Financial Hardship and Sleep Quality Among Black American Women With and Without Systemic Lupus Erythematosus.

OBJECTIVE: To compare dimensions of financial hardship and self-reported sleep quality among Black women with versus without systemic lupus erythematosus (SLE). METHODS: Participants were 402 Black women (50% with validated diagnosis of SLE) living in Georgia between 2017 and 2020. Black women with SLE were recruited from a population-based cohort established in Atlanta, and Black women without SLE were recruited to be of comparable age and from the same geographic areas as SLE women. Financial hardship was measured using three different scales: financial adjustments, financial setbacks, and financial strain. Sleep was assessed continuously using the Pittsburgh Sleep Quality Index (PSQI) scale. Each dimension of financial hardship was analyzed separately in SLE-stratified multivariable linear regression models and adjusted by sociodemographic and health status factors. RESULTS: Dimensions of financial hardship were similarly distributed across the two groups. Sleep quality was worse in Black women with, versus without, SLE (p < .001). Among Black women with SLE, financial adjustment was positively associated with a 0.40-unit increase in poor sleep quality (95% CI = 0.12-0.67, p = .005). When accounting for cognitive depressive symptoms, financial setbacks and strain were somewhat attenuated for Black women with SLE. Overall, no associations between financial hardships and sleep quality were observed for the women without SLE. CONCLUSIONS: Black women with SLE who experience financial hardships may be more at risk for poor sleep quality than Black women without SLE. Economic interventions targeting this population may help improve their overall health and quality of life.

Systemic Lupus Erythematosus: Targeted Literature Review of the Epidemiology, Current Treatment, and Disease Burden in the Asia Pacific Region.

OBJECTIVE: To understand the epidemiology, current treatment, and disease burden of systemic lupus erythematosus (SLE) in the Asia Pacific (APAC) region. METHODS: A targeted literature review of published evidence on SLE in the APAC region was conducted, using the Medline database (2008-2018), conference proceedings, and other supplementary sources. RESULTS: The current review identified 70 studies conducted in China (n = 15), Japan (n = 13), Taiwan (n = 12), Korea (n = 9), Australia (n = 7), Hong Kong (n = 6), Singapore (n = 4), and multiple places within the APAC region (n = 4). Incidence rates (per 100,000 persons per year) ranged from 0.9-8.4, while prevalence rates ranged from 3.7-127 (per 100,000 persons); however, recent data were limited. Asian patients with SLE were reported to have higher disease severity, disease activity (higher SLE disease activity index scores), and organ damage accrual, along with increased morbidity, mortality, and susceptibility to renal involvement compared with other ethnicities in the APAC region. The risk of developing SLE is higher in the Asian population. Routinely used SLE therapies included belimumab, hydroxychloroquine, cyclophosphamide, tacrolimus, azathioprine, mycophenolate mofetil, and glucocorticoids; however, prescribing patterns varied across the region. Increased disease activity was associated with high economic burden and poor quality of life for SLE patients in the APAC region. CONCLUSION: SLE remains a disease with a significant unmet medical need for an innovative therapy that is well-tolerated and effective for patients in the APAC region. Further evidence is required to better characterize the disease and fully capture the burden and impact of SLE in the APAC region. This review has highlighted where there is a paucity of data from patients across the APAC region.

Direct health system costs for systemic lupus erythematosus patients in Alberta, Canada.

Systemic lupus Erythematosus (SLE) is a chronic multi-system autoimmune disease that can affect a person's physical, mental, and social life. It imposes a substantial economic burden up on patients, carers, healthcare systems, and wider society. This is the first study to examine the direct health care costs of SLE in Alberta using real-world data. Alberta maintains a publicly funded, universally available health care system. Health service use and direct healthcare costs of SLE and non-SLE cases were determined from inpatient hospital services, fee-for-physician services, emergency services, and ambulatory care services. All costs were estimated for calendar year 2016. Data were analysed using central measures specifically the mean to determine the annual costs of SLE and non-SLE. A total number of 10,932 (Male = 2,546; Female = 8,386), and 41,851,36 (Male = 21,157,76; Female = 20,693,60) of SLE and non-SLE cases, respectively were included in this study. The mean annual costs of SLE, and non-SLE per case were $7,740.19 (Male = $7,986.59; Female = $7,665.38), and $2,479.53 (Male = $2,265.57; Female = $2,698.30), (p < 0.001) respectively. The mean annual costs of fee-for-physician services (SLE = $2,160.03; non-SLE = $840.00) (p < 0.001), inpatient hospital services (SLE = $3,462.86; non-SLE = $1,007.29), (p < 0.001) emergency services (SLE = $440.28; non-SLE = $176.65), (p < 0.001) and ambulatory care services (SLE = $1,677.03; non-SLE = $455.05) (p < 0.001) per case were estimated. The findings showed that the costs of SLE were considerably high for patients and healthcare system. This highlights the importance of appropriate treatment and management of SLE. Further studies are required to fully investigate both the direct and indirect economic burden of SLE including out-of-pocket expenses, costs to patients and caregivers and productivity loss.

