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Chhibba T, Wong ECL, Reinisch W, Targownik L, Narula N. Comparing the efficacy of vedolizumab between males and females: a post-hoc analysis of GEMINI-1 and VARSITY. Eur J Gastroenterol Hepatol 2024:00042737-990000000-00335. [PMID: 38526945 DOI: 10.1097/meg.0000000000002759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
Vedolizumab is a first-line treatment option for ulcerative colitis. There are differences in incidence of ulcerative colitis between males and females, but whether sex affects treatment outcomes is less clear. We examined sex-based differences in patients with ulcerative colitis initiated on vedolizumab from two major randomized controlled trials (RCTs). We conducted a post-hoc analysis on participants with ulcerative colitis from the VARSITY and GEMINI-1 RCTs who received vedolizumab. Outcomes of interest were rates of clinical improvement, clinical remission, and endoscopic improvement at weeks 6, 14, and 52 in male and female participants, as were differences in concentrations of trough vedolizumab and C-reactive protein; 1009 persons in GEMINI-1 and VARSITY trials were included. Male and female patients had similar disease characteristics aside from males being more likely to have Mayo 3 grade endoscopic severity at baseline (62.8 vs. 48.9%, P < 0.001). At week 6, females were more likely to have endoscopic improvement (47.4 vs. 35.2%, P = 0.001) and increased vedolizumab trough levels [34.0 (23.0-44.5) vs. 28.9 (19.0-34.6), P < 0.001]. The probability of achieving clinical remission (28.9 vs. 34.5%, P = 0.057) or endoscopic improvement (35.5 vs. 39.3%, P = 0.212) at week 52 was not different between males and females. Females with ulcerative colitis treated with vedolizumab appear more likely to achieve early endoscopic improvement than males, though longer-term outcomes demonstrated no difference. Further studies are required to better understand mechanisms through which sex or sex-associated factors could influence response to therapy in ulcerative colitis.
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Affiliation(s)
- Tarun Chhibba
- Department of Medicine, Massachusetts General Hospital (Division of Gastroenterology), Harvard University, Boston, MA, USA
| | - Emily C L Wong
- Department of Medicine (Division of Gastroenterology) and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Walter Reinisch
- Department of Medicine (Division of Gastroenterology and Hepatology), Medical University of Vienna, Vienna, Austria
| | - Laura Targownik
- Department of Medicine (Division of Gastroenterology), University of Toronto, Toronto, ON, Canada
| | - Neeraj Narula
- Department of Medicine (Division of Gastroenterology) and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
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Siffledeen J, Singh S, Shulman SM, Igoe J, Heatta-Speicher T, Leitner C, Chung CH, Targownik L. Effect of Suboptimal Disease Control on Patient Quality of Life: Real-World Data from the Observational IBD-PODCAST Canada Trial. Dig Dis Sci 2024:10.1007/s10620-024-08313-z. [PMID: 38493273 DOI: 10.1007/s10620-024-08313-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/23/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND The real-world application of STRIDE-II treatment targets to identify whether disease control is optimal in Crohn's disease (CD) and ulcerative colitis (UC) is not well known. AIMS This study aimed to estimate proportions of patients with suboptimally controlled CD and UC in real-world Canadian healthcare settings and the impact on quality of life (QoL). METHODS The noninterventional, multicenter, observational IBD-PODCAST Canada study comprised a single study visit involving routine assessments, patient- and clinician-completed questionnaires, and a retrospective chart review. Primary outcomes were proportions of patients with STRIDE-II-based red flags indicative of suboptimal disease control and mean ± standard deviation Short Inflammatory Bowel Disease Questionnaire (SIBDQ) scores. Secondary outcomes included proportions of patients and clinicians subjectively reporting suboptimal control. RESULTS Among 163 enrolled patients from 10 sites, 45/87 patients with CD (51.7%; 95% CI: 40.8%, 62.6%) and 33/76 patients with UC (43.3%; 95% CI: 32.1%, 55.3%) had suboptimal disease control based on STRIDE-II criteria. Suboptimal control was subjectively reported at lower proportions (patients: CD, 15.0%; UC, 18.6%; clinicians: CD, 19.5%; UC, 25.0%). Numerically lower SIBDQ scores were observed with suboptimal control (CD, 43.0 ± 10.8; UC, 42.5 ± 12.0) than with optimal control (CD, 58.2 ± 7.2; UC, 57.8 ± 6.6). CONCLUSIONS Approximately 50% (CD) and 40% (UC) of patients from real-world Canadian practices had suboptimal disease control based on STRIDE-II criteria. Suboptimal control was underestimated by patients and clinicians and accompanied by reduced QoL, suggesting further efforts to implement STRIDE-II treat-to-target strategies are needed.
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Affiliation(s)
- Jesse Siffledeen
- Division of Gastroenterology, Department of Medicine, University of Alberta, 13-103 Clinical Sciences Building, 11350-83 Avenue NW, Edmonton, AB, T6G 2G3, Canada.
| | - Sunny Singh
- Division of Gastroenterology, Department of Medicine, University of British Columbia, Kelowna General Hospital, Kelowna, BC, Canada
| | | | - John Igoe
- Division of Digestive Care and Endoscopy, Department of Medicine, Dalhousie University, Moncton, NB, Canada
| | | | | | | | - Laura Targownik
- Division of Gastroenterology and Hepatology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
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Raine T, Ishiguro Y, Rubin DT, Finney-Hayward T, Vladea R, Liu J, Phillips C, Cheng E, Targownik L, Loftus EV. Impact of Baseline Corticosteroid Use on the Efficacy and Safety of Upadacitinib in Patients with Ulcerative Colitis: a Post Hoc Analysis of the Phase 3 Clinical Trial Programme. J Crohns Colitis 2023:jjad190. [PMID: 37942921 DOI: 10.1093/ecco-jcc/jjad190] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND AND AIMS This post hoc analysis assessed the efficacy and safety of upadacitinib in patients with moderately to severely active ulcerative colitis stratified by corticosteroid use from the ulcerative colitis Phase 3 clinical trial programme. METHODS Patients were randomised [1:2] to 8 weeks' placebo or upadacitinib 45 mg once daily [QD]; Week 8 responders were re-randomised [1:1:1] to 52 weeks' placebo, or upadacitinib 15 or 30 mg QD. Corticosteroid dose was kept stable during induction but tapered according to a protocol-defined schedule [or investigator discretion] during maintenance Weeks 0-8. Efficacy outcomes and exposure-adjusted treatment-emergent adverse event [TEAE] rates were assessed for induction and maintenance stratified by corticosteroid use at induction baseline. RESULTS Overall, 377/988 [38%] patients were receiving corticosteroids at induction baseline [placebo, n = 133; upadacitinib 45 mg, n = 244] and 252 [37%] of the 681 clinical responders who entered maintenance were on corticosteroids at induction baseline [n = 84 for each treatment]. Similar proportions of patients receiving upadacitinib achieved clinical remission per Adapted Mayo Score with/without corticosteroids at Weeks 8 and 52. The total proportion of patients re-initiating corticosteroids was higher with placebo [24/84 (29%)] vs UPA 15 mg [16/81 (20%)] and 30 mg [11/81 (14%)]. During induction, patients receiving corticosteroids at baseline had higher rates of TEAEs, serious TEAEs, and serious infections vs those not receiving corticosteroids; however, TEAE rates were similar during maintenance after corticosteroid withdrawal. CONCLUSIONS Upadacitinib is an effective steroid-sparing treatment in patients with moderately to severely active ulcerative colitis.
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Affiliation(s)
- Tim Raine
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Yoh Ishiguro
- Department of Clinical Research, Hirosaki General Medical Centre, National Hospital Organisation, Hirosaki, Japan
| | - David T Rubin
- The University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | | | - Ramona Vladea
- AbbVie Inc., Global Medical Affairs, North Chicago, IL, USA
| | - John Liu
- AbbVie Inc., Research and Development, North Chicago, IL, USA
| | | | - Erica Cheng
- AbbVie Inc., Data and Statistical Sciences, North Chicago, IL, USA
| | - Laura Targownik
- Division of Gastroenterology and Hepatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
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Levy AR, Stock D, Paterson JM, Tamim H, Chateau D, Quail J, Ronksley PE, Carney G, Reynier P, Targownik L. Prescription ranitidine use and population exposure in 6 Canadian provinces, 1996 to 2019: a serial cross-sectional analysis. CMAJ Open 2023; 11:E1033-E1040. [PMID: 37935487 PMCID: PMC10635705 DOI: 10.9778/cmajo.20220131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND Ranitidine was the most prescribed histamine-2 receptor antagonist (H2RA) in Canada when recalled in 2019 because of potential carcinogenicity. We sought to compare geographic and temporal patterns in use of prescription ranitidine and 3 other HRAs and estimated population exposure to ranitidine in 6 provinces between 1996 and 2019. METHODS This population-based serial cross-sectional study used prescription claims for H2RAs dispensed from community pharmacies in Nova Scotia, Ontario, Manitoba, Saskatchewan, Alberta and British Columbia. We estimated the period prevalence of ranitidine use per 100 population by province, age category and sex. We estimated exposure to ranitidine between 2015 and 2019 using defined daily doses (DDDs). RESULTS Overall, 2.4 million ranitidine prescriptions were dispensed to patients aged 65 years and older, and 1.7 million were dispensed to younger adults. Among older adults, the median period prevalence of ranitidine use among females was 16% (interquartile range [IQR] 13%-27%) higher than among males. Among younger adults, the median prevalence was 50% (IQR 37%-70%) higher among females. Among older adults, between 1996 and 1999, use was highest in Nova Scotia (33%) and Ontario (30%), lower in the prairies (Manitoba [18%], Saskatchewan [26%], Alberta [17%]) and lowest in BC (11%). By 2015-2019, use of ranitidine among older adults dropped by at least 50% in all provinces except BC. We estimate that at least 142 million DDDs of prescribed ranitidine were consumed annually in 6 provinces (2015-2019). INTERPRETATION Over the 24-year period in 6 provinces, patients aged 65 years and older were dispensed 2.4 million prescriptions of ranitidine and younger adults were dispensed 1.7 million prescriptions of ranitidine. These estimates of ranitidine exposure can be used for planning studies of cancer risk and identifying target populations for cancer surveillance.
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Affiliation(s)
- Adrian R Levy
- Department of Community Health and Epidemiology (Levy, Stock), Dalhousie University, Halifax, NS; ICES (Paterson); York University (Tamim), Toronto, Ont.; National Centre for Epidemiology and Population Health (Chateau), College of Health & Medicine, Australian National University, Canberra, AU; Health Quality Council (Quail), Saskatoon, Sask.; Department of Community Health Sciences (Ronksley), University of Calgary, Calgary, Alta.; Therapeutics Initiative (Carney), University of British Columbia, Vancouver, BC; Lady Davis Institute (Reynier), Jewish General Hospital, Montréal, Que.; Department of Medicine (Targownik), University of Toronto, Toronto, Ont.
| | - David Stock
- Department of Community Health and Epidemiology (Levy, Stock), Dalhousie University, Halifax, NS; ICES (Paterson); York University (Tamim), Toronto, Ont.; National Centre for Epidemiology and Population Health (Chateau), College of Health & Medicine, Australian National University, Canberra, AU; Health Quality Council (Quail), Saskatoon, Sask.; Department of Community Health Sciences (Ronksley), University of Calgary, Calgary, Alta.; Therapeutics Initiative (Carney), University of British Columbia, Vancouver, BC; Lady Davis Institute (Reynier), Jewish General Hospital, Montréal, Que.; Department of Medicine (Targownik), University of Toronto, Toronto, Ont
| | - J Michael Paterson
- Department of Community Health and Epidemiology (Levy, Stock), Dalhousie University, Halifax, NS; ICES (Paterson); York University (Tamim), Toronto, Ont.; National Centre for Epidemiology and Population Health (Chateau), College of Health & Medicine, Australian National University, Canberra, AU; Health Quality Council (Quail), Saskatoon, Sask.; Department of Community Health Sciences (Ronksley), University of Calgary, Calgary, Alta.; Therapeutics Initiative (Carney), University of British Columbia, Vancouver, BC; Lady Davis Institute (Reynier), Jewish General Hospital, Montréal, Que.; Department of Medicine (Targownik), University of Toronto, Toronto, Ont
| | - Hala Tamim
- Department of Community Health and Epidemiology (Levy, Stock), Dalhousie University, Halifax, NS; ICES (Paterson); York University (Tamim), Toronto, Ont.; National Centre for Epidemiology and Population Health (Chateau), College of Health & Medicine, Australian National University, Canberra, AU; Health Quality Council (Quail), Saskatoon, Sask.; Department of Community Health Sciences (Ronksley), University of Calgary, Calgary, Alta.; Therapeutics Initiative (Carney), University of British Columbia, Vancouver, BC; Lady Davis Institute (Reynier), Jewish General Hospital, Montréal, Que.; Department of Medicine (Targownik), University of Toronto, Toronto, Ont
| | - Dan Chateau
- Department of Community Health and Epidemiology (Levy, Stock), Dalhousie University, Halifax, NS; ICES (Paterson); York University (Tamim), Toronto, Ont.; National Centre for Epidemiology and Population Health (Chateau), College of Health & Medicine, Australian National University, Canberra, AU; Health Quality Council (Quail), Saskatoon, Sask.; Department of Community Health Sciences (Ronksley), University of Calgary, Calgary, Alta.; Therapeutics Initiative (Carney), University of British Columbia, Vancouver, BC; Lady Davis Institute (Reynier), Jewish General Hospital, Montréal, Que.; Department of Medicine (Targownik), University of Toronto, Toronto, Ont
| | - Jacqueline Quail
- Department of Community Health and Epidemiology (Levy, Stock), Dalhousie University, Halifax, NS; ICES (Paterson); York University (Tamim), Toronto, Ont.; National Centre for Epidemiology and Population Health (Chateau), College of Health & Medicine, Australian National University, Canberra, AU; Health Quality Council (Quail), Saskatoon, Sask.; Department of Community Health Sciences (Ronksley), University of Calgary, Calgary, Alta.; Therapeutics Initiative (Carney), University of British Columbia, Vancouver, BC; Lady Davis Institute (Reynier), Jewish General Hospital, Montréal, Que.; Department of Medicine (Targownik), University of Toronto, Toronto, Ont
| | - Paul E Ronksley
- Department of Community Health and Epidemiology (Levy, Stock), Dalhousie University, Halifax, NS; ICES (Paterson); York University (Tamim), Toronto, Ont.; National Centre for Epidemiology and Population Health (Chateau), College of Health & Medicine, Australian National University, Canberra, AU; Health Quality Council (Quail), Saskatoon, Sask.; Department of Community Health Sciences (Ronksley), University of Calgary, Calgary, Alta.; Therapeutics Initiative (Carney), University of British Columbia, Vancouver, BC; Lady Davis Institute (Reynier), Jewish General Hospital, Montréal, Que.; Department of Medicine (Targownik), University of Toronto, Toronto, Ont
| | - Greg Carney
- Department of Community Health and Epidemiology (Levy, Stock), Dalhousie University, Halifax, NS; ICES (Paterson); York University (Tamim), Toronto, Ont.; National Centre for Epidemiology and Population Health (Chateau), College of Health & Medicine, Australian National University, Canberra, AU; Health Quality Council (Quail), Saskatoon, Sask.; Department of Community Health Sciences (Ronksley), University of Calgary, Calgary, Alta.; Therapeutics Initiative (Carney), University of British Columbia, Vancouver, BC; Lady Davis Institute (Reynier), Jewish General Hospital, Montréal, Que.; Department of Medicine (Targownik), University of Toronto, Toronto, Ont
| | - Pauline Reynier
- Department of Community Health and Epidemiology (Levy, Stock), Dalhousie University, Halifax, NS; ICES (Paterson); York University (Tamim), Toronto, Ont.; National Centre for Epidemiology and Population Health (Chateau), College of Health & Medicine, Australian National University, Canberra, AU; Health Quality Council (Quail), Saskatoon, Sask.; Department of Community Health Sciences (Ronksley), University of Calgary, Calgary, Alta.; Therapeutics Initiative (Carney), University of British Columbia, Vancouver, BC; Lady Davis Institute (Reynier), Jewish General Hospital, Montréal, Que.; Department of Medicine (Targownik), University of Toronto, Toronto, Ont
| | - Laura Targownik
- Department of Community Health and Epidemiology (Levy, Stock), Dalhousie University, Halifax, NS; ICES (Paterson); York University (Tamim), Toronto, Ont.; National Centre for Epidemiology and Population Health (Chateau), College of Health & Medicine, Australian National University, Canberra, AU; Health Quality Council (Quail), Saskatoon, Sask.; Department of Community Health Sciences (Ronksley), University of Calgary, Calgary, Alta.; Therapeutics Initiative (Carney), University of British Columbia, Vancouver, BC; Lady Davis Institute (Reynier), Jewish General Hospital, Montréal, Que.; Department of Medicine (Targownik), University of Toronto, Toronto, Ont
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Sharma S, Mathias H, Jones E, Heisler C, Rohatinsky N, Novak K, Leung Y, Fowler S, Kaczur M, Targownik L, Jones JL. Time for a Gut Check: A Qualitative Study of Proposed Interventions to Address Gender Inequality in Gastroenterology. J Can Assoc Gastroenterol 2023; 6:155-161. [PMID: 37811530 PMCID: PMC10558195 DOI: 10.1093/jcag/gwad022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/10/2023] Open
Abstract
Background Gender inequalities persist in medicine, particularly in some speciality fields where fewer women are employed. Although previous research has suggested potential interventions to broadly address gender inequality in medicine, no research has focused on interventions in the field of gastroenterology. The purpose of this research was to engage women in the field of gastroenterology in Canada, to identify interventions with potential to be effective in addressing gender inequality. Methods A World Café was hosted in 2019 to discuss gender inequality and interventions in gastroenterology. Twelve women employed in the field of gastroenterology (i.e. physicians, nurses, research staff, and trainees) were purposively recruited and participated in the event. The discussion rounds were audio-recorded, transcribed, and thematic analyses was conducted using Braun and Clarke's principles. Results Three key themes identifying potential interventions to address gender inequality in gastroenterology were generated: (1) Education; (2) Addressing institutional structures and polices; and 3) Role modelling and mentorship. Participants indicated that interventions should target various stakeholders, including both women and men in gastroenterology, young girls, patients, and administrators. Conclusion Many of the interventions identified by participants correspond with existing research on interventions in general medicine, suggesting that institutional changes can be made for maximum effectiveness. Some novel interventions were also identified, including publicizing instances of gender parity and supporting interventions across the educational and professional lifecourse. Moving forward, institutions must assess their readiness for change and evaluate existing policies, programs, and practices for areas of improvement.
