Background:The understanding of gender differences in inflammatory bowel disease (IBD) patients is an important step towards tailored treatment for the individual patient. The aim of this study was to compare disease phenotype, clinical manifestations, disease activity, and healthcare utilization between men and women with Crohn's disease (CD) and ulcerative colitis (UC).Methods:Two multicenter observational cohort studies with a prospective design were used to explore the differences between men and women regarding demographic and phenotypic characteristics and healthcare utilization. Detailed data on IBD-phenotype was mainly available from the Dutch IBD Biobank, while the COIN cohort provided healthcare utilization data.Results:In the Dutch IBD Biobank study, 2118 CD patients and 1269 UC patients were analyzed. Female CD patients were more often current smokers, and male UC patients were more often previous smokers. Early onset CD (<16 years) was more frequently encountered in males than in females (20% versus 12%, P < 0.01). Male CD patients were more often diagnosed with ileal disease (28% versus 20%, P < 0.01) and underwent more often small bowel and ileocecal resection. Extraintestinal manifestations (EIMs) were more often encountered in female IBD patients. In the COIN study, 1139 CD patients and 1213 UC patients were analyzed. Male CD patients used prednisone more often and suffered more often from osteopenia. IBD-specific healthcare costs did not differ between male and female IBD patients.Conclusions:Sex differences in patients with IBD include age of onset, disease location, and EIM prevalence. No large differences in therapeutic management of IBD were observed between men and women with IBD. 10.1093/ibd/izy004_video1izy004_Video_15786481854001.

Background: Nonadherence to medical therapy is frequently encountered in patients with inflammatory bowel disease (IBD). We aimed to identify predictors for future (non)adherence in IBD. Methods: We conducted a multicenter prospective cohort study with adult patients with Crohn's disease (CD) and ulcerative colitis (UC). Data were collected by means of 3-monthly questionnaires on the course of disease and healthcare utilization. Medication adherence was assessed using a visual analogue scale, ranging from 0% to 100%. Levels <80% were considered to indicate nonadherence. The Brief Illness Perception Questionnaire was used to identify illness perceptions. We used a logistic regression analysis to identify patient- and disease-related factors predictive of nonadherence 3 months after the assessment of predictors. Results: In total, 1558 patients with CD and 1054 patients with UC were included and followed for 2.5 years. On average, 12.1% of patients with CD and 13.3% of patients with UC using IBD-specific medication were nonadherent. Nonadherence was most frequently observed in patients using mesalazine (CD), budesonide (UC) and rectally administrated therapy (both CD and UC). A higher perceived treatment control and understanding of the disease were associated with adherence to medical therapy. Independent predictors of future nonadherence were age at diagnosis (odds ratio [OR]: 0.99 per year), nonadherence (OR: 26.91), a current flare (OR: 1.30) and feelings of anxiety/depression (OR: 1.17), together with an area under the receiver-operating-characteristics curve of 0.74. Conclusions: Lower age at diagnosis, flares, feelings of anxiety or depression, and nonadherence are associated with future nonadherence in patients with IBD. Altering illness perceptions could be an approach to improve adherence behavior.

Background With the increasing use of anti-TNF therapy in inflammatory bowel disease (IBD), a shift of costs has been observed with medication costs replacing hospitalization and surgery as major cost driver. We aimed to explore the evolution of IBD-related costs over two years of follow-up. Methods and Findings In total 1,307 Crohn's disease (CD) patients and 915 ulcerative colitis (UC) patients were prospectively followed for two years by three-monthly web-based questionnaires. Changes of healthcare costs, productivity costs and out-of-pocket costs over time were assessed using mixed model analysis. Multivariable logistic regression analysis was used to identify costs drivers. In total 737 CD patients and 566 UC were included. Total costs were stable over two years of follow-up, with annual total costs of €7,835 in CD and €3,600 in UC. However, within healthcare costs, the proportion of anti-TNF therapy-related costs increased from 64% to 72% in CD (p<0.01) and from 31% to 39% in UC (p < 0.01). In contrast, the proportion of hospitalization costs decreased from 19% to 13% in CD (p<0.01), and 22% to 15% in UC (p < 0.01). Penetrating disease course predicted an increase of healthcare costs (adjusted odds ratio (adj. OR) 1.95 (95% CI 1.02–3.37) in CD and age <40 years in UC (adj. OR 4.72 (95% CI 1.61–13.86)). Conclusions BD-related costs remained stable over two years. However, the proportion of anti-TNF-related healthcare costs increased, while hospitalization costs decreased. Factors associated with increased costs were penetrating disease course in CD and age <40 in UC.

