A Guide to De-escalation of Combination Therapy in Inflammatory Bowel Disease: A Retrospective Cohort Study

Background: In this nationwide study, we aimed to explore healthcare services utilization, medical management, and disease outcomes of inflammatory bowel diseases (IBD) across the 2 major ethnic groups in Israel. Methods: We utilized a cohort including all patients diagnosed with IBD in Israel since 2005. The primary outcome was steroid dependency, with secondary outcomes including use of biologics, time to surgery, and hospitalizations. Outcomes were controlled for possible inherent differences in disease course and phenotype. Results: Of the 32 491 included patients, 18 252 (56%) had Crohn's disease (CD) and 14 239 (44%) had ulcerative colitis (UC); 10% were Arabs and 90% were Jews. Jewish ethnicity was associated with lower rates of steroid dependency compared to Arab ethnicity in both CD (HR = 0.7 [95% CI, 0.6-0.8]) and UC (HR = 0.7 [95% CI, 0.6-0.8]). The risk of IBD-related surgery in CD was higher in the Arab group at both 3 and 5 years (13% vs. 10%, 16% vs 14%, respectively, P = .005). Arabs had more frequent IBD-related hospitalizations than Jews at 5 years (28% vs. 19% with at least 2 hospitalizations, P < .001). In contrast, Jewish ethnicity was associated with more frequent use of biologics during the first year from diagnosis in patients with CD (HR = 1.3 [95% CI, 1.1-1.6]) but not with UC. Conclusions: Arab ethnicity is associated with higher rates of hospitalizations, steroid dependency, and surgeries, and, on the other side, with lower utilization of biologics. Healthcare practitioners and policymakers should address potential cultural and systemic barriers in healthcare de¬livery in order to improve care across all populations.