The Effects of Social Determinants of Health on Medication Utilization in Patients with Inflammatory Bowel Disease

The Effects of Social Determinants of Health on Medication Utilization in Patients with Inflammatory Bowel Disease | 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 The Effects of Social Determinants of Health on Medication Utilization in Patients with Inflammatory Bowel Disease Maryana Stryelkina, Megan Lewis, Eric Smith, Rajesh Shah This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6890611/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Inflammatory bowel diseases (IBD), including ulcerative colitis (UC) and Crohn’s disease (CD), are chronic inflammatory conditions requiring ongoing medical management. Although disparities in outcomes across racial and ethnic groups have been reported—particularly higher rates of complications and surgeries in minority populations—the influence of social determinants of health (SDOH) on treatment patterns remains less clearly defined. This study investigates how demographic, clinical, and SDOH factors relate to the use of advanced IBD therapies. Methods: We retrospectively reviewed electronic health records of 1,360 adult patients with IBD within a large healthcare system. The primary outcome was initiation of advanced therapies, including anti-TNF agents, anti-integrins, anti-IL-12/23 agents, and small molecules. We evaluated associations with patient characteristics, including age, race, tobacco use, and reported barriers such as financial strain, food insecurity, transportation difficulties, and symptoms of depression. Statistical analyses included descriptive summaries and logistic regression, with p < 0.05 considered statistically significant. Results: Among patients with CD, younger individuals were more likely to receive anti-TNF (p = 0.01) and anti-IL-12/23 therapies (p = 0.04). In UC, younger age was also associated with greater anti-TNF use (p < 0.001). White patients with CD were more frequently prescribed anti-integrins compared to Black patients (p < 0.001). In the UC group, non-smokers were more likely than smokers to receive small molecule therapies (p = 0.028). No statistically significant relationships were observed between SDOH measures and medication utilization in either UC or CD. Crohn’s disease ulcerative colitis inflammatory bowel disease social determinants of health Introduction Inflammatory bowel diseases (IBD), including ulcerative colitis (UC) and Crohn’s disease (CD), are chronic, lifelong inflammatory disorders of the intestines. 1 , 2 Due to their progressive nature, IBD patients require close monitoring for acute flares and ongoing management. Healthcare utilization is notably higher among IBD patients, leading to increased emergency room visits, hospitalizations, and IBD-related surgeries compared to the general population. 3 Within the first 5 years of diagnosis, disease-related progression or complications lead to hospitalization in up to 20% of patients with UC and 50% of patients with CD. 4 However, early initiation of therapies can significantly improve clinical symptoms and endoscopic appearance, which correlate with reduced healthcare utilization. 5 , 6 Racial disparities have been noted in patients with IBD. Studies indicate that Black adult patients with IBD experience higher rates of complications, emergency room visits, and hospitalizations compared to non-Hispanic White patients. 1 Additionally, Tendol at el 1 found that Hispanic patients with UC are more likely to be hospitalized compared to White patients but tend to have similar surgery rates compared to White patients with UC. Despite these outcome differences, 30 days readmission rates appear similar across racial and ethnic groups . 1 Racial disparities in medication utilization in patients with IBD are unclear. While some studies indicate that Black patients are less likely to receive steroids, infliximab, and immunomodulators compared to White patients, other research suggests that Black patients have a higher likelihood of initiating anti-TNF medications. 7 , 9 , 10 , 11 These conflicting findings may stem from the limited scope of single-center studies. Larger, nationally representative studies have not demonstrated a difference in medication utilization based on race or ethnicity. 12 Our study investigates the impact of social determinants of health (SDOH) on medication utilization among adult patients with IBD within the Baylor Scott and White Health (BSWH) system. We specifically focus on financial strain, food insecurity, transportation availability, and depression risk. Our goal is to identify potential barriers to medication utilization, with the aim of improving the quality of healthcare for IBD patients. Methods Study Design and Population We conducted a retrospective cohort study of adult patients with IBD seen within the BSWH system between the years of 2013 and 2022. BSW is the largest hospital system in Texas with a diverse population of patients. The system cares for approximately 2 million unique patients annually with about 7 million patient encounters per year. All patient data were extracted from the BSW electronic medical record (Epic), which contains comprehensive demographic and clinical information. Adult patients diagnosed with IBD who received care within the BSWH system between January 1, 2013, and December 31, 2022, were included for analysis. Identification of adult patients with IBD was performed using the International Classification of Diseases, 9th Revision (ICD-9), and 10th Revision (ICD-10) codes for UC and CD. Subsequent confirmation of UC or CD diagnoses involved a manual review of patients' medical records, incorporating corroborative endoscopy, pathology, or imaging findings. Exclusion criteria were patients below 18 years of age, lack of a confirmed diagnosis of IBD, insufficient follow-up information pertaining to their condition, or incomplete clinical or SDOH information. The Montreal Classification System was used to classify IBD phenotype. 