One in six patients with systemic lupus erythematosus was readmitted within 30 days after discharge in a multistate, administrative database study of more than 800 hospitals and 55,000 hospitalizations, and these readmissions occurred more often among black and Hispanic patients than whites.
"These findings suggest potential racial disparities in factors that are known to influence readmissions, such as the quality of care delivered in the hospital or during health care transitions to the outpatient settings," lead author Dr. Jinoos Yazdany, codirector of the lupus clinic at the University of California, San Francisco, said in an interview. "Poor access to high-quality care, both in the hospital and in the outpatient clinic, may be contributing, but further research is needed to prove this."
Dr. Jinoos Yazdany
Patients with systemic lupus erythematosus (SLE) on Medicare or Medicaid also had higher readmission rates than those on private insurance, Dr. Yazdany and her associates reported Aug. 11 in Arthritis & Rheumatology.
Up to 25% of patients with SLE are hospitalized each year, and SLE has the sixth-highest readmission rate of any medical condition in the United States. To better characterize SLE readmissions, the researchers analyzed an administrative dataset representing 31,903 adult patients with SLE admitted at 810 hospitals in California, Florida, New York, Utah, and Washington during 2008-2009 (Arthritis Rheumatol. 2014 Aug. 11 [doi: 10.1002/art.38768]).
Of 55,936 total hospitalizations, 9,244 (16.5%) led to readmission within 30 days, the investigators reported. Patients were more likely to be readmitted if they were younger (odds ratio, 0.98 per year; 95% confidence interval, 0.98-0.98); black (OR, 1.18; 95% CI, 1.09-1.28); Hispanic (OR, 1.12; 95% CI, 1.02-1.22); or had Medicare or Medicaid versus private insurance (OR, 1.57; 95% CI, 1.45-1.69; and OR, 1.53; 95% CI, 1.40-1.67, respectively), the researchers added.
While SLE tends to be worse in younger patients, its greater prevalence and severity in minorities appears to be multifactorial, Dr. Yazdany said. "Environmental, psychosocial, biologic, and health care factors seem to all play a role," she noted. "This means that no one strategy will be enough to eliminate disparities in SLE."
Clinical features of SLE most often associated with readmission included lupus nephritis, serositis, and thrombocytopenia, the researchers added. New York hospitals had significantly lower risk-adjusted readmission rates than did those in California (OR, 0.77; 95% CI, 0.70-0.85), while hospitals in Florida had significantly higher rates (OR, 1.20; 95% CI, 1.11-1.32), compared with California, they reported.
"We should learn more about the systems that New York has in place for SLE patients, including whether the high concentration of dedicated SLE centers helps improve the quality of care," Dr. Yazdany said. Improving discharge planning, hospital transitions, coordination of care, and patient education are known to prevent avoidable hospitalizations in the overall population, she said. "To reduce readmissions in SLE, we need to investigate all of these strategies."
Notably, hospitals with high readmission rates for SLE did not also have higher rates for common chronic diseases such as heart disease or pneumonia, the researchers reported. "This tells us that it is important to look at SLE separately to properly target quality improvement initiatives," Dr. Yazdany said. "SLE requires highly coordinated, interdisciplinary care both in the hospital and during outpatient transitions, and our study implies that some hospital systems are doing a better job than others in caring for these patients."
Using readmissions to grade hospital quality is controversial, Dr. Yazdany noted. "However, readmissions can also serve as an outcome measure to help us identify disparities in care and to target quality improvement initiatives," she said. "Now that we know that there is significant unexplained variation in SLE readmission rates across states, the next step is to develop interventions to improve this outcome, particularly in high-risk patients."
Some states did not report whether admissions were planned, which could have led investigators to misclassify planned rehospitalizations as acute readmissions, they said. The dataset used in the study also had sparse clinical information, making it impossible to determine if readmissions were preventable, they added.
The study was partly funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. The authors reported no conflicts of interest.