Greater Health Inequities, Disparities in Demyelinating Disease Identified

Lilyana Amezcua, MD, MS

A recent narrative review concluded that racial and ethnic health disparities and care inequities in multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD) put Black, Hispanic, and Latinx individuals at a disadvantage in receiving adequate care in the US compared with White individuals. Further research is necessitated to investigate how social determinants of health (SDOH) mechanisms and structures contribute to these inequities for underrepresented populations, primarily lower rates of education, income, and access to specialty care. 

Investigators, led by Lilyana Amezcua, MD, MS, associate professor of clinical neurology, Keck School of Medicine at the University of Southern California–Los Angeles; program director, Multiple Sclerosis Fellowship; and director, Keck Huntington Beach Multiple Sclerosis Infusion Program, found a limited number of studies evaluating inequities between these populations as the role of SDOH in MS and NMOSD. However, Black, Hispanic, and Lantinx patients with MS or NMOSD were found to have increased mortality, as well as unequal access to and utilization of health care, which was impacted by SDOH. These patients also experienced higher levels of mistrust, which were similar to experiences in stroke and other neurological conditions, investigators noted. 

Black, Hispanic, and Latinx patients with specific SDOH such as a lower income, lower health literacy, lower education levels, and negative perceptions of illness in MS were associated with greater health disparities compared with White patients with MS and NMOSD. It was further concluded that Black individuals had a higher risk of developing both diseases, as well as a higher risk of associated mortality. 

While seeking to evaluate health disparities among patients with myelin oligodendrocyte glycoprotein antibody (MOG-Ab)-associated disorders, investigators found no studies that evaluated this relationship.

“Disparities in health and health care access are a persistent challenge across marginalized US populations and account for more than half of the uninsured US population,” Amezcua et al wrote. “We found Black and Hispanic and Latinx individuals are less like to have specialty care compared with White individuals. To what extent inequitable access to health care and implicit bias (ie, the idea that Black or Hispanic and Latinx individuals do not get MS) leads to delay diagnosis or underutilization of specialty services is understudied. These factors, including timely access to [disease-modifying therapy], may explain the observed differences in outcomes across racial and ethnic groups and should be accounted for in future studies of MS and NMOSD prognosis.”

A total of 10 studies found SDOH had a disproportionate impact on outcomes, utilization of health care, behaviors, and lived experience for Black, Hispanic, and Latinx patients with MS. Investigators did not find any studies that were specific to SDOH and social and community situations. Additionally, there were no studies found evaluating this relationship for patients with MOG-Ab or NMOSD.

Investigators noted limitations to the narrative review, which included limited selection to underrepresented populations in the US, as well as the potential for subjective sampling bias. Additionally, a quality assessment of the studies was not conducted due to the heterogeneity of the included studies and the variability in how race and ethnicity were defined.

Future research should include increased representation of these populations in clinical trials, as well as additional training for health care professionals on evaluating SDOH. 

“To better understand the complex interplay of SDOH and health disparities and inequities, future studies in MS, NMOSD, and other neurological conditions development of comprehensive research frameworks and care practices should be considered,” Amezcua et al wrote. “The National Institute on Minority Health and Health Disparities’ framework models multiple levels and domains by which SDOH can affect health outcomes and could act as a model across neurological diseases, particularly if it is understood that individual, community, and population-level factors can interact to affect disease.”

REFERENCE

Amezcua L, Rivera VM, Vazquez TC, Baezconde-Garbanati L, Langer-Gould A. “Health disparities, inequities, and social determinants of health in multiple sclerosis and related disorders in the US: A review.” JAMA Neurol. Published online October 4, 2021. doi:10.1001/jamaneurol.2021.3416