title: Intestinal Surgery for Crohn’s Disease: Predictors of Recovery, Quality of Life, and Costs The CHOICE trial: adalimumab demonstrates safety, fistula healing, improved quality of life and increased work productivity in patients with Crohn’s disease who failed prior infliximab therapy Social prognosis in patients with ulcerative colitis. Morbidity of juvenile onset inflammatory bowel disease: effects on education and employment in early adult life. Employment problems and prospects for patients with inflammatory bowel disease. Work disability in inflammatory bowel disease patients 10 years after disease onset: results from the IBSEN Study Validity, reliability, and responsiveness of the work productivity and activity impairment questionnaire in Crohn's disease. Remission in Patients with Crohn's Disease is Associated with Improvement in Employment and Quality of Life and a Decrease in Hospitalizations and Surgeries Efficacy and safety of adalimumab in Canadian patients with moderate to severe Crohn's disease: results of the Adalimumab in Canadian SubjeCts with ModErate to Severe Crohn's DiseaSe (ACCESS) trial. Costs of Inflammatory Bowel Disease in Germany Morbidity and functional outcome after restorative proctocolectomy for ulcerative colitis. Response and remission are associated with improved quality of life, employment and disability status, hours worked, and productivity of patients with ulcerative colitis Unemployment and Disability in Patients With Moderately to Severely Active Crohn's Disease Adalimumab improves patient-reported outcomes and reduces indirect costs in patients with moderate to severe Crohn's disease: results from the CARE trial. Ileostomy and excision of the large intestine for ulcerative colitis.
abstract: Introduction The aim of this prospect i ve study was to analyze the impact of different surgical techniques on patients undergoing intestinal surgery for Crohn ’s disease ( CD ) in terms of recovery , quality of life , and direct and indirect costs . Patients and methods Forty-seven consecutive patients admitted for intestinal surgery for CD were enrolled in this prospect i ve study . Surgical procedures were evaluated as possible predictors of outcome in terms of disability status ( Barthel ’s Index ) , quality of life ( Clevel and Global Quality of Life score ) , body image , disease activity ( Harvey – Bradshaw Activity Index ) , and costs ( calculated in 2008 Euros ) . Univariate and multivariate analyses were performed . Results Significant predictors of a long postoperative hospital stay were the creation of a stoma , postoperative complications , disability status on the third post-operative day , and surgical access ( R2 = 0.59 , p < 0.01 ) . Barthel ’s index at discharge was independently predicted by laparoscopic-assisted approach , ileal CD , and colonic CD ( R2 = 0.53 , p < 0.01 ) . The disability status at admission showed to be an independent predictor of quality of life score at follow-up . The overall cost for intestinal surgery  for CD was 12,037 ( 10,117–15,795 ) euro per patient and stoma creation revealed to be its only predictor ( p = 0.006 ) . Conclusions Laparoscopy was associated with a shorter postoperative length of stay ; stoma creation was associated with a long and expensive postoperative hospital stay , and stricturoplasty was associated with a slower recovery of bowel function Aliment Pharmacol Ther 2010 ; 32 : 1228–1239 One hundred and twenty-two r and omly selected patients with ulcerative colitis ( 28 of whom had undergone colectomy )  were interviewed to obtain data on the quality of their family , emotional , social , and professional lives . They were compared with an age- and sex-matched group of patients with acute conditions from the same area . The two groups were similar in marital status , the frequency of severe family or sexual problems , leisure activities , physical and earning capacity , the incidence of mental disorders before the interview , and intake of alcohol and psychopharmacological drugs . A higher proportion of the patients with colitis had had a higher education and belonged to higher socioeconomic groups than the controls , and this difference had been present at the time of diagnosis . These results show that patients with ulcerative colitis seem to adapt themselves well to their condition and suffer few social or professional disabilities Seventy young adults ( 50 with Crohn 's disease ( CD ) and 20 with ulcerative colitis ( UC ) ( from a geographically derived cohort of patients with juvenile onset inflammatory bowel disease were interviewed and examined at a mean of 14 ( range 5.2 - 29.5 ) years after diagnosis .  