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Affiliation(s)
- Sowmya Sharma
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore 21231, USA
| | - Holly Mathias
- School of Public Health, University of Alberta, Edmonton T6G 2R3, Canada
| | - Emma Jones
- Department of Digestive Care and Endoscopy, Department of Medicine, Dalhousie University, Halifax B3H 1V7, Canada
| | - Courtney Heisler
- Department of Digestive Care and Endoscopy, Department of Medicine, Dalhousie University, Halifax B3H 1V7, Canada
| | - Noelle Rohatinsky
- College of Nursing, University of Saskatchewan, Saskatoon S7N 2Z4, Canada
| | - Kerri Novak
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary T2N 4Z5, Canada
| | - Yvette Leung
- Department of Gastroenterology, Faculty of Medicine, University of British Columbia, Vancouver V5Z 1M9, Canada
| | - Sharyle Fowler
- Division of Gastroenterology, Department of Medicine, Royal University Hospital, University of Saskatchewan, Saskatoon S7N 0W8, Canada
| | - Melaine Kaczur
- Canadian Hub for Applied and Social Research, University of Saskatchewan, Saskatoon S7N 5B5, Canada
| | - Laura Targownik
- Department of Gastroenterology, University of Toronto, Toronto M5G 1X5, Canada
- Department of Gastroenterology, University of Manitoba, Winnipeg R3E 3P4, Canada
| | - Jennifer L Jones
- Department of Digestive Care and Endoscopy, Department of Medicine, Dalhousie University, Halifax B3H 1V7, Canada
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Duong N, Lee TH, Newman KL, Goldowsky A, Jencks KJ, Chedid V, Barrow J, Burbridge R, Chiang A, Targownik L, Simonetto DA, Paul S. Overcoming disparities for sexual and gender minority patients and providers in gastroenterology and hepatology: introduction to Rainbows in Gastro. Lancet Gastroenterol Hepatol 2023; 8:299-301. [PMID: 36796399 DOI: 10.1016/s2468-1253(23)00005-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/07/2023] [Accepted: 01/09/2023] [Indexed: 02/15/2023]
Affiliation(s)
- Nikki Duong
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University Medical Center, Richmond, VA 60637, USA.
| | - Tzu-Hao Lee
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Kira L Newman
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Health Systems, Ann Arbor, MI, USA
| | - Alexander Goldowsky
- Division of Gastroenterology and Hepatology, Boston Medical Center, Boston, MA, USA
| | - Kara J Jencks
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Health Systems, Ann Arbor, MI, USA
| | - Victor Chedid
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Jasmine Barrow
- MedStar Franklin Square Center for Digestive Disease, Baltimore, MD, USA
| | - Rebecca Burbridge
- Division of Gastroenterology, Duke University Medical Center, Durham, NC, USA
| | - Austin Chiang
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Laura Targownik
- Division of Gastroenterology and Hepatology, Department of Medicine, Mount Sinai Hospital, Temerty Faculty of Medicine at the University of Toronto, Toronto, ON, Canada
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Sonali Paul
- Section of Gastroenterology Center for Liver Diseases, University of Chicago Medicine, Chicago, IL, USA
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Sabrie N, Jogendran M, Jogendran R, Targownik L. A209 ASSESSMENT OF OUTCOMES OF PATIENTS ADMITTED WITH ACUTE, SEVERE ULCERATIVE COLITIS ON ESTABLISHED BIOLOGIC THERAPY: A SINGLE CENTRE RETROSPECTIVE ANALYSIS. J Can Assoc Gastroenterol 2023. [PMCID: PMC9991267 DOI: 10.1093/jcag/gwac036.209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Background Acute, severe, ulcerative colitis (ASUC) is associated with a high morbidity and mortality. Current guidelines recommend the initiation of high dose intravenous steroids, followed by anti-TNF therapy if a satisfactory therapeutic response is not rapidly achieved. However, guidelines are agnostic on how to manage patients who are admitted for ASUC despite being on established biologic therapy. Furthermore, short-term clinical outcomes in this population are not well characterized. Purpose The aim of this study is to assess the differences in short-term clinical outcomes in patients admitted with ASUC who are on established biologic therapy compared to those not on established biologic therapy. Method We conducted a retrospective chart review of patients admitted with ASUC to Mount Sinai Hospital (MSH) in Toronto, Ontario from January 2018 until December 2021. Patients were included if they were deemed to have a severe flare, defined as having 6 or more loose bowel movements per day with at least one of the following features: temperature of 38.0 Celsius, tachycardia, anemia, or elevated inflammatory markers. Included subjects were considered to be on established biologic therapy if they had a biologic within 56 days prior to admission, all other admitted subjects were included as controls. Our primary outcome was the difference in hospital length of stay (HLOS). We also contrasted duration of intravenous steroids, rates of surgical consultation, rates of in-hospital colectomy, and readmission rates within 90 days of discharge. Result(s) 130 charts were included in our study, 53 of which were patients on established biologic therapy, and 77 of which were patients not on established biologic therapy. The HLOS between the two groups was not significantly different, (7.23 days [established biologic therapy] vs.7.47 days [not on biologic therapy], p value = 0.77). Patients on established biologic therapy were more likely to receive an inpatient surgical consultation (33.96% vs 7.79%, p-value <0.001). However, rates of colectomy prior to discharge were not statistically different (1.89% vs 0%, p-value = 0.23). Patients on established biologic therapy were significantly more likely to be readmitted within 90 days of discharge (30.19% vs 12.99%, p-value = 0.016). Image ![]()
Conclusion(s) Although there were no differences in HLOS and colectomy rates between the 2 groups, patients with ASUC on established biologic therapy were more likely to be readmitted within 3 months of discharge. Further work is required to define optimal medical management of persons admitted with ASUC who are failing biologic therapies. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared
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Affiliation(s)
| | | | | | - L Targownik
- Gastroenterology, University of Toronto,Gastroenterology, Mount Sinai Hospital, Toronto, Canada
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8
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Kariyawasam N, Newman K, Streed CG, Rizkalla L, Vélez C, Targownik L. A103 DESIGNING QUALITATIVE RESEARCH FOR UNDERSTANDING THE EXPERIENCES OF TRANGENDER AND GENDER DIVERSE PERSONS WITH GASTROINTESTINAL DISEASE OR SEEKING GASTROINTESTINAL CARE. J Can Assoc Gastroenterol 2023. [PMCID: PMC9991378 DOI: 10.1093/jcag/gwac036.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Background Transgender and gender diverse (TGD) people make up approximately 1% of the population, with 2.1% of Generation Z adults (born 1997-2003) identifying as TGD. As a marginalized population, TGD people have been shown to have poorer access to health care services and report worse health-related outcomes. While the health care disparities faced by TGD people need to be addressed by Medicine broadly, TGD people may face unique barriers in gastrointestinal (GI) care. To date, there has been no systematic assessment of the GI health care needs of TGD people. With the aging of Generation Z, GI care providers will increasingly be responsible for the care of TGD people, and it is important to understand their needs and experiences to ensure they receive appropriate and sensitive care. Purpose Recognizing the absence of literature on the issues faced by TGD people with GI disease or seeking care for GI issues, we plan to use qualitative research methodology to aggregate and analyze narrative experiences of TGD people of diverse backgrounds, identities and experiences. Our research will focus on TGD people’s interactions with GI care providers, and on the experience of being a TGD person with GI disease or having sought evaluation of GI symptoms. Method We will use a qualitative approach to gain a broad understanding of the experiences and perceptions of TGD people with: 1) established GI diseases, in particular IBD and DGBIs (disorders of gut-brain interaction), and 2) GI symptoms or concerns requiring GI investigations. We will use snowball sampling to reach out to TGD people in Canada and the US, with the aim of achieving diverse representation across gender identity, surgical status, age, race/ethnicity, and socioeconomic status. Participants will sit for semi-structured interviews to elicit narratives about their beliefs and experiences while living with GI disease and/or seeking care for GI issues. Interview transcripts will be subjected to objective and researcher-guided thematic analysis to identify commonalities and disparities in experiences and points-of-view. Result(s) Our proposed presentation will highlight our process in designing and initiating this project. We believe our methods and approach to this work is an important discussion and will help shape next steps in this field. We may also present some of the early results of our semi-structured interviews. Conclusion(s) This work will provide a foundation to guide further research into the process and outcomes of care for TGD people with GI disease and undergoing GI evaluations and will provide a framework to develop best practices for GI care providers pertaining to the care of TGD people. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared
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Affiliation(s)
| | - K Newman
- University of Michigan, Ann Arbor, Ann Arbor
| | - C G Streed
- School of Medicine, Boston University,Center for Transgender Medicine & Surgery, Boston Medical Center, Boston, United States
| | | | - C Vélez
- Division of Gastroenterology, Massachusetts General Hospital, Boston, United States
| | - L Targownik
- University of Toronto, Toronto, Canada,Mount Sinai Hospital, Toronto, Canada
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9
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Patel A, Targownik L, Zelinsky S, Daley K, Jeffs L, Zeng L, Tabatabavakili S. A213 UNDERSTANDING PATIENT AND PHYSICIAN ATTITUDES AND EXPECTATIONS REGARDING IDENTIFYING AND MANAGING ANXIETY AND DEPRESSION IN IBD. J Can Assoc Gastroenterol 2023. [PMCID: PMC9991360 DOI: 10.1093/jcag/gwac036.213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Background Patients living with Inflammatory Bowel Disease (IBD) commonly experience a number of mental health-related challenges, specifically anxiety and mood disorders (AMDs). Although there has been an awareness of the relationship between IBD and AMD within the GI research and clinical space; detection, treatment, and management amongst care providers is limited. Therefore, we are seeking to explore the overall experiences of patients living with Inflammatory Bowel Disease to identify and evaluate their experiences in interactions with GI clinicians around mental health in diverse care settings in order to determine how to best support mental health care amongst IBD patients. Purpose We aimed to explore perspectives, experiences and barriers to engaging with mental health-related challenges amongst IBD patients when interacting with gastroenterologists over the course of their health journey. Method We conducted 5 semi-structured online focus groups co-facilitated by patient researchers in early 2020 through Zoom which spanned for a total of 2.5 hours each. Participants were recruited through social media channels, GI clinics, the IMAGINE-SPOR unit, and Crohn’s and Colitis Canada. A semi-structured interview guide was developed for patient researchers to follow during the focus groups which provided guided questions that would allow patient participants to explore and reflect on: their experiences living with IBD, their expectations around mental health support, their perception of the engagement of GIs in mental health discussions, and their expectations for mental health support and services moving forward. Audio recordings from the semi-structured focus groups were then transcribed and thematic analysis was used to identify emerging themes and patient expectations. Result(s) We identified the following key themes: 1) experiences with IBD: difficulties related to reintegrating into social settings, feelings of loneliness; 2) expectations around mental health support: the need to develop their own resiliency strategies due to the lack of structural resources regarding mental health and IBD in the clinical space; 3) GI engagement: HCPs were dismissive of mental health symptoms, often gaslighting patients when mentioning mental health concerns during clinical encounters; and 4) expectations: a need to standardize mental health care across IBD care practice with a focus on potentially integrating healthcare providers of diverse care settings to help address the need for mental health support in such a vast patient population. Conclusion(s) Our study suggests that effective detection, management and awareness, along with the integration of feedback from patient lived experiences can help inform the development of mental health support and services which cater to the needs of people living with IBD. Results from this study will be interpreted in line with insight gathered from upcoming interviews of gastroenterologists and HCPs. Please acknowledge all funding agencies by checking the applicable boxes below CIHR, Other Please indicate your source of funding; IMAGINE SPOR INCUBATOR Grant Disclosure of Interest None Declared
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Affiliation(s)
- A Patel
- Gastroenterology, Mount Sinai Hospital, Toronto
| | - L Targownik
- Gastroenterology, Mount Sinai Hospital, Toronto
| | | | - K Daley
- IMAGINE SPOR Network, Hamilton
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10
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Wang G, Boblitz A, Altaf A, Wang X, Benchimol E, Targownik L. A12 EXAMINING THE ASSOCIATIONS BETWEEN PHYSICIAN OR PATIENT GENDER WITH REFERRAL PATTERNS IN GASTROENTEROLOGY FOR NON-SCREENING INDICATIONS. J Can Assoc Gastroenterol 2023. [PMCID: PMC9991238 DOI: 10.1093/jcag/gwac036.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Background Gender biases in referral may impact patient care, and may perpetuate gender-based pay inequities. Referral patterns of male and female patients to male and female gastroenterologists (GIs) have not been previously characterized. Purpose We aimed to determine the extent to which female patients referred for consultation to gastroenterologists were preferentially channeled to female practitioners, and to further assess how gender-based referral channeling has changed over time. Method We used data from IC/ES Ontario to identify all residents of Ontario, Canada who had had a new consultation with an Ontario gastroenterologist in an ambulatory setting between Jan 1, 2002, to Dec 31, 2019, with time subdivided into early (2002-2007), mid (2008-2013), and late (2014-2019) periods. New consults were defined as any GI consultation where there had been no ambulatory visit with a different GI in the two years prior. The primary outcome was the difference in the proportion of female patients seen by male GIs vs female GIs. Descriptive statistics were used to compare patient and GI characteristics. Continuous variables were analyzed by the t-test, with p<0.05 suggestive of statistical significance. Odds ratios and their 95% CIs for the association of referral to a female GI and being a female patient were calculated. Result(s) From 2002 to 2019, the proportion of female gastroenterologists in Ontario increased from 15% (15/100) to 27% (78/292). During this 18-year period, female GIs saw a total of 17% of all consultations. Male GIs saw a greater number of consultations per year, though the gap closed over the period of observation. Specifically, each female GI in 2014-19 saw, on average, 776 patients (±41.8) compared to 578 (±59.2) in 2002-2007 (p<0.005) – a 34.5% increase; each male GI in 2014-2019 saw, on average, 905 patients (±7.2) compared to 824 (±25.0) in 2002-2007 (p<0.005) – a 9.8% increase. Female patients made up 56.7% of the total consultations over 2002-2019. There was evidence of channeling of female patients to female providers; in the early period, 72.4% of consults seen by female GIs were female, compared to only 56.8% of consults seen by male GIs (OR 2.07, 95% CI [1.98, 2.17]. By the late era (2014-2019), 64.1% of consults seen by female GIs were for female patients, compared to 53.3% for male GIs (OR 1.62, 95% CI [1.59, 1.66]. Image ![]()
Conclusion(s) There has been a significant increase in the number of female GIs in Ontario in recent years, and female GIs are seeing significantly greater patient volumes in the later eras in comparison to earlier eras. Female GIs receive a higher proportion of consultations for female patients, though this proportion is declining over time. The extent to which this gender-based referral channelling influences patient care, patient outcomes or influences the gender-based provider pay gap requires further exploration. Please acknowledge all funding agencies by checking the applicable boxes below Other Please indicate your source of funding; IMAGINE-SPOR Disclosure of Interest None Declared
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Affiliation(s)
- G Wang
- Medicine, University of Toronto
| | | | - A Altaf
- Life Stage Research Program, ICES
| | - X Wang
- Life Stage Research Program, ICES
| | - E Benchimol
- Life Stage Research Program, ICES,Pediatric Gastroenterology, Hospital for Sick Children
| | - L Targownik
- Gastroenterology, Mount Sinai Hospital, Toronto, Canada
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11
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Vukovic S, You X, Roberts S, Razak F, Verma A, Targownik L. A215 EVALUATING THE COMPARABILITY OF CARE FOR PERSONS ADMITTED TO TORONTO AREA HOSPITALS WITH ACUTE SEVERE ULCERATIVE COLITIS. J Can Assoc Gastroenterol 2023. [PMCID: PMC9991339 DOI: 10.1093/jcag/gwac036.215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Background Approximately 20% of patients with ulcerative colitis will experience an acute severe exacerbation requiring hospitalization. Acute severe ulcerative colitis (ASUC) is a medical emergency associated with significant morbidity and a mortality rate of 1%. Timely initiation of treatment and assessment of clinical response is critical in the management of ASUC. With an aim to reduce treatment variability and improve outcomes, multiple gastrointestinal societies have published guidelines highlighting recommendations for optimal care in ASUC. It remains unclear how closely these guidelines are implemented in clinical practice. Measuring adherence to these recommended processes of care may act as a surrogate measure for quality of care and a way to indirectly evaluate outcomes in the management of patients with ASUC. Studies have shown that even amongst experienced providers practice pattern variability exists. Identifying significant variations in the management of patients with ASUC will highlight where improvement in guideline dissemination and greater adherence is required. Purpose We sought to evaluate how quality of care indicators varied across 7 hospital sites for patients admitted ASUC in the Greater Toronto Area. Method Using GEMINI, a research collaborative that collects and analyses data from inpatient admissions at 7 Toronto area hospitals, we identified patients admitted to hospital with ASUC from June 2016-December 2019. Hospital sites were further categorized into 3 hospital types; 1 IBD specialty centre (ISC), 3 other academic centres (AC) and 3 community centres (CC). Process measures assessed included proportion tested for C-reactive protein at baseline and following treatment initiation, duration of corticosteroid use, timing and initiation of biologic agents, rates of venous thromboembolism prophylaxis and opioid use. Outcome measures included hospital length of stay, rates of colectomy and mortality. Result(s) 765 hospitalizations were included in the study; 320 occurring at ISC, 308 at AC and 137 at CC. Corticosteroid use on admission were highest at the ISC at 78% compared to 64% at AC and 63% at CC (p <0.001). Among those who received steroids on admission, 47% of patients remained on intravenous corticosteroids for at least 5 days in the ISC compared to 39% in AC and 75% in CC (p< 0.001). Initiation of biologic rescue therapy was highest at the ISC occurring in 37% of hospitalizations compared to 22% in AC and 23% in CC (p<0.001). In addition, VTE prophylaxis rates were highest at the ISC at 83% followed by 60% in AC and 45% in CC (p<0.001). Rates of colectomy were highest at ISC (12% of hospitalizations vs. 7% in AC). Conclusion(s) Greater adherence to indicators of quality of care were seen at the ISC compared to ACs and CCs, although patient outcomes assessed were not clearly different between sites. Further strategies are required to improve adherence to markers of quality care for patients admitted with ASUC. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared
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Affiliation(s)
- S Vukovic
- Internal Medicine, University of Toronto
| | - X You
- Internal Medicine, St. Michael's-Unity Health
| | - S Roberts
- Internal Medicine, St. Michael's-Unity Health
| | - F Razak
- Internal Medicine, St. Michael's-Unity Health
| | - A Verma
- Internal Medicine, St. Michael's-Unity Health
| | - L Targownik
- Gastroenterology, Mount Sinai Hospital, Toronto, Canada
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12
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Murthy SK, Kaplan GG, Coward S, Kuenzig E, Benchimol EI, Zubieta A, Otley A, Bitton A, Bernstein CN, Targownik L, Jones J, Begum J, Pugliese M, Singh H. A220 ONTARIO POPULATION TRENDS IN INTESTINAL AND EXTRA-INTESTINAL CANCERS OVER 25 YEARS AMONG PERSONS WITH INFLAMMATORY BOWEL DISEASES AND MATCHED CONTROLS. J Can Assoc Gastroenterol 2023. [PMCID: PMC9991309 DOI: 10.1093/jcag/gwac036.220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
NOT PUBLISHED AT AUTHOR’S REQUEST
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Affiliation(s)
| | - G G Kaplan
- Medicine, University of Calgary, Calgary
| | - S Coward
- Medicine, University of Calgary, Calgary
| | - E Kuenzig
- Pediatrics, University of Toronto, Toronto
| | | | - A Zubieta
- Medicine, University of British Columbia, Vancouver
| | - A Otley
- Pediatrics, Dalhousie University, Halifax
| | - A Bitton
- Medicine, McGill University, Montreal
| | | | | | - J Jones
- Medicine, Dalhousie University, Halifax
| | - J Begum
- Institute for Clinical Evaluative Sciences, Ottawa , Canada
| | - M Pugliese
- Institute for Clinical Evaluative Sciences, Ottawa , Canada
| | - H Singh
- Medicine, University of Manitoba, Winnipeg
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13
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Burisch J, Zhao M, Odes S, De Cruz P, Vermeire S, Bernstein CN, Kaplan GG, Duricova D, Greenberg D, Melberg HO, Watanabe M, Ahn HS, Targownik L, Pittet VEH, Annese V, Park KT, Katsanos KH, Høivik ML, Krznaric Z, Chaparro M, Loftus EV, Lakatos PL, Gisbert JP, Bemelman W, Moum B, Gearry RB, Kappelman MD, Hart A, Pierik MJ, Andrews JM, Ng SC, D'Inca R, Munkholm P. The cost of inflammatory bowel disease in high-income settings: a Lancet Gastroenterology & Hepatology Commission. Lancet Gastroenterol Hepatol 2023; 8:458-492. [PMID: 36871566 DOI: 10.1016/s2468-1253(23)00003-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 03/06/2023]
Abstract
The cost of caring for patients with inflammatory bowel disease (IBD) continues to increase worldwide. The cause is not only a steady increase in the prevalence of Crohn's disease and ulcerative colitis in both developed and newly industrialised countries, but also the chronic nature of the diseases, the need for long-term, often expensive treatments, the use of more intensive disease monitoring strategies, and the effect of the diseases on economic productivity. This Commission draws together a wide range of expertise to discuss the current costs of IBD care, the drivers of increasing costs, and how to deliver affordable care for IBD in the future. The key conclusions are that (1) increases in health-care costs must be evaluated against improved disease management and reductions in indirect costs, and (2) that overarching systems for data interoperability, registries, and big data approaches must be established for continuous assessment of effectiveness, costs, and the cost-effectiveness of care. International collaborations should be sought out to evaluate novel models of care (eg, value-based health care, including integrated health care, and participatory health-care models), as well as to improve the education and training of clinicians, patients, and policy makers.
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Affiliation(s)
- Johan Burisch
- Gastro Unit, Medical Division, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark; Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark.
| | - Mirabella Zhao
- Gastro Unit, Medical Division, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark; Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | - Selwyn Odes
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Peter De Cruz
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia; Department of Medicine, Austin Academic Centre, The University of Melbourne, Melbourne, VIC, Australia
| | - Severine Vermeire
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium; Faculty of Medicine, KU Leuven University, Leuven, Belgium
| | - Charles N Bernstein
- IBD Clinical and Research Centre, University of Manitoba, Winnipeg, MB, Canada; Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Gilaad G Kaplan
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Dana Duricova
- IBD Clinical and Research Centre for IBD, ISCARE, Prague, Czech Republic; Department of Pharmacology, Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Dan Greenberg
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel; Guilford Glazer Faculty of Business and Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Hans O Melberg
- Department of Community Medicine, University of Tromsø-The Arctic University of Norway, Tromsø, Norway; Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Mamoru Watanabe
- Advanced Research Institute, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hyeong Sik Ahn
- Department of Preventive Medicine, College of Medicine, Korea University, Seoul, South Korea
| | - Laura Targownik
- Division of Gastroenterology and Hepatology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Valérie E H Pittet
- Department of Epidemiology and Health Systems, Center for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
| | - Vito Annese
- Division of Gastroenterology, Department of Internal Medicine, Fakeeh University Hospital, Dubai, United Arab Emirates
| | - K T Park
- Stanford Health Care, Packard Health Alliance, Alameda, CA, USA; Genentech (Roche Group), South San Francisco, CA, USA
| | - Konstantinos H Katsanos
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Ioannina School of Health Sciences, Ioannina, Greece
| | - Marte L Høivik
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Zeljko Krznaric
- Department of Gastroenterology, Hepatology and Nutrition, University Hospital Zagreb, Zagreb, Croatia
| | - María Chaparro
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Universidad Autónoma de Madrid, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Peter L Lakatos
- Division of Gastroenterology, McGill University Montreal, QC, Canada; Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Javier P Gisbert
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Universidad Autónoma de Madrid, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Willem Bemelman
- Department of Surgery, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Bjorn Moum
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Richard B Gearry
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Michael D Kappelman
- Division of Pediatric Gastroenterology, Department of Pediatrics and Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ailsa Hart
- IBD Unit, St Mark's Hospital, Middlesex, UK
| | - Marieke J Pierik
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Jane M Andrews
- IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA, Australia; Faculty of Health Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Siew C Ng
- Department of Medicine and Therapeutics, Li Ka Shing Institute of Health Sciences, State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Renata D'Inca
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Pia Munkholm
- Department of Gastroenterology, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
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Heisler C, Rohatinsky N, Mirza RM, Kits O, Zelinsky S, Veldhuyzen van Zanten S, Nguyen G, McCurdy J, MacMillan M, Lakatos PL, Targownik L, Fowler S, Rioux K, Jones J. Patient-Centered Access to IBD Care: A Qualitative Study. Crohns Colitis 360 2022; 5:otac045. [PMID: 36777367 PMCID: PMC9825304 DOI: 10.1093/crocol/otac045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Indexed: 11/30/2022] Open
Abstract
Background Canada has the highest global age-adjusted incidence and prevalence rates of inflammatory bowel disease (IBD). Due to IBD patient volumes and limited resources, challenges to timely access to specialty care have emerged. To address this gap, the aim of this paper was to understand the experiences and perspectives of persons living with IBD with a focus on accessing health care. Methods Using a qualitative descriptive approach, patients diagnosed with IBD (≥18 years of age) were purposively sampled from rural and urban gastroenterology clinics and communities across Canada. Co-facilitated by a researcher and patient research partner, 14 focus groups were recorded, transcribed, and coded for themes. Thematic analysis was used to ascertain the congruence or discordance of IBD specialty care access experiences. Results A total of 63 individuals participated in the study. The majority of participants were female (41/63, 65%) and from urban/suburban regions (33/63, 52%), with a mean age of 48.39 (range 16-77 years). The analysis generated three main themes: (1) need for patient to be partner, (2) adapting IBD care access to individual context, and (3) patient-defined care priorities should guide access to IBD care. Conclusions The complexity of specialty care access for IBD patients cannot be underestimated. It is vital to possess a robust understanding of healthcare system structures, processes, and the impact of these factors on accessing care. Using a patient-centered exploration of barriers and facilitators, IBD specialty care access in Canada can be better understood and improved on provincial and national levels.
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Affiliation(s)
- Courtney Heisler
- QEII Health Sciences Centre, Division of Digestive Care & Endoscopy, Halifax, Canada
| | - Noelle Rohatinsky
- QEII Health Sciences Centre, Division of Digestive Care & Endoscopy, Halifax, Canada
| | - Raza M Mirza
- University of Saskatchewan, College of Nursing, Saskatoon, Canada
| | - Olga Kits
- University of Toronto, Institute for Life Course and Aging, Toronto, Canada
| | - Sandra Zelinsky
- Dalhousie University, Research Methods Unit, Halifax, Canada
| | | | - Geoffrey Nguyen
- University of Alberta, Faculty of Medicine and Dentistry, Edmonton, Canada
| | | | | | | | - Laura Targownik
- University of Alberta, Faculty of Medicine and Dentistry, Edmonton, Canada
| | | | - Kevin Rioux
- University of Saskatchewan, Saskatoon, Canada
| | - Jennifer Jones
- Address correspondence to: Jennifer Jones, MD, MSc, FRCPC, Room 932 Victoria Building, QEII Health Sciences Center, 1276 South Park Street, Halifax, Nova Scotia, B3H 2Y5 ()
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Targownik L, Dubinsky MC, Steinwurz F, Bushmakin AG, Cappelleri J, Tai E, Gardiner S, Hur P, Panés J. Disease Activity and Health-related Quality of Life Relationships with Work Productivity in Patients with Ulcerative Colitis in OCTAVE Induction 1&2 and OCTAVE Sustain. J Crohns Colitis 2022; 17:513-523. [PMID: 36271912 PMCID: PMC10115234 DOI: 10.1093/ecco-jcc/jjac161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Tofacitinib is an oral small molecule JAK inhibitor for the treatment of UC. We evaluated the relationship between Mayo/Inflammatory Bowel Disease Questionnaire (IBDQ) scores and Work Productivity and Activity ImpairmentUC (WPAI-UC) components in patients with UC. METHODS All available pooled data from three Phase 3 tofacitinib studies (OCTAVE Induction 1&2 and OCTAVE Sustain) were included. Relationships were estimated using repeated measures regression models with Mayo score/subscores or IBDQ total/domain scores as a separate anchor predictor and WPAI-UC components as the outcome. RESULTS Evidence for linear relationships was confirmed between Mayo/IBDQ scores and WPAI-UC components. Robust relationships between total Mayo score/IBDQ total score and WPAI-UC presenteeism, work productivity loss, and activity impairment were observed; relationships with absenteeism were weak. Total Mayo scores of 0 and 12 corresponded, on average, to WPAI-UC component scores of <15% and ≥60%, respectively, and IBDQ total scores of 224 and 32 corresponded, on average, to WPAIUC component scores of <6% and ≥90%, respectively. Presenteeism, work productivity loss, and activity impairment (all 0-100%), respectively, improved on average by 14.7, 13.6, and 16.4 percentage points for every 3-point improvement in total Mayo score, and by 8.1, 7.9, and 8.8 percentage points for every 16-point improvement in IBDQ total score. CONCLUSION Robust relationships between Mayo/IBDQ scores with WPAI-UC presenteeism, work productivity loss, and activity impairment suggest that patient productivity and nonwork activities are strongly associated with disease activity and HRQoL. The weak relationships with absenteeism suggest that patients attend work regardless of their disease activity/poor HRQoL.
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Affiliation(s)
- Laura Targownik
- Division of Gastroenterology and Hepatology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Marla C Dubinsky
- Susan and Lenard Feinstein IBD Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Flavio Steinwurz
- Unit of Inflammatory Bowel Disease, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | | | | | - Peter Hur
- Pfizer Inc, New York, NY, United States
| | - Julian Panés
- Formerly Department of Gastroenterology, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
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Kuenzig E, Lebenbaum M, Mason J, Vyas M, Kaplan G, Murthy S, Targownik L, Benchimol E. Costs of missed work among employed people with inflammatory bowel disease: a cross-sectional population-representative study. Int J Popul Data Sci 2022. [PMCID: PMC9644915 DOI: 10.23889/ijpds.v7i3.1918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
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17
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Wang M, Paterson M, Thabane L, Siegal D, Mbuagbaw L, Targownik L, Holbrook A. Association of direct oral anticoagulant-proton pump inhibitor cotherapy with adverse outcomes: protocol for a population-based cohort study. BMJ Open 2022; 12:e057991. [PMID: 35697453 PMCID: PMC9196177 DOI: 10.1136/bmjopen-2021-057991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION Proton pump inhibitors (PPIs) are widely used for primary and secondary prevention of upper gastrointestinal bleeding. However, there remains controversy about the overall net clinical benefit of PPIs (omeprazole, rabeprazole, pantoprazole, lansoprazole) when coprescribed with direct oral anticoagulants (DOACs; dabigatran, rivaroxaban, apixaban, edoxaban). Our objective is to explore the risk of clinically relevant events, including bleeding, thromboembolic events and death, in patients prescribed DOACs while taking PPIs versus no PPI. METHODS AND ANALYSIS The protocol describes a retrospective cohort study of all Ontario residents aged 66 years or older with atrial fibrillation and at least one pharmacy dispensation for a DOAC identified using linked administrative healthcare databases covering 2009-2020. Ontario drug benefit dispensation records will be used to ascertain PPI exposure during DOAC therapy. The primary outcome is a composite of clinically relevant bleeding, thrombotic events or all-cause death. A minimum of 520 patients in total with at least one of the components of the composite outcome are needed. Poisson regression with a generalised estimating equation model will be used to calculate the adjusted incidence rate difference, incidence rate ratios 95% CI, adjusting for propensity for PPI use using inverse probability of treatment weights. ETHICS AND DISSEMINATION This research is exempt from REB review under section 45 of Ontario's Personal Health Information Protection Act. We will report our findings in a peer-reviewed biomedical journal and present them at conferences. The study will provide useful evidence to optimise the coprescription of DOACs and PPIs in practice.
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Affiliation(s)
- Mei Wang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Clinical Pharmacology & Toxicology, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Michael Paterson
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- The Research Institute of St. Joseph's Hamilton, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- Biostatistics Unit, Research Institute of St. Joseph's Hamilton, Hamilton, Ontario, Canada
| | - Deborah Siegal
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, Research Institute of St. Joseph's Hamilton, Hamilton, Ontario, Canada
| | - Laura Targownik
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anne Holbrook
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Clinical Pharmacology & Toxicology, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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18
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Tandon P, Tennakoon A, Huang V, Bernstein CN, Goetgebuer R, Targownik L. OUP accepted manuscript. J Can Assoc Gastroenterol 2022; 5:184-191. [PMID: 35919760 PMCID: PMC9340635 DOI: 10.1093/jcag/gwac003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Inflammatory bowel disease (IBD) negatively affects fertility and fecundity. We aimed to determine longitudinal trends in and factors that affect pregnancy rates in women with ulcerative colitis (UC) and Crohn’s disease (CD). Methods Women in the University of Manitoba IBD Epidemiology Database aged 15 to 45 were identified between 1992 and 2018 and matched up to 10 non-IBD controls. Pregnancy and live birth rates were compared between women with and without UC or CD stratified by time-period, disease duration and maternal age at conception. Incidence rate ratios (IRR) with 95% confidence intervals (CI) were calculated. Poisson regression was used to adjust these rates for year of pregnancy, disease duration, maternal age, severity of IBD, and prior IBD-related surgery. Results Compared to controls, women with UC had lower rates of pregnancies (IRR 0.91, 95% CI: 0.82–0.99) and women with CD had lower rates of pregnancies (IRR 0.85, 95% CI: 0.79–0.93) and live births (IRR 0.83, 95% CI: 0.75–0.92). Although rates of pregnancies and live births were significantly lower in women with UC and CD compared to controls prior to 2010, there appeared to be no differences between the two groups after 2010. Prior intestinal surgery and active disease at conception appeared to lower pregnancy rates in women with UC and CD, respectively. Conclusion This study demonstrates that women with IBD have lower pregnancy rates compared to those without IBD, though these differences are no longer evident after 2010. Factors that continue to reduce these rates include prior colectomy and underlying disease activity.
