Work Loss in Patients With Celiac Disease: A Population-based Longitudinal Study

Coeliac disease: complications and comorbidities

Coeliac disease is an autoimmune disease characterized by small intestinal villus atrophy and inflammation upon exposure to gluten. It has a global prevalence of approximately 1%. Although the gluten-free diet can be an effective treatment, this diet is burdensome with practical difficulties and frequent inadvertent gluten exposure. Moreover, there are a variety of potential complications and comorbidities of coeliac disease that might be related to malabsorption and/or chronic immune activation. Overall, individuals with coeliac disease have increased mortality compared with the general population, underscoring the severity of this common disease. Comorbidities and complications that have been associated with coeliac disease include poor growth, reproductive complications, kidney and liver diseases, respiratory disease (such as pneumonia) and infections (including sepsis). Furthermore, coeliac disease has been linked to other autoimmune disease and psychiatric disease, as well as certain cancers. Data suggest that mucosal healing on a gluten-free diet might protect against some, but not all, of these complications. In this Review, we present absolute and relative risks of coeliac-associated disorders. We discuss underlying mechanisms, the role of the gluten-free diet and mucosal healing, as well as implications for follow-up and non-dietary treatment of coeliac disease.

Income and work loss in patients with Addison's disease: a nationwide population-based study

OBJECTIVE

Autoimmune Addison's disease (AAD) is associated with reduced health-related quality of life and possibly reduced employability. The aim of this study was to assess differences in income and work loss between patients with AAD and matched comparators.

DESIGN

Nationwide, cross-sectional register-based study.

METHODS

By linking the Swedish Addison Register and national health registers, we identified working age (18-64 years) individuals with AAD and general population comparators (matched 1:5 by sex, age, and county of residence). We assessed differences in taxable earnings and disposable income through quantile regression and differences in work loss through linear regression during 2019.

RESULTS

We identified 1140 cases with AAD and 5700 comparators (mean age 46.1 years, 48.4% men). Type 1 diabetes was prevalent in 15.7% and 1.1%, respectively. Work loss was higher in AAD; adjusted mean difference 14.4 days; 95% CI, 8.6-20. The adjusted median differences in taxable earnings and disposable income were non-significant overall at -617 (95% CI; -2317 to 1083) and -405 (95% CI; -1417 to 607) €. However, significantly lower taxable earnings and disposable income were found among patients with short education: -5303 (95% CI; -9603 to -992) and -3754 (95% CI; -6486 to -1022) €, or concomitant type 1 diabetes: -5808 (95% CI; -9937 to -1690) and -3349 (95% CI; -6203 to -506) €.

CONCLUSION

Patients with AAD had more work loss, yet overall similar taxable earnings and disposable incomes versus comparators. Patients with AAD with shorter education or type 1 diabetes were most socioeconomically vulnerable.

Burden of coeliac disease in Germany: real-world insights from a large retrospective health insurance claims database analysis

Background

Coeliac disease (CeD) is a chronic immune-mediated disease triggered by exposure to dietary gluten in genetically predisposed individuals. The burden of CeD on patients and the healthcare system remains poorly evaluated in Germany.

Objectives

To assess the healthcare resource utilisation (HCRU) and costs of diagnosed CeD patients in a German claims database.

Design

A retrospective CeD case-control study was conducted using German claims data between 2017 and 2021.

Methods

CeD diagnosis was defined by at least one inpatient or two outpatient diagnostic codes (International Statistical Classification of Diseases and Related Health Problems, 10th Revision, German Modification (ICD-10-GM) K90.0) within four quarters (irrespective of calendar year) for CeD during the study period. Controls (non-CeD patients) were matched in a ratio of 5:1 by age, Charlson Comorbidity Index, sex and region. HCRU (hospitalisations, outpatient visits, medication use, sick leaves) and healthcare costs (outpatient services, inpatient services, outpatient pharmaceuticals, sick leaves and aids and remedies) were compared between CeD patients and controls.

Results

From the 3,352,188 patients with continuous enrolment during the study period (2017-2021), 8258 (0.25%) patients were identified as having a CeD diagnosis. The mean number of hospitalisations and outpatient visits within 5 years was 1.8- and 1.5-fold higher among matched CeD patients (n = 8243) compared to their controls (n = 41,215), resulting in an excess healthcare cost of €5251. Inpatient expenses were the main cost driver and accounted for 31.5% of total incremental costs.

Conclusion

The current study showed that CeD patients have considerably higher HCRU and related costs compared to matched controls. Our findings suggest the need for improved treatment options for CeD patients in addition to a gluten-free diet.

