Disparities in burden of disease in patients with rheumatoid arthritis across racial and ethnic groups.

To examine racial/ethnic differences in rheumatoid arthritis (RA) disease burden and change in clinical outcomes over time. We included CorEvitas Rheumatoid Arthritis Registry patients from two time periods (2013-2015 and 2018-2020). Clinical Disease Activity Index (CDAI) (as a continuous measure and as a dichotomous measure) and the Health Assessment Questionnaire-Disability Index (HAQ-DI) were assessed at each visit. Marginal means and their corresponding 95% confidence interval (CI) by race/ethnicity were estimated for each outcome using adjusted mixed effects linear and logistic regression models. Overall and pairwise tests were conducted to detect differences between race/ethnicity groups. Of 9,363 eligible patients (8,142 White, 527 Black, 545 Hispanic, 149 Asian), most (76%-85%) were female. At Visit 1, the mean disease duration ranged from 9.8-11.8 years. Estimated CDAI was significantly higher for Hispanics compared to Whites at Visit 1 (11.1 vs. 9.9; pairwise P = 0.033) and Visit 2 (9.2 vs. 8.0, pairwise P = 0.005). Disease activity improved over the 5-year study period among all race/ethnicity groups, though Hispanics improved less than Whites. Disease activity improved over the 5-year period across all racial/ethnicity groups, and disparities between racial/ethnicity groups in disease activity and functional status did persist over time, suggesting that further effort is needed to understand the drivers of these discrepancies to close this race/ethnicity gap. Key Points • Disease activity improved over the 5-year period across all racial and ethnic groups. • Disparities between racial and ethnic groups in disease activity and functional status did persist over time, suggesting that further effort is needed to understand the drivers of these discrepancies and close this racial gap.

The genetics of rheumatoid arthritis.

RA is a chronic systemic inflammatory disease that primarily affects the small joints of the hands and feet, and results in a mean reduction in life expectancy of 3-10 years. RA is a multigene disorder with a substantial genetic component and a heritability estimate of 60%. Large-scale Genome-Wide Association Studies (GWAS) and meta-analyses have revealed common disease-associated variants in the population that may contribute cumulatively to RA pathogenesis. This review identifies the most significant genetic variants associated with RA susceptibility to date, with particular focus on the contribution of the HLA class II genes across different ethnic groups. Also discussed are the potential applications of pharmacogenomics to RA management by identifying polymorphisms associated with variation in treatment response or toxicity. The use of genetic variants to guide treatment strategy has the potential to not only reduce National Health Service costs, but also drastically improve patient experience and quality of life.

Cross-culture adaptation and validation of English version of Rheumatoid Arthritis Knowledge Assessment Scale (RAKAS) in patients with rheumatoid arthritis.

AIM: To carry out cross-culture adaptation and validation of the English version of Rheumatoid Arthritis Knowledge Assessment Scale (RAKAS) in patients with rheumatoid arthritis (RA). METHODS: A cross-sectional study was conducted for 2 months in 2 tertiary care hospitals in Karachi, Pakistan. Sample size was calculated based on item-subject ratio. The translation was carried out using standard procedures for translation and cross-culture adaptation. The validation process included estimation of discrimination power, item difficulty index, factorial, convergent, construct and known group validities and reliability. Reliability of the scale was estimated using Kuder-Richardson Formula 20 and a value of σ2  ≥ 0.6 was acceptable. SPSS v23, Remark Classic OMR v6 software and MedCalc Statistical Software v16.4.3, were used to analyze the data. The study was approved by the relevant ethics committee (IRB#NOV:15). RESULTS: The mean score was 7.68 ± 2.52 (95% CI: 7.31-8.05) for 177 patients. The σ2  = 0.601, that is, >0.6, test-retest reliability ρ = .753, P < .05. The average discrimination power = 47.27, average Item Difficulty Index = 0.557. The fit indices were acceptable in a range that established its factorial validity and average factor loading was ≥0.7 which established convergent validity. A significant association (χ2  = 33.074, P < .01) between score interpretation and previous counseling by pharmacists established its construct validity. A significant association (χ2  = 19.113, P < .05) between score interpretation and patient occupation established known group validity. CONCLUSION: The English version of RAKAS was deemed a reliable and validated tool to measure knowledge about disease in Pakistani patients with RA.

