Gastroenterology Visits Research Articles

COVID-19 vaccination safety and associated health care utilization among adults with inflammatory bowel disease – a population-based self-controlled case series analysis

Background and aimsThere is an incomplete understanding of the full safety profiles of repeated COVID-19 vaccinations in patients with inflammatory bowel disease (IBD). Among individuals with IBD, we assessed whether COVID-19 vaccines were associated with serious adverse events of special interest (AESI) and health care utilization [all-cause hospitalizations, Emergency Department (ED) visits, gastroenterology visits, IBD-related visits].MethodsUsing comprehensive administrative health data from Ontario, Canada, adults with IBD who received at least one COVID-19 vaccine from December 2020-January 2022 were included. Self-controlled case series analyses were conducted to evaluate the relative incidence rates of AESI and health care utilization outcomes across post-vaccination risk and control periods.ResultsAmong 88,407 IBD patients, 99.7% received mRNA vaccines and 75.9% received ≥ 3 doses. Relative to control periods, we did not detect an increase in AESI. IBD patients had fewer all-cause hospitalizations during post-vaccination risk periods. Patients experienced more all-cause ED visits after dose 2 [Relative Incidence (RI):1.08(95%CI:1.04–1.12)] but fewer visits after doses 3 [RI:0.85 (95%CI:0.81–0.90)] and 4 [RI:0.73 (95%CI:0.57–0.92)]. There was no increase in gastroenterologist visits or IBD-related health care utilization post-vaccination. There were fewer IBD-related hospitalizations after dose 1 [RI:0.84 (95%CI:0.72–0.98)] and 3 [RI:0.63 (95%CI:0.52–0.76)], fewer IBD-related ED visits after dose 3 [RI:0.81 (95%CI:0.71–0.91)] and 4 [RI:0.55 (95%CI:0.32–0.96)], and fewer outpatient visits after dose 2 [RI:0.91 (95%CI:0.90–0.93)] and 3 [RI:0.87 (95%CI:0.86–0.89)].ConclusionThis population-based study did not detect increased AESI, all-cause or IBD-related health care utilization following COVID-19 vaccination, suggesting a lack of association between vaccination and increased disease activity.

Racial and Ethnic Disparities in Health-Related Outcomes in Crohn's Disease: Results From the National Health and Wellness Survey.

Crohn's disease (CD) is a chronic inflammatory condition affecting the entire gastrointestinal tract that is associated with significant humanistic, clinical, and economic burdens. Few studies have assessed the association between CD severity and patient-reported outcomes (PROs), healthcare resource utilization (HCRU), and medical costs; even fewer have examined differences in disease outcomes among patients of various racial/ethnic groups. In this cross-sectional study, sociodemographic data, PROs, and economic outcomes for participants with self-reported CD were collected from the National Health and Wellness Survey (2018-2020). Multivariable analyses were used to assess the association of CD severity and race/ethnicity with health-related quality of life (HRQoL), work productivity and activity impairment (WPAI), HCRU, and medical costs. Analyses included 1077 participants with CD (818 non-Hispanic White, 109 non-Hispanic Black, and 150 Hispanic). Participants with self-reported moderate/severe CD reported significantly worse HRQoL and WPAI, greater HCRU, and higher medical costs than those with self-reported mild CD. Non-Hispanic Black participants reported better HRQoL and fewer healthcare provider visits than non-Hispanic White participants. There were no significant differences in PROs between non-Hispanic White and Hispanic groups. Interactions between race/ethnicity and CD severity emerged for some, but not all groups: Specifically, non-Hispanic Black participants with moderate/severe CD reported greater absenteeism and more gastroenterologist visits than non-Hispanic Black participants with mild CD. Participants with moderate/severe CD reported worse PROs, greater HCRU, and higher medical costs than those with mild CD. Additionally, racial/ethnic differences were found across several HCRU and economic outcomes. Further research is needed to better understand factors contributing to burden among patients with varying CD severity across racial/ethnic groups.

Inflammatory Bowel Disease Hospitalizations Are Similar for Patients Receiving Televisit-Delivered Outpatient Care and Those Receiving Traditional In-Person Care.

The coronavirus disease 2019 pandemic resulted in widespread expansion of telehealth. However, there are concerns that telehealth-delivered outpatient care may limit opportunities for managing complications and preventing hospitalizations for patients with inflammatory bowel disease (IBD). We aimed to assess the association between outpatient IBD care delivered through televisit (video or phone) and IBD-related hospitalizations. We conducted a case-control study of patients with IBD who had an IBD-related index hospitalization between April 2021 and July 2022 and received their care in the Veterans Health Administration. We matched these hospitalized patients to controls who were not hospitalized based on age, sex, race, Charlson comorbidity index, IBD type, IBD-related emergency department use, IBD-related hospitalizations, and outpatient gastroenterology visits in the preceding year. The variable of interest was the percentage of total clinic visits delivered through televisit in the year before the index hospitalization. We compared the risk of IBD-related hospitalization by exposure to televisit-delivered care using conditional logistic regression. We identified 534 patients with an IBD-related hospitalization and 534 matched controls without an IBD-related hospitalization during the study period. Patients with IBD with a higher percentage of televisit-delivered (vs in-person) outpatient care were less likely to be hospitalized during the study period (for every 10% increase in televisit use, odds ratio 0.97, 95% confidence interval 0.94-1.00; P = 0.03). Televisit-delivered outpatient IBD care is not associated with higher risk of IBD-related hospitalization. These findings may reassure clinicians that televisit-delivered outpatient care is appropriate for patients with complex chronic diseases such as IBD.

