Disparities in Enrollment in Medicare Advantage Plans With Dental Benefits.

This cross-sectional study evaluates the association of Medicare beneficiaries' sociodemographic characteristics with having Medicare Advantage plans that cover oral health services.

Substance Use Among Patients With Incident Crohn's Disease in the United States, 2010 to 2019: A Medicaid Observational Study.

BACKGROUND AND AIMS: Substance use among persons with Crohn's disease (CD) is associated with symptomatic exacerbation and poorer quality of life. However, data on the prevalence of substance use among individuals with CD are limited. Therefore, our study aimed to estimate the burden of alcohol and drug use among individuals with incident CD in the United States. We also assessed the associations between CD-related interventions and substance use after CD diagnosis. METHODS: Our retrospective cohort study of the national Medicaid databases from 2010 to 2019 identified participants with newly diagnosed CD and defined substance use (ie, alcohol, opioids, cocaine, amphetamine, and cannabis) using diagnosis codes. Multivariable logistic regression models assessed the associations between CD-related interventions and substance use after CD diagnosis. RESULTS: Overall, 16.3% of Medicaid enrollees with incident CD had substance ever-use, most commonly alcohol or opioids (each 8.0%). Any substance use saw an absolute decrease of 3.8% after CD diagnosis, but changes were less than 1% in either direction for each substance. CD-related hospitalization was associated with increased alcohol or opioid use post-CD diagnosis. Surgery was associated with lower use post-CD of opioids but not alcohol. CD medications (except steroids) were generally associated with decreased post-CD alcohol or opioid use. CONCLUSION: Among Medicaid enrollees with incident CD, alcohol and opioid use were more frequent than previously published estimates for the general US population (6% and 4%, respectively, in 2019). Consequently, medical communities must be more aware of substance use by patients with CD to provide quality patient-centered care.

Claims analysis of Medicare fee-for-service oral health care encounters, from 2019 through 2021.

BACKGROUND: Many qualifying people rely on Medicare fee-for-service (FFS) for their health care insurance, although it rarely provides coverage for oral health care services. The objective of this study was to gain insights into oral health care that is being provided by all health care provider types for Medicare FFS beneficiaries. METHODS: The authors used the Centers for Medicare & Medicaid Services Virtual Data Research Center to query 100% of Medicare FFS claims from 2019 through 2021 and identify all encounters for which there was either an oral health-related International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code or a CDT 2019-2021: Current Dental Terminology code recorded on the claim. The authors used a cross-sectional study design and calculated descriptive statistics to describe characteristics of identified oral health care encounters. The encounter level was the unit of analysis. RESULTS: A total of 2,098,056 oral health care encounters were identified through Medicare FFS claims during the study observation period, with a lower volume observed after 2019. Nearly 98% of encounters were related to those in which oral health diagnoses were recorded (International Classification of Diseases, Tenth Revision, Clinical Modification code on claim), and non-oral health care providers primarily submitted these claims. Most encounters included beneficiaries with chronic conditions, and a roughly equal proportion included those qualifying for Medicare on the basis of age and disability. CONCLUSIONS: Previously unreported characteristics of oral health care encounters were identified through administrative claims, providing insights into oral health care being provided to a subset of Medicare FFS beneficiaries. PRACTICAL IMPLICATIONS: Future research and policies should focus on strengthening medical-dental integration models and expanding access to oral health care for the Medicare FFS population.

Tobacco use in Crohn's disease patients and association with disease outcomes in the United States Medicaid population, 2010-2019.

