Corticosteroid Use, Bone Density Screening, and the Influence of Insurance in Patients with Inflammatory Bowel Disease: A Retrospective Analysis

Corticosteroid Use, Bone Density Screening, and the Influence of Insurance in Patients with Inflammatory Bowel Disease: A Retrospective Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Corticosteroid Use, Bone Density Screening, and the Influence of Insurance in Patients with Inflammatory Bowel Disease: A Retrospective Analysis Anvit Reddy, Landen Shane Burstiner, Niyati Patel, Nadim Qadir, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6524164/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Mar, 2026 Read the published version in BMC Gastroenterology → Version 1 posted 9 You are reading this latest preprint version Abstract Background: Corticosteroid use among inflammatory bowel disease (IBD) patients is common as they are highly effective in the management of flares. However, both corticosteroid use and IBD have been linked to bone mineral density deficiencies. As a result, guidelines recommend dual-energy X-ray absorptiometry (DEXA) screening in these patients. The main objectives of this study were threefold: to quantify the amount of corticosteroids prescribed per patient, assess whether patients were appropriately referred for DEXA scans according to CMS guidelines, and to evaluate the rate of completion for the ordered DEXA scans. Additionally, we aimed to evaluate whether insurance status impacted the cumulative amounts of corticosteroids prescribed and access to DEXA scans. Methods: 16,387 adult patients who were seen at two tertiary healthcare systems in the southeastern United States with a diagnosis of IBD were included. Patient characteristics and DEXA scan referral rates were obtained. Patients prescribed ≥600 prednisone equivalents were deemed to qualify for DEXA scan screening. Results: Underinsured patients (UP) were prescribed significantly more prednisone and less budesonide than insured patients (IP). There was no significant difference in scan completion rate: 66.7% for UP and 75.6% for IP. Overall, the completion rates for DEXA scans among patients prescribed ≥600 equivalents were 19.6% for UP and 20.3% for IP, with an overall rate of 20.3%. Conclusion: DEXA scan screening for bone mineralization deficits is underperformed for IBD patients on chronic steroid therapy. Insurance had no impact on the ordering or completion rate of DEXA scans in our study. Trial Registration: Retrospectively registered Osteoporosis in inflammatory bowel disease screening health maintenance corticosteroid use Introduction Inflammatory bowel disease (IBD) comprises of Crohn’s disease (CD) and ulcerative colitis (UC). Both diseases are characterized by inflammation throughout the gastrointestinal tract. The mainstay of treatment is keeping the disease process in remission and limiting disease progression [ 1 ]. Although corticosteroids can be highly effective for inducing a response in the short-term, long-term treatment is not feasible given their safety profile. Main treatments include aminosalicylcates with evolution to immunomodulators, biologics, and small molecules. Although all guidelines recommend early transition to steroid-sparing treatment alternatives, the use of corticosteroids remains high among patients with IBD [ 2 ]. Oral corticosteroids have been used in IBD management since the 1950s [ 3 ]. The mechanism of action involves modulating cytokine production, thereby inactivating pro-inflammatory transcription factors such as activator protein-1 and nuclear factor kappa B [ 4 ]. Additionally, through interactions with glucocorticoid receptors in the nucleus, inflammatory cell expression to tissues including intestinal cells is inhibited [ 2 ]. First-generation glucocorticoids such as prednisone have traditionally been used in managing IBD flares due to their systemic effects and low cost [ 5 ]. However, the systemic effects of corticosteroids lead to systemic side-effects such as hyperglycemia, cataracts, psychiatric complications, and increased fracture risk [ 3 ]. Corticosteroids contribute to bone breakdown by both stimulating osteoclastogenesis and inhibiting osteoblast number and function via inhibition of insulin-like growth factor 1 expression [ 6 ]. Therefore, they are strongly associated with bone mineralization defects [ 7 ]. Oral budesonide offers advantages to prednisone in that it is locally acting, with a low systemic bioavailability. However, the data describing budesonide’s effect on bone mineral density (BMD) is unclear. In one randomized controlled trial, budesonide and prednisolone were found to be equally effective in the management of Crohn’s disease, with patients in the budesonide arm having better-preserved bone mass [ 8 ]. A study by Cino and Greenberg however, demonstrated that budesonide did not confer an advantage over low-dose prednisone for the preservation of bone mineral density in IBD patients [ 9 ]. Corticosteroid use among IBD patients is very common and prescribed in many different settings, including primary care clinics, urgent care centers, gastroenterology clinics, emergency departments, and during hospital admissions [ 10 ]. As a result, lifetime or even yearly corticosteroid use in IBD patients is difficult to quantify. One study reported that 32% of IBD patients required at least one course of corticosteroids over 8 years, with 17% of patients having prolonged courses [ 10 ]. Another retrospective study showed 34.3% of IBD patients received at least one course of corticosteroid over a seven-year period [ 11 ]. Another study reported that corticosteroids were used in 20.1% of CD patients and 30.2% of UC patients within a one-year study period, with 13.3% of CD patients and 17.7% of UC patients having excessive corticosteroid exposure (defined in the study as multiple corticosteroid courses or courses lasting for more than three months) [ 12 ]. Another study noted that 28% of IBD patients received steroids within the 12 months observed, with 14.8% of patients receiving excess steroids (> 1 steroid prescription in 12 months or courses longer than three months) [ 13 ]. There are no studies that directly correlate yearly steroid use and BMD. In terms of quantitative steroid use, one study reported that ≥ 3,000 milligrams of corticosteroid use in any 365-day period were associated with a three times increased hazard of resective surgery compared to patients with < 3,000 milligrams (mg) of prednisone used [ 14 ]. Additionally, IBD itself predisposes patients to BMD deficiencies [ 15 ]. The etiology is multifactorial, including malnutrition, malabsorption (vitamins such as calcium and vitamin D), and systemic inflammation [ 15 , 16 ]. Inflammatory cytokines induce bone loss through imbalances in RANK ligand and osteoprotegerin pathways [ 16 ]. In the United States, dual-energy X-ray absorptiometry (DEXA) scan screening is recommended for women 65 years and older and postmenopausal women younger than 65 years who are at increased risk of osteoporosis. There are no recommendations for screening men which differs from the CMS guidelines that include younger women and men [ 17 , 18 ]. The prevalence of osteopenia and osteoporosis in IBD is as high as 77% and 13–42%, respectively [ 19 ]. As a result, DEXA scan screening in IBD patients varies from the United States Preventive Service Task Force recommendations for average-risk patients [ 17 ]. The Centers for Medicare and Medicaid Services (CMS) recommend screening IBD patients with chronic corticosteroid use (defined as prednisone equivalents greater than or equal to 10 mg per day for 60 or more consecutive days or a single prescription equating to 600 mg of prednisone or more), history of vertebral fractures, postmenopausal women, and men over 50 years old [ 18 ]. Studies have demonstrated that low socioeconomic status has been linked with poor health outcomes [ 20 ]. Underinsured and Medicaid patients with IBD were shown to have higher hospitalization rates and higher steroid prevalences [ 21 ]. There are no studies that evaluate the direct impact of insurance status on DEXA scan screening in IBD patients. The main objectives of this study were threefold: to quantify the amount of corticosteroids prescribed per patient, assess whether patients were appropriately referred for DEXA scans according to CMS guidelines, and to evaluate the rate of completion of the ordered DEXA scans. Additionally, we aimed to evaluate if insurance status impacted both the cumulative amounts of corticosteroids prescribed and access to guideline-recommended bone mineral density screening. Methods Data was exported from electronic health records of 16,387 patients who were seen at one of two tertiary healthcare systems in the southeastern United States from 2012–2023 with at least three International Classification of Disease codes representing CD or UC. Patients were excluded if they were not seen in the health system’s