Mixed Individual-Aggregate Data on All-Cause Mortality in Bullous Pemphigoid: A Meta-analysis

Billal Tedbirt, André Gillibert, Emilie Andrieu, Vivien Hébert, Sarah Bastos, Neil J. Korman, Mark B.Y. Tang, Jun Li, Luca Borradori, Begonia Cortés, Soo Chan Kim, Adrià Gual, Ting Xiao, Carilyn N. Wieland, Janet A. Fairley, Khaled Ezzedine, Pascal Joly

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14 Citations (Scopus)


Importance: The 1-year standardized mortality ratio (SMR) of bullous pemphigoid (BP) has been reported as 2.15 to 7.56 and lower in the US than in Europe. Objective: To estimate the worldwide 1-year SMR of BP. Data Sources: PubMed, Embase, Cochrane Library, Google Scholar, Lissa, and gray literature (eg, medRxiv) were screened for studies of BP published from inception to June 10, 2020, with review of reference lists. Study Selection: Retrospective and prospective studies reporting 1-year all-cause mortality rate in patients with BP and providing age statistics (eg, mean [SD]). Data Extraction and Synthesis: Two reviewers independently extracted the data. The 1-year SMR was computed in studies reporting 1-year mortality by combining information on age obtained from studies with aggregate data and individual data. Risk of representativity, misclassification, and attrition bias were assessed by a custom tool. Main Outcomes and Measures: The primary end point was the worldwide 1-year SMR. Secondary analysis included comparison of 1-year SMRs between continents in a meta-regression. Results: Three studies were performed in the US (n = 260), 1 in South America (n = 45), 16 in Asia (n = 1903), and 36 in Europe (n = 10132) for a total of 56 unique studies and 12340 unique patients included in the meta-analysis (mean [SD] age, 77.3 [12.7] years; 55.9% women). The mean (SD) patient age in the United States was 75.6 (13.7) years; in Asia, 73.8 (13.6) years; and in Europe, 78.1 (12.3) years. The worldwide 1-year SMR was estimated at 2.93 (95% CI, 2.59-3.28; I2= 85.6%) for all 56 studies. The 1-year SMR in the US was 2.40 (95% CI, 0.89-3.90; I2= 86.3%) for 3 studies; in Asia, 3.53 (95% CI, 2.85-4.20; I2= 86.3%) for 16 studies; and in Europe, 2.77 (95% CI, 2.35-3.19; I2= 86.3%) for 36 studies. After adjustment on the expected 1-year mortality rate, the European 1-year SMR did not differ significantly from the 1-year SMR in the United States (-0.48 vs Europe; 95% CI, -2.09 to 1.14; P =.56) and Asia (0.51 vs Europe; 95% CI, -0.56 to 1.58; P =.35). Risk of attrition bias was high (>10% censorship) in 16 studies (28.6%), low in 16 (28.6%), and unclear in 24 (42.9%). Only 4 studies (7.1%) had a sampling method guaranteeing the representativity of BP cases in a population. Conclusions and Relevance: Although heterogeneity was high and overall quality of follow-up was poor, this meta-analysis confirms the high mortality rate among patients with BP..

Original languageEnglish
Pages (from-to)421-430
Number of pages10
JournalJAMA Dermatology
Issue number4
Publication statusPublished - 2021 Apr

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All Science Journal Classification (ASJC) codes

  • Dermatology


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