Children with autoimmune and immune-mediated rheumatic diseases (AIIRD) receiving immunosuppressive therapies (IST) are at increased risk of morbidity from vaccine-preventable infections. The 2022 American College of Rheumatology (ACR) guidelines recommend vaccinating all children with AIIRD, with specific recommendations based on IST. Children with AIIRD receiving IST or who are immunocompromised are eligible to receive non-live vaccines, however vaccination rates remain low. The aim of this study was to understand the North American pediatric rheumatology provider approach to vaccine review and reconciliation and identify possible barriers to immunization. The Childhood Arthritis and Rheumatology Research Alliance (CARRA) Vaccination Workgroup surveyed member North American pediatric rheumatologists about their vaccination practices when caring for children with AIIRD receiving IST. A 44-question electronic survey was distributed from March-May 2022 among rheumatology providers in the CARRA network. The survey response rate was 64

Objective Recent studies suggest young adults with systemic lupus erythematosus (SLE) have high 30-day readmission rates, which may necessitate tailored readmission reduction strategies. To aid in risk stratification for future strategies, we measured 30-day rehospitalization and mortality rates among Medicare beneficiaries with SLE and determined rehospitalization predictors by age. Methods In a 2014 20% national Medicare sample of hospitalizations, rehospitalization risk and mortality within 30 days of discharge were calculated for young (aged 18-35 yrs), middle-aged (aged 36-64 yrs), and older (aged 65+ yrs) beneficiaries with and without SLE. Multivariable generalized estimating equation models were used to predict rehospitalization rates among patients with SLE by age group using patient, hospital, and geographic factors. Results Among 1.39 million Medicare hospitalizations, 10,868 involved beneficiaries with SLE. Hospitalized young adult beneficiaries with SLE were more racially diverse, were living in more disadvantaged areas, and had more comorbidities than older beneficiaries with SLE and those without SLE. Thirty-day rehospitalization was 36% among young adult beneficiaries with SLE—40% higher than peers without SLE and 85% higher than older beneficiaries with SLE. Longer length of stay and higher comorbidity risk score increased odds of rehospitalization in all age groups, whereas specific comorbid condition predictors and their effect varied. Our models, which incorporated neighborhood-level socioeconomic disadvantage, had moderate-to-good predictive value (C statistics 0.67-0.77), outperforming administrative data models lacking comprehensive social determinants in other conditions. Conclusion Young adults with SLE on Medicare had very high 30-day rehospitalization at 36%. Considering socioeconomic disadvantage and comorbidities provided good prediction of rehospitalization risk, particularly in young adults. Young beneficiaries with SLE with comorbidities should be a focus of programs aimed at reducing rehospitalizations.

OBJECTIVE:Patients with systemic lupus erythematosus experience the sixth highest rate of 30-day readmissions among chronic diseases. Timely postdischarge follow-up is a marker of ambulatory care quality that can reduce readmissions in other chronic conditions. Our objective was to test the hypotheses that 1) beneficiaries from populations experiencing health disparities, including patients from disadvantaged neighborhoods, will have lower odds of completed follow-up, and that 2) follow-up will predict longer time without acute care use (readmission, observation stay, or emergency department visit) or mortality.METHODS:This observational cohort study included hospitalizations in January-November 2014 from a 20% random sample of Medicare adults. Included hospitalizations had a lupus code, discharge to home without hospice, and continuous Medicare A/B coverage for 1 year before and 1 month after hospitalization. Timely follow-up included visits with primary care or rheumatology within 30 days. Thirty-day survival outcomes were acute care use and mortality adjusted for sociodemographic information and comorbidities.RESULTS:Over one-third (35%) of lupus hospitalizations lacked 30-day follow-up. Younger age, living in disadvantaged neighborhoods, and rurality were associated with lower odds of follow-up. Follow-up was not associated with subsequent acute care or mortality in beneficiaries age <65 years. In contrast, follow-up was associated with a 27% higher hazard for acute care use (adjusted hazard ratio [HR] 1.27 [95% confidence interval (95% CI) 1.09-1.47]) and 65% lower mortality (adjusted HR 0.35 [95% CI 0.19-0.67]) among beneficiaries age ≥65 years.CONCLUSION:One-third of lupus hospitalizations lacked follow-up, with significant disparities in rural and disadvantaged neighborhoods. Follow-up was associated with increased acute care, but 65% lower mortality in older systemic lupus erythematosus patients. Further development of lupus-specific postdischarge strategies is needed.