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Affiliation(s)
- Parul Tandon
- Division of Gastroenterology and Hepatology, University of Toronto, Toronto, Ontario, Canada
- Mount Sinai Hospital Inflammatory Bowel Disease Centre, University of Toronto, Toronto, Ontario, Canada
| | - Aruni Tennakoon
- Department of Medicine and University of Manitoba IBD Clinical and Research Centre, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Vivian Huang
- Division of Gastroenterology and Hepatology, University of Toronto, Toronto, Ontario, Canada
- Mount Sinai Hospital Inflammatory Bowel Disease Centre, University of Toronto, Toronto, Ontario, Canada
| | - Charles N Bernstein
- Department of Medicine and University of Manitoba IBD Clinical and Research Centre, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Rogier Goetgebuer
- Division of Gastroenterology and Hepatology, University of Toronto, Toronto, Ontario, Canada
- Mount Sinai Hospital Inflammatory Bowel Disease Centre, University of Toronto, Toronto, Ontario, Canada
| | - Laura Targownik
- Correspondence: Laura Targownik, MD, MSHS, FRCPC, Staff Gastroenterologist, Division of Gastroenterology, Departmental Division Director, University of Toronto, 435-600 University Avenue, Toronto, Ontario M5G 1X5, e-mail:
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19
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Lakatos PL, Kaplan GG, Bressler B, Khanna R, Targownik L, Jones J, Rahal Y, McHugh K, Panaccione R. OUP accepted manuscript. J Can Assoc Gastroenterol 2022; 5:169-176. [PMID: 35919766 PMCID: PMC9340647 DOI: 10.1093/jcag/gwac001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Crohn’s disease (CD) is associated with reduced quality of life, increased absenteeism and high direct medical costs resulting from frequent hospitalizations and surgeries. Tumor necrosis factor–alpha inhibitors (TNFi’s) have transformed the therapeutic landscape and enabled a shift from a symptom control to a treat-to-target strategy. The Effect of Tight Control Management on Crohn’s Disease (CALM) trial demonstrated tight control (TC), with TNFi dose changes informed by biochemical markers of inflammation, achieved higher mucosal healing rates compared with conventional management (CM) based on symptoms. A Markov model compared TC and CM strategies from the perspective of the Canadian public payer using patient-observation data from the CALM trial. A regression model estimated weekly CD Activity Index–based transition matrices over a 5-year horizon and included covariates to improve extrapolation of outcomes beyond the 48-week trial assessment period. Costs of CD-related hospitalizations, biomarker tests and adalimumab injections were sourced from public data. Other direct medical costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated. Absenteeism was monetized and included in a sensitivity analysis. Over the 5-year time horizon, TC reduced hospitalization costs by 64% compared with CM. Other direct medical costs were reduced by 22%; adalimumab costs increased by 38%, generating an ICER of $35,168 per QALY gained. Absenteeism costs were reduced by 54%, and, when that was included in the model, TC became dominant compared with CM. Management of CD with TC is cost-effective compared with CM in Canada and is dominant if indirect costs associated with absenteeism are included. Trial registration number: NCT01235689.
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Affiliation(s)
- Peter L Lakatos
- Department of Medicine, Division of Gastroenterology, McGill University, Montreal, Quebec, Canada
| | - Gilaad G Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Brian Bressler
- Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Reena Khanna
- London Health Sciences Centre—University Campus, London, Ontario, Canada
| | - Laura Targownik
- Mount Sinai Hospital, Joseph and Wolf Lebovic Health Complex, Toronto, Ontario, Canada
| | | | | | - Kevin McHugh
- AbbVie Corporation, Saint-Laurent, Quebec, Canada
| | - Remo Panaccione
- Correspondence: Remo Panaccione, MD, FRCPC, Department of Medicine, Snyder Institute for Chronic Diseases and Institute of Public Health, TRW 6D32, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada, e-mail:
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20
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Coward S, Windsor JW, Kuenzig ME, Bitton A, Bernstein CN, Jones JL, Khanna R, Lee K, Murthy SK, Targownik L, Benchimol E, Huang JG, Mukhtar MS, Tandon P, Kaplan GG. Crohn's and Colitis Canada's 2021 Impact of COVID-19 and Inflammatory Bowel Disease in Canada: Epidemiology-The Trends of Disease Over Time. J Can Assoc Gastroenterol 2021; 4:S20-S26. [PMID: 34755035 PMCID: PMC8570419 DOI: 10.1093/jcag/gwab029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 08/11/2021] [Indexed: 12/04/2022] Open
Abstract
At the beginning of the coronavirus disease 2019 (COVID-19) pandemic, there were many unknowns: transmission vectors of the virus, appropriate intervention strategies and if being immunocompromised due to inflammatory bowel disease (IBD), for example, or medications put a person at increased risk for severe COVID-19. Imposing and relaxing of public health restrictions at different times and in different regions in Canada led to different epidemiologies of the virus in different provinces and territories. In order to understand the waxing and waning of waves of the COVID-19 pandemic, it is necessary to understand the effective reproductive number (R t ) and the countervailing forces that exert upward or downward pressure on the spread of the virus at a given point in time. As many regions in Canada deal with a third wave, the primary forces affecting the R t of severe acute respiratory syndrome coronavirus 2 are variants of concern and the increasing vaccinations of Canadians leading to increased population-level immunity. Fortunately, for the IBD population, current research suggests that those with IBD are not at increased risk of contracting COVID-19, nor of having a more severe disease course when compared to the general population.
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Affiliation(s)
- Stephanie Coward
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Joseph W Windsor
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - M Ellen Kuenzig
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Alain Bitton
- Department of Medicine, McGill University Health Centre, McGill University, Canada
| | - Charles N Bernstein
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,University of Manitoba IBD Clinical and Research Centre, Winnipeg, Manitoba, Canada
| | - Jennifer L Jones
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Reena Khanna
- London Health Sciences Centre-University Campus, Western University, London, Ontario, Canada
| | - Kate Lee
- Crohn's and Colitis Canada, Toronto, Ontario, Canada
| | - Sanjay K Murthy
- The Ottawa Hospital IBD Centre, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Laura Targownik
- Division of Gastroenterology and Hepatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Eric Benchimol
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - James Guoxian Huang
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Mariam S Mukhtar
- Department of Internal Medicine, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Parul Tandon
- Division of Gastroenterology and Hepatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gilaad G Kaplan
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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21
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Bernstein CN, Tennakoon A, Singh H, Targownik L. Editorial: 5-ASA in IBD patients on biologics-'stop or continue'? Authors' reply. Aliment Pharmacol Ther 2021; 54:845. [PMID: 34425007 DOI: 10.1111/apt.16554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Charles N Bernstein
- Department of Internal Medicine, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,University of Manitoba IBD Clinical and Research Centre, Winnipeg, Manitoba, Canada
| | - Aruni Tennakoon
- Department of Internal Medicine, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,University of Manitoba IBD Clinical and Research Centre, Winnipeg, Manitoba, Canada
| | - Harminder Singh
- Department of Internal Medicine, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,University of Manitoba IBD Clinical and Research Centre, Winnipeg, Manitoba, Canada
| | - Laura Targownik
- Division of Gastroenterology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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22
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Moayyedi P, MacQueen G, Bernstein CN, Vanner S, Bercik P, Madsen KL, Surette M, Rioux JD, Dieleman LA, Verdú E, de Souza RJ, Otley A, Targownik L, Lavis J, Cunningham J, Marshall DA, Zelinsky S, Fernandes A. IMAGINE Network's Mind And Gut Interactions Cohort (MAGIC) Study: a protocol for a prospective observational multicentre cohort study in inflammatory bowel disease and irritable bowel syndrome. BMJ Open 2020; 10:e041733. [PMID: 33087380 PMCID: PMC7580069 DOI: 10.1136/bmjopen-2020-041733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Gut microbiome and diet may be important in irritable bowel syndrome (IBS), inflammatory bowel disease (IBD) and comorbid psychiatric conditions, but the mechanisms are unclear. We will create a large cohort of patients with IBS, IBD and healthy controls, and follow them over time, collecting dietary and mental health information and biological samples, to assess their gastrointestinal (GI) and psychological symptoms in association with their diet, gut microbiome and metabolome. METHODS AND ANALYSIS This 5-year observational prospective cohort study is recruiting 8000 participants from 15 Canadian centres. Persons with IBS who are 13 years of age and older or IBD ≥5 years will be recruited. Healthy controls will be recruited from the general public and from friends or relatives of those with IBD or IBS who do not have GI symptoms. Participants answer surveys and provide blood, urine and stool samples annually. Surveys assess disease activity, quality of life, physical pain, lifestyle factors, psychological status and diet. The main outcomes evaluated will be the association between the diet, inflammatory, genetic, microbiome and metabolomic profiles in those with IBD and IBS compared with healthy controls using multivariate logistic regression. We will also compare these profiles in those with active versus quiescent disease and those with and without psychological comorbidity. ETHICS AND DISSEMINATION Approval has been obtained from the institutional review boards of all centres taking part in the study. We will develop evidence-based knowledge translation initiatives for patients, clinicians and policymakers to disseminate results to relevant stakeholders.Trial registration number: NCT03131414.
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Affiliation(s)
- Paul Moayyedi
- Medicine, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | | | | | | | - Premysl Bercik
- Medicine, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Karen L Madsen
- Medicine, University of Alberta, Edmonton, Ontario, Canada
| | - Michael Surette
- McMaster University Faculty of Health Sciences, Hamilton, Alberta, Canada
| | - John D Rioux
- Universite de Montreal, Montreal, Ontario, Canada
| | - Levinus A Dieleman
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Elena Verdú
- Division of Gastroenterology, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Russell J de Souza
- Department of Clinical Epidemiology and Biostatistics, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | | | | | - John Lavis
- McMaster University Faculty of Health Sciences, Hamilton, Alberta, Canada
| | - Jennifer Cunningham
- Population Health Research Institute, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Deborah A Marshall
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Sandra Zelinsky
- PaCER Innovates, University of Calgary, Calgary, Alberta, Canada
| | - Aida Fernandes
- Medicine, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
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23
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Weizman AV, Bressler B, Seow CH, Afif W, Afzal NM, Targownik L, Nguyen DM, Jones JL, Huang V, Murthy SK, Nguyen GC. Providing Hospitalized Ulcerative Colitis Patients With Practice Guidelines Improves Patient-Reported Outcomes. J Can Assoc Gastroenterol 2020; 4:131-136. [PMID: 34061122 PMCID: PMC8158645 DOI: 10.1093/jcag/gwaa019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background and aims Variation in care has been demonstrated among hospitalized patients with ulcerative
colitis. Guidelines aim to reduce variation; however, it is known that the uptake of
guidelines by physicians is variable. Providing patients with guidelines is a strategy
that has not been extensively studied in inflammatory bowel disease (IBD). Our aim was
to evaluate the impact of a patient-directed educational intervention that included
treatment guidelines among hospitalized ulcerative colitis patients. Methods We performed a quality improvement, cluster-randomized trial at seven tertiary IBD
centres. Sites were randomized to implement an educational intervention or standard care
for a 6-month period between January 2017 and January 2018. The educational intervention
consisted of a patient-directed video that provided a summary of inpatient management
guidelines for ulcerative colitis. Primary outcome measures included the length of stay
and colectomy at discharge and 6 months. Patient-reported outcomes included trust in
physician and patient satisfaction at discharge and at 6 months. Results Ninety-one patients were enrolled. No statistically significant differences in length
of stay or colectomy were noted. Patients who received the intervention had higher trust
in physician as measured by Trust in Physician Score at discharge (69.5 vs. 62.6,
P = 0.028) and at 6 months (77.7 vs. 68, P = 0.008).
Patient satisfaction as measured by the CACHE questionnaire in the intervention group
was higher at discharge (72.8 vs. 67.1, P = 0.04); however, this
difference was not sustained. Conclusion Empowering patients with guidelines through an educational intervention resulted in
differences in trust in physician and patient satisfaction. Further studies are needed
for evaluating a strategy of engaging IBD patients to take a more active role in their
care. (clinicaltrials.gov, NCT02569333).
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Affiliation(s)
- Adam V Weizman
- Division of Gastroenterology, Mount Sinai Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Brian Bressler
- Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Cynthia H Seow
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Waqqas Afif
- Division of Gastroenterology, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Nooran M Afzal
- Division of Gastroenterology, Mount Sinai Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Laura Targownik
- Division of Gastroenterology, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Derek M Nguyen
- Division of Gastroenterology, Mount Sinai Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer L Jones
- Division of Gastroenterology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Vivian Huang
- Division of Gastroenterology, Mount Sinai Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sanjay K Murthy
- Division of Gastroenterology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Geoffrey C Nguyen
- Division of Gastroenterology, Mount Sinai Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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24
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Kuenzig E, Singh H, Bitton A, Kaplan GG, Carroll MW, Otley A, Stukel TA, Spruin S, Nugent Z, Tanyingoh D, Cui Y, Filliter C, Coward S, Griffiths A, Mack D, Jacobson K, Nguyen GC, Targownik L, El-Matary W, Benchimol EI. A26 PEDIATRIC-ONSET INFLAMMATORY BOWEL DISEASE INCREASES THE RISK OF VENOUS THROMBOEMBOLISM: A CANGIEC POPULATION-BASED STUDY. J Can Assoc Gastroenterol 2020. [DOI: 10.1093/jcag/gwz047.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Inflammatory bowel disease (IBD) increases the risk of venous thromboembolism (VTE) in patients of all ages but the risk of VTE among Canadian children with IBD has not previously been investigated.
Aims
Report the incidence of VTE and subtypes pulmonary embolism (PE) and deep vein thrombosis (DVT) in children with and without IBD.
Methods
Children diagnosed with IBD <16y were identified from health administrative data in Ontario (2002–2014), Alberta (2007–2015), and Nova Scotia (2002–2012) using validated algorithms and matched by age and sex to children without IBD (1:5 ratio). Validated ICD-10 codes identified hospitalizations for incident VTE (DVT, PE, and sinovenous thrombosis). Province-specific 5-year cumulative incidence per 1000 person-years (PY) of VTEs were pooled using fixed-effects generalized linear mixed models with a Freeman-Tukey double arcsine transformation. Incidence rate ratios (IRR) within 5 years of diagnosis were pooled using fixed-effects generalized linear mixed models to compare children with and without IBD, and children with Crohn’s disease (CD) and ulcerative colitis (UC).
Results
3127 children with IBD (1826 CD; 1045 UC) were matched to 15,635 children without IBD. The cumulative incidence of VTE within 5 years of IBD diagnosis was 2.8 (95% CI 2.1–3.8) per 1000 PYs compared to 0.13 (95% CI 0.07–0.24) per 1000 PYs in children without IBD (Table). The 5-year cumulative incidences of VTE, DVT, and PE were significantly higher in children with IBD than in children without IBD (VTE: IRR 21.44, 95% CI 10.73–42.82; DVT: IRR 25.15, 95% CI 11.12–56.89; PE: IRR 4.01, 95% CI 1.22–13.18). Compared to UC patients, children with CD were at lower risk of VTE (IRR 0.53, 95% CI 0.29–0.96) and numerically, but not statistically, lower risk of DVT (IRR 0.59, 95% CI 0.30–1.14).
Conclusions
Although VTEs are relatively rare among children with IBD, these children are at much greater risk than children without IBD. Gastroenterologists caring for these patients should be cognizant of VTE risk and provide appropriate prophylaxis to those at high risk of VTE.
Funding Agencies
CCC
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Affiliation(s)
- E Kuenzig
- Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - H Singh
- University of Manitoba, Winnipeg, MB, Canada
| | - A Bitton
- Royal Victoria Hospital, McGill University, Montreal, QC, Canada
| | - G G Kaplan
- Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - M W Carroll
- Pediatric Gastroenterology, Univeristy of Alberta, Edmonton, AB, Canada
| | - A Otley
- Pediatrics, Dalhousie University, Halifax, NS, Canada
| | | | | | - Z Nugent
- University of Manitoba, Winnipeg, MB, Canada
| | - D Tanyingoh
- Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Y Cui
- Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - C Filliter
- Royal Victoria Hospital, McGill University, Montreal, QC, Canada
| | - S Coward
- University of Calgary, Calgary, AB, Canada
| | - A Griffiths
- Hospital for Sick Children, Toronto, ON, Canada
| | - D Mack
- Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - K Jacobson
- BC Children’s Hospital, Vancouver, BC, Canada
| | - G C Nguyen
- Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - L Targownik
- Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - W El-Matary
- Pediatric Gastroenterology, University of Manitoba, Winnipeg, MB, Canada
| | - E I Benchimol
- Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada
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25
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Elias E, Singh H, Bernstein CN, Targownik L. A246 POPULATION WIDE STUDY OF THE EPIDEMIOLOGY AND OUTCOMES OF ANTI-TNF DOSE AUGMENTATION IN INFLAMMATORY BOWEL DISEASE. J Can Assoc Gastroenterol 2020. [DOI: 10.1093/jcag/gwz047.245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Inflammatory bowel disease (IBD) patients who experience loss of response to anti-tumor necrosis factor (anti-TNF) therapy are often treated with augmented doses of anti-TNF to recapture response. Despite this, factors associated with dose augmentation and treatment outcomes following dose augmentation remain largely undefined.
