Sex, age, socioeconomic, and racial disparities exist in the Medicaid population with respect to the burden, management, and outcomes of systemic lupus erythematosus (SLE) and lupus nephritis (LN), according to a recent literature review published in Rheumatic Disease Clinics.
SLE and LN Burden
SLE prevalence was 6 times higher in women than in men, according to a study cited by Katherine P. Pryor, MD, MS, and colleagues, the authors of the review.. Black women had higher SLE prevalence and incidence compared with White women. Adults aged 30 to 64 years were more prone to SLE than younger adults aged 18-29 years. SLE prevalence was highest in the Southern US (163.5 per 100,000 person-years) and lowest in the Northeast (125.2 per 100,000 person-years). Poor patients in the lowest quartile of socioeconomic status had the highest prevalence of SLE, whereas the 2 highest income quartiles had the lowest SLE prevalence.
LN prevalence was 30.9 per 100,000 person-years, the authors reported. As observed with SLE, LN rates were higher in the South, among women, older adults, and Black patients.
Less Access to Care
Medicaid beneficiaries traveled 19.8 more miles to see a rheumatologist than privately insured patients, according to a study included in the review. Other research found higher rates of kidney failure in areas with more Medicaid patients. Perhaps for those reasons, emergency department visits and hospitalizations were higher among Medicaid patients with SLE than patients with other insurance, according to the authors. A nationwide study on SLE found that privately insured patients were less likely to die than patients on Medicaid.
With respect to renal care, Medicaid beneficiaries were less likely to receive adequate care for LN and end-stage kidney disease (ESKD), including access to pre-ESKD nephrology care, transplant listing, preemptive transplant, or placement of permanent vascular access, studies show. Black, uninsured, and unemployed patients and Medicaid recipients all were less likely to receive initial peritoneal dialysis. Another study found delayed and lower receipt of immunosuppressive, renal-protective antihypertensive, and antimalarial medications among patients with LN receiving Medicaid than other insurance. Black, Hispanic, and younger patients with LN, however, were more likely to receive immunosuppressive drugs and hydroxychloroquine.
Differences in Medication Adherence
Nonadherence to treatment was more commonly observed among patients on Medicaid of non-White race or lower socioeconomic status, a compilation of research shows.
Fewer than 20% of Medicaid beneficiaries with SLE adhered to hydroxychloroquine therapy, according to a study of 10,268 Medicaid patients. Younger age, Black or Hispanic race, diabetes mellitus, antidepressant medication, and use of acute care were each associated with increased odds of nonadherence, according to various studies. Retinal examinations were less likely among hydroxychloroquine users receiving Medicaid than private insurance.
Only 17% of azathioprine and 21% of mycophenolate mofetil (MMF) initiators were adherent. Black or Hispanic race and younger age were associated with azathioprine nonadherence, but not MMF. LN, however, was associated with 26% decreased odds of MMF nonadherence, studies show.
Cardiovascular Events, Mortality, and Other Outcomes
Among SLE patients enrolled in Medicaid, Black and Hispanic patients had higher risks for cardiovascular events. Infection rates were higher among those with LN. Patients aged 51-64 years, Black or Native American patients, and residents from low income neighborhoods also were at higher risk for infections. Vaccination rates were suboptimal. Infection rates did not differ by specific immunosuppressive medication.
Patients with LN were 1.5-fold more likely to die than patients with SLE alone. In SLE, mortality rates were higher for Black and Native American than White patients, and lower for Hispanic and Asian patients. In LN, death risk was higher for Black than White patients, and lower for Hispanic and Asian patients.
“Disparities in outcomes observed among Medicaid SLE patients likely are multifactorial, based on biology, sociodemographics, and access to care,” Dr Pryor and colleagues concluded. “Given the complex social challenges facing many Medicaid SLE patients, this population needs more support, funding, and improved allocation of resources. Earlier and improved access to physicians, including subspecialists and higher quality of care at all stages of the disease, are warranted and hopefully would improve outcomes.”
Pryor KP, Barbhaiya M, Costenbader, Feldman CH. Disparities in lupus and lupus nephritis care and outcomes among US Medicaid beneficiaries. Rheum Dis Clin N Am 47;41-53. doi:10.1016/j.rdc.2020.09.004