Quality of care for incident lupus nephritis among Medicaid beneficiaries in the United States

Increased prevalence, ER visits, and hospitalizations in medicare systemic lupus erythematosus patients living in socially vulnerable counties: A cross-sectional study

BACKGROUND

Systemic Lupus Erythematosus (SLE) disproportionately affects women, minorities, and individuals with low socioeconomic status. We hypothesized that counties with a higher percentage of disadvantaged individuals have a higher prevalence of SLE and increased acute hospital events, including emergency room (ER) visits and hospitalizations, among Medicare patients with SLE.

METHODS

This cross-sectional study used the Centers for Disease Control and Prevention's Social Vulnerability Index (SVI) and Lupus Research Alliance's Lupus Index Medicare data. SLE was identified through Medicare fee-for-service administrative records from 2016 containing two or more ICD-10 codes for SLE. We examined SLE prevalence, acute hospital events, and their association with county-level SVI rankings.

RESULTS

The study population was 89 % female and 69 % White, with 22 % Black. SVI ranking (r = 0.508) and its subthemes correlated with SLE prevalence, with socioeconomic status and household composition showing the strongest associations (R = 0.431 and R = 0.365, respectively). Similar but weaker correlations were seen between SVI and acute healthcare events, including ER visits and hospitalizations. Limitations include the cross-sectional design preventing longitudinal analysis, reliance on administrative data potentially introducing bias, and exclusion of counties with fewer than 10 SLE patients.

CONCLUSIONS

This is the first study linking county-level vulnerability to SLE prevalence and healthcare events in a Medicare SLE population. Findings suggest that social and environmental factors influence SLE risk and healthcare utilization, much like other chronic diseases. The modest association between location and hospital/ER events suggests that structural factors may act as barriers to optimal care and outcomes.

Characterizing lupus in African American children in Southern United States

OBJECTIVE

To characterize the clinical, demographic, and socioeconomic profile of childhood systemic lupus erythematous (cSLE) in the Black Belt of the Southern United States in comparison to the current literature of predominantly Caucasian cohorts.

METHODS

This is a cross-sectional study characterizing patients with cSLE from two centers in the Southeastern United States- University of Mississippi Medical Center (UMMC) and University of Alabama at Birmingham (UAB). Demographic, social, and clinical data was retrospectively collected by medical chart review for prevalent and incident cSLE patients via electronic medical records for UMMC and the Childhood arthritis and rheumatology research alliance (CARRA) registry database for UAB. The data was combined and analyzed using SPSS statistical software.

RESULTS

Of the 45 patients,82.2%were female, 82.2% were of AA ethnicity, and 66.7% had Medicaid insurance. Mean age at diagnosis was 13.5 years (+/- 2.8). Mean American College of Rheumatology (ACR) score at diagnosis was 5.1 (+/- 1.27), the Systemic Lupus International Collaborating Clinics (SLICC score) was 8.4 (+/- 2.5). Average baseline Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) was 13.06 (+/- 9.3), SLEDAI at 6 months and 1 year respectively was 7.4 and 4.7. Average distance traveled to see a rheumatologist was 74.83 miles compared to a national average of 42.8 miles. 37/45 patients (82%) belonged to medium-high or high Social Vulnerability Index (SVI) group based on zip code.

CONCLUSION

Compared to previously described multiethnic cohorts of cSLE, this predominantly AA patient population in the Southern United States has significantly higher disease activity and greater damage accrual. Social risk factors for this population include a higher SVI, longer distance from an academic pediatric rheumatology center, and having Medicaid insurance. The effect of these factors on disparity of disease outcomes needs to be further explored with larger cohorts.

Letter to editor: Trends and disparities in cardiovascular deaths in systemic lupus erythematosus: A population-based retrospective study in the United States from 1999 to 2020

This letter addresses key limitations in the article "Trends and disparities in cardiovascular deaths in systemic lupus erythematosus: A population-based retrospective study in the United States from 1999 to 2020." While the article provides valuable insights into cardiovascular mortality among SLE patients, it overlooks critical factors such as medication adherence and sex-specific treatment responses, which could influence the reported outcomes. Additionally, the study's focus on cardiovascular deaths sidelines other relevant causes of mortality like infections and renal failure. Incorporating these considerations, along with a deeper exploration of socioeconomic disparities and healthcare infrastructure, could enhance future studies, offering a more comprehensive understanding of mortality trends in SLE patients.

Trends and disparities in cardiovascular deaths in systemic lupus erythematosus: A population-based retrospective study in the United States from 1999 to 2020

PURPOSE

This study aimed to analyze two decades of consecutive mortality data to investigate cardiovascular deaths in Systemic Lupus Erythematosus (SLE) across the United States (US), identifying patterns and disparities in mortality rates.

METHODS

A retrospective analysis was conducted using mortality data from the CDC WONDER database spanning 1999-2020. ICD-10 codes for diseases of circulatory system (I00-I99) and for SLE (M32) were used to identify cardiovascular-related deaths in SLE among adults aged 25 years and older at the time of death. Age-adjusted mortality rates (AAMRs) per 1,000,000 persons were calculated, and trends were assessed using Average Annual Percentage Change (AAPC) and Annual Percent Change (APC) using Joinpoint. Data were stratified by year, sex, race/ethnicity, and geographical regions.

RESULTS

Between 1999 and 2020, cardiovascular-related deaths in SLE accounted for 6,548 deaths among adults aged 25 and older in the US. The overall AAMR for cardiovascular-related deaths in SLE decreased from 1.81 in 1999 to 1.53 in 2020, with an AAPC of -1.00 (95% CI: -1.91 to -0.24, p=0.025). A significant decline occurred from 1999 to 2014 with an APC of -3.20 (95% CI: -5.56 to -2.18; p=0.02), followed by a notable increase of 4.73 (95% CI: 0.41 to 18.29, p=0.23) from 2014 to 2020. Women exhibited higher AAMRs compared to men (women: 2.12, men: 0.53). The AAMR decreased for both men and women, with a steeper decline for men from 1999 to 2014 (APC: -4.85 95% CI: -15.58 to -2.62; p<0.02) compared to women in the same period (APC: -2.81 95% CI: -5.78 to -1.73; p<0.03). The Black cohort had a higher AAMR (3.54 95% CI: 3.37 to 3.70), compared to the White cohort (1.12 95% CI: 1.09 to 1.16). The highest mortality was in the Western region (AAMR: 1.60 95% CI: 1.52 to 1.68). Geographically, AAMRs ranged from 0.62 in Massachusetts to 3.11 in Oklahoma. Metropolitan areas had higher AAMRs than Non-metropolitan areas [(1.41 95% CI: 1.37 to 1.45) vs (1.29 95% CI: 1.21 to 1.37)], with a significant mortality reduction in Metropolitan area from 1999-2020 (AAPC: -1.04 95% CI: -1.95 to -0.28, p=0.0064) compared to Non-metropolitan areas in the same time frame (AAPC: -0.86, 95% CI: -2.43 to 0.33 p=0.152).

CONCLUSIONS

This analysis highlights notable differences in mortality rates related to cardiovascular deaths in SLE. The target population was adult patients aged 25 and older in the United States. These results are based on demographic and geographic factors. Initially, there was a considerable decrease, but recently the mortality rates have started to rise. This highlights the importance of patient focused interventions to address disparities and improve health outcomes.

Lupus nephritis and socioeconomic status: Findings from the Southern California lupus registry

OBJECTIVE

Lupus nephritis (LN) is a major cause of morbidity and mortality in systemic lupus erythematosus (SLE). Despite multiple studies addressing healthcare disparities, disparate outcomes in LN persist. We investigate herein the association between socioeconomic status (SES) and LN as well as the association between SES, SLE disease activity index (SLEDAI), and treatment response.

METHODS

Patients were selected from the Southern California Lupus Registry (SCOLR), a registry enrolling all-comers with SLE. Analysis was completed on individuals with public vs. private insurance. Insurance and ethnicity were used as surrogate variables for SES, and we tested differences in means.

RESULTS

After adjusting for age and sex, public insurance was independently associated with the prevalence of LN. Analysis of 35 patients revealed greater proteinuria and mean SLEDAI in patients with public insurance at baseline and 6 months. Baseline, 6-, and 12-month SLEDAI means were significantly lower in Asian/Pacific Islanders (PI) compared to others. While non-Hispanic Whites demonstrated mean SLEDAI improvement over 6 months, Asians/PI, Blacks, and Hispanics demonstrated worsened disease activity on average.