Background: Capturing (non)-adherence to medical prescriptions in patients with inflammatory bowel disease (IBD) is challenging. We aimed to compare 3 different tools to measure self-assessed medication adherence of patients with IBD.Methods: Adult patients with Crohn's disease and ulcerative colitis were prospectively followed. IBD-specific medication use was collected by 3-monthly questionnaires. At 2.5 years of follow-up, medication adherence was assessed using 3 tools: (1) the 8-item Morisky Medication Adherence Scale (MMAS-8), (2) the single question how well patients take their daily medication using a Visual Analogue Scale (VAS), and (3) the Forget Medicine scale (FM), assessing how often patients forget their medication. Cross-sectional agreement among measures was visualized with scatterplots and quantified with Spearman's rank correlations.Results: In total, 913 patients with IBD were analyzed, 697 of whom received IBD-specific medication. High adherence on the MMAS-8 was consistent with high scores on the VAS and low scores on the FM. Disagreement between tools increased when patients were less adherent. A correlation of 0.44 was found between the MMAS-8 and VAS; -0.59 between the MMAS-8 and FM, and -0.55 between the VAS and FM (all P < 0.01). The VAS most optimally represented the quantitative variability of adherence, whereas the MMAS-8 and the FM might have resulted in overestimation or underestimation of adherence due to unequal differences in outcome possibilities.Conclusions: In patients with IBD, a VAS seems the most appropriate tool for quantifying medication adherence in clinical practice. The MMAS-8 may be used additionally to provide insight in specific reasons for non-adherence.

ULTRA 2 (30%, all pts, NRI) (Figure 1A), and 11 RW studies reported maintenance of remission data at 18 time points.The median proportion of pts who achieved this outcome was 53.5% (range: 11-100).Further, 16/18 time points had higher remission rates than those reported at wk 52 in ULTRA 2 (17%, all pts, NRI) (Figure 1B).Conclusions: In these RW studies, different definitions of response and remission were used, sample sizes varied, and physicians could adjust therapies to optimise outcomes.Given these differences, rates of induction and maintenance of response and remission with ADA treatment were often higher than those reported in randomised trials.

Background:The inflammatory bowel disease (IBD) disability index has recently been introduced to measure patients' physical, psychological, familial, and social limitations associated with IBD. We assessed factors related to self-reported disability and the relationship between disability and direct health care costs.Methods:A large cohort of patients with Crohn's disease (CD) and ulcerative colitis (UC) was prospectively followed for 2 years by 3 monthly web-based questionnaires. At 2 years, patients completed the IBD disability index, with lower score indicating more disability. Linear regression analysis was used to examine the impact of demographics, clinical characteristics, and illness perceptions on self-reported disability. Trends in direct health care costs across the disability severity groups minimal, mild, moderate, and severe, were tested.Results:A total of 554 patients with CD and 424 patients with UC completed the IBD disability index (response rate, 45%). Both clinical characteristics and illness perceptions significantly contributed to self-reported disability (45%-47%, P = 0.000 and 8%-12%, P = 0.000, respectively). Patients with CD scored lower on the self-reported IBD disability index than patients with UC (0.255 versus 3.890, P < 0.000), indicating more disability in patients with CD. Factors independently associated with higher self-reported disability rates were increased disease activity, illness identity (higher number of symptoms attributed to IBD), and stronger emotional response. Disease duration and disease phenotype were not associated with self-reported disability. Direct health care costs increased with the worsening of self-reported disability (P = 0.000).Conclusions:More disability was reported by patients with CD than by UC. Self-reported disability in IBD was mainly determined by clinical disease activity and illness perceptions but not by disease duration or disease phenotype.

BACKGROUND AND AIMS More data are warranted on the economic impact of different treatment strategies in ulcerative colitis (UC) patients. We compared the costs and quality of life of UC patients with a pouch reconstruction, an ileostomy or anti-tumour necrosis factor α (TNFα) therapy. METHODS UC patients filled out 3-monthly questionnaires for 2 years. Differences in 3-monthly healthcare costs, productivity costs and patient costs were tested using mixed model analysis. Quality of life was assessed employing the ) and the inflammatory bowel disease questionnaire (IBDQ). RESULTS Out of 915 UC patients, 81 (9%) had a pouch and 48 (5%) an ileostomy, and 34 (4%) were on anti-TNFα therapy. Anti-TNFα-treated patients reported high UC related-healthcare costs per 3 months (€5350). Medication use accounted for 92% of healthcare costs. UC-attributable healthcare costs were 3-fold higher in ileostomy patients compared with pouch patients (€1581 versus €407; p < 0.01). Main cost drivers in ileostomy patients were healthcare costs and ileostomy supplies (2 and 23% of healthcare costs, respectively). In pouch patients, the main cost driver was hospitalization, accounting for 50% of healthcare costs. Productivity loss did not differ between pouch and ileostomy patients (€483 versus €377; p < 0.23), but was significantly higher in anti-TNFα-treated patients (€1085). No difference was found in IBDQ scores, but pouch patients were found to have higher quality-adjusted life years than ileostomy patients and anti-TNFα-treated patients (0.90 [interquartile range 0.78-1.00] versus 0.84 [0.78-1.00] and 0.84 [0.69-1.00], respectively; p < 0.01). CONCLUSION Patients receiving anti-TNFα therapy reported the highest healthcare cost, in which medication use was the major cost driver. Ileostomy patients were three times more expensive than pouch patients due to frequent hospitalization and ileostomy supplies.

