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Perianal Fistulas Are Associated with Persistently Higher Direct Health Care Costs in Crohn’s Disease: A Population-Based Study

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Abstract

Background

The economic impact of perianal fistulas in Crohn’s disease (CD) has not been formally assessed in population-based studies in the biologic era.

Aim

To compare direct health care costs in persons with and without perianal fistulas.

Methods

We performed a longitudinal population-based study using administrative data from Ontario, Canada. Adults (> 17 years) with CD were identified between 2007 and 2013 using validated algorithms. Perianal fistula positive “cases” were matched to up to 4 “controls” with CD without perianal fistulas based on age, sex, geographic region, year of CD diagnosis and duration of follow-up. Direct health care costs, excluding drug costs from private payers, were estimated annually beginning 5 years before (lookback) and up to 9 years after perianal fistula diagnosis (study completion) for cases and a standardized date for matched controls.

Results

A total of 581 cases were matched to 1902 controls. The annual per capita direct cost for cases was similar at lookback compared to controls ($2458 ± 6770 vs $2502 ± 10,752; p = 0.952), maximally greater in the first year after perianal fistulas diagnosis ($16,032 ± 21,101 vs $6646 ± 13,021; p < 0.001) and remained greater at study completion ($11,358 ± 17,151 vs $5178 ± 9792; p < 0.001). At perianal fistula diagnosis, the cost difference was driven primarily by home care cost (tenfold greater), publicly-covered prescription drugs (threefold greater) and hospitalizations (twofold greater), whereas at study completion, prescription drugs were the dominant driver (threefold greater).

Conclusion

In our population-based cohort, perianal fistulas were associated with significantly higher direct healthcare costs at the time of perianal fistulas diagnosis and sustained long-term.

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Data availability

The data underlying this article will be shared on reasonable request to the corresponding author.

References

  1. Kaplan GG, Windsor JW. The four epidemiological stages in the global evolution of inflammatory bowel disease. Nat Rev Gastroenterol Hepatol 2021;18:56–66.

    Article  PubMed  Google Scholar 

  2. Kaplan GG. The global burden of IBD: from 2015 to 2025. Nat Rev Gastroenterol Hepatol 2015;12:720–727.

    Article  PubMed  Google Scholar 

  3. Kuenzig ME, Benchimol EI, Lee L et al. The Impact of Inflammatory Bowel Disease in Canada 2018: Direct Costs and Health Services Utilization. J Can Assoc Gastroenterol 2019;2:S17-s33.

    Article  PubMed  Google Scholar 

  4. Burisch J, Vardi H, Schwartz D et al. Health-care costs of inflammatory bowel disease in a pan-European, community-based, inception cohort during 5 years of follow-up: a population-based study. Lancet Gastroenterol Hepatol 2020;5:454–464.

    Article  PubMed  Google Scholar 

  5. Lo B, Vind I, Vester-Andersen MK et al. Direct and Indirect Costs of Inflammatory Bowel Disease: Ten Years of Follow-up in a Danish Population-based Inception Cohort. J Crohns Colitis 2020;14:53–63.

    Article  PubMed  Google Scholar 

  6. Cohen RD, Yu AP, Wu EQ et al. Systematic review: the costs of ulcerative colitis in Western countries. Aliment Pharmacol Ther 2010;31:693–707.

    Article  CAS  PubMed  Google Scholar 

  7. Targownik LE, Kaplan GG, Witt J et al. Longitudinal Trends in the Direct Costs and Health Care Utilization Ascribable to Inflammatory Bowel Disease in the Biologic Era: Results From a Canadian Population-Based Analysis. Am J Gastroenterol 2020;115:128–137.

    Article  PubMed  Google Scholar 

  8. Murthy SK, Begum J, Benchimol EI et al. Introduction of anti-TNF therapy has not yielded expected declines in hospitalisation and intestinal resection rates in inflammatory bowel diseases: a population-based interrupted time series study. Gut 2020;69:274–282.

