Increased utilization of emergency department and inpatient care by patients with hidradenitis suppurativa

Development and Validation of a META-Algorithm to Identify the Indications of Use of Biological Drugs Approved for the Treatment of Immune-Mediated Inflammatory Diseases from Claims Databases: Insights from the VALORE Project

Purpose

This research aimed to develop and validate a META-algorithm combining individual immune-mediated inflammatory disease (IMID)-specific algorithms to identify the exact IMID indications for incident biological drug users from claims data within the context of the Italian VALORE project.

Methods and Patients

All subjects with at least one dispensing of TNF-alpha inhibitors, anti-interleukin agents, and selective immunosuppressants approved for IMIDs were identified from claims databases of Latium region in Italy (observation period: 2010-2020). Validated coding algorithms for identifying individual IMIDs from claims databases were found from published literature and combined into a META-algorithm. Positive predictive value (PPV), sensitivity (Se), negative predictive value (NPV), specificity (Sp), and accuracy (Acc) were estimated for each indication against the electronic therapeutic plans (ETPs) of the Latium region as the reference standard. Lastly, the frequency of the indication of use across individual biologic drugs was compared with that reported in three other Italian regions (Lombardy, Apulia, and the Veneto region).

Results

In total, 9755 incident biological drug users with a single IMID indication were identified. Using the newly developed META-algorithm, an indication of use was detected in 95% (n=9255) of the total cohort. The estimated Acc, Se, Sp, PPV, and NPV, against the reference standard were as follows: 0.96, 0.86, 0.97, 0.82, and 0.98 for Crohn's disease, 0.96, 0.80, 0.98, 0.85, and 0.97 for ulcerative colitis, 0.93, 0.76, 0.99, 0.95, and 0.92 for rheumatoid arthritis, 0.97, 0.75, 0.99, 0.85, and 0.98 for spondylarthritis, and 0.91, 0.92, 0.91, 0.88, and 0.94 for psoriatic arthritis/psoriasis, respectively. Additionally, no substantial difference was observed in the frequency of indication of use by active ingredient among Latium and the other three Italian regions included in the study.

Conclusion

The newly developed META-algorithm demonstrated high validity estimates in the Italian claims data and was capable of discriminating with good performance among the most frequent IMID indications.

Management of Pilonidal Disease and Hidradenitis Suppurativa

Pilonidal disease and hidradenitis suppurativa affect healthy young adults, causing discomfort and pain that leads to loss of work productivity and should be approached in a personalized manner. Patients with pilonidal disease should engage in hair removal to the sacrococcygeal region and surgical options considered. Hidradenitis suppurativa can be a morbid and challenging disease process. Medical management with topical agents, antibiotics, and biologics should be used initially but wide local excision should be considered in severe or refractory cases of the disease.

Psychiatric Influences on Hidradenitis Suppurativa: A Call for Help

Background  Hidradenitis suppurativa (HS) is associated with a high prevalence of psychiatric disorders. However, no studies examine how psychiatric disorders influence surgical and financial outcomes. This study aimed to assess impact of a psychiatric diagnosis on patients treated for HS. Methods  Patients with HS were retrospectively identified at a single institution from 2010 to 2021. Cohorts were stratified by the presence of a psychiatric disorder. Demographics, comorbidities, and disease characteristics were collected. Outcomes assessed included the procedural interventions and emergency department (ED) visits. Financial distress was assessed via the COST-FACIT Version 2 survey. Results  Out of 138 patients, 40 (29.0%) completed the survey of which 19 (47.5%) had a preexisting psychiatric diagnosis. No demographic differences were found between cohorts. Mean follow-up was 16.1 ± 11.0 months. The psychiatric cohort had a higher median number of surgeries received (7.0 vs. 1.5, p  < 0.001), a higher median number of ED visits (1.0 vs. 0, p  = 0.006), and a similar hospital length of stay ( p  = 0.456). The mean COST-FACIT score of the overall study population was 19.2 ± 10.7 (grade 1 financial toxicity). The psych cohort had a lower mean COST-FACIT score (16.8 vs. 21.3, p  = 0.092) and reported greater financial hardship (3.3 vs. 1.7, p  < 0.001). On multivariate analysis, a psychiatric diagnosis was predictive of lower credit scores, more ED visits, and a higher number of surgeries. Conclusion  Preexisting psychiatric conditions in patients with HS are associated with increased health care utilization and surgical intervention with substantial financial distress. Plastic surgeons should be cognizant of such comorbid disorders to facilitate holistic care addressing all patient needs.

Inborn Errors of Immunity in Hidradenitis Suppurativa Pathogenesis and Disease Burden

Hidradenitis suppurativa (HS), also known as Verneuil's disease and acne inversa, is a prevalent, debilitating, and understudied inflammatory skin disease. It is marked by repeated bouts of pathological inflammation causing pain, hyperplasia, aberrant healing, and fibrosis. HS is difficult to manage and has many unmet medical needs. There is clinical and pharmacological evidence for extensive etiological heterogeneity with HS, suggesting that this clinical diagnosis is capturing a spectrum of disease entities. Human genetic studies provide robust insight into disease pathogenesis. They also can be used to resolve etiological heterogeneity and to identify drug targets. However, HS has not been extensively investigated with well-powered genetic studies. Here, we review what is known about its genetic architecture. We identify overlap in molecular, cellular, and clinical features between HS and inborn errors of immunity (IEI). This evidence indicates that HS may be an underrecognized component of IEI and suggests that undiagnosed IEI are present in HS cohorts. Inborn errors of immunity represent a salient opportunity for rapidly resolving the immunological landscape of HS pathogenesis, for prioritizing drug repurposing studies, and for improving the clinical management of HS.

