Candace H. Feldman
Opioid use and overdose, and certain vaccine-preventable diseases, are among conditions related to systemic lupus erythematosus that could be avoided or minimized through high-quality, timely ambulatory care, according to findings published in Arthritis Care & Research.
“Patients with lupus have been shown to have high rates of ED visits and hospitalizations,” Candace H. Feldman, MD, ScD, of Brigham and Women’s Hospital and Harvard Medical School, told Healio Rheumatology. “There are also significant racial/ethnic and socioeconomic disparities in adverse outcomes among patients with lupus. A significant proportion of these adverse outcomes, and episodes of avoidable acute care use, may be prevented if patients had sustained access to high quality outpatient care.”
“The U.S. Agency for Healthcare Research and Quality defined a set of ‘ambulatory care sensitive conditions’ for the general population and we aimed to both update these conditions and tailor them to patients with lupus,” she added. “We felt that by establishing a set of lupus-specific ambulatory care sensitive conditions, we would be able to both study the disproportionate burden of avoidable acute care use among vulnerable patient populations, as well as allocate resources and develop interventions to reduce the disparities observed.”
To compile a set of adverse SLE-related adverse outcomes that could be prevented or minimized through timely, quality ambulatory care, Feldman and colleagues conducted a literature review followed by a series of surveys with experts. For their review, the researchers searched PubMed for terms that included “systemic lupus erythematosus,” “preventable,” “ambulatory,” “hospitalization” and others. They then used the results to develop categories and conditions of interest for the expert surveys.
Opioid use and overdose, and certain vaccine-preventable diseases, are among conditions related to SLE that could be avoided or minimized through high-quality, timely ambulatory care, according to findings.
The researchers assembled a panel of 16 nationally recognized, U.S.-based experts in eight subspecialties. They included seven rheumatologists, two pediatric rheumatologists, two nephrologists, a neurologist, a cardiologist, an OB-GYN, an infectious disease physician and a joint specialty dermatologist/rheumatologist. Each expert was asked to participate in two survey rounds with controlled feedback, as well as an interactive webinar, which was used to reach a consensus on the preventability and importance of various adverse conditions. The experts solidified their set of preventable conditions during a final round of voting.
According to the researchers, the panelists ultimately came to a consensus on 25 conditions related to SLE that they agreed were important on a population level and potentially avoidable. Each of these conditions fell into one of four categories — vaccine preventable illnesses, treatment-related complications, reproductive health issues and SLE-related complications.
Among the vaccine-preventable conditions were high-grade cervical dysplasia or cervical cancer, influenza, herpes zoster, meningococcal disease, pneumococcal disease and hepatitis B. Medication-related complications included hydroxychloroquine toxicity leading to vision loss, chronic opioid use, opioid overdose, Pneumocystis jirovecii pneumonia from high doses of glucocorticoids, gastrointestinal bleeding, complications from uncontrolled glucocorticoid-induced diabetes, osteoporotic fracture and avascular necrosis.
Conditions related to reproductive health included fetal anomalies related to teratogenic medications, vascular thrombosis due to estrogen-containing contraception and positive antiphospholipid antibodies, premature ovarian insufficiency and infertility from cyclophosphamide, spontaneous abortion while taking teratogenic treatments, obstetrical complications related to antiphospholipid syndrome and neonatal lupus or congenital heart block.
Additionally, SLE-related comorbidities included vascular thrombosis, embolic stroke, lupus flare while lacking ultraviolet protection, chronic kidney disease or end-stage renal failure, and recurrent myocardial infarction.
“By recognizing adverse outcomes that are avoidable, we can implement strategies to prevent them particularly among patients who may be at highest risk,” Feldman said. “It is our hope that this helps us to begin to reduce some of the racial/ethnic and socioeconomic disparities we observe both in lupus care and outcomes.” – by Jason Laday
Disclosure: Feldman reports no relevant financial disclosures. Researcher Joseph F. Merola, MD, MMSc, of Brigham and Women’s Hospital and Harvard Medical School, reports an honorarium for consulting services from Celgene and Biogen.