Remission and Low Disease Activity Are Associated with Lower Health Care Costs in an International Inception Cohort of Patients with Systemic Lupus Erythematosus

Ann E Clarke¹, Manuel Ugarte-Gil², Megan Barber³, John Hanly⁴, Murray Urowitz⁵, Yvan St. Pierre⁶, Caroline Gordon⁷, Sang-Cheol Bae⁸, Juanita Romero-Diaz⁹, Jorge Sanchez-Guerrero¹⁰, Sasha Bernatsky⁶, Daniel Wallace¹¹, David Isenberg¹², Anisur Rahman¹³, Joan Merrill¹⁴, Paul R Fortin¹⁵, Dafna Gladman¹⁶, Ian N. Bruce¹⁷, Michelle Petri¹⁸, Ellen M. Ginzler¹⁹, Mary Anne Dooley²⁰, Rosalind Ramsey-Goldman²¹, Susan Manzi²², Andreas Jönsen²³, Ronald van Vollenhoven²⁴, Cynthia Aranow²⁵, Meggan Mackay²⁵, Guillermo Ruiz-Irastorza²⁶, S. Sam Lim²⁷, Murat Inanc²⁸, Kenneth Kalunian²⁹, Soren Jacobsen³⁰, Christine Peschken³¹, Diane Kamen³², Anca Askanase³³, Bernardo Pons-Estel³⁴ and Graciela Alarcón³⁵, ¹University of Calgary, Division of Rheumatology, Cumming School of Medicine, Calgary, AB, Canada, ²Universidad Cientifica del Sur/Hospital Guillermo Almenara Irigoyen. EsSalud, Lima, Peru, ³Cumming School of Medicine, University of Calgary, Calgary, AB, Canada, ⁴Division of Rheumatology, Queen Elizabeth II Health Sciences Center (Nova Scotia Rehabilitation Site) and Dalhousie University, Halifax, NS, Canada, ⁵University of Toronto, University Health Network, Schroeder Arthritis Institute, Toronto, ON, Canada, ⁶Research Institute of the McGill University Health Centre, Montréal, QC, Canada, ⁷Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom, ⁸Hanyang University Medical Center, Seoul, Republic of Korea, ⁹Instituto Nacional de Ciencias Medicas y Nutricion SZ, Ciudad de México, Mexico, ¹⁰Mount Sinai Hospital and University Health Network, University of Toronto, Toronto, ON, Canada, ¹¹Cedars-Sinai Medical Center, Los Angeles, CA, ¹²University College London, London, United Kingdom, ¹³Centre for Rheumatology, Department of Medicine, University College London, London, United Kingdom, ¹⁴Oklahoma Medical Research Foundation, Oklahoma City, OK, ¹⁵Centre ARThrite - CHU de Québec - Université Laval, Québec, QC, Canada, ¹⁶Toronto Western Hospital, Schroeder Arthritis Institute, Toronto, ON, Canada, ¹⁷Centre for Epidemiology Versus Arthritis, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom, ¹⁸Johns Hopkins University School of Medicine, Division of Rheumatology, Baltimore, MD, ¹⁹SUNY Downstate Health Sciences University, Department of Medicine, Brooklyn, NY, ²⁰Raleigh Neurology Associates, Chapel Hill, NC, ²¹Northwestern University Feinberg School of Medicine, Chicago, USA, Chicago, IL, ²²Allegheny Health Network, Lupus Center of Excellence, Wexford, PA, ²³Department of Clinical Sciences, Lund, Section for Rheumatology, Lund University, Lund and Skåne University Hospital, Lund, Sweden, ²⁴Amsterdam University Medical Centers, Amsterdam, Netherlands, ²⁵Feinstein Institutes for Medical Research, Manhasset, NY, ²⁶Autoimmune Diseases Research Unit, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, UPV/EHU, Barakaldo, Spain, ²⁷Emory University, Atlanta, GA, ²⁸Division of Rheumatology, Department of Internal Medicine, Istanbul Medical Faculty, Istanbul University, Istambul, Turkey, ²⁹University of California San Diego, La Jolla, CA, ³⁰Rigshospitalet, Copenhagen, Denmark, ³¹University of Manitoba, Winnipeg, MB, Canada, ³²Medical University of South Carolina, Charleston, SC, ³³Columbia University Medical Center, New York, NY, ³⁴Grupo Oroño - Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina, ³⁵The University of Alabama at Birmingham, Oakland

