Abstract
Background
Low socioeconomic status has been linked with numerous poor health outcomes, but data are limited regarding the impact of insurance status on inflammatory bowel disease (IBD) outcomes. We aimed to characterize utilization of healthcare resources by IBD patients based on health insurance status, using Medicaid enrollment as a proxy for low socioeconomic status.
Methods
We retrospectively identified adult patients with IBD engaged in a colorectal cancer surveillance colonoscopy program from July 2007 to June 2017. Our primary outcomes included emergency department (ED) visits, inpatient hospitalizations, biologic infusions, and steroid exposure, stratified by insurance status. We compared patients who had ever been enrolled in Medicaid with all other patients.
Results
Of 947 patients with IBD, 221 (23%) had been enrolled in Medicaid. Compared with patients with other insurance types, patients with Medicaid had higher rates of ever being admitted to the hospital (77.6% vs 42.6%, P < 0.0001) or visiting the ED (90.5% vs 38.4%, P < 0.0001). When adjusted for sex, age at first colonoscopy, and ethnicity, patients with Medicaid had a higher rate of inpatient hospitalizations (Rate ratio [RR] 2.95; 95% CI 2.59–3.36) and ED visits (RR 4.24; 95% CI 3.82–4.70) compared to patients with other insurance. Patients with Medicaid had significantly higher prevalence of requiring steroids (62.4% vs 37.7%, P < 0.0001), and after adjusting for the same factors, the odds of requiring steroids in the patients with Medicaid was increased (OR 3.77; 95% CI 2.53–5.62).
Conclusions
Medicaid insurance was a significant predictor of IBD care and outcomes. Patients with Medicaid may have less engagement in IBD care and seek emergency care more often.
Keywords: inflammatory bowel disease, healthcare services research, healthcare utilization, socioeconomic status
Low socioeconomic status has been linked with numerous poor health outcomes, but this association has not been studied in inflammatory bowel disease (IBD). In this study, Medicaid insurance was a significant predictor of IBD care and poor outcomes.
INTRODUCTION
Inflammatory bowel diseases (IBD), comprising Crohn’s disease (CD) and ulcerative colitis (UC), are chronic and progressive inflammatory conditions of the gastrointestinal tract, characterized by an overreactive immune response to luminal microbial antigens in genetically susceptible individuals.1, 2 In North America, the annual incidence of IBD is increasing, with CD estimated to be 0–20.2 per 100,000 person-years, and UC estimated to be 37.5–248.6 per 100,000 person-years.3–5 Recent trends in hospital utilization suggest that the burden of IBD among minority populations is increasing.6 With the changing epidemiology of IBD, socioeconomic factors continue to affect significantly the content and delivery of healthcare in IBD.7–9
Direct and indirect costs for the care of IBD patients in the United States is estimated to be over $30 billion a year.10, 11 While Medicaid may help reduce the costs and impact of several social determinants of health, patients with Medicaid remain vulnerable to underinsurance, inconsistent access because of insurance transitions, and high personal healthcare costs, all of which impact engagement in IBD care.9, 12 In a study at our institution, Medicaid insurance was a predictor of suboptimal bowel preparation for colonoscopy, which is the gold standard for diagnosing IBD, and is used to survey IBD patients for colonic dysplasia and colorectal cancer.13
Despite the relationship between Medicaid, healthcare utilization, and poor health outcomes in other disease states, there is a substantial lack of data regarding insurance status and IBD care, with only a few small studies demonstrating conflicting data.6, 8, 14, 15 Given the significant burden of IBD to the healthcare system and the broader relationship between insurance status and health outcomes, we aimed to characterize IBD outcomes and healthcare utilization of various resources by patients with IBD based on health insurance status. We hypothesized that patients with IBD who had ever had Medicaid insurance would have increased healthcare utilization, such as more hospitalizations and emergency department (ED) visits, and worse IBD care outcomes, such as more steroid prescriptions, compared with patients with other insurance coverage.
