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Dhital R, Pokharel A, Karageorgiou I, Poudel DR, Guma M, Kalunian K. Epidemiology and outcomes of emergency department visits in systemic lupus erythematosus: Insights from the nationwide emergency department sample (NEDS). Lupus 2023; 32:1646-1655. [PMID: 37961765 PMCID: PMC10666498 DOI: 10.1177/09612033231215381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 11/02/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Systemic lupus erythematosus (SLE) patients are prone to frequent emergency department (ED) visits. This study explores the epidemiology and outcomes of ED visits by patients with SLE utilizing the Nationwide Emergency Department Sample (NEDS). METHODS Using NEDS (2019), SLE ED visits identified using ICD-10 codes (M32. xx) were compared with non-SLE ED visits in terms of demographic and clinical features and primary diagnoses associated with the ED visits. Factors associated with inpatient admission were analyzed using logistic regression. Variations in ED visits by age and race were assessed. RESULTS We identified 414,139 (0.35%) ED visits for adults ≥ 18 years with SLE. ED visits with SLE comprised more women, Black patients, ages 31-50 years, Medicare as the primary payer, and had higher comorbidity burden. A greater proportion of Black and Hispanic SLE patients who visited the ED were in the youngest age category of 18-30 years (around 20%) compared to White patients (less than 10%). Non-White patients had higher Medicaid utilization (27%-32% vs 19% in White patients). Comorbidity patterns varied based on race, with more White patients having higher rates of hyperlipidemia and ischemic heart disease (IHD) and more Black patients having chronic kidney disease (CKD), hypertension, and heart failure. Categorizing by race, SLE/connective tissue disease (CTD) and infection were the most prevalent primary ED diagnosis in non-White and White patients, respectively. Age ≥ 65 years, male sex, and comorbidities were linked to a higher risk of admission. Black race (OR 0.86, p = .01) and lowest income quartile (OR 0.78, p = .003) had lower odds of inpatient admission. CONCLUSION Infection and SLE/CTD were among the top diagnoses associated with ED visits and inpatient admission. Despite comprising a significant proportion of SLE ED visits, Black patients had lower odds of admission. While the higher prevalence of older age groups, hyperlipidemia, and IHD among White patients may partly explain the disparate results, and further study is needed to understand the role of other factors including reliance on the ED for routine care compared among Black patients, differences in insurance coverage, and potential socioeconomic biases among healthcare providers.
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Affiliation(s)
- Rashmi Dhital
- Department of Medicine, Division of Rheumatology, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Ashbina Pokharel
- Department of Medicine, William Beaumont University Hospital, Royal Oak, MI, USA
| | - Ioannis Karageorgiou
- Department of Medicine, William Beaumont University Hospital, Royal Oak, MI, USA
| | - Dilli R Poudel
- Department of Medicine, Indiana Regional Medical Center, Indiana, PA, USA
| | - Monica Guma
- Department of Medicine, Division of Rheumatology, School of Medicine, University of California San Diego, La Jolla, CA, USA
- Department of Rheumatology, Veteran’s Health Administration, San Diego, CA, USA
| | - Kenneth Kalunian
- Department of Medicine, Division of Rheumatology, School of Medicine, University of California San Diego, La Jolla, CA, USA
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Mendoza-Pinto C, Etchegaray-Morales I, Munguía-Realpozo P, Solis-Poblano JC, Méndez-Martínez S, Osorio-Peña ÁD, Ayón-Aguilar J, Abud-Mendoza C, García-Carrasco M. Trends in all-cause hospitalizations for systemic lupus erythematosus in Mexico, 2000-2019. Lupus 2022; 31:1679-1684. [PMID: 36128770 DOI: 10.1177/09612033221128745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hospitalizations due to systemic lupus erythematosus (SLE) incur substantial resource use. Hospitalization trends provide a key benchmark of the disease burden. However, there is little long-term data in Mexico. Therefore, we evaluated Mexican hospitalization trends for SLE during 2000-2019. METHODS Hospitalization trends of SLE were studied using data from 2000 to 2019 releases of the National Dynamic Cubes of the General Direction of Health Information, which provides data on hospitalization discharges in Mexico. Patients aged ≥15 years hospitalized during the study period with a principal discharge diagnosis of SLE (ICD-10 code M32) were included. RESULTS From 2000 to 2019, there were 17,081 hospitalizations for SLE, of which 87.6% were in females and 87% in subjects aged 15-44 years. From 2000 to 2019, the age-standardized hospitalization rate for patients with SLE increased from 0.38 per 100,000 persons to 0.65 per 100,000 persons with an average annual percentage change (APC) of 2.9% (95% CI 6.2-63.2). Although there was a significant uptrend from 2000 through 2011, there was a significant decline from 2011 to 2019 (APC: -4.8%, 95% CI -7.0% to -2.5%). Similar trends were identified in subjects aged 15-44 years and in both sexes. The length of stay and inpatient mortality decreased between 2000-2009 and 2010-2019. CONCLUSIONS Although there was a substantial increase in SLE hospitalizations in 2000-2019, in 2011-2019, a decreased trend was reported in younger patients and in females and males. The length of stay was also reduced.
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Affiliation(s)
- Claudia Mendoza-Pinto
- Systemic Autoimmune Diseases Research Unit, Specialties Hospital UMAE-CIBIOR, 37767Mexican Social Security Institute, Puebla, México.,Department of Rheumatology, Medicine School, 3972Meritorious Autonomous University of Puebla, Puebla, Mexico
| | - Ivet Etchegaray-Morales
- Department of Rheumatology, Medicine School, 3972Meritorious Autonomous University of Puebla, Puebla, Mexico
| | - Pamela Munguía-Realpozo
- Systemic Autoimmune Diseases Research Unit, Specialties Hospital UMAE-CIBIOR, 37767Mexican Social Security Institute, Puebla, México.,Department of Rheumatology, Medicine School, 3972Meritorious Autonomous University of Puebla, Puebla, Mexico
| | - Juan Carlos Solis-Poblano
- Department of Haematology, Specialties Hospital UMAE, 37767Mexican Social Security Institute, Puebla, México
| | | | - Ángel David Osorio-Peña
- Department of Rheumatology, Medicine School, 3972Meritorious Autonomous University of Puebla, Puebla, Mexico
| | - Jorge Ayón-Aguilar
- Coordination of Health Research, 37767Mexican Social Security Institute, México
| | - Carlos Abud-Mendoza
- Department of Rheumatology, 61727Hospital Central Dr Ignacio Morones Prieto, San Luis Potosí, México
| | - Mario García-Carrasco
- Department of Rheumatology, Medicine School, 3972Meritorious Autonomous University of Puebla, Puebla, Mexico
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Bitencourt N, Makris UE, Solow EB, Wright T, Reisch EJ, Bermas BL. Predictors of Adverse outcomes in patients with systemic lupus erythematosus transitioning to adult care. Semin Arthritis Rheum 2021; 51:353-359. [PMID: 33601191 DOI: 10.1016/j.semarthrit.2021.02.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/05/2021] [Accepted: 02/06/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND The transition from pediatric to adult care is a vulnerable period for individuals with chronic diseases. We sought to identify risk factors associated with poor outcomes in patients with childhood-onset systemic lupus erythematosus (cSLE) who have transitioned to adult care. METHODS A retrospective analysis of cSLE patients was performed. Outcomes of interest were development of end-stage renal disease (ESRD) or death and time to first hospitalization following final pediatric rheumatology visit. Multivariable logistic and Cox regression models were used. RESULTS Of 190 patients with cSLE, 21 (11%) developed ESRD and 9 (5%) died following the final pediatric rheumatology visit. In logistic regression, public insurance, history of Child Protective Services involvement, and an unscheduled hospitalization during the final year in pediatric care were predictive of ESRD or death (odds ratio (95% confidence intervals (CI)) 6.7 (1.5-30.7), 6.6 (2.3-19.1), and 3.2 (1.3-8.3), respectively). Among 114 patients with healthcare utilization data, 53% had a hospitalization in adult care. In Cox regression analysis, a pediatric outpatient opioid prescription was associated with shorter time to adult hospitalization and White or Asian race was associated with longer time to adult hospitalization (hazard ratio (CI) 3.5 (1.7-7.0) and 0.1 (0.03-0.4), respectively). CONCLUSIONS Risks factors associated with poor outcomes in adult care amongst patients with cSLE include public insurance, history of Child Protective Services involvement, unscheduled care utilization in pediatric care, pediatric outpatient opioid prescription, Black race and Hispanic ethnicity. Efforts to improve long-term outcomes among patients with cSLE should focus on these populations.
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Affiliation(s)
- Nicole Bitencourt
- Division of Pediatric Rheumatology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas 75390-9063, TX, United States.
| | - Una E Makris
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, TX, United States; Medical Service, VA North Texas Health Care System, Dallas, TX, United States; Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - E Blair Solow
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Tracey Wright
- Division of Pediatric Rheumatology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas 75390-9063, TX, United States
| | - E Joan Reisch
- Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Bonnie L Bermas
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, TX, United States
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Feldman CH, Speyer C, Ashby R, L Bermas B, Bhattacharyya S, Chakravarty E, Everett B, Ferucci E, Hersh AO, Marty FM, Merola JF, Ramsey-Goldman R, Rovin BH, Son MB, Tarter L, Waikar S, Yazdany J, Weissman JS, Costenbader KH. Development of a Set of Lupus-Specific, Ambulatory Care-Sensitive, Potentially Preventable Adverse Conditions: A Delphi Consensus Study. Arthritis Care Res (Hoboken) 2021; 73:146-157. [PMID: 31628721 DOI: 10.1002/acr.24095] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/15/2019] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Individuals with systemic lupus erythematosus (SLE) are at high risk for infections and SLE- and medication-related complications. The present study was undertaken to define a set of SLE-specific adverse outcomes that could be prevented, or their complications minimized, if timely, effective ambulatory care had been received. METHODS We used a modified Delphi process beginning with a literature review and key informant interviews to select initial SLE-specific potentially preventable conditions. We assembled a panel of 16 nationally recognized US-based experts from 8 subspecialties. Guided by the RAND-UCLA Appropriateness Method, we held 2 survey rounds with controlled feedback and an interactive webinar to reach consensus regarding preventability and importance on a population level for a set of SLE-specific adverse conditions. In a final round, the panelists endorsed the potentially preventable conditions. RESULTS Thirty-five potential conditions were initially proposed; 62 conditions were ultimately considered during the Delphi process. The response rate was 100% for both survey rounds, 88% for the webinar, and 94% for final approval. The 25 SLE-specific conditions meeting consensus as potentially preventable and important on a population level fell into 4 categories: vaccine-preventable illnesses (6 conditions), medication-related complications (8 conditions), reproductive health-related complications (6 conditions), and SLE-related complications (5 conditions). CONCLUSION We reached consensus on a diverse set of adverse outcomes relevant to SLE patients that may be preventable if patients receive high-quality ambulatory care. This set of outcomes may be studied at the health system level to determine how to best allocate resources and improve quality to reduce avoidable outcomes and disparities among those at highest risk.
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Affiliation(s)
- Candace H Feldman
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Cameron Speyer
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Rachel Ashby
- Brigham and Women's Hospital, Boston, Massachusetts
| | | | | | | | - Brendan Everett
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | - Francisco M Marty
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Joseph F Merola
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Brad H Rovin
- Ohio State University Wexner Medical Center, Columbus
| | - Mary Beth Son
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Laura Tarter
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sushrut Waikar
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | - Karen H Costenbader
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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5
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Feldman CH, Xu C, Williams J, Collins JE, Costenbader KH. Patterns and predictors of recurrent acute care use among Medicaid beneficiaries with systemic lupus erythematosus. Semin Arthritis Rheum 2020; 50:1428-1436. [PMID: 32252975 PMCID: PMC7483304 DOI: 10.1016/j.semarthrit.2020.02.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 02/20/2020] [Accepted: 02/25/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVES We aimed to identify longitudinal patterns and predictors of acute care use (emergency department [ED] visits and hospitalizations) among individuals with SLE enrolled in Medicaid, the largest U.S. public insurance. METHODS Using Medicaid data (29 states, 2000-2010) we identified 18-65-year-olds with SLE (≥3 SLE ICD-9 codes, 3rd code=index date), ≥12 months of enrollment prior to the index date and ≥24 months post. For each 90-day interval post index date, patients were assigned binary indicators (1=≥1 ED visit or hospitalization, 0=none). We used group-based trajectory models to graph patterns of overall and SLE-specific acute care use, and multinomial logistic regression models to examine predictors. RESULTS Among 40,381 SLE patients, the mean age was 40.8 (SD 11.9). Using a three-group trajectory model, 2,342 (6%) were recurrent all-cause high acute care utilizers, 12,932 (32%) moderate, 25,107 (62%) infrequent; 25% were moderate or high utilizers for SLE. There were higher odds of all-cause, recurrent acute care use (vs. infrequent) among patients with severe vs. mild SLE (OR 3.37, 95% CI 3.0-3.78), chronic pain (odds ratio [OR] 1.63, 95% CI 1.15-2.32), depression (OR 1.90 95% CI 1.74-2.09), and cardiovascular disease (OR 2.29, 95% CI 2.08-2.52). Older age, male sex and hydroxychloroquine use were associated with lower odds of recurrent overall and SLE-specific acute care use. CONCLUSION Nearly 40% of Medicaid beneficiaries with SLE are recurrent all-cause acute care utilizers; 25% have recurrent use for SLE. Modifiable factors, including outpatient management of SLE and comorbidities, may reduce avoidable acute care use.
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Affiliation(s)
- Candace H Feldman
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02115, United States.
| | - Chang Xu
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02115, United States
| | - Jessica Williams
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02115, United States
| | - Jamie E Collins
- OrACORe, Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, United States
| | - Karen H Costenbader
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02115, United States
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Anandarajah A, Thirukumaran C, McCarthy K, McMahon S, Feng C, Ritchlin C. Identification and Characterization of a High-Need, High-Cost Group Among Hospitalized Patients With Systemic Lupus Erythematosus. Arthritis Care Res (Hoboken) 2020; 74:648-655. [PMID: 33202104 DOI: 10.1002/acr.24510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 10/18/2020] [Accepted: 11/10/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To identify a high-need, high-cost (HNHC) group among hospitalized lupus patients and to compare clinical and social factors of the HNHC group with those of other patients with lupus. METHODS All hospitalizations for lupus in a tertiary care center over a 3-year period were recorded. The number of admissions, 30-day readmissions, length of stay (LOS), and cost of admissions were compared for high-risk patients with those of all other hospitalized lupus patients (OHLP) during this period. We then compared clinical measures (double-stranded DNA [dsDNA] levels, complement proteins, body mass index, Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index [SDI] scores, and Case Mix Index [CMI] scores) for the HNHC cohort with those of the OHLP group. We additionally differentiated social factors (age, race and ethnicity, poverty, and medication adherence) between the 2 groups. RESULTS A total of 202 patients with lupus accounted for 467 hospitalizations over the study period. The total cost of admissions was $13,192,346. Forty-four patients had significantly higher admissions, 30-day readmissions, and LOS. Furthermore, the cost for this group was 6-fold that for the OHLP group, confirming the presence of an HNHC cohort. The HNHC group had significantly higher dsDNA levels, SDI scores, and CMI scores compared with the OHLP group. Infections were the most common cause of admission for both groups. Patients in the HNHC group were more likely to be African American, younger, diagnosed with lupus at an earlier age, to have lower medication adherence, and to be significantly more likely to live in areas of poverty. CONCLUSION A small group of patients with lupus (the HNHC group) accounts for most of the hospitalizations and cost. The HNHC group has both social and clinical factors significantly different from other patients with lupus.
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Legge A, Kirkland S, Rockwood K, Andreou P, Bae SC, Gordon C, Romero-Diaz J, Sanchez-Guerrero J, Wallace DJ, Bernatsky S, Clarke AE, Merrill JT, Ginzler EM, Fortin PR, Gladman DD, Urowitz MB, Bruce IN, Isenberg DA, Rahman A, Alarcón GS, Petri M, Khamashta MA, Dooley MA, Ramsey-Goldman R, Manzi S, Zoma AA, Aranow C, Mackay M, Ruiz-Irastorza G, Lim SS, Inanc M, van Vollenhoven RF, Jonsen A, Nived O, Ramos-Casals M, Kamen DL, Kalunian KC, Jacobsen S, Peschken CA, Askanase A, Hanly JG. Prediction of hospitalizations in systemic lupus erythematosus using the Systemic Lupus International Collaborating Clinics Frailty Index (SLICC-FI). Arthritis Care Res (Hoboken) 2020; 74:638-647. [PMID: 33152181 DOI: 10.1002/acr.24504] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 10/22/2020] [Accepted: 11/03/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The Systemic Lupus International Collaborating Clinics (SLICC) frailty index (FI) predicts mortality and damage accrual in SLE, but its association with hospitalizations has not been described. We estimated the association of baseline SLICC-FI values with future hospitalizations in the SLICC inception cohort. METHODS Baseline SLICC-FI scores were calculated. The number and duration of inpatient hospitalizations during follow-up were recorded. Negative binomial regression was used to estimate the association between baseline SLICC-FI values and the rate of hospitalizations per patient-year of follow-up. Linear regression was used to estimate the association of baseline SLICC-FI scores with the proportion of follow-up time spent in hospital. Multivariable models were adjusted for relevant baseline characteristics. RESULTS The 1549 SLE patients eligible for this analysis were mostly female (88.7%) with mean (SD) age 35.7 (13.3) years and median (IQR) disease duration 1.2 (0.9-1.5) years at baseline. Mean (SD) baseline SLICC-FI was 0.17 (0.08). During mean (SD) follow-up of 7.2 (3.7) years, 614 patients (39.6%) experienced 1570 hospitalizations. Higher baseline SLICC-FI values (per 0.05 increment) were associated with more frequent hospitalizations during follow-up (Incidence Rate Ratio 1.21; 95%CI 1.13-1.30), adjusting for baseline age, sex, corticosteroid use, immunosuppressive use, ethnicity/location, SLE disease activity index 2000 (SLEDAI-2K), SLICC/ACR damage index (SDI), and disease duration. Among patients with ≥1 hospitalization, higher baseline SLICC-FI values predicted a greater proportion of follow-up time spent hospitalized (Relative Rate 1.09; 95%CI 1.02-1.16). CONCLUSION The SLICC-FI predicts future hospitalizations among incident SLE patients, further supporting the SLICC-FI as a valid health measure in SLE.
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Affiliation(s)
- Alexandra Legge
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Susan Kirkland
- Department of Community Health & Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kenneth Rockwood
- Division of Geriatric Medicine, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Pantelis Andreou
- Department of Community Health & Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sang-Cheol Bae
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | | | | | - Daniel J Wallace
- Cedars-Sinai/David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Sasha Bernatsky
- Divisions of Rheumatology and Clinical Epidemiology, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Ann E Clarke
- Division of Rheumatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Joan T Merrill
- Department of Clinical Pharmacology, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | - Ellen M Ginzler
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Paul R Fortin
- Division of Rheumatology, CHU de Québec - Université Laval, Quebec City, Canada
| | - Dafna D Gladman
- Center for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital and University of Toronto, ON, Canada, Oakland
| | - Murray B Urowitz
- Center for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital and University of Toronto, ON, Canada, Oakland
| | - Ian N Bruce
- Arthritis Research UK Epidemiology Unit, Faculty of Biology Medicine and Health, Manchester Academic Health Sciences Center, The University of Manchester, and NIHR Manchester Musculoskeletal Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Center Manchester, UK
| | - David A Isenberg
- Center for Rheumatology, Department of Medicine, University College London, UK, London
| | - Anisur Rahman
- Center for Rheumatology, Department of Medicine, University College London, UK, London
| | - Graciela S Alarcón
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Michelle Petri
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Munther A Khamashta
- Lupus Research Unit, The Rayne Institute, St Thomas' Hospital, King's College London School of Medicine, London, UK
| | - M A Dooley
- Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC, USA, Chapel Hill
| | | | - Susan Manzi
- Lupus Center of Excellence, Allegheny Health Network, Pittsburgh, PA, USA
| | - Asad A Zoma
- Lanarkshire Center for Rheumatology, Hairmyres Hospital, East Kilbride, Scotland, UK
| | - Cynthia Aranow
- Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Meggan Mackay
- Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit, Department of Internal Medicine, BioCruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Barakaldo, Spain
| | - S Sam Lim
- Emory University School of Medicine, Division of Rheumatology, Atlanta, Georgia, USA
| | - Murat Inanc
- Division of Rheumatology, Department of Internal Medicine, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | | | - Andreas Jonsen
- Department of Clinical Sciences Lund, Rheumatology, Lund University, Lund, Sweden
| | - Ola Nived
- Department of Clinical Sciences Lund, Rheumatology, Lund University, Lund, Sweden
| | - Manuel Ramos-Casals
- Josep Font Autoimmune Diseases Laboratory, IDIBAPS, Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Spain
| | - Diane L Kamen
- Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - Soren Jacobsen
- Copenhagen Lupus and Vasculitis Clinic, 4242, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Anca Askanase
- Hospital for Joint Diseases, NYU, Seligman Center for Advanced Therapeutics, New York, NY, USA
| | - John G Hanly
- Division of Rheumatology, Department of Medicine and Department of Pathology, Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada
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Singh JA, Cleveland JD. Hospitalized Infections in Lupus: A Nationwide Study of Types of Infections, Time Trends, Health Care Utilization, and In-Hospital Mortality. Arthritis Rheumatol 2020; 73:617-630. [PMID: 33142044 DOI: 10.1002/art.41577] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 10/29/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To examine the time trends in hospitalized infections in patients with systemic lupus erythematosus (SLE), and the factors associated with health care utilization and in-hospital mortality. METHODS US National Inpatient Sample data from 1998-2016 were used to examine the epidemiology, time trends, and outcomes of 5 common hospitalized infections in patients with SLE, namely, pneumonia, sepsis/bacteremia, urinary tract infection (UTI), skin and soft tissue infections (SSTIs), and opportunistic infections (OIs). Time trends were compared using the Cochran-Armitage test. Multivariable-adjusted logistic regression models were used to examine the factors associated with health care utilization (hospital stay >3 days, hospital charges above the median, or discharge to a nonhome setting) and in-hospital mortality. RESULTS Hospitalization rates per 100,000 claims among SLE patients in 1998-2000 versus in 2015-2016 were as follows: for OIs, 1.13 versus 1.61 (1.2-fold increase); for SSTIs, 4.78 versus 12.2 (2.5-fold increase); for UTI, 1.94 versus 6.12 (3.2-fold increase); for pneumonia, 15.09 versus 17.05 (1.1-fold increase); and for sepsis, 6.31 versus 39.64 (6.3-fold increase). In 2011-2012, sepsis surpassed pneumonia as the most common hospitalized infection in patients with SLE. In multivariable-adjusted models, a diagnosis of sepsis, older age, a Deyo-Charlson common comorbidities score of ≥2, having Medicare or Medicaid insurance, and urban hospital location were significantly associated with increased odds of in-hospital mortality and with all health care utilization outcomes. African American race was significantly associated with increased odds of health care utilization. CONCLUSION The results of this study indicate that the rates of hospitalized infections increased over time in patients with SLE, and that pneumonia was surpassed by sepsis as the most common hospitalized infection. In addition, associations of risk factors with poorer outcomes were identified. These findings may help inform patients, providers, and policy makers with regard to the burden of infection in SLE, and could lead to interventions/pathways to improve outcomes.