13 For patients with UC, disease extent was classified as either proctitis (E1), left-sided colitis (E2), and extensive colitis (E3). Among patients with CD, disease location was categorized as terminal ileum (L1), colonic (L2), ileocolonic (L3), and upper gastrointestinal tract participation (L4). Disease behavior was classified as either inflammatory (B1), stricturing (B2) or fistulizing (B3). Medication Utilization Medication utilization was determined by a new prescription or order for an IBD-related medication within the study time period, which was analyzed individually (e.g., infliximab) and by medication class. Medication classes were anti-TNF, anti-IL 12/23, anti-integrin and small molecules. Social Determinants of Health SDOH information was either entered by the patient through the online check-in system or by a medical assistant on the day of the visit. SDOH variables included financial resource strain, depression assessment (PHQ-2), food security (worried or scared) and medical transportation. Financial resource strain was categorized as very hard, hard, somewhat hard, not very hard, or not hard at all. Depression assessment with the PHQ-2 score ranged from 0 to 6 with 6 being at higher risk for a depression diagnosis. Food security was stratified into two categories (worried or scared) with responses being either never true, sometimes true, or often true. Finally, medical transportation concerns were categorized either yes or no. Statistical Analysis Demographic and clinical characteristics were summarized using either mean and standard deviation for continuous variables or percentages for categorial variables. Continuous variables were compared using the Student’s t test and categorical variables were compared using either the chi square or Fisher exact test, as appropriate. Univariate and multivariate logistic regression analysis was performed to identify associations between demographic, clinical and SDOH variables with medication utilization. Variables that were significant in univariate analysis were then included in a multivariate logistic regression model for further evaluation. P values < 0.05 were considered statistically significant. All statistical testing was performed using JASP 0.18.3 for Apple (University of Amsterdam). Results 1,360 unique IBD patients were identified, of which 325 had complete clinical and SDOH data. Among these, 106 patients received advanced therapies, including biologics and small molecules. The demographic and clinical characteristics of the groups are summarized in Tables 1a and 1b for patients with CD and UC, respectively. In patients with CD, there was a trend for younger individuals to receive anti-TNF (55.8 vs. 62.4 years, p=0.01) and anti-IL-12/23 (49.9 vs. 61.4 years, p=0.04) biologics. Among the groups exposed to anti-TNF and anti-IL-12/23, no significant differences were observed in terms of sex, race, disease extent, perianal disease involvement, disease behavior, or alcohol and tobacco use. Similarly, no significant differences were found in age, sex, race, disease characteristics, alcohol use, or tobacco use in patients receiving anti-integrin or small molecule therapies. Similarly, younger patients with UC were more likely to receive anti-TNF therapies (49.4 vs 65.4 years, p < 0.001). No significant differences in age, race, or gender were observed among patients exposed to anti-IL-12/23 and small molecule therapies. However, patients prescribed integrin therapy were more likely to be White compared to Black (83% vs 0%, p < 0.001). Disease extent did not seem to influence medication utilization. Alcohol consumption did not vary significantly across therapy types; however, a notable association was observed between tobacco use and small molecule therapy. Non-tobacco users were significantly more likely to receive small molecule therapy compared to tobacco users (RR=1.8, 95% CI: 0.3-13.0, p=0.028). No significant associations were observed between tobacco use and other treatment categories such as anti-TNF, anti-IL-12/23, or integrin therapies. Regarding SDOH data, no significant associations were found between SDOH factors, including financial strain, food insecurity, transportation and depression, and medication utilization in patients with either UC or CD (Tables 2a and 2b). Discussion This comprehensive study involved 1,360 unique adult patients diagnosed with IBD. Of these, 325 had complete clinical and SDOH data available. Among these 325 patients, 106 were treated with advanced therapies, including biologics and small molecules. The study examined how demographic, clinical, and SDOH factors influenced medication usage. Significant findings included younger age was associated with anti-TNF (UC and CD) and anti-IL-12/23 (CD) use. In patients with UC, White patients were more likely to receive anti-integrin therapy compared to Black patients, while non-tobacco users were more likely to receive small molecule therapy than tobacco users. Overall, SDOH factors did not influence medication utilization. These findings highlight the impact of demographic and lifestyle factors on medication usage in IBD patients, offering insights into potential disparities and modifiable risk factors for optimal medication utilization. Previous studies have linked age to anti-TNF therapy in patients with IBD. A community-based cohort study of 494 CD patients found that those aged 18 and younger were more likely to receive infliximab than patients aged 60 and older. 8 Similarly, Flasar et al 9 , while accounting for disease severity, observed a positive correlation between age under 40 and anti-TNF therapy utilization. Our study aligns with these trends. Among patients with CD, younger individuals were more likely to receive anti-TNF therapies (mean age = 55.8 years vs. 62.4 years, p = 0.01). Additionally, our analysis revealed similar patterns for anti-IL-12/23 therapy (49.9 years vs. 65.4 years, p < 0.001). In patients with UC, younger patients were also more likely to receive anti-TNF therapies (49.4 vs. 65.4 years, p < 0.001). These results imply an age-related pattern in treatment preferences, which suggests further work is needed to understand treatment decision making in this age population. Existing research suggests varying medication usage among individuals with IBD based on race. Single center studies have suggested that Black patients are less likely to receive anti-TNF therapies when compared to White patients. 7 , 9 However, this association was not found in a multicenter cohort study, where Black patients were noted to have a higher likelihood of receiving anti-TNF therapies. 11 Nationally representative studies found no clear associations between anti-TNF usage and race. 12 , 14 Discrepancies could in part be related to underlying insurance status, since no disparities were noted between White and Black patients insured through the Medicaid program nationally. 