Alyce Anderson

Demographic and Clinical Predictors of High Healthcare Use in Patients with Inflammatory Bowel Disease.

Background:Inflammatory bowel disease (IBD) is a heterogeneous chronic inflammatory condition requiring significant healthcare expenditure. Subgroups of individuals contribute disproportionately to spending. We aimed to determine demographic and clinical factors predictive of high healthcare expenditures for IBD patients followed over a multiyear period. Methods:This was a registry analysis using a prospective observational, consented, natural history registry from a tertiary IBD center and associated medical charges, not including pharmacy expenses. The 100 patients with the highest medical charges (top 5%) were compared with the median 300 patients. Logistic regression determined demographic and clinical factors associated with high charge patients. Results:IBD patients in the high charge group had significantly more unemployment (P < 0.0001), were of black race (P = 0.013), comorbid psychiatric illness (P = 0.002), hypertension (P = 0.01), diabetes (P = 0.004), opiate use (P < 0.0001), perianal involvement (P = 0.002), penetrating disease (P < 0.0001), and extensive colitis (P = 0.01). In multivariate analysis, unemployment (Crohns disease [CD]: odds ratio [OR], 3.04; 95% confidence interval [CI], 1.32–7.02; ulcerative colitis [UC]: OR, 2.68; 95% CI, 1.20–5.99), psychiatric illness (UC: OR, 2.08; 95% CI, 1.03–4.19), opiates (CD: OR, 5.61; 95% CI, 2.67–11.82; UC: OR, 5.14; 95% CI, 2.52–10.48), prior surgery (CD: OR, 3.29; 95% CI, 1.59–6.82; UC: OR, 2.72; 95% CI, 1.39–5.32), penetrating CD (OR, 3.29; 95% CI, 1.02–10.62), and corticosteroid requirement (CD: OR, 3.78; 95% CI, 1.86–7.65; UC: OR, 2.98; 95% CI, 1.51–5.90) remained independently associated with high charges. Conclusions:High expenditure IBD patients were affected by more severe disease. The high prevalence of depression, anxiety, and chronic pain in these patients suggests the need for focused treatment of these comorbidities ultimately to reduce financial burden.

Silent Crohn's Disease: Asymptomatic Patients with Elevated C-reactive Protein Are at Risk for Subsequent Hospitalization.

Background:Patient-reported Crohns disease (CD) symptoms and endoscopic evaluation have historically guided routine care, but the risk of complications in asymptomatic patients with elevated C-reactive protein (CRP) is unknown. Methods:We conducted a prospective observational cohort study of patients with CD from a tertiary care center. Subjects with short inflammatory bowel disease questionnaire scores ≥50, Harvey–Bradshaw CD scores ⩽4, and same-day CRP measurement were eligible for inclusion. The primary outcome was disease-related hospitalization up to 24 months after the qualifying clinic visit. We assessed the relationship between CRP elevation and subsequent hospitalization. Results:There were 351 asymptomatic patients with CD (median age 40 yr; 50.4% female) who met inclusion criteria, and CRP was elevated in 19.7% of these individuals (n = 69). At 24 months, 16.8% (n = 59) of the study population had been hospitalized for CD-related complications. Significantly, more patients with an elevated CRP were hospitalized (33.3% versus 12.8%, P < 0.0001) compared with those with a normal CRP and were hospitalized at increased rate (P < 0.001) on Kaplan–Meier analysis. CRP elevation was significantly and independently associated with increased risk of hospitalization (adjusted hazard ratio 2.12; 95% confidence interval, 1.13–3.98; P = 0.02) in multivariable survival analysis. Conclusions:Asymptomatic patients with CD with elevated CRP are at a nearly 2-fold higher risk for hospitalization over the subsequent 2 years compared with asymptomatic patients with CD without CRP elevation.

Representation of Women Among Academic Grand Rounds Speakers

Representation of Women Among Academic Grand Rounds Speakers Grand rounds (GR), a time-honored method of disseminating clinical and research knowledge to medical audiences, showcases speakers as successful academic role models. Exposure to successful female role models, such as GR speakers, may positively affect the retention of women in academic medicine.1,2 In the present study, we sought to determine whether women’s representation as GR speakers reflects their representation in academic medical workforces.

