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Original article
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# Do Socio-Demographics Play a Role in the Prevalence of Red Flags and Pursuant Colonoscopies in Patients With Irritable Bowel Syndrome?

### Abstract

#### Background

Irritable bowel syndrome (IBS) is a “brain-gut disorder” that lacks laboratory, radiologic, or physical exam findings. Colonoscopies are not routinely performed unless “red flag” symptoms, such as bleeding or abnormal weight loss, are present. Socio-demographics have been implicated as sources of potential disparities in appropriate care.

#### Aims

We hypothesize that the incidence of red flag symptoms and pursuant colonoscopies differ by socio-demographic status in patients with IBS.

#### Methods

Patients diagnosed with IBS were extracted from the National Inpatient Sample 2001-2013 using the International Classification of Diseases, Ninth Revision (ICD-9) codes. Gastrointestinal bleed, blood in stool, weight loss, and anemia were pooled into red flag symptoms. Colonoscopies during the admission were identified using ICD-9 procedural codes. Chi-square analysis and binomial logistic regression were used to evaluate potential disparities with α<0.01.

#### Results

Patients with Medicaid or Medicare or those without insurance had higher odds of presenting with red flag symptoms compared to those with private insurance. Medicaid patients and uninsured patients had higher odds of undergoing colonoscopies. All patients that were not Caucasian had higher odds of presenting with red flags and subsequently undergoing colonoscopies. Older patients had higher odds of presenting with concerning red flag symptoms but lower odds of undergoing colonoscopies.

#### Conclusions

The incidence of red flag symptoms and performance of colonoscopies differed by socio-demographics in patients with IBS. Patients with non-private or those without insurance were more likely to have red flags and undergo a colonoscopy. Age and race also increased rates of red flag symptoms while having a mixed effect on pursuant colonoscopies. This may represent discrepancies in healthcare utilization in a vulnerable population.

### Introduction

#### Prediction of red flag symptoms

Using patients aged 19 to 29 as the reference, patients aged 30 to 50 and 51 to 60 were not found statistically significantly to have any differences in the occurrence of red flag symptoms, though, for the younger cohort, red flag symptoms occurred less often non-significantly. Patients aged 61 to 79 and great than 80 years old were found to have an increased odds of presenting with red flag symptoms. Those aged 61 to 79 were 1.14 times more likely to have red flag symptoms, and those aged greater than 80 were 1.63 times more likely to have red flag symptoms. Patients of any race as compared to Caucasians were more likely to have red flag symptoms. African Americans were 2.1 times more likely, Hispanic patients were 1.4 times more likely, and Asian, Pacific Islander, or Native American descents were 1.2 times more likely to have red flag symptoms. Females in the study sample were 1.2 times more likely to have red flag symptoms. With respect to median incomes, it was found that compared to the 0-25th percentile, the other quartiles had no statistically significant decreased odds of red flag symptoms. Patients with all insurances other than private insurance were more likely to have red flag symptoms. Patients with Medicaid and Medicare were 1.2 times more likely to have red flag symptoms. Those that were uninsured were 1.3 times more likely to have red flag symptoms (Table 3).

 Variable P-value Odds ratio (95% CI) Age 19 to 30 Reference 31 to 50 0.417 0.97 (0.91-1.04) 51 to 60 0.280 0.96 (0.88-1.04) 61 to 79 0.002* 1.14 (1.05-1.24) ≥ 80 <0.001* 1.63 (1.48-1.81) Race Caucasian Reference African American <0.001* 2.08 (1.94-2.22) Hispanic <0.001* 1.36 (1.26-1.47) Asian, Pacific Islander, Native American <0.001* 1.18 (1.11-1.24) Gender Males Reference Females <0.001* 1.18 (1.11-1.24) Insurance status Private insurance Reference Medicaid <0.001* 1.18 (1.10-1.27) Medicare <0.001* 1.19 (1.12-1.26) No insurance <0.001* 1.30 (1.19-1.42) Other insurance status <0.001* 1.23 (1.10-1.39) Median income quartiles 0-25th percentile Reference 26-50th percentile 0.030 0.94 (0.88-0.99) 51-75th percentile 0.279 0.97 (0.91-1.03) 76-100th percentile 0.009* 0.92 (0.87-0.98)

