COVID-19 data 'shed light' on racial, socioeconomic disparities in rheumatic disease care
In light of data suggesting that COVID-19 has disproportionately impacted already disadvantaged patient populations, rheumatologists must partner with health care providers, policymakers, community leaders and others to help close racial, ethnic and socioeconomic gaps, according to a recent editorial.
“Across our country, and around the world, it has become clear that vulnerable patients and communities are suffering disproportionately from COVID-19,” Candace H. Feldman, MD, ScD, of Brigham and Women’s Hospital and Harvard Medical School, told Healio Rheumatology. “We must recognize and address the root causes of this and act quickly to prevent the widening of health disparities going forward. It requires us, as health professionals, to also be advocates for social change.”
Rheumatologists ‘Acutely aware’ of Disparities
Feldman penned the editorial alongside Rosalind Ramsey-Goldman, MD, DrPH, of the Northwestern University Feinberg School of Medicine. Together, they wrote that rheumatologists are already “acutely aware” of increased prevalence, incidence, morbidity and mortality among racial and ethnic minorities, as well as those with lower incomes. These gaps are particularly pronounced in cases of systemic lupus erythematosus, where prolonged glucocorticoid use, paired with a lack of standard-of-care immunosuppressive use, is common, all while hydroxychloroquine is under prescribed and adherence is suboptimal, they wrote.
They further argued that structural racism, historical injustices, implicit biases among health providers and ongoing discrimination have all contributed to an under-enrollment of black patients in lupus trials, despite a two- to-threefold higher prevalence of SLE, and significantly poorer outcomes, among black individuals.
“For the past few years, Dr. Rosalind Ramsey-Goldman and I have partnered with patients, lupus organizations, community-based organizations and support groups, and community leaders in our respective cities of Chicago and Boston to better understand racial disparities in lupus care, outcomes and clinical trials enrollment,” Feldman said. “We have worked with these groups to disseminate education through the social networks of community leaders in order to promote awareness and early and sustained access to rheumatology care.”
Feldman added that their ongoing dialogue and shared experiences with these community partners taught them about the “strength and resilience” of patients living with lupus, as well as the power of social networks and communities to improve health.
“Our partners have also shed light on ongoing disparities in access to care and adverse outcomes for vulnerable populations, continued experiences of racial discrimination, and the profound impact of social determinants on mental and physical health,” she said. “Our partners have also learned to enhance their reach as community leaders through lupus-related education and continuous evaluation.”
Disparities in COVID-19 and Steps Forward
According to Feldman and Ramsey-Goldman, the COVID-19 pandemic has already begun to disproportionately affect black, Hispanic, American Indian, and lower socioeconomic-status populations throughout the United States. The authors also wrote that they expect these disparities to be even more pronounced among those with rheumatic diseases, exasperated by shortages of hydroxychloroquine. Moreover, as Medicaid limits patients to one month’s worth of medication, vulnerable patients are less likely to have adequate supplies.
Despite the efforts of some states — including Massachusetts’ Medicaid program waiving the one-month supply limit, and Illinois, Indiana, New Jersey and Ohio taking steps to ensure hydroxychloroquine access for rheumatology patients — insufficient supplies and delays in care still threaten to result in significantly poorer outcomes and worse disparities, they wrote.
To better understand the acute needs of rheumatology patients, to build trust among vulnerable communities, and to reduce the risk for widening disparities due to COVID-19, Feldman and Ramsey-Goldman proposed taking the following steps:
- Collect and release sociodemographic data both in the clinical and research setting.
- Engage in advanced care planning conversations with our patients.
- Ensure racial and ethnic diversity in clinical trial enrollment and understand confounding factors in observational studies.
- Support rheumatology-related disparities research.
- Recognize and address the inequities in access to care during the COVID-19 pandemic.
- Partner with rheumatic disease-specific organizations, as well as city, state, national and international organizations, to advocate for patients’ needs, including for regulations allowing 90-day supplies of essential medications, regardless of public or private insurance, in all states.
Feldman added that rheumatologists must also consider the impact of housing instability, food insecurity, poverty and neighborhood safety on health and the role of ongoing racial discrimination and residential segregation on the ability to access care.
“We must collect these data, along with traditional clinical indicators, and plan to address these factors both through research and through patient care,” she said. “For our patients with rheumatic diseases, we need to ensure that the changes to the way health care is provided during the pandemic do not further widen disparities.”
“We must advocate for our all of our patients, and particularly the most vulnerable, to have sustained access to essential medications and the highest quality of care,” Feldmand said. “This interdisciplinary approach will require partnerships across all sectors, public and private, to achieve health equity.” – by Jason Laday
Disclosures: Feldman reports membership on the American College of Rheumatology board of directors, as well as the Lupus Foundation of America’s medical-scientific advisory council. Ramsey-Goldman reports funding from the NIH, the Lupus Clinical Investigators Network and from Northwestern University as the Solovy Arthritis Research Society Research Professor of Medicine.