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  • IBD Fundamentals

    In this module, we will explore key aspects of IBD, including its definition and epidemiology as well as diagnosis, treatment, health maintenance, and preventative care. Additionally, we will highlight the crucial role of patient-provider partnerships, shared decision-making, approaches to patient education and empowerment, and efforts to address social determinants of health (SDOH) and racial disparities in IBD care.

  • Social determinants of health (SDOH) play a crucial role in influencing patient well-being and overall health. In this chapter, we’ll review and enhance your understanding of SDOH in IBD and offer suggestions for actionable steps to help mitigate SDOH in your patient population.

    Presented by Sophie M. Balzora, MD, FACG

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    • [00:29]

      Hello, I’m Dr. Sophie Balzora and welcome to IBDIQ, part of The IBD Project by Takeda, where we’re coming together to help enhance expertise in IBD care—right from the start. 

      In this presentation, we will review the 5 key domains of social determinants of health and their impact on patients with inflammatory bowel disease. 

      We begin with an overview of the social determinants of health, which are non-medical factors, including the conditions of birth, life, learning, work, play, worship, and aging, that influence each individual’s health outcomes.1 

      According to the U.S. Department of Health and Human Services Healthy People 2020 initiative, social determinants of health are categorized into 5 key groupings:

      Economic stability, neighborhood and built environment, education access and quality, social and community context, and healthcare access and quality.1 


      For simplicity, several factors are listed under each domain. However, by themselves and through a broad array of factors, social determinants of health factors can impact health outcomes of patients and of the community.

      The aim of this presentation is to highlight how factors in each of these 5 domains may affect the lives of your patients with IBD, and to recommend ways in which we, as healthcare providers, can take social determinants of health into consideration when managing patients and addressing their needs.

      Let’s first take a closer look at how economic instability affects patients with IBD. 

      As reported in 2021, the census data showed that 11.6% of US citizens were in poverty.2 In an observational retrospective cross-sectional study conducted in two large administrative health claims databases in the United States, the prevalence of IBD in adults was 478.4 per 100,000 in 2016.3 


      Now, I’ll briefly highlight what this means to patients with IBD4

      Results from a survey analysis of 454 US adults with self-reported IBD showed that 62% of patients with IBD experience personal and/or financial distress, 23% of patients with IBD experience financial hardship due to medical bills, and approximately 17% of patients with IBD experience medication nonadherence due to costs. Clearly, there are patients with IBD who are hampered by financial toxicity.

      Now, if we break it down to factors leading to the high medical costs of care facing these patients with IBD, then we see that individuals with lower socioeconomic status frequently have higher healthcare utilization.5 Let’s go over a representative example. This is from an analysis done by a tertiary care center in New York City with an ethnically diverse population of adults with IBD.6 As patients with low income are often covered by Medicaid, this analysis compared resource use for those on Medicaid vs other insurers.


      In addition to the unadjusted data, results from data adjusted for sex, ethnicity, and age at first colonoscopy showed that patients with lower socioeconomic status on Medicaid were hospitalized 2.95 times more often than others and had 4.24 times more emergency room visits than others!

      Further, 62.4% of these patients were given steroids, whereas 37.7% of patients with IBD not covered by Medicaid were given steroids.6 It’s also worth mentioning that 55.6% of low-income Medicaid patients were prescribed steroids for over 90 days vs 33.9%. These are the types of findings that repeatedly suggest that low socioeconomic status may be associated with barriers to IBD maintenance care and therapies. 


      It should also be noted that in a multi-cohort study that used data from 2 Finnish prospective cohort studies, low socioeconomic status has been associated with increased risk of psychotic disorders, substance abuse, heart and renal failure, and other health-impairing behaviors like self-harm,7 which may further complicate things and deeply affect their lives. 

      Next, let’s cover the “Neighborhood and Built Environment” domain of social determinants of health, which entails where your patients live and work, and what they have access to in their community.1

      First, in the US, there is geographically unequal distribution of healthcare specialists that can potentially limit access to care and impact the health of that population.8 Looking at the map, the areas with low clusters of healthcare specialists tend to be in the more rural areas. 