Patient Perspectives of Health System Barriers to Accessing Care for Hidradenitis Suppurativa: A Qualitative Study

Importance

Patient-perceived barriers to hidradenitis suppurativa (HS) care are poorly understood. Understanding health care barriers is a critical first step toward improving care for this population.

Objective

To characterize the health care experiences of people living with HS, including perceived barriers and facilitators to health care access, and to elucidate potential associations among these barriers and facilitators, health care access, and disease activity.

Design, Setting, and Participants

In this qualitative study, an inductive thematic analysis was conducted on 45 in-depth, 60- to 90-minute semistructured interviews of 45 people with HS from diverse sociodemographic backgrounds that took place between March and April 2020. Individuals were eligible if they could speak English, were 18 years or older, and were diagnosed with HS. A diagnosis of HS was confirmed through physician diagnosis or through self-reported, affirmative response to the validated screening question, "Do you experience boils in your armpits or groin that recur at least every six months?"

Main Outcomes and Measures

Interviews were audio recorded and transcribed verbatim. A modified grounded theory approach was used to develop the codebook, which investigators used for inductive thematic analysis.

Results

Among the 45 participants included, the median (IQR) age was 37 (16) years, 33 (73%) were female, and 22 (49%) were White. There were 6 interrelated themes associated with participant-perceived barriers to accessing HS care: (1) bidirectional associations of disease activity and employment, (2) association of employment with health care coverage, (3) association of health care coverage with costs and perceived access to care, (4) association of costs with access to patient-centered care, (5) health care professional attitudes and knowledge influence patient-centered care and perceived access to care and disease activity, and (6) health system characteristics influence patient-centered care and associated costs, perceived access to care, and disease activity.

Conclusions and Relevance

This qualitative study highlights themes that generate a conceptual model for understanding barriers that may act synergistically to limit health care access and influence disease activity. The disease activity of HS may be reduced when cycle elements are optimized. This study also highlights areas for future investigations and potential systems-level changes to improve access to patient-centered HS care.

A Practical Guide for Primary Care Providers on Timely Diagnosis and Comprehensive Care Strategies for Hidradenitis Suppurativa

Hidradenitis suppurativa is a chronic, progressive inflammatory disease of the skin with many systemic implications. Hidradenitis suppurativa is frequently underdiagnosed or misdiagnosed, particularly because of heterogeneity in presentation and low disease recognition. Patients can see multiple types of health care providers, including primary care providers, along their journey to an accurate diagnosis. This review provides a comprehensive overview of the clinical presentation, associated comorbidities, and life impact associated with hidradenitis suppurativa. Disease features described here can facilitate earlier identification of hidradenitis suppurativa, differentiation from common mimickers, and timely referrals for multidisciplinary management when needed. Engagement of the medical community will also support comprehensive care strategies necessary in hidradenitis suppurativa.

Factors associated with treatment satisfaction in patients with hidradenitis suppurativa: results from the Global VOICE project

BACKGROUND

Nearly half of patients with hidradenitis suppurativa (HS) report dissatisfaction with their treatment. However, factors related to treatment satisfaction have not been explored.

OBJECTIVES

To measure associations between treatment satisfaction and clinical and treatment-related characteristics among patients with HS.

METHODS

Treatment satisfaction was evaluated utilizing data from a cross-sectional global survey of patients with HS recruited from 27 institutions, mainly HS referral centres, in 14 different countries from October 2017 to July 2018. The primary outcome was patients' self-reported overall satisfaction with their current treatments for HS, rated on a five-point scale from 'very dissatisfied' to 'very satisfied'.

RESULTS

The final analysis cohort comprised 1418 patients with HS, most of whom were European (55%, 780 of 1418) or North American (38%, 542 of 1418), and female (85%, 1210 of 1418). Overall, 45% (640 of 1418) of participants were either dissatisfied or very dissatisfied with their current medical treatment. In adjusted analysis, patients primarily treated by a dermatologist for HS had 1·99 [95% confidence interval (CI) 1·62-2·44, P < 0·001] times the odds of being satisfied with current treatment than participants not primarily treated by a dermatologist. Treatment with biologics was associated with higher satisfaction [odds ratio (OR) 2·36, 95% CI 1·74-3·19, P < 0·001] relative to treatment with nonbiologic systemic medications. Factors associated with lower treatment satisfaction included smoking (OR 0·78, 95% CI 0·62-0·99; active vs. never), depression (OR 0·69, 95% CI 0·54-0·87), increasing number of comorbidities (OR 0·88 per comorbidity, 95% CI 0·81-0·96) and increasing flare frequency.

CONCLUSIONS

There are several factors that appear to positively influence satisfaction with treatment among patients with HS, including treatment by a dermatologist and treatment with a biologic medication. Factors that appear to lower treatment satisfaction include active smoking, depression, accumulation of comorbid conditions and increasing flare frequency. Awareness of these factors may support partnered decision making with the goal of improving treatment outcomes. What is already known about this topic? Nearly half of patients with hidradenitis suppurativa report dissatisfaction with their treatments. What does this study add? Satisfaction with treatment is increased by receiving care from a dermatologist and treatment with biologics. Satisfaction with treatment is decreased by tobacco smoking, accumulation of comorbid conditions including depression, and higher flare frequency. What are the clinical implications of this work? Awareness of the identified factors associated with poor treatment satisfaction may support partnered decision making and improve treatment outcomes.