CONCLUSION

Low SES, when defined by insurance, is associated with greater adverse outcomes in SLE. This is the first regional study that compares differences in treatment response in LN patients with low SES as well as association of SES with long-term outcomes in SLE and LN in southern California.

Improving Outcomes of Pediatric Lupus Care Delivery With Provider Goal-Setting Activities and Multidisciplinary Care Models

OBJECTIVE

The present study was undertaken to evaluate high-quality care delivery in the context of provider goal-setting activities and a multidisciplinary care model using an electronic health record (EHR)-enabled pediatric lupus registry. We then determined associations between care quality and prednisone use among youth with systemic lupus erythematosus (SLE).

METHODS

We implemented standardized EHR documentation tools to autopopulate a SLE registry. We compared pediatric Lupus Care Index (pLCI) performance (range 0.0-1.0; 1.0 representing perfect metric adherence) and timely follow-up 1) before versus during provider goal-setting activities and population management, and 2) in a multidisciplinary lupus nephritis versus rheumatology clinic. We estimated associations between pLCI and subsequent prednisone use adjusted for time, current medication, disease activity, clinical features, and social determinants of health.

RESULTS

We analyzed 830 visits by 110 patients (median 7 visits per patient [interquartile range 4-10]) over 3.5 years. The provider-directed activity was associated with improved pLCI performance (adjusted β 0.05 [95% confidence interval (95% CI) 0.01, 0.09]; mean 0.74 versus 0.69). Patients with nephritis in multidisciplinary clinic had higher pLCI scores (adjusted β 0.06 [95% CI 0.02, 0.10]) and likelihood of timely follow-up than those in rheumatology (adjusted relative risk [RR] 1.27 [95% CI 1.02, 1.57]). A pLCI score of ≥0.50 was associated with 0.72-fold lower adjusted risk of subsequent prednisone use (95% CI 0.53, 0.93). Minoritized race, public insurance, and living in areas with greater social vulnerability were not associated with reduced care quality or follow-up, but public insurance was associated with higher risk of prednisone use.

CONCLUSION

Greater attention to quality metrics is associated with better outcomes in childhood SLE. Multidisciplinary care models with population management may additionally facilitate equitable care delivery.

Disparities in Lupus and the Role of Social Determinants of Health: Current State of Knowledge and Directions for Future Research

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease. The complex relationships between race and ethnicity and social determinants of health (SDOH) in influencing SLE and its course are increasingly appreciated. Multiple SDOH have been strongly associated with lupus incidence and outcomes and contribute to health disparities in lupus. Measures of socioeconomic status, including economic instability, poverty, unemployment, and food insecurity, as well as features of the neighborhood and built environment, including lack of safe and affordable housing, crime, stress, racial segregation, and discrimination, are associated with race and ethnicity in the US and are risk factors for poor outcomes in lupus. In this scientific statement, we aimed to summarize current evidence on the role of SDOH in relation to racial and ethnic disparities in SLE and SLE outcomes, primarily as experienced in the U.S. Lupus Foundation of America's Health Disparities Advisory Panel, comprising 10 health disparity experts, including academic researchers and patients, who met 12 times over the course of 18 months in assembling and reviewing the data for this study. Sources included articles published from 2011 to 2023 in PubMed, Centers for Disease Control and Prevention data, and bibliographies and recommendations. Search terms included lupus, race, ethnicity, and SDOH domains. Data were extracted and synthesized into this scientific statement. Poorer neighborhoods correlate with increased damage, reduced care, and stress-induced lupus flares. Large disparities in health care affordability, accessibility, and acceptability exist in the US, varying by region, insurance status, and racial and minority groups. Preliminary interventions targeted social support, depression, and shared-decision-making, but more research and intervention implementation and evaluation are needed. Disparities in lupus across racial and ethnic groups in the US are driven by SDOH, some of which are more easily remediable than others. A multidimensional and multidisciplinary approach involving various stakeholder groups is needed to address these complex challenges, address these diminish disparities, and improve outcomes.

Does higher quality of care in systemic lupus erythematosus translate to better patient outcomes?

PURPOSE

To assess if high quality of care (QOC) in SLE results in improved outcomes of quality of life (QOL) and non-routine health care utilization (HCU).

METHODS

One hundred and forty consecutive SLE patients were recruited from the Rheumatology clinic at an academic center. Data on QOC and QOL were collected along with demographics, socio-economic, and disease characteristics at baseline. LupusPRO assessing health-related (HR) QOL and non (N)HRQOL was utilized. Follow up QOL and HCU were collected prospectively at 6 months. High QOC was defined as those meeting ≥80% of the eligible quality indicators. Univariate and multivariate regression analyses were performed with QOC and high QOC as independent variables and HRQOL and NHRQOL as dependent variables at baseline and follow up. Multivariable models were adjusted for demographics and disease characteristics. Secondary outcomes included non-routine HCU and disease activity at follow up.

RESULTS

Baseline and follow up data on 140 and 94 patients, respectively, were analyzed. Mean (SD) performance rate (QOC) was 78.6 (13.4) with 52% patients in the high QOC group. QOC was associated with better NHRQOL at baseline and follow up but not with HRQOL. Of all the NHRQOL domains, QOC was positively associated with treatment satisfaction. QOC or high QOC were not associated with non-routine HCU and were instead associated with higher disease activity at follow up.

CONCLUSION

Higher QOC predicted better NHRQOL by directly impacting treatment satisfaction in SLE patients in this cohort. Higher QOC, however, was not associated with HRQOL, HCU, or improvement in disease activity at follow up.

Racial differences in persistent glucocorticoid use patterns among medicaid beneficiaries with incident systemic lupus erythematosus

OBJECTIVE

Glucocorticoids ("steroids") are frequently used in systemic lupus erythematosus (SLE). Prolonged use may contribute to racial/ethnic disparities in avoidable adverse outcomes. We examined racial/ethnic differences in longitudinal patterns of steroid use and dose.

METHODS

We identified Medicaid beneficiaries 18-65 years with incident SLE who received steroids for 12 months following the index date. Group-based trajectory modeling was used to identify patterns of daily prednisone-equivalent steroid doses. We examined demographic, clinical and healthcare utilization factors during the baseline period and used multinomial logistic regression to estimate the odds of belonging to the higher vs. lowest steroid dose trajectories over time.

RESULTS

We identified 6314 individuals with SLE with ≥1 dispensed steroid prescription. The mean (SD) prednisone-equivalent dose was 7 (23) mg/day for Black, 7 (26) for Hispanic, 7 (13) for Asian, and 4 (10) for White individuals. Adjusted multinomial models demonstrated higher odds of belonging to the highest vs. lowest steroid trajectory for Black (OR 2.07, 95% CI 1.65-2.61), Hispanic (OR 1.81, 95% CI 1.38-2.39), and Asian (OR 2.42, 95% CI 1.53-3.83) vs. White individuals. Having >5 outpatient visits during the baseline period was associated with lower odds of being in the persistently high-dose steroid trajectory (OR 0.77; 95% CI 0.60-0.98).

CONCLUSION

Black, Hispanic, and Asian (vs. White) individuals had higher odds of persistently high-dose steroid use. Sustained access to outpatient care and the development of standardized steroid-tapering regimens from clinical trials with diverse populations may be targets for intervention to mitigate disparities in steroid-related adverse outcomes.

Race, Ethnicity, and Disparities in the Risk of End-Organ Lupus Manifestations Following a Systemic Lupus Erythematosus Diagnosis in a Multiethnic Cohort

OBJECTIVE

Data on the onset of lupus manifestations across multiple organ domains and in diverse populations are limited. The objective was to analyze racial and ethnic differences in the risk of end-organ lupus manifestations following systemic lupus erythematosus (SLE) diagnosis in a multiethnic cohort.

METHODS

The California Lupus Epidemiology Study (CLUES) is a longitudinal study of SLE. Data on major end-organ lupus manifestations were collected and categorized by organ system: renal, hematologic, neurologic, cardiovascular, and pulmonary. Multiorgan disease was defined as manifestations in ≥2 of these distinct organ systems. Kaplan-Meier curves assessed end-organ disease-free survival, and Cox proportional hazards regression estimated the rate of end-organ disease following SLE diagnosis, adjusting for age at diagnosis, sex, and self-reported race and ethnicity (White, Hispanic, Black, and Asian).

