Disparities in Clinical Outcomes Between Younger and Older Crohn’s Disease Patients With Respect to Insurance Status: An Analysis of the National Inpatient Sample 2016-2020

Background: Usage of biological therapy to manage Inflammatory bowel disease (IBD) has revolutionized disease management. However, the cost of medication has been found to be the greatest contributor to medical costs. Furthermore previous studies have found that the highest economic burden of IBD was in patient populations ages 40 and older. Given the cost and the bimodal distribution of diagnosis of IBD, our study aims to evaluate the impact of insurance status on mortality rates between patients ages 18-40 and ages 65 and older. Methods: The National Inpatient Sample (NIS) database (2016-2020) was analyzed to identify adult patients admitted with ICD-10 codes for Crohn’s disease (CD). Multivariate logistic/linear regressions were used to compare effects of insurance status (Private insurance, no insurance, Medicare, Medicaid) on mortality outcomes, length of stay (LOS), and total hospital charges (TOTCHG) in two patient populations: younger patients ages 18-40 and older patients ages 65 and older. Patient age, race, gender, Charlson Comorbidity Index (CCI) were controlled. Weighted analysis using Stata 17MP was performed. Results: A total of 313,778 adult patients were identified with IBD. CD patients between the ages of 18-40 (YCD) with private insurance had a significantly lower mortality rate (OR 0.34, P< 0.01, CI 0.20-0.57). In the same population, patients with Medicaid (-0.21 days, P< 0.05, CI -0.40- -0.15) or private insurance (-0.68 days, P< 0.01, CI -0.87- -0.50) had significantly shorter LOS, despite not having a significant difference in TOTCHG. YCD patients with no insurance have both significantly shorter LOS (-0.64 days, P< 0.01, CI -0.86- -0.42) and lower TOTCHG (-$3551.52, P< 0.05, CI -$5965.49- -$1137.56). Patients with CD ages 65 and older (OCD) with private insurance (OR 1.26, P< 0.05, CI 1.05-1.51) or no insurance (OR 2.70, P< 0.01, CI 2.10-3.47) have significantly higher mortality rates compared to OCD patients with Medicare. OCD patients with Medicaid had longer LOS (+0.84 days, P< 0.05, CI 0.074-1.61) compared to those with Medicare with no significant difference in TOTCHG. Conclusions: Within the YCD patients, those with private insurance again had a significantly lower mortality rate; while in OCD patients, those with private or no insurance had significantly higher mortality rates compared to those with Medicare. Furthermore, YCD patients with Medicaid or private insurance had shorter LOS. YCD patients with no insurance not only had lower LOS, but they also had lower TOTCHG. In the older populations, OCD patients with Medicaid had longer LOS compared to those with Medicare. We found that differences in insurance statuses have profound effects on mortality, LOS, and TOTCHG. Given the current rise of biologic usage and even dual biologic usage in treatment of moderate to severe IBD, it is important to consider the effects of insurance status on clinical outcomes. Further investigation should be targeted towards identifying underlying causes behind these disparities and economical treatment methods for patients of all insurance statuses.