Racial Differences in Contraception Encounters and Dispensing Among Female Medicaid Beneficiaries With Systemic Lupus Erythematosus

Screening to understand pregnancy preferences and offer referrals and treatment (SUPPORT): Results of a pilot quality improvement initiative

OBJECTIVE

To assess the feasibility of integrating a pregnancy intention assessment screening algorithm into the electronic medical record (EMR) at a multispecialty clinic focused on the health of women and people assigned female at birth (AFAB).

STUDY DESIGN

This pilot quality improvement project implemented a series of clinician reminders, new data fields in the patient record, and templated clinical notes to prompt care providers across specialties to ask AFAB reproductive age individuals about their desire for future pregnancies. Investigators created a novel screening question based on prior literature and expert input. Prospective observational study of one year of during-intervention EMR data on screening uptake and documentation, contraceptive use, and referrals to obstetrics and gynecology (OBGYN) for preconception care, contraceptive care, and related services.

RESULTS

SUPPORT launched in February 2020 and was paused for 6 months due to the COVID-19 pandemic. During the intervention period through July 2021, 18% of patients for whom the automated screening reminder was activated had a documented pregnancy intention. Patients were screened in OBGYN, internal medicine, and eight subspecialty medical clinics. Among those screened, individuals who reported they did not desire pregnancy in the next year were more likely to use contraception (aOR 1.8, 95% CI 1.1, 3.1). Individuals that did desire pregnancy in the next year were more likely to be subsequently referred to OBGYN (aOR 2.7, 95% CI 1.2, 6.0).

CONCLUSIONS

Despite the competing demands of the COVID-19 pandemic, the SUPPORT intervention was utilized at higher rates than prior similar interventions and across multiple disease specialties.

IMPLICATIONS

Results from the SUPPORT pilot suggest that pregnancy intention screening of reproductive age AFAB individuals with an EMR-based screening prompt is feasible at scale.

Disparities in Lupus and the Role of Social Determinants of Health: Current State of Knowledge and Directions for Future Research

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease. The complex relationships between race and ethnicity and social determinants of health (SDOH) in influencing SLE and its course are increasingly appreciated. Multiple SDOH have been strongly associated with lupus incidence and outcomes and contribute to health disparities in lupus. Measures of socioeconomic status, including economic instability, poverty, unemployment, and food insecurity, as well as features of the neighborhood and built environment, including lack of safe and affordable housing, crime, stress, racial segregation, and discrimination, are associated with race and ethnicity in the US and are risk factors for poor outcomes in lupus. In this scientific statement, we aimed to summarize current evidence on the role of SDOH in relation to racial and ethnic disparities in SLE and SLE outcomes, primarily as experienced in the U.S. Lupus Foundation of America's Health Disparities Advisory Panel, comprising 10 health disparity experts, including academic researchers and patients, who met 12 times over the course of 18 months in assembling and reviewing the data for this study. Sources included articles published from 2011 to 2023 in PubMed, Centers for Disease Control and Prevention data, and bibliographies and recommendations. Search terms included lupus, race, ethnicity, and SDOH domains. Data were extracted and synthesized into this scientific statement. Poorer neighborhoods correlate with increased damage, reduced care, and stress-induced lupus flares. Large disparities in health care affordability, accessibility, and acceptability exist in the US, varying by region, insurance status, and racial and minority groups. Preliminary interventions targeted social support, depression, and shared-decision-making, but more research and intervention implementation and evaluation are needed. Disparities in lupus across racial and ethnic groups in the US are driven by SDOH, some of which are more easily remediable than others. A multidimensional and multidisciplinary approach involving various stakeholder groups is needed to address these complex challenges, address these diminish disparities, and improve outcomes.

Researchers in rheumatology should avoid categorization of continuous predictor variables

BACKGROUND

Rheumatology researchers often categorize continuous predictor variables. We aimed to show how this practice may alter results from observational studies in rheumatology.

METHODS

We conducted and compared the results of two analyses of the association between our predictor variable (percentage change in body mass index [BMI] from baseline to four years) and two outcome variable domains of structure and pain in knee and hip osteoarthritis. These two outcome variable domains covered 26 different outcomes for knee and hip combined. In the first analysis (categorical analysis), percentage change in BMI was categorized as ≥ 5% decrease in BMI, < 5% change in BMI, and ≥ 5% increase in BMI, while in the second analysis (continuous analysis), it was left as a continuous variable. In both analyses (categorical and continuous), we used generalized estimating equations with a logistic link function to investigate the association between the percentage change in BMI and the outcomes.

RESULTS

For eight of the 26 investigated outcomes (31%), the results from the categorical analyses were different from the results from the continuous analyses. These differences were of three types: 1) for six of these eight outcomes, while the continuous analyses revealed associations in both directions (i.e., a decrease in BMI had one effect, while an increase in BMI had the opposite effect), the categorical analyses showed associations only in one direction of BMI change, not both; 2) for another one of these eight outcomes, the categorical analyses suggested an association with change in BMI, while this association was not shown in the continuous analyses (this is potentially a false positive association); 3) for the last of the eight outcomes, the continuous analyses suggested an association of change in BMI, while this association was not shown in the categorical analyses (this is potentially a false negative association).

