Inequities in Rural and Urban Health Care Utilization Among Individuals Diagnosed With Inflammatory Bowel Disease: A Retrospective Population-Based Cohort Study From Saskatchewan, Canada.

Background: Rural dwellers with inflammatory bowel disease (IBD) face barriers to accessing specialized health services. We aimed to contrast health care utilization between rural and urban residents diagnosed with IBD in Saskatchewan, Canada. Methods: We completed a population-based retrospective study from 1998/1999 to 2017/2018 using administrative health databases. A validated algorithm was used to identify incident IBD cases aged 18+. Rural/urban residence was assigned at IBD diagnosis. Outpatient (gastroenterology visits, lower endoscopies, and IBD medications claims) and inpatient (IBD-specific and IBD-related hospitalizations, and surgeries for IBD) outcomes were measured after IBD diagnosis. Cox proportional hazard, negative binomial, and logistic models were used to evaluate associations adjusting by sex, age, neighbourhood income quintile, and disease type. Hazard ratios (HR), incidence rate ratios (IRR), odds ratios (OR), and 95% confidence intervals (95% CI) were reported. Results: From 5,173 incident IBD cases, 1,544 (29.8%) were living in rural Saskatchewan at IBD diagnosis. Compared to urban dwellers, rural residents had fewer gastroenterology visits (HR = 0.82, 95% CI: 0.77-0.88), were less likely to have a gastroenterologist as primary IBD care provider (OR = 0.60, 95% CI: 0.51-0.70), and had lower endoscopies rates (IRR = 0.92, 95% CI: 0.87-0.98) and more 5-aminosalicylic acid claims (HR = 1.10, 95% CI: 1.02-1.18). Rural residents had a higher risk and rates of IBD-specific (HR = 1.23, 95% CI: 1.13-1.34; IRR = 1.22, 95% CI: 1.09-1.37) and IBD-related (HR = 1.20, 95% CI: 1.11-1.31; IRR = 1.23, 95% CI: 1.10-1.37) hospitalizations than their urban counterparts. Conclusion: We identified rural-urban disparities in IBD health care utilization that reflect rural-urban inequities in the access to IBD care. These inequities require attention to promote health care innovation and equitable management of patients with IBD living in rural areas.

Canadian Consensus Statements on the Transition of Adolescents and Young Adults with Inflammatory Bowel Disease from Pediatric to Adult Care: A Collaborative Initiative Between the Canadian IBD Transition Network and Crohn's and Colitis Canada.

Objectives: With the increased prevalence of childhood-onset inflammatory bowel disease (IBD), there is a greater need for a planned transition process for adolescents and young adults (AYA). The Canadian IBD Transition Network and Crohn's and Colitis Canada joined in collaborative efforts to describe a set of care consensus statements to provide a framework for transitioning AYA from pediatric to adult care. Methods: Consensus statements were drafted after focus group meetings and literature reviews. An expert panel consisting of 20 IBD physicians, nurses, surgeon, adolescent medicine physician, as well as patient and caregiver representatives met, discussed and systematically voted. The consensus was reached when greater than 75% of members voted in agreement. When greater than 75% of members rated strong support, the statement was rendered a strong recommendation, suggesting that a clinician should implement the statement for all or most of their clinical practice. Results: The Canadian expert panel generated 15 consensus statements (9 strong and 6 weak recommendations). Areas of focus of the statements included: transition program implementation, key stakeholders, areas of potential need and gaps in the research. Conclusions: These consensus statements provide a framework for the transition process. The quality of evidence for these statements was generally low, highlighting the need for further controlled studies to investigate and better define effective strategies for transition in pediatric to adult IBD care.

Increasing Prevalence and Direct Health Care Cost of Inflammatory Bowel Disease Among Adults: A Population-Based Study From a Western Canadian Province.

