Trends in hospitalisation rates for inflammatory bowel disease in western versus newly industrialised countries: a population-based study of countries in the Organisation for Economic Co-operation and Development
Hospitalisation rates for inflammatory bowel disease (IBD) vary across the world. We aimed to investigate temporal patterns of hospitalisation for IBD in member countries of the Organisation for Economic Co-operation and Development (OECD).
Methods
From the OECD database, we assessed IBD-related hospitalisation rates (expressed as annual rates per 100 000 inhabitants) for 34 countries from 1990 to 2016. We calculated mean hospitalisation rates for the period 2010–15 and used joinpoint regression models to calculate average annual percentage changes with 95% CIs.
Findings
Mean hospitalisation rates for IBD from 2010 to 2015 were highest in North America (eg, 33·9 per 100 000 in the USA), Europe (eg, 72·9 per 100 000 in Austria), and Oceania (eg, 31·5 per 100 000 in Australia). Hospitalisation rates for IBD were stabilising or decreasing over time in many countries in these regions but increasing in others. Countries in Asia and Latin America and the Caribbean had the lowest IBD-related hospitalisation rates but the greatest increases in rates over time. For example, Turkey had an annual hospitalisation rate of 10·8 per 100 000 inhabitants and an average annual percentage change of 10·4% (95% CI 5·2–15·9). Similarly, Chile had an annual hospitalisation rate of 9·0 per 100 000 inhabitants and an average annual percentage change of 5·9% (4·9–7·0).
Interpretation
Hospitalisation rates for IBD are high in western countries but are typically stabilising or decreasing, whereas rates in many newly industrialised countries are rapidly increasing, which reflects the known increase in IBD prevalence in these countries. Potential explanations for these trends include changes in the epidemiology of IBD, health-care delivery, and infrastructure in these countries, as well as overall country-specific patterns in hospitalisations and differences between countries in data collection methods.
Funding
None.
Introduction
The prevalence of inflammatory bowel disease (IBD) is highest in North America, Europe, and Australia.1, 2 Patients with IBD rely on several health-care resources, including medical and surgical management in hospital, which accounts for up to two-thirds of the direct health-care costs associated with IBD.3, 4, 5, 6, 7 Historically, rates of hospitalisation and intestinal resection for these patients have been highest in North America, Europe, and Australia.8 However, following the advent of biologics, several western countries have reported decreasing hospitalisation and surgical rates in patients with IBD, attributable to better control of disease.7, 8, 9, 10, 11
Epidemiological data indicate that the incidence of IBD is increasing in newly industrialised countries in Asia, the Middle East, and Latin America.12 The emergence of IBD over the past half century has paralleled economic advancement in these countries1, 12 and might be explained in part by westernisation. The hygiene hypothesis postulates that IBD occurs in genetically susceptible individuals exposed to environmental factors that alter the intestinal microbiome.1 As developing countries become increasingly industrialised and urbanised, their societies are exposed to environmental risk factors (eg, increased consumption of a western diet, reduced prevalence of breastfeeding, and increased prevalence of smoking) that have been associated with the development of IBD in western countries.1 Additionally, escalating socioeconomic status might contribute to rising incidence of IBD through improved detection resulting from increased access to medical technology, specialist care, and novel medical therapies and surgical techniques. Consequently, the increasing incidence of IBD in newly industrialised countries in Asia, the Middle East, and Latin America correlates with steadily rising hospital admission rates for IBD in these countries.13, 14
Research in context
Evidence before this study
The incidence of inflammatory bowel disease (IBD) has been stabilising or decreasing in many western countries since the turn of the 21st century, whereas newly industrialised countries are seeing an increase in incidence. The Organisation for Economic Co-operation and Development (OECD) is comprised of 36 member countries. For each OECD member country, we searched MEDLINE and Embase from 1990 onwards using the search terms (“inflammatory bowel disease”, “Crohn's disease”, “ulcerative colitis”) AND (“hospitalizations”, “hospital discharges”) to identify English-language studies that reported nationwide hospitalisation rates for IBD. Only seven OECD countries had previously reported nationwide estimates of hospitalisation rates for IBD; these estimates were consistent with hospitalisation rates for IBD reported in the OECD database (appendix pp 9–10).