Access and Cost-Related Nonadherence to Prescription Medications Among Lupus Patients and Controls: The Michigan Lupus Epidemiology and Surveillance Program.

OBJECTIVE: Medication access and adherence are important determinants of health outcomes. We investigated factors associated with access and cost-related nonadherence to prescriptions in a population-based cohort of systemic lupus erythematosus (SLE) patients and controls. METHODS: Detailed sociodemographic and prescription data were collected by structured interview in 2014-2015 from participants in the Michigan Lupus Epidemiology and Surveillance (MILES) cohort. We compared access between cases and frequency-matched controls and examined associated factors in separate multivariable logistic regression models. RESULTS: A total of 654 participants (462 SLE patients, 192 controls) completed the baseline visit; 584 (89%) were female, 285 (44%) were Black, and the mean age was 53 years. SLE patients and controls reported similar frequencies of being unable to access prescribed medications (12.1% versus 9.4%, respectively; P was not significant). SLE patients were twice as likely as controls to report cost-related prescription nonadherence in the preceding 12 months to save money (21.7% versus 10.4%; P = 0.001) but were also more likely to ask their doctor for lower cost alternatives (23.8% versus 15.6%; P = 0.02). Disparities were found in association with income, race, and health insurance status, but the main findings persisted after adjusting for these and other variables in multivariable models. CONCLUSION: SLE patients were more likely than controls from the general population to report cost-related prescription nonadherence, including skipping doses, taking less medicine, and delaying filling prescriptions; yet, <1 in 4 patients asked providers for lower cost medications. Consideration of medication costs in patient decision-making could provide a meaningful avenue for improving access and adherence to medications.

Hacking systemic lupus erythematosus (SLE): outcomes of the Waterlupus hackathon. / Sensibiliser au lupus érythémateux disséminé (LED) : résultats du programmathon Waterlupus.

INTRODUCTION: There is a growing literature demonstrating the benefits of engaging knowledge-users throughout the research process. We engaged a multi-stakeholder team to undertake a hackathon as part of an integrated knowledge translation (iKT) process to develop nonpharmacological interventions to enhance the economic lives of people with systemic lupus erythematosus (SLE). The aims of this research were to (1) increase understanding of the economic challenges of living with SLE through stakeholder engagement at a research hackathon; (2) investigate possible interventions to improve the economic lives of individuals affected by SLE in Canada; and (3) document the outcomes of the Waterlupus hackathon. METHODS: Waterlupus was held at the University of Waterloo in May 2019, attended by lupus advocacy organization representatives, researchers, physicians, individuals with lived experience and students. We conducted participant observation with participants' understanding and consent; notes from the hackathon were qualitatively analyzed to document hackathon outcomes. RESULTS: At the conclusion of the 28-hour hackathon event, five teams pitched nonpharmacological interventions to address the economic challenges of living with SLE. The winning team's pitch focussed on increasing accessibility of affordable sun-protective clothing. Other Waterlupus outcomes include increased awareness of SLE among participants, and professional and informal networking opportunities. CONCLUSION: This paper contributes to a limited literature on health hackathons. The successful outcomes of Waterlupus emphasize the value of hackathons as an iKT tool. Research about how knowledge-users perceive hackathons is an important next step.

The economic burden of systemic lupus erythematosus in commercially- and medicaid-insured populations in the United States.