Gastroenterology clinics at least once or had incomplete demographic information. Exported data included demographics, diagnoses, ordering of imaging, outpatient and inpatient prescription information, and insurance information. We chose to compare our data set to CMS guidelines instead of the American Gastroenterological Association (AGA) guidelines because they offered cumulative prednisone equivalent thresholds for DEXA screening, whereas AGA guidelines offered screening recommendations based on time of steroid use (AGA) [ 22 ]. We set our threshold for patients meeting DEXA screening guidelines at prednisone equivalents at 600mg minimum. The minimum prednisone equivalent was chosen per the CMS guidelines for DEXA screening [ 19 ]. There is no robust data on the average lifetime prescription of steroids in IBD patients nor the average corticosteroids prescribed for an IBD flare. However, guidelines recommend treating an IBD flare with “40–60 mg prednisone tapered over 4–6 weeks,” which corresponds to a minimum of 700 mg and a maximum of 2730 mg prednisone per flare [ 23 ]. Essentially, if patients are treated for a single IBD flare, the amount of prednisone used would eclipse the 600 mg threshold and warrant bone mineral density screening according to the CMS guidelines. Additionally, we wanted to assess if escalating prednisone equivalents led to increases in DEXA scans ordered. The conversion from oral budesonide to prednisone is not well-defined due to differing first-pass metabolisms. All budesonide prescriptions were converted to prednisone equivalents via the conversions from the Journal of Allergy and Clinical Immunology, which defined 0.375 mg of budesonide to equal 5 mg of prednisone [ 24 ]. The “advanced therapies” group included patients who were prescribed biologic agents, including adalimumab, infliximab, certolizumab, ustekinumab, natalizumab, vedolizumab, and risankizumab or small molecule agents, including tofacitinib and upadacitinib. Patient characteristics and outcomes were analyzed using chi-squared testing. The insured patients (IP) cohort included all funded patients who had either a government insurance provider, commercial provider or fee-assistance programs. The underinsured patient (UP) cohort included patients with self-pay and no insurance. A chi-square test of independence was performed to examine the relationship between prednisone equivalents and patients referred for DEXA Scan, and patients who completed DEXA scans among those ordered. Data was remodeled using only patients under 65 years of age in order to exclude those that qualify for age-related osteoporosis screening. Statistical significance was set at p < .05. Univariate analyses were performed to identify correlations between our three outcomes of interest (the prescription of ≥ 600 mg steroids, the ordering of DEXA scans among patients who were prescribed ≥ 600 mg steroids, and the completion of ordered DEXA scans) and prognostic factors. Factors with a p -value < 0.20 in univariate analysis were entered into the multivariate logistic model to control for potential confounding variables. Ultimately, a p -value of < 0.05 was considered to be statistically significant. Results A total of 9065 patients met inclusion criteria. Our population of patients had an average age of 50.75 ± 19.29 and average BMI of 27.07 ± 7.20 (Table 1 ). When stratified by UP vs IP, there were no significant differences in age ( p = 0.11), sex composition ( p = .052), proportion with CD vs UC ( p = 0.51, and body mass index (p = 0.96)) (Table 1 ). Table 1 Patient characteristics stratified by insurance category Underinsured ( N = 311) Insured ( N = 8754) p -value Total ( N = 9065) Mean Age ± SD (years) 49.47 ± 13.75 50.83 ± 19.58 0.11 50.75 ± 19.29 Sex, N (%) 0.052 Male 245 (45.2%) 3492 (40.97%) 3737 (41.22%) Female 297 (54.8%) 5031 (59.03%) 5328 (58.78%) Disease Subtype, N (%) 0.51 Ulcerative Colitis 118 (37.94%) 3485 (39.81%) 3603 (39.75%) Crohn’s disease 193 (62.06%) 5269 (60.19%) 5462 (60.25%) Mean Body Mass Index ± SD (kg/m 2 ) 27.08 ± 7.52 27.07 ± 7.18 0.96 27.07 ± 7.20 UP were prescribed significantly more prednisone ( p = 0.025) and significantly less budesonide (p < 0.001) than IP (Table 2 ). Overall, the average patient was prescribed 5314 ± 19584 mg of prednisone equivalents. Table 2 IBD Patients seen in the outpatient Gastroenterology clinic by insurance category Underinsured ( N = 311) Insured ( N = 8754) p -value Amount of Corticosteroids Prescribed (mean number of milligrams ± SD) Combined corticosteroids prescribed 3778 ± 9133 5369 ± 19852 0.005 Prednisone prescribed 2588 ± 7157 1659 ± 6453 0.025 Budesonide prescribed 89 ± 394 278 ± 1347 < .001 Patients who met criteria for bone density screening, had DEXA scan appropriately ordered, and/or completed the ordered DEXA scan, N (%) Patients prescribed ≥ 600 mg prednisone equivalents 133 (43%) 2900 (33%) < .001 Patients prescribed ≥ 600 mg prednisone equivalents who had DEXA ordered 39 (29%) 780 (27%) .54 Patients prescribed ≥ 600 mg prednisone equivalents who had DEXA ordered and completed it 26 (67%) 590 (76%) .20 Prescription of Advanced Therapies, N (%) Patients prescribed at least one advanced therapy 106 (34%) 3465 (40%) .051 Of the 9065 total patients included, 3033 were prescribed ≥ 600 mg equivalents of prednisone and qualified for DEXA scan screening based on our methods (Table 2 ). Compared to insured patients, a higher proportion of UP were prescribed ≥ 600 prednisone equivalents (42.8% vs 33.1%, respectively; p < 0.001) with no significant differences in biologics or small molecules prescribed ( p = .051). Among patients who qualified for DEXA scan screening, there was no significant difference in the proportion that had a DEXA scan ordered ( p = .54). Furthermore, among patients who qualified for DEXA scan screening and had a DEXA scan ordered, there was no significant difference in scan completion rate; 66.7% for UP and 75.6% for IP ( p = .205). Overall, the completion rates for DEXA scans among those who were prescribed ≥ 600 equivalents were 19.6% for UP and 20.3% for IP, with an overall rate of 20.3%. When analyses were re-conducted while excluding patients over 64 years old, the same findings remained significant. Overall, the completion rates for DEXA scans among those who were prescribed ≥ 600 equivalents, excluding patients over 64 years of age, were 17.4% for UP and 18.4% for IP, with a combined rate of 18.4%. A multivariate model was constructed as detailed in the methods section in order to adjust for covariates (age, sex composition, race, type of IBD, BMI, and insurance status). Patients of younger age (Odds ratio 1.012, 95% confidence interval [1.009–1.015]), female sex (1.134, [1.025–1.182]), lower BMI (1.011, [1.004–1.018]) and patients who were underinsured (1.508, [1.151–1.931]) had higher odds of receiving ≥ 600 mg steroids (and thus meeting criteria for DEXA scan screening). A second multivariate model was built to assess the odds of having a DEXA scan ordered among patients who were prescribed ≥ 600 mg. When adjusting for the same covariates, patients with older age (1.024, [1.018–1.029]), female sex (1.426, [1.182–1.719]), patients with Crohn's disease (OR 1.255 [1.043–1.511]), and higher BMI (1.021, [1.008–1.033]) had higher odds of having a DEXA scan ordered. Of note, among patients who were prescribed ≥ 600 mg steroids, insurance group did not significantly impact the odds of having a DEXA scan ordered (OR 1.49, [0.843–2.634]). Finally, after adjusting for the same covariates among patients who were prescribed > 600 mg steroids and had a DEXA scan ordered, only younger age had a significantly increased odds (1.010, [1.003–1.016]) of completing it. When adjusting for age, sex composition, race, type of IBD, BMI, and insurance group in a multivariate model, underinsured patients had a significantly higher odds of receiving > 600 mg of steroids (OR 1.508, [1.151–1.931]). However, using the same multivariate analysis, insurance status had no significant impact on the odds of a physician ordering a DEXA scan or on the odds of a patient completing the ordered DEXA scan. Discussion Our study showed that uninsured patients received, on average, a higher mean amount of corticosteroid prescriptions and were more likely to eclipse the 600 mg prednisone equivalents threshold which would warrant bone density screening. We were unable to find any direct comparisons published in literature as our data was cumulative. The closest comparison would be previously reported annual excessive corticosteroid use rates ranging from 13.3–17.7% [ 12 ] which, as one would expect, are lower than our results showing 33.4% of our IBD patients were prescribed enough cumulative corticosteroids to warrant bone density screening. We also demonstrated that insurance significantly impacts the type of corticosteroid prescribed. Insured patients were more likely to receive budesonide and less likely to receive prednisone, when