OBJECTIVES: Our study aimed to calculate the prevalence and estimate the direct health care costs of inflammatory bowel disease (IBD), and test if trends in the prevalence and direct health care costs of IBD increased over two decades in the province of Saskatchewan, Canada. METHODS: We conducted a retrospective population-based cohort study using administrative health data of Saskatchewan between 1999/2000 and 2016/2017 fiscal years. A validated case definition was used to identify prevalent IBD cases. Direct health care costs were estimated in 2013/2014 Canadian dollars. Generalized linear models with generalized estimating equations tested the trend. Annual prevalence rates and direct health care costs were estimated along with their 95% confidence intervals (95%CI). RESULTS: In 2016/2017, 6468 IBD cases were observed in our cohort; Crohn's disease: 3663 (56.6%), ulcerative colitis: 2805 (43.4%). The prevalence of IBD increased from 341/100,000 (95%CI 340 to 341) in 1999/2000 to 664/100,000 (95%CI 663 to 665) population in 2016/2017, resulting in a 3.3% (95%CI 2.4 to 4.3) average annual increase. The estimated average health care cost for each IBD patient increased from $1879 (95%CI 1686 to 2093) in 1999/2000 to $7185 (95%CI 6733 to 7668) in 2016/2017, corresponding to an average annual increase of 9.5% (95%CI 8.9 to 10.1). CONCLUSIONS: Our results provide relevant information and analysis on the burden of IBD in Saskatchewan. The evidence of the constant increasing prevalence and health care cost trends of IBD needs to be recognized by health care decision-makers to promote cost-effective health care policies at provincial and national levels and respond to the needs of patients living with IBD.

Population-Based Evidence From a Western Canadian Province of the Decreasing Incidence Rates and Trends of Inflammatory Bowel Disease Among Adults.

BACKGROUND AND AIMS: Canada has one of the highest inflammatory bowel disease (IBD) incidence rates worldwide. Higher IBD incidence rates have been identified among urban regions compared to rural regions. The study objectives were to (i) estimate IBD incidence rates in Saskatchewan from 1999 to 2016 and (ii) test for differences in IBD incidence rates for rural and urban regions of Saskatchewan. METHODS: A population-based study was conducted using provincial administrative health databases. Individuals aged 18+ years with newly diagnosed Crohn's disease or ulcerative colitis were identified using a validated case definition. Generalized linear models with a negative binomial distribution were used to estimate incidence rates and incidence rate ratios (IRRs) adjusted for age group, sex and rurality with 95% confidence intervals (CIs). RESULTS: The average annual incidence rate of IBD among adults in Saskatchewan decreased from 75/100,000 (95% CI 67 to 84) in 1999 to 15/100,000 (95% CI 12 to 18) population in 2016. The average annual incidence of IBD declined significantly by 6.9% (95% CI -7.6 to -6.2) per year. Urban residents had a greater overall risk of IBD (IRR = 1.19, 95% CI 1.11 to 1.27) than rural residents. This risk difference was statistically significant for Crohn's disease (IRR = 1.25, 95% CI 1.14 to 1.36), but not for ulcerative colitis (IRR = 1.08, 95% CI 0.97 to 1.19). CONCLUSIONS: The incidence of IBD in Saskatchewan dropped significantly from 1999 to 2016 with urban dwellers having a 19% higher risk of IBD onset compared to their rural counterparts. Health care providers and decision-makers should plan IBD-specific health care programs considering these specific IBD rates.

Patients' perspectives on medication for inflammatory bowel disease: a mixed-method systematic review.

Inflammatory bowel disease (IBD) is a lifelong chronic disease that frequently requires long-term medical treatment to maintain remission. Patient perspectives on IBD medication are important to understand as nonadherence to IBD medication is common. We aim to synthesize the evidence about patients' perspectives on medication for IBD. A mixed-method systematic review was conducted on Scopus, EMBASE, Web of Science, and CINAHL. The convergent integrated approach to synthesis and integration of qualitative and quantitative findings was used for data analysis. Twenty-five articles from 20 countries were included in this review (20 quantitative, 3 qualitative, and 2 mixed-method studies). Patients have identified a lack of knowledge in the areas of efficacy, side effects, and characteristics of medications as key elements. Some negative views on IBD medication may also be present (e.g. the high number of pills and potential side effects). Lack of knowledge about medication for IBD was identified as a common issue for patients. Health services delivery for IBD should take into consideration these patients' perspectives. A focus on improving patient education in these areas could help empower patients and alleviate doubts resulting in better disease management and improved healthcare outcomes.