RESULTS

Of 326 participants, 89% were female; the mean age was 45 years. Self-reported race and ethnicity were 30% White, 23% Hispanic, 11% Black, and 36% Asian. Multiorgan disease occurred in 29%. Compared to White participants, Hispanic and Asian participants had higher rates, respectively, of renal (hazard ratio [HR] 2.9 [95% confidence interval (95% CI) 1.8-4.7], HR 2.9 [95% CI 1.9-4.6]); hematologic (HR 2.7 [95% CI 1.3-5.7], HR 2.1 [95% CI 1.0-4.2]); and multiorgan disease (HR 3.3 [95% CI 1.8-5.9], HR 2.5 [95% CI 1.4-4.4]) following SLE diagnosis.

CONCLUSION

We found heightened risks of developing renal, hematologic, and multiorgan disease following SLE diagnosis among Hispanic and Asian patients with SLE, as well as a high burden of multiorgan disease among CLUES participants.

Good Long-Term Prognosis of Lupus Nephritis in the High-Income Afro-Caribbean Population of Martinique with Free Access to Healthcare

Lupus nephritis (LN) has been described as having worse survival and renal outcomes in African-descent patients than Caucasians. We aimed to provide long-term population-based data in an Afro-descendant cohort of LN with high income and easy and free access to specialized healthcare. Study design: We performed a retrospective population-based analysis using data from 2002–2015 of 1140 renal biopsies at the University Hospital of Martinique (French West Indies). All systemic lupus erythematosus patients with a diagnosis of LN followed for at least 12 months in Martinique or who died during this period were included. Results: A total of 89 patients were included, of whom 68 (76.4%) had proliferative (class III or IV), 17 (19.1%) had membranous (class V), and 4 (4.5%) had class I or II lupus nephritis according to the ISN/RPS classification. At a mean follow-up of 118.3 months, 51.7% of patients were still in remission. The rates of end-stage renal disease were 13.5%, 19.1%, and 21.3% at 10, 15, and 20 years of follow-up, respectively, and mortality rates were 4.5%, 5.6%, and 7.9% at 10, 15, and 20 years of follow-up, respectively. Conclusions: The good survival of our Afro-descendant LN patients, similar to that observed in Caucasians, shades the burden of ethnicity but rather emphasizes and reinforces the importance of optimizing all modifiable factors associated with poor outcome, especially socioeconomics.

Association of clinic setting with quality indicator performance in systemic lupus erythematosus: a cross-sectional study

BACKGROUND

Healthcare quality for systemic lupus erythematosus (SLE) is a modifiable target for improving patient outcomes. We aimed to assess the quality of care processes in different clinic settings, comparing a subspecialty lupus clinic with hospital-based and private general rheumatology clinics.

METHODS

Patients with SLE (n = 258) were recruited in 2016 from a subspecialty lupus clinic (n = 147), two hospital general rheumatology clinics (n = 56) and two private rheumatology clinics (n = 55). Data were collected from medical records and patient questionnaires. Quality of care was assessed using 31 validated SLE quality indicators (QI) encompassing diagnostic work-up, disease and comorbidity assessments, drug monitoring, preventative care and reproductive health. Per-QI performance was measured as a percentage of patients that met the QI relative to the number of patients eligible. Per-patient QI performance was calculated as a percentage of QIs met relative to the number of eligible QIs for each patient. Per-QI and per-patient QI performance were compared between the three clinic settings, and multiple regression performed to adjust for sociodemographic, disease and healthcare factors.

RESULTS

Per-QI performance was generally high across all clinic settings for diagnostic work-up, comorbidity assessment, lupus nephritis, drug monitoring, prednisolone taper, osteoporosis and pregnancy care. Median [IQR] per-patient performance on eligible QIs was higher in the subspeciality lupus clinic (66.7% [57.1-74.1]) than the hospital general rheumatology (52.7% [47.5-58.1]) and private rheumatology (50.0% [42.9-60.9]) clinics (p <0.001) and the difference remained significant after multivariable adjustment. The subspecialty lupus clinic recorded higher per-QI performance for documentation of disease activity, disease damage, cardiovascular risk factor and drug toxicity assessments, pre-immunosuppression hepatitis and tuberculosis screening, new medication counselling, vaccinations, sun avoidance education and contraception counselling.

CONCLUSIONS

SLE patients managed in a subspecialty lupus clinic recorded higher per-patient QI performance compared to hospital general rheumatology and private rheumatology clinics, in part related to better documentation on certain QIs.

The Impact of an Integrated Care Management Program on Acute Care Use and Outpatient Appointment Attendance Among High-Risk Patients With Lupus

Objective

Patients with systemic lupus erythematosus (SLE) often struggle with high acute care use (emergency department [ED] visits and hospitalizations) and missed appointments. A nurse‐led integrated care management program (iCMP) at our multihospital system coordinates care for patients at high risk for frequent acute care use due to comorbidities, demographics, and prior use patterns. We studied whether iCMP enrollment was associated with decreased acute care use and missed appointment rates among patients with SLE.

Methods

We used a validated electronic health record (EHR) machine learning algorithm to identify adults with SLE and then determined which patients were enrolled in the iCMP from January 2012 to February 2019. We then used EHR data linked to insurance claims to compare the incidence rates of ED visits, hospitalizations, potentially avoidable ED visits and hospitalizations, and missed appointments during iCMP enrollment versus the 12 months prior to iCMP enrollment. We used Poisson regression to compare incidence rate ratios (IRRs) during the iCMP versus pre‐iCMP for each use measure, adjusted for age, sex, race and ethnicity, number of comorbidities, and calendar year, accounting for within‐patient clustering.

Results

We identified 67 iCMP enrollees with SLE and linked EHR claims data. In adjusted analyses, iCMP enrollment was associated with reduced rates of ED visits (IRR 0.63, 95% confidence interval [CI] 0.47‐0.85), avoidable ED visits (IRR 0.50, 95% CI 0.28‐0.88), and avoidable hospitalizations (IRR 0.37, 95% CI 0.21‐0.65).

Conclusion

A nurse‐led iCMP was effective at decreasing the rate of all ED visits and potentially avoidable ED visits and hospitalizations among high‐risk patients with SLE. Further studies are needed to confirm these findings in other patient populations.

Avoidable Acute Care Use for Vaccine-Preventable Illnesses Among Medicaid Beneficiaries With Lupus

OBJECTIVE

Nearly 25% of patients with systemic lupus erythematosus (SLE) are hospitalized yearly, often for outcomes that may have been avoided if patients had received sustained outpatient care. We examined acute care use for vaccine-preventable illnesses to determine sociodemographic contributors and modifiable predictors.

METHODS

Using US Medicaid claims from 29 states (2000-2010), we identified adults (18-65 years) with prevalent SLE and 12 months of enrollment prior to the first SLE code (index date) to identify baseline data. We defined acute care use for vaccine-preventable illnesses as emergency department (ED) or hospital discharge diagnoses for influenza, pneumococcal disease, meningococcal disease, herpes zoster, high-grade cervical dysplasia/cervical cancer, and hepatitis B after the index date. We estimated the incidence rate of vaccine-preventable illnesses and used Cox regression to assess risk (with hazard ratios and 95% confidence intervals) by sociodemographic factors and health care utilization, adjusting for vaccinations, comorbidities, and medications.

RESULTS

Among 45,654 Medicaid beneficiaries with SLE, <10% had billing claims for vaccinations. There were 1,290 patients with ≥1 ED visit or hospitalization for a vaccine-preventable illness (6.6 per 1,000 person-years); 93% of events occurred in unvaccinated patients. Patients who were Black compared to White had 22% higher risk. Greater outpatient visits were associated with lower risk.

CONCLUSION

Medicaid beneficiaries with SLE who are not vaccinated are at risk for potentially avoidable acute care use for vaccine-preventable illnesses. Racial disparities were noted, with a higher risk among Black patients compared to White patients. Greater outpatient use was associated with reduced risk, suggesting that access to ambulatory care may reduce avoidable acute care use.

