Modifiable Risk Factors for Hospital Readmission Among Patients with Inflammatory Bowel Disease in a Nationwide Database

Abstract

Background Prior studies suggest that disease activity alone does not reliably predict hospital readmission among patients with inflammatory bowel diseases (IBD). Using a national database, we aimed to further describe the burden of readmissions for IBD and identify modifiable risk factors. Methods We performed a retrospective cohort study using 2013 data from the Nationwide Readmission Database (NRD). Using International Classification of Diseases-9th Revision, Clinical Modification (ICD-9-CM) codes, we identified adult patients with discharge diagnoses of ulcerative colitis (UC) or Crohn's disease (CD) and ascertained diagnoses of anxiety, depression, chronic pain, tobacco use, and other comorbidites during index admission. Logistic regression was used to estimate factors associated with hospital readmission. Results Among 52,498 hospitalizations of IBD patients (63% CD and 37% UC), 12,407 (24%) were readmitted within 90 days of the index hospitalization resulting in roughly $576 million in excess charges. In multivariable analysis of patients with CD, anxiety (OR 1.31, 95%CI:1.21–1.43), depression (OR 1.27, 95%CI:1.07–1.50), chronic pain (OR 1.31, 95%CI:1.18–1.46), and tobacco abuse (OR 1.13, 95%CI:1.06–1.22) were associated with a significant increase in odds of readmission. Among patients with UC, anxiety (OR 1.28, 95%CI:1.14–1.45), depression (OR 1.35, 95%CI:1.07–1.70), and chronic pain (OR 1.44, 95%CI:1.21–1.73) were associated with a significant increase in odds of readmission. Conclusions Readmission occurs frequently in patients with IBD, and is costly. Anxiety, depression, and chronic pain may represent targets for interventions to prevent 90 day hospital readmission in this population.

Depressive symptoms in inflammatory bowel disease: an extraintestinal manifestation of inflammation?

“…By contrast, larger studies have nearly all reported strong associations between depression and a worse IBD course. In database studies, a pre‐existing diagnosis of clinical depression is associated with adverse outcomes in IBD . A recent high‐quality prospective cohort study of 4314 patients with IBD over 2 years found significant associations between depressive symptoms and increased risk of multiple adverse outcomes, including relapse, hospitalization, requirement for biologicals and surgery .…”

“…By contrast, larger studies have nearly all reported strong associations between depression and a worse IBD course. In database studies, a pre-existing diagnosis of clinical depression is associated with adverse outcomes in IBD [34][35][36]. A recent high-quality prospective cohort study C. D. Moulton et al…”

“…(1·07-1·70) in adults [34] PHQ (1·1-1·6) in another [9] No increased risk of surgery in one cohort [36] but RR = 1·8 (1·2-2·6) in another [9] * All longitudinal studies with ≥ 1000 patients were included and all results are adjusted for potential confounders. in a secondary analysis of 1798 IBD patients in remission, poor sleep was associated with a twofold increase in risk of active disease over 6 months, although no association was seen in UC [54].…”

Psychological distress is highly prevalent in inflammatory bowel disease: A survey of psychological needs and attitudes

“…The bidirectional links between mental and physical health in IBD have also been established: Baseline IBD activity is associated with a nearly sixfold increase in the risk of anxiety over a period of 2 years, while anxious patients in IBD remission at baseline have a greater need for steroids, escalation of therapy, or IBD flare over time than those without anxiety. Moreover, the course of IBD is negatively affected by mental illness, resulting in more frequent flare ups, a more aggressive presentation, hospital readmissions, and increased risk of surgery …”

“…The bidirectional links between mental and physical health in IBD have also been established 5 : Baseline IBD activity is associated with a nearly sixfold increase in the risk of anxiety over a period of 2 years, while anxious patients in IBD remission at baseline have a greater need for steroids, escalation of therapy, or IBD flare over time than those without anxiety. Moreover, the course of IBD is negatively affected by mental illness, resulting in more frequent flare ups, 6,7 a more aggressive presentation, 8 hospital readmissions, 9 and increased risk of surgery. 10 Despite the high prevalence of mental illness in IBD 2 and the fact that the International IBD Guidelines 11 and the Australian IBD Standards (Standard A: High Quality Clinical Care) 12 recommend regular screening for distress and collaboration with mental health-care specialists in IBD management, recent studies demonstrated that only a fraction of patients reporting anxiety and depression receive the psychological or psychiatric help they need.…”