    Article  CAS  PubMed  Google Scholar 

  9. Schwartz DA, Loftus EV Jr, Tremaine WJ et al. The natural history of fistulizing Crohn’s disease in Olmsted County. Minnesota. Gastroenterology 2002;122:875–880.

    Article  PubMed  Google Scholar 

  10. Wewer MD, Zhao M, Nordholm-Carstensen A, et al. The Incidence and Disease Course of Perianal Crohn's Disease: A Danish Nationwide Cohort Study, 1997–2015. J Crohns Colitis 2020.

  11. Lopez N, Ramamoorthy S, Sandborn WJ. Recent advances in the management of perianal fistulizing Crohn’s disease: lessons for the clinic. Expert Rev Gastroenterol Hepatol 2019;13:563–577.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Panés J, Rimola J. Perianal fistulizing Crohn’s disease: pathogenesis, diagnosis and therapy. Nat Rev Gastroenterol Hepatol 2017;14:652–664.

    Article  PubMed  Google Scholar 

  13. Rackovsky O, Hirten R, Ungaro R et al. Clinical updates on perianal fistulas in Crohn’s disease. Expert Rev Gastroenterol Hepatol 2018;12:597–605.

    Article  CAS  PubMed  Google Scholar 

  14. Chaparro M, Zanotti C, Burgueño P et al. Health care costs of complex perianal fistula in Crohn’s disease. Dig Dis Sci 2013;58:3400–3406.

    Article  CAS  PubMed  Google Scholar 

  15. Feagan BG, Vreeland MG, Larson LR et al. Annual cost of care for Crohn’s disease: a payor perspective. Am J Gastroenterol 2000;95:1955–1960.

    Article  CAS  PubMed  Google Scholar 

  16. Lion M, Gearry RB, Day AS et al. The cost of paediatric and perianal Crohn’s disease in Canterbury, New Zealand. N Z Med J 2012;125:11–20.

    PubMed  Google Scholar 

  17. Odes S, Vardi H, Friger M et al. Effect of phenotype on health care costs in Crohn’s disease: A European study using the Montreal classification. J Crohns Colitis 2007;1:87–96.

    Article  PubMed  Google Scholar 

  18. Chen G, Pedarla V, Null KD et al. Health Care Costs and Resource Utilization Among Patients With Crohn’s Disease With and Without Perianal Fistula. Inflamm Bowel Dis 2022;28:870–877.

    Article  PubMed  Google Scholar 

  19. Hirsch RD, Keung C, Con D et al. Direct health care costs of managing perianal Crohn’s Disease in a population based cohort. Scand J Gastroenterol 2022;57:432–438.

    Article  CAS  PubMed  Google Scholar 

  20. Benchimol EI, Guttmann A, Griffiths AM et al. Increasing incidence of paediatric inflammatory bowel disease in Ontario, Canada: evidence from health administrative data. Gut 2009;58:1490–1497.

    Article  CAS  PubMed  Google Scholar 

  21. Benchimol EI, Guttmann A, Mack DR et al. Validation of international algorithms to identify adults with inflammatory bowel disease in health administrative data from Ontario, Canada. J Clin Epidemiol 2014;67:887–896.

    Article  PubMed  Google Scholar 

  22. Jehovan Fairclough TT, Moses Fung, Shane Golden, Atif Kukaswadia, G Sarah Power, Ryan Ward and Jeff McCurdy MD, PhD. Perianal Crohn’s Disease can be Accurately Identified Using Administrative Data Journal of the Canadian Association of Gastroenterology 2020;Volume 3:Pages 130–131.

  23. Wodchis WP, Austin PC, Henry DA. A 3-year study of high-cost users of health care. Cmaj 2016;188:182–188.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Cohen RD, Waters HC, Tang B et al. Effects of fistula on healthcare costs and utilization for patients with Crohn’s disease treated in a managed care environment. Inflamm Bowel Dis 2008;14:1707–1714.

