Background/Purpose: In prior studies we established that living in  communities of concentrated poverty was associated with fewer physician visits and select SLE outcomes after taking characteristics of the individual into account (Trupin, JRheumatol 2008; Tonner, Arthritis Care Res 2010) and the presence and type of insurance was associated with the quality of SLE care (Yazdany, J Gen Intern Med 2012).  Here we examine whether community characteristics affect performance on quality measures for SLE after taking individual characteristics into account.

Methods: Data derive from 3 annual waves (2009-2011) of the UCSF Lupus Outcomes Study, a prospective cohort study of persons with SLE interviewed annually by telephone. Data on 13 SLE quality indicators covering diagnosis, monitoring, treatment, and preventive services were collected.  Participant addresses were matched to information on characteristics of local communities, defined at various levels of aggregation.  Community data include the American Community Survey for neighborhood poverty level, Dartmouth Health Care Atlas for nature of health care markets, and Rural Urban Codes to categorize health care markets as rural, small city, or major city. We used general estimating equations to assess the impact of characteristics of communities and individuals on the overall “pass rate” for quality measures in SLE (number received given eligibility) and on 2 important individual quality measures, drug toxicity monitoring (RXTOX) and cardiovascular risk factor evaluation (CVD). All models controlled for age, gender, race/ethnicity, disease duration, disease activity, education, # physician visits for SLE, and presence and type of insurance. Net of 28 subjects without physician visits during the year, data on 869 were analyzed.

Results: Among the 869 participants, 93% were female, 37% non-white, mean age was 50(±13), disease duration was 17(±9), and they were eligible for 5.1 quality measures/year. Overall pass rates averaged 67% (95% CI 66-68%) over the 3 years and did not differ significantly among years. Pass rates were slightly but significantly lower in areas with the highest quartile of rheumatologists/capita (64 vs. 67- 68% in the other quartiles). Pass rates were higher in small cities than in rural or major cities (70 vs. 65-66%) and differed among the 9 major Census regions (range 59 to 71%). Size of health referral region, number of primary care physicians per capita, and concentration of poverty were not associated with overall pass rates. Over the 3 years, 31% (95%CI 29-33%), of those eligible received RXTX and 70% (95% CI 67-73%) received CVD. Health referral areas in small cities were associated with higher rates of RXTX than in major cities (78 vs. 67%). No other community characteristic was associated with RXTX and none were associated with CVD. In all models, lack of health insurance was associated with lower pass rates, while public managed care plans were associated with better quality of care among the insured.

Conclusion: Lack of consistent community effects on quality of care suggests that quality improvement efforts in SLE not be targeted geographically and that the focus should continue to be on increased access to good health insurance coverage.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/effect-of-community-characteristics-on-quality-of-care-in-systemic-lupus-erythematosus/