The Association of Socioeconomic Status with Outcomes in Cystic Fibrosis Patients in the United States

Abstract

There is considerable variability in the clinical course of disease in cystic fibrosis (CF). Although currently unidentified modifier genes might explain some of this heterogeneity, other factors are probably contributory. Socioeconomic status (SES) is an important predictor of health status in many chronic polygenic diseases, but its role in CF has not been systematically evaluated. We performed a historical cohort analysis of pediatric CF patients in the United States using National Cystic Fibrosis Foundation Patient Registry (NCFPR) data for 1986 to 1994, and used Medicaid status as a proxy for low SES. The adjusted risk of death was 3.65 times higher (95% confidence interval [CI]: 3.03 to 4.40) for Medicaid patients than for those not receiving Medicaid. The percent predicted FEV(1) of surviving Medicaid patients was less by 9.1% (95% CI: 6.9 to 11.2). Medicaid patients were 2.19 times more likely to be below the 5th percentile for weight (95% CI: 1.91 to 2.51) and 2.22 times more likely to be below the 5th percentile for height (95% CI: 1.95 to 2.52) than were non-Medicaid patients. Medicaid patients were 1.60 times more likely to require treatment for a pulmonary exacerbation (95% CI: 1.29 to 1.98). There was no difference in the number of outpatient clinic visits for Medicaid and non-Medicaid patients. We conclude that low SES is associated with significantly poorer outcomes in children with CF. Barriers in access to specialty health care do not seem to explain this difference. Further study is indicated to determine what adverse environmental factors might cluster in CF patients of low SES to cause worse outcomes.

Early Childhood Risk Factors for Decreased FEV1at Age 6-7 Years in Young Children with Cystic Fibrosis

“…Our analysis also supports previous reports that have described associations between low FEV 1 % predicted at age 6 years and low socioeconomic status (7,15). Schechter and colleagues used data from the CFFNPR from 1994 and reported that low socioeconomic status, as indicated by being a recipient of Medicaid, was associated with lower FEV 1 % predicted, including at age 6 years.…”

“…The ability to identify risk factors for low FEV 1 % predicted (FEV 1 expressed as a percentage of the predicted normal value) at age 6 could provide opportunities to intervene and slow the progression of CF lung disease. Previous studies have identified risk factors for low FEV 1 % predicted at age 6, including female sex, poor nutritional status, viral infections, persistent infection with Pseudomonas aeruginosa (P. aeruginosa), respiratory symptoms, pulmonary exacerbations, and low socioeconomic status (3)(4)(5)(6)(7)(8). It is unclear whether these risk factors remain applicable in the current era, as children with CF born today are more likely to be detected by newborn screening (NBS) and treated more aggressively with antibiotics and CF-specific therapies, and to undergo eradication therapy when P. aeruginosa is isolated from respiratory cultures (9)(10)(11).…”

A Life Course Perspective on Health Trajectories and Transitions

“…The social consequences of having a chronic disease such as CF are important, and understudied. Although social conditions do not influence the risk of having CF, there are significant differences in outcomes such as growth and lung function, and ultimately survival, in people with CF in the UK and US (Taylor-Robinson et al 2013a;Schechter et al 2001;Barr and Fogarty 2011). The analysis of UK data presented here suggests that people with the double burden of chronic illness and low SES are more likely to be excluded from the labour market.…”

“…Survival in CF has increased under the influence of improved treatment and management, improved nutrition and better living conditions (Davies et al 2007;Schechter 2004), but these improvements do not appear to have been shared equally, since studies in both the US and UK have demonstrated differences in survival by socio-economic status (SES) (Schechter et al 2001;O'Connor et al 2003;Britton 1989). The social patterning of survival in CF suggests that social factors -the 'social determinants of health' -are having an important effect on outcomes.…”

Association of increased emergency rooms costs for patients without access to necessary medications

“…35 Cystic fibrosis patients that received Medicaid coverage were found to have an adjusted risk of death 3.65 times that of non-Medicaid recipients and were 1.60 times more likely to experience pulmonary exacerbations than nonMedicaid clients. 36 Investigators have observed evidence of suboptimal provision of medications at discharge, follow-up care, and outpatient care for Medicaid recipients versus the privately insured. 37 This could partially explain the increase in negative health outcomes.…”