoperatively. Among 281 patients with ≥15 months of follow-up, 24% underwent colonoscopy 6-15 months postoperatively. Conclusions Surgical recurrence risk increases over time and the low colonoscopy rates and treatment variation postoperatively represent an opportunity for practice improvement.
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Affiliation(s)
- Matthew D Egberg
- Address correspondence to: Matthew D. Egberg, MD, MPH, MMSc, Division of Pediatric Gastroenterology and Hepatology, Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, 130 Mason Farm Road, Bioinformatics Building, #4101, Chapel Hill, NC 27599, USA ()
| | - Xian Zhang
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michael Phillips
- Department of Surgery, Division of Pediatric General Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michael D Kappelman
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA,Department of Medicine, Division of Adult Gastroenterology, Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Santhanam P, Egberg M, Kappelman MD. Higher mortality rates associated with Clostridioides difficile infection in hospitalized children with cystic fibrosis. Pediatr Pulmonol 2023; 58:484-491. [PMID: 36349995 DOI: 10.1002/ppul.26214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 08/18/2022] [Accepted: 09/28/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE(S) To determine the association of Clostridioides difficile Infection (CDI) with in-hospital mortality, Length of Stay (LOS), and hospital charges among pediatric Cystic Fibrosis (CF) hospitalizations using a large nationally representative pediatric hospital database. STUDY DESIGN We identified Cystic Fibrosis-related hospitalizations during the years 1997 to 2016 in the Kids' Inpatient Database (KID) and compared in-hospital mortality, LOS, and hospital charges among hospitalizations with and without a coexisting diagnosis of C. difficile using logistic regression models for mortality and general linear models with gamma distribution and logarithmic transformation for LOS and hospital charges. We also evaluated temporal trends in the proportion of CF hospitalizations with concomitant CDI using data published triennially RESULTS: We analyzed 21,616 pediatric CF hospitalizations between the years 1997 to 2016 and found a total of 240 (1.1%) hospitalizations with concurrent CDI diagnosis. Adjusted analyses demonstrated an association of CDI with increased mortality (OR 5.2, 95% CI 2.5-10.7), longer LOS (46.5% increment, 95% CI 36.0-57.1), and higher charges (65.8% increment, 95% CI 53.5-78.1) for all comparisons. The proportion of CF hospitalizations with CDI increased over time from 0.64% in 1997 to 1.73% in 2016 (p < 0.001). CONCLUSION(S) As CDI is associated with excess mortality, LOS, and cost in children hospitalized for CF, a healthy level of suspicion for CDI may be needed in patients with CF in the appropriate clinical context. Efforts to prevent, diagnose, and treat CDI may improve hospital outcomes among children with CF.
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Affiliation(s)
- Prathipa Santhanam
- Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Matthew Egberg
- Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michael D Kappelman
- Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Egberg MD, Zhang X, Smitherman AB, Kappelman MD. Low Risk of Lymphoma in Pediatric Patients Treated for Inflammatory Bowel Disease. Am J Gastroenterol 2023; 118:354-359. [PMID: 36219181 PMCID: PMC9898086 DOI: 10.14309/ajg.0000000000002053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 10/06/2022] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Despite the effectiveness of immune-suppressing therapies in treating pediatric inflammatory bowel diseases (IBDs), concerns of lymphoma may limit their use. We used a large administrative claims database to evaluate the risk of lymphoma in pediatric IBD and conducted a case series analysis of medication exposure in children diagnosed with lymphoma. METHODS We analyzed administrative claims from the 2007 to 2018 IQVIA database and identified pediatric (≤18 years) patients with Crohn's disease or ulcerative colitis using International Classification of Diseases, 9th or 10th Revision codes and pharmacy claims. Lymphoma cases were identified by diagnosis codes and confirmed by independent claim-by-claim review by a pediatric oncologist and gastroenterologist. We calculated incidence rates for lymphoma among patients with and without pharmacy claims for treatment followed by treatment description among those who developed lymphoma during follow-up. RESULTS A total of 10,777 pediatric patients with IBD received ≥1 IBD therapy (median age 15 years [12-17], 45% female and 61% diagnosed with Crohn's disease) during 28,292 patient-years of follow-up. Among treated patients, 5 lymphoma cases were identified (incidence rate 17.7/100,000 patient-years; 95% confidence interval 6.5-39.2). Of these, 4 were treated with a thiopurine before lymphoma diagnosis, and none received anti-tumor necrosis factor-α (anti-TNF) monotherapy. DISCUSSION The overall lymphoma incidence was low among our cohort of treated pediatric patients with IBD. We observed no cases of lymphoma among patients prescribed anti-TNF monotherapy. These findings reinforce the relative safety of anti-TNF monotherapy for the treatment of pediatric IBD.