#### Prediction of pursuant colonoscopies

Patients aged 30 to 50, 51 to 60, 61 to 79, and those greater than 80 were all found to have statistically significantly decreased odds of undergoing a colonoscopy compared to ages 19 to 29. Patients aged 30 to 50 had an odds ratio of 0.9, 51 to 60 had an odds ratio of 0.8, 61 to 79 had an odds ratio of 0.7, and ages greater than 80 had an odds ratio of 0.7. Compared to patients of Caucasian descent, African Americans were 1.2 times more likely, Hispanics were 1.3 times more likely, and Asian, Pacific Islander, and Native Americans were 1.1 times more likely to have a colonoscopy performed. Patients that were females were less likely to get a colonoscopy at an odds ratio of 0.8. Patients, as compared to the 0-25th percentile, of all median income quartiles did not have any significant increase in odds of undergoing a colonoscopy. Compared to patients with private insurance, those with Medicare did not have a statistically significant difference in odds of getting a colonoscopy but those with Medicaid and those without insurance were 1.1 and 1.6 times more likely, respectively (Table 4).

 Variable P-value Odds ratio (95% CI) Age 19 to 30 Reference 31 to 50 <0.001* 0.89 (0.84-0.94) 51 to 60 <0.001* 0.77 (0.72-0.81) 61 to 79 <0.001* 0.74 (0.69-0.79) ≥ 80 <0.001* 0.69 (0.63-0.76) Race Caucasian Reference African American <0.001* 1.24 (1.17-1.32) Hispanic <0.001* 1.33 (1.24-1.41) Asian, Pacific Islander, Native American 0.008* 1.13 (1.03-1.24) Gender Males Reference Females <0.001* 0.84 (0.80-0.87) Insurance status Private insurance Reference Medicaid <0.001* 1.13 (1.07-1.19) Medicare 0.219 0.97 (0.92-1.02) No insurance <0.001* 1.53 (1.43-1.64) Other insurance status 0.237 0.94 (0.86-1.04) Median income quartiles 0-25th percentile Reference 26-50th percentile 0.135 1.04 (0.99-1.09) 51-75th percentile 0.677 0.99 (0.94-1.04) 76-100th percentile 0.301 1.03 (0.98-1.08) Red flag symptoms Not present Reference Present <0.001* 2.49 (2.38-2.61)

### Discussion

Irritable bowel syndrome, though benign in pathology, is an enigmatic disease connected across many disciplines, including gastroenterology, psychiatry, and medicine. Patients with irritable bowel syndrome experience severe distress and disability and often are not treated appropriately due to the nonspecific constellation of symptoms, which can lead to a high healthcare utilization burden [14].

In this study, we found that the incidence of red flag symptoms and performance of colonoscopies differs by socio-demographics in patients admitted with IBS. Currently, there are many conflicting studies understanding the effect of socio-demographics; however, from this large inpatient sample, it is evident that those without insurance present more often with red flag symptoms and as a result are more likely to get colonoscopies. Those of any race other than Caucasian also have a predilection for presenting with red flag symptoms and therefore undergoing colonoscopies. The implications of this emphasize the ongoing evaluation of the social disparities present in our healthcare system.

Age was also a contributor to the disparities in patients admitted for IBS as compared to the second decade of life. Those individuals 30 to 60 years old did not show any differences, but those older than sixty were more like to demonstrate these red flag symptoms. It is reasonable to consider that older patients may be more likely to present with anemia or lower bleeding due to other comorbidities, such as polyps or diverticular disease; however, in our study, it was observed that all ages were less likely to undergo colonoscopy compared to the 19-30 age population [15]. This is unexpected as typically older patients are more likely to undergo inpatient colonoscopies compared to younger patients [16]. This disparity may be a result of a higher level of concern for these alarming symptoms being atypical or more likely concerning for inflammatory bowel disease in the younger population as compared to the older. Younger patients are more likely to present with these red flag symptoms and more likely to undergo colonoscopies. Given that these younger patients are more likely to be uninsured, as they don't qualify for government assistance for health insurance, the lack of insurance may contribute to such disparity in red flag symptoms and pursuant colonoscopies [17].