Comparative Effectiveness of Virtual Versus In-person Visits for Abdominal Pain During the COVID-19 Pandemic.

The COVID-19 pandemic has highlighted the importance of telemedicine in improving healthcare access and reducing costs. This study aimed to assess order compliance in the virtual versus in-person setting for the initial evaluation of abdominal pain (AP) prior to and during the pandemic. A retrospective evaluation of virtual and in-person outpatient gastroenterology visits for AP were identified through natural language processing from January 2019 through September 2021 at the Cleveland Clinic main campus and regional hospitals in Ohio. We assessed the number and type of orders placed for patients and measured compliance through order completion. This study received Institutional Review Board approval (IRB 21-514). Among 20,356 patients at their initial visit, 79% had orders placed, of which 40% had pandemic in-person visits, 13% had pandemic virtual visits, and 47% had pre-pandemic in-person visits. Patients seen virtually were 65.1% less likely to complete orders compared to patients seen in-person (p < 0.001) during the pandemic. Patients seen in a pandemic virtual setting were 71.0% less likely to complete imaging orders (p < 0.001), 82.6% less likely to complete procedure orders (p < 0.001), and 60.5% less likely to complete lab orders (p < 0.001). Compared with in-person visits, patients seen virtually for their first presentation of AP were less likely to complete labs, imaging, and endoscopic evaluations. In-person visits were more successful with patient order completion during the pandemic. These findings highlight that virtual visits for AP, despite convenience, may compromise care delivery and warrant additional care coordination to achieve compliance with medical recommendations.

EPISODE OF CARE MODEL PROVIDES A MORE ACCURATE ESTIMATE OF COSTS FOR PATIENTS WITH IBD COMPARED TO THE TRADITIONAL CALENDAR YEAR MODEL

Abstract INTRODUCTION Inflammatory bowel diseases (IBD) are gastrointestinal (GI) conditions characterized by chronic inflammation of the digestive tract, which are associated with significant costs. Traditionally, research has focused on the overall costs of a disease per calendar year, however examining the cost of a specific illness-related index event and the surrounding episode of care may provide a more representative estimate of the costs of care and identify opportunities for targeted value-based interventions. METHODS We conducted a cohort study using data from IBM Watson, a claims-based database covering millions of commercially insured individuals. We identified adult patients aged 18 to 65 years with encounters associated with a primary or secondary diagnosis of IBD from 01/01/2018 to 12/31/2019 based on ICD-10 codes. We defined an episode of care as 360 days of continuous care (90 days prior to the index event to 270 days after such event) around an emergency room (ER) visit, gastroenterologist visit, and non-gastroenterologist GI visit (which could include a visit to a PCP, rheumatologist, dietician, and other services attributable to IBD symptoms). Measures of cost and utilization were calculated as a per member mean over 360 days. RESULTS 105,496 IBD patients with 1 year of continuous enrollment between 01/01/2019 to 12/31/2019 (calendar year cohort) and 81,774 patients with 2 years of continuous enrollment between 1/1/2018-12/31/2019 (episode of care cohort) were identified. Among IBD patients identified in the episode of care cohort, 13,164 (16.1%) patients had an IBD-related ER visit, 42,001 (51.4%) patients had a gastroenterologist visit, and 28,699 (35.1%) patients had a non-gastroenterologist GI visit. The mean per member calendar year total cost and GI-related costs were $40,842 and $31,051 respectively, compared to $68,0565 and $54,060 for an ER episode, $42,915 and $34,870 for gastroenterologist visit episode, and $48,556 and $38,120 for a non-gastroenterologist GI visit episode. Per member GI inpatient admissions (0.84), GI ER visits (1.98), GI-tests (5.90), and GI-imaging (0.91) were highest in the ER episode of care. Per member gastroenterologist visits (2.20), GI-related medication administration services (1.22) and biologic medication (1.41) were highest in the gastroenterologist episode of care. Per member non-gastroenterologist GI visits (4.50), and non-biologic GI medications (8.26) were highest in the non-gastroenterologist GI visits episode of care (Table 1 and 2). CONCLUSION This study found large variations in costs and utilization when looking at IBD- specific episodes of care. This episode-centered approach provides insights for developing targeted strategies to identify and intervene at the critical moments when patients seek advanced care, which may lead to patient-centered and cost-efficient healthcare delivery.

