Background/Purpose: U.S. Medicaid provides medical benefits to low-income people. Although the Federal government establishes guidelines, each state sets vision benefits. The American Academy of Ophthalmology recommends a baseline retinal examination at hydroxychloroquine (HCQ) initiation and periodically thereafter, but there is lack of real-world practice information. We investigated the proportion of SLE Medicaid patients newly-initiating HCQ who receive indicated retinal exams and identified factors associated with receiving this care.

Methods: We conducted a retrospective cohort study of SLE patients 18-65 years old in Medicaid Analytic eXtract (MAX) from the 29 most populated U.S. states, 2000-2010.  SLE patients were identified by ≥ 3 codes for ICD-9 710.0, each ≥ 30 days apart, in hospital discharge diagnoses and physician visit claims. HCQ new-users were identified by a new HCQ prescription fill (index date) after 1^st SLE code, with no HCQ use in the prior 12 months. We restricted to those with ≥12 months of continuous enrollment before and after index date to assess both ophthalmologic and retinal exams, identified by CPT and HCPCS codes. Comorbidities and healthcare utilization were collected from the 12 months before index date. Examination rates were calculated across calendar years and by comorbidity and healthcare utilization subgroups. Differences between patients with and without exams were detected by the difference in means or proportions of a variable divided by a pooled estimate of the standard deviation of the variable.

Results: We identified 12,755 SLE patients newly starting HCQ. Proportions of patients undergoing exams 1 year before or after initial HCQ prescription ranged from 35.8 to 42.8% for ophthalmologic exams and 4.7 to 7.7% for retinal exams during year 2001-2009. Patients who received ophthalmologic exams, compared to those who had not, were older (40.8 ± 12.1 vs. 37.5 ± 11.5 years), more were White/Hispanic/Asian vs. Black. They also had more comorbid conditions and had received more SLE-related lab tests (ANA, anti-dsDNA, C3, C4) in the pre-index period. The proportions of lupus nephritis patients (35.2%) and pregnant patients (32.6%) who had any ophthalmologic exam were among the lowest. Overall, a high proportion of SLE patients newly starting HCQ did not have any Medicaid claims for retinal exams (92.7%) or even for any ophthalmologic exam (55.2%) in the 1 year before and 1 year after HCQ initiation. (Table)  

Conclusion: The proportions of U.S. Medicaid SLE patients starting HCQ who received ophthalmologic and retinal exams were extremely low overall, possibly due to state-dependent vision coverage. SLE patients may not be getting these indicated exams or they may be paying out-of-pocket or through supplemental vision insurance. Future studies will examine state-to-state variation in retinal exam rates and Medicaid vision coverage.