Remission and low disease activity are associated with lower healthcare costs: results from the Systemic Lupus International Collaborating Clinics (SLICC) inception cohort

Megan R W Barber; Manuel Francisco Ugarte-Gil; John G Hanly; Murray B Urowitz; Yvan St-Pierre; Caroline Gordon; Sang-Cheol Bae; Juanita Romero-Diaz; Jorge Sanchez-Guerrero; Sasha Bernatsky; Daniel J Wallace; David A Isenberg; Anisur Rahman; Joan T Merrill; Paul R Fortin; Dafna D Gladman; Ian N Bruce; Michelle Petri; Ellen M Ginzler; Mary Anne Dooley; Rosalind Ramsey-Goldman; Susan Manzi; Andreas Jönsen; Ronald F van Vollenhoven; Cynthia Aranow; Meggan Mackay; Guillermo Ruiz-Irastorza; S Sam Lim; Murat Inanc; Kenneth C Kalunian; Søren Jacobsen; Christine A Peschken; Diane L Kamen; Anca Askanase; Bernardo A Pons-Estel; Francesca S Cardwell; Graciela S Alarcón; Ann E Clarke

doi:10.1136/ard-2024-225613

Remission and low disease activity are associated with lower healthcare costs: results from the Systemic Lupus International Collaborating Clinics (SLICC) inception cohort

Ann Rheum Dis. 2024 May 16:ard-2024-225613. doi: 10.1136/ard-2024-225613. Online ahead of print.

Authors

Megan R W Barber¹, Manuel Francisco Ugarte-Gil^{2

3}, John G Hanly^{4

5}, Murray B Urowitz^{6

7}, Yvan St-Pierre⁸, Caroline Gordon⁹, Sang-Cheol Bae^{10

11}, Juanita Romero-Diaz¹², Jorge Sanchez-Guerrero^{13

14}, Sasha Bernatsky⁸, Daniel J Wallace¹⁵, David A Isenberg¹⁶, Anisur Rahman¹⁶, Joan T Merrill¹⁷, Paul R Fortin¹⁸, Dafna D Gladman^{7

19}, Ian N Bruce^{20

21}, Michelle Petri²², Ellen M Ginzler²³, Mary Anne Dooley²⁴, Rosalind Ramsey-Goldman²⁵, Susan Manzi²⁶, Andreas Jönsen²⁷, Ronald F van Vollenhoven²⁸, Cynthia Aranow²⁹, Meggan Mackay³⁰, Guillermo Ruiz-Irastorza³¹, S Sam Lim³², Murat Inanc³³, Kenneth C Kalunian³⁴, Søren Jacobsen³⁵, Christine A Peschken³⁶, Diane L Kamen³⁷, Anca Askanase³⁸, Bernardo A Pons-Estel³⁹, Francesca S Cardwell⁴⁰, Graciela S Alarcón⁴¹, Ann E Clarke⁴²

