Residence in Peripheral Regions and Low Socioeconomic Status Are Associated With Worse Outcomes of Inflammatory Bowel Diseases: A Nationwide Study From the epi-IIRN

The War in Gaza and Barriers to Inflammatory Bowel Disease Care

Objectives

Stress is associated with inflammatory bowel disease (IBD) development and exacerbation. We evaluated the impact of the war in Gaza on Israeli IBD patients and related barriers to IBD care.

Methods

Adult IBD patients were blindly enrolled to complete a patient-reported-outcome electronic questionnaire assessing symptoms, hospitalizations, medications, psychosocial factors, economic issues, and adherence to therapy during wartime.

Results

Overall, 526 participants completed the questionnaire, 67% with CD and 33% with UC. Fifty one percent had moderate-severe IBD patients. Compared to central residents, residents of peripheral regions described a higher need for financial support as their main missing aspect in IBD coping (26% vs. 17%), had increased financial difficulties attributed to wartime that led them to skip therapy (21% vs. 9%), and reported increased rates of requiring financial support to purchase biological medications (13% vs. 3%). Compared to mild patients, moderate-severe patients reported significantly more disease aggravations (47% vs. 23%), hospitalizations (16% vs. 2%), greater need for financial support as their main missing aspect in IBD coping (31% vs. 11%), increased financial difficulties attributed to wartime that led them to skip medical therapy (32% vs. 3%), increased rates of missing IBD medical therapy owing to wartime-related stress (34% vs. 11%), and increased daily cannabis use (21% vs. 9%).

Conclusions

Periphery-residents with IBD experience more financial difficulties, hospitalizations, and disease exacerbation during wartime. Efforts should be taken to minimize disparities in medical care availability and accessibility, with special emphasis on moderate-severe patients who are more prone to disease aggravations.

Ethnic Disparities in the Management of Inflammatory Bowel Disease in Israel and Impact on Outcomes

Background

In this nationwide study, we aimed to explore healthcare services utilization, medical management, and disease outcomes of inflammatory bowel diseases (IBD) across the 2 major ethnic groups in Israel.

Methods

We utilized a cohort including all patients diagnosed with IBD in Israel since 2005. The primary outcome was steroid dependency, with secondary outcomes including use of biologics, time to surgery, and hospitalizations. Outcomes were controlled for possible inherent differences in disease course and phenotype.

Results

Of the 32 491 included patients, 18 252 (56%) had Crohn's disease (CD) and 14 239 (44%) had ulcerative colitis (UC); 10% were Arabs and 90% were Jews. Jewish ethnicity was associated with lower rates of steroid dependency compared to Arab ethnicity in both CD (HR = 0.7 [95% CI, 0.6-0.8]) and UC (HR = 0.7 [95% CI, 0.6-0.8]). The risk of IBD-related surgery in CD was higher in the Arab group at both 3 and 5 years (13% vs. 10%, 16% vs 14%, respectively, P = .005). Arabs had more frequent IBD-related hospitalizations than Jews at 5 years (28% vs. 19% with at least 2 hospitalizations, P < .001). In contrast, Jewish ethnicity was associated with more frequent use of biologics during the first year from diagnosis in patients with CD (HR = 1.3 [95% CI, 1.1-1.6]) but not with UC.

Conclusions

Arab ethnicity is associated with higher rates of hospitalizations, steroid dependency, and surgeries, and, on the other side, with lower utilization of biologics. Healthcare practitioners and policymakers should address potential cultural and systemic barriers in healthcare delivery in order to improve care across all populations.

Predictors of Complicated Disease Course in Children and Adults With Ulcerative Colitis: A Nationwide Study From the epi-IIRN

BACKGROUND

Data on predictors of complicated ulcerative colitis (UC) course from unselected populations cohorts are scarce. We aimed to utilize a nationwide cohort to explore predictors at diagnosis of disease course in children and adults with UC.

METHODS

Data of patients diagnosed with UC since 2005 were retrieved from the nationwide epi-IIRN cohort. Complicated disease course was defined as colectomy, steroid-dependency, or the need for biologic drugs. Hierarchical clustering categorized disease severity at diagnosis based on complete blood count, albumin, C-reactive protein and erythrocyte sedimentation rate (ESR), analyzed together.

