DMARD non-use in low-income, elderly rheumatoid arthritis patients: results of 86 structured interviews.

INTRODUCTION: Disease-modifying antirheumatic drugs (DMARDs) have become the treatment standard for patients with rheumatoid arthritis (RA). Although several general-population studies document that a large population of patients diagnosed with RA do not use DMARDs, little is known about this group. We explored the characteristics, experiences, and knowledge of a low-income, elderly RA population not currently using DMARDs, or receiving care from a rheumatologist. METHODS: 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. The interview 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 with never users. RESULTS: A total of 86 people completed the interview. The mean age was 80 years and 89% were female. On average, disease duration was 20 years. Mean MHAQ score was 0.55 (SD = 0.55). Of 86 participants, 19 had previously used DMARDs, 10 of whom discontinued them because of 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 reported experiencing more-severe RA symptoms than never-users. CONCLUSIONS: We found that side effects or safety concerns were the primary cause for DMARD cessation among prior-users. Among never-users, most reported never discussing or being offered DMARDs, suggesting that an educational gap may deter patients with RA from using them.

Primary care physicians' perspectives towards managing rheumatoid arthritis: room for improvement.

INTRODUCTION: Many people with rheumatoid arthritis (RA) do not receive care from a rheumatologist. We surveyed primary care physicians (PCPs) to better understand their attitudes, knowledge, and practices regarding the optimal treatment of RA. METHODS: Randomly selected PCPs practicing in the US were surveyed. The survey encompassed their experience with RA, use of disease modifying anti-rheumatic drugs (DMARDs), and experience with rheumatology referrals. Logistic regression analyses described the responses and examined the correlation between physician variables and use of DMARDs. RESULTS: E-mail invitations were opened by 1, 103 PCPs and completed by 267 (25%). Most respondents were men (68%) in practice for over 10 years (64%) who reported 6 or more RA patients under their care in the last year (71%). The majority reported some RA training after medical school (59%), but only one-third felt very confident managing this condition. Most (81%) reported prescribing DMARDs, but 37% do not initiate them, with only 9% reporting being very confident starting a DMARD. In unadjusted analyses, several respondent characteristics were strongly associated with not prescribing DMARDs, but none was significant after adjustment. Almost half (44%) of PCPs noted that patients report difficulty getting appointments with rheumatologists. CONCLUSIONS: We found many PCPs are uncomfortable managing RA with DMARDs, despite common beliefs that their patients lack access to a rheumatologist. Lack of accessibility to rheumatologists and discomfort in prescribing DMARDs for patients with RA are potential barriers to optimal treatment.