Cost of Inpatient Care of Patients With Pemphigus in the United States: Translating Dollars and Cents Into Improved Patient Care

Pemphigus is an autoimmune blistering disorder that, prior to the use of prednisone, was associated with increased mortality.1 Evenwith theavailabilityof steroid-sparingagents, moderate to severe disease can be associated with clinically significantmorbidity. In this issue,Hsuet al2 demonstrate the financial burden of inpatient hospitalization of patients with pemphigus using the National Inpatient Sample (NIS) Database. The NIS is the largest publicly available all-payer hospital inpatient care database in the United States and is used by researchers and policymakers to identify, track, and analyze trends in health care utilization, access, charges, quality, and outcomes.3 Rare diseases, such as pemphigus, can be difficult to study, but large databases, such as the NIS, allow us a glimpse into the impactof thedisease fromapublichealthperspective.Hsuet al2demonstrate that evena relatively raredermatologic condition can be a considerable burden both to the patient and the medical system. Thenumberofpatients admittedwithpemphigusover the past decade is dwarfedby thenumberof patients admitted for other conditions. Patients with a primary or secondary diagnosis of pemphigus comprised less than 8 per 1 million hospitalizations per year.2 Nevertheless, the cost of hospitalization and length of staywas 50% to60%more than for patientswithout pemphigus, approaching values typically seen with more devastating illnesses, suchas coronaryatherosclerosis. Themeancosts for hospitalizationof apatientwith aprimaryor secondarydiagnosis of pemphigus in 2010 were $16 320 and $14 340 respectively.2 The Healthcare Cost and Utilization Project (HCUP)—which includes the NIS—estimated the average cost (all diagnoses) per inpatient stay in 2010 to be $9700.4 Based on the same HCUP data, the costs per stay for 5 principal diagnoses with the highest aggregate cost were as follows: $18 400 for septicemia, $17 600 for complication of device, $18 200 for acute myocardial infarction, $22 300 for respiratory failure, and $18000 for intracranial injury. The cost per stay for pemphiguswas substantially higher than the average cost for many common diseases with significant morbidity: $9000 for diabetes mellitus with complications, $10 500 for congestive heart failure, and $7400 chronic obstructive pulmonary disease. The authors2 also dissected variables that aremore likely to be associatedwith admission, increased length of stay, and increased cost. Race seems to be a significant factor in likelihood of admission. Patients who were admitted for pemphigus weremore likely to be Hispanic, Asian, Native American, black, or multiracial,2 in decreasing order of likelihood. It is unclear if there is a genetic predilection for more severe disease or if this is dependent on access to care.Not surprisingly, patientswithpemphigusweremore likely tobeolder thanpatients admittedwithotherdiagnoses. Increasingageandnumber of comorbidities increased length and cost of stay of patients hospitalized with pemphigus.2 While this is likely true for all patients in general, it ismore relevant among thosewith pemphigus because they tend to be older and have multiple comorbidities. The authors2 identify other variables that are associated with a statistically significant increased risk of admission and length and cost of stay, but the incremental increasemay not beasclinically relevant.Theadjustedodds ratio for female sex, for example, is 1.10—or a risk 10% higher than for males. It is alsounclearwhat the real-world interpretation is for these statistical values. For example, for each variable analyzed, what is the increase in the length and cost of stay in actual days and dollars? What else should thesenumbersmean tous, andwhat can we do to improve the care and outcomes of these patients? Changes in care and reimbursementhavedecreased thenumberofdermatologypatients treatedas inpatients.5,6Hsuet al,2 however, noted an increase in the admission rate of patients with a primary or secondary diagnosis of pemphigus after 2006. Could this increase in admissions for pemphigus in the face of decreasing hospital admission for dermatological diagnoses in general reflect a change in the availability of outpatientdermatologists to treat thesepatients? Is this trendalso being seen inother severedermatological diseases, suchas cutaneousT-cell lymphoma?Could this represent ageneral trend of severely ill patientsnothavingappropriatedermatologyaccess, and this lack ultimately translates into higher costs for the care of this group? Patientswith pemphigus aremore likely to have complex medical issues and multiple comorbidities. Admission gives these patients access to general medical hospitalist care, but it is not clear if the patients in this cohort had access to inpatient consultative services by dermatology. Not only is expert inpatient dermatology care important for these patients, but this expertisemust also be available at a timeof the daywhen the dermatology team can engage and directly interact with the other managing medical services. Support for dedicated Related article Opinion