P326 Impact of disease flares on resource use, health-related quality of life and productivity in untreated Crohn’s Disease patients in US: an analysis of national health and wellness survey data

Abstract Background Patients with Crohn’s Disease (CD) alternate periods of exacerbation, flares, and periods of remission. The periods of flares can be debilitating to patients causing significant discomfort impacting the patient’s health-related quality of life (HRQoL). Despite symptoms, many patients do not receive treatments for their condition thus our objective was to describe the burden related to healthcare resource utilization (HRU), HRQoL and work productivity among a real-world cohort of patients who are not receiving any prescribed medications for CD. Methods The 2019 National Health and Wellness US Survey (NHWS) data was analyzed. NHWS is a self-administered Institutional review board (IRB) approved, internet-based annual survey that assesses numerous health conditions, demographic characteristics, medical history, healthcare utilization, attitudes, and outcomes. Respondents currently not taking prescription treatment for CD were categorized by flare frequency as infrequent (0-2 flares/year), intermediate (3-6/year), and frequent (&amp;gt;1/month to &amp;lt;7/week). HRU included HCP visits, gastroenterologist visits, emergency room (ER) visits and hospitalizations. HRQoL was assessed using the 5-dimension EuroQoL questionnaire (EQ5D), and work activity impairment using the Work Productivity and Activity Impairment questionnaire. Results A total of 74,994 respondents participated in the survey, of whom 577 reported being diagnosed with CD and 231 (40.0%) of whom were not taking prescription treatment for CD. Fifty-six percent of the untreated sample reported having mild disease. Among the untreated patients, 37% reported infrequent, 21% intermediate and 42% frequent flares. The mean age of patients with frequent flares was lower than those with infrequent or intermediate flares (infrequent: 51 years; intermediate: 45 years; frequent: 41 years). The mean EQ5D summary score decreased as the frequency of flares increased (infrequent: 0.77, intermediate: 0.66 and frequent: 0.63). Patients with frequent flares had higher gastroenterologists, ER and hospitalization rates compared to patient with infrequent of intermediate flares (Table 1). Overall work impairment was reported by 40%, 52% and 63% of patients with infrequent, intermediate, and frequent flares respectively (Figure 1). Conclusion This real-world analysis shows up to two-thirds of untreated CD patients present intermediate or frequent flares. In addition, those with frequent flares experienced poorer HRQoL, lower work productivity, and had higher healthcare resource use. This study reveals a high level of disease burden in patients who are not receiving treatment, the majority of whom reported to have ‘mild’ disease.

Assessing indicators and clinical differences between functional and organic childhood constipation: a retrospective study in pediatric gastroenterology clinics.

Chronic constipation is common among children worldwide. Constipation includes functional constipation (FC) and organic constipation (OC). The early recognition of the causes of childhood constipation and its subsequent complications is important. This study aimed to evaluate the prevalence and causes of childhood constipation and compare the clinical characteristics, treatment, and outcomes of children with FC versus OC to identify the predictive factors. This retrospective cross-sectional study analyzed children with FC or OC diagnosed in pediatric gastroenterology clinics, Salmaniya Medical Complex, Bahrain, 2017-2021. The Rome IV criteria were used to define FC. A total of 7,287 gastroenterology appointments were attended by 4,346 children during the study period. Of the 639 children (14.7%) with constipation, 616 (96.4%) were included in the study. Most patients had FC (n=511, 83%), whereas 17% (n=105) had OC. FC was more common in females than in males. Children with OC were younger (P<0.001) and had lower body weights (P<0.001), more stunted growth (P<0.001), and more associated diseases (P= 0.037) than those with FC. Enuresis was the most associated disease (n=21, 3.4%). Organic causes included neurological, allergic, endocrine, gastrointestinal, and genetic diseases. Allergies to cow milk protein were the most common (n=35, 5.7%). The presence of mucus in the stool was more common in OC than in FC (P=0.041), but no other symptoms or physical findings differed. A total of 587 patients (95.3%) received medication, among which lactulose was commonly prescribed (n=395, 64.1%). There were no intergroup differences in nationality, sex, body mass index, seasonal variation, laxative type, or treatment response. A good response was observed in 114 patients (90.5%). Chronic constipation represented a significant proportion of outpatient gastroenterology visits. FC was the most common type. Young children with a low body weight, stunted growth, mucus in the stool, or associated diseases should be assessed for an underlying organic cause.

The Prevalence of Irritable Bowel Syndrome and Its Relation to Psychiatric Disorders Among Citizens of Makkah Region, Saudi Arabia.

Irritable bowel syndrome (IBS) is a chronic functional bowel disorder. Many adults worldwide have symptoms associated with IBS and are responsible for most gastroenterology visits. The aim of this study is to illustrate and analyze the prevalence of IBS among the general population in Makkah Al-Mukarramah city using the Rome IV criteria in relation to psychiatric disorders. This was a cross-sectional study conducted on Makkah citizens. The study excluded all residents in Makkah without Saudi nationality or below the age of 18. The survey was created using Google forms and shared randomly on social media. The sample size was calculated using the OpenEpi website v3.0. The online questionnaire is composed of three sections: sociodemographic data, Rome IV criteria with the Bristol Stool Scale, and lastly the Depression, Anxiety, and Stress Scale 21 (DASS-21) score for stress, anxiety, and depression. Data were analyzed using SPSS software for Windows V.23, and odds ratio (OR) with 95%confidence intervals (95% CI) was obtained for selected risk factors using logistic regression. Nine hundred and twenty-one individuals from Makkah city completed the survey. The overall IBS prevalence was 20.19%. The commonest subtypes of IBS were IBS-M followed by IBS-C (53.8% and 22%, respectively). In the multiple regression analysis, stress (P = <0.001, OR = 2.473) was statistically significantly associated with IBS. In this study, the prevalence of IBS among Makkah citizens is high. Stress was found to be a major risk factor for IBS.

