DECREASED HEALTHCARE UTILIZATION IN UNINSURED PATIENTS WITH PERIANAL CROHN’S DISEASE UNDERGOING PROCTECTOMY
Authors: Izda Vladislav , Israel Yonatan , Feeley Monica , Longley Regina , Kim Esther , Maheshwari Nikhil , Katzenstein Cecilia , Sylla Patricia , Khaitov Sergey , Greenstein Alexander , Wong Serre-Yu 
Published: January 2024

Abstract

INTRODUCTION
Perianal Crohn's disease (CD) is a debilitating subtype affecting nearly 20% of CD patients, primarily characterized by the presence of perianal fistulas. It is associated with poor health outcomes, significantly decreased quality of life, and is an independent predictor of work disability. Proctectomy is generally reserved for patients with severe, refractory disease. Social determinants of health, including health insurance status, can impact the progression and outcomes of chronic diseases. Here we examine healthcare utilization and clinical characteristics of patients with perianal CD who undergo proctectomy for those with and without health insurance.

METHODS
This retrospective study follows perianal CD patients who underwent a proctectomy from 2008 to 2021 at Mount Sinai Hospital. We collected demographic, insurance status, and clinical data, such as diagnosis-to-surgery time, hospitalization rates, number of MRIs utilized, and number of medications utilized (Tables 1 and 2). Univariate analysis comparing patients with and without insurance was performed using Chi-Square or Fisher's Exact Tests.

RESULTS
Our study included 130 patients (50.8% female) with a mean age of 52.0 ± 14.9 years. The majority were insured (n = 106, 81.5%). Results were significant for a shorter diagnosis-to-surgery time in the uninsured group (6.9 vs. 11.1 years, p = 0.050), fewer hospitalizations (p = 0.002), MRIs (p = 0.008), clinic visits (p = 0.007), as well as reduced use of antibiotics (p = 0.016), and biologics (p =0.001) in the uninsured group (Tables 1 and 2). Data trended towards a later mean age at the time of diagnosis in the uninsured group (37.8 vs. 33.1 years, p=0.241). There was no statistical difference between the groups regarding race, comorbidities, extraintestinal manifestations, presence of skin tags, strictures, and fissures, presence of proctitis or abscess at proctectomy, age at proctectomy, surgical approach, number of lifetime GI surgeries, endoscopies, or corticosteroid treatments.

DISCUSSION
Our findings suggest that the uninsured patients with perianal CD have decreased utilization of healthcare resources compared to the insured group. This disparity, combined with the observed trend of older age at, and therefore likely delay of, CD diagnosis and treatment may contribute to a more rapid and severe CD course, ultimately leading to a shorter diagnosis-to-surgery interval. This study was limited by a small, single-center population sample, as well as other confounding factors associated with lack of insurance. Future research will include multivariate analysis to identify specific discrepancies in annual healthcare utilization between these populations, evaluate the contribution of race and language to this issue, and investigate the role that a decreased delay in diagnosis could play in preventing last resort proctectomy.

Table 1 Patient Characteristics

Table 2 Comparison of Healthcare Utilization by Insurance Status