Category Archives: C. diff. infection

Contagion Live Presents: Where Are We With Clostridioides Difficile?

MEDIA PARTNER

In this episode, our 1 Big Question is: Looking at C diff as a whole, would you say the medical community is doing a better job overall of treatment and what challenges remain?

We interviewed Sahil Khanna, MBBS, MS, who is professor of Medicine in the Division of Gastroenterology and Hepatology at Mayo Clinic; Glenn Tillotson, PhD, FIDSA, FCCP, GST Micro LLC; Payal K. Patel, MD, MPH, Division of Infectious Diseases

assistant professor, University of Michigan Health System and medical director of Antimicrobial Stewardship, VA Ann Arbor; and Anurag Malani, MD, infectious diseases specialist, St. Joseph Hospital, and a fellow of Infectious Diseases Society of America (IDSA).

https://www.contagionlive.com/view/where-are-we-with-clostridioides-difficile-

C. diff. Spores and More Live Broadcast to Podcast Is Available: Prevent CDI: Boost Immunity, Restore Microbiome, Replace the Bug

 

We are pleased to share  “C. diff. Spores and More ”  with you because, as advocates of  C. diff.,  we know the importance of this cutting-edge new weekly radio show and what it means for our Foundation’s community worldwide.

 

 

July 20, 2021:  Prevent CDI: Boost Immunity, Restore Microbiome, Replace the Bug

With Guests:

Neil Clark, Chief Executive Officer, Destiny Pharma, PLC

Mr. Clark qualified as an accountant with PwC in Cambridge, UK and worked for over ten years on a variety of national and international assignments in audit, corporate finance and consultancy. In 1997, Mr Clark joined CeNeS Pharmaceuticals plc, a venture capital backed private UK biotech company. Following the successful flotation of CeNeS in 1999, he was appointed CFO. In 2005, he became CEO and led the company through to its sale in 2008. He then joined Ergomed in January 2009 and was CFO during its IPO in July 2014. Mr. Clark joined Destiny Pharma as CEO in early 2017. Mr. Clark is a Fellow of the Institute of Chartered Accountants in England and Wales and has a BSc in Bioscience from the University of Nottingham.

Dale Gerding, MD, FACP, FIDSA, FSHEA

Dr. Dale Gerding is Research Physician at the Edward Hines Jr. VA Hospital and Professor of Medicine (Retired) at Loyola University Chicago Stritch School of Medicine. He is an infectious diseases specialist and hospital epidemiologist, past president of the Society for Healthcare Epidemiology of America. He is a fellow of the Infectious Diseases Society of America, is a Master of the American College of Physicians and the 2013 recipient of the William Middleton Award, the highest research award given by the Department of Veterans Affairs. He is board certified in Internal Medicine and Infectious Diseases. His major research interest is in the epidemiology, prevention and treatment of Clostridioides difficile infection and he is the discoverer of non-toxigenic C. difficile strain M3. (NTCD-M3)

https://www.voiceamerica.com/episode/132305/prevent-cdi-boost-immunity-restore-microbiome-replace-the-bug

Neil Clark, Chief Executive Officer, Destiny Pharma PLC and Dale Gerding, MD, FACP, FIDSA, FSHEA, with our Guest Host: Kevin Hersh, shared a robust discussion which touched upon important topics focused on the what, why, and how to Prevent a C. diff. infection: Boost Immunity, Restore Microbiome, Replace the Bug. Our guests exchanged a dialogue about the science to answer the many questions about a C. difficile infection, prevention, treatments, what is recurrent C. diff., and the immune system, and how the microbiome plays a part in everything.  Click on the link provided above to access the archived episode and expand your basic CDI knowledge today.

