Significant Racial and Ethnic Disparities Exist in Health Care Utilization in Inflammatory Bowel Disease: A Systematic Review and Meta-analysis.

BACKGROUND: The incidence of inflammatory bowel disease (IBD) is rising worldwide, though the differences in health care utilization among different races and ethnicities remains uncertain. We aimed to better define this through a systematic review and meta-analysis. METHODS: We explored the impact of race or ethnicity on the likelihood of needing an IBD-related surgery, hospitalization, and emergency department visit. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated with I2 values reporting heterogeneity. Differences in IBD phenotype and treatment between racial and ethnic groups of IBD were reported. RESULTS: Fifty-eight studies were included. Compared with White patients, Black patients were less likely to undergo a Crohn's disease (CD; OR, 0.69; 95% CI, 0.50-0.95; I2 = 68.0%) or ulcerative colitis (OR, 0.58; 95% CI, 0.40-0.83; I2 = 85.0%) surgery, more likely to have an IBD-hospitalization (OR, 1.54; 95% CI, 1.06-2.24; I2 = 77.0%), and more likely to visit the emergency department (OR, 1.74; 95% CI, 1.32-2.30; I2 = 0%). There were no significant differences in disease behavior or biologic exposure between Black and White patients. Hispanic patients were less likely to undergo a CD surgery (OR, 0.57; 95% CI, 0.48-0.68; I2 = 0%) but more likely to be hospitalized (OR, 1.38; 95% CI, 1.01-1.88; I2 = 37.0%) compared with White patients. There were no differences in health care utilization between White and Asian or South Asian patients with IBD. CONCLUSIONS: There remain significant differences in health care utilization among races and ethnicities in IBD. Future research is required to determine factors behind these differences to achieve equitable care for persons living with IBD.

Clinical remission in paired phase two and three studies in inflammatory bowel disease: a systematic review with meta-analysis.

Discrepancies in phase two and three studies can result in significant patient and financial burden, as well as the nonapproval of potentially efficacious drugs. We aimed to determine whether this discrepancy exists for clinical trials in inflammatory bowel disease (IBD). Electronic databases (MEDLINE and Embase) and clinical trial repositories were searched from 1 January 1946 to 12 March 2021, for paired phase two and three studies of advanced therapies for Crohn's disease and ulcerative colitis. The primary outcome was to compare clinical remission rates between paired phase two and three studies for Crohn's disease and ulcerative colitis. Multivariable mixed-model meta-analysis was performed to calculate odds ratios (OR) with 95% confidence intervals (CI). The Cochrane risk-of-bias tool was used to grade the risk of bias. Of 2642 studies, 29 were included. Fifteen were phase three, 11 were phase two, one was phase one/two, and two were phase two/three. There were no differences in clinical remission rates between phase two and three studies for Crohn's disease (OR, 1.07; 95% CI, 0.86-1.34; P = 0.54) and ulcerative colitis (OR, 0.81; 95% CI, 0.48-1.36; P = 0.43). Furthermore, there was a lack of any appreciable differences in study characteristics, inclusion criteria and patient demographics among paired phase two and three studies. Most studies were considered low risk of bias. Overall, paired phase two and three studies demonstrate similar clinical remission rates for advanced therapies in IBD. Whether this applies to newer outcomes, such as endoscopic and mucosal healing remains to be determined.

Short-Term COVID-19 Pandemic-Related Endoscopy Delays Did Not Translate to Deleterious Outcomes for Patients With Inflammatory Bowel Disease: A Retrospective Cohort Study.