14 In our study, consistent with larger national studies, we did not find a statistically significant difference in medication utilization rates when stratified by race for CD. However, among patients with UC, we observed a notable racial disparity in medication usage. Specifically, integrin medications were predominantly prescribed to White individuals, with 83% of integrin users being White, while no Black patients received this treatment (p < 0.001). These findings highlight the need for further research to confirm and explore interventions aimed at reducing disparities and improving health outcomes across diverse patient populations. Previous research highlights the impact of smoking on CD progression and its protective effect against UC development. 16 , 17 Specifically, in the CD population, tobacco use has been associated with more complicated disease courses when compared to non-smokers. This includes an increased risk of disease relapse and a higher likelihood of surgery. 22 – 24 Additionally, smoking was found to be significantly associated with increased health care costs in CD patients. Severs et al 21 found that active smokers with CD had a significantly higher risk of requiring anti-TNF therapy. Currently, a knowledge gap exists regarding the link between tobacco use patterns and medication utilization in IBD patients. Our study found that in CD population with tobacco use, there was no difference in medication utilization. Additionally, our study revealed that non-tobacco users with UC were 1.8 times more likely to receive small molecule therapy than tobacco users (RR = 1.8, 95% CI: 0.3–13.0, p = 0.028). These findings emphasize the need to consider age and tobacco usage when tailoring treatment strategies for UC patients. Patients diagnosed with IBD often face financial constraints that can impact their access to essential medical care. These challenges may include difficulties obtaining diagnostic tests, medications, and follow-up appointments, which can lead to delays in diagnosis and treatment initiation. For example, Bernstein et al 18 conducted a population-based cohort study and found that IBD patients with indicators of lower socioeconomic status experienced poorer outcomes. These outcomes included higher rates of outpatient physician visits, hospitalizations, intensive care unit admissions, steroid use, and mortality. Similarly, Medicaid-insured patients with IBD exhibited higher rates of hospital admissions and emergency room visits compared to patients with IBD covered by other forms of insurance. 14 These findings underscore the impact of financial constraints on healthcare utilization and outcomes. Instead of examining outcomes, we explored the effect of financial strain on medication utilization patterns among IBD patients. Surprisingly, we did not find a significant difference in medication usage related to self-reported financial strain. This suggests that financial constraints may have limited influence on treatment choices within our study population and other mechanisms may be leading to increased healthcare utilization and poorer outcomes. Food insecurity significantly affects individuals with IBD, exacerbating financial strain and compromising nutritional status. IBD patients experiencing food insecurity often encounter financial hardships related to medical expenses, financial distress, and cost-related medication non-adherence. These challenges can complicate disease management and potentially lead to poorer health outcomes. 30 Additionally, food insecurity can result in nutritional deficiencies that adversely impact disease course, affecting both induction and maintenance of remission and overall quality of life. 28 In a 2015 National Health Interview Survey analysis, Nguyen et al 23 found that 1 in 8 IBD patients experience food insecurity and lack social support, both associated with increased financial toxicity. Surprisingly, our analysis did not find a correlation between food insecurity and medication utilization patterns in IBD patients. Further investigation into the interactions between food security, financial strain, insurance status, and other modifiable risk factors for medication utilization are needed to better understand these links. The impact of transportation on patients with IBD is multilevel, influencing both access to care and long-term management of symptoms. A prior observational study revealed that patients traveling longer distances to specialized centers were more likely to experience worse clinical outcomes, such as higher rates of hospital readmissions and increased use of immunomodulators and biological therapy. 26 Similarly, a nationwide Israeli study revealed that limited transportation was linked to poorer IBD outcomes, associated with higher rates of steroid dependency and surgeries. 27 However, a retrospective cohort study found no significant association between self-reported transportation difficulties and worsened IBD-related outcomes, such as hospitalizations and surgeries. 30 Our study also revealed that self-reported access to transportation did not significantly impact medication utilization. Given these differences in data between single centers and the known impact of transportation on health outcomes, future multicenter research is needed to adequately establish the impact of transportation access in IBD patient population. Depressive symptoms in patients with IBD are linked to higher rates of clinical deterioration and relapse. Specifically, depression is associated with increased likelihood of flare-ups, surgical interventions, and hospitalizations in patients with CD. 24 A large cohort study conducted in Switzerland found a significant correlation between depressive symptoms and relapse rates in both UC and CD cohorts. 29 Additionally, a smaller study showed that major depression in patients receiving infliximab therapy for active CD was associated with lower remission rates and quicker flares. 