Background and Aim: To identify demographic factors associated with tobacco use in Crohn's disease (CD) patients in the US Medicaid population and examine how tobacco use affects disease outcomes. Methods: We included Medicaid-eligible patients who had ≥1 ICD code for CD, and 1 year of eligibility before and after the initial encounter. We used ICD codes to identify tobacco use with respect to the time of diagnosis and used logistic regression to identify the association between age, sex, and race with tobacco use at any point before diagnosis and after diagnosis, and determine the association of tobacco use before and after diagnosis on disease outcomes. Results: We identified 98 176 eligible patients; 74.5% had no documented use of tobacco and 25.5% used tobacco at some point; 21.1% had used tobacco before their CD diagnosis and 11.8% had used tobacco after diagnosis. The population that used tobacco had a higher proportion of women, those who were White, non-Hispanic, and those in their middle ages (21-60) than the group that did not use tobacco. Tobacco use before diagnosis resulted in higher risk of hospitalization and surgery (OR: 1.85 and 1.36, respectively). Conclusion: Within the CD Medicaid population, tobacco use is more common in women than men, which differs from the general population, which is possibly a result of using diagnostic codes rather than survey data. Smoking cessation efforts should especially be directed at younger people who are at risk for CD, due to increased risk for more adverse outcomes among those who use tobacco before diagnosis.

Burden of Crohn's Disease in the United States Medicaid Population, 2010-2019.

BACKGROUND & AIMS: Twenty-five percent of the United States population is enrolled in Medicaid. Rates of Crohn's disease (CD) have not been estimated in the Medicaid population since the Affordable Care Act expansion in 2014. We aimed to estimate the incidence and prevalence of CD by age, sex, and race. METHODS: We identified all 2010-2019 Medicaid CD encounters using codes from the International Classification of Diseases, Clinical Modification versions 9 and 10. Individuals with ≥2 CD encounters were included. Sensitivity analyses were performed on other definitions (eg, ≥1 CD encounter). Incidence required ≥1 year of Medicaid eligibility prior to first CD encounter date (2013-2019). We calculated CD prevalence and incidence using the entire Medicaid population as the denominator. Rates were stratified by calendar year, age, sex, and race. Poisson regression models examined CD-associated demographic characteristics. We compared demographics and treatments of the entire Medicaid population with the multiple CD case definitions using percent and median. RESULTS: A total of 197,553 beneficiaries had ≥2 CD encounters. The CD point prevalence per 100,000 persons rose from 56 (2010) to 88 (2011) to 165 (2019). CD incidence per 100,000 person-years was 18 (2013) and 13 (2019). Higher incidence and prevalence rates correlated with female, white, or multiracial beneficiaries. Prevalence rates rose in later years. Incidence decreased over time. CONCLUSIONS: From 2010 to 2019, Medicaid population CD prevalence increased while incidence decreased from 2013 to 2019. Overall Medicaid CD incidence and prevalence ranges align with prior large administrative database studies.

The burden of gastrointestinal diseases in Japan, 1990-2019, and projections for 2035.

Background and Aim: Disease burden estimation allows clinicians and policymakers to plan for future healthcare needs. Although advances have been made in gastroenterology, as Japan has an aging population, disease burden assessment is important. We aimed to report gastrointestinal disease burden in Japan since 1990 and project changes through to 2035. Methods: This descriptive study examined the crude and age-standardized rates of prevalence, mortality, and disability-adjusted life years (DALYs) of 22 gastrointestinal diseases between 1990 and 2019. We used data from the Global Burden of Disease study 2019. We calculated the expected disease burden of gastrointestinal diseases by 2035 using an autoregressive integrated moving average. Results: Since 1990, cancer has accounted for most gastrointestinal disease-related causes of mortality and DALYs in Japan (77.1% and 71.2% in 1990, 79.2% and 73.7% in 2019, respectively). Although cancer-associated age-standardized mortality rates and DALYs have shown a decreasing trend, the crude rates have increased, suggesting that an aging society has a significant impact on the disease burden in Japan. Therefore, the overall gastrointestinal disease burden is expected to increase by 2035. Noncancerous chronic diseases with a high burden included cirrhosis, biliary disease, ileus, gastroesophageal reflux disorder, hernia, inflammatory bowel disease, enteric infections, and vascular intestinal disorders. In cirrhosis, the DALYs for hepatitis C decreased and the prevalence of non-alcoholic steatohepatitis increased. Conclusion: In the super-aging Japanese society, the burden of gastrointestinal diseases is expected to increase in the coming years. Colorectal, gastric, pancreatic, and liver cancers are the focus of early detection and treatment.

