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Shustak A, Wolfe L, Ambrosio M, Sharp S, Wieghard N. Disparities in postoperative outcomes among diverse patient groups with inflammatory bowel disease. Ann Gastroenterol 2024; 37:327-332. [PMID: 38779648 PMCID: PMC11107412 DOI: 10.20524/aog.2024.0871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 01/11/2024] [Indexed: 05/25/2024] Open
Abstract
Background Inflammatory bowel disease (IBD) represents a significant burden in the United States. We aim to evaluate disparities in postoperative outcomes among diverse patients undergoing surgery for IBD. Methods The National Inpatient Sample (NIS) (2016-2018) was used to calculate national estimates for a number of postoperative complications in patients with IBD. Statistical analyses were performed using SAS survey procedures when calculating the national estimates. Results A majority of the 107,375 patients (weighted) undergoing surgery for IBD were White (81.7%), rather than Black (10.1%) or Hispanic (8.2%). Black patients had higher rates of postoperative infections compared to White or Hispanic patients (4.2% vs. 3.1% vs. 2.7%, P=0.0137). There was a significant difference in morbidity and mortality, with higher rates in Black patients (20.1% vs. 17.1% vs. 17.9%, P=0.0029). Black patients experienced longer average hospital stays compared to White or Hispanic patients (12.6 vs. 9.6 vs. 11.2 days, P<0.001), despite suffering fewer comorbidities (Modified Charlson Index 1.9 vs. 2.3 vs. 2.0, P<0.001). Conclusions This study demonstrated racial disparities in postoperative outcomes, with Black patients experiencing significantly higher rates of postoperative infections, overall morbidity and mortality, and length of stay, despite suffering from fewer comorbidities. This suggests an opportunity to improve equity of care for all patients with IBD by further examining social determinants of health that have not been traditionally studied.
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Affiliation(s)
- Ashley Shustak
- Department of Colon and Rectal Surgery, Cleveland Clinic Florida, Weston, Florida (Ashley Shustak)
| | - Luke Wolfe
- Department of Biostatistics, Virginia Commonwealth University Health System, Richmond, Virginia (Matthew Ambrosio, Luke Wolfe)
| | - Matthew Ambrosio
- Department of Biostatistics, Virginia Commonwealth University Health System, Richmond, Virginia (Matthew Ambrosio, Luke Wolfe)
| | - Stephen Sharp
- Division of Colorectal Surgery, Virginia Commonwealth University Health System, Richmond, Virginia (Stephen Sharp, Nicole Wieghard), USA
| | - Nicole Wieghard
- Division of Colorectal Surgery, Virginia Commonwealth University Health System, Richmond, Virginia (Stephen Sharp, Nicole Wieghard), USA
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Tandon P, Chhibba T, Natt N, Singh Brar G, Malhi G, Nguyen GC. Significant Racial and Ethnic Disparities Exist in Health Care Utilization in Inflammatory Bowel Disease: A Systematic Review and Meta-analysis. Inflamm Bowel Dis 2024; 30:470-481. [PMID: 36975373 DOI: 10.1093/ibd/izad045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Indexed: 03/29/2023]
Abstract
BACKGROUND The incidence of inflammatory bowel disease (IBD) is rising worldwide, though the differences in health care utilization among different races and ethnicities remains uncertain. We aimed to better define this through a systematic review and meta-analysis. METHODS We explored the impact of race or ethnicity on the likelihood of needing an IBD-related surgery, hospitalization, and emergency department visit. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated with I2 values reporting heterogeneity. Differences in IBD phenotype and treatment between racial and ethnic groups of IBD were reported. RESULTS Fifty-eight studies were included. Compared with White patients, Black patients were less likely to undergo a Crohn's disease (CD; OR, 0.69; 95% CI, 0.50-0.95; I2 = 68.0%) or ulcerative colitis (OR, 0.58; 95% CI, 0.40-0.83; I2 = 85.0%) surgery, more likely to have an IBD-hospitalization (OR, 1.54; 95% CI, 1.06-2.24; I2 = 77.0%), and more likely to visit the emergency department (OR, 1.74; 95% CI, 1.32-2.30; I2 = 0%). There were no significant differences in disease behavior or biologic exposure between Black and White patients. Hispanic patients were less likely to undergo a CD surgery (OR, 0.57; 95% CI, 0.48-0.68; I2 = 0%) but more likely to be hospitalized (OR, 1.38; 95% CI, 1.01-1.88; I2 = 37.0%) compared with White patients. There were no differences in health care utilization between White and Asian or South Asian patients with IBD. CONCLUSIONS There remain significant differences in health care utilization among races and ethnicities in IBD. Future research is required to determine factors behind these differences to achieve equitable care for persons living with IBD.
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Affiliation(s)
- Parul Tandon
- Division of Gastroenterology and Hepatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Tarun Chhibba
- Division of Gastroenterology and Hepatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Navneet Natt
- Department of Medicine, Northern Ontario School of Medicine, Ontario, Canada
| | - Gurmun Singh Brar
- Division of Gastroenterology and Hepatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gurpreet Malhi
- Department of Medicine, Western University, London, Ontario, Canada
| | - Geoffrey C Nguyen
- Division of Gastroenterology and Hepatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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Kemp KM, Nagaraj PK, Orihuela CA, Lorenz RG, Maynard CL, Pollock JS, Jester T. Racial and ethnic differences in diagnosis age and blood biomarkers in a pediatric inflammatory bowel disease cohort. J Pediatr Gastroenterol Nutr 2024; 78:634-643. [PMID: 38284647 PMCID: PMC11181309 DOI: 10.1002/jpn3.12131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 09/11/2023] [Accepted: 10/04/2023] [Indexed: 01/30/2024]
Abstract
OBJECTIVE Prompt diagnosis of pediatric-onset inflammatory bowel disease (IBD) is crucial for preventing a complicated disease course; however, it is not well understood how social determinants of health might affect pediatric IBD diagnosis. This study examined differences in diagnosis age, biomarkers of disease severity, and anthropometrics with sociodemographic factors in a pediatric IBD cohort. METHODS Pediatric IBD patients (n = 114) and their parents/caregivers were enrolled from the Children's of Alabama Pediatric IBD Clinic in Birmingham, Alabama. Primary analyses examined associations of child race and ethnicity, parental income, parental education, single-parent household status, insurance type, and distance to a tertiary pediatric gastroenterology referral center with diagnosis age. Secondary analyses examined differences in biomarker levels, height, and body mass index at the time of diagnosis. RESULTS Racial and ethnic minority children were diagnosed at an older age compared to Non-Hispanic White children (14.4 ± 0.40 vs. 11.7 ± 0.38 years; p < 0.001), and this trend was robust to adjustment with other sociodemographic variables. Parental attainment of a college education attenuated the link between minority race and ethnicity and the likelihood of older age at diagnosis, while other sociodemographic variables had no moderating effect. Racial and ethnic minority children were 5.7 times more likely to have clinically elevated erythrocyte sedimentation rate at diagnosis compared to Non-Hispanic White children (p = .024). CONCLUSIONS These results suggest that child race and ethnicity may exert a primary effect on the age at diagnosis with pediatric-onset IBD. This study highlights the need for further research on racial and ethnic disparities to promote health equity in pediatric-onset IBD.
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Affiliation(s)
- Keri M. Kemp
- Cardio-Renal Physiology and Medicine Section, Division of Nephrology, Department of Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Pooja K. Nagaraj
- Department of Pediatrics, Division of Gastroenterology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Catheryn A. Orihuela
- Department of Psychology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Robin G. Lorenz
- Department of Research Pathology, Genentech, South San Francisco, California, USA
| | - Craig L. Maynard
- Department of Pathology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jennifer S. Pollock
- Cardio-Renal Physiology and Medicine Section, Division of Nephrology, Department of Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Traci Jester
- Department of Pediatrics, Division of Gastroenterology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Edwards CS, Baudino MN, Roberts CM, Basile NL, Dattilo TM, Gamwell KL, Jacobs NJ, Edwards DS, Tung J, Parker CV, Chaney JM. The contributions of clinical disease activity, functional disability, and illness intrusiveness to depressive symptoms in pediatric inflammatory bowel disease. J Pediatr Gastroenterol Nutr 2024; 78:77-84. [PMID: 38291697 DOI: 10.1002/jpn3.12056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/13/2023] [Accepted: 09/29/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND Clinical disease activity associated with inflammatory bowel disease (IBD) can place physical limitations on youths' activities of daily living. In turn, functional limitations potentially contribute to youths' heightened experience of IBD-induced intrusions on a wide range of routine and valued activities (i.e., illness intrusiveness), which can increase their risk for depressive symptoms. The present study examined the contributions of clinical disease activity, functional disability, and illness intrusiveness to depressive symptoms in youth with IBD. METHODS Youth (N = 180) completed the Functional Disability Inventory (FDI), Illness Intrusiveness Scale-Child (IIS-C), and Children's Depression Inventory-2 (CDI-2). Physicians completed the Physicians Global Assessment of disease activity (PGA). RESULTS Results revealed a mediating effect for functional disability in the association between disease activity and depressive symptoms (PGA → FDI → CDI-2); illness intrusiveness mediated the association between functional disability and depressive symptoms (i.e., FDI → IIS-C → CDI-2). Serial mediation revealed that clinical disease activity conferred an indirect effect on youth depressive symptoms through the sequential effects of functional disability and illness intrusiveness (i.e., PGA → FDI → IIS-C → CDI-2). CONCLUSIONS Taken together, these findings indicate that youth who encounter more physical limitations as a function of clinical disease activity are more likely to experience an amplified sense of IBD-related intrusions on their ability to participate in meaningful activities. In turn, heightened illness intrusiveness increases the likelihood of depressive symptoms. Clinical interventions that help youth maintain adequate functional ability in the face of IBD disease activity and encourage involvement in positively valued activities could decrease the negative impact of IBD on youths' emotional adjustment.
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Affiliation(s)
- Clayton S Edwards
- Center for Pediatric Psychology, Oklahoma State University, Stillwater, Oklahoma, USA
| | - Marissa N Baudino
- Baylor College of Medicine - Texas Children's Hospital, Houston, Texas, USA
| | - Caroline M Roberts
- Baylor College of Medicine - Texas Children's Hospital, Houston, Texas, USA
| | - Nathan L Basile
- Center for Pediatric Psychology, Oklahoma State University, Stillwater, Oklahoma, USA
| | - Taylor M Dattilo
- Center for Pediatric Psychology, Oklahoma State University, Stillwater, Oklahoma, USA
| | - Kaitlyn L Gamwell
- School of Medicine, University of South Carolina, Columbia, South Carolina, USA
| | - Noel J Jacobs
- Department of Psychology, Oklahoma City University, Oklahoma City, Oklahoma, USA
| | - Desti S Edwards
- Pediatric Gastroenterology, Oklahoma Children's Hospital OU Health, Oklahoma City, Oklahoma, USA
| | - Jeanne Tung
- Pediatric Gastroenterology, Oklahoma Children's Hospital OU Health, Oklahoma City, Oklahoma, USA
| | - Colton V Parker
- Center for Pediatric Psychology, Oklahoma State University, Stillwater, Oklahoma, USA
| | - John M Chaney
- Center for Pediatric Psychology, Oklahoma State University, Stillwater, Oklahoma, USA
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Samalik JM, Goldberg CS, Modi ZJ, Fredericks EM, Gadepalli SK, Eder SJ, Adler J. Discrepancies in Race and Ethnicity in the Electronic Health Record Compared to Self-report. J Racial Ethn Health Disparities 2023; 10:2670-2675. [PMID: 36418736 DOI: 10.1007/s40615-022-01445-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/19/2022] [Accepted: 11/01/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Racial and ethnic disparities are commonplace in health care. Research often relies on sociodemographic information recorded in the electronic health record (EHR). Little evidence is available about the accuracy of EHR-recorded sociodemographic information, and none in pediatrics. Our objective was to determine the accuracy of EHR-recorded race and ethnicity compared to self-report. METHODS Patients/guardians enrolled in two prospective observational studies (10/2014-1/2019) provided self-reported sociodemographic information. Corresponding EHR information was abstracted. EHR information was compared to self-report, considered "gold standard." Agreement was evaluated with Cohen's kappa. RESULTS A total of 503 patients (42% female, median age 12.8 years) were identified. Self-reported race (N = 484) was 73% White, 16% Black or African American (AA), 4% Asian, 5% multiracial, and 2% other. Self-reported ethnicity (N = 410) was 9% Hispanic/Latino, and 88% non-Hispanic/Latino. Agreement between self-reported and EHR-recorded race was substantial (kappa = 0.77, 95% CI 0.72-0.83). Race was discordant among 10% (47/476). Hispanic/Latino ethnicity also had strong agreement (kappa = 0.77, 95% CI 0.65-0.89). Among those who self-reported Hispanic/Latino and reported race (N = 21), race was less accurately recorded in the EHR (kappa = 0.26, 95% CI 0-0.54). Race did not match among 43% with recorded race (9/21). Among self-reported racial and/or ethnic minorities, 13% (12/164) were misclassified in the EHR as non-Hispanic White. CONCLUSIONS We found race and ethnicity are often inaccurately recorded in the EHR for patients who self-identify as minorities, leading to under-representation of minorities in the EHR. Inaccurately recorded race and ethnicity has important implications for disparity research, and for informing health policy. Reliable processes are needed to incorporate self-reported race and ethnicity in the EHR at institutional and national levels.
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Affiliation(s)
- Joann M Samalik
- Division of Pediatric Gastroenterology, 1500 E. Medical Center Dr. C.S. Mott Children's Hospital, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Caren S Goldberg
- Division of Pediatric Cardiology, 1500 E. Medical Center Dr. C.S. Mott Children's Hospital, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Zubin J Modi
- Susan B. Meister Child Health Evaluation and Research Center, 2900 Plymouth Rd, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
- Division of Pediatric Nephrology, 1500 E. Medical Center Dr. C.S. Mott Children's Hospital, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Emily M Fredericks
- Susan B. Meister Child Health Evaluation and Research Center, 2900 Plymouth Rd, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
- Division of Pediatric Psychology, 1500 E. Medical Center Dr. C.S. Mott Children's Hospital, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Samir K Gadepalli
- Susan B. Meister Child Health Evaluation and Research Center, 2900 Plymouth Rd, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
- Division of Pediatric Surgery, 1500 E. Medical Center Dr. C.S. Mott Children's Hospital, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Sally J Eder
- Susan B. Meister Child Health Evaluation and Research Center, 2900 Plymouth Rd, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jeremy Adler
- Division of Pediatric Gastroenterology, 1500 E. Medical Center Dr. C.S. Mott Children's Hospital, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.
- Susan B. Meister Child Health Evaluation and Research Center, 2900 Plymouth Rd, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.