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Affiliation(s)
- Matthew D. Egberg
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Xian Zhang
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Andrew B. Smitherman
- Department of Pediatrics, Division of Hematology and Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michael D. Kappelman
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Ungaro RC, Kappelman MD. Reappraisal of Coronavirus Disease 2019 Risk for Patients With Inflammatory Bowel Disease: Withdrawal of the British Society of Gastroenterology Inflammatory Bowel Disease Risk Grid. Gastroenterology 2023; 164:2-4. [PMID: 36162590 PMCID: PMC9514020 DOI: 10.1053/j.gastro.2022.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/13/2022] [Accepted: 09/15/2022] [Indexed: 02/03/2023]
Affiliation(s)
| | - Michael D Kappelman
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
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35
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Brenner EJ, Long MD, Kappelman MD, Zhang X, Sandler RS, Barnes EL. Development of an Inflammatory Bowel Disease-Specific Medication Adherence Instrument and Reasons for Non-adherence. Dig Dis Sci 2023; 68:58-64. [PMID: 35503483 DOI: 10.1007/s10620-022-07517-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 04/04/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Medication adherence impacts disease control in inflammatory bowel disease (IBD). Existing adherence measures such as the Morisky Medication Adherence Scale 8© are often costly, non-medication-specific, and time-consuming. AIMS We aimed to develop a non-proprietary, IBD-specific medication adherence instrument and to assess reasons for suboptimal medication adherence. METHODS We developed the IBD Medication Adherence Tool to assess frequency of adherence and indications for missed or delayed medication doses. We co-administered the IBD Medication Adherence Tool and the Morisky Medication Adherence Scale 8© (licensed for use) to participants enrolled in an internet-based cohort of adults with IBD and taking least one daily, oral IBD medication. We used Spearman's correlation to evaluate associations between the IBD Medication Adherence Tool and Morisky Medication Adherence Scale 8©. We then categorized patients as sub-optimally adherent (IBD Medication Adherence Tool score 1-4) and highly adherent (score 5) and evaluated factors associated with and reasons for suboptimal adherence using multivariable analysis. RESULTS We evaluated 514 patients (73% female, mean age 49), of whom 21.4% had suboptimal adherence. IBD Medication Adherence Tool scores were moderately correlated with Morisky Medication Adherence Scale 8© (r = 0.56, p < 0.001). The most commonly reported reasons for suboptimal adherence were forgetting, feeling well, and cost. Younger age and current smoking were associated with suboptimal adherence. CONCLUSIONS We developed a non-proprietary, IBD-specific tool to assess adherence to IBD medications, validated in a cohort of patients with IBD on daily, oral medications. Common reasons for suboptimal IBD medication adherence include forgetting, feeling well, and cost.
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Affiliation(s)
- Erica J Brenner
- Department of Pediatric Gastroenterology, University of North Carolina, 333 S. Columbia Street, 247 MacNider Hall, CB# 7229, Chapel Hill, NC, 27599, USA.
| | - Millie D Long
- Department of Gastroenterology, University of North Carolina, 130 Mason Farm Rd, Bioinformatics Building, Suite 4143, Chapel Hill, NC, 27514, USA
| | - Michael D Kappelman
- Department of Pediatric Gastroenterology, University of North Carolina, 130 Mason Farm Rd, Bioinformatics Building, Suite 4143, Chapel Hill, NC, 27514, USA
| | - Xian Zhang
- Department of Gastroenterology, University of North Carolina, 130 Mason Farm Rd, Bioinformatics Building, Suite 4143, Chapel Hill, NC, 27514, USA
| | - Robert S Sandler
- Department of Gastroenterology, University of North Carolina, 130 Mason Farm Rd, Bioinformatics Building, Suite 4143, Chapel Hill, NC, 27514, USA
| | - Edward L Barnes
- Department of Gastroenterology, University of North Carolina, 130 Mason Farm Rd, Bioinformatics Building, Suite 4143, Chapel Hill, NC, 27514, USA
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Barnes EL, Kappelman MD, Zhang X, Long MD, Sandler RS, Herfarth HH. Patients With Pouchitis Demonstrate a Significant Cost Burden in the First Two Years After Ileal Pouch-Anal Anastomosis. Clin Gastroenterol Hepatol 2022; 20:2908-2910.e2. [PMID: 34610443 PMCID: PMC8975897 DOI: 10.1016/j.cgh.2021.09.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/25/2021] [Accepted: 09/28/2021] [Indexed: 02/07/2023]
Abstract
Pouchitis, the most common long-term complication after colectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC), can lead to increased health care costs and diminished quality of life.1 In this study, we aimed to compare the total costs among patients diagnosed with pouchitis in the first 2 years after an IPAA with those among patients who were not diagnosed with pouchitis, using a large administrative claims database. Additionally, we aimed to investigate the specific drivers of cost among patients with an IPAA during the 2-year study period, including inpatient hospitalizations, emergency department visits, and pharmacy-related costs.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Michael D Kappelman
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Xian Zhang
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Millie D Long
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Robert S Sandler
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Iglay K, Bennett D, Kappelman MD, Reynolds K, Aldridge M, Karki C, Cook SF. A systematic review of epidemiology and outcomes of Crohn's disease-related enterocutaneous fistulas. Medicine (Baltimore) 2022; 101:e30963. [PMID: 36397360 PMCID: PMC10662878 DOI: 10.1097/md.0000000000030963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 09/06/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Enterocutaneous fistulas (ECF) are rare sequelae of Crohn's disease (CD) that occur either postoperatively or spontaneously. ECFs are associated with high morbidity and mortality. This systematic literature review assesses the disease burden of CD-related ECF and identifies knowledge gaps around incidence/prevalence, treatment patterns, clinical outcomes, healthcare resource utilization (HCRU), and patient-reported outcomes (PROs). METHODS English language articles published in PubMed and Embase in the past 10 years that provided data and insight into the disease burden of CD-related ECF (PROSPERO Registration number: CRD42020177732) were identified. Prespecified search and eligibility criteria guided the identification of studies by two reviewers who also assessed risk of bias. RESULTS In total, 582 records were identified; 316 full-text articles were assessed. Of those, eight studies met a priori eligibility criteria and underwent synthesis for this review. Limited epidemiologic data estimated a prevalence of 3265 persons with ECF in the USA in 2017. Clinical response to interventions varied, with closure of ECF achieved in 10% to 62.5% of patients and recurrence reported in 0% to 50% of patients. Very little information on HCRU is available, and no studies of PROs in this specific population were identified. CONCLUSION The frequency, natural history, and outcomes of ECF are poorly described in the literature. The limited number of studies included in this review suggest a high treatment burden and risk of substantial complications. More robust, population-based research is needed to better understand the epidemiology, natural history, and overall disease burden of this rare and debilitating complication of CD.
