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• W4381664085 abstract "Many of the critical disparities related to care delivery and outcomes among rural patients with inflammatory bowel disease (IBD) are attributable to inadequate access to gastroenterologists, particularly those specializing in the management of Crohn’s disease (CD) and ulcerative colitis (UC). In addition to driving potential adverse outcomes, lack of access to care for rural patients with IBD can further exacerbate existing disparities by race and ethnicity, age, and socioeconomic status. As the care of CD and UC becomes increasingly specialized, the potential exists for those patients at increased distance from an IBD specialist to be further disadvantaged. Although the evidence regarding the impact of geographic disparities on outcomes in patients with IBD is relatively limited,1Xu F. Carlson S.A. Liu Y. et al.Urban-rural differences in health care utilization for inflammatory bowel disease in the USA, 2017.Dig Dis Sci. 2022; 67: 3601-3611Crossref Scopus (5) Google Scholar, 2Benchimol E.I. Kuenzig M.E. Bernstein C.N. et al.Rural and urban disparities in the care of Canadian patients with inflammatory bowel disease: a population-based study.Clin Epidemiol. 2018; 10: 1613-1626Crossref PubMed Scopus (28) Google Scholar, 3Peña-Sánchez J.N. Osei J.A. Rohatinsky N. et al.Inequities in rural and urban health care utilization among individuals diagnosed with inflammatory bowel disease: a retrospective population-based cohort study from Saskatchewan, Canada.J Can Assoc Gastroenterol. 2023; 6: 55-63Crossref Google Scholar several studies have shown a strong association in other gastroenterology and hepatology disorders. In an analysis of the Centers for Disease Control and Prevention’s Wide-ranging Online Data for Epidemiologic Research database, Hussaini et al4Hussaini S.M.Q. Blackford A.L. Arora N. et al.Rural-urban disparities in mortality and place of death for gastrointestinal cancer in the United States from 2003 to 2019.Gastroenterology. 2022; 163: 1676-1678Abstract Full Text Full Text PDF Scopus (2) Google Scholar highlighted the specific rural-urban disparities that exist in outcomes among patients with gastrointestinal cancers, demonstrating an age-adjusted mortality rate that was 4-fold higher in rural areas compared with metropolitan areas. The authors noted that higher rates of obesity, tobacco use, and exposure, and lower screening rates for colorectal cancer in rural areas likely exacerbate other existing disparities including those of race and socioeconomic differences, whereas regionalization of health care may also paradoxically lead to an increase in traveling distance to centers with appropriate expertise.5Charlton M. Schlichting J. Chioreso C. et al.Challenges of rural cancer care in the United States.Oncology (Williston Park). 2015; 29: 633-640PubMed Google Scholar,6Birkmeyer J.D. Siewers A.E. Finlayson E.V. et al.Hospital volume and surgical mortality in the United States.N Engl J Med. 2002; 346: 1128-1137Crossref PubMed Scopus (4208) Google Scholar Additionally, in an evaluation of the Texas Cancer Registry, neighborhood-level factors were independently associated with a higher risk of hepatocellular cancer incidence, specifically being of Black race or Hispanic ethnicity, aged 60 years or older, engaged in a blue-collar occupation, or residing in socioeconomically disadvantaged neighborhoods.7Oluyomi A.O. El-Serag H.B. Olayode A. et al.Neighborhood-level factors contribute to disparities in hepatocellular carcinoma incidence in Texas.Clin Gastroenterol Hepatol. 2023; 21: 1314-1322.e5Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar There is a paucity of literature examining the impact of geographic disparities on IBD-related outcomes. In a population-based cohort study from Saskatchewan, rural residents with IBD were less likely to have a gastroenterologist as their primary IBD provider when compared with urban residents, and had lower rates of visits to an outpatient gastroenterologist when compared with their urban counterparts.3Peña-Sánchez J.N. Osei J.A. Rohatinsky N. et al.Inequities in rural and urban health care utilization among individuals diagnosed with inflammatory bowel disease: a retrospective population-based cohort study from Saskatchewan, Canada.J Can Assoc Gastroenterol. 