HISPANICS AND AFRICAN AMERICANS HAVE LOWER USE OF ILEOSTOMY AND RECTAL POUCH IN PATIENTS WITH ULCERATIVE COLITIS
Paul T. Kroner*, Alex M. Kesler, Peter Abader, Mohammad Afsh, Victor Ciofoaia, John R. Cangemi
Mayo Clinic Florida, Jacksonville, FL
Introduction
Ethnic variations in colectomy rates have been previously documented in patients with Ulcerative Colitis (UC), with African American and Hispanic patients having lower odds of colectomy compared to Caucasians. Recent studies found that Indians had a significantly higher colectomy rate than Caucasians. The aim of our study is to reassess the impact of ethnicity over the use of ileostomies and ileal pouches in the US.
Methods
Case-control study using the NIS 2014, the largest public inpatient database in the US. All patients with ICD9CM codes for UC were included. The primary outcome was determining the odds of use of ileostomy and ileal pouch across all ethnicities in patients with UC. Secondary outcomes included determining hospital length of stay (LOS), and additional hospital costs and charges stratified by ethnicity. Multivariate regression analyses were used to adjust for age, gender, Charlson Comorbidity Index income in patient zip code, hospital region, location, size and teaching status.
Results
A total of 319,560 IBD patients were identified, of which 119,480 had UC. The mean patient age was 40.3 years and 42.7% were female. For the primary outcome, when stratified by ethnicity, African American and Hispanic patients displayed lower adjusted odds of both ileostomy (aOR: 0.54, p=<0.01; aOR: 0.60, p=<0.01) and ileal pouch procedures (aOR: 0.45, p=0.01; aOR: 0.47, p=<0.01) as compared to Caucasian patients. There were no significant differences in adjusted odds ratio of undergoing ileostomy and ileal pouch procedures between Asian or Pacific Islander patients compared to Caucasian patients. For the secondary outcome, other than elevated adjusted additional costs and charges in Asian or Pacific Islander patients undergoing ileal pouch procedures, no significant differences in costs, charges, or length of stay was observed in African American and Hispanic patients compared to Caucasian patients. All results are displayed in Table 1.
Conclusion
African Americans and Hispanics with UC had significantly lower odds of ileostomy and ileal pouch procedure than Caucasians, while there was no difference seen in Asian or Pacific Islanders confirming prior NIS studies from 1998-2003. One could speculate this ethnic variation is multifactorial. African American and Hispanic patients could present at an earlier stage due to lack of access to outpatient care, or they could have less access to hospitals that specialize in colorectal surgery. Another possibility is that there is disparities in physician patient trust or patient preference for a high risk procedure such as ileostomy or ileal pouch. In order to better understand ethnic variation in colectomy, and to eliminate health care disparities future studies are needed to identify other contributing factors.
A) Adjusted odds of patients with ulcerative colitis undergoing colectomy stratified by ethnicity B) Adjusted means of resource utilization of patients with ulcerative colitis undergoing colectomy stratified by ethnicity.
| A) Variable | Adjusted Odds Ratio, (95% CI), p-value | |||
| African American | Hispanic | Asian or Pacific Islander | Other | |
| Ileostomy | 0.54 (0.40 - 0.72), <0.01 | 0.60 (0.44 -0.81), <0.01 | 0.80 (0.44 -1.46), 0.47 | 0.78 (0.51 - 1.19), 0.26 |
| Ileal Pouch | 0.45 (0.25 - 0.83), 0.01 | 0.47 (0.27 - 0.81), <0.01 | 0.65 (0.23 - 1.82), 0.41 | 0.64 (0.32 - 1,31), 0.22 |
| B) Variable | African American | Hispanic | Asian or Pacific Islander | Other |
| Costs(UC Pouch) | $-5123 (-13326 - 3080),0.22 | $2340 (-6226 - 10906), 0.59 | $20087 (12891 - 27283), <0.01 | $-1663 (-12544 - 9218), 0.76 |
| Costs (UC Ileostomy) | $11957 (-2600 - 26514), 0.11 | $6575 (-5031 - 18182), 0.27 | $34284 (-25036 - 93603), 0.26 | $26435 (-180 - 53049), 0.05 |
| Charges(UC Pouch) | $-10251 (-38609 - 18107), 0.48 | $12026 (-17213 - 41265), 0.42 | $97071 (19076 - 175065), 0.02 | $-2457 (-39810 - 34897), 0.90 |
| Charges (UC Ileostomy) | $43385 (-12269 - 99039), 0.13 | $14770 (-33775 - 6295), 0.55 | $60800 (-86359 - 207960), 0.42 | $112159 (-11197 - 235515), 0.07 |
| Additional Length of Stay in days (UC Pouch) | -0.7 (-3.05 - 1.68), 0.57 | -0.06 (-1.90 - 1.79), 0.95 | 7.7 (1.01 - 14.40), 0.02 | -3.2 (-6.15 - -0.23), 0.04 |
| Additional Length of Stay in days (UC Ileostomy) | 3.9 (-0.89 - 8.62), 0.11 | 0.9 (-3.38 - 5.17), 0.68 | 4.3 (-4.37 - 13.00), 0.33 | 5.5 (-1.78 - 12.83), 0.14 |
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