Avoidable Hospitalizations in Patients with RA
By Dani G. Contreras, MSc, & Cheryl Barnabe, MD, MSc, FRCPC
Why was this study done? People with rheumatoid arthritis (RA) may be at a higher risk for hospitalizations due to the consequences of systemic inflammation. Health service availability may also factor into the risk for hospitalization. People who may not have access to high-quality primary care may require admission for ambulatory care sensitive conditions (ACSCs), many of which reflect comorbidities associated with RA. This study aimed to estimate the rates of these avoidable hospitalizations among those with RA, compared with the general population.
What were the study methods? We conducted a retrospective cohort study using population-level administrative data in Alberta, Canada (population ~5 million people), from 2007–23. We compared hospitalization rates for ACSCs in persons meeting the case definition for RA (determined using International Classification of Diseases codes), compared with matched controls. The ACSCs included grand mal seizures, chronic lower respiratory diseases, asthma, diabetes, heart failure and pulmonary edema, hypertension and angina. We estimated incidence rate ratios for all seven ACSCs combined and for each individual ACSC, adjusting for age, sex and primary location of residence. We used a Cox proportional hazards model to identify predictors for these avoidable hospitalizations.
What were the key findings? Compared with the control population, people with RA had an 11% higher risk of avoidable hospitalizations at three years from the time they were diagnosed and a 14% higher risk at five years after diagnosis. They were specifically at a higher risk of being hospitalized for heart failure and pulmonary edema, compared with those without RA. We found that increasing age, prolonged exposure to glucocorticoids and having comorbid conditions, especially if the condition is considered an ACSC, are significant predictors for these avoidable hospitalizations.
What were the main conclusions? People with RA are at a higher risk of avoidable hospitalizations three and five years from the date of diagnosis, compared with those without RA. They are at especially high risk of being hospitalized for heart failure and pulmonary edema, compared with the general population.
What are the implications for patients & clinicians? This study highlights the need for better quality of care for persons with RA, specifically when dealing with comorbidities. We propose improved ambulatory care access and quality for RA patients, inclusive of primary and subspecialty care, to prevent unnecessary hospitalizations and reduce the burden on the acute care system.
The Study: Contreras DG, Barber CEH, Aviña-Zubieta JA, et al. Avoidable hospitalizations in persons with rheumatoid arthritis: A population-based study using administrative data. Arthritis Care Res (Hoboken). 2025 Apr 2. Epub ahead of print.
The Transition from Psoriasis to Psoriatic Arthritis
By Lihi Eder, MD, PhD
Why was this study done? Psoriatic arthritis (PsA) develops in 2-3% of individuals with psoriasis annually, often preceded by a subclinical inflammatory phase. Early identification of patients at risk for PsA remains a clinical challenge due to the absence of simple, accessible biomarkers. High-sensitivity C-reactive protein (hsCRP) is a routinely used biomarker for systemic inflammation, but its predictive value for PsA development has not been established. This study aimed to assess whether elevated hsCRP levels are associated with the future development of PsA in patients with psoriasis.
What were the study methods? The study was conducted within a prospective cohort of 589 psoriasis patients, without PsA at baseline, enrolled between 2006 and 2019. Participants were assessed annually by rheumatologists for PsA development. Baseline hsCRP levels were measured using standardized commercial assays. Multivariable Cox proportional hazards models were used to evaluate the association between hsCRP levels and PsA risk, adjusting for age, sex, psoriasis severity and duration, nail disease, body mass index (BMI), fatigue and medication use.
What were the key findings? During a mean follow-up of 7.5 years, 57 participants developed PsA. Patients who developed PsA had higher baseline hsCRP levels (5.4 mg/L), compared to those who did not (2.9 mg/L). In the multivariable model, each 1 mg/L increase in hsCRP was associated with a 4% increased risk of PsA (hazard ratio 1.04, 95% confidence interval [CI] 1.01–1.06). This association was consistent across sexes and unaffected by BMI. Higher hsCRP levels were also associated with arthralgia, obesity and female sex at baseline.
What were the main conclusions? Elevated hsCRP levels independently predicted the future development of PsA in patients with psoriasis, even after accounting for established clinical risk factors.
What are the implications for patients & clinicians? hsCRP, an inexpensive and widely available biomarker, may aid in identifying psoriasis patients at higher risk for PsA. While not sufficient alone for risk prediction, hsCRP could enhance early detection efforts when combined with clinical tools, enabling timely referral and potentially preventive interventions.
The Study: Eder L, Li X, Chandran V, et al. Association of higher levels of high-sensitivity C-reactive protein with future development of psoriatic arthritis in psoriasis: A Prospective Cohort Study. Arthritis Care Res (Hoboken). 2025 Apr 2. Epub ahead of print.
Neighborhood Conditions & Childhood Lupus
By Joyce Chang, MD, MSCE
Why was this study done? The environments in which children are born, live, grow and learn influence a wide range of health outcomes. Child opportunity encompasses neighborhood resources and conditions important for healthy childhood development. Differential access to child opportunity may drive disparities in outcomes of childhood-onset systemic lupus erythematosus (cSLE). We examined whether children with cSLE living in areas with lower child opportunity present with more severe disease and are less likely to achieve disease control.
What were the study methods? This was a retrospective study of patients with cSLE cared for at three tertiary care centers between 2016–2022. We linked census tract identifiers to the Child Opportunity Index (COI) version 2.0, a multidimensional, area-level indicator of child opportunity across domains of education, health and environment, and socioeconomic conditions. Mixed effects models were used to estimate associations between COI and primary outcomes of severe disease presentation (high disease activity scores, need for intensive care, or dialysis) and acute care visits during the first year of follow-up, adjusted for age, sex, race and ethnicity, language and insurance status.
What were the key findings? Among 538 patients with cSLE, those living in areas with low child opportunity had 1.9-fold higher adjusted odds of severe disease presentation and twofold higher adjusted incidence of acute care visits, compared to those in areas with very high opportunity. Similarly, patients with cSLE in areas with low opportunity had a substantially lower adjusted odds (OR 0.4) of achieving low disease activity with ≤7.5 mg/day of prednisone, despite adjustment for initial disease severity and disease duration.
What were the main conclusions? Structural inequities in child opportunity may contribute to disparities in disease severity when children with cSLE first present to pediatric rheumatology care, as well as the ability to achieve disease control on lower doses of prednisone, irrespective of initial disease severity.
What are the implications for patients & clinicians? In the care of children with cSLE, it is important to consider the compounded effects of individual family-level factors and local resources or neighborhood conditions. Improving access to timely pediatric rheumatology care for children with cSLE may require tailoring interventions to communities with low levels of child opportunity.
The Study: Chang JC, Liu JP, Smitherman EA, et al. Multicenter study of associations between area-level child opportunity, initial disease severity, and outcomes among children with lupus. Arthritis Care Res (Hoboken). 2025 Aug;77(8):965–974.