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Smith J, Liu C, Beck A, Fei L, Brokamp C, Meryum S, Whaley KG, Minar P, Hellmann J, Denson LA, Margolis P, Dhaliwal J. Racial Disparities in Pediatric Inflammatory Bowel Disease Care: Differences in Outcomes and Health Service Utilization Between Black and White Children. J Pediatr 2023; 260:113522. [PMID: 37244575 PMCID: PMC10894641 DOI: 10.1016/j.jpeds.2023.113522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 05/08/2023] [Accepted: 05/21/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To describe racial inequities in pediatric inflammatory bowel disease care and explore potential drivers. METHODS We undertook a single-center, comparative cohort study of newly diagnosed Black and non-Hispanic White patients with inflammatory bowel disease, aged <21 years, from January 2013 through 2020. Primary outcome was corticosteroid-free remission (CSFR) at 1 year. Other longitudinal outcomes included sustained CSFR, time to anti-tumor necrosis factor therapy, and evaluation of health service utilization. RESULTS Among 519 children (89% White, 11% Black), 73% presented with Crohn's disease and 27% with ulcerative colitis. Disease phenotype did not differ by race. More patients from Black families had public insurance (58% vs 30%, P < .001). Black patients were less likely to achieve CSFR 1-year post diagnosis (OR: 0.52, 95% CI:0.3-0.9) and less likely to achieve sustained CSFR (OR: 0.48, 95% CI: 0.25-0.92). When adjusted by insurance type, differences by race to 1-year CSFR were no longer significant (aOR: 0.58; 95% CI: 0.33, 1.04; P = .07). Black patients were more likely to transition from remission to a worsened state, and less likely to transition to remission. We found no differences in biologic therapy utilization or surgical outcomes by race. Black patients had fewer gastroenterology clinic visits and 2-fold increased odds for emergency department visits. CONCLUSIONS We observed no differences by race in phenotypic presentation and medication usage. Black patients had half the odds of achieving clinical remission, but a degree of this was mediated by insurance status. Understanding the cause of such differences will require further exploration of social determinants of health.
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Affiliation(s)
- Julia Smith
- Division of Gastroenterology, Hepatology & Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Chunyan Liu
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Andrew Beck
- Division of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Lin Fei
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Cole Brokamp
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Syeda Meryum
- Division of Gastroenterology, Hepatology & Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Kaitlin G Whaley
- Division of Gastroenterology, Hepatology & Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Phillip Minar
- Division of Gastroenterology, Hepatology & Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Jennifer Hellmann
- Division of Gastroenterology, Hepatology & Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Lee A Denson
- Division of Gastroenterology, Hepatology & Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Peter Margolis
- Division of Gastroenterology, Hepatology & Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Jasbir Dhaliwal
- Division of Gastroenterology, Hepatology & Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, Cincinnati, OH.
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Jackson JE, Rajasekar G, Vukcevich O, Coakley BA, Nuño M, Saadai P. Association Between Race, Gender, and Pediatric Postoperative Outcomes: An Updated Retrospective Review. J Surg Res 2023; 281:112-121. [PMID: 36155268 DOI: 10.1016/j.jss.2022.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 08/05/2022] [Accepted: 08/19/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION There has not been a recent evaluation of the association between racial and gender and surgical outcomes in children. We aimed to evaluate improvements in race- and gender-related pediatric postoperative outcomes since a report utilizing the Kids' Inpatient Database data from 2003 to 2006. METHODS Using Kids' Inpatient Database (2009, 2012, 2016), we identified 245,976 pediatric patients who underwent appendectomy for acute appendicitis (93.6%), pyloromyotomy for pyloric stenosis (2.7%), empyema decortication (1.6%), congenital diaphragmatic hernia repair (0.7%), small bowel resection for intussusception (0.5%), or colonic resection for Hirschsprung disease (0.2%). The primary outcome was the development of postoperative complications. Multivariable logistic regression was used to evaluate risk-adjusted associations among race, gender, income, and postoperative complications. RESULTS Most patients were male (61.5%) and 45.7% were White. Postoperative complications were significantly associated with male gender (P < 0.0001) and race (P < 0.0001). After adjustment, Black patients were more likely to experience any complication than White patients (adjusted odds ratio 1.3, confidence interval 1.2-1.4), and males were more likely than females (adjusted odds ratio 1.3, confidence interval 1.2-1.4). CONCLUSIONS No clear progress has been made in eliminating race- or gender-based disparities in pediatric postoperative outcomes. New strategies are needed to better understand and address these disparities.
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Affiliation(s)
- Jordan E Jackson
- Department of Pediatric Surgery, University of California, Davis Medical Center, Sacramento, California
| | - Ganesh Rajasekar
- Department of Public Health Sciences, Division of Biostatistics, University of California Davis, Sacramento, California
| | - Olivia Vukcevich
- Department of Pediatric Surgery, University of California, Davis Medical Center, Sacramento, California
| | - Brian A Coakley
- Division of Pediatric Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, New York
| | - Miriam Nuño
- Department of Public Health Sciences, Division of Biostatistics, University of California Davis, Sacramento, California
| | - Payam Saadai
- Department of Pediatric Surgery, University of California, Davis Medical Center, Sacramento, California.
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Cai Q, Ding Z, Fu AZ, Patel AA. Racial or ethnic differences on treatment adherence and persistence among patients with inflammatory bowel diseases initiated with biologic therapies. BMC Gastroenterol 2022; 22:545. [PMID: 36581802 PMCID: PMC9801546 DOI: 10.1186/s12876-022-02560-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 10/29/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Inflammatory bowel disease (IBD) is a chronic disease with the potential for significant morbidity in case of suboptimal treatment (e.g. low treatment adherence). In spite of immense research in IBD, literature on association of IBD with race/ethnicity is fragmented. In this study, we aimed to evaluate the association between race/ethnicity and treatment adherence and persistence among patients with Crohn's disease (CD) or ulcerative colitis (UC) initiated with biologic therapies. METHODS This observational, retrospective study utilized the Optum Clinformatics (Optum) Extended Data Mart Socioeconomic Status (SES) database. Adult patients with ≥ 2 medical claims for CD or UC diagnosis, ≥ 1 medical or pharmacy claim for corresponding FDA-approved biologic therapy, and a ≥ 12-month pre-index (index date: date of the first biologic medical/pharmacy claim) continuous health plan enrollment were included. Treatment adherence was measured as the proportion of days covered of ≥ 80% and treatment persistence by the number of days from the index date to the biologics discontinuation date. Switching among biologics was allowed for both treatment adherence and treatment persistence. Multivariable regression analyses were performed to evaluate the association between race/ethnicity and treatment adherence/persistence. RESULTS Among patients with CD (N = 1430) and UC (N = 1059) included, majority were White (CD: 80.3%, UC: 78.3%), followed by African Americans (AA; CD: 10.5%, UC: 9.7%). Among patients with CD, AA were significantly less likely to adhere to biologics (adjusted OR [95%CI]: 0.61 [0.38; 0.99]) and more likely to discontinue biologics earlier (adjusted HR [95%CI]: 1.52 [1.16; 2.0]) during the follow-up period compared to Whites, after adjusting for other patient sociodemographic and clinical characteristics. Among patients with UC, no significant differences in the treatment adherence/persistence were observed between different races/ethnicities. CONCLUSIONS Patients with CD were found to display racial differences in the treatment adherence and persistence of biologics, with significantly lower adherence and earlier discontinuation in AA compared to Whites. Such differences were not observed in patients with UC. Future studies are warranted to understand the possible reasons for racial differences, particularly in patients with CD.
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Affiliation(s)
- Qian Cai
- grid.497530.c0000 0004 0389 4927Janssen Scientific Affairs, LLC, 1125 Trenton Harbourton Rd, Titusville, NJ 08560 USA
| | - Zhijie Ding
- grid.497530.c0000 0004 0389 4927Janssen Scientific Affairs, LLC, 800 Ridgeview Drive, Horsham, PA 19044 USA
| | - Alex Z. Fu
- grid.497530.c0000 0004 0389 4927Janssen Scientific Affairs, LLC, 1125 Trenton Harbourton Rd, Titusville, NJ 08560 USA ,grid.411667.30000 0001 2186 0438Georgetown University Medical Center, 3900 Reservoir Road, Washington, DC 20057 USA
| | - Aarti A. Patel
- grid.497530.c0000 0004 0389 4927Janssen Scientific Affairs, LLC, 1125 Trenton Harbourton Rd, Titusville, NJ 08560 USA
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Predictors of Perianal Fistula Healing in Children With Newly Diagnosed Crohn Disease. J Pediatr Gastroenterol Nutr 2022; 75:709-716. [PMID: 36399175 DOI: 10.1097/mpg.0000000000003595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Perianal fistulas are among the most severe complications of Crohn disease, but limited data regarding their outcomes are available in children. Our objective was to determine predictors of perianal fistula healing among pediatric patients newly diagnosed with Crohn disease. METHODS This single-center retrospective study followed patients with perianal fistulas at Crohn disease diagnosis until fistula healing. Time to healing was analyzed using Cox proportional hazard regression models considering relevant covariates including patient demographics, disease characteristics, medical therapies [no anti-tumor necrosis factor (TNF)α therapy, anti-TNFα therapy ±therapeutic drug monitoring], and perianal surgical procedures including fistulotomy, fistulectomy, removal of perianal lesions, seton placement, and incision and drainage. RESULTS Of 485 patients identified, 107 (22%) had a perianal fistula at Crohn disease diagnosis. Multivariate analysis identified that perianal fistulotomy, fistulectomy, and lesion removal [hazard ratio (HR) 0.46; P = 0.028], non-White race (HR 0.30, P < 0.01), and male sex (HR 0.42; P = 0.02) were associated with delayed fistula healing. Faster fistula healing was associated with treatment with anti-TNFα with therapeutic drug monitoring (HR 1.78, P = 0.009). There were no other differences in healing by treatment. CONCLUSIONS Fistulotomy, fistulectomy, and perianal lesion removal as well as non-White race were associated with delayed fistula healing. Anti-TNFα therapy was associated with faster fistula healing when combined with therapeutic drug monitoring, compared to all other medical treatment groups, including anti-TNFα therapy without therapeutic drug monitoring.
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Racial/Ethnic Disparities in the Management of Pediatric Acute Pancreatitis Across Children's Hospitals. J Pediatr Gastroenterol Nutr 2022; 75:650-655. [PMID: 36305883 DOI: 10.1097/mpg.0000000000003597] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Racial or ethnic disparities in health care delivery and resource utilization have been reported in a variety of pediatric diseases. In acute pancreatitis (AP), there is an association between Black race and increased inpatient mortality. Data on the association of race and ethnicity and resource use for managing pediatric AP are lacking. The aim of this study is to investigate this potential association in pediatric AP. METHODS Retrospective study of children 0-18 years diagnosed with AP in the Pediatric Health Information System (PHIS) database from 2012 to 2018. Descriptive statistics were used to summarize cohort characteristics. Race/ethnicity classifications included non-Hispanic Black (NHB), non-Hispanic White (NHW, used as reference), Hispanic, and "Other." Associations between patient characteristics and race/ethnicity were determined using χ2 tests. Generalized linear mixed regression model was used to determine the association of race/ethnicity with odds of resource utilization, costs, and length of hospital stay after adjusting for covariates with a random intercept for site. RESULTS Five thousand nine hundred sixty-three patients from 50 hospitals were included. Adjusted analysis showed that NHB children hospitalized with AP were at lower odds of receiving opioids in the first 24 hours [adjusted odds ratio (aOR) = 0.82, 95% confidence interval (CI) = 0.70-0.98] and receiving intravenous fluids during the hospitalization (aOR = 0.64, 95% CI = 0.43-0.96) when compared with NHW children. Additionally, NHB and Hispanic children had a prolonged adjusted mean length of hospital stay and higher hospital costs when compared with NHW children. Although there was no significant association between race/ethnicity and diagnosis of pancreatic necrosis or sepsis, Hispanic and "Other" children were at higher odds of receiving antibiotics during hospitalization for AP (aOR = 1.33, 95% CI = 1.13-1.57 and aOR = 1.37, 95% CI = 1.09-1.73, respectively) than NHW children. CONCLUSIONS Disparities exist in utilization of health care interventions for pediatric AP patients by race/ethnicity. Future studies should investigate why these disparities exist and if these disparities affect outcomes.
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11
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Britto SL, Qian J, Ihekweazu FD, Kellermayer R. Racial and Ethnic Variation in Presentation, Diagnosis, Treatment, and Outcome of Pediatric Crohn Disease: A Single Center Study. J Pediatr Gastroenterol Nutr 2022; 75:313-319. [PMID: 35687587 DOI: 10.1097/mpg.0000000000003516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Disparities in health care for racial/ethnic minority children in the United States who are burdened by pediatric Crohn's disease (PCD) are not well understood. METHODS A retrospective review of the Texas Children's Hospital ImproveCareNow database from 2007 to 2015 was performed. CD patients with a minimum of 2-year follow-up were included if the onset of symptoms attributable to inflammatory bowel disease was clearly documented. We primarily aimed to identify race and ethnicity associations in diagnostic delay, presentation, treatment, and 2-year outcomes. We also examined early versus late diagnosis (ie, over 6 months from disease onset) associations with these variables unrelated to race/ethnicity. RESULTS One hundred and sixty-six PCD patients [57.8% non-Hispanic White (NH-White), 18.1% African American (AA), and 15.7% Hispanic] met selection criteria. Time to diagnosis was shorter in Hispanic patients ( P < 0.01) and they were older at diagnosis than NH-White patients ( P = 0.0164). AA patients (33%, P < 0.01) and Hispanic patients (35%, P < 0.05) had lower rates of granuloma detection than NH-White patients (63%). AA patients had lower rates of steroid-free remission (SFR) at 2 years than NH-White patients ( P < 0.05). Higher ESR and lower hemoglobin levels were associated with early diagnosis ( P < 0.01). Early diagnosis was associated with higher rates of surgery within 2 years of diagnosis ( P < 0.05). Diagnostic fecal calprotectin levels inversely associated with SFR at 2 years ( P < 0.05). Early use of biologics positively, and early use of corticosteroids negatively correlated with 2-year SFR ( P < 0.05). CONCLUSIONS Race and ethnicity may influence the diagnosis, treatment, and outcomes of PCD. This recognition presents a nidus toward establishing equity in PCD care.
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Affiliation(s)
- Savini Lanka Britto
- From the Section of Pediatric Gastroenterology, Texas Children's Hospital Baylor College of Medicine, Houston, TX
| | - Justin Qian
- From the Section of Pediatric Gastroenterology, Texas Children's Hospital Baylor College of Medicine, Houston, TX
| | - Faith Dorsey Ihekweazu
- From the Section of Pediatric Gastroenterology, Texas Children's Hospital Baylor College of Medicine, Houston, TX
| | - Richard Kellermayer
- From the Section of Pediatric Gastroenterology, Texas Children's Hospital Baylor College of Medicine, Houston, TX.,the USDA/ARS Children's Nutrition Research Center, Houston, TX
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12
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Illness stigma, body image dissatisfaction, thwarted belongingness and depressive symptoms in youth with inflammatory bowel disease. Eur J Gastroenterol Hepatol 2022; 34:919-924. [PMID: 35913777 DOI: 10.1097/meg.0000000000002420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Elevated depressive symptoms are observed in a significant number of youth with inflammatory bowel disease (IBD) and have been linked to illness stigma and social isolation. Body image dissatisfaction is an understudied variable in the pediatric IBD literature that may be related to both stigma and social difficulties. It is suspected that, due to the stigmatizing nature of IBD, some youth may feel self-conscious about their body image, which contributes to decreased feelings of social belongingness and ultimately depressive symptoms. The current study tested an illness stigma→ body image dissatisfaction→ thwarted belongingness→ depressive symptoms serial mediation model, in which IBD stigma was hypothesized to indirectly influence youth depressive symptoms through the sequential effects of stigma on body image dissatisfaction and thwarted social belongingness. METHODS Youth with IBD (N = 75) between 10 and 18 years old were recruited from a pediatric gastroenterology clinic and completed psychosocial measures. Disease severity was assessed by a physician global assessment. Current medications and BMI data were collected. RESULTS Analyses revealed significant direct effects among the modeled variables and a significant serial indirect path for illness stigma→ body image dissatisfaction→ thwarted belongingness→ depressive symptoms, controlling for sex, BMI and prednisone medication. CONCLUSIONS Youth who perceive greater IBD stigma are more likely to experience increased body image dissatisfaction due to their IBD, which may engender feelings of social estrangement and ultimately elevated depressive symptoms. Depressive symptoms and the psychosocial challenges faced by youth should be routinely monitored as part of comprehensive IBD management.
