The prevalence of Crohn’s disease (CD) and ulcerative colitis (UC) is on the rise worldwide. This rising prevalence is concerning as patients with CD and UC may frequently relapse leading to recurrent hospitalizations and increased healthcare utilization.

To identify trends and adverse outcomes for 30 d readmissions for CD and UC.

This was a retrospective, interrupted trends study involving all adult (≥ 18 years) 30 d readmissions of CD and UC from the National Readmission Database (NRD) between 2008 and 2018. Patients < 18 years, elective, and traumatic hospitalizations were excluded from this study. We identified hospitalization characteristics and readmission rates for each calendar year. Trends of inpatient mortality, mean length of hospital stay (LOS) and mean total hospital cost (THC) were calculated using a multivariate logistic trend analysis adjusting for age, gender, insurance status, comorbidity burden and hospital factors. Furthermore, trends between CD and UC readmissions were compared using regression of the interaction coefficient after adjusting for age and gender to determine relative trends between the two populations. Stata^® Version 16 software (StataCorp, TX, United States) was used for statistical analysis and P value ≤ 0.05 were considered statistically significant.

Total number of 30 d readmissions increased from 6202 in 2010 to 7672 in 2018 for CD and from 3272 in 2010 to 4234 in 2018 for UC. We noted increasing trends for 30-day all-cause readmission rate of CD from 14.9% in 2010 to 17.6% in 2018 (P-trend < 0.001), CD specific readmission rate from 7.1% in 2010 to 8.2% in 2018 (P-trend < 0.001), 30-day all-cause readmission rate of UC from 14.1% in 2010 to 15.7% in 2018 (P-trend = 0.003), and UC specific readmission rate from 5.2% in 2010 to 5.6% in 2018 (P-trend = 0.029). There was no change in the risk adjusted trends of inpatient mortality and mean LOS for CD and UC readmissions. However, we found an increasing trend of mean THC for UC readmissions. After comparison, there was no statistical difference in the trends for 30 d all-cause readmission rate, inpatient mortality, and mean LOS between CD and UC readmissions.

There was an increase in total number of 30 d readmissions for CD and UC with a trend towards increasing 30 d all-cause readmission rates.

Inflammatory bowel disease (IBD) is characterized by chronic inflammation of the gastrointestinal tract with a propensity of remission and relapse over time[1]. It consists of Crohn’s disease (CD) and ulcerative colitis (UC)[2]. The exact pathogenesis of IBD is relatively unknown, but researchers believe that factors such as immune response dysregulation, gut microbiota dysbiosis, environmental changes and genetic variants play a key role[3]. In 2017, there were 6.8 million patients with IBD worldwide with studies reporting continuously rising incidence and prevalence, particularly in North America[4]. The rising rates of IBD are concerning as it is associated with a poor quality of life and places significant social and economic burden on individuals and the United States healthcare system[5,6].

Despite outpatient management by gastroenterologists, patients with IBD are at increased risk of readmission due to relapse, complications of the disease or for additional interventions after index hospitalization. This further exacerbates the impact of the disease on individuals and the healthcare system. Additionally, studies have demonstrated that about 9%–50% of IBD readmissions are preventable and may be directly linked to the quality of hospital care and inadequate post-discharge care[7]. Hence, hospital systems have developed scoring systems to identify individuals at the highest risk of readmission and implemented strategies to reduce readmissions and improve the overall quality of care[8].

In current literature, a majority of the studies investigating readmissions of IBD have been single-center experiences or primarily focused on surgical patients[9,10]. There continues to be relative paucity of data on early (30 d) readmissions of CD and UC in the United States. Hence, this national, retrospective, interrupted trends study was designed to identify the hospitalization characteristics and estimate readmission rates of CD and UC in the United States between 2010–2018. We also identified the trends of inpatient mortality to determine improvements in therapeutic management of the disease. Furthermore, we calculated the burden of the disease on the United States healthcare system in terms of healthcare utilization and hospitalization costs.

It is essential to identify early (30 d) readmissions of IBD as they may be associated with quality of inpatient care, increased risk of adverse outcomes and place significant burden on the United States healthcare system in terms of healthcare costs and resource utilization. Additionally, as providers become aware of the magnitude of these readmissions and the patient demographics most effected, efforts could be directed at index admissions to further optimize medical therapy before discharge, promote patient education and encourage a greater degree of involvement in their care, and increase outpatient follow-up, thereby decreasing early readmissions. A single center retrospective study from 2007–2010 revealed that about 5% patients with IBD were readmitted within 1 wk of hospital discharge, 14% within 1 mo, 23% within 3 mo and about 39% within the year[16]. Another study in the United States reported similar findings with a readmission rate of 18% within 1 mo of hospital discharge[17]. In 2013, an NRD-based study estimated 3037 (7%) readmissions of IBD at 30 d[7].