Added value of this study
To our knowledge, this study is the first to evaluate hospitalisation rates and associated trends for IBD on a global scale. In view of the paradigm shift in the epidemiology of IBD throughout the world, we sought to investigate how these changes might be affecting the burden of IBD. Given that a substantial amount of the associated burden results from health-care utilisation, we calculated mean annual hospitalisation rates and average annual percentage changes in these rates for each OECD member country from 1990 to 2016. Many western countries had high hospitalisation rates that were stabilising or decreasing over time. By contrast, newly industrialised countries generally had low rates of hospitalisation for IBD, but these rates were increasing over time. These observed trends coincide with the epidemiological shifts in IBD that have been seen in western and newly industrialised nations. Several other factors that might also explain the trends observed in our study, from availability of hospital beds to the gross domestic product of a nation, were also identified. Ultimately, these trends in hospitalisations for IBD provide insight into the global burden of IBD and how it has changed since the turn of the 21st century.
Implications of all the available evidence
High or increasing IBD-related hospitalisation rates have several important clinical and policy implications. In most western countries, hospitalisation rates for IBD are decreasing, and there is a need for studies to identify the causes of this downward trend. In newly industrialised countries, where the incidence of IBD has been increasing since the turn of the century, increased surveillance of epidemiological patterns is necessary to document the trends in hospitalisation rates for IBD. Given that it is unlikely that the incidence of IBD has peaked in these countries, their governments and health-care systems must prepare clinical infrastructure to rapidly diagnose and manage IBD, or risk unnecessary morbidity and disease burden.
Data collected by the Organisation for Economic Co-operation and Development (OECD) provide unique opportunities to examine global epidemiological trends in health.15, 16, 17, 18, 19 There are 36 member countries, namely Australia, Austria, Belgium, Canada, Chile, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Japan, Latvia, Lithuania, Luxembourg, Mexico, New Zealand, Norway, Poland, Portugal, Slovakia, Slovenia, South Korea, Spain, Sweden, Switzerland, Turkey, the Netherlands, the UK, and the USA. The OECD provides a medium for governments to collaborate and work towards policy solutions related to the economic and social wellbeing of people across the world. The OECD collects international data on various topics, such as education, agriculture, migration, tax, and health; it has collected data on hospital discharges for IBD for the past 25 years. We did an exploratory analysis of hospitalisation rates in OECD member countries (using hospital discharges as a proxy for hospitalisation rates) to investigate global trends in IBD-related hospitalisations.
Section snippets
Data extraction
From a publicly available database on the OECD website,20 we obtained data on hospital discharges for IBD (measured as annual rates per 100 000 inhabitants), mean length of stay in hospital for IBD (measured annually as mean number of days spent in hospital), number of hospitals (total and publicly owned only; measured per 1 million inhabitants), number of hospital beds (in all hospitals and in publicly owned hospitals only; measured per 1000 inhabitants), health insurance coverage (measured as
Results
34 of the 36 OECD member countries had IBD-related hospital discharge rates for at least 1 year between 2010 and 2015 (table 1, figure 1); no data were available for Estonia or Greece. The median annual hospitalisation rate for IBD in all countries was 31·7 per 100 000 inhabitants (IQR 24·1–43·7). Rates were highest in North America; northern, eastern, and western Europe; and Oceania (table 1).
32 countries had sufficient data for temporal analyses (appendix pp 3–4). From 1990 to 2016,
Discussion
Our data show variable fluctuations in hospitalisation rates for IBD in OECD member countries over the past 25 years. The highest hospitalisation rates were in western countries; however, in many of these countries, hospitalisation rates were stabilising or decreasing over time. By contrast, newly industrialised countries in Asia and Latin America typically had low hospitalisation rates that were increasing over time. Understanding global trends in hospitalisation rates for IBD is essential for
Understanding and preventing the global increase of inflammatory bowel disease
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Hospitalizations for Crohn's disease—United States, 2003–13
Despite the increasing prevalence, hospitalization rates remained largely stable or decreasing in North America and Northern Europe. Heterogeneity between countries exists, with some countries reporting decreasing hospitalization rates for IBD (eg, Canada, −3.01% per year, Italy: −1.09% per year) and others reporting increasing hospitalization rates for IBD (the Netherlands, +3.25% per year, Portugal, +1.92% per year) (Supplementary Table 5).16 Although our study was not designed to explain the factors driving hospitalization trends, heterogeneity likely is explained by clinical, health system, and methodologic factors that differ between countries and studies.
The evolving epidemiologic patterns of inflammatory bowel disease (IBD) throughout the world, in conjunction with advances in therapeutic treatments, may influence hospitalization rates of IBD. We performed a systematic review with temporal analysis of hospitalization rates for IBD across the world in the 21st century.