compared to the underinsured cohort. These findings could be a reflection of the higher cost of budesonide compared to prednisone. While our study did not show a statistically significant difference in access to advanced therapies among the two groups (p = 0.051), several other studies have found that UP lacked access to advanced therapy, predisposing them to more ED visits and more frequent prednisone prescriptions [ 21 , 25 ]. DEXA scan screening for bone mineralization deficits is underperformed for IBD patients on chronic steroid therapy. We expected the underinsured cohort to have fewer DEXA scans ordered and completed, based on prior studies describing health disparities in patients that are underinsured [ 21 ]. However, insurance had no impact in the ordering, nor completion rate of DEXA scans in our study. In our facility, DEXA scans were ordered in 27% of the IBD patients who qualified for screening. While this is an obvious target for improvement, it appears to be in line with other institutions. In one study, only 10.6% of patients had DEXA scan screening performed despite using ≥ 500mg of corticosteroids within a year [ 26 ]. Another institution reported that of the eligible IBD patients, 21% and 44% were referred for DEXA scans from their Veteran’s Affairs clinic and county hospital, respectively [ 27 ]. When our patients were appropriately referred for DEXA scans, most completed them, regardless of insurance group. This suggests that a lack of recognition among physicians is currently the largest hurdle preventing patients from obtaining guideline-based bone density screening. Of note, both tertiary institutions examined in this study have relatively robust programs for certain patients with low socioeconomic status, with funding provided by city, state, and federal grants. One such program, classified under “charity insurance,” requires applicants to meet with a financial representative and provide documents that demonstrate financial or logistical needs, at which time they may qualify for a special payment card that entitles them to free or reduced-cost primary care, specialty care, and screening exams at our institution. This process takes effort on behalf of the patient, therefore this subset of patients may be more capable or motivated to follow up on healthcare recommendations, including bone mineral density screening. These patients were grouped in the Insured category as, after obtaining their insurance, they had similar coverage to a commercial-insured patients, albeit at just one health system. Among these patients, 100% of the 58 patients who had a DEXA ordered completed the scan, which far outpaced our overall average completion rate of 75.6%. While not the focus of this study, this serves as a testament to how effective local, health-system based charity opportunities can be. These “charity programs” may limit generalizability to other institutions that do not offer this level of support for patients with low socio-economic status, potentially lowering the DEXA scan ordering and completions rates further. There are inherent limitations given the retrospective nature of our study. Our study analyzed data based on corticosteroid prescriptions. Lifetime medication doses are notoriously difficult to quantify in retrospective studies, with no guarantee that patients picked them up and consumed them. Our data was collected from two large tertiary health care systems that accept referrals and patients from a wide area. This data does not include corticosteroids given during hospitalizations, at urgent cares, by non-affiliated primary doctors, or any other source not affiliated with the two large academic centers that were studied. Patients may have been previously treated with corticosteroids for years before establishing care at one of our centers and may have received steroids for other conditions (like rheumatoid arthritis), and those would not be quantified in this study. As mentioned in the methods, we chose to err on the conservative side, with the understanding that an IBD patient’s lifetime corticosteroid usage is likely, on average, far higher than the values represented here. Also, DEXA scan orders from primary care physicians outside of our network could have been present and would not be accounted for. Our study benefited from a large patient population; however, due to its size, it was difficult and imprecise to analyze incidence or temporal associations. Therefore, we do not present information on corticosteroids per year. A future quality improvement project could focus on a method of tracking cumulative steroid doses in IBD patients, considering the variety of providers that prescribe corticosteroids. Evaluating the yield of osteopenia and osteoporosis from the DEXA scans performed can help provide insight into whether current screening guidelines are appropriate. Finally, a subgroup analysis stratifying for race or sex instead of insurance status may highlight additional social disparities. Regardless of insurance status, DEXA scan rates in all cohorts studied remained substandard. Although socioeconomic disparities have been demonstrated to influence screening rates, our study suggests that other factors beyond insurance status may influence DEXA scan ordering and completion more significantly [ 21 ]. Efforts should be made to improve them, perhaps systemically by implementing a cumulative steroid database (similar to the prescription drug monitoring programs which are associated with large relative reductions in prescription opioid utilization among high-risk patients and increasing provider awareness about the disparities [ 28 ]. Abbreviations Inflammatory bowel disease (IBD) Crohn’s disease (CD) Ulcerative colitis (UC) Dual-energy X-ray absorptiometry (DEXA) Bone mineral density (BMD) Underinsured patients (UP) Insured patients (IP) Centers for Medicare and Medicaid Services (CMS) American Gastroenterological Association (AGA) Declarations Ethics Approval and consent to participate: Institutional board review was obtained for this retrospective review (IRB202202649) from the institutional board review at the University of Florida. Peter Iafrate, the IRB Chairman from the University of Florida approved the methods used to collect data included in this study. This study was approved as secondary research for which consent is not required: Secondary research uses of identifiable private information or identifiable biospecimens, if at least one of the following criteria is met: the research involves only information collection and analysis involving the investigator's use of identifiable health information when that use is regulated under 45 CFR parts 160 and 164, subparts A and E, for the purposes of “health care operations” or “research” as those terms are defined at 45 CFR 164.501 or for “public health activities and purposes” as described under 45 CFR 164.512(b). Consent for publication: All authors listed on this manuscript consent to publication. There are no identifying images, personal, or clinical details presented in this manuscript that compromise anonymity of those involved or studied. Data Availability: The data that support the findings of this study are available from the corresponding author, Anvit Reddy, upon reasonable request. The data are not publicly available in order to protect the privacy of the research participants. Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors Author Contributions: A.R.: Study design, data analysis, preparing and revising the manuscript, corresponding author L.B.: Study design, data collection, data analysis, preparing and revising the manuscript N.P. Preparing and revising the manuscript, especially the introduction N.Q.: Preparing and revising the manuscript, especially the discussion G.G.: Preparing and revising the manuscript, especially the discussion M.S.: Study inception, Study design, preparing and revising the manuscript L.S.: Study inception, Study design, preparing and revising the manuscript Conflicts of Interest: The authors whose names are listed immediately below certify that they have NO affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript. 