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13
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Li J, George Markowitz RH, Brooks AW, Mallott EK, Leigh BA, Olszewski T, Zare H, Bagheri M, Smith HM, Friese KA, Habibi I, Lawrence WM, Rost CL, Lédeczi Á, Eeds AM, Ferguson JF, Silver HJ, Bordenstein SR. Individuality and ethnicity eclipse a short-term dietary intervention in shaping microbiomes and viromes. PLoS Biol 2022; 20:e3001758. [PMID: 35998206 PMCID: PMC9397868 DOI: 10.1371/journal.pbio.3001758] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 07/14/2022] [Indexed: 11/28/2022] Open
Abstract
Many diseases linked with ethnic health disparities associate with changes in microbial communities in the United States, but the causes and persistence of ethnicity-associated microbiome variation are not understood. For instance, microbiome studies that strictly control for diet across ethnically diverse populations are lacking. Here, we performed multiomic profiling over a 9-day period that included a 4-day controlled vegetarian diet intervention in a defined geographic location across 36 healthy Black and White females of similar age, weight, habitual diets, and health status. We demonstrate that individuality and ethnicity account for roughly 70% to 88% and 2% to 10% of taxonomic variation, respectively, eclipsing the effects a short-term diet intervention in shaping gut and oral microbiomes and gut viromes. Persistent variation between ethnicities occurs for microbial and viral taxa and various metagenomic functions, including several gut KEGG orthologs, oral carbohydrate active enzyme categories, cluster of orthologous groups of proteins, and antibiotic-resistant gene categories. In contrast to the gut and oral microbiome data, the urine and plasma metabolites tend to decouple from ethnicity and more strongly associate with diet. These longitudinal, multiomic profiles paired with a dietary intervention illuminate previously unrecognized associations of ethnicity with metagenomic and viromic features across body sites and cohorts within a single geographic location, highlighting the importance of accounting for human microbiome variation in research, health determinants, and eventual therapies. Trial Registration: ClinicalTrials.gov ClinicalTrials.gov Identifier: NCT03314194.
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Affiliation(s)
- Junhui Li
- Vanderbilt Microbiome Innovation Center, Vanderbilt University, Nashville, Tennessee, United States of America
- Department of Biological Sciences, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Robert H George Markowitz
- Vanderbilt Microbiome Innovation Center, Vanderbilt University, Nashville, Tennessee, United States of America
- Department of Biological Sciences, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Andrew W Brooks
- Vanderbilt Microbiome Innovation Center, Vanderbilt University, Nashville, Tennessee, United States of America
- Department of Biological Sciences, Vanderbilt University, Nashville, Tennessee, United States of America
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Stanford University Genetics Department, Stanford University, Palo Alto, California, United States of America
| | - Elizabeth K Mallott
- Vanderbilt Microbiome Innovation Center, Vanderbilt University, Nashville, Tennessee, United States of America
- Department of Biological Sciences, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Brittany A Leigh
- Vanderbilt Microbiome Innovation Center, Vanderbilt University, Nashville, Tennessee, United States of America
- Department of Biological Sciences, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Timothy Olszewski
- Vanderbilt Microbiome Innovation Center, Vanderbilt University, Nashville, Tennessee, United States of America
- Department of Medicine, Vanderbilt University Medical Center, School of Medicine, Nashville, Tennessee, United States of America
| | - Hamid Zare
- Vanderbilt Microbiome Innovation Center, Vanderbilt University, Nashville, Tennessee, United States of America
- Institute for Software Integrated Systems, Vanderbilt University, Nashville, Tennessee, United States of America
- Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Minoo Bagheri
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Holly M Smith
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Katie A Friese
- Department of Medicine, Vanderbilt University Medical Center, School of Medicine, Nashville, Tennessee, United States of America
| | - Ismail Habibi
- School for Science and Math at Vanderbilt, Collaborative for STEM Education and Outreach, Department of Teaching and Learning, Vanderbilt University, Nashville, Tennessee, United States of America
| | - William M Lawrence
- School for Science and Math at Vanderbilt, Collaborative for STEM Education and Outreach, Department of Teaching and Learning, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Charlie L Rost
- School for Science and Math at Vanderbilt, Collaborative for STEM Education and Outreach, Department of Teaching and Learning, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Ákos Lédeczi
- Vanderbilt Microbiome Innovation Center, Vanderbilt University, Nashville, Tennessee, United States of America
- Institute for Software Integrated Systems, Vanderbilt University, Nashville, Tennessee, United States of America
- Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Angela M Eeds
- Vanderbilt Microbiome Innovation Center, Vanderbilt University, Nashville, Tennessee, United States of America
- School for Science and Math at Vanderbilt, Collaborative for STEM Education and Outreach, Department of Teaching and Learning, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Jane F Ferguson
- Vanderbilt Microbiome Innovation Center, Vanderbilt University, Nashville, Tennessee, United States of America
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Medicine, Vanderbilt University Medical Center, School of Medicine, Nashville, Tennessee, United States of America
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Vanderbilt Institute for Infection, Immunology and Inflammation, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Heidi J Silver
- Vanderbilt Microbiome Innovation Center, Vanderbilt University, Nashville, Tennessee, United States of America
- Department of Medicine, Vanderbilt University Medical Center, School of Medicine, Nashville, Tennessee, United States of America
- Tennessee Valley Healthcare System, Department of Veterans Affairs, Nashville, Tennessee, United States of America
| | - Seth R Bordenstein
- Vanderbilt Microbiome Innovation Center, Vanderbilt University, Nashville, Tennessee, United States of America
- Department of Biological Sciences, Vanderbilt University, Nashville, Tennessee, United States of America
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Vanderbilt Institute for Infection, Immunology and Inflammation, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, School of Medicine, Nashville, Tennessee, United States of America
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Taft TH, McGarva J, Omprakash TA, Tomasino K, Pandit A, Mutlu EA, Hanauer SB. Hospitalization Experiences and Post-traumatic Stress in Inflammatory Bowel Disease: Opportunities for Change. Inflamm Bowel Dis 2022; 29:675-683. [PMID: 35894686 DOI: 10.1093/ibd/izac148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Indexed: 12/09/2022]
Abstract
INTRODUCTION Medical trauma related to IBD (IBD-PTS) affects approximately 25% of patients and is associated with poor outcomes. Prior studies identify common hospitalization experiences as potentially traumatic but have not measured risk relationships for the development of IBD-PTS. We aim to investigate what aspects of hospitalizations may increase the chance of medical trauma and IBD-PTS development. METHODS Adult patients with IBD enrolled in the IBD Partners database were recruited. Study specific questionnaires included PTSD checklist, 5th edition (PCL-5), patient experience questionnaire, and items about the patient's most stressful hospitalization and nonhospital sources of medical trauma. Established criteria for the PCL-5 identified significant IBD-PTS symptoms (re-experiencing, avoidance, mood change, hyperarousal, global diagnosis). Select disease and treatment information was obtained from the main IBD Partners dataset. Univariate and multivariate statistics evaluated the relationships between hospitalization data and IBD-PTS. RESULTS There were 639 participants with at least 1 hospitalization for IBD included. Approximately two-thirds had Crohn's disease; most were White, non-Hispanic, female, middle-aged, and reported their IBD as being in remission. Forty percent of patients stated a hospitalization was a source of IBD-PTS. Frequent anxiety while hospitalized increased the odds of IBD-PTS 2 to 4 times; similar relationships existed for pain/pain control. Higher quality communication, information, and listening skills reduced the odds of IBD-PTS, albeit marginally. CONCLUSIONS Patients with IBD consistently cite hospitalizations as potential sources of medical trauma. Poorly managed anxiety and pain demonstrate the greatest chance for IBD-PTS development. Gender and racial/ethnic differences emerged for these risks. Positive interactions with the medical team may help mitigate in-hospital IBD-PTS development.
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Affiliation(s)
- Tiffany H Taft
- Northwestern University Feinberg School of Medicine, Division of Gastroenterology & Hepatology, Chicago, Illinois, USA
| | - Josie McGarva
- Northwestern University Feinberg School of Medicine, Division of Gastroenterology & Hepatology, Chicago, Illinois, USA
| | | | - Kathryn Tomasino
- Northwestern University Feinberg School of Medicine, Division of Gastroenterology & Hepatology, Chicago, Illinois, USA
| | - Anjali Pandit
- Northwestern University Feinberg School of Medicine, Division of Gastroenterology & Hepatology, Chicago, Illinois, USA
| | - Ece A Mutlu
- University of Illinois, Division of Gastroenterology, Chicago, Illinois, USA
| | - Stephen B Hanauer
- Northwestern University Feinberg School of Medicine, Division of Gastroenterology & Hepatology, Chicago, Illinois, USA
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15
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Florence-Damilola O, Aboubakr A, Anyane-Yeboa A. Inflammatory bowel disease in underserved populations: lessons for practice. Curr Opin Gastroenterol 2022; 38:321-327. [PMID: 35762691 PMCID: PMC10332404 DOI: 10.1097/mog.0000000000000855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE OF REVIEW The incidence of inflammatory bowel disease (IBD) is increasing in minority groups across the USA. There are racial and ethnic disparities in IBD care and outcomes that are rooted in historical injustice and inequities in the social determinants of health. RECENT FINDINGS Current literature has identified racial, ethnic and sociodemographic disparities in therapeutics and outcomes for IBD, including disease severity, morbidity and mortality. SUMMARY Strategies to achieve equity in IBD include tackling structural racism as a driver of health disparities and making actionable changes against multilevel barriers to care.
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Affiliation(s)
- Odufalu Florence-Damilola
- Division of GI & Liver Disease, Department of Medicine, Keck School of Medicine of USC; Los Angeles, California
| | - Aiya Aboubakr
- Department of Medicine, New York Presbyterian/Weill Cornell Medical Center; New York, NY
| | - Adjoa Anyane-Yeboa
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School; Boston, MA
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16
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The Combined Effects of Youth and Parent Illness Intrusiveness on Depressive Symptoms in Adolescents with Inflammatory Bowel Disease. J Clin Psychol Med Settings 2022; 30:238-247. [PMID: 35668287 DOI: 10.1007/s10880-022-09886-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2022] [Indexed: 10/18/2022]
Abstract
Inflammatory bowel disease (IBD) presents physical and emotional challenges for families and imposes significant lifestyle intrusions on both youth and parents. The present study examined the effects of IBD disease activity and youth illness intrusiveness on depressive symptoms in adolescents, and the moderating influence of parent illness intrusiveness on these associations. Adolescents and parents completed measures of illness intrusiveness; youth completed a measure of depressive symptoms. Physicians provided estimates of IBD disease activity. Mediation analysis revealed an IBD disease activity → youth intrusiveness → youth depressive symptoms indirect effect. Moderated mediation analyses revealed this indirect effect to be greater among youth whose parents endorsed more IBD-related intrusions. Youth encountering greater activity disruptions related to IBD are vulnerable to depressive symptoms. When parents also experience IBD-induced intrusions, youth are at even greater risk for depressive symptoms. Clinical implications are discussed within the context of youths' and parents' experiences of IBD.
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17
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Malnutrition Increases Hospital Length of Stay and Mortality among Adult Inpatients with COVID-19. Nutrients 2022; 14:nu14061310. [PMID: 35334967 PMCID: PMC8949069 DOI: 10.3390/nu14061310] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/09/2022] [Accepted: 03/11/2022] [Indexed: 12/18/2022] Open
Abstract
Background: Malnutrition has been linked to adverse health economic outcomes. There is a paucity of data on malnutrition in patients admitted with COVID-19. Methods: This is a retrospective cohort study consisting of 4311 COVID-19 adult (18 years and older) inpatients at 5 Johns Hopkins-affiliated hospitals between 1 March and 3 December 2020. Malnourishment was identified using the malnutrition universal screening tool (MUST), then confirmed by registered dietitians. Statistics were conducted with SAS v9.4 (Cary, NC, USA) software to examine the effect of malnutrition on mortality and hospital length of stay among COVID-19 inpatient encounters, while accounting for possible covariates in regression analysis predicting mortality or the log-transformed length of stay. Results: COVID-19 patients who were older, male, or had lower BMIs had a higher likelihood of mortality. Patients with malnutrition were 76% more likely to have mortality (p < 0.001) and to have a 105% longer hospital length of stay (p < 0.001). Overall, 12.9% (555/4311) of adult COVID-19 patients were diagnosed with malnutrition and were associated with an 87.9% increase in hospital length of stay (p < 0.001). Conclusions: In a cohort of COVID-19 adult inpatients, malnutrition was associated with a higher likelihood of mortality and increased hospital length of stay.
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18
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Li J, Ramgopal S, Marin JR. Racial and ethnic differences in low-value pediatric emergency care. Acad Emerg Med 2022; 29:698-709. [PMID: 35212440 DOI: 10.1111/acem.14468] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/28/2021] [Accepted: 01/06/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Disparities in health care quality frequently focus on underuse. We evaluated racial/ethnic differences in low-value services delivered in the pediatric emergency department (ED). METHODS We performed a retrospective cross-sectional study of low-value services in children discharged from 39 pediatric EDs from January 2018 to December 2019 using the Pediatric Hospital Information System. Our primary outcome was receipt of one of 12 low-value services across nine conditions, including chest radiography in asthma and bronchiolitis; beta-agonist and corticosteroids in bronchiolitis; laboratory testing and neuroimaging in febrile seizure; neuroimaging in afebrile seizure; head injury and headache; and any imaging in sinusitis, constipation, and facial trauma. We analyzed the association of race/ethnicity on receipt of low-value services using generalized linear mixed models adjusted for age, sex, weekend, hour of presentation, payment, year, household income, and distance from hospital. RESULTS We included 4,676,802 patients. Compared with non-Hispanic White (NHW) patients, non-Hispanic Black (NHB) and Hispanic patients had lower adjusted odds (aOR [95% confidence interval]) of receiving imaging for asthma (0.60 [0.56 to 0.63] NHB; 0.84 [0.79 to 0.89] Hispanic), bronchiolitis (0.84 [0.79 to 0.89] NHB; 0.93 [0.88 to 0.99] Hispanic), head injury (0.84 [0.80 to 0.88] NHB; 0.80 [0.76 to 0.84] Hispanic), headache (0.67 [0.63 to 0.72] NHB; 0.83 [0.78 to 0.88] Hispanic), and constipation (0.71 [0.67 to 0.74] NHB; 0.76 [0.72 to 0.80] Hispanic). NHB patients had lower odds (95% CI) of receiving imaging for afebrile seizures (0.89 [0.8 to 1.0]) and facial trauma (0.69 [0.60 to 0.80]). Hispanic patients had lower odds (95% CI) of imaging (0.57 [0.36 to 0.90]) and blood testing (0.82 [0.69 to 0.98]) for febrile seizures. NHB patients had higher odds (95% CI) of receiving steroids (1.11 [1.00 to 1.21]) and beta-agonists (1.38 [1.24 to 1.54]) for bronchiolitis compared with NHW patients. CONCLUSIONS NHW patients more frequently receive low-value imaging while NHB patients more frequently receive low-value medications for bronchiolitis. Our study demonstrates the differences in care across race and ethnicity extend to many services, including those of low value. These findings highlight the importance of greater understanding of the complex interaction of race and ethnicity with clinical practice.
