Objective:

To assess whether neighborhood disadvantage is associated with exposure to plasma exchange (PLEX) during attacks in patients with aquaporin-4-immunoglobulin-G+ (AQP4-IgG+) neuromyelitis optica spectrum disorder (NMOSD).

Background:

Early treatment of AQP4-IgG+ NMOSD attacks with PLEX is associated with better outcomes. However, PLEX requires significant healthcare infrastructure; therefore, PLEX exposure could be impacted by neighborhood disadvantage. 

Design/Methods:

All adult AQP4-IgG+ NMOSD patients at the Cleveland Clinic were included in this retrospective cohort study. Attacks were limited to those occurring after AQP4-IgG seropositivity. Multivariable logistic regression models evaluated the association between PLEX exposure during treatment of an attack and neighborhood disadvantage. Neighborhood disadvantage (yes or no) was determined using the Area Deprivation Index-3 (ADI-3) and defined as the most disadvantaged 15% of Americans regarding financial strength, educational attainment, economic hardship/inequality, or overall ADI. We adjusted for age, race, and insurance type (Medicaid or non-Medicaid). 

Results:

We included 168 AQP4-IgG+ NMOSD individuals. The mean age at diagnosis was 47±18 years, 89% were female, and 41% were Black. Ninety-eight individuals had a relapse after AQP4-IgG seropositivity, of which 48 (49%) received PLEX. PLEX exposure was not significantly associated with neighborhood disadvantage including financial strength (odds ratio [OR] 0.90, confidence interval [CI] 0.24-3.20, p=0.87), educational attainment (OR 1.81, CI 0.36-9.36, p=0.46), economic hardship/inequality (OR 3.58, CI 0.93-13.78, p=0.06), or overall ADI (OR 1.42, CI 0.52-3.87, p=0.49). Older age at diagnosis (OR 1.03-1.04, CI 1.01-1.07, p<0.05) and Medicaid insurance (OR 5.01-6.13, CI 1.04-30.21, p<0.05) were associated with increased odds of PLEX exposure in all multivariable models.  

Conclusions:

Neighborhood disadvantage was not associated with exposure to PLEX, suggesting that disadvantage was not a barrier. Those on Medicaid had greater odds of PLEX exposure, warranting further investigation into payor effect on PLEX exposure and underlying confounders.