Poverty Stacks the Deck Against Patients With Lupus


Those who live in low-income communities may face multiple barriers to treatment adherence.

Poor patients with systemic lupus erythematosus (SLE) who receive Medicaid are less likely to adhere to their treatment regimen than are patients who live in more affluent areas. Adherence to SLE therapy may also be lower in areas with large African American populations and limited access to health care professionals.

In addition, Medicaid patients are less likely to take hydroxychloroquine for lupus if they live in areas with fewer hospitals, high African American populations, and low provider numbers.

SLE strikes women with greater frequency than men and is more than twice as common in the African American population. Dr. Candace Feldman and colleagues at Harvard Medical School note that compliance with hydroxychloroquine therapy in lupus patients is poor at baseline.

“Studies in other chronic diseases demonstrate that where individuals live has a significant effect on their health-related behaviors and on disease control and outcomes,” said Dr. Feldman. It was this premise that led the authors to look into how location and resources contribute to adherence to treatment in SLE. They presented their findings at the recent American College of Rheumatology annual meeting in San Diego, California.

The study
Utilizing the Medicaid database, new users of hydroxychloroquine were identified and adherence was measured over a 12-month period. The study included 10,268 subjects with SLE who were new users of hydroxychloroquine.

The results
• Only 15% of subjects remained adherent to hydroxychloroquine therapy based on taking the drug on 80% or more of days covered.

• Zip codes with higher percentages of African American residents had lower odds of adherence.

• Adherence was highest in counties with more hospitals and lowest in areas with low numbers of health care professionals.

• Living in areas with higher numbers of African Americans and fewer hospitals and health care professionals independently predicted low adherence to hydroxychloroquine therapy.

Implications for physicians
• Low adherence to hydroxychloroquine therapy in SLE is widespread among Medicaid recipients.

• Patients with SLE in predominantly low-income, African American communities are at higher risk for non-compliance to hydroxychloroquine therapy.

• Lack of access to health care providers and hospitals reduces the likelihood that patients with lupus will adhere to therapy.

• Physicians should make every effort to identify barriers to care and treatment adherence, especially in low-income patients with lupus who live in isolated communities with large minority populations.


American College of Rheumatology Press Release. “Diversity Rate and Poor Access to Health Professionals May Influence Lupus Therapy Adherence.” November 4, 2017. ACR/ARHP Annual Meeting. San Diego, California.

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