Income disparities in healthcare use remain after controlling for healthcare need: evidence from Swedish register data on psoriasis and psoriatic arthritis

Area-Level Socioeconomic Status Impacts Health Care Visit Frequency by Australian Patients With Inflammatory Arthritis: Results From the Australian Rheumatology Association Database

OBJECTIVE

Individuals with inflammatory arthritis require long-term rheumatologist care for optimal outcomes. We sought to determine if socioeconomic status (SES) influences general practitioner (GP) and specialist physician visit frequency and out-of-pocket (OOP) visit costs.

METHODS

We linked data from Australian Rheumatology Association Database (ARAD) participants with rheumatoid arthritis or psoriatic arthritis to the Pharmaceutical Benefits (PBS) and Medicare Benefits Schedule from 2011 to 2018. Small-area SES was approximated as quintiles of the Index of Relative Socioeconomic Advantage and Disadvantage. A comorbidity index (Rx-Risk) was determined from PBS data. Analysis was performed using panel regression methods.

RESULTS

We included 1,916 ARAD participants (76.3% rheumatoid arthritis, 71.1% women, mean ± SD age 54 ± 12 years and disease duration 6 ± 4 years). Participants averaged 9.0 (95% confidence interval [CI] 8.6-9.4) annual GP visits and 3.9 (95% CI 3.8-4.1) annual specialist physician visits. After adjustment for sex, age, education, remoteness, and comorbidity, there was an inverse relationship between annual GP visit frequency and higher SES quintile (-0.6, 95% CI -0.9 to -0.3 visits per quintile) and a direct relationship between more frequent specialist visits and higher SES (linear slope 0.3, 95% CI 0.2-0.5 visits per quintile). Average OOP costs/visit were higher for specialist physician (AUD$38.43; 95% CI 37.34-39.53) versus GP visits (AUD$7.86; 95% CI 7.42-8.31), and higher SES was associated with greater OOP cost.

CONCLUSION

Patients with higher SES have relatively fewer GP visits and more specialist physician visits compared with patients with lower SES, suggesting individuals with lower SES may receive suboptimal specialist physician care. OOP costs may be a contributing factor.

Tree-Based Machine Learning to Identify Predictors of Psoriasis Incidence at the Neighborhood Level: A Populational Study from Quebec, Canada

BACKGROUND

Psoriasis is a major global health burden affecting ~ 60 million people worldwide. Existing studies on psoriasis focused on individual-level health behaviors (e.g. diet, alcohol consumption, smoking, exercise) and characteristics as drivers of psoriasis risk. However, it is increasingly recognized that health behavior arises in the context of larger social, cultural, economic and environmental determinants of health. We aimed to identify the top risk factors that significantly impact the incidence of psoriasis at the neighborhood level using populational data from the province of Quebec (Canada) and advanced tree-based machine learning (ML) techniques.

METHODS

Adult psoriasis patients were identified using International Classification of Disease (ICD)-9/10 codes from Quebec (Canada) populational databases for years 1997-2015. Data on environmental and socioeconomic factors 1 year prior to psoriasis onset were obtained from the Canadian Urban Environment Health Consortium (CANUE) and Statistics Canada (StatCan) and were input as predictors into the gradient boosting ML. Model performance was evaluated using the area under the curve (AUC). Parsimonious models and partial dependence plots were determined to assess directionality of the relationship.

RESULTS

The incidence of psoriasis varied geographically from 1.6 to 325.6/100,000 person-years in Quebec. The parsimonious model (top 9 predictors) had an AUC of 0.77 to predict high psoriasis incidence. Amongst top predictors, ultraviolet (UV) radiation, maximum daily temperature, proportion of females, soil moisture, urbanization, and distance to expressways had a negative association with psoriasis incidence. Nighttime light brightness had a positive association, whereas social and material deprivation indices suggested a higher psoriasis incidence in the middle socioeconomic class neighborhoods.

CONCLUSION

This is the first study to highlight highly variable psoriasis incidence rates on a jurisdictional level and suggests that living environment, notably climate, vegetation, urbanization and neighborhood socioeconomic characteristics may have an association with psoriasis incidence.

The relationship between patients' income and education and their access to pharmacological chronic pain management: A scoping review

Background

Though chronic pain is widespread, affecting about one-fifth of the world's population, its impacts are disproportionately felt across the population according to socioeconomic determinants such as education and income. These factors also influence patients' access to treatment, including pharmacological pain management.

Aim

A scoping review was undertaken to better understand the association of socioeconomic factors with physicians' pain management prescribing patterns for adults living with chronic pain.

Methods

An electronic literature search was conducted using the EMBASE, CINAHL, SCOPUS, and Ovid MEDLINE databases and 31 retrieved articles deemed relevant for analyses were critically appraised.

