Clinicians 'should be cognizant of' racial, cultural disparities during RA management
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Clinicians should be aware of racial and cultural differences in the perception of health care and tailor their approach accordingly, and reduce potential health care disparities, potential health care disparities, noted a speaker at the 2021 Interdisciplinary Autoimmune Summit.
“Recognizing that racial, ethnic, socioeconomic and other disparities exist is certainly the first step,” Junko Takeshita, MD, PhD, MSCE, an assistant professor of dermatology at the Perelman School of Medicine at the University of Pennsylvania, in Philadelphia, told attendees at the virtual conference. “We as health care providers play a critical role in ensuring the education and management of patients in an equitable manner and should remain aware of these and emerging health care disparities as we care for our patients.”
Citing a 2011 study published in JAMA by Schmaiuk et al. that compared medication use among Medicare beneficiaries with rheumatoid arthritis, Takeshita said that patients who are older, Black and have lower income are less likely to receive a disease-modifying antirheumatic drug. Covariates in the study included age, sex, race, personal income, socioeconomic status based on ZIP code, geographic division, health professional shortage area, practice mode type, year HMO began operation, plan size and profit status.
In another study, published in The Journal of Rheumatology in 2007 by Suarez-Almazor et al., patients with rheumatoid arthritis — in both public and private clinics — who were part of a racial and ethnic minority, as well as those who were uninsured, experienced delays in starting therapy.
“Non-white patients, and patients seen in the public county hospital associated clinic, experienced delays in the initiation of a DMARD, compared with white patients and patients in the private clinic, respectively,” Takeshita said. “You can see this in the percentage of untreated patients, by race and by clinic type.”
According to the study, the median time to DMARD initiation was 7 years among non-white patients, compared to just 1 year for white patients. Similarly, the median time to DMARD initiation in the public clinic was 6 years, compared to 1.5 years in the private setting.
To help understand why Black patients would be less likely to receive a DMARD for RA than white patients, Takeshita summarized a 2009 study published in Arthritis & Rheumatology, from Constantinescu et al., that examined patient preferences. In this study, Black patients were more concerned than white patients regarding the risks versus the benefits of DMARDs.
Among 136 Black and white participants with RA, the study found that Black patients assign the greatest importance to the theoretical risk for cancer associated with DMARD use and placed less importance on the potential benefits. Meanwhile, white patients were most concerned about the likelihood of disease remission and symptom improvement.
“Additionally, Black race and lower education level were each associated with higher odds of being risk-averse, independent of these other factors of marital status and income,” Takeshita said. “On the one hand, these findings suggest that racial and/or cultural differences in risk-benefit perception may contribute to differences in patient preferences for DMARD treatment, which then may also result in racial differences in DMARD treatment. And any treatment differences that are truly due to patient preferences would not constitute a health care disparity.”
However, she added that clinicians should also be aware of the long history of discrimination, both within and outside of the health care system, and how resulting medical distrust can lead to this apparent difference in patient preference and greater risk aversion among Black patients.
“As clinicians, we should be cognizant of this history and racial cultural differences in the general perceptions of medicine and health care, and tailor our counseling and education that we provide to our patients to address these differences, so that each patient is able to make a fully informed decision about their treatments, and so that we may minimize any further perpetuation of inequitable health care,” Takeshita said.
She later added: “There is still a lot that we don’t know, so further research is critical to understanding the full extent and causes of disparities in health care use and treatment for immune-mediated inflammatory diseases, so that we can ultimately eliminate them.”
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Takeshita J. Healthcare Disparities in IMIDs. Presented at: Interdisciplinary Autoimmune Summit. April 15-18, 2021 (virtual meeting).
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