Faculty Bibliography

Age is the strongest risk factor for colorectal cancer. Although there is updated guidance for the age at which to start screening, there is little guidance for individuals or their medical teams on how to decide when to stop. Current recommendations from the US Preventive Services Task Force and other societies focus primarily on age. For patients older than 85 years, guidelines discourage screening because the harms largely outweigh benefits. Although at a population level, the overall benefit of screening in older individuals decreases, one must individualize the recommendation based on comorbidities, functional status, screening history, and gender-not solely base it on age. Patient and caregiver preferences must also be thoroughly explored. Current models struggle with incorporating other colorectal cancer risk factors such as family history, previous adenomas, and modality of previous screening into recommendations and simulations, but are likely to improve with machine learning and whole electronic health record prediction-based approaches.

BACKGROUND:Repeat hospitalizations in veterans with inflammatory bowel disease (IBD) are understudied. The early readmission rate and potentially modifiable risk-factors for 90-day readmission in veterans with IBD were studied to avert avoidable readmissions. METHODS:A retrospective cohort study was conducted using the data from veterans who were admitted to the Minneapolis VA Medical Center (MVMC) between January 1, 2007, and December 31, 2013, for an IBD-related problem. All-cause readmissions within 30 and 90 days were recorded to calculate early readmission rates. The multivariate logistic regression was used to identify the potential risk factors for 90-day readmission. RESULTS:There were 130 unique patients (56.9% with Crohn's disease and 43.1% with ulcerative colitis) with 202 IBD-related index admissions. The mean age at the time of index admission was 59.8 ± 15.2 years. The median time to re-hospitalization was 26 days (IQR 10-49), with 30- and 90-day readmission rates of 17.3% (35/202) and 29.2% (59/202), respectively. Reasons for all-cause readmission were IBD-related (71.2%), scheduled surgery (3.4%) and non-gastrointestinal causes (25.4%). The following reasons were independently associated with 90-day readmission: Crohn's disease (OR 3.90; 95% CI 1.82-8.90), use of antidepressants (OR 2.19; 95% CI 1.12-4.32), and lack of follow-up within 90 days with a primary care physician (PCP) (OR 2.63; 95% CI 1.32-5.26) or a gastroenterologist (GI) (OR 2.44; 95% CI 1.20-5.00). 51.0% and 49.0% of patients had documentation of a recommended outpatient follow-up with PCP and/or GI, respectively. CONCLUSIONS:Early readmission in IBD is common. Independent risk factors for 90-day readmission included Crohn's disease, use of antidepressants and lack of follow-up visit with PCP or GI. Further research is required to determine if the appropriate timing of post-discharge follow-up can reduce IBD readmissions.

This issue provides a clinical overview of irritable bowel syndrome, focusing on diagnosis, treatment, and practice improvement. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of additional science writers and physician writers.