BACKGROUND AND AIMS Smoking affects the course of disease in patients with ulcerative colitis (UC) and Crohn's disease (CD). We aimed to study the association between smoking and extra-intestinal manifestations (EIMs) in inflammatory bowel disease (IBD). METHODS We cross-sectionally explored the association between smoking and EIMs in IBD in three cohort studies: (1) the COIN study, designed to estimate healthcare expenditures in IBD; (2) the Groningen study, focused on cigarette smoke exposure and disease behaviour in IBD; and (3) the JOINT study, evaluating joint and back manifestations in IBD. RESULTS In the COIN, Groningen and JOINT cohorts, 3030, 797 and 225 patients were enrolled, of whom 16, 24 and 23.5% were current smokers, respectively. Chronic skin disorders and joint manifestations were more prevalent in smoking IBD patients than in non-smokers (COIN, 39.1 vs 29.8%, p <0.01; Groningen, 41.7 vs 30.0%, p <0.01) in both CD and UC. In the JOINT cohort, smoking was more prevalent in IBD patients with joint manifestations than in those without (30.3 vs 13.0%, p <0.01). EIMs appeared to be more prevalent in high- than in low-exposure smokers (56.0 vs 37.1%, p = 0.10). After smoking cessation, the prevalence of EIMs in IBD patients rapidly decreased towards levels found in never smokers (lag time: COIN cohort, 1-2 years; Groningen cohort, within 1 year). CONCLUSIONS There is a robust dose-dependent association between active smoking and EIMs in both CD and UC patients. Smoking cessation was found to result in a rapid reduction of EIM prevalence to levels encountered in never smokers.

Methods: Patients with IBD from a Dutch multicenter cohort filled out 3-monthly questionnaires for 2 years. Elderly ($60 yr) and younger patients (18–60 yr) IBD were analyzed for differences in 3-monthly DHC, productivity losses, and out-of-pocket costs. Prevalence rates were obtained from a health insurance database. Estimates of annual DHC and prevalence rates were applied to the total Dutch adult population in 2011 and then projected to 2040, using predicted changes in population demography, prices, and volume. Results: IBD-attributable DHC were lower in elderly than in younger patients with IBD with respect to 3-monthly DHC (€359 versus €978, P , 0.01), productivity losses (€108 versus €456, P , 0.01), and out-of-pocket costs (€40 versus €57, P , 0.01). Between 2011 and 2040, the percentage of elderly IBD patients in the Netherlands has been projected to rise from 24% to 35%. Between 2011 and 2040, DHC of the total IBD population in the Netherlands are projected to increase from €161 to €661 million. Population aging accounted for 1% of this increase, next to rising prices (29%), and volume growth (70%). Conclusions: Population aging has a negligible effect on IBD-attributable DHC of the IBD population in the near future, because the average costs incurred by elderly patients with IBD are considerably lower than those incurred by younger patients with IBD. (Inflamm Bowel Dis 2014;20:637–645)

Background:Population aging is expected to result in a substantial additional burden on healthcare resources in the near future. We aimed to assess the current and future impact of aging on direct healthcare costs (DHC) attributed to inflammatory bowel disease (IBD). Methods:Patients with IBD from a Dutch multicenter cohort filled out 3-monthly questionnaires for 2 years. Elderly (≥60 yr) and younger patients (18–60 yr) IBD were analyzed for differences in 3-monthly DHC, productivity losses, and out-of-pocket costs. Prevalence rates were obtained from a health insurance database. Estimates of annual DHC and prevalence rates were applied to the total Dutch adult population in 2011 and then projected to 2040, using predicted changes in population demography, prices, and volume. Results:IBD-attributable DHC were lower in elderly than in younger patients with IBD with respect to 3-monthly DHC (&OV0556;359 versus &OV0556;978, P < 0.01), productivity losses (&OV0556;108 versus &OV0556;456, P < 0.01), and out-of-pocket costs (&OV0556;40 versus &OV0556;57, P < 0.01). Between 2011 and 2040, the percentage of elderly IBD patients in the Netherlands has been projected to rise from 24% to 35%. Between 2011 and 2040, DHC of the total IBD population in the Netherlands are projected to increase from &OV0556;161 to &OV0556;661 million. Population aging accounted for 1% of this increase, next to rising prices (29%), and volume growth (70%). Conclusions:Population aging has a negligible effect on IBD-attributable DHC of the IBD population in the near future, because the average costs incurred by elderly patients with IBD are considerably lower than those incurred by younger patients with IBD.

