Quality Care in Seniors With New-Onset
Rheumatoid Arthritis: A Canadian Perspective
JESSICA WIDDIFIELD,1SASHA BERNATSKY,2J. MICHAEL PATERSON,3J. CARTER THORNE,4
ALFRED CIVIDINO,5JANET POPE,6NADIA GUNRAJ,3AND CLAIRE BOMBARDIER1
Objective. To estimate the percentage of seniors with rheumatoid arthritis (RA) receiving disease-modifying antirheu-
matic drugs (DMARDs) within the first year of diagnosis.
Methods. We assembled an incident RA cohort from Ontario physician billing data for 1997–2006. We used a standard
algorithm to identify 24,942 seniors with RA based on >2 billing codes >60 days apart but within 5 years. Drug exposures
were obtained from pharmacy claims data. We followed subjects for 1 year, assessing if they had been exposed (defined
as >1 prescription) to 1 or more DMARDs within the first year of RA diagnosis. We assessed secular trends and
differences for subjects who had received rheumatology care (defined as >1 rheumatology encounter) versus those who
Results. In total, only 39% of the 24,942 seniors with new-onset RA identified over 1997–2006 were exposed to DMARD
therapy within 1 year of diagnosis. This increased from 30% in 1997 to 53% in 2006. Patients whose care involved a
rheumatologist were more likely to be exposed to DMARDs than those who had no rheumatology care. In 2006, 67% of
subjects receiving rheumatology care were exposed to DMARDs versus 21% of those with no rheumatology care.
Conclusion. Improvements in RA care have occurred, but more efforts are needed. Subjects receiving rheumatology care
are much more likely to receive DMARDs as compared to those with no rheumatology care. This emphasizes the key role
It is well known that for patients with rheumatoid arthritis
(RA), delays in initiating therapy are associated with neg-
ative health outcomes (1). Existing guidelines recommend
early and aggressive treatment (2). The Ontario Biologics
Research Initiative (OBRI) represents a collaboration of
rheumatologists, patients, decision makers, and health
care researchers. The OBRI focuses on the real-world ef-
fectiveness and safety of drug therapies for RA; part of the
work of the OBRI to date has been the evaluation of exist-
ing practice patterns in order to identify areas in need of
improvement. Much of the OBRI analyses have made
use of Ontario’s administrative health care databases,
which capture the health service encounters of all Ontario
The prevalence of RA increases with age, and although
early reports suggested that seniors with RA may have a
more benign course than their younger counterparts, more
recent studies report that the outcome in seniors with RA
may be no better, or even worse, than those who are
younger (3–5). Therefore, it is important that seniors be
The opinions, results, and conclusions are those of the
authors and are independent from the funding sources. No
endorsement by the Institute for Clinical Evaluative Sci-
ences or the Ontario Ministry of Health and Long-Term Care
is intended or should be inferred.
Supported by the Canadian Institutes of Health Research
(operating grants 82717 and 83264), the Ontario Ministry
of Health Drug Innovation Fund, and the Institute for Clin-
ical Evaluative Sciences, a nonprofit research corporation
funded by the Ontario Ministry of Health and Long-Term
Care. Dr. Bernatsky holds a Canadian Institutes of Health
Research New Investigator Award (2005–2010). Dr. Bom-
bardier holds a Canada Research Chair in Knowledge
Transfer for Musculoskeletal Care (2002–2016) and a Pfizer
Research Chair in Rheumatology.
1Jessica Widdifield, BSc, Claire Bombardier, MD, FRCPC:
University of Toronto, Toronto, Ontario, Canada;
Bernatsky, MD, PhD: McGill University, Montreal, Quebec,
MPH: Institute for Clinical Evaluative Sciences and Univer-
sity of Toronto, Toronto, and McMaster University, Hamil-
ton, Ontario, Canada;4J. Carter Thorne, MD, FRCPC: South-
lake Regional Health Centre, Newmarket, Ontario, Canada;
5Alfred Cividino, MD, FRCPC: McMaster University, Ham-
ilton, Ontario, Canada;
St. Joseph Health Care, London, Ontario, Canada.
Address correspondence to Sasha Bernatsky, MD, PhD,
Division of Clinical Epidemiology, Research Institute of the
McGill University Health Centre, 687 Pine Avenue West,
V-Building, Montreal, Quebec, H3A 1A1, Canada. E-mail:
Submitted for publication April 1, 2010; accepted in re-
vised form July 16, 2010.