Development of a screening tool to detect nutrition risk in patients with inflammatory bowel disease.

BACKGROUND AND OBJECTIVES: Malnutrition is a known complication of Inflammatory Bowel Disease (IBD). We assessed a known screening tool, as well as developed and validated a novel screening tool, to detect nutrition risk in outpatients with IBD. METHODS AND STUDY DESIGN: The Saskatchewan IBD-Nutrition Risk (SaskIBD-NR Tool) was developed and administered alongside the Malnutrition Universal Screening Tool (MUST). Nutrition risk was confirmed by the IBD dietitian (RD) and gastroenterologist (GI). Agreement between screening tools and RD/GI assessment was computed using Cohen's kappa. RESULTS: Of the 110 patients screened, 75 (68.2%) patients had Crohn's Disease and 35 (31.8%) ulcerative colitis. Mean BMI was 26.4 kg/m2 (SD=5.8). RD/GI assessment identified 23 patients (20.9%) at nutrition risk. The SaskIBD-NR tool classified 21 (19.1%) at some nutrition risk, while MUST classified 17 (15.5%). The SaskIBD-NR tool had significant agreement with the RD/GI assessment (k 0.83, p<0.001), while MUST showed a lack of agreement (k 0.15, p=0.12). The SaskIBD-NR had better sensitivity (82.6% vs 26.1%), specificity (97.7% vs 87.4%), positive predictive value (90.5% vs 35.3%), and negative predictive value (95.5% vs 81.7%) than the MUST. CONCLUSION: The SaskIBD-NR, which assesses GI symptoms, food restriction, and weight loss, adequately detects nutrition risk in IBD patients. Broader validation is required.

Biomarker-Based Models Outperform Patient-Reported Scores in Predicting Endoscopic Inflammatory Disease Activity.

Background: The Crohn's Disease Activity Index (CDAI), a scoring index including patient-reported outcomes (PROs), has known limitations for measuring intestinal inflammatory disease burden. Noninvasive markers of inflammation could prove more accurate than PROs; thus, regulatory authorities are exploring the use of PROs and endoscopic data as coprimary end points in clinical trials. The aim of this study was to assess the predictive ability of individual components of the CDAI, along with biomarker concentrations, to create models for predicting endoscopic disease activity. Methods: Between 2004 and 2006, 164 patients with established Crohn's disease (CD) undergoing clinically indicated ileocolonoscopy were recruited. Individual CDAI variables and fecal calprotectin (FC) were selected to explore their predictive accuracy for endoscopic disease activity, with the Simple Endoscopic Score-Crohn's Disease (SES-CD) as the outcome variable. Simple Poisson regression was performed on each variable, and 2 multivariate models were created (PRO-exclusive and PRO+FC [PRO+]). Additional analyses explored the patient-level agreement between models. Results: Number of liquid stools, abdominal pain, hematocrit (Hct), FC, and high-sensitivity C-reactive protein (hsCRP) correlated significantly with the SES-CD. For the prediction of SES-CD (>7 vs ≤6), the area under the curve (AUC) was 0.81, with 63% and 88% sensitivity and specificity, for the PRO+ model, compared with a 0.56 AUC, with 61% and 55%, respectively, for the PRO model. Intra-individual comparison revealed the PRO+ model to be superior in the prediction of endoscopically active disease. Conclusions: The inclusion of biomarkers significantly improved predictive accuracy for endoscopic disease activity compared with PRO-exclusive models.

Impact of an Integrated Model of Care on Outcomes of Patients With Inflammatory Bowel Diseases: Evidence From a Population-Based Study.