Background: The management of inflammatory bowel disease (IBD) requires frequent endoscopic assessment. It is unknown if measures put in place to reduce the spread of the virus SARS-CoV-2, including the delay of non-urgent patient assessments, resulted in deleterious outcomes for patients with IBD. Therefore, we aimed to determine if delays in endoscopy during the COVID-19 pandemic were associated with an increased risk of adverse IBD outcomes (emergency room, ER presentation, hospitalization, surgery, or escalation of drug therapy). Methods: A retrospective cohort study was performed in patients with IBD scheduled for outpatient endoscopies between March and August 2019 and 2020 at two tertiary care centers affiliated with Western University, London, Canada. Data pertaining to endoscopy timing, IBD drug prescription, ER attendance, hospitalization, and surgery were collected. Results: A total of 1160 endoscopies (2019, n = 718; 2020, n = 442) occurred during the study periods in 669 (2019) and 414 (2020) patients with IBD, respectively. More endoscopies were delayed in 2020 than 2019 (26.7% vs. 9.7%, respectively, P < 0.0001). Endoscopy delay was not associated with an increased risk of an adverse IBD outcome (OR = 1.23, 95%CI = 0.89-1.34, P = 0.20). Fewer adverse IBD outcomes were seen in the 2020 cohort who had endoscopy delays (n = 33/115, 28.7%) versus those without delay (n = 176/299, 58.9%, P < 0.0001). Conclusion: More endoscopy delays occurred during the COVID-19 pandemic; however, delays in general were not associated with adverse IBD outcomes, and in particular, endoscopy delays during the COVID-19 pandemic were associated with fewer deleterious IBD outcomes, suggesting that patients with IBD in need of urgent endoscopy were appropriately identified.

Increased Hospitalization for IBD Patients Seen in the ER During the COVID-19 Pandemic.

Background: During the COVID-19 pandemic, the focus of many health care systems shifted in order to prioritize and allocate resources toward treating those affected by COVID-19. What this has meant for other patient populations remains unclear. We aimed to determine if there have been changes to acute care access for patients with inflammatory bowel disease (IBD) during the COVID-19 pandemic. Methods: A retrospective cohort study was performed in IBD patients seen during (March 1, 2020 to August 31, 2020) and before (March 1, 2019 to August 31, 2019) the COVID-19 pandemic. IBD-related emergency room (ER) access, hospitalization, inpatient care and follow-up and post-discharge ER access were assessed. Results: A total of 1229 participants were included. A higher proportion of patients accessed ER during the pandemic (44.6% versus 37.2%, P = 0.0097). A higher proportion of hospitalizations resulted from IBD-related ER visits during the pandemic period (41.6% versus 32.4%, OR = 1.48, 95% CI = 1.14 to 1.94, P = 0.0047), though length of stay was shorter (7.13 ± 8.95 days versus 10.11 ± 17.19 days, P = 0.015) and use of rescue infliximab was less. No change was seen in inpatient surgical intervention. Despite similar proportions of follow-up appointments post-hospital discharge (pre-pandemic, 77.9% versus pandemic, 78.3%), more ER visits occurred in the first 30 days following hospitalization for patients in the pandemic cohort (24.4% versus 11.1%, P = 0.0015). Conclusion: These data highlight the need for ER services and hospitalization amongst IBD patients during the COVID-19 pandemic. This suggests that a return to pre-pandemic IBD care infrastructure is needed to mitigate the need for acute care access.

Risk Factors for Postpartum Disease Activity in Women With Inflammatory Bowel Disease: A Systematic Review and Meta-analysis.

BACKGROUND: Women with inflammatory bowel disease (IBD) have an increased risk of postpartum disease activity. We aimed to systematically determine the effect of various risk factors on postpartum IBD disease activity. METHODS: Electronic databases were searched through January 2021 for studies that reported risk of postpartum disease activity in women with IBD. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for the impact of IBD phenotype, disease activity, therapy de-escalation, mode of delivery, and breastfeeding on postpartum disease activity. Study bias was determined using the Quality in Prognostic Studies tool. RESULTS: Twenty-seven observational studies (3825 patients) were included, 15 of which had a high risk of confounding bias. The pooled incidence of women with postpartum active IBD was 31.9% (95% CI, 25.6-38.1). Similar results were seen with ulcerative colitis and Crohn's disease (CD; OR, 0.96; 95% CI, 0.58-1.59). Those with stricturing (OR, 3.64; 95% CI, 1.31-10.08) and penetrating (OR, 4.25; 95% CI, 1.11-16.26) CD had higher odds of postpartum active IBD. Active disease at conception (OR, 10.59; 95% CI, 1.48-76.02) and during pregnancy (OR, 4.91; 95% CI, 1.82-13.23) increased the odds of postpartum disease activity. Similarly, biologic discontinuation in the third trimester (OR, 1.77; 95% CI, 1.01-3.10) and therapy de-escalation after delivery (OR, 7.36; 95% CI, 3.38-16.0) was associated with postpartum disease activity. CONCLUSIONS: Complicated Crohn's disease, disease activity at conception and during pregnancy, and de-escalation of biologics during pregnancy or after delivery are associated with postpartum disease activity in women with IBD.

