Skip to main content

Black Race and Public Insurance Are Predictive of Inappropriate Evaluation of Iron Deficiency Anemia and Diarrhea

Digestive Diseases and Sciences volume 66, pages 2200–2206 (2021)Cite this article

Abstract

Background and Aims

Socioeconomic status, race, and insurance can impact healthcare delivery and utilization in several chronic disease states. The primary aim of our study was to determine whether race and insurance status are predictors of having an appropriate workup for celiac disease and inflammatory bowel disease (IBD) when presenting with iron deficiency anemia (IDA) and chronic diarrhea.

Methods

Medical records of patients seen at the University of Chicago Medical Center between January 1, 2006, and September 20, 2017, were reviewed. Patients with two separate encounters within 6 months associated with the diagnosis codes for both IDA and chronic diarrhea were identified. Patients without a diagnosis code for IBD and celiac disease were further grouped as those that had an “appropriate” workup and those that did not. Factors associated with the appropriate evaluation were analyzed by univariate and multivariate logistic regression.

Results

In total, 899,701 records were searched. A total of 83 patients fit inclusion into the study (8 IBD, 3 CD, 72 neither IBD or CD). Black race was associated with a 91% decreased odds of having the appropriate workup on univariate (OR 0.090, 95%CI 0.017–0.475, p = 0.005) and age-adjusted multivariate analysis (OR 0.095, 95% CI 0.017–0.527, p = 0.007). Public insurance status was significantly associated with a 90% decreased odds of appropriate workup on univariate (OR 0.102, 95% CI 0.024–0.438, p = 0.002) and age-adjusted multivariate analysis (OR 0.104, 95% CI 0.021–0.513, p = 0.005).

Conclusions

Black race and public insurance were significantly associated with not having an appropriate workup for IBD and celiac disease when presenting with iron deficiency and chronic diarrhea.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

USD 39.95

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2

References

  1. Gasche C, Lomer MC, Cavill I, Weiss G. Iron, anaemia, and inflammatory bowel diseases. Gut. 2004;53:1190–1197.

    CAS  Article  Google Scholar 

  2. Rubio-Tapia A, Hill ID, Kelly CP, Calderwood AH, Murray JA, Gastroenterology ACo. ACG clinical guidelines: diagnosis and management of celiac disease. Am J Gastroenterol. 2013;108:656–676.

    CAS  Article  Google Scholar 

  3. Schiller LR, Pardi DS, Sellin JH. Chronic diarrhea: diagnosis and management. Clin Gastroenterol Hepatol.. 2017;15:182–193.e183.

    Article  Google Scholar 

  4. World Health Organization. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. 2011.

  5. Mahadev S, Laszkowska M, Sundström J, et al. Prevalence of celiac disease in patients with iron deficiency anemia-a systematic review with meta-analysis. Gastroenterology. 2018;155:374–382.e371.

    Article  Google Scholar 

  6. Eriksson C, Henriksson I, Brus O, et al. Incidence, prevalence and clinical outcome of anaemia in inflammatory bowel disease: a population-based cohort study. Aliment Pharmacol Ther. 2018.

  7. Goddard AF, James MW, McIntyre AS, Scott BB, Gastroenterology BSo. Guidelines for the management of iron deficiency anaemia. Gut. 2011;60:1309–1316.

    CAS  Article  Google Scholar 

  8. Smalley W, Falck-Ytter C, Carrasco-Labra A, Wani S, Lytvyn L, Falck-Ytter Y. AGA clinical practice guidelines on the laboratory evaluation of functional diarrhea and diarrhea-predominant irritable bowel syndrome in adults (IBS-D). Gastroenterology. 2019;157:851–854.

    Article  Google Scholar 

  9. Baumgart DC, Sandborn WJ. Crohn’s disease. Lancet. 2012;380:1590–1605.

    Article  Google Scholar 

  10. Sewell JL, Velayos FS. Systematic review: The role of race and socioeconomic factors on IBD healthcare delivery and effectiveness. Inflamm Bowel Dis. 2013;19:627–643.

    Article  Google Scholar 

  11. Fiscella K, Franks P, Gold MR, Clancy CM. Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care. JAMA. 2000;283:2579–2584.

    CAS  Article  Google Scholar 

  12. Institute of Medicine (U.S.). Committee on the Consequences of Uninsurance. Care without coverage: too little, too late. Washington, D.C.: National Academy Press; 2002.

  13. Mardini HE, Westgate P, Grigorian AY. Racial differences in the prevalence of celiac disease in the US population: National Health and Nutrition Examination Survey (NHANES) 2009–2012. Dig Dis Sci. 2015;60:1738–1742.

    Article  Google Scholar 

  14. Thia KT, Sandborn WJ, Harmsen WS, Zinsmeister AR, Loftus EV. Risk factors associated with progression to intestinal complications of Crohn’s disease in a population-based cohort. Gastroenterology. 2010;139:1147–1155.