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Affiliation(s)
| | - Dimitri Bennett
- Takeda Pharmaceuticals, Cambridge, MA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michael D. Kappelman
- Pediatric Gastroenterology, University of North Carolina, Chapel Hill School of Medicine, Chapel Hill, NC
| | - Kamika Reynolds
- CERobs Consulting, LLC, Chapel Hill, NC
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Kaplan GG, Underwood FE, Coward S, Agrawal M, Ungaro RC, Brenner EJ, Gearry RB, Kissous-Hunt M, Lewis JD, Ng SC, Rahier JF, Reinisch W, Steinwurz F, Zhang X, Kappelman MD, Colombel JF. The Multiple Waves of COVID-19 in Patients With Inflammatory Bowel Disease: A Temporal Trend Analysis. Inflamm Bowel Dis 2022; 28:1687-1695. [PMID: 35032167 PMCID: PMC8807298 DOI: 10.1093/ibd/izab339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cases of coronavirus disease 2019 (COVID-19) have emerged in discrete waves. We explored temporal trends in the reporting of COVID-19 in inflammatory bowel disease (IBD) patients. METHODS The Surveillance Epidemiology of Coronavirus Under Research Exclusion for Inflammatory Bowel Disease (SECURE-IBD) is an international registry of IBD patients diagnosed with COVID-19. The average percent changes (APCs) were calculated in weekly reported cases of COVID-19 during the periods of March 22 to September 12, September 13 to December 12, 2020, and December 13 to July 31, 2021. RESULTS Across 73 countries, 6404 cases of COVID-19 were reported in IBD patients. COVID-19 reporting decreased globally by 4.2% per week (95% CI, -5.3% to -3.0%) from March 22 to September 12, 2020, then climbed by 10.2% per week (95% CI, 8.1%-12.3%) from September 13 to December 12, 2020, and then declined by 6.3% per week (95% CI, -7.8% to -4.7%). In the fall of 2020, weekly reporting climbed in North America (APC, 11.3%; 95% CI, 8.8-13.8) and Europe (APC, 17.7%; 95% CI, 12.1%-23.5%), whereas reporting was stable in Asia (APC, -8.1%; 95% CI, -15.6-0.1). From December 13, 2020, to July 31, 2021, reporting of COVID-19 in those with IBD declined in North America (APC, -8.5%; 95% CI, -10.2 to -6.7) and Europe (APC, -5.4%; 95% CI, -7.2 to -3.6) and was stable in Latin America (APC, -1.5%; 95% CI, -3.5% to 0.6%). CONCLUSIONS Temporal trends in reporting of COVID-19 in those with IBD are consistent with the epidemiological patterns COVID-19 globally.
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Affiliation(s)
- Gilaad G Kaplan
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Fox E Underwood
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Stephanie Coward
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Manasi Agrawal
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ryan C Ungaro
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Erica J Brenner
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Richard B, Gearry
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Michele Kissous-Hunt
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- New York Gastroenterology Associates, New York, New York, USA
| | - James D Lewis
- Department of Epidemiology and Biostatistics, The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Siew C Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Science, The Chinese University of Hong Kong, Hong Kong SAR, The People’s Republic of China
| | - Jean-Francois Rahier
- Department of Gastroenterology, Université Catholique de Louvain, Yvoir, Belgium
| | - Walter Reinisch
- Department Internal Medicine III, Division Gastroenterology & Hepatology, Medical University of Vienna, Vienna, Austria
| | - Flavio Steinwurz
- Department of Gastroenterology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Xian Zhang
- Department of Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michael D Kappelman
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jean-Frederic Colombel
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Schuchard J, Carle AC, Kappelman MD, Tucker CA, Forrest CB. Interpreting Patient-Reported Outcome Scores: Pediatric Inflammatory Bowel Disease as a Use Case. Acad Pediatr 2022; 22:1520-1528. [PMID: 34995822 PMCID: PMC9253201 DOI: 10.1016/j.acap.2021.12.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 12/22/2021] [Accepted: 12/26/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To demonstrate how to interpret Patient-Reported Outcomes Measurement Information System (PROMIS) pediatric patient-reported outcome measure (PROM) scores for patients with pediatric inflammatory bowel disease (IBD). METHODS Using data from a prospective cohort study of patients ages 8 to 23 years with IBD (n = 1049), we established disease-specific percentiles and computed the minimal clinically important difference (MCID) change score for 6 pediatric PROMs. We applied these results, general population percentiles, and the reliable change index to interpret PROM scores in a clinical trial sample of patients ages 8 to 20 years with IBD (n = 294) in which PROMIS PROMs were obtained at baseline and 3 months later. RESULTS Application of general population percentiles showed that the clinical trial sample at baseline had moderately worse self-reported health than the general population (22% of patients at or above the 95th percentile on Fatigue; 21% on Pain Interference). IBD-specific percentiles showed that the sample was somewhat worse than the reference IBD sample (8% of patients at or above the 95th percentile on Fatigue; 11% on Pain Interference). Application of the MCID threshold indicated that among the subgroup of patients that improved by 15 or more on the short Pediatric Crohn's Disease Activity Index (n = 38), 45% also improved on IBD Symptoms, 47% for Fatigue, and 65% for Pain Interference. CONCLUSION This study established IBD-specific percentiles for 6 pediatric PROMIS measures and demonstrated the application of percentiles and other methods for interpreting PROM scores.
