Differential Burden of HIV Among Adolescent Girls and Young Women by Places Associated With Sex Work: An Observational Study in Mombasa, Kenya.

BACKGROUND: The design of HIV prevention programs for adolescent girls and young women (AGYW) are informed by data on who is at highest risk and where they can be reached. Places (hotspots) associated with selling sex are an established outreach strategy for sex work (SW) programs but could be used to reach other AGYW at high risk. SETTING: This study took place in Mombasa, Kenya. METHODS: We conducted a cross-sectional, bio-behavioural survey among (N = 1193) sexually active AGYW aged 14-24 years recruited at hotspots. We compared HIV prevalence by subgroup (SW; transactional sex, TS; and non-transactional sex), stratified by hotspot type (venues and nonvenues). We examined whether associations between HIV prevalence and hotspot/subgroup remained after adjustment for individual-level risk factors, and estimated HIV prevalence ratio with and without adjustment for these individual-level factors. RESULTS: Overall HIV prevalence was 5.6%, 5.3% in venues and 7.3% in nonvenues. Overall SW HIV prevalence was 2-fold higher than among participants engaged in nontransactional sex. After adjusting for age and individual-level risk factors, HIV prevalence was 2.72 times higher among venue-based SWs (95% confidence interval: 1.56 to 4.85) and 2.11 times higher among nonvenue AGYW not engaged in SW (95% confidence interval: 0.97 to 4.30) compared with venue-based AGYW not engaged in SW. CONCLUSION: AGYW who sell sex remain at high risk of HIV across types of hotspots. The residual pattern of elevated HIV burden by AGWY subgroup and hotspot type suggests that unmeasured, network-level factors underscore differential risks. As such, hotspots constitute a "place" to reach AGYW at high risk of HIV.

Awareness and Utilization of HIV Testing and Prevention Services Among Female Sex Workers in Dnipro, Ukraine: Implications for Prevention Program Strengthening From the Dynamics Study.

Introduction: Approximately 240,000 people live with HIV in Ukraine, concentrated among key populations, including sex workers. Non-governmental organizations (NGOs) play an important role in the funding and delivery of HIV testing and prevention services in Ukraine. These services are set within the context of national healthcare reforms as well as ongoing armed conflict. This study seeks to describe and understand the usage of HIV testing and prevention services among sex workers in the eastern Ukrainian city of Dnipro. Methods: A cross-sectional bio-behavioral survey was administered in September 2017-March 2018 among 560 sex workers working in Dnipro. Descriptive analyses of survey data are presented alongside multivariable logistic regression models identifying factors associated with NGO awareness and HIV testing in the past 12 months; adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) are reported. Results: Sixty-two percent of respondents were aware of NGOs offering HIV services. Sixty-eight percent had tested for HIV in the past 12 months, and 51% of those who reported the location of their most recent test were tested at an NGO. Those with 5-9 years in sex work had greater odds of being aware of NGOs (AOR = 5.5, 95%CI: 3.2-9.7) and testing for HIV (AOR = 3.4, 95%CI: 2.0-6.0) compared to those new to the profession. Contact with outreach workers was strongly associated with increased odds of testing (AOR = 13.0, 95%CI: 7.0-24.0). Sex workers in "offices" (brothel-like venues) reported higher odds of testing than all other workplaces, while those in entertainment venues (AOR = 0.3, 95%CI: 0.2-0.5) and public places (AOR = 0.2, 95%CI: 0.1-0.3) reported lower rates. Receiving prevention services, such as free condoms, was associated with increased testing (AOR = 16.9, 95%CI: 9.7-29.3). Discussion: NGOs in Dnipro, Ukraine play an important role in HIV testing and prevention for women involved in sex work. However, focused efforts should be placed on supporting access to these services for women that are newer to sex work, and those working in entertainment venues or public places. Outreach workers appear to support access to HIV prevention information and supplies and facilitate linkages to HIV testing for sex workers.

Pregnancy and Live Birth Rates Over Time in Women With Inflammatory Bowel Disease: A Population-Based Cohort Study.