Objective In systemic lupus erythematosus, poor disease outcomes occur in young adults, patients identifying as Black or Hispanic, and socioeconomically disadvantaged patients. These identities and social factors differentially shape care access and quality that contribute to lupus health disparities in the US. Thus, our objective was to measure markers of care access and quality, including rheumatology visits (longitudinal care retention) and lupus-specific serology testing, by race and ethnicity, neighborhood disadvantage, and geographic context. Methods This cohort study used a geo-linked 20% national sample of young adult Medicare beneficiaries (ages 18–35) with lupus-coded encounters and a 1-year assessment period. Retention in lupus care required a rheumatology visit in each 6-month period, and serology testing required ≥1 complement or dsDNA antibody test within the year. Multivariable logistic regression models were fit for visit-based retention and serology testing to determine associations with race and ethnicity, neighborhood disadvantage, and geography. Results Among 1,036 young adults with lupus, 39% saw a rheumatologist every 6 months and 28% had serology testing. White beneficiaries from the least disadvantaged quintile of neighborhoods had higher visit-based retention than other beneficiaries (64% vs 30%–60%). Serology testing decreased with increasing neighborhood disadvantage quintile (aOR 0.80; 95% CI 0.71, 0.90) and in the Midwest (aOR 0.46; 0.30, 0.71). Conclusion Disparities in care, measured by rheumatology visits and serology testing, exist by neighborhood disadvantage, race and ethnicity, and region among young adults with lupus, despite uniform Medicare coverage. Findings support evaluating lupus care quality measures and their impact on US lupus outcomes.

Objectives To investigate the relationship between smoking history and pack-year exposure on the rate of end-organ damage in systemic lupus erythematosus (SLE). Methods The SLE incident cohort included patients who met American College of Rheumatology (ACR) 1997 or SLE International Collaborating Clinics (SLICC) 2012 SLE criteria and had rheumatology encounters at a US academic institution (2008–16). The primary outcome was median time to SLICC/ACR damage index (SLICC/ACR-DI) increase or death. Main explanatory variables were smoking status and pack-years. Covariates included age, sex, race, ethnicity, receipt of Medicaid, neighborhood area deprivation index, and baseline SLE damage. Damage increase-free survival was evaluated by smoking status and pack-years using Kaplan-Meier and Cox proportional hazards methods. Results Patients of Black race and Medicaid recipients were more commonly current smokers ( p’s < 0.05). Former smokers were older and more likely to have late-onset SLE (54% versus 33% of never and 29% of current smokers, p = 0.001). Median time to SLICC/ACR-DI increase or death was earlier in current or former compared to never smokers (4.5 and 3.4 versus 9.0 yrs; p = 0.002). In multivariable models, the rate of damage accumulation was twice as fast in current smokers (HR 2.18; 1.33, 3.57) and smokers with a >10 pack-year history (HR 2.35; 1.15, 3.64) versus never smokers. Conclusions In this incident SLE cohort, past or current smoking predicted new SLE damage 4-5 years earlier. After adjustment, current smokers and patients with a pack-year history of >10 years accumulated damage at twice the rate of never smokers.

Objective: Thirty-day hospital readmissions in systemic lupus erythematosus (SLE) approach proportions in Medicare-reported conditions including heart failure (HF). We compared adjusted 30-day readmission and mortality among SLE, HF, and general Medicare to assess predictors informing readmission prevention. Methods: This database study used a 20% sample of all US Medicare 2014 adult hospitalizations to compare risk of 30-day readmission and mortality among admissions with SLE, HF, and neither per discharge diagnoses (if both SLE and HF, classified as SLE). Inclusion required live discharge and >12 months of Medicare A/B before admission to assess baseline covariates including patient, geographic, and hospital factors. Analysis used observed and predicted probabilities, and multivariable GEE models clustered by patient to report adjusted risk ratios (ARRs) of 30-day readmission and mortality. Results: SLE admissions (n=10,868) were younger, predominantly female, more likely to be Black, disabled, and have Medicaid or end-stage renal disease (ESRD). Observed 30-day readmissions of 24% were identical for SLE and HF (p = 0.6), and higher than other Medicare (16%, p < 0.001). Both SLE and HF had elevated readmission risk (ARR 1.08, (95% CI (1.04, 1.13)); 1.11, (1.09, 1.13)). SLE readmissions were higher for Black (30%) versus White (21%) populations, and highest in ages 18-33 (39%) and ESRD (37%). Admissions of Black patients with SLE from least disadvantaged neighborhoods had highest 30-day mortality (9% versus 3% White). Conclusion: Thirty-day SLE readmissions rivaled HF at 24%. Readmission prevention programs should engage young, ESRD patients with SLE and examine potential causal gaps in SLE care and transitions. (c) 2021 Elsevier Inc. All rights reserved.

