Prioritizing Early Treatment may Improve Rheumatoid Arthritis Care

Results of a cohort study of patients with rheumatoid arthritis (RA) indicate that prioritization of early care, particularly for vulnerable patients, ensures the continuation of quality care, according to research published in JAMA Network.¹

“Despite advances in novel biologic therapies and evidence on early initiation of these disease-modifying antirheumatic drugs (DMARDs), quality of care for RA remains substandard,” investigators explained. “Various quality care markers have been developed to establish a standard of care and assess outcomes for RA. Studying these markers can aid in understanding treatment variations and factors affecting non-adherence. Closing these gaps may help improve outcomes and decrease financial burdens on patients and health care systems.”

Insurance claims between 2009 and 2017 were used in the retrospective cohort study to assess quality care markers in patients with RA. Of the 27 quality markers for RA developed by the Arthritis Foundation, investigators focused on 6 key measures that could be determined using insurance claims data: referral to a rheumatologist, annual physical examination, annual laboratory testing, physical therapy (PT), occupational therapy (OT), baseline hand radiographs within 1 year of initial visit, hand surgery referral, and hepatitis B screening prior to DMARD initiation. Markers were evaluated at 1-year post-diagnosis. Factors such as region of residence, income, insurance source, age, and sex, were used to investigate any potential correlations between quality care and demographic characteristics.

Adult patients (aged 18 to 64 years) with RA were identified using the MarketScan Research Database, which collects commercial and Medicare Advantage administrative claims for over 100 million individuals in the United States. Those with missing demographics or who had similarly presenting conditions to RA were excluded. The primary outcome was the prevalence of meeting successive quality care markers for RA at 1-year.

In total, 581,770 patients with RA were evaluated. Most (74.1%, n = 430,843) were female, the mean age was 48.9 years, and most (40.6%, n = 236,285) lived in the South and had an income of $45,200 or less (84.3%, n = 2490,366).

Within the study population, 68,7% (n = 399,862) patients met 1 or more quality care marker, while 31.3% (n = 181,908) met 0 markers. The most commonly met markers were annual laboratory testing (51.5%, n = 299,323) and rheumatologist referral (44.1%, n = 256,765). Screening for hepatitis B prior to initiation of DMARDs was the least met marker (3.2%, n = 18,548). Women were more likely to meet all quality care markers, with the exception of the hepatitis B screening, when compared with men (odds ratio [OR], 1.14; 95% CI, 1.12-1.16).

Although patients with a lower median household income had lower odds of receiving annual laboratory testing, a rheumatologist referral, or an annual physical examination, they were more likely to receive the other quality care markers. Individuals with Medicare and those with comorbidities were less likely to meet quality care markers.

The large sample size strengthened the study. However, claims data could not fully capture the complexity of treating RA and potentially introduces sampling bias from misclassification of treatments and incorrect coding. Insurance coverage changes may have confounded results. The lack of information regarding race, ethnicity, or educational level may have further confounded model outcomes. Additionally, as the database is comprised of claims from commercial insurance companies, the results may not be generalizable to publicly insured populations. The 1-year follow up period could be viewed as a limitation; however, adjusting the period to 2 years did not statistically change findings.

“This study proposed a sequential pathway for RA quality care markers and identified patient characteristics that show variation in meeting these markers,” investigators concluded. “Although this study is based on a hypothetical care model, it supports prior research that has found variable quality of RA care and indicates specific patient populations that can be targeted for improvement. In addition, this study supports the Arthritis Foundation guidelines and the importance of early diagnosis and care for patients with RA.”

Reference:

Seyferth AV, Cichocki MN, Wang CW, et al. Factors Associated With Quality Care Among Adults With Rheumatoid Arthritis. JAMA Netw Open. 2022;5(12):e2246299. Published 2022 Dec 1. doi:10.1001/jamanetworkopen.2022.46299