Background: Inflammatory bowel disease (IBD) negatively affects fertility and fecundity. We aimed to determine longitudinal trends in and factors that affect pregnancy rates in women with ulcerative colitis (UC) and Crohn's disease (CD). Methods: Women in the University of Manitoba IBD Epidemiology Database aged 15 to 45 were identified between 1992 and 2018 and matched up to 10 non-IBD controls. Pregnancy and live birth rates were compared between women with and without UC or CD stratified by time-period, disease duration and maternal age at conception. Incidence rate ratios (IRR) with 95% confidence intervals (CI) were calculated. Poisson regression was used to adjust these rates for year of pregnancy, disease duration, maternal age, severity of IBD, and prior IBD-related surgery. Results: Compared to controls, women with UC had lower rates of pregnancies (IRR 0.91, 95% CI: 0.82-0.99) and women with CD had lower rates of pregnancies (IRR 0.85, 95% CI: 0.79-0.93) and live births (IRR 0.83, 95% CI: 0.75-0.92). Although rates of pregnancies and live births were significantly lower in women with UC and CD compared to controls prior to 2010, there appeared to be no differences between the two groups after 2010. Prior intestinal surgery and active disease at conception appeared to lower pregnancy rates in women with UC and CD, respectively. Conclusion: This study demonstrates that women with IBD have lower pregnancy rates compared to those without IBD, though these differences are no longer evident after 2010. Factors that continue to reduce these rates include prior colectomy and underlying disease activity.

Earlier Anti-TNF Initiation Leads to Long-term Lower Health Care Utilization in Crohn's Disease but Not in Ulcerative Colitis.

BACKGROUND & AIMS: The timing of initiating biologic therapy in persons with Crohn's disease (CD) and ulcerative colitis (UC) is an area of ongoing controversy. In particular, there is concern that delaying the initiation of biologic therapy may lead to more treatment-resistant disease, which can result in more complications and hospitalizations. METHODS: We used health administrative data from Manitoba, Canada to identify all persons with a new diagnosis of inflammatory bowel disease (IBD) between 2001 and 2018 who received tumor necrosis factor antagonists (anti-TNF) therapy and had at least 1 year of post anti-TNF initiation follow-up. We measured the rates of hospitalization, surgery, and outpatient visits, prior to and for up to 5 years following anti-TNF initiation. We compared the rates of these health care utilization outcomes between persons receiving anti-TNFs within 2 years following diagnosis and those receiving anti-TNFs more than 2 years following IBD diagnosis. We used inverse probability treatment weighting to adjust for baseline differences in risk between the 2 groups. RESULTS: Among 742 persons with CD, early anti-TNF initiators had fewer IBD-specific and overall hospitalizations over the 5 years following the start of therapy. Incidence of resective surgery was also lower in earlier anti-TNF initiators with CD if the first year following initiation was excluded from the analysis. In 318 cases of UC, there was no impact of the timing of anti-TNF therapy on the rates of hospitalization and surgery. CONCLUSIONS: Earlier administration of anti-TNF therapy is associated with reduced downstream health care resource utilization in CD, though these impacts are not evident in UC.

Trends in Corticosteroid Use During the Era of Biologic Therapy: A Population-Based Analysis.

INTRODUCTION: Corticosteroids are effective for inducing clinical remission in inflammatory bowel disease (IBD), but not for maintaining remission. Reducing corticosteroid use and dependence is an important treatment goal since their use is associated with adverse events. The extent to which the improvements in IBD therapy have led to less corticosteroid use in the modern era remains unclear. METHODS: We used the University of Manitoba Inflammatory Bowel Disease Epidemiologic Database to assess the cumulative annual dosing of corticosteroids on a per-patient basis for all persons with IBD in the province of Manitoba between 1997 and 2017. Joinpoint analysis was used to assess for trends in corticosteroid use and to look at variation in the trends over time. RESULTS: The mean annual exposure to corticosteroids decreased from 419 mg/yr (1997) to 169 mg/yr (2017) for Crohn's disease (CD) (annual decline: 3.8% per year, 95% confidence interval 3.1-4.6) and from 380 to 240 mg/yr in ulcerative colitis (UC) (annual decline: 2.5% per year, 95% confidence interval 2.1-2.8). In CD, there was an acceleration in the rate of decline after 2007 (pre-2007, 1.9% decline per year; after 2007, 5.7% per year); there was no corresponding acceleration in the rate of decline in UC. DISCUSSION: Corticosteroid use has decreased in both CD and UC over the past 2 decades, becoming more pronounced after 2007 in CD. Potential explanations include introduction and increasing penetrance of biologic therapy in CD and greater awareness of corticosteroid-related adverse events in IBD. Further work is required understand the drivers of persistent corticosteroid use in IBD and how this can be further reduced.