Meeting: ACR Convergence 2022

Keywords: Disease Activity, Economics, Systemic lupus erythematosus (SLE)

Session Information

Date: Monday, November 14, 2022

Title: SLE – Diagnosis, Manifestations, and Outcomes Poster III: Outcomes

Session Type: Poster Session D

Session Time: 1:00PM-3:00PM

Background/Purpose: Remission and low disease activity (LDA) are associated with decreased flares, damage, and mortality. However, little is known about the impact of disease activity states (DAS) on health care costs. We determined the independent impact of different definitions of remission and LDA on direct and indirect costs (DC, IC) in a multicentre, multi-ethnic inception cohort.

Methods: Patients fulfilling revised ACR classification criteria for SLE from 33 centres in 11 countries were enrolled within 15 months of diagnosis and assessed annually. Patients with ≥2 annual assessments were included. Five mutually independent DAS were defined:

1) Remission off-treatment: clinical (c) SLEDAI-2K=0, without prednisone or immunosuppressants

2) Remission on-treatment: cSLEDAI-2K=0, prednisone ≤5mg/d and/or maintenance immunosuppressants

3) LDA-Toronto Cohort (TC): cSLEDAI-2K≤2, without prednisone or immunosuppressants

4) Modified Lupus LDA State (mLLDAS): SLEDAI-2K≤4, no activity in major organs/systems, no new disease activity, prednisone ≤7.5mg/d and/or maintenance immunosuppressants

5) Active: all remaining assessments

Antimalarials were permitted in all DAS. At each assessment, patients were stratified into 1 DAS; if >1 definition was fulfilled per assessment, the patient was stratified into the most stringent. The proportion of time patients were in a specific DAS at each assessment since cohort entry was determined.

At each assessment, annual DC and IC were based on health resource use and lost workforce/non-workforce productivity over the preceding year. Resource use was costed using 2021 Canadian prices and lost productivity using Statistics Canada age-and-sex-matched wages.

To examine the association between the proportion of time in a specific DAS at each assessment since cohort entry and annual DC and IC, multivariable random-effects linear regression modelling was used. Potential covariates included age at diagnosis, disease duration, sex, race/ethnicity, education, region, smoking, and alcohol use.

Results: 1631 patients (88.7% female, 48.9% White, mean age at diagnosis 34.5) were followed for a mean of 7.7 (SD 4.7) years. Across 12,281 assessments, 49.3% were classified as active (Table 1, Panel B). Patients spending < 25% vs 75-100% of their time since cohort entry in an active DAS had lower annual DC and IC (DC $4042 vs $9101, difference -$5060, 95%CI -$5983, -$4136; IC $21,922 vs $32,049, difference -$10,127, 95%CI -$16,754, -$3499) (Table 2, Panel B&C).

In multivariable models, remission and LDA (per 25% increase in time spent in specified DAS versus active) were associated with lower annual DC and IC: remission off-treatment (DC -$1296, 95%CI -$1800, -$792; IC -$3353, 95%CI -$5382, -$1323), remission on-treatment (DC -$987, 95%CI -$1550, -$424; IC -$3508, 95%CI -$5761, -$1256), LDA-TC (DC -$1037, 95%CI -$1853, -$222; IC -$3229, 95%CI -$5681, -$778) and mLLDAS (DC -$1307, 95%CI -$2194, -$420; IC -$3822, 95%CI -$6309, $-1334) (Table 3, Model B). There were no differences in costs between remission and LDA.

Conclusion: Remission and LDA are associated with lower costs, likely mediated through the known association of these DAS with more favourable clinical outcomes.