Racial disparities of delay in diagnosis and dermatologic care for hidradenitis suppurativa

Hidradenitis suppurativa is a chronic, debilitating skin disease that disproportionately affects African Americans, and care-related factors may contribute to this disparity. In this study, we investigated delay in diagnosis and dermatologic care for HS at an urban Midwestern Academic Center. A retrospective chart review of 1,190 patients with 3 or more encounters for HS between 1/1/2002 and 3/19/2019 was conducted. A total of 953 patients were included in statistical analysis. A mean (standard deviation) delay in diagnosis was 4.1 ± 7.0 years. For white patients the delay in diagnosis was 3.2 ± 6.3 years, for Black patients 4.8 ± 7.0 years, for Hispanic patients 4.7 ± 5.8 years, and for other races 4.9 ± 7.4 years (p <0.001). Among the 932 patients with known specialist visit types, 500 (53.6%) had seen dermatology including 222 (47.8%) of Black patients, 242 (59.5%) of white patients, 24 (64.9%) of Hispanic patients, and 12 (50%) patients of other races (p=0.003).White patients and Hispanic patients saw a dermatologist an average of 3.0 years after first presentation of HS and Black patients saw a dermatologist on average 5.0 years after first presentation (p=0.004). Of the patients who did see dermatology, 44.9% of Black patients, 31.6% of white patients, 23.1% of Hispanic patients, and 30.8% of other races saw surgery before dermatology (p<.001). Our results indicate that non-white patients have a longer delay in diagnosis than their white counterparts and that Black patients do not see dermatology as early in their disease course as other racial groups. Black patients also see surgery more often than white patients before seeing dermatology, which could suggest greater disease severity at presentation and diagnosis or difficult access to dermatology.

Factors Associated With Dermatologic Follow-up vs Emergency Department Return in Patients With Hidradenitis Suppurativa After an Initial Emergency Department Visit

Importance

Emergency department (ED) visitation is common for the treatment of hidradenitis suppurativa (HS), whereas dermatology outpatient care is low. The reasons underlying this differential follow-up have not been elucidated.

Objective

To assess the interventions and patient factors associated with ED return following an initial ED visit for HS.

Design, Setting, and Participants

This retrospective cohort study used data from the IBM® MarketScan® Commercial and Multi-State Medicaid databases (trademark symbols retained per database owner requirement). An HS cohort was formed from patients who had 2 or more claims for HS during the study period of 2010 to 2019 and with at least 1 ED visit for their HS or a defined proxy. Data were analyzed from November 2021 to May 2022.

Exposures

Factors analyzed included those associated with the ED visit and patient characteristics.

Main Outcomes and Measures

Primary outcomes were return to the ED or dermatology outpatient follow-up for HS or related proxy within 30 or 180 days of index ED visit.

Results

This retrospective cohort study included 20 269 patients with HS (median [IQR] age, 32 [25-41] years; 16 804 [82.9%] female patients), of which 7455 (36.8%) had commercial insurance and 12 814 (63.2%) had Medicaid. A total of 9737 (48.0%) patients had incision and drainage performed at the index ED visit, 14 725 (72.6%) received an oral antibiotic prescription, and 9913 (48.9%) received an opioid medication prescription. A total of 3484 (17.2%) patients had at least 1 return ED visit for HS or proxy within 30 days, in contrast with 483 (2.4%) who had a dermatology visit (P < .001). Likewise, 6893 (34.0%) patients had a return ED visit for HS or proxy within 180 days, as opposed to 1374 (6.8%) with a dermatology visit (P < .001). Patients with Medicaid and patients who had an opioid prescribed were more likely to return to the ED for treatment of their disease (odds ratio [OR], 1.48; 95% CI, 1.38-1.58; and OR, 1.48; 95% CI, 1.39-1.58, respectively, within 180 days) and, conversely, less likely to have dermatology follow-up (OR, 0.16; 95% CI, 0.14-0.18; and OR, 0.81; 95% CI, 0.71-0.91, respectively, within 180 days).

Conclusions and Relevance

This cohort study suggests that many patients with HS frequent the ED for their disease but are not subsequently seen in the dermatology clinic for ongoing care. The findings in this study raise the opportunity for cross-specialty interventions that could be implemented to better connect patients with HS to longitudinal care.

Phenotype Algorithms to Identify Hidradenitis Suppurativa Using Real-World Data: Development and Validation Study

BACKGROUND

Hidradenitis suppurativa (HS) is a potentially debilitating, chronic, recurring inflammatory disease. Observational databases provide opportunities to study the epidemiology of HS.

OBJECTIVE

This study's objective was to develop phenotype algorithms for HS suitable for epidemiological studies based on a network of observational databases.

METHODS

A data-driven approach was used to develop 4 HS algorithms. A literature search identified prior HS algorithms. Standardized databases from the Observational Medical Outcomes Partnership (n=9) were used to develop 2 incident and 2 prevalent HS phenotype algorithms. Two open-source diagnostic tools, CohortDiagnostics and PheValuator, were used to evaluate and generate phenotype performance metric estimates, including sensitivity, specificity, positive predictive value (PPV), and negative predictive value.