S516 Virtual Visits for Initial Evaluation of Constipation Are Associated With Reduced Outpatient Order Compliance

Introduction: In gastroenterology, telemedicine has emerged as a means for improving patient access to medical care while limiting viral transmission during the pandemic. The purpose of this study was to assess patient order compliance in the virtual vs. in-person setting during the COVID-19 pandemic for the initial evaluation of constipation. Methods: Using natural language processing, we identified outpatient gastroenterology visits (virtual and in-person) for constipation from March 2020 through December 2021. We assessed the number of orders placed for patients during these encounters and determined compliance based on order completion. A generalized linear mixed effects model with fixed effects for visit type and random intercepts for intra-patient correlation was used. A multivariable model was built controlling for age, socioeconomic status, BMI, dementia, stroke, and congestive heart failure. Results: Among 4,930 patients who presented for initial constipation evaluation since the start of the pandemic, 3,515 patients were evaluated in-person and 1,415 patients were evaluated virtually. Comparing order compliance in patients seen during the pandemic, patients seen virtually were 66% less likely to complete orders in comparison to patients seen in-person (p < .001). Patients seen in a pandemic virtual setting were 43% less likely to complete imaging orders (p < 0.001), 78% less likely to complete procedure orders (p < 0.001), and 90% less likely to complete lab orders (p < 0.001) (Table). Increased lab compliance was associated with the highest socioeconomic status ($75,000-$200,000) with patients eight times more likely to complete lab orders (p=0.049) and three times more likely to complete orders overall (p=0.021). Conclusion: Compared with in-person visits, patients seen virtually for their first presentation of constipation were less likely to complete labs, imaging and procedure evaluation ordered. In-person visits were more successful in leading to patient order completion during the pandemic. These findings suggest that virtual visits for constipation, despite convenience, may compromise care delivery; such visits may thus require additional care coordination to achieve compliance with medical recommendations. Table 1. - Order Compliance Among Patients with Pandemic Virtual vs. In-person visits Factors Odds Ratio 95% CI P-value Total Orders 0.339 [0.263,0.436] < .001 Imaging 0.103 [0.040,0.267] < .001 Procedures 0.219 [0.131,0.365] < .001 Labs 0.047 [0.024,0.092] < .001

Health care utilization differences between First Nations people and the general population with inflammatory bowel disease: a retrospective cohort study from Saskatchewan, Canada.

Indigenous people in Canada often face barriers to access specialized care, with limited data in evaluating health care utilization among Indigenous people with inflammatory bowel disease (IBD). We aimed to compare health care utilization between First Nations patients and those in the general population diagnosed with IBD in Saskatchewan. We conducted a patient-oriented, population-based, retrospective cohort study by linking administrative health databases of Saskatchewan between fiscal years 1998/99 and 2017/18. We designed and completed this study in partnership with Indigenous patients and family advocates. We applied a validated algorithm to identify IBD incident cases and then used the self-declared First Nations status variable to divide those cases. We applied a 1:5 ratio for age and sex matching and used Cox proportional models to assess associations. Hazard ratios (HRs) and 95% confidence intervals (CIs) were reported. We created a matched cohort with 696 IBD incident cases: 116 First Nations patients and 580 patients in the general population. We observed differences between the groups for IBD-specific hospital admissions (HR 1.33, 95% CI 1.01-1.75), IBD-related hospital admissions (HR 1.55, 95% CI 1.20-2.01), medication claims for IBD (HR 0.52, 95% CI 0.41-0.65) and 5-aminosalicylic acid claims (HR 0.56, 95% CI 0.45-0.71) adjusting by rural or urban residence and diagnosis type. There were no significant differences in the hazard rate of outpatient gastroenterology visits (HR 1.13, 95% CI 0.90-1.41), colonoscopies (HR 1.14, 95% CI 0.92-1.41) and surgeries for IBD (HR 1.14, 95% CI 0.80-1.64). We identified that First Nations patients diagnosed with IBD had a higher rate of hospital admissions owing to IBD than patients in the general population diagnosed with IBD. We also found an inverse association between First Nations status and having prescription medication claims for IBD.

A Quality Improvement Initiative to Reduce Abdominal X-ray use in Pediatric Patients Presenting with Constipation

To decrease the percentage of patients undergoing an abdominal radiograph for evaluation of constipation within 24hours of their initial gastroenterology visit. In January 2015, we implemented a quality improvement, evidence-based guideline (EBG) aimed at standardizing the initial assessment of patients presenting for a new outpatient gastroenterology visit with a primary complaint of constipation. Over the subsequent 5years, we followed the clinical impact of this guideline initiation with the goal of decreasing unnecessary abdominal radiograph use by 10% within 1year of EBG launch. Patients older than 6months and younger than 19years were included. In total, 6723 patients completed new patient gastroenterology visits for a primary diagnosis of constipation between 2013 and 2019. Of these, 993 (14.8%) patients had abdominal radiographs taken within 24hours of their initial visit. Over the 7years of this project, a mean frequency of abdominal radiograph use decreased from 24% to less than 11%. In addition, a 57% decrease in hospital charges related to decreased radiograph use for constipation was found. No increases in subsequent emergency department visits or hospitalization for constipation within 30days of patients' initial visits were seen. Through local adoption of an EBG, routine use of abdominal radiographs taken during a patient's initial outpatient gastroenterology visit for constipation decreased by more than 50%. This reduction was maintained over a subsequent 5-year period without any detrimental side effects.