Background Colonoscopic surveillance for neoplasia is recommended for patients with inflammatory bowel disease (IBD)-related colitis. However, data on cost-effectiveness predate current international guidelines. Objective To compare cost-effectiveness based on contemporary data between the surveillance strategies of the American Gastroenterological Association (AGA) and British Society of Gastroenterology (BSG). Design We constructed a Markov decision model to simulate the clinical course of IBD patients. Setting We compared the 2 surveillance strategies for a base case of a 40-year-old colitis patient who was followed for 40 years. Patients AGA surveillance distinguishes 2 groups: a high-risk group with annual surveillance and an average-risk group with biannual surveillance. BSG surveillance distinguishes 3 risk groups with yearly, 3-year, or 5-year surveillance. Interventions Patients could move from a no-dysplasia state with colonoscopic surveillance to 1 of 3 states for which proctocolectomy was indicated: (1) dysplasia/local cancer, (2) regional/metastasized cancer, or (3) refractory disease. After proctocolectomy, a patient moved to a no-colon state without surveillance. Main Outcome Measurements Direct costs of medical care, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. Results BSG surveillance dominated AGA surveillance with $9846 per QALY. Both strategies were equally effective with 24.16 QALYs, but BSG surveillance was associated with lower costs because of fewer colonoscopies performed. Costs related to IBD, surgery, or cancer did not affect cost-effectiveness. Limitations The model depends on the accuracy of derived data, and the assumptions that were made to reflect real-life situations. Study conclusions may only apply to the U.S. health care system. Conclusion The updated risk-profiling approach for surveillance of IBD colorectal carcinoma by the BSG guideline appears to be more cost-effective.

There is increasing demand for colonoscopy quality measures for procedures performed in ambulatory surgery centers.Benchmarks such as adenoma detection rate (ADR) are traditionally reported as static, 1-dimensional point estimates at a provider or practice level.The authors' objective was to evaluate 6-year variability of ADRs for 370 gastroenterologists from across the nation.This was an observational cross-sectional analysis involving a collaborative quality metrics database from 2007 to 2012.Subjects were those patients who underwent colonoscopies in ambulatory surgery centers.Data from 368,157 colonoscopies were included for analysis from 11 practices.Three practice sites (5, 8, and 10) were significantly above and 2 sites (3, 7) were significantly below the mean adenoma detection rate-total (ADR-T) with a 95% confidence interval (CI).High-performing sites had 9.0% higher ADR-T than sites belonging to the lowest quartile (P !.001).The mean ADR-T remained stable for 9 out of 11 sites.Regression analysis showed that the 2 practice sites where ADR-T varied had significant improvements in ADR-T during the 6-year period; for each, mean ADR-T improved an average of 0.5% per quarter for site 2 (P Z .001) and site 3 (P Z .021),which were average and low-performers, respectively.Lyndon Hernandez and colleagues found that performance disparities among practice sites remained relatively consistent over a 6-year period.The ability of some sites to be above average in ADR-T suggests that further research is needed to identify key organizational processes and physician incentives that improve the quality of colonoscopy.

Background: Inflammatory bowel disease (IBD) is associated with high costs to society. Few data on the impact of IBD on work disability and potential predictive factors are available.Aim: To assess the prevalence of and predictive factors for work disability in Crohn's disease (CD) and ulcerative colitis (UC).Methods: A web-based questionnaire was sent out in seven university hospitals and seven general hospitals in the Netherlands. Initially, 3050 adult IBD patients were included in this prospective, nationwide cohort study, whereof 2629 patients were within the working-age (18-64 years). We used the baseline questionnaire to assess the prevalence rates of work disability in CD and UC patients within working-age. Prevalence rates were compared with the Dutch background population using age- and sex-matched data obtained from Statistics Netherlands. Multivariable logistic regression analyses were performed to identify independent demographicand disease-specific risk factors for work disability.Results: In CD, 18.3% of patients was fully disabled and 8.8% partially disabled, compared to 9.5% and 5.4% in UC patients (p < 0.01), respectively. Compared to Dutch controls, the prevalence was significantly higher, especially in CD patients. Higher age, low education, depression, chronic back pain, joint manifestations and typical disease-related risk factors such as penetrating disease course and surgery in the past were all found to be associated with work disability.Conclusion: We report high work disability rates in a large sample of IBD patients in the Netherlands. CD patients suffer more frequently from work disability than UC patients. A combination of demographic and disease-related factors is predictive of work disability. (C) 2013 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved.