One-third of lupus hospitalizations lack post-discharge follow-up care
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Approximately one-third of lupus hospitalizations lack post-discharge follow-up care, with “significant disparities” reported among rural and disadvantaged localities, according to Medicare data published in Arthritis Care & Research.
Meanwhile, although follow-up was associated with more acute care, it was also linked to a 65% lower mortality rate among older patients with systemic lupus erythematosus, the researchers added.
“Given that post-discharge follow-up indicates ambulatory access and quality care, we hypothesized that lupus patients who are part of populations experiencing health disparities are less likely to receive follow-up,” Maria Schletzbaum, PhD, of the department of population health sciences at the University of Wisconsin School of Medicine and Public Health, and colleagues wrote. “Further, we hypothesized that receiving timely follow-up would be associated with lower rates of acute care use and mortality.”
To investigate the likelihood that patients with SLE would receive complete follow-up care following discharge from the hospital, Schletzbaum and colleagues conducted an observational cohort study of a 20% random sample of adults on Medicare. The researchers collected data on hospitalizations associated with a lupus diagnostic code from Jan. 1, 2014, through Nov. 30, 2014, including patients aged 18 years or older who had been discharged to a home setting with no hospice care. Additionally, patients were required to hold at least 1 year of continuous Medicare A or B coverage prior to hospitalization.
The researchers defined follow-up care as a patient receiving an ambulatory visit with a primary care provider or a rheumatologist within 30 days of initial hospital discharge. The primary area of interest was the “survival time until first acute care use encounter within 30 days of index hospitalization discharge,” Schletzbaum and colleagues wrote. Acute care was defined as inpatient hospital readmissions, inpatient observation stays and visits to the emergency department.
The analysis sample included a total of 8,606 SLE hospitalizations, representing 5,403 beneficiaries. Among these beneficiaries, 30.8% contributed multiple hospitalizations. According to the researchers, 35% of patients who were hospitalized with lupus did not experience a follow-up visit within 30 days of discharge. Factors associated with a lower likelihood of a successful follow-up visit included younger age and residence in either disadvantaged neighborhoods or rural areas.
In patients who were aged 65 years or older, follow-up was linked with a 27% higher risk for acute care (adjusted HR = 1.27; 95% CI, 1.09-1.47) but a 65% lower mortality rate (aHR = 0.35; 95% CI, 0.19-0.67).
“We found that post-discharge follow-up was associated with higher subsequent acute care use in older lupus patients but was also associated with reduced mortality — 65% lower within 30 days,” Schletzbaum and colleagues wrote. “This suggests the importance of ambulatory follow-up for positive health outcomes in lupus.”
Perspective
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Carlos M. Alonso, MD, FACR, RhMSUS
Accessibility to outpatient medical care improves outcomes after hospitalization and helps avoid inpatient episodes. This has been shown to be true across several medical conditions.
The study at hand accentuates the importance of 30-day follow-up after lupus hospitalizations. Of significance, there was a 65% lower mortality amongst patients above the age of 65 years who had adequate follow up. This was, however, associated with increased acute care use. Of interest, the association of lower mortality with post-discharge care reached statistical significance with PCP follow-up and not specifically with rheumatology follow-up.
However, rheumatology follow-up as opposed to PCP follow-up was not associated with higher subsequent acute care. The study found that those residing in rural or disadvantaged neighborhoods were more likely to miss proper ambulatory access.
Lupus is a very heterogeneous disease with multi-organ involvement. Many patients with systemic lupus erythematosus have other comorbid conditions which add complexity to their care. These patients not only need good hospital care but also timely and appropriate post-discharge care. This study confirms and adds to the growing list of studies showing the importance of accessible and high-quality outpatient care.
A multidisciplinary team approach is needed to reach these patients and ensure proper post discharge care including addressing complex medical, socio-economic and self-care factors. Adequate and comprehensive discharge planning in conjunction with instruments such as home health, telemedicine and outreach clinics need further exploration.
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