Inequities in Rural and Urban Health Care Utilization Among Individuals Diagnosed With Inflammatory Bowel Disease: A Retrospective Population-Based Cohort Study From Saskatchewan, Canada.

Rural dwellers with inflammatory bowel disease (IBD) face barriers to accessing specialized health services. We aimed to contrast health care utilization between rural and urban residents diagnosed with IBD in Saskatchewan, Canada. We completed a population-based retrospective study from 1998/1999 to 2017/2018 using administrative health databases. A validated algorithm was used to identify incident IBD cases aged 18+. Rural/urban residence was assigned at IBD diagnosis. Outpatient (gastroenterology visits, lower endoscopies, and IBD medications claims) and inpatient (IBD-specific and IBD-related hospitalizations, and surgeries for IBD) outcomes were measured after IBD diagnosis. Cox proportional hazard, negative binomial, and logistic models were used to evaluate associations adjusting by sex, age, neighbourhood income quintile, and disease type. Hazard ratios (HR), incidence rate ratios (IRR), odds ratios (OR), and 95% confidence intervals (95% CI) were reported. From 5,173 incident IBD cases, 1,544 (29.8%) were living in rural Saskatchewan at IBD diagnosis. Compared to urban dwellers, rural residents had fewer gastroenterology visits (HR = 0.82, 95% CI: 0.77-0.88), were less likely to have a gastroenterologist as primary IBD care provider (OR = 0.60, 95% CI: 0.51-0.70), and had lower endoscopies rates (IRR = 0.92, 95% CI: 0.87-0.98) and more 5-aminosalicylic acid claims (HR = 1.10, 95% CI: 1.02-1.18). Rural residents had a higher risk and rates of IBD-specific (HR = 1.23, 95% CI: 1.13-1.34; IRR = 1.22, 95% CI: 1.09-1.37) and IBD-related (HR = 1.20, 95% CI: 1.11-1.31; IRR = 1.23, 95% CI: 1.10-1.37) hospitalizations than their urban counterparts. We identified rural-urban disparities in IBD health care utilization that reflect rural-urban inequities in the access to IBD care. These inequities require attention to promote health care innovation and equitable management of patients with IBD living in rural areas.

Factors Associated with the Refusal of Direct-Acting Antiviral Agents for the Treatment of Hepatitis C in Taiwan.

Background and Objectives: Direct-acting antiviral agents (DAA) are a safe and highly effective treatment for hepatitis C virus (HCV) infection. However, the uptake of DAA treatment remains a challenge. This study aims to examine the reasons for DAA refusal among HCV patients covered by the Taiwan National Health Insurance system. Materials and Methods: This retrospective observational study covered the period from January 2009 to December 2019 and was conducted at a single hepatitis treatment center in Taiwan. This study involved chart reviews and phone-based surveys to confirm treatment status and refusal causes. To confirm treatment status, subjects with HCV without treatment records were phone-contacted to confirm treatment status. Patients who did not receive treatment were invited back for treatment. If the patient refused, the reason for refusal was discussed. Results: A total of 3566 patients were confirmed with DAA treatment; 418 patients (179 patients who were lost to contact or refused the survey and 239 patients who completed the survey of DAA refusal) were included in the no-DAA-therapy group. Factors associated with receiving DAAs were hemoglobin levels, hepatitis B virus co-infection, and regular gastroenterology visits. Meanwhile, male sex, platelet levels, and primary care physician visits were associated with DAA refusal. The leading causes of treatment refusal were multiple comorbidities, low health literacy, restricted access to hospitals, nursing home residence, and old age. The rate of DAA refusal remains high (10%). Conclusions: The reasons for treatment refusal are multifactorial, and addressing them requires complex interventions.

Relevancia y necesidades del síndrome del intestino irritable (SII): comparación con la enfermedad inflamatoria intestinal (EII). (Por favor, si no te interesa el SII, léelo.)

IntroductionIn our opinion there is an imbalance between the relevance of irritable bowel syndrome (IBS), and the resources that are provided. ObjectiveTo review the different factors that determine (or should determine) the interest of gastroenterologists in IBS, comparing it with inflammatory bowel disease (IBD). For this, 7 different areas have been analyzed: (1)Medical impact; (2)Social impact; (3)Academic importance; (4)Clinical relevance; (5)Scientific relevance; (6)Public relevance, and (7)Personal aspects of the doctor. ResultsThe prevalence is 10 times higher in IBS, which represents up to 25% of gastroenterologist visits. Both pathologies alter the quality of life, in many cases in a similar way. The social cost is very important in both cases (e.g.: absenteeism of 21% and 18%) as well as the economic cost, although much higher in medication for IBD. Academic dedication is more than double for IBD, both in university and in MIR training. Scientific relevance is greater in IBD, with a number of publications four times higher. Public relevance is not very different between the two entities, although IBD patients are more associative. Doctors prefer IBD and tend to stigmatize IBS. ConclusionIn our opinion, to reduce this imbalance between needs and resources, human and material, in IBS it is essential to make drastic changes both in educational aspects, communication skills, prioritization according to the demands of patients, and reward (personal and social) of physicians.