Use of an Integrated Care Management Program to Uncover and Address Social Determinants of Health for Individuals With Lupus

Objective

We studied patients with systemic lupus erythematosus (SLE) enrolled in a nurse‐led, multihospital, primary care–based integrated care management program (iCMP) for complex patients with chronic conditions to understand whether social determinants of health (SDoH), including food insecurity, housing instability, and financial constraints, were prevalent in this population.

Methods

The academic hospital‐based iCMP enrolls the top 2% of medically and psychosocially complex patients identified on the basis of clinical complexity health care use, and primary care provider referral. A nurse conducts needs assessments and coordinates care. We reviewed the electronic medical records of enrolled patients with SLE to identify SDoH needs and corresponding actions taken 1 year prior to iCMP enrollment using physicians’ and social workers’ notes, and during enrollment using iCMP team members’ notes.

Results

Among 69 patients with SLE in the iCMP, in the year prior to enrollment, 57% had documentation of one or more SDoH challenges, compared with 94% during enrollment. iCMP nurses discussed and addressed one or more SDoH issues for 81% of the patients; transportation challenges, medication access, mental health care access, and financial insecurity were the most prevalent. Nurses connected 75% of these patients with related resources and support.

Conclusion

Although SDoH‐related issues were not used to identify patients for the iCMP, the vast majority of enrolled medically and psychosocially complex patients with SLE had these needs. The iCMP team uncovered and addressed SDoH‐related concerns not documented prior to iCMP participation. Expansion of care management programs like the iCMP would help identify, document, and address these barriers that contribute to disparities in chronic disease care and outcomes.

Predictors of Initial Hydroxychloroquine Receipt among Medicaid Beneficiaries with Incident Systemic Lupus Erythematosus

OBJECTIVE

Although hydroxychloroquine/chloroquine (HCQ/CQ) form the cornerstone of systemic lupus erythematosus (SLE) treatment, not all patients receive this, which may contribute to disparities in outcomes. We investigated factors associated with first dispensing of HCQ/CQ.

METHODS

Using Medicaid insurance claims from 2000-2010, we identified individuals age 18-65 years with incident SLE (≥3 SLE ICD-9 codes separated by ≥30 days without prior SLE codes or HCQ/CQ use for 24 months.) The primary outcome was first dispensing of HCQ/CQ within 24 months of the first SLE code. We used Cox proportional hazards regression models to examine the association between sociodemographic factors, comorbidities, health care utilization and medication use and HCQ/CQ dispensing within 24 months of diagnosis.

RESULTS

We identified 9560 Medicaid beneficiaries with incident SLE; 41% received HCQ (N=3949) or CQ (N=14) within 24 months of diagnosis. Younger patients were more likely to receive HCQ/CQ. Black, Asian, Hispanic and American Indian/Alaska Native individuals were more likely to receive HCQ/CQ than White individuals. Alcohol, opioid, and nicotine use, diabetes, and end-stage renal disease were associated with lower dispensing. Outpatient appointments and preventive care services were associated with higher rates; more hospitalizations with lower rates.

CONCLUSION

Only 41% of Medicaid beneficiaries with SLE received HCQ/CQ within 24 months of diagnosis. Greater outpatient and preventive care increased receipt. All non-White race/ethnicities had higher rates of first dispensing. Time to initial HCQ/CQ dispensing may not explain racial/ethnic disparities in adverse outcomes, highlighting the need to consider other care quality-related issues and medication adherence challenges.

Development of a Set of Lupus-Specific, Ambulatory Care-Sensitive, Potentially Preventable Adverse Conditions: A Delphi Consensus Study

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.

Patterns and predictors of recurrent acute care use among Medicaid beneficiaries with systemic lupus erythematosus

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.

Comparative Risks of Cardiovascular Disease in Patients With Systemic Lupus Erythematosus, Diabetes Mellitus, and in General Medicaid Recipients

OBJECTIVE

Cardiovascular disease (CVD) risk is elevated in patients with systemic lupus erythematosus (SLE) and diabetes mellitus (DM), but whether risk of CVD in patients with SLE is as high as in those with DM is unknown. The present study was undertaken to compare CVD risks between patients with SLE and DM and general population US Medicaid recipients.

METHODS

In a cohort study, we identified age- and sex-matched adults (1:2:4) with SLE or DM and those from the general population using Medicaid Analytic eXtract, 2007-2010. We collected data on baseline sociodemographic factors, comorbidities, and medications. We used Cox regression models to calculate hazard ratios (HRs) of hospitalized nonfatal CVD events (combined myocardial infarction [MI] and stroke) and MI and stroke separately, accounting for competing risk of death and adjusting for covariates. We compared risks in age-stratified models.

RESULTS

We identified 40,212 SLE patients, 80,424 DM patients, and 160,848 general population patients; 92.5% were female, and the mean ± SD age was 40.3 ± 12.1 years. Nonfatal CVD incidence rate per 1,000 person-years was 8.99 for patients with SLE, 7.07 for those with DM, and 2.36 for the general population. Nonfatal CVD risk was higher in SLE compared to DM (HR 1.27 [95% confidence interval (95% CI) 1.15-1.40]), driven by excess risk at ages 18-39 years (HR 2.22 [95% CI 1.81-2.71]). Patients with SLE had higher risk of CVD compared to the general population (HR 2.67 [95% CI 2.38-2.99]).

CONCLUSION

SLE patients had a 27% higher risk of nonfatal CVD events compared to age- and sex-matched patients with DM and more than twice the risk of the Medicaid general population. The highest relative risk occurred at ages 18-39 years. These high risks merit aggressive evaluation for modifiable factors and research to identify prevention strategies.

Disparities in Lupus and Lupus Nephritis Care and Outcomes Among US Medicaid Beneficiaries

Systemic lupus erythematosus (SLE) is a serious chronic autoimmune disease with substantial morbidity and mortality. Although improved diagnostics and therapeutics have contributed to declining mortality rates, important disparities exist in SLE survival rates by race, ethnicity, gender, age, country, and social disadvantage. This review highlights the burden of SLE and lupus nephritis among Medicaid beneficiaries, outlines barriers in access to high-quality SLE care and medication adherence in the Medicaid SLE population, and summarizes disparities in adverse outcomes among SLE patients enrolled in Medicaid.

Use of Quality Measures to Identify Disparities in Health Care for Systemic Lupus Erythematosus

Assessment of quality of care for people with systemic lupus erythematosus (SLE) provides opportunities to identify gaps in health care and address disparities. Poor access to specialty care has been shown to negatively impact care in SLE and is associated with poor disease outcomes. Racial/ethnic minorities and those with low socioeconomic status are at higher risk for poor access and lower quality of care. Quality measures evaluating processes of care have shown significant deficiencies in care of SLE patients across studies. High SLE patient volume correlates with better quality of care for providers in hospital and ambulatory settings.

Quality of care for patients with SLE: data from the American College of Rheumatology's RISE registry

OBJECTIVE

Although multiple national quality measures focus on the management and safety of rheumatoid arthritis, few measures address the care of patients with SLE. We applied a group of quality measures relevant to the care of SLE patients and used the ACR's RISE registry to assess nationwide variations in care.

METHODS

Data derived from RISE and included patients with ≥2 visits with SLE codes ≥30 days apart in 2017-2018. We calculated performance on 5 quality measures: renal disease screening; blood pressure assessment and management; hydroxychloroquine (HCQ) prescribing; safe dosing for HCQ; and prolonged glucocorticoid use at doses > 7.5 mg/day. We reported performance on these measures at the practice level. We used logistic regression to assess independent predictors of performance after adjusting for sociodemographic and utilization factors.

RESULTS

We included 27,567 unique patients from 186 practices; 91.7% were female, 48% white, with mean age 53.5±15.2 years. Few patients had adequate screening for the development of renal manifestations (39.5%). Although blood pressure assessment was common (94.4%), a meaningful fraction had untreated hypertension (17.7%). Many received HCQ (71.5%), but only 62% at doses ≤ 5.0 mg/kg/day. Some received at least moderate-dose steroids for ≥ 90 days (18.5%). We observed significant practice variation on every measure.

CONCLUSION

We found potential gaps in care for patients with SLE across the U.S. Although some performance variation may be explained by differences in disease severity, dramatic differences suggest that developing quality measures to address important health care processes in SLE may improve care.

Treatment Patterns and Health Care Costs of Lupus Nephritis in a United States Payer Population

Objective

To describe the characteristics, treatment patterns, health care resource utilization (HCRU), and cost of care for members of a large United States (US) health insurance plan with lupus nephritis (LN).