Implementation and evaluation of "I-Guide," a pilot near-peer Internal Medicine mentorship program.

An Internal Medicine (IM) specific, near-peer mentorship program was initiated at the University of Ottawa (uOttawa) in 2017. Medical students were paired with IM resident mentors to improve career decision-making through student-oriented discussion topics. Program evaluation was completed using data from three participant cohorts and showed that the program had a positive impact on students' career decision-making. Given the program's flexible nature and ease of implementation, it is well suited for adaptation at other institutions.

Un programme de mentorat par les quasi-pairs spécifique à la médecine interne (MI), a été lancé à l'Université d'Ottawa en 2017. Les étudiants en médecine ont été jumelés avec des mentors résidents en MI afin d'aider les premiers à prendre des décisions concernant leur carrière par le biais de discussions sur des sujets d'intérêt pour eux. L'évaluation du programme, réalisée sur la base des données de trois cohortes de participants, a montré qu'il a eu un impact positif sur la prise de décisions des étudiants à propos de leur carrière. Étant donné la nature souple du programme et sa mise en œuvre facile, il peut être adapté sans difficulté au contexte d'autres établissements.

Active Margins, Plexitis, and Granulomas Increase Postoperative Crohn's Recurrence: Systematic Review and Meta-analysis.

BACKGROUND & AIMS: Rates of postoperative Crohn's disease recurrence remain high, although the ability to predict this risk of recurrence remains limited. As such, we aimed to determine the association of histologic features at the time of resection with postoperative recurrence. METHODS: Electronic databases were searched through February 2020 for studies that reported risk of clinical, endoscopic, or surgical postoperative recurrence in patients with positive resection margins, plexitis, or granulomas in the index specimen. Pooled risk ratios (RRs) with 95% CIs were calculated for this risk in patients with and without these histologic features. RESULTS: Twenty-one studies (2481 patients) assessed positive resection margins, 10 studies (808 patients) assessed plexitis, and 19 studies (1777 patients) assessed granulomas. Positive resection margins increased the risk of clinical (RR, 1.26; 95% CI, 1.06-1.49; I2 = 41%) and surgical (RR, 1.87; 95% CI, 1.14-3.08; I2 = 71%) recurrence, with a trend toward endoscopic recurrence (RR, 1.56; 95% CI, 0.79-3.05; I2 = 85%). Granulomas increased the risk of clinical (RR, 1.31; 95% CI, 1.05-1.64; I2 = 36%) and endoscopic (RR, 1.37; 95% CI, 1.00-1.87; I2 = 49%) recurrence, with a trend toward surgical recurrence (RR, 1.58; 95% CI, 0.89-2.80; I2 = 75%). Plexitis increased the risk of endoscopic recurrence (RR, 1.31; 95% CI, 1.00-1.72; I2 = 20%), with a trend toward clinical recurrence (RR, 1.34; 95% CI, 0.95-1.91; I2 = 46%). CONCLUSIONS: Positive resection margins, granulomas, and plexitis are predictive of postoperative Crohn's disease recurrence and should be recorded at the time of index resection.

Safety Lapses Prior to Initiation of Hemodialysis for Acute Kidney Injury in Hospitalized Patients: A Patient Safety Initiative.