P423 Treatment escalation and associated cost in German Ulcerative Colitis patients treated with advanced therapies

Abstract Background Advanced therapies used in moderate-to-severe Ulcerative Colitis (UC) may show a secondary loss of response (LOR) over time, requiring patients to undergo dose escalation or switching. Our study aimed to investigate the frequency of dose escalation in real-world practice and evaluated the associated cost. Methods Using German claims data (AOK PLUS) including prescription data, we identified UC patients by either at least two confirmed outpatient diagnoses or one primary inpatient diagnosis (ICD-10 K51). Analyzed patients initiated an advanced therapy (anti-TNF, vedolizumab, tofacitinib) between 01/01/2015-30/06/2019. Therapy escalation was defined as dose increase exceeding the recommended maintenance dose according to product labels by more than 150%. Time to first escalation was analyzed using a Kaplan-Meier estimation. The observation ended with the discontinuation of index therapy + 90 days, or loss to follow-up, whatever occurred first. End of therapy was determined in case of a supply gap of &amp;gt;60 days or switch of the advanced therapy. Patients with a follow-up &amp;lt; 6 months were excluded.Direct UC-related resource use and costs accounting for hospitalizations, outpatient treatment, drug costs according to pharmacy sales prices were reported per patient-year (PY). Results Among 574 UC patients who initiated an advanced therapy, 328 patients (median age: 37 years; female: 52.1%; biologic-naïve: 85.4%) with sufficient follow-up time (median: 12.2 months) were identified. Out of these, 59 patients (19%) were dose-escalated within the first year, whereas 73 patients (22%; anti-TNF: 61; vedolizumab: 12) were found to experience a therapy escalation during the whole follow-up time (average daily dose during maintenance therapy: adalimumab: 5.3 mg, infliximab: 14.6 mg, golimumab: 3.7 mg, vedolizumab: 11.1 mg, tofacitinib: n/a). Total observed direct cost related to UC amounted to €39,514/PY (95%-CI: 37,469-41,558), with €37,369/PY (34,852-39,885; Figure 1) caused by UC-related medication (95%). In comparison, UC-related total direct costs and drug costs for patients without any observable escalation were much lower (€30,425/PY [29,672-31,178]; p-value &amp;lt;0.001 and €28,066/PY [27,230-28,902]; p-value &amp;lt;0.001). Frequency of hospitalizations due to UC (0.3 [0.2-0.5] vs. 0.4 [0.3-0.5]; p-value: 0.947) and gastroenterologist visits (2.1 [1.6-2.6] vs. 2.3 [2.1-2.5]; p-value: 0.361) were similar among both groups. Conclusion Nearly one-fifth of observed patients required therapy escalation in the first year, most likely due to secondary LOR. This results in higher UC-related costs. Payers should consider rates and costs of dose escalations when evaluating the cost-effectiveness of advanced therapies.

P629 Rural-urban inequities in Inflammatory Bowel Disease health care access: a population-based retrospective cohort study from a Western Canadian Province

Abstract Background Inflammatory bowel disease (IBD) is a chronic digestive condition with significant complications if left untreated. Rural dwellers face barriers to access specialised health care, which is located in larger urban centres. We aimed to contrast health care utilization (outpatient gastroenterology visits, colonoscopies, claims for IBD medications, IBD-specific and IBD-related hospitalizations, and surgeries for IBD) between rural and urban residents diagnosed with IBD in the Canadian province of Saskatchewan (SK). Methods We completed a population-based retrospective study using SK administrative health databases (hospital discharge abstracts, medication claims, and physician billings) between the 1999 to 2016 fiscal years. A validated IBD algorithm requiring multiple health care contacts was used for case ascertainment. IBD incidence cases were identified by requiring eight years of continuous health care coverage without IBD health care contacts before the date of diagnosis. Cases were assigned to a rural or urban location based on their residential postal codes at the date of IBD diagnosis. Study outcomes were measured from IBD diagnosis to the end of the study period or end of health care coverage. Cox proportional regression models were used to evaluate the associations between rural-urban residence and each study outcome. Models were adjusted by sex, age, neighbourhood income quintile at IBD diagnosis, and disease type (Crohn’s disease and ulcerative colitis). Adjusted hazard ratios (HR) and 95% confidence intervals (95%CI) were reported. Results We identified 5,173 IBD incident cases in SK between 1999 and 2016; 1,544 (29.8%) individuals were living in rural locations at the date of diagnosis. Compared to urban dwellers, rural residents had lower gastroenterology visits (HR=0.82, 95%CI 0.77–0.88) and higher 5-aminosalicylic acid (5-ASA) claims (HR=1.10, 95%CI 1.02–1.18). Furthermore, rural residents had a higher risk of IBD-specific (HR=1.23, 95%CI 1.13–1.34) and IBD-related (HR=1.20, 95%CI 1.11–1.31) hospitalizations than their urban counterparts. We did not observe significant rural-urban differences in the access to colonoscopies, biologic and immune modulator therapies, and surgeries for IBD. Conclusion We identified rural-urban disparities in IBD health care access, specifically, lower outpatient gastroenterology visits, higher 5-ASA claims, and a higher risk of hospitalizations for individuals living in rural locations at IBD diagnosis. Our findings reflect rural-urban inequities in the access to IBD care that require the attention of health care providers and decision-makers to promote health care innovation and equitable management of patients with IBD living in rural areas.