Human-Centered Design of a Clinical Decision Support for Anemia Screening in Children with Inflammatory Bowel Disease.

BACKGROUND: Inflammatory bowel disease (IBD) commonly leads to iron deficiency anemia (IDA). Rates of screening and treatment of IDA are often low. A clinical decision support system (CDSS) embedded in an electronic health record could improve adherence to evidence-based care. Rates of CDSS adoption are often low due to poor usability and fit with work processes. One solution is to use human-centered design (HCD), which designs CDSS based on identified user needs and context of use and evaluates prototypes for usefulness and usability. OBJECTIVES: this study aimed to use HCD to design a CDSS tool called the IBD Anemia Diagnosis Tool, IADx. METHODS: Interviews with IBD practitioners informed creation of a process map of anemia care that was used by an interdisciplinary team that used HCD principles to create a prototype CDSS. The prototype was iteratively tested with "Think Aloud" usability evaluation with clinicians as well as semi-structured interviews, a survey, and observations. Feedback was coded and informed redesign. RESULTS: Process mapping showed that IADx should function at in-person encounters and asynchronous laboratory review. Clinicians desired full automation of clinical information acquisition such as laboratory trends and analysis such as calculation of iron deficit, less automation of clinical decision selection such as laboratory ordering, and no automation of action implementation such as signing medication orders. Providers preferred an interruptive alert over a noninterruptive reminder. CONCLUSION: Providers preferred an interruptive alert, perhaps due to the low likelihood of noticing a noninterruptive advisory. High levels of desire for automation of information acquisition and analysis with less automation of decision selection and action may be generalizable to other CDSSs designed for chronic disease management. This underlines the ways in which CDSSs have the potential to augment rather than replace provider cognitive work.

A Systematic Review of Crohn's Disease Case Definitions in Administrative or Claims Databases.

BACKGROUND: We sought to review Crohn's disease (CD) case definitions that use diagnosis, procedure, and medication claims. METHODS: We searched PubMed and Embase from inception through January 31, 2022, using terms related to CD, inflammatory bowel disease, administrative claims, or validity. Each article was scrutinized by 2 authors independently screening and abstracting data. Collected data included participant characteristics, case definition characteristics, and case definition validity. When diagnostic accuracy was provided for multiple case definitions, we extracted the case definition selected by the authors. All diagnostic accuracy characteristics were captured. RESULTS: We identified 30 studies that evaluated a case definition using claims data to identify CD patients. The most common case definition included counts of diagnosis codes (57%) followed by a combination of diagnosis codes and medications (20%). All but 1 study validated the case definition with a medical chart review. In 2 studies, the patient's primary care provider completed a survey to confirm disease status. The positive predictive value of the case definitions ranged from 18% (≥1 code at a single U.S. health plan) to 100% (≥1 code plus a relevant prescription at a U.S. hospital). More complex case definitions (eg, ≥1 code + prescription or ≥2 codes) had lower variability in positive predictive value (≥80%) and specificity (≥85%) than the ≥1 code requirement. CONCLUSIONS: Health services researchers should validate case definitions in their research cohorts. When such validation cannot be performed, we recommend using a more complex case definition. Studies without a validated CD case definition should use sensitivity analyses to confirm the robustness of their results.

This systematic review of Crohn's disease (CD) case definitions identified that complex case definitions such as ≥1 diagnosis code + ≥1 prescription had desirable diagnostic accuracy properties.

Factors Associated With Overuse of Health Care Within US Health Systems: A Cross-sectional Analysis of Medicare Beneficiaries From 2016 to 2018.

