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

Background: Usage of biological therapy to manage moderate to severe Inflammatory bowel disease (IBD) has revolutionized disease management. However, the cost of medication has been found to be the greatest contributor to medical costs. 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 ulcerative colitis (UC). 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 17 MP was performed. Results: A total of 313,778 adult patients were identified with IBD. Patients with UC between the ages of 18-40 (YUC) with private insurance had significantly shorter LOS (-0.74 days, P< 0.05, CI -1.19- -0.30) despite not having a statistically significant difference in mortality and TOTCHG when compared to YUC patients with other insurances. YUC patients with no insurance have both significantly lower LOS (-0.85 days, P< 0.05, CI -1.33- -0.37) and TOTCHG (-$10,816.61, P< 0.001, CI -$16814.19- -$4819.03). Patients ages 65 and older with UC (OUC) with private insurance (OR 1.27, P< 0.05, CI 1.06-1.52) or no insurance (OR 1.66, P< 0.01, CI 1.21-2.28) have significantly higher mortality rates compared to OUC with Medicare. Furthermore, OUC patients with Medicaid had significantly longer LOS (+2.55 days, P< 0.01, CI 1.18-3.92) and TOTCHG (+$38,456.66, P< 0.01, CI $10,828.97-$66,084.36). OUC patients with no insurance also had lower TOTCHG (-$8,001.49, P< 0.01, CI -$15721.28- -$281.69) despite no significant difference in LOS. Conclusions: YUC patients with private insurance had significantly lower LOS with no significant difference in mortality compared to all other insurance statuses. However, OUC patients with private or no insurance suffered significantly higher mortality rates compared to those with Medicare. Additionally, YUC patients with no insurance have both lower LOS and TOTCHG. Within the OUC population, patients with Medicaid had a longer LOS and higher TOTCHG. OUC patients with no insurance had lower TOTCHG. We found that differences in insurance statuses have profound effects on mortality, LOS, and TOTCHG. Given the current rise of 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.