Patients with SSc-related digital ulcers use ‘significantly more’ health care resources
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Patients with systemic sclerosis who demonstrate digital ulcers use “significantly more” health care resources annually than patients without digital ulcers, according to data published in Arthritis Care and Research.
“[Digital ulcers (DUs)] are slow to heal, specially if there is calcinosis, and can be complicated by soft tissue infections, wet and dry necrosis, eschar, underlying tissue exposure, gangrene, osteomyelitis, and amputation,” Tatiana Nevskaya, MD, PhD, of the Schulich School of Medicine and Dentistry, in Ontario, and colleagues wrote.
“DUs lead to significant morbidity and decreased quality of life through functional disability and pain,” they added. “Patients with DUs have greater work impairment and a need for paid help at home due to difficulties performing activities of daily living. Patients with DUs may require more health care resources given the medical and functional complications inherent to this disease manifestation.”
To analyze health care use among patients with SSc who have digital ulcers, Nevskaya and colleagues examined data from the Canadian Scleroderma Research Group registry. The authors analyzed patients from the registry who satisfied the 2013 American College of Rheumatology/EULAR classification criteria for SSc and completed the Resource Utilization Questionnaire (RUQ). This questionnaire measures metrics including health provider visits, diagnostics procedures performed, hospitalizations, outpatient procedures, time spent seeing health providers and time spent by others accompanying patients to provider visits.
A total of 208 patients were included in the analysis. Patients were divided into two groups — one group consisting of patients with digital ulcers, and the control group, which featured patients with no digital ulcers. In all, 104 patients with SSc with active digital ulcers at two consecutive annual visits were compared with 104 patients without ulcers. The patients were matched for age, sex, disease subtype and duration. There was 1:1 cases-to-control matching for the purpose of analysis.
Researchers used a sum of severity grades, using the Medgser Disease Severity Scale, as a global measure of disease severity and characterized ischemic complications by collecting data from the registry. Data contributing to the severity measurements included total number of digits with ulcers, digital necrosis or gangrene, a history of amputation and healed digital ulcers. The impact of the ulcers on daily life was measured with an analog scale ranging from one to 10.
Over 1 year, patients with digital ulcers were associated with a higher number of tests (P < .05) and more visits to rheumatologists (P < .0001) and internists (P = .003), according to the researchers. Additionally, patients with digital ulcers demonstrated a greater need to have someone accompany them to appointments (P < .05) and received or purchased a greater number of aids, including mobility and bathroom aids (P < .05). Patients with digital ulcers were also associated with having more severe disease (P < .0001).
“Compared to SSc patients without DUs (controls), those with active DUs utilized significantly more health resources,” Nevskaya and colleagues wrote.
“Specifically, DUs lead to increased number of medical visits and tests per year,” they added. “Patients with DUs also purchase or receive more aids, and more frequently require an accompanying person for visits and tests that may be partly explained by concomitant severe internal organ and skin involvement.”
Perspective
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David A. McLain, MD, MACR, FACP, FRCP
Digital ulcers occur in half of patients with scleroderma. Systemic sclerosis manifests with vasculopathy, fibrosis of the skin and internal organs, and autoimmunity. Vasculopathy presents clinically as Raynaud’s phenomenon, scleroderma renal crisis, pulmonary arterial hypertension and digital ulcers. Recurrence of digital ulcers occur in 30% to 66% and are difficult to manage. Patient counselling to cease smoking, avoid trauma and seek wound care are essential.
A number of medications have been used, including calcium channel blockers, PDE5 inhibitors, endothelin receptor antagonists and intravenous prostacyclins. Referral to a surgeon for debridement or amputation may be necessary. Antibiotics and analgesics are often required.
Although small in size, digital ulcers are a serious concern, an annoyance and often a disability for patients. This study showed that health care use was independently increased in patients with SSc with digital ulcers even when adjusting for other disease manifestations. They also found that digital ulcers were associated with more severe disease in other organ systems.
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