      When it comes to managing IBD, we know that regular clinic visits and ensuring adherence to medication regimens are crucial.9 


      We also know that limited access to care in rural areas may lead to increased reliance on primary care physicians, placing patients at greater potential risk for inadequate IBD-specific care.10

      Additionally, patients with IBD who live far from a hospital are more likely to require IBD-related surgery and biologic therapy than those living closer to a hospital.11 

      We must consider these opportunities to improve IBD care in rural areas to prevent challenges like disease progression, delays in initial diagnosis, and limited access to emerging and novel therapies.12

      When talking about “Neighborhood and Built Environment,” we can’t ignore the impact of the workplace environment on those with IBD.13 

      Patients with IBD may experience symptoms while working and require workplace accommodations.13 As an important reminder, IBD in some patients may be disabling. The Americans with Disabilities Act requires employers to make reasonable accommodations to enable the employee to perform the essential function of the job.14 


      However, people with IBD may encounter difficulties with attaining workplace accommodations such as remote work options, flexible hours, accessibility to a toilet, and time for medical appointments.13

      It should be stated here that it may be helpful for employers to offer accessible toilets and flexibility for medical appointments to the significantly impacted employed individuals.13 And while remote work options may help, individuals who are older, have lower education, and lower income, are less likely to have the option to work remotely according to a survey conducted by McKinsey & Company in 2022.15

      Access to nutritious food is also part of the “Neighborhood and Built Environment” social determinant of health for patients with IBD.1

      The term “Food Insecurity” is characterized by being worried about food running out, cutting portions or skipping meals due to costs, or an inability to afford a balanced meal.16 In this figure here, green areas represent 2019 data for low-income, low-access areas in urban census tracts where urban residents live more than 1 mile and where rural residents live more than 10 miles from a supermarket.17


      When it comes to the population of adult patients with IBD, 14% reported experiencing food insecurity.16 Additionally, in comparison to those without IBD, there is a 69% higher risk of food insecurity among those with IBD. In fact, among patients with very low food security, 88% reported experiencing personal and/or healthcare-related financial distress.

      Under the category of “Neighborhood and Built Environment,” housing is also a factor to take into consideration. Access to safe and stable housing, along with a clean environment, is crucial for all patients, whether they have IBD or not, to maintain their overall health.18,19 But, often, urban neighborhoods with unsuitable living conditions pose adverse health challenges because unsanitary conditions heighten disease risks and contribute to health problems. 

      Within highly populated areas, risk for infectious disease increases through amplified chances for transmission.19 


      For example, unsafe water, poor waste disposal, exposure to toxic substances, and inadequate food storage can easily spread illnesses. Additionally, poor housing conditions can adversely affect mental health, potentially leading to irritability, anxiety, and depression.

      Unfortunately, certain racial and ethnic groups and those with low socioeconomic status are disproportionately affected.19

      The CDC conducted an analysis of the American Housing Survey for 2007 and 2009.20 Based on the 2009 data, it was found that Black people are 2.3 times more likely to live in inadequate housing than White people. Additionally, income is a factor – People with low income, or $24,999 or less, are almost 5 times more likely to live in inadequate housing vs higher earners, or those making $75,000 or more.


      To mitigate the impact of housing on patient health, green spaces like public parks may exhibit protective effects on the health of individuals with low socioeconomic status.21 Leveraging green spaces can be a valuable tool as it may help to reduce exposure to air pollution, promote healthy behaviors, such as physical activity and sleep, and offer people relief from cognitive processes and stress. 

      Education is another social determinant domain that influences the outcomes of patients.1

      Based on estimates from 2003, which are the most recent data available, at least 88% of US adults have insufficient health literacy levels to navigate the healthcare system and enhance their well-being.22 

      Further, patients with low health literacy often have to endure increased hospitalization rates and emergency department visits, higher mortality and costs, decreased use of preventative care, poorer health status, and reduced ability to understand labeling and messages.22 


      So of course, health literacy is crucial for healthcare providers to successfully engage patients in shared decision-making.23 For example, let’s look at a prospective cohort study of 1,486 patients, that utilized the Crohn’s and Colitis Foundation’s IBD Partners Internet-based cohort to identify patient-specific and disease-related factors associated with high levels of patient activation and to assess the relationship between patient activation level at baseline and clinical remission with a 6-month follow-up; it was shown that when patients with IBD demonstrate having the skills, knowledge, and motivation for effective health management, known as patient activation, it was associated with increased IBD remission rates.24 

      Therefore, in clinical practice, clinicians can account for predictors of increased odds of high patient activation, including a history of IBD-related surgery and longer disease duration.24


