A183 VARIATION IN HEALTH SERVICES UTILIZATION AND RISK OF SURGERY ACROSS CHILDREN WITH INFLAMMATORY BOWEL DISEASE: A MULTIPROVINCE COHORT STUDY

Background

Marked variation in access to care and health services utilization is a marker of variation in quality of care. With the rising incidence of pediatric inflammatory bowel disease (IBD), we must understand variation in access to and outcomes of care to improve quality.

Purpose

Describe variation in care for pediatric IBD treated in 4 Canadian provinces.

Method

Incident cases of IBD diagnosed in children <16y were identified from health administrative data in Alberta (AB), Manitoba, Nova Scotia, and Ontario (ON) using validated algorithms. Children were assigned to one of 8 centres of care using a hierarchical assessment of health services use within 6 months of diagnosis. Children treated by adult gastroenterologists or community-based pediatric gastroenterologists were excluded due to small sample size. Outcomes included IBD-related hospitalizations, emergency department (ED) visits (AB/ON only), and IBD-related abdominal surgery. Hospitalizations and ED visits were counted cumulatively from 6-60 months after diagnosis. The risk of first surgery was defined during the same 6-60 month period. Mixed-effects meta-analysis was used to pool results across centres. Heterogeneity among centres was quantified using I² (variation in pooled event rates between centres) and τ (standard deviation of the true event rates). R² quantified the residual heterogeneity in outcomes not attributable to among-province variation.

Result(s)

We identified 3777 incident cases of pediatric IBD, 2936 (78%) of which were treated at 8 pediatric centres. The number of hospitalizations was 0.67 (95% CI 0.56-0.79) per person with high between-centre heterogeneity (I² 84%, τ 0.1556). Provincial differences accounted for 93% of heterogeneity across centres (residual heterogeneity: I² 29%, τ 0.0412). Hospitalizations were less frequent in AB than other provinces (0.43 vs. 0.72-0.78). Children averaged 1.94 IBD-related ED visits, with significant heterogeneity (I² 99%, τ 1.33) with 99.7% of heterogeneity attributable to among-province differences (residual heterogeneity: I² 32%; τ 0.074). Mean ED visits were 1.1 visits in ON (I² 39%) and 3.7 in AB (I² 0%). Intestinal resection was required by 12% (95% CI 0.08-0.15) of Crohn’s patients with high among-centre heterogeneity (I² 81%, τ 0.042), and low (19%) heterogeneity due to provincial differences (residual heterogeneity: I² 76%; τ 0.039). Colectomy was required by 12% (95% CI 10-14) of children with ulcerative colitis (UC) with no between-centre heterogeneity (I² 0%, τ 0).

Conclusion(s)

There is a high degree of between-province (but not between-centre, within province) variability in health services utilization among children with IBD. There was significant between-centre variability in surgery rates for Crohn’s, but not colectomy for UC. Differences in patient characteristics or provincial health systems may be more important predictors of variation in care. Surgery for Crohn’s disease may be a target for inter-centre quality improvement efforts.

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CCC

Disclosure of Interest

None Declared

A74 URGENCY FOR BOWEL MOVEMENTS IS A HIGHLY DISCRIMINATORY SYMPTOM FOR ACTIVE DISEASE IN PERSONS WITH IBD (THE MANITOBA LIVING WITH IBD STUDY)

Background

The Inflammatory Bowel Disease Symptom Inventory (IBDSI) is a validated patient self-reported measure used to assess IBD disease activity.

Purpose

We aimed to assess the prevalence of symptoms, and examine which symptoms are most associated with disease activity as measured by a symptom index and objective measure of inflammation.

Method

The Manitoba Living with IBD Study is a prospective study of 156 participants with confirmed IBD who completed bi-weekly Inflammatory Bowel Disease Symptom Inventory (IBDSI) surveys. Relative risks (RR) (with 95% confidence interval (CI)), positive and negative predictive values (PPV, NPV), and area under receiver operator curve (AUC) were reported for each symptom to predict active disease defined as: (1) active IBDSI, (2) self-reported flare, and (3) elevated fecal calprotectin (FCAL) (>250µg/g). Analyses were undertaken following stratification based on sex, and disease type (Crohn’s disease (CD) and ulcerative colitis (UC)).

Result(s)

In total, 69.2% of participants were female; 64.7% had CD. Fatigue was the most prevalent symptom in both inactive and active disease, across all 3 disease measures (IBDSI: 24.5% and 75.1%, self-reported flare: 42.2% and 72.2%, FCAL: 46.0% and 60.6%). Absence of fatigue had a high NPV for active IBDSI and self-reporting a flare in both CD and UC. Urgency had a consistently strong NPV, RR and AUC across all three disease measures in both IBD subtypes and sexes. The number of loose/liquid bowel movements predicted elevated FCAL in UC (RR in men = 3.5, 95% CI 1.2-9.9, RR in women = 1.8, 95% CI 1.2-2.7, AUC in men = 0.73, 95% CI 0.59-0.84, AUC in women = 0.65, 95% CI 0.56-0.72), as did blood in stool in females with UC (RR = 1.8, 95% CI 1.2-2.7). In men with CD, excessive bowel gas (RR = 2.0, 95% CI 1.2-3.4) and urgency (RR = 3.9, 95% CI 1.6-9.3) best predicted an elevated FCAL. No symptom was strongly predictive of elevated FCAL in females with CD.

Conclusion(s)

Fatigue was the most prevalent symptom irrespective of disease activity. Urgency stood out as being consistently associated with disease activity, irrespective of the disease measure. Individual symptoms have different impacts on subjective (IBDSI) and objective (FCAL) measures in IBD.

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None

Disclosure of Interest

None Declared

A35 FORECASTING THE INCIDENCE AND PREVALENCE OF INFLAMMATORY BOWEL DISEASE: A CANADIAN NATION-WIDE ANALYSIS

Background

Canada is currently in the third epidemiological stage in the evolution of IBD: compounding prevalence. A high incidence of IBD, in conjunction with low mortality, leads to a steadily rising prevalence over time. By understanding historical epidemiological trends, we can forecast incidence and prevalence into the future to inform healthcare systems in Canada of the rising burden of IBD to society.

Purpose

To analyze past epidemiological trends in order to forecast the overall incidence and prevalence of IBD, Crohn’s disease (CD), and ulcerative colitis (UC) and stratified by age (<18, 18-64, 65+).

Method

Canadian population-based administrative data was acquired from: AB, BC, SK, MB, QC, and ON. Data were age and sex standardized to the matching year and provincial data aggregated into a representative sample of the Canadian population for prevalence (2002-2014) and incidence (2007-2014: 5-year washout period). Incidence and prevalence (per 100,000 persons) were calculated, with 95% confidence intervals (CI), using Canadian population estimates from Statistics Canada for IBD, CD, UC (IBD-unclassifiable+UC). Autoregressive Integrated Moving Average models were created, and rates forecasted from 2014 to 2035 with 95% prediction intervals (PI). Poisson (or negative binomial) for incidence and log binomial regression for prevalence estimated the Average Annual Percentage Change (AAPC), with 95% CIs, of the forecasted data.

Result(s)

The 2014 incidence of IBD in Canada was 28.4 per 100,000 (95%CI: 27.8, 29.0) and forecasted to significantly increase (AAPC: 0.58%; 95%CI: 0.04, 1.04) from 30.0 per 100,000 in 2023 to 32.1 (95%PI: 27.9, 36.3) in 2035. Pediatric onset IBD was 13.9 per 100,000 (95%CI: 13.0, 14.9) in 2014 and is forecasted to significantly increase to 18.0 per 100,000 (95%PI: 15.7, 20.2) in 2035 with an AAPC of 1.23% (95%CI: 0.76, 1.63). Adult and elderly onset incidence rates were forecasted to remain stable. Prevalence of IBD increased between 2002 (389 per 100,000) and 2014 (636 per 100,000) and is forecasted to continue to climb by an AAPC of 2.44% (95%CI: 2.34, 2.53). In 2023, the prevalence of IBD is 825 per 100,000. By 2035 prevalence is forecasted to climb to 1075 per 100,000 (95%PI: 1047, 1103) with 470,000 Canadians living with IBD. Prevalence across all age strata were forecasted to significantly increase. The highest AAPC was seen in the elderly (2.76%; 95%CI: 2.73, 2.79) with a prevalence of 841 per 100,000 (95%CI: 834, 849) in 2014 and forecasted to climb to 1534 per 100,000 (95%PI: 1519, 1550) in 2035.

