Michael D. Kappelman

Burden of Gastrointestinal Disease in the United States: 2012 Update

BACKGROUND & AIMS Gastrointestinal (GI) diseases account for substantial morbidity, mortality, and cost. Statistical analyses of the most recent data are necessary to guide GI research, education, and clinical practice. We estimate the burden of GI disease in the United States. METHODS We collected information on the epidemiology of GI diseases (including cancers) and symptoms, along with data on resource utilization, quality of life, impairments to work and activity, morbidity, and mortality. These data were obtained from the National Ambulatory Medical Care Survey; National Health and Wellness Survey; Nationwide Inpatient Sample; Surveillance, Epidemiology, and End Results Program; National Vital Statistics System; Thompson Reuters MarketScan; Medicare; Medicaid; and the Clinical Outcomes Research Initiatives National Endoscopic Database. We estimated endoscopic use and costs and examined trends in endoscopic procedure. RESULTS Abdominal pain was the most common GI symptom that prompted a clinic visit (15.9 million visits). Gastroesophageal reflux was the most common GI diagnosis (8.9 million visits). Hospitalizations and mortality from Clostridium difficile infection have doubled in the last 10 years. Acute pancreatitis was the most common reason for hospitalization (274,119 discharges). Colorectal cancer accounted for more than half of all GI cancers and was the leading cause of GI-related mortality (52,394 deaths). There were 6.9 million upper, 11.5 million lower, and 228,000 biliary endoscopies performed in 2009. The total cost for outpatient GI endoscopy examinations was

Direct health care costs of Crohn's disease and ulcerative colitis in US children and adults.

32.4 billion. CONCLUSIONS GI diseases are a source of substantial morbidity, mortality, and cost in the United States.

Risk of Melanoma and Nonmelanoma Skin Cancer Among Patients With Inflammatory Bowel Disease

BACKGROUND & AIMS Data regarding the health care costs of inflammatory bowel disease (IBD) in the United States are limited. The objectives of this study were to estimate the direct costs of Crohns disease (CD) and ulcerative colitis (UC) in the United States, describe the distribution of costs among inpatient, outpatient, and pharmaceutical services, and identify sociodemographic factors influencing these costs. METHODS We extracted medical and pharmacy claims from an administrative database containing insurance claims from 87 health plans in 33 states, occurring between 2003 and 2004. We identified cases of CD and UC using an administrative definition. For each case, we selected up to 3 non-IBD controls. Claims were classified as inpatient, outpatient, or pharmaceutical according to Current Procedural Terminology codes or National Drug Codes. Costs were based on the paid amount of each claim. IBD-attributable costs were estimated by subtracting costs for non-IBD patients from those for patients with IBD. Logistic regression was used to identify the sociodemographic factors affecting these costs. RESULTS We identified 9056 patients with CD and 10,364 patients with UC. Mean annual costs for CD and UC were

Increased Risk for Non-Melanoma Skin Cancer in Patients With Inflammatory Bowel Disease

8265 and

Prevalence of Eosinophilic Esophagitis in the United States

5066, respectively. For CD, 31% of costs were attributable to hospitalization, 33% to outpatient care, and 35% to pharmaceutical claims. The corresponding distribution for UC was 38%, 35%, and 27%, respectively. Costs were significantly higher for children younger than 20 years compared with adults, but this did not vary substantially by sex or region. CONCLUSIONS This study demonstrates a substantial economic burden of IBD and can be used to inform health policy.

Thromboembolic risk among Danish children and adults with inflammatory bowel diseases: a population-based nationwide study

