Impatience with Inpatients: Are Hospitalization Rates Declining for IBD Patients?

Abstract

The annual costs of inflammatory bowel disease (IBD) care exceed $14 billion in the United States alone, of which hospitalization-related expenditure accounts for nearly two thirds of the cost [1]. The rising incidence and prevalence of IBD places an even greater stress on health care systems. Evaluation of current and past IBD hospitalization and readmission trends will help develop policies necessary to address the challenges faced by health systems in providing high-quality and cost-effective care for this patient population. Historically, the lack of safe and effective maintenance therapy led to unplanned hospitalizations for disease flares and complications, significantly contributing to the healthcare burden and costs associated with IBD. Nevertheless, in the last two decades there have been several changes to the management of patients with IBD including increased use of biologic therapies, and adoption of more objective treatment targets including steroid-free clinical response, biomarker targets, and endoscopic healing [2]. These practice changes were aimed at achieving superior disease control and shifting the management of IBD from high-cost inpatient hospital care to lower-cost close monitoring in ambulatory care settings [3]. Despite these advancements, it remains unclear if the risk of unplanned IBD-related hospitalizations, a useful surrogate for improved disease control, has been reduced. The existing data on the risk of hospitalization and its trend over time among patients with IBD are exceedingly heterogenous. Hospital-based studies are prone to selection bias and not representative of the entire IBD population in the community. National databases based on discharge codes or insurance claims, although useful to assess the disease burden within a region, do not provide patient-level risk estimates necessary for risk stratification and development of risk-based treatment algorithms. Therefore, the most accurate method to estimate the risk of hospitalization among IBD patients is by longitudinally tracking all patients with IBD in a community from the time of their diagnosis up to their death. Yet, such population-based inception cohort data are limited as they are often challenging to maintain and regulated by governmental policies and healthcare delivery systems. The study by Tsai et al. published in this issue of Digestive Diseases and Sciences is a systematic review and metaanalysis of population-based inception cohort studies (published up to September 3, 2019) designed to estimate the cumulative risk of IBD-related and all-cause hospitalization in patients with ulcerative colitis (UC) and Crohn’s disease (CD) [4]. They included 6 cohorts of patients with UC (17,190 patients) finding the cumulative 1-, 3and 5-year risk of UC-related hospitalization to be 10.4% (95% CI, 8.2–13.2), 17.0% (95% CI, 14.0–20.4) and 21.5% (95% CI, 18.0–25.4), respectively. In the 6 cohorts of patients with CD (23,081 patients), the cumulative 1-, 3-and 5-year risk of CD-related hospitalization was 29.3% (95% CI, 20.0–40.8), 38.5% (95% CI, 26.8–51.7) and 44.3% (95% CI, 32.7–56.5), respectively. This implies nearly a 2to 3-fold risk of disease-related hospitalization with CD as compared with UC patients at each of the three follow-up intervals. In general, the natural history of CD carries a higher disease burden compared with UC, since untreated CD is associated with complications from progressive bowel damage such as strictures, fistulae and abscesses that often require hospitalization for medical and surgical treatments. Prior studies have reported a similar trend of higher hospitalization rates among CD cohorts compared with patients with UC [5, 6]. On meta-regression analysis, the study found younger age at onset was associated with increased risk of hospitalization in UC and ileal-dominant and perianal disease was associated with increased risk of hospitalization in CD [4]. * Anand Kumar [email protected]