Sex Differences Seen in Inflammatory Arthritis Healthcare Use

Jennifer Lubell

September 30, 2022

Women with inflammatory arthritis (IA) are more likely to use healthcare services than men, a Canadian study found. The results suggest there are biological differences in disease course and sociocultural differences in healthcare access and patient behavior among the sexes, Sanjana Tarannum said in a presentation at The Lancet Summit: Sex and gender in rheumatology conference in late September.

Tarannum and colleagues also recently published the study in the Annals of the Rheumatic Diseases.

Effectively managing IA patients calls for timely access to and appropriate use of healthcare resources, said Tarannum, of the Women’s College Research Institute in Toronto, Ontario, Canada.

Sex and gender are often used interchangeably but they refer to different things. “Sex is the biological characteristic of being male or female. It relates to disease inheritance patterns, pain processing mechanisms, and immune dysregulation in the context of inflammatory arthritis,” Tarannum said during her presentation.

Gender is a sociocultural construct associated with masculine or feminine traits. In the context of IA, gender relates to coping strategies, pain perception and reporting, and healthcare-seeking behavior of patients and interaction with care providers.

A patient’s sex relates to healthcare encounters, time to diagnosis, and prescription patterns. These all affect disease outcomes. Previous studies have yielded inconsistent results and mainly focused on rheumatoid arthritis (RA) rather than other IA types such as ankylosing spondylitis (AS).

Tarannum and colleagues sought to compare healthcare usage between male and female patients for musculoskeletal-related issues before and after IA diagnosis. They used Ontario administrative health data to create three cohorts of patients with RA, AS, and psoriatic arthritis (PsA), the three most common types of IA. The patients were diagnosed during 2010-2017, and outcomes were assessed in each year for 3 years before and after diagnosis.

Healthcare use indicators included visits to physicians, musculoskeletal imaging, laboratory tests, and dispensation of drugs. Regression models adjusting for sociodemographic factors and comorbidities were used to compare male and female patients.

Sex-Related Differences Emerge in All IA Groups

The investigators assessed 41,277 patients with RA (69% female), 8150 patients with AS (51% female), and 6446 patients with PsA (54% female). Male patients had more cardiovascular disease, whereas female patients had higher incidences of depression and osteoporosis.

Similar trends of sex-related differences emerged in all three cohorts. Before diagnosis, female patients were more likely to visit rheumatologists or family physicians for musculoskeletal reasons or use musculoskeletal imaging and laboratory tests. Women were also more likely to remain in rheumatology care after diagnosis.

Men were more likely to visit the emergency department for musculoskeletal reasons immediately before diagnosis.

No sex- or gender-related differences were observed in medication use, although older females with RA or AS were more likely to get prescriptions for NSAIDs and opioids and conventional disease-modifying antirheumatic drugs, respectively.

The findings show that overall musculoskeletal healthcare use was higher in female patients with IA. “Sex differences were more pronounced the earlier the encounter was from the time of diagnosis and tended to diminish with time,” Tarannum observed. Sex differences were also more prominent in the RA and AS cohorts.

Women Seek Out Care, Do Repeat Visits

Several reasons may explain why utilization was higher in females. Women with IA have a higher overall risk of musculoskeletal conditions such as osteoarthritis, which could have driven the healthcare encounters. Numerous studies have also reported that female patients have a lower threshold for pain as well as a greater tendency to seek out healthcare.

Additionally, female patients often present with pain and fatigue, which are often misdiagnosed as fibromyalgia or depression. Therefore, they often require repeated healthcare encounters to arrive at an IA diagnosis, Tarannum said.

An early prodromal phase in females could have triggered a healthcare encounter as well.

Men, by comparison, are more likely to have acute-onset or severe disease. Objective signs and radiologic features can facilitate diagnosis in men, she said. Male patients also show more reluctance in seeking care, have a higher threshold for pain, and are less likely to have a usual source of care such as a family physician.

Higher confidence in hospital-based emergency services also could have resulted in more emergency department visits and lower healthcare use in men. Better response to treatments could also have resulted in fewer episodes of rheumatology care after diagnosis.

The results aren’t surprising, said Scott Zashin, MD, a rheumatologist in Dallas, Texas, who wasn’t a part of the study.

“At least in terms of musculoskeletal disorders, my clinical experience suggests that women are more compliant with their follow-up than male patients. Especially with gout, a common type of arthritis in men, male patients may wait until their symptoms are severe before seeking medical attention,” Zashin said.

The Enid Walker Graduate Student Award for Research in Women’s Health provided funding for this study.

Ann Rheum Dis. Published online first Sept. 16, 2022. Full text.

The Lancet Summit: Sex and gender in rheumatology: Abstract O.01. Presented on Sept. 22, 2022.

Jennifer Lubell is a freelance medical writer in the Greater Washington Area.

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