Background: Safety lapses in hospitalized patients with acute kidney injury (AKI) may lead to hemodialysis (HD) being required before renal recovery might have otherwise occurred. We sought to identify safety lapses that, if prevented, could reduce the need for unnecessary HD after AKI; Methods: We conducted a retrospective observational study that included consecutive patients treated with HD for AKI at a large, tertiary academic center between 1 September 2015 and 31 August 2016. Exposures of interest were pre-specified iatrogenic processes that could contribute to the need for HD after AKI, such as nephrotoxic medication or potassium supplement administration. Other outcomes included time from AKI diagnosis to initial management steps, including Nephrology referral; Results: After screening 344 charts, 80 patients were included for full chart review, and 264 were excluded because they required HD within 72 h of admission, were deemed to have progression to end-stage kidney disease (ESKD), or required other renal replacement therapy (RRT) modalities in critical care settings such as continuous renal replacement therapy (CRRT) or sustained low efficiency dialysis (SLED). Multiple safety lapses were identified. Sixteen patients (20%) received an angiotensin converting enzyme inhibitor or angiotensin receptor blocker after AKI onset. Of 35 patients with an eventual diagnosis of pre-renal AKI due to hypovolemia, only 29 (83%) received a fluid bolus within 24 h. For 28 patients with hyperkalemia as an indication for starting HD, six (21%) had received a medication associated with hyperkalemia and 13 (46%) did not have a low potassium diet ordered. Nephrology consultation occurred after a median (IQR) time after AKI onset of 3.0 (1.0⁻5.7) days; Conclusions: Although the majority of patients had multiple indications for the initiation of HD for AKI, we identified many safety lapses related to the diagnosis and management of patients with AKI. We cannot conclude that HD initiation was avoidable, but, improving safety lapses may delay the need for HD initiation, thereby allowing more time for renal recovery. Thus, development of automated processes not only to identify AKI at an early stage but also to guide appropriate AKI management may improve renal recovery rates.

Interventions to prevent hemodynamic instability during renal replacement therapy in critically ill patients: a systematic review.

BACKGROUND: Hemodynamic instability related to renal replacement therapy (HIRRT) may increase the risk of death and limit renal recovery. Studies in end-stage renal disease populations on maintenance hemodialysis suggest that some renal replacement therapy (RRT)-related interventions (e.g., cool dialysate) may reduce the occurrence of HIRRT, but less is known about interventions to prevent HIRRT in critically ill patients receiving RRT for acute kidney injury (AKI). We sought to evaluate the effectiveness of RRT-related interventions for reducing HIRRT in such patients across RRT modalities. METHODS: A systematic review of publications was undertaken using MEDLINE, MEDLINE in Process, EMBASE, and Cochrane's Central Registry for Randomized Controlled Trials (RCTs). Studies that assessed any intervention's effect on HIRRT (the primary outcome) in critically ill patients with AKI were included. HIRRT was variably defined according to each study's definition. Two reviewers independently screened abstracts, identified articles for inclusion, extracted data, and evaluated study quality using validated assessment tools. RESULTS: Five RCTs and four observational studies were included (n = 9; 623 patients in total). Studies were small, and the quality was mostly low. Interventions included dialysate sodium modeling (n = 3), ultrafiltration profiling (n = 2), blood volume (n = 2) and temperature control (n = 3), duration of RRT (n = 1), and slow blood flow rate at initiation (n = 1). Some studies applied more than one strategy simultaneously (n = 5). Interventions shown to reduce HIRRT from three studies (two RCTs and one observational study) included higher dialysate sodium concentration, lower dialysate temperature, variable ultrafiltration rates, or a combination of strategies. Interventions not found to have an effect included blood volume and temperature control, extended duration of intermittent RRT, and slower blood flow rates during continuous RRT initiation. How HIRRT was defined and its frequency of occurrence varied widely across studies, including those involving the same RRT modality. Pooled analysis was not possible due to study heterogeneity. CONCLUSIONS: Small clinical studies suggest that higher dialysate sodium, lower temperature, individualized ultrafiltration rates, or a combination of these strategies may reduce the risk of HIRRT. Overall, for all RRT modalities, there is a paucity of high-quality data regarding interventions to reduce the occurrence of HIRRT in critically ill patients.