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Cite Share Download PDF Status: Published Journal Publication published 17 Mar, 2026 Read the published version in BMC Gastroenterology → Version 1 posted Editorial decision: Revision requested 18 Jan, 2026 Reviews received at journal 04 Dec, 2025 Reviews received at journal 26 Nov, 2025 Reviewers agreed at journal 22 Nov, 2025 Reviewers agreed at journal 21 Nov, 2025 Reviewers invited by journal 30 May, 2025 Editor assigned by journal 02 May, 2025 Submission checks completed at journal 30 Apr, 2025 First submitted to journal 30 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6524164","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":464898665,"identity":"d464b8f4-c7c9-4ea8-b75e-bae8bed046c5","order_by":0,"name":"Anvit Reddy","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAElEQVRIiWNgGAWjYJCCAxAygfGBBIjBfLiBgYGNgJYDEC3MBmAtbImEtTBAtbCBdRDUwj+7x/DwB4Z7cnzHc8wqLGoOMxgcY2xg+FB2GKcWiTtnDIAOKzaWPPPG7IbEsTSwFsYZ53BrYbiRlgDUkpC44UYOUAubDYPB/cYGZt423FrkoVrqQVoKJP5JgG1h/otHi8GN5AMgLQkGQC0Mkm02EC2MeLQYgrScMUgwnHnmWbGEZF8ajyRQy8Gec+k4tcjdSGz+UFGRIM93PHnjZ4lvh+X4jjEffPCjzBq39yHOAxEcBszAiOEBMQ8QUA8D7A8YPxCpdBSMglEwCkYWAAAlnl5xwmHwHgAAAABJRU5ErkJggg==","orcid":"","institution":"University of Florida College of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Anvit","middleName":"","lastName":"Reddy","suffix":""},{"id":464898666,"identity":"e59f67c1-942b-421d-9266-ec4640b36162","order_by":1,"name":"Landen Shane Burstiner","email":"","orcid":"","institution":"University of Florida College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Landen","middleName":"Shane","lastName":"Burstiner","suffix":""},{"id":464898668,"identity":"4e314aee-2ba6-48c5-954f-8c07d3e81912","order_by":2,"name":"Niyati Patel","email":"","orcid":"","institution":"University of Florida College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Niyati","middleName":"","lastName":"Patel","suffix":""},{"id":464898670,"identity":"a8a3cb09-3a76-4b04-a578-dd5b7181bfc2","order_by":3,"name":"Nadim Qadir","email":"","orcid":"","institution":"University of Florida College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Nadim","middleName":"","lastName":"Qadir","suffix":""},{"id":464898671,"identity":"a9bd710d-08e0-425b-a604-c7251eaf007c","order_by":4,"name":"Gerardo Diaz-Garcia","email":"","orcid":"","institution":"University of Florida College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Gerardo","middleName":"","lastName":"Diaz-Garcia","suffix":""},{"id":464898672,"identity":"f1f5705b-57d1-4c87-9620-638f882845e9","order_by":5,"name":"Marianny Sulbaran","email":"","orcid":"","institution":"University of Florida College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Marianny","middleName":"","lastName":"Sulbaran","suffix":""},{"id":464898673,"identity":"11ee687f-e89b-4a8b-bf0d-4feaf214ca11","order_by":6,"name":"Lauren Stemboroski","email":"","orcid":"","institution":"University of Florida College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Lauren","middleName":"","lastName":"Stemboroski","suffix":""}],"badges":[],"createdAt":"2025-04-25 01:08:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6524164/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6524164/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12876-026-04717-5","type":"published","date":"2026-03-17T15:58:33+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":105223770,"identity":"e207e648-4291-4c3e-8115-c5a57a12e0d3","added_by":"auto","created_at":"2026-03-23 16:10:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":529420,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6524164/v1/e3d40510-bcff-45b8-ae41-bd98463dad0e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Corticosteroid Use, Bone Density Screening, and the Influence of Insurance in Patients with Inflammatory Bowel Disease: A Retrospective Analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eInflammatory bowel disease (IBD) comprises of Crohn\u0026rsquo;s disease (CD) and ulcerative colitis (UC). Both diseases are characterized by inflammation throughout the gastrointestinal tract. The mainstay of treatment is keeping the disease process in remission and limiting disease progression [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Although corticosteroids can be highly effective for inducing a response in the short-term, long-term treatment is not feasible given their safety profile. Main treatments include aminosalicylcates with evolution to immunomodulators, biologics, and small molecules. Although all guidelines recommend early transition to steroid-sparing treatment alternatives, the use of corticosteroids remains high among patients with IBD [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOral corticosteroids have been used in IBD management since the 1950s [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The mechanism of action involves modulating cytokine production, thereby inactivating pro-inflammatory transcription factors such as activator protein-1 and nuclear factor kappa B [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Additionally, through interactions with glucocorticoid receptors in the nucleus, inflammatory cell expression to tissues including intestinal cells is inhibited [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. First-generation glucocorticoids such as prednisone have traditionally been used in managing IBD flares due to their systemic effects and low cost [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, the systemic effects of corticosteroids lead to systemic side-effects such as hyperglycemia, cataracts, psychiatric complications, and increased fracture risk [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Corticosteroids contribute to bone breakdown by both stimulating osteoclastogenesis and inhibiting osteoblast number and function via inhibition of insulin-like growth factor 1 expression [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Therefore, they are strongly associated with bone mineralization defects [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOral budesonide offers advantages to prednisone in that it is locally acting, with a low systemic bioavailability. However, the data describing budesonide\u0026rsquo;s effect on bone mineral density (BMD) is unclear. In one randomized controlled trial, budesonide and prednisolone were found to be equally effective in the management of Crohn\u0026rsquo;s disease, with patients in the budesonide arm having better-preserved bone mass [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. A study by \u003cem\u003eCino and Greenberg\u003c/em\u003e however, demonstrated that budesonide did not confer an advantage over low-dose prednisone for the preservation of bone mineral density in IBD patients [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCorticosteroid use among IBD patients is very common and prescribed in many different settings, including primary care clinics, urgent care centers, gastroenterology clinics, emergency departments, and during hospital admissions [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. As a result, lifetime or even yearly corticosteroid use in IBD patients is difficult to quantify. One study reported that 32% of IBD patients required at least one course of corticosteroids over 8 years, with 17% of patients having prolonged courses [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Another retrospective study showed 34.3% of IBD patients received at least one course of corticosteroid over a seven-year period [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Another study reported that corticosteroids were used in 20.1% of CD patients and 30.2% of UC patients within a one-year study period, with 13.3% of CD patients and 17.7% of UC patients having excessive corticosteroid exposure (defined in the study as multiple corticosteroid courses or courses lasting for more than three months) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Another study noted that 28% of IBD patients received steroids within the 12 months observed, with 14.8% of patients receiving excess steroids (\u0026gt;\u0026thinsp;1 steroid prescription in 12 months or courses longer than three months) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. There are no studies that directly correlate yearly steroid use and BMD. In terms of quantitative steroid use, one study reported that \u0026ge;\u0026thinsp;3,000 milligrams of corticosteroid use in any 365-day period were associated with a three times increased hazard of resective surgery compared to patients with \u0026lt;\u0026thinsp;3,000 milligrams (mg) of prednisone used [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAdditionally, IBD itself predisposes patients to BMD deficiencies [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The etiology is multifactorial, including malnutrition, malabsorption (vitamins such as calcium and vitamin D), and systemic inflammation [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Inflammatory cytokines induce bone loss through imbalances in RANK ligand and osteoprotegerin pathways [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the United States, dual-energy X-ray absorptiometry (DEXA) scan screening is recommended for women 65 years and older and postmenopausal women younger than 65 years who are at increased risk of osteoporosis. There are no recommendations for screening men which differs from the CMS guidelines that include younger women and men [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The prevalence of osteopenia and osteoporosis in IBD is as high as 77% and 13\u0026ndash;42%, respectively [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. As a result, DEXA scan screening in IBD patients varies from the United States Preventive Service Task Force recommendations for average-risk patients [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The Centers for Medicare and Medicaid Services (CMS) recommend screening IBD patients with chronic corticosteroid use (defined as prednisone equivalents greater than or equal to 10 mg per day for 60 or more consecutive days or a single prescription equating to 600 mg of prednisone or more), history of vertebral fractures, postmenopausal women, and men over 50 years old [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStudies have demonstrated that low socioeconomic status has been linked with poor health outcomes [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Underinsured and Medicaid patients with IBD were shown to have higher hospitalization rates and higher steroid prevalences [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. There are no studies that evaluate the direct impact of insurance status on DEXA scan screening in IBD patients.