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Affiliation(s)
- Joyce Li
- Division of Emergency Medicine, Boston Children's Hospital Harvard Medical School Boston Massachusetts USA
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Jennifer R. Marin
- Division of Pediatric Emergency Medicine UPMC Children's Hospital of Pittsburgh University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
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19
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Unaka NI, Winn A, Spinks-Franklin A, Poitevien P, Trimm F, Nuncio Lujano BJ, Turner DA. An Entrustable Professional Activity Addressing Racism and Pediatric Health Inequities. Pediatrics 2022; 149:184453. [PMID: 35001103 PMCID: PMC9647957 DOI: 10.1542/peds.2021-054604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/17/2021] [Indexed: 02/03/2023] Open
Abstract
Racism and discrimination are the root of many pediatric health inequities and are well described in the literature. Despite the pervasiveness of pediatric health inequities, we have failed to adequately educate and prepare general pediatricians and pediatric subspecialists to address them. Deficiencies within education across the entire continuum and in our health care systems as a whole contribute to health inequities in unacceptable ways. To address these deficiencies, the field of pediatrics, along with other specialties, has been on a journey toward a more competency-based approach to education and assessment, and the framework created for the future is built on entrustable professional activities (EPAs). Competency-based medical education is one approach to addressing the deficiencies within graduate medical education and across the continuum by allowing educators to focus on the desired equitable patient outcomes and then develop an approach to teaching and assessing the tasks, knowledge, skills, and attitudes needed to achieve the goal of optimal, equitable patient care. To that end, we describe the development and content of a revised EPA entitled: Use of Population Health Strategies and Quality Improvement Methods to Promote Health and Address Racism, Discrimination, and Other Contributors to Inequities Among Pediatric Populations. We also highlight the ways in which this EPA can be used to inform curricula, assessments, professional development, organizational systems, and culture change.
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Affiliation(s)
- Ndidi I. Unaka
- Division of Hospital Medicine, Cincinnati Children’s Hospital, Cincinnati, Ohio,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio,Address correspondence to Ndidi I. Unaka, MD, MEd, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, ML 5018, Cincinnati, OH 45229. E-mail:
| | - Ariel Winn
- Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Adiaha Spinks-Franklin
- Section of Developmental Pediatrics, Department of Pediatrics, Texas Children’s Hospital/Baylor College of Medicine, Houston, Texas
| | - Patricia Poitevien
- Division of Hospitalist Medicine, Department of Pediatrics, Hasbro Children’s Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Franklin Trimm
- Office of Diversity and Inclusion, Department of Pediatrics, University of South Alabama College of Medicine, Mobile, Alabama
| | | | - David A. Turner
- The American Board of Pediatrics, Chapel Hill, North Carolina
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20
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Crispo JA, Liu LJ, Noonan VK, Thorogood NP, Kwon BK, Dvorak MF, Thibault D, Willis A, Cragg JJ. Pediatric Traumatic Spinal Cord Injury in the United States: A National Inpatient Analysis. Top Spinal Cord Inj Rehabil 2022; 28:1-12. [PMID: 35145330 PMCID: PMC8791421 DOI: 10.46292/sci21-00047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Traumatic spinal cord injury (tSCI) is a debilitating neurological condition often associated with lifelong disability. Despite this, there are limited data on pediatric tSCI epidemiology in the United States. OBJECTIVES Our primary objective was to estimate tSCI hospitalization rates among children, including by age, sex, and race. Secondary objectives were to characterize tSCI hospitalizations and examine associations between sociodemographic characteristics and tSCI etiology. METHODS We used the 2016 Kids' Inpatient Database to examine tSCI hospitalizations among children (<21 years). Descriptive statistics were used to report individual and care setting characteristics for initial tSCI hospitalizations. We used Census Bureau data to estimate tSCI hospitalization rates (number of pediatric tSCI hospitalizations / number of US children) and logistic regression modeling to assess associations between documented sociodemographic characteristics and injury etiology. RESULTS There were 1.48 tSCI admissions per 100,000 children; highest rates of hospitalization involved older (15-20 years), male, and Black children. Hospitalization involving male (adjusted odds ratio [AOR] 0.43; 95% CI, 0.33-0.58) or Black (AOR 0.37; 95% CI, 0.25-0.55) children were less likely to involve a motor traffic accident. Hospitalizations of Black children were significantly more likely to have a diagnosis of tSCI resulting from a firearm incident (AOR 18.97; 95% CI, 11.50-31.28) or assault (AOR 11.76; 95% CI, 6.75-20.50) compared with hospitalizations of White children. CONCLUSION Older, male, and Black children are disproportionately burdened by tSCI. Implementation of broad health policies over time may be most effective in reducing pediatric tSCI hospitalizations and preventable injuries.
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Affiliation(s)
- James A.G. Crispo
- Collaboration for Outcomes Research and Evaluation (CORE), Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
,Human Sciences Division, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Lisa J.W. Liu
- Collaboration for Outcomes Research and Evaluation (CORE), Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
,International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
| | - Vanessa K. Noonan
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
,Praxis Spinal Cord Institute, Vancouver, British Columbia, Canada
| | | | - Brian K. Kwon
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
,Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marcel F. Dvorak
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
,Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Dylan Thibault
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
,Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Allison Willis
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
,Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jacquelyn J. Cragg
- Collaboration for Outcomes Research and Evaluation (CORE), Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
,International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
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21
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Racial differences in the outcomes of IBD hospitalizations: a national population-based study. Int J Colorectal Dis 2022; 37:221-229. [PMID: 34694440 DOI: 10.1007/s00384-021-04052-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE There are scarce data describing the outcomes of hospitalized patients admitted with inflammatory bowel disease (IBD) stratified by race. In this retrospective cohort study, we evaluated the difference in outcomes between adult white and black patients hospitalized with a principal diagnosis of inflammatory bowel disease. METHODS Data were obtained from the 2016 and 2017 National Inpatient Sample (NIS) database. Our primary outcome was inpatient mortality while the secondary outcomes were hospital length of stay (LOS), total hospital charges (THC), red blood cell (RBC) transfusion, diagnosis of bowel perforation, and severe sepsis with septic shock. We conducted the analysis using STATA software. We used propensity-matched multivariate regression analysis to adjust for potential confounders. RESULTS Among 71 million hospital hospitalizations, we found 177,574 hospitalizations with a principal diagnosis of IBD, with 24,635 (13.9%) for black patients, 124,899 (70.3%) for white patients, and 28,040 (15.8%) were for others. There was no significant difference in inpatient mortality for black vs white patients. Among secondary outcomes, white compared to black patients had increased odds of having a diagnosis of bowel perforation when admitted with a diagnosis of IBD while there was no difference in the odds of developing septic shock. White patients admitted with a diagnosis of UC were also found to have increased total LOS and THC. CONCLUSION White patients hospitalized with a principal diagnosis of IBD had no difference in inpatient mortality or septic shock but had worse outcomes such as increased odds of bowel perforation compared to black patients.
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Daniel R, Jimenez J, Pall H. Health Equity and Social Determinants of Health in Pediatric Gastroenterology. Pediatr Clin North Am 2021; 68:1147-1155. [PMID: 34736581 DOI: 10.1016/j.pcl.2021.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Social determinants of health (SDH) as outlined by Healthy People 2020 encompasses 5 key domains: economic, education, social and community context, health and health care, and neighborhood and built environment. This article emphasizes pediatric populations and some of the existing SDH and health care disparities seen in pediatric gastroenterology. We specifically review inflammatory bowel disease, endoscopy, bariatric surgery, and liver transplantation. We also examine the burgeoning role of telehealth that has become commonplace since the coronavirus disease 2019 era.
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Affiliation(s)
- Rhea Daniel
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, McGovern Medical School, University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, TX 70007, USA
| | - Jennifer Jimenez
- Department of Pediatrics, Hackensack Meridian School of Medicine, Nutley, NJ, USA; Department of Pediatrics, K. Hovnanian Children's Hospital at Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Harpreet Pall
- Department of Pediatrics, Hackensack Meridian School of Medicine, Nutley, NJ, USA; Department of Pediatrics, K. Hovnanian Children's Hospital at Jersey Shore University Medical Center, Neptune, NJ, USA.
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Racial and Socioeconomic Disparities in Hospitalization of Pediatrics with Liver Disease from 2005 to 2015. Dig Dis Sci 2021; 66:2240-2249. [PMID: 32797346 DOI: 10.1007/s10620-020-06530-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/30/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Adult liver-related hospitalizations have recently increased in the USA, but data are limited for the pediatric population. AIMS Utilizing the Office of Statewide Health Planning and Development hospital claims database (covering > 98% of all California hospitalizations), we aimed to characterize the demographic, clinical, and socioeconomic factors of liver disease-associated admissions among children between 2005 and 2015. METHODS We used ICD-9 codes to identify admissions associated with liver disease in patients up to 21 years of age. Patient characteristics were described as percentages and evaluated using the χ2 test. We used linear regression to examine changes over time. RESULTS We analyzed 37,372 eligible admissions. Overall, close to one-third (28%) and one-half (48.0%) of admissions occurred in the age group 0-5 years and 16-21 years, respectively, with the remaining 23.1% occurring in the age group between 5 and 15 years. Over half (54.9%) were in males. By race, blacks made up half of the admission (49.7%), while by ethnicity, Hispanic also accounted for half of the admission (49.7%). Medicaid and Medicare payors were also disproportionately represented (54.6%). The most common liver disease was Alagille syndrome (29.2%) in 2005. Between 2005 and 2015, both the number of pediatric liver-associated admissions and the proportion of pediatric liver admissions over total admissions increased from 3130 to 3429 and 1.2% to 1.6%, respectively (both p = 0.001). By 2015, while Alagille syndrome admissions decreased to 26.4% (p = 0.004), NAFLD admission increased to 19.7% (p < 0.001). CONCLUSION Major disparities exist in inpatient liver disease burden for blacks and Hispanics with liver disease, while NAFLD emerged as a rapidly rising liver disease in pediatrics.
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Anyane-Yeboa A, Li B, Traboulsi C, Erondu AI, Sossenheimer P, Rai V, Rubin DT. Black Race and Public Insurance Are Predictive of Inappropriate Evaluation of Iron Deficiency Anemia and Diarrhea. Dig Dis Sci 2021; 66:2200-2206. [PMID: 32638203 DOI: 10.1007/s10620-020-06434-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 06/21/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND AIMS Socioeconomic status, race, and insurance can impact healthcare delivery and utilization in several chronic disease states. The primary aim of our study was to determine whether race and insurance status are predictors of having an appropriate workup for celiac disease and inflammatory bowel disease (IBD) when presenting with iron deficiency anemia (IDA) and chronic diarrhea. METHODS Medical records of patients seen at the University of Chicago Medical Center between January 1, 2006, and September 20, 2017, were reviewed. Patients with two separate encounters within 6 months associated with the diagnosis codes for both IDA and chronic diarrhea were identified. Patients without a diagnosis code for IBD and celiac disease were further grouped as those that had an "appropriate" workup and those that did not. Factors associated with the appropriate evaluation were analyzed by univariate and multivariate logistic regression. RESULTS In total, 899,701 records were searched. A total of 83 patients fit inclusion into the study (8 IBD, 3 CD, 72 neither IBD or CD). Black race was associated with a 91% decreased odds of having the appropriate workup on univariate (OR 0.090, 95%CI 0.017-0.475, p = 0.005) and age-adjusted multivariate analysis (OR 0.095, 95% CI 0.017-0.527, p = 0.007). Public insurance status was significantly associated with a 90% decreased odds of appropriate workup on univariate (OR 0.102, 95% CI 0.024-0.438, p = 0.002) and age-adjusted multivariate analysis (OR 0.104, 95% CI 0.021-0.513, p = 0.005). CONCLUSIONS Black race and public insurance were significantly associated with not having an appropriate workup for IBD and celiac disease when presenting with iron deficiency and chronic diarrhea.
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Affiliation(s)
- Adjoa Anyane-Yeboa
- Section of Gastroenterology, Hepatology and Nutrition, The University of Chicago Medicine, 5841 S. Maryland Ave. MC 4076, Chicago, IL, 60637, USA
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Betty Li
- Section of Gastroenterology, Hepatology and Nutrition, The University of Chicago Medicine, 5841 S. Maryland Ave. MC 4076, Chicago, IL, 60637, USA
| | - Cindy Traboulsi
- Section of Gastroenterology, Hepatology and Nutrition, The University of Chicago Medicine, 5841 S. Maryland Ave. MC 4076, Chicago, IL, 60637, USA
| | - Amarachi I Erondu
- Section of Gastroenterology, Hepatology and Nutrition, The University of Chicago Medicine, 5841 S. Maryland Ave. MC 4076, Chicago, IL, 60637, USA
| | - Philip Sossenheimer
- Section of Gastroenterology, Hepatology and Nutrition, The University of Chicago Medicine, 5841 S. Maryland Ave. MC 4076, Chicago, IL, 60637, USA
| | - Victoria Rai
- Section of Gastroenterology, Hepatology and Nutrition, The University of Chicago Medicine, 5841 S. Maryland Ave. MC 4076, Chicago, IL, 60637, USA
| | - David T Rubin
- Section of Gastroenterology, Hepatology and Nutrition, The University of Chicago Medicine, 5841 S. Maryland Ave. MC 4076, Chicago, IL, 60637, USA.
