More education linked to better patient outcomes in Cushing’s study
Low socioeconomic, educational levels tied to greater mortality long-term
People with Cushing’s disease who have more education are also more likely to have better patient outcomes — including longer survival — than those with lower educational levels, a study in Sweden found.
According to the study, which followed individuals with Cushing’s for as long as 20 years before and after diagnosis, nearly all patients experience a decline in employment rate and income, and an increasing rate of disability pension, over time.
The findings show “a significant burden of [Cushing’s disease] on socioeconomic status, which started already [six] years before … diagnosis and persisted throughout 20 years of follow-up,” the researchers wrote. “Of equal importance is that low socioeconomic status, in particular educational level, is associated with [a] worse outcome.”
Indeed, while people with Cushing’s had overall higher mortality than those without the disease, the risk of death for a patient with less education was 2.5 times higher, an analysis of outcomes found.
The study, “Socioeconomic status and its association with outcome in patients with Cushing’s disease,” was published in the European Journal of Endocrinology.
Researchers analyzed data on patient education, income, and outcomes
Cushing’s disease is one of the most common forms of Cushing’s syndrome, an umbrella term for conditions driven by elevated levels in the body of the hormone cortisol. The disease is caused by tumors in the brain’s pituitary gland that trigger the excessive production of adrenocorticotropic hormone, known ACTH, which is a signaling molecule that prompts the adrenal glands to produce cortisol.
Besides leading to several health issues that can shorten a patient’s lifespan, Cushing’s disease is also associated with cognitive and psychiatric issues that can impair quality of life.
Although socioeconomic status has been found to impact both quality of life and mortality in people from the general population and individuals with other diseases, “little is known about the socioeconomic consequences of [Cushing’s disease] and their impact on long-term [outcomes],” the researchers wrote.
To learn more, the team analyzed data from the nationwide Swedish Pituitary Register from people with Cushing’s disease who had been diagnosed between May 1991 and September 2018.
A total of 371 patients and 1,484 people without the disease, matched for age, sex, and living area, were ultimately covered in the study. Slightly more than three-quarters (76%) were women.
The patients were followed for a median of 12 years before being diagnosed with Cushing’s, and for a median of 11 years after that. Following diagnosis, they were most commonly treated with surgery alone (63%), and less frequently with surgery in combination with radiotherapy (11%) or medications (12%). At the last follow-up, the disease was controlled in 82% of the patients.
The individuals with Cushing’s most commonly had intermediate (42%) or high education (39%) levels, and a median disposable annual income after tax of 1,873 Swedish krona (about $17,600). Additionally, the majority had at least one child (77%), and more than half lived with someone else (52%).
Lower educational level linked to 2.5 times higher mortality risk
Disability pension as the main source of income was more commonly seen in patients from six years before diagnosis; this increased gradually to about 25% nine years after diagnosis. Patients also most commonly had sick leave benefits as the main source of income.
“These findings illustrate the problem with diagnostic delay in patients with [Cushing’s disease], the long-standing negative effects of [Cushing’s disease] despite biochemical remission and, not least, a need for early rehabilitation plans as part of the standard of care,” the researchers wrote.
The researchers found that the proportion of patients who were employed began to decrease seven years before diagnosis. Importantly, it was 44% lower than that of controls during the whole follow-up period, the team noted. Similarly, median income gradually declined over time and was lower than that of controls, starting in the two years preceding diagnosis.
Low educational level in patients with [Cushing’s] was associated with lower rates of employment and increased mortality.
Two and five years after diagnosis, being older and having ACTH deficiency were associated with a significantly lower probability of being employed. At two years, patients who were not in biochemical remission were 61% less likely to be employed.
Patients who were employed before diagnosis were more likely to be employed across all three time points after diagnosis, the data showed. Those with higher education levels also were more likely to be employed five and 10 years after diagnosis, the team noted.
A standardized mortality ratio, or SMR, was then used to compare the observed death rate of patients with the expected death rate in the general population. If the SMR is greater than one, it indicates that the number of deaths is higher than expected.
Cushing’s patients had a higher SMR than did controls, with a ratio of 2.65 versus 0.87. Among these individuals, those with low education levels had higher SMR — indicating worse patient outcomes — compared with those with intermediate or higher education levels (3.76 vs. 2.6 vs. 1.36).
Overall, having a low educational level was associated with a 2.5 times higher risk of mortality, the analysis found.
“Low educational level in patients with [Cushing’s] was associated with lower rates of employment and increased mortality,” the researchers wrote, noting the “significant burden” linked to the disease.
According to the team, “future efforts should aim at providing [individualized] management [programs], early intervention of neuropsychiatric comorbidities and proactive rehabilitation plans as part of standard care.”
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