30 Notably, our study did not find a correlation between depression assessed using the PHQ-2 score and medication utilization. These findings suggest additional modifying factors may influence adverse outcomes in patients with self-reported depression beyond medication selection. Our study has notable strengths, including comprehensive data analysis and a diverse patient population. However, several limitations must be acknowledged. The retrospective study design allows for confounding variables, which we attempted to control by adjusting for demographic and clinical information. Electronic health records were used for data extraction, introducing the possibility of missing data or coding errors. To mitigate this, manual chart reviews were performed. Additionally, the inclusion criteria may have introduced selection bias, as only patients within the BSWH system were included, which may limit generalizability of our findings. Despite these limitations, the study sheds light on medication utilization patterns in IBD and emphasizes the importance of addressing SDOH in healthcare delivery, recognizing that the relationship between SDOH and medication utilization is complex and context dependent. Declarations Ethics approval and consent to participate This study was reviewed and approved by the Baylor Scott & White Research Institute Institutional Review Board, which granted a waiver of informed consent due to the retrospective nature of the study and the use of anonymized data. The study was conducted in accordance with the ethical standards outlined in the Declaration of Helsinki. IRB Reference Number: 023-331 Consent for publication: Not applicable Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due to institutional policy but are available from the corresponding author upon request. Competing interests The authors declare no competing interests. Funding This research received no external funding. Authors' contributions: Study concept and design – RS; Acquisition of data –MS, ML,ES ; Analysis and interpretation of data – MS, ML,RS, ES ; Drafting of the manuscript – MS, ML,RS ; Critical revision of the manuscript – MS, ML,RS; Approval of the final manuscript – RS Acknowledgements: None Guarantor of the article : Rajesh Shah, MD, MS 4 References Tandon P, Chhibba T, Natt N, Singh Brar G, Malhi G, Nguyen GC. Significant Racial and Ethnic Disparities Exist in Health Care Utilization in Inflammatory Bowel Disease: A Systematic Review and Meta-analysis. Inflamm Bowel Dis . 2024;30(3):470-481. doi:10.1093/ibd/izad045 Bressler B, Marshall JK, Bernstein CN, et al. Clinical practice guidelines for the medical management of nonhospitalized ulcerative colitis: the Toronto consensus. 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Inflamm Bowel Dis . 2024;30(1):1-8. doi:10.1093/ibd/izad034. Kochar B, Barnes EL, Long MD, et al. Depression Is Associated With More Aggressive Inflammatory Bowel Disease. Am J Gastroenterol . 2018;113(1):80-85. doi:10.1038/ajg.2017.423 Jordi SBU, Lang BM, Auschra B, et al. Depressive symptoms predict clinical recurrence of inflammatory bowel disease. Inflamm Bowel Dis . 2022;28(4):560-571. doi:10.1093/ibd/izab136. Persoons P, Vermeire S, Demyttenaere K, et al. The impact of major depressive disorder on the short- and long-term outcome of Crohn's disease treatment with infliximab. Aliment Pharmacol Ther . 2005;22(2):101-110. doi:10.1111/j.1365-2036.2005.02535.x Shah R, Kelley J, Amundsen T, Coggins K, Edwards A, Johnson CM. Medical and social determinants of health as predictors of adverse outcomes in patients with inflammatory bowel disease. Proc (Bayl Univ Med Cent) . 2022;36(2):165-170. Published 2022 Dec 21. doi:10.1080/08998280.2022.2156025 Tables Tables 1 and 2 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files SDOHManuscriptTables.docx Cite Share Download PDF Status: Posted Version 1 posted 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. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-6890611","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":508180765,"identity":"5c4c93ca-179f-4de5-a210-421f5c94e345","order_by":0,"name":"Maryana Stryelkina","email":"","orcid":"","institution":"Baylor Scott and White Health","correspondingAuthor":false,"prefix":"","firstName":"Maryana","middleName":"","lastName":"Stryelkina","suffix":""},{"id":508180766,"identity":"ed35dade-a8a1-415f-bbc4-4528ca4703a2","order_by":1,"name":"Megan Lewis","email":"","orcid":"","institution":"Baylor Scott and White Health","correspondingAuthor":false,"prefix":"","firstName":"Megan","middleName":"","lastName":"Lewis","suffix":""},{"id":508180767,"identity":"2eeb4858-75f5-45ff-a7a7-4fff1386a9c9","order_by":2,"name":"Eric Smith","email":"","orcid":"","institution":"Baylor Scott and White Health","correspondingAuthor":false,"prefix":"","firstName":"Eric","middleName":"","lastName":"Smith","suffix":""},{"id":508180768,"identity":"9e3c41d0-0ef9-4245-b82d-6dec97c892da","order_by":3,"name":"Rajesh Shah","email":"data:image/png;base64,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","orcid":"","institution":"Baylor Scott and White Health","correspondingAuthor":true,"prefix":"","firstName":"Rajesh","middleName":"","lastName":"Shah","suffix":""}],"badges":[],"createdAt":"2025-06-13 20:23:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6890611/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6890611/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91330058,"identity":"29bc0312-2197-4fea-9bed-228735553ff0","added_by":"auto","created_at":"2025-09-15 10:47:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":420229,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6890611/v1/c7004fb8-14bd-4e5e-88b0-ca2bfc74c2b0.pdf"},{"id":90485834,"identity":"068e08a8-7cc2-43b4-ab23-58975c0590e5","added_by":"auto","created_at":"2025-09-03 08:50:32","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":42349,"visible":true,"origin":"","legend":"","description":"","filename":"SDOHManuscriptTables.docx","url":"https://assets-eu.researchsquare.com/files/rs-6890611/v1/c2a4b74209fd27ca7dd7b882.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Effects of Social Determinants of Health on Medication Utilization in Patients with Inflammatory Bowel Disease","fulltext":[{"header":"Introduction","content":"\u003cp\u003eInflammatory bowel diseases (IBD), including ulcerative colitis (UC) and Crohn’s disease (CD), are chronic, lifelong inflammatory disorders of the intestines.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Due to their progressive nature, IBD patients require close monitoring for acute flares and ongoing management. Healthcare utilization is notably higher among IBD patients, leading to increased emergency room visits, hospitalizations, and IBD-related surgeries compared to the general population.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Within the first 5 years of diagnosis, disease-related progression or complications lead to hospitalization in up to 20% of patients with UC and 50% of patients with CD.