OBJECTIVE: To estimate the economic burden of systematic lupus erythematous (SLE), stratified by disease severity, in commercially- and Medicaid-insured US populations. METHODS: Adults (≥18 years) with SLE treated with antimalarials, selected biologics, immunosuppressants, and systemic glucocorticoids (2010-2014) were identified within the commercial and Medicaid insurance IBM MarketScan® databases (index date = first SLE medication claim). Both cohorts were stratified into mild (receiving antimalarial or glucocorticoid monotherapy ≤5 mg/day) versus moderate/severe SLE (receiving glucocorticoids >5 mg/day, biologic, immunosuppressant, or combination therapy) during a 6-month exposure period. All-cause healthcare utilization and costs were evaluated during the 12 months following the exposure period. RESULTS: Among 8231 commercially-insured patients, 32.6% had mild and 67.4% had moderate/severe SLE by our definition. Among 802 Medicaid-insured patients, 25.2% had mild and 74.8% had moderate/severe SLE. Adjusted mean total healthcare costs, excluding pharmacy, for moderate/severe SLE patients were higher than for mild SLE patients in the commercially-insured ($39,021 versus $23,519; p < 0.0001) and Medicaid-insured populations ($56,050 versus $44,932; p = 0.06). In both SLE severity populations total unadjusted costs were significantly higher among Medicaid-insured than commercially-insured patients. CONCLUSION: Commercially-insured patients with treatment suggesting moderate/severe SLE incurred significantly higher adjusted mean healthcare costs, excluding pharmacy, compared with mild SLE patients. While not reaching statistical significance, moderate/severe Medicaid-insured patients had higher costs then mild SLE patients. Total unadjusted healthcare costs were significantly higher among Medicaid-insured than commercially-insured patients. These differential costs are important to consider and monitor when implementing interventions to improve health and reduce healthcare spending for SLE.

Real-world treatment patterns, healthcare resource utilisation and costs in patients with systemic lupus erythematosus treated with belimumab: a retrospective analysis of claims data in the USA.

Objective: To examine the effects of belimumab initiation on healthcare resource utilisation (HCRU) and costs in SLE. Methods: This retrospective observational cohort study used healthcare administrative claims data from the IBM MarketScan Commercial Claims and Encounters Database to identify patients with SLE billing codes who received ≥1 intravenous belimumab infusion between March 2011 and December 2015. The first belimumab administration was the 'index date'. During the 6-month postindex period, nine belimumab infusions were recommended: three during the initiation period and six during the maintenance period. HCRU and cost data for inpatient admissions, emergency department visits, physician office visits, hospital-based outpatient visits, laboratory services, other outpatient services and outpatient pharmacy prescriptions were compared in the 6-month pre/postindex periods. Results: Of the 1879 patients with SLE included, 43% received ≥3 intravenous initiation administrations. An average of 5.3 (SD: 2.4) of the nine recommended belimumab administrations were received within 6 months. In the 6-month preindex versus postindex periods, significant reductions were noted for inpatient hospitalisations (18% vs 9%, p<0.001; mean visits: 0.3 vs 0.14, p<0.001) and emergency department visits (40% vs 24%, p<0.001; mean visits; 3.53 vs 1.96, p<0.001). Mean total costs were higher in the 6-month postindex versus preindex period ($41 426 vs $29 270; p<0.001). Conclusions: In this study of real-world intravenous belimumab for SLE, adherence to recommended infusion schedules was low. Outpatient healthcare and associated costs were higher in the 6 months after belimumab was initiated, although inpatient costs were lower. Reasons for non-adherence with belimumab and implications should be investigated.

Treatment patterns and medical cost of systemic lupus erythematosus patients in Japan: a retrospective claims database study.

