A Prospective Study of the Impact of Current Poverty, History of Poverty, and Exiting Poverty on Accumulation of Disease Damage in Systemic Lupus Erythematosus

Abstract

Objective: To estimate the effect of current poverty, number of years in poverty, and exiting poverty on disease damage accumulation in systemic lupus erythematosus (SLE). Methods: For this study, 783 patients with SLE were followed up from 2003 to 2015 through annual structured interviews. Respondents were categorized in each year by whether they had a household income of ≤125% of the US federal poverty level. Linear and logistic regression analyses were used to assess the impact of poverty in 2009, number of years in poverty between 2003 and 2009, and permanent exits from poverty as of 2009 on the extent of disease damage (according to the Brief Index of Lupus Damage [BILD] score) or accumulation of a clinically meaningful increase in disease damage (defined as a minimum 2-point increase in the BILD damage score) by 2015. Results: After adjustment for sociodemographic features, health care characteristics, and health behaviors, poverty in 2009 was associated with an increased level of accumulated disease damage in 2015 (mean difference in BILD damage score between poor and non-poor 0.62 points, 95% confidence interval [95% CI] 0.25–0.98) and increased odds of a clinically important increase in damage (odds ratio [OR] 1.67, 95% CI 0.98–2.85). Being poor in every year between 2003 and 2009 was associated with greater damage (mean change in BILD score 2.45, 95% CI 1.88–3.01) than being poor for one-half or more of those years (mean change in BILD score 1.45, 95% CI 0.97–1.93), for fewer than one-half of those years (mean change in BILD score 1.49, 95% CI 1.10–1.88), or for none of those years (mean change in BILD score 1.34, 95% CI 1.20–1.49). Those exiting poverty permanently had similar increases in disease damage (mean change in BILD score 1.30, 95% CI 0.90–1.69) as those who were never in poverty (mean change in BILD score 1.36, 95% CI 1.23–1.50) but much less damage than those who remained in poverty (mean change in BILD score 1.98, 95% CI 1.59–2.38). Conclusion: The effects of current poverty, “dose” of poverty, and exiting poverty suggest that poverty plays a critical role in the accumulation of damage in patients with SLE.