bluuebunny/crossref_metadata_2025 huggingface dataset:
591 Trend Analysis of Lower Gastrointestinal Bleeding 2002-2017: A Population-Based Study
Authors: Suresh Kumar Vishnu Charan , Elangovan Abbinaya , Waghray Nisheet
Published: October 2019

INTRODUCTION:

Lower Gastrointestinal Bleeding (LGIB) is defined as the bleeding originating from the gastrointestinal tract distal to the ligament of Treitz. LGIB is commonly caused by colonic diverticula, hemorrhoids, colorectal cancer, angiodysplasia, inflammatory bowel disease (IBD), and ischemic colitis. Although the diagnosis and management of LGIB have largely evolved with recent advancements, the incidence and trends of LGIB are unclear. We sought to look at the incidence and trends of LGIB 2002-2017 using a population level database.

METHODS:

Retrospective analysis of individuals ≥ 18 years who were hospitalized with LGIB was performed using a cloud database (IBM Explorys). Explorys aggregates de-identified data across 300 hospitals in the US. ICD 9 and ICD 10 diagnosis codes are mapped using SNOMED CT (Systematized Nomenclature of Medicine - Clinical Terms) hierarchy. Using SNOMED CT codes, Individuals who had at least one inpatient encounter with SNOMED CT diagnosis code of LGIB were identified. The rates of hospitalization and annual percentage change (APC) due to various etiologies of LGIB was analyzed between 2002-2017 were calculated using Excel, 2016.

RESULTS:

Among a cohort of 51,770,740 unique patients, 2.31% hospitalizations in 2017 were due to LGIB. The most common diagnosis associated with LGIB were hemorrhoids (34.56%) followed by diverticular disease (20.03%), IBD (3.23%), colorectal cancer (2.56%), vascular insufficiency including ischemic colitis (1.26%) and angiodysplasia (0.83%). The rates of hospitalization due to LGIB increased from 0.35% in 2002 to 2.31% in 2017 (Figure 1). The APC of LGIB based on etiology is depicted in Figure 3. There was no statistically significant difference when the mean APC of the overall cases of LGIB was compared to the mean APC of individual etiologies.

CONCLUSION:

The rates of lower gastrointestinal bleeding requiring hospitalization and inpatient management have significantly increased over the last 2 decades. Among LGIB hospitalizations, the proportion of hemorrhoids and CRC have decreased while that of diverticular disease and angiodysplasia have increased over 5-year intervals (Table 1). Patient awareness, better diagnostic techniques, and aging population probably contribute to the increase in the rates of LGIB.
592 Comparison of Endoscopic Placement versus Oral Ingestion of Small Bowel Video Capsule for Evaluation of Inpatients With Small Intestinal Bleeding
Authors: Chen Brendan , Farrakhan Kanhai , Sukrit Jain , Akerman Paul , Rupawala Abbas
Published: October 2019

INTRODUCTION:

Wireless small bowel video capsule endoscopy (VCE) is used to evaluate small intestinal bleeding after upper endoscopy and colonoscopy fail to identify a source of bleeding. The majority of patients swallow the capsule but endoscopic placement in the duodenum is an option. Limited data suggests higher rate of gastric retention of capsule in inpatients due to a variety of reasons, resulting in an incomplete exam. Hypothetically, endoscopic placement should increase likelihood of complete small bowel evaluation but there is little data comparing the two approaches. We aimed to compare completion rates and outcomes of capsule studies via endoscopic placement (CS-EP) versus oral ingestion (CS-OI) in inpatients undergoing VCE.

METHODS:

Patients who had VCE studies performed inpatient for gastrointestinal bleeding at Rhode Island Hospital between April 2015 and July 2016 were identified retrospectively. Baseline patient demographics, time intervals between reported bleed, date of admission and date of discharge, capsule study, indications for capsule study, completion rates and detection of small bowel bleeding were collected. Statistical tests were done using student's t-test and chi square test.

RESULTS:

Data was available for 83 patients between April 2015 and July 2016. The most common indications were for obscure bleed (92%) followed by anemia (86%). 29 (35%) patients had small bowel capsule studies that were endoscopically placed. Majority of patients underwent endoscopic placement due to provider preference. CS-EP had a higher proportion of men than CS-OI (66% vs. 44%, P = .06). The mean duration from bleeding episode to capsule study was 8.4 days for both groups. Small bowel bleeding was more likely to be detected by CS-EP than CS-OI (34% vs. 13%, P = 0.02), however completion rates were similar between both studies (69% vs. 76%, P = 0.5). CS-EP had a longer time from study to discharge (days: 7.1 vs. 3.7, P = 0.1) and longer length of stay at the hospital (days: 11.45 vs. 7.47, P = 0.1) compared to CS-OI.

CONCLUSION:

Based on this single center study, although endoscopic placement of VCE was more likely to detect small bowel bleeding compared to oral ingestion, there was no difference in study completion rates and CS-EP group in fact had a longer length of stay. Investigation into potential causes of longer length of stay and cost of care associated with endoscopic placement are ongoing. Additional data is also being collected for capsule studies performed over several more years.
594 Weekend Admissions Do Not Affect Management of Lower GI Bleeding
Authors: Li Brian , Schwartz Jeffrey , Lipcsey Megan , Stein Daniel J. , Feuerstein Joseph
Published: October 2019

INTRODUCTION:

Lower gastrointestinal bleeding (LGIB) is a common condition requiring GI consultation and management. Current ACG guideline recommends colonoscopy within 24 hours of LGIB. However, while colonoscopy is the most common intervention, it may not be readily available at all hospitals on the weekend when many endoscopy units are closed. Previous work has found that in non-variceal upper GI hemorrhage, patients admitted on weekends had lower total endoscopy rates and high hospitalization charges. We explored these outcomes in LGIB.