The challenges of coeliac disease at work: A contestation of the politics of inclusion

By focusing on the experiences of employees living with coeliac disease as evidenced in UK employment tribunal cases, this paper interrogates the way practices of exclusion are performed in legal and organisational contexts that purport to promote values of inclusion. In paying attention to how differences are constructed and negotiated, the paper unpacks the way organisational practices mobilise an array of workplace mechanisms to produce complex dynamics of exclusion. Applying Laclau and Mouffe's logics of equivalence and difference, we show how questionable impulses and practices emerge in a workplace environment characterised by unclarity and vagueness. One impulse, for example, involves privatising and individualising the condition of employees with coeliac disease, giving rise to patronising and stigmatising attitudes that can turn them into victims. However, we also identify workplace mechanisms countering these tendencies, which can underpin forms of collective support in the struggle for recognition. Our study thus contributes to the body of sociological literature that pays attention to health-related workplace injustices by challenging the purported promotion of health-based inclusion through a focus on tribunal cases, leading to suggestions for further research into the way medical conditions are theorised and 'lived' at work.

Long-Term Cost-Effectiveness of Case Finding and Mass Screening for Celiac Disease in Children

BACKGROUND & AIMS

Celiac disease (CD) is a common yet underdiagnosed autoimmune disease with substantial long-term consequences. High-accuracy point-of-care tests for CD antibodies conducted at youth primary health care centers may enable earlier identification of CD, but evidence about the cost-effectiveness of such strategies is lacking. We estimated the long-term cost-effectiveness of active case finding and mass screening compared with clinical detection in the Netherlands.

METHODS

A decision tree and Markov model were used to simulate a cohort of 3-year-old children with CD according to each strategy, taking into account their impact on long-term costs (from a societal perspective) and quality-adjusted life-years (QALYs). Model parameters incorporated data from the GLUTENSCREEN project, the Dutch Celiac Society, the Dutch Pediatric Surveillance Unit, and published sources. The primary outcome was the incremental cost-effectiveness ratio (ICER) between strategies.

RESULTS

Mass screening produced 7.46 more QALYs and was €28,635 more costly compared with current care (ICER: €3841 per QALY), and case finding produced 4.33 more QALYs and was €15,585 more costly compared with current care (ICER: €3603 per QALY). At a willingness to pay of €20,000 per QALY, both strategies were highly cost-effective compared with current care. Scenario analyses indicated that mass screening is likely the optimal strategy, unless no benefit in detecting asymptomatic cases is assumed.

CONCLUSIONS

An earlier identification of CD through screening or case finding in children using a point-of-care tests leads to improved health outcomes and is cost-effective in the long-term compared with current care. If the feasibility and acceptability of the proposed strategies are successful, implementation in Dutch regular care is needed.

Economic Burden of Eosinophilic Esophagitis: A Nationwide Cost-of-Illness Study

INTRODUCTION

Despite its increasing prevalence, the economic impact of eosinophilic esophagitis (EoE) is understudied.

METHODS

We estimated the societal economic burden of EoE by using real-world data from Swedish health registers.

RESULTS

Patients with EoE had 45% higher societal cost ($6,290 vs $4,349) compared with the general population, primarily driven by increased healthcare costs ($2,414 vs $1,022), which accounted for 72% of the excess societal cost in EoE.

DISCUSSION

EoE is associated with a considerable economic burden to society. With the prevalence of EoE still rising, the economic burden of EoE is expected to continue to grow.

The Economic Iceberg of Celiac Disease: More Than the Cost of Gluten-Free Food

Celiac disease (CeD) is a chronic autoimmune disorder of global relevance, with the potential for acute and long-term complications. However, the economic burden of CeD is rarely considered and largely thought of as limited to the cost of gluten-free food. Fortunately, recent research has shed light on the various societal costs of CeD across the health care continuum. This article summarizes the current evidence on the economic impacts of CeD, which suggest that the societal economic burden of CeD stretches beyond the cost of gluten-free food. This review provides ample evidence of larger but hidden costs related to excess health care use for complications and comorbidities, as well as reduced productivity. Although significant advances are expected in the management of CeD, their effect on the economic burden of CeD remain uncertain. The aim of this review was to inform stakeholders across society and contribute to improved policies to support patients with CeD.

Celiac Disease-Related Conditions: Who to Test?