Background Systemic lupus erythematous (SLE) disproportionately impacts patients of color and socioeconomically disadvantaged patients. Similar disparities in HIV were reduced through a World Health Organization-endorsed Care Continuum strategy targeting “retention in care,” defined as having at least two annual visits or viral load lab tests. Using similar definitions, this study aimed to examine predictors of lupus retention in care, to develop an SLE Care Continuum and inform interventions to reduce disparities. We hypothesized that Black patients and those residing in disadvantaged neighborhoods would have lower retention in care. Methods Abstractors manually validated 545 potential adult cases with SLE codes in 2013–2014 using 1997 American College of Rheumatology (ACR) or 2012 Systemic Lupus Erythematosus International Collaborating Clinics (SLICC) criteria. We identified 397 SLE patients who met ACR or SLICC criteria for definite lupus, had at least one baseline rheumatology visit, and were alive through 2015. Retention in care was defined as having two ambulatory rheumatology visits or SLE labs (e.g., complement tests) during the outcome year 2015, analogous to HIV retention definitions. Explanatory variables included age, sex, race, ethnicity, smoking status, neighborhood area deprivation index (ADI), number of SLE criteria, and nephritis. We used multivariable logistic regression to test our hypothesis and model predictors of SLE retention in care. Results Among 397 SLE patients, 91% were female, 56% White, 39% Black, and 5% Hispanic. Notably, 51% of Black versus 5% of White SLE patients resided in the most disadvantaged ADI neighborhood quartile. Overall, 60% met visit-defined retention and 27% met complement lab-defined retention in 2015. Retention was 59% lower for patients in the most disadvantaged neighborhood quartile (adjusted OR 0.41, CI 0.18, 0.93). No statistical difference was seen based on age, sex, race, or ethnicity. More SLE criteria and non-smoking predicted greater retention. Conclusions Disadvantaged neighborhood residence was the strongest factor predicting poor SLE retention in care. Future interventions could geo-target disadvantaged neighborhoods and design retention programs with vulnerable populations to improve retention in care and reduce SLE outcome disparities.

OBJECTIVE:Recognizing smoking as a risk factor for rheumatoid arthritis (RA) severity, the present study was undertaken to evaluate patient- and health care-level predictors of smoking cessation in patients with RA to guide implementation of smoking cessation interventions.METHODS:Electronic health record data from 2 health systems were abstracted for patients with at least 2 International Classification of Disease diagnosis codes for RA between 2005 and 2016. Patients missing smoking statuses or with <6 months of follow-up were excluded. Multivariable logistic regression was used to determine predictors of smoking cessation.RESULTS:Among 3,577 patients with RA, 507 smoked at baseline, and 29% quit over a median of 4.75 years. Black male patients, ages 40-59 years and enrolled in Medicaid, were significantly more likely to be baseline smokers; however, none of these factors predicted cessation. Instead, patients new to rheumatology care were 60% more likely to quit (adjusted odds ratio [ORadj ] 1.60 [95% confidence interval (95% CI) 1.02-2.50]), and patients in the rural community health system were 66% more likely to quit (ORadj 1.66 [95% CI 1.03-2.69]). Seropositive patients were 43% less likely to quit smoking (ORadj 0.57 [95% CI 0.35-0.91]).CONCLUSION:Health care factors, including health system and being new to rheumatology care, were more predictive of smoking cessation in patients with RA than patient sociodemographic factors, suggesting an important role for health system cessation efforts for patients with RA. Seropositive patients were less likely to quit and may particularly benefit from cessation support. Emphasizing smoking cessation with new or seropositive RA patients and leveraging health system interventions could improve smoking cessation and outcomes in RA.

Abstract Background There is significant inappropriate and overuse of antibiotics in the United States. We describe patterns of self-reported actual use of antibiotics and indications in Wisconsin adults. Methods The Survey of the Health of Wisconsin (SHOW) is an annual health study of a wide range of health determinants and outcomes among a population-based sample of residents with targeted recruitment of underrepresented minorities. In 2016, SHOW initiated WARRIOR (Winning the War on Antibiotic Resistance), an ancillary study that assessed actual antibiotic use and indications among adults. Antibiotics were grouped by pharmacologic class, and indications were grouped into clinical categories. Descriptive statistics and logistic regression were used to examine factors associated with antibiotic use. Results Overall, 756 adults [435 female and 321 male; mean (SD) age=54.2 (16.5)] were recruited, and 256 (33.5%) reported antibiotic use in the past year. Females (OR=1.87, 95% CI: 1.29, 2.70), people with current comorbidities or history of certain health conditions (OR=2.04, 95% CI: 1.23, 3.39), and people with a mental health or developmental condition (OR=1.93, 95% CI: 1.33, 281) were statistically significantly more likely to report antibiotic use. BMI (kg/m2) was slightly higher among antibiotic users (31.2) than nonusers (29.8; P = 0.064). Diabetes, heavy drinking, and smoking history were not correlated with antibiotic use. Top antibiotic classes used were penicillins (31%), macrolides (12%), first-generation cephalosporins (9%), tetracyclines (8%), quinolones (7%), and nitroimidazoles (3%). Top indications reported were upper respiratory infection (URI; 32.3%), dental condition or procedure (21.0%), surgery (12.6%), lower respiratory infection (11%), urinary tract, bladder, or kidney infection (7%), skin or soft-tissue infection (6%), and insect bite or insect-borne infection (6%). Conclusion Antibiotic use varies among Wisconsin adults, and certain groups are more likely to have used antibiotics in the last year. The top two reported indications for antibiotics were categories with known high rates of inappropriate (e.g., URI) and prophylactic (i.e., dental) prescribing. Further studies are needed to determine specific opportunities to reduce antibiotic use in Wisconsin. Disclosures All authors: No reported disclosures.