Effects of Language, Insurance, and Race/Ethnicity on Measurement Properties of the PROMIS Physical Function Short Form 10a in Rheumatoid Arthritis.

OBJECTIVE: Most studies that have evaluated patient-reported outcomes, such as those utilizing the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Short Form 10a (PF10a) in rheumatoid arthritis (RA), have been performed in white and English-speaking populations. The aim of our study was to assess the measurement properties of the PF10a in a racially/ethnically diverse population with RA and to determine the effect of non-English language proficiency, insurance status, and race/ethnicity on the validity and responsiveness of the PF10a. METHODS: Data were abstracted from electronic health records for all RA patients seen in a university-based rheumatology clinic between 2013 and 2017. We evaluated the use of the PF10a, floor and ceiling effects, and construct validity across categories of language preference, insurance, and race/ethnicity. We used standardized response means and linear mixed-effects models to evaluate the responsiveness of the PF10a to longitudinal changes in the Clinical Disease Activity Index (CDAI) across population subgroups. RESULTS: We included 595 patients in a cross-sectional analysis of validity and 341 patients in longitudinal responsiveness analyses of the PF10a. The PF10a had acceptable floor and ceiling effects and was successfully implemented. We observed good construct validity and responsiveness to changes in CDAI among white subjects, English speakers, and privately insured patients. However, constructs evaluated by the PF10a were less correlated with clinical measures among Chinese speakers and Hispanic subjects, and less sensitive to clinical improvements among Medicaid patients and Spanish speakers. CONCLUSION: While the PF10a has good measurement properties and is both practical and acceptable for implementation in routine clinical practice, we also found important differences across racial/ethnic groups and those with limited English proficiency that warrant further investigation.

Trends in Joint Replacement Surgery in Patients with Rheumatoid Arthritis.

OBJECTIVE: This study analyzed trends in large total joint arthroplasties (TJA) and in the proportion of these procedures performed on patients with rheumatoid arthritis (RA). METHODS: The US Nationwide Inpatient Sample (2002-2012) was used to identify the incidences of total shoulder (TSA), elbow (TEA), knee (TKA), hip (THA), and ankle (TAA) arthroplasty and the proportion of these performed with coexisting RA. RESULTS: The prevalence of RA among patients with TJA increased 3.0%. The prevalence of RA among cases of TEA and TSA decreased by 50% (p < 0.0001) and 18% (p = 0.0016), respectively; a 38.0% decrease occurred in the prevalence of RA among TAA (p = 0.06); and nonsignificant increases were seen among THA and TKA. The average age difference between RA and non-RA patients undergoing TJA narrowed by 2 years (p < 0.0001). There was a greater reduction in the proportion of TSA, TEA, and TAA groups among women with RA than men with RA. In the TSA and TEA groups, there was a reduction in the proportion of whites with RA, but not blacks. The proportion of privately insured TSA and TAA patients with RA decreased, while patients with RA undergoing TSA, TEA, or TAA who were receiving Medicaid (government medical insurance) remained relatively stable over time. CONCLUSION: The prevalence of RA has decreased among TSA and TEA patients. A nonsignificant decline occurred among TAA patients. The average age of TJA patients with RA is beginning to mirror those without RA. Sex ratios for TSA, TEA, and TAA patients are following a similar pattern. These results may be evidence of the success of modern RA treatment strategies.

Inflammatory Arthritis Prevalence and Health Services Use in the First Nations and Non-First Nations Populations of Alberta, Canada.