Changes In Electronic Health Records (EHR) To Guide Clinicians In C. diff. Diagnostic Stewardship – To Pause Testing When Not Clinically Indicated

An intervention that required administrative approval of all Clostridioides difficile testing after

hospital day 3 out-performed electronic health record-based support in reducing

C. difficile testing, according to a study.

“We made a series of changes in the electronic health records (EHRs) that we hoped would discourage clinicians from ordering C. difficile tests when testing was not clinically indicated, such as when patients with diarrhea had a more likely explanation such as recent laxative use, or when testing was ordered on patients who were not having diarrhea or other symptoms of C. difficile infection at all,” Lewis said. “In addition, one hospital in our system independently implemented a physician ‘gatekeeper’ to approve all C. difficile test orders for admitted patients.”

“We performed this work as part of a larger quality improvement initiative with the goal of improving the accuracy of diagnosis of C. difficile infection in order to improve quality of care for patients and decrease our health system’s publicly reported rates of C. difficile,” Sarah S. Lewis, MD, MPH, associate professor of medicine in the division of infectious diseases at Duke University Medical Center, told Healio.

“We made a series of changes in the electronic health records (EHRs) that we hoped would discourage clinicians from ordering C. difficile tests when testing was not clinically indicated, such as when patients with diarrhea had a more likely explanation such as recent laxative use, or when testing was ordered on patients who were not having diarrhea or other symptoms of
C. difficile infection at all,” Lewis said. “In addition, one hospital in our system independently implemented a physician ‘gatekeeper’ to approve all C. difficile test orders for admitted patients.”

Lewis and colleagues tested the three EHR-based interventions at three hospitals. The first intervention, initiated in January 2018, alerted clinicians ordering a test if laxatives were administered within 24 hours. The second, initiated in October 2018, canceled test orders after 24 hours. Implemented in July 2019, he third intervention involved “contextual rule-driven order questions” that required justification when laxatives were administered or there was a lack of EHR documentation of diarrhea. In February 2019, one of the three hospitals then implemented the “gatekeeper intervention” requiring approval for all C. difficile tests after 3 days in the hospital.

Sarah S. Lewis

Lewis and colleagues estimated the impact of the interventions on C. difficile testing and hospital-onset C. difficile infection (HO-CDI) using an interrupted time-series analysis. They found that C. difficile testing was already declining in the preintervention period (annual change in incidence rate [IR] = 0.79; 95% CI, 0.72-0.87) and did not decrease further with the EHR interventions.

The study demonstrated, however, that the laxative alert was temporally associated with a trend reduction in HO-CDI (annual change in IR from baseline = 0.85; 95% CI, 0.75-0.96) at two hospitals. Meanwhile, the gatekeeper intervention at the third hospital was associated with level (incidence rate ratio [IRR[ = 0.5; 95% CI, 0.42-0.6) and trend reductions in C. difficile testing (annual change in IR = 0.91; 95% CI, 0.85-0.98) and level (IRR = 0.42; 95% CI, 0.22-0.81) and trend reductions in HO-CDI (annual change in IR = 0.68; 95% CI, 0.5–0.92) relative to the baseline period, the researchers reported.

“Diagnostic stewardship, or the appropriate utilization of diagnostic tests, is important for improving quality of care. Electronic decision support in the form of alerts or background logic to reinforce the desired provider behavior is attractive because it is relatively low resource, easy to implement, and can be programmed in a way that is relatively unobtrusive to the clinical workflow,” Lewis said. “However, as we and others have seen, decision support often needs to be coupled with both provider education and some form of administrative restriction to achieve desired goals.”

To read article in its entirety, please click on the link below to be redirected. Thank you.

https://www.healio.com/news/infectious-disease/20210624/test-restrictions-more-effective-than-ehrbased-support-at-reducing-c-difficile-testing?utm_source=selligent&utm_medium=email&utm_campaign=topicalert&M_BT=7301325430025

IDSA, SHEA Update ADULT C. difficile Infection (CDI) Treatment Guidelines

“The panel’s recommendations for the management of CDI are based upon evidence derived from topic-specific systematic literature reviews,” Stuart Johnson, MD, infectious disease clinician and researcher at the Edward Hines Jr. Veterans Administration Hospital, and colleagues wrote.