Importance: Overuse of health care is a pervasive threat to patients that requires measurement to inform the development of interventions. Objective: To measure low-value health care use within health systems in the US and explore features of the health systems associated with low-value care delivery. Design Setting and Participants: In this cross-sectional analysis, we identified occurrences of 17 low-value services in 3745 hospitals and affiliated outpatient sites. Hospitals were linked to 676 health systems in the US using the Agency for Healthcare Research and Quality (AHRQ) Compendium of Health Systems. The participants were 100% of Medicare beneficiaries with claims from 2016 to 2018. Exposures: We identified occurrences of 17 low-value services in 3839 hospitals and affiliated outpatient sites. Main Outcomes and Measures: Hospitals were linked to health systems using AHRQ's Compendium of Health Systems. Between March and August 2021, we modeled overuse occurrences with a negative binomial regression model including the year-quarter, procedure indicator, and a health system indicator. The model included random effects for hospital and beneficiary age, sex, and comorbidity count specific to each indicator, hospital, and quarter. The beta coefficients associated with the health system term, normalized, reflect the tendency of that system to use low-value services relative to all other systems. With ordinary least squares regression, we explored health system characteristics associated with the Overuse Index (OI), expressed as a standard deviation where the mean across all health systems is 0. Results: There were 676 unique health systems assessed in our study that included from 1 to 163 hospitals (median of 2). The mean age of eligible beneficiaries was 75.5 years and 76% were women. Relative to the lowest tertile, health systems in the upper tertile of medical groups count and bed count had an OI that was higher by 0.38 standard deviations (SD) and 0.44 SD, respectively. Health systems that were primarily investor owned had an OI that was 0.56 SD higher than those that were not investor owned. Relative to the lowest tertile, health systems in the upper tertile of primary care physicians, upper tertile of teaching intensity, and upper quartile of uncompensated care had an OI that was lower by 0.59 SD, 0.45 SD, and 0.47 SD, respectively. Conclusions and Relevance: In this cross-sectional study of US health systems, higher amounts of overuse among health systems were associated with investor ownership and fewer primary care physicians. The OI is a valuable tool for identifying potentially modifiable drivers of overuse and is adaptable to other levels of investigation, such as the state or region, which might be affected by local policies affecting payment or system consolidation.

Pre-existing Thyroid Autoimmunity and Risk of Papillary Thyroid Cancer: A Nested Case-Control Study of US Active-Duty Personnel.

PURPOSE: Thyroid autoimmunity has been associated with differentiated thyroid cancer although multiple potential biases might have influenced the results of previous studies. METHODS: We conducted a case-control study nested within the cohort of US active-duty personnel 1996-2014 to assess the association between thyroid autoimmunity, defined by serology, and thyroid cancer diagnosis. The primary exposure was thyroid peroxidase (TPO) antibody status 7-10 years before the thyroid cancer index date. We also assessed whether diagnosis of thyroid autoimmunity mediated any associations identified and if thyroid cancer features differed by autoimmunity status. RESULTS: Among 451 incident cases of papillary thyroid cancer and matched controls (median age 36 years, 61.4% men), TPO antibody positivity (v negative) 7-10 years prediagnosis was associated with thyroid cancer (odds ratio [OR] 1.90 [95% CI, 1.33 to 2.70]). Exploratory analyses suggested an increasing risk of thyroid cancer with higher TPO antibody titer (TPO antibody 550-1,399 IU/mL: OR 2.95 [95% CI, 1.37 to 6.36]; and ≥ 1,400 IU/mL: OR 3.91 [95% CI, 1.66 to 9.24]). Positive TPO antibody status remained associated with thyroid cancer after those with diagnosed autoimmunity were excluded, and the association was not mediated by diagnosis of thyroid autoimmunity. Among the cases with diagnosed autoimmunity, 58% thyroid cancers were ≤ 10 mm diameter. CONCLUSION: Longstanding prior thyroid autoimmunity up to 10 years before thyroid cancer diagnosis was associated with papillary thyroid cancer risk. The results could not be fully explained by diagnosis of thyroid autoimmunity although when autoimmunity had been identified, thyroid cancers were diagnosed at a very early stage.