Methods

A retrospective observational study was conducted using a health insurance plan database to identify adult members with a diagnosis of LN. Medical and pharmacy claims were used to describe demographics, comorbidities, HCRU, and cost patterns over a 12-month follow-up period for each patient, between January 1, 2014, and December 31, 2016. All study variables were examined descriptively.

Results

A total of 1039 patients were available for analysis (median age, 47 years; 83% female). The median Charlson Comorbidity Index (CCI) was 3.3. Less than half (41%) of patients received immunosuppressive therapies commonly used to treat LN. Evidence indicated that 58% of the study population were prescribed corticosteroid therapy, in most cases (73%) for more than 60 days. Adverse events known to be associated with corticosteroid therapy were recorded in 58% of patients. Guideline-recommended preventive therapy with hydroxychloroquine was prescribed for 54% of members with LN. Nearly half (47%) of members with LN did not see a nephrologist and more than one-third (36%) did not see a rheumatologist over 1 year of follow-up. Rates of all-cause hospitalization and emergency department (ED) use were 25% and 35%, respectively. The mean all-cause per-member-per-month (PMPM) medical cost for the study population was $2801, with LN-specific costs accounting for $1147 PMPM.

Conclusion

Patients with LN who are insured through a large US health plan appeared to underutilize outpatient specialist services and guideline-recommended hydroxychloroquine therapy. Corticosteroid use and adverse events known to be associated with corticosteroids were common in this cohort.

The economic burden of systemic lupus erythematosus in commercially- and medicaid-insured populations in the United States

OBJECTIVE

To estimate the economic burden of systematic lupus erythematous (SLE), stratified by disease severity, in commercially- and Medicaid-insured US populations.

METHODS

Adults (≥18 years) with SLE treated with antimalarials, selected biologics, immunosuppressants, and systemic glucocorticoids (2010-2014) were identified within the commercial and Medicaid insurance IBM MarketScan® databases (index date = first SLE medication claim). Both cohorts were stratified into mild (receiving antimalarial or glucocorticoid monotherapy ≤5 mg/day) versus moderate/severe SLE (receiving glucocorticoids >5 mg/day, biologic, immunosuppressant, or combination therapy) during a 6-month exposure period. All-cause healthcare utilization and costs were evaluated during the 12 months following the exposure period.

RESULTS

Among 8231 commercially-insured patients, 32.6% had mild and 67.4% had moderate/severe SLE by our definition. Among 802 Medicaid-insured patients, 25.2% had mild and 74.8% had moderate/severe SLE. Adjusted mean total healthcare costs, excluding pharmacy, for moderate/severe SLE patients were higher than for mild SLE patients in the commercially-insured ($39,021 versus $23,519; p < 0.0001) and Medicaid-insured populations ($56,050 versus $44,932; p = 0.06). In both SLE severity populations total unadjusted costs were significantly higher among Medicaid-insured than commercially-insured patients.

CONCLUSION

Commercially-insured patients with treatment suggesting moderate/severe SLE incurred significantly higher adjusted mean healthcare costs, excluding pharmacy, compared with mild SLE patients. While not reaching statistical significance, moderate/severe Medicaid-insured patients had higher costs then mild SLE patients. Total unadjusted healthcare costs were significantly higher among Medicaid-insured than commercially-insured patients. These differential costs are important to consider and monitor when implementing interventions to improve health and reduce healthcare spending for SLE.

Quality of Care for the Screening, Diagnosis, and Management of Lupus Nephritis Across Multiple Health Care Settings

OBJECTIVE

We examined quality measures for screening, diagnosis, and treatment of lupus nephritis (LN) among participants of the California Lupus Epidemiology Study across 25 different clinical sites to identify gaps in quality of care.

METHODS

Data from 250 participants with lupus were analyzed across 3 sources (medical records, physician examination, and patient interviews). Overall performance on 8 quality measures was calculated separately for participants with and without LN. We used generalized estimating equations in which the outcome was performance on measures, adjusting for participant demographics, lupus disease severity, and practice characteristics.

RESULTS

Of 148 patients without LN, 42% underwent screening laboratory tests for nephritis, 38% underwent lupus activity serum studies, and 81% had their blood pressure checked every 6 months. Of 102 LN patients, 67% had a timely kidney biopsy, at least 81% had appropriate treatment, and 78% achieved target blood pressure within 1 year of diagnosis. Overall performance in participants across quality measures was 54% (no LN) and 80% (LN). Significantly higher overall performance for screening measures for LN was seen at academic (63.4-73%) versus community clinics (37.9-38.4%). Similarly, among those with LN, higher performance in academic (84.1-85.2%) versus community clinics (54.8-60.2%) was observed for treatment measures.

CONCLUSION

In this quality-of-care analysis across 25 diverse clinical settings, we found relatively high performance on measures for management of LN. However, future work should focus on bridging the gaps in lupus quality of care for patients without nephritis, particularly in community settings.

Protecting the kidney in systemic lupus erythematosus: from diagnosis to therapy

Lupus nephritis (LN) is a common manifestation of systemic lupus erythematosus that can lead to irreversible renal impairment. Although the prognosis of LN has improved substantially over the past 50 years, outcomes have plateaued in the USA in the past 20 years as immunosuppressive therapies have failed to reverse disease in more than half of treated patients. This failure might reflect disease complexity and heterogeneity, as well as social and economic barriers to health-care access that can delay intervention until after damage has already occurred. LN progression is still poorly understood and involves multiple cell types and both immune and non-immune mechanisms. Single-cell analysis of intrinsic renal cells and infiltrating cells from patients with LN is a new approach that will help to define the pathways of renal injury at a cellular level. Although many new immune-modulating therapies are being tested in the clinic, the development of therapies to improve regeneration of the injured kidney and to prevent fibrosis requires a better understanding of the mechanisms of LN progression. This mechanistic understanding, together with the development of clinical measures to evaluate risk and detect early disease and better access to expert health-care providers, should improve outcomes for patients with LN.

Lipid Testing and Statin Prescriptions Among Medicaid Recipients With Systemic Lupus Erythematosus or Diabetes Mellitus and the General Medicaid Population

OBJECTIVE

Cardiovascular disease (CVD) risks in systemic lupus erythematosus (SLE) are similar to those in diabetes mellitus (DM). We investigated whether the numbers of lipid tests and statin prescriptions in patients with SLE are comparable with those in patients with DM and those in individuals without either disease.

METHODS

Using Analytic eXtract files from 29 states for 2007-2010, we identified a cohort of US Medicaid beneficiaries, ages 18-65 years, with prevalent SLE. Each SLE patient was matched for age and sex with 2 patients with DM and 4 individuals in the general Medicaid population who did not have either SLE or DM. We compared the proportions of patients in each cohort who received ≥1 lipid test and ≥1 statin prescription during 1-year follow-up. We used multivariable logistic regression to calculate the odds of lipid testing and receiving prescriptions for statins and conditional logistic regression to compare the matched cohorts.

RESULTS

We identified 3 Medicaid cohorts: 25,950 patients with SLE, 51,900 patients with DM, and 103,800 Medicaid recipients without either condition. In these cohorts, lipid testing was performed in 24% of patients in the SLE group, 43% of patients in the DM group, and 16% of individuals in the group with neither condition, and statin prescriptions were dispensed in 11%, 33%, and 7% of these groups, respectively. SLE patients were 66% less likely (odds ratio [OR] 0.34, 95% confidence interval [95% CI] 0.34-0.35) to have lipid tests and 82% less likely (OR 0.18, 95% CI 0.18-0.18) to fill a statin prescription compared with DM patients. SLE patients were also less likely (OR 0.89, 95% CI 0.84-0.94) to fill a statin prescription compared with individuals in the general Medicaid population.

CONCLUSION

Despite having an elevated risk of CVD, SLE patients received less lipid testing and received fewer statin prescriptions compared with age- and sex-matched DM patients and individuals in the general Medicaid population; this gap should be a target for improvement.

Baseline Retinal Examinations in Patients With Systemic Lupus Erythematosus Newly Initiating Hydroxychloroquine Treatment in a US Medicaid Systemic Lupus Erythematosus Population, 2000-2010

OBJECTIVE

Baseline retinal examinations have long been recommended for patients beginning treatment with hydroxychloroquine (HCQ), but it is unknown how well this guideline is followed. We investigated baseline eye examinations among US SLE patients enrolled in Medicaid in whom HCQ treatment was newly initiated.

