The geography of care: Urban variation in inflammatory bowel disease management and outcomes

Inflammatory bowel disease (IBD) outcomes can be influenced by geographic context. Washington, DC is marked by sharp socioeconomic and racial segregation across its eight Wards, offering a unique opportunity to study intra-city disparities in IBD care.

A retrospective cohort study of adult IBD patients receiving care at a tertiary care academic center in Washington, DC was done using electronic health records between 2023 and 2025. Patients with documented Ward-level residence were included. Patient demographics, disease characteristics, insurance coverage, and medication utilization were extracted. Ward-level differences in disease activity, treatment patterns, and healthcare utilization were assessed using regression models adjusted for age, sex, and race.

Among 253 patients (56.9 % female; 41.1 % White; 45.5 % Black), significant ward-level disparities were observed. Patients in Wards 7 and 8 had disproportionately high rates of Medicaid or uninsured status (57 %-62 %), lower utilization of maintenance therapy (43.5 % in Ward 7 vs 73.9 % overall, P = 0.021), and more frequent relapse-related clinic and emergency department visits (mean ED visits: 1.1 in Ward 7 vs 0.19 in Ward 3, P = 0.029). DMARD failure rates were significantly higher in Wards 7 and 8 compared with Ward 3 (1.7-1.8 vs 0.6, P < 0.05). In contrast, Ward 3 patients demonstrated higher private insurance coverage (91.3 %) and fewer disease relapses.

IBD patients in underserved Washington, DC wards, particularly Wards 7 and 8, experience structural disadvantages that manifest as gaps in insurance coverage, lower maintenance therapy use, increased relapse-related healthcare utilization, and higher treatment failure rates. These findings highlight the critical role of social determinants and urban geography that may shape IBD outcomes and highlight the need for geographically targeted interventions to improve equity in care.