Systemic lupus erythematosus (SLE) consistently exerts a disproportionately greater burden across certain groups, with patients from some racial, ethnic, and socioeconomic groups often experiencing delayed diagnoses, limited access to care, and poorer outcomes. Researchers and clinicians at the 2025 Congress of Clinical Rheumatology (CCR) East presented data from various studies aiming to highlight the role that health disparities can play in the treatment and outcomes of patients with SLE.

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Following these presentations, featured expert Lisa G. Criscione-Schreiber, MD, MEd, was interviewed by Conference Reporter Associate Editor-in-Chief Christopher Ontiveros, PhD. Dr Criscione-Schreiber’s clinical perspectives on these findings are presented here.

The way that I think about health disparities in SLE is really in terms of things that are different in the care of different individuals with the disease, such that one population might be getting better or worse care than another. This may be either intentionally or unintentionally related to bias or to systems issues.

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There are a lot of well-documented health disparities in SLE care, and these disparities can come from many factors in a patient’s background. For example, it is very common to see differences in outcomes for people with SLE based on race, socioeconomic status, sex, and a number of other factors. Moreover, access to care is often decreased for patients who live in rural areas. Access to care is also more challenging for individuals who have a lower socioeconomic status and a lower education attainment, and there can be so many different reasons for this.

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The disparities between outcomes for rural-based patients and for more urban-based patients were highlighted in one of the poster abstracts presented at CCR East 2025 by Anand Maligireddy, MD, and colleagues. This analysis evaluated the mortality rates of ischemic heart disease in SLE and reported that, while deaths decreased in both metropolitan and nonmetropolitan areas from 1999 to 2020, nonmetropolitan areas still had higher mortality rates.

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The first level of access barriers can be related to whether a person even gets to an appointment. Patients have to be able to schedule an appointment, get off work, and have transportation to whichever provider they are seeing. For people who live in rural areas, they might have a much harder time even being able to get to a primary care provider, especially a consistent provider who knows them and can detect if something is different. You also have to have a primary care provider who thinks about SLE as a possible diagnosis. In addition, access barriers can be based on factors such as language barriers and the ability to navigate the health care system. This can be really difficult for people with poor health literacy or for those who are undocumented, for example, who might be hesitant to seek care.

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Interestingly, there is a direct link between having SLE and being at risk for accelerated cardiovascular disease at a younger age compared with people who do not have SLE. During the presentation, “Ten Things I Want You to Know About Lupus,” by Michelle Petri, MD, MPH, at this year’s CCR East meeting, she pointed out that there is a higher risk for cardiovascular disease within the first 2 years of an SLE diagnosis, suggesting that inflammation and the effect on cardiac outcomes starts long before diagnosis. Further, in a different poster by Dr Maligireddy et al from CCR East 2025, researchers reported on sex-stratified disparities in SLE and ischemic heart disease–related mortality. This study basically found that women with SLE had higher rates of ischemic heart disease–related mortality. I think that this finding can be due to a number of different reasons, including that they are younger and/or minoritized such that providers do not think about ischemic heart disease as a possibility.

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People who cannot overcome barriers to care may develop SLE with progressive manifestations, such that by the time they are first seen for lupus, they are so sick that they have to be hospitalized. This obviously leads to worse outcomes. For instance, I have seen individuals from rural areas in our hospital with severe manifestations such as kidney failure because they were not able to access care until they had such severe edema or other symptoms that they could not work anymore. I have also seen individuals who are migrants working on local farms, and they have to keep working and sending money home to their families despite getting sick. They eventually just get to the point where they become so sick that they end up having to be hospitalized. It is a shame when those things happen because we can do so much if we can see people earlier.

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If people have barriers to accessing SLE medications, then a lot of times they end up on steroids because steroids are inexpensive. In the previously mentioned presentation by Dr Petri, she pointed out retrospective findings about the hazards of steroids (eg, they increase the risk of cardiovascular events, organ damage, osteonecrosis, and even depression). This differential treatment can lead to outcome disparities. Further, even once a patient is offered medicines, there is evidence that other factors may exist that lower medication adherence. These can be multifactorial, including things like trust in the medical system, in the safety and necessity of medications, and in their providers. Adherence may not just have to do with the ability to afford medications—it can also have to do with life circumstances that might make it more challenging to take medications.