One Quarter of Medicare Hospitalizations in Patients with Systemic Lupus Erythematosus Readmitted within Thirty Days

Effects of Social Vulnerability and Environmental Burden on Care Fragmentation and Social Needs Among Individuals With Rheumatic Conditions

OBJECTIVE

Environmental hazards and heightened neighborhood social vulnerability coexist and disproportionately affect minoritized populations. We investigated associations between exposure to adverse environmental burden concentrated in areas with high social vulnerability and care fragmentation (missed appointments, emergency department visits, and hospitalizations) and social needs (eg, food and housing insecurity) among individuals with rheumatic conditions.

METHODS

We identified adults receiving care in a Massachusetts multihospital system with at least two rheumatic disease codes and complete street addresses. Geocoded addresses were linked to the Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry Social-Environmental Ranking (SER), which combines census-tract social vulnerability variables (eg, socioeconomic status) with environmental hazards (eg, air and water pollution). Social needs were obtained from self-reported surveys. Multilevel, multinomial regression models estimated associations between SER quartiles and care fragmentation and social need burden, accounting for demographics and comorbidities.

RESULTS

Among 16,856 individuals with rheumatic conditions, 70% were female, 6% were Black, 82% were White, and 7% resided in the highest combined social vulnerability and environmental burden (SER quartile 4) areas. Among 7,083 with social needs data, 19% experienced more than one challenge. Individuals in SER quartile 4 areas (vs quartile 1) had 2.02 (95% confidence interval [CI] 1.67-2.46) times greater odds of at least four care fragmentation occurrences (vs 0) and 2.37 (95% CI 1.73-3.25) times greater odds of at least two social needs (vs 0).

CONCLUSION

Residence in areas of high combined adverse environmental burden and social vulnerability was associated with significantly greater odds of care fragmentation and social needs. Addressing structural factors and emerging environmental threats contributing to these adverse exposures is essential to reduce rheumatic disease care inequities.

Association of historical redlining and present-day racialised economic segregation with health-care utilisation among individuals with rheumatic conditions in Massachusetts and surrounding areas of the USA: a retrospective cohort study

BACKGROUND

Structural racism lies at the root of inequities; however its impact on rheumatology care is understudied. Redlining was a US federal government-sponsored practice that mapped areas with high concentrations of Black and immigrant residents as hazardous for investment. We aimed to investigate the association of historical redlining and present-day racialised economic segregation, on health-care utilisation among individuals with rheumatic conditions in the US state of Massachusetts and surrounding areas.

METHODS

This retrospective observational cohort study used multihospital data from the Mass General Brigham Research Patient Data Registry to identify individuals aged ≥ 18 years living in Massachusetts and surrounding areas, with two or more International Classification of Diseases codes for a rheumatic condition. Individuals were included if they received care between Jan 1, 2000, and May 1, 2023, at rheumatology practices affiliated with Mass General Brigham (Boston, MA, USA). Addresses were geocoded and overlaid with 1930s Home Owners' Loan Corporation (HOLC) redlining files. The Index of Concentration at the Extremes (ICE) for combined racial and income polarisation was constructed from US Census data. We used multilevel, multinomial logistic regression models to examine the odds of health-care utilisation separately by historical HOLC grade (A [best] to D [hazardous]) and ICE quintile (most deprived [1] to most privileged [5] race and income), adjusting for demographics, insurance, and comorbidities. People with lived experience of a rheumatic condition were not involved in the design or implementation of this study.

FINDINGS

The cohort comprised 5597 individuals; 3944 (70·5%) of 5597 patients were female, 1653 (29·5%) were male, 657 (11·7%) were Black, 224 (4·0%) were Hispanic, and the median age was 63 (50-73) years. 1295 (23·1%) of 5597 individuals lived in the most historically redlined areas (HOLC D) and 1780 (31·8%) lived in areas with the most concentrated present-day racialised economic deprivation (ICE quintile 1). Individuals in historically redlined areas (HOLC D) had greater odds of having four or more missed appointments (odds ratio [OR] 1·78 [95% CI 1·21-2·61]; p=0·0033) and of three or more emergency department visits (2·69 [1·48-4·89]; p=0·0011) compared with those in the most desirable neighbourhoods (HOLC A). Individuals in areas with highly concentrated racial and economic deprivation (ICE quintile 1) had greater odds of four or more missed appointments (OR 2·11 [95% CI 1·65-2·71]; p<0·0001) and of three or more emergency department visits (2·97 [2·02-4·35]; p<0·0001) versus those in areas with highly concentrated privilege (ICE quintile 5).

