Although Crohn disease (CD) and ulcerative colitis (UC) have traditionally been associated with individuals of European ancestry, inflammatory bowel diseases (IBDs) are increasing among non-white races and ethnicities. Along with these changing demographics, disparities in care and outcomes of patients with IBD have been reported. For this reason, it is vital to fully understand the effects of race and ethnicity on the diagnosis and management of IBD. These findings are based on a literature review published in Gastroenterology.
A team of researchers sought to identify disparities in care and outcomes of patients with IBD of differing races and ethnicities in an effort to improve health care equity and delivery. The United States (US) population demographics are rapidly changing. Based on census projections, by 2044, no race or ethnic group in the US will account for more than 50% of the total population, making the assessment of IBD in this cohort even more imperative.
In a large, multicenter study of pediatric patients with CD from 28 sites across the US and Canada, African American (AA) race was found to be associated with more-complex disease phenotype. In univariate comparisons, stricturing or penetrating disease was found to be more common among AA patients. In addition, AA race was associated with penetrating disease in a competing risk model.
Given these associations, the study authors suggest that AA patients and other high-risk groups may need to be prioritized for early treatment with tumor necrosis factor (TNF) to potentially reduce CD-related complications. However, consistent differences in disease extent among different races and ethnicities with UC has not been demonstrated.
Genetic factors have been found to be linked with CD and UC diagnosis, as well as response to or adverse effects from treatment therapy. One of the most common adverse events in patients treated with thiopurines is myelosuppression, which leads to a discontinuation in therapy. Approximately 25% of European patients have genetic inheritance of thiopurine methyl transferase gene (TPMT), which is associated with thiopurine-induced myelosuppression.
The researchers discovered that the prevalence of IBD in ethnic groups changes with their migration. Thus, studies of these changes may identify environmental factors that contribute to development of CD and UC.
Increased risk for IBD has been linked with a diet high in animal fats and sugar and low in fruits and vegetables. Epidemiological studies on IBD in Latin America and the Caribbean have shown that large proportions of persons with CD are from regions with evidence of higher economic development and industrialization. This is likely an effect of their exposure to features of the Western environment, including diet.
Additionally, cigarette smoking is known to increase risk for CD, though it may decrease the risk for UC. In studies of surgical outcomes, AA patients with CD were associated with higher rates of smoking compared to non-AA patients, which can affect disease course as well as surgical decision making. These environmental exposures can lead to disparities in IBD-related outcomes.
Studies have shown that there are disparities in treating AA, Hispanic and Asian patients with IBD. However, such disparities are not consistent among studies. In a recent evaluation of the Sinai-Helmsley Alliance for Research Excellence (SHARE) cohort, AA patients were more likely to receive anti-TNF therapy compared with White patients.
Likewise, an analysis of an urban safety net healthcare system found that AA, Hispanic, and White patients with IBD had similar use patterns of biologics, although it was noted that lower proportions of Hispanic patients used immunomodulators. Disparities have also been found in the use of corticosteroids. At the University of California, San Francisco, pediatric South Asian patients with IBD were more likely to undergo steroid treatment compared with White patients.
There is conflicting information on rates of surgery and surgical outcomes in patients of different races and ethnicities with IBD. When comparing outcomes after surgery, AA patients were associated with worse outcomes compared with patients of other races.
AA patients had significantly higher rates of complications after CD-related surgeries compared with patients of other races, according to an evaluation of data from the National Surgical Quality Improvement Program (NSQIP). In a separate evaluation of data from NSQIP, after adjusting for potential confounders such as age, sex, time to operation, smoking status and obesity, AA patients were found to have an increased risk for death and serious morbidity after surgery for IBD.
Enhanced recovery after surgery (ERAS) protocols have been a key factor in reducing disparities among patients of different races. The advantages of ERAS protocols, which have significantly improved IBD outcomes, were described by the authors: “ERAS protocols streamline the multidisciplinary management of patients with IBD before surgery, incorporating evidence-based practices focused on nutrition, prevention of postoperative ileus, and use of non-opioid analgesia and goal-directed fluid therapy.”
An important marker of disparities in care delivery is Emergency department (ED) use. In an assessment of an IBD registry from a large integrated health system, AA patients with UC were found to have significantly higher frequencies of ED visits compared with White patients. However, no differences in ED visits were found among Asian, Hispanic, and White patients with UC.
In a multicenter, cross-sectional study, pediatric AA patients with IBD were more likely than White patients to require repeat visits to the ED, although the researchers observed no significant race- or insurance-related differences in imaging evaluations, laboratory tests, or medication distribution.
In a nationwide study, AA patients were reported to have higher IBD-related hospitalizations compared with White and Hispanic patients. However, differences between mean number of hospitalizations for AA vs White patients have not been found in other assessments.
An important outcome for patients with CD or UC is hospital readmission. In a study of more than 4300 pediatric patients with CD, AA children had higher rates of hospital readmission compared with White children. Overall, there are disparities in postoperative readmission to the hospital.
The researchers assert that access to care can significantly affect IBD outcomes. Although studies related to access to care in CD and UC patients are lacking, minority patients with diabetes who reside in racially segregated communities reported difficulties accessing specialty care.
Insurance status has often been associated with clinical outcomes. Differences in insurance coverage directly affect patients’ abilities to afford treatment and seek subspecialty care for IBD. In nationwide studies, AA and Hispanic patients were more likely to have coverage with Medicaid or be uninsured compared with White and Asian patients.
Providers should also be aware of delays in diagnosis of IBD patients, particularly among minority populations. An evaluation of data from US pediatric gastroenterology practices found that AA children and adolescents received their diagnoses at older ages, which may indicate delays.
Low health literacy may be linked to minorities with IBD. One such study indicated that patients with adequate health literacy were more likely to be White, while patients with limited health literacy were more likely to be of non-White race or Hispanic ethnicity. Reducing this prevalence of low health literacy in IBD populations, particularly among minority patients, may improve patient engagement.
Disparities in rates of adherence to treatment among IBD populations of different races and ethnicities were also noted. In a cross-sectional study of a single tertiary-care clinic, AA patients with IBD were found to have lower rates of adherence compared with White patients. However, this association is not conclusive, as other studies on the topic have found no association between race and adherence.
Overall, the study authors determined that there are disparities in care and outcomes among patients with IBD. These findings suggest that clinicians and researchers should seek to increase their understanding of new trends in CD and UC among minority populations, as discovering disparities may lead to new therapeutic approaches and precision medicine.
Disclosure: Multiple authors declared affiliations with the pharmaceutical industry. Please refer to the original article for a full list of disclosures.
Barnes, EL, Loftus EV, Kappelman MD. Effects of race and ethnicity on diagnosis and management of inflammatory bowel diseases. Gastroenterol. Published online October 20, 2020. doi: 10.1053/j.gastro.2020.08.064.