1
|
Sura A, Failing C, Co DO, Syverson G. Childhood-Onset Systemic Lupus Erythematosus. Pediatr Rev 2024; 45:316-328. [PMID: 38821900 DOI: 10.1542/pir.2023-006011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 12/06/2023] [Accepted: 12/11/2023] [Indexed: 06/02/2024]
Affiliation(s)
- Anjali Sura
- SUNY Upstate Medical University, Syracuse, NY
| | | | - Dominic O Co
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | |
Collapse
|
2
|
Tanner TI, Agalliu I, Wahezi DM, Rubinstein TB. Relationship of regional ultraviolet index data with rash and systemic disease activity in youth with childhood-onset systemic lupus: results from the Childhood Arthritis and Rheumatology Research Alliance Registry. Pediatr Rheumatol Online J 2024; 22:54. [PMID: 38750564 PMCID: PMC11094899 DOI: 10.1186/s12969-024-00973-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/04/2024] [Indexed: 05/19/2024] Open
Abstract
OBJECTIVE To investigate the association between ultraviolet light index (UVI), as a marker for UV exposure, and seasonality with rash and systemic disease activity in youth with childhood-onset systemic lupus (cSLE) from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry. METHODS We reviewed data on rash and disease activity from Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2 K) scores from cSLE CARRA Registry participants with visits between 2010 and 2019 and obtained zipcode level UVI data from the National Oceanic and Atmospheric Administration (NOAA). Our main exposures were UVI and season during the month of visit and one month prior to visit. We used mixed-effects logistic regression models to examine associations between regional UVI (by zipcode)/season and odds of rash and severe SLEDAI-2 K score (≥ 5 vs. 0-4), adjusting for age, sex, race and income. RESULTS Among 1222 participants, with a mean of 2.3 visits per participant, 437 visits (15%) had rash and 860 (30%) had SLEDAI-2 K score ≥ 5. There were no associations between UVI during the month prior to visit or the month of the visit and odds of rash or elevated systemic activity. However, fall season was associated with increased odds of rash (OR = 1.59, p = 0.04), but not increased disease activity. CONCLUSION This study found no association between UVI and rash or UVI and disease activity. However, further studies directly measuring UV exposure and accounting for patient-level protective behavioral measures may help to better understand the complex relationship between sun exposure and SLE disease activity.
Collapse
Affiliation(s)
- Tamara I Tanner
- Division of Pediatric Rheumatology, Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA
- Division of Pediatric Rheumatology, Children's Hospital at Montefiore, Bronx, NY, USA
| | - Ilir Agalliu
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Dawn M Wahezi
- Division of Pediatric Rheumatology, Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA
- Division of Pediatric Rheumatology, Children's Hospital at Montefiore, Bronx, NY, USA
| | - Tamar B Rubinstein
- Division of Pediatric Rheumatology, Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA.
- Division of Pediatric Rheumatology, Children's Hospital at Montefiore, Bronx, NY, USA.
- Department of Psychiatry & Behavioral Sciences, Albert Einstein College of Medicine, Bronx, NY, USA.
| |
Collapse
|
3
|
Correll CK, Klein-Gitelman MS, Henrickson M, Battafarano DF, Orr CJ, Leonard MB, Mehta JJ. Child Health Needs and the Pediatric Rheumatology Workforce: 2020-2040. Pediatrics 2024; 153:e2023063678R. [PMID: 38300008 DOI: 10.1542/peds.2023-063678r] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 02/02/2024] Open
Abstract
The Pediatric Rheumatology (PRH) workforce supply in the United States does not meet the needs of children. Lack of timely access to PRH care is associated with poor outcomes for children with rheumatic diseases. This article is part of a Pediatrics supplement focused on anticipating the future pediatric subspecialty workforce supply. It draws on information in the literature, American Board of Pediatrics data, and findings from a model that estimates the future supply of pediatric subspecialists developed by the Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill, Strategic Modeling and Analysis Ltd., and the American Board of Pediatrics Foundation. PRH has a smaller workforce per capita of children than most other pediatric subspecialties. The model demonstrates that the clinical workforce equivalent of pediatric rheumatologists in 2020 was only 0.27 per 100 000 children, with a predicted increase to 0.47 by 2040. Although the model predicts a 72% increase in providers, this number remains inadequate to provide sufficient care given the number of children with rheumatic diseases, especially in the South and West regions. The likely reasons for the workforce shortage are multifactorial, including lack of awareness of the field, low salaries compared with most other medical specialties, concerns about working solo or in small group practices, and increasing provider retirement. Novel interventions are needed to increase the workforce size. The American College of Rheumatology has recognized the dire consequences of this shortage and has developed a workforce solutions initiative to tackle these problems.
Collapse
Affiliation(s)
- Colleen K Correll
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Marisa S Klein-Gitelman
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Michael Henrickson
- Department of Pediatrics, College of Medicine, University of Cincinnati, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Colin J Orr
- Department of Pediatrics
- Cecil G. Sheps Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Mary B Leonard
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Jay J Mehta
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| |
Collapse
|
4
|
Tanner TI, Agalliu I, Wahezi DM, Rubinstein T. Relationship of ultraviolet light exposure and cutaneous and systemic disease activity in youth with childhood-onset systemic lupus: Results from the Childhood Arthritis and Rheumatology Research Alliance Registry. RESEARCH SQUARE 2024:rs.3.rs-3777774. [PMID: 38260281 PMCID: PMC10802735 DOI: 10.21203/rs.3.rs-3777774/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Objective To investigate the association between sun exposure measured by ultraviolet light index (UVI) and seasonality with rash and systemic disease activity in youth with childhood-onset systemic lupus (cSLE) from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry. Methods We reviewed data on rash and disease activity from Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) scores from cSLE CARRA Registry participants with visits between 2010 and 2019 and obtained UVI data from the National Oceanic and Atmospheric Administration (NOAA). Our main exposures were UVI and season during the month of visit and one month prior to visit. We used mixed-effects logistic regression to examine an association between UVI/season and rash / SLEDAI-2K score, adjusting for age, sex, race and income. Results Among 1222 participants, with a mean of 2.3 visits/participant, 437 visits (15%) had rash and 860 (30%) had SLEDAI-2K score ≥ 5. There were no associations between UVI during the month prior to visit, or the month of the visit and odds of rash or elevated systemic activity. However, fall season was associated with increased odds of rash (OR = 1.59, p = 0.04), but there not increased disease activity. Conclusion While we found no association between UVI and rash or UVI and disease activity, further studies directly measuring UVI may help further understand whether a relationship exists between sun exposure and SLE disease activity and whether this is an area that continues to require clinical attention.