Image

Conclusion(s)

Incidence of IBD continues to rise in Canada, driven by pediatric-onset IBD. In 2023, over 320,000 Canadians (0.83%) will be living with IBD. By 2035 prevalence will exceed 1% of the population with approximately 470,000 individuals in Canada with IBD. Future research should establish the environmental determinates of IBD that may influence temporal trends in the incidence of IBD, while healthcare systems adapt to the compounding prevalence of IBD.

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CIHR, Other

Please indicate your source of funding;

The Leona M. and Harry B. Helmsley Charitable Trust

Disclosure of Interest

S. Coward: None Declared, E. Benchimol Consultant of: Hoffman La-Roche Limited and Peabody & Arnold LLP for matters unrelated to medications used to treat inflammatory bowel disease and McKesson Canada and the Dairy Farmers of Ontario for matters unrelated to medications used to treat inflammatory bowel disease., C. Bernstein Grant / Research support from: Unrestricted educational grants from Abbvie Canada, Janssen Canada, Pfizer Canada, Bristol Myers Squibb Canada, and Takeda Canada. Has received research grants from Abbvie Canada, Amgen Canada, Pfizer Canada, and Sandoz Canada and contract grants from Janssen, Abbvie and Pfizer, Consultant of: Abbvie Canada, Amgen Canada, Bristol Myers Squibb Canada, JAMP Pharmaceuticals, Janssen Canada, Pfizer Canada, Sandoz Canada, and Takeda., Speakers bureau of: Abbvie Canada, Janssen Canada, Pfizer Canada and Takeda Canada, J. A. Avina-Zubieta: None Declared, A. Bitton: None Declared, L. Hracs: None Declared, J. Jones Consultant of: Janssen, Abbvie, Pfizer, Takeda, Speakers bureau of: Janssen, Abbvie, Pfizer, Takeda, E. Kuenzig: None Declared, L. Lu: None Declared, S. Murthy: None Declared, Z. Nugent: None Declared, A. Otley Grant / Research support from: Unrestricted educational grants from AbbVie Canada and Janssen Canada, Consultant of: Advisory boards of AbbVie Canada, Janssen Canada and Nestle, R. Panaccione Consultant of: Abbott, AbbVie, Alimentiv (formerly Robarts), Amgen, Arena Pharmaceuticals, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Celltrion, Cosmos Pharmaceuticals, Eisai, Elan, Eli Lilly, Ferring, Galapagos, Fresenius Kabi, Genentech, Gilead Sciences, Glaxo-Smith Kline, JAMP Bio, Janssen, Merck, Mylan, Novartis, Oppilan Pharma, Organon, Pandion Pharma, Pendopharm, Pfizer, Progenity, Protagonist Therapeutics, Roche, Sandoz, Satisfai Health, Shire, Sublimity Therapeutics, Takeda Pharmaceuticals, Theravance Biopharma, Trellus, Viatris, UCB. Advisory Boards for: AbbVie, Alimentiv (formerly Robarts), Amgen, Arena Pharmaceuticals, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, Ferring, Fresenius Kabi, Genentech, Gilead Sciences, Glaxo-Smith Kline, JAMP Bio, Janssen, Merck, Mylan, Novartis, Oppilan Pharma, Organon, Pandion Pharma, Pfizer, Progenity, Protagonist Therapeutics, Roche, Sandoz Shire, Sublimity Therapeutics, Takeda Pharmaceuticals, Speakers bureau of: AbbVie, Amgen, Arena Pharmaceuticals, Bristol-Myers Squibb, Celgene, Eli Lilly, Ferring, Fresenius Kabi, Gilead Sciences, Janssen, Merck, Organon, Pfizer, Roche, Sandoz, Shire, Takeda Pharmaceuticals, J.-N. Pena-Sanchez: None Declared, H. Singh Consultant of: Pendopharm, Amgen Canada, Bristol Myers Squibb Canada, Roche Canada, Sandoz Canada, Takeda Canada, and Guardant Health, Inc., L. Targownik Grant / Research support from: Investigator initiated funding from Janssen Canada, Consultant of: [Advisory board] AbbVie Canada, Takeda Canada, Merck Canada, Pfizer Canada, Janssen Canada, Roche Canada, and Sandoz Canada, J. Windsor: None Declared, G. Kaplan Grant / Research support from: Ferring, Janssen, AbbVie, GlaxoSmith Kline, Merck, and Shire, Consultant of: Gilead, Speakers bureau of: AbbVie, Janssen, Pfizer, Amgen, and Takeda

A189 EMERGENCY DEPARTMENT UTILIZATION AND RISK OF INTESTINAL RESECTION IS LOWER AMONG CHILDREN DIAGNOSED WITH INFLAMMATORY BOWEL DISEASE BEFORE 10 YEARS OF AGE: A MULTIPROVINCE POPULATION-BASED COHORT STUDY

Background

In Canada, the incidence of inflammatory bowel disease (IBD) is increasing faster among those <10 years (y) of age than in any other age group. Understanding the health services burden of IBD in this population is important for health system planning.

Purpose

To compare healthcare utilization and risk of surgery among children diagnosed with IBD across age groups defined by the Paris Classification (A1a: <10y; A1b: 10 to <16y) across 5 Canadian provinces.

Method

Children diagnosed with IBD <16 years of age were identified from health administrative data using validated algorithms in Alberta, Manitoba, Nova Scotia, Ontario, and Québec. Negative binomial regression models were used to compare (1) the pre-diagnosis frequency of health services utilization (outpatient, emergency department (ED), and hospitalization) using diagnostic codes suggestive of future IBD and (2) the annual post-diagnosis frequency of IBD-specific and IBD-related (signs, symptoms, and extra-intestinal manifestations of IBD) visits among children diagnosed <10y (A1a) and 10 to <16y (A1b). Cox proportional hazard models compared the risk of surgery (identified with validated procedure codes) across age groups. All regression models were adjusted for sex, rural/urban residence, and mean neighbourhood income quintile. Province-specific event counts (all ages combined) and models (comparing age groups; reference: A1b [10 to <16y]) were pooled using random-effects meta-analysis.

Result(s)

Among 5124 children with IBD (1165 [23%] were <10y at diagnosis), the mean number of pre-diagnosis healthcare encounters was 1.0 (95% CI 0.38 to 1.68, I²=99.6%). The mean annual post-diagnosis number of IBD-specific outpatient visits was 3.2 (95% CI 1.9-4.4, I²=99.6%); hospitalizations, 0.19 (95% CI 0.17-0.21, I²=74%); ED visits, 0.17 (95% CI 0.19-0.39, I²=99%). The mean annual post-diagnosis number of IBD-related outpatient visits was 3.9 (95% CI 2.3-5.5, I²=99.7%); hospitalizations, 0.21 (95% CI 0.19-0.23, I²=79%); ED visits, 0.29 (95% CI 0.19-0.39, I²=97%). Intestinal resection or colectomy within 5y of diagnosis occurred in 13% (95%CI 8-22, I²=93%) with Crohn’s disease (CD) and 16% (95% CI 14-18, I²=40%) with ulcerative colitis. IBD-specific ED visits (RR 0.70, 95% CI 0.50-0.97, I²=80) and the risk of intestinal resection in CD (HR 0.49, 95% CI 0.26-0.92, I²=40%) were significantly lower among children diagnosed <10y. There were no age-related differences in pre-diagnosis health services utilization or other post-diagnosis outcomes, including frequency of outpatient visits to a gastroenterologist.

Conclusion(s)

Health services utilization was generally similar for children diagnosed with IBD at <10y and between 10 and <16y, except for lower rates of IBD-specific ED visits and intestinal resection in children with CD. Further exploration of between-province differences, represented by the high statistical heterogeneity (I²) in the meta-analyses, is needed to understand sources of variation in care.

