bluuebunny/crossref_metadata_2025_split huggingface dataset:
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.