ATLANTA -- A new study reveals that Black patients with rheumatoid arthritis (RA) were less likely to be prescribed a biologic treatment and more likely to use glucocorticoids, which carry a risk of serious long-term side effects. This study highlights ongoing racial disparities in the care of patients with rheumatic disease. Details of the study was shared at ACR Convergence, the ACR's annual meeting (RA is the most common type of autoimmune arthritis. It is caused when the immune system (the body's defense system) is not working properly. RA may cause pain and swelling in the joints as well as affect multiple organ systems such as the lung and eye. RA is treated with disease modifying anti rheumatic drugs, including biologics, to help stop joint pain and swelling, and also prevent joint damage. "
Racial disparities in access to care and effective treatment regimens are poorly understood in the RA population, but past research shows that non-white RA patients have a lower frequency of biologic use versus white patients, even when accounting for comparable disease activity and access to treatment. This new study looked at racial disparities in RA treatment and emergency department use in patients with RA at a single, tertiary academic center in Pennsylvania.
"With the explosion of effective therapies for rheumatoid arthritis, it is particularly important to make sure that we are treating patients in the best way possible," says the study's co-author, Michael George, MD, MSCE, Assistant Professor of Medicine at the Hospital of the University of Pennsylvania. "Variability in practice, and disparities in treatment, suggest that there is room for significant improvement. We hope that this study will add to the existing literature about disparities in rheumatoid arthritis care-understanding why they exist and finding ways to address them are key to improving the health of patients with RA."
The study used electronic health record data from 1,831 patients with RA from 2010 to 2018. Patients had at least two RA diagnoses from a rheumatology outpatient encounter and at least one prescription of a disease-modifying antirheumatic drug (DMARD) during the follow-up period, or from their first to their last clinic visit. The researchers also measured patient demographic information, medication use and comorbidities at the baseline visit and at any point during the follow-up period.
The researchers then compared the differences in patient characteristics and visits between Black and white patients. Of the 1,831 patients in the study, 82% were female, 35% were Black, 54% were white and the mean age was 55. The average follow-up period for all patients was 6.97 years. Black patients were more likely to be older, have a higher body-mass index (BMI), were former or current smokers and had higher rates of cardiovascular disease and diabetes.
The researchers found racial disparities in how RA was treated with prednisone and conventional synthetic DMARD treatments used significantly more often in Black patients than whites: 79.3% of Black patients used prednisone compared to 69.1% of whites, and 96.7% of Black patients used a conventional DMARD compared to 93.5% of whites.
Additionally, white patients in the study were significantly more likely to use a biologic, a more advanced, expensive, and effective treatment for controlling RA disease activity and preventing joint damage. According to the data, 74% of whites and 67% of Blacks were prescribed a biologic drug. Black patients also had significantly more visits to the hospital emergency department (ED) over the eight-year period.
"This project supports prior work showing reduced use of biologics and a greater use of prednisone in patients who were Black - which could potentially mean worse outcomes or increased steroid side effects in this group," says Dr. George. "A key next step that many are working on is understanding the key drivers of these disparities - understanding why they exist (e.g., access to medications, insurance, patient-provider communication, health beliefs, etc.) is important so we know how to address these disparities."
About ACR Convergence
ACR Convergence, the ACR's annual meeting, is where rheumatology meets to collaborate, celebrate, congregate, and learn. Join ACR for an all-encompassing experience designed for the entire rheumatology community. ACR Convergence is not just another meeting - it's where inspiration and opportunity unite to create an unmatched educational experience. For more information about the meeting, visit https://www.rheumatology.org/Annual-Meeting, or join the conversation on Twitter by following the official hashtag (#ACR20).
About the American College of Rheumatology
The American College of Rheumatology (ACR) is an international medical society representing over 7,700 rheumatologists and rheumatology health professionals with a mission to empower rheumatology professionals to excel in their specialty. In doing so, the ACR offers education, research, advocacy and practice management support to help its members continue their innovative work and provide quality patient care. Rheumatologists are experts in the diagnosis, management and treatment of more than 100 different types of arthritis and rheumatic diseases.
Characterization of Racial Disparities in Rheumatoid Arthritis Treatment Choice and Location of Care
Racial disparities in access to care and treatment regimens exist but remain poorly characterized in the rheumatoid arthritis (RA) patient population. Previous studies using the Ethnic Minority RA Consortium (EMRAC) have demonstrated non-Caucasian RA patients have a lower frequency of biologic use versus Caucasian patients despite controlling for comparable disease activity and access to treatment. Here we explore longitudinal racial disparities in rheumatoid arthritis treatment and emergency department (ED) use in a single tertiary academic center.
Structured de-identified data from 2010-2018 of patients who had at least two diagnoses of RA from a rheumatology outpatient encounter and at least one DMARD script during the follow-up period were extracted from the electronic health record of a single tertiary care center. Follow-up was measured from each patient's first visit to each patient's last visit within the 2010-2018 timeframe. Patient demographics were measured at the baseline visit, with medication use and comorbidities measured at baseline or at any point during follow-up. The average number of outpatient visits and ED visits per year (limited to ED visits within the health system) during follow-up were also measured. Differences in patient characteristics and visits were compared in patients who were Black versus white based on standard t-test and χ2 analysis.
A total of 1831 patients with rheumatoid arthritis were identified from 2010-2018. Baseline demographics were measured at each patient's first visit and include mean [SD] age, 55.05 [14.47] years; 1499 [81.87%] female; and 991 [54.12%] white. Average [SD] duration of follow-up for all patients was 6.97 [2.28] years. Comparing black (n=639) and white (n=991) patient demographics, significant findings include that black patients were more likely to be older, have higher BMI, former or current smoking status, and have higher rates of diabetes and cardiovascular disease (p< 0.0001). Prednisone and csDMARD use were significantly more frequent in black patients compared to white patients (79.3% vs 69.1% p< 0.0001; 96.7% vs 93.5%, p=0.005, respectively). Biologic use was significantly more common among white patients compared to black patients (white 74.3%, black 67.0% p=0.001). In terms of site of care delivery, black patients had significantly more ED visits, with a median 0.24 ED visits per patient per year versus 0.00 for white patients. A summary of the findings are shown in Table 1.
Patients who were black were less likely to receive a biologic and more likely to use glucocorticoids. ED visit use was higher in black patients, which could be related to higher rates of comorbidities, although differences in geographic location could also influence whether patients visited an ED or saw non-rheumatology providers within or outside the health system. Further studies identifying drivers of racial disparities in access to care and outcomes are needed.