Results

The available evidence indicates that patients' lower socioeconomic status is associated with a greater likelihood of being prescribed opioids to manage their chronic pain and a decreased likelihood of receiving prescription medications to manage migraines, rheumatoid arthritis, and osteoarthritis.

Conclusions

These results suggest that individuals with lower socioeconomic status do not receive equal prescription medicine opportunities to manage their chronic pain conditions. This is influenced by a variety of intersecting variables, including access to care, the potential unaffordability of certain therapies, patients' health literacy, and prescribing biases. Future research is needed to identify interventions to improve equity of access to therapies for patients with chronic pain living in lower socioeconomic situations as well as to explain the mechanism through which socioeconomic status affects chronic pain treatment choices by health care providers.

Abbreviation

SES: socioeconomic status; RA: rheumatoid arthritis; IV: intravenous; SC: subcutaneous; bDMARDs: biological disease-modifying antirheumatic drugs; DMARDS; disease-modifying antirheumatic drugs; TNFi: tumour necrosis factor inhibitors; NSAIDs: non-steroidal anti-inflammatory drugs.

Societal impact for patients with psoriasis: A nationwide Swedish register study

Background

Psoriasis is an immune-mediated chronic inflammatory disease having a significant negative health impact. Psoriasis has societal impact; loss of productivity has been estimated at approximately 10% and it may influence the patient's financial status. Relationships between quality of life, disease severity, and cost of care need exploration. Understanding the disease burden is important for health policy and research allocation. Few studies address the research gaps in socioeconomics, comorbidity, and medication use.

Objective

Observing differences in education, income, employment status, marital status, health care consumption, and drug utilization between patients with psoriasis and matched controls.

Methods

Cohort study following socioeconomics and health care consumption for all psoriasis patients from the Swedish patient register. All individuals with a first diagnosis of psoriasis in outpatient or inpatient care from 2002 to 2013 were followed until death, emigration, or end of the study.

Results

Overall, 109,803 patients were included (mean age 51.2 years, 53% women) and matched with 1.08 million controls. The levels of education and income were similar, but the proportion employed was significantly lower for patients with psoriasis. There was a tendency for fewer patients with psoriasis to be married.

Limitations

Generalizability, lack of primary care diagnoses, and lack of early treatments (available from 2005).

Conclusion

Understanding of the socioeconomic impact of psoriasis is extended by showing reductions in employment.

Does socioeconomic status affect hospital utilization and health outcomes of chronic disease patients?

This study quantifies the extent socioeconomic status (SES) affects hospital utilization and adverse hospital events of chronic disease patients. After identifying the initial first-year spell of the disease, we examine six outcomes that include measures of utilization and incidence of adverse in-hospital events. Three years of hospital administrative data from the state of Victoria, Australia, are used to extract a sample of 237,743 patients with chronic disease spells. SES is measured using the utilization records of specific health and human services. The study finds that, compared to patients with no disadvantage, SES disadvantaged patients tend to incur higher hospital costs and longer utilization by about 20% and greater incidence of in-hospital adverse outcomes by up to 80% than non-disadvantaged patients. Further analysis shows that hospital adverse outcomes indirectly contribute to about a quarter of the observed difference in hospital costs between SES disadvantaged and non-disadvantaged patients.

Depression in Psoriatic Arthritis: Dimensional Aspects and Link with Systemic Inflammation

Studying comorbidities in patients with psoriatic arthritis (PsA) provides a better understanding of the extended burden of the disease. Depression and anxiety are well recognized but understudied comorbidities in patients with PsA. The prevalence of depression is significantly higher in this patient population than in the general population, with far reaching consequences in terms of long-term quality of life. Over the past few years there has been an increasing interest in the link between inflammation and depression, with several novel studies being conducted. Recent evidence suggests a significant improvement of depression in PsA patients treated with biologic disease-modifying anti-rheumatic drugs (bDMARDs) as compared to conventional DMARDs. Depression in PsA is multidimensional, with recognized phenotypes, including cognitive disorder, alexithymia and anhedonia. The paucity of standardized, validated tools to screen these dimensional phenotypes remains an unmet need. Prevalence studies on depression in patients with PsA, mostly based on patient-reported outcomes, are only able to highlight the tip of the iceberg. A comprehensive, multi-disciplinary approach addressing the subdomains of depression is imperative for a better understanding of depression in PsA patients, as well as to find a way forward for improving their quality of life. In this scoping review, we explore existing evidence on the burden of depression in PsA patients, the link between inflammation and depression in these patients and the screening tools used to evaluate the subdomains of depression.