METHODS

Using billing codes, we identified SLE patients ages 18-65 years who were enrolled in Medicaid and residing in the 29 most populated US states, from 2000 to 2010. New users of HCQ were identified by filled prescriptions, with none filled in the preceding 12 months. Retinal examinations that were performed within 30 days before to 1 year after the index prescription were identified. We examined the proportions of patients receiving retinal examinations over the study years and compared the characteristics of those who did and those who did not receive examinations, using bivariable and multivariable logistic regression models.

RESULTS

Among 12,755 SLE patients newly starting HCQ treatment, 32.5% received baseline dilated eye examinations. The proportions of patients receiving baseline eye examinations did not significantly change from 2000 to 2010 (31.0-34.4%; P for linear trend = 0.12). Factors associated with an increased likelihood of having an examination included female sex, Asian versus white race, and a higher number of laboratory tests performed during the preceding year. Compared with white patients, lower proportions of black and Native American patients with SLE had baseline retinal examinations.

CONCLUSION

Only one-third of patients with SLE enrolled in Medicaid and in whom HCQ was newly initiated received the recommended baseline retinal examinations, and this proportion did not significantly increase from 2000 to 2010. The sociodemographic variation in this recommended care has been observed for other recommended medical care in SLE and requires both further investigation and interventions to address it.

Health service utilization among African American women living with systemic lupus erythematosus: perceived impacts of a self-management intervention

BACKGROUND

Healthcare access, utilization, and quality play critical roles in shaping mortality and morbidity among patients diagnosed with systemic lupus erythematosus (SLE), and yet healthcare access, utilization, and quality can be suboptimal for many people living with SLE. The aim of this qualitative study was to explore the perceived impact of a peer-led, group-based educational intervention (the Chronic Disease Self-Management Program [CDSMP]) on healthcare engagement behaviors among African American women with SLE.

METHODS

Participants were recruited from the WELL (Women Empowered to Live with Lupus) study, a behavioral trial of the effectiveness of the CDSMP on African American women diagnosed with SLE. We conducted two waves of qualitative, one-on-one, semi-structured interviews with 24 purposively sampled WELL participants; one interview was conducted before CDSMP participation and one after. Wave 1 interviews explored health service use behaviors at baseline; Wave 2 interviews focused on changes in these behaviors post-intervention and women's perceptions of whether and how the CDSMP shaped these changes. Transcripts were analyzed using thematic analysis methods.

RESULTS

Study participants perceived the CDSMP to be a valuable resource for supporting two distinct health service use behaviors: communicating with doctors (N = 16 [88.9%]) and managing medication side effects (N = 17 [41.2%]). Women perceived that the CDSMP had the most potent and widespread effects on patients' communication with doctors. Strategies that women believed generated improvements in patient-doctor communication included enhancing preparation for appointments and boosting patient participation during doctor's visits. Women's reported post-CDSMP improvements in health service use behaviors varied by disease severity and depression. Insurance coverage, while not probed directly during baseline interviews, emerged organically as a key factor affecting health service use behaviors; the CDSMP did not seem to improve participants' ability to circumvent insurance-related barriers to accessing care.

CONCLUSIONS

Our findings suggest that the CDSMP may help enhance healthcare service utilization among African American women with SLE by improving doctor/patient communication and medication side effect management. If future research confirms this conclusion, African American women living with SLE should be encouraged to participate in CDSMP workshops to enhance health service use behaviors.

TRIAL REGISTRATION

NCT02988661 . Registered 12/07/2016.

SLE mortality remains disproportionately high, despite improvements over the last decade

Despite a marked improvement in 10-year survival for systemic lupus erythematosus (SLE) patients over the past five decades, mortality rates from SLE remain high compared to those in the general population. SLE was also among the leading causes of death in young women in the United States during 2000-2015. However, it is encouraging that SLE mortality rates and the ratios of SLE mortality rates to non-SLE mortality rates have decreased every year since the late 1990s. Despite this improvement, disparities in SLE mortality persist according to sex, race, age, and place of residence. Furthermore, demographic and geographic variables seem to modify the effect of each other in influencing SLE mortality, leading to interactions between sex/race/ethnicity-associated factors and geographic differences. In other words, individuals of the same sex/race/ethnicity had differences in SLE mortality depending on where they lived. These observations highlight SLE as an important public health issue. The recognition of SLE as a leading cause of death in the general population might spur targeted public health programs and research funding to address the high lupus mortality.

Racial/ethnic variation in stroke rates and risks among patients with systemic lupus erythematosus

OBJECTIVE

Systemic lupus erythematosus (SLE), which is associated with increased stroke risk, is more prevalent and often more severe among Blacks, Asians, and Hispanics than Whites. We examined racial/ethnic variation in stroke rates and risks, overall and by hemorrhagic versus ischemic subtype, among SLE patients.

METHODS

Within Medicaid (2000-2010), we identified patients aged 18-65 with SLE (≥ 3 ICD-9 710.0 codes, ≥ 30days apart) and ≥12 months of continuous enrollment. Subjects were followed from index date to first stroke event, death, disenrollment, or end of follow-up. Race/ethnicity-specific annual event rates were calculated for stroke overall and by subtypes (hemorrhagic vs. ischemic). We used Cox proportional hazard models to estimate hazard ratios (HR) of stroke by race/ethnicity, adjusting for comorbidities and the competing risk of death.

RESULTS

Of 65,788 SLE patients, 93.1% were female. Racial/ethnic breakdown was 42% Black, 38% White, 16% Hispanic, 3% Asian, and 1% American Indian/Alaska Natives. Mean follow-up was 3.7 ± 3.0years. After multivariable adjustment, Blacks were at increased risk of overall stroke (HR 1.34 [95%CI 1.18-1.53), hemorrhagic stroke (HR 1.42 [1.00-2.01]), and ischemic stroke (HR 1.33 [1.15-1.52]) compared to Whites. Hispanics were at increased risk of overall stroke (HR 1.25 [1.06-1.47)] and hemorrhagic stroke (HR 1.79 [95% CI 1.22-2.61]), but not ischemic stroke, compared to Whites.

CONCLUSION

Among SLE patients enrolled in Medicaid, we observed elevated stroke risk (overall and by subtype) among Blacks and Hispanics compared to Whites, suggesting the importance of early recognition and screening for stroke risk factors among Blacks and Hispanics.

Sex Differences in Health Care Utilization, End-Stage Renal Disease, and Mortality Among Medicaid Beneficiaries With Incident Lupus Nephritis

OBJECTIVE

While systemic lupus erythematosus and lupus nephritis (LN) disproportionately affect females, previous studies suggest that males may experience poorer outcomes. We undertook this study to investigate sex differences in health care utilization, end-stage renal disease (ESRD), and mortality among patients with LN receiving Medicaid, public insurance for low-income individuals.

METHODS

Within the Medicaid Analytic eXtract (MAX) from 29 states (from 2000 to 2010), we used billing claims to identify individuals ages 5-65 years with incident LN (positive predictive value 80%). MAX data were linked to the US Renal Data System to determine ESRD and to Social Security Death Index files to determine death. We estimated adjusted incidence rate ratios (IRRs) by sex for health care utilization using Poisson regression, and we used multivariable proportional hazards models to compare risks of ESRD and death by sex.

RESULTS

Of 2,750 patients with incident LN, 283 (10%) were male. The mean ± SD follow-up period for both sexes was 3.1 ± 2.3 years. The mean ± SD age was 29.6 ± 13.9 years among females and 24.7 ± 14.1 years among males (P < 0.01). Males had fewer outpatient visits (IRR 0.88 [95% confidence interval (95% CI) 0.80-0.97]) and fewer emergency department visits (IRR 0.75 [95% CI 0.63-0.90]). The 5-year cumulative incidence of ESRD was 22.3% in males and 21.2% in females. The 5-year cumulative incidence of death was 9.4% in males and 9.8% in females. Comparing males to females, there were no sex differences in ESRD (subdistribution hazard ratio [HR] 1.05 [95% CI 0.76-1.45]) or death (HR 0.81 [95% CI 0.47-1.35]).

CONCLUSION

In this cohort of patients with incident LN, ESRD and mortality were extremely high overall but were not increased among males compared to females. In this vulnerable population, biologic and health care utilization differences by sex may not significantly affect outcomes.