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Affiliation(s)
- Julia Schuchard
- Department of Pediatrics, Children's Hospital of Philadelphia (J Schuchard and CB Forrest), Philadelphia, Pa.
| | - Adam C Carle
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine (AC Carle), Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Arts and Sciences (AC Carle), Cincinnati, Ohio; Department of Psychology, University of Cincinnati College of Arts and Sciences (AC Carle), Cincinnati, Ohio
| | - Michael D Kappelman
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine (MD Kappelman), Chapel Hill, NC
| | - Carole A Tucker
- Department of Health and Rehabilitation Sciences, Temple University College of Public Health (CA Tucker), Philadelphia, Pa
| | - Christopher B Forrest
- Department of Pediatrics, Children's Hospital of Philadelphia (J Schuchard and CB Forrest), Philadelphia, Pa
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Boehmer TK, Koumans EH, Skillen EL, Kappelman MD, Carton TW, Patel A, August EM, Bernstein R, Denson JL, Draper C, Gundlapalli AV, Paranjape A, Puro J, Rao P, Siegel DA, Trick WE, Walker CL, Block JP. Racial and Ethnic Disparities in Outpatient Treatment of COVID-19 - United States, January-July 2022. MMWR Morb Mortal Wkly Rep 2022; 71:1359-1365. [PMID: 36301738 PMCID: PMC9620572 DOI: 10.15585/mmwr.mm7143a2] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Cowherd E, Egberg MD, Kappelman MD, Zhang X, Long MD, Lightner AL, Sandler RS, Herfarth HH, Barnes EL. The Cumulative Incidence of Pouchitis in Pediatric Patients With Ulcerative Colitis. Inflamm Bowel Dis 2022; 28:1332-1337. [PMID: 35040995 PMCID: PMC9434461 DOI: 10.1093/ibd/izab320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Despite highly effective therapies, many children develop medically refractory ulcerative colitis (UC) and undergo proctocolectomy with ileal pouch-anal anastomosis (IPAA). We sought to determine the incidence, risk, and burden of pouchitis in the first 2 years following the final stage of IPAA in pediatric UC patients. METHODS Within the IQVIA Legacy PharMetrics Adjudicated Claims Database, we identified pediatric patients with UC who underwent proctocolectomy with IPAA between January 1, 2007, and June 30, 2015. We utilized International Classification of Diseases-Ninth Revision-Clinical Modification or International Classification of Diseases-Tenth Revision-Clinical Modification codes to identify patients with UC and Current Procedural Terminology codes to identify colectomy and IPAA. Continuous variables were compared using t tests and Wilcoxon rank sum testing, while categorical variables were compared using chi-square testing. RESULTS A total of 68 patients with an IPAA were identified. In the first 2 years following IPAA, the cumulative incidence of pouchitis was 54%. Patients with pouchitis required more outpatient visits in the first 2 years after IPAA (mean 21.8 vs 10.2; P = .006) and were more likely to be hospitalized compared with patients without pouchitis (46% vs 23%; P = .045). Patients with pouchitis also demonstrated higher mean total costs in year 1 and year 2 ($27 489 vs $8032 [P = .001] and $27 699 vs $6058 [P = .003], respectively). CONCLUSIONS Our findings confirm the high incidence of pouchitis demonstrated in earlier single-center studies of pediatric patients undergoing proctocolectomy with IPAA for UC. Identification of risk factors for pouchitis would be useful to optimize early intervention.
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Affiliation(s)
- Ellen Cowherd
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Matthew D Egberg
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Michael D Kappelman
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Xian Zhang
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Millie D Long
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USAand
| | - Amy L Lightner
- Digestive Disease and Surgery Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
| | - Robert S Sandler
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USAand
| | - Hans H Herfarth
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USAand
| | - Edward L Barnes
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USAand
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Jackson SL, Block JP, Rolka DB, Pavkov ME, Chevinsky JR, Lekiachvili A, Carton TW, Thacker D, Denson JL, Paranjape A, Kappelman MD, Boehmer TK, Twentyman E. COVID-19 Outcomes Stratified by Control Status of Hypertension and Diabetes: Preliminary Findings From PCORnet, U.S. AJPM Focus 2022; 1:100012. [PMID: 36942020 PMCID: PMC9271352 DOI: 10.1016/j.focus.2022.100012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Introduction Hypertension and diabetes are associated with increased COVID-19 severity, yet less is known about COVID-19 outcomes across levels of disease control for these conditions. Methods All adults aged ≥20 years with COVID-19 between March 1, 2020 and March 15, 2021 in 42 healthcare systems in National Patient-Centered Clinical Research Network were identified. Results Among 656,049 adults with COVID-19, 41% had hypertension, and 13% had diabetes. Of patients with classifiable hypertension, 35% had blood pressure <130/80 mmHg, 40% had blood pressure of 130‒139/80‒89 mmHg, 21% had blood pressure of 140‒159/90‒99 mmHg, and 6% had blood pressure ≥160/100 mmHg. Severe COVID-19 outcomes were more prevalent among those with blood pressure of ≥160/100 than among those with blood pressure of 130-139/80-89, including hospitalization (23.7% [95% CI=23.0, 24.4] vs 11.7% [95% CI=11.5, 11.9]), receipt of critical care (5.5% [95% CI=5.0, 5.8] vs 2.4% [95% CI=2.3, 2.5]), receipt of mechanical ventilation (3.0% [95% CI=2.7, 3.3] vs 1.2% [95% CI=1.1, 1.3]), and 60-day mortality (4.6% [95% CI=4.2, 4.9] vs 1.8% [95% CI=1.7, 1.9]). Of patients with classifiable diabetes, 44% had HbA1c <7%, 35% had HbA1c 7% to <9%, and 21% had HbA1c ≥9%. Hospitalization prevalence was 31.3% (95% CI=30.7, 31.9) among those with HbA1c <7% vs 40.2% (95% CI=39.4, 41.1) among those with HbA1c ≥9%; other outcomes did not differ substantially by HbA1c. Conclusions These findings highlight the importance of appropriate management of hypertension and diabetes, including during public health emergencies such as the COVID-19 pandemic.