The new guidance for CDI management in adults is as follows:

  • For patients with an initial C. difficile episode, fidaxomicin is recommended rather than a standard course of vancomycin.
  • For patients with recurrent C. difficile episodes, a standard or extended-pulsed regimen of fidaxomicin should be used rather than a standard course of vancomycin.
  • For patients with a recurrent C. difficile episode within the past 6 months, bezlotoxumab and standard-of-care antibiotics should be used rather than standard-of-care antibiotics alone.

“Head-to-head trials of differing anti-CDI recurrence strategies using narrow-spectrum antibiotics that target C. difficile, restoration of the microbiome using biotherapeutics or [fecal microbiota transplantation], or augmentation of the host immune response with agents such as bezlotoxumab given alone or in combination (eg, in combination with fidaxomicin) are needed,” the authors wrote.

 

SOURCE:  https://www.healio.com/news/infectious-disease/20210624/idsa-shea-update-guidance-for-managing-patients-with-c-difficile

A Real-World Data Analysis – Study Shows the Clinical Complications In Patients With Primary CDI and Recurrent C. difficile Infections

Reduction in recurrent C. difficile infection is an important step to reduce the burden of serious clinical complications, and new treatments are needed to reduce C. difficile infection recurrence.

Keywords Clostridium difficile infection, Clostridioides difficile infection, recurrent Clostridioides difficile infection, sepsis, real-world analysis

Clostridioides difficile infection (CDI) has a national burden of 462,100 cases in 2017 according to the latest estimate from the US Centers for Disease Control and Prevention (CDC).1 The CDC also reported that the burden of recurrent CDI (rCDI) remained unchanged over the 7 years of observation, despite a decreasing trend in healthcare-associated CDI. The clinical burden of CDI has many facets, from a prolonged hospital stay, increased risk of sepsis, and need for surgical intervention.2 Previous research has shown that septic shock complicated CDI in 34.7% of patients being mechanically ventilated.3 When managing severely ill patients with CDI, the need for colectomy may arise.4 While bowel surgery can save the lives of patients with severe CDI, the procedure carries a significant risk of mortality.5 Taken together, the unmet needs of patients with CDI and rCDI remain high, but more precise information about the clinical burden is critically needed.

Approximately 25% of patients with an initial CDI episode experience rCDI, and 40%–65% of patients with one recurrence will experience multiply-recurrent CDI (mrCDI; two or more recurrences).6,7 While there is significant knowledge about the epidemiology and clinical manifestations of CDI, fewer clinical data exist from real-world analyses of CDI and rCDI complications of sepsis and bowel surgery, and the available data are not adequately generalizable to a broad US population.7–10 Furthermore, there is limited knowledge of the clinical burden of the rapidly growing patient subgroup with mrCDI.11,12

The objective of this study was to quantify clinical complications of sepsis and bowel surgery in real-world patients who suffered CDI and rCDI. The study analyzed a large commercial healthcare claims database containing payment information for patients who received care in a variety of healthcare settings such as inpatient hospitals, outpatient hospitals, clinics, and pharmacies in the United States. Real-world analysis of cost and healthcare resource utilization in patients with CDI and rCDI was reported in a separate report.13

Study design

This longitudinal, retrospective study utilized real-world data from the PharMetrics PlusTM database (IQVIA; Durham, NC), which contains de-identified data from claims, enrollment, and demographic information for more than 140 million individuals with commercial insurance coverage throughout the United States, with data originating from over 90% of hospitals and over 90% of all US physicians.