Aim: To describe the characteristics and medication treatment patterns, healthcare resource utilization (HRU), and associated costs in Japanese patients with systemic lupus erythematosus (SLE).Methods: Claims data from the Japan Medical Data Center (JMDC) database were used to identify patients with SLE-related claims from 2010 to 2017. Algorithms were developed to retrospectively categorize patients by disease severity, treatment experience, and SLE-related manifestations such as lupus nephritis and central nervous system lupus. Descriptive and multivariate analyses were used to describe treatment pattern and estimate HRU and associated costs for the SLE cohort overall and by disease severity and complications.Results: Among 4,733 eligible patients, 2,072 (43.8%) were treatment naïve, 2,214 (46.8%) were previously treated for SLE, and 447 (9.4%) did not receive any treatment. Mean (SD) age of the total SLE cohort was 45.2 (13.1) years and mean (SD) follow-up duration was 1,137.3 (758.0) d. Based on disease severity, 1,383 (29.2%) patients had mild, 2,619 (55.3%) patients had moderate, and 731 (15.4%) patients had severe SLE. Patients on glucocorticoids (both oral and parenteral) received add-on medications the most (35.5%, p < .001). Mean annual cost per SLE patient in the post-index period, inclusive of hospitalizations, outpatient visits, and pharmacy was ¥436,836; ¥1,010,772; and ¥2,136,780 for patients with mild, moderate, and severe SLE, respectively.Limitations: The database only captured information on patients up to 75 years of age. Due to the nature of the database, biases regarding conditions that attribute to the spectrum of SLE severity, flare incidences, or individual physical status cannot be ruled out.Conclusions: This study describes the treatment patterns and economic burden experienced by Japanese patients with SLE. The results highlight an unmet need to derive better treatment strategies for patients with SLE to effectively address the disease burden in Japan.

Patient-Reported Lupus Flare Symptoms Are Associated with Worsened Patient Outcomes and Increased Economic Burden.

BACKGROUND: Lupus flares significantly contribute to health resource utilization and hospitalizations. Identification of flare activity may be hindered since validated assessment scales are rarely used in clinical practice and flare severity may fall below clinician-assessed thresholds. Therefore, patient-reported outcomes of lupus flare frequency are important assessment tools for lupus management. OBJECTIVE: To better understand the relationship between lupus flares as reported by persons with lupus and specific direct and indirect costs, including hospital admission, unplanned urgent care (UC)/emergency department (ED) visits, work productivity loss, and nonwork activity impairment. METHODS: In this cross-sectional analysis, persons with lupus were drawn from 2 enriched sampling sources. Data were collected via an online survey and included individuals with self-reported physician's diagnosis of systemic lupus erythematosus, skin or discoid lupus, or lupus nephritis. Respondents were asked the total number of hospitalizations and ED/UC visits for any reason and for lupus-related hospitalizations and ED/UC visits. Work productivity loss and nonwork activity impairment were measured via the Work Productivity and Activity Impairment - General Health scale. The sample was stratified into those with 0 flares, 1-3 flares, 4-6 flares, and 7 or more flares, with 0 flares used as the reference. Chi-square tests for trend and analyses of variance were used to evaluate differences among flare frequency groups. Multivariable regression modeling was conducted to evaluate the independent relationship of flare frequency to health care use and productivity loss. RESULTS: We studied 1,288 survey respondents with known flare frequency in the past 12 months. Flare frequency increased with duration of illness. The mean number of lupus-related hospital admissions was significantly associated with increasing flare frequency for the total sample (F = 3.9; P < 0.009). Compared to patients with no flare, those who reported flare activities had 1.72-3.13 times higher rates of hospitalizations. The mean number of lupus-related ED/UC visits were also found to be significantly associated with increasing flare frequency for the total sample (F = 23.4; P < 0.001), and rates were increased by 6.98- to 16.12-fold for unplanned ED/UC visits depending on flare frequency. Rates of employment were significantly related to increasing flare frequency. With respect to work-related impairment, absenteeism increased with greater lupus flare frequency (F = 6.2; P < 0.001), as did presenteeism (F = 31.5; P < 0.001) and the combined value of total work productivity loss (F = 30.4; P < 0.001). Mean work-related activity impairment was 12%-32% more among patients who reported flare activities compared to those who reported no flares. CONCLUSIONS: Increased lupus-related flare frequency is associated with worsened patient outcomes as measured by increased hospitalizations, visits to the ED/UC, work productivity loss, and activity impairment. This association may be an important indicator of disease severity and resource burden and therefore suggests an unmet need among patients experiencing lupus-related flares. DISCLOSURES: This study was sponsored by Mallinckrodt Pharmaceuticals via grants to Vedanta Research and The Lupus Foundation of America. Katz received consulting fees from Vedanta Research, which received grant support from Mallinckrodt Pharmaceuticals to support data collection and analysis. Nelson and Connolly-Strong are employees of Mallinckrodt Pharmaceuticals and are stockholders in the company. Reed is an employee of Vedanta Research. Daly and Topf are employees of the Lupus Foundation of America, which received grant funding to support data collection. This study was a podium presentation at The American College of Rheumatology (ACR) Annual Meeting 2018; October 19-24, 2018; Chicago, IL.