P609 Impact of accessibility of medical care and socioeconomic class on outcomes of IBD – a nationwide population study

Abstract Background Despite ongoing improvements in Inflammatory Bowel Disease (IBD) therapeutics, timely access to quality medical care likely impacts patient outcomes. Physical distance from specialty care and socioeconomic status (SES) may impact quality of care. In a nationwide population study we aimed to assess the impact of patient location and SES on IBD outcomes. Methods This Epi-IIRN project utilized a meta-database incorporating patient data of all four health maintenance organisations (HMO) in Israel, representing 98% of the population. All patients identified on the incidence cohort were followed from diagnosis until end of 2018. Regions in Israel were defined as central (coastal plain and Jerusalem corridor), northern region and southern region. SES class were defined by postcode as per Israel bureau of statistics data from SES 1 (lowest) to SES 4 (highest). Primary outcome was steroid dependency, with secondary outcomes of biologic therapy use during first year of diagnosis, surgery, gastroenterology visits, hospitalizations and mortality. Analysis was performed separately for Crohn’s disease (CD) and ulcerative colitis (UC). Results A total of 30,167 IBD patients (16,936 (56%) CD and 13,231 (44%) UC) were included: 74% of patients were in central region, 12% southern region and 14% northern region. 21% were in SES class 1 and 12% in SES 4. In CD, lower SES was associated with higher steroid dependency (37% vs 30%, p=0.002), higher surgery rates (21% vs 12%, p&amp;lt;0.001), more hospitalizations (2.4 vs 1.1, p&amp;lt;0.001), more emergency department (ER) visits (2.9 vs 1.9, p&amp;lt;0.001) and higher mortality (3.3% vs 2.5%, p=0.03). Regarding region, steroid dependency, hospitalization rate, ER visits and surgery rate were all lower in central regions compared to both northern and southern region (p&amp;lt;0.001 for both central vs northern, and central vs southern regions). Similarly, gastrointestinal specialized clinic visits were more frequent in central regions (p=0.01). In UC, lower SES was associated with lower frequency of gastrointestinal clinic visits (5.0 vs 8.5, p&amp;lt;0.001). This was associated with more hospitalizations (1.6 vs 0.7, p&amp;lt;0.001), ER visits (2.1 vs 1.6, p=0.002), surgeries (7.6% vs 5.0%, p=0.014) and higher mortality (5.1% vs 4.2%, p=0.026). By region, gastrointestinal clinic visits were more frequent, and ER visits, hospitalizations (all p&amp;lt;0.001) and surgeries (p=0.001) were all lower in central compared to both northern and southern regions. Conclusion In this nationwide analysis we show deleterious impact of both lower SES and peripheral residence on outcomes of CD and UC. Policy makers should consider these data to facilitate improved access to medical care and maximize IBD outcomes in a standardized way.

A19 HEALTH CARE UTILIZATION DIFFERENCES BETWEEN FIRST NATIONS AND THE GENERAL POPULATION WITH INFLAMMATORY BOWEL DISEASE IN SASKATCHEWAN

Abstract Background Indigenous patients with inflammatory bowel disease (IBD) have expressed concerns about barriers to access IBD care. The limited evidence of IBD among Indigenous people highlights the need for studies evaluating access to IBD care in this population. Aims We aimed to compare health care utilization between First Nations (FNs) and individuals from the general population (GP) diagnosed with IBD in Saskatchewan (SK). Methods A population-based retrospective cohort study was conducted using administrative health databases of SK from 1998 to 2017 fiscal years. As a patient-oriented research initiative, outcomes of interest were chosen in collaboration with Indigenous patients and family advocates. A validated algorithm requiring multiple health care contacts was applied to identify incident IBD cases. The self-declared FN status variable was used to divide IBD cases between FNs and the general population (GP). To balance the groups, 1:5 age and sex matching was applied. Cox-proportional models were used to estimate hazard ratios (HRs) and 95% confidence intervals (95%CI). Stratified analysis was completed for those diagnosed before and after 2008 (pre- and post-biologic eras). Results A matched cohort with 696 IBD incident cases was created (FN=116, GP=580). Comparing health care utilization of FNs and individuals from the GP with IBD, there were no statistically significant differences in outpatient gastroenterology visits (FNs=81.0%, GP=83.6%), colonoscopies (FNs=91.4%, GP=86.9%), and surgeries for IBD (FNs=31.0%, GP=33.5%). We observed differences in prescription claims for any medication for IBD (FNs=79.3%, GP=89.3%) and 5-aminosalicylic acid (5-ASA) claims (FNs=75.9%, GP=81.4%). The HRs adjusted by rural/urban residence and diagnostic type showed differences in prescription claims for any IBD medication (HR=0.52, 95%CI 0.41–0.65) and 5-ASA (HR=0.57, 95%CI 0.45–0.72). In the pre-biologic era, FNs had a lower risk of having a prescription claim for any IBD medication (HR=0.32, 95%CI 0.23–0.45) and 5-ASA (HR=0.33, 95%CI 0.24–0.47), respectively. These differences were not significant in the post-biologic era. Conclusions Our study identified an inverse association between FN status and having prescription medication claims for IBD in SK. We considered multiple confounding variables when evaluating this association but could not control by disease severity. Thus, this association might reflect a barrier to access IBD medications or that FNs with IBD might present a milder disease. Further studies should continue evaluating access to IBD care, medication use, and disease severity among FNs living with IBD. Funding Agencies Saskatchewan Centre for Patient-Oriented Research (SCPOR), Saskatchewan Health Research Foundation (SHRF), and College of Medicine, University of Saskatchewan.