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25
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Diaz A, Dalmacy D, Herbert C, Mirdad RS, Hyer JM, Pawlik TM. Association of County-Level Racial Diversity and Likelihood of a Textbook Outcome Following Pancreas Surgery. Ann Surg Oncol 2021; 28:8076-8084. [PMID: 34143339 PMCID: PMC8212582 DOI: 10.1245/s10434-021-10316-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 05/01/2021] [Indexed: 12/29/2022]
Abstract
Introduction Residential racial desegregation has demonstrated improved economic and education outcomes. The degree of racial community segregation relative to surgical outcomes has not been examined. Patients and Methods Patients undergoing pancreatic resection between 2013 and 2017 were identified from Medicare Standard Analytic Files. A diversity index for each county was calculated from the American Community Survey. Multivariable mixed-effects logistic regression with a random effect for hospital was used to measure the association of the diversity index level with textbook outcome (TO). Results Among the 24,298 Medicare beneficiaries who underwent a pancreatic resection, most patients were male (n = 12,784, 52.6%), White (n = 21,616, 89%), and had a median age of 72 (68–77) years. The overall incidence of TO following pancreatic surgery was 43.3%. On multivariable analysis, patients who resided in low-diversity areas had 16% lower odds of experiencing a TO following pancreatic resection compared with patients from high-diversity communities (OR 0.84, 95% CI 0.72–0.98). Compared with patients who resided in the high-diversity areas, individuals who lived in low-diversity areas had higher odds of 90-day readmission (OR 1.16, 95% CI 1.03–1.31) and had higher odds of dying within 90 days (OR 1.85, 95% CI 1.45–2.38) (both p < 0.05). Nonminority patients who resided in low-diversity areas also had a 14% decreased likelihood to achieve a TO after pancreatic resection compared with nonminority patients in high-diversity areas (OR 0.86, 95% CI 0.73–1.00). Conclusion Patients residing in the lowest racial/ethnic integrated counties were considerably less likely to have an optimal TO following pancreatic resection compared with patients who resided in the highest racially integrated counties. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-10316-3.
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Affiliation(s)
- Adrian Diaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA. .,National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA. .,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.
| | - Djhenne Dalmacy
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Chelsea Herbert
- Ohio University Heritage College of Osteopathic Medicine, Dublin, OH, USA
| | | | - J Madison Hyer
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
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26
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Qazi T, Smith A, Alexander M, Hammer D, Wu T, Auerbach S, Noronha A, Wasan S, Jones E, Weinberg J, Farraye FA. Disparities in Objective Sleep Quality as Assessed Through Wrist Actigraphy in Minority Patients With Inflammatory Bowel Disease. Inflamm Bowel Dis 2021; 27:371-378. [PMID: 32448906 DOI: 10.1093/ibd/izaa106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Indexed: 12/09/2022]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) is associated with a reduced quality of life. Minority patients with IBD specifically report more impairing symptoms compared with nonminority patients. Sleep quality, a key component of quality of life, is significantly compromised in minority patients compared with nonminority patients. Nevertheless, subjective and objective sleep assessments in minority patients with IBD have not explicitly been assessed. The purpose of this prospective cohort study is to assess and compare objective sleep parameters utilizing wrist actigraphy between minority and nonminority IBD patients. METHODS In this institutional review board approved study, 74 patients with IBD were recruited and stratified into 2 cohorts by self-identification: white nonminority patients and minority patients. Patients in the minority cohort included black and Hispanic individuals (black and nonblack). Exclusion criteria included significant comorbidity, a history of an underlying sleep disorder, or patients who did not self-identify into categorized cohorts. Sleep was measured not only through wrist-based actigraphy but also with sleep surveys. Sleep parameters were compared between minority and nonminority cohorts. Regression analyses were performed to assess for factors independently associated with parameters of poor sleep quality. RESULTS Sixty-four patients (86.4%) were included in the final analysis. Thirty-one individuals (48.4%) were categorized into the nonminority cohort, and 33 (51.6%) patients were in the minority cohort. A significantly higher number of minority patients had poorer sleep efficiency and fragmented sleep compared with nonminority patients (90.9% vs 67.7%; P = 0.03 and 87.8% vs 61.3%; P = 0.02). In the adjusted analysis, minority status was independently associated with poor sleep efficiency (odds ratio = 6.41; 95% confidence interval, 1.48-28.17; P = 0.0139) and fragmented sleep (odds ratio = 4.98; 95% confidence interval, 1.09-22.89; P = 0.0389). CONCLUSIONS Minority patients with IBD were shown to have poorer objective measures of sleep as assessed through wrist actigraphy compared to nonminority patients. Cultural competency in the care of minority patients with IBD, specifically focusing on the management of psychosocial issues, is needed to address these disparities in sleep. The inclusion of minority patients with IBD in studies investigating sleep and other psychosocial issues are warranted not only to assess potential disparities in disease course but also to determine the etiologies of poor sleep in minority patients with IBD.
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Affiliation(s)
- Taha Qazi
- Cleveland Clinic, Digestive Disease and Surgery Institute, Cleveland, Ohio, USA
| | - Alexander Smith
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Megan Alexander
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - David Hammer
- Department of Neurology, Boston University School of Medicine and Sleep Disorders Center, Boston Medical Center, Boston, Massachusetts, USA
| | - Ting Wu
- Department of Neurology, Boston University School of Medicine and Sleep Disorders Center, Boston Medical Center, Boston, Massachusetts, USA
| | - Sanford Auerbach
- Department of Neurology, Boston University School of Medicine and Sleep Disorders Center, Boston Medical Center, Boston, Massachusetts, USA
| | - Ansu Noronha
- Section of Gastroenterology, Boston Medical Center, Boston, Massachusetts, USA
| | - Sharmeel Wasan
- Section of Gastroenterology, Boston Medical Center, Boston, Massachusetts, USA
| | - Eric Jones
- Boston University School of Public Health, Department of Biostatistics, Boston, Massachusetts, USA
| | - Janice Weinberg
- Boston University School of Public Health, Department of Biostatistics, Boston, Massachusetts, USA
| | - Francis A Farraye
- Section of Gastroenterology, Boston Medical Center, Boston, Massachusetts, USA.,Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
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Barnes EL, Loftus EV, Kappelman MD. Effects of Race and Ethnicity on Diagnosis and Management of Inflammatory Bowel Diseases. Gastroenterology 2021; 160:677-689. [PMID: 33098884 DOI: 10.1053/j.gastro.2020.08.064] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/07/2020] [Accepted: 08/15/2020] [Indexed: 02/07/2023]
Abstract
Although Crohn's disease (CD) and ulcerative colitis (UC) have been considered as disorders that affect individuals of European ancestry, the epidemiology of the inflammatory bowel diseases (IBDs) is changing. Coupled with the increasing incidence of IBD in previously low-incidence areas, the population demographics of IBD in the United States are also changing, with increases among non-White races and ethnicities. It is therefore important to fully understand the epidemiology and progression of IBD in different racial and ethnic groups, and the effects of race and ethnicity on access to care, use of resources, and disease-related outcomes. We review differences in IBD development and progression among patients of different races and ethnicities, discussing the effects of factors such as access to care, delays in diagnosis, and health and disease perception on disparities in IBD care and outcomes. We identify research priorities for improving health equity among minority patients with IBD.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Michael D Kappelman
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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28
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Dos Santos Marques IC, Theiss LM, Wood LN, Gunnells DJ, Hollis RH, Hardiman KM, Cannon JA, Morris MS, Kennedy GD, Chu DI. Racial disparities exist in surgical outcomes for patients with inflammatory bowel disease. Am J Surg 2020; 221:668-674. [PMID: 33309255 DOI: 10.1016/j.amjsurg.2020.12.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 12/03/2020] [Accepted: 12/03/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Racial disparities in surgical outcomes exist for Black patients with IBD compared to White patients. However, previous studies fail to include other racial/ethnic populations. We hypothesized these disparities exist for Hispanic and Asian patients. METHODS This is a retrospective cohort study of patients undergoing surgery for IBD using the American College of Surgeons National Surgical Quality Improvement Program (ACS- NSQIP) database (2005-2017). Bivariate comparisons and adjusted multivariable regressions were performed to evaluate associations between race and outcomes. RESULTS Of 23,901 patients with IBD, the racial/ethnic makeup were: 88.7% White, 7.6% Black, 2.4% Hispanic and 1.4% Asian. Overall mean LOS was 8 days (SD 8.2) and significantly varied between groups (8d for White, 10d for Black, 8.5d for Hispanic, and 11.1d for Asian; p < 0.001). Hispanic patients had the highest odds of readmission (OR: 1.4; 95% CI 1.1-1.8). Black patients had increased odds of renal insufficiency (OR: 1.8; 95% CI 1.1-2.9), bleeding requiring transfusions (OR: 1.7; 95% CI 1.4-1.9), and sepsis (OR: 1.7; 95% CI 1.4-2.02) compared to White patients. CONCLUSIONS Racial disparities exist among IBD patients undergoing surgery. Black, Hispanic and Asian IBD patients experience major disparities in post-operative complications, readmissions and LOS, respectively, when compared to White patients with IBD. Future research is needed to better understand the mechanisms of these disparities including evaluation of social determinants of health.
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Affiliation(s)
| | - Lauren M Theiss
- Division of Gastrointestinal Surgery, University of Alabama at Birmingham, Birmingham, AL, United States.
| | - Lauren N Wood
- Division of Gastrointestinal Surgery, University of Alabama at Birmingham, Birmingham, AL, United States.
| | - Drew J Gunnells
- Division of Gastrointestinal Surgery, University of Alabama at Birmingham, Birmingham, AL, United States.
| | - Robert H Hollis
- Division of Gastrointestinal Surgery, University of Alabama at Birmingham, Birmingham, AL, United States.
| | - Karin M Hardiman
- Division of Gastrointestinal Surgery, University of Alabama at Birmingham, Birmingham, AL, United States.
| | - Jamie A Cannon
- Division of Gastrointestinal Surgery, University of Alabama at Birmingham, Birmingham, AL, United States.
| | - Melanie S Morris
- Division of Gastrointestinal Surgery, University of Alabama at Birmingham, Birmingham, AL, United States.
| | - Gregory D Kennedy
- Division of Gastrointestinal Surgery, University of Alabama at Birmingham, Birmingham, AL, United States.
| | - Daniel I Chu
- Division of Gastrointestinal Surgery, University of Alabama at Birmingham, Birmingham, AL, United States.
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McLoughlin RJ, Klouda A, Hirsh MP, Cleary MA, Lightdale JR, Aidlen JT. Socioeconomic disparities in the comorbidities and surgical management of pediatric Crohn's disease. Pediatr Res 2020; 88:887-893. [PMID: 32170190 DOI: 10.1038/s41390-020-0830-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 01/02/2020] [Accepted: 02/12/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND To examine differences in comorbidities and surgical management based on socioeconomics in hospitalized children with Crohn's disease (CD). METHODS Using the Kids' Inpatient Database for 2006-2012, we identified patients (<21 years) with a CD diagnosis. Cases were analyzed and stratified by median parental income by zip code. Multivariable logistic regression was performed. RESULTS Of the 28,337 pediatric CD hospitalizations identified, patients were more likely male (51.1%), non-Hispanic white (71.3%), and had a mean age of 15.9 years. The proportion of minority patients increased as income quartile declined. Higher income quartile patients were more likely to be coded with anxiety and less likely with anemia. The highest income quartile was more likely to have a bowel obstruction, and peritoneal/intestinal abscess and was also 28% more likely to undergo a major surgical procedure. CONCLUSIONS Significant variability exists in the reported comorbidities and surgical interventions associated with CD by income quartile. Lower income quartile patients are more likely to be of minority ethnicity and anemic, but less likely to undergo a major surgical procedure. Further investigation is warranted to determine whether these differences represent disease variability, differences in healthcare resource allocation, or implicit bias in management. IMPACT There is a disparity in the care of children and young adults with Crohn's disease based on parental income. Links between parental income and the treatment of Crohn's disease in children and young adults has not been assessed in national datasets in the United States. Children in the highest income quartile were more likely to undergo a major surgical procedure. The variations in healthcare for hospitalized children and young adults with CD found in this study may represent variability in patient disease, implicit bias, or a disparity in healthcare delivery across the United States.
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Affiliation(s)
- Robert J McLoughlin
- Department of General Surgery, University of Massachusetts Medical School, Worcester, MA, USA.
| | - Anna Klouda
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Michael P Hirsh
- Division of Pediatric Surgery, University of Massachusetts Children's Medical Center, Worcester, MA, USA
| | - Muriel A Cleary
- Division of Pediatric Surgery, University of Massachusetts Children's Medical Center, Worcester, MA, USA
| | - Jenifer R Lightdale
- Division of Pediatric Gastroenterology and Nutrition, University of Massachusetts Children's Medical Center, Worcester, MA, USA
| | - Jeremy T Aidlen
- Division of Pediatric Surgery, University of Massachusetts Children's Medical Center, Worcester, MA, USA
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30
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Grossman A, Mauer E, Gerber LM, Long MD, Kappelman MD, Gupta N. Black/African American Patients with Pediatric Crohn's Disease Report Less Anxiety and Fatigue than White Patients. J Pediatr 2020; 225:146-151. [PMID: 32544479 DOI: 10.1016/j.jpeds.2020.05.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 05/18/2020] [Accepted: 05/20/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To compare patient-reported outcomes in black/African American patients with white patients participating in IBD Partners Kids & Teens, in order to identify possible racial healthcare disparities in pediatric inflammatory bowel disease (IBD) as future targets for improvement. STUDY DESIGN This was a cross-sectional analysis comparing patient-reported outcomes in black/African American patients with white patients, aged 9-18 years, with IBD participating in the IBD Partners Kids & Teens cohort from August 2013 to April 2018. Secondary outcomes included number of IBD-related hospitalizations and surgeries, current medication use, and disease activity. RESULTS We included 401 patients with Crohn's disease (white = 378 [94%]; black/African American = 23 [6%]). For children with Crohn's disease, black/African American patients compared with white patients reported less anxiety (40.7 vs 47.5, P = .001) and fatigue (44.3 vs 48.4, P = .047) despite more frequently reported treatment with biologics (91% vs 61%, P = .006) and antibiotics (17% vs 5%, P = .03) and history of hospitalizations (81% vs 52%, P = .02). CONCLUSIONS Black/African American children with Crohn's disease were less likely to report anxiety or fatigue than white patients, despite an apparent more severe disease course reflected by greater reported frequency of treatment with biologics and antibiotics and history of hospitalizations.
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Affiliation(s)
| | - Elizabeth Mauer
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY
| | - Linda M Gerber
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY
| | - Millie D Long
- Department of Internal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC; Center for Gastrointestinal Biology and Disease, Chapel Hill, NC
| | - Michael D Kappelman
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC; Center for Gastrointestinal Biology and Disease, Chapel Hill, NC
| | - Neera Gupta
- Department of Pediatrics, Weill Cornell Medicine, New York, NY.
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31
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Nguyen NH, Koola J, Dulai PS, Prokop LJ, Sandborn WJ, Singh S. Rate of Risk Factors for and Interventions to Reduce Hospital Readmission in Patients With Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol 2020; 18:1939-1948.e7. [PMID: 31470176 PMCID: PMC7044053 DOI: 10.1016/j.cgh.2019.08.042] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/15/2019] [Accepted: 08/21/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We investigated 30- and 90-day rates and causes of, risk factors for, and interventions to reduce hospital readmission in patients who received medical treatment for inflammatory bowel diseases (IBD). METHODS We performed a systematic search of publications through July 1, 2018 for studies of rates of hospital readmission and associated causes and risk factors in patients who received medical treatments for IBD. Our final analysis included 17 cohort studies (6324 patients) of hospitalized adults with IBD who had received medical treatment, along with reported readmission rates with detailed chart review. We performed random effects meta-analysis to estimate 30- and 90-day rates of readmission and identified causes and risk factors associated with readmission. We also performed qualitative analyses of studies that focused on interventions to reduce readmission. RESULTS Overall, the 30-day rate of readmission was 18.1% (95% CI, 14.4-22.4) and the 90-day rate was 26.0% (95% CI, 22.7-29.6). On meta-regression, studies with higher proportions of patients with ulcerative colitis than Crohn's disease reported higher risks for readmission. Most common reasons for readmission were IBD flare, infection, or complications from unplanned surgeries during hospitalizations. Consistent risk factors for 30-day readmission were admission for pain control (odds ratio [OR], 2.27; 95% CI, 1.69-3.03), need for total parenteral nutrition on discharge (OR, 2.13; 95% CI, 1.36-3.35), and prior or unplanned surgery during admission (OR, 3.11; 95% CI, 2.27-4.25). Only 1 study focused on interventions (specialized inpatient IBD service) to reduce risk of readmission. CONCLUSIONS Overall 30- and 90-day rates of readmission for patients who received medical treatment for IBD are 18.1% and 26.0%, respectively. IBD flares and infections are common reasons for readmission, and inadequate pain control and need for parenteral nutrition were common risk factors. Interventional studies to reduce risk of readmission are needed.
