Background:
No large population-based studies have been done on systemic lupus erythematosus (SLE) mortality trends in the United States.
Objective:
To identify secular trends and population characteristics associated with SLE mortality.
Design:
Population-based study using a national mortality database and census data.
Setting:
United States.
Participants:
All U.S. residents, 1968 through 2013.
Measurements:
Joinpoint trend analysis of annual age-standardized mortality rates (ASMRs) for SLE and non-SLE causes by sex, race/ethnicity, and geographic region; multiple logistic regression analysis to determine independent associations of demographic variables and period with SLE mortality.
Results:
There were 50 249 SLE deaths and 100 851 288 non-SLE deaths from 1968 through 2013. Over this period, the SLE ASMR decreased less than the non-SLE ASMR, with a 34.6% cumulative increase in the ratio of the former to the latter. The non-SLE ASMR decreased every year starting in 1968, whereas the SLE ASMR decreased between 1968 and 1975, increased between 1975 and 1999, and decreased thereafter. Similar patterns were seen in both sexes, among black persons, and in the South. However, statistically significant increases in the SLE ASMR did not occur among white persons over the 46-year period. Females, black persons, and residents of the South had higher SLE ASMRs and larger cumulative increases in the ratio of the SLE to the non-SLE ASMR (31.4%, 62.5%, and 58.6%, respectively) than males, other racial/ethnic groups, and residents of other regions, respectively. Multiple logistic regression showed independent associations of sex, race, and region with SLE mortality risk and revealed significant racial/ethnic differences in associations of SLE mortality with sex and region.
Limitations:
Underreporting of SLE on death certificates may have resulted in underestimates of SLE ASMRs. Accuracy of coding on death certificates is difficult to ascertain.
Conclusion:
Rates of SLE mortality have decreased since 1968 but remain high relative to non-SLE mortality, and significant sex, racial, and regional disparities persist.
Primary Funding Source:
None.
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Author, Article and Disclosure Information
University of California, Los Angeles, Los Angeles, California (E.Y.Y., J.M.W., D.K.M., A.K., R.R.S.)
Charles R. Drew University of Medicine and Science, Los Angeles, California (M.S.)
UCLA Clinical and Translational Science Institute, Los Angeles, California (N.M., N.L.)
Note: Drs. Yen and Singh had full access to the data and take full responsibility for the integrity of the data and the accuracy of the analysis.
Acknowledgment: The authors thank Dr. Kenrik Duru (UCLA Division of General Internal Medicine and Health Services Research and UCLA Center for Health Policy Research) for critically reading the manuscript and the UCLA Institute for Digital Research and Education Statistical Consulting Group for statistical assistance.
Financial Support: This work was supported in part by the National Institutes of Health (P30-AG028748, R01-AI080778, R01-AR056465, S21-MD-000103, U54-MD-008149, U54-MD-007598, and UL1 TR001881-02), the Lupus Foundation of America, and the Rheumatology Research Foundation. Dr. Yen was supported by the National Institutes of Health (T32-DK-07789 and 5T32-HD-007512), the UCLA Children's Discovery and Innovation Institute, and a Mallinckrodt Research Fellowship Award.
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-0102.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement:Study protocol: Not available. Statistical code: Available from Dr. Yen (e-mail, [email protected]
Corresponding Author: Ram R. Singh, MD, Division of Rheumatology, University of California, Los Angeles, 1000 Veteran Avenue, Room 32-59, Los Angeles, CA 90095-1670; e-mail, [email protected]
Current Author Addresses: Dr. Yen: Division of Rheumatology, Department of Medicine, University of California, Los Angeles, 1000 Veteran Avenue, Room 32-59, Los Angeles, CA 90095-1670.
Dr. Shaheen: Charles R. Drew University of Medicine and Science, 1731 East 120th Street, Los Angeles, CA 90059.
Ms. Woo and Dr. McCurdy: Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, University of California, Los Angeles, 10833 Le Conte Avenue, MDCC 22-430, Los Angeles, CA 90095.
Mr. Mercer and Dr. Li: Biostatistics Program, UCLA Clinical and Translational Science Institute, 621 Charles E. Young Drive South, Los Angeles, CA 90095.
Dr. Karlamangla: Division of Geriatrics, Department of Medicine, University of California, Los Angeles, 10945 Le Conte Avenue, Suite 2339, Los Angeles, CA 90095.
Dr. Singh: Division of Rheumatology, Department of Medicine, Department of Pathology and Laboratory Medicine, and Molecular Toxicology IDP, University of California, Los Angeles, 1000 Veteran Avenue, Room 32-59, Los Angeles, CA 90095-1670.
Author Contributions: Conception and design: E.Y. Yen, M. Shaheen, A. Karlamangla, R.R. Singh.
Analysis and interpretation of the data: E.Y. Yen, M. Shaheen, J.M.P. Woo, N. Mercer, N. Li, D.K. McCurdy, A. Karlamangla, R.R. Singh.
Drafting of the article: E.Y. Yen, M. Shaheen, J.M.P. Woo, D.K. McCurdy, R.R. Singh.
Critical revision of the article for important intellectual content: E.Y. Yen, M. Shaheen, J.M.P. Woo, N. Mercer, D.K. McCurdy, A. Karlamangla, R.R. Singh.
Final approval of the article: E.Y. Yen, M. Shaheen, J.M.P. Woo, N. Mercer, N. Li, D.K. McCurdy, A. Karlamangla, R.R. Singh.
Statistical expertise: E.Y. Yen, M. Shaheen, N. Mercer, N. Li, A. Karlamangla.
Obtaining of funding: R.R. Singh.
Administrative, technical, or logistic support: D.K. McCurdy, R.R. Singh.
Collection and assembly of data: E.Y. Yen.
This article was published at Annals.org on 31 October 2017.
* Drs. Karlamangla and Singh share senior authorship of this article.
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