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Affiliation(s)
- Sandra L Jackson
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jason P Block
- Division of Chronic Disease Research Across the Lifecourse (CoRAL), Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts
| | - Deborah B Rolka
- Division for Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Meda E Pavkov
- Division for Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jennifer R Chevinsky
- Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Akaki Lekiachvili
- National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Deepika Thacker
- Nemours Cardiac Center, Nemours Children's Health, Jacksonville, Florida
| | - Joshua L Denson
- Section of Pulmonary, Critical Care, and Environmental Medicine, Tulane University School of Medicine, New Orleans, Louisiana
| | | | - Michael D Kappelman
- Department of Pediatrics, UNC School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Tegan K Boehmer
- Center for Surveillance, Epidemiology, and Laboratory Services (CSELS), Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Evelyn Twentyman
- National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention, Atlanta, Georgia
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Long MD, Weaver KN, Zhang X, Chun K, Kappelman MD. Strong Response to SARS-CoV-2 Vaccine Additional Doses Among Patients With Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol 2022; 20:1881-1883.e1. [PMID: 35150924 PMCID: PMC8826602 DOI: 10.1016/j.cgh.2022.01.056] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/24/2022] [Accepted: 01/26/2022] [Indexed: 12/12/2022]
Abstract
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has disrupted health care and has resulted in high mortality rates.1 Vaccination is an international priority to mitigate the risks of SARS-CoV-2. The initial trials for development of SARS-CoV-2 vaccines excluded individuals with immunocompromising conditions.2.
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Affiliation(s)
- Millie D. Long
- Reprint requests Address requests for reprints to: Millie D. Long, MD, MPH, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Campus Box #7080, Chapel Hill, North Carolina 27599-7080. fax: (919) 843-6899
| | - K N Weaver
- Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - X Zhang
- Department of Pediatrics, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - K Chun
- Esoterix Specialty Laboratory, LabCorp, Calabasas, CA
| | - M D Kappelman
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Pediatrics, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Xu F, deJong N, Kappelman MD, Greenlund KJ, Carlson SA. Primary Care Professionals' Attitudes Towards Vaccination Recommendation for Patients With Inflammatory Bowel Disease. Inflamm Bowel Dis 2022; 29:726-734. [PMID: 35779060 DOI: 10.1093/ibd/izac129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Immunization among patients with inflammatory bowel disease (IBD) is suboptimal. We sought to characterize attitudes of US primary care professionals (PCPs) towards immunization practices for patients with IBD. METHODS Using a web-based opt-in panel of PCPs (DocStyles survey, spring 2021, cross-sectional study), we assessed likelihood of PCPs' recommending influenza, pneumococcal disease, herpes zoster, and human papilloma virus vaccinations for IBD patients by PCP characteristics and availability of clinical tools. Reasons for unlikelihood of recommending vaccines and approaches to improve vaccine recommendation were examined. RESULTS Among 1503 PCPs, 64% recommended all vaccines. Herpes zoster vaccine was most likely to be recommended (89.8%) and pneumococcal vaccine was least likely (74.0%). Clinical tools including decision support based on electronic health records (EHRs; 48.9%) and staff tracking of patients' vaccine needs (36.3%) were significantly associated with likelihood of recommending vaccines (P < .001). A greater likelihood of vaccine recommendation was observed for pediatricians vs other medical specialties, group outpatient clinic vs other worksites, and seeing >50 patients/week (P < .05). One-third of PCPs were unlikely to recommend ≥1 vaccine, and the top reason reported was unfamiliarity with vaccine guidelines for patients with IBD (48.0%). A review of guidelines or continued medical education (63.0%) and decision support from EHRs (51.2%) were the most frequently selected approaches identified to improve certainty of vaccine recommendation. CONCLUSIONS There is room for improvement of vaccination recommendations by PCPs. Promoting continuing education and use of clinical tools may help support PCP immunization practices for patients with IBD.