    Article  PubMed  Google Scholar 

  25. Rubin DT, Griffith J, Zhang Q et al. The Impact of Intestinal Complications on Health Care Costs Among Patients With Inflammatory Bowel Disease Treated With Anti-Tumor Necrosis Factor Therapies. Inflamm Bowel Dis 2021;27:1201–1209.

    Article  PubMed  Google Scholar 

  26. Colombel JF, Panaccione R, Bossuyt P et al. Effect of tight control management on Crohn’s disease (CALM): a multicentre, randomised, controlled phase 3 trial. Lancet 2018;390:2779–2789.

    Article  Google Scholar 

  27. D’Haens G, Baert F, van Assche G et al. Early combined immunosuppression or conventional management in patients with newly diagnosed Crohn’s disease: an open randomised trial. Lancet 2008;371:660–667.

    Article  CAS  PubMed  Google Scholar 

  28. Tandon P, Rhee GG, Schwartz D et al. Strategies to Optimize Anti-tumor Necrosis Factor Therapy for Perianal Fistulizing Crohn’s Disease: A Systematic Review. Dig Dis Sci 2019;64:3066–3077.

    Article  CAS  PubMed  Google Scholar 

  29. Strik AS, Löwenberg M, Buskens CJ et al. Higher anti-TNF serum levels are associated with perianal fistula closure in Crohn’s disease patients. Scand J Gastroenterol 2019;54:453–458.

    Article  CAS  PubMed  Google Scholar 

  30. Yarur AJ, Kanagala V, Stein DJ et al. Higher infliximab trough levels are associated with perianal fistula healing in patients with Crohn’s disease. Aliment Pharmacol Ther 2017;45:933–940.

    Article  CAS  PubMed  Google Scholar 

  31. Patented Medicine Prices Review Board: Market Intelligence Report: Biologic Response Modifier Agents (http://www.pmprb-cepmb.gc.ca/view.asp?ccid51286&ang5en)(2015) Accessed December 4, 2019.

  32. Dewint P, Hansen BE, Verhey E et al. Adalimumab combined with ciprofloxacin is superior to adalimumab monotherapy in perianal fistula closure in Crohn’s disease: a randomised, double-blind, placebo controlled trial (ADAFI). Gut 2014;63:292–299.

    Article  CAS  PubMed  Google Scholar 

  33. West RL, van der Woude CJ, Hansen BE et al. Clinical and endosonographic effect of ciprofloxacin on the treatment of perianal fistulae in Crohn’s disease with infliximab: a double-blind placebo-controlled study. Aliment Pharmacol Ther 2004;20:1329–1336.

    Article  CAS  PubMed  Google Scholar 

  34. Schwartz DA, Wang A, Ozbay B et al. Comparison of Health Care Utilization and Costs Between Patients with Perianal Fistulizing Crohn’s Disease Treated with Biologics with or Without Previous Seton Placement. Inflamm Bowel Dis 2017;23:1860–1866.

    Article  PubMed  Google Scholar 

  35. Chapuis-Biron C, Bourrier A, Nachury M et al. Vedolizumab for perianal Crohn’s disease: a multicentre cohort study in 151 patients. Aliment Pharmacol Ther 2020;51:719–727.

    Article  CAS  PubMed  Google Scholar 

  36. Chapuis-Biron C, Kirchgesner J, Pariente B, et al. Ustekinumab for Perianal Crohn's Disease: The BioLAP Multicenter Study From the GETAID. Am J Gastroenterol 2020.

  37. Panés J, García-Olmo D, Van Assche G et al. Long-term Efficacy and Safety of Stem Cell Therapy (Cx601) for Complex Perianal Fistulas in Patients With Crohn’s Disease. Gastroenterology 2018;154:1334-1342.e4.

    Article  PubMed  Google Scholar 

  38. Panés J, García-Olmo D, Van Assche G et al. Expanded allogeneic adipose-derived mesenchymal stem cells (Cx601) for complex perianal fistulas in Crohn’s disease: a phase 3 randomised, double-blind controlled trial. Lancet 2016;388:1281–1290.