In our study, the total number of 30 d readmissions of CD increased from 6202 in 2010 to 7672 in 2018 and for UC from 3,272 in 2010 to 4,234 in 2018, both with a female predominance (Tables 1 and 2). This coincides with rising prevalence of CD and UC in the general population[18]. We also noted an increasing trend for 30 d all-cause readmission rates and disease specific readmission rates for 30 d readmissions of CD and UC (Table 3). These findings may, in part, be due to a rising prevalence of IBD in the general population which increased significantly from 0.9% (2 million adults) in 1999 to 1.3% (3 million adults) in 2015, an increase in the flare-ups of IBD which may account for about 50% of the readmissions or due to non-IBD related causes such as infections secondary to the widespread use of biological agents or immunosuppressants[16,18,19]. We performed a trend comparison between 30 d all-cause readmission rate of CD and UC. It was not statistically significant and signified that all-cause readmissions for both CD and UC were increasing proportionately in the United States.

The mean age for 30 d readmissions increased for both CD and UC without a statistically significant trend. The difference in the mean age between the two groups is approximately 7 years. These finding align with current literature which reports that patients with CD tend to be younger and the mean age at the time of diagnosis of CD is usually 5–10 years earlier than that of UC[20]. From a gender standpoint, there is a lower risk of CD until puberty for females when compared to males, after which there is a reversal of this risk[21]. For UC, males and females have a similar incidence until the age of 45 after which males exhibit higher risk of incident UC than females[21]. However, for readmissions of CD and UC, a slight female predominance has been noted in literature[22]. Similarly in our study, a slight female predominance was noted for CD and UC readmissions. Furthermore, we did not find a statistically significant readmission trend for gender over time which implied that the readmission rates for both genders have remained relatively stable. Moreover, we noted an increase in the overall comorbidity burden for 30 d readmissions of CD and UC. This was expected as readmissions for individuals with multiple concurrent co-morbidities have been increasing.

From a hospital perspective, large bed-sized hospitals had the highest proportions of 30 d readmissions of CD and UC. This may be due to the fact that larger hospitals have a higher capacity of in-patient admissions. Additionally, metropolitan teaching hospitals consistently had the highest readmission rates with an increasing trend. This may be because these hospitals are usually tertiary care referral center accepting complex patients from large geographical areas and hence, are well equipped with the necessary resources and specialists to manage these readmissions and their complications. Moreover, an urban location, consisting of a greater population density which may be attributed to a demographic shift of non-urban/rural population to urban locations between 2010 and 2018, is more likely to yield higher readmissions[23].

Furthermore, IBD readmissions have been associated with significant inpatient mortality and healthcare burden. As per literature, frailty and length of intensive care unit stay is independently associated with higher rates of inpatient mortality for IBD readmissions[16,24]. From 2010–2014, a study reported that the inpatient mortality for 30 d readmissions of CD was 2.85% per year, the LOS was 6 d, and cost of hospitalization was $11402[25]. In 2017, for 30 d readmissions of UC, literature reported an inpatient mortality of 1.99% along with longer LOS and higher hospitalization costs compared to index admission[26]. In our study, despite an increasing co-morbidity burden (CCI) for the study period, inpatient mortality, and mean LOS for 30 d readmissions of CD and UC did not have a significant change in the risk adjusted trend (Table 3) over time. These stable mortality and LOS trends may reflect optimal guideline driven therapeutic management for the study period. However, the mean THC for 30 d readmission of UC increased from $13783 in 2010 to $15929 (P-trend = 0.009) with an increasing trend, while no trend in THC was identified for CD readmissions. Furthermore, a trend comparison of mean THC between CD and UC yielded a statistically significant trend towards increasing mean THC for 30 d readmissions of UC relative to 30 d readmissions of CD. The exact reason for these THC findings is unclear but may be attributed to an increased complexity and complications of UC readmission requiring immediate higher level of care, additional endoscopic interventions, and a multi-disciplinary team approach for management.

Directing our focus to individual calendar years, we noted a decrease in the total number of readmissions for both CD and UC from 2016 to 2018 (Tables 1 and 2). Similarly, the 30 d all-cause readmissions rate and disease specific readmission rate also decreased from 2016 to 2018 (Table 3). These findings may be due to an overall decrease in the readmissions for one particular calendar year and do not reflect an overall trend. In fact, as discussed earlier, when trended from 2010 to 2018, we noted an increasing trend for all-cause readmissions rate and disease specific readmission rate, and with respect to 2010, there was an overall increase in the total number of 30 d readmissions of CD and UC. Hence, future larger studies are needed to assess rate of readmissions from 2018 to evaluate the trends further.

In conclusion, the total number of 30 d readmission for CD and UC increased. UC readmissions were older than CD readmissions. We noted an increasing trend for 30 d all-cause readmission rate for CD and UC. However, there was no statistical change in the risk adjusted trends of inpatient mortality and mean LOS for these readmissions. The mean total healthcare cost for 30 d readmissions of UC had a rising trend while no trend was observed for CD readmissions. Future prospective studies are needed to further study these findings.