The value of the Skåne Health-care Register: Prospectively collected individual-level data for population-based studies

Aims: This study aimed to examine the population-based Skåne Health-care Register (SHR) regarding feasibility for scientific research and also strengths and weaknesses. Methods: To analyse the feasibility of the SHR, we performed a bibliographic search for peer-reviewed articles based on SHR data from 2000 to 2018. To analyse strengths and weaknesses, we used original SHR data about coverage and validity. Results: We identified 58 articles based on SHR data, covering different study designs and disorders. Most studies focused on musculoskeletal disorders with a cohort design. The majority of all consultations recorded in the SHR have an assigned diagnosis. However, this differs between the levels of care and between types of consultation. For inpatient care, the proportion of consultations with an assigned diagnosis was close to 100% between 1998 and 2017. The proportion of consultations with an assigned diagnosis was lowest within primary care, although the proportion markedly increased in 2004 when the prerequisite for consultation reimbursement was linked to the requirement for an assigned diagnosis. Limitations are that the SHR does not cover health-care provided within nursing homes and equivalent facilities or treatments received by the population of Skåne outside the region. Conclusions: The SHR may be used as a reliable data source for analyses of clinical changes and improvements. Extended use of the SHR in a research context may highlight important shortcomings within the register and thus serve as a way of indirect quality control. To enhance the use of the SHR further, better harmonisation between registers, within and outside of the region and internationally, is of crucial importance.

Systematic review of mental health comorbidities in psoriatic arthritis

OBJECTIVE

In this systematic review and meta-analysis of psoriatic arthritis (PsA) studies, we pooled data from existing literature to (1) estimate the prevalence of mental health disorders in PsA patients and (2) compare disease activity in PsA patients with and without these comorbidities.

METHOD

We searched PubMED, Web of Science, Scopus, PsycINFO and the Cochrane Library using a predefined protocol in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Where possible, meta-analysis was performed using random effects model. Prevalence estimates were pooled according to the severity of mental health disorders.

RESULTS

A total of 24 studies, amounting to 31,227 PsA patients, were included for review. Anxiety and depression were the only consistently reported mental health disorders, defined using a range of screening criteria/thresholds. Anxiety prevalence ranged from 4 to 61% with a pooled estimate of 33% (95%CI 17 to 53%) having at least mild anxiety and 21% (95%CI 14 to 29%) at least moderate. Depression prevalence ranged from 5 to 51%, with 20% (95%CI 8 to 35%) having at least mild and 14% (95%CI 8 to 21%) at least moderate. Only two studies compared disease activity according to the presence of mental health comorbidities; both reported higher disease activity and pain among those with comorbid anxiety and depression.

CONCLUSIONS

Anxiety and depression are highly prevalent among PsA patients. Studies of other mental health disorders were scarce. More studies are needed on the impact of these comorbidities on disease activity and long-term outcomes.Key Points• One in three patients with psoriatic arthritis has at least mild anxiety, while 1 in 5 reported at least mild depression.• PsA patients with anxiety and/or depression reported greater disease activity.• More research is needed on other mental health comorbidities, particularly sleep, suicide/self-harm and substance misuse.

Cost and Cost Effectiveness of Treatments for Psoriatic Arthritis: A Systematic Literature Review

BACKGROUND

Psoriatic arthritis is a long-term inflammatory arthropathy occurring in a subgroup of patients with psoriasis. In addition to irreversible bone erosions, joint destruction, and skin manifestations, psoriatic arthritis is associated with numerous comorbid conditions. Over the last 5 years, new treatments emerged; the analysis and comparisons of their additional costs and the added benefits have become increasingly important to optimize the limited resources available.

METHODS

A systematic literature review covering PubMed, EMBASE, and the Cochrane Library was performed from May 2012 to October 2017 focusing on the most recent evidence of costs, benefits, and burden of psoriatic arthritis and its treatments. All economic evaluations assessing the burden of patients with psoriatic arthritis and written in English were eligible for inclusion. We also performed an assessment of the quality of the studies.

RESULTS

Of the 1652 references found in the literature search, nine cost-effectiveness analyses and 12 cost-of-illness studies were included in the current review. Patients with psoriatic arthritis incur substantially higher direct and indirect costs, as compared with patients with psoriasis without arthritis or patients with other inflammatory diseases. The cost of treatment with biologic therapies is the major predictor of the total cost. However, individuals with psoriatic arthritis are also affected by substantial productivity losses and indirect costs. Biologic therapies are generally cost effective vs. conventional therapies (e.g., synthetic drugs) for treating psoriatic arthritis.

CONCLUSIONS

Psoriatic arthritis is associated with a significant economic burden and biologic therapies contribute significantly to these costs. Biologic therapies are more effective than disease-modifying anti-rheumatic drugs for the symptoms and signs of psoriatic arthritis and for improving quality of life and inhibiting structural radiological damage. Therefore, biologic therapies are cost effective compared with conventional therapies: the increased direct cost associated with biologic drugs is offset by the significant improvement in the efficacy of treatments and in patient management of psoriatic arthritis.