    Article  Google Scholar 

  15. Freeman HJ. Adult celiac disease and its malignant complications. Gut Liver. 2009;3:237–246.

    Article  Google Scholar 

  16. Bottaro G, Cataldo F, Rotolo N, Spina M, Corazza GR. The clinical pattern of subclinical/silent celiac disease: an analysis on 1026 consecutive cases. Am J Gastroenterol. 1999;94:691–696.

    CAS  PubMed  Google Scholar 

  17. Lo W, Sano K, Lebwohl B, Diamond B, Green PH. Changing presentation of adult celiac disease. Dig Dis Sci. 2003;48:395–398.

    Article  Google Scholar 

  18. Harper JW, Holleran SF, Ramakrishnan R, Bhagat G, Green PH. Anemia in celiac disease is multifactorial in etiology. Am J Hematol. 2007;82:996–1000.

    Article  Google Scholar 

  19. Gisbert JP, Gomollón F. Common misconceptions in the diagnosis and management of anemia in inflammatory bowel disease. Am J Gastroenterol. 2008;103:1299–1307.

    Article  Google Scholar 

  20. Abu Daya H, Lebwohl B, Lewis SK, Green PH. Celiac disease patients presenting with anemia have more severe disease than those presenting with diarrhea. Clin Gastroenterol Hepatol. 2013;11:1472–1477.

    Article  Google Scholar 

  21. Koutroubakis IE, Ramos-Rivers C, Regueiro M, et al. Persistent or recurrent anemia is associated with severe and disabling inflammatory bowel disease. Clin Gastroenterol Hepatol. 2015;13:1760–1766.

    Article  Google Scholar 

  22. Sofia MA, Rubin DT, Hou N, Pekow J. Clinical presentation and disease course of inflammatory bowel disease differs by race in a large tertiary care hospital. Dig Dis Sci. 2014;59:2228–2235.

    Article  Google Scholar 

  23. Anyane-Yeboa A, Yamada A, Haider H, et al. A comparison of the risk of postoperative recurrence between African–American and Caucasian patients with Crohn’s disease. Aliment Pharmacol Ther. 2018.

  24. Dotson JL, Kappelman MD, Chisolm DJ, Crandall WV. Racial disparities in readmission, complications, and procedures in children with Crohn’s disease. Inflamm Bowel Dis. 2015;21:801–808.

    Article  Google Scholar 

  25. Dotson JL, Cho M, Bricker J, et al. Race differences in initial presentation, early treatment, and 1-year outcomes of pediatric Crohn’s disease: results from the improvecarenow network. Inflamm Bowel Dis.. 2017;23:767–774.

    Article  Google Scholar 

  26. Fiscella K, Sanders MR. Racial and ethnic disparities in the quality of health care. Annu Rev Public Health. 2016;37:375–394.

    Article  Google Scholar 

  27. Marrast LM, Zallman L, Woolhandler S, Bor DH, McCormick D. Minority physicians’ role in the care of underserved patients: diversifying the physician workforce may be key in addressing health disparities. JAMA Intern Med. 2014;174:289–291.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Section of Gastroenterology, Hepatology and Nutrition, The University of Chicago Medicine, 5841 S. Maryland Ave. MC 4076, Chicago, IL, 60637, USA

    Adjoa Anyane-Yeboa, Betty Li, Cindy Traboulsi, Amarachi I. Erondu, Philip Sossenheimer, Victoria Rai & David T. Rubin

  2. Harvard T.H. Chan School of Public Health, Boston, MA, USA

    Adjoa Anyane-Yeboa

Authors
  1. Adjoa Anyane-Yeboa
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Betty Li
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Cindy Traboulsi
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Amarachi I. Erondu
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Philip Sossenheimer
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Victoria Rai
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. David T. Rubin
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

AAY was involved in drafting of manuscript, data acquisition, analysis and interpretation, revision of manuscript, and drafting of tables and figures; BL was involved in data acquisition, drafting of manuscript, and tables and figures; CT was involved in data analysis and interpretation, and critical revision of manuscript; AIE was involved in data analysis and interpretation, and critical revision of manuscript; PS was involved in data analysis and interpretation, drafting of tables and figures, and critical revision of manuscript; VR was involved in data analysis and interpretation, drafting of tables and figures, and critical revision of manuscript; DTR was involved in study concept and design, drafting of manuscript, critical revision of manuscript, and final approval of manuscript.

Corresponding author

Correspondence to David T. Rubin.

Ethics declarations

Conflict of interest

The authors declare that the have no conflict of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Anyane-Yeboa, A., Li, B., Traboulsi, C. et al. Black Race and Public Insurance Are Predictive of Inappropriate Evaluation of Iron Deficiency Anemia and Diarrhea. Dig Dis Sci 66, 2200–2206 (2021). https://doi.org/10.1007/s10620-020-06434-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10620-020-06434-9

Keywords

  • Inflammatory bowel disease
  • Celiac disease
  • Health disparity
  • Race
  • Black