BACKGROUND AND AIMS: Studies evaluating the impact of integrated models of care [IMC] for inflammatory bowel disease [IBD] on disease-related outcomes are needed. We compared the risk of IBD-related outcomes and prescription medication claims between patients exposed and non-exposed to an IMC. METHODS: A retrospective population-based matched cohort study was conducted between 2009 and 2015, using administrative health data of Saskatchewan, Canada. Patients aged 18+ years with a diagnosis of IBD were identified with a validated administrative definition. Cases were classified as exposed and non-exposed to the IMC for IBD and matched based on propensity scores and disease duration. IBD-related hospitalisations, surgeries, prescription medication claims, and corticosteroid dependency [CsDep] were measured. Cox and logistic regression models evaluated differences between the groups, estimating hazard [HRs] and odds [ORs] ratios with corresponding confidence intervals [CIs]. RESULTS: In total, 2312 matched patients were included; 24.3% were exposed individuals. Compared with non-exposed, exposed patients had a lower risk of IBD-related surgeries [HR = 0.78, 95% CI 0.61-0.99], higher risk of prescriptions of immune modulators [HR = 1.68, 95% CI 1.42-1.99], and biologics [HR = 1.85, 95% CI 1.52-2.27], and a lower risk of 5-aminosalicylic acid prescriptions [HR = 0.81, 95% CI 0.69-0.95]. A lower risk of IBD-related hospitalisations among exposed ulcerative colitis [UC] patients [HR = 0.66, 95% CI 0.49-0.89] was identified in stratified analyses. The odds of CsDep among exposed UC patients was 0.39 [95% CI 0.15-0.98]. CONCLUSIONS: The observed differences in disease-related outcomes and use of steroid-sparing maintenance therapies between exposed and non-exposed individuals support the concept that enhanced quality of care can be achieved within IMC for IBD.

SMAD3 gene variant is a risk factor for recurrent surgery in patients with Crohn's disease.

BACKGROUND AND AIMS: More than 80% of Crohn's disease (CD) patients will require surgery. Surgery is not curative and rates of re-operation are high. Identification of genetic variants associated with repeat surgery would allow risk stratification of patients who may benefit from early aggressive therapy and/or post-operative prophylactic treatment. METHODS: CD patients who had at least one CD-related bowel resection were identified from the Prospective Registry in IBD Study at Massachusetts General Hospital (PRISM). The primary outcome was surgical recurrence. Covariates and potential interactions were assessed using the Cox proportional hazard model. Kaplan-Meier curves for time to surgical recurrence were developed for each genetic variant and analyzed with the log-rank test. RESULTS: 194 patients were identified who had at least 1 resection. Of these, 69 had two or more resections. Clinical predictors for repeat surgery were stricturing (HR 4.18, p=0.022) and penetrating behavior (HR 3.97, p=0.024). Smoking cessation was protective for repeat surgery (HR 0.45, p=0.018). SMAD3 homozygosity for the risk allele was also independently associated with increased risk of repeat surgery (HR 4.04, p=0.001). NOD2 was not associated with increased risk of surgical recurrence. CONCLUSION: Stricturing and penetrating behavior were associated with increased risk of surgical recurrence, while smoking cessation was associated with a decreased risk. A novel association between SMAD3 and increased risk of repeat operation and shorter time to repeat surgery was observed. This finding is of particular interest as SMAD3 may represent a new therapeutic target specifically for prevention of post-surgical disease recurrence.

Efficacy and safety of natalizumab in Crohn's disease patients treated at 6 Boston academic hospitals.

BACKGROUND: Despite trials demonstrating its efficacy, many physicians harbor concerns regarding the use of natalizumab in the treatment of patients with refractory Crohn's disease (CD). The purpose of this study was to perform a descriptive analysis of a series of CD patients not currently enrolled in a clinical trial. METHODS: A retrospective case review of patients treated with natalizumab at 6 sites in Massachusetts: Boston Medical Center, Beth Israel Deaconess Medical Center, Brigham & Women's Hospital, Lahey Clinic, Massachusetts General Hospital, and UMass Medical Center. RESULTS: Data on 69 CD patients on natalizumab were collected. At the start of treatment, patients' disease duration was 12 years. A high proportion of patients were women (68%), presented with perianal disease (65%) and upper gastrointestinal tract involvement (14%). Prior nonbiologic therapies were steroids (96%), thiopurines (94%), antibiotics (74%), methotrexate (58%), and at least two anti-tumor necrosis factor agent failures (81%). Sixty-nine percent (44 of 64 patients) with available medical evaluation had a partial or complete clinical response. Loss of response was 13% after an average of 1 year of treatment. Adverse events were infusion reactions, headaches, fever, and infections. No case of progressive multifocal leukoencephalopathy was observed. CONCLUSIONS: In our clinical experience outside the context of a clinical trial, natalizumab is largely reserved for CD patients with extensive ileocolonic disease who have failed conventional immunosuppressants and of at least 2 anti-tumor necrosis factor agents. This drug is, however, well tolerated and offers significant clinical improvement for more than a year in one-third of these difficult-to-treat CD patients.

