Radiating disparity in IBD.

In remote corners of the rapidly expanding IBD literature universe, two separate areas of investigation and controversy continue to grow independently. The first is in regard to the risks of diagnostic radiation exposure, whereas the second concerns the disparities in access to care and health care resource utilization in IBD patients. Abdominal imaging is frequently utilized to diagnose disease, detect complications, and ascertain response to treatment in IBD patients. Given a 20-fold rise in the amount of CT imaging between 1980 and 2000, it is not surprising that an estimated three-quarters of the radiation to which IBD patients are exposed is due to CT scanning [1, 2], mostly from abdomino-pelvic examinations, which have largely supplanted conventional contrast enterography in IBD patients. As an example, an 840 % increase in CT enterography use was reported between 2002 and 2007 [3]. Further, as many as 1 in 6 IBD patients are exposed to moderate-high cumulative effective doses (CED) of diagnostic ionizing radiation as measured in millisieverts (mSv) [4]. These figures are important, as frequent exposure to low levels of ionizing radiation have been hypothesized to increase the incidence of malignancy, with as many as 2 % of all cancers worldwide attributable to diagnostic radiation exposure [1, 5]. Although equipoise exists as to the legitimacy of this possible association, there is nonetheless a growing interest in and discussion surrounding the limitation of diagnostic radiation exposures in IBD patients to what is truly necessary for optimal patient management [6]. Parallel to concerns about radiation exposure, several studies have revealed that the IBD universe is not immune to some of the issues that plague the field of medicine as a whole. Racial and socioeconomic disparities in the availability, delivery, and utilization of IBD healthcare resources have been repeatedly demonstrated [7–9]. As these disparities have included differences in use of highly effective medical therapies, emergency department (ED) visits, and gastroenterologist subspecialist care, resultant differences in the degree and frequency of diagnostic radiation exposures are likely. Possible reasons may include barriers to highly effective medical therapy, delays in definitive surgical therapy, and reduced access to gastroenterology specialist and IBD subspecialist care. In this issue of Digestive Diseases and Sciences, Hou et al. [10] report the findings of a retrospective cohort study with the aim of identifying factors associated with highdose radiation exposure in a cohort of IBD patients treated in a county-based ‘‘safety net’’ healthcare system in Houston, TX, USA, from 2000 to 2010. Such healthcare delivery systems are designed to offer universal care access regardless of ability to pay. Since these systems have high proportions of uninsured and under-insured individuals, it is likely that this study population is enriched in IBD patients at risk for increased diagnostic radiation exposure stemming from care disparity issues. The authors identified all possible IBD patients from the 3 inpatient and 14 outpatient facilities in the studied healthcare system using ICD-9 codes. The authors subsequently reviewed electronic medical records and applied accepted IBD diagnostic criteria to reasonably verify a racially and ethnically diverse 278-patient IBD cohort. M. Flasar (&) S. Patil Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, 100 North Greene Street, Lower Level, Baltimore, MD 21201, USA e-mail: mflasar@medicine.umaryland.edu