Biological and steroid use in relationship to quality measures in older patients with inflammatory bowel disease: a US Medicare cohort study

Objectives: To examine the frequency and predictors of antitumour necrosis factor (TNF) use, and to describe steroid utilisation among US patients with inflammatory bowel disease (IBD) aged 65 years and older prior to the publication of a new Medicare quality measure calling for the use of anti-TNFs and other steroid-sparing agents. Design: Retrospective cohort study. Setting: This study utilised 2006-2009 claims data for a national sample of Medicare beneficiaries. Participants: Patients with IBD (> 1 claim for ICD codes 555. xx, 556.xx) without anti-TNF contraindications, enrolled in Medicare parts A and B >= 12 months and part D >= 6 months were included (n=8502). Outcome measures: We estimated incidence rate ratios (IRR) and 95% CIs predicting new anti-TNF therapy using multivariable Poisson regression. Results: This nationally representative study of older patients with IBD estimated that only 3.7% received anti-TNFs. New anti-TNF use (1.4%) was associated with younger age, absence of Medicaid coverage, hospitalisation, and higher preceding use of burst (IRR=2.35, CI 1.59 to 3.47) and maintenance steroids (IRR=2.40, CI 1.05 to 5.48). Among anti-TNF users, we observed high rates of concurrent maintenance steroid use (19%). Conclusions: Anti-TNF use was very low in this population of older patients with IBD and, importantly, was often combined with maintenance steroid use despite guidelines suggesting reduced needs. Expanding IBD-specific quality measures to include steroid taper plans may cue appropriate maintenance regimens that include anti-TNFs and other steroid sparing agents while reducing protracted concomitant steroid use as intended by current quality measures.