METHODS:

This national inpatient sample (NIS) from 2016 was queried for all cases of confirmed lower GI bleeding as the primary diagnosis code based on ICD-10. This included bleeding AVMs, diverticular hemorrhage, rectal ulcers, radiation proctitis and other anal/rectal hemorrhage. Outcomes for patients admitted on a weekend (Saturday/Sunday) were compared to weekday admissions using survey-adjusted Chi-square and correlation for comparisons and logistic/linear regression to examine mortality, length of stay, and hospitalization costs. Adjustment was made for the Elixhauser mortality score (a validated measure of comorbidities), colonoscopy, and transfusion in the regression.

RESULTS:

In 2016, 92,065 patients were admitted for LGIB overall. Of these, 23,070 (25%) were admitted on a weekend. See table 1 for causes of bleeding. For weekend admissions, mortality (0.8% vs 0.9%, P = 0.626), transfusion rate (28.8% vs 30.1%, P = 0.113), colonoscopy rate (58.4% vs 58.1%, P = 0.749), angiography rate (3.3% vs 3.3%, P = 0.894), mean days to colonoscopy (1.8 vs 1.8, P = 0.157), length of stay (4.1 vs 4.2 days, P = 0.068), and charges ($40,552 vs $40,604, P = 0.956) were all similar to weekday admissions. In the multivariable regression, colonoscopy (OR=2.7, P < 0.001) and Elixhauser score (OR=1.09, P < 0.001) but not weekday admission (OR=1.13, P = 0.535) or freedom from transfusion (OR=0.78, P = 0.140) predicted mortality. Length of stay (0.1 day difference, P = 0.053) and charges ($14 difference, P = 0.987) were also not affected by weekend admission after adjustment for the same covariates.

CONCLUSION:

In this estimate of all U.S. lower GI bleeding admissions from 2016, weekend admission did not affect outcomes including mortality, length of stay or total charges. Time to colonoscopy was similar. Undergoing colonoscopy was associated with a 2.7 times lower odds of mortality.
605 Independent Risk Factors for Severity and Mortality in Lower Gastrointestinal Bleeding and Proposal of New Prognosis Score
Authors: Bellido Alvaro , Espinoza-Ríos Jorge , Pinto Jose , Bravo Eduar , Gomez Paul , Tagle Martin
Published: October 2019

INTRODUCTION:

Risk stratification is key in the assessement and management of patients with lower gastrointestinal bleeding (LGIB). AIM: To identity risk factors for mortality and severity, namely: critical care requirement, prolonged hospitalization, rebleeding, blood transfusions, re-admissions or surgery in a cohort of patients with LGIB in a hospital in Peru.

METHODS:

Analytic prospective cohort study, performed between June 2016 and April 2018 in a tertiary care hospital. The sample size (80 Patients) was calculated considering an incidence of 0.3% with a confidence level of 95%. Data was collected during the hospitalization, including sex, age, comorbidities, medication, etiology, time to colonoscopy, vital signs, laboratory and the outcomes. The independent factors were determined using binomial logistic regression, these factors were used to developed a score. Thirty – day survival was calculated using a Kaplan-Meier curve.

RESULTS:

A total of 98 patients were included, of which 13 patients (13, 3%) died, and 56 (57, 1%) met severity criteria. Sixty-two patients (63, 3%) were male, the average age was 54.89 ± 19.37 years. The most frequent etiologies were hemorrhoids (20.4%), colorectal cancer (19.4%), and diverticulosis (13.3%). Thirteen patients died and the most frequent cause of death was pneumonia in twelve (92.3%). The independent risks factor for mortality was Glasgow scale under 15, and for severe bleeding were: Systolic blood pressure under 100 mm Hg and albumin lower than 2, 8 g/dL. With these factors the score SGA (S systolic, G Glasgow, and A albumin) was developed. An area under Receiving Operator Curve (AUC ROC) of 87.5% with a P < 0.000, the value of 2 or more predicted mortality with a sensitivity of 90.9% and a specificity of 69.7%, positive predictive value 33.7%, negative predictive value 97.9%. The value 2 or more predicted severity with a sensitivity of 59.6% and a specificity of 93.3%, positive predictive value 93.3%, negative predictive value 59.6%. The survival curve with the kaplan meier test is statistically significant, when comparing the value 0 or 1 versus the value 2 or 3.

CONCLUSION:

We found a high mortality rate and frequent severity parameters in our population with LGIB, the main risk factors being systolic blood pressure under 100 mm Hg, Glasgow score lower than 15, and albumin lower than 2.8 g/dL. Early identification of these associated factors would improve the management of LGB in the emergency room.
608 Prevalence of Acid Suppressive Prophylaxis in Hospitalized Patients for Peptic Ulcer Disease and Complications: Retrospective Study
Authors: Kaddourah Osama , Elkafrawy Ahmed A. , Noman Anas , Abuamr Khalil
Published: October 2019

INTRODUCTION:

An NSAID is present in about 8% of all prescriptions written by primary care physicians. Among GI-related adverse drug events, 23.5% were related to NSAIDs, 45% were considered avoidable. Risk factors associated with peptic ulcer disease include: History of peptic ulcer or ulcer bleeding, positive status of H Pylori, age (>65 years), Concomitant use of warfarin, steroids, anti-platelets. Study in France, showed that gastroprotection was not prescribed in 16% of patients on NSAIDs and risk factors for GI toxicity. Misoprostol and PPI therapy are proved to reduce the risk of GI toxicity. Current guidelines recommend that high risk patients should be prescribed COX2 selective agents by itself or non-selective agents with gastroprotection.

