In-hospital mortality for ulcerative colitis (UC) has been dropping over the past decade. Better treatments, and appropriately quick referrals to specialty care, seem to explain the trend.
Rates of in-hospital mortality associated with inflammatory bowel disease (IBD) are readily available through the National Hospital Discharge Survey—a nationally representative database. University of California at San Francisco researchers used this database to compare information on nearly 18,000 patients with IBD from 1994-1996 to 2003-2006. Over these time periods, the odds of in-hospital mortality among hospitalized patients with IBD decreased by 17%, they report in BMC Gastroenterology.
The mortality trend for IBD-associated hospitalizations appeared to be driven primarily by UC. “Although UC accounted for only a third of IBD-associated hospitalizations, more than half of deaths were in hospitalizations with UC, and UC conferred a 41% increased odds of death compared with Crohn’s disease,” they wrote. Overall, in-hospital deaths for IBD were significantly reduced, but mortality did not change among patients with Crohn’s disease. These results were not explained by changes in the age of patients over these time periods, comorbidities, or hospital practices.
So what led to the reduction in in-hospital mortality? The authors speculate that improvements in health care contributed significantly, but they admit that their analysis was limited to hospitalizations of patients with a primary diagnosis of IBD. This suggests that an improvement in IBD care alone was not the only factor. Improvements in IBD care would be better assessed in an ambulatory setting, they note, and they call for prospectively collected, nationally representative, ambulatory data for IBD.
Sustained improvements in the quality of care for IBD inpatients clearly led to lower death rates in a British audit of UC patients published earlier this year in The Lancet. Data gathered in 2010 in the third national UK clinical audit of adult IBD inpatient care showed a marked improvement from the two previous audits, conducted in 2006 and 2008. For patients admitted with UC, mortality was halved over the 3 rounds of the audit, the British researchers report.
Fewer in-hospital deaths seem to indicate that improvements have been made in treatments available for IBD. It may be that patients with IBD are reaching specialist care more quickly. Other new research shows that gastroenterologists can have a noteworthy impact on the quality of care that patients with UC receive in the hospital relative to outcomes for patients treated by generalists.
A population-based cohort study published in Gut included more than 4000 Canadian patients with UC hospitalized between 2002 and 2008. Those admitted by non-gastroenterologists had a higher in-hospital mortality rate (1.1) than those admitted by gastroenterologists (0.2%). In-hospital colectomy rates were about 5% for both groups of patients.
After adjusting for covariates, generalists’ care was associated with a greater risk of in-hospital mortality compared with gastroenterologists’ care, the Toronto researchers report. Among patients who were discharged from the hospital without a colectomy, those who were admitted under non-gastroenterologists had a greater 1-year risk of death than patients who were admitted under the care of gastroenterologists.
The bottom line? Experienced specialty care appears to make a lifesaving difference for patients with severe UC—a difference that is probably important enough to shift national statistics.