RESULTS

We developed 2 prevalent and 2 incident HS algorithms. Validation showed that PPV estimates were highest (mean 86%) for the prevalent HS algorithm requiring at least two HS diagnosis codes. Sensitivity estimates were highest (mean 58%) for the prevalent HS algorithm requiring at least one HS code.

CONCLUSIONS

This study illustrates the evaluation process and provides performance metrics for 2 incident and 2 prevalent HS algorithms across 9 observational databases. The use of a rigorous data-driven approach applied to a large number of databases provides confidence that the HS algorithms can correctly identify HS subjects.

The road to biologics in patients with hidradenitis suppurativa: a nationwide drug utilization study

BACKGROUND

Prolonged systemic antibiotic treatment is often a part of management of hidradenitis suppurativa (HS). Although biologic therapies are now available, the patient's treatment journey leading to biologic therapy is unclear.

OBJECTIVES

To examine treatment patterns and duration of systemic treatment use in patients with HS preceding biologic therapy.

METHODS

We identified all patients with HS receiving treatment with biologics in the Danish National Patient Registry from 2010 to 2018 and extracted their entire prescription history of specific systemic treatments from the Danish National Prescription Registry since its inception in 1995. The patients' treatment journeys are graphically displayed through Sankey diagrams and box plots generated to show temporal distributions. Descriptive patient characteristics were presented as frequencies with percentages for categorical variables and as means with SDs or medians with interquartile ranges (IQRs) for continuous variables.

RESULTS

A total of 225 patients with HS were included. Patients had most frequently been treated with penicillin (n = 214; 95·1%), dicloxacillin (n = 194; 86·2%), tetracycline (n = 145; 64·4%) and rifampicin/clindamycin (n = 111; 49·3%), as well as the retinoids isotretinoin and acitretin, and dapsone. Prior to biologic therapy, patients received a mean of 4·0 (SD 1·3) different systemic therapies, across a mean of 16·9 (SD 11·3) different treatment series. The mean time from first systemic therapy until biologic therapy was initiated was 15·3 (SD 5·1) years [8·2 (SD 5·9) years when excluding penicillin and dicloxacillin].

CONCLUSIONS

Patients with HS who receive biologic therapy have long preceding treatment histories with multiple drug classes and treatment series, many of which are supported by relatively weak evidence in HS. Delay in the initiation of biologic therapy may represent a missed opportunity to prevent disease progression. What is already known about this topic? The treatment journey leading to biologic therapy in patients with HS has not previously been investigated. What does this study add? Our data from 225 patients with HS illustrate that patients who receive biologic therapy have long preceding treatment histories with multiple drug classes and treatment series, many of which are supported by relatively weak evidence in HS.

Hidradenitis-suppurativa-bedingte Kosten, ein Plädoyer für Aufmerksamkeit: eine systematische Literaturübersicht

Die Daten zu Hidradenitis suppurativa (HS)-bedingten Kosten sind begrenzt und inhomogen. Sie sind jedoch erheblich. Wir führten eine systematische Sichtung der Literaturberichte durch, in denen finanzielle Daten über jeden Gesundheitsbereich oder andere Ausgaben dokumentiert wurden, die durch HS und/oder HS-bedingte Auswirkungen auf Beschäftigung, Einkommen und persönliches wirtschaftliche Entwicklung entstanden sind (indirekte Kosten). Dafür wurden drei elektronische Datenbanken durchsucht (MEDLINE, ScienceDirect und die Cochrane Library -letzte Suche: 14. September 2021). Alle Kosten wurden inflationsbereinigt (2022) und in US-Dollar umgerechnet. Es wurden 23 Artikel eingeschlossen (18 Krankheitskostenstudien, 4 Beobachtungsstudien und 1 Fallserie), in denen ökonomische Daten von 77.287 HS-Patienten erfasst wurden. Die durch HS entstandenen durchschnittlichen jährlichen Kosten pro Patient reichten von 258 $ bis 8.078 $. Diese Zahl erhöhte sich bei chirurgischen Eingriffen, Krankheitsprogression, Antibiotika-Versagen und bestimmten Begleitkrankheiten. Der kostspieligste Faktor war die stationäre Versorgung, gefolgt von ambulanter und Notfallversorgung. Signifikante Unterschiede wurden zwischen den USA und den übrigen untersuchten Ländern beobachtet. Im Vergleich zu Psoriasis-Patienten waren Krankenhausaufenthalte bei HS wahrscheinlicher, länger und kostspieliger, während die weniger kostspielige ambulante Versorgung bei HS-Patienten verringert war. Das Vermeiden der Krankheitsprogression durch frühzeitige Diagnose und Optimierung der ambulanten dermatologischen Versorgung könnte HS-bedinge Ausgaben reduzieren.