METHODS:

We performed a retrospective chart review of patients at Truman Medical Center Hospital Hill, Missouri who were hospitalized for NSAID-related peptic ulcer disease from the time period of January 2013 till September 2018. We further included only patients with risk factors of peptic ulcer disease and should have been on gastroprotective agents prior to presentation.

RESULTS:

Our sample included 81 patients hospitalized for NSAID-related peptic disease with risk factors for peptic ulcer disease. Mean age was 58.2 years old. More than half of patients were male (56.8%). Around 47% were smokers and 41% were alcohol current users. Around third of patients were taking aspirin daily and only 13% were on anticoagulation. More than half of patient had History of peptic ulcer (52%) and 38% had history of bleeding ulcer. Only 44.4% of our patients were on gastroprotective agents prior to presentation. Significant portion of our sample presented with ulcer complication (i.e., bleeding, perforation) at 74.1% (60/81). About 60% of patient were anemic at presentation. 31% of patients presented with significant bleeding requiring more than 2 units of packed RBC. Gastroprotective agent prescription prior to presentation was significantly associated with aspirin use (P-value 0.038), anticoagulation (P-value 0.023), Hx coronary artery disease (P-value 0.023), history of peptic ulcer in the past (P-value 0.002) and anemia (P-value 0.003).

CONCLUSION:

Significant portion of patients who were hospitalized with peptic ulcer disease complications were not on gastroprotective agents although indicated. Risk stratification and PPI prescription when appropriate should be implemented more aggressively in outpatient setting.
609  The Unseen Bleed: Does the Degree of Anemia Mirror Hiatal Hernia Size?
Authors: Lorio Eric , Wisnewski Nicole , Vizuete John A.
Published: October 2019

INTRODUCTION:

Multiple studies have established a relationship between esophageal hiatal hernias (HH) and iron deficiency anemia (IDA), often attributed to presence of Cameron lesions. Small hernias are often detected incidentally, and most do not lead to anemia. This study is designed to evaluate if size of hernia directly correlates with degree of anemia, particularly in very large hernias, a finding that could provide insight into the management of these patients in the future.

METHODS:

Electronic medical records from 5/2016 to 5/2019 were retrospectively reviewed. Patients with a diagnosis of iron deficiency anemia with complete endoscopic workup including EGD, colonoscopy, and complete small bowel capsule were included. Exclusion criteria included an alternative source for anemia such as celiac disease, peptic ulcer, or significant small bowel AVMs. Collected information included standard demographics, size of hiatal hernia, nadir hemoglobin (Hgb) during visit, presence or absence of Cameron lesions, and other capsule endoscopy findings. Analysis of associations between hernia size at the time of capsule endoscopy and nadir Hgb was formulated using Pearson's correlation testing. Graphic representation of results was depicted via linear regression modeling. Two-score T testing was also utilized to examine whether significant differences in degree of anemia exist between small (<5 cm) and large (≥5 cm) hiatal hernias.

RESULTS:

45 patients were included in the final dataset (78% women, 22% men). Only 7% (3/45) had visible Cameron lesions on upper endoscopy. Overall, degree of anemia did not correlate to size of hiatal hernia as Pearson's correlation testing identified an r = -0.234 (P = 0.136). However, when controlling for hiatal hernias ≥5 cm, a statistically significant inverse relationship was noted between nadir hemoglobin levels and size of hiatal hernia, r = -0.362 (P = 0.041). Figure 1 summarizes these results. 2 score T-testing identified no significant difference in the mean nadir hemoglobin between small and large hiatal hernias, t = -0.029 (P = 0.488).

CONCLUSION:

A linear relationship between hernia size and degree of anemia appears to exist when esophageal hiatal hernias are 5 cm or larger, but even 3-4 cm hernias can result in significant iron loss. Clinicians should also be aware that Cameron lesions are not required to develop profound IDA. Our study is limited by sample size but offers some evidence that hernias larger than 5 cm should be considered for surgical repair.
617 Outcomes of Patients With Small Bowel Angiodysplasia Treated With a Small Bowel Radiofrequency Ablation Catheter: A Multicenter Case Series
Authors: Lara Luis , Silva Rogelio , Thakkar Shyam , Stanich Peter P. , Samarasena Jason
Published: October 2019

INTRODUCTION:

Small bowel angioectasia (SBA) are the most common cause of small bowel GI bleeding, usually treated with argon plasma coagulation (APC). Bleeding recurs in >40%. The outcomes of patients with SBA treated with a dedicated radiofrequency ablation catheter was reported.

METHODS:

Patients were treated using a commercially available small bowel radiofrequency ablation catheter (SBRFA) during enteroscopy which is 25 mm wide, 260 cm long, and the treatment paddle is 7.5 mm wide deployed, and 10 mm long. The paddle was advanced to the lesion, and gentle pressure was applied delivering 10 J/cm2 with each application. The same area could be treated twice. Patient demographics, pre and post treatment hemoglobin, time to recurrent bleeding, and need for repeated therapy were reported.