Details of  education and employment  were collected as part of a structured clinical interview . Although 57 % had had periods of absence from school of two months or more , their school examination pass rates were similar to those of the healthy population . The achievements of CD patients were consistently better than those of the UC group . In 15 patients , relapses of inflammatory bowel disease had adversely affected examination performance or prevented them from sitting school examinations . Extra tuition in hospital had been provided for only four patients , and three others had had privately arranged tuition at home . Fifty per cent proceeded to full time higher education . At the time of review , seven patients were full time students , one was a university research fellow , 47 were in full time and three in part time employment , one was self employed , four were housewives , and only six were involuntarily unemployed . All four unemployed CD patients attributed this to inflammatory bowel disease , but other factors were relevant in the unemployed UC patients . Few had direct evidence of rejection by employers on health grounds , though some did not declare their illness to prospect i ve employers A r and om sample of 170 patients ( 88 men ) with chronic inflammatory bowel disease ( 75 ulcerative colitis ) were first interviewed in 1978 about their employment status , problems at work , and influence of surgery .  Surgery had been carried out on 120 and 53 had an ileostomy . After six years 144 ( 92 % ) of the 156 survivors replied to a follow up postal question naire . Of the initial sample , 122 ( 72 % ) were working and there were only three ( 1 % ) registered unemployed . After six years a similar proportion were working and only seven ( 5 % ) were unemployed . Continuity of employment was good with 57 % in the same job . Changes in work because of health had been made by 72 patients mainly caused by bowel disease . After surgery 10 % completely changed and 22 % modified their work while a few had to retrain or retire . Panproctocolectomy and ileostomy result ed in more changes and longer time off work after surgery than colectomy and ileorectal anastomosis , with 35 % and 17 % respectively off work after one year . Problems at work , in particular general malaise and arthritis were experienced by 34 ( 28 % ) patients . Fewer problems were experienced by patients with a stoma who also had less sickness absence than those without a stoma . Colleagues and employers were usually supportive although some patients encountered discrimination especially those with a stoma or working in the food industry . Few patients had been counselled on their work . In general employment prospect s and time off work were good and employers should be encouraged to take an optimistic and supportive role . Doctors should consider that convalescence after surgery may be longer than they perceive and must provide better counselling for patients Objective To compare the work disability ( WD ) rate in inflammatory bowel disease ( IBD ) patients 10 years after disease onset , with the WD rate in the background population , and to assess whether clinical or demographic factors in the early disease course could predict WD after 10 years disease . Design A large , population -based inception cohort ( the Inflammatory Bowel in South Eastern Norway cohort ) was prospect ively followed up at 1 , 5 and 10 years after diagnosis . At the 10-year follow-up data on WD were collected . Data on  disability pension ( DP )  in the background population were retrieved from public data bases . We calculated overall and age-st and ardised relative risks ( RR ) for  DP .  Logistic regression analysis was used to examine predictive factors . Results A total of 518 patients completed the 10-year follow-up ( response rate 83.5 % ) . The overall disability rate in the IBD population was 18.8 % , and the RR was 1.8 ( 95 % CI 1.4 to 2.3 ) for ulcerative colitis ( UC ) and 2.0 ( 95 % CI 1.4 to 2.7 ) for Crohn 's disease ( CD ) . The RR for DP was highest in patients aged below 40 years while patients aged over 60 years had no increased RR . Steroid treatment at the 1-year follow-up predicted WD after 10 years disease in both CD and UC . In UC , increased C-reactive protein ( CRP ) or erythrocyte sedimentation rate ( ESR ) at diagnosis , early colectomy , and more than two relapses during the first year of the disease also predicted WD . Conclusion Ten years after disease onset IBD patients had an increased RR for DP as compared with the background population . The youngest patients had the highest RR . Markers of severe disease course predicted WD BACKGROUND Crohn 's disease ( CD ) is a chronic inflammatory bowel disease usually diagnosed in early adult life and characterized by unpredictable flares and debilitating symptoms such as diarrhea , abdominal pain , and fever , which can interfere with a patient 's ability to work and perform daily activities . OBJECTIVE The aim of this study was to assess the validity , reliability , and responsiveness of the Work Productivity and Activity Impairment question naire in CD ( WPAI : CD ) . METHODS The WPAI : CD was tested in CD patients enrolled in a 26-week r and omized clinical trial of cer-tolizumab pegol versus placebo . Discriminative validity of WPAI : CD absenteeism , presenteeism(reduced on-the-job effectiveness ) , overall work productivity loss ( absenteeism + presenteeism ) , and activity impairment scores was assessed relative to 5 measures of disease severity and health status : CD Activity Index ( CDAI ) , Short Form-36 physical component summary ( PCS ) and mental health component summary ( MCS ) scores , Inflammatory Bowel Disease Question naire ( IBDQ ) , and the 5-dimensional EuroQoL health-related quality -of-life visual analog scale ( EQ-VAS ) . Responsiveness was assessed by comparing changes in WPAI : CD scores from baseline to week 26 for patients in remission ( CDAI < 150 points ) versus no remission . St and ardized Response Means ( SRMs ) were calculated to evaluate the magnitude of the changes . RESULTS A total of 662 patients ( mean [ range ] age , 37.4 [ 18 - 77 ] years ; male , 288 [ 43.5 % ] ; white , 629 [ 95.0 % ] ) were enrolled in the study . Patients with CD of the worst severity ( CDAI > median ) showed significantly higher impairment in work ( + 10.5 % ) and activities ( + 10.4 % ) versus patients with " best health " ( no problems ) ( both , P < or = 0.001 ) . Patients with " worst " IBDQ , PCS , MCS , and EQ-VAS scores also showed significantly higher impairments in work ( IBDQ , VAS -24.2 % ; PCS , -24.1 % ; MCS , -15.9 % ; EQ-VAS , -16.5 % ) and activities ( IBDQ , -23.3 % ; PCS , -21.8 % ; MCS , -16.5 % ; EQ-VAS , -17.2 % ) versus " best " scores ( all , P < 0.05 ) . There were significant differences between WPAI : CD impairment scores for patients in remission versus patients failing to achieve remission ( P < 0.05 ) . SRMs were small ( ie , < 0.5 ) in the nonre-mission group , and moderate to large ( ie , > 0.5 ) for patients in remission . CONCLUSIONS The discriminative validity , reliability , and responsiveness of the WPAI : CD were demonstrated . The WPAI : CD may be useful for evaluating drug impact on CD OBJECTIVES :  Hospitalization , surgery , work loss , and impaired quality of life contribute to the cost and burden of care for patients with Crohn 's disease . We examined the impact of remission on patients ' employment , quality of life , and hospitalization and  surgery  in a clinical trial to vali date clinical remission , as defined by the Crohn 's disease activity index ( CDAI ) , as the key treatment goal in managing Crohn 's disease . METHODS : ACCENT I evaluated the efficacy and safety of long-term dosing of infliximab compared to a single dose of infliximab in 573 patients with moderately-to-severely active Crohn 's disease . At wk 54 , employment status was compared between patients in CDAI remission and those not in CDAI remission , for those not employed at baseline . Physical component summary ( PCS ) and mental component summary ( MCS ) scores of the SF-36 question naire were also compared between these two groups . The numbers of Crohn's-related hospitalizations and surgeries were compared among four groups of patients who spent 0–25 % , 25–50 % , 50–75 % , and 75–100 % of time , respectively , in CDAI remission during the study . RESULTS : At baseline , patients had a severely impaired quality of life and a high unemployment rate ( 38.4 % ) . Among the group of patients who were unemployed at baseline , 31 % of those patients who achieved CDAI remission ( CDAI < 150 ) at wk 54 were employed , compared to 16 % who were not in CDAI remission at wk 54 ( p < 0.05 ) . PCS and MCS scores of patients in CDAI remission at wk 54 were significantly higher ( p < 0.0001 ) , indicating better mental and physical functioning , than those of patients not in CDAI remission at wk 54 , and were similar to those of the general U.S. population . Hospitalization and surgery rates decreased as the percentage of time patients were in CDAI remission increased ( p < 0.01 and p < 0.05 , respectively ) . CONCLUSIONS : CDAI remission is associated with reduced hospitalizations and surgeries , increased