Diversity rate, poor access to health care affects nonadherence to lupus therapy

SAN DIEGO — Medicaid beneficiaries with lupus who live in areas with a greater proportion of African-American residents, fewer hospitals and limited access to health professionals may have lower adherence to therapy, according to data presented at the American College of Rheumatology Annual Meeting.

“Adherence is a complex behavior that has an important effect upon disease activity, morbidity and mortality among patients with SLE,” Candace Feldman, MD, MPH, ScD, assistant professor of medicine at Harvard Medical School, said in a press release. “To date, most interventions to improve adherence among SLE patients have been unsuccessful and significant racial/ethnic and socioeconomic disparities persist. Understanding the influence of area-level factors on this behavior may provide additional clues to inform future interventions.”

Prior research has showed patient age, poverty and race were associated with nonadherence to hydroxychloroquine (HCQ), the backbone of therapy for patients with lupus. However, the relationship between HCQ adherence and contextual factors, such as zip code-level poverty and concentration of health care resources, remains unknown. Researchers examined patients with SLE enrolled in Medicaid from 2000 to 2010. They included patients taking HCQ with no use in 6 months or less, with 1 year or more of continuous enrollment with complete therapy dispensing data following HCQ initiation. During this 1-year period, Feldman and colleagues used medication refill data to measure adherence, defined as 80% or greater of days covered, to HCQ therapy.

Of 10,268 new HCQ users with SLE, 15% were adherent to therapy. Zip codes with greater percentages of African-American residents showed lower odds of adherence to HCQ after investigators adjusted for individual-level characteristics and controlled for concentrations of residents below the poverty line and educational attainment. Counties with more hospitals had greater odds of HCQ adherence compared to counties with the fewest number of hospitals (OR 1.32; 1.08-1.6), and odds of adherence were lower in areas with a shortage of health care professionals (OR 0.86; 0.75-1). These findings demonstrated that Medicaid beneficiaries with lupus who lived in areas with greater percentages of African-American residents, fewer hospitals and a shortage of health care providers had lower odds of adherence to HCQ.

“The limited data available to us to protect patient anonymity did not allow for further investigation of the potential association between racial residential segregation and adherence,” Feldman said in the release. “Further studies are needed to better understand the mechanisms by which these contextual factors influence adherence behavior, and how recognition of these factors could be incorporated into future interventions to improve adherence and reduce disparities.” – by Savannah Demko

Reference:
Feldman C, et al. Abstract 920. Presented at: American College of Rheumatology Annual Meeting; Nov. 3-8, 2017; San Diego.

Disclosures: The authors report no relevant financial disclosures.