Rise in Health Care Visits Heralds Lupus in Youth

March 30, 2018
Gregory M. Weiss, MD

Consider screening for systemic lupus erythematosus in young patients who exhibit an escalating pattern of health care utilization.

Key points
• Youth experience high health care utilization during the 1-year period before systemic lupus erythematosus (SLE) is diagnosed.

• Young patients may present with thromboembolism, thrombocytopenia, chest pain, fever, or acute kidney failure before receiving a diagnosis of SLE.

• Psychiatric disorders commonly precede the SLE diagnosis and serve to increase health care utilization.

Background
SLE is characterized by chronic autoimmune insults, is often difficult to diagnose, and is frequently underdiagnosed in youth. It has been observed that youth with SLE often have higher mortality and increased rates of renal and neuropsychiatric complications.

Dr. Joyce C. Chang and colleagues at Perelman School of Medicine in Philadelphia, PA, point out that vague clinical symptoms and later diagnoses in youth with SLE may be avoided by examining the trajectory from symptoms to diagnosis in other young people with an eventual diagnosis of SLE.

The researchers sought to examine health care utilization in the year preceding SLE diagnosis, to determine common reasons for pre-diagnosis care visits, and to identify common patient characteristic leading to increased utilization. They recently presented their findings in Arthritis Care & Research.

The study
The researchers conducted a retrospective, population-based cohort study comparing youth with SLE to healthy controls. A large nationwide database was utilized to examine health care utilization leading up to diagnosis of SLE. Ultimately, 682 subjects with SLE were included and compared with 1364 controls.

The results
• Significantly more subjects with SLE had at least one psychiatric diagnosis prior to first diagnosis of SLE (17% vs 7%, P < .001).

• Subjects with SLE had subsequent diagnoses of nephritis (24%), seizure or stroke (10%), and psychiatric disorders (25%).

• Youth with SLE had significantly more health care visits in the year before diagnosis when compared with controls (P < .001).

• Among those with SLE, visit frequency increased as the index date approached.

• Youth with SLE had significantly more non-psychiatric visits across all settings than did controls (P < .001).

• Common presenting diagnoses included primary thrombocytopenia, unspecified, and chest pain, unspecified.

• Having any preceding psychiatric diagnosis was the most strongly associated with increased utilization across all health care settings.

Please click below for the implications of this study for clinicians.

Implications for clinicians
• Consider screening for SLE in young patients who exhibit an escalating pattern of health care visits.

• Be vigilant for presenting diagnoses that commonly precede the diagnosis of SLE, including venous thromboembolism, thrombocytopenia, chest pain, fever, and acute kidney failure.

• Since psychiatric disorders commonly precede a diagnosis of SLE in young people, resources should be available to treat patients’ mental health as well as their lupus.

• “Efforts directed toward guiding work-up of patients presenting with early features might shorten the interval from symptom onset to SLE diagnosis,” said the researchers.

References:

Chang JC, Mandell DS, Knight AM. High health care utilization preceding diagnosis of systemic lupus erythematosus in youth. Arthritis Care Res. 2017 Dec 1. doi:10.1002/acr.23485.

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