Abstract and Introduction
Objective: The aim of this study was to evaluate referral and treatment delays by ethnicity/race in patients with rheumatoid arthritis (RA) treated at an academic rheumatology center.
Methods: We reviewed the medical records of all RA patients evaluated at an outpatient clinic between 2011 and 2016 to identify newly diagnosed and naive-to-treatment patients. We determined the durations between symptom onset and first rheumatology visit and time to initiate treatment. Data extraction included referral source, demographics, treatment, and laboratory tests. Routine use of a multidimensional health assessment questionnaire allowed us to calculate baseline RAPID3 (routine assessment of patient index data 3) scores. Comparisons between self-reported ethnicity/race groups were performed. We used logistic regression models to analyze associations between baseline variables and early referral.
Results: Data from 152 disease-modifying antirheumatic drug-naive RA patients were included in the study; 35% were white, 37% black, 20% Hispanic, and 8% other. The range in median time to first rheumatology visit was 6 to 8 months for all patient groups, except Hispanic. This group had a median time of 22.7 months (p = 0.01). The referral pattern was considerably variable between-groups; 40% of Hispanic patients were self-referred (p = 0.01). There were no statistically significant between-group differences for time to treatment initiation according to ethnicity/race. RAPID3 scores (p = 0.04) and erythrocyte sedimentation rates (p = 0.01) were significantly higher in the black and Hispanic groups. A high C-reactive protein value at baseline was associated with earlier referral.
Conclusions: There is significant delay in initial presentation to a rheumatologist that was associated with a higher disease severity at presentation, especially for Hispanic patients.
Health disparities and inequities disproportionately affect racial and ethnic minority groups experiencing musculoskeletal conditions, including rheumatoid arthritis (RA). This problem is of particular concern in patients with RA because the chronic course of the disease leads to significant long-term disability and increased risk of mortality if not treated early. Without appropriate treatment, patients with RA have decreased work productivity and higher unemployment rates that result in significant negative effects at the individual and societal levels.[3–5]
Since the 1990s, scientific evidence has indicated that the prognosis for patients with RA improves when the disease is diagnosed and treated soon after symptom onset.[6–9] Multiple guidelines recommend initiation of disease-modifying antirheumatic drug (DMARD) treatment as early as possible after symptom onset, ideally during the initial 4 to 5 months when the disease is most susceptible to treatment. However, despite the evidence and recommendations,[7,11] the median time for treatment initiation remains suboptimal and unsatisfactory,[12,13] especially in minorities and lower-income patients. Examination of European registries has revealed that, since 2000, significant reductions in diagnostic delays have been apparent for European patients with RA and for patients with other inflammatory conditions (eg, psoriatic arthritis and ankylosing spondylitis). However, there are no results available for US patients for the same period.
Given the importance of early initiation of treatment, a better understanding of referral patterns and the baseline characteristics in a diverse population of US patients may help to identify potential sources of delay in treatment initiation. In this study, we examined the following: (1) potential disparities in rheumatology referral and treatment initiation in patients with RA in routine care, (2) baseline patient characteristics associated with early referral, and (3) level of improvement according to patient-reported outcomes in those patients with RA who received early, versus those who received delayed, treatment.
J Clin Rheumatol. 2020;26(7):279-284. © 2020 Lippincott Williams & Wilkins