New DMARD initiation among patients with RA needs improvement regardless of residence
Click Here to Manage Email Alerts
PHILADELPHIA — The initiation of disease-modifying antirheumatic drugs among U.S. veterans with active rheumatoid arthritis requires improvement, regardless of rural or urban setting, according to a presentation at ACR Convergence 2022.
“We hypothesized that there may be an urban-rural health disparity in using DMARDs in rheumatoid arthritis for treat-to-target based on other studies showing urban-rural health disparities in rheumatic disease,” Luke Desilet, DO, a rheumatology fellow at the University of Nebraska Medical Center, told Healio. “But interestingly, we did not find an urban-rural disparity in initiation of DMARD therapy in those who required a new DMARD by a treat-to-target strategy.”
The researchers identified 1,461 U.S. veterans from the Veterans Affairs RA registry from 2003 to 2020. Patients included in the analysis had “persistently active” RA, defined by two consecutive visits with moderate or high disease activity as scored by DAS28. The Veterans Health Administration provided data on participants’ urban or rural residence. According to the poster presentation, the primary endpoint was the initiation of a new DMARD within 1 year. The secondary outcomes were the initiation of specific categories of DMARD, which included conventional synthetic DMARDs, TNF inhibitor biologic DMARDs, and non-TNF inhibitor biologic or targeted synthetic DMARDs.
Of the 1,461 veterans included in the observational study, 62% (n = 902) resided in urban areas and 38% (n = 559) resided in rural areas. Desilet and colleagues found that rural patients were more likely to be male, white, current smokers, with more baseline prednisone and prior DMARD use compared with urban patients.
At 40% (n = 363) for urban patients and 42% (n = 234) for rural patients, new DMARD initiation was similar between the two groups. When researchers enacted multivariable adjustment, they observed no association of new DMARD initiation between urban residence compared with rural residence (adjusted OR = 1.19; 95% CI, 0.87 - 1.64).
“While that’s encouraging, that there doesn’t seem to be disparity, only 40% of patients in both urban and rural populations actually received a new DMARD within 1 year when indicated by treat-to-target,” Desilet said. “This is a suboptimal number. Our study couldn’t estimate other things like dosage estimates, costs, patient preferences, or contraindications to certain medications so that number may be affected by those factors. But from the data we can see, it looks like treat-to-target is sub optimally utilized in this population.”
The findings demonstrated no real difference in new DMARD initiation utilizing treat-to-target strategies among veterans with active rheumatoid arthritis when comparing rural and urban residences.
However, while there was no significant difference in new DMARD initiation between urban and rural residences, uptake of new DMARD initiation was “suboptimal” at less than 50%.
“To improve treat-to-target, it’s definitely a multilevel effort,” Desilet said. “It doesn’t just work on the clinician or the health care system level and I think there are a lot of factors at play. From the clinician end, as a rheumatologist, treat-to-target includes using a validated scoring method for assessing disease activity in rheumatoid arthritis and monitoring that to make adjustments in shared decision making with the patient, if indicated. From a health care system level, coordination of care can require a lot of different things like specialty pharmacy, nursing support, and care coordination support. From an outside the health care system level, payers also play a major role in their coverage of certain DMARDs. If we’re looking to make adjustments, oftentimes insurance and government payers play a role in what we can do.”
Collapse
Desilet L, et al. Abstract 0095. Presented at: ACR Convergence 2022; November 11-14, 2022; Philadelphia (hybrid meeting).
Click Here to Manage Email Alerts