INTERPRETATION

Historical redlining could be a structural determinant of inequities in present-day health-care utilisation patterns. Policy interventions that dismantle structural racism could reduce inequities in access to care for individuals with rheumatic conditions.

FUNDING

Bristol Myers Squibb Foundation.

Therapeutic Hydroxychloroquine Blood Levels Are Associated With Fewer Hospitalizations and Possible Reduction of Health Disparities in Lupus

OBJECTIVE

Nonadherence to receiving hydroxychloroquine (HCQ) is associated with a three-fold higher risk of lupus-related hospitalization. Monitoring HCQ blood levels could improve adherence to receiving HCQ and efficacy. Yet, HCQ level monitoring is not routinely done partially due to cost and coverage concerns. To establish HCQ level monitoring cost-effectiveness, we reported the following: (1) risk of acute care by HCQ blood levels, and (2) cost of HCQ monitoring versus acute care visits.

METHODS

HCQ blood levels were measured during routine lupus visits. HCQ levels were categorized as follows: (1) subtherapeutic (<750 ng/mL), (2) therapeutic (750-1,200 ng/mL), or (3) supratherapeutic (>1,200 ng/mL). All lupus-related acute care visits (emergency room visits/hospitalizations) after the index clinic visit until next follow-up were abstracted. In our primary analysis, we examined associations between HCQ levels and time to first acute care visit in all patients and subgroups with higher rates of acute care.

RESULTS

A total of 39 lupus-related acute care visits were observed in 181 patients. Therapeutic HCQ blood levels were associated with 66% lower rates of acute care. In our cohort, two groups, Black or Hispanic patients and those with public insurance, faced three to four times higher rates of acute care. Levels within 750 to 1,200 ng/mL were associated with 95% lower rates of acute care use in subgroups with higher acute care use.

CONCLUSION

HCQ blood levels within 750 to 1,200 ng/mL are associated with lower rates of acute care in all patients with lupus, including groups with higher rates of acute care. Future clinical trials should establish the causal association between HCQ level monitoring and acute care in patients with lupus.

Rates, Diagnoses, and Predictors of Unplanned 30-Day Readmissions of Critical Care Survivors Hospitalized for Lung Involvement in Systemic Lupus Erythematosus: An Analysis of National Representative US Readmissions Data

INTRODUCTION/OBJECTIVES

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that frequently involves the lungs, contributing to significant morbidity in hospitalized patients. Critical care survivors with lung involvement in SLE are at particularly high risk for unplanned hospital readmissions, which can reflect the complexity of their disease, which often affects multiple organs and requires immunosuppressive therapy that increases infection risk. Severe pulmonary complications, critical illness sequelae, and challenges in medication adherence or follow-up care further contribute to their vulnerability. These factors result in frequent complications and flare-ups, making unplanned readmissions common in this population. This study assessed rates, most common reasons, and predictors of all-cause and SLE-related 30-day readmission among critically ill patients hospitalized for lung involvement in SLE.

METHODS

We analyzed the 2021 National Readmissions Database. Critically ill non-elective adult hospitalizations for lung involvement in SLE were identified for analysis using a combination of the ICD-10 diagnostic code for SLE with lung involvement (M32.13) and presence of any procedure codes for mechanical ventilation, tracheostomy, extracorporeal membrane oxygenation, or bronchoscopy. Non-lung-related SLE admissions, non-SLE-related lung disorders, patients with concomitant COPD, history of COVID-19 or severe asthma, patients transferred in from other hospitals or admitted for <24 hours, and patients with a DNR order were excluded. We used χ2 tests to compare baseline characteristics between readmissions and index hospitalizations. Stata ranking commands were used to identify the most recurrent diagnoses associated with 30-day readmissions. We used multivariate Cox regression analysis to identify independent predictors of readmissions.

