Causes and Predictors of Early Hospital Readmission in Systemic Lupus Erythematosus

Risk factors for hospitalization in Mexican patients with systemic lupus erythematosus

INTRODUCTION

Systemic lupus erythematosus (SLE) is an autoimmune disease that often requires hospitalization. Most hospitalizations are due to infections and/or disease activity, for which several risk factors have been described in non-Mestizo patients.

OBJECTIVE

To identify risk factors for hospitalization in patients with systemic lupus erythematosus (SLE).

METHODS

This was an observational case-control study of patients with SLE in San Luis Potosí, Mexico, evaluated from January 2019 to October 2020. We compared hospitalized lupus patients with non-hospitalized lupus patients. We used descriptive statistics and logistic regression to describe potential risk factors.

RESULTS

Of a total of 202 patients, 89 (45.1%) were hospitalized; these patients were younger, had shorter disease duration, higher disease activity scores (systemic lupus erythematosus disease activity index-SLEDAI), and more accumulated damage than non-hospitalized patients. The primary reasons for hospitalization were disease activity (60.7%), kidney disease, infection, and drug toxicity (5.6%). Multivariate analysis revealed several risk factors associated with hospitalization, including elevated creatinine, C-reactive protein, neutrophil levels, and constitutional symptoms, while prolonged international normalized ratio (INR), longer stay in the intensive care unit (ICU), and vasopressor use were associated with mortality. The use of antimalarials was a protective factor against hospitalization. Survival analysis revealed that patients with hospital-acquired infections had a lower probability of survival.

CONCLUSIONS

Disease activity was the most common reason for hospitalization; kidney, constitutional, and hematological factors were associated with hospitalization; and the use of antimalarial was a protective factor for hospitalization.

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.

Reasons for hospitalisation in patients with systemic lupus erythematosus in a university hospital in Buenos Aires

OBJECTIVE

To determine the reasons for hospitalisation in patients with systemic lupus erythematosus (SLE) admitted to the Hospital de Clínicas "José de San Martín" Buenos Aires, Argentina.

METHODS

We retrospectively analysed the clinical histories of SLE patients (SLICC 2012) during or prior to hospitalisation, from 1-2014 to 12-2017. Demographic data, reasons for hospitalisation, treatments, SLEDAI-2 K and comorbid conditions.

RESULTS

121 hospitalisations corresponding to 72 patients, 25 patients (34.7%) were hospitalised more than once. Females (83.3%), the median length of disease until admission was 5 years. There was more than one reason for hospitalisation in 32, a total of 164 reasons. The main reason was relapse of disease (52.4%). The most frequent manifestations were renal involvement, serositis and pulmonary involvement. Infections were the second reason for hospitalisation (26.8%); urinary tract, pneumonia and soft tissue. Cardiovascular involvement 4.9%. Hospitalisation in a closed unit 14.05%, mortality 2.48%.

CONCLUSION

Relapse of disease and infections were the main reasons for hospitalisation; admission secondary to infection was higher than that reported in other series.

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.

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

OBJECTIVE

Thirty-day hospital readmissions in systemic lupus erythematosus (SLE) approach proportions in Medicare-reported conditions including heart failure (HF). We compared adjusted 30-day readmission and mortality among SLE, HF, and general Medicare to assess predictors informing readmission prevention.

METHODS

This database study used a 20% sample of all US Medicare 2014 adult hospitalizations to compare risk of 30-day readmission and mortality among admissions with SLE, HF, and neither per discharge diagnoses (if both SLE and HF, classified as SLE). Inclusion required live discharge and ≥12 months of Medicare A/B before admission to assess baseline covariates including patient, geographic, and hospital factors. Analysis used observed and predicted probabilities, and multivariable GEE models clustered by patient to report adjusted risk ratios (ARRs) of 30-day readmission and mortality.

RESULTS

SLE admissions (n=10,868) were younger, predominantly female, more likely to be Black, disabled, and have Medicaid or end-stage renal disease (ESRD). Observed 30-day readmissions of 24% were identical for SLE and HF (p = 0.6), and higher than other Medicare (16%, p < 0.001). Both SLE and HF had elevated readmission risk (ARR 1.08, (95% CI (1.04, 1.13)); 1.11, (1.09, 1.13)). SLE readmissions were higher for Black (30%) versus White (21%) populations, and highest in ages 18-33 (39%) and ESRD (37%). Admissions of Black patients with SLE from least disadvantaged neighborhoods had highest 30-day mortality (9% versus 3% White).

CONCLUSION

Thirty-day SLE readmissions rivaled HF at 24%. Readmission prevention programs should engage young, ESRD patients with SLE and examine potential causal gaps in SLE care and transitions.

Low ambient temperature increases hospital re-admissions for systemic lupus erythematosus in humid subtropical region: a time series study

Currently, the correlation between ambient temperature and systemic lupus erythematosus (SLE) hospital admissions remains not determined. The aim of this study was to explore the correlation between ambient temperature and SLE hospital admissions in Hefei City, China. An ecological study design was adopted. Daily data on SLE hospital admissions in Hefei City, from January 1, 2007, to December 31, 2017, were obtained from the two largest tertiary hospitals in Hefei, and the daily meteorological data at the same period were retrieved from China Meteorological Data Network. The generalized additive model (GAM) combined with distributed lag nonlinear model (DLNM) with Poisson link was applied to evaluate the influence of ambient temperature on SLE hospital admissions after controlling for potential confounding factors, including seasonality, relative humidity, day of week, and long-term trend. There were 1658 SLE hospital admissions from 2007 to 2017, including 370 first admissions and 1192 re-admissions (there were 96 admissions with admission status not stated). No correlation was observed between ambient temperature and SLE first admissions, but a correlation was found between low ambient temperature and SLE re-admissions (RR: 2.53, 95% CI: 1.11, 5.77) (3.5 °C vs 21 °C). The effect of ambient temperature on SLE re-admissions remained for 2 weeks but disappeared in 3 weeks. Exposure to low ambient temperature may increase hospital re-admissions for SLE, and thus it is important for SLE patients to maintain a warm living environment and avoid exposure to lower ambient temperature.