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Affiliation(s)
- Jasvinder A Singh
- University of Alabama at Birmingham and Birmingham VA Medical Center
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9
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Abstract
Systemic lupus erythematosus (SLE) disproportionately affects those with low socioeconomic status. Evidence from the past 2 decades has revealed clearer distinctions on the mechanisms of poverty that affect long-term outcomes in SLE. Poverty exacerbates direct, indirect, and humanistic costs and is associated with worse SLE disease damage, greater mortality, and poorer quality of life. Ongoing commitments from medicine and society are required to reduce disparities, improve access to care, and bolster resilience in persons with SLE who live in poverty.
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Brown EA, Gebregziabher M, Kamen DL, White BM, Williams EM. Examining Racial Differences in Access to Primary Care for People Living with Lupus: Use of Ambulatory Care Sensitive Conditions to Measure Access. Ethn Dis 2020; 30:611-620. [PMID: 32989361 PMCID: PMC7518530 DOI: 10.18865/ed.30.4.611] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background People living with lupus may experience poor access to primary care and delayed specialty care. Purpose To identify characteristics that lead to increased odds of poor access to primary care for minorities hospitalized with lupus. Methods Cross-sectional design with 2011-2012 hospitalization data from South Carolina, North Carolina, and Florida. We used ICD-9 codes to identify lupus hospitalizations. Ambulatory care sensitive conditions were used to identify preventable lupus hospitalizations and measure access to primary care. Logistic regression was used to estimate the odds ratio for the association between predictors and having poor access to primary care. Sensitivity analysis excluded patients aged >65 years. Results There were 23,154 total lupus hospitalizations, and 2,094 (9.04%) were preventable. An adjusted model showed minorities aged ≥65 years (OR 2.501, CI 1.501, 4.169), minorities aged 40-64 years (OR 2.248, CI: 1.394, 3.627), minorities with Medicare insurance (OR 1.669, CI:1.353,2.059) and minorities with Medicaid (OR 1.662,CI:1.321, 2.092) had the highest odds for a preventable lupus hospitalization. Minorities with Medicare had significantly higher odds for ≥3 hospital days (OR 1.275, CI: 1.149, 1.415). Whites with Medicare (OR 1.291, CI: 1.164, 1.432) had the highest odds for ≥3 days. Conclusions Our data show that middle-aged minorities living with lupus and on public health insurance have a higher likelihood of poor access to primary care. Health care workers and policymakers should develop plans to identify patients, explore issues affecting access, and place patients with a community health worker or social worker to promote better access to primary care.
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Affiliation(s)
- Elizabeth A. Brown
- Department of Health Professions, College of Health Professions, Medical University of South Carolina (MUSC), Charleston, SC
| | | | - Diane L. Kamen
- Department of Medicine, College of Medicine, MUSC, Charleston, SC
| | - Brandi M. White
- Division of Health Sciences, Education, and Research, College of Health Sciences, University of Kentucky, Lexington, KY
| | - Edith M. Williams
- Department of Public Health Sciences, College of Medicine, MUSC, Charleston, SC
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11
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Twumasi AA, Shao A, Dunlop-Thomas C, Drenkard C, Cooper HL. Exploring the Perceived Impact of the Chronic Disease Self-Management Program on Self-Management Behaviors among African American Women with Lupus: A Qualitative Study. ACR Open Rheumatol 2020; 2:147-157. [PMID: 32037683 PMCID: PMC7077773 DOI: 10.1002/acr2.11117] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 12/20/2019] [Indexed: 01/11/2023] Open
Abstract
Objective To qualitatively explore the processes through which the Chronic Disease Self‐Management Program (CDSMP)—a peer‐led, group‐based educational intervention for people with chronic conditions—affects self‐management behaviors among African American women with systemic lupus erythematosus (SLE). Methods Using a longitudinal pre‐ and postintervention design, we conducted two waves of one‐on‐one, semistructured interviews with 24 purposefully sampled participants. Wave 1 interviews explored self‐management behaviors at baseline; wave 2 interviews focused on changes in these behaviors postintervention. Transcripts were analyzed using thematic analysis methods. Results Study participants perceived the CDSMP to be a valuable resource that helped them improve fundamental self‐management behaviors, including exercise, relaxation, diet, and medication adherence. We found, with few exceptions, that in this sample, women's reported changes in self‐management behaviors did not vary by participant age, education, SLE disease severity, or depression status. Our analysis suggests that the CDSMP had the most widespread perceived effects on relaxation and exercise. Strategies that generated improvements in relaxation and exercise included goal setting, action planning, encouragement to pursue low‐impact physical activity, and introduction of mindfulness techniques to better manage SLE symptoms. Conclusion Our findings suggest that African American women with SLE perceived the CDSMP as an effective educational self‐management intervention. The program can potentially catalyze improvements in self‐management behaviors in this population, regardless of demographic or disease characteristics.
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Affiliation(s)
- Abena A Twumasi
- Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Anna Shao
- Emory University Rollins School of Public Health, Atlanta, Georgia
| | | | | | - Hannah L Cooper
- Emory University Rollins School of Public Health, Atlanta, Georgia
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12
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Brown EA, Dismuke-Greer CE, Ramakrishnan V, Faith TD, Williams EM. Impact of the Affordable Care Act Medicaid Expansion on Access to Care and Hospitalization Charges for Lupus Patients. Arthritis Care Res (Hoboken) 2020; 72:208-215. [PMID: 31562794 DOI: 10.1002/acr.24080] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 09/24/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To examine the impact of the Affordable Care Act on preventable hospitalizations and associated charges for patients living with systemic lupus erythematosus, before and after Medicaid expansion. METHODS A retrospective, quasi-experimental study, using an interrupted time series research design, was conducted to analyze data for 8 states from the Healthcare Cost and Utilization Project state inpatient databases. Lupus hospitalizations with a principal diagnosis of predetermined ambulatory-care sensitive (ACS) conditions were the unit of primary analysis. The primary outcome variable was access to care measured by preventable hospitalizations caused by an ACS condition. RESULTS There were 204,150 lupus hospitalizations in the final analysis, with the majority (53.5%) of lupus hospitalizations in states that did not expand Medicaid. In unadjusted analysis, Medicaid expansion states had significantly lower odds of having preventable lupus hospitalizations (odds ratio [OR] 0.958); however, after adjusting for several covariates, Medicaid expansion states had increased odds of having preventable lupus hospitalizations (OR 1.302). Adjusted analysis showed that those individuals with increased age, public insurance (Medicare or Medicaid), no health insurance, rural residence, or low income had significantly higher odds of having a preventable lupus hospitalization. States that expanded Medicaid had $523 significantly more charges than states that did not expand Medicaid. Older age and rural residence were associated with significantly higher charges. CONCLUSION Our findings suggest that while Medicaid expansion increased health insurance coverage, it did not address other issues related to access to care that could reduce the number of preventable hospitalizations.
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13
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Kuo CF, Burns PB, Chen JS, Wang L, Chung KC. Risk of preventable hospitalization before and after diagnosis among rheumatoid arthritis patients compared to non-rheumatoid arthritis controls. Joint Bone Spine 2019; 87:149-156. [PMID: 31811929 DOI: 10.1016/j.jbspin.2019.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/20/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The purpose of the study is to investigate the risk of preventable hospitalization among patients with rheumatoid arthritis (RA). METHODS We identified 11,852 incident RA patients and 59,260 age-, sex-, and index year-matched controls from the Taiwan National Health Insurance Database. Index date was the RA diagnosis date for cases, which was assigned to their matched controls. The odds ratios (OR) of preventable hospitalizations between RA patients and controls were estimated using a mixed effect model adjusted for age, sex, patient characteristics, Elixhauser comorbidity index, medical utilization and regional medical resources. RESULTS The overall annualized incidence of preventable hospitalization in RA patients and controls was 38.7 vs. 20.9 events per 1,000 person-years (adjusted OR, 1.61; 95% confidence interval [CI], 1.51-1.71). The adjusted OR of preventable hospitalization in RA patients compared to matched controls was 1.17 (1.00-1.37) one year prior to RA diagnosis and remained elevated after RA diagnosis. Adjusted ORs (95% CI) for specific preventable hospitalization categories were 1.93 (1.58-2.36) for chronic obstructive pulmonary disease, 1.64 (1.21-2.21) for asthma, 1.95 (1.78-2.13) for bacterial pneumonia, and 1.59 (1.44-1.75) for urinary tract infection. When assessing the trend of individual preventable hospitalizations before and after diagnosis, bacterial pneumonia and urinary tract infection hospitalizations had a significantly higher OR in RA patients one year before diagnosis and five years afterward (adjusted OR ranges 2.75 to 4.48 and 1.83 to 3.07 respectively, all P-values<0.05) CONCLUSION: RA is independently associated with a higher risk of preventable hospitalization specifically for chronic lung diseases and infections.
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Affiliation(s)
- Chang-Fu Kuo
- Division of Rheumatology, Orthopaedics, and Dermatology, School of Medicine, University of Nottingham, Nottingham, UK; Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Patricia B Burns
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, United States
| | - Jung-Sheng Chen
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Lu Wang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Kevin C Chung
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, United States.
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14
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Williams EM, Dismuke CL, Faith TD, Smalls BL, Brown E, Oates JC, Egede LE. Cost-effectiveness of a peer mentoring intervention to improve disease self-management practices and self-efficacy among African American women with systemic lupus erythematosus: analysis of the Peer Approaches to Lupus Self-management (PALS) pilot study. Lupus 2019; 28:937-944. [PMID: 31166867 PMCID: PMC6597273 DOI: 10.1177/0961203319851559] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The Peer Approaches to Lupus Self-management (PALS) program was developed as a peer mentoring tool to improve health behaviors, beliefs, and outcomes in African American women with systemic lupus erythematosus (SLE). This study aims to assess the cost of the PALS intervention and determine its effectiveness when compared to existing treatments. METHODS Peer mentors and mentees were paired on shared criteria such as life stage, marital status, or whether they were mothers. This 12-week program consisted of a weekly peer mentoring session by telephone. Cost of healthcare utilization was evaluated by assessing the healthcare costs pre- and post-intervention. Validated measures of quality of life, self-management, disease activity, depression, and anxiety were collected. Total direct program costs per participant were totaled and used to determine average per unit improvement in outcome measures. The benefit-cost ratio and pre- versus post-intervention hospital charges were examined. RESULTS A total of 20 mentees and 7 mentors were enrolled in the PALS program. All PALS pairs completed 12 sessions lasting an average of 54 minutes. Mentees reported statistically significant decreases in patient-reported disease activity, depression, and anxiety, with improved trends in patient activation or patient engagement in their disease and management. The total cost per patient was $1291.50, which was $107.62 per patient per week. There was a savings of $23,417 per individual receiving the intervention with a benefit-cost ratio of 18.13 per patient. CONCLUSION These findings suggest that the PALS intervention was effective in improving patient-level factors and was cost-effective. Future research will need to validate these findings in a larger sample.