RESULTS:

20 subjects were treated from March to October 2018: 6 females (age 68; SD 11.1) and 14 males (age 73; SD 10.4). Three subjects had a left ventricular assist device (LVAD). 19 (95%) had at least one previous EGD (total at least 43, range 1 to >10), and at least one previous colonoscopy (total 42, range 1 to >10). 14 subjects (70%) had an abnormal video capsule endoscopy; 14 (70%) had previous APC. Median hemoglobin before treatment was 8.3 g/dL (5.1-14.4), and 13 subjects (65%) had a mean of 4 (SD 2.1) units of blood transfused. A median of 23 SBA were treated (2 to 99 total). No other treatments such as APC were used. Median follow-up was 195 days (30-240). The most recent median hemoglobin in 15 subjects (75%) was 9.4 g/dL (5 to 13) (P = 0.04). Repeat endoscopy rate was 20%; once in 2 subjects (at 45 and 210 days after SBRFA), and twice in one subject (60 days after SBRFA treatment). One subject with LVAD had a repeat upper endoscopy and no treatment, one subject with GAVE had a push enteroscopy and no treatment, and the third subject with LVAD had two assisted enteroscopies: SBA were re-treated with APC once, and no treatment was needed the last time. One patient with an LVAD had overt ileum bleeding and underwent embolization. 2 subjects (10%) required repeat blood transfusion (2 units each). Two deaths at 60 and 180 days were unrelated to GIB.

CONCLUSION:

In this series of SBRFA therapy of SBA up to 240 days of follow up 3/20 subjects (15%) required repeat endoscopy. Repeated endotherapy was necessary in 1 subject. All subjects with LVAD had repeat procedures. 2 subjects required more blood transfusions. The data compares favorably to historical SBA outcomes but comparative studies are needed.
626 HAS-BLED Scores Underestimate Gastrointestinal Bleeding Risk Among Those With H. pylori
Authors: Faye Adam , Hung Kenneth , Cheng Kimberly , Parikh Neal , Knotts Rita , Freedberg Daniel , Lebwohl Benjamin
Published: October 2019

INTRODUCTION:

Gastrointestinal bleeding (GIB) in the setting of anti-coagulation is associated with considerable morbidity and mortality. Prediction models, such as the HAS-BLED score, are recommended by guidelines and used by clinicians to assess the risk of major bleeding among atrial fibrillation patients treated with warfarin. Whether gastric colonization by H. pylori (HP) confers bleeding risk that is unaccounted for by the HAS-BLED score is unknown. We hypothesized that HAS-BLED scores (ranging from 0-9, with higher scores indicating higher bleeding risk) would be lower among patients with upper GIB who have gastric colonization by HP than in those without HP.

METHODS:

We examined all patients at a single medical center who had an upper endoscopy for suspected GIB between 2011-2018 with findings of a gastric or duodenal ulcer. Only patients who were tested for H. pylori by any modality and had taken warfarin within one week prior to endoscopy were included in the analysis. We calculated the HAS-BLED score for all patients, and compared the HAS-BLED scores of HP-positive and HP-negative patients using the Wilcoxon rank-sum test. In a secondary analysis, we classified patients as having a high risk for bleeding (score ≥3) or low risk for bleeding (score <3), and used Fisher's exact test to compare the prevalence of a high risk score between the HP positive and negative groups.

RESULTS:

Of the 1,578 bleeding events reviewed, 62 patients were determined to be taking warfarin within one week of the GIB and had HP status checked. HP testing was positive in 12/62 (19%) patients and negative in 50/62 (81%) patients. Multiple individual components of the HAS-BLED score differed between HP positive and negative patients (Table 1). The median scores for HP positive and negative patients were 2 (IQR, 2-2.25) and 3 (IQR, 2-4), respectively (P < .01). In our secondary analysis, 3/12 (25%) of HP positive patients were classified as high risk for bleeding by the HAS-BLED score whereas 32/50 (64%) were classified as such among HP negative patients (P = 0.02).

CONCLUSION:

Among patients with warfarin-associated upper GIB, those who were HP positive had significantly lower HAS-BLED scores as compared to those who were HP negative. The HAS-BLED prediction model may not account for GIB risk associated with HP colonization. Further studies should assess whether prediction models should include HP status, and whether screening for HP when starting anticoagulation is warranted.
637 Clinical Prediction Model and Decision Support Tool for Ustekinumab in Crohn's Disease
Authors: Dulai Parambir , Guizzetti Leonard , Ma Tony , Jairath Vipul , Singh Siddharth , Feagan Brian G. , Gasink Christopher , Pires Antonio , Sandborn William J.
Published: October 2019

INTRODUCTION:

Identifying predictors of response to treatment with ustekinumab (UST) may improve therapeutic decisions. We created a clinical decision support tool (CDST) for UST therapy in active Crohn's disease (CD).

METHODS:

Patients from the UNITI trials were included if they received IV UST induction and SQ UST maintenance irrespective of Week 8 response status (derivation set; n = 781). Cox proportional hazard analyses were used to identify baseline factors associated with clinical remission (CDAI 150) by Week 16. The final model was transformed into a CDST and patients were stratified into 3 response probability groups (low, intermediate, high). Secondary analyses were performed to assess the ability of the CDST to predict exposure-efficacy relationships as measured by reduction in CDAI from baseline and differences in trough UST concentrations at weeks 8 and 16.

