Decreased healthcare utilization in uninsured patients with perianal crohn's disease undergoing proctectomy

Introduction: Perianal Crohn's disease (CD) is a debilitating manifestation of CD associated with poor outcomes, decreased quality of life, and is an independent predictor of work disability. Proctectomy is a last resort reserved for patients with severe, refractory disease, and can be associated with high morbidity. Here we investigate the effect of insurance status on these patients’ healthcare utilization, and its impact on disease progression. Methods: This is a retrospective study following perianal CD patients who underwent a proctectomy from 2008 - 2021 at Mount Sinai Hospital. Patient characteristics were compared using Chi-Square or Fisher's Exact Tests. Outcome variables were compared using univariate analysis between patients with and without insurance. Results: Our study included 130 patients (50.8% female) with a mean age of 52.0 ± 14.9 years, and the majority were insured (n = 106, 81.5%). Results were significant for a shorter diagnosis-to-surgery time in the uninsured group (6.9 vs 11.1 years, P = 0.050), fewer hospitalizations (P = 0.002), MRIs (P = 0.008), clinic visits (P = 0.007), antibiotics (P = 0.016) , and biologics (P = 0.001) in the uninsured group (Table 1). Additionally, data trended towards a later mean age at time of diagnosis in the uninsured group (37.8 vs 33.1 years, P = 0.241). There was no statistical difference between the groups regarding race, comorbidities, extraintestinal manifestations, presence of skin tags, strictures, and fissures, presence of proctitis or abscess at proctectomy, age at proctectomy, surgical approach, number of lifetime GI surgeries, endoscopies, or corticosteroid treatments. Conclusion: Results suggest that the vulnerable, perianal CD uninsured sub-population has decreased utilization of healthcare resources compared to the insured group. This disparity, combined with the observed trend of older age at, and therefore likely delay of, CD diagnosis may contribute to a more rapid and severe CD course, ultimately leading to a shorter diagnosis-to-surgery interval. This study was limited by a small, single-center population sample, as well as other confounding factors associated with lack of insurance. Future research will include multivariate analysis to identify specific discrepancies in annual healthcare utilization between these populations, evaluate the contribution of race and language to this issue, and investigate the role that a decreased delay in diagnosis could play in preventing last resort proctectomy. Table 1. - Differences in Healthcare Resource Utilization Between Perianal Crohn's Disease Patients Undergoing Proctectomy With Insurance Compared to Those Without Insurance Insurance (106) No Insurance (24) P-value Gender 0.594 Male (%) 51 (48.1) 13 (54.2) Female (%) 55 (51.9) 11 (45.8) Smoking status 0.354 Never and unknown (%) 69 (65.1) 18 (75.0) Ever-smoker (current and former) (%) 37 (34.9) 6 (25.0) Ethnicity 0.611 White (%) 72 (67.9) 15 (62.5) Non-White (%) 34 (32.1) 9 (37.5) Primary Language 0.022* English (%) 103 (97.2) 20 (83.3) Non-English (%) 3 (2.8) 4 (16.7) Number of Comorbidities 0.276 None (%) 36 (34.0) 11 (45.8) > = 1 (%) 70 (66.0) 13 (54.2) Age at Time of Diagnosis (years) 0.241 Mean 33.1 37.8 Median 27.2 34.1 StD 17.9 17.1 Extraintestinal Manifestations 0.921 No (%) 63 (59.4) 14 (58.3) Yes (%) 43 (40.6) 10 (41.7) Perianal Wound Modifiers (skin tag, anal fissure or stricture) 1.000 No (%) 15 (14.2) 3 (12.5) Yes (%) 91 (85.8) 21 (87.5) Presence of Proctitis at Proctectomy 0.953 No (%) 36 (34.0) 8 (33.3) Yes (%) 70 (66.0) 16 (66.7) Presence of Abscess at Proctectomy 1.000 No (%) 88 (83.0) 20 (83.3) Yes (%) 18 (17.0) 4 (16.7) Length of IBD at Proctectomy (years) 0.050* Mean 11.1 6.9 Median 9.1 4.7 StD 9.7 7.7 Age at Proctectomy (years) 0.854 Mean 44.5 43.9 Median 42.6 43.4 StD 14.8 14.8 Surgical Approach 0.113 Laparoscopic (%) 49 (57.0) 7 (36.8) Open (%) 37 (43.0) 12 (63.2) GI Hospitalizations 0.002* None (%) 69 (65.1) 23 (95.8) > = 1 (%) 37 (34.9) 1 (4.2) Endoscopies 0.058 < = 1 (%) 66 (62.3) 20 (83.3) >1 (%) 40 (37.7) 4 (16.7) MRI's 0.008* None (%) 43 (40.6) 17 (70.8) >0 (%) 63 (59.4) 7 (29.2) GI Surgeries 0.190 0 (%) 5 (4.7) 2 (8.3) 1 (%) 33 (31.1) 11 (45.8) 2+ (%) 68 (64.1) 11 (45.8) Clinic Visits 0.007* 0 (%) 3 (2.8) 5 (20.8) 1 - 4 (%) 43 (40.6) 10 (41.7) 5+ (%) 60 (56.6) 9 (37.5) Antibiotic Classes 0.016* 0 (%) 6 (5.7) 6 (25.0) 1 - 2 (%) 31 (29.2) 7 (29.2) 3+ (%) 69 (65.1) 11 (45.8) Biologic Classes 0.001* 0 (%) 13 (12.3) 10 (41.7) 1 (%) 54 (50.9) 12 (50.0) 2+ (%) 39 (36.8) 2 (8.3) Lifetime Use of Corticosteroids 0.052 No (%) 31 (29.2) 12 (50.0) Yes (%) 75 (70.1) 12 (50.0) *= P < 0.05.