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Affiliation(s)
- Edith M. Williams
- Department of Public Health Sciences, Medical University of South Carolina, 135 Cannon Street, Suite CS303, Charleston, SC 29425, USA
| | - Clara L. Dismuke
- Veterans Health Administration, Charleston Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Department of Veterans Affairs Medical Center, 109 Bee Street, Charleston, SC 29401, USA
- College of Medicine, Center for Health Disparities Research, Medical University of South Carolina, 135 Rutledge Ave, Suite 280, Charleston, SC 29425, USA
| | - Trevor D. Faith
- Department of Public Health Sciences, Medical University of South Carolina, 135 Cannon Street, Suite CS303, Charleston, SC 29425, USA
| | - Brittany L. Smalls
- Center for Health Services Research, College of Medicine, University of Kentucky, 740 S. Limestone Street, Suite J530, Lexington, KY 40536, USA
| | - Elizabeth Brown
- Division of Healthcare Studies, Department of Health Professions, College of Health Professions, Medical University of South Carolina, 151-B Rutledge Ave, Charleston, SC 29425, USA
| | - James C. Oates
- Division of Rheumatology and Immunology, College of Medicine, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC 29425, USA
| | - Leonard E. Egede
- Division of General Internal Medicine, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI 53226, USA
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15
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Tejera Segura B, Rua-Figueroa I, Pego-Reigosa JM, del Campo V, Wincup C, Isenberg D, Rahman A. Can we validate a clinical score to predict the risk of severe infection in patients with systemic lupus erythematosus? A longitudinal retrospective study in a British Cohort. BMJ Open 2019; 9:e028697. [PMID: 31203250 PMCID: PMC6589043 DOI: 10.1136/bmjopen-2018-028697] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE Severe infections are a major cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE). Our primary objective was to use data from a large Spanish cohort to develop a risk score for severe infection in SLE, the SLE Severe Infection Score (SLESIS) and to validate SLESIS in a separate cohort of 699 British patients. DESIGN AND SETTING Retrospective longitudinal study in a specialist tertiary care clinic in London, UK. PARTICIPANTS Patients fulfilling international classification criteria for SLE (n=209). This included 98 patients who had suffered severe infections (defined as infection leading to hospitalisation and/or death) and 111 randomly selected patients who had never suffered severe infections. OUTCOMES We retrospectively calculated SLESIS at diagnosis for all 209 patients. For the infection cases we also calculated SLESIS just prior to infection and compared it to SLESIS in 98 controls matched for disease duration. We carried out receiver operator characteristic (ROC) analysis to quantify predictive value of SLESIS for severe infection. RESULTS Median SLESIS (IQR) at diagnosis was higher in the infection group than in the control group (4.27 (3.18) vs 2.55 (3.79), p=0.0008). Median SLESIS prior to infection was higher than at diagnosis (6.64 vs 4.27, p<0.001). In ROC analysis, predictive value of SLESIS just before the infection (area under the curve (AUC)=0.79) was higher than that of SLESIS at diagnosis (AUC=0.63). CONCLUSIONS We validated the association of SLESIS with severe infection in an independent cohort. Calculation of SLESIS at each clinic visit may help in management of infection risk in patients with SLE. Prospective studies are needed to confirm these findings.
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Affiliation(s)
| | - Iñigo Rua-Figueroa
- Rheumatology Department, Doctor Negrín University Hospital of Gran Canaria, Las Palmas de Gran Canaria, Spain
- RELESSER Study Group, Spain
| | - Jose Maria Pego-Reigosa
- Rheumatology Department, University Hospital Vigo, IRIDIS Group, Instituto de Investigación Sanitaria Galicia Sur (IISGS), Vigo, Spain
- RELESSER Study Group, Spain
| | - Victor del Campo
- Preventive Medicine and Epidemiology Department, University Hospital Vigo, IRIDIS Group, Instituto de Investigación Sanitaria Galicia Sur (IISGS), Vigo, Spain
| | - Chris Wincup
- Centre for Rheumatology Research, University College London, London, UK
| | - David Isenberg
- Centre for Rheumatology Research, University College London, London, UK
| | - Anisur Rahman
- Centre for Rheumatology Research, University College London, London, UK
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16
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Hannah J, Galloway J, Kaul A. Changing hospitalization trends for systemic lupus erythematosus and rheumatoid arthritis in England. Lupus 2019; 28:906-913. [PMID: 31159650 DOI: 10.1177/0961203319853357] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Systemic lupus erythematosus (SLE) is a chronic, multisystemic, immune-mediated disorder associated with a substantial hospitalization risk. As a comparatively rare disease, there is a sparsity of research examining the burden of hospital admission in the contemporary era. We aim to describe national trends in hospitalization rates in England between 1998 and 2015 for SLE, using rheumatoid arthritis (RA) and general population rates as comparison cohorts for benchmarking. METHODS Hospital admission rates, emergency and day-case admission rates, length of stay and bed days used were calculated using finished consultant episodes from Hospital Episode Statistics data. Cochran-Armitage tests and linear regression quantified the significance and magnitude of change over time. RESULTS SLE admissions increased from 8.97 to 9.04 per 100,000 (p < 0.001) between 1998 and 2015. By comparison, RA admissions rose from 71.0 to 171.6 per 100,000 (p < 0.001) and all-cause admissions rose from 24,500 to 34,500 per 100,000 (p < 0.001). Emergency admissions decreased both for SLE (2.6 to 1.2 per 100,000) and RA (12.8 to 4.4 per 100,000) despite all-cause emergency admissions increasing from 9400 to 10,300 per 100,000. SLE and RA day cases increased, whilst median length of stay decreased. Despite increasing admissions, total bed days for SLE and RA fell by 60% and 90%, respectively. CONCLUSIONS Whilst all-cause emergency admissions rose in the general population, those for SLE fell. Length of stay and bed days reduced and day cases increased, probably reflecting changing therapeutic strategies. This potentially large reduction in resource utilization warrants consideration when assessing the impact of new therapies.
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Affiliation(s)
- J Hannah
- 1 Department of Rheumatology, King's College Hospital, London, UK
| | - J Galloway
- 2 Department of Academic Rheumatology, King's College Hospital, London, UK
| | - A Kaul
- 3 Department of Rheumatology, St George's University Hospital, London, UK
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17
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Gergianaki I, Fanouriakis A, Adamichou C, Spyrou G, Mihalopoulos N, Kazadzis S, Chatzi L, Sidiropoulos P, Boumpas DT, Bertsias G. Is systemic lupus erythematosus different in urban versus rural living environment? Data from the Cretan Lupus Epidemiology and Surveillance Registry. Lupus 2018; 28:104-113. [PMID: 30522399 DOI: 10.1177/0961203318816820] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Examining urban-rural differences can provide insights into susceptibility or modifying factors of complex diseases, yet limited data exist on systemic lupus erythematosus (SLE). OBJECTIVE To study SLE risk, manifestations and severity in relation to urban versus rural residence. METHODOLOGY Cross-sectional analysis of the Crete Lupus Registry. Demographics, residency history and clinical data were obtained from interviews and medical records ( N=399 patients). Patients with exclusively urban, rural or mixed urban/rural residence up to enrolment were compared. RESULTS The risk of SLE in urban versus rural areas was 2.08 (95% confidence interval: 1.66-2.61). Compared with rural, urban residence was associated with earlier (by almost seven years) disease diagnosis - despite comparable diagnostic delay - and lower female predominance (6.8:1 versus 15:1). Rural patients had fewer years of education and lower employment rates. Smoking was more frequent among urban, whereas pesticide use was increased among rural patients. A pattern of malar rash, photosensitivity, oral ulcers and arthritis was more prevalent in rural patients. Residence was not associated with organ damage although moderate/severe disease occurred more frequently among rural-living patients (multivariable adjusted odds ratio: 2.17, p=0.011). CONCLUSION Our data suggest that the living environment may influence the risk, gender bias and phenotype of SLE, not fully accounted for by sociodemographic factors.
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Affiliation(s)
- I Gergianaki
- 1 Rheumatology, Clinical Immunology and Allergy, University of Crete School of Medicine, Iraklio, Greece.,2 Laboratory of Autoimmunity and Inflammation, Institute of Molecular Biology-Biotechnology, FORTH, Iraklio, Greece
| | - A Fanouriakis
- 3 Rheumatology, Clinical Immunology, 4th Department of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - C Adamichou
- 1 Rheumatology, Clinical Immunology and Allergy, University of Crete School of Medicine, Iraklio, Greece
| | - G Spyrou
- 1 Rheumatology, Clinical Immunology and Allergy, University of Crete School of Medicine, Iraklio, Greece
| | - N Mihalopoulos
- 4 Environmental Chemical Processes Laboratory (ECPL), Department of Chemistry, University of Crete, Greece.,5 Institute for Environmental Research and Sustainable Development (IERSD), National Observatory of Athens (NOA), Athens, Greece
| | - S Kazadzis
- 5 Institute for Environmental Research and Sustainable Development (IERSD), National Observatory of Athens (NOA), Athens, Greece.,6 Physikalisch-Meteorologisches Observatorium Davos, World Radiation Centre (PMOD/WRC), Davos, Switzerland
| | - L Chatzi
- 7 Department of Social Medicine, University of Crete School of Medicine, Iraklio, Greece.,8 Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, USA.,9 Department of Genetics & Cell Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - P Sidiropoulos
- 1 Rheumatology, Clinical Immunology and Allergy, University of Crete School of Medicine, Iraklio, Greece.,2 Laboratory of Autoimmunity and Inflammation, Institute of Molecular Biology-Biotechnology, FORTH, Iraklio, Greece
| | - D T Boumpas
- 2 Laboratory of Autoimmunity and Inflammation, Institute of Molecular Biology-Biotechnology, FORTH, Iraklio, Greece.,3 Rheumatology, Clinical Immunology, 4th Department of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece.,10 Joint Rheumatology Programme, National and Kapodistrian University of Athens Medical School, Athens, Greece.,11 University of Cyprus, Medical School, Nikosia, Cyprus.,12 Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - G Bertsias
- 1 Rheumatology, Clinical Immunology and Allergy, University of Crete School of Medicine, Iraklio, Greece.,2 Laboratory of Autoimmunity and Inflammation, Institute of Molecular Biology-Biotechnology, FORTH, Iraklio, Greece
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18
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Lee J, Lin J, Suter LG, Fraenkel L. Persistently Frequent Emergency Department Utilization Among Persons With Systemic Lupus Erythematosus. Arthritis Care Res (Hoboken) 2018; 71:1410-1418. [PMID: 30295422 DOI: 10.1002/acr.23777] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 10/02/2018] [Indexed: 11/05/2022]
Abstract
OBJECTIVE In order to identify opportunities to improve outpatient care, we evaluated patients with systemic lupus erythematosus (SLE) who persistently frequent the emergency department (ED). METHODS We conducted a retrospective study of patients with SLE who frequented the ED for ≥3 visits in a calendar year, from 2013 to 2016. Persistent users were those who met criteria for persistent use for at least 2 of the 4 years, and limited users for 1 of the 4 years. Each ED encounter was categorized as SLE-related, infection-related, pain-related, or other. We compared ED use between persistent and limited users, and analyzed factors associated with pain-related encounters among persistent users through multivariate logistic regression. RESULTS We identified 77 participants who had 1,143 encounters as persistent users, and 52 participants who had 335 encounters as limited users. Persistent users accounted for 77% of ED use by patients with SLE who frequented the ED. Pain-related ED visits were more common among persistent users (32%) than limited users (18%). Among persistent users, most pain-related encounters were discharged from the ED (69%) or within 48 hours of admission (20%). Persistent users with pain-related encounters accounting for >10% of ED use were more likely to be obese, have fewer comorbid conditions, and be on long-term opioid therapy. CONCLUSION Pain is a major cause of ED use. Patients with SLE who persistently utilize the ED for pain are likely to be noncritically ill, as evidenced by frequent discharges from the ED and short-stay admissions. Patients with SLE who persistently frequent the ED for pain represent a viable target for interventions to improve outpatient quality of care.
