Electronic health records (EHRs) are designed to provide physicians with a complete picture of a patient’s condition, improving care and decreasing costs for those with chronic illnesses, such as systemic lupus erythematosus (SLE). However, despite the widespread adoption of these systems, few mechanisms exist to exchange data about patients who receive care from multiple institutions or providers. This lack of data exchange may leave some patients at a disadvantage and may increase care inequalities for patient populations that already experience disparities.
In their latest research, published in the September issue of Arthritis Care & Research, Theresa L. Walunas, PhD, and colleagues from the Northwestern University Feinberg School of Medicine in Chicago sought to understand the effect of care fragmentation on patients with SLE, specifically examining their risk of infection and disease-related damage. The researchers used data from the Chicago HealthLNK Data Repository, which includes EHR from six local medical institutions.
For this study, care fragmentation was defined as patients having one or more visits with a 710.0 ICD-9 code at two or more institutionsbetween Jan. 1, 2006, and Dec. 31, 2012.
The Results
Researchers identified 4,276 patients with SLE, of whom 856 (20%) received care at more than one health care institution, resulting in care fragmentation. Patients who experienced fragmented care visited an average of two institutions and were more likely to be African-American and the beneficiaries of public insurance.
These patients also had a significantly higher median number of months in the care system (66 vs. 61) and a higher median number of visits for SLE-related care (15 vs. 10). However, researchers found no difference in the average number of visits per month. The authors note this suggests that although the patients with fragmented care had more visits, no difference existed in the rate at which care was received between the patient populations. Therefore, “time and visit numbers are not likely the drivers behind the outcomes we have observed,” write the authors.
Also, patients who experienced fragmented care were more likely to experience severe infection than patients receiving care within only one health care institute. The majority of infections were bacterial infections.
In unadjusted analyses, care fragmentation, public insurance and African-American race independently resulted in an increased likelihood that a patient would experience a severe infection.
Researchers also examined how care fragmentation, insurance status and race affect comobidities, which indicate the degree of SLE-related damage to the cardiovascular system and kidneys. “When we assessed common indicators of SLE-derived damage, we observed that patients with care fragmentation were more likely to have been documented with cardio vascular disease, stroke, nephritis and end-stage renal disease,” write the authors. The risk of these comorbidities was also associated with being African-American and the use of public insurance.
“Our data suggest that care fragmentation plays an independent role in increasing the frequency of disease-related morbidity damage in the SLE patients from an urban environment and worsens existing disparities already experienced by African-American patients and patients who are the beneficiaries of public insurance,” the authors write. “Combined with previous research suggesting that existing damage is a predictor of future damage accrual for SLE patients, our study suggests that improving care coordination and access to a more complete set of medical record data may be a key strategy for improving health outcomes for SLE patients.”
Walunas TL, Jackson KL, Chung AH, et al. Disease outcomes and care fragmentation among patients with systemic lupus erythematosus. Arthritis Care Res (Hoboken). 2017 Sep:69(8):1369–1376. doi: 10.1002/acr.23161. [Epub ahead of print]