RESULTS:

In the derivation analysis, baseline albumin g/L (HR 1.041, 95% CI 1.019–1.063), no prior smoking history (HR 1.233, 95% CI 0.995–1.527), absence of baseline actively draining fistula (HR 1.330, 95% CI 0.906–1.952), absence of prior bowel surgery (HR 1.425, 95% CI 1.140–1.781), and absence of prior exposure to tumor necrosis factor antagonist (HR 1.591, 95% CI 1.214–1.900), were associated with achieving clinical remission by Week 16 of UST therapy. Rates of clinical remission at weeks 3, 6, 8, and 16 were significantly higher in the high probability group versus the intermediate and low probability groups (Table 1). The high probability group had a significantly greater reduction from baseline in CDAI compared to the intermediate and low probability groups at week 8 (high vs. intermediate 94 vs. 54 P < 0.0001; high vs. low 94 vs. 40, P < 0.0001) and week 16 (high vs. intermediate 155 vs. 112 P < 0.0001; high vs. low 155 vs. 84, P < 0.0001). The high probability group had significantly higher trough UST concentrations compared to the intermediate and low probability groups at week 8 (high vs. intermediate 5.2 vs. 3.6 μg/mL P = 0.052; high vs. low 5.2 vs. 2.2 μg/mL, P < 0.0001) and week 16 (high vs. intermediate 2.9 vs. 2.1 μg/mL P = 0.0053; high vs. low 2.9 vs. 1.2 μg/mL, P < 0.0001).

CONCLUSION:

Predictors of response to UST were identified and successfully modelled into a CDST which can stratify the probability of achieving early clinical remission and rapidity in onset of action in individual CD patients. A statistically significant relationship between UST trough concentrations, probability groups, and efficacy was observed.
641 A Quality Improvement Initiative to Reduce Insurance-Related Delays in Patient Access to Biologic Therapies for Inflammatory Bowel Disease
Authors: Scherl Ellen J. , Fajardo Kristina I. , Simone Laura , Carter Jeff , Sapir Tamar , Yang Stevie , Galati Jonathan S. , Chabouni Fatiha , Krichevsky Brian , Crawford Carl V.
Published: October 2019

INTRODUCTION:

Most quality improvement (QI) initiatives in inflammatory bowel disease (IBD) address clinical processes such as screening and vaccinations. Applying the principles and methods of QI, we conducted an initiative that encompassed insurance-related workflow processes required for prompt patient access to biologic IBD therapies.

METHODS:

The QI cohort comprised 22 gastroenterologists who were attending staff in an academic medical center (N = 14) or center-affiliated community clinics (N = 8). At baseline, the gastroenterologists completed a survey designed to assess their self-reported knowledge and practices involving insurance-related processes. We retrospectively audited the charts for 200 of the gastroenterologists' patients with confirmed active ulcerative colitis or Crohn's disease who had been prescribed a biologic medication. Assessments included the number of days between prescription request and various milestones involving prior authorization (PA) and prescriptions being filled and dispensed. In the intervention phase, the gastroenterologists and their clinical teams participated in a series of accredited grand rounds activities. Participants received audit feedback and developed action plans to reduce identified delays in patient access to biologic medications. Six months after the interventions, we audited the charts of 100 additional patients, assessing the same temporal measures as in the baseline review.

RESULTS:

The baseline survey findings indicated that 41% (21% academic vs 75% community) of gastroenterologists reported having limited or no confidence in understanding pre-authorization requirements; 18% (29% vs 0%) had standardized letters of necessity for patients needing biologics; and 9% (7% vs 13%) received approval for treatment coverage within 3-4 days. Patient characteristics were similar across the 2 sampling periods; median age was 37 (19-82) years, 54% were female, 62% had Crohn's disease, and 88% were covered by commercial insurance (Table 1). Across the baseline to follow-up audits, the mean number of days was reduced for key milestones, including prescription request to PA approval (11 vs 7 days), prescription written (18 vs 10 days), and prescription dispensed (43 vs 21 days; Figure 1).

CONCLUSION:

These findings reflect the potential for extending QI principles and methods to workflow processes in order to reduce insurance-related delays and facilitate prompt patient access to needed biologic therapies.
660 Prevalence of IBD Among Asian Subgroups in a Northern California Managed Care Organization
Authors: Nguyen Jonathan , Wei Julia , Ramalingam Nirmala , Hassid Benjamin
Published: October 2019

INTRODUCTION:

The prevalence of inflammatory bowel disease (IBD, ulcerative colitis (UC) and Crohn's disease (CD)) has been estimated to be approximately 400-600 per 100,000 persons in the United States,3 but this relies on data skewed heavily towards Caucasian populations. Previous studies have suggested that IBD prevalence in Asia is much lower, around 30-60 per 100,000.7 A recent study highlighted higher rates and more extensive UC in migrant groups than in their home countries.5 However, the overall trend with IBD being more prevalent in Caucasians compared to Asians has been shown previously. One caveat to this is in South Asians, who have a higher incidence and prevalence of UC compared to the indigenous population of the UK.5 In this study we seek to further breakdown the prevalence of IBD among Asian subgroups in a Northern California integrated health care delivery system.

METHODS:

Adults aged 18 years and older diagnosed with IBD between 1/1/2014-12/31/2014 were identified with ICD-9 diagnosis codes for UC (556.x) and CD (555.x). We calculated overall period prevalence of IBD, UC and CD by race/ethnicity, including Asian subtypes.

