Optimal Therapy for RA More Likely Under Rheumatologist Care

Alice Goodman

November 14, 2012

WASHINGTON — In 2009, 10% of Medicare patients received steroids as their sole treatment for rheumatoid arthritis (RA), instead of the recommended disease-modifying antirheumatic drugs (DMARDs), according to a new study.

These patients who received suboptimal therapy were more likely to be low income and to have been treated by a practitioner who was not a rheumatologist.

"Access to a rheumatologist was the single strongest predictor of DMARD use. Medicare recipients who did not have access to a rheumatologist were more likely to be treated with steroids alone, which is not recommended therapy. This study suggests that it is important to track the use of DMARDs as a performance measure in Medicare recipients," said study coauthor Jinoos Yazdany, MD, assistant professor at the University of California, San Francisco.

"This information may be useful to payers and health systems seeking to improve performance on quality measures for RA," she added.

"Improving quality of healthcare and removing disparities is important. Equity is one of the key components of quality care," Dr. Yazdany noted a press conference here at ACR 2012.

To achieve these goals, the investigators tracked the use of DMARDs (recommended in current American College of Rheumatology guidelines) and steroid therapy in a random sample of Medicare beneficiaries with RA. In that cohort, 7974 were treated with a DMARD; of those not treated with a DMARD, 824 (about 10%) received at least 6 months of steroids as the sole therapy for RA.

The patients who received only steroids were more likely to be 85 years and older than 65 to 69 years (17% vs 7%), and were more likely to have a low than a high income (13% vs 9%). The strongest predictor of steroid-only treatment for RA was access to a rheumatologist; only 6% of patients treated by a rheumatologist received steroids alone, compared with 16% of patients treated by other practitioners.

There was a strong association between steroid-only therapy and more inpatient admissions and comorbidities, Dr. Yazdany said.

"Patients with multiple risk factors — that is, low income, older age, and no contact with a rheumatologist — fared worse in terms of receiving recommended treatment," she said.

The same group of investigators conducted a study of a random sample of RA patients who received low-income subsidies through Medicare Part D. They found that subsidized patients were more likely to use biologics than those affected by the coverage gap in Part D who faced higher costs (i.e., the "doughnut hole"). This suggests that the coverage gap prevents patients who face substantial cost-sharing from accessing biologics through Part D.

"There are no generic equivalents of biologics, and 100% of RA patients will reach the doughnut hole. However, low-income patients receive a subsidy to fill the doughnut hole and are not exposed to cost-sharing for Part D. We compared the population who faced the doughnut hole with those who received a low-income subsidy," Dr. Yazdany explained.

Of the 5808 Medicare recipients with prescription coverage in 2009, 679 (12%) used biologic DMARDs, 5129 (88%) used nonbiologic DMARDs, and 1414 (24%) received a low-income subsidy. More biologic DMARD users received a low-income subsidy under Part D than nonbiologic users (44% vs 22%).

Dr. Yazdany said that the Affordable Care Act will eliminate the doughnut hole by 2020, and Part D will shift coinsurance so that patients will be responsible for 25% of drug costs until they reach the "catastrophic" level of $4000 per year.

"Our analysis suggests that patients will fare about the same as with the doughnut hole. We will still have a problem. We have to figure out how to pay for these expensive drugs," she noted.

Chris Tonner, MD, from the University of California, San Francisco, presented both sets of results at the meeting.

The moderator of the press conference, Kelly Weselman, MD, a rheumatologist at WellStar Rheumatology in Atlanta, Georgia, said such issues are common. "I see this every day in my practice, where choice of therapy is driven by financial considerations. These studies can be used to guide policy makers as we move forward."

"It is interesting that access to a rheumatologist drives the use of DMARDs and the nonuse of steroids as sole therapy for RA," Dr. Weselman added. "Rheumatologists do a better job of educating patients because they have more knowledge about the recommended medications. If a patient is prescribed a drug by a primary care physician who is not comfortable with antirheumatic drugs, the patient is less likely to use it," she said.

Dr. Yazdany and Dr. Tonner have disclosed no relevant financial relationships. Dr. Weselman reports participating in the Sunstone Study, funded by Genentech, for the postmarketing surveillance of rituximab in RA patients.

ACR 2012: Abstract 2559 presented November 14, 2012; Abstract 2464 presented November 13, 2012.