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CCC

Disclosure of Interest

E. Kuenzig: None Declared, H. Singh Consultant of: Amgen Canada, Bristol-Myers Squibb Canada, Sandoz Canada, Roche Canada, Takeda Canada and Guardant Health, A. Bitton: None Declared, G. Kaplan Grant / Research support from: Ferring, Consultant of: AbbVie, Janssen, Pfizer, Amgen, Sandoz, Pendophram, and Takeda, Speakers bureau of: AbbVie, Janssen, Pfizer, Amgen, Sandoz, Pendophram, and Takeda, M. Carroll: None Declared, A. Otley Grant / Research support from: Research support: AbbVie Global. Research site: AbbVie, Pfizer, Eli-Lily, Janssen, Consultant of: AbbVie Canada, T. Stukel: None Declared, S. Spruin: None Declared, A. Griffiths Grant / Research support from: Abbvie, Consultant of: Abbvie, Amgen, BristolMyersSquibb, Janssen, Lilly, Takeda, Speakers bureau of: Abbvie, Janssen, Takeda, D. Mack: None Declared, K. Jacobson Grant / Research support from: Abbvie Canada and Janssen Canada, Consultant of: Abbvie Canada, Janssen Canada, Merck Canada and Mylan Pharmaceuticals, Speakers bureau of: Abbvie Canada and Janssen Canada, G. Nguyen: None Declared, L. Targownik Grant / Research support from: Janssen Canada, Consultant of: AbbVie Canada, Sandoz Canada, Takeda Canada, Merck Canada, Pfizer Canada, Janssen Canada, and Roche Canada, W. El-Matary Consultant of: Abbvie and MERCK, Speakers bureau of: Abbvie and MERCK, E. Benchimol Consultant of: McKesson Canada, Dairy Farmers of Ontario (unrelated to medications used to treat inflammatory bowel disease)

A210 THE BURDEN OF IBD HOSPITALIZATION IN CANADA: AN ASSESSMENT OF THE CURRENT AND FUTURE BURDEN IN A NATION-WIDE ANALYSIS

Background

Hospitalizations pose a significant burden on both the individual and the healthcare system. Those with inflammatory bowel disease (IBD) are at increased risk of hospitalization as compared to the general population due to flaring of disease activity and complications related to IBD. The advent of biologics over the past twenty years may have influenced the rates of hospitalization for IBD.

Purpose

To assess current and forecast the overall hospitalization rates of those with IBD stratified by types of hospitalizations (all cause hospitalizations, IBD-related, and IBD-specific).

Method

Population-based administrative data on hospitalization of IBD (2002-2014) were obtained from: AB, BC, MB, and SK. Data were age and sex standardized to the matching year and aggregated into a representative sample of the Canadian population. Hospitalization rates were assessed as follows: 1. All cause hospitalizations: all admissions regardless of indication; 2. IBD-specific: an admission directly resulting from IBD (e.g., IBD-flare); 3. IBD-related: an admission for IBD, or a symptom or comorbidity associated with IBD (e.g. rheumatoid arthritis). Using prevalence estimates from the provinces, hospitalization rates (per 100 persons with IBD) were calculated, with 95% confidence intervals (CI). Autoregressive Integrated Moving Average models were created to estimate number of hospitalizations and corresponding prevalence to forecast hospitalization rates to 2030 with 95% prediction intervals (PI). Poisson (or negative binomial) regression estimated the Average Annual Percentage Change (AAPC), with 95% CIs, of the forecasted data.

Result(s)

In 2002 there were 35.3 per 100 (95%CI: 34.7, 35.9) all cause hospitalizations for IBD patients and this decreased to 24.9 per 100 (24.5, 25.2) in 2014. Similar trends were seen for IBD-specific hospitalizations [16.8 per 100 (95%CI: 16.4, 17.2) in 2002 to 8.7 per 100 (95%CI: 8.5, 9.0) in 2014] and IBD-related (22.6 per 100 (95%CI: 22.1, 23.1) in 2002 to 13.4 per 100 (95%CI: 13.2, 13.7) in 2014). When forecasted out to 2030 all hospitalization types were significantly decreasing—the AAPC for all cause hospitalizations was -2.12% (95%CI: -2.31, -1.93), -3.77% (95%CI: -4.63, -3.08) for IBD-specific, and -3.09% (95%CI: -3.65, -2.62) for IBD-related. By 2030, the rates of hospitalization are forecasted to be 17.0 per 100 (95%PI: 16.2, 17.9), 4.6 per 100 (95%PI: 3.7, 5.4), and 7.9 per 100 (95%PI: 6.9, 8.9) for all cause, IBD-specific, and IBD-related, respectively.

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Conclusion(s)

In Canada, rates of hospitalizations for those with IBD have decreased from 2002 to 2014. The use of anti-TNF therapy in conjunction with the evolution of clinical monitoring, management and guidelines, likely has contributed to dropping hospitalization rates. Forecast models estimate a continued drop in hospitalization rates out to 2030. Importantly, healthcare resource planning should account for the shift from hospital-based to clinic-centric models of IBD care.

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CIHR

Disclosure of Interest

S. Coward: None Declared, E. Benchimol Consultant of: Hoffman La-Roche Limited and Peabody & Arnold LLP for matters unrelated to medications used to treat inflammatory bowel disease and McKesson Canada and the Dairy Farmers of Ontario for matters unrelated to medications used to treat inflammatory bowel disease., C. Bernstein Grant / Research support from: Unrestricted educational grants from Abbvie Canada, Janssen Canada, Pfizer Canada, Bristol Myers Squibb Canada, and Takeda Canada. Has received research grants from Abbvie Canada, Amgen Canada, Pfizer Canada, and Sandoz Canada and contract grants from Janssen, Abbvie and Pfizer, Consultant of: Abbvie Canada, Amgen Canada, Bristol Myers Squibb Canada, JAMP Pharmaceuticals, Janssen Canada, Pfizer Canada, Sandoz Canada, and Takeda., Speakers bureau of: Abbvie Canada, Janssen Canada, Pfizer Canada and Takeda Canada, J. A. Avina-Zubieta: None Declared, A. Bitton: None Declared, L. Hracs: None Declared, J. Jones Consultant of: Janssen, Abbvie, Pfizer, Takeda, Speakers bureau of: Janssen, Abbvie, Pfizer, Takeda, E. Kuenzig: None Declared, L. Lu: None Declared, S. Murthy: None Declared, Z. Nugent: None Declared, A. Otley Grant / Research support from: Unrestricted educational grants from AbbVie Canada and Janssen Canada, Consultant of: Advisory boards of AbbVie Canada, Janssen Canada and Nestle, R. Panaccione Consultant of: Abbott, AbbVie, Alimentiv (formerly Robarts), Amgen, Arena Pharmaceuticals, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Celltrion, Cosmos Pharmaceuticals, Eisai, Elan, Eli Lilly, Ferring, Galapagos, Fresenius Kabi, Genentech, Gilead Sciences, Glaxo-Smith Kline, JAMP Bio, Janssen, Merck, Mylan, Novartis, Oppilan Pharma, Organon, Pandion Pharma, Pendopharm, Pfizer, Progenity, Protagonist Therapeutics, Roche, Sandoz, Satisfai Health, Shire, Sublimity Therapeutics, Takeda Pharmaceuticals, Theravance Biopharma, Trellus, Viatris, UCB. Advisory Boards for: AbbVie, Alimentiv (formerly Robarts), Amgen, Arena Pharmaceuticals, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, Ferring, Fresenius Kabi, Genentech, Gilead Sciences, Glaxo-Smith Kline, JAMP Bio, Janssen, Merck, Mylan, Novartis, Oppilan Pharma, Organon, Pandion Pharma, Pfizer, Progenity, Protagonist Therapeutics, Roche, Sandoz Shire, Sublimity Therapeutics, Takeda Pharmaceuticals, Speakers bureau of: AbbVie, Amgen, Arena Pharmaceuticals, Bristol-Myers Squibb, Celgene, Eli Lilly, Ferring, Fresenius Kabi, Gilead Sciences, Janssen, Merck, Organon, Pfizer, Roche, Sandoz, Shire, Takeda Pharmaceuticals, J.-N. Pena-Sanchez: None Declared, H. Singh Consultant of: Pendopharm, Amgen Canada, Bristol Myers Squibb Canada, Roche Canada, Sandoz Canada, Takeda Canada, and Guardant Health, Inc.,, L. Targownik Grant / Research support from: Investigator initiated funding from Janssen Canada, Consultant of: [Advisory board] AbbVie Canada, Takeda Canada, Merck Canada, Pfizer Canada, Janssen Canada, Roche Canada, and Sandoz Canada, J. Windsor: None Declared, G. Kaplan Grant / Research support from: Ferring, Janssen, AbbVie, GlaxoSmith Kline, Merck, and Shire, Consultant of: Gilead, Speakers bureau of: AbbVie, Janssen, Pfizer, Amgen, and Takeda

A169 THE DIRECT COSTS OF INFLAMMATORY BOWEL DISEASE IN CANADA: A POPULATION-BASED ANALYSIS OF HISTORICAL AND CURRENT COSTS

Background

Inflammatory bowel disease (IBD) is a costly disease to manage due to hospitalizations, regular ambulatory monitoring, and expensive pharmaceutical therapies. While hospitalization rates have fallen, the increased use of biologics have escalated the cost of care to the healthcare system.