Celiac disease (CeD) is a chronic immune-mediated condition triggered by gluten consumption in genetically predisposed individuals. Approximately 1% of the general population is affected by the disorder. Disease presentation is heterogeneous and, despite growing awareness among physicians and the public, it continues to be underestimated. The most effective strategy for identifying undiagnosed CeD is proactive case finding through serologic testing in high-risk groups. We reviewed the most recent evidence on the association between CeD and more than 20 conditions. In light of this review, CeD screening is recommended in individuals with (1) autoimmune disease and accompanying symptoms suggestive of CeD; (2) diseases that may mimic CeD (eg, irritable bowel syndrome [IBS], inflammatory bowel disease [IBD], and microscopic colitis); and (3) among patients with conditions with a high CeD prevalence: first-degree relatives, idiopathic pancreatitis, unexplained liver enzyme abnormalities, autoimmune hepatitis, primary biliary cholangitis, hyposplenism or functional asplenia with severe bacterial infection, type 1 diabetes mellitus, Hashimoto's thyroiditis and Graves' disease, Sjögren's syndrome, dermatitis herpetiformis, recurrent aphthous syndrome and enamel defects, unexplained ataxia, peripheral neuropathy, delayed menarche or premature menopause, Down syndrome, Turner syndrome, Williams syndrome, chronic fatigue syndrome, IgA nephropathy, and IgA deficiency. CeD serology should be the initial step in the screening process. However, for patients with any of the aforementioned disorders who are undergoing upper endoscopy, biopsies should be performed to rule out CeD.

Psychometric validation of the celiac disease-specific quality of life survey (CD-QOL) in adults with celiac disease in the United States

PURPOSE

Celiac disease and its treatment negatively impact quality of life, indicating potential need for measurement of disease-specific quality of life domains to inform interdisciplinary intervention. The Celiac Disease Quality of Life Survey (CD-QOL) has been used in clinical research; however, its factor structure has not been confirmed and psychometric properties have not been evaluated in English-speaking adults in the U.S.

AIMS

(1) Confirm the factor structure of the 20-item English CD-QOL; (2) assess psychometric properties including internal consistency reliability, convergent validity, known groups validity, and incremental validity.

METHODS

453 adults with self-reported Celiac disease (M_age = 40.57; 88% female; 92% White) completed the CD-QOL and validated measures of generic health-related quality of life (SF-36), gluten-free diet adherence (CDAT), anxiety and depression symptoms (PROMIS), and physical symptoms (CSI) as part of the iCureCeliac^® patient-powered research network.

RESULTS

Confirmatory factor analysis found superior fit for a bifactor structure with one general factor and four group factors. Ancillary bifactor analyses suggest the CD-QOL can be considered primarily unidimensional. Total and three subscale scores demonstrated acceptable internal consistency reliability. Convergent and known groups validity were supported. The CD-QOL demonstrated some incremental validity over the SF-36.

CONCLUSION

The English CD-QOL can be used as a measure of disease-specific quality of life among adults with Celiac disease in the U.S. Compared to generic instruments, the CD-QOL appears to better capture specific cognitive and affective aspects of living with Celiac disease. Use of a total score is recommended. Its utility as a screening and outcome measurement tool in clinical settings should be examined.

Diagnostic Delay in Coeliac Disease: A Survey among Danish Patients

BACKGROUND

Coeliac disease affects around 1% of the population, although many cases remain undiagnosed. Underdiagnosis and diagnostic delay in coeliac disease may cause health complications and be a burden for both the patient and society. Casuistic reports indicate that the diagnostic delay may be significant in Danish patients.

AIM

To investigate the diagnostic delay among Danish patients with coeliac disease.

METHODS

We performed a survey among coeliac disease patients to investigate the diagnostic delay. A web-based questionnaire was sent to all members of The Danish Coeliac Society.

RESULTS

The questionnaire was completed by 1,392 individuals with a diagnosis of coeliac disease (78.1% women; mean age: 42.8 years). The mean delay was 1.8 (SD 5.0) years from the first symptom to the first health care contact and 5.8 (SD 9.5) years from the first symptom to diagnosis; 18.6% of the participants reported a total diagnostic delay of more than 10 years. Among the patient-reported reasons for delay were misunderstandings, unspecific symptoms, and a lack of knowledge or focus on coeliac disease among the doctors. In total, 52.7% rated the time to diagnosis to have been "too long," and 20.1% were not satisfied with the diagnostic process. However, the majority were "to some extent" or "very" satisfied with the diagnostic process.

CONCLUSION

We found evidence of a significant diagnostic delay among Danish patients with coeliac disease. This was primarily due to the delay from the time of first health care contact to the time of diagnosis. This study highlights the importance of raising awareness of coeliac disease among health care professionals.