ASSOCIATIONS BETWEEN COMBINED ENVIRONMENTAL BURDEN AND SOCIAL VULNERABILITY AND CARE FRAGMENTATION AMONG INDIVIDUALS WITH RHEUMATIC CONDITIONS

Background: Environmental hazards and heightened neighborhood social vulnerability coexist in the U.S. and disproportionately affect historically marginalized populations. Certain exposures like neighborhood poverty and air pollution contribute independently to rheumatic disease burden and severity and are likely linked to inequities in care and outcomes. Adverse environmental exposures concentrated in areas with high social vulnerability, key elements of environmental injustice, may lead to fragmented care, and highlight modifiable pathways to reduce rheumatic disease inequities. Objectives: We investigated associations between the U.S. CDC/ATSDR Social-Environmental Ranking (SER)[1], part of the Environmental Justice Index, integrating census tract-level data on environmental factors with social vulnerabilities, and care fragmentation (recurrent missed appointments, Emergency Department (ED) visits and hospitalizations) among individuals with rheumatic conditions. Methods: We identified individuals with ≥2 ICD-9 or 10 codes for systemic rheumatic conditions, crystalline arthritis, and/or osteoarthritis receiving rheumatology care at a multihospital healthcare organization in Massachusetts, U.S. (1/2000-5/2023). We restricted the cohort to individuals with ≥1 encounter in the past 3 years beginning on 5/1/20 (index date) with ≥2 prior rheumatic disease codes and a complete street address. We used ArcGIS Desktop 10.9 to geocode addresses, which we linked to the census tract CDC/ATSDR SER. The SER combines two subindices: social vulnerability (racial/ethnic minority status, socioeconomic status, household characteristics and housing type) and environmental burden (air pollution, potentially hazardous and toxic sites, built environment, transportation infrastructure and water pollution). Baseline individual-level characteristics (e.g., demographics, comorbidities) were obtained from electronic health record data in the 12 months prior to the index date. Multilevel, multinomial regression models were used to estimate the associations between the SER and care fragmentation (missed outpatient appointments, ED visits and hospitalizations) for the three years following the index date, accounting for individual-level characteristics. Results: Among 14,376 individuals identified, 7,187 had inflammatory arthritis, 5,209 connective tissue diseases, 1,451 vasculitis, 2,585 crystalline arthritis and 7,074 osteoarthritis. The mean (SD) age was 60.5 (15.5) years, 70% were female, 81% were white, 6% Black, 2% Hispanic and 7% resided in areas with the poorest nationally defined SER (Quartile 4) (Figure 1). Patients living in SER Quartile 4 areas with the highest combined social and environmental vulnerability, had 3.03 (95% CI 2.28-4.04) times higher odds of having ≥3 ED visits (vs. 0), 1.89 (95% CI 1.55-2.32) times higher odds of ≥4 missed appointments (vs. 0) and 1.46 (95% CI 1.17-1.84) times higher odds of ≥3 hospitalizations (vs.0) compared to individuals living in the least vulnerable SER Quartile 1, after accounting for individual-level factors (Table 1). Similar associations were seen with the environmental burden subindex. Conclusion: Residence in areas of high versus low combined adverse environmental burden and social vulnerability was associated with significantly greater odds of care fragmentation, with the strongest impact on recurrent ED visits. The SER includes high level screening data regarding environmental hazards, which may not represent actual individual-level exposures. Further studies are urgently needed to understand more granular associations between environmental exposures and social inequities, which may limit access to consistent, high-quality care for the most vulnerable individuals with rheumatic conditions. REFERENCES: [1]   Centers for Disease Control and Prevention and Agency for Toxic Substances Disease Registry. 2022 Environmental Justice Index. https://www.atsdr.cdc.gov/placeandhealth/eji/index.html . Figure 1. Map of the distribution of SER quartiles in a MA, U.S. area with individuals with rheumatic conditions Acknowledgements: NIL. Disclosure of Interests: Candace Feldman OM1, Inc. (Healthcare company), Harvard Pilgrim (for a project which was funded by GSK), Pfizer Pharmaceuticals, Bristol Myers Squibb Foundation, Leah Santacroce: None declared, Sherry Yang: None declared, Ana Valle: None declared, Paul Dellaripa: None declared. DOI: 10.1136/annrheumdis-2024-eular.2414 Keywords: Geographical differences, Public health, Health services research Citation: , volume 83, supplement 1, year 2024, page 532Session: Public Health Poster Tour (Poster Tours)

Geographical differences, Public health, Health services research