BACKGROUND & AIMS Patients with inflammatory bowel disease (IBD) are at risk for certain malignancies. We aimed to determine the risk of melanoma and nonmelanoma skin cancer (NMSC) in patients with IBD and how medications affect these risks. METHODS We performed retrospective cohort and nested case-control studies using administrative data from the LifeLink Health Plan Claims Database from 1997 to 2009. The cohort comprised 108,579 patients with IBD, and each was matched to 4 individuals without IBD. The risk of melanoma and NMSC was evaluated by incidence rate ratio (IRR) and by adjusted Cox proportional hazard ratio (HR) modeling. In nested case-control studies, patients with melanoma or NMSC were matched to 4 patients with IBD without melanoma or NMSC. Conditional logistic regression was used to determine associations between medications and both skin cancers. RESULTS In the cohort, IBD was associated with an increased incidence of melanoma (IRR, 1.29; 95% confidence interval [CI], 1.09-1.53). Risk was greatest among individuals with Crohns disease (IRR, 1.45; 95% CI, 1.13-1.85; adjusted HR, 1.28; 95% CI, 1.00-1.64). The incidence of NMSC also increased among patients with IBD (IRR, 1.46; 95% CI, 1.40-1.53) and was greatest among those with CD (IRR, 1.64; 95% CI, 1.54-1.74). In the nested case-control studies, therapy with biologics increased the risk of melanoma (odds ratio [OR], 1.88; 95% CI, 1.08-3.29). Patients who had been treated with thiopurines had an increased risk of NMSC (OR, 1.85; 95% CI, 1.66-2.05). CONCLUSIONS Immunosuppression increases the risk of melanoma and NMSC among patients with IBD. The risk of melanoma is increased by use of biologics, and the risk of NMSC is increased by use of thiopurines. Patients with IBD should be counseled and monitored for skin cancer.

Prevalence and epidemiology of overweight and obesity in children with inflammatory bowel disease

BACKGROUND & AIMS Patients with inflammatory bowel disease (IBD) might be at increased risk for certain malignancies. We evaluated the risk of non-melanoma skin cancer (NMSC) in patients with IBD and determined how immunosuppressive and biologic medications affect this risk. METHODS We performed retrospective cohort and nested case-control studies by using administrative data from PharMetrics Patient Centric Database. In the cohort study, 26,403 patients with Crohns disease (CD) and 26,974 patients with ulcerative colitis (UC) were each matched to 3 non-IBD controls. NMSC risk was evaluated by incidence rate ratio (IRR). In the nested case-control study, 387 CD patients and 355 UC patients with NMSC were each matched to 4 IBD patients without NMSC by using incidence density sampling. Conditional logistic regression was used to determine the association between specific IBD medication use and NMSC. RESULTS In the cohort study, the incidence of NMSC was higher among patients with IBD compared with controls (IRR, 1.64; 95% confidence interval [CI], 1.51-1.78). In the nested-case control study, recent thiopurine use (< or =90 days) was associated with NMSC (adjusted odds ratio [OR], 3.56; 95% CI, 2.81-4.50), as was recent biologic use among patients with CD (adjusted OR, 2.07; 95% CI, 1.28-3.33). Persistent thiopurine use (>365 days) was associated with NMSC (adjusted OR, 4.27; 95% CI, 3.08-5.92), as was persistent biologic use among patients with CD (adjusted OR, 2.18; 95% CI, 1.07-4.46). CONCLUSIONS Patients with IBD, especially those who receive thiopurines, are at risk for NMSC. Appropriate counseling and monitoring of such patients with IBD are recommended.

Isotretinoin Use and the Risk of Inflammatory Bowel Disease: A Case–Control Study

BACKGROUND & AIMS Eosinophilic esophagitis (EoE) has become a major cause of upper gastrointestinal morbidity in children and adults. However, there are few data on the nationwide prevalence of EoE. We aimed to estimate the prevalence of EoE in the United States. METHODS We collected health insurance claims from a large database that represented the U.S. commercially insured population. We analyzed data from 2008 to 2011, identifying cases of EoE by using a previously validated definition, and calculated a period prevalence by using data from 2009 to 2011. EoE was defined as any instance of the International Classification of Diseases, 9th revision code 530.13. We calculated the prevalence of the code in the database and standardized the estimate to the U.S. population. RESULTS Of 35,575,388 individuals in this database, 16,405 had at least 1 code for EoE. The mean age was 33.5 years, 65% were male, 55.8% had dysphagia, and 52.8% had a diagnostic code for at least 1 allergic condition. Among 11,569,217 individuals with continuous insurance coverage between mid-2009 and mid-2011, 6513 had at least 1 code for EoE. When standardized to the U.S. population, the estimated period prevalence of EoE was 56.7/100,000 persons, translating to approximately 152,152 cases in the U.S. Prevalence peaked in men 35-39 years old, with a rate of 114.6/100,000 persons. CONCLUSIONS Despite its relatively recent description, EoE is frequently diagnosed in the United States, with an estimated prevalence of 56.7/100,000 persons. This estimate depends on the accuracy of the International Classification of Diseases, 9th revision code, but it could be an underestimate, because knowledge of the code and recognition of EoE are increasing.

