Newswise — WASHINGTON – According to research presented this week at the American College of Rheumatology Annual Meeting in Washington, D.C. differences by income and geographic region may prevent Medicare recipients with rheumatoid arthritis from receiving the latest RA treatments. Rheumatoid arthritis is a chronic disease that causes pain, stiffness, swelling, limitation of motion and loss of function of multiple joints. Though joints are the principal areas affected by RA, inflammation can develop in other organs as well. An estimated 1.3 million Americans have RA, and the disease typically affects women twice as often as men.
“Our study shows that critical RA therapies are not reaching everyone. Older and poorer patients are particularly vulnerable, and patients who do not see a rheumatologist are the least likely to receive appropriate treatment for RA. The study highlights the urgent need to facilitate and improve access to rheumatologists,” says Jinoos Yazdany, MD, MPH, co-investigator of the study and assistant professor in residence and at the University of California, San Francisco in Calif.
Many studies have suggested that treating rheumatoid arthritis with disease-modifying anti-rheumatic drugs (also called DMARDs) is effective at controlling disease progression. However, additional studies reveal that only 60 percent of Medicare patients with RA receive DMARDs. Researchers from the University of California, San Francisco, recently investigated the total number of Medicare patients with RA and if these patients received steroids alone to treat the disease. However, most experts do not use steroids alone without DMARDs to treat RA. This is because modern DMARD medications are more effective at controlling RA symptoms and may help patients achieve remission faster.
Researchers reviewed a random sample of patients who were eligible to receive government health insurance from the U.S. Medicare fee-for-service program. Participants were at least 65 years-old with two reports of physician visits to treat RA. Participants were also enrolled in the government prescription program, Medicare Part D, and received either a DMARD or glucocorticoids annually. Researchers examined factors that contributed to continued use of glucocorticoids as the only therapy to treat RA such as income, access to specialty care and additional medical conditions.
Of the 8,062 participants, 10 percent were identified as receiving only steroids to treat RA. In adjusted analyses, steroids as the only treatment was higher among those with advanced age (18 percent among those at least 85 years-old compared to 11 percent in those between the ages of 74-79 years-old), and among low-income beneficiaries (12 percent versus 10 percent in those with higher incomes).
Additionally, having a rheumatologist prescribe one or more medications was associated with significantly lower rates of steroid only use (7 percent versus 16 percent). Inpatient admissions such as hospital visits were also strongly associated with steroid use as the only therapy. Nationally, the results were consistent with marginally higher rates of steroid only use in the Middle Atlantic region (13 percent) compared to the Pacific region (8 percent).
The study highlights that many Medicare patients who would benefit from DMARDs are not receiving them. Low- income patients and those who do not see rheumatologists are particularly vulnerable.
“Our findings strongly suggest that even minimal contact with a rheumatologist, i.e. one visit per year, significantly impacts the use of DMARD therapy in patients with active RA. This information may be useful to payers and health systems seeking to improve performance on quality measures for RA,”says Dr. Yazdany.
Funding for this study was provided by the National Institute of Health, the National Institute of Arthritis and Musculoskeletal and Skin Diseases, University of California, San Francisco Resource Allocation Program and University of California, San Francisco Rosalind Russell Center for Arthritis.
The American College of Rheumatology is an international professional medical society that represents more than 9,000 rheumatologists and rheumatology health professionals around the world. Its mission is to advance rheumatology. The ACR/ARHP Annual Meeting is the premier meeting in rheumatology. For more information about the meeting, visit www.acrannualmeeting.org or join the conversation on Twitter by using the official hashtag: #ACR2012.
Learn more about living well with rheumatic disease as well as rheumatologists and the role they play in health care. Also, discover the ACR’s Simple Tasks campaign, which highlights the severity of rheumatic diseases and the importance of early and appropriate referral to a rheumatologist.
Editor’s Notes: Chris Tonner, MPH, will present this research during the ACR Annual Meeting at the Walter E. Washington Convention Center at 9:00 AM on Wednesday, November 14 in Room 207 A. Dr. Yazdany will be available for media questions and briefing at 1:30 PM on Monday, November 12 in the on-site press conference room, Room 203 A–B.
Presentation Number: 2599
Quality of Care for Medicare Recipients with Rheumatoid Arthritis: Vulnerable Populations More Likely to Receive Therapy with Glucocorticoids Alone
Chris Tonner (University of California San Francisco, San Francisco, Calif.) Jinoos Yazdany (University of California San Francisco, San Francisco, Calif.) Gabriela Schmajuk (University of California San Francisco, San Francisco, Calif.) Amal N. Trived (Brown University, Providence, R.I.)Grace Lin (University of California San Francisco, San Francisco, Calif.)
Background/Purpose: Use of disease-modifying anti-rheumatic drugs (DMARDs) is a nationally endorsed quality measure, yet recent studies suggest that only 60% of Medicare recipients with rheumatoid arthritis (RA) use DMARDs. We investigated the prevalence and predictors of receiving glucocorticoids alone for the treatment of RA in a nationwide sample of Medicare beneficiaries.
Methods: Data derive from a 5% random sample of U.S. Medicare fee-for-service beneficiaries. We included individuals ≥65 years with at least two face-to-face clinical encounters for RA and Part D drug claims for either a DMARD anytime during the year or sustained glucocorticoid monotherapy, defined as an annual dispensed glucocorticoid supply of ≥180 days or an annual dispensed dosage of ≥900 mg of prednisone (or steroid equivalent). Using multivariate logistic regression, we examined predictors of sustained glucocorticoid monotherapy including sociodemographic characteristics, income (low-income defined as Medicare eligible for reduced cost sharing or state buy-in), health service utilization (number of inpatient and outpatient encounters and prescribing physician specialty) and medical co-morbidities. In addition, we used the Area Resource File to examine area level predictors of socio-economic status, health care shortage areas, and Census geographic divisions. From the regression models, we calculated adjusted group proportions and 95% confidence intervals.
Results: Of the 8,062 beneficiaries, 10% (n = 830) were classified as receiving glucocorticoid monotherapy. In adjusted analyses, we found that glucocorticoid monotherapy was higher among those with advanced age (18% among those ≥85 years compared to 11% in those 74-79 years), Blacks (12% versus 10% in Whites), and among low-income beneficiaries (12% versus 10% in those with higher incomes). Having a rheumatologist prescribe one or more medications during the measurement year was associated with significantly lower rates of glucocorticoid monotherapy (7% versus 16%). More inpatient admissions and medical co-morbidities were also positively associated with glucocorticoid monotherapy. There was little variation across the nation, with marginally higher rates of glucocorticoid monotherapy in the Middle Atlantic region (13%) compared to the Pacific region (8%).
Conclusion: Approximately 10% of Medicare recipients with RA were treated with sustained courses of glucocorticoids alone in 2009. Compared to DMARD users, glucocorticoid monotherapy users were older, more likely to be Black, had lower income, had more medical comorbidities and hospitalizations, and were less likely to have a rheumatologist prescribing their RA medication. Although advanced age and accompanying medical co-morbidities may appropriately limit the use of DMARDs, differences by race, income and geographic region suggest disparities in quality of care.
Please visit www.rheumatology.org to view the full abstract
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