Association of dermatomyositis with systemic and opportunistic infections in the United States.

Patients with dermatomyositis have multiple risk factors for serious and opportunistic infections, including immune dysregulation, long-term systemic corticosteroid treatment and comorbid health conditions. We sought to determine whether dermatomyositis is associated with increased odds and burden of systemic, opportunistic and antibiotic-resistant infections. We analyzed data from the Nationwide Inpatient Sample from 2002 to 2012, containing a cross-sectional representative 20% sample of all hospitalizations in the US. Overall, dermatomyositis was associated with serious infections in adults (multivariable logistic regression; adjusted odds ratio [95% confidence interval]: 2.19 [2.08-2.30]) and children (1.45 [1.20-1.76]). In particular, dermatomyositis was significantly associated with 32 of 48 and 15 of 48 infections examined in adults and children, respectively, including infections of skin, bone, joints, brain, heart, lungs, and gastrointestinal system, as well sepsis, antibiotic-resistant and opportunistic infections. Predictors of infections included non-white race/ethnicity, insurance status, history of long-term systemic corticosteroid usage, Cushing's syndrome (likely secondary to corticosteroid usage), diabetes, and cancer. Serious infections were associated with significantly increased inpatient cost and death in dermatomyositis patients. In conclusion, dermatomyositis is associated with higher odds, costs and inpatient mortality from serious and opportunistic infections.

Positron emission tomography costs less to patients than conventional screening for malignancy in dermatomyositis.

BACKGROUND: Dermatomyositis (DM) is associated with malignancy and interstitial lung disease. Many malignancies associated with DM occur in organs not routinely screened by national guidelines; thus, best screening practices are still debated. Positron emission tomography (PET) has been suggested as a single study alternative to more complex screening panels and may also be valuable in detecting interstitial lung disease progression. Criticisms of PET screening exams have focused on cost and radiation exposure. OBJECTIVE: To compare the cost of PET and its variants to conventional malignancy screening panels, and to review concerns regarding radiation exposure in PET. METHODS: Four variants of PET and PET-CT were included in the study. The conventional screening panel was defined as CT of the abdomen and pelvis without contrast, CT of the thorax without contrast, CEA, CA 19.9, PSA (men), mammography (women), transvaginal ultrasound (women), cytopathology (women), and CA 125 (women). The MarketScan® Commercial Claims and Encounters database, a collection of private insurance claims data from 53 million Americans, was queried for every instance of each test from 2005 to 2014 and the mean inflation-adjusted cost of each was recorded. The mean total cost to insurance companies and the mean out-of-pocket costs to patients for PET variants were compared to the costs for conventional panels. Additionally, the cost of pulmonary function tests (PFT) from the same period was evaluated. RESULTS: From 2005-2014, the mean inflation-adjusted costs of PET have trended downward, but the mean cost of PET-CT have trended upward. The mean total cost to insurance companies for PET-CT whole body was $730.70 and $537.62 greater than the cost of conventional panels for men and women, respectively. The out-of-pocket patient costs for PET-CT whole body was $109.82 and $111.33 less than the cost of conventional panels for men and women, respectively. The mean total cost of PFT was $205.02. CONCLUSIONS: The cost of PET-CT whole body was greater than conventional panels for insurance companies, but patient out-of-pocket costs were lower. PET-CT may also have added value in detecting and monitoring interstitial lung disease progression in DM patients. More data are needed on the efficacy of PET-CT in detecting malignancy in DM patients; however, the cost difference is less than expected, suggesting the single scan could be a reasonable alternative to the conventional screening panel in some patients.

Inpatient burden of juvenile dermatomyositis among children in the United States.

BACKGROUND: Juvenile dermatomyositis (JDM) is a rare autoimmune disease that causes significant morbidity and quality of life impairment. Little is known about the inpatient burden of JDM in the US. Our goal was to determine the prevalence and risk factors for hospitalization with juvenile dermatomyositis and assess inpatient burden of JDM. METHODS: Data on 14,401,668 pediatric hospitalizations from the 2002-2012 Nationwide Inpatient Sample (NIS) was analyzed. ICD-9-CM coding was used to identify hospitalizations with a diagnosis of JDM. RESULTS: There were 909 and 495 weighted admissions with a primary or secondary diagnosis of JDM, respectively. In multivariable logistic regression models with stepwise selection, female sex (logistic regression; adjusted odds ratio [95% confidence interval]) (2.22 [2.05-2.42]), non-winter season (fall: 1.18[1.06-1.33]; spring (1.13 [1.01-1.27]; summer (1.53 [1.37-1.71]), non-Medicaid administered government insurance coverage (2.59 [2.26-2.97]), and multiple chronic conditions (2-5: 1.41[1.30-1.54]; 6+: 1.24[1.00-1.52]) were all associated with higher rates of hospitalization for JDM. The weighted total length of stay (LOS) and inflation-adjusted cost of care for patients with a primary inpatient diagnosis of JDM was 19,159 days and $49,339,995 with geometric means [95% CI] of 2.50 [2.27-2.76] days and $7350 [$6228-$8674], respectively. Costs of hospitalization in primary JDM and length of stay and cost in secondary JDM were significantly higher compared to those without JDM. Notably, race/ethnicity was associated with increased LOS (log-linear regression; adjusted beta [95% confidence interval]) (Hispanic: 0.28 [0.14-0.41]; other non-white: 0.59 [0.31-0.86]) and cost of care (Hispanic: 0.30 [0.05-0.55]). CONCLUSION: JDM contributes to both increased length of hospitalization and inpatient cost of care. Non-Medicaid government insurance was associated with higher rates of hospitalization for JDM while Hispanic and other non-white racial/ethnic groups demonstrated increased LOS and cost of care.

