United States Medicaid Beneficiaries Not Adequately Following Lupus Treatment Plans

Newswise — SAN DIEGO – Medicaid beneficiaries with lupus are not adequately following their treatment plans, and this puts them at risk for poor health outcomes, according to research presented this week at the American College of Rheumatology Annual Meeting in San Diego. For most lupus medications, fewer than one in three beneficiaries were found to be adherent.

Systemic lupus erythematosus, also called SLE or lupus, is a chronic inflammatory disease that can affect the skin, joints, kidneys, lungs, nervous system, and/or other organs of the body. The most common symptoms include skin rashes and arthritis, often accompanied by fatigue and fever. Lupus occursmostly in women, typically developing in individuals in their twenties and thirties – prime child-bearing age.

Immunosuppressive and anti-malarial drugs are the cornerstones of treatment for patients with lupus, and these treatments have been shown to improve patient outcomes by reducing disease activity, joint and organ damage, and death. Researchers from The University of California and Brigham and Women’s Hospital in Boston recently examined adherence to these medications in a nationwide study of Medicaid beneficiaries with lupus.

“This study is important because it is the first time we have national data about a very vulnerable group of patients, Medicaid beneficiaries with lupus, and our study paints a sobering picture of medication adherence in this group of patients” explains Jinoos Yazdany, MD, MPH; associate clinical director, Lupus Clinic, University of California, San Francisco Medical Center; and lead investigator in the study.

Dr. Yazdany’s team reviewed Medicaid records of lupus patients who had received either an immunosuppressive — e.g., oral cyclophosphamide (Cytoxan®) mycophenolate mofetil (CellCept®) or leflunomide (Arava®), methotrexate (Trexall®; Rheumatrex®), or tacrolimus (Prograf®) — or an anti- malarial — e.g., hydroxychloroquine (Plaquenil®) — drug through an outpatient pharmacy between the years of 2000 and 2006. The researchers used pharmacy claims to assess adherence to these treatments by noting the amount of medication dispensed over a six-month period following the initial prescription.

“We observed each patient over a fixed interval of 180 days to ensure all patients were studied for the same time period,” explains Dr. Yazdany, whose team also took sociodemographic characteristics and geographic region into consideration when looking at adherence. Additionally, Dr. Yazdany’s team made a point to examine the number of patients considered at least 80 percent adherent to their treatment plans.

"Adherence was very low for all drugs. We were surprised to find that less than one in three patients were adherent to most of the drugs we examined. What clinicians need to realize is that a majority of this vulnerable population is not taking their lupus medication as prescribed, putting them at risk for poor health outcomes,” says Dr. Yazdany.

The Medicaid records of 23,187 people with lupus who were taking at least one immunosuppressive or anti-malarial drug were included in the study. The average age of those reviewed was 38, and the majority (94 percent) were females; however, the racial and ethnic makeup of the group was diverse (40 percent African American, 34 percent Caucasian, 16 percent Hispanic, five percent Asian, five percent Other, and one percent Native American). And, most patients resided in the Southern United States.

Patients’ adherence ranged from 31.1 percent for the immunosuppressant tacrolimus to 56.9 percent for the anti-malrial hydroxychloroquine. Across all medications, researchers found African Americans had lower adherence when compared to Caucasians. For many medications, Asians had higher adherence than Caucasians. For example, for hydroxychloroquine, adherence was significantly higher among Asians, and lower in African Americans, Hispanics, and Native Americans when compared to Caucasians. The researchers note that these racial/ethnic differences require further investigation. A more complete analysis to better understand additional factors is planned.

Finally, Dr. Yazdany’s team found adherence to be the lowest for patients residing in the Midwest, and highest for those in the Northeast.

The smallest group of all: those who were considered adherent at least 80 percent of the time.

“This study tells us that working with lupus patients to improve adherence is central to improving health outcomes,” explains Dr. Yazdany “It is important for patients to understand the life-saving nature of these medications and to communicate with their doctors if they have concerns about their medications.”