\u003c/p\u003e \u003cp\u003e The main objectives of this study were threefold: to quantify the amount of corticosteroids prescribed per patient, assess whether patients were appropriately referred for DEXA scans according to CMS guidelines, and to evaluate the rate of completion of the ordered DEXA scans. Additionally, we aimed to evaluate if insurance status impacted both the cumulative amounts of corticosteroids prescribed and access to guideline-recommended bone mineral density screening.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eData was exported from electronic health records of 16,387 patients who were seen at one of two tertiary healthcare systems in the southeastern United States from 2012\u0026ndash;2023 with at least three International Classification of Disease codes representing CD or UC. Patients were excluded if they were not seen in the health system\u0026rsquo;s Gastroenterology clinics at least once or had incomplete demographic information. Exported data included demographics, diagnoses, ordering of imaging, outpatient and inpatient prescription information, and insurance information.\u003c/p\u003e \u003cp\u003eWe chose to compare our data set to CMS guidelines instead of the American Gastroenterological Association (AGA) guidelines because they offered cumulative prednisone equivalent thresholds for DEXA screening, whereas AGA guidelines offered screening recommendations based on time of steroid use (AGA) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. We set our threshold for patients meeting DEXA screening guidelines at prednisone equivalents at 600mg minimum. The minimum prednisone equivalent was chosen per the CMS guidelines for DEXA screening [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere is no robust data on the average lifetime prescription of steroids in IBD patients nor the average corticosteroids prescribed for an IBD flare. However, guidelines recommend treating an IBD flare with \u0026ldquo;40\u0026ndash;60 mg prednisone tapered over 4\u0026ndash;6 weeks,\u0026rdquo; which corresponds to a minimum of 700 mg and a maximum of 2730 mg prednisone per flare [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Essentially, if patients are treated for a single IBD flare, the amount of prednisone used would eclipse the 600 mg threshold and warrant bone mineral density screening according to the CMS guidelines. Additionally, we wanted to assess if escalating prednisone equivalents led to increases in DEXA scans ordered.\u003c/p\u003e \u003cp\u003eThe conversion from oral budesonide to prednisone is not well-defined due to differing first-pass metabolisms. All budesonide prescriptions were converted to prednisone equivalents via the conversions from the Journal of Allergy and Clinical Immunology, which defined 0.375 mg of budesonide to equal 5 mg of prednisone [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The \u0026ldquo;advanced therapies\u0026rdquo; group included patients who were prescribed biologic agents, including adalimumab, infliximab, certolizumab, ustekinumab, natalizumab, vedolizumab, and risankizumab or small molecule agents, including tofacitinib and upadacitinib.\u003c/p\u003e \u003cp\u003ePatient characteristics and outcomes were analyzed using chi-squared testing. The insured patients (IP) cohort included all funded patients who had either a government insurance provider, commercial provider or fee-assistance programs. The underinsured patient (UP) cohort included patients with self-pay and no insurance. A chi-square test of independence was performed to examine the relationship between prednisone equivalents and patients referred for DEXA Scan, and patients who completed DEXA scans among those ordered. Data was remodeled using only patients under 65 years of age in order to exclude those that qualify for age-related osteoporosis screening. Statistical significance was set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05.\u003c/p\u003e \u003cp\u003eUnivariate analyses were performed to identify correlations between our three outcomes of interest (the prescription of \u0026ge;\u0026thinsp;600 mg steroids, the ordering of DEXA scans among patients who were prescribed\u0026thinsp;\u0026ge;\u0026thinsp;600 mg steroids, and the completion of ordered DEXA scans) and prognostic factors. Factors with a \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.20 in univariate analysis were entered into the multivariate logistic model to control for potential confounding variables. Ultimately, a \u003cem\u003ep\u003c/em\u003e-value of \u0026lt;\u0026thinsp;0.05 was considered to be statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 9065 patients met inclusion criteria.\u003c/p\u003e \u003cp\u003eOur population of patients had an average age of 50.75\u0026thinsp;\u0026plusmn;\u0026thinsp;19.29 and average BMI of 27.07\u0026thinsp;\u0026plusmn;\u0026thinsp;7.20 (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). When stratified by UP vs IP, there were no significant differences in age (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.11), sex composition (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.052), proportion with CD vs UC (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.51, and body mass index (p\u0026thinsp;=\u0026thinsp;0.96)) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient characteristics stratified by insurance category\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnderinsured\u003c/p\u003e \u003cp\u003e(\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;311)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInsured\u003c/p\u003e \u003cp\u003e(\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;8754)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e(\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9065)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean Age\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49.47\u0026thinsp;\u0026plusmn;\u0026thinsp;13.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.83\u0026thinsp;\u0026plusmn;\u0026thinsp;19.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50.75\u0026thinsp;\u0026plusmn;\u0026thinsp;19.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, \u003cem\u003eN\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.052\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e245 (45.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3492 (40.97%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3737 (41.22%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e297 (54.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5031 (59.03%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5328 (58.78%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisease Subtype, \u003cem\u003eN\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUlcerative Colitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e118 (37.94%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3485 (39.81%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3603 (39.75%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCrohn\u0026rsquo;s disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e193 (62.06%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5269 (60.19%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5462 (60.25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean Body Mass Index\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.08\u0026thinsp;\u0026plusmn;\u0026thinsp;7.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.07\u0026thinsp;\u0026plusmn;\u0026thinsp;7.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27.07\u0026thinsp;\u0026plusmn;\u0026thinsp;7.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eUP were prescribed significantly more prednisone (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.025) and significantly less budesonide (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) than IP (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Overall, the average patient was prescribed 5314\u0026thinsp;\u0026plusmn;\u0026thinsp;19584 mg of prednisone equivalents.