Predictors of Hospitalization, Length of Stay, and Cost of Care Among Adults With Dermatomyositis in the United States.

OBJECTIVE: To determine the prevalence and risk factors for hospitalization with dermatomyositis and assess inpatient burden of dermatomyositis. METHODS: Data on 72,651,487 hospitalizations from the 2002-2012 Nationwide Inpatient Sample, a 20% stratified sample of all acute-care hospitalizations in the US, were analyzed. International Classification of Diseases, Ninth Revision, Clinical Modification coding was used to identify hospitalizations with a diagnosis of dermatomyositis. RESULTS: There were 9,687 and 43,188 weighted admissions with a primary or secondary diagnosis of dermatomyositis, respectively. In multivariable logistic regression models with stepwise selection, female sex (logistic regression: adjusted odds ratio 2.05 [95% confidence interval (95% CI) 1.80, 2.34]), nonwhite race (African American: 1.68 [1.57, 1.79]; Hispanic: 2.38 [2.22, 2.55]; Asian: 1.54 [1.32, 1.81]; and multiracial/other: 1.65 [1.45, 1.88]), and multiple chronic conditions (2-5: 2.39 [2.20, 2.60] and ≥6: 2.80 [2.56, 3.07]) were all associated with higher rates of hospitalization for dermatomyositis. The weighted total length of stay (LOS) and inflation-adjusted cost of care for patients with a primary inpatient diagnosis of dermatomyositis was 80,686 days and $168,076,970, with geometric means of 5.38 (95% CI 5.08, 5.71) and $11,682 (95% CI $11,013, $12,392), respectively. LOS and costs of hospitalization were significantly higher in patients with dermatomyositis compared to those without. Notably, race/ethnicity was associated with increased LOS (log-linear regression: adjusted ß [95% CI] for African American: 0.14 [0.04, 0.25] and Asian: 0.38 [0.22, 0.55]) and cost of care (Asian: 0.51 [0.36, 0.67]). CONCLUSION: There is a significant and increasing inpatient burden for dermatomyositis in the US. There appear to be racial differences, as nonwhites have higher prevalence of admission, increased LOS, and cost of care.

Healthcare resource utilization and work loss in dermatomyositis and polymyositis patients in a privately-insured US population.

Background Dermatomyositis and polymyositis (DM/PM) are inflammatory myopathies characterized by muscle inflammation/weakness. Patients with DM/PM have a reduced quality-of-life and are at an increased risk for several comorbidities. Studies have assessed the incidence and prevalence of DM/PM; however, no study has estimated the burden of the diseases in terms of both healthcare resource utilization (HCRU) and work loss incurred by patients. Objective To provide a comprehensive, current estimate of the annual HCRU and work loss in DM/PM patients in the US. Methods All patients (aged 18-64 years) with a first diagnosis of DM/PM between January 1, 1998 and March 31, 2014 ('index date') were selected from a de-identified privately-insured administrative claims database. DM/PM patients were required to have continuous health-plan enrollment 12 months prior to and following their index date. Propensity-score (1:1) matching of DM/PM patients with non-DM/PM controls was carried out based on a logistic regression of demographic characteristics, comorbidities, costs, and HCRU to control for these confounding factors. Burden of HCRU and work loss (disability days and medically-related absenteeism) were compared between the matched DM/PM and the non-DM/PM cohorts over the 12-month period after the index date ('outcome period'). Results Of the 2617 DM/PM patients that met sample selection criteria, 2587 (98.9%) were matched with a non-DM/PM control. During the outcome period, DM/PM patients had significantly increased HCRU across places of service, including 44% more inpatient admissions (3.6 vs 2.5, p < 0.001), increased visits with specialists such as rheumatologists, neurologists and physical therapists, and filled 4.7 more prescriptions (32.2 vs 27.5, p < 0.001) than matched control patients. The increased HCRU led to significantly more medically-related work loss among DM/PM patients than matched controls (p < 0.001). Conclusions DM/PM imposes a substantial increase in healthcare resource use and is associated with statistically significantly greater work loss in the first year following diagnosis.

Cost-utility analysis of intravenous immunoglobulin for the treatment of steroid-refractory dermatomyositis in Thailand.