2023; 6: 55-63Crossref Google Scholar Additionally, rural patients demonstrated an increased risk for IBD-specific and IBD-related hospitalizations compared with urban residents with IBD. Canada has proven to be a particularly interesting region to study geographic disparities given the large geographic area and low population density present in multiple provinces. In an evaluation of health care use among patients with IBD from Alberta, Manitoba, and Ontario, rural patients with CD and UC had lower rates of visits to gastroenterologists and increased rates of hospitalization and visits to the emergency department than urban patients.2Benchimol E.I. Kuenzig M.E. Bernstein C.N. et al.Rural and urban disparities in the care of Canadian patients with inflammatory bowel disease: a population-based study.Clin Epidemiol. 2018; 10: 1613-1626Crossref PubMed Scopus (28) Google Scholar This increased use of health care resources ultimately resulted in increased costs for both the health care system and the rural patients. In an evaluation of discharge data from the United States, Kaplan et al8Kaplan G.G. McCarthy E.P. Ayanian J.Z. et al.Impact of hospital volume on postoperative morbidity and mortality following a colectomy for ulcerative colitis.Gastroenterology. 2008; 134: 680-687Abstract Full Text Full Text PDF PubMed Scopus (235) Google Scholar demonstrated an increased risk of death among patients undergoing colectomy at a low-volume hospital, with mortality also being higher in rural hospitals. As demonstrated in other areas of gastroenterology and hepatology, geographic disparities in IBD likely exacerbate preexisting disparities caused by racial, ethnic, and socioeconomic differences. Decreasing the burden of disparities among patients in rural settings and improving access to care among patients with IBD remain critical goals. Perhaps chief among these is improving access to appropriate subspecialists and more importantly, multidisciplinary care, including a dietician, pharmacist, and psychologist. Other important goals are improving access to emerging and current therapies for IBD, including opportunities to enroll in clinical trials. The challenges and the opportunities in improving IBD care in rural areas are outlined in Figure 1. Given the issues with access to care brought on by geographic distance to IBD centers and subspecialty care, one of the most prominent challenges faced by rural patients with IBD is timely and accurate diagnosis. Multiple recent studies have demonstrated potential phenotypic differences among patients of different races and ethnicities;9Kugathasan S. Denson L.A. Walters T.D. et al.Prediction of complicated disease course for children newly diagnosed with Crohn's disease: a multicentre inception cohort study.Lancet. 2017; 389: 1710-1718Abstract Full Text Full Text PDF PubMed Scopus (381) Google Scholar, 10Nguyen G.C. Torres E.A. Regueiro M. et al.Inflammatory bowel disease characteristics among African Americans, Hispanics, and non-Hispanic Whites: characterization of a large North American cohort.Am J Gastroenterol. 2006; 101: 1012-1023Crossref PubMed Scopus (222) Google Scholar, 11Flasar M.H. Quezada S. Bijpuria P. et al.Racial differences in disease extent and severity in patients with ulcerative colitis: a retrospective cohort study.Dig Dis Sci. 2008; 53: 2754-2760Crossref PubMed Scopus (19) Google Scholar however, as clinicians and researchers, we must also be cognizant of potential barriers in care delivery and access that can influence diagnostic delays and thus disease progression. As an illustrative example, in a pediatric CD inception cohort, patients of Black or Mixed race constituted 12% of individuals with an inflammatory phenotype; however, they were overrepresented among those patients with complicated phenotypes of stricturing (17%) and penetrating (38%) disease.9Kugathasan S. Denson L.A. Walters T.D. et al.Prediction of complicated disease course for children newly diagnosed with Crohn's disease: a multicentre inception cohort study.Lancet. 2017; 389: 1710-1718Abstract Full Text Full Text PDF PubMed Scopus (381) Google Scholar When delays in diagnosis are compounded by delays in initiation of appropriate therapy and increased resource use as demonstrated in the Canadian studies, then disparities in outcomes can be further exacerbated among rural patients with IBD. Although the COVID pandemic has highlighted the potential role that telemedicine and digital health technologies can play in patients with IBD,12Nguyen N.H. Martinez I. Atreja A. et al.Digital health technologies for remote monitoring and management of inflammatory bowel disease: a systematic review.Am J Gastroenterol. 