Reduced Unplanned Care and Disease Activity and Increased Quality of Life After Patient Enrollment in an Inflammatory Bowel Disease Medical Home

BACKGROUND & AIMS: Specialty medical homes (SMHs) are a new health care model in which a multidisciplinary team and specialists manage patients with chronic diseases. As part of a large integrated payer–provider network, we formed an inflammatory bowel diseases (IBDs) SMH and investigated its effects on health care use, disease activity, and quality of life (QoL). METHODS: We performed a retrospective analysis of 322 patients (58% female; mean age, 34.6 y; 62% with Crohns disease; 32% with prior IBD surgery) enrolled in an IBD SMH, in conjunction with the University of Pittsburgh Medical Center Health Plan, from June 2015 through July 2016. Patients had at least 1 year of follow up. We evaluated changes in numbers of emergency department visits and hospitalizations from the year before vs after SMH enrollment. Secondary measures included IBD activity assessments and QoL. RESULTS: Compared to the year before IBD SMH enrollment, patients had a 47.3% reduction in emergency department visits (P < .0001) and a 35.9% reduction in hospitalizations (P = .008). In the year following IBD SMH enrollment, patients had significant reductions in the median Harvey–Bradshaw Index score (reduced from 4 to 3.5; P = .002), and median ulcerative colitis activity index score (from 4 to 3; P = .0003), and increases in QoL (median short inflammatory bowel disease questionnaire score increased from 50 to 51.8; P < .0001). Patients in the most extreme (highest and lowest) quartiles had the most improvement when we compared scores at baseline vs after enrollment. Based on multivariable regression analysis, use of corticosteroids (odds ratio [OR], 2.72; 95% CI, 1.32–5.66; P = .007) or opioids (OR, 3.20; 95% CI, 1.32–7.78; P = .01), and low QoL (OR, 4.44; 95% CI, 1.08–18.250; P = .04) at enrollment were significantly associated with persistent emergency department visits and hospitalizations. CONCLUSIONS: We found development of an IBD SMH to be feasible and significantly reduce unplanned care and disease activity and increase patient QoL 1 year after enrollment.

Accuracy of Skin Cancer Diagnosis by Physician Assistants Compared With Dermatologists in a Large Health Care System

Importance Physician assistants (PAs) are increasingly used in dermatology practices to diagnose skin cancers, although, to date, their diagnostic accuracy compared with board-certified dermatologists has not been well studied. Objective To compare diagnostic accuracy for skin cancer of PAs with that of dermatologists. Design, Setting, and Participants Medical record review of 33 647 skin cancer screening examinations in 20 270 unique patients who underwent screening at University of Pittsburgh Medical Center–affiliated dermatology offices from January 1, 2011, to December 31, 2015. International Classification of Diseases, Ninth Revision code V76.43 and International Classification of Diseases and Related Health Problems, Tenth Revision code Z12.83 were used to identify pathology reports from skin cancer screening examinations by dermatologists and PAs. Exposure Examination performed by a PA or dermatologist. Main Outcomes and Measures Number needed to biopsy (NNB) to diagnose skin cancer (nonmelanoma, invasive melanoma, or in situ melanoma). Results Of 20 270 unique patients, 12 722 (62.8%) were female, mean (SD) age at the first visit was 52.7 (17.4) years, and 19 515 patients (96.3%) self-reported their race/ethnicity as non-Hispanic white. To diagnose 1 case of skin cancer, the NNB was 3.9 for PAs and 3.3 for dermatologists (P < .001). Per diagnosed melanoma, the NNB was 39.4 for PAs and 25.4 for dermatologists (P = .007). Patients screened by a PA were significantly less likely than those screened by a dermatologist to be diagnosed with melanoma in situ (1.1% vs 1.8% of visits, P = .02), but differences were not significant for invasive melanoma (0.7% vs 0.8% of visits, P = .83) or nonmelanoma skin cancer (6.1% vs 6.1% of visits, P = .98). Conclusions and Relevance Compared with dermatologists, PAs performed more skin biopsies per case of skin cancer diagnosed and diagnosed fewer melanomas in situ, suggesting that the diagnostic accuracy of PAs may be lower than that of dermatologists. Although the availability of PAs may help increase access to care and reduce waiting times for appointments, these findings have important implications for the training, appropriate scope of practice, and supervision of PAs and other nonphysician practitioners in dermatology.