Validation of claims-based indicators used to identify flare-ups in inflammatory bowel disease.

Background & Aims:There are currently no validated claims-based indicators for identifying a worsening of disease in patients with inflammatory bowel disease (IBD). Therefore, we aimed to develop and validate indicators that identify flare-ups of IBD using data from Danish nationwide registries.Methods:Using Danish nationwide administrative data, we identified all patients with Crohn’s disease (CD) or ulcerative colitis (UC) who had at least one measurement of faecal calprotectin between 1 January 2015 and 31 June 2017. We tested several different claims-based indicators of disease flare-ups against levels of faecal (F-)calprotectin (no flare-up: <250 mg/kg; mild flare-up: 250–1000 mg/kg; severe flare-up: ⩾1000 mg/kg). A generalised estimating equation was used to evaluate whether the proposed indicators could predict disease activity.Results:A total of 890 children and 4719 adults with CD, and 592 children and 5467 adults with UC were included in the study. During the observation period, 48–61% and 48–55% of the CD and UC patients, respectively, had no flare-up, 26–29% (CD) and 24–26% (UC) experienced a mild flare-up, and 12–23% (CD) and 21–27% (UC) experienced a severe flare-up. Combinations of indicators that could predict a flare-up in CD and UC adults included hospitalisation, surgery, initiation or switch of biological therapy, treatment with systemic steroids, locally acting steroids or topical 5-aminosalicylates, colonoscopy/sigmoidoscopy, and magnetic resonance imaging/computed tomography. In children, only the number of gastroenterology visits was significant as an indicator among UC patients, and none were seen in children with CD. Overall, the indicator combinations resulted in a predictive ability of 0.62–0.67.Conclusion:Administrative claims data can be useful for identifying patients exhibiting (F-calprotectin defined) flare-ups of their IBD. Clinically relevant events captured in the Danish national patient registry are associated with increased levels of calprotectin and hence increased disease activity, and can be used as valid outcomes in future studies.

S1225 The Impact of COVID-19 Pandemic on Gastroenterology (GI) Outpatient Care: Pros and Cons of Telehealthcare

INTRODUCTION: COVID-19 pandemic has ravaged the world with more than 1 million cases, and 110,000 deaths as of June 2020. This pandemic impacted our healthcare system by all angles including outpatient care. Telehealth was extensively utilized. We conducted a study to assess the impact of Telehealth during the COVID-19 Pandemic on patient care. METHODS: A retrospective analysis of outpatient gastroenterology (GI) visits were conducted. General demographic information, labs, imaging, interpreter use, duration visit, medications, endoscopic procedures were collected. Statistical analysis was performed using STATA software V.16. RESULTS: In a total sample size of 151 patients, the mean age was 51 ± 13.5 years with 74 males and 77 females. The majority of the patients were Hispanics (n = 101), followed by Asians (n = 33), White (n = 10) and African American (n = 7). 26% patients were unable to reach (n = 26), 1% died of COVID19 (n = 3). The mean duration of telehealth conversation was 20 minutes. The most common diagnosis of GI visit were dyspepsia (n = 42), followed by cirrhosis (n = 15), IBD (n = 11), PUD (n = 9), dysphagia (n = 8) and GI bleeding (n = 7). The patients received various drug treatments based on their clinical condition including PPI (n = 31); H2-blockers (n = 8); 5-ASA (n = 7); diuretics (n = 6); Biologic therapy (n = 5); beta-blockers (n = 5); lactulose (n = 3); and rifaximin (n = 3). 6 patients were unable to get the refill of their medications and 8 patients were afraid to get the refill (Figure 1). 34% patients missed blood work for their follow-up (n = 51) and 15% patients had delay in getting imaging as diagnostic and screening (n = 23). 59 patients needed to have procedures, 3% urgent (n = 4), 9% time essential (n = 14), and 26% required routine screening (n = 40) (Figure 2). Lastly, there was 3 patients who had confirmed COVID19 and required hospitalization with good recovery. CONCLUSION: Despite a dramatic shift in the outpatient care to telehealth medicine, many clinicians expect future roles in telehealth. There are many barriers to outpatient care especially in this pandemic, summarized by a delay in getting blood work, medications and fear of approaching hospitals for medication refill.Figure 1.: Showing the impact of COVID-19 on Diagnosis and Management of GI.Figure 2.: Showing the acuity and type of GI procedures affected by the COVID19.