Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2019 Jul;71(7):903-913.
doi: 10.1002/acr.23721.

Area-Level Predictors of Medication Nonadherence Among US Medicaid Beneficiaries With Lupus: A Multilevel Study

Candace H Feldman  1 , Karen H Costenbader  1 , Daniel H Solomon  1 , S V Subramanian  2 , Ichiro Kawachi  2
Affiliations

Area-Level Predictors of Medication Nonadherence Among US Medicaid Beneficiaries With Lupus: A Multilevel Study

Candace H Feldman et al. Arthritis Care Res (Hoboken). 2019 Jul.

Abstract

Objective: Adherence to hydroxychloroquine (HCQ) treatment in patients with systemic lupus erythematous (SLE) is suboptimal. Although individual-level factors, including younger age and non-white race/ethnicity, have been implicated, contextual factors have not been explored. The aim of this study was to investigate the effect of contextual factors, including racial composition, socioeconomic status, and the concentration of health care resources, on adherence to HCQ among SLE patients enrolled in Medicaid.

Methods: We identified SLE patients from 28 states in the US who enrolled in Medicaid (2000-2010) and in whom HCQ treatment was newly initiated (no use for ≥6 months). We required 12 months of continuous enrollment with complete drug dispensing data and measured adherence using the proportion of days covered (PDC). We identified individual-level variables from Medicaid, zip code-level, county-level and state-level sociodemographic variables from the American Community Survey, and health resources from Area Health Resources Files. We used 4-level hierarchical multivariable logistic regression models to examine the odds ratios (ORs) and 95% credible intervals (95% CrIs) of adherence (PDC ≥80%) versus nonadherence.

Results: Among 10,268 patients with SLE in whom HCQ treatment was initiated, 15% were adherent to treatment. After we adjusted for individual-level characteristics, we observed lower odds of adherence among patients living in zip code areas with a higher percentage of black individuals (highest tertile OR 0.81 [95% CrI 0.69-0.96] versus lowest tertile). This association persisted after controlling for area-level educational attainment, percent below federal poverty level (FPL), urbanicity, and health care resources. We did not observe statistically significant associations with zip code-level percent Hispanic, percent white, education, or percent below FPL. The odds of adherence were higher in counties with more hospitals (OR 1.30 [95% CrI 1.07-1.58]).

Conclusion: Among Medicaid beneficiaries with SLE, we observed significant effects of racial composition and hospital concentration on HCQ adherence. Interventions that acknowledge and address contextual factors should be considered in order to reduce high rates of nonadherence in vulnerable populations.

PubMed Disclaimer

Figures

Figure 1.
Figure 1.
Social ecological model adapted to demonstrate potential multilevel contributors to adherence behavior among patients with SLE
See this image and copyright information in PMC

References

    1. Feldman CH, Hiraki LT, Liu J, Fischer MA, Solomon DH, Alarcon GS, et al. Epidemiology and sociodemographics of systemic lupus erythematosus and lupus nephritis among US adults with Medicaid coverage, 2000–2004. Arthritis Rheum. 2013;65(3):753–63. - PMC - PubMed
    1. Lim SS, Bayakly AR, Helmick CG, Gordon C, Easley KA, Drenkard C. The incidence and prevalence of systemic lupus erythematosus, 2002–2004: The Georgia Lupus Registry. Arthritis Rheumatol. 2014;66(2):357–68. - PMC - PubMed
    1. Petri M, Perez-Gutthann S, Longenecker JC, Hochberg M. Morbidity of systemic lupus erythematosus: role of race and socioeconomic status. Am J Med. 1991;91(4):345–53. - PubMed
    1. Gomez-Puerta JA, Barbhaiya M, Guan H, Feldman CH, Alarcon GS, Costenbader KH. Racial/Ethnic variation in all-cause mortality among United States medicaid recipients with systemic lupus erythematosus: a Hispanic and asian paradox. Arthritis Rheumatol. 2015;67(3):752–60. - PMC - PubMed
    1. Feldman CH, Yazdany J, Guan H, Solomon DH, Costenbader KH. Medication Nonadherence Is Associated With Increased Subsequent Acute Care Utilization Among Medicaid Beneficiaries With Systemic Lupus Erythematosus. Arthritis Care Res (Hoboken). 2015;67(12):1712–21. - PMC - PubMed

Publication types

MeSH terms

LinkOut - more resources