Estimating the cost of skin cancer detection by dermatology providers in a large healthcare system

Background: Data on the cost and efficiency of skin cancer detection through total body skin examination are scarce. Objective: To determine the number needed to screen (NNS) and biopsy (NNB) and cost per skin cancer diagnosed in a large dermatology practice in patients undergoing total body skin examination. Methods: This is a retrospective observational study. Results: During 2011‐2015, a total of 20,270 patients underwent 33,647 visits for total body skin examination; 9956 lesion biopsies were performed yielding 2763 skin cancers, including 155 melanomas. The NNS to detect 1 skin cancer was 12.2 (95% confidence interval [CI] 11.7‐12.6) and 1 melanoma was 215 (95% CI 185‐252). The NNB to detect 1 skin cancer was 3.0 (95% CI 2.9‐3.1) and 1 melanoma was 27.8 (95% CI 23.3‐33.3). In a multivariable model for NNS, age and personal history of melanoma were significant factors. Age switched from a protective factor to a risk factor at 51 years of age. The estimated cost per melanoma detected was

Group-Based Trajectory Modeling of Healthcare Financial Charges in Inflammatory Bowel Disease: A Comprehensive Phenotype.

32,594 (95% CI

Low Rates of Dermatologic Care and Skin Cancer Screening Among Inflammatory Bowel Disease Patients

27,326‐

Peripheral Eosinophilia in Patients With Inflammatory Bowel Disease Defines an Aggressive Disease Phenotype

37,475). Limitations: Data are from a single health care system and based on physician coding. Conclusion: Melanoma detection through total body skin examination is most efficient in patients ≥50 years of age and those with a personal history of melanoma. Our findings will be helpful in modeling the cost effectiveness of melanoma screening by dermatologists.

Lasting Impact of Clostridium difficile Infection in Inflammatory Bowel Disease: A Propensity Score Matched Analysis.

Objectives:Inflammatory bowel disease (IBD) is a heterogeneous group of chronic inflammatory gastrointestinal conditions with variable disease courses often requiring significant healthcare expenditures. We aimed to identify disease trajectory patterns based on longitudinal financial expenditures and to assess the association of classic disease activity parameters with financial charges.Methods:This was an analysis of a consented, prospective, natural history IBD registry (2009–2013) from a tertiary IBD center of 2,203 patients and their associated medical charges excluding pharmacy expenses. We applied group-based trajectory modeling to longitudinal healthcare financial charges to determine patterns of charges. We assessed the association between charge patterns and disease activity, quality of life, healthcare utilization, and medication requirement.Results:The final model included 1,600 IBD patients with 5-year charges. We identified six distinct trajectories over the study period. Consistently High charges were associated with Crohn’s disease (66.0% Consistently High patients, P<0.01), perianal involvement (22.6%, P<0.01), ulcerative colitis extent (89.7% extensive, P=0.01), prior IBD surgery (52.5%, P<0.01), and depression/anxiety (36.2%, P<0.01). Compared with other trajectories, Consistently High charges had higher 5-year disease activity indices (Harvey–Bradshaw P<0.01; ulcerative colitis activity index P<0.01), elevated C-reactive protein rates (72.3%, P<0.01), IBD surgery (64.5%, P<0.01), hospitalization (97.2%, P<0.01), corticosteroid (70.9%, P<0.01) and antitumor necrosis factor requirement (50.4%, P<0.01), and worse quality of life (P<0.01). Annual trends in parameters were reflected in temporal changes in financial charges. The majority of financial burden stemmed from inpatient care.Conclusions:Healthcare financial charges represent a novel phenotype in IBD that reflect trends in classic disease activity parameters and allow for subgroup identification of temporal disease trajectories.