Data from Stephen Smith - Curated by EPG Health - Last updated 23 October 2018
The resources required for IBD management
IBD is a chronic debilitating condition that often requires substantial healthcare resources such as ongoing assessments, biological treatment, hospitalisation and surgery. While significant advances have been made in the management of IBD, has this had a significant impact on the costs that patients and/or society must bear? A series of presentations and posters at UEG Week 2018 explored resource utilisation, the costs associated with IBD management and whether we can predict who may need additional resources.
What do patients want?
Before exploring the different resources patients with IBD use, perhaps it’s worth considering what they want and the factors that can improve living with a chronic condition. This topic was addressed in a poster by Dr Ignacio Marín-Jiménez of the Hospital Universitario Gregorio Marañón in Madrid, Spain.
Using the IEXPAC (Instrument to Evaluate the eXperience of Patients with Chronic diseases) scale, 341 patients helped identify healthcare factors that offer a better experience. Patients showed a clear preference for being followed-up by the same physician (vs. a different physician, p=0.002), having a follow-up with a nurse (vs. no nurse follow-up; p<0.001) and receiving fewer medicines (p=0.01). Patients also indicated that they preferred receiving subcutaneous/intravenous treatments in a sub-score related to patient-healthcare professional relationship (p=0.018) possibly related to a feeling of more personalised care.
Unsurprisingly, patients with IBD reported wanting a stable partnership with their medical team. While a reasonable request, this may have budgetary and time implications if increased follow-ups are required.
Predicting the need for surgery in IBD
While the management of IBD may come with various associated costs, hospitalisation and surgery place a significant resource burden on healthcare systems. Many patients with IBD will ultimately require surgical treatment for their condition, but the need for surgery and hospitalisation among newly diagnosed patients is largely unknown. In a poster presented by Dr María Chaparro from the Hospital Universitario de La Princesa in Madrid, Spain, the frequency of hospitalisation and surgery among an inception cohort of 3,469 adults with newly diagnosed IBD (50% Crohn’s disease, 45% ulcerative colitis, 5% indeterminate colitis) was assessed.
After a median follow-up of 3 months (range 0–12 months) 149 (4.3%) of patients had undergone 188 surgical interventions. Interestingly, the need for surgery was significantly higher among patients with Crohn’s disease (131 surgeries) than ulcerative colitis (18 surgeries; p<0.01). Within the Crohn’s disease group, those with an inflammatory behaviour had lower rates of surgery than those with strictures or fistula (5.6%, 14% and 32%, respectively, p<0.01) while those with perianal disease were also more likely to require surgery versus those without (34% vs. 5.2%; p=0.01). Meanwhile, 26% of all newly diagnosed patients required hospitalisation within the first three months with 81% of cases occurring at disease diagnosis.
With hospitalisation and surgery placing a significant burden on patients as well as healthcare systems, is it possible to predict which patients may require surgery during the course of their
disease? Dr Sofia Xavier from the Hospital da Senhora da Oliveira in Guimãraes, Portugal presented retrospective data from 43 adult patients with stricturing Crohn’s disease who had at least one prior hospitalisation and a minimum of one year of follow-up.
Of this patient group, 53.5% required surgery for their Crohn’s disease. Surprisingly, a family history of IBD, smoking habits, age at diagnosis and the presence of perianal disease were not significantly associated with a need for surgery. However, female patients required surgery more frequently than male patients (73.9% vs. 30.0%; p=0.004) while patients with stricturing behaviour at diagnosis were more likely to require surgery than those with inflammatory behaviour (65.6% vs. 18.2%; p=0.006).
Other factors associated with an increased need for surgery at first hospitalisation included those in Table 1.
Table 1: Factors associated with an increased need for surgery at first hospitalisation.
Dr Xavier also observed that those patients receiving an anti-TNF treatment before first hospitalisation were significantly less likely to require surgery. So, could anti-TNF treatment reduce
the surgical burden of patients with IBD?
Cost-savings with biologics?
While much discussion around the use of biologics has focussed on the costs, could the improvements in patient outcomes off-set the increased expenditure? Dr Johan Burisch from North
Zealand University Hospital in Frederikssund, Denmark and several colleagues from across Europe sought to answer this question with a prospective long-term analysis of direct healthcare costs in patients with IBD. An inception cohort of 1,362 patients with IBD from 20 European countries were followed for 5 years and costs for investigations, treatments, hospitalisation and surgery were assessed.
Figure 1: A) Total expenditure for patients with Crohn’s disease and breakdown of the percentage costs for hospitalisation, surgery and biological therapy. B) Total expenditure for patients with ulcerative colitis and breakdown of the percentage costs for hospitalisation, surgery and biological therapy.
For both Crohn’s disease and ulcerative colitis costs steadily decreased over the course of follow-up while the percentage attributed to the provision of biologicals rapidly increased. However,
increasing biologic costs were paralleled by reduced costs for hospitalisation, surgery and other non-biologic treatments. This data suggests that despite their relatively high acquisition cost, treatment with biologics offers an overall cost-saving effect through the reduced need for other healthcare resources.
The societal cost of IBD?
In the biologic era, direct costs for the management of IBD appear to decrease over time but what are the indirect costs of IBD and how much burden is placed on patients and society as a whole? Results from a population-based inception cohort in Copenhagen, Denmark were shared by Dr Bobby Lo from Copenhagen University Hospital, Hvidovre, Denmark.
All incident patients diagnosed with Crohn’s disease (n = 213) or ulcerative colitis (n = 300) in 2003–2004 were followed prospectively for 10 years. During this period, 65% and 60% of patients with Crohn’s disease and ulcerative colitis, respectively had at least one paid sick-leave with a median duration of 8.4 months for those with Crohn’s disease and 5.1 months for those with ulcerative colitis. Meanwhile, 36% of patients with Crohn’s disease and 39% with ulcerative colitis were unemployed at least once during follow-up with median durations of 5.3 and 6.6 months, respectively. Interestingly, and perhaps surprisingly, these indirect costs to society were no different to those observed in a population of 10,259 healthy matched controls so while the total indirect costs observed in patients with IBD were €14.4 million, this is no different to the general population.
Therefore, current treatment strategies appear to be able to keep patients with IBD working and active members of society. However, this study was performed in Denmark where there is universal and free access to healthcare and so the results may not be applicable to countries with different healthcare systems or reduced access to medication.
UEG Week 2018 has provided us with some fascinating insights into the resource requirements and costs of managing IBD, but also how we may be able to predict and potentially avoid some of those costs. Join us again tomorrow when we will be sharing some of the latest data on the clinical course of IBD in different populations and if we should be concerned about comorbid cancer in our patients?