Hidradenitis suppurativa-related expenditure, a call for awareness: systematic review of literature

Data regarding hidradenitis suppurativa (HS)-related expenditure is limited and non-homogeneous, but HS does incur significant expenses. We performed a systematic review of literature reports documenting financial data regarding any healthcare domain or other expenditure incurred by HS and/or HS impact on work, income and personal economic growth (indirect costs). Three electronic databases were searched (MEDLINE, ScienceDirect, and the Cochrane Library - last search date: September 14^th , 2021). All costs were adjusted for inflation (2022) and converted into US dollars. Twenty-three papers were included (18 cost-of-illness studies, 4 observational studies and 1 case series), drawing economic data from 77,287 HS patients. The total mean cost incurred by HS per patient per year ranged from $ 258 to $ 8,078. This number increased in case of surgical intervention, disease progression, antibiotic failure and certain comorbid diseases. The costliest healthcare sector was inpatient care, followed by outpatient and emergency care. Significant differences were observed between the USA and the rest of studied countries. Hospitalization was likelier, lengthier, and costlier for HS compared to psoriasis patients, whereas the less costly outpatient care appeared to be reduced among HS patients. Preventing disease progression by optimizing early diagnosis and dermatology outpatient care could decrease HS-related expenditure.

Atopic dermatitis is associated with hidradenitis suppurativa diagnosis: A single institution retrospective cohort study

Background

Hidradenitis suppurativa (HS) and atopic dermatitis (AD) are both chronic inflammatory skin diseases. An association between these 2 conditions can have important potential implications for elucidating pathogenesis, disease course, and treatment.

Objective

To investigate the association between AD and HS.

Methods

We performed a retrospective cohort study of patients seen at Duke University Medical Center from 2007 to 2017 who had AD compared with a control group without an AD diagnosis. The association of AD and HS was evaluated using a logistic regression model after adjusting for other confounders including age, sex, and race.

Results

Of 28,780 patients with an AD diagnosis, 325 (1.1%) were diagnosed with HS compared with 76 (0.2%) within the 48,383 patients in the non-AD group. An adjusted logistic regression model demonstrated an increased odds ratio of having HS diagnosis in the AD group as compared with the control non-AD group (odds ratio: 5.57, 95% confidence interval: 4.30-7.21, P < .001).

Limitations

This was a retrospective study performed at a single institution with the possibility of surveillance bias being present.

Conclusions

Patients with AD are more likely to be diagnosed with HS than patients without AD. Further research is needed to understand the pathophysiologic mechanism and potential treatment implications.

Differences Between Children and Adults With Hidradenitis Suppurativa

Importance

Up to 50% of patients may have hidradenitis suppurativa (HS) onset between age 10 and 21 years. To our knowledge, little is known about how adolescents with HS utilize health care during their journey to receiving a diagnosis.

Objective

To assess the clinical characteristics and health care utilization patterns of pediatric vs adult patients with HS.

Design, Setting, and Participants

This retrospective cohort study included adult and pediatric patients with HS claims from the MarketScan medical claims database during the study period, January 1, 2012, to December 31, 2016. The data were analyzed between March 1 and March 31, 2021.

Exposures

Clinical characteristics and health care utilization patterns of pediatric vs adult patients with HS.

Main Outcomes and Measures

Health care utilization patterns were examined and included concurrent diagnoses, outpatient care by discipline, and emergency/urgent care and inpatient claims.

Results

This study included 8727 members, comprising 1094 pediatric (155 male [14.2%] and 939 female patients [85.8%]; mean [SD] age, 14.3 [2.47] years) and 7633 adult patients (1748 men [22.9%] and 5885 women [77.1%]; mean [SD] age, 37.2 [12.99] years). Pediatric patients were likely to see pediatricians, dermatologists, emergency department (ED) staff, and family physicians before diagnosis and commonly received diagnoses of folliculitis and comedones. Pediatric patients with HS had high rates of comorbid skin and general medical conditions, including acne vulgaris (558 [51.0%]), acne conglobata (503 [45.9%]), obesity (369 [33.7%]), and anxiety disorders (367 [33.6%]). A higher percentage of pediatric than adult patients had HS-specific claims for services rendered by emergency and urgent care physicians (35.6% vs 28.2%; P < .001; and 18.1% vs 13.4%; P < .001; respectively). However, adult patients were more likely to have inpatient stays (2.38% vs 4.22%; P = .002). Pediatric patients had 2.24 ED claims per person, while adults had 3.5 claims per person. The mean cost per ED claim was similar between groups ($413.27 vs $682.54; P = .18). The largest component of the total 5-year disease-specific cost was the cost of inpatient visits for pediatric and adult patients with HS.

Conclusions and Relevance

This cohort study suggests that pediatric patients utilize high-cost ED care when HS can often be treated as an outpatient. These data suggest that there are opportunities to improve recognition of HS in pediatric patients by nondermatologists and dermatologists.

Economic analysis of the costs associated with Hidradenitis suppurativa at a German University Hospital

Background and objectives

Hidradenitis suppurativa (HS) significantly affects the patient`s quality of life and leads to multiple medical consultations. Aim of this study was to assess the utilization of medical care of HS patients.

Patients and methods

All patients presenting in 2017 for an outpatient, day patient and / or inpatient treatment with leading claim type HS at the Department of Dermatology, University Hospital Würzburg, were included. Primary outcome was the economic burden of HS patients, measured by resource utilization in €.

Results

The largest share of the direct medical costs for HS were the inpatient costs with a leading surgical diagnosis-related group (DRG). Antiseptics were the predominant topical prescription. While doxycycline was the most frequently prescribed systemic therapy, adalimumab was the main cost driver. The difference between in-patient (€ 110.25) and outpatient (€ 26.34) direct non-medical costs was statistically significant (p < 0.001). With regards to indirect medical costs, a statistically significantly higher loss of gross value added (inpatient mean € 1,827.00; outpatient mean € 203.00) and loss of production (inpatient mean € 1,026.00; outpatient mean € 228.00) could be noted (p < 0.001), respectively.