Risk factors for infections after endoscopic retrograde cholangiopancreatography (ERCP): a retrospective cohort analysis of US Medicare Fee-For-Service claims, 2015-2021.

OBJECTIVE: Contaminated reprocessed duodenoscopes pose a serious threat to patients in the endoscopy unit. Despite manufacturer changes to reprocessing guidelines, 20% of reprocessed duodenoscopes meet criteria for quarantine-level contamination based on microbiological or ATP testing. We aimed to examine risk factors for postendoscopic retrograde cholangiopancreatography (ERCP) infection. DESIGN: Retrospective cohort analysis. SETTING: US Medicare Fee-For-Service claims (2015-2021) and all-payer data (2017). PARTICIPANTS: In the Medicare data, 823 575 ERCP procedures were included. The all-payer five-state data, 16 609 procedures were included. INTERVENTIONS: ERCP was identified by Current Procedural Terminology and International Classification of Disease (ICD) procedure codes. We identified inpatient infections using ICD diagnosis codes. OUTCOME MEASURES: A logistic regression model predicted risk factors for infections occurring within 7-day and 30-day periods following ERCP. 7-day and 30-day all-cause hospitalisations and post-ERCP pancreatitis were also examined. RESULTS: Post-ERCP infection occurred within 3.5% of 7-day and 7.7% of 30-day periods in Medicare. Disposable duodenoscopes were billed in 711 procedures, with 1.4% (n=10, 7-day) and 3.5% (n=25, 30-day) post-ERCP infections. Urgent ERCPs were the strongest risk factor for infections in the 7-day period (OR 3.3, 95% CI 3.2 to 3.4). Chronic conditions, sex (male), age (older) and race (non-white) were also risk factors. In the all-payer five-state data, fewer infections (2.4%, 7 days) were observed. No difference arose between Medicare and other payers for 7-day period infections (OR 1.0, 95% CI 0.7 to 1.3). CONCLUSIONS: Urgent ERCPs, patient chronic conditions and patient demographics are post-ERCP infection risk factors. Patients with infection risk factors should be targeted for specialised infection control prevention measures, including disposable duodenoscopes.

A micro-costing analysis of outpatient flexible cystoscopy: implications for adoption of single-use flexible cystoscopes.

PURPOSE: To evaluate the total cost of outpatient flexible cystoscopy associated with reusable device purchase, maintenance, and reprocessing, and to assess potential cost benefits of single-use flexible cystoscopes. METHODS: Cost data regarding the purchasing, maintaining, and reprocessing of reusable flexible cystoscopes were collected using a micro-costing approach at a high-volume outpatient urology clinic. We estimated the costs to facilities with a range of annual procedure volumes (1000-3000) performed with a fleet of cystoscopes ranging from 10 to 25. We also compared the total cost per double-J ureteral stent removal procedure performed using single-use flexible cystoscopes versus reusable devices. RESULTS: The cost associated with reusable flexible cystoscopes ranged from $105 to $224 per procedure depending on the annual procedure volume and cystoscopes available. As a practice became more efficient by increasing the ratio of procedures performed to cystoscopes in the fleet, the proportion of the total cost due to cystoscope reprocessing increased from 22 to 46%. For ureteral stent removal procedures, the total cost per procedure using reusable cystoscopes (range $165-$1469) was higher than that using single-use devices ($244-$420), unless the annual procedure volume was sufficiently high relative to the number of reusable cystoscopes in the fleet (≥ 350 for a practice with ten reusable cystoscopes, ≥ 700 for one with 20 devices). CONCLUSION: The cost of reprocessing reusable cystoscopes represents a large fraction of the total cost per procedure, especially for high-volume facilities. It may be economical to adopt single-use cystoscopes specifically for stent removal procedures, especially for lower-volume facilities.

Underutilization of Needle Biopsy Before Breast Surgery: A Measure of Low-Value Care.