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Affiliation(s)
- Nghia H. Nguyen
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Jejo Koola
- Division of Hospital Medicine, Department of Medicine, University of California San Diego, La Jolla, California,Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, California
| | - Parambir S. Dulai
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Larry J. Prokop
- Department of Library Services, Mayo Clinic, Rochester, Minnesota
| | - William J. Sandborn
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Siddharth Singh
- Division of Gastroenterology, University of California, San Diego, La Jolla, California; Division of Biomedical Informatics, Department of Medicine, University of California, San Diego, La Jolla, California.
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Denning NL, Glick RD, Rich BS. Outpatient follow-up after pediatric surgery reduces emergency department visits and readmission rates. J Pediatr Surg 2020; 55:1037-1042. [PMID: 32171531 DOI: 10.1016/j.jpedsurg.2020.02.050] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 02/20/2020] [Indexed: 11/19/2022]
Abstract
PURPOSE The factors affecting outpatient follow-up (OFU) after pediatric surgery have not been well studied. We evaluate factors impacting OFU and the effect of OFU in pediatric surgical patients. METHODS A retrospective review of all pediatric patients operated on by the Division of Pediatric Surgery from February 1st to September 30th, 2017, and subsequently discharged was performed. RESULTS 1242 patients were identified. Overall OFU was 69.6%. Language and distance between patient residence and the hospital had no impact on OFU. Inpatient surgical patients followed-up at a higher rate than ambulatory surgical patients (72.7% vs 64.8%, p < 0.01). Out-of-system transfers had the lowest OFU rate at 52.8% (p < 0.001). Insurance type and patient age had a significant impact on OFU rates. Thirty-day ED visit and readmission rates were significantly lower in those patients with OFU than in those without (8.8% vs 12.7%, p = 0.04 and 3.7% to 11.0%, p < 0.001, respectively). OFU was more beneficial in patients with inpatient procedures or longer hospitalization lengths of stay than in the cohort of ambulatory patients. CONCLUSIONS Socioeconomic status, hospital presentation, and procedural complexity influenced rates of OFU. OFU was associated with significant reductions in 30-day ED visits and readmissions, and this benefit was more pronounced for complex procedures or patients. TYPE OF STUDY Retrospective review. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Naomi-Liza Denning
- Cohen Children's Medical Center, Division of Pediatric Surgery, Northwell Health, 269-01 76(th) Ave, Queens, NY 11040
| | - Richard D Glick
- Cohen Children's Medical Center, Division of Pediatric Surgery, Northwell Health, 269-01 76(th) Ave, Queens, NY 11040
| | - Barrie S Rich
- Cohen Children's Medical Center, Division of Pediatric Surgery, Northwell Health, 269-01 76(th) Ave, Queens, NY 11040.
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Adler J, Lin CC, Gadepalli SK, Dombkowski KJ. Association Between Steroid-Sparing Therapy and the Risk of Perianal Fistulizing Complications Among Young Patients With Crohn Disease. JAMA Netw Open 2020; 3:e207378. [PMID: 32515798 PMCID: PMC7284306 DOI: 10.1001/jamanetworkopen.2020.7378] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE Perianal fistulizing complications (PFCs) develop in 15% to 30% of patients with Crohn disease (CD), are difficult to treat, worsen quality of life, increase cost of care, and commonly recur. Evidence-based strategies to prevent PFCs are lacking. OBJECTIVES To investigate the effectiveness of medical therapy for reducing risk of PFCs among young people with CD and to test the hypothesis that steroid-sparing therapy (SST) use would be associated with reduced risk of PFC development. DESIGN, SETTING, AND PARTICIPANTS In this comparative effectiveness analysis of commercial administrative claims from January 1, 2001, through June 30, 2016, patients who did or did not initiate SST were matched via propensity score to adjust for all available confounders. Using Optum's Clinformatics Data Mart, a deidentified database of US commercial administrative claims, all patients aged 5 to 24 years with CD (January 1, 2001, through June 30, 2016) were identified. The index date was the CD diagnosis date. Patients with PFCs or SST use at or before CD diagnosis were excluded. The dates of analysis were October 2017 to February 2020. EXPOSURES The primary exposure of interest was SST initiation, including immunomodulators and/or anti-tumor necrosis factor α (anti-TNFα) medications, initiated before either PFC development or the end of the study period. MAIN OUTCOMES AND MEASURES The primary outcome was PFC development. Propensity score matching was used to balance baseline characteristics. Cox proportional hazards multivariable regression analyses were used to estimate hazard ratios (HRs) with 95% CIs for PFC development. RESULTS Among 2214 young people with CD without PFCs identified, the mean (SD) age at CD diagnosis was 17.0 (4.5) years, and 1151 (52.0%) were male. Among the cohort, 1242 patients (56.1%) initiated SST before PFC development or the end of 24-month follow-up. After propensity score matching, 972 patients remained in each treatment group. Overall, 384 of 1944 (19.8%) developed PFCs within 2 years of the index date. The use of SST was associated with a 59% decreased risk of PFC development (hazard ratio [HR], 0.41; 95% CI, 0.33-0.52; P < .001) in 2 years compared with no SST use. Among those who developed PFCs, 55% fewer SST users underwent ostomy than SST nonusers. The use of immunomodulators alone, anti-TNFα alone, and combination therapy was associated with 52% (HR, 0.48; 95% CI, 0.37-0.62; P < .001), 47% (HR, 0.53; 95% CI, 0.36-0.78; P = .001), and 83% (HR, 0.17; 95% CI, 0.09-0.30; P < .001) reductions in the risk of 2-year PFC development, respectively, compared with no SST use. CONCLUSIONS AND RELEVANCE In this study, PFC development was common among young patients with CD. The use of SST was lower than expected. Compared with no SST, patients who initiated SST were 59% less likely to develop PFCs and fewer underwent ostomy. These results indicate that PFCs may be preventable and emphasize the importance of considering SST for all patients with CD.
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Affiliation(s)
- Jeremy Adler
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of Michigan, Ann Arbor
- Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Chun Chieh Lin
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Neurology, University of Michigan, Ann Arbor
| | - Samir K. Gadepalli
- Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Division of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor
| | - Kevin J. Dombkowski
- Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
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Barnes EL, Bauer CM, Sandler RS, Kappelman MD, Long MD. Black and White Patients With Inflammatory Bowel Disease Show Similar Biologic Use Patterns With Medicaid Insurance. Inflamm Bowel Dis 2020; 27:364-370. [PMID: 32405642 PMCID: PMC7885313 DOI: 10.1093/ibd/izaa090] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Prior studies have identified racial disparities in the treatment and outcomes of inflammatory bowel disease (IBD). These disparities could be secondary to differences in biology, care delivery, or access to appropriate therapy. The primary aim of this study was to compare medication use among Medicaid-insured black and white patients with IBD, given uniform access to gastroenterologists and therapies. METHODS We analyzed Medicaid Analytic eXtract data from 4 states (California, Georgia, North Carolina, and Texas) between 2006 and 2011. We compared the use of IBD-specific therapies, including analyses of postoperative therapy among patients with Crohn disease (CD). We performed bivariate analyses and multivariable logistic regression, adjusting for potential confounders. RESULTS We identified 14,735 patients with IBD (4672 black [32%], 8277 with CD [58%]). In multivariable analysis, there was no significant difference in the odds of anti-tumor necrosis factor use by race for CD (adjusted odds ratio [aOR] = 1.13; 95% confidence interval [CI], 0.99-1.28] or ulcerative colitis (aOR = 1.12; 95% CI, 0.96-1.32). Black patients with CD were more likely than white patients to receive combination therapy (aOR = 1.50; 95% CI, 1.15-1.96), and black patients were more likely than white patients to receive immunomodulator monotherapy after surgery for CD (31% vs 18%; P = 0.004). CONCLUSIONS In patients with Medicaid insurance, where access to IBD-specific therapy should be similar for all individuals, there was no significant disparity by race in the utilization of IBD-specific therapies. Disparities in IBD treatment discussed in prior literature seem to be driven by socioeconomic or other issues affecting access to care.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA,Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA,Address correspondence to: Edward L. Barnes, MD, MPH, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Campus Box #7080, 130 Mason Farm Road, Chapel Hill, NC 27599-7080 ()
| | - Christina M Bauer
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA,Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Robert S Sandler
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michael D Kappelman
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA,Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Millie D Long
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA,Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Agrawal M, Cohen-Mekelburg S, Kayal M, Axelrad J, Galati J, Tricomi B, Kamal K, Faye AS, Abrudescu P, Scherl E, Lawlor G, Sultan K, Lukin D, Colombel JF, Ungaro RC. Disability in inflammatory bowel disease patients is associated with race, ethnicity and socio-economic factors. Aliment Pharmacol Ther 2019; 49:564-571. [PMID: 30663075 DOI: 10.1111/apt.15107] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 10/22/2018] [Accepted: 11/30/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Race, ethnicity and socio-economic status impact clinical outcomes in inflammatory bowel disease (IBD) patients. However, their impact on disability has not been studied. AIM To determine the association between race, ethnicity and socio-economic factors with disability in IBD, using the validated IBD disability index (IBD-DI). METHODS Ambulatory IBD patients were enrolled at five academic centres participating in the New York Crohn's and Colitis Organization. We assessed the IBD-DI, and collected clinical and socio-economic data. Factors associated with moderate-to-severe disability (IBD-DI score > 35) on univariable analysis were tested in multivariable models with adjusted odds ratios (aOR) and 95% confidence intervals (CI) reported. RESULTS In this study, 323 patients (57.3% CD, 51.4% female) were enrolled; 17.7% were Hispanic, 17% were non-Hispanic black, 56.0% were non-Hispanic Caucasian and 9.3% belonged to non-Hispanic non-black minority races. However, 39.0% of patients were publicly insured and 38.4% of patients had low annual household income (<$50 000). 100 (31.0%) patients reported moderate-to-severe disability. On multivariable analysis, Hispanic ethnicity (aOR 2.7, 95% CI 1.3-5.6), non-Hispanic non-black minority race (aOR 3.5, 95% CI 1.3-8.9), public payer (aOR 2.1, 95% CI 1.1-4.0) and low annual household income (aOR 3.0, 95% CI 1.7-5.4) were associated with moderate-to-severe disability controlling for disease characteristics. CONCLUSIONS IBD patients who are minorities, have public insurance, or low household income, are 2-3 times more likely to report moderate-to-severe disability independent of disease characteristics in the United States. Future studies are needed to study their complex relationship and to mitigate disability.
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Affiliation(s)
- Manasi Agrawal
- Division of Gastroenterology, Montefiore Medical Center, Bronx, New York.,Division of Gastroenterology, Lenox Hill Hospital, New York, New York
| | | | - Maia Kayal
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York
| | - Jordan Axelrad
- Division of Gastroenterology and Hepatology, Columbia University Medical Center, New York, New York.,Division of Gastroenterology and Hepatology, New York University Langone Medical Center, New York, New York
| | - Jonathan Galati
- Division of Gastroenterology and Hepatology, Weil Cornell Medical Center, New York, New York
| | - Brad Tricomi
- Albert Einstein College of Medicine, Bronx, New York
| | - Kanika Kamal
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York
| | - Adam S Faye
- Division of Gastroenterology and Hepatology, Columbia University Medical Center, New York, New York
| | - Paul Abrudescu
- Division of Gastroenterology and Hepatology, Northwell University, Long Island, New York
| | - Ellen Scherl
- Division of Gastroenterology and Hepatology, Weil Cornell Medical Center, New York, New York
| | - Garrett Lawlor
- Division of Gastroenterology and Hepatology, Columbia University Medical Center, New York, New York
| | - Keith Sultan
- Division of Gastroenterology and Hepatology, Northwell University, Long Island, New York
| | - Dana Lukin
- Division of Gastroenterology, Montefiore Medical Center, Bronx, New York.,Division of Gastroenterology and Hepatology, Weil Cornell Medical Center, New York, New York
| | | | - Ryan C Ungaro
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York
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Dotson JL, Kappelman MD, Bricker J, Andridge R, Chisolm DJ, Crandall WV. Multicenter Evaluation of Emergency Department Treatment for Children and Adolescents With Crohn's Disease According to Race/Ethnicity and Insurance Payor Status. Inflamm Bowel Dis 2019; 25:194-203. [PMID: 29850811 DOI: 10.1093/ibd/izy192] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Racial and socioeconomic disparities exist in the treatment and outcomes of children and adults with Crohn's disease (CD). This study investigated the impact of race and insurance status on emergency department (ED) evaluation and treatment among children with CD in the United States. METHODS Data from the Pediatric Health Information System included ED visits between January 2007 and December 2013 for patients aged ≤21 years with a primary diagnosis of CD, or a secondary diagnosis of CD plus a primary CD-related diagnosis. Analyses were performed using mixed-effects logistic regression. RESULTS Subjects included 2618 unique patients (black, 612 [23%]; white, 2006 [77%]) with 3779 visits from 38 hospitals, a median age of 14.0 ± 4.0 years, and 50% male. White children had a higher median neighborhood income and were more likely to have private insurance (57% vs 30%; P < 0.001). Emergency department visits for privately insured patients had higher odds of complete blood count (odds ratio [OR], 1.43; 95% CI, 1.08-1.90) and C-reactive protein/erythrocyte sedimentation rate (OR, 1.39; 95% CI, 1.06-1.82) vs Medicaid insured. Visits for white children had higher odds of receiving antiemetics (OR, 1.52; 95% CI, 1.06-2.17) vs black children. The proportion of patients with repeat visits was greater for black children (33%) than white children (22%; P < 0.001) and greater for Medicaid-insured (27%) than privately insured patients (21%; P < 0.01). CONCLUSIONS This cross-sectional database study demonstrated that black children and those with Medicaid insurance made more ED visits and received somewhat fewer treatments, which may be explained by greater use of the ED for routine care. An opportunity exists for better outpatient management of children with IBD so that nonemergent problems are more effectively handled.
