title: Out-of-pocket Cost Burden in Pediatric Inflammatory Bowel Disease: A Cross-sectional Cohort Analysis.
abstract: BACKGROUND
  Pediatric inflammatory bowel disease (IBD), consisting of Crohn's disease (CD) and ulcerative colitis (UC), can result in significant morbidity requiring frequent health care utilization. Although it is known that the overall financial impact of pediatric IBD is significant, the direct out-of-pocket (OOP) cost burden on the parents of children with IBD has not been explored. We hypothesized that affected children with a more relapsing disease course and families in lower income strata, ineligible for need-based assistance programs, disparately absorb ongoing financial stress.
  
  
  METHODS
  We completed a cross-sectional analysis among parents of children with IBD residing in California using an online HIPAA-secure Qualtrics survey. Multicenter recruitment occurred between December 4, 2013 and September 18, 2014 at the point-of-care from site investigators, informational flyers distributed at regional CCFA conferences, and social media campaigns equally targeting Northern, Central, and Southern California. IBD-, patient-, and family-specific information were collected from the parents of pediatric patients with IBD patients younger than 18 years of age at time of study, carry a confirmed diagnosis of CD or UC, reside in and receive pediatric gastroenterology care in California, and do not have other chronic diseases requiring ongoing medical care.
  
  
  RESULTS
  We collected 150 unique surveys from parents of children with IBD (67 CD; 83 UC). The median patient age was 14 years for both CD and UC, with an overall 3.7 years (SD 2.8 yr) difference between survey completion and time of IBD diagnosis. Annually, 63.6%, 28.6%, and 5.3% of families had an OOP cost burden >$500, >$1000, and >5000, respectively. Approximately one-third (36.0%) of patients had emergency department (ED) visits over the past year, with 59.2% of these patients spending >$500 on emergency department copays, including 11.1% who spent >$5000. Although 43.3% contributed <$500 on procedure and test costs, 20.0% spent >$2000 in the past year. Families with household income between $50,000 and $100,000 had a statistically significant probability (80.6%) of higher annual OOP costs than families with lower income <$50,000 (20.0%; P < 0.0001) or higher income >$100,000 (64.6%; P < 0.05). Multivariate analysis revealed that clinical variables associated with uncontrolled IBD states correlated to higher OOP cost burden. Annual OOP costs were more likely to be >$500 among patients who had increased spending on procedures and tests (odds ratio [OR], 5.63; 95% confidence interval [CI], 2.73-11.63), prednisone course required over the past year (OR, 3.19; 95% CI, 1.02-9.92), at least 1 emergency department visit for IBD symptoms (OR, 2.84; 95% CI, 1.33-6.06), at least 4 or more outpatient primary medical doctor visits for IBD symptoms (OR, 2.82; 95% CI, 1.40-5.68), and history of 4 or more lifetime hospitalizations for acute IBD care (OR, 2.60; 95% CI, 1.13-5.96).
  
  
  CONCLUSIONS
  Previously undocumented, a high proportion of pediatric IBD families incur substantial OOP cost burden. Patients who are frequently in relapsing and uncontrolled IBD states require more acute care services and sustain higher OOP cost burden. Lower middle income parents of children with IBD ineligible for need-based assistance may be particularly at risk for financial stress from OOP costs related to ongoing medical care.
authors.affiliation: *School of Medicine, Stanford University, Palo Alto, California; †Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Oakland Children's Hospital, Oakland, California; ‡Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, California; §Department of Pediatrics, Division of Gastroenterology, Santa Clara Valley Medical Center, San Jose, California; ‖Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California; and ¶Department of Pediatrics, Division of Gastroenterology, Children's Hospital Central California, Madera, California; **Department of Pediatrics, Division of Gastroenterology and Nutrition, California Pacific Medical Center, San Francisco, California.
authors.forename: Aaron T
authors.initials: AT
authors.lastname: Sin
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Damman
authors.forename: David A
authors.initials: DA
authors.lastname: Ziring
authors.forename: Elizabeth E
authors.initials: EE
authors.lastname: Gleghorn
authors.forename: Manuel G
authors.initials: MG
authors.lastname: Garcia-Careaga
authors.forename: Roberto R
authors.initials: RR
authors.lastname: Gugig
authors.forename: Anna K
authors.initials: AK
authors.lastname: Hunter
authors.forename: Jennifer C
authors.initials: JC
authors.lastname: Burgis
authors.forename: Dorsey M
authors.initials: DM
authors.lastname: Bass
authors.forename: K T
authors.initials: KT
authors.lastname: Park
mesh_terms: D000293:Adolescent; D002140:California; D002648:Child; D015331:Cohort Studies; D003093:Colitis, Ulcerative / Q000191:economics*; D017281:Cost of Illness; D003424:Crohn Disease / Q000191:economics*; D003430:Cross-Sectional Studies; D004636:Emergency Service, Hospital / Q000191:economics; D005382:Financing, Personal / Q000191:economics*; D019538:Health Care Surveys / Q000706:statistics & numerical data; D006760:Hospitalization / Q000191:economics; D006801:Humans; D009819:Office Visits / Q000191:economics; D010290:Parents; D012959:Socioeconomic Factors
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