Intest Res.  2018 Apr;16(2):216-222. 10.5217/ir.2018.16.2.216.

Characteristics and management of patients with inflammatory bowel disease between a secondary and tertiary hospitals: a propensity score analysis

• Song KH
• Kim ES
• Lee YJ
• Jang BI
• Kim KO
• Kwak SG
• Lee HS
• on behalf of Crohn's and Colitis Association in Daegu-Gyeongbuk (CCAiD)

• KMID: 2417673
• DOI: http://doi.org/10.5217/ir.2018.16.2.216

Abstract

BACKGROUND/AIMS
This study aimed to compare the clinical characteristics and management patterns of inflammatory bowel disease (IBD) patients in a secondary hospital (SH) with those in tertiary referral centers (TRC).
METHODS
Data from IBD patients in SH and 2 TRCs were retrospectively reviewed. The cumulative thiopurine use rate was compared between hospitals after controlling for different baseline characteristics using propensity score matching.
RESULTS
Among the total of 447 patients with IBD, 178 Crohn's disease (CD) and 269 ulcerative colitis (UC) patients were included. Regarding initial CD symptoms, patients from SH were more likely to show perianal symptoms, such as anal pain or discharge (56.6% vs. 34.3%, P=0.003), whereas those from TRCs more often had luminal symptoms, such as abdominal pain (54.9% vs. 17.1%, P < 0.001), diarrhea (44.1% vs. 18.4%, P < 0.001), and body weight loss (9.8% vs. 1.3%, P=0.025). Complicating behaviors, such as stricturing and penetrating, were significantly higher in TRCs, while perianal disease was more common in SH. Ileal location was more frequently observed in TRCs. For UC, SH had a more limited extent of disease (proctitis 58.8% vs. 21.2%, P < 0.001). The cumulative azathioprine use rate in SH was significantly lower than that in TRCs in both CD and UC patients after controlling for disease behavior, location, and perianal disease of CD and extent of UC.
CONCLUSIONS
The clinical characteristics and management of the IBD patients in SH were substantially different from those in TRCs. Thiopurine treatment was less commonly used for SH patients.

Keyword

Inflammatory bowel disease; Secondary care; Tertiary care centers; Propensity score

MeSH Terms

Abdominal Pain
Azathioprine
Body Weight
Colitis, Ulcerative
Crohn Disease
Diarrhea
Humans
Inflammatory Bowel Diseases*
Phenobarbital
Propensity Score*
Retrospective Studies
Secondary Care
Tertiary Care Centers*
Azathioprine
Phenobarbital

Figure

• 

  Fig. 1 Matching flow of the patients.

• 

  Fig. 2 Kaplan-Meier analysis of cumulative use of treatment after matching. (A) Thiopurine in CD, (B) thiopurine in UC, (C) anti-tumor necrosis factor (anti-TNF) in CD, and (D) anti-TNF in UC. SH, secondary hospital; TRC, tertiary referral centers.

Reference

1. Baumgart DC, Bernstein CN, Abbas Z, et al. IBD Around the world: comparing the epidemiology, diagnosis, and treatment: proceedings of the World Digestive Health Day 2010: Inflammatory Bowel Disease Task Force meeting. Inflamm Bowel Dis. 2011; 17:639–644. PMID: 20725944.

2. Thia KT, Loftus EV Jr, Sandborn WJ, Yang SK. An update on the epidemiology of inflammatory bowel disease in Asia. Am J Gastroenterol. 2008; 103:3167–3182. PMID: 19086963.

3. Ng SC, Tang W, Ching JY, et al. Incidence and phenotype of inflammatory bowel disease based on results from the Asia-Pacific Crohn's and Colitis Epidemiology Study. Gastroenterology. 2013; 145:158–165.e2. PMID: 23583432.

4. Ng WK, Wong SH, Ng SC. Changing epidemiological trends of inflammatory bowel disease in Asia. Intest Res. 2016; 14:111–119. PMID: 27175111.

5. Tursi A, Elisei W, Picchio M. Incidence and prevalence of inflammatory bowel diseases in gastroenterology primary care setting. Eur J Intern Med. 2013; 24:852–856. PMID: 23867759.