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIBD Patients seen in the outpatient Gastroenterology clinic by insurance category\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnderinsured\u003c/p\u003e \u003cp\u003e(\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;311)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInsured\u003c/p\u003e \u003cp\u003e(\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;8754)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmount of Corticosteroids Prescribed (mean number of milligrams\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombined corticosteroids prescribed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3778\u0026thinsp;\u0026plusmn;\u0026thinsp;9133\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5369\u0026thinsp;\u0026plusmn;\u0026thinsp;19852\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrednisone prescribed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2588\u0026thinsp;\u0026plusmn;\u0026thinsp;7157\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1659\u0026thinsp;\u0026plusmn;\u0026thinsp;6453\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBudesonide prescribed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89\u0026thinsp;\u0026plusmn;\u0026thinsp;394\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e278\u0026thinsp;\u0026plusmn;\u0026thinsp;1347\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients who met criteria for bone density screening, had DEXA scan appropriately ordered, and/or completed the ordered DEXA scan, \u003cem\u003eN\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients prescribed\u0026thinsp;\u0026ge;\u0026thinsp;600 mg prednisone equivalents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e133 (43%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2900 (33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients prescribed\u0026thinsp;\u0026ge;\u0026thinsp;600 mg prednisone equivalents who had DEXA ordered\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e780 (27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients prescribed\u0026thinsp;\u0026ge;\u0026thinsp;600 mg prednisone equivalents who had DEXA ordered and completed it\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e590 (76%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrescription of Advanced Therapies, \u003cem\u003eN\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients prescribed at least one advanced therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e106 (34%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3465 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.051\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOf the 9065 total patients included, 3033 were prescribed\u0026thinsp;\u0026ge;\u0026thinsp;600 mg equivalents of prednisone and qualified for DEXA scan screening based on our methods (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Compared to insured patients, a higher proportion of UP were prescribed\u0026thinsp;\u0026ge;\u0026thinsp;600 prednisone equivalents (42.8% vs 33.1%, respectively; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) with no significant differences in biologics or small molecules prescribed (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.051). Among patients who qualified for DEXA scan screening, there was no significant difference in the proportion that had a DEXA scan ordered (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.54). Furthermore, among patients who qualified for DEXA scan screening \u003cem\u003eand\u003c/em\u003e had a DEXA scan ordered, there was no significant difference in scan completion rate; 66.7% for UP and 75.6% for IP (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.205). Overall, the completion rates for DEXA scans among those who were prescribed\u0026thinsp;\u0026ge;\u0026thinsp;600 equivalents were 19.6% for UP and 20.3% for IP, with an overall rate of 20.3%.\u003c/p\u003e \u003cp\u003eWhen analyses were re-conducted while excluding patients over 64 years old, the same findings remained significant. Overall, the completion rates for DEXA scans among those who were prescribed\u0026thinsp;\u0026ge;\u0026thinsp;600 equivalents, excluding patients over 64 years of age, were 17.4% for UP and 18.4% for IP, with a combined rate of 18.4%.\u003c/p\u003e \u003cp\u003eA multivariate model was constructed as detailed in the methods section in order to adjust for covariates (age, sex composition, race, type of IBD, BMI, and insurance status). Patients of younger age (Odds ratio 1.012, 95% confidence interval [1.009\u0026ndash;1.015]), female sex (1.134, [1.025\u0026ndash;1.182]), lower BMI (1.011, [1.004\u0026ndash;1.018]) and patients who were underinsured (1.508, [1.151\u0026ndash;1.931]) had higher odds of receiving\u0026thinsp;\u0026ge;\u0026thinsp;600 mg steroids (and thus meeting criteria for DEXA scan screening).\u003c/p\u003e \u003cp\u003eA second multivariate model was built to assess the odds of having a DEXA scan ordered among patients who were prescribed\u0026thinsp;\u0026ge;\u0026thinsp;600 mg. When adjusting for the same covariates, patients with older age (1.024, [1.018\u0026ndash;1.029]), female sex (1.426, [1.182\u0026ndash;1.719]), patients with Crohn's disease (OR 1.255 [1.043\u0026ndash;1.511]), and higher BMI (1.021, [1.008\u0026ndash;1.033]) had higher odds of having a DEXA scan ordered. Of note, among patients who were prescribed\u0026thinsp;\u0026ge;\u0026thinsp;600 mg steroids, insurance group did not significantly impact the odds of having a DEXA scan ordered (OR 1.49, [0.843\u0026ndash;2.634]).\u003c/p\u003e \u003cp\u003eFinally, after adjusting for the same covariates among patients who were prescribed\u0026thinsp;\u0026gt;\u0026thinsp;600 mg steroids and had a DEXA scan ordered, only younger age had a significantly increased odds (1.010, [1.003\u0026ndash;1.016]) of completing it.\u003c/p\u003e \u003cp\u003eWhen adjusting for age, sex composition, race, type of IBD, BMI, and insurance group in a multivariate model, underinsured patients had a significantly higher odds of receiving\u0026thinsp;\u0026gt;\u0026thinsp;600 mg of steroids (OR 1.508, [1.151\u0026ndash;1.931]). However, using the same multivariate analysis, insurance status had no significant impact on the odds of a physician ordering a DEXA scan or on the odds of a patient completing the ordered DEXA scan.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study showed that uninsured patients received, on average, a higher mean amount of corticosteroid prescriptions and were more likely to eclipse the 600 mg prednisone equivalents threshold which would warrant bone density screening. We were unable to find any direct comparisons published in literature as our data was cumulative. The closest comparison would be previously reported annual excessive corticosteroid use rates ranging from 13.3\u0026ndash;17.7% [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] which, as one would expect, are lower than our results showing 33.4% of our IBD patients were prescribed enough cumulative corticosteroids to warrant bone density screening. We also demonstrated that insurance significantly impacts the type of corticosteroid prescribed. Insured patients were more likely to receive budesonide and less likely to receive prednisone, when compared to the underinsured cohort. These findings could be a reflection of the higher cost of budesonide compared to prednisone. While our study did not show a statistically significant difference in access to advanced therapies among the two groups (p\u0026thinsp;=\u0026thinsp;0.051), several other studies have found that UP lacked access to advanced therapy, predisposing them to more ED visits and more frequent prednisone prescriptions [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDEXA scan screening for bone mineralization deficits is underperformed for IBD patients on chronic steroid therapy. We expected the underinsured cohort to have fewer DEXA scans ordered and completed, based on prior studies describing health disparities in patients that are underinsured [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, insurance had no impact in the ordering, nor completion rate of DEXA scans in our study. In our facility, DEXA scans were ordered in 27% of the IBD patients who qualified for screening. While this is an obvious target for improvement, it appears to be in line with other institutions. In one study, only 10.6% of patients had DEXA scan screening performed despite using \u0026ge; 500mg of corticosteroids within a year [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Another institution reported that of the eligible IBD patients, 21% and 44% were referred for DEXA scans from their Veteran\u0026rsquo;s Affairs clinic and county hospital, respectively [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhen our patients were appropriately referred for DEXA scans, most completed them, regardless of insurance group. This suggests that a lack of recognition among physicians is currently the largest hurdle preventing patients from obtaining guideline-based bone density screening.