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Increases at Age 18 among Patients with Inflammatory Bowel Diseases, A Nationwide Analysis of the Insured.
Govani SM, Higgins PD, Rubenstein J, Stidham RW, Waljee J, Waljee AK. Increases at Age 18 among Patients with Inflammatory Bowel Diseases, A Nationwide Analysis of the Insured. Paper presented at: Digestive Disease Week Annual Conference; 2016 May 22; San Diego, CA.
Title: Computed Tomography Utilization Abruptly Increases at Age 18 among Patients with Inflammatory Bowel Diseases, A Nationwide Analysis of the Insured.
Authors: Shail M. Govani, Peter D.R. Higgins, Joel H. Rubenstein, Ryan W. Stidham, Jennifer F. Waljee, Akbar K. Waljee
Background and Aims: Computed tomography (CT) is an important tool in the management of inflammatory bowel diseases (IBD). However, CT delivers significant radiation with each scan. Patients with IBD have an increased risk of undergoing repeated CT scans, which can increase cancer risk. Based on data from atomic bomb survivors, the risk of malignancy is increased from radiation exposure before age 35. Significant work has been done to improve awareness of this issue among providers. We aimed to compare the use of CT in IBD patients in patients less than 18 years old, 18-35, and over 35 using an administrative database. If this physician education was effective, we expected to see reduced use of CT scan in all IBD patients < 35 years old.
Methods: The Marketscan (Truven) database from 2009-2013 was used to identify patients with IBD with an Emergency Department (ED) or inpatient visit. Patients were classified as having IBD based on the presence of 1 inpatient code or 2 outpatient codes with an ICD-9CM code of 555.x or 556.x and uninterrupted insurance coverage. Analysis was limited to patients with pharmacy coverage and visits in which the IBD diagnosis code was the 1st or 2nd recorded diagnosis. CT abdomen/pelvis use was determined by CPT coding. Logistic regression was used to model the effect of age on the odds of CT use after accounting for gender, disease type, surgery in the prior 90 days, and medications.
Results: Between 2009 and 2013, there were 44,322 patients with IBD with 76,673 ED or inpatient visits in this cohort. Sixty percent of the cohort had Crohn's disease (CD). During the first visit with an IBD code, 7.9% were below age 18 and 57.0% were female. CT scans were utilized in 29.7% of these visits. In univariate analysis, patients younger than 18 were much less likely to undergo CT (OR 0.45, 95%CI 0.42-0.49, p < 0.001) compared to those 18- 35. Patients older than 35 were only slightly more likely to undergo CT (OR 1.11, 95%CI: 1.07-1.15) compared to those 18-35. Patients with CD and a recent surgery were more likely to undergo CT while those on narcotics, steroids and immunomodulators were less likely. In multivariate analysis, adjusting for medications, recent surgery, and gender, younger patients remained less likely to undergo CT (OR 0.42, 95%CI: 0.39-0.46) compared to those 18-35. In contrast, only a small increase in CT rate (OR 1.07, 95%CI: 1.03-1.11) was seen in the patients over 35 years old in this multivariate model. Predicted probability of CT use by age demonstrates the abrupt increase in CT use at age 18 (Figure).
Conclusions: Patients with IBD who present to the ED or are hospitalized undergo CT scan 30% of the time. It appears that pediatric providers limit radiation exposure among those below 18 while adult providers are not as cautious with radiation exposure for the young adult population. Increased awareness of the risks of cumulative radiation exposure in the young adult population is needed.