Aims
To examine the epidemiology of anti-TNF dose augmentation and determine the associated treatment outcomes among a province-wide cohort of anti-TNF treated IBD subjects.
Methods
The University of Manitoba Inflammatory Bowel Disease Epidemiological Database was used to identify patients receiving infliximab or adalimumab maintenance therapy for IBD in the Canadian province of Manitoba. Anti-TNF dose augmentation was defined as a ≥50% increase in anti-TNF dose or a shortening of dosing interval to ≤42 days for infliximab or ≤10 days for adalimumab. Anti-TNF failure was defined as corticosteroid use, IBD-related hospitalization, resective IBD surgery, or change in anti-TNF agent. Competing risks regression using a proportional subhazards model was used to determine the associations between dose augmentation, anti-TNF failure, anti-TNF discontinuation and a number of patient, disease, and treatment factors.
Results
871 persons (624 Crohn’s disease (CD), 247 ulcerative colitis (UC)) using anti-TNF maintenance therapy were identified. Cumulative incidence of dose augmentation among continued users was 25.7% at 90 days, 52.3% at 1 year, and 72.8% at 5 years. Anti-TNF failure occurred in 261 of 575 dose augmented subjects, with corticosteroid use the most common failure-defining event. Failure of standard dose anti-TNF in the 90 days preceding dose augmentation was strongly associated with failure of dose augmentation (HR 2.98 (2.27–3.93); p<0.0001). Persons with CD were less likely to receive corticosteroids but more likely to switch anti-TNF agents than persons with UC.
Conclusions
Rates of adverse IBD outcomes remain high after dose augmentation, particularly when dose augmentation is undertaken shortly after (or in response to) one of these adverse events. Our data suggest that dose augmentation may not be as effective as uncontrolled observational studies have indicated.
Funding Agencies
None
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Affiliation(s)
- E Elias
- University of Manitoba, Winnipeg, MB, Canada
| | - H Singh
- University of Manitoba, Winnipeg, MB, Canada
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26
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Sasson AN, Targownik L, Vagianos K, Bernstein CN. A230 GAPS IN IDENTIFYING FOOD-RELATED QUALITY OF LIFE AND HYPERVIGILANCE IN AT-RISK INDIVIDUALS WITH IBD: REVIEW OF VALIDATED SCREENING TOOLS. J Can Assoc Gastroenterol 2020. [DOI: 10.1093/jcag/gwz047.229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Inflammatory bowel disease (IBD) has a profound impact on psychosocial aspects of food and nutrition, thereby affecting food-related quality of life (QoL). While there is literature on associated prevalence of increased anxiety in individuals with IBD, there is limited data on its contribution to hypervigilance and orthorexia with food intake. Many patients with IBD have strong beliefs about dietary symptom triggers, which can lead to avoidance behaviors and decreased nutrient intake. This can exacerbate malnutrition and disordered eating, as well as increase disease-related stress and negatively impact coping. While there are validated scales evaluating anxiety-related, QoL-related and food-related behaviors in IBD, a combined screening tool to assess this comorbid axis is not well described.
Aims
To conduct a systematic review of existing literature in order to inform practice and facilitate development of an effective food-related hypervigilance and QoL evaluation in IBD patients
Methods
The literature was systematically searched through September 2019, using an electronic database querying Embase, PubMed, MEDLINE, Cochrane Library and PsycINFO. We searched original articles describing development, validation and measurement properties for screening tools on anxiety, QoL and food-related behaviors in IBD from 1975 to 2018. The primary outcome of interest was to evaluate the current measurements of the validated tools to identify whether a screening tool highlighting all above parameters exists for patients with IBD.
Results
Initial database search resulted in 5548 articles. After screening titles and abstracts, 168 were included. After full text review and deduplication, 23 validated scales were identified for use in IBD patients with respect to measuring anxiety, health-related QoL and food-related behaviors. There was substantial heterogeneity in IBD populations using the assessment tools (adult vs. pediatric, CD vs. UC, inpatient vs. outpatient). The breakdown of studies identified: 2 studies (8.6%) evaluated QoL and anxiety, 2 studies (8.6%) evaluated QoL and food-related behaviors. The remainder of studies individually assessed QoL, anxiety and food-related behaviors (47.8%, 26% and 8.6% respectively). None of the tools performed satisfactory to establish all three measurements in individuals with IBD.
Conclusions
Recent evidence suggests the presence of dietary hypervigilance in individuals with chronic GI conditions potentially leading to food restrictive behaviors impacting QoL. Screening models evaluating multivariable relations of anxiety in food-related behaviors and QoL in IBD is lacking. Efforts should be made to develop and validate a multi-assessment screening tool to aid in early identification of this prevalence in IBD patients to facilitate improved management outcomes.
Funding Agencies
None
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Affiliation(s)
- A N Sasson
- Gastroenterology, University of Toronto, Toronto, ON, Canada
| | - L Targownik
- Gastroenterology, University of Toronto, Toronto, ON, Canada
| | - K Vagianos
- University of Manitoba, Winnipeg, MB, Canada
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Heisler C, Mirza R, Kits O, Zelinsky S, Veldhuyzen van Zanten S, Nguyen GC, MacMillan MA, Lakatos PL, Targownik L, Fowler S, Rioux KP, Jones J. A61 FOCUSING ON THE FUTURE: REDUCING BARRIERS AND IMPROVING ACCESS TO IBD SPECIALTY CARE ACROSS CANADA. J Can Assoc Gastroenterol 2020. [DOI: 10.1093/jcag/gwz047.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
Canada has the highest global age-adjusted incidence and prevalence rates of Inflammatory Bowel Disease (IBD). Resulting from compounding prevalence and limited resources, timely access to specialty care is a challenge faced by patients and healthcare providers. Despite this issue, there has been no published research elucidating the patient perspective using qualitative approaches to compare and contrast the patient experience across Canada.
Aims
To elicit a qualitative data stream to better understand phenomena related to access to healthcare for Canadians living with IBD from a patient-centered perspective.
Methods
Patients diagnosed with IBD (≥18 years of age) were recruited from gastroenterology clinics and communities through IBD specialists and Crohn’s & Colitis Canada. To ensure geographic diversity and representation, patients were recruited from urban and rural regions. In order to acquire multiple access perspectives, patients were invited to bring a family member who was involved in their care to the focus groups. Co-facilitated by a researcher and a patient research partner, the focus groups were held in Nova Scotia, New Brunswick, Quebec, Ontario, Manitoba, Saskatchewan, and British Columbia. All focus groups were audio recorded, transcribed, and coded for themes. Themes were distilled through qualitative thematic analysis using Atlas.ti software to ascertain congruence or discordance of IBD specialty care access experiences.
Results
A total of 63 participants were recruited in fourteen focus groups across seven provinces. The majority of participants were female (41/63, 65%) and from urban/suburban regions (34/63, 54%). The mean age of participants was 48 years (SD=16 years, range=16 to 77 years). Preliminary analyses illustrated three patient-identified access barrier themes: 1) Lack of multidisciplinary care (psycho-social and nutrition support), 2) Diagnostic delay, and 3) Inability to effectively receive and provide communication with healthcare providers. In response, four solutions were proposed: 1) Integration of holistic care into the clinical practice, 2) Readily accessible psycho-social and nutritional support, 3) Increased patient advocacy, and 4) Continuity and liaison through provision of a healthcare navigator resource.
Conclusions
The complexity of specialty care access for IBD patients in Canada cannot be underestimated. It is vital to possess a robust understanding of healthcare system structures, processes, and the significant impact these factors have on patients and the care received. Through the use of patient-centered exploration of barriers and facilitators, access to IBD specialty care in Canada can be better understood and improved on both a provincial and national scale.
Funding Agencies
CIHRNova Scotia Health Authority Research Fund
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Affiliation(s)
- C Heisler
- Gastroenterology, Research Services, QEII Health Sciences Centre, Halifax, NS, Canada
| | - R Mirza
- University of Toronto, Toronto, ON, Canada
| | - O Kits
- Dalhousie University, Halifax, NS, Canada
| | - S Zelinsky
- Patient Research Partner, 100 Mile House, BC, Canada
| | | | - G C Nguyen
- Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - M A MacMillan
- Gastroenterology, Dalhousie University, Halifax, NS, Canada
| | - P L Lakatos
- IBD Centre, McGill University Health Center, Montreal, QC, Canada
| | - L Targownik
- Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - S Fowler
- University of Saskatchewan, Saskatoon, SK, Canada
| | - K P Rioux
- University of Victoria, Victoria, BC, Canada
| | - J Jones
- Medicine, Dalhousie University, Halifax, NS, Canada
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Coward S, Benchimol EI, Bernstein CN, Bitton A, Carroll MW, Jelinski S, Jones J, Kuenzig E, Leddin D, Murthy S, Nguyen GC, Otley A, Rezaie A, Peña-Sánchez J, Singh H, Stach J, Targownik L, Windsor JW, Kaplan GG. A64 HOSPITALIZATION IN INFLAMMATORY BOWEL DISEASE: A POPULATION-BASED COMPARISON OF DEFINITIONS. J Can Assoc Gastroenterol 2020. [DOI: 10.1093/jcag/gwz047.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Most administrative studies of hospitalization in inflammatory bowel disease (IBD) use two definitions: IBD in any diagnostic position (IBD-ANY), and IBD as the most responsible diagnostic (IBD-MRD). There is a third less commonly used definition: total hospitalization; this definition captures all hospitalizations of prevalent IBD patients and therefore it can give a more realistic picture of the burden of IBD.
Aims
To compare differing definitions (total, IBD-ANY, and IBD-MRD) of hospitalizations.
Methods
A previously defined population-based IBD prevalent cohort for Alberta (n=30,698) was used to pull all hospital admissions from the Discharge Administrative Database (DAD; 2002–2015). Three hospitalization definitions were used: i. Total (all hospitalizations of prevalent cohort independent of presence of code for IBD); ii. IBD-ANY (code for IBD [K50.x; K51.x] contained in any diagnosis field); and, iii. IBD-MRD (most responsible diagnosis was IBD). Age- and sex- standardized rates (2015 Canadian population) were calculated using the prevalent population. Log-linear regression was performed to calculate Average Annual Percentage Change (AAPC) with associated 95% confidence intervals (CI) of each type of hospitalization. We assessed the top five most common most-responsible diagnosis codes for hospitalizations that were contained in the total hospitalizations but not an IBD-ANY hospitalization.
Results
From 2002 to 2015, 63.5% of IBD prevalent patients in AB had ≥1 hospitalization; 44.2% had ≥1 IBD-ANY hospitalization; 28.6% had ≥1 IBD-MRD hospitalization; and, 40.6% had a hospitalization that did not contain a code for IBD. All hospitalization rates decreased significantly over time. Of the top five most common most responsible diagnosis, contained in admissions that were not IBD-ANY, three were gastroenterological: i. K52.9 (non-infective gastroenteritis); ii. A09.9 (diarrhea and gastroenteritis of presumed infectious origin); and, iii. Z43.2 (attention to ileostomy).
Conclusions
Total hospitalizations is an important measure to report since accounting for all hospitalizations of IBD patients is necessary in order to allocate healthcare resources appropriately. To be able to ensure these patients receive the care they need we need to be able to accurately assess the true burden of IBD.
Funding Agencies
CIHR
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Affiliation(s)
- S Coward
- University of Calgary, Calgary, AB, Canada
| | - E I Benchimol
- Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada
| | | | - A Bitton
- Royal Victoria Hospital, McGill University, Montreal, QC, Canada
| | - M W Carroll
- Pediatric Gastroenterology, Univeristy of Alberta, Edmonton, AB, Canada
| | - S Jelinski
- Department of Medicine, Alberta Health Services, Edmonton, AB, Canada
| | - J Jones
- Medicine, Dalhousie University, Halifax, NS, Canada
| | - E Kuenzig
- Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - D Leddin
- Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - S Murthy
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - G C Nguyen
- Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - A Otley
- Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - A Rezaie
- University of Calgary, Calgary, AB, Canada
| | - J Peña-Sánchez
- Community Health and Epidemiology, University of Saskatchewan, Saskatoon, SK, Canada
| | - H Singh
- University of Manitoba, Winnipeg, MB, Canada
| | - J Stach
- Department of Medicine, Alberta Health Services, Edmonton, AB, Canada
| | - L Targownik
- Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | | | - G G Kaplan
- University of Calgary, Calgary, AB, Canada
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Murthy SK, Begum J, Benchimol EI, Bernstein CN, Kaplan GG, McCurdy JD, Singh H, Targownik L, Taljaard M. Introduction of anti-TNF therapy has not yielded expected declines in hospitalisation and intestinal resection rates in inflammatory bowel diseases: a population-based interrupted time series study. Gut 2020; 69:274-282. [PMID: 31196874 PMCID: PMC6984056 DOI: 10.1136/gutjnl-2019-318440] [Citation(s) in RCA: 126] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 04/23/2019] [Accepted: 04/23/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To better understand the real-world impact of biologic therapy in persons with Crohn's disease (CD) and ulcerative colitis (UC), we evaluated the effect of marketplace introduction of infliximab on the population rates of hospitalisations and surgeries and public payer drug costs. DESIGN We used health administrative data to study adult persons with CD and UC living in Ontario, Canada between 1995 and 2012. We used an interrupted time series design with segmented regression analysis to evaluate the impact of infliximab introduction on the rates of IBD-related hospitalisations, intestinal resections and public payer drug costs over 10 years among patients with CD and 5 years among patients with UC, allowing for a 1-year transition. RESULTS Relative to what would have been expected in the absence of infliximab, marketplace introduction of infliximab did not produce significant declines in the rates of CD-related hospitalisations (OR at the last observation quarter 1.06, 95% CI 0.811 to 1.39) or intestinal resections (OR 1.10, 95% CI 0.810 to 1.50), or in the rates of UC-related hospitalisations (OR 1.22, 95% CI 1.07 to 1.39) or colectomies (OR 0.933, 95% CI 0.54 to 1.61). The findings were similar among infliximab users, except that hospitalisation rates declined substantially among UC patients following marketplace introduction of infliximab (OR 0.515, 95% CI 0.342 to 0.777). There was a threefold rise over expected trends in public payer drug cost among patients with CD following infliximab introduction (OR 2.98,95% CI 2.29 to 3.86), suggesting robust market penetration in this group, but no significant change among patients with UC (OR 1.06, 95% CI 0.955 to 1.18). CONCLUSIONS Marketplace introduction of infliximab has not yielded anticipated reductions in the population rates of IBD-related hospitalisations or intestinal resections, despite robust market penetration among patients with CD. Misguided use of infliximab in CD patients and underuse of infliximab in UC patients may largely explain our study findings.
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Affiliation(s)
- Sanjay K Murthy
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada,Division of Gastroenterology, The Ottawa Hospital IBD Centre, Ottawa, Ontario, Canada,Clinical Epidemiology Program, OttawaHospital Research Institute, Ottawa, Ontario, Canada,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Eric I Benchimol
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada,ICES uOttawa, Ottawa, Ontario, Canada,Children’sHospital of Eastern Ontario (CHEO) Inflammatory Bowel Disease Centre, Divisionof Gastroenterology, Hepatology and Nutrition, Ottawa, Ontario, Canada,Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada,CHEOResearch Institute, Ottawa, Ontario, Canada
| | - Charles N Bernstein
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada,Health Sciences Centre Winnipeg, Winnipeg, Manitoba, Canada
| | - Gilaad G Kaplan
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada,Foothills Medical Centre, Division of Gastroenterology and Hepatology, Calgary, Alberta, Canada
| | - Jeffrey D McCurdy
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada,Division of Gastroenterology, The Ottawa Hospital IBD Centre, Ottawa, Ontario, Canada,Clinical Epidemiology Program, OttawaHospital Research Institute, Ottawa, Ontario, Canada
| | - Harminder Singh
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada,Health Sciences Centre Winnipeg, Winnipeg, Manitoba, Canada
| | - Laura Targownik
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada,Health Sciences Centre Winnipeg, Winnipeg, Manitoba, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, OttawaHospital Research Institute, Ottawa, Ontario, Canada,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
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Secrest MH, Azoulay L, Dahl M, Clemens KK, Durand M, Hu N, Targownik L, Turin TC, Dormuth CR, Filion KB. A population-based analysis of antidiabetic medications in four Canadian provinces: Secular trends and prescribing patterns. Pharmacoepidemiol Drug Saf 2019; 29 Suppl 1:86-92. [PMID: 31464069 DOI: 10.1002/pds.4878] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 05/14/2019] [Accepted: 07/09/2019] [Indexed: 11/08/2022]
Abstract
PURPOSE To use the Canadian Network for Observational Drug Effect Studies (CNODES) to describe drug utilization of antidiabetic medications in four Canadian provinces. METHODS With the use of data from CNODES, we constructed cohorts of patients with type 2 diabetes in four Canadian provinces (Manitoba, Ontario, Quebec, and Saskatchewan) who received their first-ever prescription for a noninsulin antidiabetic medication during the study period, defined as the earliest date of data availability in each province (range: 1993-1998) to the latest date of the data extraction in each province (range: 2013-2014). Prescriptions rates were calculated for all prescriptions by class and described over time. RESULTS Across provinces, we identified 650 830 patients who initiated antidiabetic medications during the study period. In most provinces, the overall prescription rate of antidiabetic medications increased during the last two decades. Metformin particularly increased in popularity, surpassing sulfonylureas in all provinces as the most widely prescribed antidiabetic medication by the early 2000s. Thiazolidinediones grew in popularity from the onset of their availability until 2006 to 2007, at which point they rapidly declined. Dipeptidyl peptidase-4 inhibitors saw substantial growth in several provinces following their addition to provincial formularies in 2008 to 2012, while glucagon-like peptide-1 agonists experienced modest growth. Insulin prescription rates remained constant or steadily increased over the last two decades. CONCLUSIONS CNODES can be used for cross-jurisdictional drug utilization studies. In Canada, trends in antidiabetic medication prescriptions followed changing guidelines reflecting up-to-date knowledge of drug effectiveness and safety.