RESULTS

A total of 13 471 patients with UC (1427 [11%] pediatric-onset) including 103 212 person-years of follow-up were included. Complicated disease course was recorded in 2829 (21%) patients: 1052 (7.9%) escalated to biologics, 1357 (10%) experienced steroid-dependency, and 420 (3.1%) underwent colectomy. Probabilities of complicated disease course at 1 and 5 years from diagnosis were higher in pediatric-onset (11% and 32%, respectively) than adult-onset disease (4% and 16%; P < .001). In a Cox multivariate model, complicated course was predicted by induction therapy with steroids (hazard ratio [HR], 1.5; 95% CI, 1.2-2.0), extraintestinal manifestations (HR, 1.3; 95% CI, 1.03-1.5) and the disease severity clusters of blood tests (HR, 1.8; 95% CI, 1.01-3.1), while induction therapy with enemas (HR, 0.6; 95% CI, 0.5-0.7) and older age (HR, 0.99; 95% CI, 0.98-0.99) were associated with noncomplicated course.

CONCLUSION

In this nationwide cohort, the probability of complicated disease course during the first 5 years from diagnosis was 32% in pediatric-onset and 16% in adults with UC and was associated with more severe clusters of routinely collected laboratory tests, younger age at diagnosis, extraintestinal manifestations, and type of induction therapy.

Predictors of Complicated Disease Course in Adults and Children With Crohn's Disease: A Nationwide Study from the epi-IIRN

BACKGROUND

Since data on predictors of complicated Crohn's disease (CD) from unselected populations are scarce, we aimed to utilize a large nationwide cohort, the epi-IIRN, to explore predictors of disease course in children and adults with CD.

METHODS

Data of patients with CD were retrieved from Israel's 4 health maintenance organizations, whose records cover 98% of the population (2005-2020). Time-to-event modeled a complicated disease course, defined as CD-related surgery, steroid-dependency, or the need for >1 class of biologics. Hierarchical clustering categorized disease severity at diagnosis based on available laboratory results.

RESULTS

A total of 16 659 patients (2999 [18%] pediatric-onset) with 121 695 person-years of follow-up were included; 3761 (23%) had a complicated course (750 [4.5%] switched to a second biologic class, 1547 [9.3%] steroid-dependency, 1463 [8.8%] CD-related surgery). Complicated disease was more common in pediatric- than adult-onset disease (26% vs 22%, odds ratio, 1.3; 95% confidence interval [CI], 1.2-1.4). In a Cox multivariate model, complicated disease was predicted by induction therapy with biologics (hazard ratio [HR], 2.1; 95% CI, 1.2-3.6) and severity of laboratory tests at diagnosis (HR, 1.7; 95% CI, 1.2-2.2), while high socioeconomic status was protective (HR, 0.94; 95% CI, 0.91-0.96). In children, laboratory tests predicted disease course (HR, 1.8; 95% CI, 1.2-2.5), as well as malnutrition (median BMI Z score -0.41; 95% CI, -1.42 to 0.43 in complicated disease vs -0.24; 95% CI, -1.23 to 0.63] in favorable disease; P < .001).

CONCLUSIONS

In this nationwide cohort, CD course was complicated in one-fourth of patients, predicted by laboratory tests, type of induction therapy, socioeconomic status, in addition to malnutrition in children.

Challenges in IBD Research 2024: Pragmatic Clinical Research

Pragmatic clinical research is 1 of the 5 focus areas of the Challenges in IBD Research 2024, a multidisciplinary effort by scientists, clinicians, patients, and funders to identify priorities for patient-centric research. This summary provides a comprehensive overview of current gaps in inflammatory bowel disease (IBD) clinical research and actionable approaches to address them. This review is focused on identifying research that is needed to achieve the best outcomes for patients in clinical practice. Research gaps include understanding the needs of understudied patient groups and addressing barriers to care so all patients receive optimal care, validating and using biomarkers to enable early diagnosis and result in better outcomes for adults and children with IBD, and determining the optimal sequencing of treatments (medical, surgical, adjunct) in children and adults. Inclusive pragmatic research is needed to address these gaps and lead to improvements in patient care and outcomes for all populations of patients with IBD.