Lupus outcomes worse among patients experiencing economic insecurity
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Key takeaways:
- Food, housing and financial insecurities were highly prevalent among patients with SLE.
- The findings were similar after controlling for other factors, suggesting economic insecurities pose a “unique risk factor” for those with SLE, the researchers wrote.
Economic insecurities are “highly prevalent” among patients with systemic lupus erythematosus, and those with more insecurities demonstrate worse self-reported outcomes regardless of poverty or education, according to data.
“Although social determinants of health encompass a wide range of social risk factors, only a select few have been examined in SLE, such as income, education level, and health insurance status,” Donavon Sandoval-Heglund, a medical student at the University of California, San Francisco, and colleagues wrote in The Lancet Rheumatology. “These factors have been associated with disease activity, damage accrual, and mortality. After accounting for social determinants of health like poverty, education, and health insurance status, there are still variations in SLE outcomes that could be related to additional social determinants of health.
“Recently, some researchers have investigated the concept of economic insecurity, including difficulty paying for food, medications, or housing and found strong associations with several chronic disease outcomes,” they added. “These measures might be particularly salient in the case of a complex chronic disease like SLE, which requires significant personal costs even among patients with health insurance.”
To examine the association between patient-reported SLE outcomes — such as physical and cognitive function, pain interference and fatigue — and social determinants of health “above and beyond income, education and health insurance,” Sandoval-Heglund and colleagues conducted a cross-sectional analysis of data from the California Lupus Epidemiology Study. The analysis included 252 patients with SLE residing in the San Francisco Bay Area, of whom 90% were female with a mean age of 49.7 years (standard deviation [SD] = 13.4). Participants were additionally recruited from bay area rheumatology clinics.
Data included in the analysis spanned from Feb. 25, 2015, to Jan. 10, 2018. Outcomes were measured with clinically validated short forms and questionnaires administered through the California Lupus Epidemiology Study. Insecurities regarding housing, food, finances and ability to afford SLE care were measured via questions such as, “How often in the past 12 months would you say you were worried or stressed about having enough money to pay your rent/mortgage?”
According to the researchers, 54% of all participants reported at least one economic insecurity. All patient-reported outcomes were scored significantly worse among those with any type of economic insecurity. The worst outcomes were reported among those with two or more economic insecurities. In addition, these associations remained after controlling for other factors, such as poverty and comorbidities, suggesting economic insecurities pose “a unique risk factor” for worse SLE outcomes, the authors wrote.
Adjusted mean scores among patients with no insecurity vs. any insecurity were 48.9 (95% CI, 47.5-50.3) vs. 45.7 (95% CI, 44.3-47), respectively, for physical function, 52 (95% CI, 50.5-53.5) vs. 54.4 (95% CI, 53-55.8) for pain interference, 50.5 (95% CI, 48.8-52.3) vs. 54.9 (95% CI, 53.3-56.5) for fatigue, 49.9 (95% CI, 48.3-51.6) vs. 52.9 (95% CI, 51.4-54.5) for sleep disturbance, 49·3 (95% CI, 47.7-50.9) vs. 45.6 (95% CI, 44.1-47) for cognitive function, 4.4 (95% CI, 3.6-5.1) vs. 6.1 (95% CI, 5.4-6.8) for Patient Health Questionnaire-8 measures, and 3.3 (95% CI, 2.6-4.1) vs. 5.2 (95% CI, 4.5-5.9) for General Anxiety Disorder-7 measures.
“Our findings suggest that economic insecurities are highly prevalent and impactful exposures for those living with SLE,” Sandoval-Heglund and colleagues wrote. “Having any of the examined insecurities was associated with worse outcomes across a breadth of domains.
“Importantly, many of these economic insecurities are modifiable with the appropriate interventions, such as long-term rent subsidies, child tax credits, and food programs,” they added. “Studies examining the effects and cost-effectiveness of interventions that address economic insecurity are needed given the striking health disparities in SLE. Increased recognition of the importance of these social exposures and knowledge of available resources to provide to patients experiencing economic insecurity, might have potential to improve outcomes for those with SLE.”
Perspective
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David A. McLain, MD, MACR, FACP, FRCP
Economic insecurity arises when there is an insufficient availability of resources to cover basic necessities such as food, housing, medical care and other essentials. The impact of economic instability on health has been extensively studied, revealing significant associations with various forms of insecurity and economic status. These insecurities are linked to a range of health outcomes, including mortality.
The magnitude of food insecurity as a social determinant of health is highlighted by the fact that, in 2020, approximately 13.8 million U.S. households experienced food insecurity. Beyond financial aspects, neighborhood conditions pose challenges regarding access to food, particularly in urban, rural and low-income areas with limited access to full-service supermarkets or grocery stores.
Disparities exist, with predominantly Black and Hispanic neighborhoods having fewer full-service supermarkets compared with predominantly white and non-Hispanic neighborhoods. Convenience stores in these areas often feature higher prices, lower-quality offerings, and a limited variety compared to supermarkets.
Housing instability presents its own set of challenges, including difficulty paying rent, overcrowding, frequent relocation, and excessive spending on housing. These experiences can negatively impact physical health and create barriers to accessing health care.
The repercussions of economic instability on health extend to the affordability of basic medical care, leading to potential complications of existing conditions and poorer outcomes. The inverse relationship between income and disease prevalence is evident, with poor adults being almost five times more likely to report fair or poor health compared to those with higher incomes.
Low-income individuals also exhibit higher rates of heart disease, diabetes, stroke, chronic arthritis, and other chronic disorders. Furthermore, low-income groups demonstrate higher rates of risk factors, such as three times higher smoking rates and elevated obesity rates, compared with higher-income groups. Aerobic exercise rates are nearly double in the highest income level, compared with the lowest, and mental health surveys reveal more pathology in the lowest income group.
Policy domains that may appear unrelated to health, such as education, employment, wages, economic opportunities, transportation, housing, crime, taxes, economic development, and the environment, can significantly influence the overall health of a population.
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