Background SLE patients of lower socioeconomic position (SEP) exhibit increased morbidity and mortality but less clear is whether the disease incidence is increased in the setting of poverty and whether a more severe disease phenotype develops in poorer patients. Crucial etiologic factors for SLE may predominate in genetically-predisposed individuals of lower SEP. Lack of running water at age 12 and frequent childhood infections- both of which are associated with poverty, have been implicated in some groups. In our cohort of black patients in Barbados, we sought to determine by comparison with the general population if SLE clusters in persons of lower SEP and if poorer patients had a more severe disease phenotype.
Methods Patients from the Barbados National Lupus Registry (universal access to care) were included if they had a clinical diagnosis of SLE made by a rheumatologist in the 7 year period 2008–2014.
The clinical status was assessed at the end of 2017 ensuring all patients had at least 3 years of follow up – the period of time within which most severe SLE organ involvement develops. Private health insurance coverage was used a proxy for SEP. Patients were divided into 2 groups based on the presence or absence of health insurance at disease diagnosis. We investigated the effect of SEP on major organ involvement (yes/no), SLE nephritis (yes/no), neuropsychiatric disease (yes/no), and vital status in December 2017 (alive, alive with chronic kidney disease, died).
Results In a subset of 135 patients with SLE (F=126), 29 (21%) had private healthcare insurance at diagnosis (median age 32), the remaining 106 (79%) did not (median age 35). This compares to a national prevalence of private healthcare of 24% (95% CI 21% to 26%). The association between health insurance status and each of the four complications/outcomes is presented in table 1. After adjusting for disease duration, patients without private health insurance at diagnosis had more complicated SLE and worse SLE outcomes (Odds Ratios>1) in all cases. For two of these clinical complications (major organ involvement and SLE nephritis) the effects were borderline statistically significant at the 5% level.
Conclusions Socioeconomic determinants appear to affect the severity of SLE in Barbados with poorer patients having a more severe disease phenotype.
The high morbidity and mortality documented in the international literature in the setting of poverty may be due to a combination of social issues and the presence of more aggressive disease from the outset.
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