Relative environmental and social disadvantage in patients with idiopathic pulmonary fibrosis.

BACKGROUND: Air pollution exposure is associated with disease severity, progression and mortality in patients with idiopathic pulmonary fibrosis (IPF). Combined impacts of environmental and socioeconomic factors on outcomes in patients with IPF are unknown. The objectives of this study were to characterise the relationships between relative environmental and social disadvantage with clinical outcomes in patients with IPF. METHODS: Patients with IPF were identified from a longitudinal database at University of California, San Francisco. Residential addresses were geocoded and linked to the CalEnviroScreen 3.0 (CES), a tool that quantifies environmental burden in California communities, combining population, environmental and pollution vulnerability into individual and composite scores (higher scores indicating greater disadvantage). Unadjusted and adjusted linear and logistic regression and Fine and Gray proportional hazards models were used. RESULTS: 603 patients were included. Higher CES was associated with lower baseline forced vital capacity ( ß =-0.073, 95% CI -0.13 to -0.02; p=0.006) and diffusion capacity of the lung for carbon monoxide ( ß =-0.11, 95% CI -0.16 to -0.06; p<0.001). Patients in the highest population vulnerability quartile were less likely to be on antifibrotic therapy (OR=0.33; 95% CI 0.18 to 0.60; p=0.001) at time of enrolment, compared with those in the lowest quartile. An association between CES and mortality was suggested, but sensitivity analyses demonstrated inconsistent results. Relative disadvantage of the study cohort appeared lower compared with the general population. CONCLUSIONS: Higher environmental exposures and vulnerability were associated with lower baseline lung function and lower antifibrotic use, suggesting that relative socioenvironmental disadvantage has meaningful impacts on patients with IPF.

Neighborhood Health and Outcomes in Idiopathic Pulmonary Fibrosis.

Rationale: Living in a disadvantaged neighborhood has been associated with worse survival in people with idiopathic pulmonary fibrosis (IPF), however, prior studies have only examined the impact of neighborhood health on outcomes in IPF as a composite measure. Objectives: To investigate the association between neighborhood health and disease severity, measured by pulmonary function at presentation, and death in follow-up, with an additional focus on the contributions of the neighborhood's underlying physical and social factors to these outcomes. Methods: In a retrospective study of participants from the University of California, San Francisco, IPF Cohort (2001-2020), geocoded home addresses were matched to the California Healthy Places Index (HPI), a census-tract measure of neighborhood health. The HPI comprises 25 indicators of neighborhood health that are organized into eight physical and social domains, each of which is weighted and summed to provide a composite HPI score. Regression models were used to examine associations between the HPI as a continuous variable, in quartiles, and across each physical and social domain of the HPI (higher values indicate greater advantage) and forced vital capacity (FVC) percent predicted (% predicted), diffusing capacity of the lung for carbon monoxide (DlCO) % predicted, and death, adjusting for demographic and clinical covariates. We also studied the interaction between disease severity at presentation and neighborhood health in our time-to-event models. Results: In 783 participants with IPF, each 10% increase in HPI was associated with a 1% increase in FVC % predicted and DlCO % predicted (95% confidence intervals [CIs] = 0.55, 1.72; and 0.49, 1.49, respectively). This association appeared primarily driven by the economic, education, access, and social HPI domains. We also observed differences in the associations of HPI with mortality depending on disease severity at presentation. In participants with normal to mildly impaired FVC % predicted (⩾70%) and DlCO % predicted (⩾60%), decreased HPI was associated with higher mortality (hazard ratio = 2.91 Quartile 1 vs. Quartile 4; 95% CI = 1.20, 7.05). No association was observed between the HPI and death for participants with moderate to severely impaired FVC % predicted and DlCO % predicted. Conclusions: Living in disadvantaged neighborhoods was associated with worse pulmonary function in participants with IPF and was independently associated with increased mortality in participants with normal to mild physiological impairment at presentation.

Disparities in Antifibrotic Medication Utilization Among Veterans With Idiopathic Pulmonary Fibrosis.

BACKGROUND: Two antifibrotic medications, pirfenidone and nintedanib, are approved for the treatment of idiopathic pulmonary fibrosis (IPF). Little is known about their real-world adoption. RESEARCH QUESTION: What are the real-world antifibrotic utilization rates and factors associated with uptake among a national cohort of veterans with IPF? STUDY DESIGN AND METHODS: This study identified veterans with IPF who received care either provided by the Veterans Affairs (VA) Healthcare System or non-VA care paid for by the VA. Patients who had filled at least one antifibrotic prescription through the VA pharmacy or Medicare Part D between October 15, 2014, and December 31, 2019, were identified. Hierarchical logistic regression models were used to examine factors associated with antifibrotic uptake, accounting for comorbidities, facility clustering, and follow-up time. Fine-Gray models were used to evaluate antifibrotic use by demographic factors, accounting for the competing risk of death. RESULTS: Among 14,792 veterans with IPF, 17% received antifibrotics. There were significant disparities in adoption, with lower uptake associated with female sex (adjusted OR, 0.41; 95% CI, 0.27-0.63; P < .001), Black race (adjusted OR, 0.60; 95% CI, 0.49-0.73; P < .001), and rural residence (adjusted OR, 0.88; 95% CI, 0.80-0.97; P = .012). Veterans who received their index diagnosis of IPF outside the VA were less likely to receive antifibrotic therapy (adjusted OR, 0.15; 95% CI, 0.10-0.22; P < .001). INTERPRETATION: This study is the first to evaluate the real-world adoption of antifibrotic medications among veterans with IPF. Overall uptake was low, and there were significant disparities in use. Interventions to address these issues deserve further investigation.