Disclosures: A. Clarke, AstraZeneca, Bristol Myers Squibb (BMS), GlaxoSmithKline (GSK); M. Ugarte-Gil, Janssen, Pfizer; M. Barber, Sanofi-Genzyme, AbbVie/Abbott, GlaxoSmithKlein(GSK), AstraZeneca, Janssen; J. Hanly, None; M. Urowitz, None; Y. St. Pierre, None; C. Gordon, UCB, Amgen, Astra-Zeneca, AbbVie, Sanofi, MGP; S. Bae, None; J. Romero-Diaz, Biogen; J. Sanchez-Guerrero, None; S. Bernatsky, None; D. Wallace, None; D. Isenberg, Merck/MSD, astra zeneca, Eli Lilly, Servier, Amgen; A. Rahman, None; J. Merrill, UCB, GlaxoSmithKline, AbbVie, EMD Serono, Remegen, Celgene/Bristol Myers Squibb, AstraZeneca, Amgen, Janssen, Lilly, Genentech, Aurinia, Astellas, Alexion, Sanofi, Zenas, Proventio; P. Fortin, AstraZeneca, GlaxoSmithKlein(GSK); D. Gladman, AbbVie, Amgen, Eli Lilly, Janssen, Gilead, Novartis, Pfizer, Bristol-Myers Squibb(BMS), Galapagos, UCB Pharma, Celgene; I. Bruce, AstraZeneca, Bristol-Myers Squibb(BMS), Eli Lilly, Aurinia, Janssen, GlaxoSmithKlein(GSK); M. Petri, Exagen, AstraZeneca, Alexion, Amgen, AnaptysBio, Argenx, Aurinia, Biogen, Caribou Biosciences, CVS Health, EMD Serono, Eli Lilly, Emergent Biosolutions, GlaxoSmithKline (GSK), IQVIA, Janssen, Kira Pharmaceuticals, MedShr, Sanofi, SinoMab, Thermofisher, BPR Scientific Advisory Committee; E. Ginzler, Aurinia Pharma; M. Dooley, None; R. Ramsey-Goldman, None; S. Manzi, AstraZeneca, GlaxoSmithKline (GSK), Exagen Diagnostics Inc, AbbVie, HGS, Cugene, Lilly, UCB Advisory Board, Lupus Foundation of America; A. Jönsen, None; R. van Vollenhoven, Bristol Myers Squibb (BMS), GlaxoSmithKline (GSK), UCB, Merck/MSD, Pfizer, Roche, AbbVie, AstraZeneca, Biogen, Galapagos, Janssen, Miltenyi, R-Pharma; C. Aranow, None; M. Mackay, None; G. Ruiz-Irastorza, None; S. Lim, None; M. Inanc, None; K. Kalunian, AbbVie/Abbott, Amgen, AstraZeneca, Aurinia, Biogen, Bristol Myers Squibb (BMS), Eli Lilly, Equillium, Genentech, Gilead, Janssen, Roche, Lupus Research Alliance, Pfizer, Sanford Consortium, Viela, Nektar; S. Jacobsen, None; C. Peschken, None; D. Kamen, None; A. Askanase, AstraZeneca, GlaxoSmithKlein(GSK), Aurinia, Amgen, Pfizer, Idorsia, Eli Lilly, UCB, AbbVie/Abbott, Janssen, Bristol-Myers Squibb(BMS); B. Pons-Estel, None; G. Alarcón, None.

To cite this abstract in AMA style:

Clarke A, Ugarte-Gil M, Barber M, Hanly J, Urowitz M, St. Pierre Y, Gordon C, Bae S, Romero-Diaz J, Sanchez-Guerrero J, Bernatsky S, Wallace D, Isenberg D, Rahman A, Merrill J, Fortin P, Gladman D, Bruce I, Petri M, Ginzler E, Dooley M, Ramsey-Goldman R, Manzi S, Jönsen A, van Vollenhoven R, Aranow C, Mackay M, Ruiz-Irastorza G, Lim S, Inanc M, Kalunian K, Jacobsen S, Peschken C, Kamen D, Askanase A, Pons-Estel B, Alarcón G. Remission and Low Disease Activity Are Associated with Lower Health Care Costs in an International Inception Cohort of Patients with Systemic Lupus Erythematosus [abstract]. Arthritis Rheumatol. 2022; 74 (suppl 9). https://acrabstracts.org/abstract/remission-and-low-disease-activity-are-associated-with-lower-health-care-costs-in-an-international-inception-cohort-of-patients-with-systemic-lupus-erythematosus/. Accessed .

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