Prediction of hospitalizations in systemic lupus erythematosus using the Systemic Lupus International Collaborating Clinics Frailty Index (SLICC-FI)

OBJECTIVE

The Systemic Lupus International Collaborating Clinics (SLICC) frailty index (FI) predicts mortality and damage accrual in SLE, but its association with hospitalizations has not been described. We estimated the association of baseline SLICC-FI values with future hospitalizations in the SLICC inception cohort.

METHODS

Baseline SLICC-FI scores were calculated. The number and duration of inpatient hospitalizations during follow-up were recorded. Negative binomial regression was used to estimate the association between baseline SLICC-FI values and the rate of hospitalizations per patient-year of follow-up. Linear regression was used to estimate the association of baseline SLICC-FI scores with the proportion of follow-up time spent in hospital. Multivariable models were adjusted for relevant baseline characteristics.

RESULTS

The 1549 SLE patients eligible for this analysis were mostly female (88.7%) with mean (SD) age 35.7 (13.3) years and median (IQR) disease duration 1.2 (0.9-1.5) years at baseline. Mean (SD) baseline SLICC-FI was 0.17 (0.08). During mean (SD) follow-up of 7.2 (3.7) years, 614 patients (39.6%) experienced 1570 hospitalizations. Higher baseline SLICC-FI values (per 0.05 increment) were associated with more frequent hospitalizations during follow-up (Incidence Rate Ratio 1.21; 95%CI 1.13-1.30), adjusting for baseline age, sex, corticosteroid use, immunosuppressive use, ethnicity/location, SLE disease activity index 2000 (SLEDAI-2K), SLICC/ACR damage index (SDI), and disease duration. Among patients with ≥1 hospitalization, higher baseline SLICC-FI values predicted a greater proportion of follow-up time spent hospitalized (Relative Rate 1.09; 95%CI 1.02-1.16).

CONCLUSION

The SLICC-FI predicts future hospitalizations among incident SLE patients, further supporting the SLICC-FI as a valid health measure in SLE.

A Quality Improvement Intervention to Reduce 30-Day Hospital Readmission Rates among Patients with Systemic Lupus Erythematosus

OBJECTIVE

Systemic lupus erythematosus (SLE) has one of the highest 30-day hospital readmission rates among chronic diseases in the United States. This quality improvement initiative developed and assessed the feasibility of a multidisciplinary post-discharge intervention to reduce 30-day readmission rates among SLE patients.

METHODS

A retrospective study was performed using electronic health records of patients with SLE admitted to a university hospital prior to (non-intervention group) and after initiation of the study intervention (intervention group). The study population included patients with a diagnosis of SLE who were admitted to the hospital for any reason during an eight month time period. The intervention involved sending a templated message at the time of discharge to the rheumatology clinic nurses which prompted the nurses to call the patient to coordinate future visits and provide education. The primary outcome was the 30-day hospital readmission rate. Data was analyzed using a multivariate mixed binomial regression model.

RESULTS

There were 59 hospitalizations in the non-intervention group and 73 hospitalizations in the intervention group during the eight-month study period. The 30-day readmission rate was 29% in the non-intervention group and 19% in the intervention group. The difference in readmission rates between the two groups was not statistically significant based on the multivariate model.

CONCLUSION

Our study demonstrates the feasibility of implementing a multi-disciplinary post-discharge intervention to reduce readmission rates for patients with SLE in a large academic medical center. Further investigation is warranted to determine if this approach reduces the unacceptably high hospital readmission rates among SLE patients.

Reasons for Hospitalisation in Patients with Systemic Lupus Erythematosus in a University Hospital in Buenos Aires

OBJECTIVE

To determine the reasons for hospitalisation in patients with systemic lupus erythematosus (SLE) admitted to the Hospital de Clínicas «José de San Martín» Buenos Aires, Argentina.

METHODS

We retrospectively analysed the clinical histories of SLE patients (SLICC 2012) during or prior to hospitalisation, from 1-2014 to 12-2017. Demographic data, reasons for hospitalisation, treatments, SLEDAI-2K and comorbid conditions.

RESULTS

121 hospitalisations corresponding to 72 patients, 25 patients (34.7%) were hospitalised more than once. Females (83.3%), the median length of disease until admission was 5 years. There was more than one reason for hospitalisation in 32, a total of 164 reasons. The main reason was relapse of disease (52.4%). The most frequent manifestations were renal involvement, serositis and pulmonary involvement. Infections were the second reason for hospitalisation (26.8%); urinary tract, pneumonia and soft tissue. Cardiovascular involvement 4.9%. Hospitalisation in a closed unit 14.05%, mortality 2.48%.

CONCLUSION

Relapse of disease and infections were the main reasons for hospitalisation; admission secondary to infection was higher than that reported in other series.