Racial and Ethnic Disparities in Access to Emerging and Frontline Therapies in Common Dermatological Conditions: A Cross-Sectional Study

Michael A. Bell, M.Sc., Katherine A. Whang, B.S., Jamael Thomas, M.D., M.P.H., Crystal Aguh, M.D., Shawn G. Kwatra, M.D.

Abstract:

Objective: This study investigates possible race- and ethnicity-related disparities in the treatment of acne, atopic dermatitis, and psoriasis of newly approved treatments as well as existing therapies.
Methods: Aggregate level data was collected from patient medical records between 2013 and 2018. The odds ratio of patients who had been prescribed treatments for acne, atopic dermatitis, and psoriasis per racial and ethnic group were calculated using a 95% confidence interval after applying Bonferroni correction to account for multiple comparisons.
Results: Black patients with acne had statistically significant (p < 0.001) lower odds of receiving isotretinoin 0.26 [0.22e0.30], adapalene 0.72 [0.67e0.78], tazarotene 0.74 [0.64e0.86], and dapsone 0.39 [0.34e0.45] than white patients. The exceptions were tretinoin 1.28 [1.23e1.34] and benzoyl peroxide 3.00 [2.79e3.23] (p < 0.001). Hispanic patients with acne had statistically lower odds of receiving tretinoin 0.86 [0.79e0.95] (p < 0.001) compared to non-Hispanics. Black patients with atopic dermatitis were less likely to receive desonide 0.90 [0.78e0.93], tacrolimus 0.75 [0.68e0.83], pimecrolimus 0.71 [0.60e0.84], crisaborole 0.39 [0.26e0.57], dupilumab 0.42 [0.27e0.65]. The exception was hydrocortisone 2.50 [2.34e2.65] (p < 0.001). There was no statistically significant difference for Hispanics compared to non-Hispanics. Black patients with psoriasis had a lower likelihood of receiving cyclosporine 0.54 [0.35e0.83] and etanercept 0.65 [0.49e0.87].
Conclusions: This study demonstrates a racial and ethnic disparity in accessing newly approved and standard of care medical therapies for acne, atopic dermatitis, and psoriasis within the past three years.

Keywords: Acne vulgaris Atopic dermatitis Biologics Disparities Psoriasis Race

INTRODUCTION

Previous studies have established racial differences in acne management, however little is known about racial and ethnic disparities in management of most other dermatologic conditions including psoriasis and atopic dermatitis.1,2 Such disparities may be accentuated in relation to the latest therapies, such as biologics, which often require lengthy prior authorizations and expensive co- payments. This study characterizes the race- and ethnicity- related prescribing patterns of newly approved treatments as well as standard-of-care therapies to determine disparities in the treatment of acne, atopic dermatitis, and psoriasis.

MATERIAL AND METHODS

Aggregate level data, exempt from institutional review board approval, was collected from patient medical records seen at an urban academic medical center in Baltimore between August 1, 2013 and August 1, 2018 using the electronic medical record system Epic. Patient race and ethnicity was determined by how the patient self-identified in Epic. All patients were at least 18 years old. Medical records were searched using SNOMED Clinical Terms concepts, which are a computer processable collection of medical terms that provide the core general terminology for electronic health records. Patients with the condition of interest were identified by visit diagnosis, billing diag- nosis, or problem list entry of acne vulgaris, atopic dermatitis, or psoriasis. During data collection, standard therapies, including first line and alternative treatments according to guidelines by the American Academy of Dermatology, were cross-referenced with the FDA’s Novel Drug Approvals for 2015 to 2017.3e9 Patients were considered to be on treatment if a specified medication was documented as active during the query date range. We compared the number of patients with the aforementioned conditions and on medication with race- and ethnicity- matched control groups. The odds ratio (OR) and p-values for each comparison were calculated using a 95% confidence interval. Statistical significance was assessed by using the chi-square test, and the P value for significance was set at p < 0.05 after applying Bonferroni correction to account for multiple comparisons.