MATERIALS AND METHODS
Patient Population
We identified all patients aged 18 years or older with IBD based on International Classification of Diseases documentation engaged in a colonoscopy surveillance program who were retrospectively evaluated at New York Presbyterian-Columbia University Medical Center from January 2007 to June 2017. Patients with IBD were considered engaged in a colonoscopy surveillance program if they had 2 or more colonoscopies coded as “surveillance” procedures after more than 8 years of disease. Patients (n = 201) with less than 1 year of follow-up in a surveillance program or whose utilization was considered an extreme outlier (greater than 20 ED visits or hospitalizations) during the follow-up period were excluded.
Variables and Outcomes
We recorded the following variables from the electronic medical record: insurance status, demographics, colonoscopies, ED visits, inpatient hospitalizations, steroid prescriptions, and infliximab or vedolizumab prescriptions. Data on noninfusion parenteral therapy (eg, adalimumab) were not available in our institutional prescribing medical record. “Medicaid insurance” was defined as ever having received Medicaid. All other insurance was defined as ever having received Medicare, or private/commercial insurance, but never having received Medicaid during that period.
Our primary outcomes represented healthcare utilization including ED visits, inpatient hospitalizations, ever requiring a biologic infusion, ever requiring steroids, and high-dose steroid use. Appropriate adherence to a colonoscopy surveillance program was defined as consecutive surveillance colonoscopies </ = 3 years apart as per current American Gastroenterological Association (AGA) screening recommendations.16 For length of hospital stay, if a patient had greater than 1 visit, the duration for the longest hospital visit was selected. “High-dose steroids” were defined as greater than 20 mg of prednisone or other steroid equivalent. “Prolonged steroid course” included steroid prescriptions lasting longer than 90 days. Biologic infusions included infliximab and vedolizumab. Full outpatient prescribing data of subcutaneous administration of biologics, such as adalimumab, certolizumab pegol, or golimumab, were not available in our medical record for analysis.
Statistics
We compared continuous variables using the Student t test and categorical variables using the chi-squared test. Rates were expressed as number of events per person-year. Rates of ED visits and hospitalizations were compared using rate ratios calculated via multivariable Poisson regression. We used multivariable logistic regression to determine predictors of ever requiring a biologic infusion or high-dose steroids. Models included sex, age at first colonoscopy in a surveillance program, ethnicity, and insurance status.
ETHICAL CONSIDERATIONS
This study was approved by the Institutional Review Board of Columbia University Medical Center (Protocol Number AAAN3966).
RESULTS
We identified 947 patients with IBD who were engaged in a colonoscopy surveillance program (see Table 1). The mean age was 48 years; 51.1% were men; 621 (65.5%) were white; and 152 (16.2%) were Hispanic. Of these patients, 221 (23.3%) were covered by Medicaid. The remaining patients were covered by Medicare or private insurance. The median follow-up time was 4.3 years.
TABLE 1.
Characteristics of Patients With IBD in a Colorectal Cancer Surveillance Colonoscopy Program
| Variable | N = 947 |
| Age (years) [mean (SD), median (IQR)] | 48.0 (18.1), 51.0 (30) |
| Male sex [n(%)] | 484 (51.1) |
| Ethnicity [n(%)] | |
| White | 621 (65.6) |
| Black | 55 (5.8) |
| Asian | 19 (2.0) |
| Othera | 34 (3.6) |
| Unknown | 218 (23.0) |
| Hispanic | 152 (16.2) |
| Non-Hispanic | 588 (62.0) |
| Unknown | 207 (21.8) |
| Insurance [n(%)] | |
| Medicaid | 221 (23.3) |
| Medicare | 243 (25.7) |
| Privateb | 483 (51.0) |
| Rate of surveillance colonoscopies (number colonoscopies per person-year) | 0.70 |
| All surveillance colonoscopy intervals are compliant [n(%)]c | 575 (56.6) |
| Rate of ED visits | 0.56 |
| Rate of inpatient hospitalizations (number of inpatient hospitalizations per person-year) | 0.38 |
| Days of hospitalization (days) [mean (SD), median (IQR)] | 4.8 (9.5), 0 (6) |
| Ever requiring any steroids [n(%)]d | 339 (35.8) |
| Intravenous steroids [n(%)] | 254 (26.8) |
| Oral steroids [n(%)] | 235 (24.8) |
| Ever having received a PO steroid dose >20 mg prednisone or equivalent [n(%)]e | 108 (31.9) |
| Ever requiring PO steroid course >90 days [n(%)]f | 93 (9.8) |
| Rate of steroid courses (number of steroid courses per person-year) | 0.35 |
| Ever requiring a biologic infusion [n(%)]f | 206 (21.8) |
| Rate of biologic doses (number of biologic doses per person-year) | 0.039 |
| Follow-up time [mean (SD), median (IQR)] | 4.6 (2.4), 4.3 (2.2) |
a“Other” ethnicity includes American Indian, Pacific Islander, Latin, Middle Eastern, and other.