3J. Michael Paterson, MSc, Nadia Gunraj, BSc,
6Janet Pope, MD, FRCPC, MPH:
Arthritis Care & Research
Vol. 63, No. 1, January 2011, pp 53–57
© 2011, American College of Rheumatology
SPECIAL ARTICLE: QUALITY OF CARE IN THE RHEUMATIC DISEASES
offered prompt and appropriate care, including access to
rheumatologists and disease-modifying antirheumatic drugs
The main objective of the current study was to estimate
the percentage of seniors with RA exposed to DMARDs
within the first year of diagnosis.
PATIENTS AND METHODS
We assembled an incident RA cohort age ?65 years using
the administrative health databases of the Ontario Health
Insurance Plan (OHIP) for January 1997 to March 2007.
In the province of Ontario, all 13 million residents are
covered by universal public health insurance. The OHIP
physician billing database contains information regarding
physician services, including the service provided and the
patient’s diagnosis, coded using International Classifica-
tion of Diseases, Ninth Revision (ICD-9) codes. Medication
exposures were determined using the pharmacy claims
database of the Ontario Drug Benefit Program, which cov-
ers residents who are ages ?66 years or receiving social
assistance. We used a previously published algorithm to
identify RA patients within the OHIP billing data, based
on at least 2 billing code diagnoses of RA (ICD-9 code 714)
more than 60 days apart but within 5 years. We further
required patients to have at least one prescription for a
glucocorticoid, DMARD, or biologic response modifier
during the entire study period (6,7). In an attempt to ex-
clude potential prevalent cases of RA migrating into the
province, individuals who did not have contact with On-
tario’s health care system within the 5 years prior to diag-
nosis were excluded.
We followed subjects with incident RA (by our defini-
tion) for a period of 1 year, assessing whether subjects
received at least 1 DMARD (methotrexate, hydroxychloro-
quine, sulfasalazine, azathioprine, leflunomide, or cyclo-
phosphamide) prescription within the first year of RA
diagnosis. We assessed secular trends and differences for
subjects who had received rheumatology care (defined as 1
or more rheumatologist encounter within the billing data)
versus those who had not.
We performed logistic regression analyses to determine
whether demographics (age, sex, urban versus rural resi-
dence, socioeconomic status [SES], calendar year, and
clinical factors [comorbidity, proxies for disease severity])
were associated with DMARD use, after accounting for
whether patients saw a rheumatologist. SES was defined
as the patient’s neighborhood income quintile from the
Table 1. Demographics and clinical features of seniors for those referred versus those not referred*
(n ? 24,942)
Seen by a rheumatologist in the first
year after cohort entry
No (n ? 10,793)Yes (n ? 14,149)
Age, mean ? SD years
Calendar year of entry
Charlson comorbidity index
No. of drugs in the year prior to entry, mean ? SD
Presence of extraarticular features of RA
No. of physician visits in the year prior to entry, mean ? SD
74.6 ? 6
75 ? 6.28
74.2 ? 5.76
9.2 ? 5.7
13.8 ? 9.51
9 ? 5.7
12.9 ? 9.33
9.4 ? 5.6
14.5 ? 9.59
* Values are the number (percentage) unless otherwise indicated. RA ? rheumatoid arthritis.
54Widdifield et al
Statistics Canada Census. The measure of comorbidity
was the Deyo-Charlson comorbidity index, derived from
hospital discharge abstracts (8,9). For patients who did
not receive inpatient care during the period of analysis, a
variable for “missing” was included as a separate Charlson
category. As an additional measure of comorbidity, we
counted the number of prescription drugs each patient
received in the preceding year (10).
Proxies for disease severity included prescriptions for
nonsteroidal antiinflammatory drugs and systemic cortico-
steroids in the first year of RA diagnosis, as well as the
presence of extraarticular features of RA at cohort entry.
A sensitivity analysis was performed to explore the po-
tential effects of disease severity on DMARD use. A similar
regression model was constructed that included frequency
of physician visits in the first year (measured as a contin-
uous variable) as a proxy for disease severity, replacing the
binary variable of contact with a rheumatologist.
Finally, we performed secondary analyses to assess
whether DMARD use increased significantly after the emer-
gence of a national consensus statement. In 2004, the
Canadian Rheumatology Association (CRA) convened an
expert panel regarding optimal therapy in early RA. This
led to the development and dissemination of a consensus
statement, which reinforced the importance of early RA
treatment with DMARDs (11). Secondary analyses exam-
ined whether DMARD prescription in early RA increased
in the period following as compared to before the devel-
opment and dissemination of this consensus statement.
