S48 Health Disadvantage Is Associated With Persistent GI Symptoms in Adults With Crohn’s Disease in Endoscopic Remission

Abstract

Background: While it is widely recognized that patients’ socioeconomic status and living environments play crucial roles in the management and clinical course of CD, there is a scarcity of health disparities research beyond the associations with race, ethnicity, and insurance coverage. We herein examine the relationship between the symptomatic and inflammatory burden of CD and social determinants of health (SDOH) compassing encompass neighborhood environments and community conditions, including access to education, job opportunities, transportation, and dietary resources. Methods: We performed a retrospective cohort study on adults with CD enrolled in a tertiary referral center biobank in Southern California from 2014-2021. We included patients with standardized clinical disease activity assessments (2-item patient-reported outcome [PRO-2] for abdominal pain [AP] and stool frequency [SF]; remission: AP ≤3 and SF≤1) within 7 days of an ileocolonoscopy scored by the Simple Endoscopic Score for Crohn Disease (remission <3). Health disadvantage was assessed using the California Healthy Places Index (SDOH index), a zip code-based system that ranks communities’ SDOH domains using weighted z-scores (0-100 percentile) from the most health disadvantage (low score) to the most health advantaged (high score) in 8 subdomains: economy, education, healthcare access, housing, neighborhoods, clean environment, transportation, and social environment. Multivariate regression models were created from patient/SDOH factors (dependent variable) that were statistically significant (P < 0.05) on univariate logistic regression to compare the differences between patient with and without active GI symptoms (independent variable) despite endoscopic remission. SDOH subdomains were classified as below (health disadvantage) or above the median (reference) on the SDOH Index. Results: Of the 353 ileocolonoscopies (cases) from 216 unique patients with CD, 151 cases (43%) from 108 unique patients had endoscopic remission. Health disadvantage was not associated with endoscopic disease activity (P = 0.95) with 42% (25/59) and 43% (126/294) of patients below and above the SDOH index median, respectively, were in endoscopic remission. Patients with health disadvantage (below median on the SDOH Index) were more likely to report GI symptoms despite endoscopic remission (OR 2.7, 95% CI 1.1-6.5, P = 0.03). On univariate analysis, poor economic conditions (OR 2.4, 95% CI 1.0-5.7, P = 0.04), low education attainment (OR 3.9, 95% CI 1.8-8.2, P = 0.0004), unfavorable neighborhood conditions (OR 3.1, 95% CI 1.6-6.3, P = 0.001), and poor healthcare access (OR 2.3, 95% CI 1.1-4.4, P = 0.02) were risk factors for persistent GI symptoms. Females (OR 2.8, 95% CI 1.4-5.7, P = 0.003) and smokers (OR 2.6, 95% CI 1.2-5.8, P = 0.02) also reported more persistent GI symptoms. On multivariable analysis, unfavorable neighborhood conditions (aOR 2.9, 95% CI 1.3-6.5, P = 0.01), smoking (aOR 2.6, 95% CI 1.1-6.4, P = 0.02), and female gender (aOR 2.8, 95% CI 1.3-6.5, P = 0.01) remained as risk factors for persistent GI symptoms despite endoscopic remission. Conclusion(s): Health disadvantage, specifically poor neighborhood conditions, may be non-inflammatory risk factors for persistent gastrointestinal symptoms of adults with Crohn’s disease in endoscopic remission. Further investigations into the role of social determinants of health and environmental risk factors in the clinical course and manifestation of IBD are warranted.