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Affiliation(s)
- Fang Xu
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA, 30341, USA
| | - Neal deJong
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC 27599, USA
| | - Michael D Kappelman
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC 27599, USA
| | - Kurt J Greenlund
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA, 30341, USA
| | - Susan A Carlson
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA, 30341, USA
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Forrest CB, Schuchard J, Bruno C, Amaral S, Cox ED, Flynn KE, Hinds PS, Huang IC, Kappelman MD, Krishnan JA, Kumar RB, Lai JS, Paller AS, Phipatanakul W, Schanberg LE, Sumino K, Weitzman ER, Reeve BB. Self-Reported Health Outcomes of Children and Youth with 10 Chronic Diseases. J Pediatr 2022; 246:207-212.e1. [PMID: 35247394 PMCID: PMC9232908 DOI: 10.1016/j.jpeds.2022.02.052] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 02/22/2022] [Accepted: 02/24/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To identify pediatric patient-reported outcomes (PROs) that are associated with chronic conditions and to evaluate the effects of chronic disease activity on PROs. STUDY DESIGN Participants (8-24 years old) and their parents were enrolled into 14 studies that evaluated Patient-Reported Outcome Measurement Information System PROs across 10 chronic conditions-asthma, atopic dermatitis, cancer, cancer survivors, chronic kidney disease, Crohn's disease, juvenile idiopathic arthritis, lupus, sickle cell disease, and type 1 diabetes mellitus. PRO scores were contrasted with the US general population of children using nationally representative percentiles. PRO-specific coefficients of variation were computed to illustrate the degree of variation in scores within vs between conditions. Condition-specific measures of disease severity and Cohen d effect sizes were used to examine PRO scores by disease activity. RESULTS Participants included 2975 child respondents and 2392 parent respondents who provided data for 3409 unique children: 52% were 5-12 years old, 52% female, 25% African American/Black, and 14% Hispanic. Across all 10 chronic conditions, children reported more anxiety, fatigue, pain, and mobility restrictions than the general pediatric population. Variation in PRO scores within chronic disease cohorts was equivalent to variation within the general population, exceeding between-cohort variation by factors of 1.9 (mobility) to 5.7 (anxiety). Disease activity was consistently associated with poorer self-reported health, and these effects were weakest for peer relationships. CONCLUSIONS Chronic conditions are associated with symptoms and functional status in children and adolescents across 10 different disorders. These findings highlight the need to complement conventional clinical evaluations with those obtained directly from patients themselves using PROs.
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Affiliation(s)
| | | | - Cortney Bruno
- Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Sandra Amaral
- Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Elizabeth D. Cox
- University of Wisconsin-Madison Schools of Medicine and Public Health, Madison, WI
| | | | | | - I-Chan Huang
- St. Jude Children’s Research Hospital, Memphis, TN
| | | | | | - Rajesh B. Kumar
- Northwestern University Feinberg School of Medicine and the Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Jin-Shei Lai
- Northwestern University Feinberg School of Medicine
| | | | | | | | - Kaharu Sumino
- Washington University School of Medicine, St. Louis, MO
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Kerur B, Fiedler K, Stahl M, Hyams J, Stephens M, Lu Y, Pfefferkorn M, Alkhouri R, Strople J, Kelsen J, Siebold L, Goyal A, Rosh JR, LeLeiko N, Van Limbergen J, Guerrerio AL, Maltz RM, Karam L, Crowley E, Griffiths AM, Heyman MB, Deneau M, Benkov K, Noe J, Moulton D, Pappa H, Galanko J, Snapper S, Muise AM, Kappelman MD, Benchimol EI. Utilization of Antitumor Necrosis Factor Biologics in Very Early Onset Inflammatory Bowel Disease: A Multicenter Retrospective Cohort Study From North America. J Pediatr Gastroenterol Nutr 2022; 75:64-69. [PMID: 35622080 DOI: 10.1097/mpg.0000000000003464] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Research on the utilization and effectiveness of antitumor necrosis factor (TNF) biologics in children with very early onset inflammatory bowel disease (VEOIBD) is urgently needed. Here we describe anti-TNF use and durability in a multicenter cohort. METHODS We performed a retrospective cohort study of patients diagnosed with VEOIBD (<6 years) between 2008 and 2013 at 25 North American centers. We performed chart abstraction at diagnosis and 1, 3, and 5 years after diagnosis. We examined the rate of initiation and durability of infliximab and adalimumab and evaluated associations between treatment durability and the following covariates with multivariate Cox proportional hazard regression: age at diagnosis, sex, disease duration, disease classification, and presence of combined immunomodulatory treatment versus monotherapy. RESULTS Of 294 children with VEOIBD, 120 initiated treatment with anti-TNF therapy and 101 had follow-up data recorded [50% Crohn disease (CD), 31% ulcerative colitis (UC), and 19% IBD unclassified (IBD-U)]. The cumulative probability of anti-TNF treatment was 15% at 1 year, 30% at 3 years, and 45% at 5 years from diagnosis; 56 (55%) were treated between 0 and 6 years old. Anti-TNF durability was 90% at 1 year, 75% at 3 years, and 55% at 5 years. The most common reason for discontinuation of anti-TNF were loss of response in 24 (57%) children. Children with UC/IBD-U had lower durability than those with CD (hazard ratio [HR] 0.17; 95% confidence interval [CI], 0.06-0.51; P = 0.001). CONCLUSIONS Utilization and durability of anti-TNF in VEOIBD is relatively high and comparable with older children. Having Crohn disease (compared with UC/IBD-U) is associated with greater durability.