b“Private” includes all private insurance.
cAll colonoscopy intervals are defined as compliant if all intervals were < = 3 years, based on AGA recommendations.
dEver requiring any steroids, ever requiring intravenous steroids, and ever requiring oral steroids were each calculated out of 947 patients.
eEver requiring PO steroid course >20 mg prednisone or equivalent and ever requiring PO steroid course >90 days were calculated out of the total patients who ever required steroids.
fEver requiring a biologic infusion was calculated out of 947 patients.
Abbreviations: IBD, inflammatory bowel disease.
Overall, the study population underwent 0.7 surveillance colonoscopies per person-year (Table 1). Of these procedures, 575 (56.6%) were done at appropriate screening intervals per AGA recommendations.16 The patients required 0.56 ED visits and 0.38 inpatient hospitalizations per person-year, with a mean hospital stay of 4.8 days. Of these patients, 339 (35.8%) were treated with steroids, with similar numbers requiring a combination of intravenous and oral steroids compared to oral steroids only (245 (26.8%) vs 235 (24.8%), respectively). Of 339 patients who ever required steroids, 108 (31.9%) required oral doses greater than 20 mg prednisone or the equivalent, and 93 (27.4%) required a PO steroid courses lasting more than 90 days, and 206 (21.8%) were treated with a biologic infusion during the study period.
Compared with patients covered by other insurance modalities, patients covered by Medicaid were younger (42.2 vs 49.8 years, P < 0.0001) and included a smaller subset of men (43.9% vs 53.3% P = 0.014; Table 2). While patients covered by other insurance modalities were predominantly white (77%) and non-Hispanic (75.0%), patients covered by Medicaid were 28.0% white and 43.4% Hispanic.
TABLE 2.
Characteristics of Patients With IBD in a Surveillance Colonoscopy Program at a Single Center by Insurance Status
| Variable | Medicaid | All Other Insurance | P Value |
|---|---|---|---|
| Age (years) | 42.2 | 49.8 | <0.0001 |
| Male sex [n (%)] | 97 (43.9) | 387 (53.3) | 0.014 |
| Race [n (%)] | <0.0001 | ||
| White | 62 (28.0) | 559 (77.0) | |
| Black | 29 (13.1) | 26 (3.6) | |
| Asian | 2 (0.9) | 17 (2.3) | |
| Otherb | 22 (10.0) | 12(1.7) | |
| Unknown | 106 (48.0) | 112 (15.4) | |
| Ethnicity [n (%)] | <0.0001 | ||
| Hispanic | 96 (43.4) | 57 (7.9) | |
| Non-Hispanic | 43 (19.5) | 545 (75.0) | |
| Unknown | 82 (37.1) | 124 (17.1) | |
| All surveillance colonoscopy intervals are compliant (n) | 135 (61.1) | 400 (55.1) | 0.12 |
| Ever admitted to the hospital [n (%)] | 172 (77.8) | 309 (42.6) | <0.0001 |
| Ever visited the emergency department [n (%)] | 200 (90.5) | 279 (38.4) | <0.0001 |
| Days of hospitalization (days)c | 9.3 | 3.4 | <0.00001 |
| Ever requiring steroids [n (%)] | 138 (62.4) | 201 (27.7) | <0.0001 |
| Ever requiring intravenous steroids [n (%)] | 102 (46.2) | 152 (20.9) | <0.0001 |
| Ever requiring oral steroids [n (%)] | 96 (43.4) | 139 (19.2) | <0.0001 |
| Ever having received a PO steroid dose >20 mg prednisone or equivalent ([n (%)] | 45 (83.3) | 63 (84.0) | 0.91 |
| Ever requiring PO steroid course >90 days [n (%)] | 50 (55.6) | 43 (33.9) | 0.001 |
| Ever requiring a biologic infusion [n (%)]d | 71(25.9) | 115 (14.1) | <0.0001 |
| Follow-up time (years) | 4.2 | 4.8 | 0.0017 |
a“All other insurance” includes Medicare and private insurance.