We systematically reviewed Medline and Embase for population-based studies reporting hospitalization rates for IBD, Crohn’s disease (CD), or ulcerative colitis (UC) in the 21st century. Log-linear models were used to calculate the average annual percentage change (AAPC) with associated 95% confidence intervals (95% CIs). Random-effects meta-analysis pooled country-level AAPCs. Data were stratified by the epidemiologic stage of a region: compounding prevalence (stage 3) in North America, Western Europe, and Oceania vs acceleration of incidence (stage 2) in Asia, Eastern Europe, and Latin America vs emergence (stage 1) in developing countries.
Hospitalization rates for a primary diagnosis of IBD were stable in countries in stage 3 (AAPC, −0.13%; 95% CI, −0.72 to 0.97), CD (AAPC, 0.20%; 95% CI, −1.78 to 2.17), and UC (AAPC, 0.02%; 95% CI, −0.91 to 0.94). In contrast, hospitalization rates for a primary diagnosis were increasing in countries in stage 2 for IBD (AAPC, 4.44%; 95% CI, 2.75 to 6.14), CD (AAPC, 8.34%; 95% CI, 4.38 to 12.29), and UC (AAPC, 3.90; 95% CI, 1.29 to 6.52). No population-based studies were available for developing regions in stage 1 (emergence).
Hospitalization rates for IBD are stabilizing in countries in stage 3, whereas newly industrialized countries in stage 2 have rapidly increasing hospitalization rates, contributing to an increasing burden on global health care systems.
Population-based data on epidemiology of Inflammatory Bowel Diseases (IBD) in Brazil are scarce. This study aims to define temporal trends of incidence and prevalence rates of Crohn's disease (CD) and ulcerative colitis (UC) in Brazil.
All IBD patients from the public healthcare national system were included from January 2012 to December 2020. Average Annual Percent Change (AAPC) and 95% confidence intervals (CI) were calculated using log-linear regression for incidence and binomial regression for prevalence. Moran's I autocorrelation index was used to analyse clustering of cities by level of prevalence.
A total of 212,026 IBD patients were included. Incidence of IBD rose from 9.4 in 2012 to 9.6 per 100,000 in 2020 (AAPC=0.8%; 95% CI -0.37, 1.99); for UC, incidence increased from 5.7 to 6.9 per 100,000 (AAPC=3.0%; 95% CI 1.51, 4.58) and for CD incidence decreased from 3.7 to 2.7 per 100,000 (AAPC=-3.2%; 95% CI -4.45, -2.02). Prevalence of IBD increased from 30.0 in 2012 to 100.1 per 100,000 in 2020 (AAPC=14.8%; CI 14.78-14.95); for UC, from 15.7 to 56.5 per 100,000 (AAPC=16.0%; CI 15.94, 16.17); for CD from 12.6 to 33.7 per 100,000 (AAPC=12.1% CI 11.95, 12.02). A south-north gradient was observed in 2020 prevalence rates of IBD [I=0.40 (p<0.0001)], CD [I=0.22 (p<0.0001)] and UC [I=0.42 (p<0.0001)].
Incidence of CD is decreasing whereas of UC is increasing, leading to stabilization in the incidence of IBD from 2012 to 2020 in Brazil. Prevalence of IBD has been climbing with 0.1% of Brazilians living with IBD in 2020.
A potential stopgap would be to leverage epidemiologic and clinical outcome data from existing registries, which were originally developed to support more common diseases.38 Collaborations such as the Global Burden of Disease initiative and the Organisation for Economic Co-operation and Development have significantly enhanced understandings of IBD epidemiology, cost of illness, and the projected impact on healthcare services,39,40 yet analyses as relate to the subgroup of patients with PSC-IBD have not been presented. Similarly, datasets that were synthesized to understand how SARS-CoV-2 affects patients with IBD, liver disease, and cancer may be interrogated to further understanding of PSC prevalence, clinical course, and patient-reported outcomes.
The aim of this study was to quantify the global epidemiology of primary sclerosing cholangitis (PSC), alongside the incidence of liver transplantation, cancer, and death, through robust systematic review of population-based data.
We searched MEDLINE and EMBASE up to and including June 30, 2020 to identify population-based studies reporting the incidence and/or prevalence of PSC. Studies that did not report original data, or of exclusively pediatric-onset disease (diagnosis age <16 years) or exclusively PSC-associated with inflammatory bowel disease were excluded.