46-Year Trends in Systemic Lupus Erythematosus Mortality in the United States, 1968 to 2013: A Nationwide Population-Based Study

BACKGROUND

No large population-based studies have been done on systemic lupus erythematosus (SLE) mortality trends in the United States.

OBJECTIVE

To identify secular trends and population characteristics associated with SLE mortality.

DESIGN

Population-based study using a national mortality database and census data.

SETTING

United States.

PARTICIPANTS

All U.S. residents, 1968 through 2013.

MEASUREMENTS

Joinpoint trend analysis of annual age-standardized mortality rates (ASMRs) for SLE and non-SLE causes by sex, race/ethnicity, and geographic region; multiple logistic regression analysis to determine independent associations of demographic variables and period with SLE mortality.

RESULTS

There were 50 249 SLE deaths and 100 851 288 non-SLE deaths from 1968 through 2013. Over this period, the SLE ASMR decreased less than the non-SLE ASMR, with a 34.6% cumulative increase in the ratio of the former to the latter. The non-SLE ASMR decreased every year starting in 1968, whereas the SLE ASMR decreased between 1968 and 1975, increased between 1975 and 1999, and decreased thereafter. Similar patterns were seen in both sexes, among black persons, and in the South. However, statistically significant increases in the SLE ASMR did not occur among white persons over the 46-year period. Females, black persons, and residents of the South had higher SLE ASMRs and larger cumulative increases in the ratio of the SLE to the non-SLE ASMR (31.4%, 62.5%, and 58.6%, respectively) than males, other racial/ethnic groups, and residents of other regions, respectively. Multiple logistic regression showed independent associations of sex, race, and region with SLE mortality risk and revealed significant racial/ethnic differences in associations of SLE mortality with sex and region.

LIMITATIONS

Underreporting of SLE on death certificates may have resulted in underestimates of SLE ASMRs. Accuracy of coding on death certificates is difficult to ascertain.

CONCLUSION

Rates of SLE mortality have decreased since 1968 but remain high relative to non-SLE mortality, and significant sex, racial, and regional disparities persist.

PRIMARY FUNDING SOURCE

None.

Disease Outcomes and Care Fragmentation Among Patients With Systemic Lupus Erythematosus

OBJECTIVE

To examine the impact of care fragmentation across multiple health care institutions on disease outcomes in patients with systemic lupus erythematosus (SLE).

METHODS

Using the Chicago HealthLNK Data Repository, an assembly of electronic health records from 6 institutions, we identified patients with SLE, using International Classification of Diseases, Ninth Revision (ICD-9) codes, whose care was delivered at more than 1 organization. We examined whether patients had severe infections or comorbidities (ICD-9 code defined) that indicated SLE-induced damage. T-tests and chi-square tests were used to examine differences between fragmentation groups. Logistic regression was used to assess factors contributing to the occurrence of disease outcomes.

RESULTS

We identified 4,276 patients with SLE. A total of 856 (20%) received care from more than 1 health care institution. African American patients and patients with public insurance were more likely to experience care fragmentation compared to white and private insurance patients (odds ratio [OR] 1.66, 95% confidence interval [95% CI] 1.44-1.97 and OR 1.63, 95% CI 1.42-1.95). We identified increased risk of infections (OR 1.57, 95% CI 1.30-1.88), cardiovascular disease (OR 1.51, 95% CI 1.23-1.86), end-stage renal disease (OR 1.34, 95% CI 1.05-1.70), nephritis (OR 1.28, 95% CI 1.07-1.54), and stroke (OR 1.28, 95% CI 1.01-1.62) among patients with fragmented care, adjusted for age, sex, race, insurance status, length of followup time, and total visit count.

CONCLUSION

In this cross-site cohort of SLE patients, care fragmentation is associated with increased risk of severe infection and comorbidities. These results suggest that improved health information exchange could positively impact outcomes for SLE patients.

Quality of Care for Systemic Lupus Erythematosus: Mind the Knowledge Gap

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.

Evaluation of quality indicators and disease damage in childhood-onset systemic lupus erythematosus patients

The aim of this study was to describe compliance with select quality indicators and assess organ-specific dysfunction in a childhood-onset systemic lupus erythematosus population by using a validated damage index and to evaluate associations between compliance with quality indicators and disease damage. A retrospective chart review was performed on patients diagnosed with systemic lupus erythematosus prior to age 18 followed at a single center in the USA from 1999 to 2012 (n = 75). Data regarding quality indicators and outcome variables, including the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index, were collected. The median disease duration was 3.8 years. The proportion of patients or patient-years in which care complied with the proposed quality measures was 94.4% for hydroxychloroquine use, 84.3% for vitamin D recommendation,75.8% for influenza vaccination (patient-years), 67.2% for meningococcal vaccination, 49.0% for ophthalmologic examination (patient-years), 31.7% for pneumococcal vaccination, and 28.6% for bone mineral density evaluation. Disease damage was present in 41.3% of patients at last follow-up, with an average damage index score of 0.81. Disease damage at last follow-up was associated with minority race/ethnicity (p = 0.008), bone mineral density evaluation (p = 0.035), and vitamin D recommendation (p = 0.018). Adherence to quality indicators in a childhood-onset systemic lupus erythematosus population is varied, and disease damage is prevalent. This study highlights the importance of quality improvement initiatives aimed at optimizing care delivery to reduce disease damage in pediatric lupus patients.

Rheumatologists' perception of systemic lupus erythematosus quality indicators: significant interest and perceived barriers

Differences in quality of care may contribute to health disparities in systemic lupus erythematosus (SLE). Studies show low physician adherence rates to the SLE quality indicators but do not assess physician perception of SLE quality indicators or quality improvement. Using a cross-sectional survey of rheumatologists in the southeastern USA, we assessed the perception and involvement of rheumatologists in quality improvement and the SLE quality indicators. Using electronic mail, an online survey of 32 questions was delivered to 568 rheumatologists. With a response rate of 19% (n = 106), the majority of participants were male, Caucasian, with over 20 years of experience, and seeing adult patients in an academic setting. Participants had a positive perception toward quality improvement (81%) with a majority responding that the SLE quality indicators would significantly impact quality of care (54%). While 66% of respondents were familiar with the SLE quality indicators, only 18% of respondents reported using them in everyday practice. The most commonly reported barrier to involvement in quality improvement and the SLE quality indicators was time. Rheumatologists had a positive perception of the SLE quality indicators and agreed that use of the quality indicators could improve quality of care in SLE; however, they identified time as a barrier to implementation. Future studies should investigate methods to increase use of the SLE quality indicators.

A systems approach to renal inflammation in SLE

Lupus disease and its complications including lupus nephritis (LN) are very disabling and significantly impact the quality of life and longevity of patients. Broadly immunosuppressive treatments do not always provide the expected clinical benefits and have significant side effects that contribute to patient morbidity. In the era of systems biology, new strategies are being deployed integrating diverse sources of information (molecular and clinical) so as to identify individual disease specificities and select less aggressive treatments. In this review, we summarize integrative approaches linking molecular disease profiles (mainly tissue transcriptomics) and clinical phenotypes. The main goals are to better understand the pathogenesis of lupus nephritis, to identify the risk factors for renal flare and to find the predictors of both short and long-term clinical outcome. Identification of common key drivers and additional patient-specific key drivers can open the door to improved and individualized therapy to prevent and treat LN.

Insights into the epidemiology and management of lupus nephritis from the US rheumatologist's perspective

Lupus nephritis is a common and severe manifestation of systemic lupus erythematosus that disproportionately affects nonwhites and those in lower socioeconomic groups. This review discusses recent data on the incidence, prevalence, and outcomes of patients with lupus nephritis with a focus on low-income US Medicaid patients. We also review recent guidelines on diagnosis, treatment, and screening for new onset and relapses of lupus nephritis. Finally, we discuss the management of lupus nephritis from a rheumatologist's perspective, including vigilance for the common adverse events related to disease and treatment, and we review prevention and new treatment strategies.

Incidence of End-Stage Renal Disease Among Newly Diagnosed Systemic Lupus Erythematosus Patients: The Georgia Lupus Registry

OBJECTIVE

To estimate and identify factors associated with the incidence of all-cause end-stage renal disease (ESRD) among newly diagnosed systemic lupus erythematosus (SLE) patients.