employment , and normalized quality of life . Sustained CDAI remission should be the key therapeutic goal in managing Crohn 's disease OBJECTIVE To evaluate open-label adalimumab therapy for clinical effectiveness , fistula healing , patient-reported outcomes and safety in Canadian patients with moderate to severe Crohn 's disease ( CD ) who were either naive to or previously exposed to antitumour necrosis factor ( anti-TNF ) therapy . METHODS Patients with moderate to severe CD ( CD activity index [ CDAI ] score of greater than 220 , or Harvey-Bradshaw index [ HBI ] of 7 or greater ) were eligible . Patients received open-label adalimumab as induction ( 160 mg and 80 mg subcutaneously [ sc ] ) at weeks 0 and 2 , respectively and maintenance ( 40 mg sc every other week ) therapy . At or after eight weeks , patients with flare or nonresponse could have their dosage increased to 40 mg sc weekly . Patients were followed for a minimum of six months or until adalimumab was commercially available in Canada . RESULTS Of the 304 patients enrolled , 160 were infliximab experienced , while 144 were anti-TNF naive .  HBI remission ( HBI score of 4 or lower ) at week 24 was achieved by 53 % of anti-TNF-naive and 36 % of infliximab-experienced patients ( P<0.01 ; P<0.001 for both groups for all visits versus baseline ) . Fistula healing rates at week 12 were 48 % for anti-TNF-naive patients , and 26 % for infliximab-experienced patients . At week 24 , fistula healing rates were significantly greater for the anti-TNF-naive group ( 60 % versus 28 % ; P<0.01 ) . Improvements in quality of life and work productivity were sustained from week 4 to week 24 for all patients . Serious infections occurred in 2 % of patients . CONCLUSIONS Adalimumab therapy induced and sustained steroidfree remission in both infliximab-experienced and anti-TNF-naive patients with moderate to severe CD . Clinical ly meaningful rates of fistula healing were also observed . Improvements in patient-reported outcomes were sustained throughout the 24-week study period Abstract Introduction : Inflammatory bowel disease ( IBD ) is a chronic condition that afflicts young adults in their economically productive years . The goal of this study was to determine the costs of IBD in Germany from a societal perspective , using cost diaries . Methods : Members of the German Crohn ’s Disease and Ulcerative Colitis Association who had IBD were recruited by post , and those who agreed to participate documented their IBD-associated costs prospect ively in a diary over 4 weeks . They documented their use of healthcare facilities , medications , sick leave and out-of-pocket expenditures , as well as general demographic information , the status and history of their IBD , and long-term disability . Item costs were calculated according to national sources . Cost data were calculated using non-parametric bootstrapping and presented as mean costs ( year 2004 ) over 4 weeks . Results : The cost diaries were returned by 483 subjects ( Crohn ’s disease : n = 241 , ulcerative colitis : n = 242 ) with a mean age of 42 years and an average disease duration of 13 years ( SD ± 8.09 ) . The cost diaries were regarded as ‘ easy to complete ’ by 89 % of participants . The mean 4-week costs per subject were € 1425 ( 95 % CI 1201 , 1689 ) for Crohn ’s disease and € 1015 ( 95 % CI 832 , 1258 ) for ulcerative colitis . Of the total costs for Crohn ’s disease , 64 % were due to indirect costs such as early retirement or sick leave and 32 % were due to direct medical costs . In contrast , of the total costs for ulcerative colitis , 41 % were due to direct medical costs and 54 % to indirect costs . Conclusions : This is the first comprehensive cost study for Crohn ’s disease and ulcerative colitis in Germany . The most important economic factors that influenced the cost profiles of both diseases were the long-term productivity losses due to an ongoing inability to work and the cost of medications . Results indicate significant cost differences between Crohn ’s disease and ulcerative colitis . This data provides initial cost estimates that can be analysed further with respect to cost determinants and disease-specific costs in the future OBJECTIVE To find out whether a threefold increase in follow up ( median 108 compared with 36 months ) influenced major morbidity and functional outcome between the first 32 and the last 32 patients consecutively operated on with J-pouch ileoanal anastomosis for ulcerative colitis from 1984 to 1997 . DESIGN Retrospective and prospect i ve study . SETTING University hospital , Norway . PATIENTS 64 patients with ulcerative colitis who had proctocolectomy and ileal pouch-anal anastomoses .  