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Affiliation(s)
- Matthew H Secrest
- Centre for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Laurent Azoulay
- Centre for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital, McGill University, Montreal, Quebec, Canada.,Gerald Bronfman Department of Oncology, McGill University, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Matthew Dahl
- Department of Community Health Sciences, Manitoba Centre for Health Policy, Winnipeg, Manitoba, Canada
| | - Kristin K Clemens
- Department of Medicine, and Epidemiology and Biostatistics, Western University, London, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada
| | - Madeleine Durand
- Internal Medicine Service, Centre Hospitalier Universitaire de Montreal (CHUM), Montreal, Quebec, Canada
| | - Nianping Hu
- The Health Quality Council, Saskatoon, Saskatchewan, Canada
| | - Laura Targownik
- Department of Community Health Sciences, Manitoba Centre for Health Policy, Winnipeg, Manitoba, Canada.,Section of Gastroenterology, Division of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Tanvir C Turin
- Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Colin R Dormuth
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kristian B Filion
- Centre for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital, McGill University, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.,Department of Medicine, McGill University, Montreal, Quebec, Canada
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Panaccione R, Steinhart AH, Bressler B, Khanna R, Marshall JK, Targownik L, Afif W, Bitton A, Borgaonkar M, Chauhan U, Halloran B, Jones J, Kennedy E, Leontiadis GI, Loftus EV, Meddings J, Moayyedi P, Murthy S, Plamondon S, Rosenfeld G, Schwartz D, Seow CH, Williams C, Bernstein CN. Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Luminal Crohn's Disease. Clin Gastroenterol Hepatol 2019; 17:1680-1713. [PMID: 30853616 DOI: 10.1016/j.cgh.2019.02.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 02/21/2019] [Accepted: 02/25/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Crohn's disease (CD) is a lifelong illness with substantial morbidity, although new therapies and treatment paradigms have been developed. We provide guidance for treatment of ambulatory patients with mild to severe active luminal CD. METHODS We performed a systematic review to identify published studies of the management of CD. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Statements were developed through an iterative online platform and then finalized and voted on by a group of specialists. RESULTS The consensus includes 41 statements focused on 6 main drug classes: antibiotics, 5-aminosalicylate, corticosteroids, immunosuppressants, biologic therapies, and other therapies. The group suggested against the use of antibiotics or 5-aminosalicylate as induction or maintenance therapies. Corticosteroid therapies (including budesonide) can be used as induction, but not maintenance therapies. Among immunosuppressants, thiopurines should not be used for induction, but can be used for maintenance therapy for selected low-risk patients. Parenteral methotrexate was proposed for induction and maintenance therapy in patients with corticosteroid-dependent CD. Biologic agents, including tumor necrosis factor antagonists, vedolizumab, and ustekinumab, were recommended for patients failed by conventional induction therapies and as maintenance therapy. The consensus group was unable to clearly define the role of concomitant immunosuppressant therapies in initiation of treatment with a biologic agent. CONCLUSIONS Optimal management of CD requires careful patient assessment, acknowledgement of patient preferences, evidence-based use of existing therapies, and thorough assessment to define treatment success.
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Affiliation(s)
- Remo Panaccione
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - A Hillary Steinhart
- Division of Gastroenterology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Brian Bressler
- Department of Medicine, Division of Gastroenterology, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Reena Khanna
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - John K Marshall
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Laura Targownik
- Section of Gastroenterology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Waqqas Afif
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Alain Bitton
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Mark Borgaonkar
- Faculty of Medicine, Memorial University, St John's, Newfoundland, Canada
| | - Usha Chauhan
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Brendan Halloran
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Jennifer Jones
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Erin Kennedy
- Division of General Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Grigorios I Leontiadis
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Jonathan Meddings
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul Moayyedi
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Sanjay Murthy
- Division of Gastroenterology, University of Ottawa, Ottawa, Ontario, Canada
| | - Sophie Plamondon
- Department of Medicine, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Greg Rosenfeld
- Division of Gastroenterology, Pacific Gastroenterology Associates, Vancouver, British Columbia, Canada
| | - David Schwartz
- Inflammatory Bowel Disease Center, Vanderbilt University, Nashville, Tennessee
| | - Cynthia H Seow
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Charles N Bernstein
- Section of Gastroenterology, University of Manitoba, Winnipeg, Manitoba, Canada
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Elias E, Oketola A, Krishnan S, Singh H, Targownik L, Bernstein CN. A40 IBD PATIENTS RECEIVING INFLIXIMAB IN COMBINATION WITH AN IMMUNOMODULATOR ARE LESS LIKELY TO DEVELOP SECONDARY LOSS OF RESPONSE. J Can Assoc Gastroenterol 2019. [DOI: 10.1093/jcag/gwz006.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- E Elias
- University of Manitoba, Winnipeg, MB, Canada
| | - A Oketola
- University of Manitoba, Winnipeg, MB, Canada
| | - S Krishnan
- University of Manitoba, Winnipeg, MB, Canada
| | - H Singh
- University of Manitoba, Winnipeg, MB, Canada
| | - L Targownik
- University of Manitoba, Winnipeg, MB, Canada
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33
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Elias E, Krishnan S, Oketola A, Singh H, Bernstein CN, Targownik L. A132 ANTI-TNF DOSE AUGMENTATION FREQUENTLY OCCURS IN THE ABSENCE OF OBJECTIVE EVIDENCE OF DISEASE ACTIVITY. J Can Assoc Gastroenterol 2019. [DOI: 10.1093/jcag/gwz006.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- E Elias
- University of Manitoba, Winnipeg, MB, Canada
| | - S Krishnan
- University of Manitoba, Winnipeg, MB, Canada
| | - A Oketola
- University of Manitoba, Winnipeg, MB, Canada
| | - H Singh
- University of Manitoba, Winnipeg, MB, Canada
| | | | - L Targownik
- University of Manitoba, Winnipeg, MB, Canada
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Weizman AV, Nguyen GC, Seow CH, Targownik L, Murthy SK, Boland K, Afzal NM, Khanna R, Jones J, Afif W, Halder S, Reinglas J, Fowler S, Huang V, Kaplan GG, Melmed GY. Appropriateness of Biologics in the Management of Crohn's Disease Using RAND/UCLA Appropriateness Methodology. Inflamm Bowel Dis 2019; 25:328-335. [PMID: 30346529 DOI: 10.1093/ibd/izy333] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND 3 classes of biologics are now available for the treatment of Crohn's disease. The availability of multiple treatment options has led to questions regarding the appropriateness of each agent for a given patient. We aimed to evaluate physician preferences for the use of specific biologic agents in a variety of Crohn's disease management scenarios using the RAND/UCLA Appropriateness Methodology. METHODS A panel consisting of members of the CINERGI group (Canadian IBD Network for Research and Growth in Quality Improvement) was assembled. A literature review was performed on factors identified as influential upon choice of biologic therapy. Clinical scenarios were developed, and panelists rated the appropriateness of biologic therapy classes in each scenario individually and again during a face-to-face meeting after moderated discussion. RESULTS Two hundred eighty-eight modifications of 3 clinical scenarios were rated. Factors that influenced biologic choice included perianal disease, antidrug antibody status, extraintestinal manifestations, consideration of potential pregnancy, and history of serious infection or malignancy. Anti-TNF therapy was considered appropriate in the postoperative patient. Ustekinumab and vedolizumab were considered appropriate in patients without perianal disease over the age of 65 with a history of malignancy or serious infection. The use of anti-TNF therapy was considered inappropriate in some scenarios whereby drug level was adequate and no antidrug antibody (ADA) was detectable. CONCLUSIONS We evaluated the appropriateness of the 3 available classes of biologics in a number of scenarios for the treatment of Crohn's disease. History of serious infection and malignancy, particularly in individuals over 65 years, and consideration of future pregnancy were patient-specific variables that impacted treatment decisions. These findings can serve as a guide for providers considering biologic therapy in patients with Crohn's disease. UNLABELLED 10.1093/ibd/izy333_video1izy333.video15850922807001.
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Affiliation(s)
- Adam V Weizman
- Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto Toronto, Ontario, Canada
| | - Geoffrey C Nguyen
- Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto Toronto, Ontario, Canada
| | - Cynthia H Seow
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Laura Targownik
- Division of Gastroenterology, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sanjay K Murthy
- Division of Gastroenterology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Karen Boland
- Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto Toronto, Ontario, Canada
| | - Nooran M Afzal
- Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto Toronto, Ontario, Canada
| | - Reena Khanna
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada
| | - Jennifer Jones
- Division of Gastroenterology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Waqqas Afif
- Division of Gastroenterology, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Smita Halder
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jason Reinglas
- Division of Gastroenterology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sharyle Fowler
- Division of Gastroenterology, Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Vivian Huang
- Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto Toronto, Ontario, Canada
| | - Gilaad G Kaplan
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gil Y Melmed
- Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center Los Angeles, California, USA
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Bernstein CN, Shafer LA, Singh H, Targownik L. Reply to Letter to Editor of Dr. Elia. Inflamm Bowel Dis 2019; 25:e9. [PMID: 29800145 DOI: 10.1093/ibd/izy176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Charles N Bernstein
- University of Manitoba IBD Clinical and Research Centre, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Leigh Anne Shafer
- University of Manitoba IBD Clinical and Research Centre, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Harminder Singh
- University of Manitoba IBD Clinical and Research Centre, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Laura Targownik
- University of Manitoba IBD Clinical and Research Centre, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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Secrest MH, Platt RW, Dormuth CR, Chateau D, Targownik L, Nie R, Doyle CM, Dell'Aniello S, Filion KB. Extreme restriction design as a method for reducing confounding by indication in pharmacoepidemiologic research. Pharmacoepidemiol Drug Saf 2019; 29 Suppl 1:26-34. [DOI: 10.1002/pds.4708] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 09/27/2018] [Accepted: 11/14/2018] [Indexed: 01/24/2023]
Affiliation(s)
- Matthew H. Secrest
- Centre for Clinical EpidemiologyLady Davis Research Institute, Jewish General Hospital, McGill University Montreal Canada
| | - Robert W. Platt
- Centre for Clinical EpidemiologyLady Davis Research Institute, Jewish General Hospital, McGill University Montreal Canada
- Department of Epidemiology, Biostatistics and Occupational HealthMcGill University Montreal Canada
- Department of PediatricsMcGill University Montreal Canada
| | - Colin R. Dormuth
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of MedicineUniversity of British Columbia Vancouver Canada
| | - Dan Chateau
- Department of Community Health Sciences, Manitoba Centre for Health Policy, College of Medicine, Faculty of Health SciencesUniversity of Manitoba Winnipeg Canada
| | - Laura Targownik
- Department of Community Health Sciences, Manitoba Centre for Health Policy, College of Medicine, Faculty of Health SciencesUniversity of Manitoba Winnipeg Canada
| | - Rui Nie
- Centre for Clinical EpidemiologyLady Davis Research Institute, Jewish General Hospital, McGill University Montreal Canada
| | - Carla M. Doyle
- Centre for Clinical EpidemiologyLady Davis Research Institute, Jewish General Hospital, McGill University Montreal Canada
- Department of Epidemiology, Biostatistics and Occupational HealthMcGill University Montreal Canada
| | - Sophie Dell'Aniello
- Centre for Clinical EpidemiologyLady Davis Research Institute, Jewish General Hospital, McGill University Montreal Canada
| | - Kristian B. Filion
- Centre for Clinical EpidemiologyLady Davis Research Institute, Jewish General Hospital, McGill University Montreal Canada
- Department of Epidemiology, Biostatistics and Occupational HealthMcGill University Montreal Canada
- Division of Clinical Epidemiology, Department of MedicineMcGill University Montreal Canada
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Steinhart AH, Panaccione R, Targownik L, Bressler B, Khanna R, Marshall JK, Afif W, Bernstein CN, Bitton A, Borgaonkar M, Chauhan U, Halloran B, Jones J, Kennedy E, Leontiadis GI, Loftus EV, Meddings J, Moayyedi P, Murthy S, Plamondon S, Rosenfeld G, Schwartz D, Seow CH, Williams C. Clinical Practice Guideline for the Medical Management of Perianal Fistulizing Crohn's Disease: The Toronto Consensus. Inflamm Bowel Dis 2019; 25:1-13. [PMID: 30099529 DOI: 10.1093/ibd/izy247] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Fistulas occur in about 25% of patients with Crohn's disease (CD) and can be difficult to treat. The aim of this consensus was to provide guidance for the management of patients with perianal fistulizing CD. METHODS A systematic literature search identified studies on the management of fistulizing CD. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Statements were developed through an iterative online platform using a modified Delphi process, then finalized, and voted on by a group of specialists. RESULTS The quality of evidence for treatment of fistulizing CD was generally of very low quality, and because of the scarcity of good randomized controlled trials (RCTs), these consensus statements generally provide conditional suggestions (5 of 7 statements). Imaging and surgical consultations were recommended in the initial assessment of patients with active fistulizing CD, particularly those with complicated disease. Antibiotic therapy is useful for initial symptom control. Antitumor necrosis factor (anti-TNF) therapy was recommended to induce symptomatic response, and continued use was suggested to achieve and maintain complete remission. The use of concomitant immunosuppressant therapies may be useful to optimize pharmacokinetic parameters when initiating anti-TNF therapy. When there has been an inadequate symptomatic response to medical management strategies, surgical therapy may provide effective fistula healing for some patients. CONCLUSIONS Optimal management of perianal fistulizing CD requires a collaborative effort between gastroenterologists and surgeons and may include the evidence-based use of existing therapies, as well as surgical assessments and interventions when needed. 10.1093/ibd/izy247_video1izy247.video15978518763001.
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Affiliation(s)
- A Hillary Steinhart
- Division of Gastroenterology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Remo Panaccione
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Laura Targownik
- Section of Gastroenterology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Brian Bressler
- Department of Medicine, Division of Gastroenterology, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Reena Khanna
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - John K Marshall
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Waqqas Afif
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Charles N Bernstein
- Section of Gastroenterology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alain Bitton
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Mark Borgaonkar
- Faculty of Medicine, Memorial University, St John's, Newfoundland, Canada
| | - Usha Chauhan
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Brendan Halloran
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Jennifer Jones
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Erin Kennedy
- Division of General Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Grigorios I Leontiadis
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Edward V Loftus
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jonathan Meddings
- Division of Gastroenterology, University of Ottawa, Ottawa, Ontario, Canada
| | - Paul Moayyedi
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Sanjay Murthy
- Division of Gastroenterology, University of Ottawa, Ottawa, Ontario, Canada
| | - Sophie Plamondon
- Department of Medicine, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Greg Rosenfeld
- Division of Gastroenterology, Pacific Gastroenterology Associates, Vancouver, British Columbia, Canada
| | - David Schwartz
- Inflammatory Bowel Disease Center, Vanderbilt University, Nashville, Tennessee, USA
| | - Cynthia H Seow
- Departments of Medicine & Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Chadwick Williams
- Division of Digestive Care & Endoscopy, Department of Medicine, Dartmouth General Hospital, Halifax, Nova Scotia, Canada
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Steinhart AH, Panaccione R, Targownik L, Bressler B, Khanna R, Marshall JK, Afif W, Bernstein CN, Bitton A, Borgaonkar M, Chauhan U, Halloran B, Jones J, Kennedy E, Leontiadis GI, Loftus EV, Meddings J, Moayyedi P, Murthy S, Plamondon S, Rosenfeld G, Schwartz D, Seow CH, Williams C. Clinical Practice Guideline for the Medical Management of Perianal Fistulizing Crohn's Disease: The Toronto Consensus. J Can Assoc Gastroenterol 2018; 1:141-154. [PMID: 31799497 DOI: 10.1093/jcag/gwy047] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Fistulas occur in about 25% of patients with Crohn's disease (CD) and can be difficult to treat. The aim of this consensus was to provide guidance for the management of patients with perianal fistulizing CD. Methods A systematic literature search identified studies on the management of fistulizing CD. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Statements were developed through an iterative online platform using a modified Delphi process, then finalized, and voted on by a group of specialists. Results The quality of evidence for treatment of fistulizing CD was generally of very low quality, and because of the scarcity of good randomized controlled trials (RCTs), these consensus statements generally provide conditional suggestions (5 of 7 statements). Imaging and surgical consultations were recommended in the initial assessment of patients with active fistulizing CD, particularly those with complicated disease. Antibiotic therapy is useful for initial symptom control. Antitumor necrosis factor (anti-TNF) therapy was recommended to induce symptomatic response, and continued use was suggested to achieve and maintain complete remission. The use of concomitant immunosuppressant therapies may be useful to optimize pharmacokinetic parameters when initiating anti-TNF therapy. When there has been an inadequate symptomatic response to medical management strategies, surgical therapy may provide effective fistula healing for some patients. Conclusions Optimal management of perianal fistulizing CD requires a collaborative effort between gastroenterologists and surgeons and may include the evidence-based use of existing therapies, as well as surgical assessments and interventions when needed.