Conclusions

The present study on disease-specific costs of HS confirms that the hospital care of patients with this disease is cost-intensive. However, the primary goal of physicians is not and should not be to save costs regarding their patients`treatment, but rather the premise to utilize the existing resources as efficient as possible. Reducing the use of costly therapeutics and inpatient stays therefore requires more effective therapy options with an improved cost-benefit profile.

Hidradenitis Suppurativa From a Patient Perspective Including Symptoms and Self-Treatment

INTRODUCTION

Hidradenitis Suppurativa (HS) is a chronic inflammatory disordercommonly affecting body folds. It can significantly impair quality of life due to the physical, psychological, and socialturmoil experienced by patients. Treatment remains a challenge.Limited data on the HS patient experience, such as self-treatment exists.

METHODS

This was a single-center cross-sectional study, utilizing a paper-based survey. Surveys were mailed out to all HS patients from the dermatology clinic and completed on a voluntary basis. Demographics, disease characteristics, medical and family history, treatments tried, and life quality were documented.

RESULTS

The response rate was 49.4% (41/83), with a female predominance (26/41). Eighty-five percent (35/41) were Caucasian with an average age and BMI of 39.0 ± 16.78 and 30.71 ± 7.02, respectively. In total, 24.4% (10/41), 56.0% (23/41), and 19.5% (8/41) had Hurley I, II, and III, respectively. Lesions affected the genital region (75.6%), thigh/groin (68.2%), and axilla (46.3). Almost half (49%) of patients experienced an average of 1-2 flares per month. The most bothersome symptoms were pain (92.7%), discharge (68.3%), malodor (63.4%), and itch (61%). Depression (53.7%), severe facial acne (14.6%), and hypertension (14.6%) were the most common co-morbidities. Treatments used included antibiotics (82.9%) and surgical excision (34.2%) were. Over 90% of patients reportedself-treatment of lesions by squeezing (80.5%), soaking (53.7%), and lancing (41.4%).

CONCLUSIONS

This study provides insight into the patient perspective of HS. We identify itch as a symptom that is not frequently associated with HS and reveal how commonly patients utilize various types of self-treatment in their experience of disease.

Yin and Yang: A disrupted skin microbiome and an aberrant host immune response in hidradenitis suppurativa

The skin microbiome plays an important role in maintaining skin homeostasis by controlling inflammation, providing immune education and maintaining host defense. However, in many inflammatory skin disorders the skin microbiome is disrupted. This dysbiotic community may contribute to disease initiation or exacerbation through the induction of aberrant immune responses in the absence of infection. Hidradenitis suppurativa (HS) is a complex, multifaceted disease involving the skin, innate and adaptive immunity, microbiota and environmental stimuli. Herein, we discuss the current state of HS skin microbiome research and how microbiome components may activate pattern recognition receptor (PRR) pathways, metabolite sensing pathways and antigenic receptors to drive antimicrobial peptide, cytokine, miRNA and adaptive immune cell responses in HS. We highlight the major open questions that remain to be addressed and how antibiotic therapies for HS likely influence both microbial burden and inflammation. Ultimately, we hypothesize that the two-way communication between the skin microbiome and host immune response in HS skin generates a chronic positive feed-forward loop that perpetuates chronic inflammation, tissue destruction and disease exacerbation.

Delayed Diagnosis of Hidradenitis Suppurativa and Its Effect on Patients and Healthcare System

BACKGROUND

Hidradenitis suppurativa (HS) is a neglected chronic inflammatory disease with long delay in diagnosis. Besides pain, purulent discharge, and destruction of skin architecture, HS patients experience metabolic, musculoskeletal, and psychological disorders.

OBJECTIVES

To determine the delay in HS diagnosis and its consequences for patients and the healthcare system.

METHODS

This was a prospective, multicenter, epidemiologic, non-interventional cross-sectional trial carried out in Germany and based on self-reported questionnaires and medical examinations performed by dermatologists. In total, data of 394 adult HS patients were evaluated.

RESULTS

The average duration from manifestation of first symptoms until HS diagnosis was 10.0 ± 9.6 (mean ± SD) years. During this time, HS patients consulted on average more than 3 different physicians - most frequently general practitioners, dermatologists, surgeons, gynecologists - and faced more than 3 misdiagnoses. Diagnosis delay was longer in younger and non-smoking patients. In most cases, HS was correctly diagnosed by dermatologists. The longer the delay of diagnosis, the greater the disease severity at diagnosis. Delayed HS diagnosis was also associated with an increased number of surgically treated sites, concomitant diseases, and days of work missed.

CONCLUSION

This study demonstrates an enormous delay in the diagnosis of HS, which results in more severe disease. It also shows for the first time that a delay in diagnosis of a chronic inflammatory disease leads to a higher number of concomitant systemic disorders. In addition to the impaired health status, delayed diagnosis of HS was associated with impairment of the professional life of affected people.

Clinical Characteristics of Hidradenitis Suppurativa Patients from a Reference Centre in Kaunas, Lithuania

INTRODUCTION

Clinical data on hidradenitis suppurativa (HS) derived mainly from studies in Western Europe and the USA, raising the risk of potential selection bias. According to the official data, during 2006-2015 the incidence of HS in Lithuania was 23.5 cases per 100,000 population with a female-to-male ratio of 2:1. A more fine-grained data set would however be of great relevance to further understanding this disease. Collection of standardized data enables the comparison of populations of patients across samples.