Improved Outcomes in a Quality Improvement Collaborative for Pediatric Inflammatory Bowel Disease

Background Recommendations for venous thromboembolism (VTE) prophylaxis in patients with inflammatory bowel disease (IBD) can be refined by incorporating patient-specific risk factors. Objectives To determine the risk of deep venous thrombosis (DVT) and pulmonary embolism (PE) in children and adults with Crohns disease and ulcerative colitis and evaluate whether this risk varies by age and/or presence of other risk factors. Methods We performed a cohort study using Danish administrative data. Incidence rates of DVT and PE were calculated among patients with IBD and an age- and gender-matched comparison population and compared using Cox proportional hazards regression. We performed additional analyses stratifying by age, gender and disease type and restricting outcomes to unprovoked events (occurring without known malignancy, surgery, fracture/trauma or pregnancy). We next performed a nested case–control study to adjust for additional co-morbidities (congestive heart failure, diabetes, myocardial infarction and stroke) and the use of hormone replacement and antipsychotic medications. Results The study included 49 799 patients with IBD (14 211 Crohns disease, 35 229 ulcerative colitis) and 477 504 members of the general population. VTE risk was elevated in patients with IBD (HR=2.0 (95% CI 1.8 to 2.1) for total events, HR=1.6 (95% CI 1.5 to 1.8) for unprovoked events). Although the incidence of VTE increased with age, the RR was higher in younger patients. Among those ≤20 years old, HRs were 6.0 (95% CI 2.5 to 14.7) for DVT and 6.4 (95% CI 2.0 to 20.3) for PE. After further adjusting for co-morbidity and medication use in the case-control analysis, ORs for all events remained in the 1.5–1.8 range. Discussion Patients with IBD have twice the incidence of PE or DVT as does the general population. This risk persisted after taking into account other VTE risk factors. Relative risks were particularly high at young ages, though actual incidence increased with age. These findings can further inform risk–benefit analysis of VTE prophylaxis.

Short pediatric Crohn's disease activity index for quality improvement and observational research†

Background: Obesity is a significant public health threat to children in the United States. The aims were to: 1) Determine the prevalence of obesity in a multicenter cohort of children with inflammatory bowel disease (IBD); 2) Evaluate whether overweight and obese status is associated with patient demographics or disease characteristics. Methods: We used data from the ImproveCareNow Collaborative for pediatric IBD, a multicenter registry of children with IBD, collected between April 2007 and December 2009. Children ages 2–18 years were classified into body mass index (BMI) percentiles. Bivariate analyses and multivariate logistic regression were used to compare demographic and disease characteristics by overweight (BMI >85%) and obese (BMI >95%) status. Results: The population consisted of 1598 children with IBD. The prevalence of overweight/obese status in pediatric IBD is 23.6%, (20.0% for Crohns disease [CD] and 30.1% for ulcerative colitis [UC] and indeterminate colitis [IC]). African American race (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.10–2.48) and Medicaid insurance (OR 1.67, 95% CI 1.19–2.34) were positively associated with overweight/obese status. Prior IBD‐related surgery (OR 1.73, 95% CI 1.07–2.82) was also associated with overweight and obese status in children with CD. Other disease characteristics were not associated with overweight and obesity in children with IBD. Conclusions: Approximately one in five children with CD and one in three with UC are overweight or obese. Rates of obesity in UC are comparable to the general population. Obese IBD patients may have a more severe disease course, as indicated by increased need for surgery. Sociodemographic risk factors for obesity in the IBD population are similar to those in the general population. (Inflamm Bowel Dis 2010;)