Introduction: The rate of hospitalization and/or surgery in inflammatory bowel disease (IBD) varies widely between patients and centers. The aim of our study was to identify factors affecting these outcomes in 2 different patient care settings. Methods: We conducted a multi-center retrospective cohort study among IBD patients followed at one of 2 large urban hospital systems- one university-based practice and one safety-net hospital. Two authors extracted patient demographics, clinical characteristics, endoscopic data, clinic utilization, and IBDrelated outcomes for each patient. Multivariate logistic regression was used to identify factors associated with our primary outcome of interest, hospitalization and/or surgery. Results: A total of 452 IBD patients were identified, with 227 having Crohn’s disease (CD) and 225 ulcerative colitis (UC). Two-thirds of patients (n=291) were followed at the safety-net hospital and one-third (n=161) followed at the university hospital. Median age of cohort was 43 years, and majority (54%) was female. Our cohort was racially diverse (47% white, 29% black, and 20% Hispanic). Twothirds of patients (n=304) underwent surgery or had a hospitalization during follow-up, including 51% (n=116) of CD patients and 84% (n=188) of UC patients. Significant predictors of surgery/hospitalization on multivariate analysis included male gender (odds ratio [OR] 1.8, 95% confidence interval [CI] 1.1-2.8), active smoking status (OR 2.3, 95% CI 1.4-3.8), severe disease requiring anti-TNF therapy (OR 3.4, 95% CI 2.1-5.5), and care at a safety net hospital (OR 3.8, 95% CI 2.2-6.4). Age, race, family history of IBD, and number of missed clinic visits were significant on univariate analysis but not multivariate analysis. This suggests the higher rate of no-show appointments among patients at the safety-net hospital (mean 3.4 vs. 1.0; p<0.001) did not completely explain differences in outcomes between the 2 hospital systems. Care at a safety net hospital was significantly associated with hospitalization/surgery, after adjusting for disease severity on multivariate analysis, in both patients with CD (OR 3.5, 95% CI 1.4-8.9) and UC (OR 13.2, 95% CI 4.4-39.5). A higher proportion of patients followed at the safety net hospital underwent surgery/hospitalization in CD (65% vs. 27%; p<0.001) and UC (91% vs. 69%; p<0.001). Conclusion: IBD patients treated at a safety net hospital have higher rates of hospitalization and surgery, even after adjusting for patient demographics, disease severity, and clinic utilization. This variation in outcomes suggests a need to improve quality measures and provide standardization in IBD care.