\u003c/p\u003e \u003cp\u003e Of note, both tertiary institutions examined in this study have relatively robust programs for certain patients with low socioeconomic status, with funding provided by city, state, and federal grants. One such program, classified under \u0026ldquo;charity insurance,\u0026rdquo; requires applicants to meet with a financial representative and provide documents that demonstrate financial or logistical needs, at which time they may qualify for a special payment card that entitles them to free or reduced-cost primary care, specialty care, and screening exams at our institution. This process takes effort on behalf of the patient, therefore this subset of patients may be more capable or motivated to follow up on healthcare recommendations, including bone mineral density screening. These patients were grouped in the Insured category as, after obtaining their insurance, they had similar coverage to a commercial-insured patients, albeit at just one health system. Among these patients, 100% of the 58 patients who had a DEXA ordered completed the scan, which far outpaced our overall average completion rate of 75.6%. While not the focus of this study, this serves as a testament to how effective local, health-system based charity opportunities can be. These \u0026ldquo;charity programs\u0026rdquo; may limit generalizability to other institutions that do not offer this level of support for patients with low socio-economic status, potentially lowering the DEXA scan ordering and completions rates further.\u003c/p\u003e \u003cp\u003eThere are inherent limitations given the retrospective nature of our study. Our study analyzed data based on corticosteroid prescriptions. Lifetime medication doses are notoriously difficult to quantify in retrospective studies, with no guarantee that patients picked them up and consumed them. Our data was collected from two large tertiary health care systems that accept referrals and patients from a wide area. This data does not include corticosteroids given during hospitalizations, at urgent cares, by non-affiliated primary doctors, or any other source not affiliated with the two large academic centers that were studied. Patients may have been previously treated with corticosteroids for years before establishing care at one of our centers and may have received steroids for other conditions (like rheumatoid arthritis), and those would not be quantified in this study. As mentioned in the methods, we chose to err on the conservative side, with the understanding that an IBD patient\u0026rsquo;s lifetime corticosteroid usage is likely, on average, far higher than the values represented here. Also, DEXA scan orders from primary care physicians outside of our network could have been present and would not be accounted for. Our study benefited from a large patient population; however, due to its size, it was difficult and imprecise to analyze incidence or temporal associations. Therefore, we do not present information on corticosteroids per year.\u003c/p\u003e \u003cp\u003eA future quality improvement project could focus on a method of tracking cumulative steroid doses in IBD patients, considering the variety of providers that prescribe corticosteroids. Evaluating the yield of osteopenia and osteoporosis from the DEXA scans performed can help provide insight into whether current screening guidelines are appropriate. Finally, a subgroup analysis stratifying for race or sex instead of insurance status may highlight additional social disparities.\u003c/p\u003e \u003cp\u003eRegardless of insurance status, DEXA scan rates in all cohorts studied remained substandard. Although socioeconomic disparities have been demonstrated to influence screening rates, our study suggests that other factors beyond insurance status may influence DEXA scan ordering and completion more significantly [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Efforts should be made to improve them, perhaps systemically by implementing a cumulative steroid database (similar to the prescription drug monitoring programs which are associated with large relative reductions in prescription opioid utilization among high-risk patients and increasing provider awareness about the disparities [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eInflammatory bowel disease (IBD)\u003c/p\u003e\n\u003cp\u003eCrohn’s disease (CD)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUlcerative colitis (UC)\u003c/p\u003e\n\u003cp\u003eDual-energy X-ray absorptiometry (DEXA)\u003c/p\u003e\n\u003cp\u003eBone mineral density (BMD)\u003c/p\u003e\n\u003cp\u003eUnderinsured patients (UP)\u003c/p\u003e\n\u003cp\u003eInsured patients (IP)\u003c/p\u003e\n\u003cp\u003eCenters for Medicare and Medicaid Services (CMS)\u003c/p\u003e\n\u003cp\u003eAmerican Gastroenterological Association (AGA)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and consent to participate:\u0026nbsp;\u003c/strong\u003eInstitutional board review was obtained for this retrospective review\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e(IRB202202649) from the institutional board review at the University of Florida. Peter Iafrate, the IRB Chairman from the University of Florida approved the methods used to collect data included in this study. This study was approved as secondary research for which consent is not required: Secondary research uses of identifiable private information or identifiable biospecimens, if at least one of the following criteria is met: the research involves only information collection and analysis involving the investigator's use of identifiable health information when that use is regulated under 45 CFR parts 160 and 164, subparts A and E, for the purposes of “health care operations” or “research” as those terms are defined at 45 CFR 164.501 or for “public health activities and purposes” as described under 45 CFR 164.512(b).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eAll authors listed on this manuscript consent to publication. There are no identifying images, personal, or clinical details presented in this manuscript that compromise anonymity of those involved or studied.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability:\u0026nbsp;\u003c/strong\u003eThe data that support the findings of this study are available from the corresponding author, Anvit Reddy, upon reasonable request. The data are not publicly available in order to protect the privacy of the research participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA.R.: Study design, data analysis, preparing and revising the manuscript, corresponding author\u003c/p\u003e\n\u003cp\u003eL.B.: Study design, data collection, data analysis, preparing and revising the manuscript\u003c/p\u003e\n\u003cp\u003eN.P. Preparing and revising the manuscript, especially the introduction\u003c/p\u003e\n\u003cp\u003eN.Q.: Preparing and revising the manuscript, especially the discussion\u003c/p\u003e\n\u003cp\u003eG.G.: Preparing and revising the manuscript, especially the discussion\u003c/p\u003e\n\u003cp\u003eM.S.: Study inception, Study design, preparing and revising the manuscript\u003c/p\u003e\n\u003cp\u003eL.S.: Study inception, Study design, preparing and revising the manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors whose names are listed immediately below certify that they have NO affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.\u003c/p\u003e\n\u003cp\u003eAnvit Reddy, Landen Shane Burstiner, Niyati Patel, Nadim Qadir, Gerardo Diaz-Garcia, Marianny Sulbaran, Lauren Stemboroski\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBruscoli S, et al. Glucocorticoid Therapy in Inflammatory Bowel Disease: Mechanisms and Clinical Practice. Front Immunol. 2021;12:691480. Print.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTalley NJ, et al. An Evidence-Based Systematic Review on Medical Therapies for Inflammatory Bowel Disease. Am J Gastroenterol. 2011;106(1):S2\u0026ndash;25. quiz S26. Print.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCai Z, Wang S, Li J. Treatment of Inflammatory Bowel Disease: A Comprehensive Review. Front Med (Lausanne). 2021;8:765474. Print.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrattsand R, Linden M. Cytokine Modulation by Glucocorticoids: Mechanisms and Actions in Cellular Studies. Aliment Pharmacol Ther. 1996;10(2):81\u0026ndash;90. discussion 91\u0026thinsp;\u0026ndash;\u0026thinsp;2. Print.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeuerstein JD et al. 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Corticosteroid Use and Complications in a Us Inflammatory Bowel Disease Cohort. PLoS ONE. 2016;11(6):e0158017. Print.