IBD Updates: Outcomes of VEO-IBD, PIANO Study Update, and Insurance-Disparity Relationship

Outcomes of VEO-IBD. B Kerur et al. Inflamm Bowel Dis 2021; 27: 295-302. Bowel Disease in North America: A Retrospective Cohort Study The study population included 269 children (105 [39%] Crohn’s disease, 106 [39%] ulcerative colitis, and 58 [22%] IBD unclassified). Key findings:

  • By the end of follow-up, stricturing/penetrating occurred in 7 (6.6%) children.
  • Median age at diagnosis was 4.2 years. 71 (26%) were ❤ yrs.
  • Only 5 (1.7%) had a coexisting immunological disorder.
  • Over 5 years, cumulative use of an immunomodulator and biologic was 61% and 41% respectively. Exclusive enteral nutrition was used in 10 children (4%).
  • 11.5% (n=19) had a change in diagnosis from UC/IBD-U to Crohn’s disease
  • The risk of any bowel surgery in Crohn’s disease was 3% by 1 year, 12% by 3 years, and 15% by 5 years and did not differ by age at diagnosis.
  • The risk of colectomy in ulcerative colitis/IBD unclassified was 0% by 1 year, 3% by 3 years, and 14% by 5 years and did not differ by age of diagnosis.

Related blog posts:

IBD Therapies and Newborn Outcomes (also covered in a prior blog post: Disease Activity, Not Medications, Linked to Neonatal Outcomes in Women with IBD). U Mahadevan et al. Gastroenterol 2021; 160: 1131-1139. Pregnancy and Neonatal Outcomes After Fetal Exposure to Biologics and Thiopurines Among Women With Inflammatory Bowel Disease

In this PIANO study (2007-2019), pregnant women with IBD were enrolled in a prospective, observational, multicenter study across the United States. PIANO is an acronym for Pregnancy in Inflammatory Bowel Disease and Neonatal Outcomes.

Exposure was to thiopurines (n = 242), biologics (n = 642), or both (n = 227) vs unexposed (n = 379). 

Disparity Not Apparent Among Insured Population. EL Barnes et al. Inflamm Bowel Dis 2021; 27: 364-370. Black and White Patients With Inflammatory Bowel Disease Show Similar Biologic Use Patterns With Medicaid Insurance

In this study, which analyzed Medicaid Analytic eXtract data from 4 states (California, Georgia, North Carolina, and Texas) between 2006 and 2011, the authors identified 14,735 patients with IBD (4672 black [32%]). Key finding: “In patients with Medicaid insurance, where access to IBD-specific therapy should be similar for all individuals, there was no significant disparity by race in the utilization of IBD-specific therapies.”

Life in the balance (book)

While a recent blog (“There is More to Life Than Death”) referred to the complexity of  population-based medical decisions when relying solely on mortality, clearly mortality matters a lot.  In the same NEJM issue, an article highlights the difference that expanded Medicaid coverage has on mortality in adults (NEJM 2012; 367: 1025).

Traditionally, Medicaid has covered only low-income children, parents, pregnant women, and disabled persons.  In the past decade, several states expanded coverage to include nondisabled adults without dependent children.  This study examined these efforts in three states (New York, Arizona & Maine).  Then, effects on mortality were examined from 1997-2007 in these states as well as bordering states who did not expand coverage.  This time period allowed data to be analyzed five years prior to change and five years afterwards.

Findings:

  • By broadening eligibility requirements, there was a 25% increase in Medicaid coverage.
  • States with Medicaid expansions reduced all-cause mortality by 19.6 deaths per 100,000 adults; this was a relative reduction of 6.1%.
  • Mortality reductions were greatest for older adults (35-64), nonwhites, and residents of poorer counties.
  • The authors note that these changes do not prove causality.  However, there are implications for the affordable care act which allows expansion of eligibility up to 138% of the federal poverty level.

Despite apparent improvement in mortality, the cost, logistics and politics of expanding medical coverage remain unclear. In Georgia, the decisions on expanding medical coverage are quite controversial (see links below). My view: I think everyone in this country needs at least basic medical coverage.  This saves lives.

Deal rejects expansion of Medicaid | www.ajc.com

Expand Medicaid? – Blogs – Atlanta Journal-Constitution