CONCLUSIONS

Categorization of continuous predictor variables alters the results of analyses and could lead to different conclusions; therefore, researchers in rheumatology should avoid it.

Racial differences in persistent glucocorticoid use patterns among medicaid beneficiaries with incident systemic lupus erythematosus

OBJECTIVE

Glucocorticoids ("steroids") are frequently used in systemic lupus erythematosus (SLE). Prolonged use may contribute to racial/ethnic disparities in avoidable adverse outcomes. We examined racial/ethnic differences in longitudinal patterns of steroid use and dose.

METHODS

We identified Medicaid beneficiaries 18-65 years with incident SLE who received steroids for 12 months following the index date. Group-based trajectory modeling was used to identify patterns of daily prednisone-equivalent steroid doses. We examined demographic, clinical and healthcare utilization factors during the baseline period and used multinomial logistic regression to estimate the odds of belonging to the higher vs. lowest steroid dose trajectories over time.

RESULTS

We identified 6314 individuals with SLE with ≥1 dispensed steroid prescription. The mean (SD) prednisone-equivalent dose was 7 (23) mg/day for Black, 7 (26) for Hispanic, 7 (13) for Asian, and 4 (10) for White individuals. Adjusted multinomial models demonstrated higher odds of belonging to the highest vs. lowest steroid trajectory for Black (OR 2.07, 95% CI 1.65-2.61), Hispanic (OR 1.81, 95% CI 1.38-2.39), and Asian (OR 2.42, 95% CI 1.53-3.83) vs. White individuals. Having >5 outpatient visits during the baseline period was associated with lower odds of being in the persistently high-dose steroid trajectory (OR 0.77; 95% CI 0.60-0.98).

CONCLUSION

Black, Hispanic, and Asian (vs. White) individuals had higher odds of persistently high-dose steroid use. Sustained access to outpatient care and the development of standardized steroid-tapering regimens from clinical trials with diverse populations may be targets for intervention to mitigate disparities in steroid-related adverse outcomes.

Reproductive concerns and contributing factors in women of childbearing age with systemic lupus erythematosus

OBJECTIVES

Reproductive concerns are common in women of childbearing age with systemic lupus erythematosus (SLE) with inadequate disclosure. This study aimed to investigate the contributing factors of reproductive concerns and to evaluate their impact on health-related quality of life.

METHODS

One hundred eighty women of childbearing age with SLE were enrolled in this cross-sectional study in Affiliated Hospital of Nantong University from March 2021 to December 2021. A series of questionnaires were conducted: Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), the Hospital Anxiety and Depression Scale (HADS), the Multidimensional Fatigue Inventory (MFI-20), Female Sexual Distress Scale-Revised (FSDS-R), Family Assessment Device (APGAR), the Medical Coping Modes Questionnaire (MCMQ), the Short-Form 36 (SF-36), and the Chinese version of Reproductive Concerns After Cancer (RCAC). Independent t test, one-way ANOVA, Mann-Whitney U test, Pearson/Spearman, and multiple linear stepwise regression were used to analyze the data.

RESULTS

The results indicated that female SLE patients were more concerned about the child's health and personal health than becoming pregnant, fertility potential, partner disclose and acceptance; SLE patients with the characteristics of living in rural residence, having no reproductive history, fearing unexpected pregnancy, sexual distress, and depression showed more serious fertility concerns. Meanwhile, most female SLE patients adopted active confrontation when facing reproductive concerns, and these patients were significantly lower in the dimension score of mental related quality of life.

CONCLUSIONS

Our study demonstrated that female SLE patients should be paid more attention to their fertility concerns and effective intervention measures should be carried out to relieve their reproductive concerns, so as to improve their long-term quality of life if their disease condition permits.

Effectiveness of reproductive health counseling of women with systemic lupus erythematosus: observational cross-sectional study at an academic lupus clinic

Systemic lupus erythematosus (SLE) affects women of childbearing age. To optimize fetal and maternal outcomes, effective reproductive health counseling is crucial. To analyze the effectiveness of reproductive health counseling in women with SLE and identify gaps in patient educational needs. Cross-sectional study including women aged 18-45 years fulfilling ACR'97 and/or SLICC criteria, followed at an academic lupus clinic. Participants fulfilled a questionnaire evaluating brief obstetric history, knowledge about impact of SLE in pregnancy outcomes, recall of reproductive health counseling, contraception use and reproductive healthcare received. Effectiveness of reproductive health counseling was analyzed, and potential predictors of contraceptive use (age, previous spontaneous abortion, level of knowledge about SLE and reproductive planning) were tested by multiple regression analysis. We enrolled 108 women (mean age: 34.4 ± 7.1 years; mean disease duration: 10.3 ± 7.3 years). 64.8% of the patients recalled receiving information about family planning, and 81% about contraception. Only 38% declared to be well informed about the impact of SLE on pregnancy. In this cohort, 23.2% wanted a pregnancy in the future; the remainder already had the children they wanted or planned a subsequent pregnancy. Contraceptive use was reported by 79.6% of the patients (oral contraceptives by 39.8% and intrauterine device by 20.4%), while 11.1% reported unprotected intercourses. No statistically significant predictors of contraceptive use were identified. In this academic Lupus Clinic, most SLE women of childbearing age received effective reproductive health counseling and use contraceptive methods. Their unmet needs were identified to guide optimization of patient counseling.