BACKGROUND: Breast core needle biopsy (CNB) can obviate the need for breast surgery in patients with an unknown breast lesion; however, variation in compliance with this guideline may represent a disparity in health care and a surrogate measure of unnecessary surgery. We evaluated variation in breast CNB rates prior to initial breast cancer surgery. METHODS: We performed a retrospective analysis using Medicare claims from 2015 to 2017 to evaluate the proportion of patients who received a CNB within 6 months prior to initial breast cancer surgery. Outlier practice pattern was defined as a preoperative CNB rate ≤ 70%. Logistic regression was used to evaluate surgeon characteristics associated with outlier practice pattern. RESULTS: We identified 108,935 female patients who underwent initial breast cancer surgery performed by 3229 surgeons from July 2015 to June 2017. The mean CNB rate was 86.7%. A total of 7.7% of surgeons had a CNB performed prior to initial breast surgery ≤ 70% of the time, and 2.0% had a CNB performed ≤ 50% of the time. Outlier breast surgeons were associated with practicing in a micropolitan area (odds ratio [OR] 1.88, 95% confidence interval [CI] 1.29-2.73), in the South (OR 1.84, 95% CI 1.20-2.84) or West region (OR 1.78, 95% CI 1.11-2.86), > 20 years in practice (OR 1.52, 95% CI 1.09-2.11), and low breast cancer surgery volume (< 30 cases in the study period; OR 4.03, 95% CI 2.75-5.90). CONCLUSIONS: Marked variation exists in whether a breast core biopsy is performed prior to initial breast surgery, which may represent unnecessary surgery on individual patients. Providing surgeon-specific feedback on guideline compliance may reduce unwarranted variation.

Endoscope infection transmission state-of-the-art: beyond duodenoscopes to a culture of infection prevention.

PURPOSE OF REVIEW: The elevator mechanism of the duodenoscope was the focus of endoscopically transmitted infections prior to the COVID-19 pandemic. Since that time, the 'suspicious suspects' in the endoscopy unit have grown in number in the eyes of both patients and endoscopists. RECENT FINDINGS: This review summarizes the existing guidelines related to infection control in the endoscopy unit and emerging technologies to address gaps, identifies recommendations proposed during the COVID-19 pandemic, and reminds the reader that infection prevention has not changed since the emergence of COVID-19, only the importance of infection prevention has increased in visibility. SUMMARY: Infection prevention has been and will always be necessary in the gastrointestinal endoscopy unit. Although outbreaks of antibiotic-resistant organisms and infectious diseases like COVID-19 raise the profile of infection control, there have been no major changes to infection control practice recommendations because of the global pandemic. The history of lapses in infection control, persistent contamination of reprocessed endoscopes, and failure of many endoscopy units to identify certain endoscopic procedures as aerosol-generating procedures prior to the pandemic emphasize the need for better knowledge and implementation of infection control practices within endoscopy units.

Clinical codes combined with procedure codes increase diagnostic accuracy of Crohn's disease in a US Military health record.

Background and aims: Previous examinations of International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes to predict accuracy of diagnosis in inflammatory bowel disease have had limited chart review to confirm diagnosis. We aimed to evaluate using the ICD-9-CM for identifying Crohn's disease (CD) in a large electronic health record (EHR) database. Methods: This is a retrospective case-control study with a 3:1 allocation of EHRs of active duty service members diagnosed with CD from 1996 to 2012. Subjects were selected by having two ICD-9-CM codes for CD during the study period. Gastroenterologists reviewed each chart and confirmed the diagnosis of CD by analysing medication history and clinical, endoscopic, histological, and radiographic exams. Results: 300 cases of CD were selected; 14 cases were discarded due to lack of data, limiting our analysis to 284 subjects. Two diagnostic codes for CD had sensitivity, specificity, and positive predictive value (PPV) of 1.0, 0.53, and 0.69, respectively, for confirmed CD. If two encounters listing CD were with a gastroenterologist, the sensitivity, specificity, and PPV was 0.76, 0.81, and 0.80, respectively. If a colonoscopy was performed within 90 days of any three encounters with a CD code, the sensitivity, specificity, and PPV was 0.51, 0.94, and 0.89, respectively. Conclusions: The poor PPV of ICD-9-CM codes in making the diagnosis of CD should be taken into consideration when interpreting results and when conducting research using such codes. Limiting these codes to those patients who have been given this diagnosis by a gastroenterologist, or to those who have had a colonoscopy near the time of diagnosis, increases the PPV.

