P036 Socioeconomic Disparities in IBD: Outcomes in Emergency Department Utilization and Outpatient Follow-Up
Authors: Horton Nicholas , Kaur Randeep , Sadiq Omar , Abu Ghanimeh Mouhanna , Singh Meher , Kaur Nirmal 
Published: December 2019

BACKGROUND:
The association of socioeconomic status, emergency department (ED) utilization, and access to outpatient gastroenterology care in inflammatory bowel disease (IBD) remains underexplored. We sought to identify associations between overall socioeconomic deprivation and these outcomes in IBD patients.

METHODS:
Our historical cohort included 743 unique IBD patients with a total of 6,036 all-cause ED visits during a 51-month period (January 1, 2015 to April 1, 2019). Detailed demographic variables were recorded for all subjects. Zip codes were used to approximate the level of socioeconomic deprivation via the Area Deprivation Index (ADI), a comprehensive score developed at the University of Wisconsin based on a composite score including 17 different factors related to income, education, employment, and housing quality (1). ADI scores of these IBD patients were divided into quartiles (quartile 4 = most deprived) and then compared with outcomes, including average number of ED visits, average hours spent in ED per visit, acuity level of ED visits (by Emergency Severity Index levels 1–5, with level 1 = highest acuity), admission rates, total outpatient GI visits and IBD-specialist visits, percent attending any outpatient GI visit or IBD specialist visit, and initiation of any outpatient steroid-sparing therapies. Univariate comparisons were performed using analysis of variance (ANOVA) for continuous variables and chi-square tests for categorical variables. Statistical significance was set at P < 0.05.

RESULTS:
743 IBD patients (60% female, age 48 ± 18 yrs, 446 with Crohn's disease (CD), 297 with ulcerative colitis (UC)) were evaluated. Basic demographics were similar overall, with significant differences noted in race (P < 0.001) and insurance coverage (P < 0.001). Increased ED visits were noted with increased ADI in IBD patients overall (P = 0.003) as well as in the subgroup with CD (P = 0.040). Patients with increased ADI averaged fewer hours in the ED (P = 0.043), although they presented with significantly higher acuity (P = 0.007). There was a trend towards decreased GI clinic visits with increased ADI, but this did not reach statistical significance (p = 0.055). There was a significant difference between ADI quartiles in terms of those who successfully attended at least one GI clinic follow-up visit for all IBD patients (P = 0.007) and specifically for those with CD (P = 0.012). Patients with increased ADI attended fewer IBD-specific clinic follow up (P = 0.044). Significant differences regarding access to outpatient steroid-sparing therapy were seen across ADI quartiles (P = 0.044).

CONCLUSION(S):
Our study demonstrates increased ED utilization and decreased access to outpatient gastroenterology and IBD specialty care in IBD patients with lower socioeconomic status. Limitations include minor differences in baseline demographics including race and insurance coverage, although confounding was minimized by utilization of a comprehensive assessment of socioeconomic status through the ADI model. Our findings highlight the need for better access to outpatient IBD care in more economically deprived areas, and community health intervention programs to improve awareness of specialty care.