Bharati Kochar, MD, on Pharmacoequity for Older Patients With IBD

Dr Bharati Kochar discusses the topic of pharmacoequity for older patients with IBD, ensuring that patients over 65 have access to advanced therapies as well as ancillary services that help manage their disease and prevent complications.

Bharati Kochar, MD, MS, is a gastroenterologist and inflammatory bowel disease specialist at the Massachusetts General Hospital and assistant professor of medicine at Harvard Medical School. 

Welcome to this podcast from the AIBD Network. I'm your host, Rebecca Mashaw, and I'm very happy to welcome this morning Dr. Bharati Kochar, who's going to talk about one of her primary interests, which is the treatment of older adults with IBD. And today we're going to specifically talk about the concept of pharmacoequity for these patients. Dr. Kochar is an assistant professor at Harvard Medical School and a specialist in the treatment of inflammatory bowel disease at Massachusetts General Hospital in Boston. Thanks for joining us today. It's good to see you.

Dr Kochar:

It's great to be here. Rebecca, thank you so much for having me. And I commend you on the use of the term older adults. I really appreciate that. Thanks.

Rebecca Mashaw:

I have learned that lesson from you. Thank you. So to begin with, would you define pharmacoequity for us?

Dr Kochar:

Sure. So this is a term that was coined by who's a cardiologist. And the idea behind this term is that we needed to think about how all individuals have access to high quality medications that are required to manage their need. And the equity part of this is because, um, this is not the case necessarily in the United States. And so patients, depending on how they are insured or where they may be or who they're being treated by, um, have inequitable access to pharmaceutical agents for their chronic diseases.

Rebecca Mashaw:

In the recent article that you coauthored on this particular study, you noted that the prevalence of IBD in the United States is highest at older ages, specifically those in the group from 65 to 79. That was a real surprise. How do you account for that?

Dr Kochar:

That is a surprise, isn't it? We often think about IBD as a disease of younger people, but thankfully due to a combination of factors that include things like improved treatments—and we know that we've made leaps and strides in our treatments, really since the biologic era— life expectancy in patients with IBD has thankfully been preserved, whereas, in the 1950s and ‘60s, Crohn's and ulcerative colitis were diseases of cachexia. And so patients died young either because of their disease or the treatments, as in the chronic steroids for their disease. And so, thankfully due to a number of steroids-sparing agents and improved access, there's now preserved life expectancy. We don't expect patients with IBD to die younger than they normally otherwise would, and in general, the population on the whole is aging.

The data that I cite is actually, from Dr. Lewis and Dr. Kappelman. They published a very nice epidemiologic update, using a number of various data sources, across the United States and gastro in 2023. They have a visual abstract that very nicely shows you that the highest prevalences are above the age of 60 in the United States. This isn't entirely surprising. In 2015, the CDC estimated that around the year 2010, 20 6% of Americans living with IBD were 65 years and older, and we know that the population of older adults is just rising in the western world. And so it's not, I guess, entirely surprising, but it's certainly interesting to note.

Rebecca Mashaw:

And even as this number of older adults is rising and the number of older adults with IBD is increasing, you pointed out that they are much less likely to be able to access modern therapeutic agents for IBD treatment. Why is this the case?

Dr Kochar:

That is the million-dollar question, Rebecca. I can't necessarily tell you exactly why, but we do know, and there's been a number of analyses both in the United States and recently from the Danish registrars as well, that demonstrate that older patients with IBD are less likely to be treated with all sorts of steroid-sparing agents, including mesalamine, compared with younger patients, and seem to have an equal likelihood of treatment with steroids, and very interestingly, seem to have a greater chance of needing surgery, especially within 5 years of treatment compared with younger patients. Now, these are of course, retrospective studies and so it's hard to know if is this because their disease is different? At presentation, we used to traditionally think that IBD got milder as people got older. And this is certainly the case for some of our patients. But we also know that there's a number of patients who have robust flares of their disease as they're older, and that older patients with newly diagnosed IBD don't always necessarily have milder IBD.

So we don't truly know if it's a different disease process at older ages or if there's a lot of hesitancy for prescription, especially with the modern therapeutic agents just because, you know, we as clinicians want to do no harm first, and that's certainly how we're trained and taught. And when we don't necessarily know if this is a safe medication in the patient in front of us, we may be less likely to recommend it. So this has to do with clinical trial representation, right. We did an analysis that demonstrated that of the published studies after the year 2000 of modern therapeutic agents to treat IBD that were approved in the United States, fewer than 1% of patients included were 65 years and older. Some of the more recent studies have maybe about % to 6% of patients who are 60 or 65 years and older, but still that's not 25 or 30%, which is the group that we're seeing in our clinical practice.

And so, clinical trial representation is very important for clinician comfort and prescription. And subgroup analyses of older patients in these clinical trials are important. Retrospective studies are hard for older people because it doesn't necessarily capture the diversity of their overall health as well, and they tend to be more medically complicated. So there's a number of factors that include things like just lack of knowledge and perhaps hesitancy in prescription.