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Affiliation(s)
- Jiha Lee
- Yale University School of Medicine, New Haven, Connecticut, and University of Michigan, Ann Arbor
| | - Judith Lin
- Yale University School of Medicine, New Haven, Connecticut
| | - Lisa Gale Suter
- Yale University School of Medicine, New Haven, Connecticut, and VA Connecticut Healthcare System, West Haven, Connecticut
| | - Liana Fraenkel
- Yale University School of Medicine, New Haven, Connecticut, and VA Connecticut Healthcare System, West Haven, Connecticut
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19
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Nangit A, Lin C, Ishimori ML, Spiegel BMR, Weisman MH. Causes and Predictors of Early Hospital Readmission in Systemic Lupus Erythematosus. J Rheumatol 2018; 45:929-933. [PMID: 29657150 DOI: 10.3899/jrheum.170176] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We investigated characteristics of adult patients with systemic lupus erythematosus (SLE) readmitted to the hospital within 30 days of discharge, in an attempt to identify the causes of early readmission. METHODS We performed a retrospective case-control study examining all inpatient electronic health records of patients with SLE at Cedars-Sinai Medical Center over a 2.5-year period (2012-2014). Patients were included if they had an International Classification of Diseases, 9th ed diagnosis of SLE and were readmitted within 30 days of their initial hospitalization. Patients with SLE not readmitted during this time period were used as a control group. Demographic and clinical variables for each patient were collected, and we used the Charlson Comorbidity Index to characterize comorbidities. The Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI) was used to assess the chronic damage of SLE. Stepwise multivariable logistic regression analysis was used to predict factors associated with readmission. RESULTS In total, 570 hospitalizations representing 455 unique patients met our inclusion and exclusion criteria. Of these, 154 patients (34%) underwent readmission within 30 days of their initial hospitalization. Patients in the early readmission group were more likely to have government-sponsored Medicaid insurance and were significantly associated with an increased SDI (OR 1.27, 95% CI 1.1-1.48), lower serum hemoglobin (OR 0.82, 95% CI 0.72-0.93), and lower serum albumin (OR 0.66, 95% CI 0.47-0.91). CONCLUSION One-third of hospitalized patients with SLE were readmitted within 30 days at our institution. We identified characteristics of this at-risk population at time of discharge with high specificity, in hopes of reducing this costly outcome.
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Affiliation(s)
- Angelica Nangit
- From the Departments of Rheumatology, Internal Medicine, and Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, California, USA.,A. Nangit, MD, Rheumatology, Cedars-Sinai Medical Center; C. Lin, MD, Internal Medicine, Cedars-Sinai Medical Center; M.L. Ishimori, MD, Rheumatology, Cedars-Sinai Medical Center; B.M. Spiegel, MD, Gastroenterology, Cedars-Sinai Medical Center; M.H. Weisman, MD, Rheumatology, Cedars-Sinai Medical Center
| | - Connie Lin
- From the Departments of Rheumatology, Internal Medicine, and Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, California, USA.,A. Nangit, MD, Rheumatology, Cedars-Sinai Medical Center; C. Lin, MD, Internal Medicine, Cedars-Sinai Medical Center; M.L. Ishimori, MD, Rheumatology, Cedars-Sinai Medical Center; B.M. Spiegel, MD, Gastroenterology, Cedars-Sinai Medical Center; M.H. Weisman, MD, Rheumatology, Cedars-Sinai Medical Center
| | - Mariko L Ishimori
- From the Departments of Rheumatology, Internal Medicine, and Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, California, USA.,A. Nangit, MD, Rheumatology, Cedars-Sinai Medical Center; C. Lin, MD, Internal Medicine, Cedars-Sinai Medical Center; M.L. Ishimori, MD, Rheumatology, Cedars-Sinai Medical Center; B.M. Spiegel, MD, Gastroenterology, Cedars-Sinai Medical Center; M.H. Weisman, MD, Rheumatology, Cedars-Sinai Medical Center
| | - Brennan M R Spiegel
- From the Departments of Rheumatology, Internal Medicine, and Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, California, USA.,A. Nangit, MD, Rheumatology, Cedars-Sinai Medical Center; C. Lin, MD, Internal Medicine, Cedars-Sinai Medical Center; M.L. Ishimori, MD, Rheumatology, Cedars-Sinai Medical Center; B.M. Spiegel, MD, Gastroenterology, Cedars-Sinai Medical Center; M.H. Weisman, MD, Rheumatology, Cedars-Sinai Medical Center
| | - Michael H Weisman
- From the Departments of Rheumatology, Internal Medicine, and Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, California, USA. .,A. Nangit, MD, Rheumatology, Cedars-Sinai Medical Center; C. Lin, MD, Internal Medicine, Cedars-Sinai Medical Center; M.L. Ishimori, MD, Rheumatology, Cedars-Sinai Medical Center; B.M. Spiegel, MD, Gastroenterology, Cedars-Sinai Medical Center; M.H. Weisman, MD, Rheumatology, Cedars-Sinai Medical Center.
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Lin CH, Hung PH, Hu HY, Chen YJ, Guo HR, Hung KY. Infection-related hospitalization and risk of end-stage renal disease in patients with systemic lupus erythematosus: a nationwide population-based study. Nephrol Dial Transplant 2018; 32:1683-1690. [PMID: 28011646 DOI: 10.1093/ndt/gfw407] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 09/29/2016] [Indexed: 11/13/2022] Open
Abstract
Background Infections are a major cause of morbidity in patients with systemic lupus erythematosus (SLE), and may lead to death. No nationally representative study of patients with SLE has examined the rates of infection-related hospitalization and the risk of end-stage renal disease (ESRD). Methods We conducted a nationwide cohort study of 7326 patients with newly diagnosed SLE and no history of ESRD. All data were from Taiwan's National Health Insurance claims database for the period 2000-11. Results Among all SLE patients, 316 (4.3%) developed ESRD (mean follow-up time: 8.1 years). Multivariate Cox regression analysis indicated that the risk of ESRD increased with the number of infection-related hospitalizations. For patients with three or more infection-related admissions, the hazard ratio (HR) for ESRD was 5.08 [95% confidence interval (CI): 3.74-6.90] relative to those with no infection-related admission. Analysis by type of infection indicated that bacteremia patients had the greatest risk for ESRD (HR: 4.82; 95% CI: 3.40-6.85). Analysis of age of SLE onset indicated that patients with juvenile-onset (<18 years) and three or more infection-related hospitalizations had a greatly increased risk for ESRD (HR: 14.49; 95% CI: 5.34-39.33). Conclusions Infection-related hospitalizations are associated with a significantly increased risk of ESRD in patients with SLE, especially those with juvenile-onset SLE. Among patients with different types of infectious diseases, those with bacteremia were more likely to develop ESRD.
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Affiliation(s)
- Chien-Hung Lin
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Pediatrics, Zhongxing Branch, Taipei City Hospital, Taipei, Taiwan
| | - Peir-Haur Hung
- Department of Internal Medicine, Ditmanson Medical Foundation Chia-yi Christian Hospital, Chia-yi, Taiwan.,Department of Applied Life Science and Health, Chia-Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Hsiao-Yun Hu
- Department of Education and Research, Taipei City Hospital, Taipei, Taiwan
| | - Yann-Jang Chen
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - How-Ran Guo
- Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Occupational and Environmental Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Kuan-Yu Hung
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
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Grabar S, Groh M, Bahuaud M, Le Guern V, Costedoat-Chalumeau N, Mathian A, Hanslik T, Guillevin L, Batteux F, Launay O. Pneumococcal vaccination in patients with systemic lupus erythematosus: A multicenter placebo-controlled randomized double-blind study. Vaccine 2017; 35:4877-4885. [PMID: 28784280 DOI: 10.1016/j.vaccine.2017.07.094] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 07/24/2017] [Accepted: 07/26/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Invasive pneumococcal disease and respiratory tract infections are both frequent and severe in patients with systemic lupus erythematosus (SLE). This study aimed to compare the immunological efficacy and safety of pneumococcal vaccination with the 23-valent polysaccharide (PPS) vaccine alone to a sequential immunization with the 7-valent pneumococcal conjugate (PnCj) vaccine followed by PPS in patients with SLE and stable diseaase. METHODS Multicenter randomized placebo-controlled double-blind trial: PPS vaccine alone (placebo-PPS group) or PnCj vaccine followed by PPS vaccine (PnCj-PPS group) 24weeks later. The primary endpoint was the rate of responders at week 28 to at least 5 of the 7 serotypes (4, 6B, 9V, 14, 18C, 19F and 23F) shared by both PPS and PnCj. Pneumococcal IgG antibodies' opsonophagocytic activity (OPA) were also assessed. RESULTS Twenty-five patients in the placebo-PPS group and 17 in the PnCj-PPS group were included in a modified intention-to-treat analysis. The primary endpoint was reached in 72% (18/25) in the placebo-PPS and 76% (13/17) in the PnCj-PPS group (p=0.75). There was no difference in the rates of responders with OPA. At week 52, 13/18 (72%) patients in the placebo-PPS group and 10/13 (77%) patients in the PnCj-PPS group (p=0.77) that met the primary endpoint at week 28 were still responders to ≥5/7 serotypes shared by both PPS and PnCj vaccines. Nine SLE flares were reported in 6 patients (4 in the placebo-PPS and 2 in the PnCj-PPS groups respectively, p=0.70). CONCLUSION Sequential administration of PnCj vaccine followed by PPS vaccine is safe and shows short-term immunological efficacy in patients with SLE but was not superior to the PPS vaccine alone. TRIAL REGISTRATION www.clinicaltrials.gov, NCT NCT00611663.
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Affiliation(s)
- Sophie Grabar
- Université Paris Descartes, Sorbonne Paris Cité AP-HP, Unité de Biostatistique et Epidémiologie, Groupe Hospitalier Cochin Broca Hôtel-Dieu, Paris, France; INSERM, UPMC Université Paris 06, Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136), F75013 Paris, France
| | - Matthieu Groh
- Université Paris Descartes, Sorbonne Paris Cité AP-HP, Service de Médecine Interne, Centre de Référence National pour les Maladies Auto-Immunes Rares (Vascularites et Sclérodermie Systémique), Paris, France
| | - Mathilde Bahuaud
- Université Paris Descartes, Sorbonne Paris Cité AP-HP, Département d'Immunologie Biologique, Groupe Hospitalier Cochin Broca Hôtel-Dieu, Paris, France
| | - Véronique Le Guern
- Université Paris Descartes, Sorbonne Paris Cité AP-HP, Service de Médecine Interne, Centre de Référence National pour les Maladies Auto-Immunes Rares (Vascularites et Sclérodermie Systémique), Paris, France
| | - Nathalie Costedoat-Chalumeau
- Université Paris Descartes, Sorbonne Paris Cité AP-HP, Service de Médecine Interne, Centre de Référence National pour les Maladies Auto-Immunes Rares (Vascularites et Sclérodermie Systémique), Paris, France
| | - Alexis Mathian
- Université Pierre et Marie Curie, Sorbonne Paris Cité AP-HP, Service de Médecine Interne 2, Centre de Référence National pour le Lupus et le Syndrome des Antiphospholipides, institut E3M, Paris, France
| | - Thomas Hanslik
- Université Versailles Saint-Quentin-en-Yvelines, APHP, Service de Médecine Interne, Hôpital Ambroise Paré, Boulogne-Billancourt, France
| | - Loïc Guillevin
- Université Paris Descartes, Sorbonne Paris Cité AP-HP, Service de Médecine Interne, Centre de Référence National pour les Maladies Auto-Immunes Rares (Vascularites et Sclérodermie Systémique), Paris, France
| | - Frédéric Batteux
- Université Paris Descartes, Sorbonne Paris Cité AP-HP, Département d'Immunologie Biologique, Groupe Hospitalier Cochin Broca Hôtel-Dieu, Paris, France
| | - Odile Launay
- Inserm, CIC 1417, Paris, France; Université Paris Descartes, Sorbonne Paris Cité AP-HP, Groupe Hospitalier Cochin Broca Hôtel-Dieu, Fédération d'Infectiologie, Paris, France; Inserm, F-CRIN I-REIVAC, France.
