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Type: Journal article
Title: Digital ulcers in systemic sclerosis: their epidemiology, clinical characteristics, and associated clinical and economic burden
Author: Morrisroe, K.
Stevens, W.
Sahhar, J.
Ngian, G.-S.
Ferdowsi, N.
Hill, C.L.
Roddy, J.
Walker, J.
Proudman, S.
Nikpour, M.
Citation: Arthritis Research and Therapy, 2019; 21(1):299-1-299-12
Publisher: Springer Nature
Issue Date: 2019
ISSN: 1478-6354
Statement of
Kathleen Morrisroe, Wendy Stevens, Joanne Sahhar, Gene-Siew Ngian, Nava Ferdowsi, Catherine L. Hill, Janet Roddy, Jennifer Walker, Susanna Proudman, and Mandana Nikpour
Abstract: Background: To determine the frequency and clinical characteristics of systemic sclerosis-related digital ulcers, and associated direct health care costs, quality of life, and survival. Methods: Digital ulcers (DUs) were defined as an area with a visually discernible depth and a loss of continuity of epithelial coverage. DU severity was calculated based on the physician reported highest number of new DUs at clinical review (mild = 1-5 DUs, moderate 6-10 DUs, severe > 10 DUs). Healthcare use was captured through data linkage, wherein SSc clinical data captured prospectively in a dedicated clinical database were linked with health services databases to capture hospital admissions, emergency department (ED) presentations and ambulatory care (MBS) utilization and cost for the period 2008-2015. Healthcare cost determinants were estimated using logistic regression. Results: Among 1085 SSc patients, 48.6% experienced a DU over a mean follow-up of 5.2 ± 2.5 years. Those who developed DUs were more likely to have diffuse disease subtype (34.9% vs 18.2%, p < 0.001), anti-Scl-70 antibody (18.9% vs 9.3%, p < 0.001), and a younger age at SSc onset (43.6 ± 13.9 vs 48.8 ± 14.0 years, p < 0.001) in addition to reduced health-related quality of life (HRQoL) measured by the SF-36 but without a significant impact on survival. SSc patients with a history of a DU utilized significantly more healthcare resources per annum than those without a DU, including hospitalizations, ED presentation, and ambulatory care services. Total healthcare services, excluding medications, were associated with an annual excess cost per DU patient of AUD$12,474 (8574-25,677), p < 0.001, driven by hospital admission and ED presentation costs. Conclusion: DUs place a large burden on the patient and healthcare system through reduced HRQoL and increased healthcare resource utilization and associated cost.
Keywords: Systemic sclerosis; scleroderma; digital ulceration; economic burden
Rights: © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.
DOI: 10.1186/s13075-019-2080-y
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