And then what we talk a lot about in this piece is just policy level issues in the United States. When you're 65 years and older, you're eligible for Medicare for the most part and Medicare actually has traditionally been phenomenal for older people because it focuses very much on hospital-based treatments. Hospitalizations are very well covered. But IBD is an outpatient specialty and a number of our modern therapeutic agents are not infusion-based.

And so the coverage for these modern medications is actually very limited. There's also antikickback legislation, which prohibits pharmaceutical companies from providing prescription assistance programs to patients on governmental insurance like Medicare and Medicaid. Medicare advantage plans also focus on keeping patients out of sort of chronic condition care; therefore that healthier older patient. And sometimes people don't plan to be sick when they're older, you know? So, I know that was a long answer, but there's a number of reasons for why this might be the case.

Rebecca Mashaw:

And that's fine, because you actually answered a couple of questions I had, and one of them was about the observations you made relating to Medicare and Medicare Advantage plans and how they contribute to this lack of equity. But one of the other points that you made along those lines was that sometimes this prevents patients with IBD who are covered by Medicare and supplemental insurance from accessing multidisciplinary care, like getting coverage for consultations on diet and other types of lifestyle changes that can help with controlling symptoms and making the patient feel better. So that was an interesting point as well. Can you tell us a little bit about what you saw there?

Dr Kochar:

Thank you for noting that. You know, every IBD conference that you go to these days will really home in on how interdisciplinary IBD care needs to be where we really need an IBD trained dietician, an IBD specific GI psychologist, having, you know, access to high quality ancillary services like this becomes very important for young healthy people with IBD, but they are then especially important for the older adult with IBD, where their diet may be even more complicated perhaps because of diabetes or their kidney disease or their heart failure and the need to be on a low sodium diet or a number of other comorbidities. And yet Medicare policy has a very limited band for whom they cover dietary services. And it's something like, I think it's, you need a diagnosis of either chronic kidney disease or diabetes to have Medicare cover a dietician service.

If you don't have a good private secondary, which is a number of people, you might not have access to a dietician and benefit from their services. GI psychology is limited all around, but again, mental health services are very limited in their outpatient coverage for patients with Medicare specifically. So it's very interesting to me that I think the patients that could really benefit the most from this interdisciplinary approach to IBD care that we know is needed to provide high quality services are the patients that seem to be the least able to access them.

Rebecca Mashaw:

You also mentioned something I found very interesting about how we tend to define age chronologically without considering functional status or multimorbidity, and that may not correlate with age and also among older adults, treatment decision making needs to consider factors beyond safety and efficacy and also account for quality of life and what you term life space mobility. I have heard other IBD specialists talk about having patients come in who are 75, they've got IBD they're doing very well. There are some guidelines that suggest that you stop scoping people at this age, and yet some of these physicians will say, this patient could live to be a hundred. This patient is in great shape, they're active, they're fit, they don't have a lot of comorbidities. I have a 65-year-old patient, however, who I'll be surprised if they make it to 75. So it's that that whole business of taking the whole patient into consideration when you're making these decisions. Can you tell us a little more about this, and especially about this life space mobility that was very interesting.

Dr Kochar: Absolutely. So, I can take no credit for that very impressive term. It was developed by a group of geriatricians led by Baker and I think published maybe in the early two thousands or so in a in a very nice JAMA article. And so the idea is exactly what you said, right? You can't sort of say, well, this person's 80 and you know, they're done. And this person's 65, and so let's just kind of keep doing absolutely everything. But this idea of life space mobility is, you know, where you are in your life and how much you're able to do what you want to do. And that's different things for different people. I have the 45-year-old that wants to retire, and I have the 79-year-old that is so busy at work that they cannot call me back because, you know, they're running a very large company or, you know, doing busy doing other important things.

And then, you know, we have the 85-year-olds that have their travel plans laid out because they worked for 40 years and really want to maximize what's left of their time here. And so just the ability to do what you want to do I think is very, very important, especially as you get older. And I think that our job as IBD clinicians for older patients is actually to achieve this life space mobility for people. So I tell my patients, you know, often, like your colon and your bowels are important for your quality of life. They're quite frankly, not that important for your quantity of life, right? I mean without a heart you could die; without a liver, you can die. This is not necessarily a fully vital organ, but it becomes critical for how you experience life.

So the goal of treating your IBD, I think either for a younger patient or the older patient is not just to expand their lifespan, but really so that they can live the life that they want to live. And so when you make these decisions for people based on their chronologic age, things like, well, you're 77, you know, do we really need to make sure that every bowel movement is perfect or you're 65, you know, we must make sure that every bowel movement is perfect without taking into account everything else that's going on in their life. I think we end up doing our patients a disservice. And I think the other thing that we don't really think about as a society is when we invest in treating our older patients well, you can really have a number of unmeasured benefits to society on the whole.