Purpose

To assess historical direct healthcare costs of the IBD population in Canada.

Method

Population-based administrative costing data were obtained from: Alberta, British Columbia, and Manitoba. Costs were calculated based on administrative data (2009 to 2016) which captured: hospitalizations, physician costs, ambulatory care such as: emergency visits, day surgery, and colonoscopy (AB only), and medication costs of IBD-specific medications, such as: mesalamine, biologics, steroids, and immunomodulators. Costs were converted to 2020 dollars using the consumer price index. Average annual cost per person (ACPP) was calculated for each province. Using province specific IBD prevalence estimates these ACPP were meta-analyzed to obtain the annual weighted costs, with 95% confidence intervals (CI), and these costs underwent meta-regression to ascertain the average annual change in cost per year. An Autoregressive Integrated Moving Average model was created to estimate the ACPP in 2023 with 95% prediction intervals (PI). Canada-wide total direct care costs of IBD patients, in billions (B), were calculated using the ACPP, Canada-specific IBD prevalence estimates (historical and forecasted), and total Canadian population calculations from Statistics Canada (historical and forecasted).

Result(s)

In 2009 the ACPP was $7000 (95%CI: 5389, 8610), representing $1.18B (95%CI: 0.91B, 1.45B) in direct healthcare costs in Canada for all IBD patients. The ACPP in 2016 was increased to $10,336 (95%CI: 6803, 13869), which equates to $2.37B (95%CI: 1.56B, 3.18B) per year in direct healthcare costs. From 2009 to 2016, the ACPP increased an average of $450 (95%CI: 132, 767) per year. If these historical trends continue to 2023 the ACPP is forecasted to be $13,333 (95%PI: 12827, 13839) per person per year. The largest contributor to these costs is medications—accounting for an estimated 50% of the total costs of IBD patients.

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Conclusion(s)

The direct healthcare cost of IBD has risen steadily from 2009 to 2016 when the healthcare system spent over $10,000 per person with IBD and $2.37B nationwide. The primary driver of costs is medical management. Forecast models estimate that the annual cost may be over $13,000 per person in 2023. However, these estimates do not account for advent and increased uptake of novel biologics and small molecules, nor the downward cost pressure of biosimilars. These costs are those paid directly by the healthcare system and do not account for those born by the individual—it is estimated that the true cost of IBD (direct and indirect) is much higher.

Please acknowledge all funding agencies by checking the applicable boxes below

CIHR

Disclosure of Interest

S. Coward: None Declared, E. Benchimol Consultant of: Hoffman La-Roche Limited and Peabody & Arnold LLP for matters unrelated to medications used to treat inflammatory bowel disease and McKesson Canada and the Dairy Farmers of Ontario for matters unrelated to medications used to treat inflammatory bowel disease., C. Bernstein Grant / Research support from: Unrestricted educational grants from Abbvie Canada, Janssen Canada, Pfizer Canada, Bristol Myers Squibb Canada, and Takeda Canada. Has received research grants from Abbvie Canada, Amgen Canada, Pfizer Canada, and Sandoz Canada and contract grants from Janssen, Abbvie and Pfizer, Consultant of: Abbvie Canada, Amgen Canada, Bristol Myers Squibb Canada, JAMP Pharmaceuticals, Janssen Canada, Pfizer Canada, Sandoz Canada, and Takeda., Speakers bureau of: Abbvie Canada, Janssen Canada, Pfizer Canada and Takeda Canada, J. A. Avina-Zubieta: None Declared, A. Bitton: None Declared, L. Hracs: None Declared, J. Jones Consultant of: Janssen, Abbvie, Pfizer, Takeda, Speakers bureau of: Janssen, Abbvie, Pfizer, Takeda, E. Kuenzig: None Declared, L. Lu: None Declared, S. Murthy: None Declared, Z. Nugent: None Declared, A. Otley Grant / Research support from: Unrestricted educational grants from AbbVie Canada and Janssen Canada, Consultant of: Advisory boards of AbbVie Canada, Janssen Canada and Nestle, R. Panaccione Consultant of: Abbott, AbbVie, Alimentiv (formerly Robarts), Amgen, Arena Pharmaceuticals, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Celltrion, Cosmos Pharmaceuticals, Eisai, Elan, Eli Lilly, Ferring, Galapagos, Fresenius Kabi, Genentech, Gilead Sciences, Glaxo-Smith Kline, JAMP Bio, Janssen, Merck, Mylan, Novartis, Oppilan Pharma, Organon, Pandion Pharma, Pendopharm, Pfizer, Progenity, Protagonist Therapeutics, Roche, Sandoz, Satisfai Health, Shire, Sublimity Therapeutics, Takeda Pharmaceuticals, Theravance Biopharma, Trellus, Viatris, UCB. Advisory Boards for: AbbVie, Alimentiv (formerly Robarts), Amgen, Arena Pharmaceuticals, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, Ferring, Fresenius Kabi, Genentech, Gilead Sciences, Glaxo-Smith Kline, JAMP Bio, Janssen, Merck, Mylan, Novartis, Oppilan Pharma, Organon, Pandion Pharma, Pfizer, Progenity, Protagonist Therapeutics, Roche, Sandoz Shire, Sublimity Therapeutics, Takeda Pharmaceuticals, Speakers bureau of: AbbVie, Amgen, Arena Pharmaceuticals, Bristol-Myers Squibb, Celgene, Eli Lilly, Ferring, Fresenius Kabi, Gilead Sciences, Janssen, Merck, Organon, Pfizer, Roche, Sandoz, Shire, Takeda Pharmaceuticals, J.-N. Pena-Sanchez: None Declared, H. Singh Consultant of: Pendopharm, Amgen Canada, Bristol Myers Squibb Canada, Roche Canada, Sandoz Canada, Takeda Canada, and Guardant Health, Inc.,, L. Targownik Grant / Research support from: Investigator initiated funding from Janssen Canada, Consultant of: [Advisory board] AbbVie Canada, Takeda Canada, Merck Canada, Pfizer Canada, Janssen Canada, Roche Canada, and Sandoz Canada, J. Windsor: None Declared, G. Kaplan Grant / Research support from: Ferring, Janssen, AbbVie, GlaxoSmith Kline, Merck, and Shire, Consultant of: Gilead, Speakers bureau of: AbbVie, Janssen, Pfizer, Amgen, and Takeda

A26 DECONSTRUCTING DISTRESS: STAKEHOLDER ENGAGEMENT FOR EVIDENCE-BASED, PATIENT-CENTERED INTERVENTIONS FOR THE MANAGEMENT OF IBD-ASSOCIATED PSYCHOLOGICAL DISTRESS

Background

The growing prevalence of Inflammatory Bowel Disease (IBD) along with increasing complexity of providing high-quality, patient-centered care within a resource-constrained healthcare environment presents a major challenge. IBD-related psychological distress (IBD-PD) is the emotional impact of IBD and is associated with mental health disorders, increased disease severity, and premature mortality. With estimates of nearly 90% of IBD patients experiencing PD, the inability to provide high-quality, person-centered care for IBD-PD that is proportionate to clinical need is a significant care gap in the Canadian healthcare system.

Aims

To generate stakeholder-derived data to inform the design and development of stepped-intensity, cognitive behavioral therapy-based interventions for IBD-PD using evidence-based, patient–centered interventions and implementation strategies.

Methods

Virtual semi-structured interviews were conducted from September to October 2021. The interview guide was developed iteratively by researchers, IBD care providers, and patient research partners and guided by the COM-B Model of Behaviour and the Theoretical Domains Framework. Questions assessed perceptions, experiences, barriers, and facilitators to accessing IBD-PD care. Adults diagnosed with IBD were recruited from academic centers across Canada. Interviews were co-facilitated by a researcher and patient research partner, audio recorded, and transcribed. Using thematic analysis, codes were generated to identify themes using an inductive approach.