OBJECTIVES

To present a cohort of HS patients with uniformly collected data according to European Hidradenitis Suppurativa Foundation/European Reference Network-Skin recommendations.

METHODS

The demographic and clinical data of a total of 37 HS patients, included over a 3-year period (from 2016 to January 2019) in a local database of the reference centre of Rare Skin Diseases in the Hospital of the Lithuanian University of Health Sciences Kauno Klinikos, were analysed. Non-parametric tests such as χ2 and Mann-Whitney were used for assessing interdependence between qualitative data. Logistic regression analysis was performed to find out the factors statistically related with significant diagnostic delay.

RESULTS

The mean duration of diagnosis delay was 5.5 (±5.9) years in females and 6.6 (±8.2) years in males. A significant delay (>2 years) was reported in 29/37 (78.4%) cases and was not related with sex, age at HS diagnosis or disease severity. The groin area was more affected in females than in males. There was no statistically significant difference between sex and Hurley stage, HS Physician Global Assessment, International Hidradenitis Suppurativa Severity Score System, visual analogue scale and Dermatology Life Quality Index scores. Combined (medical and surgery) HS treatment was applied to 46.0% and monotherapy (medical or surgery) to 54.0% of patients.

CONCLUSIONS

Standardized collection of epidemiological and clinical data is required to improve the quality of HS patient data and allow for international comparisons and pooling of data for research purposes.

Epidemiology of hidradenitis suppurativa in Germany - an observational cohort study based on a multisource approach

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic, debilitating inflammatory skin disease. In Germany, there are no population-based data on the epidemiology of HS.

OBJECTIVES

The objective of this study was to examine the occurrence of HS in inpatient as well as in outpatient settings.

METHODS

We used three data sources for analysing the prevalence, incidence and case-related occurrence of HS in different settings: data of two German statutory health insurance (SHI) companies and hospital discharge data provided by the Federal Statistical Office. The studied period was from 2010 to 2015.

RESULTS

In a representative sample of about 2.3 million insurees (out of 5.9 million total persons) of the SHI DAK-Gesundheit, 791 were diagnosed with HS in 2010. This coding prevalence of 0.03% is in accordance with the data of another SHI (Barmer) on about 9 million total insurees. In 2015, at least 34.7% of incident persons with HS had one potential misdiagnosis in 2014.

CONCLUSION

This population-based study analyses the prevalence and incidence of HS in Germany. The coding prevalence of 0.03% observed in two independent SHI data sets is lower than expected. The findings of considerable potential misdiagnosis add to the underdiagnosis of HS in general and underline the need for future strategies to early detection and valid diagnosis of HS.

Disease burden and cost of hidradenitis suppurativa: a retrospective examination of US administrative claims data

OBJECTIVES

Hidradenitis suppurativa (HS) causes substantial morbidity and quality-of-life impairment. We examined demographic/clinical characteristics of patients with HS and treatment patterns, prevalence and healthcare resource utilisation/expenditures related to HS in the real-world.

DESIGN

Retrospective claims data of MarketScan Commercial, Medicare Supplemental and Medicaid databases (2009-2014).

SETTING

USA.

PARTICIPANTS

Patients aged ≥12 years with ≥3 non-diagnostic outpatient or inpatient claims with an HS diagnosis code and ≥12 months continuous enrolment with medical and pharmacy benefits before (preindex) and after (postindex) the earliest diagnosis of HS (index) were included.

RESULTS

There were 11 325 Commercial/Medicare patients (mean age 37.4 years) and 5164 Medicaid patients (mean age 28.3 years). HS was more common in Medicaid than Commercial/Medicare patients (0.301% and 0.098%, respectively, in 2014). Cellulitis and psychiatric disorders were the most common comorbidities and oral antibiotics and narcotics were the most frequently prescribed drugs preindex, with ≥10% increase postindex in both populations. HS-related inpatient costs decreased while outpatient costs increased from preindex to postindex. Medicaid patients had several risk factors that may be associated with poor outcomes (eg, high rates of prescription pain medication use, comorbidities, drug discontinuation/interruption/holiday, emergency department (ED) visits and hospitalisation).

CONCLUSIONS

Commercial/Medicare and Medicaid HS beneficiaries experience high comorbidity burden but use different treatment modalities to manage HS. Results suggest a substantial unmet need exists among this patient population, with Medicaid patients experiencing a particularly high burden of disease and expensive healthcare resource utilisation.

Evaluating patients' unmet needs in hidradenitis suppurativa: Results from the Global Survey Of Impact and Healthcare Needs (VOICE) Project

BACKGROUND

A needs assessment for patients with hidradenitis suppurativa (HS) will support advancements in multidisciplinary care, treatment, research, advocacy, and philanthropy.

OBJECTIVE

To evaluate unmet needs from the perspective of HS patients.

METHODS

Prospective multinational survey of patients between October 2017 and July 2018.

RESULTS

Before receiving a formal HS diagnosis, 63.7% (n = 827) of patients visited a physician ≥5 times. Mean delay in diagnosis was 10.2 ± 8.9 years. Patients experienced flare daily, weekly, or monthly in 23.0%, 29.8%, and 31.1%, respectively. Most (61.4% [n = 798]) rated recent HS-related pain as moderate or higher, and 4.5% described recent pain to be the worst possible. Access to dermatology was rated as difficult by 37.0% (n = 481). Patients reported visiting the emergency department and hospital ≥5 times for symptoms in 18.3% and 12.5%, respectively. An extreme impact on life was reported by 43.3% (n = 563), and 14.5% were disabled due to disease. Patients reported a high frequency of comorbidities, most commonly mood disorders. Patients were dissatisfied with medical or procedural treatments in 45.9% and 34.6%, respectively.

