Widening Disparities Among Patients With Rheumatic Diseases in theCOVID-19 Era: An Urgent Call to Action
Widening Disparities Among Patients With Rheumatic Diseases in theCOVID-19 Era: An Urgent Call to Action
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DOI：
10.1002/art.41306
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发表时间：
2020-08-09
影响因子：
13.3
通讯作者：
Ramsey-Goldman, Rosalind
中科院分区：
文献类型：
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作者：
Feldman, Candace H.;Ramsey-Goldman, Rosalind
来自美国多个公共卫生部门的最新数据强调，2019年冠状病毒病（COVID-19）感染在弱势人群中造成了不成比例的负担，这是采取行动的紧急呼吁（1,2）。作为风湿病学家，我们敏锐地意识到较高的发病率和死亡率，对于我们治疗的一些疾病，少数民族和社会经济地位较低的个体（SES）的发病率和患病率较高（3-6）。合并症是常见的，及时获得亚专科护理是有限的，接受高质量的护理是不常见的，护理往往是碎片化的，频繁的，可避免的急性护理使用（7,8）。在系统性红斑狼疮（SLE）患者中，这些差异已被证明特别明显，长期使用糖皮质激素和延迟或缺乏标准治疗免疫抑制剂的使用是常见的，羟氯喹（HCQ）， SLE治疗的主干，以防止发作和器官损害，处方不足，依从性不佳(9)。此外，尽管SLE的患病率至少高出2 - 3倍，且预后明显较差，但与白人相比，非裔美国人参加临床试验的可能性要小得多（10,11）。结构性种族主义，研究中的历史不公正，医疗服务提供者的隐性偏见，以及导致患者不信任的持续歧视经历，都导致了这种登记不足（10,11）。因此，我们经常在最需要的人群中推荐尚未得到充分研究的治疗方法。种族歧视的经历也与风湿性疾病活动的增加和更大的器官损伤有关（12）。很大一部分患有系统性风湿病的个体在其病程的某个阶段接受免疫抑制治疗，这些药物与患者潜在的自身免疫性疾病相结合，增加了他们对严重感染的易感性。在SLE患者中，特别是那些受医疗补助计划（低收入美国人最大的公共健康保险公司）保险的患者，需要住院治疗的严重感染是常见的，非裔美国人比白人更有可能经历这些（13）。COVID-19大流行已经开始不成比例地影响非洲裔美国人、西班牙裔美国人、美洲印第安人以及社会经济地位较低的个体，我们预计，在风湿病患者中，这种差异将更加明显（1,2）。其中许多人在基线时表现更为严重，风湿病控制较差，由于拥挤或不稳定的生活环境和经济拮据，可能无法遵循保持社交距离的建议。此外，在无法持续获得高质量门诊服务的患者中，更频繁地使用糖皮质激素不仅会增加感染风险，还会导致心血管疾病和糖尿病，这是导致COVID-19预后较差的已知危险因素（9,13,14）。这些因素引起了我们最脆弱的患者在短期感染风险和短期和长期控制风湿病方面的重大关注。目前，HCQ正被推广为COVID-19的潜在治疗方法，这导致我们的风湿病患者的药物短缺。医疗补助计划将患者的药物供应限制在1个月以内。这意味着我们最脆弱的病人也是最不可能获得充足供应的病人。最近，马塞诸塞州的医疗补助组织MassHealth覆盖了
Recent data from multiple public health departments across the US emphasizing the disproportionate burden of coronavirus disease 2019 (COVID-19) infections in vulnerable populations serve as an urgent call to action (1, 2). As rheumatologists, we are acutely aware of the higher morbidity and mortality rates, and for a number of the diseases we treat, the higher incidence and prevalence among racial/ethnic minorities and individuals of lower socioeconomic status (SES)(3–6). Comorbidities are frequent, timely access to subspecialty care is limited, receipt of high-quality care is less common, and care is more often fragmented, with frequent, avoidable acute care use (7, 8). Among patients with systemic lupus erythematosus (SLE), where these disparities have been shown to be particularly pronounced, prolonged glucocorticoid use and delayed or lack of standard-of-care immunosuppressive use is common, and hydroxychloroquine (HCQ), the backbone of SLE therapy to prevent flares and organ damage, is underprescribed and adherence is suboptimal (9). In addition, despite an at least 2–3-fold higher prevalence of SLE and significantly poorer outcomes, African American individuals are much less likely to be enrolled in clinical trials compared to white individuals (10, 11). Structural racism, historic injustices in research, implicit bias by health providers, and ongoing experiences of discrimination contributing to patient distrust all contribute to this under-enrollment (10, 11). As a result, we often recommend treatments that have not been well-studied in the populations that may need them the most. Experiences of racial discrimination have also been associated with increased rheumatic disease activity and greater organ damage (12). A significant proportion of individuals with systemic rheumatic diseases receive immunosuppressive therapy at some point during their disease course, and these medications combined with patients’ underlying autoimmune conditions increase their susceptibility to severe infection. Among patients with SLE, particularly those insured by Medicaid (the largest public health insurer of low-income Americans), serious infections requiring hospitalization are common and African Americans are more likely than white individuals to experience them (13). The COVID-19 pandemic has already begun to disproportionately affect African American, Hispanic, and American Indian individuals, and individuals of lower socioeconomic status, and we expect that among patients with rheumatic diseases, the disparities will be even more pronounced (1, 2). Many of these individuals have more severe manifestations and less well controlled rheumatic diseases at baseline and may not be able to follow social distancing recommendations due to crowded or unstable living situations and financial constraints. In addition, more frequent glucocorticoid use among patients who lack sustained access to high-quality outpatient care not only heightens the risk for infection, but also causes cardiovascular disease and diabetes, known risk factors for poorer outcomes from COVID-19 (9, 13, 14). These factors raise significant concern for our most vulnerable patients in terms of short-term infection risk and both short-term and longterm control of their rheumatic disease. HCQ is now being promoted as a potential treatment for COVID-19, which has resulted in medication shortages for our rheumatologic patients. Medicaid limits patients to 1-month supplies of their medications. This means that our most vulnerable patients are also those least likely to have a sufficient supply. Recently, MassHealth, Massachusetts’ Medicaid organization which covers