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Comorbid Conditions are Associated With Emergency Department Visits, Hospitalizations, and Medical Charges of Patients With Systemic Lupus Erythematosus. J Clin Rheumatol 2017; 23:19-25. [PMID: 28002152 DOI: 10.1097/rhu.0000000000000437] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND/OBJECTIVES In addition to increase mortality, comorbidities can increase medical costs for systemic lupus erythematosus (SLE). Healthcare utilization can dramatically increase medical costs. It is essential to better understand the comorbidities that can lead to healthcare utilization, such as emergency department visit and/or hospitalization, for SLE patients. Therefore, the objective of this study was to examine the associations between comorbidities and healthcare utilization and medical charges of patients with SLE. METHODS Nebraska statewide emergency departments (ED) discharge and hospitals discharge data from 2007 to 2012 were used to study the comorbid conditions of patients with SLE. SLE was defined using the standard International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes (710.0). RESULTS There were more comorbid conditions in patients with SLE than patients without SLE. Comorbid conditions were majorly related to ED visits and hospitalizations of patients with SLE. Chest pain, abdominal pain, injury, acute respiratory infections, symptoms of digestive systems, headache, myalgia and myositis, noninfectious gastroenteritis and colitis, and symptoms of skin and other integumentary systems are common comorbid conditions for ED visits. Infections, cardiovascular diseases, fractures, chronic obstructive pulmonary disease (COPD) and allied conditions, cerebrovascular diseases, and episodic mood disorder are common comorbid conditions for hospitalizations of patients with SLE. In addition, the numbers of comorbid conditions were significantly associated with the length of hospital stay and hospital charges for SLE patients. CONCLUSION The findings in this study indicated that comorbid conditions are associated with healthcare utilization and medical charges of patients with SLE.
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Golder V, Morand EF, Hoi AY. Quality of Care for Systemic Lupus Erythematosus: Mind the Knowledge Gap. J Rheumatol 2017; 44:271-278. [DOI: 10.3899/jrheum.160334] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2016] [Indexed: 02/03/2023]
Abstract
Systemic lupus erythematosus (SLE) is a prototypical chronic multiorgan autoimmune disorder that can lead to significant burden of disease and loss of life expectancy. The disease burden is the result of a complex interplay between genetic, biologic, socioeconomic, and health system variables affecting the individual. Recent advances in biological understanding of SLE are yet to translate to transformative therapies, and genetic and socioeconomic variables are not readily amenable to intervention. In contrast, healthcare quality, a variable readily amenable to change, has been inadequately addressed in SLE, despite evidence in other chronic diseases that quality of care is strongly associated with patient outcomes. This article will analyze the available literature on the quality of care relevant to SLE, identify knowledge gaps, and suggest ways to address this in future research.
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Anandarajah AP, Luc M, Ritchlin CT. Hospitalization of patients with systemic lupus erythematosus is a major cause of direct and indirect healthcare costs. Lupus 2016; 26:756-761. [DOI: 10.1177/0961203316676641] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives The objective of this study was to calculate the direct and indirect costs of admission for systemic lupus erythematosus (SLE) patients, identify the population at risk and investigate potential reasons for admission. Methods We conducted a financial analysis of all admissions for SLE to Strong Memorial Hospital between 1 July 2013 and 30 June 2015. Patient and financial records for admissions with a SLE diagnosis for the above period were retrieved. The total cost of admissions was used as a measure of direct costs and the length of stay used to assess indirect costs. Additionally, we analyzed the demographics of the hospitalized population. Results The average, annual cost of confirmed admissions to Strong Memorial Hospital for SLE was US$3.9–6.4 m. The mean annual cost per patient for hospitalization was US$51,808.41. The length of stay for all SLE patients was 1564–2507 days with an average of 8.5 days per admission. The majority of patients admitted were young women from the city of Rochester. Infections were the most common reason for admissions. Conclusion We demonstrated that admissions are a source of high direct and indirect costs to the hospital and a significant financial burden to the patient. Implementing measures to improve the quality of care for SLE patients will help decrease the morbidity and lower the economic costs to hospitals.
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Affiliation(s)
| | - M Luc
- University of Rochester Medical Center, Rochester, USA
| | - C T Ritchlin
- University of Rochester Medical Center, Rochester, USA
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Murray SG, Schmajuk G, Trupin L, Gensler L, Katz PP, Yelin EH, Gansky SA, Yazdany J. National Lupus Hospitalization Trends Reveal Rising Rates of Herpes Zoster and Declines in Pneumocystis Pneumonia. PLoS One 2016; 11:e0144918. [PMID: 26731012 PMCID: PMC4701172 DOI: 10.1371/journal.pone.0144918] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 11/26/2015] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE Infection is a leading cause of morbidity and mortality in systemic lupus erythematosus (SLE). Therapeutic practices have evolved over the past 15 years, but effects on infectious complications of SLE are unknown. We evaluated trends in hospitalizations for severe and opportunistic infections in a population-based SLE study. METHODS Data derive from the 2000 to 2011 United States National Inpatient Sample, including individuals who met a validated administrative definition of SLE. Primary outcomes were diagnoses of bacteremia, pneumonia, opportunistic fungal infection, herpes zoster, cytomegalovirus, or pneumocystis pneumonia (PCP). We used Poisson regression to determine whether infection rates were changing in SLE hospitalizations and used predictive marginals to generate annual adjusted rates of specific infections. RESULTS We identified 361,337 SLE hospitalizations from 2000 to 2011 meeting study inclusion criteria. Compared to non-SLE hospitalizations, SLE patients were younger (51 vs. 62 years), predominantly female (89% vs. 54%), and more likely to be racial/ethnic minorities. SLE diagnosis was significantly associated with all measured severe and opportunistic infections. From 2000 to 2011, adjusted SLE hospitalization rates for herpes zoster increased more than non-SLE rates: 54 to 79 per 10,000 SLE hospitalizations compared with 24 to 29 per 10,000 non-SLE hospitalizations. Conversely, SLE hospitalizations for PCP disproportionately decreased: 5.1 to 2.5 per 10,000 SLE hospitalizations compared with 0.9 to 1.3 per 10,000 non-SLE hospitalizations. CONCLUSIONS Among patients with SLE, herpes zoster hospitalizations are rising while PCP hospitalizations are declining. These trends likely reflect evolving SLE treatment strategies. Further research is needed to identify patients at greatest risk for infectious complications.
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Affiliation(s)
- Sara G. Murray
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Gabriela Schmajuk
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
- Department of Medicine, Veterans Administration, San Francisco, California, United States of America
| | - Laura Trupin
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Lianne Gensler
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Patricia P. Katz
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
- Phillip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, United States of America
| | - Edward H. Yelin
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
- Phillip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, United States of America
| | - Stuart A. Gansky
- Division of Oral Epidemiology and Dental Public Health, Department of Preventive and Restorative Dental Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Jinoos Yazdany
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
- Phillip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, United States of America
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Tektonidou MG, Wang Z, Dasgupta A, Ward MM. Burden of Serious Infections in Adults With Systemic Lupus Erythematosus: A National Population-Based Study, 1996-2011. Arthritis Care Res (Hoboken) 2015; 67:1078-85. [PMID: 25732901 PMCID: PMC4516647 DOI: 10.1002/acr.22575] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Revised: 02/09/2015] [Accepted: 02/24/2015] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To compare rates of hospitalization for serious infections, trends in rates from 1996 to 2011, and in-hospital mortality between patients with systemic lupus erythematosus (SLE) and those without SLE in a national sample. METHODS We analyzed hospitalizations for pneumonia, bacteremia/sepsis, urinary tract infections, skin infections, and opportunistic infections among adults in the Nationwide Inpatient Sample. We compared rates of hospitalization yearly among patients with SLE and the general population. We also computed odds ratios (ORs) for in-hospital mortality. RESULTS In 1996, the estimated number of hospitalizations for pneumonia in patients with SLE was 4,382, followed by sepsis (2,305), skin infections (1,422), urinary tract infections (643), and opportunistic infections (370). Rates were much higher in patients with SLE than in those without SLE, with age-adjusted relative risks ranging from 5.7 (95% confidence interval [95% CI] 5.5-6.0) for pneumonia to 9.8 (95% CI 9.1-10.7) for urinary tract infection in 1996. Risks increased over time, so that by 2011, all relative risks exceeded 12.0. Overall risk of in-hospital mortality was higher in SLE only for opportunistic infections (adjusted OR 1.52 [95% CI 1.12-2.07]). However, in pneumonia and sepsis, mortality risks were higher in SLE among those who required mechanical ventilation. CONCLUSION Hospitalization rates for serious infections in SLE increased substantially between 1996 and 2011, reaching over 12 times higher than in patients without SLE in 2011. Reasons for this acceleration are unclear. In-hospital mortality was higher among patients with SLE and opportunistic infections and those with pneumonia or sepsis who required mechanical ventilation.
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Affiliation(s)
| | - Zhong Wang
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | - Abhijit Dasgupta
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | - Michael M Ward
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
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Piga M, Casula L, Perra D, Sanna S, Floris A, Antonelli A, Cauli A, Mathieu A. Population-based analysis of hospitalizations in a West-European region revealed major changes in hospital utilization for patients with systemic lupus erythematosus over the period 2001-2012. Lupus 2015. [PMID: 26199283 DOI: 10.1177/0961203315596597] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The objective of this paper is to evaluate hospital admissions in systemic lupus erythematosus (SLE) patients through a retrospective population-based study analyzing hospitalization data during 2001-2012 in Sardinia, an Italian region with universal health system coverage. METHODS Data on the hospital discharge records with the ICD-9-CM code for SLE (710.0) were obtained from the Department of Health and Hygiene and analyzed, mostly focusing on primary and non-primary diagnosis and Diagnosis-Related Group (DRG) code. In order to establish the significance of the annual trend for number and type of primary and non-primary discharge diagnosis, the two-tailed Cochran-Armitage test for trend was applied. In order to estimate SLE prevalence, data from administrative database and medical records were assembled. RESULTS This study included 6222 hospitalizations in 1675 patients (87% women). Hospitalizations with SLE as primary diagnosis were 3782 (58.0%) and significantly decreased during the study period. The annual number of renal, hematologic and neuropsychiatric disorders as non-primary diagnosis associated with SLE remained constant; however, their percentage increased (p < 0.0001) because of a declining number of admissions for SLE without associated diagnosis and without complications. Hospitalizations with SLE as non-primary diagnosis showed a significant upward trend in number and percentage of cerebrovascular accident (p = 0.0004), acute coronary syndrome (p = 0.0004) and chronic renal failure (p = 0.0003) as underlying primary diagnosis, while complications of pregnancy, labor and childbirth (p = 0.3375), malignancies (p = 0.6608) and adverse drug reactions (p = 0.2456) did not show statistically significant changes. Infections showed an increasing trend between 2001 and 2012 but did not reach statistical significance (p = 0.0304). After correction for hospitalization (93.8%) and survival (91.1%) rates calculated over the study period, the 2012 SLE prevalence in Sardinia was estimated to be 99.3 per 100,000 inhabitants. CONCLUSIONS While overall hospitalizations for SLE patients declined, those for cerebrovascular accident, acute coronary syndrome and chronic renal failure as underlying primary diagnosis increased during the study period.