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eA focused retrospective study on differences. in IBD characteristics between Black and White patients in the south, Burstiner, Landen Shane. Am J Med Sci, 365, Issue 6, 488\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNancey S, et al. Prevalence of the Oral Corticosteroid Exposure and Excessive Use in Patients with Inflammatory Bowel Disease: Data from Four French Referral Centers of the International Dice Study. J Clin Med. 2024;13:9. Print.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSelinger CP, et al. Assessment of Steroid Use as a Key Performance Indicator in Inflammatory Bowel Disease-Analysis of Data from 2385 Uk Patients. Aliment Pharmacol Ther. 2019;50(9):1009\u0026ndash;18. Print.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTargownik LE et al. Prevalence of and Outcomes Associated with Corticosteroid Prescription in Inflammatory Bowel Disease. Inflamm Bowel Dis 20.4 (2014): 622\u0026thinsp;\u0026ndash;\u0026thinsp;30. Print.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSzafors P, Che H, Barnetche T, Morel J, Gaujoux-Viala C, Combe B, Lukas C. Risk of fracture and low bone mineral density in adults with inflammatory bowel diseases. A systematic literature review with meta-analysis. Osteoporos Int. 2018;29:2389\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKreienbuehl AS, Rogler G, Emanuel B, Biedermann L, Meier C, Juillerat P, Restellini S, Hruz P, Vavricka SR, Aeberli D, Seibold F. Bone health in patients with inflammatory bowel disease. Swiss Med Wkly. 2024;154:3407.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCurry SJ, et al. Screening for Osteoporosis to Prevent Fractures: Us Preventive Services Task Force Recommendation Statement. JAMA. 2018;319(24):2521\u0026ndash;31. Print.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInflammatory Bowel Disease. (Ibd): Preventive Care: Corticosteroid Related Iatrogenic.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInjury. \u0026ndash; Bone Loss Assessment. Ed. Care, National Quality Strategy Domain: Effective Clinical2019. Print.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFarraye FA, et al. Acg Clinical Guideline: Preventive Care in Inflammatory Bowel Disease. Am J Gastroenterol. 2017;112(2):241\u0026ndash;58. Print.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAxelrad JE, et al. Increased Healthcare Utilization by Patients with Inflammatory Bowel Disease Covered by Medicaid at a Tertiary Care Center. Inflamm Bowel Dis. 2019;25(10):1711\u0026ndash;17. Print.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAGA Clinical Practice Update on Noncolorectal Cancer Screening and Vaccinations in Patients With Inflammatory Bowel Disease. Expert Review Caldera, Freddy Clinical Gastroenterology and Hepatology, Volume 23, Issue 5, 695\u0026ndash;706.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKornbluth A, Sachar DB, and Practice Parameters Committee of the American College of Gastroenterology. Ulcerative Colitis Practice Guidelines in Adults: American College of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol 105.3 (2010): 501\u0026thinsp;\u0026ndash;\u0026thinsp;23; quiz 24. Print.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEquivalent Dosage of Commonly Used SCS, Published July. 2015. Accessed April 8, 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.jacionline.org/cms/10.1016/j.jaci.2015.07.046/attachment/9e6d93c6-b64b-4468-8cf5-38a0e9b551e9/mmc2.pdf\u003c/span\u003e\u003cspan address=\"https://www.jacionline.org/cms/10.1016/j.jaci.2015.07.046/attachment/9e6d93c6-b64b-4468-8cf5-38a0e9b551e9/mmc2.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNguyen GC, et al. Hospitalizations for Inflammatory Bowel Disease: Profile of the Uninsured in the United States. Inflamm Bowel Dis. 2009;15(5):726\u0026ndash;33. Print.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLo B et al. Incidence, Risk Factors and Evaluation of Osteoporosis in Patients with Inflammatory Bowel Disease: A Danish Population-Based Inception Cohort with 10 Years of Follow-Up. J Crohns Colitis 14.7 (2020): 904\u0026thinsp;\u0026ndash;\u0026thinsp;14. Print.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWehbeh AMD, Phatharacharukul PMD, Fayad NF, MD. FACG1. 844\u0026emsp;Improvement of Osteoporosis Screening Among IBD Patients at GI Fellows\u0026rsquo; Clinics. The American Journal of Gastroenterology 114(): p S489, October 2019. | \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.14309/01.ajg.0000592912.33515.ab\u003c/span\u003e\u003cspan address=\"10.14309/01.ajg.0000592912.33515.ab\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang HY et al. Impact of Florida's Prescription Drug Monitoring Program and Pill Mill Law on High-Risk Patients: A Comparative Interrupted Time Series Analysis. Pharmacoepidemiol Drug Saf 27.4 (2018): 422\u0026thinsp;\u0026ndash;\u0026thinsp;29. Print.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Osteoporosis in inflammatory bowel disease, screening, health maintenance, corticosteroid use","lastPublishedDoi":"10.21203/rs.3.rs-6524164/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6524164/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Corticosteroid use among inflammatory bowel disease (IBD) patients is common as they are highly effective in the management of flares. However, both corticosteroid use and IBD have been linked to bone mineral density deficiencies. As a result, guidelines recommend dual-energy X-ray absorptiometry (DEXA) screening in these patients. The main objectives of this study were threefold: to quantify the amount of corticosteroids prescribed per patient, assess whether patients were appropriately referred for DEXA scans according to CMS guidelines, and to evaluate the rate of completion for the ordered DEXA scans. Additionally, we aimed to evaluate whether insurance status impacted the cumulative amounts of corticosteroids prescribed and access to DEXA scans.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e 16,387 adult patients who were seen at two tertiary healthcare systems in the southeastern United States with a diagnosis of IBD were included. Patient characteristics and DEXA scan referral rates were obtained. Patients prescribed ≥600 prednisone equivalents were deemed to qualify for DEXA scan screening.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Underinsured patients (UP) were prescribed significantly more prednisone and less budesonide than insured patients (IP). There was no significant difference in scan completion rate: 66.7% for UP and 75.6% for IP. Overall, the completion rates for DEXA scans among patients prescribed ≥600 equivalents were 19.6% for UP and 20.3% for IP, with an overall rate of 20.3%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e DEXA scan screening for bone mineralization deficits is underperformed for IBD patients on chronic steroid therapy. Insurance had no impact on the ordering or completion rate of DEXA scans in our study.\u003c/p\u003e\n\u003cp\u003eTrial Registration: Retrospectively registered\u003c/p\u003e","manuscriptTitle":"Corticosteroid Use, Bone Density Screening, and the Influence of Insurance in Patients with Inflammatory Bowel Disease: A Retrospective Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-03 13:59:45","doi":"10.21203/rs.3.rs-6524164/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-18T05:20:47+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-04T20:11:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-26T14:57:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"35970262306420849653943191560810408655","date":"2025-11-22T11:12:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"222589572691865896246448573398725230776","date":"2025-11-21T05:40:19+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-30T15:19:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-02T09:31:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-30T23:37:53+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Gastroenterology","date":"2025-04-30T23:36:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2d699b1e-12d8-4673-8959-38fce2bf806a","owner":[],"postedDate":"June 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-23T16:07:40+00:00","versionOfRecord":{"articleIdentity":"rs-6524164","link":"https://doi.org/10.1186/s12876-026-04717-5","journal":{"identity":"bmc-gastroenterology","isVorOnly":false,"title":"BMC Gastroenterology"},"publishedOn":"2026-03-17 15:58:33","publishedOnDateReadable":"March 17th, 2026"},"versionCreatedAt":"2025-06-03 13:59:45","video":"","vorDoi":"10.1186/s12876-026-04717-5","vorDoiUrl":"https://doi.org/10.1186/s12876-026-04717-5","workflowStages":[]},"version":"v1","identity":"rs-6524164","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6524164","identity":"rs-6524164","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}