key: cord-0690651-ye6zke4m authors: Deputy, Mohammed; Sahnan, Kapil; Worley, Guy; Patel, Komal; Balinskaite, Violeta; Bottle, Alex; Aylin, Paul; Burns, Elaine M; Hart, Ailsa; Faiz, Omar title: The use of, and outcomes for, inflammatory bowel disease services during the Covid‐19 pandemic: a nationwide observational study date: 2022-02-07 journal: Aliment Pharmacol Ther DOI: 10.1111/apt.16800 sha: eb02d9f350540ea9db0083fd029fb7342036af6a doc_id: 690651 cord_uid: ye6zke4m BACKGROUND: Inflammatory bowel disease (IBD) services have been particularly affected by the Covid‐19 pandemic. Delays in referral to secondary care and access to investigations and surgery have been exacerbated. AIMS: To investigate the use of and outcomes for emergency IBD care during the Covid‐19 pandemic. METHODS: Nationwide observational study using administrative data for England (2015‐2020) comparing cohorts admitted from 1 January 2015, to 31 January 2020 (pre‐pandemic) and from 1 February 2020, to 31 January 2021 (pandemic). Autoregressive integrated moving average forecast models were run to estimate the counterfactual IBD admissions and procedures for February 2020 to January 2021. RESULTS: Large decreases in attendances to hospital for emergency treatment were observed for both acute ulcerative colitis (UC, 16.4%) and acute Crohn’s disease (CD, 8.7%). The prevalence of concomitant Covid‐19 during the same episode was low [391/16 494 (2.4%) and 349/15 613 (2.2%), respectively]. No significant difference in 30‐day mortality was observed. A shorter median length of stay by 1 day for acute IBD admissions was observed (P < 0.0001). A higher rate of emergency readmission within 28 days for acute UC was observed (14.1% vs 13.4%, P = 0.012). All IBD procedures and investigations showed decreases in volume from February 2020 to January 2021 compared with counterfactual estimates. The largest absolute deficit was in endoscopy (17 544 fewer procedures, 35.2% reduction). CONCLUSION: There is likely a significant burden of untreated IBD in the community. Patients with IBD may experience clinical harm or protracted decreases in quality of life if care is not prioritised. The global covid-19 pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus has disrupted the provision of elective and emergency healthcare services. 1, 2 In response to the pandemic, both patient behaviour and government policy changed quickly. A national lockdown was instituted in the United Kingdom and the public was advised to stay at home. It is thought that inflammatory bowel disease (IBD) services have been particularly affected. This is because these services fall under the category of providing care for "benign" diseases. The IBD-UK survey has highlighted the needs of these patients and demonstrated delays in referral to secondary care and access to investigations and surgery even before the pandemic occurred. 3 In this nationwide observational study, we investigate the process and outcome of secondary and tertiary IBD services during the pandemic in England by: 1. Comparing the outcome (mortality, length of stay and readmission) of emergency medical IBD care (acute ulcerative colitis and flare of Crohn's disease) in the pandemic with a historical cohort. 2. Estimating the prevalence of Covid-19 during emergency medical admissions for IBD. 3 . Quantifying the decrease in provision of elective and emergency IBD investigations and procedures during the pandemic with ARIMA models to predict the counterfactual where the pandemic did not occur. A nationwide observational study of IBD services was performed using Hospital Episode Statistics (HES) Admitted Patient Care database. The use of HES in research has been described previously. 4 The HES data are the routinely collected administrative inpatient healthcare data for all National Health Service (NHS) patients in England, treated in both NHS and private hospitals. The data include patient demographic and socioeconomic data, coded diagnostic and procedural data, and outcome data such as mortality and length of stay. 4 The study population was patients admitted in England between 1 January 2015, and 31 January 2021, aged 18 years and older, and given a coded diagnosis of IBD in keeping with a previous or new diagnosis of IBD. The epidemic was defined as beginning 1 February 2020 to ensure we captured any difference in presentations or outcomes in the period before the national lockdown was announced by the UK government on 23 March 2020. We investigated two types of emergency IBD admission and eight emergency and elective procedures for IBD. These are outlined in Table 1 . Emergency IBD admissions were identified by World Health Organisation International Classification of Disease 10th Revision (ICD-10) codes in the primary diagnosis field admitted as an emergency. IBD procedures were identified by Office of Population Version 4 (OPCS-4) code in any procedure field with a diagnosis of IBD in any diagnosis field. The specific codes used in each analysis can be found in Supplementary Table S1. Mortality was defined as 30-day all-cause in-hospital mortality. 