OBJECTIVE: To estimate prevalence of rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic disease (PsD), and crystal-related arthritis and health care use for inflammatory arthritis in First Nations and non-First Nations patients in Alberta, Canada. METHODS: Population-based cohorts of adults with RA, AS, PsD, and crystal-related arthritis were defined, with First Nations determination by premium payer status, to estimate prevalence rates. Rates of outpatient primary care, specialist visits, and hospitalizations (all-cause, inflammatory-arthritis specific) were estimated. RESULTS: RA affected 3 times as many First Nations residents compared to non-First Nations residents (standardized rate ratio [SRR] 3.2, 95% confidence interval [95% CI] 2.9-3.4). AS and PsD were more prevalent in First Nations (AS 0.6 per 100 residents; SRR 2.7, 95% CI 2.3-3.2 and PsD 0.3 per 100 residents; SRR 1.5, 95% CI 1.3-1.9), whereas crystal-related arthritis was less prevalent (SRR 0.7, 95% CI 0.6-0.7). First Nations patients were more likely to have primary care visits (SRR 1.7, 95% CI 1.6-1.8) and less likely to have specialist visits (SRR 0.6, 95% CI 0.6-0.7) for RA relative to non-First Nations individuals. In PsD and crystal-related arthritis, First Nations people had higher rates of cause-specific hospitalizations. CONCLUSION: The estimated prevalence of RA, AS, and PsD was higher in the First Nations population, while crystal-related arthritis was less prevalent compared to the non-First Nations population. First Nations people were more likely to see primary care physicians and were less likely to see specialists for inflammatory arthritis care.

Use of Biologic Therapy in Racial Minorities With Rheumatoid Arthritis From 2 US Health Care Systems.

BACKGROUND: In the United States, there is racial/ethnic disparity in the care of rheumatoid arthritis (RA), yet there are limited data regarding the impact of varied health care systems on treatment outcomes. OBJECTIVE: The aim fo this study was to compare the frequencies of use of disease-modifying antirheumatic drugs and biologic agents in racial minorities with RA in a single-payer and variable-access health systems. METHODS: Rheumatoid arthritis disease status was examined in the Ethnic Minority Rheumatoid Arthritis Consortium (EMRAC) and Veterans Affairs Rheumatoid Arthritis Registry (VARA); frequencies of prednisone and disease-modifying antirheumatic drugs and biologic agent use at enrollment were documented. Comparisons in frequencies of RA therapies between RA cohorts and white and nonwhite racial subsets were evaluated. RESULTS: The combined cohorts provided 2899 subjects for analysis (EMRAC = 943, VARA = 1956). Routine Assessment of Patient Index Data 3 and Disease Activity Score in 28 Joints scores were equivalent (cohort, racial subsets), as was biologic agent use (26% vs. 28%) between whites and nonwhites. Disease-modifying antirheumatic drug use was greater in EMRAC nonwhites compared with their white counterparts, but similar to all VARA patients (33% vs. 22% [P < 0.001], 36%, 39%, respectively). However, biologic agent use was significantly greater in EMRAC versus VARA patients (37% vs. 22%, P < 0.001). In VARA patients, there was no difference in biologic agent use among racial subsets (22% vs. 21%). In EMRAC patients, biologic agent use was greater in whites than in nonwhites (EMRAC white 45% vs. EMRAC nonwhite 33%, P < 0.001; odds ratio, 1.66) and compared with all VARA subjects (EMRAC white 45% vs. all VARA 22%, P < 0.001; odds ratio, 2.91). Younger age, advanced education, longstanding disease, and severe disease were associated with biologic agent use. CONCLUSIONS: When compared with more variable-access systems, a VA system of care that includes a single-payer insurance may afford equality in use of biologic agents among different racial subsets.

Claims for disease-modifying therapy by Alberta non-insured health benefits clients.

