Drugs that suppress the immune system make it harder to fight infection, study says
MONDAY, Aug. 11, 2014 (HealthDay News) -- One in six hospitalized lupus patients requires readmission to the hospital within a month after discharge, according to a new study.
While patients' disease severity contributed to readmission rates, other population differences suggest hospitals might be able to reduce rehospitalizations through better discharge plans and by addressing disparities in health care, said Dr. Jinoos Yazdany, lead researcher and associate professor of medicine at the University of California, San Francisco.
Lupus is a disease in which the immune system attacks the body. Although researchers don't understand all of its causes, there is a genetic component to the disease, Yazdany said. Drugs that suppress the immune system can help control lupus but often with bad side effects.
Lupus afflicts approximately 10 times more women than men and disproportionately affects racial and ethnic minorities and lower socioeconomic groups, she said.
"There are likely environmental, psychosocial, biological and even health care factors that play a role," Yazdany said. "No one strategy is going to be enough to eliminate these differences we see in lupus prevalence."
For the study, published online Aug. 11 in Arthritis & Rheumatology, Yazdany's team analyzed hospital discharge records in 2008 and 2009 for about 32,000 patients from more than 800 hospitals in New York, Florida, Utah, California and Washington.
Causes of initial hospitalization generally fell into three categories, Yazdany said. The first arose from the disease itself, such as inflammation or organ failure. The second resulted from other conditions, such as heart disease or diabetes, which commonly coexist with lupus.
The last category included infections. The same drugs that suppress the immune system so that lupus can't attack the body also reduce a person's ability to fight off bacterial and viral infections.
These reasons also provide clues regarding the study's finding that 16.5 percent of patients were readmitted to the hospital within 30 days.
"If you have more severe manifestations of the lupus that brought you to the hospital, you're going to be treated with aggressive immunosuppressants, and that's going to increase your risk of infection," said Dr. Joan Merrill, medical director of the Lupus Foundation of America and head of clinical pharmacology research at Oklahoma Medical Research Foundation. "That's going to increase your risk of rehospitalization, and/or if the treatments don't work, then you're at risk of organ failure."
Indeed, more severe disease was associated with a higher likelihood of readmission. Three conditions in particular dominated the readmissions: low blood platelet count; kidney inflammation (called lupus nephritis); and an inflammation of the linings of the organs (serositis).
"Thirty-day hospitalization readmission rates are sometimes used as a measure of quality, but with sick people, it can really be a measure of the severity of their illness," said Dr. David Pisetsky, a professor of medicine at Duke University School of Medicine and a member of the scientific advisory board at the Lupus Research Institute.
However, other important differences emerged. Black and Hispanic patients were more likely to be readmitted than white patients. "That suggests there may be a racial disparity in the things that influence readmission, such as the quality of care delivered or the transition to the outpatient setting, or poor access to outpatient care. But we need further research to find out whether that's the case," Yazdany said.
Patients covered by Medicaid and Medicare, the U.S. publicly funded insurance programs, were also about 1.5 times more likely to be readmitted than privately insured patients.
"You have to get the disease under control, and for people who are on Medicare or Medicaid and don't have access to medications, that can be more difficult," Pisetsky said.
Further, New York had the lowest readmission rates of the five states studied. That suggests room for quality improvement, Yazdany said, though she added that New York has a higher concentration of dedicated lupus centers than many other places.
"Evidence suggests the rate of readmissions can be reduced by improving discharge planning and the transition process out of the hospital," Yazdany said.
An effective transition requires coordination of care between health care providers at the hospital and a patient's outpatient doctors, she said. It also requires that patients know when their follow-up outpatient appointments are, what symptoms to worry about and whom to call if needed.
"We have a lot of work to do in educating and supporting patients in managing their disease," Yazdany said. And lupus patients "should be very proactive," she added.
Learn more about lupus at the Lupus Foundation of America (http://www.lupus.org/answers/entry/what-is-lupus ).
SOURCES: Jinoos Yazdany, M.D., M.P.H., associate professor, medicine, University of California, San Francisco; Joan Merrill, M.D., medical director, Lupus Foundation of America, and head, clinical pharmacology research program, Oklahoma Medical Research Foundation, Oklahoma City; David Pisetsky, M.D., Ph.D., professor, medicine, Duke University School of Medicine, Durham, N.C., and scientific advisory board member, Lupus Research Institute, New York City; Aug. 11, 2014, Arthritis & Rheumatology