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e However, early initiation of therapies can significantly improve clinical symptoms and endoscopic appearance, which correlate with reduced healthcare utilization.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eRacial disparities have been noted in patients with IBD. Studies indicate that Black adult patients with IBD experience higher rates of complications, emergency room visits, and hospitalizations compared to non-Hispanic White patients.\u003c/span\u003e\u003csup\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eAdditionally, Tendol at el\u003c/span\u003e\u003csup\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003efound that Hispanic patients with UC are more likely to be hospitalized compared to White patients but tend to have similar surgery rates compared to White patients with UC.\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eDespite these outcome differences, 30 days readmission rates appear similar across racial and ethnic groups\u003c/span\u003e.\u003csup\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eRacial disparities in medication utilization in patients with IBD are unclear. While some studies indicate that Black patients are less likely to receive steroids, infliximab, and immunomodulators compared to White patients, other research suggests that Black patients have a higher likelihood of initiating anti-TNF medications.\u003c/span\u003e\u003csup\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThese conflicting findings may stem from the limited scope of single-center studies. Larger, nationally representative studies have not demonstrated a difference in medication utilization based on race or ethnicity.\u003c/span\u003e\u003csup\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eOur\u003c/span\u003e study investigates the impact of social determinants of health (SDOH) on medication utilization among adult patients with IBD within the Baylor Scott and White Health (BSWH) system. We specifically focus on financial strain, food insecurity, transportation availability, and depression risk. Our goal is to identify potential barriers to medication utilization, with the aim of improving the quality of healthcare for IBD patients.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eStudy Design and Population\u003c/span\u003e\u003c/p\u003e\u003cp\u003eWe conducted a retrospective cohort study of adult patients with IBD seen within the BSWH system between the years of 2013 and 2022. BSW is the largest hospital system in Texas with a diverse population of patients. The system cares for approximately 2\u0026nbsp;million unique patients annually with about 7\u0026nbsp;million patient encounters per year. All patient data were extracted from the BSW electronic medical record (Epic), which contains comprehensive demographic and clinical information. Adult patients diagnosed with IBD who received care within the BSWH system between January 1, 2013, and December 31, 2022, were included for analysis. Identification of adult patients with IBD was performed using the International Classification of Diseases, 9th Revision (ICD-9), and 10th Revision (ICD-10) codes for UC and CD. Subsequent confirmation of UC or CD diagnoses involved a manual review of patients' medical records, incorporating corroborative endoscopy, pathology, or imaging findings. Exclusion criteria were patients below 18 years of age, lack of a confirmed diagnosis of IBD, insufficient follow-up information pertaining to their condition, or incomplete clinical or SDOH information.\u003c/p\u003e\u003cp\u003eThe Montreal Classification System was used to classify IBD phenotype.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e For patients with UC, disease extent was classified as either proctitis (E1), left-sided colitis (E2), and extensive colitis (E3). Among patients with CD, disease location was categorized as terminal ileum (L1), colonic (L2), ileocolonic (L3), and upper gastrointestinal tract participation (L4). Disease behavior was classified as either inflammatory (B1), stricturing (B2) or fistulizing (B3).\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eMedication Utilization\u003c/span\u003e\u003c/p\u003e\u003cp\u003eMedication utilization was determined by a new prescription or order for an IBD-related medication within the study time period, which was analyzed individually (e.g., infliximab) and by medication class. Medication classes were anti-TNF, anti-IL 12/23, anti-integrin and small molecules.\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSocial Determinants of Health\u003c/span\u003e\u003c/p\u003e\u003cp\u003eSDOH information was either entered by the patient through the online check-in system or by a medical assistant on the day of the visit. SDOH variables included financial resource strain, depression assessment (PHQ-2), food security (worried or scared) and medical transportation. Financial resource strain was categorized as very hard, hard, somewhat hard, not very hard, or not hard at all. Depression assessment with the PHQ-2 score ranged from 0 to 6 with 6 being at higher risk for a depression diagnosis. Food security was stratified into two categories (worried or scared) with responses being either never true, sometimes true, or often true. Finally, medical transportation concerns were categorized either yes or no.\u003c/p\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eDemographic and clinical characteristics were summarized using either mean and standard deviation for continuous variables or percentages for categorial variables. Continuous variables were compared using the Student’s t test and categorical variables were compared using either the chi square or Fisher exact test, as appropriate. Univariate and multivariate logistic regression analysis was performed to identify associations between demographic, clinical and SDOH variables with medication utilization. Variables that were significant in univariate analysis were then included in a multivariate logistic regression model for further evaluation. P values \u0026lt; 0.05 were considered statistically significant. All statistical testing was performed using JASP 0.18.3 for Apple (University of Amsterdam).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e1,360 unique IBD patients were identified, of which 325 had complete clinical and SDOH data. Among these, 106 patients received advanced therapies, including biologics and small molecules.