Results

As of October 2021, six interviews have been completed, with data collection ongoing. The mean participant age was 34.3 years (range 21–55 years) with 100% of respondents being female. The majority of participants worked full time (4/6, 67%) and all had completed at least high school. Diagnoses of Crohn’s Disease (3/6, 50%) and ulcerative colitis (3/6, 50%) were evenly distributed. Thematic analyses identified five major themes: 1) Lack of holistic care and acknowledgement of IBD-PD; 2) System-level and financial barriers to psychological support; 3) Lack of psychological support from providers with an understanding of IBD; 4) Preference for individualized virtual-based support; 5) Heavy reliance on informal support structures (caregivers) due to lack of access to formal psychological support.

Conclusions

As part of human-centered design, stakeholder engagement is key to understanding behavioral, social, attitudinal, and environmental barriers and facilitators for accessing IBD-PD care. Interviews are ongoing and specific intervention functions will be defined and incorporated into patient-centered implementation strategies.

Funding Agencies

None

A159 OPIOID USE IS DECLINING AMONG PEOPLE WITH INFLAMMATORY BOWEL DISEASE: A POPULATION-BASED STUDY

Background

Patients with inflammatory bowel disease (IBD) are more likely to use opioids than those without IBD and are more susceptible to the negative consequences of opioid use, including increased risk of death.

Aims

Examine trends in the use of opioids among people with and without IBD, where opioids were prescribed, and who prescribed them.

Methods

We identified Ontarians with IBD (7/2012–3/2017) from population-based health administrative data using validated algorithms. We matched each patient with IBD on age and sex to 5 people without IBD. We calculated age- and sex-standardized quarterly rates of patients taking opioids, characterized as any, chronic (>90 days), or acute (≤90 days) among people with and without IBD. Among people with IBD, we identified the location of the last healthcare interaction prior to filling the prescription (hospital, emergency department [ED], outpatient clinic), presuming this was where the opioid was prescribed. Opioids prescribed after outpatient visits were stratified by specialty (gastroenterologist, family physician/internist, surgeon, other). Average quarterly percentage change was calculated using Poisson regression, adjusting for age, sex, income, and rural/urban household.

Results

Of 92,233 IBD patients (mean 47 y at study entry, 45% male, 50% Crohn’s), 56% had at least 1 opioid prescription during the study period. Opioid use was more common among people with IBD (any: IRR 2.11, 95% CI 2.08–2.14; chronic: IRR 2.61, 95% CI 2.54–2.69; acute: IRR 1.82, 95% CI 1.79–1.94), Figure A. Among IBD patients, any opioid use decreased by 0.5% (95%CI 0.4–0.5) per quarter, from 13.4% (95%CI 13.1–13.6) to 12.7% (95%CI 12.5–13.0). Chronic opioid use decreased by 0.3% (95%CI 0.2–0.4) per quarter while acute opioid use among IBD patients decreased by 0.6% (95% CI 0.5–0.7) per quarter. Most opioids were prescribed after an outpatient visit (70.2%), most often (82.7%) by a family physician or internist. Total outpatient prescriptions declined by 1.9% (95%CI 1.7–2.0) per quarter, from 5.8% (95%CI 5.6–5.9) to 3.8% (95%CI 3.7–3.9). Relative quarterly decreases were similar across all specialties, Figure B.

Conclusions

Opioid use remains common among IBD patients but has decreased since 2012. The prescriptions most often originated after outpatient visits to family physicians and internists rather than gastroenterologists or surgeons.

Trends in (A) the acute and chronic opioid use among those with and without IBD and (B) the specialist prescribing opioids to IBD patients when the most recent healthcare contact was an outpatient visit.

Funding Agencies

American College of Gastroenterology

A162 CHRONIC OPIOID THERAPY IS ASSOCIATED WITH INCREASED HEALTH SERVICES UTILIZATION AND DIRECT HEALTHCARE COSTS: A POPULATION-BASED STUDY

Background

Opioid use is more common among people living with Inflammatory bowel disease (IBD).

Aims

Investigate the associations between receiving chronic opioid therapy and health services utilization and direct healthcare costs among IBD patients receiving chronic opioid therapy.

Methods

We identified prevalent cases of IBD in Ontario (7/2012–3/2017) from population-based health administrative data using previously validated algorithms. Patients with ongoing opioid use for >90 days (chronic opioid recipients) were matched based on age, sex, IBD type, and disease duration with up to 5 IBD patients with no period of chronic opioid use. For the year after becoming a chronic opioid recipient (i.e., from the 91^st day of chronic opioid therapy), we determined: 1) the mean (SD) number of IBD-specific, IBD-related, and all-cause outpatient visits, emergency department (ED) visits, and hospitalizations; and 2) total, hospitalization, ED, and outpatient healthcare costs. IBD-specific visits had a diagnostic code for Crohn’s disease or ulcerative colitis; IBD-related visits additionally included diagnostic codes for signs, symptoms, and extra-intestinal manifestations of IBD. Patients were censored at the time of a new cancer diagnosis or upon initiation of palliative care. We used Poisson models to compare the number of healthcare encounters in chronic opioid recipients and patients with no period of chronic opioid therapy then used generalized linear models with a gamma distribution and log-link to compare direct healthcare costs in the two groups. Regression models accounted for matching and were adjusted for income, rural/urban household, and comorbidities (resource intensity using the John Hopkins ACG Index).

Results

We identified 9913 IBD patients with at least one period of chronic opioid therapy matched to 44,274 without chronic opioid therapy (mean 43 y at chronic opioid use, 43% male, 58% Crohn’s). Patients receiving chronic opioid therapy had significantly more health care encounters (Figure A). Annual per capita total health care cost among chronic opioid recipients was $13,452 (SD 33,777) compared to $5140 (SD 28,999) among patients with no chronic opioid therapy (Figure B). After adjustment, healthcare costs were approximately double in chronic opioid recipients and was consistent for all cost types (overall, hospitalization, ED, and outpatient).

Conclusions

IBD patients who were chronic opioid users had significantly more health services utilization and direct healthcare costs compared to patients without periods of chronic opioid use. These associations persisted after adjusting for the resource intensity of any co-occurring conditions.

Health services utilization (A) and direct healthcare costs (B) among people with inflammatory bowel disease (IBD) who are chronic opioid users compared to those without a period of chronic opioid use.

Funding Agencies

American College of Gastroenterology

A158 COMPARING CORTIMENT® AND PREDNISONE IN ULCERTATIVE COLITIS: A POPULATION-BASED STUDY OF OUTCOMES

Background

In August 2016 Cortiment® was approved for use in ulcerative colitis (UC) patients in Canada, but not approved for reimbursement; the Canadian Agency for Drugs and Technology in Health cited no comparable benefit for its use over other approved UC medications. Real-world data comparing Cortiment® to other UC medications is limited, especially during the COVID-19 pandemic where the use of steroids is counter-indicated for COVID-19-related outcomes.

Aims

To examine the comparative risk of hospitalization, surgery, and infection after initiation of Cortiment® or oral corticosteroids among UC patients using real-world data

Methods

Using population-based data from Alberta Canada, two cohorts were compared: 1. Patients dispensed Cortiment® and an ICD diagnostic code for UC [9: 556.X; 10: K51.X] (August 1, 2016 to October 31, 2019); and, 2. Validated (algorithm) UC patients dispensed a >30 day supply or >500mg in 24 hours of prednisone/prednisolone (April 1, 2016 to October 31, 2019). All hospitalizations, IBD-surgery, or infections (i.e., pneumonia, c.diff, sepsis, tuberculosis) that occurred 6 or 12 months from initial medication dispensing were identified. Cox-proportional hazard models, with Hazard Ratios (HR), assessed comparative outcomes. Kaplan-Meier survival curves were created, and Poisson regression (or negative binomial) used to assess the Average Monthly Percentage Change (AMPC) with associated 95% confidence intervals (CI).

Results

We identified 917 Cortiment® and 2,404 Prednisone patients. Over the study period, prednisone dispensing significantly decreased (AMPC:-2.53% [CI:-2.85,-2.21]) while Cortiment® remained stable. Dispensing of Cortiment® significantly decreased the hazard of hospitalization (all types, except surgery) at 12 months as compared to prednisone, and significantly decreased the hazard of an infection at both 6 and 12 months (Table 1, Fig 1).