So, you know, when you're keeping your older patients healthy, many of them want to continue working, even if it's not necessarily for financial reasons, but to have purpose, or they want to volunteer in their community, or they want to be there for their family and do very meaningful things in that way. And yet as a society, we're so hesitant to invest in high cost medications for older patients. And so I think we lose a lot of societal benefit in that way. I have a number of patients who are older and it was purely their IBD that got them to stop working or volunteering or being there for their family. And that's very, very hard to see as well.

Rebecca Mashaw:

That leads very nicely to my next question, which is about how restricting access to newer drug therapies, to safer types of steroids, which you mentioned in your article that some are more difficult for patients to tolerate than others or have greater side effects, restricting access to this interdisciplinary care. This could likely increase the total cost of care for many of these patients, could it not? Or they could require surgery, hospitalization. You mentioned losing the ability to work, which many people do want to do. It's no longer automatic retirement at 65. They could lose the ability to live independently, which is a terrible fate for many people. That's something that's very important to them. So tell us a little bit about what you think about those points.

Dr Kochar:

I think you hit the nail on the head, right? I mean, it's very shortsighted to say, well, this medication costs $30,000 an injection, you know, every 8 weeks, and we don't want taxpayers paying for that. When taxpayers could be benefiting as older people continue to work and contribute with their own income taxes and taxes and all of that. And so I think, you know, I know that a lot of our medications are very high cost and I understand that they cost a lot to come into the pipeline and get approved. And, that's a whole other topic that I can't broach. But I think restricting access because of governmental insurance and making this difficult for older people because we sort of as a society don't always feel that older people need cutting edge care, is very, very shortsighted.

I think you actually gain tremendously by keeping patients healthy, especially at the end of their life. There's more and more data suggesting that you know, of all of our health care dollars, most of it is really at the end of life, and I'm not suggesting it's all because of IBD, but I am saying that, you know, keeping our patients out of hospitals, out of chronic care facilities, out of physical therapy services because they've lost all of their muscle mass from their chronic steroids since budesonide can't be covered or they can't get another novel agent, is overall much more beneficial. And these are things that are harder to quantify.

Rebecca Mashaw:

You and your coauthors developed some recommendations for how to achieve pharmacoequity for older adults. Can you talk a little bit about that for us?

Dr Kochar:

Sure. I think it is actually kind of a long listand it addresses a number of contributing factors, including trying to understand the reasons for disparate outcomes, addressing the massive underrepresentation in IBD clinical trials, but I should note that this is not an IBD-specific problem. Clinical trials of all medications actually underrepresent older patients, and this was very nicely highlighted in the recent case of dementia, which is very much an older adult  issue. And I think we also touch upon policy issues like the poor access to prescription assistance programs and medication coverage by governmental insurance, and other things like working on flexibility, site of care delivery, expanding access to ancillary services like we discussed.

And so this was both a research agenda because there's obviously a lot more to learn but this is also a policy agenda. And our hope is that the GI societies can serve to champion policy and advocacy for older patients with chronic GI conditions. IBD is obviously the one that I focus on and, and care most deeply about, but this is really happening to older patients across the board and across chronic disease conditions. As the burden of chronic disease increases and newer diagnoses are also made at older ages, we're not really equipped as a society to help those who are amongst our most vulnerable.

Rebecca Mashaw:

Well, this is really interesting and I'm sure that there's, as you say, much more to learn through research. The clinical trial issue is one that's definitely at the top of the list I think for many people who work in IBD, and we've talked about that a little bit on some of our podcasts. Um, so I'll be interested to see what comes next for you. Do you have any other research of your own planned into some of these topics and any other activities that you plan to get involved in?

Dr Kochar:

That's a great question. Thank you for asking. We have a number of things that are ongoing. The biggest project so far is funded by the Crohn’s and Colitis Foundation and supported as well by the National Institute of Aging. It is a multisite cohort of older patients, who are 60 years and older, and we're preferentially recruiting those who are on immunosuppressive treatments and doing functional assessments. So there's no other sort of cohort looking at physical function things—like gait speed, grip strength, chair stands, and geriatric depression scales and all of that. And trying to understand its change over time. Because the question I think in older patients is not just our traditional outcomes of, you know, clinical remission, endoscopic remission, some kind of objective biomarker, radiologic, histologic remission, but also, what is it doing to the geriatric syndromes that IBD most commonly affects—things like sarcopenia and frailty and cognition, perhaps.

And so trying to understand how treating IBD can improve a patient overall. So certainly clinically we all see this, but we don't have any quantified measure on what we can do. I think can certainly help counsel patients as we talk about novel treatment options. We're in the midst of preparing some of the data from in-depth qualitative interviews that we've conducted with older adults to really understand what their treatment priorities are. There's no literature like that so far. So we have a number of ongoing studies, a lot more ideas in the pipeline., I'm just very excited that you're interested in this work. Thank you.

Rebecca Mashaw:

Well, we certainly are interested in this work on the AIBD network, and we hope to get back with you before long to talk about what's happening now and what you're up to next. So thank you so much for spending this time with us today. It's a very interesting subject.

Dr Kochar:

Thank you, Rebecca. It's a pleasure to be here.