RESULTS

Out of 3,472 index hospitalizations analyzed, 2,641 were discharged alive. Five hundred ninety-three (593; 22.5%) readmissions occurred within 30 days. Lung involvement in SLE was the most common reason for readmission (137; 23.1% of readmissions). Approximately 31.9% (189) of readmissions were due to other SLE-related complications. Readmissions were associated with higher inpatient mortality (18 (3.1%) versus 43 (1.6%); P=0.022), longer hospital stay (8 versus 5.2 days; P<0.001), younger mean age (26 versus 31 years; P=0.010), higher mean hospital costs (US $84,830 versus $64,628; P<0.001), and higher prevalence of heart failure (146 (24.6%) versus 526 (19.6%); P=0.024), CKD (435 (73.3%) versus 1,573 (58.6%); P<0.001), and anemia (138 (23.2%) versus 432 (16.1%); P=0.003) compared with index hospitalizations. Age ≥60 years (adjusted hazard ratio (AHR): 1.22; P=0.028), multiple (≥3) procedures during the initial admission (AHR: 2.57; P=0.003), discharge AMA (AHR: 1.68; P=0.047), lack of insurance/self-pay (AHR: 1.23; P=0.034), another coexisting autoimmune disorder (AHR: 1.19; P=0.041), index hospitalizations in the highest income quartile (AHR: 2.05; P=0.006), hyperlipidemia (AHR: 1.89; P=0.026), coexisting kidney disease (AHR: 1.56; P=0.017), and heart failure (AHR: 1.11; P=0.031) were significantly correlated with 30-day readmissions.

CONCLUSIONS

SLE lung readmissions were associated with worse outcomes than index hospitalization. Age ≥60 years, multiple procedures, discharge AMA, lack of insurance, kidney disease, and heart failure are significant predictors of readmission.

Receipt of rheumatology care and lupus-specific labs among young adults with systemic lupus erythematosus: A US Medicare retention in care cohort study

OBJECTIVE

In systemic lupus erythematosus, poor disease outcomes occur in young adults, patients identifying as Black or Hispanic, and socioeconomically disadvantaged patients. These identities and social factors differentially shape care access and quality that contribute to lupus health disparities in the US. Thus, our objective was to measure markers of care access and quality, including rheumatology visits (longitudinal care retention) and lupus-specific serology testing, by race and ethnicity, neighborhood disadvantage, and geographic context.

METHODS

This cohort study used a geo-linked 20% national sample of young adult Medicare beneficiaries (ages 18-35) with lupus-coded encounters and a 1-year assessment period. Retention in lupus care required a rheumatology visit in each 6-month period, and serology testing required ≥1 complement or dsDNA antibody test within the year. Multivariable logistic regression models were fit for visit-based retention and serology testing to determine associations with race and ethnicity, neighborhood disadvantage, and geography.

RESULTS

Among 1,036 young adults with lupus, 39% saw a rheumatologist every 6 months and 28% had serology testing. White beneficiaries from the least disadvantaged quintile of neighborhoods had higher visit-based retention than other beneficiaries (64% vs 30%-60%). Serology testing decreased with increasing neighborhood disadvantage quintile (aOR 0.80; 95% CI 0.71, 0.90) and in the Midwest (aOR 0.46; 0.30, 0.71).

CONCLUSION

Disparities in care, measured by rheumatology visits and serology testing, exist by neighborhood disadvantage, race and ethnicity, and region among young adults with lupus, despite uniform Medicare coverage. Findings support evaluating lupus care quality measures and their impact on US lupus outcomes.

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.

Associations of Postdischarge Follow-Up With Acute Care and Mortality in Lupus: A Medicare Cohort Study

OBJECTIVE

Patients with systemic lupus erythematosus experience the sixth highest rate of 30-day readmissions among chronic diseases. Timely postdischarge follow-up is a marker of ambulatory care quality that can reduce readmissions in other chronic conditions. Our objective was to test the hypotheses that 1) beneficiaries from populations experiencing health disparities, including patients from disadvantaged neighborhoods, will have lower odds of completed follow-up, and that 2) follow-up will predict longer time without acute care use (readmission, observation stay, or emergency department visit) or mortality.

METHODS

This observational cohort study included hospitalizations in January-November 2014 from a 20% random sample of Medicare adults. Included hospitalizations had a lupus code, discharge to home without hospice, and continuous Medicare A/B coverage for 1 year before and 1 month after hospitalization. Timely follow-up included visits with primary care or rheumatology within 30 days. Thirty-day survival outcomes were acute care use and mortality adjusted for sociodemographic information and comorbidities.

RESULTS

Over one-third (35%) of lupus hospitalizations lacked 30-day follow-up. Younger age, living in disadvantaged neighborhoods, and rurality were associated with lower odds of follow-up. Follow-up was not associated with subsequent acute care or mortality in beneficiaries age <65 years. In contrast, follow-up was associated with a 27% higher hazard for acute care use (adjusted hazard ratio [HR] 1.27 [95% confidence interval (95% CI) 1.09-1.47]) and 65% lower mortality (adjusted HR 0.35 [95% CI 0.19-0.67]) among beneficiaries age ≥65 years.

CONCLUSION

One-third of lupus hospitalizations lacked follow-up, with significant disparities in rural and disadvantaged neighborhoods. Follow-up was associated with increased acute care, but 65% lower mortality in older systemic lupus erythematosus patients. Further development of lupus-specific postdischarge strategies is needed.

Predictors of Thirty-Day Hospital Readmissions in Systemic Lupus Erythematosus in the United States: A Nationwide Study

OBJECTIVE

To evaluate independent risk factors for readmission and to determine the major reasons for readmission in a nationally representative sample of patients with systemic lupus erythematosus (SLE).

METHODS

We used the Nationwide Readmissions Database to identify adults with SLE who were discharged from hospital to home during January-November of 2016 and 2017. Thirty-day all-cause readmissions were identified. A multivariable adjusted survey-specific logistic regression model was used to identify factors associated with readmission.

RESULTS

A total of 132,400 hospitalized adults with SLE were discharged home during the study period; 88.3% were female, with a median age of 51.0 years (interquartile range 38.7-61.9 years). Of these, 18,973 individuals (14.3%) were readmitted within 30 days of discharge from their index hospitalization. In multivariable analyses, the factors associated with the highest odds for readmission were autoimmune hemolytic anemia (odds ratio [OR] 1.86 [95% confidence interval (95% CI) 1.51-2.29]), glomerular disease (OR 1.27 [95% CI 1.19-1.36]), pericarditis (OR 1.35 [95% CI 1.14-1.60]), heart failure (OR 1.34 [95% CI 1.24-1.44]), age 18-30 years (OR 1.28 [95% CI 1.17-1.41] versus age ≥​65 years), and Medicare (OR 1.20 [95% CI 1.13-1.28]) and Medicaid insurance (OR 1.26 [95% CI 1.18-1.34]). Sepsis (7.6%), SLE (7.4%), heart failure (3.5%), and pneumonia (3.2%) were among the most common causes for readmission.

CONCLUSION

In this nationally representative study of SLE readmissions, the strongest risk factors for 30-day readmission were younger age, SLE-related manifestations, and public insurance. These results identify patient groups with SLE that would benefit from postdischarge interventions designed to reduce hospitalizations and improve health outcomes.

An ecological approach to understanding and addressing health inequities of systemic lupus erythematosus

Systemic Lupus Erythematosus (SLE) is a complex chronic autoimmune disease disproportionally afflicting women and, in particular, American Indian/Alaska Native, Black, and Hispanic women. These groups of women have significantly worse SLE-related health outcomes which are partially attributable to their exposure to marginalizing and interconnecting social issues like racism, sexism, economic inequality, and more. Although these groups of women have higher rates of SLE and though it is well known that they are at risk of exposure to marginalizing social phenomena, relatively little SLE literature explicitly links and addresses the relationship between marginalizing social issues and poor SLE-health outcomes among these women. Therefore, we developed a community-engaged partnership with two childhood-SLE diagnosed women of color to identify their perspectives on which systemic issues impacted on their SLE health-related outcomes. Afterward, we used Cochrane guidelines to conduct a rapid review associated with these identified issues and original SLE research. Then, we adapted an ecological model to illustrate the connection between systems issues and SLE health outcomes. Finally, we provided recommendations for ways to research and clinically mitigate SLE health inequities.

Age-Stratified 30-day Rehospitalization and Mortality and Predictors of Rehospitalization Among Patients With Systemic Lupus Erythematosus: A Medicare Cohort Study

OBJECTIVE

Recent studies suggest young adults with systemic lupus erythematosus (SLE) have high 30-day readmission rates, which may necessitate tailored readmission reduction strategies. To aid in risk stratification for future strategies, we measured 30-day rehospitalization and mortality rates among Medicare beneficiaries with SLE and determined rehospitalization predictors by age.

METHODS

In a 2014 20% national Medicare sample of hospitalizations, rehospitalization risk and mortality within 30 days of discharge were calculated for young (aged 18-35 yrs), middle-aged (aged 36-64 yrs), and older (aged 65+ yrs) beneficiaries with and without SLE. Multivariable generalized estimating equation models were used to predict rehospitalization rates among patients with SLE by age group using patient, hospital, and geographic factors.