Conclusions

The use of Cortiment® in a real-world setting is associated with fewer deleterious outcomes, and its use during a pandemic should be preferred, especially when it’s counterpart can exacerbate negative COVID-19-related outcomes.

Table 1

Kaplan-Meier Survival Curves of 1-year Outcomes: A) All Hospitalizations; B) IBD-Related Hospitalizations; C) IBD-Specific Hospitalizations; and, D) Any Infection.

Dashed Line

Cortiment Cohort

Solid Line

Prednisone/Prednisolone Cohort

Funding Agencies

Ferring Pharmaceuticals

A172 THE ASSOCIATION OF EFFICACY, OPTIMISM, UNCERTAINTY AND HEALTH ANXIETY IN INFLAMMATORY BOWEL DISEASE ACTIVITY OVER TIME

Aims

We aimed to assess if the presence of positive or negative psychological attributes are associated with disease activity in a prospective inflammatory bowel disease (IBD) cohort using validated psychological assessment tools and various measures of disease activity.

Methods

The study included 146 adults with confirmed and recently active IBD enrolled in a prospective longitudinal cohort study. Demographics, disease information, validated measures of psychological functioning related to self-efficacy, optimism, health anxiety and intolerance of uncertainty were collected at baseline, week 26 and week 52. Disease activity indicators included fecal calprotection (FCAL), the Inflammatory Bowel Disease Symptom Inventory (IBDSI), and self-reported flares and were collected at study baseline, week 26 and week 52. Logistic regression was used to identify the relationship between psychological functioning and disease activity.

Results

Participants’ mean age was 42.9 years (SD 12.6; range 18–70), with 70.5% women. Almost two thirds (65.1%) had a diagnosis of Crohn’s disease (CD), 34.2% had ulcerative colitis (UC), and 0.7% (n=1) was IBD unclassified. 22% had income &lt;$50,000 and 63% were in a current relationship. Patient-reported active disease (i.e., IBDSI; flare self-report) was significantly less likely with higher self-efficacy [OR= 0.87, 95% CI 0.82–0.93 (IBDSI); OR= 0.86, 95% CI 0.81–0.91 (self-report)] and significantly more likely with higher health anxiety (OR=1.09, 95% CI 1.04–1.15) with the association remaining for self-reported flares after adjusting for demographic variables. The psychological attributes were not associated with active disease based on FCAL levels.

Conclusions

Higher health anxiety increases the likelihood of experiencing an IBD flare, while higher general self-efficacy may be protective of a disease flare.

Funding Agencies

None

A155 REAL-WORLD USE OF CORTIMENT IN ULCERATIVE COLITIS: A POPULATION-BASED STUDY

Background

Ulcerative colitis (UC) is a relapsing and remitting disease with variable severity. BudesonideMMX (Cortiment®) was approved by Health Canada for the treatment of mild to moderate UC in July 2016. It offers the advantage of extensive first pass hepatic metabolism resulting in decreased systemic corticosteroid toxicity. Most public drug plans in Canada do not cover it, limiting its use to private insurance and self-pay.

Aims

To characterize the UC patients who use Cortiment® and explore prescribing patterns and short-term outcomes.

Methods

Population-based administrative data identified patients who were covered by the Alberta Health Care Insurance Plan and dispensed Cortiment® from August 1, 2016 to December 31, 2017. Analyses identified: age, sex, rural/urban status, Material [MDI] and Social Deprivation Indices [SDI], UC-related medications 6-months before and 10-weeks following Cortiment® dispensing, and disease exacerbation indicators (new dispense of corticosteroids, hospitalization with inflammatory bowel disease (IBD) as most responsible diagnosis, or IBD-related surgery).

Results

We identified 427 UC patients dispensed Cortiment®. The median age was 47 years (25th %: 35; 75th %: 59) and 57.4% were females. Most individuals (91.3%, n=390) resided in an urban setting, as compared to approximately 73% of all UC cases. Distribution of patients across SDI was consistent while the MDI had a higher proportion in the more well-off categories. 77.5% had a UC-related drug therapy in the 6 months prior to Cortiment® dispensing and 71.7% had a UC-related drug dispensed in the 10-weeks following. Approximately, 30% had a disease exacerbation indicators in the 10 weeks following dispensing: 24.8% new corticosteroid, 3.7% UC-related hospitalization, and &lt;2.3% UC-related surgery.

Conclusions

Despite lack of public drug coverage, Cortiment® was dispensed across socioeconomic classes. The high dispensing within urban sites suggests that rural UC patients may have less access to Cortiment®. While a quarter of Cortiment® dispensings had a new concurrent dispensing of prednisone, &lt;5% of these patients were admitted to hospital for a flare of UC.

Funding Agencies

Ferring Pharmaceuticals

A224 THE MANITOBA LIVING WITH IBD STUDY: MEDICATION ADHERENCE AND MARS-5 VALIDATION

Background

Medication non-adherence in IBD has previously been reported to be quite variable, ranging from 7 to 73%, and is considered to be an important contributor to disease flares. While there is currently no gold standard for medication adherence reporting in IBD, the Medication Adherence Reporting Scale 5 (MARS-5) has frequently been used in this population, but never validated.

Aims

This study aimed to analyze medication adherence rates in a cohort of persons with IBD in Manitoba, report predictors of medication non-adherence on self-reported symptoms, and validate the MARS-5 as a medication adherence tool.

Methods

55 subjects were prospectively followed with biweekly online surveys in the Manitoba Living with IBD Study. Subjects not taking any medications for IBD or only taking as needed, missing adherence data and those lost to follow-up were excluded, leaving 112 subjects. Descriptive data on demographics, surgeries, IBD medications, medication adherence, and measures of disease activity utilizing IBDSI-SF scores were collected. Mean annual medication adherence percentage, IBDSI-SF(&gt;14=active for Crohn’s,&gt;13=active for UC) and MARS-5 scores were calculated. Logistic regression analysis was performed to determine variables associated with medication adherence and to validate the MARS-5.

Results

Mean age was 42.9 years (SD 12.8), with 71.4% being female. Crohn’s disease (CD) was diagnosed in 67.9%, with 37.5% having undergone at least one abdominal surgery. 70.5% of patients were on 2 or more IBD medications. Mean IBDSI score was 15.5 and mean MARS-5 score was 22.5. 20 (17.9%) patients reported a mean adherence of &lt;90% across all medications- 18 were oral medication users, 1 was on an infusion biologic and 1 on subcutaneous adalimumab. 10 (9.8%) had adherence &lt;80%, all of which were to oral medications. Multivariate regression analysis revealed only a diagnosis of Crohn’s disease (OR 4.62; 95% CI 1.37–15.7; p=0.014) to be a predictor of adherence. Disease activity as defined by IBDSI (OR 0.43, 95% CI 0.13–1.45; p=0.139) and fecal calprotectin &gt;250ug/L (OR 1.04, 95% CI 0.35–3.11; p=0.724), age &gt;55 (OR 2.37, 95% CI 0.65–8.65; p=0.476), female sex (OR 0.38, 95% CI 0.097–1.52; p=0.150) and stress (OR 0.67, 95% CI 0.19–2.32; p=0.498) were not shown to be predictors. MARS-5 was compared to percentage adherence, showing moderate correlation (Pearson r=0.46). Logistic regression analysis showed each additional MARS-5 point was associated with a 1.7 times greater odds of &gt;90% adherence.

Conclusions

We report a highly adherent Manitoba IBD cohort. A diagnosis of CD was the only predicitor of adherence. MARS-5 showed moderate correlation with mean percentage adherence values, suggesting it is a valid assessment tool for determining medication adherence in an IBD population.

Funding Agencies

None

Independent Validation of a Self-Report Version of the IBD Disability Index (IBDDI) in a Population-Based Cohort of IBD Patients

INTRODUCTION

A new clinician-administered inflammatory bowel disease (IBD) Disability Index (IBDDI) was recently developed and validated among a population in France. We aimed to validate the IBDDI in a North American setting and adapt for use as a self-report tool.

METHODS

Persons 18-65 years old from the population-based University of Manitoba IBD Research Registry were mailed a self-administered survey. This survey included the IBDDI and several scales that should correlate with a disability measure- the World Health Organization (WHO) Disability Assessment Scale (WHODAS) 2.0, Work and Social Adjustment Scale (WSAS), the Inflammatory Bowel Disease Questionnaire (IBDQ), and the K6-Kessler Emotional Distress Scale. We used Pearson correlation coefficients to assess construct validity, Cronbach's alpha to assess internal consistency, and Factor analysis to assess which of the IBDDI items likely belonged to a single IBD-related disability factor.