Collapse
|
5
|
Campbell JA, Wilson L, Shenoi S. Barriers and Solutions for Pediatric Rheumatology Referrals in a Rural Area: Physician Survey Results From Montana State. J Clin Rheumatol 2023; 29:370-374. [PMID: 37644647 DOI: 10.1097/rhu.0000000000002017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
BACKGROUND Currently, there are 9 states across the United States that do not have a pediatric rheumatologist, including the state of Montana. Patients in these states are often cared for by outreach clinics staffed by pediatric rheumatology (PR) providers from other states or looked after by in-state adult rheumatologists or in-state primary care providers. METHODS Using a web-based survey, we determined barriers and potential solutions to PR referrals from referring providers (including primary care providers and subspecialists) in Montana state. RESULTS Eighty-five Montana referring providers responded, with 44% being pediatric physicians and 33% being family medicine physicians. Other respondents were adult rheumatologists, pediatric and family medicine advanced practice providers, orthopedic surgeons, and pediatric subspecialists. Eighty-five percent of providers had previously referred a patient to PR. Referring providers rated difficulty referring MT patients to PR as 27 (on a linear numeric scale of 0-100, with 0 being very difficult) and noted lack of access to local pediatric rheumatologist as the most significant barrier to referral. The top patient barrier as perceived by 95% of providers was travel time. Potential solutions to improve care included presence of local pediatric rheumatologist with 50 miles, development of algorithms for common PR complaints, and outreach clinics. CONCLUSION Referring providers in Montana report difficulty in referring to PR, with lack of access and travel time being key barriers. Improving access through expanding local PR workforce and increasing access through outreach clinics may help reduce these barriers.
Collapse
Affiliation(s)
- Julie A Campbell
- From the Pediatric Rheumatology, Seattle Children's Hospital and University of Washington, Seattle, WA
| | - Lauren Wilson
- Pediatric Hospital Medicine, Community Medical Center, Missoula, MT
| | - Susan Shenoi
- From the Pediatric Rheumatology, Seattle Children's Hospital and University of Washington, Seattle, WA
| |
Collapse
|
6
|
Woo JM, Simmonds F, Dennos A, Son MBF, Lewandowski LB, Rubinstein TB. Health Equity Implications of Missing Data Among Youths With Childhood-Onset Systemic Lupus Erythematosus: A Proof-of-Concept Study in the Childhood Arthritis and Rheumatology Research Alliance Registry. Arthritis Care Res (Hoboken) 2023; 75:2285-2294. [PMID: 37093036 PMCID: PMC10593908 DOI: 10.1002/acr.25136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 03/15/2023] [Accepted: 04/18/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVE Health disparities in childhood-onset systemic lupus erythematosus (SLE) disproportionately impact marginalized populations. Socioeconomically patterned missing data can magnify existing health inequities by supporting inferences that may misrepresent populations of interest. Our objective was to assess missing data and subsequent health equity implications among participants with childhood-onset SLE enrolled in a large pediatric rheumatology registry. METHODS We evaluated co-missingness of 12 variables representing demographics, socioeconomic position, and clinical factors (e.g., disease-related indices) using Childhood Arthritis and Rheumatology Research Alliance Registry childhood-onset SLE enrollment data (2015-2022; n = 766). We performed logistic regression to calculate odds ratios (ORs) and 95% confidence intervals (95% CIs) for missing disease-related indices at enrollment (Systemic Lupus Erythematosus Disease Activity Index 2000 [SLEDAI-2K] and/or Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index [SDI]) associated with data missingness. We used linear regression to assess the association between socioeconomic factors and SLEDAI-2K at enrollment using 3 analytic methods for missing data: complete case analysis, multiple imputation, and nonprobabilistic bias analyses, with missing values imputed to represent extreme low or high disadvantage. RESULTS On average, participants were missing 6.2% of data, with over 50% of participants missing at least 1 variable. Missing data correlated most closely with variables within data categories (i.e., demographic). Government-assisted health insurance was associated with missing SLEDAI-2K and/or SDI scores compared to private health insurance (OR 2.04 [95% CI 1.22, 3.41]). The different analytic approaches resulted in varying analytic sample sizes and fundamentally conflicting estimated associations. CONCLUSION Our results support intentional evaluation of missing data to inform effect estimate interpretation and critical assessment of causal statements that might otherwise misrepresent health inequities.
Collapse
Affiliation(s)
- Jennifer M.P. Woo
- Epidemiology Branch, National Institute of Environmental Health Sciences (NIEHS), National Institutes of Health (NIH), Department of Health and Human Services (DHHS), Research Triangle Park, NC, USA
| | - Faith Simmonds
- Lupus Genomics and Global Health Disparities Unit, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, DHHS, Bethesda, MD, USA
| | - Anne Dennos
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Mary Beth F. Son
- Division of Immunology, Boston Children’s Hospital, Boston MA, USA
| | - Laura B. Lewandowski
- Lupus Genomics and Global Health Disparities Unit, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, DHHS, Bethesda, MD, USA
| | - Tamar B. Rubinstein
- Division of Pediatric Rheumatology, Children’s Hospital at Montefiore, Bronx, NY, USA
- Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Bronx, NY, USA
| |
Collapse
|
7
|
Stubbs LA, Ferry AM, Guffey D, Loccke C, Wade EM, Pour P, Ardalan K, Chira P, Ganske IM, Glaser D, Higgins G, Luca N, Moore KF, Sivaraman V, Stewart K, Vasquez-Canizares N, Hunt RD, Maricevich RS, Torok KS, Li SC. Barriers to care in juvenile localized and systemic scleroderma: an exploratory survey study of caregivers' perspectives. Pediatr Rheumatol Online J 2023; 21:39. [PMID: 37098622 PMCID: PMC10131373 DOI: 10.1186/s12969-023-00819-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/12/2023] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND Juvenile localized scleroderma (LS) and systemic sclerosis (SSc) are rare pediatric conditions often associated with severe morbidities. Delays in diagnosis are common, increasing the risk for permanent damage and worse outcomes. This study explored caregiver perspectives on barriers they encountered while navigating diagnosis and care for their child's scleroderma. METHODS In this cross-sectional study, caregivers of juvenile LS or SSc patients were recruited from a virtual family scleroderma educational conference and a juvenile scleroderma online interest group. The survey queried respondents about their child's condition and factors affecting diagnosis and treatment. RESULTS The response rate was 61% (73/120), with 38 parents of LS patients and 31 parents of SSc patients. Most patients were female (80%) and over half were non-Hispanic white (55%). Most families had at least one person with a college education or higher (87%), traveled ≤ 2 h to see their rheumatologist (83%), and had private insurance (75%). Almost half had an annual household income ≥ $100,000 (46%). Families identified the following factors as barriers to care: lack of knowledge about scleroderma in the medical community, finding reliable information about pediatric scleroderma, long wait times/distances for a rheumatology/specialist appointment, balance of school/work and child's healthcare needs, medication side effects, and identifying effective medications. The barrier most identified as a major problem was the lack of knowledge about juvenile scleroderma in the medical community. Public insurance, household income less than $100,000, and Hispanic ethnicity were associated with specific barriers to care. Lower socioeconomic status was associated with longer travel times to see the rheumatologist/specialist. Diagnosis and systemic treatment initiation occurred at greater than one year from initial presentation for approximately 28% and 36% of patients, respectively. Families of LS patients were commonly given erroneous information about the disease, including on the need and importance of treating active disease with systemic immunosuppressants in patients with deep tissue or rapidly progressive disease. CONCLUSION Caregivers of children with LS or SSc reported numerous common barriers to the diagnosis, treatment, and ongoing care of juvenile scleroderma. The major problem highlighted was the lack of knowledge of scleroderma within the general medical community. Given that most of the caregiver respondents to the survey had relatively high socioeconomic status, additional studies are needed to reach a broader audience, including caregivers with limited English proficiency, geographical limitations, and financial constraints, to determine if the identified problems are generalizable. Identifying key care barriers will help direct efforts to address needs, reduce disparities in care, and improve patient outcomes.
