Article Text

Download PDFPDF

603 Remission and low disease activity are associated with lower health care costs in an international inception cohort of patients with systemic lupus erythematosus
  1. Ann E Clarke1,
  2. Manuel Francisco Ugarte-Gil2,
  3. Megan RW Barber1,
  4. John G Hanly3,
  5. Murray B Urowitz4,
  6. Yvan St Pierre5,
  7. Caroline Gordon6,
  8. Sang-Cheol Bae7,
  9. Juanita Romero-Diaz8,
  10. Jorge Sanchez-Guerrero4,
  11. Sasha Bernatsky5,
  12. Daniel J Wallace9,
  13. David A Isenberg10,
  14. Anisur Rahman10,
  15. Joan T Merrill11,
  16. Paul R Fortin12,
  17. Dafna D Gladman4,
  18. Ian N Bruce13,
  19. Michelle Petri14,
  20. Ellen M Ginzler15,
  21. Mary Anne Dooley16,
  22. Rosalind Ramsey-Goldman17,
  23. Susan Manzi18,
  24. Andreas Jönsen19,
  25. Ronald FVan Vollenhoven20,
  26. Cynthia Aranow21,
  27. Meggan Mackay21,
  28. Guillermo Ruiz-Irastorza22,
  29. S Sam Lim23,
  30. Murat Inanc24,
  31. Kenneth C Kalunian25,
  32. Soren Jacobsen26,
  33. Christine A Peschken27,
  34. Diane L Kamen28,
  35. Anca Askanase29,
  36. Bernardo A Pons-Estel30 and
  37. Graciela S Alarcón31
  1. 1Cumming School of Medicine, University of Calgary, Alberta, Canada
  2. 2Universidad Cientifica del Sur, School of Medicine, Lima, Peru and Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Rheumatology, Lima, Peru
  3. 3Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
  4. 4Schroder Arthritis Institute, Krembil Research Institute, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
  5. 5Research Institute of the McGill University Health Center, Montreal, Canada
  6. 6Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
  7. 7Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Hanyang University Institute for Rheumatology and Hanyang University Institute of Bioscience and Biotechnology, Seoul, Republic of Korea
  8. 8Instituto Nacional de Ciencias Médicas y Nutricion, Mexico City, Mexico
  9. 9Cedars-Sinai/David Geffen School of Medicine at the University of California, Los Angeles
  10. 10University College London, London, UK
  11. 11Department of Clinical Pharmacology, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
  12. 12Centre ARThrite, CHU de Québec –Universite Laval, Québec City, Canada
  13. 13Arthritis Research UK Epidemiology Unit, Institute of Inflammation and Repair, Manchester Academic Health Sciences Centre, the University of Manchester, and NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals National Health Service Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
  14. 14Johns Hopkins University School of Medicine, Baltimore, Maryland, US
  15. 15State University of New York Downstate Health Sciences University, Brooklyn, New York, US
  16. 16Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, North Carolina, US
  17. 17Northwestern University and Feinberg School of Medicine, Chicago, Illinois, US
  18. 18Alleghany Health Network, Pittsburgh, Pennsylvania, US
  19. 19Lund University, Lund, Sweden
  20. 20Department of Rheumatology and Clinical immunology, Amsterdam University Medical Centers, Amsterdam, Netherlands
  21. 21Feinstein Institute for Medical Research, Manhasset, New York, US
  22. 22BioCruces Bizkaia Health Research Institute, University of the Basque Country, Autoimmune Diseases Research Unit, Barakaldo, Spain
  23. 23Emory University School of Medicine, Atlanta, Georgia, US
  24. 24Istanbul University, Istanbul, Turkey
  25. 25University of California Los Angeles School of Medicine, La Jolla, California, US
  26. 26Copenhagen Lupus and Vasculitis Clinic, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
  27. 27University of Manitoba, Winnipeg, Manitoba, Canada
  28. 28Medical University of South Carolina, Charleston, South Carolina, US
  29. 29Hospital for Joint Diseases, New York University Seligman Center for Advanced Therapeutics, New York, New York, US
  30. 30Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
  31. 31The University of Alabama at Birmingham, Birmingham, Alabama, US


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 (table 1, Panel A). 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% -$16,754, - $3499) (table 2, Panel B&C).

In multivariable models, remission and LDA (per 25% increase in time spent in specified DAS vs 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.

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

Abstract 603 Table 1

Patient Characteristics

Abstract 603 Table 2

Annual Direct and Indirect Costs Stratified by Proportion of Time since Cohort Entry in Specified Disease Activity States

Abstract 603 Table 3

Multivariable Models of the Impact of Disease Activity States Since Cohort Entry on Annual Direct and Indirect Costs

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: .

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.