Frailty Increases Repeated ED Visits in Adults at or Under Age 65 With SLE, Study Suggests

Frailty increased danger of repeated emergency department (ED) visits in adults with frailty at or under 65 years of age with systemic lupus erythematosus (SLE) relative to similar non-frail adults with SLE, according to Lupus Science and Medicine.

Frailty is a possible aim for efforts to improve care quality in SLE and is a risk factor for adverse health in adults with SLE including those under 65 years old. ED use is high in adults with SLE, but to the researchers’ knowledge, if frailty is linked with ED use isn’t known.

First, researchers evaluated risk of ED use among adults with frailty with SLE at or under 65 years of age relative to adults with SLE within the same age group who are not frail.

Frailty is a syndrome of decreased homeostatic reserve and exists in up to 81% of patients with SLE, and estimates increased health care utilization, including in those under 65 years. ED use is a vital target for quality improvement, and ED use is disproportionately high among patients with SLE.

Researchers used the MarketScan Medicaid subset from 2011 to 2015 where they identified beneficiaries 18-65 years with SLE (3 years or longer of SLE International Classification of Diseases, Ninth Revision codes of 30 days or more apart). Comparators without a systemic rheumatic disease (SRD) were matched 4:1 on gender and age. Frailty status in 2011 was decided using 2 claims-based frailty indices (CFIs). Researchers compared risk of recurrent ED use among beneficiaries with frailty and those without frailty with SLE.

Then, out of 2262 beneficiaries with SLE and 9048 comparators without SRD, 28.8% and 11.6% were frail, respectively, according to both CFIs. Frail beneficiaries with SLE had significantly greater danger of recurrent use of ED (HR 1.75; 95% CI, 1.48-2.08), compared with non-frail beneficiaries with SLE.

In a single-center, longitudinal cohort of 152 women with prevent SLE with a mean age of 48 years, frailty as defined by the Fried phenotypical definition was present in 20% of patients at baseline.

A cross-sectional analysis of a second single-center longitudinal cohort of 67 women with prevalent SLE saw that 18% and 27% of participants were frail according to the Fried phenotype and self-report FRAIL scale, respectively.

Necessitating a “dual diagnosis” of frailty using the disease-agnostic Fried phenotype and FRAIL scale and the SLE-specific SLICC-FI might be the most specific when identifying frailty in beneficiaries with SLE in administrative datasets. But ED visit incidence and risk of recurrent ED use were similar despite if beneficiaries with SLE were classified as frail based on 1 or both CFIs in the study conducted by the researchers.

In the researchers’ study, hydroxychloroquine and immunosuppressive medication use was less common among participants who were frail than participants who were not frail with SLE at baseline.

ED use is costly and linked with adverse health outcomes in patients with SLE.

“In a recent analysis of electronic healthcare record data, 29.3% of patients with SLE were found to have ≥1 ED visit in 2015, corresponding with median annual cost of ED-related care of $1023, up from 22.8% in 2011; 36.9% of patients with severe SLE visited the ED at least once over the study period from 2011 to 2015, corresponding with median annual cost of $2513 in 2015.5,” detailed the researchers.

Some limitations are present in the study. Researchers could not validate either CFI against the Fried frailty phenotype or the SLICC-FI in people with SLE, and it is not known which metric best identifies frailty in younger adults with SLE.But, both CFIs have been validated in Medicare beneficiaries at or under the age of 65 years old.

“Targeting behavioral or pharmacological interventions for frailty, such as through tailored physical activity programming, or individual frailty components may complement efforts to enhance health-related quality of life among patients with SLE. Frail patients with SLE also may benefit from quality improvement efforts to improve access to ambulatory care and overall healthcare outcomes,” concluded the researchers.

Reference

Lieber SB, Nahid M, Navarro-Millán I, Rajan M, Sattui SE, Mandl LA. Frailty and emergency department utilisation in adults with systemic lupus erythematosus ≤65 years of age: an administrative claims data analysis of Medicaid beneficiaries. Lupus Sci Med. Published online July 31, 2023. doi:10.1136/lupus-2023-000905