2022; 117: 78-97Crossref Scopus (10) Google Scholar significant disparities in digital access (including adequate broadband Internet) exist among nonmetropolitan households and racial and ethnic minority and lower-income households.13Curtis M.E. Clingan S.E. Guo H. et al.Disparities in digital access among American rural and urban households and implications for telemedicine-based services.J Rural Health. 2022; 38: 512-518Crossref PubMed Scopus (28) Google Scholar Thus, rather than alleviating geographic disparities, the increased use of telemedicine and virtual care services may instead exacerbate existing disparities without novel methods of care delivery in vulnerable populations, especially among those patients with IBD who are older, have noncommercial insurance, and are Black.14Shah K.P. Triana A.J. Gusdorf R.E. et al.Demographic factors associated with successful telehealth visits in inflammatory bowel disease patients.Inflamm Bowel Dis. 2021; 28: 358-363Crossref Scopus (6) Google Scholar Additionally, challenges continue to exist for licensing requirements to deliver telemedicine and reimbursement once delivered, and in the absence of newer nationwide laws, both issues are increasingly prominent with the lapsing of the COVID-19 public health emergency laws in many US states. Lack of digital access in rural areas may also decrease availability of novel therapies for the treatment of IBD. Residing in a rural area has long been recognized as a potential barrier to participation in clinical trials,15Friedman D.B. Foster C. Bergeron C.D. et al.A qualitative study of recruitment barriers, motivators, and community-based strategies for increasing clinical trials participation among rural and urban populations.Am J Health Promot. 2015; 29: 332-338Crossref PubMed Scopus (58) Google Scholar with 1 recent report among patients with metastatic melanoma demonstrating that patients in the Southern United States and those in rural areas were significantly more likely to have poor access to a clinical trial.16Mulligan K.M. Zheng D.X. Xu J.R. et al.Geographic disparities in access to immunotherapy clinical trials for metastatic melanoma.Arch Dermatol Res. 2023; 315: 1033-1036Crossref Scopus (2) Google Scholar Although similar data do not exist for IBD clinical trial eligibility and access, the need for frequent in-person visits during clinical trials with potential costs of both gas mileage and childcare, when paired with the need for digital access and/or broadband Internet for stool diaries and other patient-reported outcome measurements, leaves rural patients with IBD at a distinct disadvantage for clinical trial participation in the current paradigm. Early identification of patients with suspected IBD in rural areas would be an ideal first step because earlier treatment with appropriate therapies has been shown to prevent disease complications associated with IBD. Strategies to achieve this include education of primary care physicians and advanced practice providers in rural areas for early identification of patients with possible IBD. Criteria have been developed for referral from primary care practices to a gastroenterologist, such as IBD-REFER to screen patients at risk for IBD.17Atia O. Shosberger A. Focht G. et al.Development and validation of the IBD-REFER criteria: early referral for suspected inflammatory bowel diseases in adults and children.Crohns Colitis 360. 2020; 2otaa027Google Scholar Here, at least 1 major criteria (bloody diarrhea for >1 week or diarrhea without blood for >1 month or recurrent perianal abscess/fistula) or 2 minor criteria (weight loss, family history, elevated inflammation markers, or other abdominal symptoms) should result in a referral to a gastroenterologist. Concurrent to this, efforts to increase the primary care workforce in rural areas might also help to improve early identification of IBD by improving access. Studies have consistently shown that students from rural backgrounds are much more likely to decide to practice in rural settings, especially when from groups that are traditionally underrepresented in medicine.18Shipman S.A. Wendling A. Jones K.C. et al.The decline in rural medical students: a growing gap in geographic diversity threatens the rural physician workforce.Health Aff (Millwood). 