Hospitalizations for Inflammatory Bowel Disease Among Medicare Fee-for-Service Beneficiaries — United States, 1999–2017

Crohn's disease and ulcerative colitis, collectively referred to as inflammatory bowel disease (IBD), are conditions characterized by chronic inflammation of the gastrointestinal tract. The incidence and prevalence of IBD is increasing globally, and although the disease has little impact on mortality, the number of older adults with IBD is expected to increase as the U.S. population ages (1). Older adults with IBD have worse hospitalization outcomes than do their younger counterparts (2). CDC analyzed Medicare Provider Analysis and Review (MedPAR) data to estimate IBD-related hospitalization rates and hospitalization outcomes in 2017 among Medicare fee-for-service beneficiaries aged ≥65 years, by selected demographics and trends in hospitalization rates and by race/ethnicity during 1999-2017. In 2017, the age-adjusted hospitalization rate for Crohn's disease was 15.5 per 100,000 Medicare enrollees, and the IBD-associated surgery rate was 17.4 per 100 hospital stays. The age-adjusted hospitalization rate for ulcerative colitis was 16.2 per 100,000 Medicare enrollees, and the surgery rate was 11.2 per 100 stays. During 1999-2017, the hospitalization rate for both Crohn's disease and ulcerative colitis decreased among non-Hispanic white (white) beneficiaries, but not among non-Hispanic black (black) beneficiaries. Health care utilization assessment is needed among black beneficiaries with IBD. Disease management for older adults with IBD could focus on increasing preventive care and preventing emergency surgeries that might result in further complications.

Crohn's disease and ulcerative colitis, collectively referred to as inflammatory bowel disease (IBD), are conditions characterized by chronic inflammation of the gastrointestinal tract. The incidence and prevalence of IBD is increasing globally, and although the disease has little impact on mortality, the number of older adults with IBD is expected to increase as the U.S. population ages (1). Older adults with IBD have worse hospitalization outcomes than do their younger counterparts (2). CDC analyzed Medicare Provider Analysis and Review (MedPAR) data to estimate IBD-related hospitalization rates and hospitalization outcomes in 2017 among Medicare fee-forservice beneficiaries aged ≥65 years, by selected demographics and trends in hospitalization rates and by race/ethnicity during 1999-2017. In 2017, the age-adjusted hospitalization rate for Crohn's disease was 15.5 per 100,000 Medicare enrollees, and the IBD-associated surgery rate was 17.4 per 100 hospital stays. The age-adjusted hospitalization rate for ulcerative colitis was 16.2 per 100,000 Medicare enrollees, and the surgery rate was 11.2 per 100 stays. During 1999-2017, the hospitalization rate for both Crohn's disease and ulcerative colitis decreased among non-Hispanic white (white) beneficiaries, but not among non-Hispanic black (black) beneficiaries. Health care utilization assessment is needed among black beneficiaries with IBD. Disease management for older adults with IBD could focus on increasing preventive care and preventing emergency surgeries that might result in further complications.