Antitumour necrosis factor-α agents and development of new-onset cirrhosis or non-alcoholic fatty liver disease: a retrospective cohort.

Objective: Elevated tumour necrosis factor (TNF)-α has been implicated in the progression of liver fibrosis and pathogenesis of non-alcoholic fatty liver disease (NAFLD). We aim to investigate the impact of anti-TNF-α agents on the development of cirrhosis and NAFLD. Design: This retrospective cohort study used a US claims database between 1 January 2010 and 31 December 2016. We identified adult patients with ankylosing spondylitis, inflammatory bowel disease, psoriatic arthritis or rheumatoid arthritis. Anti-TNF-α agents of interest included adalimumab, certolizumab, etanercept, golimumab and infliximab. The primary composite outcome was the development of new-onset cirrhosis, NAFLD or non-alcoholic steatohepatitis (NASH). The secondary outcomes were the development of (1) cirrhosis and (2) NAFLD or NASH. Propensity score for anti-TNF-α agent use was generated by logistic regression. Cox proportional hazard models adjusting for the propensity score were used with regard to time-varying anti-TNF-α agent exposure. Results: This study included 226 555 incident patients with immune-related diseases. During the median 1.5 years follow-up, there was an increased hazard with anti-TNF-α agent use in regard to liver outcomes (composite outcome HR: 1.47, 95% CI 1.27 to 1.70; cirrhosis HR 1.47, 95% CI 0.96 to 2.23; NAFLD or NASH HR 1.53, 95% CI 1.32 to 1.77). The composite outcome hazard was increased for each immune-related disease (HR 1.25-1.90). Conclusion: In the short term, we did not observe a beneficial effect of anti-TNF-α agent use for development of cirrhosis, NAFLD or NASH in patients with immune-related diseases.

Levels of Vitamin D Are Low After Crohn's Disease Is Established But Not Before.

BACKGROUND & AIMS: Low serum levels of vitamin D have been associated with Crohn's disease (CD). However, it is unclear whether low vitamin D levels cause CD or CD reduces serum vitamin D. METHODS: United States military personnel with CD (n = 240) and randomly selected individuals without CD (controls, n = 240) were matched by age, sex, race, military branch, and geography. We measured 25-hydroxyvitamin D in sera 8-3 years (pre-2) and 3 years to 3 months before diagnosis (pre-1) and 3 months before through 21 months after diagnosis (pre-0). We genotyped VDR and GC vitamin D related polymorphisms. We used conditional logistic regression, including adjustments for smoking, season, enlistment status, and deployment, to estimate relative odds of CD according to vitamin D levels and interactions between genetic factors and levels of vitamin D. RESULTS: Levels of vitamin D before diagnosis were not associated with CD in pre-2 (P trend = .65) or pre-1 samples (P trend = .84). However, we found an inverse correlation between CD and highest tertile of vitamin D level in post-diagnosis samples (P trend = .01; odds ratio, 0.51; 95% CI, 0.30-0.86). Interactions were not detected between vitamin D levels and VDR or GC polymorphisms. We observed an association between VDR Taq1 polymorphism and CD (independent of vitamin D) (P = .02). CONCLUSIONS: In serum samples from military personnel with CD and matched controls, we found no evidence for an association between CD and vitamin D levels up to 8 years before diagnosis. However, we observed an inverse-association between post-diagnosis vitamin D levels and CD. These findings suggest that low vitamin D does not contribute to development of CD-instead, CD leads to low vitamin D.