Variations in DMARD receipt exist in Medicare managed care patients with RA

An analysis of data from more than 90,000 Medicare managed care enrollees who received care for rheumatoid arthritis (RA) found that more than one-third did not receive the recommended treatment with a disease-modifying antirheumatic drug (DMARD), and that receipt varied by demographic factors, socioeconomic status, geographic location, and health plan, according to a study in the February 2 issue of JAMA.

Despite evidence-based guidelines recommending early and aggressive treatment of active RA, recent population-based studies of DMARD receipt in patients with RA report low rates of use, although these data may not be broadly generalizable because of several limitations.

Gabriela Schmajuk, MD, MS, of Stanford University, Stanford, Calif., and colleagues examined sociodemographic, community, and health plan factors associated with DMARD receipt among Medicare managed care enrollees. Researchers analyzed Healthcare Effectiveness Data and Information Set (HEDIS) data for 93,143 patients who were at least aged 65 years old with at least 2 diagnoses of RA within a year (during 2005 to 2008). The average age of patients was 74 years; 75% were women and 82% were white.

Overall performance on the HEDIS measure for RA in the study sample was 63%. In 2005, 59% of the sample received a DMARD, increasing to 67% in 2008. The largest difference in performance on the HEDIS RA measure was based on age: participants aged 85 years and older had a 30 percentage point lower rate of DMARD receipt (95% CI, -29 to -32; P<.001) compared with patients aged 65 to 69 years old. Other participant categories less likely to receive a DMARD were men (95% CI, -5 to -2; P<.001); individuals identified by race as black (95% CI, -6 to -2; P<.001); individuals with low personal income (95% CI, -8 to -5; P<.001); participants in lowest zip code-based socioeconomic status (95% CI, -6 to -2; P<.001) or enrolled in for-profit health plans (95% CI, -7 to 0; P<.001); and individuals in the Middle Atlantic (95% CI, -13 to -2; P<.001) and South Atlantic (95% CI, -20 to -3; P<.001) regions.

“Patients living in a health professional shortage area had slightly lower performance [-3 percentage points]. In addition, patients enrolled in a for-profit health plan had a 4 percentage point lower rate of DMARD receipt compared with patients enrolled in a not-for-profit health plan,” the authors wrote. Performance varied widely by health plan, with rates ranging from 16% to 87%.

The authors added: “Given the enormous individual and societal costs associated with RA, and increasing substantial evidence that DMARDs can reduce these costs, variations in DMARD receipt based on demographics, socioeconomic status, and geography are unacceptable. Because optimizing DMARD use is the primary mechanism for decreasing the significant public health impact of RA in the United States, targeting educational and quality improvement interventions to patients who are underusing DMARDs and their clinicians will be important to eliminate these disparities.”