Study population

Individuals included in the study were aged between 18 and 64 years and had at least one inpatient visit with a diagnosis of CDI (Supplementary Table 1) or one outpatient visit with a CDI diagnosis code followed by an outpatient CDI treatment. The requirement of an observable CDI treatment for an outpatient CDI visit ensured that follow-up visits would not be counted as a recurrence. Treatment was defined as an outpatient prescription for vancomycin, fidaxomicin, metronidazole, rifaximin, or bezlotoxumab, or fecal microbiota transplant (FMT).

Index CDI episodes occurred between 1 January 2010 and 30 June 2017, the latest data cutoff available at the time of the study (Figure 1). Only patients who were continuously enrolled and observable 6 months before and 12 months after the first date of the index CDI episode were included. The pre-index period was used to quantify pre-CDI healthcare exposure and to minimize the likelihood that the first CDI diagnosis was a recurrent episode, while the post-index requirement allowed sufficient time for observing recurrences as well as ensured accurate quantification of post-index complications.

Figure 1. Study design: (a) the index CDI episode was followed by a 14-day claim-free period after last CDI claim and an 8-week period to identify rCDI and (b) the red star indicates a hypothetical point at which the first rCDI episode occurs during the 8-week window after the claim-free period. Following this first rCDI episode, a new 14-day claim-free period occurs plus a new window for a subsequent rCDI episode. Multiple rCDI could occur after an index CDI event in this manner, up until 12 months following the index CDI date.

For this type of analysis, the beginning and end of CDI episodes must be clearly defined to capture the primary CDI event and the recurrences. A CDI episode started from the date of the index (first) CDI claim observed in the study time frame. Each CDI episode included consecutive medical claims with a CDI diagnosis and prescription medication fills that are common treatment for CDI. Medical claims included any inpatient and outpatient services with a CDI code. Each CDI episode would end after a 14-day CDI-claim-free period was observed (Figure 1). An episode of rCDI was defined as a second or subsequent CDI episode, using the same criteria as above for the index CDI episode, within an 8-week window following the end of the previous CDI episode. This 8 week window has been used by the CDC to define recurrences.14 CDI events that occurred later than each 8-week window were not counted as recurrences and therefore were excluded in this analysis. mrCDI could occur after an index CDI event, up until 12 months following the index CDI date. The study population was stratified into mutually exclusive groups of patients with 0 rCDI (had primary CDI only), 1 rCDI, 2 rCDI, or 3+ rCDI.

Outcomes

Clinical complications were quantified for the 12-month period after an index CDI, for all study patients and by cohorts for number of rCDI episodes (0 rCDI, 1 rCDI, 2 rCDI, or 3+ rCDI). Sepsis, subtotal colectomy, and diverting loop ileostomy were identified by a medical claim with relevant codes (Supplementary Table 1). If there were multiple medical claims with sepsis diagnosis code, claims occurring with service dates within a 7-day period were grouped together as a single acute sepsis episode.

Data analysis

Patient characteristics and clinical complications for the cohorts were displayed using counts and percentages for categorical variables and measures of central tendency (mean (standard deviation—SD)) for continuous variables. Statistical analyses were conducted with SAS, version 9.3 (SAS Institute, Inc., Cary, NC, USA).

Demographic and baseline characteristics

A total of 46,571 patients with an index CDI episode were included: 3129 (6.7%) experienced one recurrence, 472 (1.0%) had two recurrences, and 134 (0.3%) developed three or more recurrences (Table 1). The mean (SD) age was 47.4 (12.7) years, and 62.4% were female (Table 1). The mean (SD) baseline Charlson comorbidity index (CCI) score, by increasing the rCDI group, was 1.2 (1.9), 1.5 (2.2), 1.8 (2.3), and 2.3 (2.5). Autoimmune diseases (such as ulcerative colitis, Crohn’s disease, type 1 diabetes, rheumatoid arthritis, or multiple sclerosis) were present in 18.1%, 23.1%, 24.6%, and 39.6% of patients, by increasing the rCDI cohort.

Table 1. Demographic and baseline characteristics.

Table 1. Demographic and baseline characteristics.