RESULTS:

Among 7,766 Kaiser Permanente Northern California (KPNC) members with IBD, the prevalence of IBD was higher in Caucasians compared to Asians (377 vs 125 per 100,000, P < 0.01 Table 1). However, when Asians were further subclassified, the period prevalence among South Asians was significantly higher than not only the other Asian subgroups, but also the Caucasian group (504 vs 377 per 100,000). Breaking up IBD into CD and UC, the period prevalence among Asians continued to be significantly lower than Caucasians (Table 2). However, among South Asians the prevalence of UC is again higher than that of Caucasians (417 vs 208 per 100,000). Interestingly, the prevalence of CD is less among South Asians compared to Caucasians (87 vs 169 per 100,000).

CONCLUSION:

Our data from a diverse patient population in Northern California show an overall lower prevalence of IBD in Asian compared to Caucasian patients overall but a higher prevalence among South Asians. Our data is consistent with prior Canadian and UK studies.5 Most American studies combine South Asians into the Asian category, which shows a deceptively decreased prevalence compared to the Caucasian population. Further studies are needed to understand the etiology of this finding and seek to further explore the differences among Asian subpopulations.
665 Hospital Teaching Status on Healthcare Expenditure Amongst Patients Admitted for Inflammatory Bowel Disease in the U.S.
Authors: Patel Kalpesh , Patel Pavan , Yang Grace H. , Verma Siddharth
Published: October 2019

INTRODUCTION:

Crohn's disease (CD) and ulcerative colitis (UC) are inflammatory bowel diseases (IBDs) with an increasing prevalence in developed and developing countries. IBD ranks as 1 of the top 5 most expensive gastrointestinal disorders and costs are estimated to exceed $6 billion dollars per year in the United States. As we know IBD, represents a complex disease that has many related complications and the costs of treating these patients remains substantial. The primary aim of our study was to assess the differences in cost in patients admitted for inflammatory bowel disease to teaching and non-teaching hospitals. We also evaluated length of stay, patient demographics, primary payer information, hospital bed size, hospital region, procedures performed, and IBD related complications.

METHODS:

The National Inpatient Sample (NIS) is the largest all-payer inpatient database consisting of approximately 20% of all inpatient admissions to nonfederal hospitals in the United States. We collected data from years 2008 to 2014. Cases of IBD flare were identified using the International Classification of Diseases, Ninth Edition, Clinical Modification codes. Differences in cost, length of stay, patient demographics, primary payer information, hospital bed size, hospital region, procedures performed, and IBD related complications were evaluated for patients with IBD admitted to teaching and non-teaching hospitals.

RESULTS:

Between 2008 and 2014, there were 622,444 cases of IBD admissions identified. There were 346,528 cases admitted to teaching hospitals and 275,916 cases admitted to non-teaching hospitals. The costs in dollars per case in the teaching hospital group for CD and UC were $12,168 and $14,558, respectively, versus $9,648 for CD and 10,572 for UC (P < 0.001) in the non-teaching hospital group. The teaching hospital group did have higher IBD related complications, including fistula or abscess, strictures, obstruction, perianal abscesses, and malnutrition. Despite the increase in cost in the teaching hospital group, the length of stay was similar in both groups (P = 0.245).

CONCLUSION:

Our results showed the costs were higher for IBD exacerbations in the teaching hospital group. Despite having higher costs and having more IBD related complications in certain areas, the length of stay was similar between both groups. Prospective studies can further evaluate the utilization of resources in this complex disease.
667 Comparison of Morbidity and Mortality in Ulcerative Colitis Patient Admissions With Cytomegalovirus and Clostridium difficile Infections
Authors: Senatore Frank , Bhurwal Abhishek , Seril Darren
Published: October 2019

INTRODUCTION:

The incidence of ulcerative colitis (UC) is increasing throughout developed countries including the United States creating a significant economic burden. Clostridium difficile (C. diff) infection is a virulent pathogen commonly encountered in UC patients. Cytomegalovirus (CMV) infection is also well described in patients with severe UC, but its role as a pathogen is still evolving. Both infections have been associated with a poorer prognosis, especially in immunocompromised patients. Our study sought to compare rates of colectomy, length of stay (LOS) and inpatient mortality in UC patients admitted with flares compared to UC patients admitted with flares associated with either CMV or C. diff infection.

METHODS:

This was a retrospective cohort study using the 2011-2014 Nationwide Inpatient Sample (NIS) utilizing International Classification of Diseases, 9th Revision. Study included All patients above 18 years with principal or secondary discharge diagnoses of UC. Additional codes were utilized to identify CMV associated disease and presence of C. diff in the UC cohort. Outcomes included in-hospital mortality, LOS and colectomy rates between the UC cohorts (flare, CMV associated disease and C. diff). Proportions were compared using fisher's exact test and continuous variables using student t-test. Multivariable and Poisson regression was performed for length of stay and hospitalization charges. All statistics were performed utilizing STATA software.

RESULTS:

There were no gender differences between the three cohorts while the mean age of UC patients with CMV was 42.94 years compared to 46.96 and 46.63 years in UC flare and UC patients with C. diff, respectively (Table 1). Hispanics were more commonly found to have UC with CMV associated disease (14.07%) vs UC flare (9.61%) and UC with C. diff (10.59%) (P = 0.001). Steroid dependence was present in 6.53% of UC, 10.11% C. diff, and 18.11% of CMV flares (P = 0.001). Colectomy rates were 1.71%, 3.99% and 9.98% for UC, C. diff and CMV cohorts, respectively (P = 0.0001). LOS days was 4.71 in UC, 7.28 in C. diff, and 11.47 in CMV flares (P = 0001). In-patient mortality was 0.3%, 1.31% and 0.55% for UC, C. diff and CMV cohorts, respectively (P = 0.00001).

