Quality of care for incident lupus nephritis among Medicaid beneficiaries in the United States.

Abstract

We investigated the quality of care and factors associated with variations in care among a national cohort of Medicaid enrollees with incident lupus nephritis. Using Medicaid Analytic eXtract files from 47 US states and the District of Columbia for 2000-2006, we identified a cohort of individuals with incident lupus nephritis. We assessed performance on 3 measures of health care quality: receipt of immunosuppressive, renal-protective antihypertensive, and antimalarial medications. We examined performance on these measures over 1 year and applied multivariable logistic regression models to understand whether sociodemographic, geographic, or health care access factors were associated with higher performance on quality measures. We identified 1,711 Medicaid enrollees with incident lupus nephritis. Performance on quality measures was low at 90 days (21.9% for immunosuppressive therapy, 44.0% for renal protection, and 36.4% for antimalarials) but increased by 1 year (33.7%, 56.4%, and 45.8%, respectively). Younger individuals, African Americans, and Hispanics were more likely to receive immunosuppressive therapy and hydroxychloroquine. Younger individuals were less likely to receive renal-protective antihypertensive medications. We found significant geographic variation in performance, with patients in the Northeast receiving higher quality of care compared to other regions. Poor access to health care, as assessed by having a greater number of treat-and-release emergency department visits compared to ambulatory encounters, was associated with lower receipt of recommended treatment. These nationwide data suggest low overall quality of care and potential delays in care for Medicaid enrollees with incident lupus nephritis. Significant regional differences also suggest room for quality improvement.