Pre-index healthcare exposures

During the 6-month baseline period, antibiotics were prescribed for ⩾76% of patients in all groups (Table 1). Gastric acid–suppressing agents were prescribed, by increasing the rCDI cohort, for 27.9%, 32.9%, 39.0%, and 38.1% of patients. Gastrointestinal surgery or administration of chemotherapy was more frequently noted with higher rCDI cohorts during the baseline period. Baseline healthcare exposure was generally highest for those in the 3+ rCDI group, with 86.6% having an outpatient hospital visit, 60.5% having ⩾1 inpatient admission, and 57.5% having an ED visit within 6 months immediately preceding the index CDI episode (Table 1).

Treatment patterns

At the time of the study, standard of care for CDI treatment primarily involved the use of antibiotics, while FMT was used rarely. Across all index and rCDI episodes (n = 46,571), vancomycin was used to treat 16,215 (34.8%), metronidazole was used to treat 25,298 (54.3%), and fidaxomicin was used to treat 1738 (3.7%) of patients. For recurrences, vancomycin was the most commonly prescribed antibiotic used, with 55% receiving this with their first recurrence, 56% with their second recurrence, and 60% with the third recurrence (Figure 2). As expected, metronidazole treatment rates were lower for recurrences versus primary CDI, particularly in patients with second or third recurrences (19% and 17%, respectively). Fidaxomicin was used to treat a minority of patients at each recurrence episode.

Figure 2. Vancomycin was the most commonly prescribed antibiotic to treat the first, second, and third rCDI episodes, followed by metronidazole and then fidaxomicin.

Few study patients (333/46,571; 0.72%) had FMT procedures in the year after index episode. The proportion of patients who received FMT procedures was slightly higher during the later study years between 2014 and 2017 (0.89%) compared with 2010 and 2013 (0.54%). Among the 333 patients who had FMT, 364 procedures were conducted, with 27 patients having ⩾2 FMT procedures. More than half (55.6%) of the FMT procedures were performed in patients who had no recurrences (i.e. to treat the index CDI episode), corresponding to FMT being performed in 0.43% (185/42,836) of the cohort with no recurrence. The utilization of FMT increased with the number of recurrences experienced: 3.1% (97/3129) of patients with one recurrence, 8.1% (38/472) with two recurrences, and 9.7% (13/134) with three or more recurrences received FMT.

Post-index clinical complications

During the 12-month follow-up, sepsis occurred in 16.5%, 27.3%, 33.1%, and 43.3% of patients by increasing the rCDI group. The proportion of patients who had two sepsis episodes during follow-up was highest for the 3+ rCDI cohort (Figure 3(a)). No patient had more than two sepsis episodes during the 12-month follow-up period. Likewise, subtotal colectomy or diverting loop ileostomy was performed in 4.6%, 7.3%, 8.9%, and 10.5% of patients, respectively, during the follow-up (Figure 3(b)).

Figure 3. Rates of (a) sepsis and (b) subtotal colectomy or diverting loop ileostomy during the 12 months after index CDI, by recurrence cohort.

CDI and rCDI are associated with substantial patient and healthcare burden. Within our study, patients with mrCDI had high rates of all-cause sepsis and the need for surgical intervention via subtotal colectomy or diverting loop ileostomy. Mirroring the high clinical burden of mrCDI seen in this analysis, patients with three or more recurrences also had the highest healthcare resource utilization and total, all-cause, direct medical costs of all recurrence cohorts.13