30-day mortality was evaluated up until February 2021. Readmission was defined as readmission within 28 days of discharge to any NHS hospital for any reason. Length of stay was calculated as the difference between the admission date and discharge date in days. The models were used to forecast the counterfactual (the expected number based on pre-pandemic levels) for 12 months and then compared with the observed counts to calculate deficits. Relative deficits were calculated by dividing absolute deficits by the forecast volume and multiplying by 100. Proportions were compared with the chi-squared test and medians were compared with the Mann-Whitney test. All statistical analyses were performed in SAS version 9.4. A sensitivity analysis was conducted where emergency admissions with a code for ulcerative colitis or Crohn's disease in any diagnosis position were included. ARIMA models were constructed for these analyses, and the deficit based on pre-pandemic trends in admissions was calculated. were similar to those admitted before ( Table 2 ). The 30-day in-hospital mortality for acute colitis was not significantly different in the pandemic compared with the historical cohort (1.0% vs 1.0% P = 0.754) ( Table 4 ). The median length of stay was statistically shorter by 1 day in the pandemic (6 days vs 7 days, P < 0.0001). The 28-day readmission rate was slightly higher during the pandemic (14.1% vs 13.4%, P = 0.0195). A flowchart of the initial ulcerative colitis admissions identified and subsequent exclusions are displayed in Figure 2 . Table 3 ). The 30-day mortality was not significantly different during the pandemic when compared with the historical cohort (0.5% vs 0.6% P = 0.408) ( Table 4 ). The median length of stay was statistically shorter by 1 day in the pandemic (5 days vs 6 days, P < 0.0001). The 28-day readmission rate was 16.0% during the pandemic and this was not significantly different compared with the historical cohort (P = 0.821). A flowchart of the initial Crohn's disease admissions identified and subsequent exclusions are displayed in Figure 3 . All IBD investigations and procedures analysed demonstrated a decrease in frequency recorded compared with the central estimate of the forecast. Table 5 (Table 5 ). When the diagnostic code for ulcerative colitis was in a secondary position a large range of primary diagnosis codes were observed. The The ongoing impact after the first wave and in developing countries is not well described. How IBD and its medical treatment are risk factors for contracting Sars-CoV-2 and the resulting outcome for patients has been investigated previously in cohort studies and case reports. Two systematic reviews of these studies from earlier in the pandemic (2020) concluded that IBD patients were not at greater risk of being infected with SARS-CoV-2 than the general population. 13, 14 However, there is evidence that steroids may be associated with a worse prognosis and there are mixed findings for immunomodulators. 13 The risk of adverse outcomes may be higher in ulcerative colitis. 13 The latest data from the SECURE-IBD international registry suggested that combination therapy and thiopurines may be associated with an increased risk of severe Covid-19 infection. 15 Lastly, a recent nationwide registry study of patients with inflammatory disease in Denmark found that IBD patients with Covid-19 were not at higher risk of requiring invasive ventilation, longer hospital stay or death. 16 Our study adds evidence that IBD patients admitted as emergencies had similar outcomes for 30- This is also consistent with a previous large multi-centre observational study (PROTECT-ASUC) for outcomes for acute colitis during the pandemic. 17 There are limitations to this study. The accuracy of the clinical coding underlying the diagnostic and procedural coding can be a concern but accuracy rates are improving and the routinely collected data are robust for research. 28 Secondary diagnoses are likely under-recorded but are accurate when included. 29, 30 This study is unable to quantify the morbidity of untreated disease outside of hospital. Some of the procedures that have not been performed due to the pandemic may no longer be indicated and the deficits are overestimated. This study has demonstrated large decreases in medical admissions and procedures for IBD. There is likely a large burden of untreated IBD disease that must be addressed as we emerge from the covid-19 pandemic. Guarantor of the article: Professor Omar Faiz. Author contributions: MD, KS, GW, KP, OF designed the study. MD and VB performed the data extraction and analysis and constructed the prediction models. All authors wrote and edited the manuscript. 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A record linkage cohort study Improving the accuracy of HES comorbidity codes by better documentation in surgical admission proforma Additional supporting information will be found online in the Supporting Information section. ARIMA models were built using the following steps: