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Medicare beneficiaries 65 and older with lupus faced dramatically higher mortality when they received no follow-up care during the month after a hospital stay, researchers found.

Death rates within 30 days of discharge were 65% higher in the absence of 30-day follow-up compared with older lupus patients who did receive it, according to Christie M. Bartels, MD, MS, of the University of Wisconsin in Madison, and colleagues.

Those who had follow-up outpatient care within the 30-day post-discharge window also were 27% more likely to be readmitted or seen in an emergency department, the researchers . That finding was a bit of a surprise: Bartels' group hypothesized that follow-up would "predict longer time without acute care use," as seen in studies of other conditions. While acute-care visits after discharge are often considered adverse outcomes (suggesting inadequate care during the initial admission), it appears that they helped keep older lupus patients alive, at least during the study's 30-day window for analysis.

Lack of follow-up care was associated with factors including residence in rural areas or poor sections of cities.

"The results indicate a need for better ambulatory access or outreach to lupus patients, particularly those residing in rural and disadvantaged neighborhoods," Bartels and colleagues concluded.

Medicare data covering beneficiaries' hospitalizations during January-November 2014 for a 20% random sample were the study's basis. This sample included 8,606 hospitalizations with a lupus code, including 5,403 individual patients (1,663 had multiple admissions). Two-thirds of the sample were disabled as their primary reason for Medicare enrollment, and half were also on Medicaid. As a result, only 39% of patients were 65 or older.

About half the under-65 group had no follow-up ambulatory care within 30 days of discharge; in those 65 and older, about 60% did have follow-up care. Patients living in small towns or very rural areas were about 30% less likely to have follow-up compared with urban or suburban patients. The impact of neighborhood economic deprivation was smaller, with an odds ratio of 0.98 per decile on the Area Deprivation Index, but this was statistically significant at 14 days and just short of it at 30 days.

Within 30 days of discharge, the following occurred in the total sample:

• 34.2% visited an emergency department
• 22.4% were readmitted for treatment
• 4.9% were readmitted for observation
• 1.3% died

However, the 30-day death rate was 3.9% for those 65 or older with no follow-up, compared with 0.7% for those who did have some type of ambulatory visit after discharge.

Mortality in those younger than 65 was also numerically increased with lack of follow-up care (1.2% vs 0.5%), but this fell short of statistical significance because there were many fewer deaths overall in this age group.

Limitations to the study included the reliance on administrative data and, perhaps most importantly, the restriction to 30 days of follow-up after discharge. Also, only outpatient visits with primary care providers or rheumatologists were counted as follow-up care, not those with other specialists such as nephrologists. As well, the researchers had no data on patients' lupus severity or treatments given during admission.

"Future studies should examine multi-payor cohorts, especially in younger patients with lupus, and evaluate associations with mortality risk in cohorts with a greater number of outcome events," Bartels and colleagues wrote.

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