Background/Purpose: Unequal healthcare access and utilization may contribute to the striking sociodemographic disparities seen in outcomes for children with lupus nephritis. Medicaid is the U.S. federal-state program providing health insurance to low-income children and parents. We investigated variation in US nationwide frequencies of emergency department (ED), outpatient and inpatient visits among children with lupus nephritis enrolled in Medicaid, 2000-2004, in the months preceding the development of end-stage renal disease (ESRD).

Methods: We identified all children aged 3 to <18 years with SLE (≥3 ICD-9 codes of 710.0, each >30 days apart) in the Medicaid Analytic eXtract (MAX) from 2000-2004. This dataset contains all outpatient and inpatient Medicaid claims for enrollees in 47 U. S. states and the District of Columbia. These data were linked to those from the U.S. Renal Data System, which includes information on essentially all ESRD patients in the U.S., for the same years. We compared utilization of ED, outpatient and inpatient visits per year in the Medicaid enrolled time prior to development of ESRD for those in different categories according to: region of residence in the US, residence in a US designated Health Professional Shortage Area (HPSA), and quartiles of rheumatologist number in state of residence. Multivariable generalized linear models were adjusted for each of these variables along with enrollee age, race, sex, months of Medicaid enrollment and a validated measure of socioeconomic status combining seven US Census zip code level variables.

Results: Of the 254 pediatric lupus nephritis patients identified, the mean age was 14.2 (± 2.4) years; 72% were female, 61% were African American and 19% were Hispanic. Mean duration of Medicaid enrollment prior to the onset of ESRD was 28.5 (±16.4) months. Among all patients there was an average of 2.0 (± 2.4) ED visits per year, 10.8 (± 9.4) outpatient visits and 2.4 (± 2.6) inpatient visits. In multivariable adjusted models, children residing in areas with the lowest quartile of rheumatologists per state had on average 4.2 more ED visits per year (p=0.001) compared with those in the highest quartile of rheumatologists per state. Children residing in the West had on average 5.4 more outpatient visits per year (p= 0.03), and those in the South had 1.2 fewer inpatient visit per year (p= 0.03) than those in the Northeast. We did not observe statistically significant variation in utilization by HPSA.

Conclusion: We observed significant differences in health care utilization among children enrolled in Medicaid with lupus nephritis prior to the onset of ESRD. Low number of rheumatologists per state was the most important factor associated with more annual ED visits. This finding in addition to regional variation in annual inpatient and outpatient visits within this medically complex and low-income Medicaid population deserves further investigation.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/variation-in-healthcare-utilization-by-region-and-number-of-rheumatologists-per-state-among-pediatric-medicaid-patients-with-lupus-nephritis-prior-to-end-stage-renal-disease-in-the-united-states-2000/