Lupus Low Disease Activity State and Reduced Direct Health Care Costs in Patients With Systemic Lupus Erythematosus.

OBJECTIVE: Treat-to-target end points for systemic lupus erythematosus (SLE) have been assessed for their impact on damage accrual and flare, but whether they have an impact on the high health care utilization and costs in SLE has not been studied. The purpose of this study was to examine our hypothesis that the recently described lupus low disease activity state (LLDAS) would be associated with reduced health care cost. METHODS: Data from a single tertiary hospital longitudinal SLE cohort were assessed. Baseline demographics, disease activity (Systemic Lupus Erythematosus Disease Activity Index 2000 [SLEDAI-2K], physician global assessment [PhGA], and flare index), and medication use were evaluated, and direct health care utilization and cost data were obtained from hospital information systems. LLDAS was defined as previously published: briefly, SLEDAI-2K ≤4 with no new activity, PhGA ≤1, prednisolone ≤7.5 mg/day, and optimal standard immunosuppressive agents. Analysis was performed using multivariable linear regression. RESULTS: Two hundred SLE patients, contributing 357.8 person-years of observation, were included. A history of lupus nephritis was present in 42% of patients, and damage (Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index >0) was present at study commencement in 57.3% of patients. The mean ± SD annual direct medical cost per patient was US$7,413 ± 13,133/year. In multivariable analysis, increased cost was associated with the presence of baseline organ damage (41.7% increase; P = 0.009) and corticosteroid use (>7.5-15 mg/day: 55.7% increase; P = 0.02; and >15 mg/day: 202% increase; P < 0.001). In contrast, spending ≥50% of the observation period in LLDAS was associated with a 25.9% reduction in annual direct medical cost (P = 0.04). CONCLUSION: Greater time spent in LLDAS was associated with significantly reduced direct hospital health care costs among patients with SLE.

Socioeconomic status at diagnosis influences the incremental direct medical costs of systemic lupus erythematosus: A longitudinal population-based study.

OBJECTIVES: To assess the incremental direct medical costs of a population-based cohort of incident systemic lupus erythematosus (SLE) for the first five years after diagnosis, and impact of socioeconomic status (SES) on such incremental costs. METHODS: From the administrative health databases in British Columbia, Canada, we identified all adults with newly-diagnosed SLE from 1996 to 2010 and obtained a sample from the general non-SLE population matched on sex, age, and calendar-year. We captured costs for outpatient encounters, hospitalisations, and dispensed medications. Using two-part generalised linear models, we estimated per-person-year incremental costs of SLE (difference in costs between SLE and non-SLE, controlling for covariates) during the first five years after diagnosis, and assessed differences in incremental costs across SES groups. RESULTS: We included 4679 newly-diagnosed SLE (86% identified from hospitalisations or rheumatologists) and 23,219 non-SLE individuals. Per-person direct costs for SLE in the first year after diagnosis averaged $13,038 (2013 Canadian), with 61% from hospitalisations, 23% from outpatient encounters, and 16% from medications; costs for non-SLE averaged $2,431. Following adjustment, incremental costs of SLE during the first five years after diagnosis averaged $10,078 per-person-year (95% CI=$2062-$32,254). Predicted incremental hospitalisation, outpatient, and medication costs were all significantly-greater for the low-SES patients versus high-SES (additional $1922 per-person-year in incremental costs for low-SES). Similar patterns were observed when restricting to those followed the full five-years after index date. CONCLUSION: Even in a single-payer, publicly-funded healthcare setting, low SES at SLE diagnosis was associated with significantly-greater direct medical costs for the management of SLE and associated complications.

Real-world medication use and economic outcomes in incident systemic lupus erythematosus patients in the United States.