During the 12-month follow-up, rates of sepsis were notable and highest for patients with three or more recurrences. Over 40% of patients with three or more recurrences went on to develop sepsis during the study period, and over 30% had two sepsis episodes. As there are few distinguishing factors for patients who suffer one versus multiple recurrences, the higher rate of sepsis in patients with more recurrences is likely due to this high-risk cohort having more opportunities to suffer such adverse outcomes.13 In a retrospective study performed at two large institutions, Falcone et al.15 demonstrated that 18.3% of patients with CDI developed a bloodstream infection (BSI) within 30 days following the CDI episode, most of whom were being treated for a CDI recurrence. Furthermore, the 30-day mortality rates for those with or without BSI were 38.9% versus 13.1% (p < 0.001), respectively.15 Ianiro et al.,16 reporting the results of a single-center study of patients with rCDI, found a 22% rate of BSI after rCDI treatment with antibiotics, and a 90-day mortality rate of 52.5% for those who developed a BSI. Sepsis carries a significant economic burden, with a mean cost of over US $16,000 per hospitalization in the United States; sepsis cases not diagnosed until after admission and those with higher severity had a higher economic burden than average.17 Among patients readmitted with rCDI in the State Inpatient Databases, there is a significant gap in reimbursement of almost US $8000 to US $18,000 for patients who present with rCDI and septicemia on admission.18 There are several theories regarding the pathophysiological basis for BSI in patients with CDI and rCDI. Most focus on disruption of the gut microbiota and/or a cellular inflammatory response, resulting from an impaired gut barrier function and immune response to CDI toxins.19,20 Regardless of mechanism, our study, which had longer follow-up than other studies, revealed that in a broad population of patients with CDI, 16.5% of patients developed BSI and greater than 25% of those with one or more recurrence suffered this complication. We believe this indicates that the consequence of sepsis/BSI in patients with CDI might be more significant than previously thought when considered across a larger population.

The burden of colectomy was also apparent in the study population, with ~5% of those with no recurrences undergoing the surgery and >10% of those with three or more recurrences. Other studies estimated colectomy rates of 1.2%–8.7% in patients with CDI (initial and rCDI).12,2123 In the National Hospital Discharge Survey, 1.3% of patients with CDI required a colectomy.24 Our colectomy data trended higher than previous reports, which may be related to the large cohort size, real-world nature of the data analyzed, the younger age of the population studied, a longer follow-up period, and/or a broader group of healthcare settings. Colectomies create a significant burden for the patient and the healthcare system. Colectomy to treat CDI is associated with a lengthy hospital stay, with a mean (SD) stay of 33 (28) days for those who survived to discharge.25 Colectomy is also a significant predictor of mortality following CDI (odds ratio: 3.14).24 The in-hospital mortality rate following colectomy for CDI varies widely but is substantial, ranging from 36% to 80%.25 Over 75% of those who have a colectomy for CDI suffer colectomy-related morbidity within 30 days, with 65% of patients suffering serious complications.26 These post-operative complications underscore the patient’s burden of CDI, especially those with mrCDI. The cost of a colectomy to treat rCDI is estimated at US $39,000 (2016 dollars]).23 In patients readmitted for rCDI after a major operating room procedure, there is average reimbursement gap of US $20,000.18

Despite being a new therapeutic paradigm for rCDI, FMT use was observable during the study period. The use of FMT for rCDI has gained momentum in recent years, with the enforcement discretion by the FDA and the advent of stool banks.27 FMT remained a rare observation in this claims data set, which may be attributable to FMT being considered a novel and relatively unknown management option during the study period, a lack of coverage for the procedure by health plans, cash payment for the procedure (which would not be captured by the database), or underreporting/miscoding of FMT procedures. A small number of patients (0.7% of the entire cohort) received FMT, with a slight increase in FMT rates with more recurrent episodes. Interestingly, the timing of FMT procedures was largely not in accordance with current or prior guidelines, with most of our observed FMT procedures performed after the index CDI.4,28 An analysis from the Indiana University Hospital reported data from patients with severe and fulminant CDI who received FMT.29 The median number of prior CDI was 0, meaning that at least half of the 225 patients received FMT after their primary infection. Our data may reflect similar use pattern; however, this practice would be considered experimental and did not align well with available guideline recommendations at the time or currently.28,30 Additional research on the practice patterns of FMT is needed to evaluate appropriateness of use.