2019; 38: 2011-2018Crossref PubMed Scopus (49) Google Scholar Greater recruitment toward a diverse medical school student body, especially those from rural backgrounds and underrepresented in medicine groups, and providing exposure to rural training experiences, would help to address the shortage of providers in rural areas.18Shipman S.A. Wendling A. Jones K.C. et al.The decline in rural medical students: a growing gap in geographic diversity threatens the rural physician workforce.Health Aff (Millwood). 2019; 38: 2011-2018Crossref PubMed Scopus (49) Google Scholar Triage tools to understand when a gastroenterology provider should refer a patient to an IBD center have been developed, requiring at least 1 major criterion (eg, multiple prior IBD-related surgeries, coexistent autoimmune diseases, prolonged corticosteroid usage) or at least 2 minor criteria (eg, Clostridioides difficile infection, medication nonadherence, use of opioids).19Scott F.I. Ehrlich O. Wood D. et al.Creation of an inflammatory bowel disease referral pathway for identifying patients who would benefit from inflammatory bowel disease specialist consultation. Inflamm Bowel Dis Published online October 22, 2022.https://doi.org/10.1093/ibd/izac216Google Scholar Future development of tools for remote passive monitoring of physiological data including step counts, sleep and heart rate variability, and using wearables and biosensors, will also aid early identification of disease progression in the hub-and-spoke model of care. Additional enhancements for improving care of patients with IBD living in rural areas include maximizing value at each in-person clinical visit using point-of-care tools. These include options currently available, such as intestinal ultrasound, and anticipated ones, such as point-of-care therapeutic drug monitoring assays and novel biomarkers of treatment response and disease progression. Recognizing the potential disparities that may exist in digital access among patients in rural areas,20Dorsey E.R. Topol E.J. State of telehealth.N Engl J Med. 2016; 375: 154-161Crossref PubMed Scopus (669) Google Scholar policy makers, researchers, and physicians could embrace the recent advances in telemedicine and other approaches to digital care and use novel methods to extend these to provide care for new populations of patients in rural areas. Rapid shifts in the ability to deliver virtual care occurred early in the COVID pandemic, spurring innovation and payer support for telemedicine that was previously not present.21Siegel C.A. Management of inflammatory bowel disease with telemedicine.Gastroenterol Hepatol. 2020; 16: 526Google Scholar These same innovations should be expanded to vulnerable populations in rural areas. In Ontario, the Promoting Access and Care through Centres of Excellence (PACE) Telemedicine Program was developed to address geographic disparities in access to care.22Habashi P. Bouchard S. Nguyen G.C. Transforming access to specialist care for inflammatory bowel disease: the PACE telemedicine program.J Can Assoc Gastroenterol. 2019; 2: 186-194Crossref PubMed Google Scholar Through this initiative, telemedicine consultations with gastroenterologists specializing in IBD, a colorectal surgeon, nurses, and a dietician were offered through a secure online platform to patients living at least 100 km from the primary IBD center. Patients conducted the visit via a telemedicine host site near their home, usually at a local hospital or family health site, resulting in an average distance of travel avoided of 818 km per visit. When the intentional recruitment of patients in rural or underserved areas is paired with the potential for digital health monitoring systems to reduce the number of emergency department visits and hospitalizations among patients with IBD,23Zhen J. Marshall J.K. Nguyen G.C. et al.Impact of digital health monitoring in the management of inflammatory bowel disease.J Med Syst. 2021; 45: 23Crossref PubMed Scopus (9) Google Scholar deliberate and well-planned interventions to increase digital access and relieve geographic disparities become an attractive option for future work. A similar model is currently being explored in the Northern New England region by setting up a virtual IBD clinic designed to provide multidisciplinary consultation for patients with IBD living in rural areas in the region and also serve as a provider mentorship program.21Siegel C.A. Management of inflammatory bowel disease with telemedicine.Gastroenterol Hepatol. 