      The relationship that patients have with their surrounding community can impact health and well-being.1 

      As a determinant of health, social and community context affects patients with IBD. First, I want to highlight that there is a need for increased recruitment of underrepresented minority individuals into IBD clinical trials.1

      According to responses from the 2015 National Health Interview Survey, among those diagnosed with IBD, approximately 13% were Hispanic, 76% were White, and 5% were Black.25 However, racial and ethnic minority groups are notably under-represented in clinical trials.26 In the 2020 census report, Black and Hispanic people accounted for over 30% of the population.26 Despite that, White patients make up almost 90% of study participants in clinical trials. In IBD clinical trials specifically, the representation of non-White populations is also limited.26


      This underrepresentation, in addition to challenges that affect non-White populations with IBD, like access to care and financial barriers, could contribute to delays in diagnosis and the initiation of appropriate treatment for IBD.26

      Stress, anxiety, and depression can contribute to the recurrence and aggravation of IBD, with the effects mediated by reactions of the neuronal, endocrine, and immune systems.27

      A large population-based cohort study including 6,119 patients with IBD found increased incidence of mental disorders such as depression and anxiety compared with matched cohorts.28 And, it is known that emotional disorders and/or depression can exacerbate IBD symptoms and increase disease severity.27 

      So when considering “Social and Community Context” as a social determinant of health, take into consideration that patients with IBD are often exposed to stress. 


      When they encounter discrimination, especially racism, it may trigger a stress response with negative emotional and physiological effects, including cortisol release and cardiovascular changes.29

      The key point to be made here is that IBD is closely linked to psychosocial distress and is often worsened by stress, emphasizing the need to address mental health as a crucial part of comprehensive care.27,29

      Last, but not least, let’s talk about the healthcare system, another social determinant we must consider.1 

      As you probably know, people in certain geographical locations in the US are less likely to have health insurance, as shown on the map here.30 For these individuals, including those with IBD, the lack of insurance coverage for comprehensive care could lead to financial strain and worsen clinical outcomes.31

      For patients in the United States who do have insurance coverage, the type and quality of insurance coverage can affect access to healthcare providers and treatments, which then directly impacts patient health outcomes.1,32 


      For example, as previously mentioned, low-income Medicaid patients typically have higher rates of ever being admitted to the hospital or visiting the ED compared to those with other types of insurance.6 

      Further, a study conducted using a database from the University of Chicago Medical Center to determine whether race and insurance status influence IBD diagnostic workup showed that patients on public health insurance, such as Medicaid or Medicare, have a 90% reduction in the likelihood of undergoing an appropriate workup for IBD and celiac disease, potentially contributing to underdiagnosis.32 

      At the beginning of this chapter, I mentioned that a key consideration is for all healthcare practitioners to account for social determinants of health when managing patients in our care. To this end, I want to emphasize that there are practices that we can do that can be impactful. 


      These include the following1:

      Advocate for policies that address inequities in social determinants of health. 

      Increase recruitment of underrepresented minority populations in clinical trials.

      Provide resources for low-income patients with IBD.

      Advocate for more GI providers in community settings.

      And enact mandatory implicit bias and anti-racism training. 

      These strategies could be used to address social determinants of health and take steps toward achieving health equity.1

      Lastly, it needs to be reiterated that to achieve health equity in IBD, it requires us all to implement targeted strategies at various levels.1 

      It means that we should shift away from race-based education; medical trainees should prioritize race-conscious medicine that acknowledges the impact of racism on health.1

      Healthcare providers should undergo implicit bias and anti-racism training, coupled with conscious action and self-reflection around one’s own beliefs and biases, to become more aware during interactions with vulnerable patient populations.1


      Practices and hospital systems need to integrate discussions on social determinants of health at the point of care and invest in community health.1

      This means that every community needs to establish more public-private collaborations and share resources to support patients with low income.1

      The healthcare industry should fund equity-based research to ensure diverse grant review committees and to boost clinical trial participation among under-represented populations.1

      And it means that policy makers can advocate for equitable policies and provide the NIH with funding for health equity research.1

      So, let’s do all that we can to promote change and improvement.

      As a passionate advocate for social determinants of health and health equity, I thank you for your interest and for spending some time with IBDIQ today to help adapt to the evolving care needs of all IBD patients.