Receipt of Disease-Modifying Antirheumatic Drugs Among Patients With Rheumatoid Arthritis in Medicare Managed Care Plans

Stanford University, Department of Medicine, Division of Rheumatology, 1000 Welch Rd, Ste 203, Stanford, CA 94304, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 02/2011; 305(5):480-6. DOI: 10.1001/jama.2011.67
Source: PubMed


In 2005, the Healthcare Effectiveness Data and Information Set (HEDIS) introduced a quality measure to assess the receipt of disease-modifying antirheumatic drugs (DMARDs) among patients with rheumatoid arthritis (RA).
To identify sociodemographic, community, and health plan factors associated with DMARD receipt among Medicare managed care enrollees.
We analyzed individual-level HEDIS data for 93,143 patients who were at least 65 years old with at least 2 diagnoses of RA within a measurement year (during 2005-2008). Logistic regression models with generalized estimating equations were used to determine factors associated with DMARD receipt and logistic regression was used to adjust health plan performance for case mix.
Receipt or nonreceipt of DMARD.
The mean age of patients was 74 years; 75% were women and 82% were white. Overall performance on the HEDIS measure for RA was 59% in 2005, increasing to 67% in 2008 (P for trend <.001). The largest difference in performance was based on age: patients aged 85 years and older had a 30 percentage point lower rate of DMARD receipt (95% confidence interval [CI], -29 to -32 points; P < .001), compared with patients 65 to 69 years of age, even after adjusting for other factors. Lower percentage point rates were also found for patients who were men (-3 points; 95% CI, -5 to -2 points; P < .001), of black race (-4 points; 95% CI, -6 to -2 points; P < .001), with low personal income (-6 points; 95% CI, -8 to -5 points; P < .001), with the lowest zip code-based socioeconomic status (-4 points; 95% CI, -6 to 2 points; P < .001), or enrolled in for-profit health plans (-4 points; 95% CI, -7 to 0 points; P < .001); and in the Middle Atlantic region (-7 points; 95% CI, -13 to -2 points; P < .001) and South Atlantic regions (-11 points; 95% CI, -20 to -3 points; P < .001) as compared with the Pacific region. Performance varied widely by health plan, ranging from 16% to 87%.
Among Medicare managed care enrollees carrying a diagnosis of RA between 2005 and 2008, 63% received a DMARD. Receipt of DMARDs varied based on demographic factors, socioeconomic status, geographic location, and health plan.

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Available from: Edward H Yelin, Aug 10, 2015
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    • "Several other insurance claims-based studies have confirmed that increasing age may act as a deterrent for using DMARDs [13-15]. Low-socioeconomic status and lack of rheumatic disease specialty care have also been identified as predictors of suboptimal DMARD use in populations, after adjusting for health care and drug-insurance benefits [15,16]. "
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    ABSTRACT: Disease modifying anti-rheumatic drugs (DMARDs) have become the treatment standard for patients with rheumatoid arthritis (RA). While several general population studies document that a large population of patients diagnosed with RA do not use DMARDs, little is known about this group. This paper explores the characteristics, experiences, and knowledge of a low-income, elderly RA population not currently using DMARDs, or being followed by a rheumatologist. We administered structured telephone interviews to participants enrolled in a large pharmacy benefits program for the elderly, who had two diagnoses of RA >=7 days apart and no DMARD prescriptions or rheumatologist visits in the prior year. It contained questions concerning each participant's sociodemographic information, disease activity, DMARD experiences, and the Modified Health Assessment Questionnaire (MHAQ). We described responses and compared prior users versus never users. In this study 86 people completed the interview. The mean age was 80 and 89% were female. On average, disease duration was 20 years. Mean MHAQ score was 0.55 (SD = 0.55). Out of 86 participants, 19 had previously used DMARDs, 10 of whom discontinued them due to side effects or safety concerns. Among 67 never-users, 35 (52.2%) reported that their physicians had never offered them DMARDs, 13 (19.4%) described fear of side effects, and 49 (73.1%) knew nothing about them. Prior-users described more severe RA symptoms than never-users. We found side effects or safety concerns were the primary cause for DMARD cessation among prior-users. Among never-users, most report never discussing or being offered DMARDs, suggesting that an educational gap may deter patients with RA from using them.
    Full-text · Article · Jan 2014 · Arthritis research & therapy
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    • "The prescription of a DMARD for patients with RA is considered a standard of effective care [1] and there is increasing expectation for rheumatologists to objectively measure RA disease activity and to strive to treat patients to achieve low disease activity [2,3]. However a recent study of Medicare managed care enrollees found only 63% received a DMARD [4]. The explanation for underutilization is not fully known; however DMARD decisions are complex and require patients to consider important tradeoffs. "
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    ABSTRACT: Background: The causes of the underutilization of disease modifying anti-rheumatic drugs (DMARDS) for rheumatoid arthritis (RA) are not fully known, but may in part, relate to individual patient factors including risk perception. Our objective was to identify the determinants of risk perception (RP) in RA patients and predictors of their willingness to take a proposed DMARD (DMARD willingness). Methods: A cross-sectional mail survey of RA patients in a community rheumatology practice. Patients were presented a hypothetical decision scenario where they were asked to consider switching DMARDs. They evaluated how risky the proposed medication was and how likely they would be to take it. Results: The completed sample included 1009 RA patients. The overall survey response rate was 71%. Patient characteristics: age 61.6 years (range 18-93), 75% female, minority 6.5%, low or marginal health literacy 8.8%, depression 15.0%, duration RA 13.1 years (range 0.5 – 68). Regression models demonstrated that health literacy, independent of low educational achievement or other demographic (including race), was a common predictor of both RP and DMARD willingness. There was partial mediation of the effects of HL on DMARD willingness through RP. Depression and happiness had no significant effect on RP or DMARD willingness. RP was influenced by negative RA disease and treatment experience, while DMARD willingness was affected mainly by perceived disease control. Conclusions: Risk aversion may be the result of potentially recognizable and correctable cognitive defect. Heightened clinician awareness, formal screening for low health literacy or cognitive impairment in high-risk populations, may identify patients could benefit from additional decision support. Keywords: Decision-making, Risk perception, Depression, Health disparity, Disease-modifying anti-rheumatic drugs, Rheumatoid arthritis
    Full-text · Article · Aug 2013 · BMC Medical Informatics and Decision Making
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    • "Second, the reduced use of DMARDs in older patients has been found in several other analyses of RA [4,6,7]. Older individuals may have comorbidities that would be relative contraindications to DMARD use. "
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    ABSTRACT: Introduction Numerous studies across different health systems have documented that many patients with rheumatoid arthritis (RA) do not receive disease-modifying anti-rheumatic drugs (DMARDs). Relatively little is known about correlates of DMARD use and whether there are socioeconomic and demographic disparities. We examined DMARD use during 2001 to 2006 in the Medicare Current Beneficiary Survey (MCBS), a longitudinal US survey of randomly selected Medicare beneficiaries. Methods Participants in MCBS with RA were included in the analyses, and DMARD use was based on an in-home assessment of all medications. Variables included as potential correlates of DMARD use in weighted regression models included race/ethnicity, insurance, income, education, rheumatology visit, region, age, gender, comorbidity index, and calendar year. Results The cohort consisted of 509 MCBS participants with a diagnosis code for RA. Their median age was 70 years, 72% were female, and 24% saw a rheumatologist. Rates of DMARD use ranged from 37% among those <75 years of age to 25% of those age 75 to 84 and 4% of those age 85 and older. The multivariable adjusted predictors of DMARD use include: visit with a rheumatologist in the prior year (odds ratio, OR, 7.74, 95% CI, 5.37, 11.1) and older patient age (compared with <75 years, ages 75 to 84, OR 0.58, 95% CI 0.37, 0.92, and 85 and over, OR 0.09, 95% CI 0.02, 0.31). In those without a rheumatology visit, lower income and older age were associated with a significantly reduced probability of DMARD use; no association of DMARD use with income or age was observed for subjects seen by rheumatologists. Race and ethnicity were not significantly associated with receipt of DMARDs. Conclusions Among individuals not seeing rheumatologists, lower income and older age were associated with a reduced probability of DMARD use.
    Full-text · Article · Mar 2013 · Arthritis research & therapy
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