RESULTS

In response to the survey request,1143 (46% of those contacted) participated (61% female, mean age 51, 52% with Crohn's disease). On an index scale from 0-100, 14% had a score ≥50 (extreme disability, 18% of those with Crohn's disease; 10% of those with ulcerative colitis). There were strong correlations between IBDDI and WSAS (0.76), WHODAS (0.76), K6 (0.73), and an inverse correlation with IBDQ (-0.86). The Cronbach's alpha was high (0.88). All but 2 items (number of liquid stools in the past week and arthritis/arthralgia) of the 14 identified for IBDDI loaded highly onto a single factor (factor loading > 0.40).

CONCLUSIONS

The findings support the validity of this new self-report version of the IBDDI as a sound measure of disability in IBD.

A comparison of the gut microbiome between long-term users and non-users of proton pump inhibitors

BACKGROUND

Proton pump inhibitor (PPI) use is associated with an increased risk of Clostridium difficile infection (CDI), though the mechanism is unclear. PPI induced alterations to the gut microbiome may facilitate the emergence of CDI, though the effects of PPIs on gut microbiota are not well characterised. [Correction added on 10 March 2016, after first online publication: microflora has been changed to microbiota throughout the article.]

AIM

To compare the faecal microbiomes of long-term PPI users to those with no history of PPI use.

METHODS

We used a population-based database to identify individuals with ≥5 years of continuous PPI use along with non-PPI using controls. Stool samples were subjected to microbiological analysis, with hierarchical clustering at genus level, along with alpha and beta diversity measures comparing the two groups. Metadata was accounted for using quantile regression to eliminate potential confounding variables in taxonomic abundance comparisons.

RESULTS

Sixty-one subjects (32 PPI, 29 controls) were analysed. While no significant differences in alpha diversity were found between the PPI users and controls, a moderate shift of the PPI users away from the non-PPI user cluster in the beta diversity was observed. After controlling for pertinent confounders, we discovered a decrease in Bacteroidetes and an increase in Firmicutes at the phylum level. We also performed species classifications and found Holdemania filiformis and Pseudoflavonifractor capillosus to be increased and decreased in the PPI cohort, respectively.

CONCLUSIONS

Long-term PPIs use has an effect on the gut microbiome. The alteration in the ratio of Firmicutes to Bacteroidetes may pre-dispose to the development of CDI.

Predicting complicated Crohn's disease and surgery: phenotypes, genetics, serology and psychological characteristics of a population-based cohort

BACKGROUND

Predictors of complicated Crohn's disease (CD), defined as stricturing or penetrating behaviour, and surgery have largely been derived from referral centre populations.

AIM

To investigate whether serological markers, susceptibility genes or psychological characteristics are associated with complicated CD or surgery in a population-based cohort.

METHODS

One hundred and eighty-two members of the Manitoba IBD Cohort with CD phenotyped using the Montreal classification underwent genetic and serological analysis at enrolment and after 5 years. One hundred and twenty-seven had paired sera at baseline and 5 years later and their data were used to predict outcomes at a median of 9.3 years. Serological analysis consisted of a seven antibody panel, and DNA was tested for CD-associated NOD2 variants (rs2066845,rs2076756,rs2066847), ATG16L1 (rs3828309, rs2241880) and IL23R (rs11465804). Psychological characteristics were assessed using semi-structured interviews and validated survey measures.

RESULTS

Sixty-five per cent had complicated CD and 42% underwent surgery. Multivariate analysis indicated that only ASCA IgG-positive serology was predictive of stricturing/penetrating behaviour (OR = 3.01; 95% CI: 1.28-7.09; P = 0.01) and ileal CD (OR = 2.2; 95% CI: 1.07-4.54, P = 0.03). Complicated CD behaviour was strongly associated with surgery (OR = 5.6; 95% CI: 2.43-12.91; P < 0.0001), whereas in multivariate analysis, only ASCA IgG was associated (OR = 2.66; 95% CI, 1.40-5.06, P = 0.003). ASCA titre results were similar at baseline and follow-up. Psychological characteristics were not significantly associated with disease behaviour, serological profile or genotype.

CONCLUSIONS

ASCA IgG at baseline was significantly associated with stricturing/penetrating disease at 9-10 years from diagnosis. Stricturing/penetrating disease was significantly associated with surgery. In a model including serology, the genotypes assessed did not significantly associate with complicated disease or surgery.

The effect of proton pump inhibitors on fracture risk: report from the Canadian Multicenter Osteoporosis Study

A large Canadian cohort was studied over 10 years to see if proton pump inhibitor (PPI) use increased the risk of sustaining a fragility fracture. We found an increased risk of fracture in individuals who used PPIs. The risk remained after controlling for other known fracture risk factors.

INTRODUCTION

Multiple retrospective studies have linked proton pump inhibitor use with increased risk of fragility fracture. We prospectively studied the association between PPI use and fracture in a large cohort over a 10-year period while controlling for known fracture risk factors.

METHODS

We studied 9,423 participants in the Canadian Multicenter Osteoporosis Study. The cohort was formed in 1995-1997 and followed for 10 years with monitoring for incident nontraumatic fracture and PPI use. Cox regression analyses were used to assess the association between PPI use and incident fracture risk.

RESULTS

PPI use, coded as a time-dependent variable, was associated with a shorter time to first nontraumatic fracture, hazard ratio (HR)=1.75 (95% confidence interval (CI) 1.41-2.17, p<0.001). After controlling for multiple risk factors, including femoral neck bone density, the association remained significant, HR=1.40 (95% CI 1.11-1.77, p=0.004). Similar results were obtained after controlling for bisphosphonate use, using PPI "ever" use, or when the outcome was restricted to hip fracture.

CONCLUSIONS

In this large prospective population-based cohort study, we found an association between PPI use and increased risk of fragility fracture. Although the increased risk found was modest, this finding is important, given the high prevalence of PPI use and the excess morbidity and mortality associated with osteoporosis-related fractures.

Gastrointestinal symptoms before and during menses in women with IBD

BACKGROUND

It is believed that women with inflammatory bowel disease (IBD) have heightened symptoms around their menses. However, there is little information regarding normative changes and which symptoms emerge in relation to menses.

AIM

To determine the relationship between gastrointestinal and other symptoms and menses in a population-based cohort of women with IBD vs. healthy women.

METHODS

Women enrolled in the University of Manitoba IBD Research Registry who were between 18 and 65 years were mailed a survey. A control group of adult women were recruited through out-patient gynaecology clinics. Participants were asked to consider their menstrual periods in the recent several months and report on symptoms 1-5 days prior to and during the days of their menses.

RESULTS

There were 151 premenopausal women with Crohn's disease (CD), 87 with ulcerative colitis (UC) and 156 premenopausal controls. Mean age of menses onset was similar in all three cohorts and the percentage in each group with regular menstrual periods was similar. Premenstrually, abdominal pain was less commonly reported in UC (36.8%) than CD (51%, P = 0.034) and controls (57.6%, P = 0.002). Premenstrually, and during menses diarrhoea was more commonly reported in CD (47.7% and 59.6% respectively) than UC (26.4% P = 0.001 and 42.5%, P = 0.01 respectively) and controls (24.4%, P < 0.0001 and 28.2%, P < 0.0001 respectively). Premenstrually, women with CD (46%) vs. UC (26%) were more likely to report worsening of their IBD symptoms (P = 0.0007), but there was no difference between CD (47%) and UC (39%) for reporting worsening during menses (P = 0.24).

CONCLUSIONS

Compared to healthy women, women with IBD had similar symptom experiences premenstrually, except that those with CD were more likely to have increased diarrhoea premenstrually. During menses, women with CD or UC were more likely to experience diarrhoea than healthy controls.

Underutilization of gastroprotective strategies in aspirin users at increased risk of upper gastrointestinal complications

BACKGROUND

Aspirin use is with an increased risk of upper gastrointestinal complications (UGICs). Proton pump inhibitors (PPIs) decrease the risk of UGICs among aspirin users. The distribution of risk factors for UGIC and PPI utilization among aspirin users remains uncharacterized.

AIM

To determine the prevalence and predictors of PPI use in high-risk aspirin users.