Anxiety and Depression Leads to Anti-Tumor Necrosis Factor Discontinuation in Inflammatory Bowel Disease.

BACKGROUND & AIMS: Anxiety and mood disorders (AMDs) are common among persons with inflammatory bowel diseases (IBD) and are associated with increased health care use and lower quality of life. We assessed the effects of AMDs on persistence on anti-tumor necrosis factor (anti-TNF) therapy in patients with IBD, and risk of IBD-related adverse outcomes after therapy initiation. METHODS: We identified all persons with IBD in Manitoba, Canada who were dispensed an anti-TNF agent from 2001 through 2016 and then identified those with a validated administrative definition of AMD in the 2 years before initiation of therapy. Survival analysis was used to assess the association between active AMDs and anti-TNF discontinuation and the first occurrence of an IBD-related adverse outcome (defined as IBD-related hospitalization or surgery, new or recurrent corticosteroid use, switching to an alternative anti-TNF, or death). We used Cox proportional hazards multivariable regression models to adjust for demographic and clinical factors associated with outcomes. RESULTS: We identified 1135 persons with IBD who began anti-TNF therapy; 178 of these patients (15.7%) met the diagnostic criteria for an AMD. AMDs significantly increased risk of discontinuation of anti-TNF therapy (adjusted hazard ratio, 1.28; 95% CI, 1.03-1.59) and discontinuation in the 1 year following anti-TNF initiation (hazard ratio, 1.50; 95% CI, 1.15-1.94). There was no association between AMDs and subsequent risk of IBD-related adverse events. CONCLUSIONS: Patients with IBD and an AMD within 2 years before starting anti-TNF therapy are at increased risk of discontinuing therapy, compared to patients with IBD without AMD. Studies are needed to determine if treatment of AMDs increases compliance with treatment.

Combined Biologic and Immunomodulatory Therapy is Superior to Monotherapy for Decreasing the Risk of Inflammatory Bowel Disease-Related Complications.

BACKGROUND AND AIMS: The combination of infliximab and azathioprine is more efficacious than either therapy alone for Crohn's disease [CD] and ulcerative colitis [UC]. However, it is uncertain whether these benefits extend to real-world clinical practice and to other combinations of biologics and immunomodulators. METHODS: We collected health administrative data from four Canadian provinces representing 78 413 patients with inflammatory bowel disease [IBD] of whom 11 244 were prescribed anti-tumour necrosis factor [anti-TNF] agents. The outcome of interest was the first occurrence of treatment failure: an unplanned IBD-related hospitalization, IBD-related resective surgery, new/recurrent corticosteroid use or anti-TNF switch. Multivariable Cox proportional hazards modelling was used to assess the association between the outcome of interest and receiving combination therapy vs anti-TNF monotherapy. Multivariable regression models were used to assess the impact of choice of immunomodulator or biologic on reaching the composite outcome, and random effects generic inverse variance meta-analysis of deterministically linked data was used to pool the results from the four provinces to obtain aggregate estimates of effect. RESULTS: In comparison with anti-TNF monotherapy, combination therapy was associated with a significant decrease in treatment ineffectiveness for both CD and UC (CD: adjusted hazard ratio [aHR] 0.77, 95% confidence interval [CI] 0.66-0.90; UC: aHR 0.72, 95% CI 0.62-0.84). Combination therapy was equally effective for adalimumab and infliximab in CD. In UC azathioprine was superior to methotrexate as the immunomodulatory agent (aHR = 1.52 [95% CI 1.02-2.28]) but not CD (aHR = 1.22 [95% CI 0.96-1.54]). CONCLUSION: In an analysis of a database of real-world patients with IBD, combination therapy decreased the likelihood of treatment failure in both CD and UC.

