Josh Bricker

Race Differences in Initial Presentation, Early Treatment, and 1-year Outcomes of Pediatric Crohn's Disease: Results from the Improvecarenow Network

Background: Racially disparate care has been shown to contribute to suboptimal health care outcomes for minorities. Using the ImproveCareNow network, we investigated differences in management and outcomes of pediatric patients with Crohns disease at diagnosis and 1-year postdiagnosis. Methods: ImproveCareNow is a learning health network for pediatric inflammatory bowel disease. It contains prospective, longitudinal data from outpatient encounters. This retrospective study included all patients with Crohns disease ⩽21 years, September 2006 to October 2014, with the first recorded encounter ⩽90 days from date of diagnosis and an encounter 1 year ±60 days. We examined the effect of race on remission rate and treatment at diagnosis and 1 year from diagnosis using t-tests, Wilcoxon rank-sum tests, &khgr;2 statistic, and Fishers exact tests, where appropriate, followed by univariate regression models. Results: Nine hundred seventy-six patients (Black = 118 (12%), White = 858 (88%), mean age = 13 years, 63% male) from 39 sites were included. Black children had a higher percentage of Medicaid insurance (44% versus 11%, P < 0.001). At diagnosis, Black children had more active disease according to physician global assessment (P = 0.027), but not by short Pediatric Crohns Disease Activity Index (P = 0.67). Race differences in treatment were not identified. Black children had lower hematocrit (34.8 versus 36.7, P < 0.001) and albumin levels (3.6 versus 3.9, P = 0.001). At 1 year, Black children had more active disease according to physician global assessment (P = 0.016), but not by short Pediatric Crohns Disease Activity Index (P = 0.06). Conclusions: Black children with Crohns disease may have more severe disease than White children based on physician global assessment. Neither disease phenotype differences at diagnosis nor treatment differences at 1-year follow-up were identified.

North American Pediatric Gastroenterology Fellowship Needs Assessment in Inflammatory Bowel Disease: Trainee and Program Director Perspectives.

Background:Pediatric inflammatory bowel disease (IBD) care is complex and rapidly evolving. The Crohns and Colitis Foundation of America and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition cosponsored a needs assessment survey of pediatric gastroenterology trainees and program directors (PDs) to inform on educational programming. Methods:A Web-based, self-completed survey was provided to North American trainees and PDs during the 2013–2014 academic year. Standard descriptive statistics summarized demographics and responses. Results:One hundred sixty-six of 326 (51%) trainees (62% female) and 37 of 74 (50%) PDs responded. Median trainees per program = 5 and median total faculty = 10 (3 IBD experts); 15% of programs did not have a self-identified “IBD expert” faculty member. Sixty-nine percent of trainees were confident/somewhat confident in their IBD inpatient training, whereas 54% were confident/somewhat confident in their outpatient training. Trainees identified activities that would most improve their education, including didactics (55%), interaction with national experts (50%), trainee-centered IBD Web resources (42%), and increased patient exposure (42%). Trainees were most confident in managing inpatient active Crohns disease/ulcerative colitis, phenotype classification, managing biological therapies, and using clinical disease activity indices. They were least confident in managing J-pouch complications, performing pouchoscopy, managing extraintestinal manifestations, and ostomy-related complications. Eighty-five percent would like an IBD-focused training elective. Most directors (86%) would allow trainees to do electives at other institutions. Conclusions:This IBD needs assessment survey of pediatric gastroenterology trainees and PDs demonstrated a strong resource commitment to IBD training and clinical care. Areas for educational enrichment emerged, including pouch and ostomy complications.

Assessment of sex differences for treatment, procedures, complications, and associated conditions among adolescents hospitalized with Crohn's disease

Background:Sex differences among adults in healthcare treatment and outcomes have been reported; however, there is a paucity of literature regarding pediatric populations, particularly adolescents with Crohns disease (CD). The objective was to identify whether sex differences exist with respect to complications, procedures, and medication usage (corticosteroids, biological agents, and total parenteral nutrition) among hospitalized adolescents with CD. Methods:Adolescents with CD (n = 5782) hospitalized between April 1, 2004, and June 30, 2012, were selected from the Pediatric Health Information System database with a 1:1 ratio of males to females by hospital. Frequency of disease complications, associated conditions, procedures performed, and medication usage were analyzed with nonparametric statistical tests for the existence of sex differences. Results:Five thousand seven hundred eighty-two patients were included with a median age of 15 years. Females were slightly more likely to have anemia (29% versus 25%, P = 0.012), infection (12% versus 8%, P = 0.001), and mood disorder (9% versus 6%, P < 0.001), whereas males had more maturational delays (3% versus 1%, P = 0.004) and malnutrition (18% versus 14%, P = 0.027). Among procedures, only one category demonstrated a sex difference: females had more blood product transfusions (9% versus 6%, P < 0.001). Female rates for corticosteroids (62%), biological agents (16%), and total parenteral nutritionTPN (18%) were not statistically different from those for males (62%, 15%, and 20%, respectively). There were no differences in length of stay by sex. Conclusions:This cross-sectional study of an administrative database identified few sex differences among adolescents with CD. The effect sizes were universally small and generally consistent with known sex differences unrelated to IBD.

Multicenter Evaluation of Emergency Department Treatment for Children and Adolescents With Crohn’s Disease According to Race/Ethnicity and Insurance Payor Status

Background Racial and socioeconomic disparities exist in the treatment and outcomes of children and adults with Crohns disease (CD). This study investigated the impact of race and insurance status on emergency department (ED) evaluation and treatment among children with CD in the United States. Methods Data from the Pediatric Health Information System included ED visits between January 2007 and December 2013 for patients aged ≤21 years with a primary diagnosis of CD, or a secondary diagnosis of CD plus a primary CD-related diagnosis. Analyses were performed using mixed-effects logistic regression. Results Subjects included 2618 unique patients (black, 612 [23%]; white, 2006 [77%]) with 3779 visits from 38 hospitals, a median age of 14.0 ± 4.0 years, and 50% male. White children had a higher median neighborhood income and were more likely to have private insurance (57% vs 30%; P < 0.001). Emergency department visits for privately insured patients had higher odds of complete blood count (odds ratio [OR], 1.43; 95% CI, 1.08-1.90) and C-reactive protein/erythrocyte sedimentation rate (OR, 1.39; 95% CI, 1.06-1.82) vs Medicaid insured. Visits for white children had higher odds of receiving antiemetics (OR, 1.52; 95% CI, 1.06-2.17) vs black children. The proportion of patients with repeat visits was greater for black children (33%) than white children (22%; P < 0.001) and greater for Medicaid-insured (27%) than privately insured patients (21%; P < 0.01). Conclusions This cross-sectional database study demonstrated that black children and those with Medicaid insurance made more ED visits and received somewhat fewer treatments, which may be explained by greater use of the ED for routine care. An opportunity exists for better outpatient management of children with IBD so that nonemergent problems are more effectively handled.