Doses of Disparity: Gaps in the Management of Crohn’s Disease

Abstract

Introduction

Crohn’s Disease (CD) is a chronic inflammatory bowel disease commonly treated with biologics (e.g., infliximab, adalimumab), immunomodulators (e.g., azathioprine, methotrexate), aminosalicylates (e.g. mesalamine), corticosteroids or, when severe, surgical intervention. While studies suggest that African Americans have a lower incidence of CD than European Americans, the incidence of CD is on the rise among African American populations, with these patients often presenting with more severe disease at diagnosis. Socioeconomic barriers, provider bias, and healthcare disparities may contribute. This study examines whether African American patients are more or less likely to receive biologics or immunomodulators before surgery compared to European American patients.

Methods

We conducted a retrospective cohort study using the TriNetX Global Network, a de-identified electronic health record-based database, encompassing 33,802 patients from 140 healthcare organizations. CD patients were identified using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes. Two cohorts were defined based on ethnic identification— European American and African American—and were matched 1:1 using propensity score matching for age, sex, comorbidities, literacy and socioeconomic factors. Baseline data were extracted from the 12 months preceding the index event, with the data spanning a period of 20 years. The primary outcomes were the proportions of patients prescribed traditional corticosteroids, aminosalicylates, immunomodulators, or biologics as determined by RxNorm codes. Group differences were evaluated using Z-tests and Kaplan–Meier survival analysis.

Results

After matching, each cohort comprised 33,802 patients with comparable demographics (mean age 40.5 ± 18.3 years; 58.4% female, 41.6% male). While African American patients had higher corticosteroid utilization when compared to European Americans (40.8% vs 37%), notable differences emerged in the other treatment modalities. African American patients had lower utilization rates of aminosalicylates (13.4% vs 14.3%) immunomodulators (8.9% vs 11.3%), and biologics (16.7% vs 17.8%). All the results were statistically significant.

Conclusion

.These findings reveal meaningful disparities in therapeutic treatment patterns of CD despite established guidelines for standard of care. The observed differences in non-surgical approaches may contribute to divergent long-term outcomes, potentially leading to higher rates of surgical intervention in African American patients. This illustrates the need for further studies to investigate whether these discrepancies lead to higher rates of surgical intervention in African American patients and underscores the importance of early pharmacological interventions to ensure equitable care across ethnic groups in the United States.