2020; 16: 526Google Scholar This model is called RADIUS (Rural APPs Delivering IBD Care in the United States). Within the Veterans Health Administration, a program was initiated to distribute electronic tablets to high-need Veterans with social and clinical access barriers.24Zulman D.M. Wong E.P. Slightam C. et al.Making connections: nationwide implementation of video telehealth tablets to address access barriers in Veterans.JAMIA Open. 2019; 2: 323-329Crossref PubMed Scopus (75) Google Scholar This initiative specifically targeted those who did not own a device or owned one with suboptimal bandwidth for a quality video session, and had additional barriers to access, such as distance from the nearest Veterans Health Administration medical center, transportation issues, or were homebound or had difficulty leaving home. The tablets have built-in Wi-Fi or 4G mobile data connectivity and prepaid access to a national wireless provider’s data network. The devices were also preconfigured with appropriate security features and encryption, and loaded with videoconferencing software and mobile apps that did not allow for any other connectivity outside of the Veterans Health Administration environment for virtual visits. This initiative was successful in that 81% (5503/6745) of Veterans used the tablets for a clinical encounter during the study period. Although expanding access to telemedicine is only 1 example, such novel techniques have the potential to expand care and increase value to a currently underserved (and potentially untreated) population with IBD. A similar pathway increasing access to telemedicine services via a hub-and-spoke model through preloaded devices with built-in Wi-Fi, encryption, and necessary software and apps or designated telemedicine hubs (such as local hospitals or clinics) and IBD champions at referral centers of excellence, could offer significant benefits to rural patients with IBD. Such a program would identify patients with a diagnosis of CD or UC who do not have access to regular care and are at high risk for development of complications, thus offering the opportunity for timely, potentially cost-saving, and disease-modifying interventions. Such concepts would require commitments from multiple stakeholders, including IBD specialist champions and their respective health care systems who would triage and manage these telemedicine referrals, and the local providers (either gastroenterologists, advanced practice providers, or primary care physicians) who would facilitate referral after initial presentation/diagnosis. Novel approaches to management and improving access to care may also have significant implications for future partnerships with pharmaceutical colleagues and industry partners. As noted previously, significant disparities exist among rural patients with regards to clinical trial participation. The identification of patients with IBD for clinical trials has been well recognized as a critical issue in the current era,25Harris M.S. Wichary J. Zadnik M. et al.Competition for clinical trials in inflammatory bowel diseases.Gastroenterology. 2019; 157: 1457-1461Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar particularly patients without prior exposure to biologic or small molecule therapies. This presents an opportunity to identify patients residing in rural areas with a new diagnosis of IBD without prior exposure to biologics. Novel approaches include using decentralized trial designs that involve home visits for research laboratory studies and physical assessment, and increased use of telemedicine. Thus if novel methods of patient enrollment from rural areas prove successful, the pharmaceutical industry may be a valuable stakeholder in future iterations of these concepts and efforts. We believe that the recognition of geographic disparities and their impact on many other areas of care among patients with IBD is critical in the ultimate goal of achieving health equity for all patients with CD and UC. Given the numerous examples of the impact of geographic factors on outcomes in other disease states, and the evidence of potential novel interventions to relieve the burden of geographic disparities among patients with IBD, new methods to extend care to rural patients with CD and UC are needed. Proactively addressing these disparities by offering timely intervention and improved access to specialty care and appropriate therapies offers a significant potential to improve outcomes in this population." @default.
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• W4381664085 title "Health Disparities in Inflammatory Bowel Disease Care Driven by Rural Versus Urban Residence: Challenges and Potential Solutions" @default.
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