Substandard Therapy in Rheumatoid Arthritis Save

Clinicians could improve outcomes in their patients with rheumatoid arthritis (RA) by paying attention to certain markers of care quality, such as early referral to certified rheumatologists and prescribing standard drugs for RA, new research suggested.

Tellingly, the analysis of insurance claims data covering more than half a million RA patients found that fewer than half had been referred to a rheumatologist within 1 year of initial diagnosis, according to Kevin C. Chung, MD, MS, of the University of Michigan Medical School in Ann Arbor, and colleagues -- and other quality markers were met even less often.

In fact, management in fully 31.3% met none of six care quality markers examined in the study, reported in JAMA Network Open. The six were derived from Arthritis Foundation recommendations and included:

1. Rheumatologist referral
2. Prescription of disease-modifying anti-rheumatic drugs (DMARDs) coupled with hepatitis B screening
3. Hand x-rays in first year after diagnosis
4. Annual physical exam
5. Annual lab testing
6. Referral for occupational or physical therapy or hand surgery

The analysis covered some 581,000 individuals with RA diagnoses included in the IBM Truven MarketScan database of medical insurance claims from 2009 to 2017. Patients with non-RA forms of inflammatory arthritis were generally excluded, but those with comorbid osteoarthritis were not. People younger than 18 or older than 64 were also excluded. Mean age at the first record of RA diagnosis in the final sample was 49, and about three-quarters were women.

Care in about 68% of cases met at least one of these markers, but not one of them was met in as many as half. Rheumatologist referral, at 44.1%, occurred most commonly, followed by DMARD prescription with hepatitis B screening at 32.5%. The other four markers were met in fewer than 10% of cases. Referral for occupational or physical therapy almost never happened in the first year of treatment (0.3% and 0.7%, respectively).

Chung and colleagues also looked at how the markers related to each other. Oddly, an early rheumatologist referral correlated negatively with the likelihood of DMARD prescription (OR 0.24, 95% CI 0.24-0.25) and with subsequent referrals for hand surgery or physical/occupational therapy. It did, however, increase the odds of hand x-rays and lab testing.

Furthermore, the group wrote, "Our study indicates that receiving DMARDs with or without hepatitis B screening is associated with greater odds of meeting later quality care markers, such as radiographs, annual laboratory testing, annual physical examination, and [physical/occupational therapy] or hand surgery referral."

Chung and colleagues speculated that DMARD prescription predicts patients' overall treatment adherence, such that "long-term outcomes for patients with RA may be improved through direct disease activity and the downstream effects of meeting additional quality care markers."

Other findings in the study, the clinical relevance of which are uncertain, included:

• Men were less likely than women to meet most quality markers
• Lower income correlated with lower odds of meeting some, but higher odds for others
• Coverage through Medicare was associated with lower odds of meeting markers compared with other types of insurance

"Although this study is based on a hypothetical care model," Chung and colleagues concluded, "it supports prior research that has found variable quality of RA care and indicates specific patient populations that can be targeted for improvement."

Limitations included reliance on claims data, which are not comprehensive and, in particular, omitted important potential confounders such as race/ethnicity and educational attainment. Also, the data on Medicare recipients did not distinguish between Medicare Advantage versus "original" Medicare.

The follow-up period of 1 year was also a limitation, although the researchers did examine a 2-year window and found that it "did not statistically change the results." Finally, the study did not address clinical outcomes such as achievement of low disease activity, and thus could not confirm that they correlated with the care quality markers chosen.

JAMA Network Open

Source Reference: Seyferth AV, et al "Factors associated with quality care among adults with rheumatoid arthritis" JAMA Netw Open 2022; DOI: 10.1001/jamanetworkopen.2022.46299.