Longitudinal Trends in the Direct Costs and Health Care Utilization Ascribable to Inflammatory Bowel Disease in the Biologic Era: Results From a Canadian Population-Based Analysis.

OBJECTIVES: The prevalence of inflammatory bowel disease (IBD) is increasing. The total direct costs of IBD have not been assessed on a population-wide level in the era of biologic therapy. DESIGN: We identified all persons with IBD in Manitoba between 2005 and 2015, with each matched to 10 controls on age, sex, and area of residence. We enumerated all hospitalizations, outpatient visits and prescription medications including biologics, and their associated direct costs. Total and per capita annual IBD-attributable costs and health care utilization (HCU) were determined by taking the difference between the costs/HCU accrued by an IBD case and their controls. Generalized linear modeling was used to evaluate trends in direct costs and Poisson regression for trends in HCU. RESULTS: The number of people with IBD in Manitoba increased from 6,323 to 7,603 between 2005 and 2015. The total per capita annual costs attributable to IBD rose from $3,354 in 2005 to $7,801 in 2015, primarily driven by an increase in per capita annual anti-tumor necrosis factor costs, which rose from $181 in 2005 to $5,270 in 2015. There was a significant decline in inpatient costs for CD ($99 ± 25/yr. P < 0.0001), but not for ulcerative colitis ($8 increase ±$18/yr, P = 0.63). DISCUSSION: The direct health care costs attributable to IBD have more than doubled over the 10 years between 2005 and 2015, driven mostly by increasing expenditures on biological medications. IBD-attributable hospitalization costs have declined modestly over time for persons with CD, although no change was seen for patients with ulcerative colitis.

Trends of Utilization of Tumor Necrosis Factor Antagonists in Children With Inflammatory Bowel Disease: A Canadian Population-Based Study.

BACKGROUND: Population-based studies examining the prevalence of anti-tumor necrosis factor (anti-TNF) antagonist utilization in children and young adults with inflammatory bowel disease (IBD) are lacking. We aimed to describe the trend of anti-TNF utilization in pediatric IBD over time. METHODS: Survival analyses were performed for all patients diagnosed with IBD before age 18 years in the province of Manitoba to determine the time from diagnosis to first anti-TNF prescription in different time eras (2005-2008, 2008-2012, 2012-2016). RESULTS: There were 291 persons diagnosed with IBD (157 with Crohn's disease [CD] and 134 with ulcerative colitis [UC]) over the study period. The likelihood of being initiated on an anti-TNF by 1, 2, and 5 years postdiagnosis was 18.4%, 30.5%, and 42.6%, respectively. The proportion of persons aged <18 years utilizing anti-TNFs rose over time; in 2010, 13.0% of CD and 4.9% of UC; by 2016, 60.0% of CD and 25.5% of UC. For those diagnosed after 2012, 42.5% of CD and 28.4% of UC patients had been prescribed an anti-TNF antagonist within 12 months of IBD diagnosis. Initiating an anti-TNF without prior exposure to an immunosuppressive agent increased over time (before 2008: 0%; 2008-2012: 18.2%; 2012-2016: 42.8%; P < 0.001). There was a significant reduction in median cumulative dose of corticosteroids (CS) in the year before anti-TNF initiation (2005-2008: 4360 mg; 2008-2012: 2010 mg; 2012-2016: 1395 mg prednisone equivalents; P < 0.001). CONCLUSIONS: Over a period of 11 years, anti-TNFs are being used earlier in the course of pediatric IBD, with a parallel reduction in the cumulative CS dose.

The Effect of Initiation of Anti-TNF Therapy on the Subsequent Direct Health Care Costs of Inflammatory Bowel Disease.