Aims: Systemic lupus erythematosus (SLE) is a multifaceted autoimmune disease involving multiple organs systems and places a significant economic burden on SLE patients. There is a literature gap regarding the standard of care and economic burden in SLE patients, their families, and society. This study assessed medication use patterns among SLE patients and generated the annual and total economic burden associated with the illness.Materials and methods: Adult patients with ≥2 medical claims on different dates for SLE diagnoses were identified from 01 January 2013 to 31 December 2015 using two large administrative claims databases representative of the commercially insured US population. Patient demographics and clinical characteristics during 1-year pre-SLE diagnosis were assessed. Outcomes including the proportion of patients who used SLE medications and annual costs were assessed 1-year post-SLE diagnosis. Total costs related to SLE were extrapolated to the US population to estimate the economic burden based on SLE prevalence.Results: A total of 30,086 SLE patients were identified. The most common baseline comorbidities were hypertension and infections. Corticosteroids and hydroxychloroquine were the most common SLE medications. Biologics utilization was minimal. SLE patients had, on average, 26.0 physician visits, 23.7 prescription claims, 1.7 inpatient admissions, and 2.0 hospital days per patient 1-year post-SLE diagnosis. Annual all-cause median costs among all SLE patients were $8712 per patient per year. Total costs ranged between $1.4-1.6 and $2.8-3.2 billion per year, depending on prevalence estimates.Conclusions: Our findings indicate a nominal use of biologics (∼2%) among SLE patients; despite belimumab being one of the few approved treatments for SLE in the USA. These data reveal an unmet need for availability of advanced SLE therapy, and future studies are warranted concerning the underlying causes. SLE is also associated with a substantial economic burden of ≤3.2 billion per year. These findings may assist in future planning and resource allocation.

Economic Evaluation of Damage Accrual in an International Systemic Lupus Erythematosus Inception Cohort Using a Multistate Model Approach.

OBJECTIVE: There is a paucity of data regarding health care costs associated with damage accrual in systemic lupus erythematosus. The present study was undertaken to describe costs associated with damage states across the disease course using multistate modeling. METHODS: Patients from 33 centers in 11 countries were enrolled in the Systemic Lupus International Collaborating Clinics (SLICC) inception cohort within 15 months of diagnosis. Annual data on demographics, disease activity, damage (SLICC/American College of Rheumatology Damage Index [SDI]), hospitalizations, medications, dialysis, and selected procedures were collected. Ten-year cumulative costs (Canadian dollars) were estimated by multiplying annual costs associated with each SDI state by the expected state duration using a multistate model. RESULTS: A total of 1,687 patients participated; 88.7% were female, 49.0% were white, mean ± SD age at diagnosis was 34.6 ± 13.3 years, and mean time to follow-up was 8.9 years (range 0.6-18.5 years). Mean annual costs were higher for those with higher SDI scores as follows: $22,006 (Canadian) (95% confidence interval [95% CI] $16,662, $27,350) for SDI scores ≥5 versus $1,833 (95% CI $1,134, $2,532) for SDI scores of 0. Similarly, 10-year cumulative costs were higher for those with higher SDI scores at the beginning of the 10-year interval as follows: $189,073 (Canadian) (95% CI $142,318, $235,827) for SDI scores ≥5 versus $21,713 (95% CI $13,639, $29,788) for SDI scores of 0. CONCLUSION: Patients with the highest SDI scores incur 10-year cumulative costs that are ~9-fold higher than those with the lowest SDI scores. By estimating the damage trajectory and incorporating annual costs, data on damage can be used to estimate future costs, which is critical knowledge for evaluating the cost-effectiveness of novel therapies.

Impact of the Affordable Care Act Medicaid Expansion on Access to Care and Hospitalization Charges for Lupus Patients.