\u0026nbsp;The demographic and clinical characteristics of the groups are summarized in Tables 1a and 1b for patients with CD and UC, respectively. In patients with CD, there was a trend for younger individuals to receive anti-TNF (55.8 vs. 62.4 years, p=0.01) and anti-IL-12/23 (49.9 vs. 61.4 years, p=0.04) biologics. Among the groups exposed to anti-TNF and anti-IL-12/23, no significant differences were observed in terms of sex, race, disease extent, perianal disease involvement, disease behavior, or alcohol and tobacco use. Similarly, no significant differences were found in age, sex, race, disease characteristics, alcohol use, or tobacco use in patients receiving anti-integrin or small molecule therapies.\u003c/p\u003e\n\u003cp\u003eSimilarly, younger patients with UC were more likely to receive anti-TNF therapies (49.4 vs 65.4 years, p \u0026lt; 0.001). No significant differences in age, race, or gender were observed among patients exposed to anti-IL-12/23 and small molecule therapies. However, patients prescribed integrin therapy were more likely to be White compared to Black (83% vs 0%, p \u0026lt; 0.001). Disease extent did not seem to influence medication utilization. Alcohol consumption did not vary significantly across therapy types; however, a notable association was observed between tobacco use and small molecule therapy. Non-tobacco users were significantly more likely to receive small molecule therapy compared to tobacco users (RR=1.8, 95% CI: 0.3-13.0, p=0.028). No significant associations were observed between tobacco use and other treatment categories such as anti-TNF, anti-IL-12/23, or integrin therapies.\u003c/p\u003e\n\u003cp\u003eRegarding SDOH data, no significant associations were found between SDOH factors, including financial strain, food insecurity, transportation and depression, and medication utilization in patients with either UC or CD (Tables 2a and 2b).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis comprehensive study involved 1,360 unique adult patients diagnosed with IBD. Of these, 325 had complete clinical and SDOH data available. Among these 325 patients, 106 were treated with advanced therapies, including biologics and small molecules. The study examined how demographic, clinical, and SDOH factors influenced medication usage. Significant findings included younger age was associated with anti-TNF (UC and CD) and anti-IL-12/23 (CD) use. In patients with UC, White patients were more likely to receive anti-integrin therapy compared to Black patients, while non-tobacco users were more likely to receive small molecule therapy than tobacco users. Overall, SDOH factors did not influence medication utilization. These findings highlight the impact of demographic and lifestyle factors on medication usage in IBD patients, offering insights into potential disparities and modifiable risk factors for optimal medication utilization.\u003c/p\u003e\u003cp\u003ePrevious studies have linked age to anti-TNF therapy in patients with IBD. A community-based cohort study of 494 CD patients found that those aged 18 and younger were more likely to receive infliximab than patients aged 60 and older.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Similarly, Flasar et al\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e, while accounting for disease severity, observed a positive correlation between age under 40 and anti-TNF therapy utilization. Our study aligns with these trends. Among patients with CD, younger individuals were more likely to receive anti-TNF therapies (mean age\u0026thinsp;=\u0026thinsp;55.8 years vs. 62.4 years, p\u0026thinsp;=\u0026thinsp;0.01). Additionally, our analysis revealed similar patterns for anti-IL-12/23 therapy (49.9 years vs. 65.4 years, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In patients with UC, younger patients were also more likely to receive anti-TNF therapies (49.4 vs. 65.4 years, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). These results imply an age-related pattern in treatment preferences, which suggests further work is needed to understand treatment decision making in this age population.\u003c/p\u003e\u003cp\u003eExisting research suggests varying medication usage among individuals with IBD based on race. Single center studies have suggested that Black patients are less likely to receive anti-TNF therapies when compared to White patients.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e However, this association was not found in a multicenter cohort study, where Black patients were noted to have a higher likelihood of receiving anti-TNF therapies.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Nationally representative studies found no clear associations between anti-TNF usage and race.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Discrepancies could in part be related to underlying insurance status, since no disparities were noted between White and Black patients insured through the Medicaid program nationally.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e In our study, consistent with larger national studies, we did not find a statistically significant difference in medication utilization rates when stratified by race for CD. However, among patients with UC, we observed a notable racial disparity in medication usage. Specifically, integrin medications were predominantly prescribed to White individuals, with 83% of integrin users being White, while no Black patients received this treatment (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). These findings highlight the need for further research to confirm and explore interventions aimed at reducing disparities and improving health outcomes across diverse patient populations.\u003c/p\u003e\u003cp\u003ePrevious research highlights the impact of smoking on CD progression and its protective effect against UC development.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Specifically, in the CD population, tobacco use has been associated with more complicated disease courses when compared to non-smokers. This includes an increased risk of disease relapse and a higher likelihood of surgery.\u003csup\u003e\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Additionally, smoking was found to be significantly associated with increased health care costs in CD patients. Severs et al\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e found that active smokers with CD had a significantly higher risk of requiring anti-TNF therapy.