6. Ye BD, Jang BI, Jeen YT, et al. Diagnostic guideline of Crohn's disease. Korean J Gastroenterol. 2009; 53:161–176. PMID: 19835218.

7. Choi CH, Jung SA, Lee BI, et al. Diagnostic guideline of ulcerative colitis. Korean J Gastroenterol. 2009; 53:145–160. PMID: 19835217.

8. Thomas A, Lodhia N. Advanced therapy for inflammatory bowel disease: a guide for the primary care physician. J Am Board Fam Med. 2014; 27:411–420. PMID: 24808120.

9. Torjesen I. Care of IBD patients compromised by poor communication between primary and secondary care. BMJ. 2012; 344:e2675. DOI: 10.1136/bmj.e2675. PMID: 22498956.

10. Ye BD, Yang SK, Cho YK, et al. Clinical features and long-term prognosis of Crohn's disease in Korea. Scand J Gastroenterol. 2010; 45:1178–1185. PMID: 20560811.

11. Bernell O, Lapidus A, Hellers G. Risk factors for surgery and postoperative recurrence in Crohn's disease. Ann Surg. 2000; 231:38–45. PMID: 10636100.

12. Reenaers C, Pirard C, Vankemseke C, Latour P, Belaiche J, Louis E. Long-term evolution and predictive factors of mild inflammatory bowel disease. Scand J Gastroenterol. 2016; 51:712–719. PMID: 26815198.

13. Riegler G, Tartaglione MT, Carratú R, et al. Age-related clinical severity at diagnosis in 1705 patients with ulcerative colitis: a study by GISC (Italian Colon-Rectum Study Group). Dig Dis Sci. 2000; 45:462–465. PMID: 10749318.

14. Choi JH, Kim ES, Cho KB, et al. Old age at diagnosis is associated with favorable outcomes in Korean patients with inflammatory bowel disease. Intest Res. 2015; 13:60–67. PMID: 25691844.

15. Fischer SH, Tjia J, Reed G, Peterson D, Gurwitz JH, Field TS. Factors associated with ordering laboratory monitoring of high-risk medications. J Gen Intern Med. 2014; 29:1589–1598. PMID: 24965280.

16. Yang SK, Hong M, Baek J, et al. A common missense variant in NUDT15 confers susceptibility to thiopurine-induced leukopenia. Nat Genet. 2014; 46:1017–1020. PMID: 25108385.

17. Takatsu N, Matsui T, Murakami Y, et al. Adverse reactions to azathioprine cannot be predicted by thiopurine S-methyltransferase genotype in Japanese patients with inflammatory bowel disease. J Gastroenterol Hepatol. 2009; 24:1258–1264. PMID: 19682195.

18. Connell WR, Kamm MA, Ritchie JK, Lennard-Jones JE. Bone marrow toxicity caused by azathioprine in inflammatory bowel disease: 27 years of experience. Gut. 1993; 34:1081–1085. PMID: 8174958.

19. Fraser AG, Orchard TR, Jewell DP. The efficacy of azathioprine for the treatment of inflammatory bowel disease: a 30 year review. Gut. 2002; 50:485–489. PMID: 11889067.

20. Lee KM, Kim YS, Seo GS, Kim TO, Yang SK. IBD Study Group of the Korean Association for the Study of Intestinal Diseases. Use of thiopurines in inflammatory bowel disease: a consensus statement by the Korean Association for the Study of Intestinal Diseases (KASID). Intest Res. 2015; 13:193–207. PMID: 26130993.

21. Kim HS, Cheon JH, Jung ES, et al. A coding variant in FTO confers susceptibility to thiopurine-induced leukopenia in East Asian patients with IBD. Gut. 2017; 66:1926–1935. PMID: 27558924.

22. Sulz MC, Siebert U, Arvandi M, et al. Predictors for hospitalization and outpatient visits in patients with inflammatory bowel disease: results from the Swiss Inflammatory Bowel Disease Cohort Study. Eur J Gastroenterol Hepatol. 2013; 25:790–797. PMID: 23571609.