There is currently minimal research comparing socio-demographic status with red flag symptoms or colonoscopies in patients with IBS. To our knowledge, this is the largest and most comprehensive analysis of factors associated with colonoscopies in patients with IBS and as they relate to demographic factors. Patients with non-private insurance and those who are uninsured are more likely to experience red flag symptoms compared to those with private insurance, and those with Medicaid and no insurance are also more likely to undergo a colonoscopy.

Endoscopic procedures like colonoscopy constitute 50-75% of the entire cost of the workup for IBS, making it the most expensive portion [18]. Despite the current colorectal cancer recommendation that normal screening colonoscopies should be held every 10 years, nearly 50% of Medicare patients had a repeat colonoscopy in less than seven years without any clear indication for the early examination [19-20]. This reflects a potential overuse of screening colonoscopies, creating a financial burden and increasing patient mortality [19]. Based on our results, a healthcare utilization discrepancy may also be seen in patients with IBS who are either uninsured or receiving Medicaid, as we found that they are more likely to undergo a colonoscopy. As observed in other studies, we also observed a negative trend in the number of patients diagnosed with IBS undergoing colonoscopies inpatient as well as the average length of stay, which may demonstrate increased proficiency in understanding IBS and the risk of observation in this patient population, however, our trends demonstrated a continued increase in hospital costs [21]. This trend demonstrates the importance of preventing hospitalizations and further exploring treatment options.

IBS typically has three modalities of treatment, including nutritional therapy, drug therapy, or psychotherapy. Although there has been a lack of studies to demonstrate the effects of vitamins and digestive enzymes, there have been many subjective reports of improvement. The use of prebiotics and probiotics are now being subjected to further studies, as they may have a significant role in altering the gut flora. The balancing act, however, is the cost of these medications as the exploitation of “natural remedies” has driven the demand. Shown to decrease the overall healthcare costs by decreasing additional medications, requiring consulting different services, and decreasing hospital length of stay, treatment with these medications may benefit patients who may not be able to afford their admission to the hospital [22-23]. Drug therapy also reflects this increased focus on the alteration of gut microbiota. Drug therapy initially involved antispasmodic drugs, low-dose antidepressants, and laxatives or motility accelerants. However, there is now a focus on agents that alter the microbiome, including medications such as rifaximin. Finally, the last treatment arm of this disease includes the use of psychotherapy to address the “brain” aspect of the “brain-gut syndrome.” Patients are known to have somatic symptoms that are an extension of the patient’s negative feelings. With psychotherapy, patients can reduce psychological stress, which improves their brain-gut signaling. However, the economic burden of all these medications and treatments makes them less viable, especially to those with a low socioeconomic status. The inability to access these medications continues the positive effect of delaying presentation and presenting with the various red flag symptoms [23].

### Conclusions

Irritable bowel syndrome, a disease of the "brain-gut axis," is a very common disorder that has yet to have a definitive treatment. Though experienced by many, studies demonstrate the unequal distribution of IBS, as it affects certain demographics disproportionately. The goal of this study was to understand different factors that sway the decision to perform a colonoscopy on a patient with IBS. As the American College of Gastroenterology (ACG) guidelines recommend, a colonoscopy is typically only performed when there is the presence of red flag symptoms such as weight loss, luminal blood loss, or anemia. Through the analysis of this large inpatient database, it was found that uninsured patients were more likely to present red flag symptoms and undergo colonoscopies. All non-Caucasian races were also at high risk for presenting with red flag symptoms and undergoing colonoscopies. Finally, we found that a patient's older age predisposed them to a high risk of red flag symptoms; they underwent colonoscopies at a lower rate as compared to their younger counterparts. The importance of understanding the role socio-demographic factors play in patients with IBS is underrated, as we demonstrate the higher hospital utilization costs attributed to performing more colonoscopies due to increased occurrences of red flag symptoms. Further research must be done to understand how to mitigate the socio-economic disparities present to improve patient outcomes and hospitalization costs.

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###### Ethics Statement and Conflict of Interest Disclosures

Human subjects: All authors have confirmed that this study did not involve human participants or tissue. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Original article
peer-reviewed

9.7