BACKGROUND: Anti-tumor necrosis factor (anti-TNF) drugs are highly effective in the treatment of moderate-to-severe Crohn's disease (CD) and ulcerative colitis (UC), but they are very costly. Due to their effectiveness, they could potentially reduce future health care spending on other medical therapies, hospitalization, and surgery. The impact of downstream costs has not previously been quantified in a real-world population-based setting. METHODS: We used the University of Manitoba IBD Database to identify all persons in a Canadian province with CD or UC who received anti-TNF therapy between 2004 and 2016. All inpatient, outpatient, and drug costs were enumerated both in the year before anti-TNF initiation and for up to 5 years after anti-TNF initiation. Costs before and after anti-TNF initiation were compared, and multivariate linear regression analyses were performed to look for predictors of higher costs after anti-TNF initiation. RESULTS: A total of 928 people with IBD (676 CD, 252 UC) were included for analyses. The median cost of health care in the year before anti-TNF therapy was $4698 for CD vs $6364 for UC. The median cost rose to $39,749 and $49,327, respectively, in the year after anti-TNF initiation, and to $210,956 and $245,260 in the 5 years after initiation for continuous anti-TNF users. Inpatient and outpatient costs decreased in the year after anti-TNF initiation by 12% and 7%, respectively, when excluding the cost of anti-TNFs. CONCLUSIONS: Direct health care expenditures markedly increase after anti-TNF initiation and continue to stay elevated over pre-initiation costs for up to 5 years, with only small reductions in the direct costs of non-drug-related health care.

Upfront Combination Therapy, Compared With Monotherapy, for Patients Not Previously Treated With a Biologic Agent Associates With Reduced Risk of Inflammatory Bowel Disease-related Complications in a Population-based Cohort Study.

BACKGROUND & AIMS: Although guidelines recommend inclusion of immune modulators in anti-tumor necrosis factor (TNF) initiation therapy for Crohn's disease (CD) or ulcerative colitis (UC), there are limited data on the incremental effectiveness of this treatment strategy from the real world. METHODS: We collected data from the Manitoba Inflammatory Bowel Disease (IBD) Epidemiology database on persons with CD (n=852) or UC (n=303), from 2001 through 2016, who began treatment with a TNF antagonist. New and/or continuing users of immunomodulators at the time anti-TNF therapy began were considered recipients of combination therapy. The main outcome was treatment ineffectiveness (IBD-related hospitalization, intestinal resection, corticosteroid use, or change of anti-TNF agent) during TNF antagonist-based therapy or within 90 days after the anti-TNF agent was discontinued. We used Cox proportional hazards models to assess the association between concomitant use of immunomodulators and treatment ineffectiveness. RESULTS: In patients with CD, combination therapy was associated with a significant decrease in likelihood of treatment ineffectiveness (adjusted hazard ratio [aHR] for ineffectiveness, 0.62; 95% CI, 0.49-0.79). However, this association was not significant in patients with UC (aHR, 0.82; 95% CI, 0.56-1.20). In patients with CD, combination therapy was also associated with increased time to first IBD-related hospitalization (aHR 0.53; 95% CI, 0.36-0.80) and switching anti-TNF agents (aHR, 0.63; 95% CI, 0.41-0.97), but not associated with IBD-related surgery (aHR, 0.76; 95% CI, 0.51-1.12) or new or recurrent use of corticosteroids (aHR, 0.75; 95% CI, 0.55-1.04). CONCLUSION: In an analysis of a database of real-world patients with IBD, we associated initiation therapy with a combination immune modulators and anti-TNF agents with a decreased likelihood of treatment ineffectiveness for patients with CD but not UC.

Temporal Trends in Initiation of Therapy With Tumor Necrosis Factor Antagonists for Patients With Inflammatory Bowel Disease: A Population-based Analysis.

