Prescribing for Rheumatoid Arthritis Leaves Much to Be Desired

Atlanta—Many patients with rheumatoid arthritis (RA) are not being treated appropriately, according to 2 studies presented at the ACR meeting. The first study showed that only about half of all RA patients with high disease activity or moderate disease activity with a poor prognosis are being treated according to the 2008 ACR guidelines. The second study found that one third of RA patients on Medicare were not receiving any disease-modifying antirheumatic drugs (DMARDs). The first study was based on the CORRONA (Consortium of Rheumatology Researchers of North America) registry of approximately 23,000 patients treated by rheumatologists. Most patients with low disease activity were receiving therapy consistent with ACR guidelines; however, only 42% of those with moderate disease activity and 50% of those with high disease activity were receiving treatment commensurate with ACR-recommended treatment, said lead author Leslie R. Harrold, MD, University of Massachusetts Medical School in Worcester, Massachusetts. “The study suggests that publication of the guidelines did not change rheumatologists’ prescribing patterns,” Dr. Harrold indicated. The study included biologic-naïve RA patients cared for by US rheumatologists participating in the CORRONA registry between 6 and 18 months after the guidelines were published. Among methotrexate-only users, 91% to 95% of those with low disease activity scores and 79% to 89% of those with moderate disease activity scores and good prognosis were receiving nonbiologic DMARDs. Among those with moderate disease activity and poor prognosis, 34% to 38% were receiving care consistent with the guidelines. Among those with high disease activity, approximately 44% were receiving care consistent with the guidelines. In multiple nonbiologic DMARD users, 44% to 53% of those with moderate disease activity had guideline-consistent care, and 50% to 53% of those with high disease activity received guideline-consistent care. The second study was based on records for approximately 93,000 Medicare beneficiaries with RA included in the Healthcare Effectiveness Data and Information Set (HEDIS). Gabriela Schmajuk, MD, of Stanford University, Palo Alto, California, reported that approximately 35,000 patients (38%) were not receiving conventional or biologic DMARDs in 2008. The study found a wide variation in DMARD use among 245 health plans providing HEDIS data, ranging from 13% to 91%. Health maintenance organization plans instituted after 1999 were more likely to be low-performing plans with low use of DMARDs, Dr. Schmajuk continued, even after adjusting for other characteristics. Factors strongly associated with low DMARD use included age ≥85 years (41.5% used DMARDs), male sex (60.9% used DMARDs), nonwhite race (blacks, 56.6%; other nonwhite, 58.2%), low income (55%), geographic region (Mid-Atlantic or South Atlantic, >50%), and health professional shortage area (62%). The percentage of those receiving guideline-recommended drugs did increase over time, she commented. In 2005, 41% of Medicare recipients with RA in the HEDIS database were not receiving biologic or nonbiologic DMARD therapy, and in 2008, about 20% of RA patients failed to have DMARD treatment. The authors emphasized that quality improvement initiatives are needed so that older RA patients in low-performing plans and areas of the country receive recommended treatment.