RESULTS

Among 1.39 million Medicare hospitalizations, 10,868 involved beneficiaries with SLE. Hospitalized young adult beneficiaries with SLE were more racially diverse, were living in more disadvantaged areas, and had more comorbidities than older beneficiaries with SLE and those without SLE. Thirty-day rehospitalization was 36% among young adult beneficiaries with SLE-40% higher than peers without SLE and 85% higher than older beneficiaries with SLE. Longer length of stay and higher comorbidity risk score increased odds of rehospitalization in all age groups, whereas specific comorbid condition predictors and their effect varied. Our models, which incorporated neighborhood-level socioeconomic disadvantage, had moderate-to-good predictive value (C statistics 0.67-0.77), outperforming administrative data models lacking comprehensive social determinants in other conditions.

CONCLUSION

Young adults with SLE on Medicare had very high 30-day rehospitalization at 36%. Considering socioeconomic disadvantage and comorbidities provided good prediction of rehospitalization risk, particularly in young adults. Young beneficiaries with SLE with comorbidities should be a focus of programs aimed at reducing rehospitalizations.

Association of Area-Level Heat and Social Vulnerability With Recurrent Hospitalizations Among Individuals With Rheumatic Conditions

OBJECTIVE

Climate and social vulnerability contribute to morbidity and health care utilization. We examined associations between the neighborhood Social Vulnerability Index (SVI) and the Heat Vulnerability Index (HVI) and recurrent hospitalizations among individuals with rheumatic conditions.

METHODS

Using a Massachusetts multihospital centralized clinical data repository, we identified individuals ≥18 years of age with a rheumatic condition who received rheumatology care within 3 years of April 2021. We defined the index date as 2 years before the last encounter and the baseline period as 1 year pre-index date. Addresses were geocoded and linked by census tract to the SVI and the HVI. We used multilevel, multinomial logistic regression to examine the odds of 1-3 and ≥4 hospitalizations (reference = 0) over 2 years post index date by vulnerability index, adjusting for age, gender, race/ethnicity, insurance, and comorbidities.

RESULTS

Among 14,401 individuals with rheumatic conditions, the mean ± age was 61.9 ± 15.7 years, 70% were female, 79% White, 7% Black, and 2% Hispanic. There were 8,251 hospitalizations; 11,649 individuals (81%) had 0 hospitalizations, 2,063 (14%) had 1-3, and 689 (5%) had ≥4. Adjusting for individual-level factors, individuals living in the highest versus lowest SVI areas had 1.84 times higher odds (95% confidence interval [95% CI] 1.43-2.36) of ≥4 hospitalizations. Individuals living in the highest versus lowest HVI areas had 1.64 times greater odds (95% CI 1.17-2.31) of ≥4 hospitalizations.

CONCLUSION

Individuals with rheumatic conditions living in areas with high versus low social and heat vulnerability had significantly greater odds of recurrent hospitalizations. Studies are needed to determine modifiable factors to mitigate risks.

Health Literacy and Patient Activation in the Pediatric to Adult Transition in Systemic Lupus Erythematosus: Patient and Health Care Team Perspectives

Objective

Methods

Results

Conclusion

Prevalence of hospital readmissions and related factors in patients with autoimmune diseases

OBJECTIVE

Autoimmune diseases generate an impact on the morbidity and mortality of patients and are a burden for the health system through hospital admissions and readmissions. The prevalence of readmission of patients with these diseases has not yet been described as a group, but rather as sub-phenotype. The objective of this study is to determine the prevalence of hospital readmissions in a Colombian population with autoimmunity and the factors related to readmission.

METHODS

All patients with autoimmune diseases who were evaluated by the rheumatology service and hospitalized between August 2018 and December 2019 at the Fundación Hospital Infantil Universitario De San José de Bogotá were described. A bivariate analysis was done, and three multivariate logistic regression models were built with the dependent variable being readmission.

RESULTS

Of the total 199 admissions, 131 patients were evaluated and 32% were readmitted. The most frequent sub-phenotype in both groups (readmission and no readmission) was SLE (51% and 59%). The most frequent cause of hospitalization and readmission was disease activity (68.7% and 64.3%). History of hypertension was associated with readmission (adjusted OR: 2.98-95% CI: 1.15-7.72). In a second model adjusted for confounding variables, no factor was associated. In a third model analyzing the history of kidney disease and previous use of immunosuppressants (adjusted for confounding variables), the previous use of immunosuppressants was related to readmission (OR: 2.78-95% CI 1.12-6.89).

CONCLUSION

Up to a third of patients with autoimmunity were readmitted and arterial hypertension was an associated factor. This suggested a greater systemic compromise and accumulated damage in patients who have these two conditions that may favor readmission. A history of immunosuppressant use may play a role in readmission, possibly by increasing the risk of developing infections.