Discussion
During 1999-2017, the overall hospitalization rate for both Crohn's disease and ulcerative colitis decreased among older adults, with a sharper decline in the hospitalization rate for ulcerative colitis. A previous study also reported that the 2013 hospitalization rate for Crohn's disease decreased compared with that in 2003 among adults aged 65-84 and ≥85 years (3). The overall decline in hospitalization rates during the current study period was accompanied by the evolution of biologic therapies to treat IBD. A unique geographic pattern of hospitalization rates at the state level was observed for each disease. The geographic variation was similar to that in the previous study, which used the Nationwide Inpatient Sample of adults aged ≥18 years with hospitalizations for any listed diagnosis of Crohn's disease (3). In addition, the IBD-related hospitalization rate was higher among beneficiaries who were urban residents than among those who were rural residents. An urban living environment was previously found to be associated with a higher risk of developing IBD, although rural residents might also have limited health care access to receive IBD-related care or diagnosis (4).
Readmissions were defined as all-cause acute admissions whose discharge destinations were not against medical advice or expired. Multiple readmissions within the 30-day time frame from one index admission were counted as one readmission. A readmission from a previous index admission could be also counted as a new index admission if it met the selection criteria for an index admission (https://www.medicare.gov/hospitalcompare/data/30-day-measures.html). To calculate 30-day all-cause readmission rate, n = 3,022 for Crohn's disease; n = 3,060 for ulcerative colitis. ¶ ¶ 30-day mortality rate was defined as number of all-cause deaths occurred within 30 days from IBD-related admissions per 100 hospital stays. Hospitalizations were excluded if patients were discharged against medical advice. More information is available at https://www.medicare.gov/hospitalcompare/data/30-day-measures.html. To calculate 30-day all-cause readmission rate, n = 4,781 for Crohn's disease; n = 4,932 for ulcerative colitis. *** Geometric mean is the xth root of the product of the length of stay (days) from x patients (x indicates the number of patients), which, because it is not influenced by outliers, is used here rather than arithmetic mean. † † † International Classification of Diseases, Tenth Edition, Clinical Modification diagnosis codes K50 (Crohn's disease) and K51 (ulcerative colitis). § § § Data were suppressed according to the cell size suppression (https://www.resdac.org/articles/cms-cell-size-suppression-policy) or if the relative standard error was >0.3. ¶ ¶ ¶ Other includes Hispanic, Asian, Native American, and all others. **** Urban areas include large metro, large fringe metro, medium metro, or small metro. Rural areas include micropolitan and noncore. The definition is based on 2013 National Center for Health Statistics Urban-Rural Classification Scheme for Counties (https://www.cdc.gov/nchs/data/series/sr_02/sr02_166.pdf ).

Summary
What is already known about this topic?
The number of older adults with Crohn's disease or ulcerative colitis, collectively referred to as inflammatory bowel disease (IBD), is expected to increase as the U.S. population ages.
What is added by this report?
In 2017, the hospitalization rates for Crohn's disease and ulcerative colitis (approximately 16 hospitalizations per 100,000 Medicare beneficiaries) were higher among urban than rural beneficiaries. Surgery rates for Crohn's disease and ulcerative colitis were 17 and 11 per 100 stays, respectively. During 1999-2017, hospitalization rates for IBD decreased among whites but not among blacks.
What are the implications for public health practice?
Disease management among older adults with IBD could focus on achieving and maintaining remission and preventing IBD-related emergency surgery.
prevalence was higher among blacks than that among whites and Hispanics (6). Another study found lower use of biologics or lower adherence to medications among blacks (7), which could contribute to the higher ratio of IBD hospitalization to IBD prevalence among this group.
The findings in the report are subject to at least three limitations. First, Medicare data are collected for insurance reimbursement purposes and are not designed for research. The collected data do not include information about healthrisk behaviors and additional demographic variables, which limited the ability to study these measures. Second, diagnoses or procedures might be subject to coding errors. Finally, the study population is limited to Medicare fee-for-service beneficiaries. Therefore, the findings might not be generalizable to all U.S. adults aged ≥65 years.
IBD management is challenging because comorbidities and polypharmacy are common among older adults. For older adults, the necessity of surgery should be carefully evaluated based on an individual patient's disease severity and comorbid mental and physical conditions (8). If surgery is indicated and performed, early intervention, together with pain control and a proper discharge plan might prevent poor hospitalization outcomes, such as readmissions, and might ultimately reduce health care costs (9). In addition, further assessment of health care utilization among blacks with IBD is needed. Optimal multidisciplinary disease management, including outpatient follow-up visits and receiving recommended preventive care such as vaccinations and cancer screening (10), is important to maintain remission, improve quality of life, and prevent surgery and hospitalization among the growing population of older adults with IBD.