BACKGROUND & AIMS: Anti-tumor necrosis factor (anti-TNF) agents are effective treatments for Crohn's disease (CD) and ulcerative colitis (UC). We aimed to determine their patterns of use and changes in these patterns over time, as well as use of immunomodulators and corticosteroids before anti-TNF therapy for persons with inflammatory bowel diseases. METHODS: We used the University of Manitoba IBD Epidemiology Database to identify all anti-TNF users with CD and UC from 2001 through 2014. We assessed changes in the prevalence and incidence of anti-TNF use during different time periods (April 2001-March 2005, April 2005-March 2009, or April 2009-March 2013). We also characterized patterns of corticosteroid use, corticosteroid dependence, and immunomodulator use before anti-TNF administration and determined how these changed over time. The primary end point was change in time to first receipt of anti-TNF among the different time periods. RESULTS: We identified 950 persons (761 with CD and 189 with UC) who received anti-TNF agents. The cumulative prevalence of persons with current or prior anti-TNF exposure in 2014 was 20.4% for CD and 6.0% for UC. In 2014 the cumulative incidence values of anti-TNF exposure within 5 years of diagnosis were 23.4% for patients with CD and 7.8% for patients with UC. Most users of anti-TNF agents had evidence of corticosteroid dependence (more than 2 g prednisone within any 12-month period) before initiation of anti-TNF therapy. Cumulative corticosteroid exposure before anti-TNF use decreased over time for patients with UC, but not significantly for patients with CD. There was no increase over time in the use of concomitant immunomodulators with anti-TNF therapy. CONCLUSIONS: Use of anti-TNF agents increased from 2001 through 2014, with a concomitant significant decrease in cumulative use of corticosteroids before anti-TNF therapy for patients with UC. However, there has been no reduction in cumulative use of corticosteroids before anti-TNF therapy for patients with CD and no change in use of immunomodulators by patients with CD. These findings indicate a continuing need for optimization of anti-TNF therapy for patients with inflammatory bowel disease.

Factors Associated with Discontinuation of Anti-TNF Inhibitors Among Persons with IBD: A Population-Based Analysis.

INTRODUCTION: Antitumor necrosis factor (anti-TNF) medications are known to be highly efficacious in persons with moderate-to-severe inflammatory bowel disease (IBD). There is a paucity of data from population-based sources to elucidate persistence with these medications in the general population of IBD. Discontinuation of anti-TNF therapy is a marker of lack of effectiveness, intolerance, and patient/physician practice preferences. METHODS: We identified all persons with IBD in Manitoba who were dispensed infliximab (IFX) and adalimumab (ADA) between 2001 and 2014. Subjects were followed longitudinally to assess rates of completion of anti-TNF induction, duration of continued use, intraclass substitution, and dose adjustments. Cox proportional hazards models were used to test demographic and clinical factors associated with anti-TNF therapy discontinuation. RESULTS: Overall, 925 of 8651 persons (10.7%) with IBD were prescribed an anti-TNF drug (705 Crohn's disease: 523 IFX and 182 ADA; 220 ulcerative colitis: 214 IFX and 6 ADA). Approximately four-fifths of persons starting on anti-TNF therapy completed induction. At 1 and 5 years, persistence rates with the original anti-TNF were approximately 60% and 40%, respectively. Immunomodulator use at the time of anti-TNF dispensation was associated with a decreased likelihood of anti-TNF discontinuation in both Crohn's disease and ulcerative colitis. ADA users with Crohn's disease who reached maintenance phase had a higher risk of discontinuation than IFX users (hazard ratio 1.64, 95% confidence interval 1.15-2.37). CONCLUSIONS: Approximately two-fifths of anti-TNF users discontinue use within 1 year of initiation, and three-fifths will have discontinued at 5 years. Concomitant IM therapy has a modest effect on discontinuation rates.

Differences in the burden of psychiatric comorbidity in MS vs the general population.