RESULTS & DISCUSSION

Between August 1, 2013 and August 1, 2018, we identi- fied 26,646 black or African American and 14,260 white or Caucasian patients with acne vulgaris. Within this five- year period, black or African American patients with acne had statistically significant (p < 0.001) lower odds of receiving most medications including systemic and topical retinoids, and topical anti-bacterial agents than their white or Caucasian counterparts, with the exception of treti- noindpossibly for its use in treating post-inflammatory hyperpigmentation, a sequelae of acne more common in darker skinned individuals (Figure 1). We identified 2,153 Hispanic or Latino patients and 39,860 non-Hispanic or Latino patients with acne vulgaris. Hispanic or Latino patients with acne had significantly lower odds of receiving tretinoin and dapsone compared to non-Hispanic or Latino patients (Figure 1B).
Among patients with atopic dermatitis, 9,885 black or African American and 9,062 white or Caucasian patients were identified; 1,410 Hispanic or Latino and 21,132 non- Hispanic or Latino patients were identified. Black patients with atopic dermatitis were less likely to receive medica- tions including topical corticosteroids, topical calcineurin inhibitors, a topical phosphodiesterase 4 inhibitor and a biologic than white or Caucasian patients (p < 0.001), with the exception of hydrocortisone (Figure 1C).
Among patients with psoriasis, 1,682 black or African American and 11,338 white or Caucasian patients were identified; 540 Hispanic or Latino and 14,131 non-

ACCESS TO EMERGING AND FRONTLINE THERAPIES

Hispanic or Latino patients were identified. Black patients with psoriasis tended broadly to have a lower likelihood of being on medication compared to white or Caucasian pa- tients (Figure 1E). A similar trend was also seen in His- panic or Latino patients compared to non-Hispanic or Latino patients (Figure 1D).
Our data suggest racial and ethnic disparities have persisted and may preclude full use of the range of ther- apeutic modalities among certain populations. Although legislation has increased access to health care among low- income and low-education individuals, not all demographic subgroups have benefited equally.10,11 It has been reported that differences between non-Hispanic white Americans and either black or Hispanic Americans, in terms of health insurance coverage, affordability, and access to care, remains relatively unchanged.11 Addition- ally, while insurance strongly influences medication use, a number of other factors are contributory, including potential implicit biases of prescribers.2,10 One qualitative study in biologic-naïve patients with psoriasis suggested that communities of color are unfamiliar with biologic treatment options and may lack exposure to such treat- ment.12 More work is needed to investigate and combat the multi-level reasons perpetuating racial- and ethnic- disparities in access to dermatological therapy.
This study has a number of limitations. Because of the anonymized data collection method, an individual patient’s dermatological condition duration and severity were not available. Similarly, we were unable to identify the number of patients having the skin condition as a manifestation of another disease process or as a complication of treatment. We were unable to stratify patients by age based on the software tool used for this study. Because these data were collected from an entire hospital system, these data may represent a variety of clinical specialties (including der- matologists, primary care physicians, and advanced prac- tice providers among others) and professional status. Furthermore, we were unable to collect the number of the study patients who received routine care at the institution and the number that received consultation for the visit.

IMPLICATIONS

Here, we describe the disparities in care that racial mi- norities face when seeking treatment for acne, atopic dermatitis, and psoriasis. The general trend of newly approved medications less frequently prescribed among minority populations compared to non-minority pop- ulations most prominently includes decreased use of cri- soborole and dupilumab in black patients for atopic dermatitis. Similarly, well-established and gold standard treatments, such as isotretinoin for acne are significantly less frequently prescribed to black patients. Altogether, these findings could suggest barriers in access to emerging and frontline therapies for minority populations; it is significant for dermatologists to know of inequities in the management of diseases commonly encountered in prac- tice so as to be better equipped to identify vulnerable patients, combat barriers to care, and expand our under- standing of health disparities.

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