\u003c/p\u003e\u003cp\u003eCurrently, a knowledge gap exists regarding the link between tobacco use patterns and medication utilization in IBD patients. Our study found that in CD population with tobacco use, there was no difference in medication utilization. Additionally, our study revealed that non-tobacco users with UC were 1.8 times more likely to receive small molecule therapy than tobacco users (RR\u0026thinsp;=\u0026thinsp;1.8, 95% CI: 0.3\u0026ndash;13.0, p\u0026thinsp;=\u0026thinsp;0.028). These findings emphasize the need to consider age and tobacco usage when tailoring treatment strategies for UC patients.\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ePatients diagnosed with IBD often face financial constraints that can impact their access to essential medical care. These challenges may include difficulties obtaining diagnostic tests, medications, and follow-up appointments, which can lead to delays in diagnosis and treatment initiation. For example, Bernstein et al\u003c/span\u003e\u003csup\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003econducted a population-based cohort study and found that IBD patients with indicators of lower socioeconomic status experienced poorer outcomes. These outcomes included higher rates of outpatient physician visits, hospitalizations, intensive care unit admissions, steroid use, and mortality. Similarly, Medicaid-insured patients with IBD exhibited higher rates of hospital admissions and emergency room visits compared to patients with IBD covered by other forms of insurance.\u003c/span\u003e\u003csup\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThese findings underscore the impact of financial constraints on healthcare utilization and outcomes. Instead of examining outcomes, we explored the effect of financial strain on medication utilization patterns among IBD patients. Surprisingly, we did not find a significant difference in medication usage related to self-reported financial strain. This suggests that financial constraints may have limited influence on treatment choices within our study population and other mechanisms may be leading to increased healthcare utilization and poorer outcomes.\u003c/span\u003e\u003c/p\u003e\u003cp\u003eFood insecurity significantly affects individuals with IBD, exacerbating financial strain and compromising nutritional status. IBD patients experiencing food insecurity often encounter financial hardships related to medical expenses, financial distress, and cost-related medication non-adherence. These challenges can complicate disease management and potentially lead to poorer health outcomes.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e Additionally, food insecurity can result in nutritional deficiencies that adversely impact disease course, affecting both induction and maintenance of remission and overall quality of life.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e In a 2015 National Health Interview Survey analysis, Nguyen et al\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e found that 1 in 8 IBD patients experience food insecurity and lack social support, both associated with increased financial toxicity. Surprisingly, our analysis did not find a correlation between food insecurity and medication utilization patterns in IBD patients. Further investigation into the interactions between food security, financial strain, insurance status, and other modifiable risk factors for medication utilization are needed to better understand these links.\u003c/p\u003e\u003cp\u003eThe impact of transportation on patients with IBD is multilevel, influencing both access to care and long-term management of symptoms. A prior observational study revealed that patients traveling longer distances to specialized centers were more likely to experience worse clinical outcomes, such as higher rates of hospital readmissions and increased use of immunomodulators and biological therapy. \u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e Similarly, a nationwide Israeli study revealed that limited transportation was linked to poorer IBD outcomes, associated with higher rates of steroid dependency and surgeries.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e However, a retrospective cohort study found no significant association between self-reported transportation difficulties and worsened IBD-related outcomes, such as hospitalizations and surgeries.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e Our study also revealed that self-reported access to transportation did not significantly impact medication utilization. Given these differences in data between single centers and the known impact of transportation on health outcomes, future multicenter research is needed to adequately establish the impact of transportation access in IBD patient population.\u003c/p\u003e\u003cp\u003eDepressive symptoms in patients with IBD are linked to higher rates of clinical deterioration and relapse. Specifically, depression is associated with increased likelihood of flare-ups, surgical interventions, and hospitalizations in patients with CD.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e A large cohort study conducted in Switzerland found a significant correlation between depressive symptoms and relapse rates in both UC and CD cohorts.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e Additionally, a smaller study showed that major depression in patients receiving infliximab therapy for active CD was associated with lower remission rates and quicker flares.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e Notably, our study did not find a correlation between depression assessed using the PHQ-2 score and medication utilization. These findings suggest additional modifying factors may influence adverse outcomes in patients with self-reported depression beyond medication selection.\u003c/p\u003e\u003cp\u003eOur study has notable strengths, including comprehensive data analysis and a diverse patient population. However, several limitations must be acknowledged. The retrospective study design allows for confounding variables, which we attempted to control by adjusting for demographic and clinical information. Electronic health records were used for data extraction, introducing the possibility of missing data or coding errors. To mitigate this, manual chart reviews were performed. Additionally, the inclusion criteria may have introduced selection bias, as only patients within the BSWH system were included, which may limit generalizability of our findings. Despite these limitations, the study sheds light on medication utilization patterns in IBD and emphasizes the importance of addressing SDOH in healthcare delivery, recognizing that the relationship between SDOH and medication utilization is complex and context dependent.