We identified 25,141 seniors with new-onset RA (accord-
ing to our definition) over 1997–2006. We excluded 199
who had no contact with the health care system in the 5
years prior to their RA diagnosis, for a total study sample
of 24,942. The majority of subjects (17,027 [68.3%]) were
women, and the mean ? SD age at cohort entry was 74.6 ?
6.01 years. A significant minority (4,038 [16.2%]) resided
in rural areas. The Charlson comorbidity index values
were 1 or greater in 6.5%, with the majority of subjects
having no hospitalization during the period of interest.
Table 1 compares those who received care from a rheu-
matologist versus those who did not, in terms of demo-
graphics and clinical features. Seniors who saw a rheuma-
tologist were more likely to live in urban (versus rural)
areas, and were more likely to have ?1 extraarticular fea-
ture of RA. In the 24,942 seniors with new-onset RA iden-
tified over 1997–2006, 39% (n ? 9,737) were exposed to
DMARD therapy within 1 year of diagnosis. This increased
from 30% in 1997 to 53% in 2006 (Figure 1).
Overall, 56% of patients saw a rheumatologist within
the first year of RA diagnosis. This percentage increased
over time, from 47% in 1997 to 69% in 2006. In 1997,
the percentage of early RA patients prescribed a DMARD
was 51% among those who saw a rheumatologist com-
pared to 11% of those who had no such contact. In 2006,
the same figures were 67% and 21%, respectively (Figure
1). Therefore, much of the increase in DMARD exposure
from 1997–2006 was related to increasing exposure to
In half of the cases, the initial DMARD prescribed was
hydroxychloroquine (51.6%). The next most common first-
use DMARD was methotrexate (36.3%), followed by sul-
fasalazine (6.3%). Combination therapy was prescribed in
5.8% of cases, with the most common combination ther-
apy being hydroxychloroquine and methotrexate. In the
other subjects, the first medication exposures were varied,
but included (in descending order) azathioprine, lefluno-
mide, and cyclophosphamide. Five individuals were iden-
tified as receiving a biologic response-modifying drug
prior to their first DMARD prescription.
The results of the logistic regression analyses (Table 2)
showed that seniors receiving care from a rheumatologist
were 10 times more likely to receive a DMARD in the first
year of RA diagnosis, as compared to those without rheu-
matology care. There was also less DMARD use among
seniors with increasing age. As expected, DMARD use was
correlated with steroid use.
Interestingly, prior to controlling for whether or not a
patient had encountered a rheumatologist, the odds ratio
(OR) for rural residence suggested less DMARD prescrip-
tions for rural residents (0.92, 95% confidence interval
[95% CI] 0.86–0.99). However, after adjusting for the
lower rate of rheumatology encounters among subjects
from rural areas, rural residents were relatively more likely
to receive a DMARD prescription within the first year of
RA diagnosis (OR 1.18, 95% CI 1.09–1.28).
In terms of the subanalyses for time periods before and
after the CRA guidelines, we did indeed observe a signif-
icant increase in DMARD use over 2004–2006 versus
2001–2003. The percentage of early RA patients exposed
to DMARDs over 2001–2003 was 40% (95% CI 39–41%)
compared to 50% (95% CI 49–51%) in 2004–2006. This
substantial increase is statistically significant (OR 9%,
95% CI 10–11%). However, when we looked at early pe-
riods, the percentage of early RA patients exposed to
DMARDs in 1998–2000 was 32% (95% CI 31–33%), indi-
cating an increase during 1998–2000 versus 2001–2003,
even before publication of the CRA consensus statement.
Figure 1. Percentages of patients with new-onset rheumatoid
arthritis who received disease-modifying antirheumatic drugs
(DMARDs; methotrexate, hydroxychloroquine, sulfasalazine, aza-
thioprine, leflunomide, cyclophosphamide, and combinations)
within the first year of diagnosis and who were seen by a rheu-
matologist within the first year of diagnosis.
Rheumatoid Arthritis Care in Seniors 55
Earlier population-based assessments have demonstrated
that many Canadians are not provided optimal RA therapy
(12,13); this seems especially true for older persons with
RA. Our work emphasizes that even in the setting of uni-
versal health insurance, suboptimal treatment of RA oc-
curs. Our results support an earlier study by Shipton et al,
which suggested that the problem is at least in part due to
poor access to specialty care (14). The problems do not lie
only in the failure to establish therapy. Increasing age is
associated with a greater risk of methotrexate discontinu-
ation in RA (15).
