The management of inflammatory bowel disease (IBD) in children presents notable challenges, particularly within rural settings. Our study aimed to pinpoint the clinical and socioeconomic factors predicting unplanned healthcare utilization among children with IBD receiving care at an academic center serving a predominantly rural area. We found that laboratory markers of inflammation, Medicaid insurance, and female sex, were associated with increased unplanned healthcare utilization. Interestingly, patients residing farther away from our clinic were less likely to experience unplanned health visits. These findings underscore the substantial impact of clinical and socioeconomic factors on the burden of IBD experienced by young patients, as well as the strain placed on healthcare systems in rural communities.

Our investigation revealed a significantly heightened likelihood of unplanned health visits among female patients, consistent with findings from previous studies [6, 14]. One study noted that female patients with IBD, when compared to male counterparts, reported lower quality of life, exhibited a higher prevalence of depression associated with IBD, and experienced increased disease activity [14]. Furthermore, IBD impacts the onset and regularity of women's menstrual cycles, with hormone fluctuations during the menstrual cycle known to influence IBD-related symptoms [15].

Patients covered by Medicaid insurance exhibited a higher frequency of unplanned visits compared to those with commercial insurance. This association has been documented among adults and children with IBD, and may stem from transportation obstacles, barriers to adherence to routine care, and other forms of hardship experienced by Medicaid-insured patients [6, 16, 17]. Medicaid-insured children with Crohn’s disease also have higher rates of repeat ED visits when compared to children with private insurance [16]. Children with public insurance may be more likely to use the ED for routine care, compared to those with commercial insurance, potentially due to factors such as convenience and the absence of copayments [18].

IBD is characterized by periods of remission and flare-ups. Elevated ESR and CRP levels are often associated with active inflammation, particularly in Crohn’s disease. In our multivariable analysis, CRP values greater than 10 mg/L predicted a higher hazard of all-cause and IBD-related unplanned visits. Other studies have analyzed the utility of biomarkers such as CRP and fecal calprotectin in IBD, and similarly found CRP to be a good predictor of disease activity and complications in IBD [19,20,21]. We were unable to analyze calprotectin due to missing data from the majority of planned visits (399 of 471 planned visits included in the analysis). In contrast to prior research, [4] we did not find that presence of specific symptoms during office visits predicted future ED visits or hospitalizations. We also found that lower hemoglobin was associated with higher hazard of IBD-related unplanned healthcare utilization. Similarly, a study of adults with Crohn’s disease found that anemia, tachycardia and elevated alkaline phosphatase were independently associated with ED returns within 30 days [13].

Patients residing at a greater distance from our healthcare institution exhibited a reduced likelihood of experiencing unplanned visits. This could be due to the inconvenience of traveling long distances, limited access to transportation or seeking care at urgent care center or ED affiliated with other health systems. In addition, patients living farther away may have preferentially utilized other modalities such as phone calls or online messages to connect with their gastroenterologist which may have prevented ED visits [22]. Other studies have found that patients with IBD in rural settings have a higher likelihood of ED and urgent care visits and are less likely to visit their gastroenterologist compared to those living in urban areas [10, 11, 23].

The study has certain limitations, most notably the inability to capture data on urgent care and ED visits at other nearby health systems which may not have been recorded. In addition, we did not record certain forms of healthcare utilization, such as phone calls and online messages to the clinic staff, which utilize significant resources and have been shown to occur at a high frequency in children with active IBD [22]. Our study was completed at a single center and had a small sample size, which may limit generalizability. Since this was a retrospective study, we did not have data available to calculate disease activity indices which incorporate clinical, laboratory and endoscopic parameters at a given point in time. The number of unique patients in our study was limited, although our analysis of each planned visit as a separate observation improved statistical power for detecting differences in unplanned visits based on time-varying measures.