BACKGROUND: Uncontrolled disease activity in inflammatory diseases of the joints, skin and bowel leads to morbidity and disability. Disease-modifying therapies are widely used to suppress this disease activity, but cost-coverage is variable. For Treaty First Nations and Inuit people in Canada without alternative private or public health insurance, cost-coverage for disease-modifying therapy is provided through Non-Insured Health Benefits (NIHB). Our objective was to describe the prevalence and patterns of treatment with disease-modifying therapy for the NIHB claimant population, and also examine adjuvant therapy (analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids) use. METHODS: Cases (n = 2512) were defined by ≥1 claim for a disease-modifying anti-rheumatic drug (DMARD) or biologic between 1999 and 2012 in the NIHB pharmacy claim database. The proportion of the population with claims for individual agents and drug classes annually was calculated to estimate annual incidence and prevalence rates for use of disease-modifying therapy, and the prevalence of use of individual DMARDs, biologics and adjuvants. Differences in the proportion accessing adjuvant therapies and median doses in the 6 months following initiation of disease-modifying therapies was estimated. RESULTS: The incidence rate of treatment was calculated at an average of 127.5 cases per 100,000 population between 2001 and 2012, and the cumulative prevalence, accounting for patients lost to the database, increased and then stabilized at 1.3 % in the last three years of the study. Annual dispensation of methotrexate, combination DMARD therapy and biologic therapy approached 35 %, 19 %, and 10 % of the cohort respectively. A declining prevalence of claims for acetaminophen (28 % to 15 %) and anti-inflammatories (73 % to 63 %) occurred from 2000 to 2012, however corticosteroid (32 %) and opioid (65 %) dispensation remained stable. The proportion of patients with claims for NSAIDs (69.9 % to 61.1 %, p = 0.002), oral corticosteroids (45.4 % to 33.6 %, p < 0.001) and parenteral corticosteroids (16.2 % to 8.3 %, p = 0.002) decreased in the 6 months following biologic initiation. CONCLUSIONS: The proportion of NIHB clients with active claims for disease-modifying therapy is lower than expected based on existing epidemiologic knowledge of the prevalence of inflammatory conditions in the First Nations and Inuit populations. These findings should be further explored in order to optimize treatment outcomes for NIHB claimants with inflammatory disease.

Telomere length, endothelial activation and carotid atherosclerosis in black and white African patients with rheumatoid arthritis.

OBJECTIVES: Our objective was to examine associations of traditional and non-traditional cardiovascular risk factors with relative leukocyte telomere length and confounder adjusted relationships of relative telomere length with endothelial activation and carotid atherosclerosis in black and white African patients with rheumatoid arthritis (RA). METHODS: Relative telomere length of leukocyte DNA in whole blood was determined using quantitative RT-PCR in 205 (101 black) African patients with RA. RESULTS: In demographic characteristic adjusted analysis, relative telomere length tended to be larger in black compared to white patients (median (IQR)=0.54 (0.42-0.54) and 0.48 (0.37-0.60) (p=0.07), respectively). In black patients, waist circumference, systolic, diastolic and mean blood pressure were associated with relative telomere length (ß (SE)=-0.00270 (0.00114) (p=0.02), -0.00185 (0.00060) (p=0.003), -0.00243 (0.00112) (p=0.03) and -0.00225 (0.00075) (p=0.003), respectively); in white patients, age, anti-cyclic citrullinated antibody positivity, biologic agent use, a cholesterol-HDL cholesterol ratio of >4 and the number of major traditional risk factors were related to relative telomere length (ß (SE) =-0.00242 (0.00113) (p=0.03), 0.06629 (0.03374) (p=0.05), -0.09321 (0.04310) (p=0.03), 0.08225 (0.03420) (p=0.02) and 0.04046 (0.01719) (p=0.02), respectively). One SD increase in relative telomere length was associated with carotid plaque (OR (95% CI)=1.65 (0.99-2.75) (p=0.05)) and vascular cell adhesion molecule-1 concentrations (ß (SE)=-0.05031 (0.02480) (p=0.04)) in black and white patients, respectively. CONCLUSIONS: This study disclosed paradoxically direct relationships between relative telomere length and cardiovascular risk factors in white and atherosclerosis in black African RA patients. The role of relative telomere length in cardiovascular risk and its stratification in RA requires longitudinal investigation.

Socioeconomic factors and self-reported health outcomes in African Americans with rheumatoid arthritis from the Southeastern United States: the contribution of childhood socioeconomic status.

