Length of stay, mortality fall, hospital charges rise in systemic sclerosis with infection
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Patients with systemic sclerosis who are hospitalized for serious infection have, from 1998 to 2016, experienced a growing number of charges but decreasing lengths of stay and mortality, researchers reported in Arthritis Research & Therapy.
“Systemic sclerosis is a systemic autoimmune disease associated with high morbidity and mortality and frequent hospitalizations,” Jasvinder A. Singh, MD, of the Birmingham (Ala.) Veterans Affairs Medical Center, told Healio Rheumatology. “Recent studies indicated the infections are becoming an increasingly common contributor to mortality in hospitalized SSc patients. A recent systematic review of infections in connective tissue diseases found that most studies of infections were focused on people with lupus and only one study included people with SSc. Thus, knowledge gaps in the epidemiology of infections exist in SSc.”
To analyze the incidence, time trends and outcomes of serious infections among patients with systemic sclerosis, Singh and co-author John D. Cleveland, MD, of the University of Alabama at Birmingham, studied data from the U.S. National Inpatient Sample. According to the researchers, this database includes a 20% stratified sample of discharge records from all participating community hospitals from all participating states, and is the largest publicly available, de-identified, all-payer inpatient health care cohort in the country.
Focusing on data from 1998 to 2016, Singh and Cleveland studied the epidemiology, time trends and outcomes of five types of infections among hospitalized patients with systemic sclerosis. These included opportunistic infections, skin and soft-tissue infections, urinary tract infections, pneumonia and sepsis/bacteremia. In all, they identified and analyzed 61,615 cases in patients with systemic sclerosis and 49,904,955 in those without systemic sclerosis. The researchers then conducted multivariable-adjusted logistic regression analyses to examine the independent associations of healthcare use and in-hospital mortality factors.
According to the researchers, the most common serious infections among hospitalized patients with systemic sclerosis during the study period were: pneumonia, at 45%; sepsis, at 32%; skin and soft-tissue infections, at 19%; urinary tract infections, with 3%; and opportunistic infections, at 3%. However, during the period from 2013 to 2014, sepsis surpassed pneumonia as the most common serious infection, and by 2015-2016, sepsis was 1.8 times more common than pneumonia.
In addition, during the study period, hospital charges increased even as lengths of stay and in-hospital mortality decreased — overall and for each infection.
Multivariable-adjusted analyses demonstrated that sepsis, being 80 years of age or older and having a Deyo-Charlson scoreof 2 or greater were associated with a significantly higher likelihood of healthcare use and in-hospital mortality. Meanwhile, Medicare or Medicaid insurance, Northeast location, urban teaching or non-teaching hospital and medium or large hospital bed size were associated with a significantly higher chance of healthcare use.
“This epidemiological study of common, serious infections in hospitalized SSc patients, over time, can help clinicians understand the time-trends in serious infections overall and/or specific serious infections compared to each other and over time,” Singh said. “Recognition of several modifiable independent risk factors for poorer outcomes in SSc patients hospitalized with serious infections can help the development and testing of new interventions for improving outcomes, and/or the institution of care pathways or algorithms in inpatient settings as quality improvement initiatives to improve outcomes and reduce associated mortality further.”
Perspective
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Vickie L. Sayles, MHA, BSN, CRNI, RN-BC
In a national study of people with scleroderma, a determination was made by Singh and Cleveland that these patients have a higher incidence of serious infections (pneumonia, sepsis), health care utilization and in-patient mortality.
Patients with scleroderma are already immunocompromised and adding the medications that treat this complex disease further compromises their immune status. It is important for rheumatology providers to educate their patients about the signs and symptoms of infection so that this population seeks aggressive treatment before hospitalization and further complications occur.
Although serious infections in the general population are treatable in most cases, for those with scleroderma on immunosuppressive therapy, early diagnosis and appropriate treatment of infection is critical, especially for those with severe visceral organ involvement. Educating patients about medication side effects, when to hold their medications, and when to seek medical attention is paramount to prevent poor outcomes and decrease mortality from this debilitating disease.
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