Elucidating Social Determinants and Mental Health Needs to Achieve Equity in Rheumatic Disease Care

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PROJECT SUMMARY/ABSTRACT The rheumatic diseases systemic lupus erythematosus, rheumatoid arthritis, and osteoarthritis together affect up to one-quarter of the U.S. population, with huge physical, social, psychological and financial burdens. Profound disparities in care and outcomes are seen among those afflicted with these diseases, with women and historically marginalized populations disproportionally impacted. Social determinants of health (SDoH) including social risk factors such as food insecurity and financial strain, as well as potential buffers of these risks such as social support, are not routinely assessed as part of rheumatology care yet directly impact the health of individuals with rheumatic diseases and likely exacerbate disparities. Those suffering with these rheumatic diseases are much more likely to have mental health conditions, notably major depression and post-traumatic stress disorder (PTSD), and emerging research points to shared genetic predisposition to mental health disorders and autoimmune rheumatic diseases. Many individuals with rheumatic diseases do not receive timely, high-quality care or adequate preventive healthcare resulting in increased emergency department visits and hospitalizations for oftentimes avoidable outcomes including vaccine-preventable infections and major cardiovascular events. Leveraging All of Us data from a large and diverse U.S. population, we propose novel studies to address modifiable barriers to healthcare access and outcomes for patients with rheumatic diseases, a unique at-risk group due to the physical and financial burdens of these diseases and the historically marginalized populations most affected. To date, the influence of SDoH and mental health conditions, and potential buffering factors that could be optimized, have been poorly examined and little addressed. We will investigate these crucial questions within All of Us with >50,000 individuals with rheumatic diseases with linked electronic health records, surveys regarding SDoH, demographics, healthcare access, and genotyping data. Among individuals with rheumatic disease, we will 1) use a social risk factor index to assess the effects of SDoH on recurrent, avoidable acute care use and 2) examine the impact of depression and PTSD on avoidable hospitalizations and cardiovascular events, accounting for social factors. We will employ validated polygenic risk scores for depression and PTSD to understand differences in genetic risk among individuals with rheumatic diseases and assess effects of high genetic risk on acute care use as possible markers for undiagnosed, untreated disease. Our findings, understanding the interplay of these understudied factors, will allow interventions to begin to achieve equitable care and outcomes for those most affected by the rheumatic diseases.