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Abstract Number: 2051

Modification of Effects of Household Income and Homeownership By Block Group Poverty on Health Outcomes in a Cohort of African Americans with Rheumatoid Arthritis

Rebecca J. Cleveland1, Jennifer Smith2, Antoine A. Baldassari1, Beth L. Jonas3, Doyt L. Conn4, Larry W. Moreland5, S. Louis Bridges Jr.6 and Leigh F. Callahan7, 1Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, 2Heritage College of Medicine, Ohio University, Athens, OH, 3Thurston Arthritis Research Ct, University of North Carolina at Chapel Hill, Chapel Hill, NC, 4Rheumatology, Emory Univ School of Medicine, Atlanta, GA, 5University of Pittsburgh, Pittsburgh, PA, 6University of Alabama at Birmingham, Birmingham, AL, 7Thurston Arthritis Res Ctr, University of North Carolina, Chapel Hill, NC

Meeting: 2014 ACR/ARHP Annual Meeting

Keywords: poverty, race/ethnicity, rheumatoid arthritis (RA) and socio-economic inequities

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Session Information

Title: Epidemiology and Public Health (ARHP)

Session Type: Abstract Submissions (ARHP)

Background/Purpose We previously found that household income less than $30k/yr and not owning a home influenced rheumatoid arthritis (RA) disease severity measures. We sought to further expand our findings to explore whether block group poverty (BGP) modified the associations between income and homeownership with RA health outcomes (RAHO).

Methods We carried out a cross-sectional analysis in 898 African American participants with RA in the CLEAR Registry. We assessed the main effects of BGP (≥20% vs. <20%) on RAHO, and explored whether BGP modified the associations between income or homeownership and RAHO. Multivariate regression models for continuous, binary and count outcomes were used to estimate beta coefficients (β), odds ratios (OR) and prevalence rate ratios (PRR), respectively, and their 95% confidence intervals (CI). Associations between income and homeownership on RAHO were stratified by BGP and interaction p-values calculated. All analyses were adjusted for gender, age, body mass index, disease duration, pack-years of smoking, number of comorbidities, current Methotrexate/Leflunomide use, current biologics use and study site.

Results The cohort had a mean age of nearly 55 years, was largely female, and had disease duration of nearly 8 years. In regression models comparing the effects of BGP ≥20% with BGP <20% on RAHO, we observed strong positive associations with DAS, JSN and joint erosions as well as with HAQ score (Table 1). Stratification of the effect of income on RAHO by BGP poverty revealed no statistically significant interaction. However, when stratifying the analyses of homeownership, we observed effect modification that narrowly missed statistical significance (Table 2). Notably, among those who lived in an area with BGP ≥20%, non-homeowners had a 69% higher Joint Alignment and Motion (JAM) score than homeowners (PRR=1.69; 95% CI=1.09-2.62), whereas there was no association with JAM score for homeownership among those living in an area with BGP <20% (interaction p-value=0.11). Other associations which narrowly missed statistically significant interactions were observed for joint space narrowing, joint erosion, and DAS (interaction p-values=0.13, 0.05, and 0.14, respectively).

Conclusion Our results suggest that block group poverty modifies the association between homeownership and joint damage measures. These findings suggest that further research is warranted to identify the underlying factors for these associations; for example monetary reasons precluding medication purchase or access to adequate medical care.

 

Table 1. Adjusted‡ estimates of cross-sectional associations of block group poverty≥20%£ with

 

disease severity of rheumatoid arthritis in the total cohort of CLEAR African Americans

 

Total Cohort (CLEAR I & II) (N=898)

Block group

poverty  ≥20%

Disease activity

DAS (0-10)* (β)

0.29 (0.08,0.50)¶

CRP levels (log mg/L) (0-386) (β)

0.08 (-0.14,0.31)

No. of Joint swelling (0-42)*

1.07 (0.90,1.28)

No. of Joint tenderness (0-42)

1.14 (0.99,1.33)

Joint damage

Erosion (0-180) (PRR)

1.39 (1.01,1.90)¥

JSN score (0-166) (PRR)

1.28 (1.04,1.58)¥

JAM score (0-126)* (PRR)

1.12 (0.89,1.42)

Autoantibody status

ACPA, % Positive (OR)

1.20 (0.88,1.63)

IgA-RF, % Positive (OR)

1.05 (0.77,1.44)

IgM-RF, % Positive (OR)

0.97 (0.69,1.38)

Self-report health status

Fatigue VAS (0-10) (β)

0.10 (-0.31,0.51)

Pain VAS (0-10) (β)

0.26 (-0.13,0.64)

HAQ Score (0-3) (β)

0.15 (0.05,0.24)¶

RAI Score (1-5) (β)

0.09 (-0.04,0.22)

HRQOL

Limited activity days (0-30) (PRR)

1.03 (0.89,1.19)

Mentally Unhealthy days (0-30) (PRR)

0.95 (0.82,1.09)

Physically Unhealthy days (0-30) (PRR)

0.96 (0.85,1.07)

‡Adjusted for study site, gender, age, body mass index, disease duration, pack-years of smoking, number of

comorbidities, current Methotrexate/Leflunomide use and current biologics

 

£Referent=Block group poverty <20%

 

*90 outlying values omitted from analysis

 

€Odds ratios (95% confidence intervals)

 

¥P-value <0.05, ¶P-value <0.01

 

 

DAS: disease activity score; CRP: C-reactive protein; JSN: Joint-Space Narrowing; JAM: Joint Alignment and Motion 

Score; ACPA: Anti-Citrullinated Peptide Antibodies; IgA-RF: Rheumatoid factor targeting Immunoglobulin A; IgM-RF:

Rheumatoid factor targeting Immunoglobulin M; VAS: Visual Analog Scale; HAQ: Health Assessment Questionnaire

(disability); RAI: Rheumatology Attitudes Index (helplessness); HRQOL: Health-Related Quality of Life.

