Younger patients on public insurance at highest risk for lupus hospital readmission
Click Here to Manage Email Alerts
The strongest risk factors for 30-day hospital readmission in patients with systemic lupus erythematosus are younger age, public insurance use and SLE-related manifestations, according to data in Arthritis Care and Research.
“The study was conceived during the last few months of my residency training before starting a fellowship in rheumatology; I was eager to apply my prior experience in clinical epidemiology to rheumatologic disease research,” Rayan Najjar, MD, MPH, of the University of Washington, in Seattle, the lead author of the study, told Healio. “The study leverages the Nationwide Readmissions Database to evaluate independent risk factors for readmission in a sample of patients with SLE.”
To identify individual risk factors that may predict hospital readmissions, Najjar and colleagues analyzed data from the Nationwide Readmissions Database (NRD) from the Healthcare Cost and Utilization Project. The database contains information detailing 36 million discharges from 28 states in the United States, the researchers wrote.
The study included adult patients hospitalized with SLE who were discharged between January and November of 2016 and 2017. Patients diagnosed with only cutaneous lupus were not included in the study. Additionally, the authors did not include patients who were missing length-of-stay information or expected payor data, as well as patients who stayed for 30 or more days. The researchers used the data to identify the patients’ first readmission within 30 days of discharge. The 40 most commons for readmission and costs for readmission services were recorded.
After accounting for exclusions, 71,213 patients with SLE were admitted and included in the analysis. Among those patients, 18,973 were readmitted within 30 days of their initial discharge. Compared with patients who were not readmitted to the hospital within 30 days, patients who were readmitted were younger, had higher rates of Medicare or Medicaid coverage (P < .0001) and demonstrated more glomerular disease, pleurisy and thrombocytopenia, according to the researchers.
More than 50% of readmissions happened by day 11. Other variables associated with increased rates of readmission included being aged 18 to 30 years, compared with those aged older than 65 years (OR = 1.28; 95% CI, 1.17-1.41), glomerular disease (OR = 1.27; 95% CI, 1.19-1.36), congestive heart failure (OR = 1.34; 95% CI, 1.24-1.44), pericarditis (OR = 1.35; 95% CI, 1.14-1.60), pleurisy (OR = 1.24; 95% CI, 1.10-1.40), psychoses (OR = 1.23; 95% CI, 1.11-1.37) and autoimmune hemolytic anemia (OR = 1.74; 95% CI, 1.41-2.16).
“We found that the strongest risk factors for 30-day readmission were younger age, SLE-related manifestations and public insurance,” Najjar said.
“These results identify patient groups with SLE that would benefit from post-discharge interventions designed to reduce hospitalizations and improve health outcomes,” Najjar added. “In addition to the patient morbidity that results in readmissions, we report on the cost and duration of readmissions, which denote the importance of the early post-hospitalization period as a potential area for improvement in health outcomes, and to alleviate the impact on the health care system.”
Perspective
Back to Top
David A. McLain, MD, MACR, FACP, FRCP
Systemic lupus erythematosus ranks among the top 10 medical conditions associated with readmission. Single center studies have identified risk factors for readmission, including severe active SLE, infection, male sex and Medicaid insurance. A study looking at five American states found readmission factors included severe SLE disease activity, younger age, female sex, non-white race and Medicare or Medicaid insurance.
The present study used a nationwide readmission database that receives data from non-federal acute care hospitals in 28 states. They found that sepsis, SLE activity, heart failure, and pneumonia were the most common reasons for readmission. The most commonly associated factors were autoimmune hemolytic anemia, glomerular disease, pericarditis, heart failure, an age range of 18 to 30 years and Medicare or Medicaid insurance.
The younger patients were found to have a higher prevalence of the more severe SLE manifestations including autoimmune hemolytic anemia, glomerular disease, leukopenia, pericarditis, pleurisy, seizure, and thrombocytopenia. In my experience, the sickest SLE patients are often teenagers.
The readmission for infection is not unexpected in an SLE population, as we know SLE itself predisposes to infection even without treatment. When you add in corticosteroids and immunosuppressives, infection becomes a major issue with the care of lupus patients.
One of the shortcomings of this analysis was the lack of prescription drug information (type of immunosuppressive, dose of corticosteroids, etc.) that would correlate with readmission rates. Medicaid insurance is a marker for socioeconomic situations and may reflect sicker SLE patients, lack of timely outpatient care, lack of social support and/or lack of understanding of the disease and/or treatment protocol. Medicare insurance may reflect age, disability and chronicity with lupus such as heart failure, renal failure and frailty.
This type of analysis is helpful to the practitioner to reinforce our own experience with the lupus patient who is often very sick, very immunosuppressed and difficult to manage.
Collapse
Read more about
Click Here to Manage Email Alerts