Collapse
Affiliation(s)
- Leigh A Stubbs
- Department of Pediatrics, Division of Rheumatology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Andrew M Ferry
- Department of Plastic Surgery, Division of Pediatric Plastic Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Danielle Guffey
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX, USA
| | - Christina Loccke
- Board of Directors, National Scleroderma Foundation, Danvers, MA, USA
| | | | - Pamela Pour
- Advisory Board Member, Scleroderma Foundation Michigan Chapter, Southfield, MI, USA
| | - Kaveh Ardalan
- Department of Pediatrics, Division of Rheumatology, Duke University School of Medicine, Durham, NC, USA
| | - Peter Chira
- Department of Pediatrics, Division of Rheumatology, University of California San Diego, San Diego, CA, USA
| | - Ingrid M Ganske
- Department of Plastic and Oral Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Daniel Glaser
- Department of Pediatrics, Section of General Pediatrics, Yale University, New Haven, CT, USA
| | - Gloria Higgins
- Department of Pediatrics, Division of Rheumatology, Ohio State University College of Medicine and Nationwide Children's Hospital, Columbus, OH, USA
| | - Nadia Luca
- Department of Pediatrics, Division of Pediatric Rheumatology, University of Calgary and Alberta Children's Hospital Research Institute, Calgary, AB, Canada
| | - Katharine F Moore
- Department of Pediatrics, Division of Pediatric Rheumatology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Vidya Sivaraman
- Department of Pediatrics, Division of Rheumatology, Ohio State University College of Medicine and Nationwide Children's Hospital, Columbus, OH, USA
| | - Katie Stewart
- Department of Pediatrics, Division of Pediatric Rheumatology, University of Texas Southwestern, Dallas, TX, USA
| | - Natalia Vasquez-Canizares
- Department of Pediatrics, Division of Pediatric Rheumatology, Albert Einstein College of Medicine and Children's Hospital at Montefiore, Bronx, NY, USA
| | - Raegan D Hunt
- Department of Dermatology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Renata S Maricevich
- Department of Plastic Surgery, Division of Pediatric Plastic Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Kathryn S Torok
- Department of Pediatrics, Division of Pediatric Rheumatology, University of Pittsburgh and Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Suzanne C Li
- Department of Pediatrics, Division of Pediatric Rheumatology, Joseph M. Sanzari Children's Hospital, Hackensack Meridian School of Medicine, 30 Prospect Avenue, Hackensack, NJ, 07601, USA.
| |
Collapse
|
8
|
Myers AL, Fussell JJ, Moffatt ME, Boyer D, Ross R, Dammann CEL, Degnon L, Weiss P, Sauer C, Vinci RJ. The Importance of Subspecialty Pediatricians to the Health and Wellbeing of the Nation's Children. J Pediatr 2023:13365. [PMID: 36894130 DOI: 10.1016/j.jpeds.2023.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 03/11/2023]
Abstract
Through this review of published literature, it is clear that children benefit in measurable ways when they receive care from trained pediatric subspecialists. The improved outcomes provided by pediatric subspecialists supports the care provided in the patient's pediatric medical home and emphasizes the importance of care coordination between all components of the pediatric workforce. The AAP highlights this in a recent policy statement by stating the care provided by pediatric clinicians "encompasses diagnosis and treatment of acute and chronic health disorders; management of serious and life-threatening illnesses; and when appropriate, referral of patients with more complex conditions for medical subspecialty or surgical specialty care" Explicit in this statement is the emphasis on the role of complex care coordination between pediatric specialist and primary care pediatricians and that collaboration and guidance by the pediatrician is central to providing optimal care of patients. 65 Improving health outcomes early in life is an important public health strategy for modifying the complications from childhood chronic disease and highlights the role of pediatricians in mitigating the long-term consequences of antecedents of adult disease. 66 The recent announcement of the National Academies of Science, Engineering, and Medicine (NASEM)'s plan for a Consensus Study on The Pediatric Subspecialty Workforce and Its Impact on Child Health and Well-being is a related and exciting development, on a national scale. 67 In response to shortages and geographic maldistributions of pediatric subspecialists, the NASEM committee intends to assess the impact of current pediatric clinical workforce trends on child health and well-being, in order to develop informed strategies to ensure an adequate, high-quality pediatric workforce, with a robust research portfolio that informs those recommendations. While this large, national initiative will surely lead to a better understanding of and strategies to implement across the pediatric subspecialty workforce, more well-designed studies that specifically measure child outcomes related to access to pediatric subspecialty care, would add meaningfully to the body of pediatric literature and to our national pediatric advocacy initiatives.
Collapse
Affiliation(s)
- Angela L Myers
- Professor of Pediatrics, Children's Mercy, Kansas City, University of Missouri-Kansas City, KC, MO
| | - Jill J Fussell
- Professor, University of Arkansas for Medical Sciences/Arkansas Children's Hospital, Little Rock, AR
| | - Mary E Moffatt
- Professor of Pediatrics, Children's Mercy, Kansas City, University of Missouri-Kansas City, KC, MO
| | - Debra Boyer
- DIO/Chief Medical Education Officer, Professor of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Robert Ross
- Children's Hospital of Michigan, Professor of Pediatrics, Central Michigan University College of Medicine, Detroit, MI
| | | | | | - Pnina Weiss
- Professor of Pediatrics, Yale School of Medicine, New Haven, CT
| | - Cary Sauer
- Professor of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Robert J Vinci
- Professor of Pediatrics, Boston University School of Medicine, Boston, MA
| |
Collapse
|
9
|
Davis A, Faerber J, Ardalan K, Katcoff H, Klein-Gitelman M, Rubinstein TB, Cidav Z, Mandell DS, Knight A. The Effect of Psychiatric Comorbidity on Healthcare Utilization for Youth With Newly Diagnosed Systemic Lupus Erythematosus. J Rheumatol 2023; 50:204-212. [PMID: 36109077 DOI: 10.3899/jrheum.220052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To examine the effect of psychiatric diagnoses on healthcare use in youth with systemic lupus erythematosus (SLE) during their first year of SLE care. METHODS We conducted a retrospective cohort study using claims from 2000 to 2013 from Clinformatics Data Mart (OptumInsight). Youth aged 10 years to 24 years with an incident diagnosis of SLE (≥ 3 International Classification of Diseases, 9th revision, codes for SLE 710.0, > 30 days apart) were categorized as having: (1) a preceding psychiatric diagnosis in the year before SLE diagnosis, (2) an incident psychiatric diagnosis in the year after SLE diagnosis, or (3) no psychiatric diagnosis. We compared ambulatory, emergency, and inpatient visits in the year after SLE diagnosis, stratified by nonpsychiatric and psychiatric visits. We examined the effect of childhood-onset vs adult-onset SLE by testing for an interaction between age and psychiatric exposure on outcome. RESULTS We identified 650 youth with an incident diagnosis of SLE, of which 122 (19%) had a preceding psychiatric diagnosis and 105 (16%) had an incident psychiatric diagnosis. Compared with those without a psychiatric diagnosis, youth with SLE and a preceding or incident psychiatric diagnosis had more healthcare use across both ambulatory and emergency settings for both nonpsychiatric and psychiatric-related care. These associations were minimally affected by age at time of SLE diagnosis. CONCLUSION Psychiatric comorbidity is common among youth with newly diagnosed SLE and is associated with greater healthcare use. Interventions to address preceding and incident psychiatric comorbidity may decrease healthcare burden for youth with SLE.