INTERVENTIONS The pouches were mainly h and anastomosed ( n = 61 ) to the dentate line after mucosectomy or anastomosed by double stapling technique without mucosectomy ( n = 3 ) . The 58 patients who still had their pouches responded to a question naire on functional outcome and satisfaction . MAIN OUTCOME MEASURES Morbidity , functional outcome , and patients ' satisfaction . RESULTS Major morbidity in these 64 patients comprised pelvic sepsis in 3 ( 5 % ) , operation for intestinal obstruction in 5 ( 8 % ) , pouchitis in 12 ( 19 % ) , fistulas in 7 ( 11 % ) and pouch excision in 6 ( 9 % ) . Thirteen patients ( 20 % ) had 35 reoperations and 11 patients ( 17 % ) had 22 re-laparotomies . There were more complications among the first 32 patients with the longest follow up than among the last 32 patients , but this difference was significant only concerning the rate of reoperations ( 31 % compared with 9 % ) because of the higher number of pouch excisions ( 5 compared with 1 ) in this group . There were no significant differences in the functional outcome and degree of patient satisfaction between the first 29 and the last 29 patients . Respective values for 24 hour median stool freqency were 7.0 and 6.3 , leakage of stool 48 % and 38 % , ability to defer defaecation 86 % and 97 % , perineal irritation 59 % and 48 % , use of antidiarrhoeal medication 55 % and 52 % , and wearing of pad 28 % and 38 % . Sexual life ( n = 57 ) was improved in 11 ( 19 % ) and reduced in 7 ( 12 % ) . Potency was reduced in 5 ( 15 % ) and ejaculation in 4 ( 12 % ) , one of whom ( 3 % ) had retro grade ejaculation . Three ( 5 % ) received disability pensions and five ( 9 % ) had reduced workload . After the pouch operation 48 ( 91 % ) felt better and 3 ( 6 % ) felt worse because of frequent bowel emptying , perineal eczema , or pouch fistula . CONCLUSION Continence-preserving proctocolectomy carries considerable morbidity , but the long term functional outcome is satisfactory and does not seem to deteriorate substantially Background : Impairment of health‐related quality of life , employment , and productivity has been documented in patients with moderate to severe ulcerative colitis . Methods : Using prospect ively collected data from the Active Ulcerative Colitis Trials 1 and 2 , we examined the impact of clinical response or remission , as defined using the Mayo score , on health‐related quality of life , employment , disability , productivity , and hours worked per week . These analyses were based on observed data and included all 728 patients , regardless of their r and omized treatment group ( i.e. ,  placebo and infliximab patients were grouped for analysis ) . Changes in Inflammatory Bowel Disease Question naire ( IBDQ ) and Medical Outcomes Study 36‐Item Short Form ( SF‐36 ) scores among nonresponders , responders , and patients in remission were compared . In addition , changes in employment , disability status , productivity , and hours worked per week of patients in clinical remission and patients not in clinical remission were compared . Results : Ulcerative colitis patients in clinical response or remission had significantly improved IBDQ and SF‐36 scores at week 30 compared with those of nonresponders ( P < 0.001 ) . Among those not employed at baseline , including those receiving disability compensation , greater percentages of patients in remission at week 30 were employed ( 20.6 % ) and not receiving disability compensation ( 58.8 % ) than were those not in remission ( 8.3 % and 20.0 % , respectively ; P < 0.05 for both comparisons ) . At week 30 , improvements from baseline in productivity and both actual and fully productive hours worked per week were greater for patients in remission compared with those not in remission ( P < 0.05 for all three comparisons ) . Conclusions : These results confirm the validity of response and remission as defined using the Mayo score Goals : Unemployment and disability rates in Crohn 's disease patients from the ACCENT I trial were assessed . Factors associated with employment and disability status were explored . Background : Limited data regarding unemployment and disability status in patients with active Crohn 's disease are available . Study : Baseline data were used to assess unemployment and disability rates . Logistic regression analysis examined factors that were associated with employment and disability status . Analysis of variance was used to compare quality of life . Results : The baseline full- and part-time employment rates were 48 % and 13 % , respectively , with 39 % of patients unemployed and 