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Affiliation(s)
- M Piga
- Rheumatology Unit, University Clinic AOU of Cagliari, Italy
| | - L Casula
- Rheumatology Unit, University Clinic AOU of Cagliari, Italy Regional Epidemiological Observatory, Department of Health and Hygiene, Sardinian Regional Government, Cagliari, Italy
| | - D Perra
- Rheumatology Unit, University Clinic AOU of Cagliari, Italy
| | - S Sanna
- Rheumatology Unit, University Clinic AOU of Cagliari, Italy
| | - A Floris
- Rheumatology Unit, University Clinic AOU of Cagliari, Italy
| | - A Antonelli
- Regional Epidemiological Observatory, Department of Health and Hygiene, Sardinian Regional Government, Cagliari, Italy
| | - A Cauli
- Rheumatology Unit, University Clinic AOU of Cagliari, Italy
| | - A Mathieu
- Rheumatology Unit, University Clinic AOU of Cagliari, Italy
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Williams EM, Ortiz K, Flournoy-Floyd M, Bruner L, Kamen D. Systemic lupus erythematosus observations of travel burden: A qualitative inquiry. Int J Rheum Dis 2015; 18:751-60. [PMID: 26176174 DOI: 10.1111/1756-185x.12614] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS Explorations of travel impediments among patients suffering from rheumatic diseases have been very limited. Research has consistently indicated a shortage of rheumatologists, resulting in patients potentially having to travel long distances for care. The purpose of our study was to explore how systemic lupus erythematosus (SLE) patients experience travel issues differentially by race and socio-economic status. METHODS We conducted semi-structured interviews and a brief demographic survey with 10 patients diagnosed with SLE. Interview transcripts were coded and analyzed using NVivo Analysis Software to facilitate the reporting of recurrent themes and supporting quotations, and an initial codebook was independently developed by two researchers on the study team and then verified together. RESULTS Patients described three major areas of concern with respect to travel burden in accessing their rheumatologists: reliance on caregivers; meeting financial priorities; and pain and physical limitations. CONCLUSIONS Our data suggest general traveling challenges interfering with medical appointment compliance for several participants and the importance of socio-economic issues when considering travel issues. This study highlights an important area with implications for adherence to medical appointments and participation in research among patients with SLE.
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Affiliation(s)
- Edith M Williams
- Institute for Partnerships to Eliminate Health Disparities, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Kasim Ortiz
- Department of Health Services Policy & Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Minnjuan Flournoy-Floyd
- Institute for Partnerships to Eliminate Health Disparities, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Larisa Bruner
- Office of Public Health Practice, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Diane Kamen
- Division of Rheumatology and Immunology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
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The prevalence and burden of systemic lupus erythematosus in a medicare population: retrospective analysis of medicare claims. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2015; 13:9. [PMID: 26019689 PMCID: PMC4445996 DOI: 10.1186/s12962-015-0034-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 04/21/2015] [Indexed: 11/11/2022] Open
Abstract
Background Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder which can affect multiple organs of the body, requiring ongoing disease management and healthcare resource utilization. The economic impact of SLE has not been evaluated in a Medicare population to date. This study was conducted to assess the prevalence of SLE and its burden in terms of healthcare resource utilization and costs in a US Medicare population. Methods This was a retrospective observational study using Medicare medical claims data (5% random sample) for the period spanning 2003 to 2007. SLE patients were identified by having ≥2 medical claims with a primary or secondary diagnosis of ICD-9 code 710.0X. The earliest quarter of SLE diagnosis was defined as the index quarter. Prevalence of SLE, the proportion of SLE cases on disability benefits, and the contribution of SLE to new disability cases were evaluated. Healthcare resource utilization and direct medical costs (2008 US dollars) over 12 months were compared between a cohort of patients with SLE and a cohort without SLE matched on key demographics. Differences in outcomes between cohorts were assessed using McNemar’s test for dichotomous variables and paired t-tests for continuous variables. Results A total of 13,348 patients with SLE were identified. The prevalence of SLE was approximately 3 per 1000 Medicare beneficiaries. After matching, the sample consisted of 6,707 SLE and 13,414 non-SLE patients. On average, the SLE cohort compared with the non-SLE cohort had 2.4 times more physician visits, 2.7 times more hospitalizations, 2.2 times more outpatient visits, and 2.1 times more emergency room visits. A medical cost surplus of approximately $10,229 per patient per year in the SLE cohort relative to the non-SLE cohort was driven largely by inpatient hospitalization costs (p < 0.001). Conclusions SLE prevalence was 3 per 1,000 Medicare patients. Patients with SLE consumed significantly more health care resources with significantly greater costs compared with those without SLE. Added costs were largely attributable to inpatient hospitalizations. The Medicare population is an important target for efforts to improve SLE disease management and reduce costs.
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Chen CH, Huang KY, Wang JY, Huang HB, Chou P, Lee CC. Combined effect of individual and neighbourhood socioeconomic status on mortality of rheumatoid arthritis patients under universal health care coverage system. Fam Pract 2015; 32:41-8. [PMID: 25304308 DOI: 10.1093/fampra/cmu059] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The National Health Insurance program in Taiwan is a public insurance system for the entire population of Taiwan initiated since March 1995. However, the association of socioeconomic status (SES) and prognosis of rheumatoid arthritis (RA) patients under this program has not been identified. OBJECTIVES Using the National Health Insurance Research Database in Taiwan, we aimed to examine the combined effect of individual and neighbourhood SES on the mortality rates of RA patients under a universal health care coverage system. MEASURES A study population included patients with RA from 2004 to 2008. The primary end point was the 5-year overall mortality rate. Individual SES was categorized into low, moderate and high levels based on the income-related insurance payment amount. Neighbourhood SES was defined by household income and neighbourhoods were grouped as an 'advantaged' area or a 'disadvantaged' area. The Cox proportional hazards regression model was used to compare outcomes between different SES categories. A two-sided P value < 0.05 was considered statistically significant. RESULTS Medical data of 23900 RA patients from 2004 to 2008 were reviewed. Analysis of the combined effect of individual SES and neighbourhood SES revealed that 5-year mortality rates were worse among RA patients with a low individual SES compared to those with a high SES (P < 0.001). In the Cox proportional hazards regression model, RA patients with low individual SES in disadvantaged neighbourhoods incurred the highest risk of mortality (Hazard ratio = 1.64; 95% confidence interval, 1.26-2.13, P < 0.001). CONCLUSIONS RA patients with a low SES have a higher overall mortality rate than those with a higher SES, even with a universal health care system. It is crucial that more public policy and health care efforts be put into alleviating the health disadvantages, besides providing treatment payment coverage.
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Affiliation(s)
- Cheng-Hsin Chen
- Department of Internal Medicine, Cardinal Tien Hospital, School of Medicine, Fu-Jen Catholic University, New Taipei City
| | - Kuang-Yung Huang
- Division of Allergy, Immunology, and Rheumatology, Department of Internal Medicine, Buddhist Dalin Tzu Chi General Hospital, Chiayi, School of Medicine, Tzu Chi University, Hualian, Department of Life Science and Institute of Molecular Biology, National Chung Cheung University, Chiayi
| | - Jen-Yu Wang
- Department of Internal Medicine, Cardinal Tien Hospital, School of Medicine, Fu-Jen Catholic University, New Taipei City
| | - Hsien-Bin Huang
- Department of Life Science and Institute of Molecular Biology, National Chung Cheung University, Chiayi
| | - Pesus Chou
- Community Medicine Research Center and Institute of Public Health, National Yang-Ming University, Taipei
| | - Ching-Chih Lee
- School of Medicine, Tzu Chi University, Hualian, Department of Life Science and Institute of Molecular Biology, National Chung Cheung University, Chiayi, Community Medicine Research Center and Institute of Public Health, National Yang-Ming University, Taipei, Department of Otolaryngology, Department of Education and Center for Clinical Epidemiology and Biostatistics, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan, Republic of China.
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Lawson EF, Trupin L, Yelin EH, Yazdany J. Reasons for failure to receive pneumococcal and influenza vaccinations among immunosuppressed patients with systemic lupus erythematosus. Semin Arthritis Rheum 2015; 44:666-71. [PMID: 25701500 DOI: 10.1016/j.semarthrit.2015.01.002] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 01/15/2015] [Accepted: 01/16/2015] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To better understand why immunosuppressed individuals with systemic lupus erythematosus (SLE) fail to receive influenza and pneumococcal vaccines. METHODS These cross-sectional data were derived from the 2009 cycle of the Lupus Outcomes Study (LOS), an annual longitudinal telephone survey of individuals with confirmed SLE. Respondents were included in the analysis if they had taken immunosuppressive medications in the past year. We assessed any prior receipt of pneumococcal vaccine and influenza vaccine in the past year, and then elicited reasons for not receiving vaccination. We used bivariate statistics and multivariate logistic regression to assess frequency and predictors of reported reasons for not obtaining influenza or pneumococcal vaccines. RESULTS Among 508 respondents who received immunosuppressants, 485 reported whether they had received vaccines. Among the 175 respondents who did not receive an influenza vaccine, the most common reason was lack of doctor recommendation (55%), followed by efficacy or safety concerns (21%), and lack of time (19%). Reasons for not receiving pneumococcal vaccine (N = 159) were similar: lack of recommendation (87%), lack of time (7%), and efficacy or safety concerns (4%). Younger, less-educated, non-white patients with shorter disease duration, as well as those immunosuppressed with steroids alone, were at the greatest risk for not receiving indicated vaccine recommendations. CONCLUSIONS The most common reason why individuals with SLE did not receive pneumococcal and influenza vaccines was that physicians failed to recommend them. Data suggest that increasing vaccination rates in SLE will require improved process quality at the provider level, as well as addressing patient concerns and barriers.
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Affiliation(s)
- Erica F Lawson
- Department of Pediatrics, Division of Rheumatology, Box 0632, 550 16th Street, 5th floor, San Francisco, CA 94143-0632.
| | - Laura Trupin
- Department of Medicine, Division of Rheumatology, Box 0920, 3333 California St., Suite 270, San Francisco, CA 94143-0920
| | - Edward H Yelin
- Department of Medicine, Division of Rheumatology, Box 0920, 3333 California St., Suite 270, San Francisco, CA 94143-0920
| | - Jinoos Yazdany
- Department of Medicine, Division of Rheumatology, Box 0920, 3333 California St., Suite 270, San Francisco, CA 94143-0920
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Zhu TY, Tam LS, Li EK. The socioeconomic burden of systemic lupus erythematosus: state-of-the-art and prospects. Expert Rev Pharmacoecon Outcomes Res 2014; 12:53-69. [DOI: 10.1586/erp.11.92] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Drenkard C, Rask KJ, Easley KA, Bao G, Lim SS. Primary preventive services in patients with systemic lupus erythematosus: study from a population-based sample in Southeast U.S. Semin Arthritis Rheum 2013; 43:209-16. [PMID: 23731530 DOI: 10.1016/j.semarthrit.2013.04.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Revised: 04/03/2013] [Accepted: 04/11/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Systemic lupus erythematosus (SLE) patients are at risk for complications that can be mitigated by appropriate preventive care. We examined the receipt of immunizations, cancer screening, and cardiovascular risk preventive services in a predominantly Black cohort of SLE patients from the Southeast U.S. To identify gaps in primary preventive services (PPS) that might be specific to SLE as opposed to local health system factors, we used as reference a population-based sample from the same area. METHODS A cross-sectional design was used to characterize the percentage of PPS received by 751 SLE patients from Atlanta, GA, and 9040 subjects from the same community, of whom 938 had diabetes. Factors associated with the receipt of PPS were examined with multivariable analysis of variance. RESULTS Approximately 65% of recommended PPS were provided to the SLE, overall community (OC), and diabetes samples. However, only 22.5%, 45.7%, and 27.6% of SLE, OC, and diabetes subjects, respectively, received all recommended services. Factors associated with a higher percentage of PPS received by SLE patients included older age (63.6% if age ≥65 years, 45.8% if age between 18 and 35 years), having medical insurance (61.1% for insured, 49.7% for uninsured), having a primary care physician (PCP) (59.0% if patient had PCP, 51.8% if patient did not have PCP), and being a non-smoker (61.9% for non-smokers, 49.9% for smokers). CONCLUSIONS Less than one-quarter of SLE patients from a southeast U.S. community received all the recommended services that were studied. Further research is warranted to unravel the barriers that prevent SLE patients from reaching appropriate standards of preventive care.