What factors may have contributed to improved rheu-
matology care for seniors with RA in Ontario over our
study interval? Some have indicated that clinical guide-
lines may indeed have a role (16). Our subanalyses suggest
that appropriate drug therapy for older individuals with
RA has improved since the CRA consensus statement was
established. However, given the increase in DMARD use
during 1998–2000 versus 2001–2003, awareness of the
need for early therapy was apparently increasing even
before the CRA consensus statement was published.
Our data also suggested an increasing recognition of the
need for prompt referral of patients with early RA to a
rheumatologist. This occurred in the absence of any in-
crease in the per capita ratio of rheumatologists in Ontario.
As of 2006, there were 152 rheumatologists in Ontario
(representing 126 full-time equivalents as based on the
American College of Rheumatology standard of at least
32 hours per week of direct clinical care ). The overall
provincial per capita provision in 2006 was 1.20 rheuma-
tologists per 100,000 population (1.00 full-time equiva-
lents per 100,000), which is actually 25% less than the
figures in 1997 (18). In recent years, there have been other
rheumatology manpower trends in Ontario, including
more female rheumatologists (25% in 1992 versus 37% in
2006), and a small but steady increase over time in average
number of years of experience (14 in 1992 versus 18 in
2006) and the number of clinic half days worked per week
(8.89 in 1997 versus 9.58 in 2006).
Despite improvements in care, our findings suggest that
DMARD use in older RA patients remains suboptimal in
Ontario. This is particularly true in patients who do not
have access to a rheumatologist. Among these patients,
fewer than 20% received a DMARD in the first year of
diagnosis. We interpret this as emphasizing the important
role rheumatologists play in RA care.
Administrative data are efficient tools for evaluating
quality of care. However, they have several important
limitations. Our analyses were limited to persons ages
?65 years. In Ontario, analyses of younger individuals are
difficult, as prescription drug insurance is continuous for
seniors only. Also, administrative data preclude clinical
confirmation of diagnoses and disease onset. Future work
will include assessment of the validity of RA diagnosis
coding in Ontario administrative data. It is possible that
some of the RA patients we studied were prevalent rather
than incident cases. However, the rates of DMARD use we
observed are a problem regardless of whether cases were
incident or prevalent, since recent data show that most
patients with longstanding RA indeed require continuous
DMARD treatment (19). We note that the 5 individuals
who received a biologic drug prior to their DMARD may be
indicative of prevalent cases misclassified as new onset
according to our administrative definition. Alternatively,
these individuals may have received the drug for another
indication (e.g., inflammatory bowel disease or psoriasis),
or they could represent rare severe cases of RA and/or
special circumstances, in which early access to biologics
was granted on an exceptional basis.
In conclusion, some improvements in RA care have
occurred over time, but more efforts are needed, especially
for vulnerable populations like seniors. Future OBRI re-
search will further delineate practice patterns, the influ-
ence of funding, and the real-world effectiveness and
safety of antirheumatic therapies.
Table 2. Odds of a senior receiving a disease-modifying
antirheumatic drug within the first year of RA diagnosis
from the multivariable regression for the effects of
demographic and clinical factors*
OR (95% CI)
Income quintile (ref. ? 1)†
Calendar year of entry (ref. ? 1997)
Presence of extraarticular RA features
Charlson comorbidity index (ref. ? 0)‡
No. of drugs in the year prior to index
NSAID use in year 1
Systemic steroid use in year 1
* RA ? rheumatoid arthritis; OR ? odds ratio; 95% CI ? 95%
confidence interval; NSAID ? nonsteroidal antiinflammatory drug.
† We used information from the Statistics Canada Census on neigh-
borhood income levels for the dissemination area in which each
‡ Derived from hospital encounters, based on administrative data-
56Widdifield et al
The authors would like to acknowledge contributions from
members of the OBRI: Catherine Hofstetter, Anne Lyddiatt,
and Annette Wilkins.
All authors were involved in drafting the article or revising
it critically for important intellectual content, and all authors
approved the final version to be submitted for publication.
Dr. Bernatsky had full access to all of the data in the study and
takes responsibility for the integrity of the data and the accuracy
of the data analysis.
Study conception and design. Widdifield, Bernatsky, Paterson,
Thorne, Cividino, Pope, Bombardier.
Acquisition of data. Gunraj.
Analysis and interpretation of data. Widdifield, Bernatsky,
Paterson, Thorne, Cividino, Pope, Gunraj, Bombardier.
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Rheumatoid Arthritis Care in Seniors57