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Affiliation(s)
- Basavaraj Kerur
- From the University of Massachusetts Medical School (UMMS), Worcester, MA
| | - Karoline Fiedler
- the The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Jeffrey Hyams
- the Connecticut Children's Medical Center, Hartford, CT
| | - Michael Stephens
- the Center for Individualized Medicine, Mayo Clinic, Rochester, MN
| | - Ying Lu
- the Cohen Children's Medical Center of New York, New Hyde Park, NY
| | | | | | - Jennifer Strople
- the Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Judith Kelsen
- the Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Leah Siebold
- the UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Alka Goyal
- the Stanford University School of Medicine, Palo Alto, CA
| | - Joel R Rosh
- the Goryeb Children's Hospital/Atlantic Health System, Morristown, NJ
| | - Neal LeLeiko
- the Morgan Stanley Children's Hospital of NewYork, Columbia University, New York, NY
| | - Johan Van Limbergen
- the Amsterdam University Medical Centres, Emma Children's Hospital, Amsterdam, Netherlands
| | | | - Ross M Maltz
- the Nationwide Children's Hospital, Columbus, OH
| | - Lina Karam
- the Texas Children's Hospital, Houston, TX
| | - Eileen Crowley
- the Children's Hospital, London Health Science Centre, University of Western Ontario, London, Ontario, Canada
| | - Anne M Griffiths
- the The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Mark Deneau
- the University of Utah/Intermountain Primary Children's Hospital, Salt Lake City, UT
| | - Keith Benkov
- the Icahn School of Medicine at Mount Sinai, New York, NY
| | - Joshua Noe
- the Medical College of Wisconsin, Milwaukee, WI
| | - Dedrick Moulton
- the Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Helen Pappa
- the Cardinal Glennon Children's Hospital, St Louis, MO
| | - Joseph Galanko
- the University of North Carolina in Chapel Hill, Chapel Hill, NC
| | - Scott Snapper
- the Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Aleixo M Muise
- the The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Eric I Benchimol
- the Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa
- the The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Barnes EL, Nowell WB, Venkatachalam S, Dobes A, Kappelman MD. Racial and Ethnic Distribution of Inflammatory Bowel Disease in the United States. Inflamm Bowel Dis 2022; 28:983-987. [PMID: 34473272 DOI: 10.1093/ibd/izab219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND The current burden of Crohn's disease (CD) and ulcerative colitis (UC) in minority populations is largely unknown. We sought to evaluate the relative prevalence of CD and UC across racial and ethnic groups within the National Patient-Centered Clinical Research Network (PCORnet). METHODS We queried electronic health records from 337 centers from January 2013 to December 2018. We compared the relative prevalence of CD and UC across racial/ethnic groups to the general PCORnet populations using χ 2 and univariable logistic regression. RESULTS Among 39,864,077 patients, 114,168 had CD, and 98,225 had UC. Relative to the overall PCORnet population, Black adult patients were significantly less likely than White patients to have a diagnosis of CD (odds ratio [OR], 0.53; 95% CI, 0.52-0.54) or UC (OR, 0.41; 95% CI, 0.40-0.43). Pediatric Black patients were also less likely to have a diagnosis of CD (OR, 0.41; 95% CI, 0.39-0.43) or UC (OR, 0.38; 95% CI, 0.35-0.41). Adult Hispanic patients were less likely to have a diagnosis of CD (OR, 0.33; 95% CI, 0.32-0.34) or UC (OR, 0.45; 95% CI, 0.44-0.46) compared with non-Hispanic patients. Similarly, pediatric Hispanic patients were less likely to have a diagnosis of CD (OR, 0.34; 95% CI, 0.32-0.36) or UC (OR, 0.50; 95% CI, 0.47-0.53). CONCLUSIONS Despite the increasing racial and ethnic diversity in the United States, these data suggest that CD and UC are modestly less prevalent among patients of non-White races and Hispanic ethnicity.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | | | - Michael D Kappelman
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Weaver KN, Kappelman MD, Long MD. COVID-19 Vaccination Among Individuals With Inflammatory Bowel Disease: Perception, Efficacy, and Safety. Gastroenterol Hepatol (N Y) 2022; 18:388-399. [PMID: 36397773 PMCID: PMC9666812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
The COVID-19 pandemic, caused by SARSCoV-2, has been the most significant global health crisis of the past century. The development of safe and effective vaccines has led to a reduction in COVID19-related hospitalizations and deaths; however, the clinical trials that led to US Food and Drug Administration Emergency Use Authorization and/or approval of the vaccines in the United States did not include individuals with inflammatory bowel disease (IBD). Because individuals with IBD are commonly treated with immunosuppressive medications, there had been concern for reduced vaccine efficacy in this population. This article provides an overview of the peer-reviewed literature addressing COVID-19 vaccination in individuals with IBD; details the perceptions of patients with IBD of COVID-19 vaccines, including how gastroenterologists can help to reduce vaccine hesitancy; and describes the humoral immune response to COVID-19 vaccines, with a majority of patients with IBD seroconverting following complete vaccination regardless of medication exposure. Additionally, low rates of IBD flare and similar rates of vaccine-related adverse events to those in the general population are described. Finally, the article provides current recommendations from the Centers for Disease Control and Prevention for COVID-19 vaccination in individuals with IBD.
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Affiliation(s)
- Kimberly N. Weaver
- Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Michael D. Kappelman
- Department of Pediatrics, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Millie D. Long
- Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Nguyen NH, Zhang X, Long MD, Sandborn WJ, Kappelman MD, Singh S. Patient-Reported Outcomes and Risk of Hospitalization and Readmission in Patients with Inflammatory Bowel Diseases. Dig Dis Sci 2022; 67:2039-2048. [PMID: 34110539 PMCID: PMC8986995 DOI: 10.1007/s10620-021-07082-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/26/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Patient-reported outcome measures (PROMs) provide a wholesome view of patient well-being. We conducted a retrospective cohort study to evaluate whether PROMs inform risk of unplanned healthcare utilization in patients with IBD. METHODS We identified adult patients with IBD who completed at least two surveys in a large Internet-based cohort within 1 year. We evaluated the association between baseline patient characteristics, disease activity indices, medication use, and PROMs, assessed using NIH Patient-Reported Outcome Measurement Information System (PROMIS) and subsequent risk of incident hospitalization (at time of first follow-up) within 1 year, and readmission within 1 year (in patients with hospitalization at first follow-up), using multivariable logistic regression. RESULTS Of 7902 patients with IBD (45.5 year, 72% females, 63% Crohn's disease), 1377 (17.4%) were hospitalized within 1 year. Among PROMs, pain interference (adjusted OR per 5-point increase in PROMIS, 1.09; 95% CI 1.05-1.14), but not depression, anxiety, fatigue or sleep disturbance, was predictive of higher risk of hospitalization. Prior surgery or hospitalization, symptomatic disease, biologic, and corticosteroid use were also associated with higher risk of hospitalization. Of 521 patients hospitalized with IBD, 133 (25.5%) were readmitted within 1 year. Anxiety and pain interference were predictive of higher risk of readmission, whereas depression was associated with lower risk of readmission. CONCLUSIONS In a large Internet-based cohort study, PROMs may have a modest effect on modifying risk of unplanned healthcare utilization in patients with IBD, with pain interference being most consistently associated with increased risk of hospitalization and readmission.