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Affiliation(s)
- Cristina Drenkard
- Department of Medicine, Emory University School of Medicine, Atlanta, GA.
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Kang SC, Hwang SJ, Chang YS, Chou CT, Tsai CY. Characteristics of comorbidities and costs among patients who died from systemic lupus erythematosus in Taiwan. Arch Med Sci 2012; 8:690-6. [PMID: 23056082 PMCID: PMC3460506 DOI: 10.5114/aoms.2012.30293] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Revised: 02/21/2012] [Accepted: 03/11/2012] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Systemic lupus erythematosus (SLE) is prevalent among young female adults, particularly in Asia. In Taiwan, features of end-of-life SLE patients remain unclear. MATERIAL AND METHODS Data regarding SLE patients whose hospitalization ended up with death were collected and analyzed from the repository of the National Health Insurance Research Database, Taiwan, from 2005 to 2007. RESULTS A total of 302 subjects were enrolled and the majority of these were young to middle-aged women (45.8 ±18.5 years); only one third of them were treated by rheumatologists. Eight patients (2.6%) with comorbid cancers received hospice care. Sepsis/bacteremia (42.1%) was the major acute comorbidity. Nephropathy/nephritis (35.1%) represented the major chronic comorbidity. Among 27 subjects with comorbid cancers, gynecological cancers were the most common (18%). Among the inpatient costs, the cost of prescriptions accounted for the majority (21.7 ±11.5%). Under a multivariate logistic regression, advanced age (≥ 65 years) correlated positively with acute lower respiratory conditions (ALRC) and diabetes mellitus (DM), and male gender correlated negatively with nephropathy/nephritis. The nephropathy/nephritis correlated positively with hospital stays > 14 days. The ALRC was closely associated with acute respiratory failure, but not with shock. However, shock was closely associated with hospital stays ≥ 14 days and sepsis/bacteremia. Cancer development was inversely correlated to nephropathy/nephritis, acute respiratory failure, and shock (all p < 0.05). CONCLUSIONS The end-of-life SLE patients revealed aforementioned characteristics and relationships. Sepsis/bacteremia, acute respiratory failure, and ALRC contributed most frequently to the ultimate death of acutely ill SLE patients.
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Affiliation(s)
- Shih-Chao Kang
- Division of Family Medicine, National Yang-Ming University Hospital, Yilan, Taiwan
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Shinn-Jang Hwang
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
- Department of Family Medicine, Taipei Veterans General Hospital, Taiwan
| | - Yu-Sheng Chang
- Division of Allergy, Immunology and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taiwan
| | - Chung-Tei Chou
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
- Division of Allergy, Immunology and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taiwan
| | - Chang-Youh Tsai
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
- Division of Allergy, Immunology and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taiwan
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Pons-Estel GJ, Saurit V, Alarcón GS, Hachuel L, Boggio G, Wojdyla D, Alfaro-Lozano JL, de la Torre IG, Massardo L, Esteva-Spinetti MH, Guibert-Toledano M, Gómez LAR, Costallat LTL, Del Pozo MJS, Silveira LH, Cavalcanti F, Pons-Estel BA. The impact of rural residency on the expression and outcome of systemic lupus erythematosus: data from a multiethnic Latin American cohort. Lupus 2012; 21:1397-404. [PMID: 22941567 DOI: 10.1177/0961203312458465] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The objective of this paper is to examine the role of place of residency in the expression and outcomes of systemic lupus erythematosus (SLE) in a multi-ethnic Latin American cohort. PATIENTS AND METHODS SLE patients (< two years of diagnosis) from 34 centers constitute this cohort. Residency was dichotomized into rural and urban, cut-off: 10,000 inhabitants. Socio-demographic, clinical/laboratory and mortality rates were compared between them using descriptive tests. The influence of place of residency on disease activity at diagnosis and renal disease was examined by multivariable regression analyses. RESULTS Of 1426 patients, 122 (8.6%) were rural residents. Their median ages (onset, diagnosis) were 23.5 and 25.5 years; 85 (69.7%) patients were Mestizos, 28 (22.9%) Caucasians and 9 (7.4%) were African-Latin Americans. Rural residents were more frequently younger at diagnosis, Mestizo and uninsured; they also had fewer years of education and lower socioeconomic status, exhibited hypertension and renal disease more frequently, and had higher levels of disease activity at diagnosis; they used methotrexate, cyclophosphamide pulses and hemodialysis more frequently than urban patients. Disease activity over time, renal damage, overall damage and the proportion of deceased patients were comparable in rural and urban patients. In multivariable analyses, rural residency was associated with high levels of disease activity at diagnosis (OR 1.65, 95% CI 1.06-2.57) and renal disease occurrence (OR 1.77, 95% CI 1.00-3.11). CONCLUSIONS Rural residency associates with Mestizo ethnicity, lower socioeconomic status and renal disease occurrence. It also plays a role in disease activity at diagnosis and kidney involvement but not on the other end-points examined.
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Affiliation(s)
- G J Pons-Estel
- Department of Autoimmune Diseases, Institut Clínic de Medicina i Dermatologia, Hospital Clínic, Spain.
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Lawson EF, Yazdany J. Healthcare quality in systemic lupus erythematosus: using Donabedian's conceptual framework to understand what we know. ACTA ACUST UNITED AC 2012; 7:95-107. [PMID: 22448191 DOI: 10.2217/ijr.11.65] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Healthcare quality improvement has the potential to reduce the striking disparities in health outcomes among patients with systemic lupus erythematosus (SLE). Donabedian's framework for assessment of healthcare quality, which divides factors impacting quality into structures, processes and outcomes, provides a theoretical framework for research and interventions in quality improvement. This review applies Donabedian's model to current research describing quality of care in SLE, highlighting structures and processes that may lead to improved outcomes. Work remains to be done to develop meaningful metrics to assess quality and to understand the structures and processes that improve outcomes. Quality indicators have emerged as an important tool to measure quality, but further validation is required to define their validity and feasibility in clinical practice, as well as their association with improved outcomes. Implementation science also shows promise as a means to create meaningful systematic improvements in healthcare quality for patients with SLE.
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Affiliation(s)
- Erica F Lawson
- University of California, San Francisco, Department of Pediatrics, Division of Rheumatology, 3333 California Street, Box 0920, San Francisco, CA 94143, USA
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Chen Y, Chen GL, Zhu CQ, Lu X, Ye S, Yang CD. Severe systemic lupus erythematosus in emergency department: a retrospective single-center study from China. Clin Rheumatol 2011; 30:1463-9. [DOI: 10.1007/s10067-011-1826-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Revised: 07/23/2011] [Accepted: 07/28/2011] [Indexed: 12/12/2022]
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Tonner C, Trupin L, Yazdany J, Criswell L, Katz P, Yelin E. Role of community and individual characteristics in physician visits for persons with systemic lupus erythematosus. Arthritis Care Res (Hoboken) 2010; 62:888-95. [PMID: 20535800 DOI: 10.1002/acr.20125] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To examine the effects of individual and local level socioeconomic status (SES) and health care access characteristics on the number of self-report physician visits for systemic lupus erythematosus (SLE). METHODS Data derived from 755 adult participants from the 2004 to 2007 Lupus Outcomes Study (LOS) resulted in a sample of 2,926 repeated-measures observations. The outcome measure was the number of physician visits in the prior 12 months. Information on disease activity and manifestations, demographics, health insurance, and specialty of the participants' main SLE physician was collected through yearly LOS interviews. Local area measures including neighborhood poverty, the number of subspecialists per capita, and hospital market areas were added from secondary data sources. We used a mixed model with repeated measures to estimate the number of physician visits for SLE by SES and health care access characteristics, as well as the extent of concentrated poverty and number of subspecialists per capita in the local community, and whether these relationships varied by specific hospital market area. Multivariate models were adjusted for demographic and health status covariates. RESULTS LOS respondents reported a mean +/- SD of 11.8 +/- 10.7 (range 0-52) physician visits for SLE. After adjustment, having less than a high school education, receiving care in a health maintenance organization, being treated by a generalist, and living in a community of concentrated poverty were associated with a significantly lower number of physician visits for SLE. These relationships varied by hospital market areas. CONCLUSION Beyond health status, the number of physician visits for SLE varies by SES, neighborhood poverty, and characteristics of the health care system.
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Affiliation(s)
- Chris Tonner
- University of California, San Francisco, CA 94143, USA.
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Panopalis P, Gillis JZ, Yazdany J, Trupin L, Hersh A, Julian L, Criswell LA, Katz P, Yelin E. Frequent use of the emergency department among persons with systemic lupus erythematosus. Arthritis Care Res (Hoboken) 2010; 62:401-8. [PMID: 20391487 DOI: 10.1002/acr.20107] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To describe characteristics of systemic lupus erythematosus (SLE) patients who are frequent users of the emergency department and to identify predictors of frequent emergency department use. METHODS Data for this study were derived from the University of California, San Francisco Lupus Outcomes Study, a large cohort of persons with SLE who undergo annual structured interviews. Participants were categorized into 1 of 3 levels of emergency department utilization: nonusers (no visits in the preceding year), occasional users, (1-2 visits), and frequent users (> or =3 visits). We compared characteristics of the 3 groups and determined predictors of frequent emergency department use (> or =3 visits) using multivariate logistic regression, adjusting for a variety of potential confounding covariates. RESULTS Of 807 study participants, 499 (62%) had no emergency department visits; 230 (28%) had occasional emergency department visits (1-2 visits); and 78 (10%) had frequent (> or =3 visits) emergency department visits. Frequent users were younger, less likely to be employed, and less likely to have completed college. They also had greater disease activity, worse general health status, and more depressive symptoms. Frequent emergency department users were more likely to have Medicaid as their principal insurance. In multivariate logistic regression, older age predicted a lower likelihood of frequent emergency department visits, whereas greater disease activity and having Medicaid insurance predicted a higher likelihood of frequent emergency department visits. CONCLUSION In persons with SLE, greater disease activity and Medicaid insurance are associated with more frequent emergency department use.
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Affiliation(s)
- Pantelis Panopalis
- Rosalind Russell Medical Research Center for Arthritis, University of California, San Francisco, CA 94143-0920, USA.
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Abstract
PURPOSE OF REVIEW Systemic lupus erythematosus (SLE), an inflammatory rheumatic disease characterized by autoantibody production and diverse clinical manifestations, disproportionately affects vulnerable groups: women, racial and ethnic minorities, the poor and those lacking medical insurance and education. We summarize the current knowledge of the disparities observed in SLE and highlight recent research that aims to dissect the causes of these disparities and identify the potentially modifiable factors contributing to them. RECENT FINDINGS Several remediable causes, including lack of education, self-efficacy and access to quality, experienced healthcare have been found to contribute to observed disparities in SLE prevalence and outcomes. SUMMARY SLE is associated with alarming disparities in incidence, severity and outcomes. The causes of these disparities are under study by several research groups. Identifying potentially correctable contributory factors should allow the development of effective strategies to improve the healthcare delivery and outcomes in all SLE patients.
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Losina E, Katz JN. Ambulatory care–sensitive hospitalizations: Does one size fit all? ACTA ACUST UNITED AC 2008; 59:159-61. [DOI: 10.1002/art.23351] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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