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Disparities Seen in RA (rheumatoid arthritis) Drug Therapy
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Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disorder that may affect many tissues and organs, but principally attacks synovial joints. The process produces an inflammatory response of the synovium (synovitis) secondary to hyperplasia of synovial cells, excess synovial fluid, and the development of pannus in the synovium. The pathology of the disease process often leads to the destruction of articular cartilage and ankylosis of the joints. Rheumatoid arthritis can also produce diffuse inflammation in the lungs, pericardium, pleura, and sclera, and also nodular lesions, most common in subcutaneous tissue. Although the cause of rheumatoid arthritis is unknown, autoimmunity plays a pivotal role in both its chronicity and progression, and RA is considered a systemic autoimmune disease.
About 1% of the world's population is afflicted by rheumatoid arthritis, women three times more often than men. Onset is most frequent between the ages of 40 and 50, but people of any age can be affected. It can be a disabling and painful condition, which can lead to substantial loss of functioning and mobility if not adequately treated. It is a clinical diagnosis made on the basis of symptoms, physical exam, radiographs (X-rays) and labs, although the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) publish diagnostic guidelines. Diagnosis and long-term management are typically performed by a rheumatologist, an expert in auto-immune diseases.[1]
Various treatments are available. Non-pharmacological treatment includes physical therapy, orthoses, occupational therapy and nutritional therapy but do not stop progression of joint destruction. Analgesia (painkillers) and anti-inflammatory drugs, including steroids, are used to suppress the symptoms, while disease-modifying antirheumatic drugs (DMARDs) are required to inhibit or halt the underlying immune process and prevent long-term damage. In recent times, the newer group of biologics has increased treatment options.[1]
The name is based on the term "rheumatic fever", an illness which includes joint pain and is derived from the Greek word peuma-rheuma (nom.), peumatoc-rheumatos (gen.) ("flow, current"). The suffix -oid ("resembling") gives the translation as joint inflammation that resembles rheumatic fever. The first recognized description of rheumatoid arthritis was made in 1800 by Dr Augustin Jacob Landré-Beauvais (1772–1840) of Paris.[2]
Older Rheumatoid Arthritis Patients Don't Get Needed Medicines
By Nicole Ostrow - Feb 1, 2011
More than one in three older patients with rheumatoid arthritis covered by some privately managed Medicare plans aren't getting medicines that lessen the severity of the debilitating condition, research showed.
Overall, 63 percent of patients enrolled in Medicare- managed care plans received drugs from 2005 to 2008 to treat the disease, according to a study today in the Journal of the American Medical Association. Patients ages 85 and older were less likely than those ages 65 to 69 to receive the drugs, as were men, people with low incomes and those living in the Middle and South Atlantic regions of the U.S., the study said.
Today's study is the largest to look at the use of these drugs in rheumatoid arthritis patients, lead study author Gabriela Schmajuk said. Medicines used to manage the condition are among the top 10 best-sellers in the U.S. including Roche Holding AG and Biogen Idec Inc.'s Rituxan, also called MabThera; Abbott Laboratories' Humira; Pfizer Inc. and Amgen Inc.'s Enbrel; and Merck & Co. and Johnson & Johnson's Remicade.
"Patients and doctors need to be aware that patients with active rheumatoid arthritis need to be taking disease-modifying agents," said Schmajuk, a post-doctoral scholar at Stanford University near Palo Alto, California, in a Jan. 29 e-mail. "Patients need to be proactive about asking for these medications or asking to be referred to a provider that specializes in rheumatic diseases."
Unknown Cause
It isn't known what causes rheumatoid arthritis, where the body's immune system turns on itself, and there isn't a known cure. About 1.3 million Americans have rheumatoid arthritis, which can leave patients unable to care for themselves, according to the Arthritis Foundation.
The study included information on patients enrolled in Medicare-managed care plans, which are alternatives to traditional fee-for-service plans for Medicare, the U.S. government's health plan for the elderly and disabled. The managed care plans provide hospital, outpatient and pharmacy coverage to more than 8 million Medicare beneficiaries, representing about 15 percent of all Medicare patients, Schmajuk said.
Researchers in the study used data from the National Committee for Quality Assurance to determine the use of the medicines from 2005 through 2008 in 93,143 patients who were at least 65 years old.
Patients diagnosed with rheumatoid arthritis need to have received at least one, one-month prescription for a disease modifying drug over a one-year period to be considered receiving treatment, she said. To be adequately treated, patients need to use the drugs continuously, not just one month a year, she said.
More Patients
The percentage of patients receiving the treatments rose to 67 percent in 2008 from 59 percent in 2005, the first year the health plans had to report rheumatoid arthritis drug use, the paper showed.
The researchers found that the largest difference in use was based on age. Those 85 and older had a 30 percentage point lower rate of treatment than those ages 65 to 69, the authors said.
Aside from age, gender and economic status, the researchers also found a 70 percentage point difference in coverage among the best and worst managed care plans. The names of individual company plans are not disclosed in the study or available from the National Committee for Quality Assurance database.
Patients Increasing
The number of patients receiving treatment is increasing over time, Susan Pisano, a spokeswoman for the trade group, America's Health Insurance Plans, said today in a telephone interview.
"If you measure something in health care and you provide feedback to the doctor, hospital or health plan it has an opportunity to put in place systems, approaches and steps to improve," she said. "And you do see improvement. This data offers us an opportunity to do better."
Schmajuk said it's not clear why there is so much variation among health plans. The age discrepancies may occur because doctors think patients ages 85 and older may not be healthy enough to take these drugs, which have potentially serious side effects, or because they have milder cases of the disease. More studies are needed to address these questions, she said.
The study has "opened up the door to say we need to look at this more closely," said Patience White, a rheumatologist and vice president for public health at the Atlanta-based non- profit Arthritis Foundation, today in a telephone interview. "This is a very serious disease."
More studies are needed to confirm the findings and try to determine why there is a variation among people receiving the arthritis treatments, Schmajuk said.
Receipt of Disease-Modifying Antirheumatic Drugs Among Patients With Rheumatoid Arthritis in Medicare Managed Care Plans - pdf attached
JAMA. Feb 1 2011
Despite evidence-based guidelines recommending early and aggressive treatment of active rheumatoid arthritis (RA),1 ,2 recent population-based studies of disease-modifying antirheumatic drug (DMARD) use in patients with RA report consistently low rates of DMARD receipt (30%-52%).3 ,4,5 ,6,7
In summary, we found significant differences in DMARD receipt based on individual, community, and health plan characteristics. Given the enormous individual and societal costs associated with RA, and increasing substantial evidence that DMARDs can reduce these costs, variations in DMARD receipt based on demographics, socioeconomic status, and geography are unacceptable. Because optimizing DMARD use is the primary mechanism for decreasing the significant public health impact of RA in the United States, targeting educational and quality improvement interventions to patients who are underusing DMARDs and their clinicians will be important to eliminate these disparities. Additional studies of population-wide cohorts that include clinical data and disease activity measures are needed to validate our findings.
The largest difference in performance on the HEDIS RA measure was based on age: participants aged 85 years and older had a 30 percentage point lower rate of DMARD receipt (95% CI 29-32 points) compared with patients 65 to 69 years old, even after adjusting for other factors (Table 3). Other participant categories less likely to receive a DMARD were men, individuals identified by race as black or other, individuals with low personal income, participants in lower socioeconomic status zip codes, and individuals in the Middle and South Atlantic regions. Patients living in a health professional shortage area had slightly lower performance (-3 percentage points; 95% CI, -1 to -5 points). In addition, patients enrolled in a for-profit health plan had a 4 percentage point lower rate of DMARD receipt (95% CI, 0 to -7 points) compared with patients enrolled in a not-for-profit health plan.
Individuals with both personal and neighborhood poverty had the lowest performance on the HEDIS RA measure (-7.1 percentage points; 95% CI, -9.8 to -4.4 points) compared with those without low personal income and living in any of the top 4 quintiles of socioeconomic status zip codes, individuals with only 1 type of poverty-a slightly better living standard (low personal income only, -6.9 percentage points; 95% CI, -8.9 to -5.0 points), and lowest socioeconomic status zip codes only (-2.4 percentage points; 95% CI, -4.1 to -0.8 points).
Performance varied widely by health plan (Figure) with rates ranging from 16% to 87%, even after adjusting for case mix. The range of adjustment due to case mix was -16% to +21% (mean, -1%; interquartile range, -4% to 1%).
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