Fatigue in Inflammatory Bowel Disease Linked to Substantial Economic Burden
Key findings
- This retrospective case–control study of insurance claims evaluated healthcare resource utilization and all-cause and inflammatory bowel disease (IBD)-related direct healthcare costs for newly diagnosed patients with IBD who did or did not have fatigue
- Patients with IBD experiencing fatigue had significantly greater rates of hospitalizations, emergency department visits, outpatient visits and IBD-related surgeries than IBD patients without fatigue
- Overall total healthcare costs, both IBD-related and all-cause, were also significantly higher in patients with fatigue than in those without fatigue, and this was true regardless of IBD subtype or disease severity
- Patients who have IBD and persistent fatigue should be evaluated to determine whether treatable conditions such as anemia, nutrient deficiencies, psychosomatic disorders, sleep disturbances, or medication use could be contributing
Fatigue is one of the most common symptoms of inflammatory bowel disease (IBD), reported to affect up to 80% of patients with active disease. Even 50% of patients with inactive IBD continue to report substantial fatigue.
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Ashwin N. Ananthakrishnan, MBBS, MPH, director of the Crohn's and Colitis Center in the Division of Gastroenterology at Massachusetts General Hospital and associate professor of Medicine at Harvard Medical School, and colleagues recently became the first to systematically study how fatigue affected healthcare resource utilization and associated costs in a large U.S. population with IBD. Their report in Crohn's and Colitis 360 documents a substantial impact of fatigue regardless of IBD severity.
Methods
This study was a retrospective analysis of medical and pharmacy claims stored in the IBM MarketScan commercial claims database. Data on adults newly diagnosed with IBD were collected from January 1, 2000, to March 31, 2019.
To be included, patients had to have a fatigue diagnosis after their IBD diagnosis, with no evidence of a fatigue diagnosis within the previous 12 months, and no other chronic disease that could be the primary cause of fatigue.
23,631 patients with IBD were identified to have fatigue (cases), and 89,084 did not (controls). Each case was matched with a pool of controls based on the date of IBD diagnosis, age, and sex. Then, using 1:1 propensity score matching, controls were assigned the same index date of fatigue as the matched cases (imputed fatigue index date).
Healthcare resource utilization and costs were assessed in the 12 months after the fatigue index date for cases or after the imputed fatigue index date for controls.
Characteristics of the Cohort
Propensity score matching resulted in 21,321 cases and an identical number of controls. In both cohorts, 88% of patients had mild disease, 12% had moderate to severe disease, 60% were female, and the average age was 46.
Healthcare Resource Utilization
Rates of healthcare resource utilization were significantly higher among IBD patients with fatigue than those without (P<0.0001 for all comparisons):
- Hospitalizations—incidence rate ratio (IRR), 1.89
- Emergency department (ED) visits—IRR, 1.69
- Outpatient visits—IRR, 1.42
- IBD-related surgery—IRR, 1.91
Direct Healthcare Costs
IBD-related direct healthcare costs were defined as any claim that had a diagnosis of IBD, a code for any IBD-related surgery, or a pharmacy claim for therapies commonly prescribed to treat IBD.
In 2019 dollars, IBD-related costs per patient per year were significantly higher for cases than controls:
- Medical—$6,355 vs. $3,379 (P<0.0001)
- Pharmacy—$4,517 vs. $4,123 (P=0.0003)
- Overall—$10,872 vs. $7,502 (P<0.0001)
Results were similar for all-cause medical, pharmacy, and total healthcare costs.
When categorized by type of visit, costs of IBD-related care were nearly doubled in patients with fatigue (all P<0.0001):
- Hospitalizations—$4,237 vs. $1,968
- ED visits—$247 vs. $141
- Outpatient visits—$1,499 vs. $1,025
The trend was similar for all-cause medical costs.
Subgroup Analyses
Healthcare resource utilization and total costs were significantly higher in patients with fatigue than those without fatigue regardless of IBD subtype (Crohn's disease vs. ulcerative colitis) or disease severity (mild vs. moderate/severe).
Practical Suggestions for Clinicians
Several tools to measure fatigue have been validated in patients with IBD: the Functional Assessment of Chronic Illness Therapy–Fatigue (FACIT-Fatigue), the Inflammatory Bowel Disease Fatigue (IBD-F) scale and the Multidimensional Assessment Fatigue (MAF) scale. The latter two have demonstrated good test–retest reliability after six weeks.
Patients who have IBD and persistent fatigue should be evaluated to determine whether anemia, nutrient deficiencies, psychosomatic disorders, sleep disturbances, or medication use could be contributing. Modifications to the treatment regimen or additional interventions may be warranted.
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