    Article  PubMed  Google Scholar 

  39. Khalili H, Chan SSM, Lochhead P et al. The role of diet in the aetiopathogenesis of inflammatory bowel disease. Nat Rev Gastroenterol Hepatol 2018;15:525–535.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Khalili H, Håkansson N, Chan SS et al. Adherence to a Mediterranean diet is associated with a lower risk of later-onset Crohn’s disease: results from two large prospective cohort studies. Gut 2020;69:1637–1644.

    Article  PubMed  Google Scholar 

  41. Lo CH, Lochhead P, Khalili H et al. Dietary Inflammatory Potential and Risk of Crohn’s Disease and Ulcerative Colitis. Gastroenterology 2020;159:873-883.e1.

    Article  CAS  PubMed  Google Scholar 

  42. Park SH, Aniwan S, Scott Harmsen W et al. Update on the Natural Course of Fistulizing Perianal Crohn’s Disease in a Population-Based Cohort. Inflamm Bowel Dis 2019;25:1054–1060.

    Article  PubMed  Google Scholar 

  43. Adler J, Lin CC, Gadepalli SK et al. Association Between Steroid-Sparing Therapy and the Risk of Perianal Fistulizing Complications Among Young Patients With Crohn Disease. JAMA Netw Open 2020;3:e207378.

    Article  PubMed  PubMed Central  Google Scholar 

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Funding

Takeda Canada provided funding to IQVIA for conducting this research. IQVIA provided research support. There was no medical writing assistance for this study. This study made use of de-identified data from the ICES Data Repository, which is managed by the Institute for Clinical Evaluative Sciences with support from its funders and partners: Canada’s Strategy for Patient-Oriented Research (SPOR), the Ontario SPOR Support Unit, the Canadian Institutes of Health Research and the Government of Ontario. The opinions, results and conclusions reported are those of the authors. No endorsement by ICES or any of its funders or partners is intended or should be inferred.

Author information

Authors and Affiliations

  1. Division of Gastroenterology and Hepatology, The Ottawa Hospital, Department of Medicine, University of Ottawa, Ottawa, ON, Canada

    Jeffrey D. McCurdy

  2. The Ottawa Hospital Research Institute, Ottawa, Canada

    Jeffrey D. McCurdy

  3. Takeda Canada Inc., Toronto, Canada

    Johnny H. Chen, G. Sarah Power & Ryan Ward

  4. IQVIA Solutions Inc., 6700 Century Ave #300, Mississauga, ON, Canada

    Shane Golden & Atif Kukaswadia

  5. Division of Gastroenterology and Hepatology, Mount Sinai Hospital, University of Toronto, Toronto, Canada

    Laura E. Targownik

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  1. Jeffrey D. McCurdy
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Contributions

JM: Study design, interpretation of data, drafting manuscript. RW, AK, JC: Study design, interpretation of data and critical review of manuscript. JC: Interpretation of data, drafting and critical review of the manuscript. SG and GSP: Study design, data analysis, interpretation of data and critical review of manuscript. LT: Interpretation of data and critical review of manuscript.

Corresponding author

Correspondence to Jeffrey D. McCurdy.

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Competing interest

JM: Consultancy fees and/or honoraria: Janssen, Abbvie, Takeda, Pfizer. LT: Consultancy fees and/or honoraria: Janssen, Abbvie, Takeda, Pfizer. RW and JC: employees of Takeda. AK, SG and GSP: employees of IQVIA who provided consulting services to Takeda.

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McCurdy, J.D., Chen, J.H., Golden, S. et al. Perianal Fistulas Are Associated with Persistently Higher Direct Health Care Costs in Crohn’s Disease: A Population-Based Study. Dig Dis Sci 68, 4350–4359 (2023). https://doi.org/10.1007/s10620-023-08096-9

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  • DOI: https://doi.org/10.1007/s10620-023-08096-9

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