The Use of, and Outcomes for, Inflammatory Bowel Disease Services During the Covid-19 Pandemic

A Nationwide Observational Study

Mohammed Deputy; Kapil Sahnan; Guy Worley; Komal Patel; Violeta Balinskaite; Alex Bottle; Paul Aylin; Elaine M Burns; Ailsa Hart; Omar Faiz

Disclosures

Aliment Pharmacol Ther. 2022;55(7):836-846. 

In This Article

Results

Medical Admission for Acute Colitis: Patient Characteristics and Outcomes

16 494 patients were admitted from February 2020 to January 2021 with acute ulcerative colitis, with large decreases in admissions observed in March and April (Figure 1). ARIMA modelling predicted 19,721 admissions from February 2020 to January 2021 giving a shortfall of 3227 admissions (16.4%) compared with the counterfactual. The characteristics of patients admitted during the pandemic were similar to those admitted before (Table 2).

Figure 1.

Admission time series and forecast for acute ulcerative colitis and acute Crohn's disease (January 2015 to January 2021)

The 30-day in-hospital mortality for acute colitis was not significantly different in the pandemic compared with the historical cohort (1.0% vs 1.0% P = 0.754) (Table 4). The median length of stay was statistically shorter by 1 day in the pandemic (6 days vs 7 days, P < 0.0001). The 28-day readmission rate was slightly higher during the pandemic (14.1% vs 13.4%, P = 0.0195).

A flowchart of the initial ulcerative colitis admissions identified and subsequent exclusions are displayed in Figure 2.

Figure 2.

Flowchart of initial included episodes and subsequent exclusions for acute ulcerative colitis

Medical Admission for Flare of Crohn's Disease: Patient Characteristics and Outcomes

A total of 15,613 patients were admitted from February 2020 to January 2021 with a flare of Crohn's disease. Again, the largest decreases in attendances were seen in March and April 2021 (Figure 1). ARIMA modelling predicted 17,102 admissions from February 2020 to January 2021 and there was a shortfall of 1489 (8.7%) admissions compared with the counterfactual. The characteristics of patients admitted during the pandemic were similar to those admitted historically (Table 3).

The 30-day mortality was not significantly different during the pandemic when compared with the historical cohort (0.5% vs 0.6% P = 0.408) (Table 4). The median length of stay was statistically shorter by 1 day in the pandemic (5 days vs 6 days, P < 0.0001). The 28-day readmission rate was 16.0% during the pandemic and this was not significantly different compared with the historical cohort (P = 0.821).

A flowchart of the initial Crohn's disease admissions identified and subsequent exclusions are displayed in Figure 3.

Figure 3.

Flowchart of initial included episodes and subsequent exclusions for acute Crohn's disease

Prevalence of Covid-19 During Emergency Medical IBD Admissions

A total of 391/16 494 (2.4%) patients admitted for acute ulcerative colitis after 1 February 2020, until 31 January 2021 had a concomitant secondary diagnosis of Covid-19. A total of 349/15 613 (2.2%) patients admitted for a flare of Crohn's disease after 1 February 2020, until 31 January 2021 had a concomitant secondary diagnosis of covid-19.

IBD Investigations and Procedures

All IBD investigations and procedures analysed demonstrated a decrease in frequency recorded compared with the central estimate of the forecast. Table 5 shows the central estimate of the decrease in volume from February 2020 to January 2021 with an accompanying 95% CI. The three largest absolute deficits were observed for diagnostic or therapeutic colonoscopy or flexible sigmoidoscopy; ileostomy reversals; and ileal resection/strictureplasty or ileocecal resection for Crohn's disease. The three largest relative estimated deficits were seen in ileostomy reversals (40.8%, 1819 fewer procedures), perianal CD fistula surgery (36.9%, 322 fewer procedures) and lower GI endoscopy (35.2%, 17 544 fewer procedures). The forecast for IPAA surgery included negative values in the 95% confidence intervals meaning the forecast model was not reliable for prediction and so further calculation of the deficit was not possible.

Figure 4 shows an array of time series plots for selected IBD procedures and investigations from January 2015 to January 2021. The forecasts for the counterfactual scenario where the Covid-19 pandemic had not occurred are shown with plots in red with 95% confidence bands. Observing the plots shows clear patterns: colonoscopy and flexible sigmoidoscopy, ileostomy reversals, perianal CD fistula surgery and right-sided or ileal resection or strictureplasty for Crohn's disease showed large decreases in volume in the first wave of the pandemic especially in March and April 2020. Most procedures showed a recovery in volume recorded after April. Less dramatic decreases in volume were observed for drainage of perianal sepsis in Crohn's disease, emergency and elective colectomy (with a larger decrease in elective colectomy), and pouch surgery (Figure 4) but a deficit was observed for all procedures when comparing observed volume with the central estimate of the forecast (Table 5).

Figure 4.

Admission time series and forecasts for eight different procedures for IBD

Sensitivity Analysis

When the diagnostic code for ulcerative colitis was in a secondary position a large range of primary diagnosis codes were observed. The most frequent codes used were: J181 lobar pneumonia, unspecified (3.7% of all primary diagnosis codes); N390 urinary tract infection, site not specified (2.7%); A419 sepsis, unspecified (2.7%) and A099 gastroenteritis and colitis of unspecified origin (2.5%). There were 78,101 admissions forecast with a diagnosis of ulcerative colitis in any position from February 2020 to January 2021 compared with an observed 65,058 admissions (16.7% deficit).

When Crohn's disease was coded for in a secondary diagnosis position a large range of primary diagnosis codes were observed. The most frequent codes were: R104 Other and unspecified abdominal pain (3.2% of all primary diagnosis codes); J181 lobar pneumonia, unspecified (3.1%); K566 Other and unspecified intestinal obstruction (2.9%), and A099 gastroenteritis and colitis of unspecified origin (2.7%). There were 79,987 admissions forecast with a diagnosis of Crohn's disease in any position from February 2020 to January 2021 compared with an observed 67,263 admissions (15.9% deficit).

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