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The American Journal of Managed Care October 2019
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Inflammatory Bowel Disease Readmissions Are Associated With Utilization and Comorbidity
Shirley Cohen-Mekelburg, MD, MS; Russell Rosenblatt, MD, MS; Beth Wallace, MD, MS; Nicole Shen, MD, MS; Brett Fortune, MD, MSc; Akbar K. Waljee, MD, MSc; Sameer Saini, MD, MS; Ellen Scherl, MD; Robert Burakoff, MD; and Mark Unruh, PhD
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Alison Sexton Ward, PhD; Mina Kabiri, PhD; Aylin Yucel, PhD, MSc, MBA, MHSA, PharmD; Alison R. Silverstein, MPH; Emma van Eijndhoven, MS, MA; Charles Bowers, MD; Mark Bensink, PhD, MSc, MEd; and Dana Goldman, PhD
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Jonathan L. Vandergrift, MS; and Bradley M. Gray, PhD
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James D. Chambers, PhD; Ari D. Panzer, BS; David D. Kim, PhD; Nikoletta M. Margaretos, BA; and Peter J. Neumann, ScD
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Inflammatory Bowel Disease Readmissions Are Associated With Utilization and Comorbidity

Shirley Cohen-Mekelburg, MD, MS; Russell Rosenblatt, MD, MS; Beth Wallace, MD, MS; Nicole Shen, MD, MS; Brett Fortune, MD, MSc; Akbar K. Waljee, MD, MSc; Sameer Saini, MD, MS; Ellen Scherl, MD; Robert Burakoff, MD; and Mark Unruh, PhD
Thirty-day readmissions related to inflammatory bowel disease are common and associated with longer length of stay and a higher likelihood of having an associated comorbid condition compared with index hospitalizations.
ABSTRACT

Objectives: Hospital care accounts for up to one-third of the cost of inflammatory bowel disease (IBD) management. A select group of patients with IBD is responsible for a large proportion of this utilization, demonstrating the burden of frequent hospitalizations. We aim to better understand the burden of 30-day readmissions among patients with IBD using a national hospital database.

Study Design: Retrospective cohort study of state-specific inpatient databases.

Methods: The State Inpatient Databases for New York and Florida were used to identify patients with IBD hospitalized between 2009 and 2013. The prevalence of 30-day IBD-specific readmission was determined. The association between 30-day readmission and visit outcomes, specifically length of stay and a composite of comorbid conditions (venous thromboembolism, pneumonia, sepsis, Clostridium difficile infection, enteral and parenteral nutrition, and blood transfusion), was analyzed using multivariable logistic regression.

Results: Patients with IBD accounted for 35,514 and 39,506 inpatient stays in New York and Florida, respectively. Of these stays, 13.7% to 16.2% resulted in a 30-day readmission. On multivariable analysis, 30-day readmissions were associated with a longer length of stay than index hospitalizations by 1.00 day (adjusted regression coefficient, 1.00; 95% CI, 0.73-1.26) and a higher likelihood of having a comorbid condition (adjusted odds ratio, 1.83; 95% CI, 1.68-1.99) in New York. Similar associations were confirmed in Florida.

Conclusions: Nearly 1 in 7 hospitalizations of patients with IBD lead to a 30-day readmission. These IBD-specific readmissions are associated with increased utilization and comorbidity. Patients at risk for readmission need to be targeted to improve outcomes and IBD care quality.

Am J Manag Care. 2019;25(10):In Press
Takeaway Points

Nearly 1 in 7 inflammatory bowel disease (IBD) hospitalizations lead to a 30-day readmission. These IBD-specific readmissions are associated with increased utilization and comorbidity. An awareness of the downstream outcomes associated with 30-day readmissions should drive health system and provider efforts to reduce IBD readmissions and improve outcomes.
  • Among patients with IBD hospitalized in New York and Florida between 2009 and 2013, 13.7% to 16.2% of inpatient stays resulted in a 30-day readmission.
  • Thirty-day readmissions were associated with a longer length of stay than index hospitalizations.
  • Thirty-day readmissions were associated with a higher likelihood of having an associated comorbid condition.
Inflammatory bowel disease (IBD) is a chronic relapsing/remitting disease that often requires multispecialty care, medication infusions, surgical resection, and acute hospitalizations. Patients with IBD have high healthcare utilization and carry incremental lifetime healthcare costs that are significantly higher than those of controls without IBD. Hospital care accounts for up to one-third of this cost.1-3