BACKGROUND: There is abundant evidence that low socioeconomic status (SES) is associated with worse health outcomes among people with Rheumatoid Arthritis (RA); however, the influence of socioeconomic disadvantage in early life has yet to be studied within that population. METHODS: Data originated from the cross-sectional arm of the Consortium Evaluation of African-Americans with Rheumatoid Arthritis (CLEAR II), which recruited African-Americans with RA from six sites in the Southeastern United States. We used linear regression models to evaluate associations of parental homeownership status and educational level at participant time of birth with participant-reported fatigue (Visual Analog scale, cm), pain (Visual Analog scale, cm), disability (Health Assessment Questionnaire) and helplessness (Rheumatology Attitudes Index), independently of participant homeownership status and educational level. Models included random effects to account for intra-site correlations, and were adjusted for variables identified using backward selection, from: age, disease-duration, sex, medication use, body-mass index, smoking history. RESULTS: Our sample included 516 CLEAR II participants with full data on demographics and covariates. 89% of participants were women, the mean age was 54.7 years and mean disease duration was 10.8 years. In age adjusted models, parental non-homeownership was associated with greater fatigue (ß = 0.75, 95% CI = 0.36-1.14), disability (ß = 0.12, 95% CI = 0.04-0.19) and helplessness (ß = 0.12, 95% CI = 0.03-0.21), independently of participant homeownership and education; parental education had a further small influence on self-reported fatigue (ß = 0.20, 95% CI = 0.15-0.24). CONCLUSIONS: Parental homeownership, and to a small extent parental education, had modest but meaningful relationships with self-reported health among CLEAR II participants.

The importance of assessment and management of morning stiffness in Asian patients with rheumatoid arthritis: Recommendations from an expert panel.

OBJECTIVE: In patients with rheumatoid arthritis (RA), morning stiffness is linked more to functional disability and pain than disease activity, as assessed by joint counts and markers of inflammation. As part of the Asia Pacific Morning Stiffness in Rheumatoid Arthritis Expert Panel, a group of eight rheumatologists met to formulate consensus points and develop recommendations for the assessment and management of morning stiffness in RA. METHODS: On the basis of a systematic literature review and expert opinion, a panel of Asian rheumatologists formulated recommendations for the assessment and medical treatment of RA. RESULTS: The panel agreed upon 10 consensus statements on morning stiffness, its assessment and treatment. Specifically, the panel recommended that morning stiffness, pain and impaired morning function should be routinely assessed in clinical practice. Although there are currently no validated tools for these parameters, they should be assessed as part of the patients' reported outcomes in RA. The panel also agreed on the benefits of low-dose glucocorticoids in RA, particularly for the improvement of morning stiffness. CONCLUSIONS: These recommendations serve to guide rheumatologists and other stakeholders on the assessment and management of morning stiffness, and help implement the treat-to-target principle in the management of RA.

Poverty, Depression, or Lost in Translation? Ethnic and Language Variation in Patient-Reported Outcomes in Rheumatoid Arthritis.

OBJECTIVE: Despite advances in therapies, disparities in outcomes have been documented for rheumatoid arthritis (RA) patients for both ethnicity and English language proficiency. The goals of these analyses were to compare differences in RA patient-reported outcomes, by both self-identification of ethnicity and English language proficiency, and to identify factors that might explain differences among groups. METHODS: Data were collected through structured telephone interviews of a longitudinal cohort with physician-diagnosed RA (n = 438); only women were included (n = 335). Three groups were defined based on self-reported ethnicity and English proficiency: white/English (n = 219), Hispanic/English (n = 39), and Hispanic/Spanish (n = 77). Outcomes examined were patient-reported physical functioning, pain, and presence of moderate or severe fatigue. Multivariate regression analyses compared outcomes among groups, adjusting for sociodemographic characteristics, health and disease factors, and depression. RESULTS: Hispanic/Spanish women had worse function, pain, and fatigue than either English-proficient group. Depression was associated with all outcomes (P < 0.0001), and accounted for greater differentials in scores than ethnicity/language proficiency. In interaction analyses, differences between women who were and were not depressed were greater for Hispanic/English than for Hispanic/Spanish. Nondepressed Hispanic/Spanish scores were significantly worse than nondepressed Hispanic/English, i.e., the impact of depression was less for Hispanic/Spanish women because both depressed and nondepressed women in this group reported worse outcomes. After adjustment for sociodemographic factors and depression, language remained significantly associated with outcomes. CONCLUSION: Disparities in patient-reported outcomes may be driven less by ethnicity than by sociodemographic or psychological factors. Measurement instruments that are not culturally appropriate and equivalent may also hamper meaningful analyses of disparities.

The risk of cancer in patients with rheumatoid arthritis taking tumor necrosis factor antagonists: a nationwide cohort study.