OBJECTIVE: We aimed to compare the incidence and prevalence of psychiatric comorbidity in the multiple sclerosis (MS) population and in controls matched for age, sex, and geographic area. METHODS: Using population-based administrative health data from 4 Canadian provinces, we identified 2 cohorts: 44,452 persons with MS and 220,849 controls matched for age, sex, and geographic area. We applied validated case definitions to estimate the incidence and prevalence of depression, anxiety, bipolar disorder, and schizophrenia from 1995 to 2005. We pooled the results across provinces using meta-analyses. RESULTS: Of the MS cases, 31,757 (71.3%) were women with a mean (SD) age at the index date of 43.8 (13.7) years. In 2005, the annual incidence of depression per 100,000 persons with MS was 979 while the incidence of anxiety was 638, of bipolar disorder was 328, and of schizophrenia was 60. The incidence and prevalence estimates of all conditions were higher in the MS population than in the matched population. Although the incidence of depression was higher among women than men in both populations, the disparity in the incidence rates between the sexes was lower in the MS population (incidence rate ratio 1.26; 95% confidence interval: 1.07-1.49) than in the matched population (incidence rate ratio 1.50; 95% confidence interval: 1.21-1.86). Incidence rates were stable over time while prevalence increased slightly. CONCLUSIONS: Psychiatric comorbidity is common in MS, and more frequently affected the MS population than a matched population, although the incidence was stable over time. Men with MS face a disproportionately greater relative burden of depression when they develop MS than women.

Comorbidity increases the risk of hospitalizations in multiple sclerosis.

OBJECTIVE: We aimed to evaluate the association between comorbidity and rates of hospitalization in the multiple sclerosis (MS) population as compared to a matched cohort from the general population. METHODS: Using population-based administrative data from the Canadian province of Manitoba, we identified 4,875 persons with MS and a matched general population cohort of 24,533 persons. We identified all acute care hospitalizations in the period 2007-2011. Using general linear models, we evaluated the association between comorbidity status and hospitalization rates (all-cause, non-MS-related, MS-related) in the 2 populations, adjusting for age, sex, and socioeconomic status. RESULTS: Comorbidity was common in both cohorts. Over the 5-year study period, the MS population had a 1.5-fold higher hospitalization rate (adjusted rate ratio [aRR] 1.56; 95% confidence interval [CI] 1.44-1.68) than the matched population. Any comorbidity was associated with a 2-fold increased risk of non-MS-related hospitalization rates (aRR 2.21; 95% CI 1.73-2.82) in the MS population, but a nearly 4-fold increase in hospitalization rates in the matched population (aRR 3.85; 95% CI 3.40-4.35). Comorbidity was not associated with rates of hospitalization for MS-related reasons, regardless of how comorbidity status was defined. CONCLUSIONS: In the MS population, comorbidity is associated with an increased risk of all-cause hospitalizations, suggesting that the prevention and management of comorbidity may reduce hospitalizations.

Dramatically changing rates and reasons for hospitalization in multiple sclerosis.

OBJECTIVE: We aimed to describe hospitalizations in the multiple sclerosis (MS) population, and to evaluate temporal trends in hospitalizations in the MS population compared to the general population. METHODS: Using population-based administrative data, we identified 5,797 persons with MS and a matched general population cohort of 28,769 persons. Using general linear models, we evaluated temporal trends in hospitalization rates and length of stay in the 2 populations over the period 1984-2011. RESULTS: In 1984 the hospitalization rate was 35 per 100 person-years in the MS population and 10.5 in the matched population (relative risk [RR] 3.33; 95% confidence interval: 1.67-6.64). Over the study period hospitalizations declined 75% in the MS population but only 41% in the matched population. The proportion of hospitalizations due to MS declined substantially from 43.4% in 1984 to 7.8% in 2011. The 3 most common non-MS-related reasons for admission in the MS population were diseases of the digestive, genitourinary, and circulatory systems. Admissions for bacterial pneumonia, influenza, urinary tract infections, and pressure ulcers occurred more often in the MS population than in the general population, while admissions for circulatory system disease and neoplasms occurred less often. Older age, male sex, and lower socioeconomic status were associated with increased hospitalization rates for non-MS-related reasons. CONCLUSIONS: Although hospitalization rates have declined dramatically in the MS population over the last quarter century, they remain higher than in the general population. Admissions for MS-related reasons now constitute only a small proportion of the reasons for hospitalization.