OBJECTIVE: To examine the impact of the Affordable Care Act on preventable hospitalizations and associated charges for patients living with systemic lupus erythematosus, before and after Medicaid expansion. METHODS: A retrospective, quasi-experimental study, using an interrupted time series research design, was conducted to analyze data for 8 states from the Healthcare Cost and Utilization Project state inpatient databases. Lupus hospitalizations with a principal diagnosis of predetermined ambulatory-care sensitive (ACS) conditions were the unit of primary analysis. The primary outcome variable was access to care measured by preventable hospitalizations caused by an ACS condition. RESULTS: There were 204,150 lupus hospitalizations in the final analysis, with the majority (53.5%) of lupus hospitalizations in states that did not expand Medicaid. In unadjusted analysis, Medicaid expansion states had significantly lower odds of having preventable lupus hospitalizations (odds ratio [OR] 0.958); however, after adjusting for several covariates, Medicaid expansion states had increased odds of having preventable lupus hospitalizations (OR 1.302). Adjusted analysis showed that those individuals with increased age, public insurance (Medicare or Medicaid), no health insurance, rural residence, or low income had significantly higher odds of having a preventable lupus hospitalization. States that expanded Medicaid had $523 significantly more charges than states that did not expand Medicaid. Older age and rural residence were associated with significantly higher charges. CONCLUSION: Our findings suggest that while Medicaid expansion increased health insurance coverage, it did not address other issues related to access to care that could reduce the number of preventable hospitalizations.

Cost-effectiveness of a peer mentoring intervention to improve disease self-management practices and self-efficacy among African American women with systemic lupus erythematosus: analysis of the Peer Approaches to Lupus Self-management (PALS) pilot study.

OBJECTIVE: The Peer Approaches to Lupus Self-management (PALS) program was developed as a peer mentoring tool to improve health behaviors, beliefs, and outcomes in African American women with systemic lupus erythematosus (SLE). This study aims to assess the cost of the PALS intervention and determine its effectiveness when compared to existing treatments. METHODS: Peer mentors and mentees were paired on shared criteria such as life stage, marital status, or whether they were mothers. This 12-week program consisted of a weekly peer mentoring session by telephone. Cost of healthcare utilization was evaluated by assessing the healthcare costs pre- and post-intervention. Validated measures of quality of life, self-management, disease activity, depression, and anxiety were collected. Total direct program costs per participant were totaled and used to determine average per unit improvement in outcome measures. The benefit-cost ratio and pre- versus post-intervention hospital charges were examined. RESULTS: A total of 20 mentees and 7 mentors were enrolled in the PALS program. All PALS pairs completed 12 sessions lasting an average of 54 minutes. Mentees reported statistically significant decreases in patient-reported disease activity, depression, and anxiety, with improved trends in patient activation or patient engagement in their disease and management. The total cost per patient was $1291.50, which was $107.62 per patient per week. There was a savings of $23,417 per individual receiving the intervention with a benefit-cost ratio of 18.13 per patient. CONCLUSION: These findings suggest that the PALS intervention was effective in improving patient-level factors and was cost-effective. Future research will need to validate these findings in a larger sample.

Direct cost of lupus care in the developing world: the case of Colombia.

BACKGROUND: Lupus is a chronic autoimmune and incurable rheumatic disease and has a global prevalence of 3.2-517.5 cases per 100,000 people. However, currently there is no knowledge regarding the actual direct cost of patients with lupus to healthcare systems in developing countries. This study aimed to determine the direct cost of lupus care in Colombia. METHODS: To identify patients with lupus, claims data of 2 years from two health insurers were subjected to an algorithm according to International Statistical Classification of Diseases and Related Health Problems 10th Revision codes. Multivariate linear regression analyses were used to assess the direct cost of lupus care. RESULTS: The average annual per-patient, all-claims, all-cause direct cost was $2355; this is approximately 9 times the average annual premium received by health insurers for covering the public benefits package. Approximately 50% of direct costs are not included in the public benefits package. The incidence of one or more condition is 98.4%. The direct cost incurred by patients with two comorbidities was 1.8 times more, with three chronic conditions was 1.9 times more and with six chronic conditions was 4.5 times more than that incurred by patients with only lupus. CONCLUSIONS: The direct cost of lupus care in the developing world may be higher than expected; in addition, access to healthcare may not be equal for the entire population.

Detection of subclinical synovial hypertrophy by musculoskeletal gray-scale/ power Doppler ultrasonography in systemic lupus erythematosus patients: A cross-sectional study.