CONCLUSION:

This study demonstrates that patients admitted with UC flares associated with C. diff or CMV infection have higher morbidity and mortality than patients with UC flares alone. Immunocompromised patients should warrant a higher index of suspicion for these infections.
672 Defining Meaningful Attributes for the Treatment of IBD From Patients' Perspective
Authors: Louis Edouard , Ramos Juan , Cuervo Jesus , Kopylov Uri , Barreiro de Acosta Manuel , McCartney Sara , Rosenfeld Greg , Bettenworth Dominik , Hart Ailsa , Novak Kerri , Donnet Xavier , Easton David , Saldana Roberto , Protze Katja , Tzur Eyal , Lehrer Gabriela Alperovich , Casellas Francesc
Published: October 2019

INTRODUCTION:

Crohn's disease (CD) and ulcerative colitis (UC) are chronic, debilitating inflammatory bowel diseases (IBD). Medications used to treat IBD pts have distinct characteristics. Research into patient preferences indicates values regarding medical treatment may vary depending on clinical disease phenotype.1–4 We present a descriptive system that includes the most relevant attributes for IBD treatment focusing on the patient perspective.

METHODS:

A three-step approach was used to develop the descriptive system. First, a literature review was performed and an initial list of attributes was developed and classified within domains and categories. Second, a focus group meeting was conducted with eight patient representatives and nine gastroenterologists. Using feedback elicited from the focus group meeting, the research team constructed an initial draft of the descriptive system, including a subset of domains and attributes. Third, all participants of the focus group meeting participated in two-rounds of structured online interviews. The structured interviews were used to refine the wording used for naming and defining each attribute and the levels of those attributes in the initial descriptive system.

RESULTS:

We identified 32 eligible publications and a list of 127 attributes grouped into 7 domains (effectiveness, side-effects, health related quality of life [HRQoL], well-being, available evidence, administration/convenience, and other) was developed. This list was discussed in the focus group meeting and a draft of the descriptive system containing 16 relevant attributes was constructed. The same attributes were defined for UC and CD while taking into consideration that the relative weights for each disease may differ. During the first round of interviews, patients ranked all attributes included in the descriptive system and based on the second round of interviews, the final descriptive system containing a total of 3 domains, 10 attributes, and their corresponding levels was developed (Table 1).

CONCLUSION:

This qualitative research shows which attributes within the domains of efficacy, complications/risk, and HRQoL patients value most when making treatment decisions. We developed a descriptive system that outlines the IBD treatments by means of the 10 most relevant attributes, which should be considered by physicians and nurses when discussing treatment options with a patient. These attributes will be weighted in a future study based on patient preferences.
695 Time to Flexible Sigmoidoscopy or Colonoscopy in Patients Admitted With Ulcerative Colitis Has Decreased in the Past 5 Years
Authors: Kroner Paul T. , Picco Michael , Cangemi John R. , Farraye Francis A.
Published: October 2019

INTRODUCTION:

Early evaluation of patients with ulcerative colitis (UC) with flexible sigmoidoscopy (FS) or colonoscopy (C) enables assessment of disease activity, exclusion of infectious pathogens, or other conditions that may present similarly to UC. Early FS is also associated with improved outcomes of patients with active UC. The aim of this study was to determine the temporal trends in timing of FS/C in relation to day of admission in patients with UC in the past 5 years.

METHODS:

Retrospective cohort study using the NIS 2012-2016. Patients with an ICD9-10 principal diagnosis code for UC were included. Elective admissions were excluded. FS/C were identified using ICD9-10 procedural codes. Early FS/C was defined as performed within 48 hours of admission. Primary outcome was to determine the trends in timing of FS/C in patients admitted for UC. Secondary outcomes were determining the odds of early FS/C, inpatient mortality, morbidity, hospitalization length (LOS), total hospitalization charges and costs in patients undergoing early vs. non-early FS/C. Logistic regression was used to adjust for gender, age, Charlson Comorbidity Index, median zip code income, hospital region, location, size and teaching status.

RESULTS:

156,720 patients with UC and were included. 3,845 (2.5%) underwent FS and 18,835 (12.0%) underwent C. The mean age was 45.4 years and 53.4% were female. The mean time to FS decreased from 3.2 to 3.0 days, while the mean time to C decreased from 2.8 to 2.5 days in the study period (P = 0.05). The total FS/C increased from 1,155 (3.9%) to 11,727 (35.5%) from 2012 to 2016. 13.3% of patients underwent C at teaching vs. 9.8% at non-teaching centers, while 2.6% underwent FS at teaching vs. 2.1% at non-teaching centers (P = 0.05). Early FS/C was associated with decreased odds of shock and multiorgan failure, as well as decreased resource utilization and LOS (Tables 1 and 2).