 

 

 

 


Table 2.  Adjusted‡ estimates for the association of household income <$30k£ and not owning your home† with disease severity

measures in the CLEAR cohort, stratified by block group poverty

RA outcome

Household Income <$30k

 

Non-Homeowner

 

Poverty <20%

Poverty ≥20%

P€

Poverty <20%

Poverty ≥20%

P€

Disease activity

 

 

 

DAS (0-10)* (β)

0.31 (-0.02,0.64)

0.45 (0.04,0.85)¥

0.595

0.38 (0.07,0.70)¥

0.13 (-0.22,0.48)

0.141

CRP levels (log mg/L) (0-386) (β)

0.17 (-0.19,0.52)

0.03 (-0.40,0.46)

0.994

0.17 (-0.16,0.50)

0.13 (-0.24,0.50)

0.514

No. of Joint swelling (0-42)*

1.39 (1.06,1.82)¶

1.42 (1.03,1.98)¥

0.595

1.24 (0.96,1.61)

1.19 (0.87,1.61)

0.598

No. of Joint tenderness (0-42)

1.25 (0.99,1.57)

1.34 (1.02,1.76)¥

0.679

1.33 (1.07,1.66)¥

1.25 (0.98,1.59)

0.516

Joint damage

 

 

 

Erosion (0-180) (PRR)

1.20 (0.74,1.94)

1.16 (0.54,2.51)

0.799

0.97 (0.62,1.52)

1.29 (0.68,2.44)

0.019

JSN score (0-166) (PRR)

1.29 (0.97,1.71)

1.30 (0.73,2.33)

0.962

1.08 (0.83,1.41)

1.37 (0.91,2.08)

0.143

JAM score (0-126)* (PRR)

1.26 (0.91,1.76)

1.22 (0.73,2.04)

0.852

1.23 (0.88,1.72)

1.69 (1.09,2.62)¥

0.109

Autoantibody status

 

 

 

ACPA, % Positive (OR)

1.43 (0.90,2.28)

1.22 (0.68,2.21)

0.907

1.47 (0.95,2.28)

0.89 (0.54,1.49)

0.237

IgA-RF, % Positive (OR)

1.20 (0.74,1.95)

1.18 (0.66,2.10)

0.747

1.32 (0.83,2.08)

1.02 (0.61,1.69)

0.370

IgM-RF, % Positive (OR)

1.80 (1.06,3.06)¥

1.55 (0.83,2.90)

0.677

1.13 (0.68,1.87)

1.13 (0.65,1.95)

0.717

Self-report health status

 

 

 

Fatigue VAS (0-10) (β)

0.33 (-0.29,0.95)

0.89 (0.09,1.69)¥

0.139

0.73 (0.16,1.31)¥

0.53 (-0.14,1.21)

0.802

Pain VAS (0-10) (β)

1.25 (0.66,1.83)µ

1.46 (0.73,2.19)µ

0.355

1.24 (0.69,1.78)µ

0.83 (0.21,1.45)¶

0.457

HAQ Score (0-3) (β)

0.40 (0.26,0.54)µ

0.30 (0.12,0.47)¶

0.538

0.26 (0.12,0.40)µ

0.18 (0.02,0.33)¥

0.549

RAI Score (1-5) (β)

0.46 (0.26,0.67)µ

0.52 (0.28,0.75)µ

0.677

0.37 (0.17,0.56)µ

0.43 (0.23,0.63)µ

0.878

HRQOL

 

 

 

Limited activity days (0-30) (PRR)

1.27 (1.02,1.58)¥

1.23 (0.91,1.67)

0.935

1.16 (0.95,1.42)

1.20 (0.93,1.55)

0.508

Mentally Unhealthy days (0-30) (PRR)

1.20 (0.98,1.47)

1.44 (1.06,1.95)¥

0.285

1.25 (1.03,1.52)¥

1.08 (0.83,1.39)

0.329

Physically Unhealthy days (0-30) (PRR)

1.08 (0.91,1.29)

1.31 (1.04,1.65)¥

0.192

1.09 (0.92,1.28)

1.17 (0.96,1.42)

0.228

‡Adjusted for study site, gender, age, body mass index, disease duration, pack-years of smoking, number of comorbidities, current Methotrexate/Leflunomide

use and current biologics

 

£Referent=Annual household income ≥$30k; †Referent=Owning your home

 

€Interaction P-value

 

*90 outlying values omitted from analysis

 

¥P-value <0.05, ¶P-value <0.01, µP-value <0.001

 

DAS: disease activity score; CRP: C-reactive protein; JSN: Joint-Space Narrowing; JAM: Joint Alignment and Motion  Score; ACPA: Anti-Citrullinated Peptide

Antibodies; IgA-RF: Rheumatoid factor targeting Immunoglobulin A; IgM-RF: Rheumatoid factor targeting Immunoglobulin M; VAS: Visual Analog Scale; HAQ:

Health Assessment Questionnaire (disability); RAI: Rheumatology Attitudes Index (helplessness); HRQOL: Health-Related Quality of Life.

 

 


Disclosure:

R. J. Cleveland,
None;

J. Smith,
None;

A. A. Baldassari,
None;

B. L. Jonas,
None;

D. L. Conn,
None;

L. W. Moreland,
None;

S. L. Bridges Jr.,
None;

L. F. Callahan,
None.

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