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Affiliation(s)
- A Hillary Steinhart
- Division of Gastroenterology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Remo Panaccione
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Laura Targownik
- Section of Gastroenterology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Brian Bressler
- Department of Medicine, Division of Gastroenterology, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Reena Khanna
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - John K Marshall
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Waqqas Afif
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Charles N Bernstein
- Section of Gastroenterology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alain Bitton
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Mark Borgaonkar
- Faculty of Medicine, Memorial University, St John's, Newfoundland, Canada
| | - Usha Chauhan
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Brendan Halloran
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Jennifer Jones
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Erin Kennedy
- Division of General Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Grigorios I Leontiadis
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Edward V Loftus
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jonathan Meddings
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul Moayyedi
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Sanjay Murthy
- Division of Gastroenterology, University of Ottawa, Ottawa, Ontario, Canada
| | - Sophie Plamondon
- Department of Medicine, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Greg Rosenfeld
- Division of Gastroenterology, Pacific Gastroenterology Associates, Vancouver, British Columbia, Canada
| | - David Schwartz
- Inflammatory Bowel Disease Center, Vanderbilt University, Nashville, Tennessee, USA
| | - Cynthia H Seow
- Departments of Medicine & Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Chadwick Williams
- Division of Digestive Care & Endoscopy, Department of Medicine, Dartmouth General Hospital, Halifax, Nova Scotia, Canada
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Panaccione R, Steinhart AH, Bressler B, Khanna R, Marshall JK, Targownik L, Afif W, Bitton A, Borgaonkar M, Chauhan U, Halloran B, Jones J, Kennedy E, Leontiadis GI, Loftus EV, Meddings J, Moayyedi P, Murthy S, Plamondon S, Rosenfeld G, Schwartz D, Seow CH, Williams C, Bernstein CN. Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Luminal Crohn's Disease. J Can Assoc Gastroenterol 2018; 2:e1-e34. [PMID: 31294378 PMCID: PMC6619415 DOI: 10.1093/jcag/gwz019] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background & Aims Crohn’s disease (CD) is a lifelong illness with substantial morbidity, although new therapies and treatment paradigms have been developed. We provide guidance for treatment of ambulatory patients with mild to severe active luminal CD. Methods We performed a systematic review to identify published studies of the management of CD. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Statements were developed through an iterative online platform and then finalized and voted on by a group of specialists. Results The consensus includes 41 statements focused on 6 main drug classes: antibiotics, 5-aminosalicylate, corticosteroids, immunosuppressants, biologic therapies, and other therapies. The group suggested against the use of antibiotics or 5-aminosalicylate as induction or maintenance therapies. Corticosteroid therapies (including budesonide) can be used as induction, but not maintenance therapies. Among immunosuppressants, thiopurines should not be used for induction, but can be used for maintenance therapy for selected low-risk patients. Parenteral methotrexate was proposed for induction and maintenance therapy in patients with corticosteroid-dependent CD. Biologic agents, including tumor necrosis factor antagonists, vedolizumab, and ustekinumab, were recommended for patients failed by conventional induction therapies and as maintenance therapy. The consensus group was unable to clearly define the role of concomitant immunosuppressant therapies in initiation of treatment with a biologic agent. Conclusions Optimal management of CD requires careful patient assessment, acknowledgement of patient preferences, evidence-based use of existing therapies, and thorough assessment to define treatment success.
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Affiliation(s)
- Remo Panaccione
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - A Hillary Steinhart
- Division of Gastroenterology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Brian Bressler
- Department of Medicine, Division of Gastroenterology, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Reena Khanna
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - John K Marshall
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Laura Targownik
- Section of Gastroenterology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Waqqas Afif
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Alain Bitton
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Mark Borgaonkar
- Faculty of Medicine, Memorial University, St John's, Newfoundland, Canada
| | - Usha Chauhan
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Brendan Halloran
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Jennifer Jones
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Erin Kennedy
- Division of General Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Grigorios I Leontiadis
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Jonathan Meddings
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul Moayyedi
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Sanjay Murthy
- Division of Gastroenterology, University of Ottawa, Ottawa, Ontario, Canada
| | - Sophie Plamondon
- Department of Medicine, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Greg Rosenfeld
- Division of Gastroenterology, Pacific Gastroenterology Associates, Vancouver, British Columbia, Canada
| | - David Schwartz
- Inflammatory Bowel Disease Center, Vanderbilt University, Nashville, Tennessee
| | - Cynthia H Seow
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Charles N Bernstein
- Section of Gastroenterology, University of Manitoba, Winnipeg, Manitoba, Canada
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Abstract
Proton pump inhibitors (PPIs) are among the most widely used class of drugs prescribed over the long term in all of clinical medicine with 8-10% of ambulatory adults have been prescribed a PPI in the past 30 days. However, numerous studies have raised doubts about the long term safety of PPI use. The purpose of this review is threefold: (i) To provide an overview of the current evidence demonstrating associations between PPI use and adverse health outcomes and the likelihood of the associations being causal (Why?); (ii) To be able to identify long-term PPI users in whom the intensity of PPI therapy could be reduced or in whom PPIs could be eliminated outright (Who?); and (iii) To provide strategies on how to reduce or stop chronic PPI therapy while maintaining symptom control and reducing the risk for symptom or upper GI disease recurrence (How?).
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Affiliation(s)
- Laura Targownik
- Section of Gastroenterology, Department of Internal Medicine, Max Rady School of Medicine at University of Manitoba, Winnipeg, Manitoba, Canada
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Elias E, Oketola A, Bernstein CN, Singh H, Targownik L. A92 ANTI-TNF DOSE AUGMENTATION FREQUENTLY OCCURS IN THE ABSENCE OF OBJECTIVE EVIDENCE OF DISEASE ACTIVITY. J Can Assoc Gastroenterol 2018. [DOI: 10.1093/jcag/gwy009.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- E Elias
- University of Manitoba, Winnipeg, MB, Canada
| | - A Oketola
- University of Manitoba, Winnipeg, MB, Canada
| | | | - H Singh
- University of Manitoba, Winnipeg, MB, Canada
| | - L Targownik
- University of Manitoba, Winnipeg, MB, Canada
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Hansen T, Targownik L, Walker JR, Bernstein MT, Sexton K, Bernstein CN. A161 EVALUATING THE DIFFERENCES IN PERCEIVED STRESS AMONG NON-INFLAMMATORY AND INFLAMMATORY IBD FLARES. J Can Assoc Gastroenterol 2018. [DOI: 10.1093/jcag/gwy009.161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- T Hansen
- University of Manitoba, Winnipeg, MB, Canada
| | - L Targownik
- University of Manitoba, Winnipeg, MB, Canada
| | - J R Walker
- University of Manitoba, Winnipeg, MB, Canada
| | | | - K Sexton
- University of Manitoba, Winnipeg, MB, Canada
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Benchimol EI, Bernstein CN, Nguyen GC, Targownik L, Guttmann A, Jones J, Potter BK, Kuenzig E, Catley CA, Tanyingoh D, Nugent Z, Mojaverian N, Underwood F, Kaplan GG. A31 DISPARITIES IN THE CARE OF RURAL AND URBAN CANADIANS WITH INFLAMMATORY BOWEL DISEASE: A POPULATION-BASED STUDY. J Can Assoc Gastroenterol 2018. [DOI: 10.1093/jcag/gwy009.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- E I Benchimol
- Canadian Gastro-Intestinal Epidemiology Consortium (CanGIEC), Institute for Clinical Evaluative Sciences (ICES), Children’s Hospital of Eastern Ontario IBD Centre, Department of Pediatrics, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - C N Bernstein
- CanGIEC, University of Manitoba IBD Clinical and Research Centre, Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - G C Nguyen
- CanGIEC, ICES, Mount Sinai Hospital Centre for IBD, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - L Targownik
- CanGIEC, University of Manitoba IBD Clinical and Research Centre, Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - A Guttmann
- ICES, Department of Paediatrics, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - J Jones
- CanGIEC, Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - B K Potter
- ICES, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - E Kuenzig
- Canadian Gastro-Intestinal Epidemiology Consortium (CanGIEC), Institute for Clinical Evaluative Sciences (ICES), Children’s Hospital of Eastern Ontario IBD Centre, Department of Pediatrics, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - C A Catley
- ICES, University of Ottawa, Ottawa, ON, Canada
| | - D Tanyingoh
- CanGIEC, University of Calgary IBD Clinic, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Z Nugent
- CanGIEC, University of Manitoba IBD Clinical and Research Centre, Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | | | - F Underwood
- CanGIEC, University of Calgary IBD Clinic, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - G G Kaplan
- CanGIEC, University of Calgary IBD Clinic, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Elias E, Oketola A, Targownik L, Singh H, Bernstein CN. A93 NO INCREASE IN IMMUNOMODULATOR USE IN COMBINATION WITH ANTI-TNF THERAPY IN THE POST SONIC ERA. J Can Assoc Gastroenterol 2018. [DOI: 10.1093/jcag/gwy009.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- E Elias
- University of Manitoba, Winnipeg, MB, Canada
| | - A Oketola
- University of Manitoba, Winnipeg, MB, Canada
| | - L Targownik
- University of Manitoba, Winnipeg, MB, Canada
| | - H Singh
- University of Manitoba, Winnipeg, MB, Canada
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Vigod SN, Kurdyak P, Brown HK, Nguyen GC, Targownik L, Seow C, Benchimol EI. A5 FIRST-ONSET PSYCHIATRIC DISORDERS IN PREGNANT AND POST-PARTUM WOMEN WITH INFLAMMATORY BOWEL DISEASE IN ONTARIO, CANADA: A POPULATION-BASED STUDY. J Can Assoc Gastroenterol 2018. [DOI: 10.1093/jcag/gwy009.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- S N Vigod
- Institute for Clinical Evaluative Sciences, Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - P Kurdyak
- Institute for Clinical Evaluative Sciences, Department of Psychiatry, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - H K Brown
- Institute for Clinical Evaluative Sciences, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - G C Nguyen
- Mount Sinai Hospital Centre for IBD, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - L Targownik
- University of Manitoba IBD Clinical and Research Centre, Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - C Seow
- University of Calgary IBD Centre, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - E I Benchimol
- Institute for Clinical Evaluative Sciences, Children’s Hospital of Eastern Ontario IBD Centre, Department of Pediatrics, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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Singh H, Nugent Z, Yu BN, Lix LM, Targownik L, Bernstein C. Hospital discharge abstracts have limited accuracy in identifying occurrence of Clostridium difficile infections among hospitalized individuals with inflammatory bowel disease: A population-based study. PLoS One 2017; 12:e0171266. [PMID: 28199401 PMCID: PMC5310850 DOI: 10.1371/journal.pone.0171266] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Accepted: 01/17/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Hospital discharge databases are used to study the epidemiology of Clostridium difficile infections (CDI) among hospitalized patients with inflammatory bowel disease (IBD). CDI in IBD is increasingly important and accurately estimating its occurrence is critical in understanding its comorbidity. There are limited data on the reliability of the International Classification of Diseases 10th revision (ICD-10) (now widely used in North America) CDI code in determining occurrence of CDI among hospitalized patients. We compared the performance of ICD-10 CDI coding to laboratory confirmed CDI diagnoses. METHODS The University of Manitoba IBD Epidemiology Database was used to identify individuals with and without IBD discharged with CDI diagnoses between 07/01/2005 and 3/31/2014. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of ICD-10 CDI code was compared to laboratory CDI diagnoses recorded in a province wide CDI dataset. Multivariable logistic regression models were performed to test the predictors of diagnostic inaccuracy of ICD-10 CDI code. RESULTS There were 273 episodes of laboratory confirmed CDI (hospitalized and non-hospitalized) among 7396 individuals with IBD and 536 among 66,297 matched controls. The sensitivity, specificity, PPV and NPV of ICD-10 CDI code in discharge abstracts was 72.8%, 99.6%, 64.1% and 99.7% among those with IBD and 70.8%, 99.9%, 79.0% and 99.9% among those without IBD. Predictors of diagnostic inaccuracy included IBD, older age, increased co-morbidity and earlier years of hospitalization. CONCLUSIONS Identification of CDI using ICD-10 CDI code in hospital discharge abstracts may not identify up to 30% of CDI cases, with worse performance among those with IBD.
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Affiliation(s)
- Harminder Singh
- Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,University of Manitoba IBD Clinical and Research Center, Winnipeg, Manitoba, Canada.,Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Zoann Nugent
- Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,University of Manitoba IBD Clinical and Research Center, Winnipeg, Manitoba, Canada.,CancerCare Manitoba, Department of Epidemiology and Cancer Registry, Winnipeg, Manitoba, Canada
| | - B Nancy Yu
- Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,Public Health Branch, Manitoba Health, Seniors and Active Living, Winnipeg, Manitoba, Canada
| | - Lisa M Lix
- Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Laura Targownik
- Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,University of Manitoba IBD Clinical and Research Center, Winnipeg, Manitoba, Canada
| | - Charles Bernstein
- Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,University of Manitoba IBD Clinical and Research Center, Winnipeg, Manitoba, Canada
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Filion KB, Azoulay L, Platt RW, Dahl M, Dormuth CR, Clemens KK, Hu N, Paterson JM, Targownik L, Turin TC, Udell JA, Ernst P. A Multicenter Observational Study of Incretin-based Drugs and Heart Failure. N Engl J Med 2016; 374:1145-54. [PMID: 27007958 DOI: 10.1056/nejmoa1506115] [Citation(s) in RCA: 167] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND There is concern that antidiabetic incretin-based drugs, including dipeptidyl peptidase 4 (DPP-4) inhibitors and glucagon-like peptide 1 (GLP-1) analogues, can increase the risk of heart failure. Ongoing clinical trials may not have large enough samples to effectively address this issue. METHODS We applied a common protocol in the analysis of multiple cohorts of patients with diabetes. We used health care data from four Canadian provinces, the United States, and the United Kingdom. With the use of a nested case-control analysis, we matched each patient who was hospitalized for heart failure with up to 20 controls from the same cohort; matching was based on sex, age, cohort-entry date, duration of treated diabetes, and follow-up time. Cohort-specific hazard ratios for hospitalization due to heart failure among patients receiving incretin-based drugs, as compared with those receiving oral antidiabetic-drug combinations, were estimated by means of conditional logistic regression and pooled across cohorts with the use of random-effects models. RESULTS The cohorts included a total of 1,499,650 patients, with 29,741 hospitalized for heart failure (incidence rate, 9.2 events per 1000 persons per year). The rate of hospitalization for heart failure did not increase with the use of incretin-based drugs as compared with oral antidiabetic-drug combinations among patients with a history of heart failure (hazard ratio, 0.86; 95% confidence interval [CI], 0.62 to 1.19) or among those without a history of heart failure (hazard ratio, 0.82; 95% CI, 0.67 to 1.00). The results were similar for DPP-4 inhibitors and GLP-1 analogues. CONCLUSIONS In this analysis of data from large cohorts of patients with diabetes, incretin-based drugs were not associated with an increased risk of hospitalization for heart failure, as compared with commonly used combinations of oral antidiabetic drugs. (Funded by the Canadian Institutes of Health Research; ClinicalTrials.gov number, NCT02456428.).