CONCLUSION:

For this dataset, FS/C rates were low in hospitalized patients with UC but are performed more frequently and earlier in the course of an admission. The total number and proportional use of inpatient FS/C increased from 2012-2016. This may reflect an increasing awareness of improved outcomes from earlier disease staging and/or earlier diagnosis of alternate disease processes that can be treated in a timely manner. Early FS/C was also associated with decreased costs, charges and length of hospitalization. These findings further highlight the importance of early endoscopic intervention in patients admitted with UC.
701 Item-Level Improvements in Inflammatory Bowel Disease Questionnaire Scores in Patients With Ulcerative Colitis Treated With Tofacitinib Induction Therapy
Authors: Dubinsky Marla C. , DiBonaventura Marco , Fan Haiyun , Bushmakin Andrew G. , Cappelleri Joseph C. , Maller Eric , Thorpe Andrew J. , Salese Leonardo , Panés Julian
Published: October 2019

INTRODUCTION:

Tofacitinib is an oral, small molecule Janus kinase inhibitor for the treatment of ulcerative colitis (UC). Significant improvements have been reported in all Inflammatory Bowel Disease Questionnaire (IBDQ) domains for tofacitinib vs placebo (PBO) in patients (pts) with UC in OCTAVE Induction 1 & 2 and OCTAVE Sustain.
1
The effect of tofacitinib on items within each IBDQ domain has not yet been analyzed.

METHODS:

We examined the effect of tofacitinib induction (10 mg twice daily [BID]) on individual IBDQ items in adults with moderate to severe UC. Data were pooled from the randomized, Phase 3 OCTAVE Induction 1 & 2 studies (NCT01465763 & NCT01458951).
2
Pts self-administered the IBDQ at baseline (BL), Week (Wk) 4, and Wk 8. IBDQ domains are: bowel symptoms (10 items), systemic symptoms (5 items), emotional function (12 items), and social function (5 items); higher scores indicate better health-related quality of life (HRQoL).
1,3
Change from BL (CFB) in IBDQ items was analyzed for tofacitinib vs PBO using a linear mixed-effects model, with fixed effects (treatment, study, prior tumor necrosis factor inhibitor treatment, BL corticosteroid use, geographical region, week, treatment-by-week interaction, and BL score) and a random effect (pts). No multiplicity adjustment was performed.

RESULTS:

Significant improvements (P < 0.05) were observed in all IBDQ items with tofacitinib 10 mg BID vs PBO at Wks 4 and 8. The largest treatment differences (CFB; domain) were: “bowel movements been loose” at Wks 4 and 8 and also “problem with rectal bleeding” at Wk 8 (all 1.1 points) for the bowel symptoms domain; “getting a good night's sleep” at Wk 4 (0.8) and 8 (0.9) for the systemic symptoms domain; “fear of not finding a washroom” at Wk 4 (0.6) and 8 (0.8) and also “felt embarrassed” and “felt angry” at Wk 4 (both 0.6) for the emotional function domain; and “avoid attending events” at Wk 4 (0.8) and 8 (1.0) and also “difficulty doing leisure/sports” at Wk 8 (1.0) for the social function domain (Table 1).

CONCLUSION:

Tofacitinib improved all bowel-related and systemic symptoms, and all emotional and social functioning IBDQ items vs PBO, highlighting the broad impact of tofacitinib on HRQoL. This analysis provides a useful perspective on the most improved IBDQ domains with tofacitinib induction therapy, which may facilitate patient-physician dialogue.
707 Platelet to Albumin Ratio: An Early Predictor of Colectomy in Acute Ulcerative Colitis
Authors: Paknikar Raghavendra , Dwadasi Sujaata , Goens Donald , Zafer Maryam , Micic Dejan
Published: October 2019

INTRODUCTION:

Acute ulcerative colitis (UC) is associated with significant morbidity and comes with a high risk of surgery. Prior clinical predictors have often included Day 3 laboratory values to assess risk of colectomy. Utilization of readily available data on admission may expedite medical decisions allowing for prompt initiation of therapies. Our aim was to identify early laboratory predictors of colectomy at the time of admission.

METHODS:

We designed a retrospective study including patients >18 years old with an admission for acute UC at a single academic center between 1/1/2013 and 4/1/2018. Cases were identified using the ICD-9 code 556.X and ICD-10 code K51.X and separately manually verified. Clinical variables of interest and laboratory values were obtained via chart review or extracted from the electronic medical record. Statistical analysis was conducted using JMP ® 13.1.0. Data was analyzed using Wilcoxon rank-sum test for continuous variables, Fischer's exact test for categorical variables, followed by multivariate logistic regression for predictive modeling of in-hospital colectomy.

RESULTS:

262 patients admitted with acute UC were reviewed. 59 (22.5%) required inpatient colectomy. 188 of these patients had complete platelet and albumin laboratory data. Basic demographic variables and significant predictors of colectomy in univariate analysis are described in Table 1. Platelet to Albumin ratio (PAR) was found to be the strongest assessed univariate predictor of colectomy (AUC = 0.72, P-value < 0.0001). The optimal PAR cutoff to predict colectomy was 129 (Sensitivity = 70%, Specificity = 72%). Final multivariate logistic regression model with only significant covariates included PAR score (categorical), outside hospital transfer, and number of prior biologics with an area under curve (AUC) = 0.84. PAR remained statistically significant in this model (OR: 6.48, 95% CI: 2.73-15.34). Admission platelet count and admission albumin were also predictors of colectomy in both univariate and separate multivariate analyses, whereas CRP on admission, CRP on Day 3, and CRP to Albumin ratio were not predictive of colectomy (Table 2).

CONCLUSION:

PAR ratio was found to be a robust predictor of in-hospital colectomy in acute UC. This simple laboratory tool may provide a means to quantify early risk of in-hospital colectomy. As such, an elevated PAR identified on admission can help guide therapeutic strategies aimed at mitigating risk for colectomy in high risk groups.