Collapse
Affiliation(s)
- Alaina Davis
- A. Davis, MD, MPH, Department of Pediatrics, Division of Pediatric Rheumatology, Monroe Carell Junior Children's Hospital at Vanderbilt, Nashville, Tennessee, USA;
| | - Jennifer Faerber
- J. Faerber, PhD, Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kaveh Ardalan
- K. Ardalan, MD, MS, Department of Pediatrics (Division of Pediatric Rheumatology), Duke University School of Medicine, Durham, North Carolina, and Departments of Pediatrics and Medical Social Sciences, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Hannah Katcoff
- H. Katcoff, MPH, Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Marisa Klein-Gitelman
- M. Klein-Gitelman, MD, MPH, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Tamar B Rubinstein
- T.B. Rubinstein, MD, Department of Pediatrics, Division of Pediatric Rheumatology, Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Zuleyha Cidav
- Z. Cidav, PhD, Leonard Davis Institute of Health Economics, University of Pennsylvania, and Center for Mental Health, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David S Mandell
- D.S. Mandell, ScD, Center for Mental Health, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrea Knight
- A. Knight, MD, MSCE, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, and PolicyLab, Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania, USA, and Division of Rheumatology, Hospital for Sick Children, Toronto, Ontario, Canada
| |
Collapse
|
10
|
Hasan B, Fike A, Hasni S. Health disparities in systemic lupus erythematosus-a narrative review. Clin Rheumatol 2022; 41:3299-3311. [PMID: 35907971 PMCID: PMC9340727 DOI: 10.1007/s10067-022-06268-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 06/21/2022] [Accepted: 06/26/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW To describe root causes of health disparities by reviewing studies on incidence and outcomes of systemic lupus erythematosus (SLE) related to ethnic, race, gender, or socioeconomic differences and to propose solutions. RECENT FINDINGS SLE outcomes have steadily improved over the past 40 years but are not uniformly distributed across various racial and ethnic groups. Belonging to racial and ethnic minority has been cited as a risk factor for more severe disease and poor outcome in SLE. Population-based registries have demonstrated that Black patients with SLE have significantly lower life expectancy compared to White patients. Lower socioeconomic status has been shown to be one of the strongest predictors of progression to end stage renal disease in lupus nephritis. An association between patient experiences of racial discrimination, increased SLE activity, and damage has also been described. The lack of representation of marginalized communities in lupus clinical trials further perpetuates these disparities. To that end, the goal of a rheumatology workforce that resembles the patients it treats has emerged as one of many solutions to current shortfalls in care. Disparities in SLE incidence, treatment, and outcomes have now been well established. The root causes of these disparities are multifactorial including genetic, epigenetic, and socioeconomic. The underrepresentation of marginalized communities in lupus clinical trials further worsen these disparities. Efforts have been made recently to address disparities in a more comprehensive manner, but systemic causes of disparities must be acknowledged and political will is required for a sustained positive change.
Collapse
Affiliation(s)
- Bilal Hasan
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, MD USA
| | - Alice Fike
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, MD USA
| | - Sarfaraz Hasni
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, MD USA
| |
Collapse
|
11
|
Hussain A, Maheshwari MV, Khalid N, Patel PD, Alghareeb R. Diagnostic Delays and Psychosocial Outcomes of Childhood-Onset Systemic Lupus Erythematosus. Cureus 2022; 14:e26244. [PMID: 35911281 PMCID: PMC9313193 DOI: 10.7759/cureus.26244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2022] [Indexed: 11/15/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder that manifests in affected individuals with a variety of clinical features and involves multiple organs. Despite recent advances over the past decades, higher morbidity and mortality have been reported by studies in patients with childhood-onset systemic lupus erythematosus (cSLE) compared to patients with adult-onset. The interplay of several factors can cause diagnostic delays resulting in worse disease activity, multiple organ damage, increased risk of hospitalization, and management with aggressive treatment. Significant factors include demographic, clinical, and socioeconomic characteristics of patients with cSLE. Moreover, despite recent advances in lupus treatment, prolonged disease duration in these young patients can result in debilitating psychosocial outcomes and can significantly impact their health-related and general quality of life (QOL). Important domains affected include patient self-esteem, education, employment, healthcare utilization, and mental health. In this review, we examined the barriers that lead to a delay in diagnosing lupus in the pediatric population and addressed cSLE morbimortality and its long-term impact on patient health-related and general QOL.
Collapse
|
12
|
Chang JC, Weiss PF, Xiao R, Atkinson MA, Wenderfer SE. Use of renin angiotensin aldosterone system inhibitors in children with lupus and time to glucocorticoid discontinuation. Kidney Int 2022; 102:395-404. [PMID: 35618096 PMCID: PMC9329244 DOI: 10.1016/j.kint.2022.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 03/07/2022] [Accepted: 04/08/2022] [Indexed: 02/06/2023]
Abstract
There is little data to inform use of renin angiotensin aldosterone system (RAAS) inhibitors in pediatric patients with systemic lupus erythematosus (SLE). Here, we sought to characterize RAAS inhibitor use in pediatric SLE, and determine whether early RAAS inhibitor initiation among children with incident lupus nephritis is associated with decreased duration of chronic glucocorticoid exposure. A retrospective cohort study was performed of children (ages 5-18) with SLE and/or lupus nephritis in the Truven MarketScanΤΜ Medicaid and Commercial databases (2013-2018) and estimated RAAS inhibitor use. Among incident nephritis cases, we used competing risk hazard models with inverse probability of treatment weighting to estimate the association between RAAS inhibitor initiation less than 180 days after diagnosis and time to glucocorticoid discontinuation with kidney failure as a competing event. Among 592 children with nephritis and 1407 children with non-kidney SLE, 67% and 15% ever received RAAS inhibitors, respectively. Median duration of RAAS inhibitor use among 323 incident users was 14 and 9 months in children with and without nephritis, respectively. Medicaid enrollment was independently associated with greater likelihood of RAAS inhibitor use, irrespective of nephritis. Among 158 incident nephritis cases, early RAAS inhibitor initiation was significantly associated with a faster rate of glucocorticoid discontinuation (adjusted sub-distribution hazard ratio 1.81, 95% confidence interval [1.09 - 3.00]). Thus, early initiation of RAAS inhibitors may have a role in children newly diagnosed with lupus nephritis; not only those with refractory proteinuria after induction therapy. Hence, integrated health systems data could be leveraged to confirm these findings and optimize adjunctive therapies in pediatric lupus.