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Affiliation(s)
- Kristian B Filion
- From the Center for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital (K.B.F., L.A., P.E.), the Departments of Medicine (K.B.F., P.E.), Oncology (L.A.), Pediatrics (R.W.P.), and Epidemiology, Biostatistics, and Occupational Health (R.W.P.), McGill University, and the Research Institute of the McGill University Health Centre (R.W.P.), Montreal, the Manitoba Centre for Health Policy, Department of Community Health Sciences (M.D., L.T.), and the Section of Gastroenterology, Division of Internal Medicine (L.T.), University of Manitoba, Winnipeg, the Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver (C.R.D.), the Department of Medicine, Western University, London, ON (K.K.C.), the Health Quality Council, Saskatoon, SK (N.H.), the Institute for Clinical Evaluative Sciences (J.M.P., J.A.U.), Institute of Health Policy, Management and Evaluation, University of Toronto (J.M.P.), and the Cardiovascular Division, Women's College Hospital, Peter Munk Cardiac Centre of the University Health Network, and the University of Toronto (J.A.U.), Toronto, the Department of Family Medicine, McMaster University, Hamilton, ON (J.M.P.), and the Department of Family Medicine, University of Calgary, Calgary, AB (T.C.T.) - all in Canada
| | - Laurent Azoulay
- From the Center for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital (K.B.F., L.A., P.E.), the Departments of Medicine (K.B.F., P.E.), Oncology (L.A.), Pediatrics (R.W.P.), and Epidemiology, Biostatistics, and Occupational Health (R.W.P.), McGill University, and the Research Institute of the McGill University Health Centre (R.W.P.), Montreal, the Manitoba Centre for Health Policy, Department of Community Health Sciences (M.D., L.T.), and the Section of Gastroenterology, Division of Internal Medicine (L.T.), University of Manitoba, Winnipeg, the Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver (C.R.D.), the Department of Medicine, Western University, London, ON (K.K.C.), the Health Quality Council, Saskatoon, SK (N.H.), the Institute for Clinical Evaluative Sciences (J.M.P., J.A.U.), Institute of Health Policy, Management and Evaluation, University of Toronto (J.M.P.), and the Cardiovascular Division, Women's College Hospital, Peter Munk Cardiac Centre of the University Health Network, and the University of Toronto (J.A.U.), Toronto, the Department of Family Medicine, McMaster University, Hamilton, ON (J.M.P.), and the Department of Family Medicine, University of Calgary, Calgary, AB (T.C.T.) - all in Canada
| | - Robert W Platt
- From the Center for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital (K.B.F., L.A., P.E.), the Departments of Medicine (K.B.F., P.E.), Oncology (L.A.), Pediatrics (R.W.P.), and Epidemiology, Biostatistics, and Occupational Health (R.W.P.), McGill University, and the Research Institute of the McGill University Health Centre (R.W.P.), Montreal, the Manitoba Centre for Health Policy, Department of Community Health Sciences (M.D., L.T.), and the Section of Gastroenterology, Division of Internal Medicine (L.T.), University of Manitoba, Winnipeg, the Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver (C.R.D.), the Department of Medicine, Western University, London, ON (K.K.C.), the Health Quality Council, Saskatoon, SK (N.H.), the Institute for Clinical Evaluative Sciences (J.M.P., J.A.U.), Institute of Health Policy, Management and Evaluation, University of Toronto (J.M.P.), and the Cardiovascular Division, Women's College Hospital, Peter Munk Cardiac Centre of the University Health Network, and the University of Toronto (J.A.U.), Toronto, the Department of Family Medicine, McMaster University, Hamilton, ON (J.M.P.), and the Department of Family Medicine, University of Calgary, Calgary, AB (T.C.T.) - all in Canada
| | - Matthew Dahl
- From the Center for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital (K.B.F., L.A., P.E.), the Departments of Medicine (K.B.F., P.E.), Oncology (L.A.), Pediatrics (R.W.P.), and Epidemiology, Biostatistics, and Occupational Health (R.W.P.), McGill University, and the Research Institute of the McGill University Health Centre (R.W.P.), Montreal, the Manitoba Centre for Health Policy, Department of Community Health Sciences (M.D., L.T.), and the Section of Gastroenterology, Division of Internal Medicine (L.T.), University of Manitoba, Winnipeg, the Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver (C.R.D.), the Department of Medicine, Western University, London, ON (K.K.C.), the Health Quality Council, Saskatoon, SK (N.H.), the Institute for Clinical Evaluative Sciences (J.M.P., J.A.U.), Institute of Health Policy, Management and Evaluation, University of Toronto (J.M.P.), and the Cardiovascular Division, Women's College Hospital, Peter Munk Cardiac Centre of the University Health Network, and the University of Toronto (J.A.U.), Toronto, the Department of Family Medicine, McMaster University, Hamilton, ON (J.M.P.), and the Department of Family Medicine, University of Calgary, Calgary, AB (T.C.T.) - all in Canada
| | - Colin R Dormuth
- From the Center for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital (K.B.F., L.A., P.E.), the Departments of Medicine (K.B.F., P.E.), Oncology (L.A.), Pediatrics (R.W.P.), and Epidemiology, Biostatistics, and Occupational Health (R.W.P.), McGill University, and the Research Institute of the McGill University Health Centre (R.W.P.), Montreal, the Manitoba Centre for Health Policy, Department of Community Health Sciences (M.D., L.T.), and the Section of Gastroenterology, Division of Internal Medicine (L.T.), University of Manitoba, Winnipeg, the Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver (C.R.D.), the Department of Medicine, Western University, London, ON (K.K.C.), the Health Quality Council, Saskatoon, SK (N.H.), the Institute for Clinical Evaluative Sciences (J.M.P., J.A.U.), Institute of Health Policy, Management and Evaluation, University of Toronto (J.M.P.), and the Cardiovascular Division, Women's College Hospital, Peter Munk Cardiac Centre of the University Health Network, and the University of Toronto (J.A.U.), Toronto, the Department of Family Medicine, McMaster University, Hamilton, ON (J.M.P.), and the Department of Family Medicine, University of Calgary, Calgary, AB (T.C.T.) - all in Canada
| | - Kristin K Clemens
- From the Center for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital (K.B.F., L.A., P.E.), the Departments of Medicine (K.B.F., P.E.), Oncology (L.A.), Pediatrics (R.W.P.), and Epidemiology, Biostatistics, and Occupational Health (R.W.P.), McGill University, and the Research Institute of the McGill University Health Centre (R.W.P.), Montreal, the Manitoba Centre for Health Policy, Department of Community Health Sciences (M.D., L.T.), and the Section of Gastroenterology, Division of Internal Medicine (L.T.), University of Manitoba, Winnipeg, the Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver (C.R.D.), the Department of Medicine, Western University, London, ON (K.K.C.), the Health Quality Council, Saskatoon, SK (N.H.), the Institute for Clinical Evaluative Sciences (J.M.P., J.A.U.), Institute of Health Policy, Management and Evaluation, University of Toronto (J.M.P.), and the Cardiovascular Division, Women's College Hospital, Peter Munk Cardiac Centre of the University Health Network, and the University of Toronto (J.A.U.), Toronto, the Department of Family Medicine, McMaster University, Hamilton, ON (J.M.P.), and the Department of Family Medicine, University of Calgary, Calgary, AB (T.C.T.) - all in Canada
| | - Nianping Hu
- From the Center for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital (K.B.F., L.A., P.E.), the Departments of Medicine (K.B.F., P.E.), Oncology (L.A.), Pediatrics (R.W.P.), and Epidemiology, Biostatistics, and Occupational Health (R.W.P.), McGill University, and the Research Institute of the McGill University Health Centre (R.W.P.), Montreal, the Manitoba Centre for Health Policy, Department of Community Health Sciences (M.D., L.T.), and the Section of Gastroenterology, Division of Internal Medicine (L.T.), University of Manitoba, Winnipeg, the Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver (C.R.D.), the Department of Medicine, Western University, London, ON (K.K.C.), the Health Quality Council, Saskatoon, SK (N.H.), the Institute for Clinical Evaluative Sciences (J.M.P., J.A.U.), Institute of Health Policy, Management and Evaluation, University of Toronto (J.M.P.), and the Cardiovascular Division, Women's College Hospital, Peter Munk Cardiac Centre of the University Health Network, and the University of Toronto (J.A.U.), Toronto, the Department of Family Medicine, McMaster University, Hamilton, ON (J.M.P.), and the Department of Family Medicine, University of Calgary, Calgary, AB (T.C.T.) - all in Canada
| | - J Michael Paterson
- From the Center for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital (K.B.F., L.A., P.E.), the Departments of Medicine (K.B.F., P.E.), Oncology (L.A.), Pediatrics (R.W.P.), and Epidemiology, Biostatistics, and Occupational Health (R.W.P.), McGill University, and the Research Institute of the McGill University Health Centre (R.W.P.), Montreal, the Manitoba Centre for Health Policy, Department of Community Health Sciences (M.D., L.T.), and the Section of Gastroenterology, Division of Internal Medicine (L.T.), University of Manitoba, Winnipeg, the Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver (C.R.D.), the Department of Medicine, Western University, London, ON (K.K.C.), the Health Quality Council, Saskatoon, SK (N.H.), the Institute for Clinical Evaluative Sciences (J.M.P., J.A.U.), Institute of Health Policy, Management and Evaluation, University of Toronto (J.M.P.), and the Cardiovascular Division, Women's College Hospital, Peter Munk Cardiac Centre of the University Health Network, and the University of Toronto (J.A.U.), Toronto, the Department of Family Medicine, McMaster University, Hamilton, ON (J.M.P.), and the Department of Family Medicine, University of Calgary, Calgary, AB (T.C.T.) - all in Canada
| | - Laura Targownik
- From the Center for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital (K.B.F., L.A., P.E.), the Departments of Medicine (K.B.F., P.E.), Oncology (L.A.), Pediatrics (R.W.P.), and Epidemiology, Biostatistics, and Occupational Health (R.W.P.), McGill University, and the Research Institute of the McGill University Health Centre (R.W.P.), Montreal, the Manitoba Centre for Health Policy, Department of Community Health Sciences (M.D., L.T.), and the Section of Gastroenterology, Division of Internal Medicine (L.T.), University of Manitoba, Winnipeg, the Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver (C.R.D.), the Department of Medicine, Western University, London, ON (K.K.C.), the Health Quality Council, Saskatoon, SK (N.H.), the Institute for Clinical Evaluative Sciences (J.M.P., J.A.U.), Institute of Health Policy, Management and Evaluation, University of Toronto (J.M.P.), and the Cardiovascular Division, Women's College Hospital, Peter Munk Cardiac Centre of the University Health Network, and the University of Toronto (J.A.U.), Toronto, the Department of Family Medicine, McMaster University, Hamilton, ON (J.M.P.), and the Department of Family Medicine, University of Calgary, Calgary, AB (T.C.T.) - all in Canada
| | - Tanvir C Turin
- From the Center for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital (K.B.F., L.A., P.E.), the Departments of Medicine (K.B.F., P.E.), Oncology (L.A.), Pediatrics (R.W.P.), and Epidemiology, Biostatistics, and Occupational Health (R.W.P.), McGill University, and the Research Institute of the McGill University Health Centre (R.W.P.), Montreal, the Manitoba Centre for Health Policy, Department of Community Health Sciences (M.D., L.T.), and the Section of Gastroenterology, Division of Internal Medicine (L.T.), University of Manitoba, Winnipeg, the Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver (C.R.D.), the Department of Medicine, Western University, London, ON (K.K.C.), the Health Quality Council, Saskatoon, SK (N.H.), the Institute for Clinical Evaluative Sciences (J.M.P., J.A.U.), Institute of Health Policy, Management and Evaluation, University of Toronto (J.M.P.), and the Cardiovascular Division, Women's College Hospital, Peter Munk Cardiac Centre of the University Health Network, and the University of Toronto (J.A.U.), Toronto, the Department of Family Medicine, McMaster University, Hamilton, ON (J.M.P.), and the Department of Family Medicine, University of Calgary, Calgary, AB (T.C.T.) - all in Canada
| | - Jacob A Udell
- From the Center for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital (K.B.F., L.A., P.E.), the Departments of Medicine (K.B.F., P.E.), Oncology (L.A.), Pediatrics (R.W.P.), and Epidemiology, Biostatistics, and Occupational Health (R.W.P.), McGill University, and the Research Institute of the McGill University Health Centre (R.W.P.), Montreal, the Manitoba Centre for Health Policy, Department of Community Health Sciences (M.D., L.T.), and the Section of Gastroenterology, Division of Internal Medicine (L.T.), University of Manitoba, Winnipeg, the Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver (C.R.D.), the Department of Medicine, Western University, London, ON (K.K.C.), the Health Quality Council, Saskatoon, SK (N.H.), the Institute for Clinical Evaluative Sciences (J.M.P., J.A.U.), Institute of Health Policy, Management and Evaluation, University of Toronto (J.M.P.), and the Cardiovascular Division, Women's College Hospital, Peter Munk Cardiac Centre of the University Health Network, and the University of Toronto (J.A.U.), Toronto, the Department of Family Medicine, McMaster University, Hamilton, ON (J.M.P.), and the Department of Family Medicine, University of Calgary, Calgary, AB (T.C.T.) - all in Canada
| | - Pierre Ernst
- From the Center for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital (K.B.F., L.A., P.E.), the Departments of Medicine (K.B.F., P.E.), Oncology (L.A.), Pediatrics (R.W.P.), and Epidemiology, Biostatistics, and Occupational Health (R.W.P.), McGill University, and the Research Institute of the McGill University Health Centre (R.W.P.), Montreal, the Manitoba Centre for Health Policy, Department of Community Health Sciences (M.D., L.T.), and the Section of Gastroenterology, Division of Internal Medicine (L.T.), University of Manitoba, Winnipeg, the Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver (C.R.D.), the Department of Medicine, Western University, London, ON (K.K.C.), the Health Quality Council, Saskatoon, SK (N.H.), the Institute for Clinical Evaluative Sciences (J.M.P., J.A.U.), Institute of Health Policy, Management and Evaluation, University of Toronto (J.M.P.), and the Cardiovascular Division, Women's College Hospital, Peter Munk Cardiac Centre of the University Health Network, and the University of Toronto (J.A.U.), Toronto, the Department of Family Medicine, McMaster University, Hamilton, ON (J.M.P.), and the Department of Family Medicine, University of Calgary, Calgary, AB (T.C.T.) - all in Canada
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Targownik L. Author's reply to Witham and colleagues. Assoc Med J 2012. [DOI: 10.1136/bmj.e5852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abstract
BACKGROUND Rofecoxib and celecoxib (coxibs) effectively treat chronic arthritis pain and reduce ulcer complications by 50% compared with nonselective nonsteroidal anti-inflammatory drugs (NSAIDs). However, their absolute risk reduction is small and the cost-effectiveness of treatment is uncertain. OBJECTIVE To determine whether the degree of risk reduction in gastrointestinal complications by coxibs offsets their increased cost compared with a generic nonselective NSAID. DESIGN Cost-utility analysis. DATA SOURCES Systematic review of MEDLINE and published abstracts. TARGET POPULATION Patients with osteoarthritis or rheumatoid arthritis who are not taking aspirin and who require long-term NSAID therapy for moderate to severe arthritis pain. PERSPECTIVE Third-party payer. INTERVENTIONS Naproxen, 500 mg twice daily, and coxib, once daily. Patients intolerant of naproxen were switched to a coxib. TIME HORIZON Lifetime. OUTCOME MEASURES Incremental cost per quality-adjusted life-year (QALY) gained. RESULTS OF BASE-CASE ANALYSIS Using a coxib instead of a nonselective NSAID in average-risk patients cost an incremental 275 809 dollars per year to gain 1 additional QALY. RESULTS OF SENSITIVITY ANALYSIS The incremental cost per QALY gained decreased to 55 803 dollars when the analysis was limited to the subset of patients with a history of bleeding ulcers. The coxib strategy became dominant when the cost of coxibs was reduced by 90% of the current average wholesale price. In probabilistic sensitivity analysis, if a third-party payer was willing to pay 150 000 dollars per QALY gained, then 4.3% of average-risk patients would fall within the budget. CONCLUSIONS The risk reduction seen with coxibs does not offset their increased costs compared with nonselective NSAIDs in the management of average-risk patients with chronic arthritis. However, coxibs may provide an acceptable incremental cost-effectiveness ratio in the subgroup of patients with a history of bleeding ulcers.
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Affiliation(s)
- Brennan M R Spiegel
- Veterans Administration Greater Los Angeles Healthcare System, David Geffen School of Medicine at University of California, CURE Digestive Diseases Research Center, Los Angeles, CA 90073, USA
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Abstract
Current guidelines for the management of patients with compensated cirrhosis recommend universal screening endoscopy followed by prophylactic beta-blocker therapy to prevent initial hemorrhage in those found to have esophageal varices. However, the cost-effectiveness of this recommendation has not been established. Our objective was to determine whether screening endoscopy is cost-effective compared with empiric medical management in patients with compensated cirrhosis. Decision analysis with Markov modeling was used to calculate the cost-effectiveness of 6 competing strategies: (1) universal screening endoscopy (EGD) followed by beta-blocker (BB) therapy (EGD-->BB) if varices are present, (2) EGD followed by endoscopic band ligation (EBL) (EGD-->EBL) if varices are present, (3) selective screening endoscopy (sEGD) in high risk patients followed by BB therapy if varices are present (sEGD-->BB), (4) selective screening endoscopy followed by EBL (sEGD-->EBL) if varices are present, (5) empiric beta-blocker therapy in all patients, and (6) no prophylactic therapy ("Do Nothing"). Cost estimates were from a third-party payer perspective. The main outcome measure was the cost per initial variceal hemorrhage prevented. The "Do Nothing" strategy was the least expensive yet least effective approach. Compared with the "Do Nothing" strategy, the empiric beta-blocker strategy cost an incremental $12,408 per additional variceal bleed prevented. Compared with the empiric beta-blocker strategy, in turn, both the EGD-->BB and the EGD-->EBL strategies cost over $175,000 more per additional bleed prevented. The sEGD-->BB and sEGD-->EBL strategies were more expensive and less effective than the empiric beta-blocker strategy. In conclusion, empiric beta-blocker therapy for the primary prophylaxis of variceal hemorrhage is a cost-effective measure, as the use of screening endoscopy to guide therapy adds significant cost with only marginal increase in effectiveness.
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Affiliation(s)
- Brennan M r Spiegel
- Division of Gastroenterology, Greater Los Angeles VA Healthcare System, CA 90073, USA
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