METHODS

Using questionnaires and administrative records, we collected information on aspirin and PPI utilization and risk factors for UGICs from a stratified random sample of subjects with established cardiovascular disease. We calculated the proportion of aspirin users with UGIC risk factors and determined the prevalence of PPI use among aspirin users with risk factors. Regression analysis was used to determine predictors of PPI use among aspirin users.

RESULTS

Overall response rate was 35%, of whom 86% were regular aspirin users. Seventy-one per cent of aspirin users had at least one risk factor (in addition to cardiac disease) for the development of UGICs. Although a history of UGIC was predictive of PPI use, 44% of aspirin users with a prior history of UGICs did not receive a concomitant PPI, and only 23% of subjects with additional UGIC risk factors were prescribed a PPI.

CONCLUSION

There is a high prevalence of UGIC risk factors among aspirin users, and many are not prescribed PPIs as a gastroprotective strategy.

Differences in the management of Crohn's disease among experts and community providers, based on a national survey of sample case vignettes

BACKGROUND

When faced with the same set of facts, healthcare providers often make different diagnoses, employ different tests and prescribe disparate therapies.

AIM

To perform a national survey to measure process of care and variations in decision-making in Crohn's disease, and the compared results between experts and community providers.

METHODS

We constructed a survey with five vignettes to elicit provider beliefs regarding the appropriateness of diagnostic tests and therapies in Crohn's disease. We measured agreement between community gastroenterologists and Crohn's disease experts, and measured variation within each group using the RAND Disagreement Index (DI), which is a validated measure of provider variation.

RESULTS

We received 186 responses (42% response rate). Experts and community providers generally agreed on diagnostic testing decisions in Crohn's disease. However, there was a significant disagreement between groups for several decisions (use of 5-aminosalicylate in particular), and there was evidence of 'extreme variation' (defined as DI > 1.0) within groups across a range of decisions.

CONCLUSIONS

Although experts and community providers are in general consensus about diagnostic decision-making in Crohn's disease, extreme variation exists both between and within groups for key therapeutic decisions in Crohn's disease. We must understand and decrease this variation prior to future efforts of creating explicit quality indicators in Crohn's disease.

An assessment of endoscopic and concomitant management of acute variceal bleeding at a tertiary care centre

BACKGROUND

Several therapies have been demonstrated to be beneficial in the management of acute variceal bleeding (AVB). The aim of the present study was to characterize the use of these therapies at a Canadian tertiary care centre.

PATIENTS AND METHODS

A comprehensive chart review was performed to assess the management of all adult cirrhotic patients with AVB who were admitted to a university-affiliated, tertiary care centre between April 2001 and March 2004.

RESULTS

A total of 81 AVB patients were identified with a mean age of 53.7+/-13.2 years and a median model for end-stage liver disease score of 14. Endoscopy was performed within 8.2+/-7.6 h of admission. Variceal banding was performed for 87% of patients with esophageal varices, which were the most common source of bleeding (80%). Octreotide was used in 82% of patients for a mean duration of 74.3+/-35.4 h; prophylactic antibiotics were used in 25% of patients and beta-blockers were used in 24% of patients without any contraindications. Follow-up endoscopy was arranged for 46 of 71 (65%) survivors. Prophylactic antibiotic use was associated with the presence of ascites, while beta-blockers were used more often in the last year of the study.

CONCLUSIONS

There is a disconnection between the use of evidence-based recommendations and routine clinical practices in the management of AVB. Deficiencies identified include the lack of use of prophylactic antibiotics and beta-blockers, variable use of octreotide and inadequate follow-up recommendations. There is a need to identify measures to improve the process of care for patients with AVB which would ensure optimal management of these patients.

Pre-endoscopic proton pump inhibitor therapy reduces recurrent adverse gastrointestinal outcomes in patients with acute non-variceal upper gastrointestinal bleeding

BACKGROUND

Proton pump inhibitors (PPIs) following endoscopic haemostasis reduce rebleeding rates in patients with high-risk acute non-variceal upper gastrointestinal bleeding. Many advocate the use of PPIs prior to endoscopy, although its incremental benefit is unproven.

AIM

To determine if providing PPIs before endoscopy reduces adverse gastrointestinal outcomes in acute non-variceal upper gastrointestinal bleeding patients.

METHODS

We performed a retrospective review to identify patients presenting to two tertiary care centres with acute non-variceal upper gastrointestinal bleeding between 1999 and 2004. Subjects receiving PPI therapy before endoscopy were compared with those not receiving pre-endoscopic PPI therapy. The primary outcome measure was the development of any adverse bleeding outcome (rebleeding, surgery for control of bleeding, in-hospital mortality, readmission within 30 days for acute non-variceal upper gastrointestinal bleeding).

RESULTS

385 patients were included in our study [132 (12 intravenous/120 po) pre-endoscopic PPI vs. 253 no pre-endoscopic PPI]. Patients receiving pre-endoscopic PPI therapy were significantly less likely to develop adverse outcomes compared with those not given pre-endoscopic PPIs (25% vs. 13%, P = 0.005). Rebleeding, upper gastrointestinal surgery, mortality and length of hospital stay were also significantly lower in patients receiving pre-endoscopic PPI.

CONCLUSIONS

The use of PPIs before endoscopy significantly reduces the risk of developing adverse gastrointestinal outcomes in patients with acute non-variceal upper gastrointestinal bleeding. Future studies are required to better characterize this relationship.

Physicians' approaches to the use of gastroprotective strategies in low-risk non-steroidal anti-inflammatory drug users

BACKGROUND

Many doctors unnecessarily prescribe gastroprotective strategies to non-steroidal anti-inflammatory drugs users at low risk of non-steroidal anti-inflammatory drug-related gastrointestinal complications.

AIM

To identify factors that predict the overuse of gastroprotective strategies in low-risk non-steroidal anti-inflammatory drug users.

METHODS

We distributed a questionnaire to family doctors and general internists consisting of a clinical vignette describing a low-risk hypothetical patient with osteoarthritis who was a candidate for non-steroidal anti-inflammatory drug therapy. Respondents were asked whether they would prescribe this patient a gastroprotective strategy and to estimate the annual risk of that patient developing a gastrointestinal complication with non-steroidal anti-inflammatory drug use. Respondents inappropriately recommending a gastroprotective strategy were compared with respondents who opted not to use gastroprotection.

RESULTS

We received 340 responses (response rate of 28.3%), of which 278 supplied analysable data. Thirty-five percent of respondents inappropriately recommended a gastroprotective strategy for the low-risk subject. Inappropriate prescribers were significantly more likely to overestimate the risk of gastrointestinal complications with traditional non-steroidal anti-inflammatory drugs and this was strongly predictive of gastroprotective strategy recommendation in logistic regression.

CONCLUSIONS

Many doctors inappropriately recommend gastroprotective strategies in low-risk non-steroidal anti-inflammatory drug users. Improving doctors' awareness of non-steroidal anti-inflammatory drug-associated gastrointestinal risks may lead to a decrease in inappropriate utilization of gastroprotective strategies in low-risk patients.

The prevalence of risk factors for gastrointestinal complications and use of gastroprotection among persons hospitalized for cardiovascular disease

BACKGROUND

Aspirin is often used in patients with cardiovascular disease, but it can also cause gastrointestinal complications. Proton pump inhibitors reduce the risk of gastrointestinal complications in aspirin users with a history of gastrointestinal complications.

AIM

To determine the prevalence of gastrointestinal risk factors in aspirin users and the prevalence of proton pump inhibitor utilization in high-risk patients.

METHODS

We reviewed all patients admitted to hospital between April and October 2004 with a diagnosis of cardiovascular disease. We collected data on demographics, medication use, comorbid illnesses, previous gastrointestinal complications, and medication use on admission and discharge.

RESULTS

A total of 324 patients were admitted with cardiovascular disease of whom 94% were discharged on aspirin. Seventy-eight per cent of patients admitted had at least one gastrointestinal risk factor in addition to having cardiovascular disease, and 15% had three or more additional gastrointestinal risk factors. Patients with additional gastrointestinal risk factors were more likely to be prescribed proton pump inhibitor therapy (27% vs. 10%, P < 0.001). Only 10% of proton pump inhibitor-naíve high-risk aspirin users were prescribed a proton pump inhibitor upon discharge.

CONCLUSIONS

The majority of high-risk aspirin users are not receiving proton pump inhibitors for gastroprotection. Further work is required to encourage providers to consider the use of gastroprotective strategies in appropriate patients.