A select group of patients with IBD is responsible for a large proportion of this inpatient healthcare utilization, demonstrating the burden of frequent hospitalizations.4 Chronic and complex medical diseases, such as IBD, have been linked to high readmission rates, which are a substantial burden to the US healthcare system.5-8 Single-center studies report an all-cause 30-day readmission rate of nearly 20% among patients with IBD compared with a 30-day combined readmission rate of 22.9% for patients with heart failure, acute myocardial infarction, and pneumonia—the conditions targeted as part of the Hospital Readmissions Reduction Program.5,6,9

Readmissions are considered a surrogate for poor inpatient care quality and an important end point in the assessment of high-value care.10,11 Studies in the cardiology and surgical literatures have shown that hospital readmissions are more likely to be associated with higher mortality, longer length of stay, and lower likelihood of discharge home.12-14 However, the association between IBD readmissions and hospital outcomes has not been described.

With a heightened emphasis on high-value care and the high readmission rates among patients with IBD, we aimed to better understand the association between IBD readmissions and visit outcomes using 2 state-specific inpatient databases. We hypothesized that 30-day readmissions in IBD are associated with poor hospitalization outcomes, specifically increased length of stay and higher rates of comorbid conditions affecting the hospitalization.

METHODS

We performed a retrospective cohort study using the State Inpatient Databases (SIDs) for New York and Florida from 2009 to 2013. The SIDs are all-payer state-specific databases of inpatient stays supported through the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project (HCUP).15 The SIDs of New York and Florida were chosen because the states have large, diverse populations. These state-specific SIDs also allow for year-to-year follow-up throughout the study period.16

Inclusion and Exclusion Criteria

Adult IBD hospitalizations were identified using any diagnosis of Crohn disease or ulcerative colitis, identified by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 555.x or 556.x, respectively. This definition of IBD has previously been well validated.7 Visits with indeterminate IBD, as defined by a diagnosis of both ulcerative colitis and Crohn disease within the same encounter, were excluded, given difficulty differentiating IBD type.7 Using patient identifiers, visits were linked to measure 30-day readmission. Patients who died during the index hospitalization and those with less than 30 days of follow-up (ie, index admission within the last 3 months of the study period) were also excluded (Figure 1). Our final study population consisted of IBD-specific hospitalizations, defined as a primary diagnosis of IBD or a secondary diagnosis of IBD associated with a primary diagnosis of an IBD-related complication, to exclude readmissions and hospital outcomes that might be primarily driven by other conditions.17,18 A primary diagnosis of an IBD complication was defined using a previously published schema that includes 9 major complications identified by ICD-9-CM codes (active fistulizing disease or intra-abdominal abscess, stricture, bowel obstruction, perianal abscess, lower gastrointestinal hemorrhage, hypovolemia, electrolyte imbalance, anemia, and malnutrition).17,18

Objectives

The primary objective was to determine the prevalence of 30-day IBD-specific readmissions from 2009 to 2013. Our secondary objective was to compare visit-level outcomes associated with readmission, specifically readmission length of stay and a composite of associated comorbid conditions that affect hospitalization. A comorbid condition was defined as a composite of Clinical Classifications Software (CCS) codes for venous thromboembolism, pneumonia, sepsis, Clostridium difficile infection, enteral or parenteral nutrition, or blood transfusion. CCS is a tool used to group diagnoses and procedures into meaningful categories using ICD-9-CM codes.19 A subgroup analysis was performed to compare 30-day readmission with visit-level outcomes (readmission length of stay and associated comorbid conditions) among only patients who had multiple hospitalizations over the total study period to account for disease severity.


 
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