Assessing the Impact of Medication-Induced Adrenal Insufficiency and Access to Care on Inpatient Clinical Outcomes in Patients With Inflammatory Bowel Disease: An Analysis of the National Inpatient Sample, 2016-2020
Background:
Corticosteroids are a nonselective anti-inflammatory that have long been used in the management of inflammatory and autoimmune disorders. In inflammatory bowel disease (IBD), steroids have been used as a rescue therapy to induce remission. Largely due to adverse effects, there is no recommended role of their use as maintenance therapy. Our study sought to investigate the impact of steroid-induced adrenal insufficiency (AI) on clinical outcomes in hospitalized patients with IBD. Additionally, we sought to investigate the clinical consequences associated with disparities in access to care.
Methods:
The National Inpatient Sample (NIS) database (2016-2020) was analyzed to identify adult patients admitted with ICD-10 CM codes for Drug-induced adrenocortical insufficiency (AI), Crohn’s disease (CD), and Ulcerative colitis (UC) respectively. Multivariate logistic regression analysis and multivariate regression analysis were used to estimate the odds ratios of mortality rate, length of hospital stay (LOS) and total hospitalization charges (TOTCHG) among inflammatory bowel disease patients. Weighted analysis using Stata 17 MP was performed. Patient age, race, gender, primary insurance payer, and Charlson Comorbidity Index (CCI) were controlled in the regression analyses.
Results:
Our study showed a significantly increased likelihood of mortality amongst patients with drug-induced AI (OR 2.49, CI 1.54-4.02, <italic>P<</italic> 0.001). In addition, LOS was on average 4.46 days (CI 3.38-5.54, <italic>P<</italic> 0.0001) longer and TOTCHG was on average $61,158 (CI $34,895-$87,421, <italic>P<</italic> 0.001) higher. Access to healthcare was also evaluated by primary insurance payer status, such as private insurance, Medicare, Medicaid, or no insurance. Our analysis showed that patients with Medicaid (OR 1.35, CI 1.20-1.53, <italic>P<</italic> 0.0001) and no insurance (OR 1.57, CI 1.36-1.81, <italic>P<</italic> 0.0001) have significantly higher mortality rates when compared to patients with Medicare.
Conclusions:
Our study found that steroid-induced AI puts patients with IBD at an increased risk for inpatient mortality. Furthermore, medication-induced AI is associated with an increased burden to the healthcare system in terms of inpatient LOS as well as total charges incurred. Achieving steroid-free remission is absolutely paramount for patients with IBD, as is having access to therapeutic options to achieve remission. Many patients unfortunately are unable to maintain a state of remission due to lack of access to biologic agents. When controlling for all other factors, patients with Medicaid and uninsured patients were found to be at an increased risk for inpatient mortality from their insurance status alone. Our findings provide novel insight to the clinical sequelae suffered by underserved patient populations without access to the agents required to achieve and maintain remission.
