key: cord-0836830-op6s8tr4
authors: Feldman, Candace H.; Ramsey‐Goldman, Rosalind
title: Widening Disparities Among Patients with Rheumatic Diseases in the COVID‐19 Era: An Urgent Call to Action
date: 2020-05-07
journal: Arthritis Rheumatol
DOI: 10.1002/art.41306
sha: cfcaa926a2966c1c2a22aff7bfbccab1e335cb45
doc_id: 836830
cord_uid: op6s8tr4

Recent data from multiple public health departments across the U.S. highlighting the disproportionate burden of COVID‐19 infections in vulnerable populations serve as an urgent call to action. As rheumatologists, we are acutely aware of the higher morbidity and mortality, and for a number of our diseases, the higher incidence and prevalence among racial/ethnic minorities and individuals of lower socioeconomic status (SES). Comorbidities are frequent, timely access to subspecialty care is limited, receipt of high quality care is less common, and care is more often fragmented with frequent, avoidable acute care use.

Recent data from multiple public health departments across the U.S. highlighting the disproportionate burden of COVID-19 infections in vulnerable populations serve as an urgent call to action.(1, 2) As rheumatologists, we are acutely aware of the higher morbidity and mortality, and for a number of our diseases, the higher incidence and prevalence among racial/ethnic minorities and individuals of lower socioeconomic status (SES). (3) (4) (5) (6) Comorbidities are frequent, timely access to subspecialty care is limited, receipt of high quality care is less common, and care is more often fragmented with frequent, avoidable acute care use. (7, 8) Among patients with systemic lupus erythematosus (SLE) where these disparities have been shown to be particularly pronounced, prolonged glucocorticoid use and delayed or lack of standard-of-care immunosuppressive use is common, and hydroxychloroquine, the backbone of SLE therapy to prevent flares and organ damage, is under-prescribed and adherence is suboptimal. (9) In addition, despite at least two-tothree-fold higher prevalence of SLE and significantly poorer outcomes, black individuals compared to white, are much less likely to be enrolled in clinical trials.(10, 11) Structural racism, historical

This article is protected by copyright. All rights reserved injustices in research, implicit bias by health providers and ongoing experiences of discrimination contributing to patient distrust, all contribute to this under-enrollment. (10, 11) As a result, we often recommend treatments that have not been well-studied in the populations that may need them the most. Experiences of racial discrimination have also been associated with increased rheumatic disease activity and greater organ damage. (12) A significant proportion of individuals with systemic rheumatic diseases at some point receive immunosuppressive therapy during their disease course and these medications combined with their underlying autoimmune conditions increase their susceptibility to severe infection. Among patients with SLE, particularly those insured by Medicaid, the largest public health insurance for low income Americans, serious infections requiring hospitalization are common and black individuals are more likely than white to experience them. (13) The COVID-19 pandemic has already begun to disproportionately affect black, Hispanic, American Indian, and lower socioeconomic status individuals, and we expect that among patients with rheumatic diseases, the disparities will be even more pronounced.(1, 2) Many of these individuals have more severe manifestations and less well controlled rheumatic diseases at baseline and may not be able to follow social distancing recommendations due to crowded or unstable living situations and financial constraints. In addition, more frequent glucocorticoid use among patients who lack sustained access to high quality outpatient care not only heightens infection risk, but also causes cardiovascular disease and diabetes, known risk factors for poorer outcomes from COVID-19. (9, 13, 14) These factors raise significant concern for our most vulnerable patients in terms of short-term infection risk and both short and long-term control of their rheumatic disease.

Hydroxychloroquine is now being promoted as a potential treatment of COVID-19, which has resulted in medication shortages for our rheumatology patients. Medicaid limits patients to onemonth supplies of their medications. This means that our most vulnerable patients are also those least likely to have a sufficient supply. Recently, MassHealth, Massachusetts' Medicaid organization, which covers nearly 2 million residents, waived this one-month supply limit, and other states including Illinois, Indiana and Ohio have attempted to preserve hydroxychloroquine access for rheumatology patients. Insufficient supplies of essential medications, combined with potentially

This article is protected by copyright. All rights reserved more severe disease and delays to initial care at the outset, will likely result in significantly poorer outcomes and widening disparities months down the road when these same patients are unable to get this medication refilled.

Over the past three years, we have engaged in an academic-community partnership in the greater Boston and Chicago areas. We have worked alongside community leaders to better understand the impact of neighborhood factors and social determinants on health, of experiences of racial discrimination, and of SLE-related health disparities by race within our cities.(15) Now more than ever, we recognize the need to partner with our communities to better understand the acute needs of our rheumatology patients, to build trust, and to intervene to reduce the risk of widening disparities due to COVID-19. We propose the following call to action: 1) Collect and release sociodemographic data both in the clinical and research setting. There are multiple registries both locally and internationally collecting data on the burden of COVID-19 among patients with rheumatic diseases. In addition to collecting and releasing data on race and ethnicity, it is imperative to consider measures of SES (occupation, education, income), as well as neighborhood deprivation, racial residential segregation, and social determinants of health. These include questions about employment, financial and housing stability, food insecurity, neighborhood safety, access to medications and healthcare, child and elder care, and experiences of racial discrimination. Only by understanding the impact of these factors on the burden and spread of disease, and on access to care, will we be able to develop comprehensive strategies to reduce disparities and improve the health of our entire population. As these factors also directly impact patient care and outcomes, they should be incorporated into routine clinical visits.

2) Engage in advanced care planning conversations with our patients. While traditionally thought to be in the domain of primary care providers and geriatricians, as rheumatologists we have well-established, long-term relationships with our patients as we care for their complex chronic diseases. Prior studies suggest that black and Hispanic individuals, as well as

This article is protected by copyright. All rights reserved individuals with less education and lower income are less likely to have engaged in advanced care planning. (16) Rheumatologists should join the charge and advocate to be part of these essential conversations with our patients, particularly with those who are older and chronically ill, both prior to and during serious acute illness. (17) 3) Ensure racial/ethnic diversity in clinical trial enrollment and understand confounding factors in observational studies. Racial and ethnic minorities are underrepresented in medical research. Particular attention to these populations as we investigate treatments and prophylaxis using rheumatology-related and other medications for COVID-19 is essential. It is also critical to recognize the role of both historical and current racial discrimination when we promote diverse enrollment. (11) In addition, when we conduct observational studies examining the effects of rheumatic disease medications on COVID-19 incidence and severity, we need to recognize differences in the burden of comorbidities, in prior access to care, and in receipt of HCQ and immunosuppressive medications by race/ethnicity and SES that may confound associations.

Health and Health Disparities, the National Institute on Aging and the National Institute of Mental Health issued a Notice of Special Interest to respond to the urgent need for research on the impact of COVID-19 disease among health disparity populations. We appeal to the National Institute for Arthritis and Musculoskeletal and Skin Disease to similarly recognize the potential for widening disparities caused by COVID-19 in our vulnerable rheumatology patient population and support additional research to intervene quickly to address this.

Recognize and address the inequities in access to care during this pandemic. Telemedicine and virtual visits may not be accessible to patients who do not have reliable phones, computers or internet access. Unstable or crowded living situations, and lack of childcare may also make these encounters challenging. Patients who may feel less comfortable in the

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