Affiliations

¹ Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
² Grupo Peruano de Estudio de Enfermedades Autoinmunes Sistémicas, Universidad Cientifica del Sur, Lima, Peru.
³ Rheumatology, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Peru.
⁴ Division of Rheumatology, Department of Medicine and Department of Pathology, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada.
⁵ Dalhousie University, Halifax, Nova Scotia, Canada.
⁶ Lupus Program, Centre for Prognosis Studies in the Rheumatic Diseases, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada.
⁷ Krembil Research Institute, Toronto, Ontario, Canada.
⁸ Research Institute of the McGill University Health Center, Montreal, Quebec, Canada.
⁹ Rheumatology Research Group, Birmingham University Medical School, Birmingham, UK.
¹⁰ Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea (the Republic of).
¹¹ Hanyang Institute of Bioscience and Biotechnology, Seoul, Korea (the Republic of).
¹² Immunology and Rheumatology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Tlalpan, Mexico.
¹³ University Health Network, Toronto, Ontario, Canada.
¹⁴ Mount Sinai Hospital, Toronto, Ontario, Canada.
¹⁵ Division of Rheumatology, Cedars-Sinai Medical Center, Los Angeles, California, USA.
¹⁶ Centre for Rheumatology, Department of Medicine, University College London, London, UK.
¹⁷ Department of Clinical Pharmacology, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA.
¹⁸ Centre ARThrite, CHU de Québec, Université Laval, Quebec City, Quebec, Canada.
¹⁹ Lupus Program, Centre for Prognosis in The Rheumatic Diseases, University of Toronto, Toronto, Ontario, Canada.
²⁰ Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
²¹ The Kellgren Centre for Rheumatology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK.
²² Division of Rheumatology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA.
²³ Department of Medicine, SUNY Downstate Medical Center, Brooklyn, New York, USA.
²⁴ Thurston Arthritis Research Centre, University of North Carolina, Chapel Hill, North Carolina, USA.
²⁵ Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.
²⁶ Lupus Center of Excellence, Allegheny Health Network, Pittsburgh, Pennsylvania, USA.
²⁷ Lund University, Clinical Sciences, Lund, Sweden.
²⁸ Rheumatology and Immunology Center, University of Amsterdam, Amsterdam, The Netherlands.
²⁹ The Feinstein Institute for Medical Research, Manhasset, New York, USA.
³⁰ Feinstein Institute for Medical Research, Manhasset, New York, USA.
³¹ Biobizkaia Health Research Institute, Hospital Universitario Cruces, Barakaldo, Spain.
³² School of Medicine, Emory University, Atlanta, Georgia, USA.
³³ Division of Rheumatology, Department of Internal Medicine, Istanbul University, Istanbul Medical Faculty, Capa, Istanbul, Turkey.
³⁴ University of California School of Medicine, La Jolla, California, USA.
³⁵ Copenhagen Lupus and Vasculitis Clinic, Center for Rheumatology and Spine Diseases, Rigshospitalet, Copenhagen, Denmark.
³⁶ University of Manitoba, Winnipeg, Manitoba, Canada.
³⁷ Medical University of South Carolina, Charleston, South Carolina, USA.
³⁸ Division of Rheumatology, Columbia University Lupus Center, Columbia University College of Physicians & Surgeons, New York, New York, USA.
³⁹ Grupo Oroño, Centro Regional de Enfermedades Autonmunes y Reumáticas, Rosario, Argentina.
⁴⁰ Geography & Environmental Management, University of Waterloo, Waterloo, Ontario, Canada.
⁴¹ Department of Medicine, Division of Clinical Immunology and Rheumatology, School of Medicine, The University of Alabama, Birmingham, Alabama, USA.
⁴² Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada aeclarke@ucalgary.ca.

PMID: 38754981
DOI: 10.1136/ard-2024-225613

Abstract

Objectives: This study aims to determine the independent impact of definitions of remission/low disease activity (LDA) on direct/indirect costs (DCs, ICs) in a multicentre inception cohort.

Methods: Patients from 31 centres in 10 countries were enrolled within 15 months of diagnosis and assessed annually. Five mutually exclusive disease activity states (DAS) were defined as (1) remission off-treatment: clinical (c) SLEDAI-2K=0, without prednisone/immunosuppressants; (2) remission on-treatment: cSLEDAI-2K=0, prednisone ≤5 mg/day and/or maintenance immunosuppressants; (3) LDA-Toronto Cohort (TC): cSLEDAI-2K≤2, without prednisone/immunosuppressants; (4) modified lupus LDA state (mLLDAS): SLEDAI-2K≤4, no activity in major organs/systems, no new activity, prednisone ≤7.5 mg/day and/or maintenance immunosuppressants and (5) active: all remaining assessments.At each assessment, patients were stratified into the most stringent DAS fulfilled and the proportion of time in a DAS since cohort entry was determined. Annual DCs/ICs (2021 Canadian dollars) were based on healthcare use and lost workforce/non-workforce productivity over the preceding year.The association between the proportion of time in a DAS and annual DC/IC was examined through multivariable random-effects linear regressions.

Results: 1692 patients were followed a mean of 9.7 years; 49.0% of assessments were active. Remission/LDA (per 25% increase in time in a remission/LDA state vs active) were associated with lower annual DC/IC: remission off-treatment (DC -$C1372; IC -$C2507), remission on-treatment (DC -$C973; IC -$C2604,) LDA-TC (DC -$C1158) and mLLDAS (DC -$C1040). There were no cost differences between remission/LDA states.

Conclusions: Our data suggest that systemic lupus erythematosus patients who achieve remission, both off and on-therapy, and reductions in disease activity incur lower costs than those experiencing persistent disease activity.

Keywords: Economics; Epidemiology; Health services research; Lupus Erythematosus, Systemic; Risk Factors.