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Affiliation(s)
- Jennifer L Dotson
- Division of Pediatric Gastroenterology, Hepatology and Nutrition.,The Center for Innovation in Pediatric Practice, The Research Institute, Nationwide Children's Hospital, Columbus, Ohio
| | - Michael D Kappelman
- University of North Carolina at Chapel Hill, Department of Pediatrics, Division of Gastroenterology and Hepatology, Chapel Hill, North Carolina
| | - Josh Bricker
- The Center for Innovation in Pediatric Practice, The Research Institute, Nationwide Children's Hospital, Columbus, Ohio
| | - Rebecca Andridge
- Biostatistics, College of Public Health, The Ohio State University, Columbus, Ohio
| | - Deena J Chisolm
- The Center for Innovation in Pediatric Practice, The Research Institute, Nationwide Children's Hospital, Columbus, Ohio
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Anyane-Yeboa A, Yamada A, Haider H, Wang Y, Komaki Y, Komaki F, Pekow J, Dalal S, Cohen RD, Cannon L, Umanskiy K, Smith R, Hurst R, Hyman N, Rubin DT, Sakuraba A. A comparison of the risk of postoperative recurrence between African-American and Caucasian patients with Crohn's disease. Aliment Pharmacol Ther 2018; 48:933-940. [PMID: 30126019 PMCID: PMC6669906 DOI: 10.1111/apt.14951] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 05/14/2018] [Accepted: 07/28/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Many patients with Crohn's disease will develop complications that require surgery. Recurrence after surgery is common. AIM To assess racial differences in postoperative recurrence between African-Americans and Caucasians. METHODS Medical records of Crohn's disease patients who underwent surgery (ileal, colonic, or ileocolonic resection) between June 2014 and June 2016 were reviewed. The primary endpoints were clinical and endoscopic remission at 6-12 months after a Crohn's disease surgery. Secondary outcomes included biological and histologic remission. Risks of recurrence were assessed by univariate, multivariate, and propensity score-matched analysis. RESULTS Thirty-six African-American and 167 Caucasian patients with Crohn's disease were included for analysis. There was no difference in disease location, disease behaviour, type of surgery performed, and pre- or postoperative medication use between the two groups. The rate of endoscopic remission did not differ between African-American and Caucasian patients (50% vs 42%, P = 0.76), and race did not influence the risk of endoscopic recurrence on univariate, multivariate, or propensity score-matched analysis. The rate of clinical remission was significantly lower in African-American patients compared to Caucasian patients (36% vs. 63%, P = 0.008). African-American race was significantly associated with clinical recurrence on univariate (odds ratio (OR) 6.76, 95% CI 1.50-30.40; P = 0.01), multivariate (OR 5.02, 95% CI 1.60-15.80; P = 0.006), and propensity-matched analysis (68% vs. 32% in Caucasians, P = 0.005). Rates of biologic and histologic remission were similar between the two groups on all analyses. CONCLUSIONS We found that African-American patients with Crohn's disease have a similar degree of objective measures of mucosal inflammation after surgery including endoscopic recurrence as compared to Caucasian patients. However, African-American race was significantly associated with clinical recurrence, suggesting the presence of ethnic variation in postoperative presentation in Crohn's disease.
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Affiliation(s)
- Adjoa Anyane-Yeboa
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, USA
| | - Akihiro Yamada
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, USA
| | - Haider Haider
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, USA
| | - Yunwei Wang
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, USA
| | - Yuga Komaki
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, USA
| | - Fukiko Komaki
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, USA
| | - Joel Pekow
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, USA
| | - Sushila Dalal
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, USA
| | - Russell D Cohen
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, USA
| | - Lisa Cannon
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, USA
| | - Konstantin Umanskiy
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, USA
| | - Radhika Smith
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, USA
| | - Roger Hurst
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, USA
| | - Neil Hyman
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, USA
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, USA
| | - Atsushi Sakuraba
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, USA
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Montgomery SR, Butler PD, Wirtalla CJ, Collier KT, Hoffman RL, Aarons CB, Damrauer SM, Kelz RR. Racial disparities in surgical outcomes of patients with Inflammatory Bowel Disease. Am J Surg 2018; 215:1046-1050. [PMID: 29803499 DOI: 10.1016/j.amjsurg.2018.05.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 04/05/2018] [Accepted: 05/11/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Inflammatory Bowel Disease (IBD) has not historically been a focus of racial health disparities research. IBD has been increasing in the black community. We hypothesized that outcomes following surgery would be worse for black patients. METHODS A retrospective cohort study of death and serious morbidity (DSM) of patients undergoing surgery for IBD was performed using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP 2011-2014). Multivariable logistic regression modeling was performed to evaluate associations between race and outcomes. RESULTS Among 14,679 IBD patients, the overall rate of DSM was 20.3% (white: 19.3%, black 27.0%, other 23.8%, p < 0.001). After adjustment, black patients remained at increased risk of DSM compared white patients (OR: 1.37; 95% CI 1.14-1.64). CONCLUSIONS Black patients are at increased risk of post-operative DSM following surgery for IBD. The elevated rates of DSM are not explained by traditional risk factors like obesity, ASA class, emergent surgery, or stoma creation.
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Affiliation(s)
- Samuel R Montgomery
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Paris D Butler
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Chris J Wirtalla
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Karole T Collier
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Rebecca L Hoffman
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Cary B Aarons
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Scott M Damrauer
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Rachel R Kelz
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, United States.
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Proksell SS, Greer JB, Theisen BK, Davis PL, Rosh JR, Keljo DJ, Goyal A, Shah SA, Brand MH, Herfarth HH, Cross RK, Siegel CA, Koltun WA, Isaacs KL, Regueiro MD. IBD LIVE Case Series: Case 9: Do Race and Extraintestinal Manifestations Affect Treatment of Severe Crohn's Colitis? Inflamm Bowel Dis 2018; 24:698-713. [PMID: 29562279 DOI: 10.1093/ibd/izx114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Indexed: 12/09/2022]
Affiliation(s)
- Siobhan S Proksell
- Gastroenterology Fellow Year Iii, Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Julia B Greer
- Assistant Professor of Medicine, Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Brian K Theisen
- Assistant Professor of Pathology, Department of Pathology, George Washington University Hospital, Washington, D.C
| | - Peter L Davis
- Clinical Associate Professor of Radiology, Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Joel R Rosh
- Director, Division of Gastroenterology and Nutrition, Goryeb Children's Hospital, Atlantic Health, Morristown, New Jersey.,Professor of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - David J Keljo
- Interim Chief, Pediatric Gastroenterology, Hepatology, and Nutrition and Co-Director, Inflammatory Bowel Disease Center, Children's Hospital of Pittsburgh of Upmc, Pittsburgh, Pennsylvania.,Professor of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alka Goyal
- Associate Professor of Pediatrics, Director of Inflammatory Disease Service, Division of Gastroenterology, Hepatology and Nutrition, Children's Mercy Hospital, Kansas City, Missouri
| | - Samir A Shah
- Chief of Gastroenterology, The Miriam Hospital, Providence, Rhode Island.,Clinical Professor of Medicine, Warren Alpert School of Medicine At Brown University, Providence, Rhode Island
| | - Myron H Brand
- Clinical Professor of Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.,Medical Director, Shoreline Surgery Endoscopy Center, Connecticut Gastroenterology Consultants, New Haven, Connecticut
| | - Hans H Herfarth
- Professor of Medicine, Division of Gastroenterology and Hepatology, Co-Director Unc Multidisciplinary Center For Inflammatory Bowel Diseases, University of North Carolina, Chapel Hill, North Carolina
| | - Raymond K Cross
- Professor of Medicine, Director of Inflammatory Bowel Disease Program, University of Maryland School of Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Baltimore, Maryland
| | - Corey A Siegel
- Associate Professor of Medicine and of The Dartmouth Institute For Health Policy & Clinical Practice, Geisel School of Medicine At Dartmouth, Hanover, New Hampshire.,Director of The Inflammatory Bowel Disease Center At The Dartmouth-Hitchcock Medical Center In Lebanon, New Hampshire
| | - Walter A Koltun
- Chief, Division of Colon and Rectal Surgery, Milton S. Hershey Medical Center, Hershey, Pennsylvania.,Director, Hershey Penn State IBD Center, Professor of Surgery, Peter and Marshia Carlino Chair In IBD, Penn State College of Medicine, Hershey, Pennsylvania
| | - Kim L Isaacs
- Professor of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina
| | - Miguel D Regueiro
- Professor of Medicine, Associate Chief For Education, Co-Director, Inflammatory Bowel Disease Center, Head, IBD Clinical Program, Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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40
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Shi H, Levy AN, Trivedi HD, Chan FKL, Ng SC, Ananthakrishnan AN. Ethnicity Influences Phenotype and Outcomes in Inflammatory Bowel Disease: A Systematic Review and Meta-analysis of Population-based Studies. Clin Gastroenterol Hepatol 2018; 16:190-197.e11. [PMID: 28603049 PMCID: PMC5722715 DOI: 10.1016/j.cgh.2017.05.047] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 05/03/2017] [Accepted: 05/24/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Inflammatory bowel diseases (IBDs) (Crohn's disease [CD], ulcerative colitis) are global diseases. Similarities and differences in disease presentation and outcomes across different geographic regions and ethnic groups have not been compared previously. METHODS We performed a systematic review and meta-analysis of population-based cohort studies examining the phenotype and outcome of IBD across ethnic groups categorized as Whites, Blacks, Hispanics, and Asians. Further stratification was performed by migration status (native or immigrant). Pooled proportions of disease location, behavior, medication, and surgery use were calculated by using a random-effects model and compared statistically. RESULTS Our final analysis included 198 unique studies reporting outcomes on 525,425 IBD patients (Caucasian, 65%; Asian, 30%; Hispanic, 2%; and Black, 1%). CD in Asians but not other ethnicities demonstrated a strong male predominance. Family history of IBD was infrequent in Asian patients. Both Black and Asian CD patients demonstrated perianal involvement more frequently. Surgery for both CD and UC was less common in Asians than Caucasians. Compared with native residents, a family history of IBD was reported more often among immigrant IBD patients, but no significant differences were noted in phenotype. CONCLUSIONS We demonstrate significant variation in the demographic distribution, familial predisposition, phenotype, and outcomes of IBD between Caucasians, Blacks, Hispanics, and Asians. There is need for further study to understand the biology behind this variation.
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Affiliation(s)
- Haiyun Shi
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Disease, LKS Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong,Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research center for Digestive Disease, China
| | - Alexander N Levy
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Hirsh D Trivedi
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Francis KL Chan
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Disease, LKS Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong
| | - Siew C Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Disease, LKS Institute of Health Sciences, Chinese University of Hong Kong, Hong Kong.
| | - Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts and Harvard Medical School, Boston, Massachusetts.
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Abstract
BACKGROUND Genetic and other biological factors may lead to differences in disease behavior among children with inflammatory bowel disease of different races, which may be further modified by disparities in care delivery. Using the Kids' Inpatient Database, we aimed to evaluate differences in the management of pediatric patients with inflammatory bowel disease by race, focusing on length of stay (LOS). METHODS We performed a cross-sectional analysis using 2000 to 2012 data from the Kids' Inpatient Database, a nationally representative database. We identified pediatric patients (≤18 years of age) with discharge diagnoses of Crohn's disease (CD) or ulcerative colitis (UC). We used multivariable logistic regression to evaluate the relationship between race and LOS, controlling for age, payer status need for surgery, and year of admission. RESULTS We identified 27,295 hospitalizations for children with inflammatory bowel disease (62% CD and 38% UC), Compared with white patients with CD, black (adjusted odds ratio 1.37; 95% confidence interval, 1.22-1.53; P < 0.001) and Hispanic patients (adjusted odds ratio: 1.37; 95% confidence interval: 1.19-1.59; P < 0.001) with CD demonstrated increased odds of a LOS greater than the 75th percentile. When compared with white patients with UC, Hispanic patients also demonstrated increased odds of a LOS greater than the 75th percentile (adjusted odds ratio: 1.20; 95% confidence interval, 1.02-1.42, P = 0.015). CONCLUSIONS After controlling for age, year of admission, and clinical phenotypes, black and Hispanic patients with CD and Hispanic patients with UC had longer LOS than white patients. These may be due to differences in provider/hospital characteristics, socioeconomic differences, and/or differences in genetics and other biological factors (see Video Abstract, Supplemental Digital Content 1, http://links.lww.com/IBD/B656).
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Chotai S, Guidry BS, Chan EW, Sborov KD, Gannon S, Shannon C, Bonfield CM, Wellons JC, Naftel RP. Unplanned readmission within 90 days after pediatric neurosurgery. J Neurosurg Pediatr 2017; 20:542-548. [PMID: 29027867 DOI: 10.3171/2017.6.peds17117] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Readmission and return to operating room after surgery are increasingly being used as a proxy for quality of care. Nearly 60% of these readmissions are unplanned, which translates into billions of dollars in health care costs. The authors set out to analyze the incidence of readmission at their center, to define causes of unplanned readmission, and to determine the preoperative and surgical variables associated with readmissions following pediatric neurosurgery. METHODS A total of 536 children who underwent operations for neurosurgical diagnoses between 2012 and 2015 and who were later readmitted were included in the final analysis. Unplanned readmissions were defined to have occurred as a result of complications within 90 days after index surgery. Patient records were retrospectively reviewed to determine the primary diagnosis, surgery indication, and cause of readmission and return to operating room. The cost for index hospitalization, readmission episode, and total cost were derived based on the charges obtained from administrative data. Bivariate and multivariable analyses were conducted. RESULTS Of 536 patients readmitted in total, 17.9% (n = 96) were readmitted within 90 days. Of the overall readmissions, 11.9% (n = 64) were readmitted within 30 days, and 5.97% (n = 32) were readmitted between 31 and 90 days. The median duration between discharge and readmission was 20 days (first quartile [Q1]: 9 days, third quartile [Q3]: 36 days). The most common reason for readmission was shunt related (8.2%, n = 44), followed by wound infection (4.7%, n = 25). In the risk-adjusted multivariable logistic regression model for total 90-day readmission, patients with the following characteristics: younger age (p = 0.001, OR 0.886, 95% CI 0.824-0.952); "other" (nonwhite, nonblack) race (p = 0.024, OR 5.49, 95% CI 1.246-24.2); and those born preterm (p = 0.032, OR 2.1, 95% CI 1.1-4.12) had higher odds of being readmitted within 90 days after discharge. The total median cost for patients undergoing surgery in this study cohort was $11,520 (Q1: $7103, Q3: $19,264). For the patients who were readmitted, the median cost for a readmission episode was $8981 (Q1: $5051, Q3: $18,713). CONCLUSIONS Unplanned 90-day readmissions in pediatric neurosurgery are primarily due to CSF-related complications. Patients with the following characteristics: young age at presentation; "other" race; and children born preterm have a higher likelihood of being readmitted within 90 days after surgery. The median cost was > $8000, which suggests that the readmission episode can be as expensive as the index hospitalization. Clearly, readmission reduction has the potential for significant cost savings in pediatric neurosurgery. Future efforts, such as targeted education related to complication signs, should be considered in the attempt to reduce unplanned events. Given the single-center, retrospective study design, the results of this study are primarily applicable to this population and cannot necessarily be generalized to other institutions without further study.