Collapse
Affiliation(s)
- Joyce C Chang
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia Research Institute, Philadelphia PA; Division of Immunology, Boston Children's Hospital and Harvard Medical School, Boston MA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA.
| | - Pamela F Weiss
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia Research Institute, Philadelphia PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA; Division of Rheumatology, The Children's Hospital of Philadelphia, Philadelphia PA
| | - Rui Xiao
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | - Scott E Wenderfer
- Pediatric Nephrology, Baylor College of Medicine, Texas Children's Hospital, Houston TX
| |
Collapse
|
13
|
A Quality Improvement Approach to Ensuring Access to Specialty Care for Pediatric Patients. Pediatr Qual Saf 2022; 7:e566. [PMID: 35720858 PMCID: PMC9197355 DOI: 10.1097/pq9.0000000000000566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 04/09/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction: With pediatric rheumatologists in short supply, maximizing appointment availability and streamlining primary/specialty collaboration are essential. Lack of an efficient referral process impacts outcomes, quality of life, satisfaction, affordability, and resource allocation. Before this quality improvement project, our clinic had a 3- to 5-month backlog for new referrals. Methods: Using the model for improvement with numerous rapid-cycle plan-do-study-act cycles, this team restructured processes, developed a triage tool for communication across the care continuum, maximized staff roles in multiple areas, and instituted cross-disciplinary communication strategies to reduce appointment delays while significantly increasing efficiency. Results: The team succeeded in decreasing time from referral to specialty consult by 60%, decreasing no-show rates from 15% to 6%, and increasing throughput by an average of 45 more patients per month. Most new patients can now see our specialists within 23 days, meaning the children in our community have 65% shorter wait times for rheumatology services. Conclusion: The use of a triage algorithm with structured communication allows multidisciplinary care teams at both the referring and receiving providers to efficiently and accurately place patients into specialty care. This highly scalable and transferable project was accomplished with no direct financial outlay yet yielded significant returns by standardizing processes, empowering the entire care team to build skills, and improving communication.
Collapse
|
14
|
Ezeh N, Ardalan K, Buhr KA, Nguyen C, Al Ahmed O, Ardoin SP, Barton V, Bell S, Brandling-Bennett H, Castelo-Soccio L, Chiu YE, Chong BF, Lara-Corrales I, Cintosun A, Curran ML, Diaz LZ, Elman SA, Faith EF, Garcia-Romero MT, Grossman-Kranseler J, Hogeling M, Hudson AD, Hunt RD, Ibler EM, Marques MC, Monir RL, Oza V, Paller AS, Putterman E, Rodriguez-Salgado P, Schoch JJ, Truong A, Wang J, Lee LW, Vleugels RA, Klein-Gitelman MS, von Scheven E, Werth VP, Arkin LM. Cross-Sectional Characteristics of Pediatric-Onset Discoid Lupus Erythematosus: Results of a Multicenter, Retrospective Cohort Study. J Am Acad Dermatol 2022; 87:559-566. [PMID: 35487332 PMCID: PMC10082546 DOI: 10.1016/j.jaad.2022.04.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 04/07/2022] [Accepted: 04/08/2022] [Indexed: 11/15/2022]
Abstract
• Discoid lupus may be associated with SLE. In this study, most children with discoid lupus did not have systemic disease. Concurrent SLE was highest in female adolescents (>10 years of age) with generalized discoid lupus, who had clinically aggressive disease. • Discoid lupus in adolescence should prompt thorough evaluation for SLE.
Collapse
Affiliation(s)
- N Ezeh
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - K Ardalan
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, Departments of Pediatrics and Medical Social Sciences, Northwestern University Feinberg School of Medicine/Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - K A Buhr
- Department of Biostatistics & Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - C Nguyen
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - O Al Ahmed
- Department of Pediatrics, Nationwide Children's Hospital/Ohio State University, Columbus OH
| | - S P Ardoin
- Department of Pediatrics, Nationwide Children's Hospital/Ohio State University, Columbus OH
| | - V Barton
- Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina, Charleston, SC
| | - S Bell
- Department of Pediatrics, Division of Rheumatology, University of California at San Francisco, San Francisco, CA
| | - H Brandling-Bennett
- Division of Dermatology; Department of Pediatrics, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, WA
| | - L Castelo-Soccio
- Children's Hospital of Philadelphia, Department of Pediatrics, Section of Dermatology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Y E Chiu
- Departments of Dermatology (Section of Pediatric Dermatology) and Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - B F Chong
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, TX; Department of Pediatrics, Division of Allergy/Immunology/Rheumatology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - I Lara-Corrales
- Department of Pediatrics, Section of Dermatology, The Hospital for Sick Children/University of Toronto, Toronto, ON
| | - A Cintosun
- Department of Pediatrics, Section of Dermatology, The Hospital for Sick Children/University of Toronto, Toronto, ON
| | - M L Curran
- Department of Pediatrics, Section of Rheumatology, Children's Hospital Colorado/University of Colorado School of Medicine, Aurora, CO
| | - L Z Diaz
- Department of Pediatrics, Division of Dermatology, Dell Medical School/Dell Children's Hospital, Austin, TX
| | - S A Elman
- Department of Dermatology, Boston's Children Hospital/Harvard Medical School, Boston, MA
| | - E Fernandez Faith
- Department of Pediatrics, Nationwide Children's Hospital/Ohio State University, Columbus OH
| | - M T Garcia-Romero
- Department of Dermatology, National Institute for Pediatrics, Mexico City, MX
| | - J Grossman-Kranseler
- Division of Dermatology; Department of Pediatrics, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, WA
| | - M Hogeling
- Department of Dermatology, University of California at Los Angeles, Los Angeles, CA
| | - A D Hudson
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, TX
| | - R D Hunt
- Department of Dermatology and Pediatrics, Texas Children's Hospital, Houston, TX
| | - E M Ibler
- Departments of Dermatology (Section of Pediatric Dermatology) and Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - M C Marques
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD
| | - R L Monir
- Department of Dermatology, University of Florida School of Medicine, Gainesville, FL
| | - V Oza
- Departments of Pediatrics and Dermatology, New York University Grossman School of Medicine, New York, NY
| | - A S Paller
- Departments of Dermatology and Pediatrics, Northwestern University Feinberg School of Medicine/Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - E Putterman
- Children's Hospital of Philadelphia, Department of Pediatrics, Section of Dermatology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - P Rodriguez-Salgado
- Department of Dermatology, National Institute for Pediatrics, Mexico City, MX
| | - J J Schoch
- Department of Dermatology, University of Florida School of Medicine, Gainesville, FL
| | - A Truong
- Department of Dermatology, University of California at Los Angeles, Los Angeles, CA
| | - J Wang
- Departments of Pediatrics and Dermatology, New York University Grossman School of Medicine, New York, NY
| | - L Wine Lee
- Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina, Charleston, SC
| | - R A Vleugels
- Department of Dermatology, Boston's Children Hospital/Harvard Medical School, Boston, MA
| | - M S Klein-Gitelman
- Department of Pediatrics, Northwestern University Feinberg School of Medicine/Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - E von Scheven
- Department of Pediatrics, Division of Rheumatology, University of California at San Francisco, San Francisco, CA
| | - V P Werth
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania and Corporal Michael J. Crescenz VAMC, Philadelphia, PA
| | - L M Arkin
- Departments of Dermatology and Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI.