LIMITATIONS

Data were self-reported. Patients with more severe disease may have been selected.

CONCLUSION

HS patients have identified several critical unmet needs that will require stakeholder collaboration to meaningfully address.

Hemoglobin Levels and Serum C-Reactive Protein in Patients With Moderate to Severe Hidradenitis Suppurativa

INTRODUCTION

Anemia of chronic inflammation is associated with many inflammatory diseases. Little is known about anemia in hidradenitis suppurativa (HS). This study aimed to review the levels of hemoglobin (Hb) and investigate its relationship with serum C-reactive protein (CRP) and disease severity in HS patients.

METHODS

This was a retrospective chart review of all HS patients from 2015 to 2017 with Hb and CRP blood work. Patient demographics, disease severity, and laboratory results were extracted. Data were analyzed descriptively. A linear regression model was used for the association between Hb and CRP. Two-tailed t-tests and one-way ANOVA were used to compare differences between sexes and disease severities.

RESULTS

Of the 25 patients included, 14 (56%) were female. The median age and disease duration of all patients were 41 years (range, 19-56 years) and 10 years (range, 1-40 years), respectively. The overall median CRP level was 11.5 mg/dL (range, 1-86.7 mg/dL). The median Hb levels for women and men were and 123.5 g/L (range, 90-142 g/L) and 152.0 g/L (range, 109-166 g/L), respectively. Anemia was found in 42.9% (6/14) of women and 27.3% (3/11) of men. There was an inverse relationship between Hb and CRP levels in both sexes (men: r = ‒0.88; P = .0006; women r = ‒0.65; P = .012).

CONCLUSIONS

Anemia was prevalent in the HS population, and Hb levels inversely correlated with CRP. Physicians should be aware that anemia is common in inflammatory states, and that CRP could be a biomarker in patients with HS.

Demographic and health care service utilization by 4417 patients with hidradenitis suppurativa

BACKGROUND

Data on the health care utilization of patients with hidradenitis suppurativa (HS) in primary care settings are scarce.

OBJECTIVE

To investigate the health care service utilization of patients with HS.

METHODS

In a cross-sectional study, patients with HS were compared with 2 age- and sex-matched control groups-general population enrollees of Clalit Health Services and a group of patients with psoriasis. Health care services data included inpatient and outpatient community clinic visits and pharmacy claims for topical and systemic treatments. Multivariate analysis of the data for patients with HS and controls was performed.

RESULTS

The study included 4417 patients with HS, 22,085 general population enrollees, and 4417 patients with psoriasis. On the basis of multivariate analyses, patients with HS had more annual dermatology clinic visits compared with the general population enrollees (odds ratio [OR], 6.49; 95% confidence interval [CI], 7.06-5.97) and patients with psoriasis (OR, 1.32; 95% CI, 1.44-1.21), more annual surgical clinic visits (OR, 3.78; 95% CI 3.28-4.36 and OR, 1.65; 95% CI, 1.42-1.91, respectively), and more hospitalizations (OR, 2.21; 95% CI, 1.89-2.56 and OR, 1.51; 95% CI, 1.28-1.78, respectively).

LIMITATIONS

Underestimation of HS frequency was possible.

CONCLUSIONS

The burden on health care systems due to patients with HS is greater than that due to patients with psoriasis and the general population.

Sex- and Age-Adjusted Population Analysis of Prevalence Estimates for Hidradenitis Suppurativa in the United States

Importance

The true prevalence of hidradenitis suppurativa (HS) is unknown.

Objective

To establish standardized overall and group-specific prevalence estimates for HS in the United States.

Design, Setting, and Participants

This retrospective analysis included a demographically heterogeneous population-based sample of more than 48 million unique patients across all US census regions. As of October 27, 2016, a total of 47 690 patients with HS were identified using electronic health record data.

Main Outcomes and Measures

Standardized overall point prevalence for HS and sex-, age-, and race-specific prevalence estimates of HS in the general US population.

Results

Of the 47 690 patients with HS (26.2% men and 73.8% women), the overall HS prevalence in the US population sample was 0.10%, or 98 per 100 000 persons (95% CI, 97-99 per 100 000 persons). The adjusted prevalence in women was 137 per 100 000 (95% CI, 136-139 per 100 000), more than twice that of men (58 per 100 000; 95% CI, 57-59 per 100 000; P < .001). The prevalence of HS was highest among patients aged 30 to 39 years (172 per 100 000; 95% CI, 169-275 per 100 000) compared with all other age groups (range, 15-150 per 100 000; P < .001). Adjusted HS prevalences among African American (296 per 100 000; 95% CI, 291-300 per 100 000) and biracial (218 per 100 000; 95% CI, 202-235 per 100 000) patients were more than 3-fold and 2-fold greater, respectively, than that among white patients (95 per 100 000; 95% CI, 94-96 per 100 000; P < .001).

Conclusions and Relevance

Hidradenitis suppurativa is an uncommon, but not rare, disease in the United States that disproportionately affects female patients, young adults, and African American and biracial patients.