b“Other ethnicity” includes American Indian, Pacific Islander, Latin, Middle Eastern, and other.
cAmong patients who are hospitalized.
dBiologic infusion includes infliximab and vedolizumab infusions.
Abbreviations: IBD, inflammatory bowel disease.
Compared with other insurance modalities, patients covered by Medicaid had significantly higher rates of ever being admitted to the hospital (77.6% vs 42.6%, P < 0.0001) or ever visiting the ED (90.5% vs 38.4%, P < 0.0001; Table 2). The mean length of hospitalization was 9.3 days for patients covered by Medicaid, as compared to 3.4 days for patients covered by other insurance modalities (P < 0.0001). For patients with Medicaid, the incidence of ED visits was 2.2 visits per person-year, and the incidence of inpatient hospitalizations was 1.1 hospitalizations per person-year. For patients with other insurance coverage, the incidence of ED visits was 0.4 visits per person-year, and the incidence of inpatient hospitalization was 0.4 hospitalizations per person-year. Patients covered by Medicaid had a 6.6 times higher rate of ED visits (Rate ratio (RR) 6.60, 95% CI 6.07–7.16, P < 0.0001) and 2.86 times higher rate of inpatient hospitalizations (RR 2.86, 95% CI 2.59–3.15, <0.0001) than patients covered by other insurance modalities. When adjusted for sex, age at first colonoscopy encounter, and ethnicity, patients with Medicaid still had a 2.95 times higher rate of inpatient hospitalizations (RR 2.95, 95% CI 2.59–03.36, P < 0.0001; Table 3). When adjusted for the same factors, we also found that patients with Medicaid had a 4.24 times higher rate of ED visits than patients with other insurance modalities (RR 4.24, 95% CI 3.82–4.70, P < 0.0001; Table 3). Black patients had an increased rate of hospitalization (RR 1.50, 95% CI 1.25–1.78, P < 0.0001) and ED visits (RR 1.40, 95% CI 1.21–1.63, P < 0.0001) compared to white patients when adjusting for sex, age at first colonoscopy encounter, ethnicity, and Medicaid insurance. Hispanic patients had a decreased rate of inpatient hospitalization (RR 0.78, 95% CI 0.67–0.91, P < 0.0001) but had an increased rate of ED visits (RR 1.48, 95% CI 1.31–1.68, P < 0.0001) compared to non-Hispanic patients when adjusting for sex, age at first colonoscopy encounter, ethnicity, and Medicaid insurance.
TABLE 3.
Demographic Predictors of Inpatient Hospitalizations and Emergency Department Visits: Multivariableb Poisson Regression
| Characteristic | Inpatient Hospitalizations | Emergency Department Visits | ||
|---|---|---|---|---|
| Rate Ratio | 95% CI | Rate Ratio | 95% CI | |
| Female | 0.76a | 0.69, 0.84 | 0.89a | 0.82, 0.96 |
| Age at first colonoscopy encounter | 1.00 | 0.99, 1.01 | 0.99a | 0.99, 1.0 |
| Ethnicity | ||||
| White | Ref | Ref | Ref | Ref |
| Black | 1.50a | 1.25, 1.78 | 1.40a | 1.21, 1.63 |
| Asian | 1.54a | 1.11, 2.14 | 1.31 | 0.94, 1.81 |
| Other | 1.69a | 1.29, 2.21 | 1.43a | 1.18, 1.75 |
| Unknown | 1.35a | 1.14, 1.60 | 1.56a | 1.38, 1.78 |
| Non-Hispanic | Ref | Ref | Ref | Ref |
| Hispanic | 0.78a | 0.67, 0.91 | 1.48a | 1.31, 1.68 |
| Unknown | 0.72a | 0.62, 0.89 | 1.59a | 1.38, 1.83 |
| Medicaid insurance | 2.95a | 2.59, 3.36 | 4.24a | 3.82, 4.70 |
a P value < 0.05
bAdjusted for all variables in the table
Abbreviations: Ref, reference.