25 % receiving disability compensation . Only 14 % of 225 unemployed patients felt well enough to work if a job were available . Younger age , female gender , shorter disease duration , and prior bowel resection predicted a higher likelihood of unemployment . Younger age and female gender also predicted a higher likelihood of not being employed full-time . Prior bowel resection predicted a higher likelihood of receiving disability compensation . Quality of life ( Inflammatory Bowel Disease Question naire , Short Form-36 ) scores were significantly higher in employed patients . Conclusions : Patients with moderately to severely active Crohn 's disease had low employment and high disability rates . Given their economic importance , assessment of these outcomes should be integrated into future evaluations of therapy , including clinical trials BACKGROUND AND AIMS Crohn 's disease negatively affects patients '  quality of life and ability to work . We investigated the impact of adalimumab on work productivity , daily activities , and quality of life in an open-label trial ( N=945 ) . The population comprised both infliximab-naïve and -exposed patients , including infliximab primary non-responders . METHODS Patients received adalimumab induction therapy ( 160 mg/80 mg at Weeks 0/2 ) , followed by adalimumab 40 mg every other week for up to 20 weeks ( patients with flares/non-response could receive 40 mg weekly at/after Week 12 ) . The Work Productivity and Activity Impairment Question naire and Short Inflammatory Bowel Disease Question naire were assessed . Indirect cost savings were estimated based on the average work productivity improvements at Week 20 . RESULTS Mean baseline scores indicated severe productivity impairment and poor quality of life . At Week 20 , 60 % of infliximab-naïve and 47 % of infliximab primary non-responders achieved clinical ly important improvements ( ≥9 points ) on the Short Inflammatory Bowel Disease Question naire , and 51 % and 43 % , respectively , achieved the minimum clinical ly important difference ( improvement ≥7 percentage points ) for total work productivity impairment ( non-responder imputation ) . At Week 20 , 64 % of infliximab-naïve and 55 % of infliximab primary non-responders achieved clinical ly important improvements in total activity impairment . Estimated 20-week total indirect productivity-related cost savings were € 3070 per infliximab-naïve patient and € 2059 per infliximab-exposed patient . CONCLUSIONS Adalimumab therapy significantly improved work productivity and disease-specific quality of life for patients with moderate to severe Crohn 's disease . Patients who failed prior infliximab therapy and patients naïve to infliximab benefited from adalimumab , with potentially greater benefits for  infliximab-naïve patients ( NCT00409617 ) Abstract 442 patients with ulcerative colitis were su bmi tted to an operative programme of ileostomy and removal of the large bowel , between the years 1947 and 1965 ; of the 85 deaths , 46 were due to operation . Of the 39 late deaths , carcinoma ( 15 cases ) and liver failure ( 7 cases ) were the most common causes . Only 2 of the late deaths were attributable to surgical treatment and were due to obstruction . Initially emergency operation predominated over elective . During the period this position was reversed . A r and om group of 100 patients ( 38 men and 62 women ) were brought to hospital for review five or more years after surgery . Although the ability to work and enjoy leisure and the state of nutrition was satisfactory in this group an increased infertility was observed in females and sexual disability was noted in the males . A further 62 men were interviewed . The cause of sexual disability seems to be technical failure in removal of the rectum . With experience this should be avoidable . Cancer is a serious risk in patients with disease persisting for ten years . It remains a risk if any part of the large intestine is retained
target: The majority of the studies reported a high burden of work-related outcomes among inflammatory bowel disease patients regardless of the methodology used .
  Inflammatory bowel disease patients experience a high burden in work-related outcomes .
background: BACKGROUND & AIMS Inflammatory bowel disease has considerable effects on work-related outcomes and leads to high societal costs due to sick leave and disability pension .
  The aims of this study were to systematic ally review evidence on work-related outcomes that are relevant to productivity losses and to evaluate whether medical or surgical interventions have a positive impact on patients ' work ability .