Of 4922 published studies, 17 fulfilled inclusion criteria; 16 documenting incidence and 14 prevalence. The highest reported incidence of PSC was reported in Northern Europe (Finland, 1.58 and Norway, 1.3 per-100,000 population, respectively) and North America (Minnesota, 1.47); with the lowest being observed across the Mediterranean Basin (Italy, 0.1). Prevalence ranged from 31.7 in Finland and 23.99 in Minnesota, to 1.33 in Singapore and 0.0 in Alaska. Of studies reporting temporal occurrence, an increase in disease incidence was observed across North America and Northern Europe (4 studies), alongside an increase in prevalence over time (4 studies). The incidence and risks for clinical outcomes were presented by 9 of the included studies. Median transplant-free survival ranged from 9.7 (United States) to 20.6 years (Netherlands), with standardized mortality ratios of 2.5 and 4.2 compared with the control population. The standardized incidence of cholangiocarcinoma ranged from 235 (Finland) to 398 (Netherlands).
Estimates of PSC incidence and prevalence vary, with most studies conducted in North America and Western Europe; the latter showing a steady increase in disease occurrence over time. Further research is needed to understand changes in disease epidemiology, including etiological drivers, the implications of rising case burden on health care policy, and better appreciation of PSC in the developing world.
We conducted a systematic review with meta-analysis to estimate rates and trends of colectomy in patients with ulcerative colitis (UC), and of primary and re-resection in patients with Crohn’s disease (CD), focusing on contemporary risks.
Through a systematic review until September 3, 2019, we identified population-based cohort studies that reported patient-level cumulative risk of surgery in patients with UC and CD. We evaluated overall and contemporary risk (after 2000) of surgery and analyzed time trends through mixed-effects meta-regression.
In patients with UC (26 studies), the overall 1-, 5-, and 10-year risks of colectomy was 4.0% (95% CI, 3.3–5.0), 8.8% (95% CI, 7.7–10.0), and 13.3% (95% CI, 11.3–15.5), respectively, with a decrease in risk over time (P < .001). Corresponding contemporary risks were 2.8% (95% CI, 2.0–3.9), 7.0% (95% CI, 5.7–8.6), and 9.6% (95% CI, 6.3–14.2), respectively. In patients with CD (22 studies), the overall 1-, 5-, and 10-year risk of surgery was 18.7% (95% CI, 15.0–23.0), 28.0% (95% CI, 24.0–32.4), and 39.5% (95% CI, 33.3–46.2), respectively, with a decrease in risk over time (P < .001). Corresponding contemporary risks were 12.3% (95% CI, 10.8–14.0), 18.0% (95% CI, 15.4–21.0), and 26.2% (95% CI, 23.4–29.4), respectively. In a meta-analysis of 8 studies in patients with CD with prior resection, the cumulative risk of a second resection at 5 and 10 years after the first resection was 17.7% (95% CI, 13.5–22.9) and 31.3% (95% CI, 24.1–39.6), respectively.
Patient-level risks of surgery have decreased significantly over time, with a 5-year cumulative risk of surgery of 7.0% in UC and 18.0% in CD in contemporary cohorts. This decrease may be related to early detection and/or better treatment.
These interventions can improve quality of care, and potentially reduce costs in resource-limited settings by reducing morbidity and the need for hospitalisation for surgery, and permit the reallocation of resources for care by IBD specialists.61 Hospitalisation rates for IBD in many newly industrialised countries are rapidly increasing, which reflects the known increase in IBD prevalence and health-care burden in these countries.62 The risk of opportunistic infections in patients with IBD is high, especially with combined immunomodulator therapy, presence of malnutrition, and increasing age.7
Inflammatory bowel disease (IBD) is increasing in prevalence in resource-limited settings in Asia. Although the prevalence of IBD is lower in these settings than in high-income countries, the high disease burden due to large population size is projected to overtake that of high-income countries in the near future. Unique challenges exist for diagnosing and managing IBD in Asia. On one hand, the inadequate disease awareness in physicians and the general population, the scarcity of diagnostic services, the infectious mimics of IBD (specifically intestinal tuberculosis), and the widespread use of empirical antibiotics and antitubercular therapy pose diagnostic challenges. On the other hand, the absence of a centralised health-care delivery system or universal health insurance, the high cost of therapy, limited access to biologics, and the high risk of opportunistic infections with immunosuppressive therapy present therapeutic challenges. The high probability of tuberculosis reactivation often precludes biological therapy because Asia is highly endemic for tuberculosis and has a high prevalence of latent tuberculosis. Current screening strategies are often ineffective in ruling out latent tuberculosis. Hence, management strategies are often modified according to these challenges. This Series paper discusses the challenges in the diagnosis and management of IBD in resource-limited settings in Asia.
