Background/Purpose: The contribution of uneven health care quality to racial/ethnic and socioeconomic disparities in lupus nephritis outcomes is unknown.  We aimed to assess performance on two health care quality measures in a nationwide cohort of Medicaid recipients with incident lupus nephritis.

Methods: We used Medicaid analytic extract (MAX) data from 2000-2004 containing person-level files on Medicaid eligibility, utilization and payments.  We identified patients meeting a validated administrative data definition of incident lupus nephritis, and used this group as the denominator population for both quality metrics (QMs).  Numerator components included:

QM1 :  Induction therapy with glucocorticoids and another immunosuppressant (azathioprine, mycophenolate mofetil, mycophenolic acid, cyclophosphamide, cyclosporine A, or tacrolimus)

within 30 days of lupus nephritis onset.

QM2 : Use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARB)

within 90 days of lupus nephritis onset. 

We used multivariate logistic regression models to examine sociodemographic (age, sex, race/ethnicity), geographic (U.S. region), and health care (health professional shortage areas, HPSAs, from the Area Resource File) predictors of higher performance. In additional analyses, we extended the time period for both QMs to 365 days to assess whether performance improved with time. 

Results: 974 Medicaid recipients met the definition of incident lupus nephritis.   Mean age was 39 years (SD 12, range 18-64), 93% were female, and most were African American (African American 48%, White 27%, Hispanic 13%, Asian 6%).  Individuals were geographically dispersed (20% Midwest, 22% Northeast, 34% South, 24% West), and 41% resided in partial or complete HPSAs. Only 19.5% received care consistent with all numerator components of QM1; 25% of individuals received only steroids, and 13% received immunosuppressants alone. When the timeframe for QM1 was extended to one year, performance rose to 30%.  For QM2, 30% of individuals received an ACE/ARB within 90 days. When this timeframe was extended to one year, performance rose to 58%.  In multivariate logistic regression models, those living in the South were less likely to receive recommended therapy for lupus nephritis (QM1; OR 0.53, CI 0.28-0.99), while younger individuals were more likely to receive treatment (OR for 18-34 years versus referent 51-64 years 3.5, CI 1.6-7.6).  Individuals in the Midwest were less likely to receive an ACE/ARB (QM2; OR 0.52, CI 0.34-0.80), while African Americans were more likely (OR 1.7, CI 1.2-2.4).

Conclusion: These data suggest substantial gaps and delays in care for U.S. Medicaid patients with incident lupus nephritis.  A large number received steroid monotherapy or no immunosuppressant within one month, although performance improved by one year.  Use of ACE/ARBs was low in the first 90 days, but rose to 58% by one year.  Geographic differences were observed, with individuals in the South and Midwest being less likely to receive recommended care.  The contribution of state Medicaid policies, specialty care access, and drug coverage policies to these observed geographic differences warrants investigation.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/assessment-of-quality-of-care-for-incident-lupus-nephritis-in-the-u-s-medicaid-population/