INTRODUCTION: The association between cancer and use of biologic therapy among rheumatoid arthritis (RA) patients remains controversial. We aimed to compare the relative risk of cancer development between RA patients taking tumor necrosis factor α (TNFα) antagonists and those taking nonbiologic disease-modifying anti-rheumatic drugs (nbDMARDs). METHODS: We conducted a nationwide cohort study between 1997 and 2011 using the Taiwan National Health Insurance Research Database. The risk of newly diagnosed cancer was compared between patients starting TNF-α antagonists (biologics cohort) and matched subjects taking nbDMARDs only (nbDMARDs cohort). Cumulative incidences and hazard ratios (HR) were calculated after adjusting for competing mortality. Standardized incidence ratio (SIR) was calculated for cancer risk. Multivariate analyses were performed using Cox proportional hazards model. RESULTS: We compared 4426 new users of TNF-α antagonists and 17704 users of nbDMARDs with similar baseline covariate characteristics. The incidence rates of cancer among biologics and nbDMARDs cohorts were 5.35 (95% confidence interval (CI) 4.23 to 6.46) and 7.41 (95% CI 6.75 to 8.07) per 1000 person-years, respectively. On modified Cox proportional hazards analysis, the risk of cancer was significantly reduced in subjects in biologics cohort (adjusted HR 0.63, 95% CI 0.49 to 0.80, P < .001), after adjusting for age, gender, disease duration, major co-morbidities, and prior use of DMARDs and corticosteroids. However, there was an increased risk for hematologic cancers in biologics cohort, yet without statistical significance. The effect of biologics was consistent across all multivariate stratified analyses and the association between biologics use and cancer risk was independent of dosage of concomitant nbDMARDs. CONCLUSION: These findings suggested that RA patients taking TNF-α antagonist are associated with a lower risk of cancer, but not for hematologic cancers, than RA patients taking nbDMARDs alone.

Association between helplessness, disability, and disease activity with health-related quality of life among rheumatoid arthritis patients in a multiethnic Asian population.

To investigate the association between helplessness, disability, and disease activity with health-related quality of life (HRQoL) in a multiethnic cohort of rheumatoid arthritis (RA) patients in Singapore. This cross-sectional study was conducted at Tan Tock Seng Hospital, Department of Rheumatology, Allergy and Immunology, from October 2010 to October 2011. All patients fulfilled the American College of Rheumatology 1987 criteria for RA. Socio-demographics, clinical, and patient-reported outcome (PRO) variables were collected. HRQoL outcomes were Short Form 36 (SF-36) physical and mental component summary (PCS and MCS) scores and Short Form 6 Dimensions (SF-6D) utilities. Stepwise multiple linear regression analyses were performed using HRQoL outcomes as dependent variables in separate models and with adjustment for helplessness (Rheumatology Attitudes Index, RAI), disability (Health Assessment Questionnaire, HAQ), and disease activity (Disease Activity in 28 joints) followed by socio-demographic, clinical, and PRO variables. Complete data were provided by 473 consenting subjects [mean (SD) age: 60.02 (11.04) years, 85 % female, 77 % Chinese]. After adjustment for all measured covariates, only RAI and HAQ scores remained significantly associated with SF-36 MCS (ß: -0.9, p < 0.001; ß: -7.0, p < 0.001) and SF-6D utilities (ß: -0.005, p < 0.001; ß: -0.081, p < 0.001), respectively, while only HAQ scores were significantly associated with SF-36 PCS (ß: -7.7, p < 0.001). Interventions to address the sense of helplessness and to prevent or reduce disability could improve HRQoL of RA patients.

Racial and ethnic disparities in disease activity in patients with rheumatoid arthritis.

