Hospitalizations for Inflammatory Bowel Disease Among Medicare Fee-for-Service Beneficiaries — United States, 1999–2017

Fang Xu, PhD; Anne G. Wheaton, PhD; Yong Liu, MD; Hua Lu, MS; Kurt J. Greenlund, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2019;68(49):1134-1138. 

In This Article

Discussion

During 1999–2017, the overall hospitalization rate for both Crohn's disease and ulcerative colitis decreased among older adults, with a sharper decline in the hospitalization rate for ulcerative colitis. A previous study also reported that the 2013 hospitalization rate for Crohn's disease decreased compared with that in 2003 among adults aged 65–84 and ≥85 years.[3] The overall decline in hospitalization rates during the current study period was accompanied by the evolution of biologic therapies to treat IBD. A unique geographic pattern of hospitalization rates at the state level was observed for each disease. The geographic variation was similar to that in the previous study, which used the Nationwide Inpatient Sample of adults aged ≥18 years with hospitalizations for any listed diagnosis of Crohn's disease.[3] In addition, the IBD-related hospitalization rate was higher among beneficiaries who were urban residents than among those who were rural residents. An urban living environment was previously found to be associated with a higher risk of developing IBD, although rural residents might also have limited health care access to receive IBD-related care or diagnosis.[4]

The current study indicated that hospitalization rates were higher among older Medicare beneficiaries with ulcerative colitis and among younger beneficiaries with Crohn's disease; however, the rate of IBD-associated surgery was lower among older beneficiaries for both conditions. Surgery is indicated in severe cases or for patients who fail to respond to medication. Although the overall IBD-associated surgical rates have declined in recent decades, possibly because of new medication treatment,[5] in the current analysis, approximately 10% of hospitalizations for ulcerative colitis and nearly 20% of hospitalizations for Crohn's disease still required surgery. The lower surgery rates among older beneficiaries might reflect an increased concern for postoperative complications, mortality, prolonged hospital stay, and hospital-acquired infections among older patients.[2]

This is the first study to document the temporal trends in IBD-associated hospitalization during the past 2 decades among older adults in United States by race/ethnicity. In contrast to the decreased hospitalization rates for both diseases observed among whites, no significant temporal changes in hospitalization rates among blacks were observed. In addition, in 2017, blacks experienced lower hospitalization rates for both Crohn's disease and ulcerative colitis than did whites. These findings are consistent with those in a previous study in which reported rates of IBD incidence, prevalence, and hospitalization in blacks and Hispanics were lower than were those reported for whites.[6] However, this previous study also found that the ratio of IBD-associated hospitalizations and mortality to IBD prevalence was higher among blacks than that among whites and Hispanics.[6] Another study found lower use of biologics or lower adherence to medications among blacks,[7] which could contribute to the higher ratio of IBD hospitalization to IBD prevalence among this group.

The findings in the report are subject to at least three limitations. First, Medicare data are collected for insurance reimbursement purposes and are not designed for research. The collected data do not include information about health-risk behaviors and additional demographic variables, which limited the ability to study these measures. Second, diagnoses or procedures might be subject to coding errors. Finally, the study population is limited to Medicare fee-for-service beneficiaries. Therefore, the findings might not be generalizable to all U.S. adults aged ≥65 years.

IBD management is challenging because comorbidities and polypharmacy are common among older adults. For older adults, the necessity of surgery should be carefully evaluated based on an individual patient's disease severity and comorbid mental and physical conditions.[8] If surgery is indicated and performed, early intervention, together with pain control and a proper discharge plan might prevent poor hospitalization outcomes, such as readmissions, and might ultimately reduce health care costs.[9] In addition, further assessment of health care utilization among blacks with IBD is needed. Optimal multidisciplinary disease management, including outpatient follow-up visits and receiving recommended preventive care such as vaccinations and cancer screening,[10] is important to maintain remission, improve quality of life, and prevent surgery and hospitalization among the growing population of older adults with IBD.

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