| |
Collapse
|
15
|
Abstract
Health and health care disparities in pediatric rheumatology are prevalent among socially disadvantaged and marginalized populations based on race/ethnicity, socioeconomic position, and geographic region. These groups are more likely to experience greater disease severity, morbidity, mortality, decreased quality of life, and poor mental health outcomes, which are in part due to persistent structural and institutional barriers, including decreased access to quality health care. Most of the research on health and health care disparities in pediatric rheumatology focuses on juvenile idiopathic arthritis and childhood-onset systemic lupus erythematosus; there are significant gaps in the literature assessing disparities associated with other pediatric rheumatic diseases. Understanding the underlying causes of health care disparities will ultimately inform the development and implementation of innovative policies and interventions on a federal, local, and individual level.
Collapse
Affiliation(s)
- Alisha M Akinsete
- Division of Pediatric Rheumatology, Department of Pediatrics, Children's Hospital at Montefiore/Albert Einstein College of Medicine, 3415 Bainbridge Avenue, Bronx, NY 10467, USA. https://twitter.com/@akinsetemd
| | - Jennifer M P Woo
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, 111 TW Alexander Drive, Research Triangle Park, NC 27709, USA. https://twitter.com/@jmpwoo
| | - Tamar B Rubinstein
- Division of Pediatric Rheumatology, Department of Pediatrics, Children's Hospital at Montefiore/Albert Einstein College of Medicine, 3415 Bainbridge Avenue, Bronx, NY 10467, USA.
| |
Collapse
|
16
|
Trindade VC, Carneiro-Sampaio M, Bonfa E, Silva CA. An Update on the Management of Childhood-Onset Systemic Lupus Erythematosus. Paediatr Drugs 2021; 23:331-347. [PMID: 34244988 PMCID: PMC8270778 DOI: 10.1007/s40272-021-00457-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 02/06/2023]
Abstract
Childhood-onset systemic lupus erythematosus (cSLE) is a prototype of a multisystemic, inflammatory, heterogeneous autoimmune condition. This disease is characterized by simultaneous or sequential organ and system involvement, with unpredictable flare and high levels of morbidity and mortality. Racial/ethnic background, socioeconomic status, cost of medications, difficulty accessing health care, and poor adherence seem to impact lupus outcomes and treatment response. In this article, the management of cSLE patients is updated. Regarding pathogenesis, a number of potential targets for drugs have been studied. However, most treatments in pediatric patients are off-label drugs with recommendations based on inadequately powered studies, therapeutic consensus guidelines, or case series. Management practices for cSLE patients include evaluations of disease activity and cumulative damage scores, routine non-live vaccinations, physical activity, and addressing mental health issues. Antimalarials and glucocorticoids are still the most common drugs used to treat cSLE, and hydroxychloroquine is recommended for nearly all cSLE patients. Disease-modifying antirheumatic drugs (DMARDs) should be standardized for each patient, based on disease flare and cSLE severity. Mycophenolate mofetil or intravenous cyclophosphamide is suggested as induction therapy for lupus nephritis classes III and IV. Calcineurin inhibitors (cyclosporine, tacrolimus, voclosporin) appear to be another good option for cSLE patients with lupus nephritis. Regarding B-cell-targeting biologic agents, rituximab may be used for refractory lupus nephritis patients in combination with another DMARD, and belimumab was recently approved by the US Food and Drug Administration for cSLE treatment in children aged > 5 years. New therapies targeting CD20, such as atacicept and telitacicept, seem to be promising drugs for SLE patients. Anti-interferon therapies (sifalimumab and anifrolumab) have shown beneficial results in phase II randomized control trials in adult SLE patients, as have some Janus kinase inhibitors, and these could be alternative treatments for pediatric patients with severe interferon-mediated inflammatory disease in the future. In addition, strict control of proteinuria and blood pressure is required in cSLE, especially with angiotensin-converting enzyme inhibitor and angiotensin receptor blocker use.
Collapse
Affiliation(s)
- Vitor Cavalcanti Trindade
- Children and Adolescent Institute, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Magda Carneiro-Sampaio
- Children and Adolescent Institute, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Eloisa Bonfa
- Rheumatology Division, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 647, Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Clovis Artur Silva
- Children and Adolescent Institute, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil.
- Rheumatology Division, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 647, Cerqueira César, São Paulo, SP, 05403-000, Brazil.
| |
Collapse
|
17
|
Neely J, Shalen J, Sturrock H, Kim S. Access to Care and Diagnostic Delays in Juvenile Dermatomyositis: Results From the Childhood Arthritis and Rheumatology Research Alliance Legacy Registry. ACR Open Rheumatol 2021; 3:349-354. [PMID: 33932146 PMCID: PMC8126761 DOI: 10.1002/acr2.11246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 02/10/2021] [Indexed: 11/09/2022] Open
Abstract
Objective To determine factors associated with diagnostic delays and outcomes in juvenile dermatomyositis (JDM) in the Childhood Arthritis and Rheumatology Research Alliance Legacy Registry (CLR). Methods This was a cross‐sectional study of subjects aged 0 to 17 years with JDM enrolled to the CLR from 2010 to 2015. Access to care was measured by calculating the distance from the subject zip code of residence to the treating pediatric rheumatology center and determining the state density of pediatric rheumatologists based on the 2015 American College of Rheumatology Workforce Study. Delay was categorized as early (<30 days), typical (1‐3 months), moderate (3‐12 months), and severe (>12 months). Ordered generalized additive models were used to determine the association between these measures and diagnostic delays. Results The median time to diagnosis was 3.1 months; 37.2% of patients experienced moderate delays, and 14.6% experienced severe delays. In a univariate analysis, younger age of disease onset and male sex were associated with delays. Using a generalized additive model accounting for age, sex, race, and ethnicity, increasing distance from treating pediatric rheumatologist and younger age at disease onset were associated with diagnostic delay. There was no association between the state density of rheumatologists and diagnostic delays in this model. Conclusion In the CLR, we found moderate to severe diagnostic delays in the majority of subjects with JDM. Our data suggest that access to care, measured as the distance traveled to treating rheumatologist, is an important factor associated with delays in care but also highlight age as a contributing factor, suggesting that JDM may be less recognizable in young children.