BACKGROUND: Observational studies of patients with rheumatoid arthritis have suggested that racial and ethnic disparities exist for minority populations. We compared disease activity and clinical outcomes across racial and ethnic groups using data from a large, contemporary US registry. METHODS: We analyzed data from 2 time periods (2005-2007 and 2010-2012). The Clinical Disease Activity Index was examined as both a continuous measure and a dichotomous measure of disease activity states. Outcomes were compared in a series of cross-sectional and longitudinal multivariable regression models. RESULTS: For 2005-2007, significant differences of mean disease activity level (P < .001) were observed across racial and ethnic groups. Over the 5-year period, modest improvements in disease activity were observed across all groups, including whites (3.7; 95% confidence interval [CI], 3.2-4.1) compared with African Americans (4.3; 95% CI, 2.7-5.8) and Hispanics (2.7; 95% CI, 1.2-4.3). For 2010-2012, significant differences of mean disease activity level persisted (P < .046) across racial and ethnic groups, ranging from 11.6 (95% CI, 10.4-12.8) in Hispanics to 10.7 (95% CI, 9.6-11.7) in whites. Remission rates remained significantly different across racial/ethnic groups across all models for 2010-2012, ranging from 22.7 (95% CI, 19.5-25.8) in African Americans to 27.4 (95% CI, 24.9-29.8) in whites. CONCLUSIONS: Despite improvements in disease activity across racial and ethnic groups over a 5-year period, disparities persist in disease activity and clinical outcomes for minority groups versus white patients.

Racial/ethnic differences in the use of biologic disease-modifying antirheumatic drugs among California Medicaid rheumatoid arthritis patients.

OBJECTIVE: To assess racial/ethnic differences in the use of biologic disease-modifying antirheumatic drugs (DMARDs) among California Medicaid (Medi-Cal) rheumatoid arthritis (RA) patients. METHODS: Medi-Cal patient level data for 5,385 DMARD recipients between ages 18 and 100 years with at least 1 diagnosis of RA (International Classification of Disease, Ninth Revision, Clinical Modification code 714.xx) and the use of 1 DMARD between January 1, 1998 and December 31, 2005 were collected. The outcome of interest was the choice of either standard DMARDs (methotrexate, lefluonomide, hydroxychloroquine, and sulfasalazine) or biologic DMARDs (adalimumab, etanercept, anakinra, and infliximab). A univariate analysis and logistic regression model were applied to examine the association of the choice of DMARD among different racial/ethnic groups. RESULTS: In the univariate analysis, biologic DMARD use was significantly associated with race/ethnicity (P < 0.001). In the multivariate logistic regression model, after adjusting for age, sex, insurance coverage, 12 comorbid conditions, RA-related drug prescription, RA-related inpatient stay, and rehabilitation visits, African Americans had 53% lower odds of receiving biologic DMARDs as compared to whites, whereas Hispanics had 36% increased odds of receiving biologic DMARDs as compared to whites. CONCLUSION: In this Medi-Cal population, with its racial diversity and relatively homogenous socioeconomic status and health care benefits, racial/ethnic differences were found in RA patients receiving biologic DMARDs.

Racial and ethnic disparities in disease activity and function among persons with rheumatoid arthritis from university-affiliated clinics.

OBJECTIVE: Health outcomes in rheumatoid arthritis (RA) have improved significantly over the past 2 decades. However, research suggests that disparities exist by race/ethnicity and socioeconomic status, with certain vulnerable populations remaining understudied. Our objective was to assess disparities in disease activity and function by race/ethnicity and explore the impact of language and immigrant status at clinics serving diverse populations. METHODS: We examined a cross-sectional study of 498 adults with confirmed RA at 2 rheumatology clinics: a university hospital clinic and a public county hospital clinic. Outcomes included the Disease Activity Score in 28 joints (DAS28) and its components, and the Health Assessment Questionnaire (HAQ), a measure of function. We estimated multivariable linear regression models including interaction terms for race/ethnicity and clinic site. RESULTS: After adjusting for age, sex, education, disease duration, rheumatoid factor status, and medication use, clinically meaningful and statistically significant differences in DAS28 and HAQ scores were seen by race/ethnicity, language, and immigrant status. Lower disease activity and better function was observed among whites compared to nonwhites at the university hospital. This same pattern was observed for disease activity by language (English compared to non-English) and immigrant status (US-born compared to immigrant) at the university clinic. No significant differences in outcomes were found at the county clinic. CONCLUSION: The relationship between social determinants and RA disease activity varied significantly across clinic setting with pronounced variation at the university, but not at the county clinic. These disparities may be a result of events that preceded access to subspecialty care, poor adherence, or health care delivery system differences.