METHODS

Data from a national registry of treated ESRD were linked to data from a lupus registry of SLE patients who were newly diagnosed and living in Atlanta, Georgia, 2002-2004 (median followup 7.8 years). Cumulative incidence and incidence rates (ESRD treatment initiations per 1,000 patient-years) were calculated, and age- and race-adjusted Poisson models were used to calculate incidence rate ratios (IRRs).

RESULTS

Among 344 newly diagnosed SLE patients, 29 initiated ESRD treatment over 2,603.8 years of followup. Incidence rates were 13.8 (95% confidence interval [95% CI] 9.4-20.3) among black patients and 3.3 (95% CI 0.8-13.0) among white patients, per 1,000 patient-years; corresponding 5-year cumulative incidence was 6.4% and 2.5% among black and white patients, respectively. Lupus nephritis documented prior to 2005, which occurred in 80% of those who progressed to ESRD, was the strongest risk factor for incident ESRD (IRR 6.7 [95% CI 2.7-16.8]; incidence rate 27.6 per 1,000 patient-years). Results suggested that patients who were black versus white (IRR 3.9 [95% CI 0.9-16.4]) or <18 years old (versus ≥30 years old) at diagnosis (IRR 2.1 [95% CI 0.9-5.3]) may be more likely to progress to ESRD, but incidence did not differ by sex or other characteristics.

CONCLUSION

The incidence of all-cause ESRD among patients with a recent diagnosis of SLE is high in Georgia. Interventions to decrease ESRD incidence among newly diagnosed SLE patients should target young and black patients, as well as patients with lupus nephritis.

What is damaging the kidney in lupus nephritis?

Despite marked improvements in the survival of patients with severe lupus nephritis over the past 50 years, the rate of complete clinical remission after immune suppression therapy is <50% and renal impairment still occurs in 40% of affected patients. An appreciation of the factors that lead to the development of chronic kidney disease following acute or subacute renal injury in patients with systemic lupus erythematosus is beginning to emerge. Processes that contribute to end-stage renal injury include continuing inflammation, activation of intrinsic renal cells, cell stress and hypoxia, metabolic abnormalities, aberrant tissue repair and tissue fibrosis. A deeper understanding of these processes is leading to the development of novel or adjunctive therapies that could protect the kidney from the secondary non-immune consequences of acute injury. Approaches based on a molecular-proteomic-lipidomic classification of disease should yield new information about the functional basis of disease heterogeneity so that the most effective and least toxic treatment regimens can be formulated for individual patients.

A highlight from the LUPUS 2014 meeting: eight great ideas

This review describes eight 'great ideas' regarding bench-to-bedside considerations in systemic lupus erythematosus (SLE) presented at the second international LUPUS meeting in Quebec, September 2014. The topics included: correcting the impaired clearance of apoptotic fragments; optimisation of clinical trial design: the PERFECT (Pre Evaluation Reducing Frighteningly Elevated Coverable Targets) study; lipidomics and metabolomics in SLE; importance of the inflammasome; identification and treatment of asymptomatic autoimmunity: prevention of SLE; combining low doses of hydroxychloroquine and quinacrine for long-term maintenance therapy of SLE; reducing emergency room visits and the critical relevance of the autoantigen.

Sociodemographic and geographic predictors of quality of care in United States patients with end-stage renal disease due to lupus nephritis

OBJECTIVE

To describe end-stage renal disease (ESRD) quality of care (receipt of pre-ESRD nephrology care, access to kidney transplantation, and placement of permanent vascular access for dialysis) in US patients with ESRD due to lupus nephritis (LN-ESRD) and to examine whether quality measures differ by patient sociodemographic characteristics or US region.

METHODS

National surveillance data on patients in the US in whom treatment for LN-ESRD was initiated between July 2005 and September 2011 (n = 6,594) were analyzed. Odds ratios (ORs) and hazard ratios (HRs) with 95% confidence intervals (95% CIs) were determined for each quality measure, according to sociodemographic factors and US region.

RESULTS

Overall, 71% of the patients received nephrology care prior to ESRD. Black and Hispanic patients were less likely than white patients to receive pre-ESRD care (OR 0.73 [95% CI 0.63-0.85] and OR 0.73 [95% CI 0.60-0.88], respectively) and to be placed on the kidney transplant waitlist within the first year after the start of ESRD (HR 0.78 [95% CI 0.68-0.91] and HR 0.82 [95% CI 0.68-0.98], respectively). Those with Medicaid (HR 0.51 [95% CI 0.44-0.58]) or no insurance (HR 0.36 [95% CI 0.29-0.44]) were less likely than those with private insurance to be placed on the waitlist. Only 24% had a permanent vascular access, and placement was even less likely among the uninsured (OR 0.62 [95% CI 0.49-0.79]). ESRD quality-of-care measures varied 2-3-fold across regions of the US, with patients in the Northeast and Northwest generally having higher probabilities of adequate care.

CONCLUSION

LN-ESRD patients have suboptimal ESRD care, particularly with regard to placement of dialysis vascular access. Minority race/ethnicity and lack of private insurance are associated with inadequate ESRD care. Further studies are warranted to examine multilevel barriers to, and develop targeted interventions to improve delivery of, care among patients with LN-ESRD.

Interactions between patients, providers, and health systems and technical quality of care

OBJECTIVE

Prior studies have established disparities by race/ethnicity and socioeconomic status (SES) in the kind, quantity, and technical quality of systemic lupus erythematosus (SLE) care and outcomes. In this study we evaluate whether disparities exist in assessments of interactions with health care providers and health plans and whether such interactions affect the technical quality of SLE care.

METHODS

Data derive from the Lupus Outcomes Study (LOS). Principal data collection is an annual structured phone interview including items from the Consumer Assessment of Health Plans and Interpersonal Processes of Care Scale measuring dimensions of health care interactions. We use general estimating equations to assess whether disparities exist by race/ethnicity and SES in being in the lowest quartile of ratings of such interactions and whether ratings in the lowest quartile of interactions are associated with technical quality of care after adjustment for sociodemographic and disease characteristics.

RESULTS

In the 2012 LOS interview, there were 793 respondents, of whom 640 had ≥1 visit to their principal SLE provider. Nonwhite race/ethnicity and education were not associated with low ratings on any dimension of provider or system interaction; poverty was associated only with low ratings of health plan interactions. After adjustment for demographics, SLE status, and health care variables, ratings in the lowest quartile on all dimensions were associated with significantly lower technical quality of care.

CONCLUSION

Ratings in the lowest quartile on all dimensions of interactions with providers and the health care system were associated with lower technical quality of care, potentially resulting in poorer SLE outcomes.

Thirty-day hospital readmissions in systemic lupus erythematosus: predictors and hospital- and state-level variation

OBJECTIVE

Systemic lupus erythematosus (SLE) has one of the highest hospital readmission rates among chronic conditions. This study was undertaken to identify patient-level, hospital-level, and geographic predictors of 30-day hospital readmissions associated with SLE.

METHODS

Using hospital discharge databases from 5 geographically dispersed states, we studied all-cause readmission of SLE patients between 2008 and 2009. We evaluated each hospitalization as a possible index event leading up to a readmission, our primary outcome. We accounted for clustering of hospitalizations within patients and within hospitals and adjusted for hospital case mix. Using multilevel mixed-effects logistic regression, we examined factors associated with 30-day readmission and calculated risk-standardized hospital-level and state-level readmission rates.

RESULTS

We examined 55,936 hospitalizations among 31,903 patients with SLE. Of these hospitalizations, 9,244 (16.5%) resulted in readmission within 30 days. In adjusted analyses, age was inversely related to risk of readmission. African American and Hispanic patients were more likely to be readmitted than white patients, as were those with Medicare or Medicaid insurance (versus private insurance). Several clinical characteristics of lupus, including nephritis, serositis, and thrombocytopenia, were associated with readmission. Readmission rates varied significantly between hospitals after accounting for patient-level clustering and hospital case mix. We also found geographic variation, with risk-adjusted readmission rates lower in New York and higher in Florida as compared to California.

CONCLUSION

We found that ~1 in 6 hospitalized patients with SLE were readmitted within 30 days of discharge, with higher rates among historically underserved populations. Significant geographic and hospital-level variation in risk-adjusted readmission rates suggests potential for quality improvement.