Collapse
Affiliation(s)
| | | | | | - Susan Kim
- University of California, San Francisco
| | | |
Collapse
|
18
|
Abstract
This chapter describes the musculoskeletal (MSK) context in children and young people as an important contributor to the global non-communicable disease burden. Through selected MSK conditions, we describe the impact on patients, families and communities and highlight the challenges that need to be addressed. We focus on opportunities for better working together and describe exemplar initiatives to raise awareness, workforce capacity building, models of care and research agendas to have a greater global context.
Collapse
|
19
|
Arora S, Yazdany J. Use of Quality Measures to Identify Disparities in Health Care for Systemic Lupus Erythematosus. Rheum Dis Clin North Am 2020; 46:623-638. [PMID: 32981640 DOI: 10.1016/j.rdc.2020.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
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.
Collapse
Affiliation(s)
- Shilpa Arora
- Division of Rheumatology, Rush University Medical Center, 1611 West Harrison Street, Suite 510, Chicago, IL 60612, USA
| | - Jinoos Yazdany
- Division of Rheumatology, University of California, San Francisco, 1001 Potrero Avenue, Suite 3300, San Francisco, CA 94110, USA.
| |
Collapse
|
20
|
Abstract
Disparities in prevalence, disease severity, physical and mental morbidity, and mortality exist in childhood-onset systemic lupus (cSLE) that lead to worse outcomes in children with systemic lupus erythematosus from socially disadvantaged backgrounds. Important gaps exist in knowledge regarding many individual race/ethnicities across the globe, the interaction between race/ethnicity and poverty, and drivers for identified disparities. Large cSLE registries will facilitate investigating disparities in groups of patients that have yet to be identified. Social-ecological models can inform approaches to investigate, monitor, and address disparities in cSLE.
Collapse
|
21
|
Abstract
PURPOSE OF REVIEW Provide an update of studies published in last 2 years on the outcomes and therapies in childhood-onset systemic lupus erythematous (cSLE). RECENT FINDINGS Additional evidence has been provided about the benefits of universal hydroxychloroquine in SLE patients, although antimalarial maculopathy may be more prevalent than previously thought. Recent studies support lower glucocorticoid doses than used in the past may provide comparable therapeutic benefits, and cSLE patients can mount adequate immunogenic response and sustain long-term seroprotective titers when vaccinated. Long-term studies of adults with cSLE confirmed that damage accrual increases with disease duration. Cardiovascular disease, renal transplants, replacement arthroplasties, and myocardial infarctions occur between 20 and 40 years of age. Higher prednisone doses predicted higher damage trajectory and antimalarial exposure was protective. There were no prospective clinical trials published in pediatric patients with cSLE, but positive results from phase II trials with bariticinib and ustekinumab in adult SLE may raise the expectation that these drugs could be beneficial when used in cSLE. SUMMARY The dire need for more clinical trials and licensed medications for cSLE persist as well as decreasing damage accrual.
Collapse
|
22
|
Assessment of traditional and non-traditional risk factors for premature atherosclerosis in children with juvenile dermatomyositis and pediatric controls. Pediatr Rheumatol Online J 2020; 18:25. [PMID: 32183829 PMCID: PMC7079406 DOI: 10.1186/s12969-020-0415-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/02/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Children with juvenile dermatomyositis (JDM), the most common inflammatory myopathy of childhood, may be at increased risk of premature atherosclerosis given a host of traditional and non-traditional risk factors. The primary aim of this study was to determine the underlying frequency of premature atherosclerosis in children with JDM compared to pediatric controls using flow-mediated dilation as a measure of endothelial function. METHODS Children and adolescents with and without JDM were evaluated for traditional atherosclerotic risk factors and assessment of endothelial function, using Endothelial Pulse Amplitude Testing (Endo-PAT). RESULTS In this study, 75% of pediatric controls were of Black or Hispanic descent (compared to 55% in the JDM group) and 70% were found to live in a household with a medium income less than $50,000/year (compared to 45% in the JDM group). Among traditional atherogenic risk factors, lipoprotein A appeared to be different between controls and JDM patients (66 nmol/L and 16.5 nmol/L, respectively). Using a reactive hyperemia index (RHI) < 1.67 as evidence of endothelial dysfunction, 75% of controls were defined as having endothelial dysfunction compared to 50% in JDM group. When controlled for lipoprotein A as an atherogenic confounder, JDM patients were found to have a 41% increase in RHI, thus indicating less endothelial dysfunction compared to controls. CONCLUSIONS In this study, we have shown that atherogenic risk factors are present in the pediatric population and may be associated with endothelial dysfunction, even at very young ages. Despite increasing concerns that children with rheumatologic disorders may be at increased risk of developing premature atherosclerosis, traditional and sociodemographic features may play a greater role in the ultimate development of cardiovascular disease.
Collapse
|
23
|
Ardoin SP, Daly RP, Merzoug L, Tse K, Ardalan K, Arkin L, Knight A, Rubinstein T, Ruth N, Wenderfer SE, Hersh AO. Research priorities in childhood-onset lupus: results of a multidisciplinary prioritization exercise. Pediatr Rheumatol Online J 2019; 17:32. [PMID: 31262324 PMCID: PMC6600895 DOI: 10.1186/s12969-019-0327-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 05/07/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Childhood-onset systemic erythematosus lupus (cSLE) is characterized by more severe disease, widespread organ involvement and higher mortality compared to adult-onset SLE. However, cSLE is largely underfunded to carry out necessary research to advance the field. Few commonly used SLE medications have been studied in children, and important knowledge gaps exist concerning epidemiology, genetics, pathophysiology and optimal treatments for cSLE. METHODS In order to assess highest cSLE research priority areas, the Lupus Foundation of America (LFA) and Childhood Arthritis and Rheumatology Research Alliance (CARRA) administered a cSLE research prioritization survey to pediatric rheumatologists, dermatologists and nephrologists with expertise in lupus. Members of LFA and CARRA's SLE Committee identified a list of cSLE research domains and developed a 17-item tiered, web-based survey asking respondents to categorize the research domains into high, medium, or low priority areas. For domains identified as high priority, respondents ranked research topics within that category. For example, for the domain of nephritis, respondents ranked importance of: epidemiology, biomarkers, long-term outcomes, quality improvement, etc. The survey was distributed to members of CARRA, Midwestern Pediatric Nephrology Consortium (MWPNC) and Pediatric Dermatology Research Alliance (PeDRA) Connective Tissue Disease group. RESULTS The overall response rate was 256/752 (34%). The highest prioritized research domains were: nephritis, clinical trials, biomarkers, neuropsychiatric disease and refractory skin disease. Notably, nephritis, clinical trials and biomarkers were ranked in the top five by all groups. Within each research domain, all groups showed agreement in identifying the following as important focus areas: determining best treatments, biomarkers/pathophysiology, drug discovery/novel treatments, understanding long term outcomes, and refining provider reported quality measures. CONCLUSION This survey identified the highest cSLE research priorities among leading rheumatology, dermatology and nephrology clinicians and investigators engaged in care of children with lupus. There is a strong need for multidisciplinary collaboration moving forward, which was indicated as highly important among stakeholders involved in the survey. These survey results should be used as a roadmap to guide funding and specific research programs in cSLE to address urgent, unmet needs among this population.