Effects of cancer treatment on inflammatory bowel disease remission and reactivation.

BACKGROUND & AIMS: Little is known about the effects of cancer therapy for extraintestinal malignancy in patients with inflammatory bowel diseases (IBDs). METHODS: We analyzed data from the Massachusetts General Hospital and the Brigham and Women's Hospital on 84 patients diagnosed with Crohn's disease, ulcerative colitis, or indeterminate colitis found to have a solid malignant extraintestinal neoplasm between January 15, 1993, and December 15, 2011. We investigated the incidence of remission with cancer treatment (cytotoxic chemotherapy, hormone therapy, or both) among patients with active IBD (n = 15) and time to disease activation after cancer treatment of those with inactive disease (n = 69). Cox proportional hazards models and survival curves were constructed to identify independent predictors of these outcomes. RESULTS: Among patients with active IBD at cancer diagnosis, 66.7% (n = 10/15) achieved remission during cancer treatment; the median duration of remission was 27 months. Ninety percent of these patients had received cytotoxic chemotherapy. For patients with IBD in remission at cancer diagnosis, 17.4% (n = 12/69) developed active IBD; the type of treatment was the strongest predictor of IBD reactivation. The risk of IBD reactivation was greatest among patients who received a combination of cytotoxic chemotherapy and adjuvant hormone therapy (hazard ratio, 12.25; 95% confidence interval, 1.51-99.06) or only hormone therapy (hazard ratio, 11.56; 95% confidence interval, 1.39-96.43). Ninety percent of patients who received cytotoxic chemotherapy remained in remission at 5 years compared with 64% of those who received only hormone therapy or the combination of cytotoxic chemotherapy and adjuvant hormone therapy (log rank, P = .02). CONCLUSIONS: IBD is more likely to remit among patients who receive cytotoxic chemotherapy for solid malignancies than those who receive only hormone therapy or the combination of cytotoxic chemotherapy and adjuvant hormone therapy. Among patients with inactive IBD at the time of cancer diagnosis, hormonal therapy, alone or in combination with cytotoxic chemotherapy, increases the risk of IBD reactivation.

Endoscopist-administered propofol: a retrospective safety study.

BACKGROUND: Propofol is an anesthetic agent that is commonly used for conscious sedation. Propofol has advantages as a sedative agent for endoscopic procedures including rapid onset, short half-life and rapid recovery time. However, concerns exist regarding the potential for respiratory depression, hypotension, perforation due to deep sedation and the need for monitoring by an anesthetist. Propofol has been used under endoscopist supervision at the Stanton Territorial Hospital in Yellowknife, Northwest Territories since 1996 (approximately 7000 cases). METHODS: A retrospective chart review of endoscopic procedures conducted at the Stanton Territorial Hospital between January 1996 and May 2007 was performed. A random sample of 680 procedures was reviewed from a total of 6396 procedures. RESULTS: The mean (+/- SD) baseline systolic blood pressure (SBP) was 122.8+/-17.0 mmHg. The mean lowest SBP was 101.7+/-14.5 mmHg. The mean absolute drop in SBP was 21.1+/-16.7 mmHg, with a mean per cent drop of 16.3%+/-11.7%. Eighty-eight patients (12.9%) developed transient hypotension (SBP lower than 90 mmHg). All patients regained normal blood pressure spontaneously on repeated measurement. No patients required intravenous fluid resuscitation. The mean O2 saturation was 96.4%+/-2.1%. One patient (0.1%) transiently desaturated (O2 saturation 89%), but recovered spontaneously on repeat measurement with no intervention. No procedures were aborted for patient safety. There were no major complications, including perforation or death. There was one mucosal tear during nontherapeutic colonoscopy (0.1%). CONCLUSIONS: Propofol can be safely administered in a community hospital setting under endoscopist supervision, with no additional support or monitoring.