Patients covered by Medicaid had significantly higher rates of requiring any steroids (62.4% vs 37.7%, P < 0.0001), including intravenous steroids (46.2% vs 20.9, P < 0.0001) and oral steroids (43.4% vs 19.2%, P < 0.0001; Table 2). However, there was no significant difference between patients covered by Medicaid versus other insurance modalities with regard to high-dose steroid administration (83.3% vs 84%, P = 0.91). There was a difference in the proportion of patients with Medicaid who required oral steroids for more than 90 days, compared to all others (55.6% vs 33.9%, P < 0.001). Patients covered by Medicaid were also more likely to be given biologic infusions compared to those covered by other insurance (26.2% vs 13.4%, P < 0.0001).
After adjusting for sex, age at first colonoscopy encounter, and ethnicity, there was no significant association between having Medicaid coverage and requiring biologic infusions (OR 1.19; 95% CI 0.73–1.094, P = 0.49). After adjusting for the same factors, the odds of requiring steroids in the Medicaid population was 3.77 times the odds of requiring steroids for patients with other insurances (OR 3.77; 95% 2.53–5.62 P < 0.0001, Table 4). Being black was associated with an increased odds of requiring steroids (OR 2.49, 95% CI 1.32–4.66, P = 0.004), but there was no significant association with requiring biologic infusions (OR1.69, 95% CI 0.82–3.51, P = 0.16) compared with being white when adjusting for sex, age at first colonoscopy encounter, ethnicity, and Medicaid insurance. Hispanic ethnicity was not associated with ever requiring steroids (OR 1.17, 95% CI 0.75–1.85, P = 0.49) or biologic infusion (OR 1.65, 95% CI 0.97, 2.84, P = 0.066) compared with non-Hispanic ethnicity when adjusting for sex, age at first colonoscopy encounter, ethnicity, and Medicaid insurance.
TABLE 4.
Demographic Predictors of Ever Requiring Steroids: Multivariablea Logistic Regression
| Characteristic | Odds Ratio | 95% CI | P value |
|---|---|---|---|
| Female Sex | 0.99 | 0.75, 1.33 | 0.98 |
| Age at first colonoscopy encounter | 0.98 | 0.98, 0.99 | 0.18 |
| Ethnicity | |||
| White | Ref | Ref | Ref |
| Black | 2.49 | 1.32, 4.66 | 0.004 |
| Asian | 0.65 | 0.20, 2.16 | 0.48 |
| Other | 0.86 | 0.38, 1.98 | 0.73 |
| Unknown | 1.10 | 0.65, 1.84 | 0.73 |
| Non-Hispanic | Ref | Ref | Ref |
| Hispanic | 1.17 | 0.75, 1.85 | 0.49 |
| Unknown | 0.70 | 0.40, 1.20 | 0.19 |
| Medicaid insurance | 3.77 | 2.53, 5.62 | <0.0001 |
aAdjusted for all variables in the table
Abbreviations: Ref, reference.