Collapse
Affiliation(s)
- Stacy P. Ardoin
- 0000 0004 0392 3476grid.240344.5Division of Pediatric Rheumatology, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205 USA
| | - R Paola Daly
- 0000 0004 0616 4647grid.429277.dLupus Foundation of America, Washington, DC USA
| | - Lyna Merzoug
- 0000 0004 0616 4647grid.429277.dLupus Foundation of America, Washington, DC USA
| | - Karin Tse
- 0000 0004 0616 4647grid.429277.dLupus Foundation of America, Washington, DC USA
| | - Kaveh Ardalan
- 0000 0004 0388 2248grid.413808.6Ann & Robert H. Lurie Children’s Hospital, Chicago, IL USA
| | - Lisa Arkin
- 0000 0001 0701 8607grid.28803.31University of Wisconsin, Madison, WI USA
| | | | - Tamar Rubinstein
- 0000 0004 0566 7955grid.414114.5Children’s Hospital at Montefiore, Bronx, NY USA
| | - Natasha Ruth
- 0000 0001 2189 3475grid.259828.cMedical University of South Carolina, Charleston, SC USA
| | - Scott E. Wenderfer
- 0000 0001 2200 2638grid.416975.8Texas Children’s Hospital, Houston, TX USA
| | - Aimee O. Hersh
- 0000 0001 2193 0096grid.223827.eUniversity of Utah, Salt Lake City, UT USA
| | | |
Collapse
|
24
|
Aggarwal A, Phatak S, Srivastava P, Lawrence A, Agarwal V, Misra R. Outcomes in juvenile onset lupus: single center cohort from a developing country. Lupus 2018; 27:1867-1875. [DOI: 10.1177/0961203318791046] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction About 10–20% of systemic lupus erythematosus (SLE) patients have onset in childhood and have more severe organ involvement. Survival of juvenile SLE patients is improving worldwide. Long-term data of childhood onset SLE from developing countries is scarce. Methods Clinical and laboratory data at initial presentation and follow-up visits were retrieved from clinic files, hospital information system and personal interviews. Treatment received, complications, flares, outcomes and death were recorded. Survival was calculated using Kaplan–Meier survival curves and regression analysis was done for predictors of mortality. Results Children with SLE ( n = 273, 250 girls) had a median age at onset of 14 years and duration of illness prior to diagnosis at our hospital of 1 year. Fever and arthritis were the most common presenting manifestations. Renal disease was seen in 60.5% and central nervous system (CNS) disease in 29%. The median follow-up period in 248 patients was 3.5 years. Fourteen children died, and 10 of these had active disease at the time of death. The mean actuarial survival was 24.5 years and survival rates at 1, 5 and 10 years were 97.9%, 95% and 89% respectively. Fever, CNS disease, anti-dsDNA levels and serious infections predicted death on univariate and multivariate analysis. Infections were seen in 72 children (26.3%), and 38 of these infections were serious. One-third of the patients had damage on the last follow-up. Flares were seen in 120 children, the majority being major flares. Conclusion Outcomes of pediatric SLE in North Indian children are similar to those seen in developed countries. Infections pose a major challenge in these patients.
Collapse
Affiliation(s)
- A Aggarwal
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - S Phatak
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - P Srivastava
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - A Lawrence
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - V Agarwal
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - R Misra
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| |
Collapse
|
25
|
McCormick N, Marra CA, Sadatsafavi M, Aviña-Zubieta JA. Incremental direct medical costs of systemic lupus erythematosus patients in the years preceding diagnosis: A general population-based study. Lupus 2018; 27:1247-1258. [PMID: 29665755 DOI: 10.1177/0961203318768882] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective We estimated the incremental (extra) direct medical costs of a population-based cohort of newly diagnosed systemic lupus erythematosus (SLE) for five years before and after diagnosis, and the impact of sex and socioeconomic status (SES) on pre-index costs for SLE. Methods We identified all adults newly diagnosed with SLE over 2001-2010 in British Columbia, Canada, and obtained a sample of non-SLE individuals from the general population, matched on sex, age, and calendar-year of study entry. We captured costs for all outpatient encounters, hospitalisations, and dispensed medications each year. Using generalised linear models, we estimated incremental costs of SLE each year before/after diagnosis (difference in costs between SLE and non-SLE, controlling for covariates). Similar models were used to examine the impact of sex and SES on costs within SLE. Results We included 3632 newly diagnosed SLE (86% female, mean age 49.6 ± 15.9) and 18,060 non-SLE individuals. Over the five years leading up to diagnosis, per-person healthcare costs for SLE patients increased year-over-year by 35%, on average, with the biggest increases in the final two years by 39% and 97%, respectively. Per-person all-cause medical costs for SLE the year after diagnosis (Year + 1) averaged C$12,019 (2013 Canadian) with 58% from hospitalisations, 24% outpatient, and 18% from prescription medications; Year + 1 costs for non-SLE averaged C$2412. Following adjustment for age, sex, urban/rural residence, socioeconomic status, and prior year's comorbidity score, SLE was associated with significantly greater hospitalisation, outpatient, and medication costs than non-SLE in each year of study. Altogether, adjusted incremental costs of SLE rose from C$1131 per person in Year -5 (fifth year before diagnosis) to C$2015 (Year -2), C$3473 (Year -1) and C$6474 (Year + 1). In Years -2, -1 and +1, SLE patients in the lowest SES group had significantly greater costs than the highest SES. Unlike the non-SLE cohort, male patients with SLE had higher costs than females. Annual incremental costs of SLE males (vs. SLE females) rose from C$540 per person in Year -2, to C$1385 in Year -1, and C$2288 in Year + 1. Conclusion Even years before diagnosis, SLE patients incur significantly elevated direct medical costs compared with the age- and sex-matched general population, for hospitalisations, outpatient care, and medications.
Collapse
Affiliation(s)
- N McCormick
- 1 Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, BC, Canada.,2 Arthritis Research Canada, Richmond, BC, Canada
| | - C A Marra
- 1 Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, BC, Canada.,2 Arthritis Research Canada, Richmond, BC, Canada.,3 School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - M Sadatsafavi
- 1 Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, BC, Canada
| | - J A Aviña-Zubieta
- 2 Arthritis Research Canada, Richmond, BC, Canada.,4 Division of Rheumatology, Department of Medicine, The University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|