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Affiliation(s)
- Nghia H Nguyen
- Division of Gastroenterology, Department of Medicine, University of California San Diego, 9452 Medical Center Dr., ACTRI 1W501, La Jolla, CA, 92093, USA
| | - Xian Zhang
- Division of Gastroenterology and Hepatology, University of North Carolina At Chapel Hill, Chapel Hill, NC, USA
| | - Millie D Long
- Division of Gastroenterology and Hepatology, University of North Carolina At Chapel Hill, Chapel Hill, NC, USA
| | - William J Sandborn
- Division of Gastroenterology, Department of Medicine, University of California San Diego, 9452 Medical Center Dr., ACTRI 1W501, La Jolla, CA, 92093, USA
| | - Michael D Kappelman
- Division of Gastroenterology and Hepatology, University of North Carolina At Chapel Hill, Chapel Hill, NC, USA
| | - Siddharth Singh
- Division of Gastroenterology, Department of Medicine, University of California San Diego, 9452 Medical Center Dr., ACTRI 1W501, La Jolla, CA, 92093, USA.
- Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, CA, USA.
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Ricciuto A, Lamb CA, Benchimol EI, Walker GJ, Kennedy NA, Kuenzig ME, Kaplan GG, Kappelman MD, Ungaro RC, Colombel JF, Brenner EJ, Agrawal M, Reinisch W, Griffiths AM, Sebastian S. Inflammatory Bowel Disease Clinical Activity is Associated with COVID-19 Severity Especially in Younger Patients. J Crohns Colitis 2022; 16:591-600. [PMID: 34570886 PMCID: PMC8522422 DOI: 10.1093/ecco-jcc/jjab172] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND AIMS Age is a major prognostic factor for COVID-19 outcomes. The effect of inflammatory bowel disease [IBD] activity on COVID-19 is unclear. We examined the relationship between IBD activity and COVID-19 severity according to age. METHODS We included IBD patients diagnosed with COVID-19, reported to SECURE-IBD between March 13, 2020 and August 3, 2021. Clinical IBD activity was measured by physician global assessment [PGA]. COVID-19-related outcomes were [1] intensive care unit [ICU] admission, ventilation or death, and [2] hospitalization. Using generalized estimating equations, we determined adjusted odds ratios [aOR, 95% confidence interval] for moderate and severe PGA vs clinical remission/mild PGA, controlling for demographics, medications and COVID-19 diagnosis period. We performed stratified analyses by age [≤50 vs >50 years]. RESULTS Among 6078 patients, adverse COVID-19 outcomes were more common with active IBD: ICU/ventilation/death in 3.6% [175/4898] of remission/mild, 4.9% [45/920] of moderate and 8.8% [23/260] of severe [p < 0.001]; and hospitalization in 13% [649/4898] of remission/mild, 19% [178/920] of moderate and 38% [100/260] of severe [p < 0.001]. Stratified by decade, effect sizes were larger for younger patients. In patients ≤50 years, severe PGA was independently associated with ICU/ventilation/death (aOR 3.27 [1.15-9.30]) and hospitalization (aOR 4.62 [2.83-7.55]). In contrast, severe PGA was not independently associated with COVID-19 outcomes in those older than 50 years. CONCLUSIONS Clinically active IBD may be a risk factor for severe COVID-19, particularly in younger patients. IBD disease control, including through medication compliance, and strategies to mitigate the risk of COVID-19 infection amongst patients with active IBD [e.g. distancing, immunization] are key to limit adverse COVID-19 outcomes.
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Affiliation(s)
- Amanda Ricciuto
- SickKids IBD Centre, Division of Gastroenterology, Hepatology & Nutrition, The Hospital for Sick Children
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Christopher A Lamb
- Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Gastroenterology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Eric I Benchimol
- SickKids IBD Centre, Division of Gastroenterology, Hepatology & Nutrition, The Hospital for Sick Children
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
| | - Gareth J Walker
- Department of Gastroenterology, Torbay and South Devon NHS Foundation Trust, Torquay, UK
| | - Nicholas A Kennedy
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter IBD Research Group, University of Exeter, Exeter, UK
| | - M Ellen Kuenzig
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada
| | - Gilaad G Kaplan
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Ryan C Ungaro
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Erica J Brenner
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Manasi Agrawal
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Anne M Griffiths
- SickKids IBD Centre, Division of Gastroenterology, Hepatology & Nutrition, The Hospital for Sick Children
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Shaji Sebastian
- Department of Gastroenterology, Hull University Teaching Hospitals NHS Trust, Hull, UK
- Faculty of Health Sciences, University of Hull, Hull, UK
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