The recurrence rates seen in our study are somewhat lower than those reported in the literature.6,31 These lower rates are likely due to our study including a younger cohort (aged 18–64 years) than other studies, which are predominantly a population aged 65 years or older, the data source being solely an employer-covered population (which tends to be healthier on average than the entire adult population), in addition to the stringent criteria we used to identify rCDI cases, as detailed by literture13,3133 To address the key objective of quantifying the occurrence of clinical complications, our study included patients who had a minimum of 18 months of continuous enrollment (6-month look back plus 12-month follow-up). This criterion excluded patients who disenrolled before 12-month follow-up, including patients who died or those who lost or changed health insurance for any reason, the reason for which the database does not disclose to protect patient’s privacy. Importantly, exclusion of patients who died during the study period after index CDI ensured that the study cohorts were sufficiently homogeneous, as the level and type of medical care provided to dying patients would have been distinctly different, potentially skewing the data and rendering it less valuable. The impact of these inclusion criteria is that, given the potential mortality consequence of CDI complications reported in the literature, this analysis may have underestimated the proportion of patients who developed sepsis or required colectomy. Claims data can be limited by the misclassification of medical conditions or by missing events/diagnoses. In this study, CDI was identified by diagnosis codes and CDI-related treatments and not by diagnostic test results, which may have resulted in random misclassifications. In addition, claims-related bias may have resulted in an underreporting of sepsis event counts (i.e. sepsis occurred during a hospitalization but was not coded). As this was a descriptive study and was not designed for hypothesis testing, we did not perform a sample size calculation a priori; the sample from the commercial claims database resulting from the inclusion criteria was used for the analyses. Despite the potential limitations and underestimations, we believe that our study provides a good cross-sectional view of a broad population in the United States who experienced CDI and rCDI and resulted in a large population (~46,000) of individuals with CDI to describe. In addition, the incidence of CDI-related surgeries and sepsis was further detailed in cohorts stratified by rCDI group. The results may be generalized to adult populations younger than 65 years who remained with a healthcare system for at least 1 year after the primary CDI episode. Specifically, healthcare decision makers may use our findings to estimate the lower bound of the clinical burden of rCDI.

Our findings indicate that, among patients with more rCDI, there was a parallel trend for higher rates of colectomy and sepsis. These complications have been documented in previous studies to be associated with poor outcomes. Reduction in rCDI may be an important step to reduce the burden of serious clinical complications.

Medical writing and editorial support was provided by Agnella Izzo Matic, Ph.D., CMPP (AIM Biomedical, LLC) and was funded by Ferring Pharmaceuticals, Inc. Portions of the data contained in this article appeared in abstract/poster form at ACG Annual Scientific Meeting, 25–30 October 2019.

Author contributions
L.S., D.N.D., N.S., K.L., and W.W.N. designed and conducted the study. All authors analyzed and interpreted the data, drafted and critically revised the article for important intellectual content, and approved the article for publication.

Declaration of conflicting interests
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: M.B., L.S., W.W.N., and D.N.D. are employees of Ferring Pharmaceuticals, Inc. P.F. has served as a consultant to and on the speaker’s bureau for Merck and Co and has served as a consultant for Ferring Pharmaceuticals, Inc. and Roche Pharmaceuticals. N.C.S. and K.L. are employees of Precision Health Economics and Outcomes Research and provided consulting services to Ferring Pharmaceuticals, Inc.

Ethical approval
This study was exempt from institutional review board approval, as it did not involve any interventional biomedical research with human subjects. Ethical approval was not sought for this study because the data used were de-identified medical and pharmacy claims data, and they were obtained by HIPAA-compliant methods.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by Ferring Pharmaceuticals, Inc. (Parsippany, NJ).

Source:  https://journals.sagepub.com/doi/full/10.1177/2050312120986733