Burden of depressive symptoms in South African public healthcare patients with established rheumatoid arthritis: a case-control study.

OBJECTIVES: The burden of depressive symptoms and how demographic and disease characteristics relate to depressive symptoms in patients with rheumatoid arthritis (RA) that belong to developing populations, are currently unknown and were therefore assessed in a case-control study in public healthcare patients in South Africa, a lower-middle income country. Public healthcare attendance is a surrogate of belonging to the developing population in South Africa. METHODS: Demographic and RA features were recorded in 441 public and 202 private healthcare patients. The outcome characteristic was the Arthritis Impact Measure Scales (AIMS) depression score. Relationships of patient characteristics and public healthcare attendance with depressive symptoms were determined in multivariable regression models. RESULTS: The mean ± SD AIMS depression score was 3.6±2.1 and 2.3±1.7 in public and private healthcare patients, respectively (p<0.0001 before and after adjustment for covariates). Physical disability was associated with depressive symptoms in both healthcare sectors. Other characteristics that were related to depressive symptoms comprised younger age, male sex and pain in public healthcare patients and fatigue and non-use of disease modifying agents in private healthcare patients. In all patients, public healthcare attendance (standardised ß [95% CI]=0.22 [0.12, 0.32], p<0.0001) and physical disability (standardised ß [95% CI]=0.25 [0.16, 0.34], p<0.0001) were most strongly associated with depressive symptoms. CONCLUSIONS: The burden of depressive symptoms is markedly enhanced in our developing population with RA, independent of age, sex, ethnic origin and disease characteristics. In this setting, the role of social factors should be assessed and, despite restricted resources, depressive symptoms should be routinely addressed.

Socioeconomic disparities in self-reported arthritis for Indigenous and non-Indigenous Australians aged 18-64.

OBJECTIVE: To examine socioeconomic disparities in arthritis among non-remote Indigenous and non-Indigenous Australian adults aged 18-64. METHODS: Weighted data on self-reported arthritis and several socioeconomic measures from two nationally representative surveys conducted in 2004-2005 were analysed using logistic regression. RESULTS: Current diagnosed arthritis was more commonly reported by Indigenous than non-Indigenous people across all age groups. After adjusting for age and sex, arthritis was significantly more common among those of lower socioeconomic status (SES) in the non-Indigenous population for all SES variables examined. In the Indigenous population, associations between SES and arthritis were significant for household income and employment status, but not for education, post-school qualifications, home ownership, area-level disadvantage, or area of residence. CONCLUSIONS: The SES disparities were less consistent in the Indigenous than the non-Indigenous population, and within the Indigenous population, they were less consistent for arthritis than those previously reported for diabetes among the same survey participants. Although some of the differences may be due to self-reporting of disease, these findings also suggest the potential salience of factors occurring across the SES spectrum, especially among Indigenous Australians.

Racial disparities in treatment preferences for rheumatoid arthritis.

BACKGROUND: Data suggest that differences in patient preferences may account for racial disparities in the use of medical interventions. Racial disparities have also been noted in outcomes and the delivery of healthcare services in chronic disease. Whether treatment preferences in chronic disease differ by race is not known. METHODS: We elicited treatment preferences for aggressive therapy in patients with rheumatoid arthritis who identified themselves as being black or white. RESULTS: One hundred fifty consecutive eligible patients were invited to participate. Of these, 136 subjects completed the interview. In unadjusted analysis, 51% of white participants preferred aggressive therapy compared with 16% of blacks (P < 0.0001). Subjects who were married and reported having at least some college education had stronger preferences for aggressive therapy compared with their respective counterparts. After adjusting for covariates, race remained the strongest predictor of aggressive therapy examined in this study [adjusted odds ratio (95% confidence interval) = 11.2 (1.9-64.9)]. CONCLUSIONS: In this study, fewer black patients preferred aggressive treatment compared with white patients with similar disease severity. These results have important clinical implications because use of aggressive treatment improves both short- and long-term outcomes in rheumatoid arthritis. Efforts to improve patient education and physician communication should be made to ensure that all patients have an accurate understanding of the benefits, as well as risks, associated with the best available treatment options.