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cbr\u003eThis study was reviewed and approved by the Baylor Scott \u0026amp; White Research Institute Institutional Review Board, which granted a waiver of informed consent due to the retrospective nature of the study and the use of anonymized data. The study was conducted in accordance with the ethical standards outlined in the Declaration of Helsinki. IRB Reference Number:\u0026nbsp;023-331\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003cbr\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to institutional policy but are available from the corresponding author upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cbr\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cbr\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions:\u0026nbsp;\u003c/strong\u003eStudy concept and design – RS; Acquisition of data –MS, ML,ES ; Analysis and interpretation of data – MS, ML,RS, ES ; Drafting of the manuscript – MS, ML,RS ; Critical revision of the manuscript – MS, ML,RS; Approval of the final manuscript – RS\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements: None\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGuarantor of the article\u003c/strong\u003e: Rajesh Shah, MD, MS\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTandon P, Chhibba T, Natt N, Singh Brar G, Malhi G, Nguyen GC. 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Smoking in Crohn\u0026apos;s disease: effect on localisation and clinical course. \u003cem\u003eGut\u003c/em\u003e. 1992;33(6):779-782. doi:10.1136/gut.33.6.779.\u003c/li\u003e\n\u003cli\u003eCosnes J, Carbonnel F, Carrat F, Beaugerie L, Cattan S, Gendre J. Effects of current and former cigarette smoking on the clinical course of Crohn\u0026apos;s disease. \u003cem\u003eAliment Pharmacol Ther\u003c/em\u003e. 1999;13(11):1403-1411. doi:10.1046/j.1365-2036.1999.00630.x\u003c/li\u003e\n\u003cli\u003eSevers M, Mangen MJ, van der Valk ME, et al. Smoking is Associated with Higher Disease-related Costs and Lower Health-related Quality of Life in Inflammatory Bowel Disease. \u003cem\u003eJ Crohns Colitis\u003c/em\u003e. 2017;11(3):342-352. doi:10.1093/ecco-jcc/jjw160\u003c/li\u003e\n\u003cli\u003eBernstein CN, Walld R, Marrie RA. 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Distance to Specialist Care and Disease Outcomes in Inflammatory Bowel Disease. \u003cem\u003eInflamm Bowel Dis\u003c/em\u003e. 2017;23(7):1234-1239. doi:10.1097/MIB.0000000000001133\u003c/li\u003e\n\u003cli\u003eParedes Amenabar C, Cortes Espinosa T, L\u0026oacute;pez Gom\u0026eacute;z J, et al. P057\u0026emsp;How Distance Between Residence and Treatment Center Impact the Outcome of Patients With Inflammatory Bowel Disease at CMN 20. \u003cem\u003eAm J Gastroenterol\u003c/em\u003e. 2021;116(Suppl 1):S15. doi:10.14309/01.ajg.0000798828.47393.3f\u003c/li\u003e\n\u003cli\u003eLedder O, Harel S, Lujan R, et al. Residence in peripheral regions and low socioeconomic status are associated with worse outcomes of inflammatory bowel diseases: a nationwide study from the epi-IIRN. \u003cem\u003eInflamm Bowel Dis\u003c/em\u003e. 2024;30(1):1-8. doi:10.1093/ibd/izad034.\u003c/li\u003e\n\u003cli\u003eKochar B, Barnes EL, Long MD, et al. 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Published 2022 Dec 21. doi:10.1080/08998280.2022.2156025\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 and 2 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Crohn’s disease, ulcerative colitis, inflammatory bowel disease, social determinants of health","lastPublishedDoi":"10.21203/rs.3.rs-6890611/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6890611/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e\u003cbr\u003e\n Inflammatory bowel diseases (IBD), including ulcerative colitis (UC) and Crohn’s disease (CD), are chronic inflammatory conditions requiring ongoing medical management. Although disparities in outcomes across racial and ethnic groups have been reported—particularly higher rates of complications and surgeries in minority populations—the influence of social determinants of health (SDOH) on treatment patterns remains less clearly defined. This study investigates how demographic, clinical, and SDOH factors relate to the use of advanced IBD therapies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe retrospectively reviewed electronic health records of 1,360 adult patients with IBD within a large healthcare system. The primary outcome was initiation of advanced therapies, including anti-TNF agents, anti-integrins, anti-IL-12/23 agents, and small molecules. We evaluated associations with patient characteristics, including age, race, tobacco use, and reported barriers such as financial strain, food insecurity, transportation difficulties, and symptoms of depression. Statistical analyses included descriptive summaries and logistic regression, with p \u0026lt; 0.05 considered statistically significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003cbr\u003e\n Among patients with CD, younger individuals were more likely to receive anti-TNF (p = 0.01) and anti-IL-12/23 therapies (p = 0.04). In UC, younger age was also associated with greater anti-TNF use (p \u0026lt; 0.001). White patients with CD were more frequently prescribed anti-integrins compared to Black patients (p \u0026lt; 0.001). In the UC group, non-smokers were more likely than smokers to receive small molecule therapies (p = 0.028). No statistically significant relationships were observed between SDOH measures and medication utilization in either UC or CD.\u003c/p\u003e","manuscriptTitle":"The Effects of Social Determinants of Health on Medication Utilization in Patients with Inflammatory Bowel Disease","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-03 08:50:28","doi":"10.21203/rs.3.rs-6890611/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cf6431c6-a2b2-4c59-b102-100b762149c7","owner":[],"postedDate":"September 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-15T10:38:51+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-03 08:50:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6890611","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6890611","identity":"rs-6890611","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}