INTRODUCTION: Intravenous immunoglobulin (IVIG) has been shown to be effective in treating steroid-refractory dermatomyositis (DM). There remains no evidence of its cost-effectiveness in Thailand. OBJECTIVE: Our objective was to estimate the cost utility of IVIG as a second-line therapy in steroid-refractory DM in Thailand. METHODS: A Markov model was developed to estimate the relevant costs and health benefits for IVIG plus corticosteroids in comparison with immunosuppressant plus corticosteroids in steroid-refractory DM from a societal perspective over a patient's lifetime. The effectiveness and utility parameters were obtained from clinical literature, meta-analyses, medical record reviews, and patient interviews, whereas cost data were obtained from an electronic hospital database and patient interviews. Costs are presented in $US, year 2012 values. All future costs and outcomes were discounted at a rate of 3% per annum. One-way and probabilistic sensitivity analyses were also performed. RESULTS: Over a lifetime horizon, the model estimated treatment under IVIG plus corticosteroids to be cost saving compared with immunosuppressant plus corticosteroids, where the saving of costs and incremental quality-adjusted life-years (QALYs) were $US4738.92 and 1.96 QALYs, respectively. Sensitivity analyses revealed that probability of response of immunosuppressant plus corticosteroids was the most influential parameter on incremental QALYs and costs. At a societal willingness-to-pay threshold in Thailand of $US5148 per QALY gained, the probability of IVIG being cost effective was 97.6%. CONCLUSIONS: The use of IVIG plus corticosteroids is cost saving compared with treatment with immunosuppressant plus corticosteroids in Thai patients with steroid-refractory DM. Policy makers should consider using our findings in their decision-making process for adding IVIG to corticosteroids as the second-line therapy for steroid-refractory DM patients.

Healthcare costs of inflammatory myopathies.

OBJECTIVE: Little information exists regarding the economic burden related to inflammatory myopathies. Our objective was to estimate health services costs in a large, unselected, population-based sample of patients with inflammatory myopathies. METHODS: We identified subjects with polymyositis and dermatomyositis from administrative healthcare databases (covering all beneficiaries, about 7.5 million) in Quebec province, Canada. Average estimates of health services costs (physician visits, diagnostic tests and procedures, outpatient surgeries and procedures, acute care hospitalizations) for 2003 were calculated by multiplying health service use levels by the appropriate unit prices, determined from government fee schedules and other sources. Multiple linear regression analyses were performed to establish whether specific factors (age, sex, disease duration, region of residence, socioeconomic status, type of myositis, disease severity) were associated with cost. RESULTS: We identified 1102 subjects with inflammatory myopathy from January 1, 1989, to January 1, 2003. About two-thirds were women (68.9%); average age at case ascertainment was 57.4 years (SD 18.4). The average cost of all reimbursed health services, in 2008 Canadian dollars, was $4099 per patient (SD $9639). Costs increased with age, and were highest early in the disease course. Greater disease severity (defined as the need for prior hospitalization for myositis) was also a strong predictor of both physician costs and total costs. CONCLUSION: These results indicate significant economic burden related to inflammatory myopathies, with important demographic predictors. Our estimates suggest that the health services costs in inflammatory myopathies may equal, or exceed, those of other serious diseases, such as rheumatoid arthritis and systemic sclerosis.

The economic impact of intermittent high-dose intravenous versus oral corticosteroid treatment of juvenile dermatomyositis.

OBJECTIVE: To perform a cost-identification and cost-effectiveness analysis comparing oral corticosteroids (OCS) with high-dose intermittent intravenous corticosteroid (IVCS) regimens in the treatment of juvenile dermatomyositis (JDM). METHODS: Children previously diagnosed and treated for JDM (without myositis-specific or myositis-associated autoantibodies) at a single medical center by a single provider were identified. Two treatment protocols were compared: OCS and IVCS. Data on initial disease severity, time to remission, resource use, and costs generated were collected from patient records. Incremental cost-effectiveness ratios (ICE) were constructed. RESULTS: Patients treated with IVCS achieved median remission 2 years earlier at median increased cost of $13,736. The ICE ratio comparing IVCS to OCS is $6,868 per year of disease avoided. CONCLUSION: This study suggests that, although IVCS treatments are costly, they are cost-effective.

The challenge of caring for indigent children with rheumatologic diseases.

Poverty and lack of insurance prevent complete access to tertiary care for many children with rheumatologic diseases. Long-term solutions to provide community based support for local teams and other services are needed. Physicians need to work with colleagues in health care systems and government to make the health care system fully available to all families. Medical schools can act as catalysts in helping government agencies redefine policies to support outreach and other health care programs for the indigent. Governmental agencies must collaborate with insurance companies to change policies so as to cover all aspects of service, including those provided by arthritis health professionals. With coordinated effort, the goal of adequate services to indigent children with rheumatologic and other chronic illnesses can become reality.