Patient and Provider Distributions Reveal Regional Disparities in Advanced Therapy Utilization for Ulcerative Colitis in the United States

Background:
Biologics and small molecules, known as ‘advanced therapies’ (ATs), are used to treat moderate to severe ulcerative colitis (UC). However, treatment barriers such as insurance coverage, prescriber access, and treatment associated risks hinder optimal uptake of therapy. We hypothesized that regional disparities in access to prescribers may be a key factor that contributes to low utilization of ATs for UC in the US. This study aimed to uncover treatment access disparities by analyzing prescription patterns related to AT use in UC across US states and regions.
Methods:
We used the Optum claims database to identify UC patients and the prescribers of ATs in each US state from January 2016 to October 2022. This period covered 80,594,332 million individuals in the database with 70,416,470 (87%) having medical or pharmacy coverage during our study period. UC patients were identified using specific criteria and UC-related ICD codes from medical and pharmacy claims. For UC patients identified by 3-digit zip code, state and region, we gathered data on their demographics, use of ATs and data on AT prescribing patterns of their providers. We determined a UC patient-to-prescriber ratio (PPR) for each 3-digit zip code, state and region. We evaluated variations in demographics of AT users, as well as PPR by states and regions to determine potentially underserved areas for UC care.
Results:
The Optum study cohort mirrors the age, gender, and racial distribution seen in US census data, representing the general US population. The UC prevalence in the Optum database was approximately 250/100,000, which aligns with the known prevalence of UC in the US. Regional analysis, based on US Census region categories, shows that the northeast has the highest UC prevalence at 433/100,000, followed by the Midwest and South, while the West has the lowest prevalence at 287/100,000. Despite having the highest UC prevalence, the northeast has one of the lowest rates of advanced therapy utilization (8.8%) compared with the Midwest (12%) and the highest patient-to-provider ratios (7.4) compared with the Midwest (3.3). There was a negative correlation between PPR and AT utilization for all states combined suggesting that low AT utilization is correlated with high PPR, or insufficient AT-prescribers for the prevalent UC population. Within the northeast census region, New York had one of the highest PPR and lowest AT utilization. Three-digit zip codes in NY with high population density (e.g., 111, 112, 113) had high PPRs above 50 and the lowest AT utilization in the state (<10%), identifying potential areas for improving medical access to UC providers and treatments.
Conclusions:
Understanding nationwide, regional, and statewide variations in utilization of ATT and PPR for UC highlights regional variations in treatment patterns. These patterns identify specific regions based on 3-digit zip codes with high PPR and low AT utilization that may be areas for improving access to prescribers and ATs to reduce the burden of disease. These regions may require novel methods for patient outreach from providers such as extended telehealth networks or mobile health units to achieve improved treatment coverage for patients with UC.