Identifying Social Determinants of Mortality in Systemic Lupus Erythematosus

Social determinants including local welfare spending and income inequality may contribute to mortality rates among patients with systemic lupus erythematosus (SLE), according to a letter published in Arthritis Care & Research¹ and supported by the National Longitudinal Mortality Study.²

Based on the findings of a study conducted by Yelin and colleagues,³ poverty is associated with higher mortality rates among patients with SLE because of increasing accumulation of damage from disease. The authors of the letter suggest several alternative mechanisms for the contribution of poverty to high mortality rates in this patient population.

Cardiovascular disease (CVD) is the leading cause of death among patients with SLE, and SLE itself is an independent risk factor for CVD.⁴ The risk for CVD-specific death is declining and is predicted to continue declining because of improved control of risk factors such as hypertension and diabetes.⁵

Based on recent guidelines from the American College of Cardiology/American Heart Association,⁶ health insurance is also a key enabling factor that encourages the management of CVD risk factors, which decreases the probability of life-threatening CV conditions developing. This implies that control of CVD risk factors in nonelderly patients with SLE who have adequate insurance coverage and who are not considered to be poor may be a robust, sustainable way to reduce overall mortality in this population.

According to the study by Yelin and colleagues,³ the uninsured rate among participants in the Lupus Outcomes Study decreased from 18.2% in 2010 to 10.3% in 2016, as more than 10 million individuals obtained insurance from Medicaid expansion in 33 states.⁷

The authors concluded that nonelderly adults with SLE who are near the federal poverty level have particular challenges in trying to meet their healthcare needs because of the effects of socioeconomic conditions and healthcare policies.

References

1. Khullar N, Ukken J, Froehlich M, et al. Social determinants of mortality in U.S. lupus patients [published online April 2, 2018].  Arthritis Care Res (Hoboken). doi: 10.1002/acr.23565.
2. Kim D. The associations between US state and local social spending, income inequality, and individual all-cause and cause-specific mortality: the National Longitudinal Mortality Study.  Prev Med. 2016;84:62-68.
3. Yelin E, Yazdany J, Trupin L. The relationship between poverty and mortality in systemic lupus erythematosus [published online October 3, 2017].  Arthritis Care Res (Hoboken). doi: 10.1002/acr.23428
4. Bernatsky S, Boivin JF, Joseph L, et al. Mortality in systemic lupus erythematosus.  Arthritis Rheum. 2006;54(8):2550-2557.
5. Weir HK, Anderson RN, Coleman King SM, et al. Heart disease and cancer deaths – trends and projections in the United States, 1969-2020.  Prev Chronic Dis. 2016;13:E157.
6. Goff DC Jr, Lloyd-Jones DM, Bennett G, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.  Circulation. 2014;129(25 suppl 2):S49-S73.
7. Kaiser Family Foundation. Status of State Action on the Medicaid Expansion Decision. https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act. Updated April 5, 2018. Accessed March 5, 2018.