The American College of Rheumatology is an international professional medical society that represents more than 9,000 rheumatologists and rheumatology health professionals around the world. Its mission is to advance rheumatology. The ACR/ARHP Annual Meeting is the premier meeting in rheumatology. For more information about the meeting, visit http://www.acrannualmeeting.org/ or join the conversation on Twitter by using the official hashtag: #ACR13.

Editor’s Notes: Editor’s Notes: Dr. Yazdany will present this research during the ACR Annual Meeting at the San Diego Convention Center from 9:00 – 11:00 AM in Exhibit Hall B2 C-D on Monday October 28. Dr. Yazdany will be available for media questions and briefing at 1:30 PM Tuesday, October 29 in the on-site press conference room, 27 AB.

Abstract Number: 1588

Poor Adherence To Medications For Systemic Lupus Erythematosus Among U.S. MedicaidBeneficiaries

Jinoos Yazdany, University of California, San Francisco, San Francisco, CA, Jun Liu, Brigham and Women’s Hospital, Boston, Massachusetts, Boston, CA, Graciela S. Alarcon, University of Alabama at Birmingham, Birmingham, AL, Karen H. Costenbader, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA and Candace H. Feldman, Brigham and Women's Hospital, Boston, MA

Background/Purpose: Immunosuppressive and anti-malarial drugs are the cornerstones of treatment for patients with systemic lupus erythematosus (SLE) and have been shown to improve outcomes, including reduced disease activity, damage and mortality. We examined adherence to treatment with these medications in a nationwide study of Medicaid beneficiaries with SLE.

Methods: We used U.S. Medicaid Analytic eXtract (MAX) data from 2000-2006 containing person-level files on Medicaid eligibility, utilization and payments. We identified patients meeting a validated administrative SLE definition, who had received either an immunosuppressive (oral cyclophosphamide, mycophenolate mofetil, mycophenolic acid, azathioprine, leflunomide, methotrexate, or tacrolimus) or anti-malarial (hydroxychloroquine) drug through an outpatient pharmacy over the period of observation. Pharmacy claims were used to assess adherence to drugs by calculating a medication possession ratio (MPR), defined as the proportion of days covered by the total days' supply dispensed after the first claim for each drug. We observed each patient over a fixed interval of 180 days to ensure all patients were studied for the same time interval. Data were stratified by sociodemographic characteristics and geographic region and we used Fisher's exact test to compare MPRs between groups. In addition, we examined the percentage of patients considered adherent, defined as having a MPR greater than or equal to 80%.

Results: 23,187 patients with SLE were taking at least one immunosuppressive or anti-malarial drug. Mean age was 38 years (SD 12) and 94% were female. The sample was diverse (40% Black, 34% White, 16% Hispanic, 5% Asian, 5% Other, and 1% Native). Most resided in the U.S. South (36% vs. 18% Midwest, 23% Northeast, 22% West). MPRs ranged from 31.1% for tacrolimus to 56.9% for hydroxychloroquine (Table). Across all medications, Blacks had lower adherence compared to Whites. For many medications, Asians had higher adherence than Whites. For example, for hydroxychloroquine, the MPR was significantly higher among Asians (63, SD 27), and lower in Blacks (53, SD 29), Hispanics(57, SD 28), and Native populations (56, SD 26) compared to Whites (59, SD 31; p<0.0001 for group comparisons). MPRs were lowest for patients residing in the Midwest, and highest for those in the Northeast (p<0.01 across drugs). A minority of patients had MPRs greater than or equal to 80% (range 14% for tacrolimus to 40% for mycophenolate mofetil; Table).

Conclusion: Our study demonstrates poor adherence to all classes of medications used to treat SLE among Medicaid beneficiaries. Although adherence was low across all racial/ethnic groups and regions examined, it was particularly low among Blacks, Hispanics and Native populations, as well as for those residing in the Midwest. These findings suggest that a majority of Medicaid beneficiaries may be at risk for inadequate clinical response because of poor adherence.

Disclosures: J. Yazdany, NoneJ. Liu, NoneG. S. Alarcon, NoneK. H. Costenbader, NoneC. H. Feldman, None