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

Discussion

This study has found large decreases in emergency and elective activity for IBD services on a national scale during the pandemic. Most striking amongst these data are the reductions in the frequency of attendance to secondary care for emergency IBD care and reductions in procedures and investigations for IBD. It is concerning that thousands of fewer patients have attended hospital for acute IBD during the first year of the pandemic. Diagnostic and therapeutic lower GI endoscopy, ileostomy reversals and operations for ileal Crohn's disease were particularly affected. There has been a significant change in the treatment of perianal Crohn's disease, with less drainage of sepsis and fewer operations for perianal fistula. Surgery for ulcerative colitis has been affected, with fewer elective and emergency colectomies and fewer IPAA operations. A shorter length of stay by 1 day was observed for both acute UC and CD admissions. There was a slightly higher rate of emergency readmission within 28 days for acute UC admissions. Finally, the prevalence of concomitant covid-19 infection was low in the emergency admissions for UC and CD during the first year of the pandemic.

IBD services, especially for surgery and endoscopy, have been negatively impacted globally. Most evidence for this comes in the form of cross-sectional and survey data at the height of the pandemic. For example, cross-sectional data from a single centre in Spain found that rates of emergency department visits and admissions for IBD fell by 58% and 50% respectively in March and April 2020.[8] In the UK, paediatric IBD services have been negatively affected with over half of patients unable to access diagnostic endoscopy at the peak of the first wave.[9] Extrapolating from nationwide histopathology registry data in the Netherlands, there are large estimated falls in endoscopy (59.7%) and surgery (14.2%).[10] Survey data from China also suggest delayed diagnostic procedures, biologic therapy and elective surgery.[11] Lastly, survey data from Canada show evidence of delays in care with a median delay of 10 weeks for surgery.[12] Most of these data come from developed countries affected during 2020. The ongoing impact after the first wave and in developing countries is not well described.

How IBD and its medical treatment are risk factors for contracting Sars-CoV-2 and the resulting outcome for patients has been investigated previously in cohort studies and case reports. Two systematic reviews of these studies from earlier in the pandemic (2020) concluded that IBD patients were not at greater risk of being infected with SARS-CoV-2 than the general population.[13,14] However, there is evidence that steroids may be associated with a worse prognosis and there are mixed findings for immunomodulators.[13] The risk of adverse outcomes may be higher in ulcerative colitis.[13] The latest data from the SECURE-IBD international registry suggested that combination therapy and thiopurines may be associated with an increased risk of severe Covid-19 infection.[15] Lastly, a recent nationwide registry study of patients with inflammatory disease in Denmark found that IBD patients with Covid-19 were not at higher risk of requiring invasive ventilation, longer hospital stay or death.[16] Our study adds evidence that IBD patients admitted as emergencies had similar outcomes for 30-day in-hospital mortality and readmission within 28 days when compared with historical cohorts during the first wave of the pandemic in England. The decrease in length of stay we observed for acute IBD admissions may reflect the zeal of clinicians to keep acute admissions as short as possible during the pandemic.

This is also consistent with a previous large multi-centre observational study (PROTECT-ASUC) for outcomes for acute colitis during the pandemic.[17] This is reassuring: despite resources being stretched, healthcare services were able to manage the emergency patients well. This study has shown a similarly reassuring finding for acute CD admissions.

However, there is likely a burden of unmeasured morbidity in the community that this study can only indirectly measure. Exactly how large this burden is and whether it has led to complications should be the focus of future research. Excess mortality has been demonstrated in England and Wales for the population as a whole, and up to a fifth of this is due to non-covid-19 causes.[18] It is unclear if IBD patients had excess mortality in the community during the first wave. Admissions for ischaemic heart disease and high-risk emergency general surgery did decrease during the first wave of the pandemic, giving indirect evidence that out of hospital deaths may have increased.[1,2]

The evidence regarding UC colectomy rates in recent years is conflicting. Some studies suggest that colectomy rate is decreasing in the era of access to biologic medications.[19,20] However, HES analysis of emergency admissions for UC before the pandemic has demonstrated a decrease in short-term colectomy rate in recent years that does not persist long-term.[20] The PROTECT-ASUC found that the practice of gastroenterologists and colorectal surgeons had changed, with more patients receiving rescue therapy in the form of biologicals, ciclosporin or tofacitinib.[17] This study suggests the trend to delay colectomy for patients undergoing emergency admission for ulcerative colitis has been exacerbated due to the pandemic. The ensuing effect on the quality of life of patients is hard to quantify and needs to be investigated.

Restorative surgery with IPAA is an important viable option for patients who have had colectomy for UC and would like to live without an ileostomy.[21] This study was unable to produce a reliable model of the counterfactual IPAA procedures as the confidence intervals crossed zero. What we do know is that the volume of IPAA in England has dropped to a low likely not seen since the 1980s.[22] This study has shown that along with the decrease in restorative surgery after colectomy, a significant number of ileostomies were not reversed during the pandemic. Again, there may be an ensuing decrease in the quality of life of IBD patients because of increasing time living with an ileostomy.

These data also show we are now treating fewer CD patients with surgery than before. It has been demonstrated that laparoscopic ileocaecal resection is a reasonable alternative to infliximab therapy in a randomised control trial.[23] The pandemic has meant that Crohn's disease patients in England were less likely to be offered this operation in 2020 according to these data.

The decreases in procedures for perianal CD are concerning. It is known that patients with perianal Crohn's disease have a much lower quality of life.[24] Surgical drainage of sepsis is a key part of the management of perianal CD, and the observed decrease in surgical drainage in this study is concerning for a burden of untreated complicated disease in this population.[25]

There are stark decreases in lower GI endoscopy demonstrated in this study. IBD may not be prioritised as urgently, and these patients may have their procedures postponed. This study included both diagnostic and therapeutic colonoscopy and flexible sigmoidoscopy in the procedure count. IBD patients require endoscopy for diagnosis, monitoring, surveillance and treatment.[26] The long-term impact of this deficit is difficult to unpick. In future more patients will be triaged with non-invasive investigations that mitigate the need for endoscopy or they may be investigated in other ways such as with CT colonography. The impact on training future endoscopists will be significant, and measures have been taken to improve this.[27]

Taken as a whole, the postponement and cancellation of these procedures could represent a decrease in quality of life for IBD patients. This is a secondary harm of a pandemic and exacerbated by what was a necessary response from government and healthcare providers. We recommend that when planning surgical theatre lists, those IBD cases where the quality of life is significantly impacted should be taken into account.

The main strength of this study is the use of routinely collected administrative data that covers all NHS care in hospitals in England. This gives a count of all activity and is not subject to selection bias. Our sensitivity analyses used admissions where ulcerative colitis or Crohn's disease were recorded in any diagnosis position. Some of these admissions could be where the ulcerative colitis or Crohn's disease is recorded as comorbidity. However, a proportion would be admissions due to acute IBD such as those with sepsis, unspecified abdominal pain or unspecified bowel obstruction. Accounting for these admissions, similar decreases in admissions were observed in 2020 as in our main analysis.

There are limitations to this study. The accuracy of the clinical coding underlying the diagnostic and procedural coding can be a concern but accuracy rates are improving and the routinely collected data are robust for research.[28] Secondary diagnoses are likely under-recorded but are accurate when included.[29,30] This study is unable to quantify the morbidity of untreated disease outside of hospital. Some of the procedures that have not been performed due to the pandemic may no longer be indicated and the deficits are overestimated.

This study has demonstrated large decreases in medical admissions and procedures for IBD. There is likely a large burden of untreated IBD disease that must be addressed as we emerge from the covid-19 pandemic.

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