Rurality Does Not Account for Disparities in Veteran Care for Rheumatoid Arthritis

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A new study found only modest differences in initiating biologic therapies among veterans with rheumatoid arthritis (RA) residing in rural and urban areas in the Veterans’ Affairs (VA) healthcare system, suggesting that other factors are important in explaining disparities in this population.¹

“Racial and ethnic disparities in RA outcomes are well recognized. However, whether disparities in RA treatment selection and outcomes differ by urban versus rural residence, independent of race, have not been studied,” lead investigator Anisha Naik, MBBS, MPH, VA Puget Sound Health Care System, Seattle, Washington, and colleagues wrote.¹

In this retrospective cohort study utilizing national U.S. Veterans Affairs databases, we identified adult patients with RA based on presence of diagnostic codes and DMARD use. We included patients receiving an initial prescription of methotrexate (index date) between 2005 and 2014, with data through 2016 used for follow-up. Urban-rural status was categorized using the Veteran Health Administration's Urban/Rural classification. Our primary outcome of interest was time to biologic initiation within two years of starting methotrexate. Multivariable Cox proportional hazards models were conducted adjusting for demographics, comorbidities, and rheumatoid factor or anti-CCP positivity.¹

Naik and colleagues analyzed 17,395 veterans with RA, 88% of which were male and 42% of which resided rurally, which fulfilled eligibility criteria. Of these participants, only 3259 (19%) initiated a biologic within the first 2 years of follow-up. Multivariable analyses revealed that veterans residing in urban areas had statistically significant higher biologic use compared to those residing in rural areas (adjusted hazard ratio (aHR), 1.10 [95% CI, 1.02-1.18]), although the differences were not great.¹

“Our study found only modest differences in initiation of biologic therapies among rural versus urban residing Veterans with RA in the VA healthcare system. These findings suggest that disparities are not easily explained by rurality within the VA healthcare system,” Naik and colleagues concluded.¹

Other recent research investigating care for rheumatic disease in military service members found that nearly half (52%) of active duty service members diagnosed with fibromyalgia fail to receive follow-up care within 3 months of diagnosis and those that did generally received highly variable care as according to treatment guidelines.²

Participants were often prescribed non-opioid pain medications (72%), followed by muscle relaxants (44%), opioids (32%), anxiolytics (31%), gabapentinoids (26%), serotonin-norepinephrine reuptake inhibitor (SNRI; 21%), selective serotonin reuptake inhibitors (SSRI; 20%), and tramadol (15%). Notably, opioid prescription goes against current recommendations for treating fibromyalgia and tramadol use for fibromyalgia is only weakly supported.²

Utilized health care including exercise classes (52%), behavioral health care (52%), or physical therapy (50%) within 3 months of diagnosis. Other therapies were less frequently utilized, including physical interventions (41%), chiropractic care (40%), massage therapy (40%), transcutaneous electrical nerve stimulation (33%), self-care education (29%), biofeedback and other muscle relaxation therapies (22%), and acupuncture or dry needling (14%).²

The investigators also found significant differences in treatment types and prescribed medications between male and female service members, as well as Black, White, Latinx, and Asian service members.²

REFERENCES

1. Naik A, Baraff A, Wysham AD, et al. Escalation to Biologics After Methotrexate Among US Veterans with Rheumatoid Arthritis Grouped by Rural Versus Urban Areas. Arth. Care Res. Published online October 28, 2024. doi.org/10.1002/acr.25457

2. Herrera GF, Carreño PK, Wondwossen Y, Velosky AG, Patzkowski MS, Highland KB. Fibromyalgia Diagnosis and Treatment Receipt in the U.S. Military Health System. Mil Med. Published online August 12, 2024. doi:10.1093/milmed/usae384