OBJECTIVE: Laboratory investigations are invasive methods. Magnetic resonance imaging (MRI) has a small field of view. Ultrasound can be performed at multiple parts of the body. The objective of the study was to find out subclinical synovial hypertrophy in systemic lupus erythematosus patients using gray-scale/power Doppler ultrasonography. METHODS: A total of 247 systemic lupus erythematosus (without musculoskeletal involvement) patients from 21 February 2017 to 28 October 2018 were included in the cross-sectional study. Patients were subjected to physical examinations, laboratory tests, and gray-scale/power Doppler ultrasonography examinations. Synovial hypertrophy was confirmed if it was present in at least 4 out of 100 of the examined location sites. MRI examinations were performed for confirmation purposes. Spearman correlation was performed between imaging and laboratory investigations at the 99% confidence level. RESULTS: No correlation was observed for results of synovial hypertrophy between physical examinations/laboratory tests and gray-scale/power Doppler ultrasonography examinations except erythrocyte sedimentation rate (r = 0.354). Cost of laboratory tests (315.47 ± 19.15 ¥/person) for subclinical synovial hypertrophy detection was higher than that of gray-scale/power Doppler ultrasonography examinations (135.47 ± 8.17 ¥/person, P <0.0001, q = 230.87). Results of gray-scale/power Doppler ultrasonography have a correlation with results of MRI (r = 0.34). CONCLUSION: Only perform gray-scale/power Doppler ultrasonography examinations for regular maintenance of rheumatologic disease in systemic lupus erythematosus patients.

Health-related quality of life in patients with systemic lupus erythematosus: a Spanish study based on patient reports.

INTRODUCTION AND OBJECTIVES: Systemic lupus erythematosus (SLE) is a disease that significantly affects the quality of life and welfare of patients. SLE patients can be classified into multimorbidity levels using Clinical Risk Groups (CRGs) to help to incorporate predictive models of health needs. The goal of this study was to correlate CRGs with health-related quality of life (HR-QoL) and costs in SLE patients. METHODS: A questionnaire was administered to SLE patients in four hospital centers of the Valencian Community (Spain) between October 2015 and March 2016. The factors studied included HR-QoL (EQ-5D-5L and VAS), disease activity (SLAI/SELENA), damage (SLICC/ACR), and severity (IGK). RESULTS: The patients (N = 190, 92.06% female, age (mean ± SD) 47.23 ± 13.43 years) were sorted according to health status in nine CRGs. We found that most SLE patients (> 70%) were in CRGs 5 and 6. The main HR-QoL issues in these patients were related to mobility, ability to perform usual activities, and pain/discomfort. The scores (mean ± SD) for EQ-5D-5L and VAS were 0.74 ± 0.25 and 65.67 ± 23.52, respectively. We found that the age of the patients negatively affected their HR-QoL (r = - 0.266). SLE direct costs per patient increased with each CRG group, representing 71.92% of the total costs, while indirect costs were highly variable. The average cost per patient with SLE amounted to €8432.85 (year 2014). CONCLUSIONS: Patients' quality of life is related with age, disease activity, damage, and severity. Age was the parameter which most affects HR-QoL. Most costs of SLE are concentrated in two CRGs in which the HR-QoL deteriorates sharply.

Poverty, Neighborhoods, Persistent Stress, and Systemic Lupus Erythematosus Outcomes: A Qualitative Study of the Patients' Perspective.

OBJECTIVE: To obtain the perspective of individuals with systemic lupus erythematosus (SLE) regarding the role of poverty, neighborhood, and chronic stress in SLE outcomes. METHODS: Through annual structured interviews as part of the Lupus Outcomes Study, 723 persons with SLE were followed from 2003 to 2015 in order to establish the effect of combinations of poverty, persistent poverty, residence in an area of concentrated poverty, access to health care, and chronic stress on accumulated damage. We obtained a sample of 28 of the 723 individuals on the basis of household income, geography, and outcomes in their last interview, and administered qualitative interviews to explore their perspectives on the impact of these factors on SLE outcomes. The interviews were recorded, transcribed, and analyzed using a grounded theory approach. RESULTS: Persons in poverty frequently reported that poverty necessitated a choice to deal with food, medical care, and housing insecurity on a daily basis and to relegate their management of SLE to occurrences of disease flares. They also reported that exposure to crime in their neighborhoods was a stressor that triggered worse disease activity. Affluent participants reported that neighborhood neither helped nor hindered dealing with SLE, because they relied on networks not tied to neighborhoods to deal with SLE. CONCLUSION: Mitigating poverty and reducing exposure to crime through moving to safer neighborhoods are factors identified by individuals with SLE as potentially critical in disease outcomes.