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Abstract Number: 0574

Is Hydroxychloroquine Use a Proxy for Health Care Access? Predictors of First Dispensing Among Medicaid Beneficiaries with Incident Lupus

Katherine Pryor1, Chang Xu1, Jamie Collins1, Karen Costenbader2 and Candace Feldman1, 1Brigham and Women's Hospital, Boston, 2Brigham and Women's Hospital and Harvard Medical School, Boston, MA

Meeting: ACR Convergence 2020

Keywords: Access to care, Disparities, Quality Indicators, Systemic lupus erythematosus (SLE), Women's health

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Session Information

Date: Saturday, November 7, 2020

Session Title: Health Services Research Poster

Session Type: Poster Session B

Session Time: 9:00AM-11:00AM

Background/Purpose: Hydroxychloroquine/chloroquine (HCQ/CQ) is considered to be the backbone of systemic lupus erythematosus (SLE) care. Differences in receipt of HCQ/CQ may exacerbate disparities in adverse events, as well as bias observational studies examining the association between HCQ/CQ use and outcomes. We investigated factors associated with first dispensing of HCQ/CQ among individuals with incident SLE. We hypothesized that individuals receiving HCQ/CQ may have better health care access, as measured by outpatient visits and preventive care (e.g., cancer screening and vaccinations), and fewer comorbidities.

Methods: Using Medicaid claims from 2000-2006 (47 states) and 2007-2010 (29 states), we identified individuals age 18-65 years with incident SLE (>3 SLE ICD-9 codes separated by >30 days within 24 months. We required 24 months of continuous enrollment without SLE codes and without HCQ/CQ use prior to the first SLE code (index date). The primary outcome was the first dispensing of HCQ/CQ on or within 24 months of the index date. We used Cox proportional hazards regression models to examine the association (HR, 95% CI) between baseline sociodemographic factors, comorbidities, health care utilization, preventive care and medication use and time to first HCQ/CQ dispensing in the first 24 months following SLE diagnosis. 

Results: We identified 9560 Medicaid beneficiaries with incident SLE; 41% received HCQ (N=3949) or CQ (N=14) within 24 months of diagnosis. The mean age was 35.7 (SD 11.7) years for HCQ/CQ users and 39.9 (SD 12.2) years for non-users. Seventy-two percent received any glucocorticoids within 24 months of diagnosis; of these, 51% also received HCQ/CQ. Cox models demonstrated that younger patients (age 18-25) were 2.3 times more likely to receive HCQ/CQ compared with 51-65 year-olds (Table 1). All racial/ethnic groups were more likely to receive HCQ/CQ than whites. Alcohol use disorder, opioid use, diabetes, end-stage renal disease and smoking were associated with a lower rate of dispensing. Receiving 1-2 preventive care services was associated with 29% higher rate of receipt; >2 with a 46% higher rate. Individuals with more outpatient visits were more likely to receive HCQ/CQ while those with more hospitalizations were less likely.

Conclusion: HCQ/CQ use is central to SLE treatment however only 41% of Medicaid beneficiaries with SLE received HCQ/CQ within 2 years of diagnosis. Preventive care and outpatient visits, markers of access to health care, were associated with higher rates of initial HCQ/CQ dispensing, whereas frequent hospitalizations, high-risk lifestyles and complex comorbidities were associated with lower rates. All non-white races had higher rates of first dispensing compared to whites suggesting that in this Medicaid population, initial HCQ/CQ dispensing differences likely do not explain racial/ethnic disparities in adverse outcomes. Overall these findings suggest that we must cautiously interpret potential physiologic effects of HCQ/CQ on outcomes in observational studies comparing users to non-users as they may be biased by differences in access to care and measured and unmeasured confounders.


Disclosure: K. Pryor, None; C. Xu, None; J. Collins, None; K. Costenbader, Glaxo Smith Kline, 5, UpToDate, 7, Lupus Foundation of America, 6, Neutrolis Inc, 5; C. Feldman, Merck, 5, Voyager Therapeutics, 5, Biogen, 8.

To cite this abstract in AMA style:

Pryor K, Xu C, Collins J, Costenbader K, Feldman C. Is Hydroxychloroquine Use a Proxy for Health Care Access? Predictors of First Dispensing Among Medicaid Beneficiaries with Incident Lupus [abstract]. Arthritis Rheumatol. 2020; 72 (suppl 10). https://acrabstracts.org/abstract/is-hydroxychloroquine-use-a-proxy-for-health-care-access-predictors-of-first-dispensing-among-medicaid-beneficiaries-with-incident-lupus/. Accessed June 29, 2022.
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