Addressing Social Determinants to Achieve Equity in Care for Patients with Rheumatoid Arthritis

Results of a recent study showed that a disproportionately large percentage of socially deprived, Medicaid-covered, and high comorbidity patients with rheumatoid arthritis (RA) were cared for by a small number of rheumatology practices. Further studies are necessary in these high-deprivation areas to create a more even distribution of specialty care for this patient population, according to research published in ACR Open Rheumatology.¹

“RA is associated with significant morbidity and mortality, particularly in patients who are seropositive and who have persistently high disease activity,” Sharon Dowell, MD, Associate Professor of Medicine, Division of Rheumatology, Howard University College of Medicine, and colleagues, wrote. “Clinical outcomes are partially determined by social and nonclinical factors that influence timely access to specialty care, early diagnosis, and initiation of effective therapy. In the United States, regional variations exist in the quality of care of patients with RA and are exacerbated by inequity in RA disease outcomes across ethnic subsets.”

Comorbidity in this patient population is associated with worse outcomes and higher health care use. Those in underrepresented ethnic groups may lack preventative care or management of comorbid diseases.² Further, patients with lower socioeconomic status (SES) tend to have higher rates of comorbidity.

A retrospective cohort analysis of Rheumatology Informatics System for Effectiveness (RISE) registry data was collected to determine factors associated with regional variation of disease burden in patients with RA living in the United States. The registry is the largest electronic health record (EHR)-based rheumatology registry in the country and contains data for over 2.4 million patients. Information included RA disease activity, SES, health insurance type, geographic region, and comorbidity burden.

Disease activity was determined via the Clinical Disease Activity Index (CDAI) and Routine Assessment of Patient Index Data-version 3 (RAPID3). Low SES was defined as an Area Deprivation Index (ADI) score of >80. Median travel distance to rheumatology practices zip codes was calculated and linear regression evaluated links between RA disease activity and comorbidity, determined using the Rx-Risk Comorbidity Index, while adjusting for sex, age, race, region, and insurance type.

A total of 184,722 patients with RA from 182 RISE locations were included in the analysis. Most (69.4%) patients were White and 77.2% were female with a mean age of 64 years. Insurance coverage was similar for both government (30%) and private (30%), which didn’t vary between races or ethnicities.

Disease activity was higher in patients with Medicaid or Medicare coverage (4.60 units [95% confidence interval [CI]: 4.30-4.89]; 1.44 units [1.31-1.57], respectively) and African Americans (mean adjusted increase of 1.73 [95% CI: 1.58 – 1.88]). Burden was also higher in those from Southern regions, with a mean adjusted increase of 1.22 units compared with the Northeast and 1.77 points compared with the Midwest.

A greater prevalence of comorbidity occurred in patients in the South and those with Medicare or Medicaid insurance. A moderate correlation between comorbidity and disease activity was also observed (RAPID3 0.28, CDAI 0.15).

High deprivation areas were predominantly located in Southern regions. The mean national ADI score was 45.6; however, there was a 2- to 3-fold greater prevalence of socially deprived subsets in the South. Although most patients lived within 50 miles of their provider, patients who lived more than 200 miles away from a specialist (2.9%) were primarily located in Southern (4.1%) and Western (2.1%) regions of the United States. Approximately 10% of rheumatology practices (fewer than 20 practices) cared for more than 50% of patients with Medicaid and a high ADI score.

Using retrospective data from nonacademic rheumatology practice sites may have limited the results and reduced generalizability among all practice types, such as academic medical centers. However, the inclusion of a large cohort of real-world patients with RA and geographic representation allowed investigators to evaluate social determinants of health and disease-specific variables.

“To achieve equity in care, patients should ideally have equal access to rheumatologists irrespective of place of domicile or insurance type,” investigators concluded. “The higher burden (and cost) of care required for patients with comorbidity should be accounted for within value-based metrics and reimbursement models with expanded coverage for social support services. Incentives that encourage practices to include Medicaid-eligible participants in their clientele, with changes in the compensation structure (eg, risk-based adjustment), need to be considered.”

References

1. ^{Dowell S, Yun H, Curtis JR, et al. Geographic Variation in Disease Burden and Mismatch in Care of Patients With Rheumatoid Arthritis in the United States [published online ahead of print, 2023 Feb 21]. ACR Open Rheumatol. 2023;10.1002/acr2.11532. doi:10.1002/acr2.11532}
2. ^{Curtis JR, Chen L, Greenberg JD, et al. The clinical status and economic savings associated with remission among patients with rheumatoid arthritis: leveraging linked registry and claims data for synergistic insights. Pharmacoepidemiol Drug Saf 2017;26:310–9.}