DISCUSSION
In this study of ethnically diverse adult patients with IBD at a major tertiary referral center in New York City, being black, being Hispanic, and having ever been covered by Medicaid insurance were all significant predictors of healthcare utilization and IBD care outcomes. After adjusting for demographics, Medicaid insurance was the strongest predictor of ED visits, hospitalizations, and exposures to steroids. Even though Medicaid is designed to improve healthcare quality and minimize the impact of social determinates of health, these data suggest that patients with IBD who ever required Medicaid may have less engagement in IBD care and seek emergency care more often. Further, ED providers may perceive substantial barriers in this population in accessing maintenance IBD care and therapies, and be more likely to admit for hospitalization and/or prescribe steroids and management strategies with fewer perceived barriers.
In multiple disease states, such as asthma, diabetes, and hypertension, Medicaid has been associated with significantly worse health outcomes, poor engagement in care, and increased utilization of hospital-based care.17–21 Our data are consistent and add to scant existing data on IBD demonstrating that black patients and those with Medicaid insurance more frequently use the ED and are more often exposed to steroids.14, 22 This finding is likely multifactorial and may be due to a combination of reduced availability of treatments, multiple barriers to adherence, and lack of a multicultural, collaborative relationship with healthcare providers. We found that patients with Medicaid had an increased use of biologic infusions, although this finding should be interpreted with caution because we were unable to identify those who were prescribed injectable biologics. Therefore, it is possible that patients with Medicaid had disease activity that was more severe (as reflected by increased use of intravenous biologics) or that they were comparable, but that patients with other insurance were more likely to use noninjectable biologics.
Although individual patient-level characteristics such as disease severity, radiography, endoscopy, and laboratory values were unavailable for review in the present study, a recent systematic review found no major differences in disease location and behavior, upper gastrointestinal tract and perianal involvement, and extraintestinal manifestations, among the patients.23 Further, in the present study ethnicity and insurance status did not predict exposure to high-dose steroids, an indicator of disease that is more severe, suggesting that severity of illness was similar between groups and that our findings are unlikely due to major differences in disease characteristics.
There are several limitations to the current study inherent to a retrospective study design conducted at a single center. Our analyses do not prove a cause-and-effect relationship between insurance status and IBD outcomes. The observed associations could have been due to the presence of factors that contribute to the natural course of IBD, disease exacerbations, and individualized decision-making in management, especially for patients who required hospitalization and steroids. As the study population represented patients with 8 years or more of IBD, this may limit the generalizability of our data to patients with shorter durations of IBD. We were limited in our analysis of outpatient prescribing for commercially insured patients cared for by private physicians. Difficulty with access to biologics could account for some of our results. However, data were not available in our institutional prescribing medical record on noninfusion parenteral therapy (eg, adalimumab), and thus, we are unable to confirm this in our analysis, given lack of data on biologic use. In addition, we had a large number of patients coded as “Other” or “Unknown” for ethnicity. As a single tertiary center in an urban environment, our results may not be generalizable to other settings. In our center, we have a dedicated Medicaid gastroenterology and hepatology clinic, suggesting that these findings are likely independent of ability to access outpatient care. However, we are unable to query the outpatient medical record for patients with insurance other than Medicaid, to compare number of outpatient visits as a proxy for comparing access to outpatient care. Finally, we were unable to capture the data of uninsured patients, who may have substantially worse IBD outcomes compare with patients with Medicaid.
CONCLUSION
To our knowledge, this is one of the largest studies examining the impact of ethnicity and insurance status on IBD care and outcomes. We identified disparities in healthcare resource utilization and IBD medical management in both ethnic minority groups and those with Medicaid insurance.
This study highlights the need to change healthcare models to better serve the growing needs of chronically ill IBD patients. Studies show that improving social support systems for patients and creating chronic care models that include patient and provider-oriented education, care management, and information system changes have had the most success in improving the care of chronically ill patients.24–26 In particular, case management to assist patients in navigating the healthcare system has shown benefits in improving care, and it could be used to address disparities in this IBD population. Future prospective studies are needed to characterize fully these inequalities and develop effective solutions.
ACKNOWLEDGMENTS
Dr. Sharma has been funded by NIH NIDDK T32 Training Grant DK083256-06 where she obtained the research skills necessary to perform this study.
Disclosure of funding: No funding was received specifically for this study.
Sources of support to acknowledge: NIH NIDDK T32 Grant DK083256-06.
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