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Expert Critique
FROM THE ASCO Reading Room
There are several triggers for IBD flares that may result in an ER visit or hospital stay. Some flares are caused by worsening disease and loss of response to their current medications. Other causes include complications of IBD, such as the formation of an intra-abdominal abscess in the setting of Crohn’s disease, or complications that may result from treatment with immunosuppressive medications, such as infections. Further, flares may result from smoking; using non-steroidal anti-inflammatory medications, such as ibuprofen; or lack of medication compliance. Medication non-compliance can occur when patients feel better and no longer feel the need to stay on treatment or due to financial constraints, which may result in spacing out doses longer than prescribed.
One way several academic centers are trying to decrease the number of ER visits and hospital stays for their IBD patients is by creating an “IBD Home” model. The first step is to identify the IBD patients at the highest risk for frequent ER visits and hospitalization based on their prior behavior. Then, the IBD providers reach out to these patients more frequently through phone calls or more frequent office visits in an attempt to treat symptoms of a flare earlier and keep patients out of the ER. They also encourage patients to contact their IBD provider prior to going to the ER as some symptoms may be amenable to outpatient treatment in the GI office. However, because of the complexity of these diseases, some ER visits are simply unavoidable.
Inflammatory bowel disease (IBD) flares are associated with emergencies and high emergency department (ED) utilization, sometimes followed by hospitalization and surgery. ED visits are an increasingly costly component of IBD healthcare, and gastroenterologists are seeking ways to minimize the factors that lead to the visits.
As with the situation for any serious chronic disease, some IBD-related ED visits will be necessary, but patient education and good treatment compliance can reduce the need.
"Better control and getting our patients into steroid-free clinical remission and healing their mucosa will hopefully prevent the complications that lead to ED visits and hospitalization and surgery," Adam S. Cheifetz, MD, of Beth Israel Deaconess Medical Center and Harvard ľֱ School in Boston, told ľֱ. "Patient education should stress the importance of compliance and becoming active participants in their healthcare. Patients should be advised to call their doctor's office first, but if they sound sick enough, sometimes the ER is the best place for them." Cheifetz said that in his practice, he reviews treatment compliance issues several times a year with patients to ensure that they understand that non-adherence carries a significantly higher risk of serious relapses.
At Boston's Brigham and Women's Hospital, a comprehensive care program has been put in place to reduce ER use through measures such as frequent patient contact, health and wellness coaching, and nutrition counseling. "Our center really tries to focus on creating almost a medical home for IBD to prevent ER use and hospitalization," Jessica R. Allegretti, MD, MPH, said in an interview.
An increasingly common clinical concept, the "IBD home" model is also in place at the University of Pittsburgh and Mount Sinai Hospital in New York City.
Brigham and Women's Hospital's Circle Program recently concluded a randomized study, presented at Digestive Diseases Week 2016, that identified patients potentially at high risk for emergency visits and hospitalization with a view to reducing the need for these. "We encourage patients to reach out to their regular providers first, because many can be handled as outpatients. But sometimes there are true emergencies that require hospitalization and we actually send them there," Allegretti said.
Cheifetz noted that Crohn's disease patients are more likely than ulcerative colitis patients to end up seeking emergency care owing to the penetrating and structuring complications of Crohn's and the associated risk of toxic megacolon, acute perforations, abdominal abscesses, and small bowel obstructions. "Because Crohn's patients are more prone to these, with these issues at the back of their minds, physicians tend to send Crohn's patients to the ER more quickly," he said.
Smoking, overuse of NSAIDs, and stress can all increase the risk of flares that may end up in the ED, while exercise and medication compliance can reduce the risk, Cheifetz added.
Looking at the national picture, in 2016, Mahesh Gajendran, MD, and colleagues reported on during 2009-2011 in adults with a primary ED diagnosis of IBD from the and found encouragingly stable rates of ED visits during 2009-2011. Adult IBD patients constituted 0.09% of the total ED visits, with Crohn's disease contributing 69% of IBD-related visits. The hospitalization rate arising from IBD visits was 59.9% nationally and ranged from 56% in the west to 69% in the northeast.
The two most significant conditions associated with hospitalization were intra-abdominal abscess (odds ratio 24.22) and bowel obstruction (OR 17.77). Other factors were anemia (OR 7.54), malnutrition (OR 6.29), hypovolemia and electrolyte abnormalities (OR 5.57), and fever and abnormal white cell count (OR 3.18).
The authors observed a lower chance of admission to hospital in Crohn's disease patients (OR 0.66), low-income patients (OR 0.90), and female patients (OR 0.87). Intra-abdominal abscess (OR 18.41), bowel obstruction (OR 9.24), Crohn's disease (OR 1.89), and being age 65 or older (OR 1.63) correlated significantly with surgical intervention.
It also appears that a history of frequent phone calls to medical centers can predict which patients will use the ED: by University of Pittsburgh researchers assessed associations over a couple of years between clinical factors, telephone call patterns, and future ED visits or hospitalizations based on more than 50,000 telephone records logged in 2009 and 2010 at a tertiary-care IBD clinic. The study found that 15% of patients made more than 10 calls a year, and these accounted for half of all calls to the clinic; 42% of those making more than eight calls within 30 days were seen in the ED or hospitalized within the following year. Of those patients having more than 10 telephone encounters per year, more had Crohn's disease and more were female.
Other research has suggested that women may be heavier users of the ED for IBD flares. For example, a in 2013 by Anita Sivaraman, MD, and colleagues found that women frequented the ED with IBD-related symptoms more than men did, despite having equivalent outpatient gastroenterology visits. Women had an average of 0.59 IBD-related ED visits versus men's average of 0.22. "These findings may be attributed to disease perception, pain tolerance, or confounding genitourinary etiologies," the researchers wrote. But according to Cheifetz, there is some suggestion that women are more compliant with medication than men are, especially younger men, which should theoretically cut the risk of emergency events.
In other IBD demographics, Ricardo Chia, MD, and colleagues in 2015 that according to a 208-patient chart review African Americans, even with regular GI care for IBD, made significantly more visits to the ED of a university medical center than whites did, perhaps reflecting greater disease severity. And in a 2017 study, Natasha Bollegala, MD, and Geoffrey Nguyen, MD, found that a lack of private insurance coverage predicted treat-and-release visits to the ED. "There's a concern for the 20% of patients who may lose insurance coverage under new healthcare legislation," Cheifetz said.
In terms of cost burden, a study by Sushil Kumar Garg, MD, and associates found a rise in total costs per ED visit for ulcerative colitis patients from 2006 to 2016 but also found an increase in direct discharges from the ED without hospital admission, and speculated that higher charges per visit might relate to more imaging and other diagnostic tests.
"Once they're there, emergency physicians tend to hop on imaging quickly, and especially Crohn's patients are at a concerning increased risk of exposure to ionizing radiation," Cheifetz explained.
Bottom line, he added: "While the ER should not be used in lieu of regular care, be aware of the emergencies associated with IBD, and certainly use the ER when necessary, when the risk of significant complications is high."