Low continuity of care in IBD worsens outcomes
SAN DIEGO — In patients with inflammatory bowel disease, continuity of care was found to be low and was associated with poorer outcomes, including flares, increased immunomodulator or biologic use, hospitalization and surgery, according to a study presented at Digestive Disease Week.
“The United States’ health care system is marked by substantial fragmentation, with patients pursuing and receiving care by multiple providers often at different institutions,” Shirley Cohen-Mekelburg, MD, from University of Michigan, Ann Arbor, said during her presentation. “This fragmentation in care has been tied to duplication in testing, increased utilization and poor chronic disease outcomes. While care coordination interventions exist, they have been less focused on patients with complex conditions that require comanagement with specialists,” including IBD.
Optimal management of IBD is limited by fragmentation in care, according to Cohen-Mekelburg. Coordination among gastroenterologists, primary care physicians and sometimes surgeons is important to improve disease management and preventative care, she added, but it is unknown how care for IBD patients is distributed across providers.
Cohen-Mekelburg and colleagues analyzed data from the Veterans Health Administration (VHA) Corporate Data Warehouse to determine the framework of doctor-patient relationships in IBD.
The researchers tracked gastroenterologist, primary care and total outpatient visits for the first 3 years after the initial IBD visit. The Bice-Boxerman continuity of care index was used to compute care continuity by provider over that 3-year period.
Cohen-Mekelburg and colleagues assessed how continuity of care impacts outcomes, including flares requiring corticosteroids, use of an immunomodulator or biologic, hospitalization and surgery, by using a multivariable logistic regression model that controlled for age and Charlson comorbidity index.
A total of 46,309 veterans with IBD (93% men; 75% white) seen between 1999 and 2015 were enrolled in the study. The mean age of patients was 58.4 years (standard deviation, 15.8 years) and the mean Charlson comorbidity index score was 1.07 (standard deviation, 1.62).
Within the first 3 years of an initial IBD encounter, 16% of participants experienced a flare, 14% had severe disease, 6% needed to be hospitalized and 3% needed to undergo surgery.
Participants visited their primary care physician more often than their gastroenterologist with a median of six visits (interquartile range, 3-10) versus one (IQR, 0-3), respectively . Nearly half (47%) of participants did not have a gastroenterologist. The rest had one (13%) or more (40%) GI providers.
Overall, participants saw a median of 12 total providers (IQR, 6-23) during the first 3 years, with a median of one gastroenterologist at up to four institutions and a median of four primary care providers (IQR, 2-6) at up to six institutions.
On average, the mean continuity of care index was 0.23 (standard deviation, 0.23). Patients receiving a lower continuity of care were more likely to have a flare requiring corticosteroids, use an immunomodulator or biologic, be hospitalized and undergo surgery.
Continuity of care is “highly variable” across patients with IBD, according to Cohen-Mekelburg. The difference in continuity of care is likely due to numerous contributing factors, including confusion about provider accountability, less of a focus on coordination and specialty care and poor access to specialty care.
“Even in an integrated system with systematic efforts to enhance continuity and coordination, continuity for patients with IBD is low and lower continuity of care is associated with worse outcomes,” she said. “To address this, current barriers to continuity of care need to be evaluated. We need to provide primary care physicians and gastroenterologists with communication and coordination resources to better manage patients with IBD together.” – by Alaina Tedesco
Cohen-Mekelburg S, et al. Abstract 107. Presented at: Digestive Disease Week; May 18-21, 2019; San Diego.
Disclosures: The authors report no relevant financial disclosures.