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Barnes EL, Kochar B, Long MD, Martin CF, Crockett SD, Korzenik JR, Kappelman MD. The Burden of Hospital Readmissions among Pediatric Patients with Inflammatory Bowel Disease. J Pediatr 2017; 191:184-189.e1. [PMID: 29037795 PMCID: PMC5792080 DOI: 10.1016/j.jpeds.2017.08.042] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 07/06/2017] [Accepted: 08/16/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the burden and predictors of hospital readmissions among pediatric patients with inflammatory bowel disease using the Nationwide Readmissions Database. STUDY DESIGN We performed a retrospective cohort study using 2013 Nationwide Readmissions Database. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify patients <18 years with diagnoses of ulcerative colitis (UC) or Crohn's disease (CD). Demographic factors and details of hospitalizations were evaluated using survey procedures in SAS v 9.4 (SAS Institute, Cary, North Carolina). Multivariable logistic regression was used to estimate ORs and 95% CIs of readmission. RESULTS Among 2733 hospitalizations (63% CD, 37% UC), 611 (22%) patients were readmitted within 90 days of the index hospitalization. Readmission resulted in weighted estimates of 11 440 excess days of hospitalization and total charges of over $107 million. For CD, male sex (aOR 1.36, 95% CI 1.03-1.81) and co-existing anxiety or depression (aOR 1.89, 95% CI 1.06-3.40) were associated with increased readmissions, while patients who underwent surgery had decreased readmissions (aOR 0.40, 95% CI 0.24-0.65). In patients with UC, an index admission of >7 days was associated with increased readmissions (aOR 1.69, 95% CI 1.09-2.62). CONCLUSIONS Readmission occurs frequently in children with inflammatory bowel disease and is associated with significant cost and resource burdens. Among patients with CD, psychiatric comorbidities such as anxiety and depression are apparent drivers of readmission.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Bharati Kochar
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Millie D Long
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Center for Gastrointestinal Biology and Disease, Chapel Hill, NC
| | - Christopher F Martin
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Center for Gastrointestinal Biology and Disease, Chapel Hill, NC
| | - Seth D Crockett
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Center for Gastrointestinal Biology and Disease, Chapel Hill, NC
| | - Joshua R Korzenik
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, MA
| | - Michael D Kappelman
- Center for Gastrointestinal Biology and Disease, Chapel Hill, NC; Division of Pediatric Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Modifiable Risk Factors for Hospital Readmission Among Patients with Inflammatory Bowel Disease in a Nationwide Database. Inflamm Bowel Dis 2017; 23:875-881. [PMID: 28426473 PMCID: PMC5512697 DOI: 10.1097/mib.0000000000001121] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Previous studies suggest that disease activity alone does not reliably predict hospital readmission among patients with inflammatory bowel diseases (IBDs). Using a national database, we aimed to further describe the burden of readmissions for IBD and identify modifiable risk factors. METHODS We performed a retrospective cohort study using 2013 data from the Nationwide Readmission Database (NRD). Using International Classification of Diseases, ninth Revision, Clinical Modification (ICD-9-CM) codes, we identified adult patients with discharge diagnoses of ulcerative colitis or Crohn's disease and ascertained diagnoses of anxiety, depression, chronic pain, tobacco use, and other comorbidities during index admission. Logistic regression was used to estimate factors associated with hospital readmission. RESULTS Among 52,498 hospitalizations of patients with IBD (63% Crohn's disease and 37% ulcerative colitis), 12,407 (24%) were readmitted within 90 days of the index hospitalization, resulting in roughly $576 million in excess charges. In multivariable analysis of patients with Crohn's disease, anxiety (odds ratio [OR] 1.31, 95% confidence interval [CI], 1.21-1.43), depression (OR 1.27, 95% CI, 1.07-1.50), chronic pain (OR 1.31, 95% CI, 1.18-1.46), and tobacco abuse (OR 1.13, 95% CI, 1.06-1.22) were associated with a significant increase in odds of readmission. Among patients with ulcerative colitis, anxiety (OR 1.28, 95% CI, 1.14-1.45), depression (OR 1.35, 95% CI, 1.07-1.70), and chronic pain (OR 1.44, 95% CI, 1.21-1.73) were associated with a significant increase in odds of readmission. CONCLUSIONS Readmission occurs frequently in patients with IBD and is costly. Anxiety, depression, and chronic pain may represent targets for interventions to prevent 90-day hospital readmission in this population.
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Race Differences in Initial Presentation, Early Treatment, and 1-year Outcomes of Pediatric Crohn's Disease: Results from the ImproveCareNow Network. Inflamm Bowel Dis 2017; 23:767-774. [PMID: 28426457 DOI: 10.1097/mib.0000000000001046] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Racially disparate care has been shown to contribute to suboptimal health care outcomes for minorities. Using the ImproveCareNow network, we investigated differences in management and outcomes of pediatric patients with Crohn's disease at diagnosis and 1-year postdiagnosis. METHODS ImproveCareNow is a learning health network for pediatric inflammatory bowel disease. It contains prospective, longitudinal data from outpatient encounters. This retrospective study included all patients with Crohn's disease ≤21 years, September 2006 to October 2014, with the first recorded encounter ≤90 days from date of diagnosis and an encounter 1 year ±60 days. We examined the effect of race on remission rate and treatment at diagnosis and 1 year from diagnosis using t-tests, Wilcoxon rank-sum tests, χ statistic, and Fisher's exact tests, where appropriate, followed by univariate regression models. RESULTS Nine hundred seventy-six patients (Black = 118 (12%), White = 858 (88%), mean age = 13 years, 63% male) from 39 sites were included. Black children had a higher percentage of Medicaid insurance (44% versus 11%, P < 0.001). At diagnosis, Black children had more active disease according to physician global assessment (P = 0.027), but not by short Pediatric Crohn's Disease Activity Index (P = 0.67). Race differences in treatment were not identified. Black children had lower hematocrit (34.8 versus 36.7, P < 0.001) and albumin levels (3.6 versus 3.9, P = 0.001). At 1 year, Black children had more active disease according to physician global assessment (P = 0.016), but not by short Pediatric Crohn's Disease Activity Index (P = 0.06). CONCLUSIONS Black children with Crohn's disease may have more severe disease than White children based on physician global assessment. Neither disease phenotype differences at diagnosis nor treatment differences at 1-year follow-up were identified.
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Silber JH, Rosenbaum PR, Calhoun SR, Reiter JG, Hill AS, Even-Shoshan O, Greeley WJ. Outcomes, ICU Use, and Length of Stay in Chronically Ill Black and White Children on Medicaid and Hospitalized for Surgery. J Am Coll Surg 2017; 224:805-814. [PMID: 28167226 DOI: 10.1016/j.jamcollsurg.2017.01.053] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 01/23/2017] [Accepted: 01/24/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND With increasing Medicaid coverage, it has become especially important to determine whether racial differences exist within the Medicaid system. We asked whether disparities exist in hospital practice and patient outcomes between matched black and white Medicaid children with chronic conditions undergoing surgery. STUDY DESIGN We conducted a matched cohort study, matching 6,398 pairs within states on detailed patient characteristics using data from 25 states contributing adequate Medicaid Analytic eXtract claims for admissions of children with chronic conditions undergoing the same surgical procedures between January 1, 2009 and November 30, 2010 for ages 1 to 18 years. RESULTS The black patient 30-day revisit rate was 19.3% vs 19.8% in matched white patients (p = 0.61), 30-day readmission rates were 7.0% vs 6.9% (p = 0.43), and 30-day mortality rates were 0.38% vs 0.19% (p = 0.06), respectively. A higher percentage of black patients exceeded their own state's individual median length of stay (44.0% vs 39.6%; p < 0.001) and median ICU length of stay (25.9% vs 23.8%; p < 0.001). Intensive care unit use was higher in black patients (25.9% vs 23.8%; p < 0.001). After adjusting for multiple testing, only 2 states were found to differ significantly by race (New York for length of stay and New Jersey for ICU use). CONCLUSIONS We did not observe disparities in 30-day revisits and readmissions for chronically ill children in Medicaid undergoing surgery, and only slight differences in length of stay, ICU length of stay, and use of the ICU, where blacks displayed somewhat elevated rates compared with white controls.
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Affiliation(s)
- Jeffrey H Silber
- Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, The University of Pennsylvania School of Medicine, Philadelphia, PA; Department of Anesthesiology and Critical Care, The University of Pennsylvania School of Medicine, Philadelphia, PA; Department of Health Care Management, The Wharton School, The University of Pennsylvania, Philadelphia, PA; The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA.
| | - Paul R Rosenbaum
- Department of Statistics, The Wharton School, The University of Pennsylvania, Philadelphia, PA; The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA
| | - Shawna R Calhoun
- Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Joseph G Reiter
- Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Alexander S Hill
- Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Orit Even-Shoshan
- Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - William J Greeley
- Department of Anesthesiology and Critical Care, The University of Pennsylvania School of Medicine, Philadelphia, PA
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Silber JH, Rosenbaum PR, Calhoun SR, Reiter JG, Hill AS, Guevara JP, Zorc JJ, Even-Shoshan O. Racial Disparities in Medicaid Asthma Hospitalizations. Pediatrics 2017; 139:peds.2016-1221. [PMID: 28025238 DOI: 10.1542/peds.2016-1221] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Black children with asthma comprise one-third of all asthma patients in Medicaid. With increasing Medicaid coverage, it has become especially important to monitor Medicaid for differences in hospital practice and patient outcomes by race. METHODS A multivariate matched cohort design, studying 11 079 matched pairs of children in Medicaid (black versus white matched pairs from inside the same state) admitted for asthma between January 1, 2009 and November 30, 2010 in 33 states contributing adequate Medicaid Analytic eXtract claims. RESULTS Ten-day revisit rates were 3.8% in black patients versus 4.2% in white patients (P = .12); 30-day revisit and readmission rates were also not significantly different by race (10.5% in black patients versus 10.8% in white patients; P = .49). Length of stay (LOS) was also similar; both groups had a median stay of 2.0 days, with a slightly lower percentage of black patients exceeding their own state's median LOS (30.2% in black patients versus 31.8% in white patients; P = .01). The mean paired difference in LOS was 0.00 days (95% confidence interval, -0.08 to 0.08). However, ICU use was higher in black patients than white patients (22.2% versus 17.5%; P < .001). After adjusting for multiple testing, only 4 states were found to differ significantly, but only in ICU use, where blacks had higher rates of use. CONCLUSIONS For closely matched black and white patients, racial disparities concerning asthma admission outcomes and style of practice are small and generally nonsignificant, except for ICU use, where we observed higher rates in black patients.
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Affiliation(s)
- Jeffrey H Silber
- Center for Outcomes Research, and .,Departments of Pediatrics.,Anesthesiology and Critical Care, School of Medicine.,Health Care Management, and.,Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul R Rosenbaum
- Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, Pennsylvania.,Statistics, The Wharton School, and
| | | | | | | | - James P Guevara
- Departments of Pediatrics.,Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, Pennsylvania.,Divisions of General Pediatrics, and
| | - Joseph J Zorc
- Departments of Pediatrics.,Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
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Toh JWT, Stewart P, Rickard MJFX, Leong R, Wang N, Young CJ. Indications and surgical options for small bowel, large bowel and perianal Crohn's disease. World J Gastroenterol 2016; 22:8892-8904. [PMID: 27833380 PMCID: PMC5083794 DOI: 10.3748/wjg.v22.i40.8892] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 08/26/2016] [Accepted: 09/28/2016] [Indexed: 02/06/2023] Open
Abstract
Despite advancements in medical therapy of Crohn's disease (CD), majority of patients with CD will eventually require surgical intervention, with at least a third of patients requiring multiple surgeries. It is important to understand the role and timing of surgery, with the goals of therapy to reduce the need for surgery without increasing the odds of emergency surgery and its associated morbidity, as well as to limit surgical recurrence and avoid intestinal failure. The profile of CD patients requiring surgical intervention has changed over the decades with improvements in medical therapy with immunomodulators and biological agents. The most common indication for surgery is obstruction from stricturing disease, followed by abscesses and fistulae. The risk of gastrointestinal bleeding in CD is high but the likelihood of needing surgery for bleeding is low. Most major gastrointestinal bleeding episodes resolve spontaneously, albeit the risk of re-bleeding is high. The risk of colorectal cancer associated with CD is low. While current surgical guidelines recommend a total proctocolectomy for colorectal cancer associated with CD, subtotal colectomy or segmental colectomy with endoscopic surveillance may be a reasonable option. Approximately 20%-40% of CD patients will need perianal surgery during their lifetime. This review assesses the practice parameters and guidelines in the surgical management of CD, with a focus on the indications for surgery in CD (and when not to operate), and a critical evaluation of the timing and surgical options available to improve outcomes and reduce recurrence rates.
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African Americans Have Better Outcomes for Five Common Gastrointestinal Diagnoses in Hospitals With More Racially Diverse Patients. Am J Gastroenterol 2016; 111:649-57. [PMID: 27002802 DOI: 10.1038/ajg.2016.64] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 02/01/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We sought to characterize the relationship between hospital inpatient racial diversity and outcomes for African-American patients including rates of major complications or mortality during hospitalization for five common gastrointestinal diagnoses. METHODS Using the 2012 National Inpatient Sample database, hospital inpatient racial diversity was defined as the percentage of African-American patients discharged from each hospital. Logistic regression was used to predict major complication rates or death, long length of stay, and high total charges. Control variables included age, gender, payer type, patient location, area-associated income quartile, hospital characteristics including size, urban vs. rural, teaching vs. nonteaching, region, and the interaction of the percentage of African Americans with patient race. RESULTS There were 848,395 discharges across 3,392 hospitals. The patient population was on average 27% minority (s.d.±21%) with African Americans accounting for 14% of all patients. Overall, African-American patients had higher rates of major complications or death relative to white patients (adjusted odds ratio (aOR) 1.19; 95% confidence interval (CI) 1.16-1.23). However, when treated in hospitals with higher patient racial diversity, African-American patients experienced significantly lower rates of major complications or mortality (aOR 0.80; 95% CI 0.74-0.86). CONCLUSIONS African Americans have better outcomes for five common gastrointestinal diagnoses when treated in hospitals with higher inpatient racial diversity. This has major ramifications on total hospital charges.
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Abstract
BACKGROUND Immunomodulator and biological use in African Americans (AA) with Crohn's disease (CD) has been reported to be lower than in whites (W); less data exist for Hispanics (H). METHODS Medicaid databases from 3 states were examined for patients with CD from August 1998 to July 2009. CD-related treatments, comorbidities, location, surgery, and health care utilization were assessed from diagnosis until the first biological claim or end of claims. A Cox proportional hazard regression model was used to assess the effect of race on biological initiation. RESULTS A total of 5575 patients with CD (3590 W; 924 AA; 494 H; and 567 "other") were analyzed; 18%, 17%, and 17% of W, AA, and H patients, respectively, started immunomodulators (P = not significant); and 7%, 9%, and 5% of W, AA, and H, respectively, initiated biologics after CD diagnosis (P = not significant). After adjusting for demographics and CD-related medications and comorbidities in Cox models, no association was found between AA and W for biological use (hazard ratio 1.19; 95% confidence interval [CI], 0.91-1.54) or H and W (hazard ratio 0.68, 95% CI, 0.45-1.02). Analyzing patients hospitalized after CD diagnosis (n = 3428) to adjust for disease severity demonstrated that H were significantly less likely to use biologics than W (hazard ratio 0.40, 95% CI, 0.22-0.74). No differences between W and AA were found. CONCLUSIONS Our findings suggest that differences between AA and W in exposure to immunomodulators or biologics may not exist, although they may be present in H with more severe disease. Further research is needed to confirm these findings.
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