A Qualitative Analysis of the Impact of COVID-19 on IBD Management Among Vulnerable Patient Populations

Introduction: Since the onset of the COVID-19 pandemic, three surges in California resulted in severe case outbreaks and fatalities. In this unprecedented time, there were rapid changes in healthcare delivery as remote access became the norm. The aim of this study was to understand the IBD patient experience with the changes in healthcare delivery during the COVID-19 pandemic, particularly those who are members of vulnerable populations. Methods: Patients with established primary IBD at the Colitis and Crohn’s Disease Center at University of California San Francisco (UCSF) or the Gastroenterology Division at Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG), were identified for study inclusion. A standardized questionnaire invited patients to provide their perspective on how the changes in health delivery and economic/financial stability impacted their IBD management and disease control. Participants were invited to participate in a qualitative interview. From October 2020 to December 2020, in-depth, semi-structured interviews were conducted and analyzed using qualitative techniques. Results: A total of 178 surveys were completed and examined experience of care and patient perceptions about COVID-19 related to IBD (Figure 1). In addition, 21 participants (8 at UCSF and 13 at ZSFG) completed interviews, yielding 8.03 hours of interviews and 217 pages of transcript. Analysis revealed 7 primary themes mechanisms by which the COVID-19 pandemic impacted IBD care: age, language, medication use, lockdown, stress, technology, and access (Table 1). Patients who did not speak English were more likely to report difficulties using technology software with telehealth visits and contacting their IBD providers with updates in symptoms. Conclusion: In this qualitative study of IBD patients, among vulnerable patient groups, barriers of language discordance, technology aversion, age and financial/emotional stress contributed to perceptions of worsened care and IBD activity during the COVID-19 pandemic. This study highlights that in IBD, vulnerable patient groups particularly those with lower socioeconomic status and language discordance from their providers, may face more challenges with changes to healthcare delivery and have difficulty in access to care and conveying changes in IBD activity.Figure 1.: Endoscopic Results at Week 12: Values above brackets are differences vs PBO adjusted for stratification factors (95% CI). ***P ≤ .001 vs PBO. AP, abdominal pain; CD, Crohn’s disease; CDAI, CD Activity Index; PBO, placebo; RZB, risankizumab; SES CD, Simple Endoscopic Score for CD; SF, stool frequency. Endoscopic remission: SES-CD ≤ 4 and ≥ 2-point reduction from baseline and no subscore >1 in any individual variable. Ulcer-free endoscopy: SES-CD ulcerated surface subscore of 0 in patients with SES-CD ulcerated surface subscore ≥ 1 at baseline. CDAI clinical response: ≥ 100-point decrease in CDAI from baseline. Endoscopic response: > 50% decrease from baseline in SES-CD (or for patients with isolated ileal disease and baseline SES-CD of 4, ≥ 2-point reduction from baseline). Data for endoscopic response alone has been reported previously.1,2 Enhanced clinical response: ≥ 60% decrease from baseline in average daily SF and/or ≥ 35% decrease from baseline in average daily AP and both not worse than baseline, and/or clinical remission (average daily SF ≤ 2.8 and not worse than baseline and average daily AP ≤ 1 and not worse than baseline).Table 1.: Crude Odds Ratio and Adjusted Differences for Primary and Secondary Outcomes in Patients with Crohn’s Disease with High Output ECF Requiring PN vs ECF Not Requiring PN